COVID-19 VACCINES: ADVERSE EVENTS FOLLOWING IMMUNISATION

Patients rely on healthcare providers as their most credible and frequent source of vaccine information. It is therefore crucial that healthcare providers are informed and have evidence-based, objective and clear guidance on vaccine efficacy and specific adverse events following immunisation (AEFI). Reported serious AEFIs are extremely rare for the COVID-19 vaccines. This article discusses the main AEFIs attributed to COVID-19 vaccines, including neurological complications of Guillain-Barré syndrome (GBS) and acute transverse myelitis (ATM), thrombosis;cardiac complications, including myocarditis, pericarditis and cardiomyopathy;and allergic reactions such as anaphylaxis, urticaria and skin rashes. The benefits of COVID-19 vaccination outweigh the risks;however, it is important that healthcare providers are aware of the risks and know how to recognise and manage them.

Tourists and tour operators as citizen scientists: potential and challenges

Wildlife tour operators often visit natural habitats regularly and remote ones less often. Academic researchers and their students often do not have the budget to do so, or to send research assistants. Keepers in wildlife parks and zoos and ecolodge managers often have the opportunity to observe animals almost daily, but may lack the time to sit and watch for many hours. There would appear to be much scope for tour operations and their tourists to participate in citizen science. There are already numerous examples, from day-trippers photographing whale tails on cruises to help monitor migratory individuals, to experiences such as 'Wildlife of the Mongolian Steppes', a two-week citizen science excursion run by the Earthwatch Institute and Denver Zoo to collect data on Mongolian wildlife in cooperation with local researchers. Potential and actual problems of using tourists and tour operators as citizen scientists have been voiced, but there are ways of overcoming at least some of them. Tour operators looking for ways of engaging domestic tourists now that Covid-19 lockdown prevents many international visits may consider the potential for incorporating citizen science activities that offer their guests a food learning experience, a sense of achievement and perhaps a closer look at some species than would normally be possible.

Viral infections, COVID-19 and asthma: Preventing viral exacerbations of asthma

Asthmatics are particularly vulnerable to viral illnesses, which cause the vast majority of asthma exacerbations. The most common viruses responsible for these exacerbations are the human rhinovirus and influenza virus. Influenza vaccine provides a reasonable prevention strategy for influenza infection, but there is not an effective vaccine against the rhinovirus. This is a major reason for effective control of chronic asthma and strategies to prevent viral upper-respiratory tract infections in asthmatics. COVID-19 does not appear to be more severe in asthmatics, especially if they are well controlled. This virus also does not seem to be more common in asthmatics. However, in times of pandemic virus diseases, it is necessary that asthma and allergic rhinitis are well controlled. It is important to distinguish COVID-19 from asthma exacerbations, because the treatments differ. Asthma therapies are not contraindicated in COVID-19-infected patients, as adverse events do not occur in this group.

Summary of childhood asthma guidelines, 2021: A consensus document

Asthma is the most common chronic illness of childhood. The prevalence is rising and the mortality and morbidity from asthma are unacceptably high in South Africa. It is important to make a correct diagnosis based, most importantly, on the clinical history and supported by investigations. The appropriate drug and device must be chosen to achieve good asthma control. Patients must be followed up regularly and their asthma control must be assessed. The treatment can then be adjusted according to the level of control. The COVID-19 pandemic has placed new challenges on the care of our asthmatics. Asthma education and adherence are important components of management of the condition.

Parental access to hospitalised children during infectious disease pandemics such as COVID-19.

The COVID-19 pandemic has resulted in many hospitals severely limiting or denying parents access to their hospitalised children. This article provides guidance for hospital managers, healthcare staff, district-level managers and provincial managers on parental access to hospitalised children during a pandemic such as COVID-19. It: (i) summarises legal and ethical issues around parental visitation rights; (ii) highlights four guiding principles; (iii) provides 10 practical recommendations to facilitate safe parental access to hospitalised children; (iv) highlights additional considerations if the mother is COVID-19-positive; and (v) provides considerations for fathers. In summary, it is a child's right to have access to his or her parents during hospitalisation, and parents should have access to their hospitalised children; during an infectious disease pandemic such as COVID-19, there is a responsibility to ensure that parental visitation is implemented in a reasonable and safe manner. Separation should only occur in exceptional circumstances, e.g. if adequate in-hospital facilities do not exist to jointly accommodate the parent/caregiver and the newborn/infant/child. Both parents should be allowed access to hospitalised children, under strict infection prevention and control (IPC) measures and with implementation of non-pharmaceutical interventions (NPIs), including handwashing/sanitisation, face masks and physical distancing. Newborns/infants and their parents/caregivers have a reasonably high likelihood of having similar COVID-19 status, and should be managed as a dyad rather than as individuals. Every hospital should provide lodger/boarder facilities for mothers who are COVID-19-positive, COVID-19-negative or persons under investigation (PUI), separately, with stringent IPC measures and NPIs. If facilities are limited, breastfeeding mothers should be prioritised, in the following order: (i) COVID-19-negative; (ii) COVID-19 PUI; and (iii) COVID-19-positive. Breastfeeding, or breastmilk feeding, should be promoted, supported and protected, and skin-to-skin care of newborns with the mother/caregiver (with IPC measures) should be discussed and practised as far as possible. Surgical masks should be provided to all parents/caregivers and replaced daily throughout the hospital stay. Parents should be referred to social services and local community resources to ensure that multidisciplinary support is provided. Hospitals should develop individual-level policies and share these with staff and parents. Additionally, hospitals should ideally track the effect of parental visitation rights on hospital-based COVID-19 outbreaks, the mental health of hospitalised children, and their rate of recovery.

Reactive urticaria and severe thrombocytosis in a child with SARS-CoV-2 infection

Coronavirus SARS-CoV-2 has made a significant impact around the world through COVID-19 and its related complications. Individuals with comorbid conditions and the elderly have been at risk of significant inflammatory complications, including the cytokine release syndrome (CRS) and acute respiratory distress syndrome (ARDS). Children, on the other hand, have been less affected and have had less severe disease. However, reports from Europe and North America have described clusters of children and adolescents with paediatric multisystem inflammatory syndrome. Both adults and children have also exhibited a number of unusual disease manifestations. We present the case of a South African child, infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presenting with reactive urticaria and thrombocytosis, further broadening the clinical spectrum of COVID-19 in children.

Protecting asthmatics from covid-19

The coronavirus disease 2019 (COVID-19) is caused by a severe acute respiratory syndrome 2 virus (SARS-CoV-2). Infections were first detected in Wuhan, China in late 2019 and the infection has recently spread worldwide and been declared a pandemic by the World Health Organization. The disease presents with a spectrum of respiratory manifestations that range from asymptomatic cases, to patients with mild and severe symptoms, either with or without pneumonia. Symptoms include fever, upper respiratory tract coryza, cough and acute lower respiratory tract infection. Asthmatics have, thus far, only shown slightly higher risk for hospitalisation but not for mortality. However, this may change in South Africa. Asthmatics are advised to keep their asthma under control and to continue using controller medication. It is critical for all of us, especially asthmatics, to practice ‘social distancing’, wash hands frequently and practise sneeze and cough etiquette.

Diagnosis of community-acquired pneumonia in children: South African Thoracic Society guidelines (part 2)

Background. Accurate diagnosis and attribution of the aetiology of pneumonia are important for measuring the burden of disease, implementing appropriate treatment strategies and developing more effective interventions. Objectives. To produce revised guidelines for the diagnosis of pneumonia in South African (SA) children, encompassing clinical, radiological and aetiological methods. Methods. An expert group was established to review diagnostic evidence and make recommendations for a revised SA guideline. Published evidence was reviewed and graded using the British Thoracic Society grading system. Results. Diagnosis of pneumonia should be considered in a child with acute cough, fast breathing or difficulty breathing. Revised World Health Organization guidelines classify such children into: (i) severe pneumonia;(ii) pneumonia (tachypoea or lower chest indrawing);or (iii) no pneumonia. Malnourished or immunocompromised children with lower chest indrawing should be managed as cases of severe pneumonia. Pulse oximetry should be done, with hospital referral for oxygen saturation <92%. A chest X-ray is indicated in severe pneumonia or when tuberculosis (TB) is suspected. Microbiological investigations are recommended in hospitalised patients or in outbreak settings. Improved aetiological methods show the importance of co-infections. Blood cultures have a low sensitivity (<5%), for diagnosing bacterial pneumonia. Highly sensitive, multiplex tests on upper respiratory samples or sputum detect multiple potential pathogens in most children. However, even in symptomatic children, it may be impossible to distinguish colonising from causative organisms, unless identification of the organism is strongly associated with attribution to causality, e.g. respiratory syncytial virus, Mycobacterium tuberculosis, Bordetella pertussis, influenza, para-influenza or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Investigations for TB should be considered in children with severe pneumonia who have been hospitalised, in a case of a known TB contact, if the tuberculin skin test is positive, if a child is malnourished or has lost weight, and in children living with HIV. Induced sputum may provide a higher yield than upper respiratory sampling for B. pertussis, M. tuberculosis and Pneumocystis jirovecii. Conclusions. Advances in clinical, radiological and aetiological methods have improved the diagnosis of childhood pneumonia.

COVID-19 in children: Should we be worried?

Reports indicate that children infected with SARS-CoV-2 have thus far presented with less severe disease than adults. Anxiety regarding a greater ability to transmit the virus is largely unfounded and has played a significant role in the decision to allow children to return to school. In some patients, however, especially in infants and in those with underlying comorbidities, severe disease must be anticipated and planned for accordingly. The most relevant severe clinical presentation in addition to the established respiratory complications, is that of a multisystem inflammatory disorder, with features resembling Kawasaki disease. The impact of the pandemic on the economic and social wellbeing of children, including food insecurity and care when parents are ill, cannot be ignored. During this pandemic, it is imperative to ensure access to routine and emergency medical services to sick children. In so doing, potentially devastating medical and socioeconomic consequences can be mitigated.

Prevention of community-acquired pneumonia in children: South African Thoracic Society guidelines (part 4)

BACKGROUND. More comprehensive immunisation regimens, strengthening of HIV prevention and management programmes and improved socioeconomic conditions have impacted on the epidemiology of paediatric community-acquired pneumonia (CAP) in South Africa (SA). OBJECTIVES. To summarise effective preventive strategies to reduce the burden of childhood CAP. METHODS. An expert subgroup reviewed existing SA guidelines and new publications focusing on prevention. Published evidence on pneumonia prevention informed the revisions;in the absence of evidence, expert opinion was used. Evidence was graded using the British Thoracic Society (BTS) grading system. RECOMMENDATIONS. General measures for prevention include minimising exposure to tobacco smoke or air pollution, breastfeeding, optimising nutrition, optimising maternal health from pregnancy onwards, adequate antenatal care and improvement in socioeconomic and living conditions. Prevention of viral transmission, including SARS-CoV-2, can be achieved by hand hygiene, environmental decontamination, use of masks and isolation of infected people. Specific preventive measures include vaccines as contained in the Expanded Programme on Immunisation schedule, isoniazid prophylaxis for tuberculosis, co-trimoxazole prophylaxis for HIV-infected infants and children who are immunosuppressed, and timely diagnosis of HIV, as well as antiretroviral therapy (ART) initiation. HIV-infected children treated with ART from early infancy, and HIV-exposed children, have similar immunogenicity and immune responses to most childhood vaccines as HIV-unexposed infants. VALIDATION. These recommendations are based on available published evidence supplemented by the consensus opinion of SA paediatric experts, and are consistent with those in published international guidelines.