Prof Colleen Aldous: Measles is back and South Africa is asking the wrong question.

South Africa recorded 3,891 confirmed measles cases between December 2025 and mid-August 2026, with new infections reported in every province. While vaccine hesitancy is often blamed, NICD data shows a sharper problem: coverage with the first dose of the DTP vaccine, a proxy for routine immunisation, fell from 87% in 2019 to 67% in 2025. Alongside 480 rubella cases in the same period, the outbreak raises questions about clinic access and missed opportunities within the health system, not just parental refusal. WHO recommends 95% coverage with two measles doses to prevent outbreaks. The piece argues government and citizens share responsibility for closing the gap..By Professor Colleen Aldous.Measles should be a disease we discuss in history books, not in weekly surveillance reports.But by 16 August 2026, South Africa had recorded 3,891 laboratory- confirmed measles cases since the end of December 2025. Another 144 cases were detected in the most recent reporting week, with new cases reported across all provinces. The National Institute for Communicable Diseases has described a continuing increase in measles cases nationally. That should concern us, but not simply because measles has returned. It should concern us because measles is telling us something about the health of our immunisation system. The most immediate explanation is often vaccine hesitancy. Yes, reluctance to vaccinate is an important issue. The NICD itself has called for greater public engagement to build trust in vaccines and address hesitancy. Misinformation, distrust of institutions, complacency about diseases that younger parents may rarely have seen, and the legacy of the COVID-19 vaccine debate, including legitimate public questions about the safety, effectiveness and communication surrounding newer mRNA vaccines, all deserve careful attention. But blaming hesitant parents is too easy. A more uncomfortable statistic emerged this month. WHO and UNICEF estimates indicate that coverage with the first dose of the diphtheria-tetanus-pertussis-containing vaccine, DTP1, fell in South Africa from 87% in 2019 to 67% in 2025. Coverage with the third dose fell from 85% to 65%. These figures do not tell us how many South African children are vaccinated against measles. DTP coverage is important for another reason - it is used as an indicator of how successfully routine immunisation services are reaching children and keeping them within the vaccination programme. UNICEF has also cautioned that administrative data may not capture all vaccinations delivered in the private sector. The precise figures therefore need to be interpreted carefully. But even with that qualification, the trend is troubling. It suggests that South Africa may have a broader problem with routine childhood immunisation that cannot automatically be explained by people actively refusing vaccines.Vaccination is a reciprocal responsibility Public-health discussions about childhood vaccination are often framed around individual responsibility.Parents have an obligation to protect their children against preventable disease. Vaccination also protects not only the individual child, but others who remain vulnerable, including babies who are too young to be fully immunised, people with weakened immune systems, and those who do not develop adequate immunity after vaccination. With measles, community protection is particularly important. It is one of the most contagious infections known. Because it spreads so efficiently, WHO recommends maintaining at least 95% coverage with two doses of measles-containing vaccine to prevent outbreaks and achieve elimination. Vaccination therefore cannot be regarded simply as a private decision. But responsibility runs in both directions. If society expects parents to vaccinate their children, the state has an equally serious obligation to make vaccination accessible, reliable and easy to obtain. A parent cannot reasonably be held solely responsible for missing childhood immunisations if the clinic is difficult to reach, vaccine services are unreliable, appointments require repeated visits, or attendance means losing a day's wages. Nor should a child leave a healthcare facility without receiving an indicated routine vaccine simply because immunisation was not the reason for that particular visit. That is why the causes of declining routine immunisation coverage need to be established rather than assumed. How much is due to parents actively refusing vaccines? How much results from children simply not reaching services? How much reflects missed vaccination opportunities within the health system? Are vaccines consistently available where they are needed? And are the causes the same in affluent suburbs, informal settlements and remote rural communities? Until we can answer these questions, "vaccine hesitancy" risks becoming a convenient explanation for what may be a considerably more complex problem..Measles is not a harmless childhood illness There is another reason not to be complacent. Those old enough to remember measles may remember it as one of the illnesses that almost every child once contracted. That familiarity can make it seem relatively benign. It is not. Measles can cause pneumonia, severe diarrhoea, encephalitis, blindness and death. Young children and people with impaired immunity are particularly vulnerable. According to the World Health Organization, approximately 95,000 people died from measles globally in 2024, mostly among unvaccinated or under-vaccinated children. At the same time, measles vaccination is estimated to have prevented almost 59 million deaths between 2000 and 2024. Those two figures capture the central paradox.Measles remains dangerous, but its major burden is also largely preventable. There is another warning in South Africa's current surveillance data. During the same reporting period in which the NICD recorded the measles cases, it identified 480 laboratory-confirmed cases of rubella. Most occurred in children between one and 14 years of age. Rubella is usually a relatively mild childhood illness. Its real danger is the teratogenic effects that occur when a woman becomes infected during pregnancy, particularly early pregnancy. Congenital rubella syndrome can result in miscarriage, stillbirth or severe abnormalities in the developing fetus. The simultaneous circulation of measles and rubella should therefore be viewed as more than a collection of infectious-disease statistics. It is a warning about gaps in population protection.We need accountability on both sides None of this means that vaccine hesitancy should be ignored. Public-health authorities need to communicate clearly, respond to legitimate questions, counter misinformation and rebuild trust where it has been lost. Parents also have responsibilities. Refusing an effective childhood vaccine without a sound medical reason is not a decision whose consequences necessarily stop with one's own child..Read more:.Ramaphosa says Mpox crisis in Africa is a chance to redress mistakes.But government must accept their end of the bargain.We need transparent information about which children are being missed and why. We need to distinguish refusal from failure of access. We need better district-level understanding of where vaccination coverage is falling. And when children do encounter the health system, routine immunisation opportunities should not be unnecessarily lost.Most importantly, interventions should respond to the actual reason for low coverage. If the problem is misinformation, the answer is better communication and trusted community engagement. If the problem is access, the answer is better service delivery. If the problem is missed opportunities inside clinics, the answer lies within the health system itself. Treating all three problems as "vaccine hesitancy" will solve none of them. The most important question raised by the present measles outbreak is therefore not simply, why are people not vaccinating their children? It is why are South African children not being vaccinated? The questions sound similar, but they are not. The first places responsibility primarily on parents. The second forces us to examine parents, communities, healthcare workers, service delivery and government together. South Africa will not control measles through persuasion alone, and it will not control it through clinics alone. Successful vaccination depends on a social contract. Citizens must be willing to protect their children and one another, while the state must provide services that make doing so easy, dependable and trustworthy. A health system cannot demand responsibility from citizens without demonstrating responsibility itself. The return of measles should remind us of both..Sign up for your early morning brew of the BizNews Insider to keep you up to speed with the content that matters. The newsletter will land in your inbox every morning on weekdays. Register here.Support South Africa's bastion of independent journalism, offering balanced insights on investments, business, and the political economy, by joining BizNews Premium. Register here.If you prefer WhatsApp for updates, sign up to the BizNews channel here.

Prof Colleen Aldous: Measles is back and South Africa is asking the wrong question.

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