Australia’s diphtheria outbreak is not only a warning about falling vaccination rates, but also about the consequences of weakened public health systems and longstanding inequities, say experts in this report by Croakey’s Jason Staines.
It also highlights the need to tackle housing insecurity – a topic notably absent from much of the media coverage of housing-related reforms in the recent Federal Budget.
Jason Staines writes:
Australia’s worst diphtheria outbreak since records began has raised concerns about falling vaccination rates and the role of misinformation in undermining public confidence in vaccination.
More than 260 cases have been recorded nationally this year, with the majority in the Northern Territory and Western Australia, prompting a $7.2 million Commonwealth support package aimed at boosting vaccination rates and strengthening the health workforce in affected areas.
However, while misinformation, disinformation and declining trust in institutions are part of the challenge, health experts and sector leaders say falling vaccination rates cannot be understood simply as a problem of “anti-vax sentiment”.
Instead, they point to a combination of workforce shortages, access barriers, poverty, fragmented services and weakening trust in health systems, particularly in rural, remote and Aboriginal communities.
Complicated picture
The current outbreak has largely affected Aboriginal and Torres Strait Islander communities, with health authorities saying contributing factors include overcrowding, lower routine immunisation rates, limited access to culturally safe care and high rates of skin infections in some areas.
The outbreak comes amid broader concerns about vaccine-preventable diseases in Australia. According to the Australian Institute of Health and Welfare (AIHW), notifications for many vaccine-preventable diseases fell during the COVID-19 pandemic, partly because of public health restrictions and changes in healthcare-seeking behaviour, but have increased again since 2023 as those measures were relaxed.
While diseases such as measles, rubella and diphtheria remain relatively rare due to historically high vaccination rates, the AIHW warns that maintaining strong immunisation coverage remains critical to preventing outbreaks and limiting the spread of disease through the community.
The CDC said the current outbreak also illustrated the importance of booster vaccinations. While vaccination remains the best protection against severe diphtheria, immunity can wane over time.
According to the CDC, 84 per cent of respiratory diphtheria cases and 73 per cent of cutaneous cases in the current outbreak had received at least three valid vaccine doses. Among respiratory cases, the median time since the last vaccination was seven years, increasing to nine years among hospitalised patients.
The spokesperson told Croakey the fact that many people had been vaccinated within the previous decade had “likely contributed to most notified cases being mild”.
The Australian Indigenous Doctors’ Association (AIDA) said outbreak vulnerability could not be separated from broader structural conditions.
AIDA CEO Dr Peter Malouf told Croakey that factors including “overcrowded housing, poverty, remoteness, limited access to primary health care, and underinvestment in prevention” were “crucial to understanding how this outbreak developed and why certain communities face higher exposure”.
Malouf said rates of vaccination varied significantly depending on “geography, access to services, workforce availability, and whether health services are properly resourced to deliver sustained, high-quality care”.
He said remote and regional communities often faced “restricted access to reliable health and medical services, inconsistent service delivery that often overlooks town camps and families outside the community, and shortages in culturally appropriate health education resources”.
Malouf also said health literacy needed to be understood carefully in communities where English may be a second, third or fourth language, and where information was not always delivered “in clear, culturally relevant and locally trusted ways”.
“There is also ongoing trauma from the pandemic, where public health awareness was often inconsistent, inappropriate, or absent in some communities,” he said.
“That experience has left a legacy of mistrust, not because communities are unwilling to protect themselves, but because systems failed to communicate with respect, transparency and cultural safety.”
Malouf argued the current outbreak should shift focus “from individual behaviour to public accountability”.
“The problem is not that communities are hard to reach, but that systems have failed to reach them properly,” he said.
Health experts caution against viewing Aboriginal and Torres Strait Islander vaccination rates as uniformly low. National data shows many First Nations communities have achieved strong vaccination coverage, particularly where Aboriginal Community Controlled Health Organisations (ACCHOs) have been able to deliver locally led and culturally safe services.
According to Indigenous Health Performance Framework data, 96 per cent of First Nations children aged five were fully immunised in 2022, compared with 94 per cent of other Australian children. However, coverage varied considerably between jurisdictions and age groups, with lower rates recorded in some regions. The data also show childhood vaccination rates declined following the COVID-19 pandemic, mirroring broader national trends.
The experience of the COVID-19 response demonstrated the effectiveness of community-controlled approaches, with Aboriginal health organisations and governments working together to develop local plans and vaccination strategies tailored to individual communities.
The Aboriginal Health Council of Western Australia (AHCWA) similarly described the outbreak as “a direct consequence of long-term under-investment in the environmental determinants of health”.
In a media release, AHCWA said crowded living conditions and limited access to functioning washing facilities were helping drive transmission, particularly because many cases involved cutaneous diphtheria spreading through infected skin sores.
AHCWA chair Vicki O’Donnell said vaccination remained essential, but was not enough on its own. “To reduce rates of disease we need parity in community infrastructure, essential services and living conditions — including housing, water, sewerage and waste management,” she said.
O’Donnell said inadequate housing often resulted in failures of basic “health hardware” such as showers, laundry facilities and reliable hot water, making infection control more difficult. She said Aboriginal Community Controlled Health Services were “best placed to deliver these practical, culturally secure solutions”.
Meanwhile, much of the media coverage of housing-related reforms announced in the Federal Budget has been focused firmly on the interests of homeowners and buyers, rather than the urgent need – for the sake of health, wellbeing and equity – to improve housing security for people who may not be in the home buyers’ market.
Role of misinformation
Researchers and clinicians say misinformation and declining trust have further complicated vaccination efforts in the years since the COVID-19 pandemic.
This issue was also highlighted in a new National Immunisation Strategy for 2025–30, released a year ago, which identifies several priorities for action, including building public trust and understanding in the value of immunisation, and combatting misinformation.
Writing in The Conversation when the strategy was released, public health experts said childhood immunisation coverage had fallen from almost 95 per cent in 2020 to around 92 per cent nationally.
They argued the pandemic had left “some people with lingering questions and misperceptions about vaccines, supercharged by misinformation and increasing political polarisation of vaccination”.
Another article in The Conversation argued misinformation often relies on logical fallacies and emotionally persuasive arguments rather than evidence, including anecdotal reasoning, false dichotomies and appeals to popularity.
GPs say they are seeing the effects directly in clinics.
Royal Australian College of General Practitioners (RACGP) NSW and ACT Chair Dr Rebekah Hoffman said most patients remained supportive of vaccination, but attitudes had shifted in recent years.
“The majority of my patients remain absolutely pro-vaccine, but there’s an emerging vocal minority who’ve shifted a little, and a larger group who’ve become quietly uncertain,” she told Croakey.
“What’s changed isn’t so much outright refusal as a kind of ambient scepticism that wasn’t there five years ago.”
Hoffman said misinformation had become increasingly sophisticated and difficult for some patients to identify. “Patients who previously vaccinated without question now arrive with a list of concerns they’ve found online, and some of that content is polished enough that it’s genuinely difficult to identify as false,” she said.
She said the COVID pandemic had “turbocharged distrust in health institutions”, while social media algorithms were increasingly reinforcing fears and scepticism.
The Australian Centre for Disease Control (CDC) told Croakey the factors influencing vaccination uptake were “complex and context dependent”, varying across different communities and population groups.
A CDC spokesperson said data from the National Vaccination Insights Project pointed to both “growing behavioural drivers, such as safety concerns and mistrust in vaccine information” and structural barriers including “appointment availability, cost, and service accessibility”.
“Restoring Australia’s progress in vaccination and protection against vaccine-preventable diseases relies on coordinated, whole-of-system responses to strengthen vaccine confidence, rebuild trust, and improve access to services,” the spokesperson said.
Political context
Concerns about misinformation and declining trust in vaccination have also increasingly intersected with mainstream political debate in Australia, just as has happened in the United States under Trump and his Secretary of Health and Human Services, anti-vaccine activist Robert F Kennedy Jr.
One Nation has repeatedly campaigned against COVID-19 vaccine mandates and continues to call for a royal commission into Australia’s pandemic response. In parliamentary speeches and policy statements, party leader Senator Pauline Hanson has argued governments overreached during the pandemic, and has questioned the safety and effectiveness of COVID vaccines.
Growing political support for One Nation – with several recent polls showing the party drawing support comparable to, or in some cases exceeding, Labor’s primary vote – raises important questions and challenges for public health advocates and programs.
Health groups have long warned political messaging around vaccination can influence people who are uncertain rather than firmly opposed to vaccines.
In 2017, after Hanson publicly questioned vaccine safety and encouraged parents to “do their own research”, then-Australian Medical Association (AMA) president Dr Michael Gannon said he was “utterly appalled” by the comments.
“She needs to realise that she’s a serious player in Australian politics now,” Gannon said at the time. “You know, with eight, nine, 10 per cent of Australians indicating an intention to vote for One Nation, she can no longer make fringe statements that are dangerous to the health of the whole community.”
Gannon argued the greater concern for public health was not people fundamentally opposed to vaccination, but those who were uncertain or susceptible to misleading information.
A question of access
Several health organisations stressed that misinformation alone could not explain falling vaccination rates. National Rural Health Alliance (NRHA) chief executive Susanne Tegen said the “biggest barrier is not mainly ‘anti-vax sentiment’”.
“It is access failure compounded by workforce shortages, tyranny of distance, cost, service fragmentation and declining trust in governments and systems,” she told Croakey.
Tegen said rural and remote communities often had “fewer sustainable local services, long travel, limited appointment availability, fewer GPs/nurses/pharmacists, weaker outreach capacity, and poorer access to culturally safe services”.
She said these pressures often turned intended vaccination into missed opportunities. “In rural areas, access issues often convert ‘I intend to vaccinate’ into ‘I missed the window’ or ‘I cannot afford to do this now’,” she said.
The Australian Primary Health Care Nurses Association (APNA) similarly argued convenience and accessibility were central issues. APNA president Denise Lyons said practical barriers could prevent people from staying up to date with vaccinations.
“The ‘logistics’ of vaccination — that is, booking appointments, taking time off work, making travel arrangements with all the associated indirect costs, can all create barriers to people getting vaccinated,” she told Croakey.
Lyons said primary healthcare nurses were already heavily involved in vaccination delivery, education and monitoring, but funding arrangements limited how flexibly nurses could work in communities.
She said current Medicare arrangements made it financially difficult for practices to deploy nurses into underserved communities or mobile vaccination clinics. “We need to allow our primary health nurses to do the job that they’re trained for, to work to their full scope of practice, to be out amongst the community delivering vaccinations and educating people about the importance of immunisation,” she said.
The Australian College of Nursing (ACN) said nurses already play a central role in maintaining vaccination coverage across Australia. National Director Education, Dr Zachary Byfield, told Croakey that nurses were “Australia’s largest vaccinating workforce” and delivered vaccines through general practice, school-based immunisation programs, community health services, Aboriginal medical services and other settings.
Along with others, Byfield argued that access remained a critical issue. “While misinformation and hesitancy contribute to vaccination coverage trends and receive significant attention, access to vaccination remains a key factor,” he said.
Byfield said nurses were “consistently ranked the most trusted profession” and were well placed to provide information and advice to people with concerns about vaccination. However, he said the profession’s capacity remained underutilised because of funding arrangements and workforce shortages, particularly in regional and remote Australia.
The college is calling for the creation of a Nurse Payment Administrator to support nurse-led vaccination services and expand access through community clinics and other non-traditional settings, he said.
Global connections
The concerns raised by Australian health organisations are also playing out internationally. Public health experts note that infectious disease outbreaks are increasing globally, driven by a complex mix of factors including population growth, urbanisation, international travel, conflict, climate change and disruptions to health systems.
Bangladesh is currently experiencing one of its worst measles outbreaks in decades, despite previously being recognised for achieving high childhood vaccination coverage. Public health experts have linked the outbreak to political instability, disruptions to vaccination programs, workforce shortages and vaccine supply problems that emerged after widespread unrest and changes in government.
The outbreak serves as a reminder that gains in disease prevention can be quickly reversed when health systems are weakened. It also highlights the importance of maintaining routine vaccination programs and public health infrastructure even during periods of political, economic or social disruption.
Australian health authorities are also monitoring increased measles activity, with recent cases linked to overseas travel and outbreaks in parts of South-East Asia. The NSW Government has urged travellers to ensure they are vaccinated before travelling overseas.
Building trust
Across the responses to Croakey, one theme emerged consistently: vaccination programs work best when they are local, trusted and embedded in ongoing primary healthcare rather than relying solely on emergency campaigns or broad public messaging.
AIDA’s Malouf said “community engagement not as optional but as a fundamental part of public health”, and argued governments should “fund and empower Aboriginal and Torres Strait Islander health leadership as an integral component”.
He said that “genuine engagement requires Indigenous leadership from the start, not as a remedial step during outbreaks”.
NRHA’s Tegen said successful immunisation efforts in the early 2000s had depended on “local strategy, trust, recall and consistency” for many years. “With social media, COVID and distrust, the strategy has to be local, trust-led and consistency integrated,” she said.
The RACGP’s Hoffman similarly argued that trusted clinicians remained critical, but needed time and support to have effective conversations with patients. “
A meaningful vaccine conversation with a hesitant patient takes 15–20 minutes minimum,” she said. She added that confrontational approaches could “entrench resistance”, while culturally safe services and community health workers were essential for reaching populations at higher risk.
Several organisations also pointed to the importance of sustained community engagement rather than short-term campaigns.
Writing in The Conversation, researchers noted that governments had invested heavily in community relationships during the COVID vaccine rollout, but many of those initiatives had since been dissolved due to a lack of ongoing funding.
Experts argue that governments now need to focus not only on public messaging, but on strengthening the systems and conditions that support vaccination uptake in everyday life.
Suggested measures include nurse-led vaccination reform, expanded outreach and school-based programs, stronger reminder and recall systems, culturally safe care, improved rural workforce capacity and sustained investment in community-controlled health services.
Many of the reforms identified by stakeholders are reflected in the National Immunisation Strategy 2025–30, which places a strong emphasis on trust, community engagement, equitable access and improving vaccination uptake among priority populations, including Aboriginal and Torres Strait Islander communities.
According to the National Immunisation Strategy Implementation Plan, Commonwealth funding supporting immunisation activities exceeds $664 million in 2025–26. The Department of Health, Disability and Ageing is working with states and territories to implement the strategy, which was one of the first major deliverables of the interim Australian Centre for Disease Control.
However, several organisations interviewed for this story suggested the success of the strategy will ultimately depend less on its stated ambitions than on sustained implementation, long-term funding and the ability to translate national priorities into locally led services and community relationships.
AHCWA said governments must “move beyond pilots and instead sustainably invest in addressing the underlying causes of disease”.
The CDC also emphasised that vaccination coverage was only one part of the response.
“The public health response requires strong primary and community care, especially for case management including treatment with antibiotics and follow up of contacts,” the spokesperson said.
They added that the outbreak was “another reminder of those fundamental social determinants of health that continue to present a disproportionate risk of disease in Aboriginal and Torres Strait Islander communities”.
“It is also a reminder of the importance of the Aboriginal Community Controlled Health Sector as key partners in preparedness for public health challenges and outbreak response in communities.”
While misinformation remains a significant concern, organisations say Australia’s vaccination challenges are also deeply tied to broader questions of trust, access and inequality.
The current diphtheria outbreak, they suggest, is not only a warning about falling vaccination rates, but about the consequences of weakened public health systems and longstanding social inequities.
The CDC noted that diphtheria notifications have begun to decline in recent weeks, which it said was likely due, at least in part, to the coordinated effort to identify cases, follow up contacts and deliver vaccinations in affected communities.
See Croakey’s archive of articles on infectious diseases and the social determinants of health
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