Health Sector Shortcomings Associated with Measles Outbreaks in Cape Town, South Africa

Vimbai Chasi, Ailsa Holloway, Christopher Garimoi Orach


Measles is viewed mainly as a public health concern constituting an object of study through epidemiological methods. However, the complexity of the risk factors that drive measles outbreaks suggests the need for wider and more inclusive conceptualisation beyond conventional biomedical methods. This prompted the application of a more integrative research approach to measles outbreaks in Cape Town.

The study employed a mixed-methods approach, including an epidemiological analysis of measles cases to identify and characterise measles outbreaks. Qualitative methods were used to identify and differentiate key health sector shortcomings as well as risk governance deficit areas associated with the progression of measles risk.

Results underlined the value of applying an integrated epidemiological and risk governance framework. They included multi-scalar institutional shortcomings that revealed systemic issues in the management of measles outbreaks. These were wide-ranging, and indicated system-wide issues related to monitoring and early detection, reflected at national, provincial and health worker levels.

The research identified recurrent shortcomings at provincial level. These included a focus/investment on mass rather than routine vaccination; as well as, poor mass immunisation planning due to systemic under-estimation of the exposed population (due to use of live births statistics and exclusion of in-migration data, which artificially inflated vaccination coverage). A further limitation was indicated by difficulties in involving key stakeholders in Outbreak Response Immunisation (ORI) and Supplementary Immunisation Activities (SIAs) (especially the Education Department). At health worker level, poor completion of case investigation forms was a recurrent deficit, constraining accurate characterisation of specific outbreaks. An emergent shortcoming following the 2009-2011 outbreak was the failure/delayed diagnosis of the index measles case, which critically delayed intervention, limiting effectiveness of ORI. These findings underline the value of applying an integrative risk lens to the understanding of epidemic risk in urban settings with high levels of population mobility/migration, where public health services face multiple pressures.


risk governance, outbreak risk, disaster risk, vaccine, measles, re-emerging infectious diseases, Cape Town

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