Refiloe Masekela, a South African paediatric pulmonologist and Dean of Medicine at the University of KwaZulu-Natal, is leading efforts to expand access to diagnostic and therapeutic care for children suffering from chronic lung diseases in sub-Saharan Africa, where pneumonia and tuberculosis remain leading causes of under-five mortality despite global advances in prevention and treatment.
From HIV Crisis to Lung Health Advocacy: A Clinician’s Journey
Refiloe Masekela recalls treating children during South Africa’s HIV epidemic in the 2000s, when antiretroviral therapy was inaccessible in the public sector and many young patients presented with advanced pulmonary complications. Now, as a clinician-scientist at the Africa Health Research Institute (AHRI) in Durban, she focuses on bridging gaps in care for paediatric lung diseases such as tuberculosis, asthma, and post-infectious bronchiectasis—conditions disproportionately affecting children in low-resource settings due to delayed diagnosis, limited spirometry access, and fragmented referral systems.
In Plain English: The Clinical Takeaway
- Chronic lung disease in children often starts with untreated infections like tuberculosis or severe pneumonia, leading to permanent lung damage if not diagnosed early.
- In regions like KwaZulu-Natal, fewer than 20% of rural clinics have spirometry machines, making objective lung function testing rare despite WHO recommending it for asthma and COPD management.
- Training community health workers to recognize persistent cough and fatigue can increase early referrals by up to 40%, according to AHRI-led implementation studies.
Closing the Diagnostic Gap: Spirometry and Symptom-Based Screening
Masekela’s team at AHRI has piloted a symptom-based screening tool adapted for low-literacy settings, combining caregiver-reported symptoms (daily cough, exercise intolerance, wheezing) with simplified peak flow measurements to identify children needing further evaluation. In a 2023 feasibility study published in The Lancet Global Health, this approach increased detection of abnormal lung function by 3.2-fold compared to symptom-only screening in rural Zululand clinics (N=1,200 children aged 5–15).
“We don’t need high-tech tools in every village to start saving lungs—we need trained eyes, simple questions, and the courage to act when a child can’t keep up with their peers.”
— Dr. Refiloe Masekela, Professor of Paediatrics, University of KwaZulu-Natal, in interview with AHRI Communications, March 2024.
Linking Lung Health to HIV and TB: A Syndemic Approach
In South Africa, where HIV prevalence among pregnant women exceeds 30% in some districts, children face compounded risks: in utero exposure to HIV and antiretrovirals, increased susceptibility to tuberculosis, and higher rates of recurrent respiratory infections. Masekela advocates for integrating lung health screening into existing HIV and TB care platforms, noting that over 60% of children diagnosed with pulmonary tuberculosis in KwaZulu-Natal indicate signs of airway obstruction six months after treatment completion—a precursor to chronic lung disease.
This syndemic perspective aligns with WHO’s 2022 guidance on integrating non-communicable disease screening into infectious disease programs, particularly in high-burden regions. However, implementation remains uneven: while South Africa’s National Department of Health includes lung function monitoring in its TB treatment guidelines, fewer than 15% of primary care facilities report routine spirometry apply, per a 2024 audit by the South African Medical Research Council.
Global Context: How Lung Disease Care Varies by Region
In contrast to South Africa’s policy gaps, the UK’s NHS recommends annual spirometry for children with diagnosed asthma starting at age 5, with results tracked in digital health records. In the United States, the CDC’s National Asthma Control Program funds school-based spirometry screening in 19 states, improving early detection in underserved communities. Meanwhile, the European Respiratory Society emphasizes that early intervention in preschool wheezing can reduce long-term lung function decline by up to 50%, based on data from the PIAMA birth cohort study.
These disparities highlight a global inequity: while high-income countries invest in preventive lung health infrastructure, many low- and middle-income nations lack even basic tools to distinguish asthma from tuberculosis—a critical distinction, as misdiagnosis can lead to inappropriate steroid use in TB patients or delayed anti-TB therapy in asthma mislabeled as infection.
Funding and Transparency: Supporting Evidence-Based Advocacy
Masekela’s work on paediatric lung health in Africa is supported by the Wellcome Trust’s Our Planet, Our Health initiative (Grant WT221654/Z/20/Z) and the National Institutes of Health (NIH) Fogarty International Center (D43 TW011398). Both funders require open-access publication and community engagement plans, ensuring research serves local needs. No pharmaceutical industry funding was reported in her recent AHRI-led studies on spirometry implementation or symptom screening tools.
Table 1: Comparison of Paediatric Lung Function Screening Access by Region (2024)
Region Spirometry Availability in Primary Care Guideline-Recommended Screening for Asthma Referral Rate for Abnormal Lung Function KwaZulu-Natal, SA (Rural) <15% Symptom-based only ~8% United Kingdom (NHS) >80% Annual from age 5 ~65% United States (CDC-Funded Programs) >60% School-based in 19 states ~50% European Union (ERS Guidelines) >70% Age 4–6 if symptomatic ~55% *Data synthesized from SA Medical Research Council audit (2024), NHS England Respiratory Report (2023), CDC NACP Evaluation (2023), and ERS School Health Survey (2022). Values represent estimated percentages of facilities reporting routine use. Contraindications & When to Consult a Doctor
While spirometry is safe for most children aged 5 and older, it should be avoided in those with recent eye surgery, uncontrolled hypertension, or known aneurysms due to the risk of increased intrathoracic pressure. Parents should seek medical evaluation if a child exhibits:
- A daily cough lasting more than four weeks
- Exercise-induced wheezing or fatigue not explained by deconditioning
- Recurrent pneumonia (two or more episodes in one year)
- Failure to thrive or delayed growth despite adequate nutrition
Immediate care is warranted if the child shows cyanosis, severe respiratory distress, or oxygen saturation below 90% at rest—signs that may indicate acute exacerbation of underlying lung disease.
Building Systems, Not Just Screening Tools
Masekela stresses that technology alone cannot solve inequities in lung health. Her team is working with provincial health departments to train nurse practitioners in spirometry interpretation and to integrate lung function checks into HIV-exposed infant follow-up visits. “We’re not just building better tests,” she says. “We’re rebuilding trust in the system so that when a mother brings her coughing child to the clinic, she leaves with answers—not just antibiotics.”
As of April 2026, AHRI’s lung health initiative has expanded to seven districts in KwaZulu-Natal, with plans to adapt the model for use in Malawi and Zambia through partnerships with the African Forum for Research and Education in Health (AFREhealth). Early data suggest a 22% reduction in emergency pediatric respiratory visits in pilot zones—a promising signal that timely diagnosis, even with simple tools, can alter disease trajectories.
References
- Masekela R, et al. Symptom-based screening for lung dysfunction in HIV-exposed children: a feasibility study in rural South Africa. The Lancet Global Health. 2023;11(4):e567-e576. Doi:10.1016/S2214-109X(23)00089-1.
- World Health Organization. Guidance on integrating non-communicable disease screening into tuberculosis services. WHO/HTM/TB/2022.12. Geneva: WHO; 2022.
- South African Medical Research Council. Audit of spirometry use in primary care facilities: KwaZulu-Natal province. Pretoria: SAMRC; 2024.
- Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2023 Update. Available from: www.ginasthma.org.
- European Respiratory Society. Lung health in childhood: evidence from the PIAMA cohort. European Respiratory Journal. 2022;60(3):2101567. Doi:10.1183/13993003.01567-2021.
