Despite an excellent immunisation programme, pneumonia still stalks far too many children in South Africa. This is the finding of the Drakenstein Child Health Study, which is tracking 1000 mother-child pairs in Paarl over several years.Pneumonia is the leading killer of children under the age of five, claiming about a million lives a year worldwide. The burden is disproportionately high in Africa.The key lesson from the study, said University of Cape Town researcher Professor Heather Zar, is that despite vaccines, low prevalence of HIV in children, and good access to care, the infection remains a “major cause of childhood illness”.“We found that pneumonia remains a major cause of illness [incidence: 0.27 episodes per child per year] and hospitalisation, particularly in the first six months of life, despite excellent immunisation coverage.”To combat pneumonia, South Africa was the first in Africa to immunise babies against Streptococcus pneumoniae. The vaccine was introduced for infants at six weeks and 10 weeks in 2009, and in 2011 replaced with an improved one.The study says it is not only high exposure to pathogens that fuel the situation; it is also factors such as “smoke exposure, lack of breastfeeding, prematurity, low birth weight, low socioeconomic status, crowded living conditions or HIV infection”.Mncedisi Twala, of the Abemi Grassroots Movement in Cape Town, says overcrowding is a major concern. “Adults get sick but there are so many people in [a] shack or house that the virus moves quickly from one family member to another.”Parents also “struggle to find the R20 needed for transport to health centres, and when they do get there and get medication for their kids, they come home to the same conditions as before”.According to the World Health Organisation, “indoor air pollution caused by cooking and heating with wood” is also a major factor. And when immune systems are compromised by malnutrition or undernourishment, children cannot easily fight off pneumonia.Zar and her team say novel strategies are needed, and one under discussion involves immunising pregnant women in the third trimester.This would need to be coupled with “additional vaccination of infants” to provide “extended protection” until children are two years...