ENDORSEMENT: South African Thoracic Society, South African Society of Paediatric Infectious Diseases, United South African Neonatal Association. OBJECTIVE: To develop and publish a guideline for doctors managing acute viral bronchiolitis, because this condition is extremely common in South Africa, it is responsible for significant morbidity in the population, and subsequently a great deal of patient and parental distress, and the disease is costly, since many children are unnecessarily subjected to investigations and treatment strategies that are of no proven benefit. The main aims of the guideline are to promote an improved standard of treatment based on understanding of the disease and its management, and to encourage costeffective and appropriate management. EVIDENCE: A detailed literature review was conducted and summarised into this document by a selected working group of paediatricians from around the country. RECOMMENDATIONS: These include the appropriate diagnostic and management strategies for acute viral bronchiolitis.

OBJETIVO: Documentar a alteração em função pulmonar de uma população pediátrica com fibrose cística tratada no Red Cross War Memorial Children's Hospital, Cidade do Cabo, África do Sul, entre janeiro de 1999 e dezembro de 2006. MÉTODOS: Revisão retrospectiva dos prontuários médicos e melhores resultados de espirometria em intervalos de 3 meses. RESULTADOS: Um total de 1.139 testes de função pulmonar de 79 pacientes mostrou melhora significativa ao longo dos 8 anos estudados. Ao comparar o primeiro trimestre de 1999 com o último trimestre de 2006, 78 testes de função pulmonar foram realizados em 65 pacientes com números iguais de pacientes em ambos os grupos e semelhante em termos de gênero, idade, idade ao diagnóstico, etnia, genótipo da fibrose cística e número de pacientes colonizados com Staphylococcus aureus ou Pseudomonas aeruginosa.Em 2006, 15 pacientes (38,5%) estavam em tratamento com azitromicina, comparados com um (2,6%) paciente em 1999 (p = 0,0003). Volume expiratório forçado no primeiro segundo mediano (intervalo interquartil), capacidade vital forçada e fluxo expiratório médio entre 25 e 75% da capacidade vital forçada aumentaram de 61% (51-73), 63% (52-89) e 40% (27-57) previstos no primeiro trimestre de 1999 para 81% (69-100, p = 0,004), 82% (70-98, p = 0,007) e 62% (41-87, p = 0,01) previstos durante o último trimestre de 2006, respectivamente. CONCLUSÕES: Testes de função pulmonar aumentaram em 20% ao longo de 8 anos em grupos comparáveis de pacientes. Isso provavelmente reflete a melhora na prestação de cuidados a crianças sul-africanas com fibrose cística.

OBJECTIVE: To document the change in pulmonary function of a pediatric cystic fibrosis population managed at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa, between January 1999 and December 2006. METHODS: Retrospective review of the medical records and best spirometry results within 3-monthly intervals. RESULTS: A total of 1,139 pulmonary function tests from 79 patients showed a significant improvement over the 8 years studied. When comparing the first quarter of 1999 with the last quarter of 2006, 78 pulmonary function tests were performed on 65 patients with equal patient numbers in both groups and similar in terms of gender, age, age at diagnosis, ethnicity, cystic fibrosis genotype and number of patients colonized with either Staphylococcus aureus or Pseudomonas aeruginosa. In 2006, 15 patients (38.5%) were on azithromycin treatment compared to one (2.6%) patient in 1999 (p = 0.0003). Median (interquartile range) forced expiratory volume in 1 second, forced vital capacity, and average expiratory flow between 25 and 75% of forced vital capacity increased from 61% (51-73), 63% (52-89), and 40% (27-57), predicted in the first quarter of 1999, to 81% (69-100, p = 0.004), 82% (70-98, p = 0.007), and 62% (41-87, p = 0.01), predicted during the last quarter of 2006, respectively. CONCLUSIONS: Pulmonary function tests increased by 20% over 8 years in comparable patient groups. This likely reflects improved care of South African children with cystic fibrosis.

Pneumonia is a major cause of childhood mortality and morbidity. Streptococcus pneumoniae is the most important bacterial pathogen causing pneumonia in children. The HIV epidemic has increased the burden and severity of childhood pneumococcal pneumonia and invasive disease fortyfold. Pneumococcal conjugate vaccine (PCV) is a highly effective intervention to reduce invasive pneumococcal disease and pneumonia. Studies evaluating a 9-valent PCV in South Africa and The Gambia reported a 72 - 77% reduction in vaccine-serotype-specific invasive disease in vaccinated children. As many of the pneumococcal serotypes associated with antibiotic resistance are included in PCV, vaccination has also been associated with a reduction in antimicrobial-resistant invasive disease. PCV may also reduce childhood mortality, especially in places with limited access to health care, as shown in Gambian study in which PCV reduced childhood mortality by 16%. In addition to the direct effects of PCV, there is a substantial reduction in disease burden through indirect protection of non-vaccinated populations. PCV is immunogenic in HIV-infected children and provides protection against invasive disease or pneumonia in a substantial number of children. Although the efficacy of PCV for prevention of invasive disease or pneumonia is lower in HIV-infected compared to -uninfected children, the overall burden of disease prevented is much greater in HIV-infected children because of the higher burden of pneumococcal disease in these children. Consequently, vaccine-preventable invasive disease is almost 60 times higher in HIV-infected compared to -uninfected children, while the reduction in pneumonia in HIV-infected children is 15 times greater. However, the long-term efficacy of PCV wanes in HIV-infected children who are not taking antiretroviral therapy, and booster doses are probably indicated. Although there is concern about the potential for replacement disease due to non-vaccine serotypes, a substantial and sustained reduction in invasive disease has occurred overall in populations with widespread childhood immunisation. Routine childhood immunisation is now the standard of care in most developed countries. However, PCV is much less accessible to children in developing countries due to cost and availability. Cost-effectiveness analysis indicates that use of PCV is potentially highly cost-effective, at tiered pricing, even in very low-income countries. Widespread availability and vaccination with PCV is urgently needed for all children under 2 years of age in South Africa. In addition, the use of PCV for all HIV-infected children under 9 years should be prioritised.