Cases of rubella spike countrywide while diphtheria hits Western Cape despite being preventable by vaccination

The National Department of Health has confirmed a surge in seasonal rubella cases in South Africa, with 10,137 positive cases identified between January and November 2024. Rubella is a mild, contagious viral infection best known for its distinctive red rash.

The department stated that more than 90% of the cases occurred in children under 15, with only one patient over the age of 50. It added that if children are not vaccinated against rubella, and never come into contact with the virus through natural infection, children will remain susceptible to it.

Rubella is transmitted through direct contact with nasal or throat secretions of infected individuals. According to the National Institute for Communicable Diseases (NICD), the non-pharmaceutical interventions during the Covid-19 pandemic, such as lockdown, social distancing and mask-wearing, meant that the “natural seasonal transmission” of rubella was interrupted. Far fewer children contracted the virus through natural infection and built up immunity during this period.

“For 2020 to 2022, almost no rubella cases were identified from the National Department of Health/NICD fever-rash surveillance. Children who would have been infected with rubella over the past three years are now becoming infected with [it],” said the NICD, in its explanation for this year’s large seasonal increase in infections.

Another factor behind the surge in cases is that vaccination against rubella has not been part of the Department of Health’s routine expanded programme on immunisation prior to this year.

“The Department of Health is presently rolling out the combined measles-rubella-containing vaccine (MRCV), which will be administered to six- and 12-months-old children as soon as each province exhausts their stock of measles-containing vaccine (MCV),” stated the NICD.

The Centre for Vaccines and Immunology at the NICD identified the increase in rubella cases this year, with figures surpassing those from fever-rash surveillance records since 2015.

Among the provinces, Gauteng had the highest number of rubella infections at 2,603, followed by KwaZulu-Natal with 1,996 and the Western Cape at 1,338, said the National Department of Health.

What to look out for

The symptoms of rubella can include:

• Fever;


• A maculopapular rash;


• Myalgia;


• Enlarged lymph nodes;


• Headaches; and


• Conjunctivitis.

Occasionally, people who contract rubella may develop joint pain, low platelets and mild encephalitis.

In rare cases, pregnant women who are vulnerable to rubella – due to not being vaccinated against it, nor contracting it naturally at some point in their lives – can be at risk of passing rubella infection on to their unborn children, resulting in “congenital rubella infection”, according to the NICD.

“Fortunately, this is uncommon, as studies have shown that up to 98% of women of child-bearing age are immune to rubella,” it said.

“Congenital rubella syndrome may lead to foetal death or congenital abnormalities such as congenital heart disease, blindness and deafness. Any pregnant woman who has been exposed to a case of rubella, or a person with fever and rash should report this urgently to their health practitioner.

“A pregnant woman who is diagnosed with rubella infection should undergo specialist obstetric evaluation.”

In all cases where a person meets the case definition for rubella, they need to be notified and a blood specimen should be sent to the NICD for rubella antibody testing.

However, due to a backlog of tests, the NICD said that priority rubella testing should be requested:

• When a pregnant woman in her first trimester of pregnancy is exposed to a case of rubella or a person with fever and rash;


• When a test is required to rule out a diagnosis of rubella or measles in a patient who is severely ill and is admitted to hospital; and


• When a neonate is suspected of having congenital rubella syndrome.

Western Cape diphtheria cases

Byron la Hoe, spokesperson for the Western Cape Department of Health and Wellness, told Daily Maverick that between 25 November and 18 December, five laboratory-confirmed cases of diphtheria were identified in areas of the Cape Metro District, including Philippi, Lotus River, Athlone and a local correctional facility. All patients are between the ages of 28 and 34. There has been one death as a result of the disease.

“We can confirm that two laboratory-confirmed diphtheria cases involving adults have been identified in two different areas within Philippi. These cases had no apparent epidemiological links,” said La Hoe.

“A public health response was initiated following the laboratory-confirmed cases… This response includes ongoing contact tracing within the affected communities, a correctional facility and consulting healthcare workers, as well as the collection of swabs for diphtheria screening, provision of prophylaxis (antibiotics) and targeted vaccination of at-risk persons as per the guidelines.”

The department has urged healthcare workers and facilities in the province to have a “high index of suspicion for diphtheria” while notifying and reporting suspected cases, said La Hoe.

“We ask residents not to panic while efforts to control diphtheria cases are under way,” said the department on Wednesday, 18 December.

The department noted that children without full immunisation and adults with waning immunity were at higher risk of contracting the disease, especially in crowded conditions.

Symptoms of diphtheria include:

• Sore throat;


• Fever;


• Chills;


• Nausea; and


• Difficulty swallowing or breathing.

Immunity gaps

Among the partners the department is working with to manage the cases are the NICD, the National Health Laboratory Services and the City of Cape Town.

Prof Cheryl Cohen, head of the Centre for Respiratory Diseases and Meningitis at the NICD, told Daily Maverick that the institute was providing reference laboratory testing, including confirmation of the organism, detailed strain characterisation and antimicrobial susceptibility testing. It was also providing epidemiologic support.

When asked about the possible factors behind the diphtheria cases, Cohen said it could be linked to “immunity gaps related to low vaccine coverage of the diphtheria vaccine, particularly the booster doses”.

“Diphtheria vaccine is given as part of the expanded programme on immunisation as part of a combination vaccine. This vaccine is recommended to be given at age six, 10 and 14 weeks, followed by a booster dose at 18 months, and at six and 12 years of age,” she explained.

“The booster doses are essential for long-term protection, but coverage of these doses is very low as parents often don’t bring their children for vaccination after the first two years of life. Parents are urged to prioritise and remember to bring their children to any vaccine clinic to receive these booster doses at six and 12 years of age, as well as to complete the full course of scheduled vaccines in the first two years of life.”

Cohen urged any person who suspected they had diphtheria to urgently visit their nearest clinic. DM