Below 95%: Trends in immunisation Coverage and Health System Drivers of the re-emergence of vaccine-preventable diseases in KwaZulu-Natal, South Africa (2018/2019–2024/2025)
1
Health Research & Knowledge Management, KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1763
ABSTRACT
BACKGROUND:
Routine childhood immunisation is essential for preventing vaccine-preventable diseases (VPDs) such as measles, rubella and diphtheria1. In South Africa, disruptions to primary health care (PHC) services during the coronavirus disease 2019 (COVID-19) pandemic coincided with renewed outbreaks of these diseases. KwaZulu-Natal (KZN) has experienced repeated outbreaks despite long-standing implementation of the Expanded Programme on Immunisation (EPI). Understanding immunisation trends and health system drivers is critical for strengthening outbreak prevention and health system resilience.
METHODS:
A retrospective ecological analysis was conducted using District Health Information System (DHIS) data from all eleven districts in KwaZulu-Natal for the period 2018/2019 to 2024/2025 financial years (FYs). Immunisation indicators included immunisation under one year coverage, measles-rubella (MR) first and second dose coverage, and diphtheria-tetanus-acellular pertussis, inactivated polio, Haemophilus influenzae type b and hepatitis B (DTaP/IPV/Hib/HBV) first to fourth dose coverage and measles first-to-second dose drop-out rates. Descriptive analyses, repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc testing, and linear regression analyses were performed using the online statistical tool, Statisty App, to assess temporal trends, district-level variation and associations with primary health care utilisation.
RESULTS:
Immunisation coverage declined significantly during the COVID-19 period (2020/2021–2021/2022 FYs) and did not fully recover by 2024/2025 FY. Provincial measles first-to-second dose drop-out rates worsened from −1.0% in 2018/2019 to −24.2% in 2024/2025, with the greatest deterioration observed in socio-economically vulnerable districts. Primary health care utilisation was moderately associated with early-schedule immunisations but showed weak or non-significant associations with second-dose and booster vaccinations, indicating challenges in continuity of care.
CONCLUSIONS:
The re-emergence of vaccine-preventable diseases in KwaZulu-Natal reflects systemic weaknesses in immunisation follow-up rather than access alone. These findings highlight the need for post-pandemic recovery strategies that prioritise continuity of care, targeted outreach and defaulter tracing to rebuild population immunity and reduce inequities across districts.
Routine childhood immunisation is essential for preventing vaccine-preventable diseases (VPDs) such as measles, rubella and diphtheria1. In South Africa, disruptions to primary health care (PHC) services during the coronavirus disease 2019 (COVID-19) pandemic coincided with renewed outbreaks of these diseases. KwaZulu-Natal (KZN) has experienced repeated outbreaks despite long-standing implementation of the Expanded Programme on Immunisation (EPI). Understanding immunisation trends and health system drivers is critical for strengthening outbreak prevention and health system resilience.
METHODS:
A retrospective ecological analysis was conducted using District Health Information System (DHIS) data from all eleven districts in KwaZulu-Natal for the period 2018/2019 to 2024/2025 financial years (FYs). Immunisation indicators included immunisation under one year coverage, measles-rubella (MR) first and second dose coverage, and diphtheria-tetanus-acellular pertussis, inactivated polio, Haemophilus influenzae type b and hepatitis B (DTaP/IPV/Hib/HBV) first to fourth dose coverage and measles first-to-second dose drop-out rates. Descriptive analyses, repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc testing, and linear regression analyses were performed using the online statistical tool, Statisty App, to assess temporal trends, district-level variation and associations with primary health care utilisation.
RESULTS:
Immunisation coverage declined significantly during the COVID-19 period (2020/2021–2021/2022 FYs) and did not fully recover by 2024/2025 FY. Provincial measles first-to-second dose drop-out rates worsened from −1.0% in 2018/2019 to −24.2% in 2024/2025, with the greatest deterioration observed in socio-economically vulnerable districts. Primary health care utilisation was moderately associated with early-schedule immunisations but showed weak or non-significant associations with second-dose and booster vaccinations, indicating challenges in continuity of care.
CONCLUSIONS:
The re-emergence of vaccine-preventable diseases in KwaZulu-Natal reflects systemic weaknesses in immunisation follow-up rather than access alone. These findings highlight the need for post-pandemic recovery strategies that prioritise continuity of care, targeted outreach and defaulter tracing to rebuild population immunity and reduce inequities across districts.
| eISSN: | 2654-1459 |
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