In recent weeks, both rubella and diphtheria viruses have captured the local media’s attention based on a spike in reported cases across the country. Here is a brief alert into the current situation and potential risks in the local context.

Rubella outbreak in South Africa:

In late 2024, the National Institute for Communicable Diseases (NICD) confirmed a rubella outbreak in South Africa. While a seasonal increase in rubella is expected from September to December each year, 2024 saw a marked rise in cases compared to previous years. The latest NICD report (November 2024) shows 9019 laboratory-confirmed cases, compared to 869 cases in 2023. Over >90% of these cases affected individuals under the age of 15, with most cases recorded in Gauteng and Western Cape provinces.

The NICD attributes the surge to an “immunity gap”, caused by many children entering 2024 without prior exposure or vaccination against rubella. Contributing factors include missed vaccinations, the absence of rubella vaccination in the routine Expanded Programme of Immunisation (EPI) before 2024, and interrupted transmission during the COVID-19 pandemic due to non-pharmaceutical interventions like social distancing and mask-wearing.

Rubella (also known as German measles) is an infectious disease typically resulting in mild, self-limiting illness in children. Rubella presents with a maculopapular rash, myalgia (muscle pain), fever, enlarged lymph nodes, headache, and conjunctivitis. It poses significant risks for pregnant women, particularly in the first trimester. It can lead to Congenital Rubella Syndrome (CRS) in the fetus, causing heart defects, blindness, deafness, and other severe abnormalities.

The disease spreads through droplets from coughs or sneezes of an infected person. There is no specific treatment for rubella and symptoms are usually managed through supportive care (rest, fluid and mild pain reliver’s) and isolation to prevent further spread. The most effective prevention strategy is effective vaccination.

As vaccination against rubella has historically not been part of the routine EPI, the Department of Health (DoH) is planning to roll out a combined measles-rubella-containing vaccine (MRCV) from 2025; this is to replace the current measles-containing vaccine (MCV) for children aged 6 and 12 months. As we exit the rubella season, there is no need for panic, but it is crucial to stay informed and vigilant. Early detection and vaccination are essential to prevent severe disease and further spread. (1) (2) (3) (4) (5) (6) (7)

Diphtheria outbreak in South Africa:

On 21 January 2025 the NICD issued an alert for all clinicians to be vigilant for respiratory diphtheria and advised that all suspected cases should be sent for laboratory diagnostic testing. Between 1 January 2024 and 15 January 2025, Corynebacterium diphtheriae was detected in 40 individuals across the country. This comprised of 20 respiratory diphtheria cases and 20 asymptomatic carriers found during contact tracing. The average age of those with respiratory diphtheria was 22 years (ranging between 4 – 41), with a 25% mortality (death) rate. Most cases (92%) were identified in the Western Cape. It is unclear what has caused this increase in cases. Dipththeria is usually uncommon in South Africa, with reported cases usually being sporadic. Diphtheria vaccination is part of the routine EPI, as a combination vaccine [Diphtheria. Tetanus, Acellular Pertussis, Inactivated Polio Vaccine and Haemophilus Influenzae Type B and Hepatitis B (DTaP-IPV-Hib-HBV)]; administered at week 6, 10, 14 and 18 of life. (13)

Diphtheria is a contagious bacterial infection that affects individuals differently, while some may remain carriers and appear asymptomatic, others develop mild to severe symptoms; with complications being potentially fatal. Symptoms include a sore throat, low-grade fever, malaise, adherent membrane (thick grey membrane around tonsils, pharynx, and/or nasal cavity), and/ or marked cervical lymphadenopathy (swelling of lymph nodes in the neck). Systemic manifestations can also occur and involve the heart, nervous system, and kidneys and in rare cases, diphtheria may present as vaginal, eye (conjunctival), or ear infections.

Diphtheria is transmitted from person to-person through droplets from coughs or sneezes of an infected individual. It primarily affects unvaccinated children, but anyone can be susceptible. High-risk groups include partially or unvaccinated individuals, and people living in crowded conditions. Treatment includes antibiotic therapy (azithromycin or penicillin) and diphtheria antitoxin (DAT) for severe cases, with careful airway management due to the risk of obstruction. Vaccination is the best method to prevent diphtheria and its spread yet despite the availability of a safe and effective vaccine, outbreaks have been increasing due to under vaccination. (8) (9) (10) (11) (12)

References

  1. SABC News: NICD warns of Rubella outbreak in SA. 19 Dec 2024.
  2. NICD: Surge in Rubella cases in SA (Nov 2024). 18 Dec 2024.
  3. IOL News: “Do Not Panic”: Health Dept sounds alrarm on rising Rubella cases across SA. 20 Dec 2024.
  4. Surge in Rubella Cases in South Africa (November 2024). National Institute of Communicable Diseases. [Online] December 18, 2024. [Cited: January 16, 2025.] https://www.nicd.ac.za/surge-in-rubella-cases-in-south-africa november-2024/.
  5. NDoH. Health alerts public of rising rubella cases around the country. South African Government. [Online] December 19, 2024. [Cited: January 16, 2025.] https://www.gov.za/news/media-statements/health-alerts-public-rising rubella-cases-around-country-19-dec-2024.
  6. Rubella. Edwards, MS and Shetty, A. s.l. : UpToDate, 2024.
  7. NICD. Report: Rubella in South Africa, 2024 . [Online] December 19, 2024. [Cited: January 16, 2025.] chrome-extension:// efaidnbmnnnibpcajpcglclefindmkaj/https://www.nicd.ac.za/wp-content/ uploads/2024/11/Increase-in-Rubella-Cases-Report-November-2024.pdf.
  8. WHO. World Health Organization. Diphtheria. [Online] July 12, 2024. [Cited: January 16, 2025.] https://www.who.int/news-room/fact-sheets/detail/ diphtheria.
  9. Da Costa, D. The Pathcare News – Diphtheria alert. PathCare. [Online] December 2024. [Cited: January 16, 2025.] https://www.pathcare.co.za/wp content/uploads/2024/12/Diphtheria-alert.pdf.
  10. Clinical manifestations, diagnosis, and treatment of diphtheria. Barroso, L and Pegram, PS. s.l. : UpToDate, 2023.
  11. NICD – Diphtheria Cases Rise in South Africa: What You Need to Know. 21 Jan 2025.
  12. MedicineHealth: S Doerr. Diptheria. https://www.emedicinehealth.com/ diphtheria/article_em.htm . Accessed on 23/01/2025.
  13. Department of Health South Africa. Expanded Program on Immunisation in South Africa. [Online] May 08, 2024. [Cited: January 27, 2025.] chrome extension://efaidnbmnnnibpcajpcglclefindmkaj/https://knowledgehub.health. gov.za/system/files/2024-05/VACCINE%20HESITANCY%20WEBINAR_ OVERVIEW%20OF%20EPI_MAY_2024_FINAL.pdf