Every day New Zealand children with serious health issues are falling through the cracks of the public health system. In the final part of a five-day series, the Herald looks at what's working, what's going wrong and what needs to change to ensure every Kiwi kid is being given the best chance to develop.
New Zealand is on the verge of losing "elimination" status for measles as the current outbreak spreads across the country.
The problem is one of many in the field of preventable diseases affecting children. Babies are vulnerable to whooping cough because many mothers have not received vaccinations and there are calls for a new vaccine to protect children from a fresh strain of meningococcal disease.
Of particularly pressing concern, the Herald can reveal the World Health Organisation (WHO) will likely pull New Zealand's "elimination" status if disease numbers cannot be curbed by March next year.
This would officially signal our country losing herd immunity (protection for everyone through high vaccination levels) to the highly contagious disease, putting thousands of Kiwis at risk.
A Herald analysis has shown vaccination rates dropping across the country as fewer families immunise their babies. Data from every neighbourhood in New Zealand shows just 77 per cent of 6-month-olds are now getting their vaccines on time, down 4.5 percentage points since rates peaked in 2016.
Hundreds of children have been hospitalised for measles during this year's outbreak and experts warn this will likely continue unless nationwide immunisation rates improve.
"Unless New Zealand can do more to improve our community immunity to stop these cases continuing to spread to others we are at significant risk of losing our elimination status," Immunisation Advisory Centre director and GP Dr Nikki Turner told the Herald.
Measles is a highly infectious airborne virus which affects both children and adults and can be life-threatening.
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Turner said it would take several years to get that status back which was a "huge concern" as further outbreaks would be likely.
The disease would no longer be coming from abroad but could also start from within New Zealand, Turner said.
She said the outbreak in the Counties Manukau region was of biggest concern because it had been consistent since March. Only 61 per cent of infants in that region were being immunised on time.
New Zealand gained the WHO measles elimination status for the first time in 2017 after proving there had been no outbreak for more than three years. The WHO aims for 95 per cent immunity coverage nationwide. However, New Zealand currently only has 91 per cent, with timely infant immunisation rates as low as 61 per cent in some regions.
As the outbreak continues to spread, the number of Kiwi kids becoming infected is soaring, with 21 children contracting the disease just last week. Almost half of those were under the age of 3.
Of the 258 children infected since the outbreak began in January, 199 were not vaccinated against the disease. Seven were only partially vaccinated, the status for 32 was unknown and 20 had been fully vaccinated.
Experts interviewed said the vaccine did not mean people were 100 per cent bullet-proof but that immunising was still the best chance of protecting New Zealanders against the disease.
Children are supposed to get vaccinations for measles, mumps and rubella (MMR) at 15 months and again at 4 years old. Getting both jabs gives them a 99 per cent chance of lifetime immunity, and even one jab provides 95 per cent immunity.
Auckland Regional Public Health Service is currently advising doctors to give infants their first MMR jab at 12 months instead of 15 months because of the current outbreak.
Turner said making that recommendation mandatory across the country was being discussed with Government and there was no reason it shouldn't be extended.
Meanwhile, at least 50 Auckland early childhood centres and schools have reported measles cases with some temporarily closing their doors as a result.
Auckland Regional Public Health Service (ARPHS) has been asking schools and early learning services to check staff immunity.
Turner said the rising trend of measles was also being influenced by "historical gaps" in the immunisation record such as the generation of New Zealanders in their teens to mid-30s who were more likely than any other age group not to have received a vaccine.
She said that was because New Zealand did not have the National Immunisation Register at the time; it was introduced in 2005.
"So we didn't know how many kids had been immunised. We also didn't have outreach centres and didn't follow up with families like we do now."
While these changes in practice have been helping to ensure newborns are being immunised, the number of babies born in the 1990s who had their shots is still unknown.
"This is something we are looking into," Turner said.
Within the next four years hundreds of Kiwi kids, particularly babies, are expected to end up in hospital with whooping cough.
Though the disease does not always cause serious harm, it can become life-threatening if a large number of people are infected - particularly for babies as they have lower immunity than adults, University of Auckland senior lecturer and vaccinologist Dr Helen Petousis-Harris said.
She, along with other experts interviewed, said New Zealand's "extremely low rate" of mums getting vaccinated against the disease when pregnant was part of the issue.
"And much of that is about awareness," University of Auckland researcher and infectious diseases paediatrician Emma Best said.
The Ministry of Health introduced the fully funded immunisation for women between 28–38 weeks of gestation in 2013.
However, a 2018 University of Auckland study showed maternal immunisation coverage was as low as 13 per cent with considerable variation between district health boards.
The study found that more than 80 per cent of babies with whooping cough in Auckland had not received maternal vaccination.
New Zealand is in the process of climbing its way out of a whooping cough epidemic which started in October 2017 but due to the nature of the disease experts warn outbreaks tend to return every three to four years.
During the recent outbreak, which officially ended in March, 1827 children were reported to have been infected with the disease. Of this, 218 were hospitalised - 153 being babies.
An epidemic in 2012, before the free vaccine, involved hundreds of hospitalisations and three deaths of infants, including two who were too young to be immunised.
Turner said half of the babies who catch whooping cough before age 12 months require hospitalisation and around 2 per cent of those die from the infection. However, no deaths have been recorded during the latest epidemic.
Best said babies were particularly vulnerable to the disease because they couldn't get their first dose of the vaccine until 6 weeks of age and their immunity is a lot weaker than adults.
"That's why it's so important for mums to get a dose of the vaccine during pregnancy, which is funded, to ensure their child has the best chance of being protected against the disease."
Parents are also advised to vaccinate their baby at 6 weeks, 3 months and 5 months. New Zealand children are also funded for booster vaccines at 4 years and 11 years of age.
While the number of children infected by meningococcal disease remains low, cases have been increasing steadily since 2014.
Researchers say this is largely to do with a new strain of the disease, known as W, emerging throughout the country.
Up until June this year - the most recent data available - 50 New Zealanders were reported as infected with invasive meningococcal disease. That's compared to 42 Kiwis during the same period last year, and 34 the year before.
The number of people who have died by the disease has remained steady with four in 2017, three in 2018 and two so far this year.
The majority of cases reported this year have been children under the age of 4, making up 21 out of 50 cases.
Best said meningococcal disease was a huge concern because the majority of cases were babies and children under 5.
"We are certainly seeing a change in the type of meningococcal and there are vaccines available but they aren't funded yet. Other countries do it so I think New Zealand needs to as well."
Publicly funded meningococcal ACWY vaccine is only available to New Zealanders at risk of getting infected with the disease and there is a strict criteria for that.
After Northland experienced an outbreak of meningococcal C in 2011, the DHB ran an emergency vaccination programme.
During last year's outbreak of the meningococcal W strain in Northland, the Ministry of Health started offering free vaccinations to children aged from 9 months to under 5, and teenagers. More than 32,000 children and youth were vaccinated, and since then only one case of that strain has been recorded in the region - which was an unvaccinated baby.
Any New Zealander can pay to get the vaccine from their GP but it costs about $100.
An application to fund the vaccine nationwide is currently being considered by Pharmac.
Barriers stopping children from getting care
One of the biggest drivers for the drop in immunisation rates was the increase of extreme poverty, Turner said.
"For children and parents in poverty, accessing preventive health becomes harder because people are moving around a lot, they aren't well engaged with a regular general practice and often because they can't afford it.
"For the doctors, these are the children who require a lot of extra effort, a lot of re-call reaching out to ensure they are getting vaccinated."
Turner said times were also changing as often both parents were working and it was more difficult to get their kids to the doctor during working hours.
"A lot of low income working parents find it very hard to get into a GP because they were often only open Monday to Friday."
Hauora Māori lecturer Esther Willing, from the University of Otago, spoke to the Herald earlier in the month about increasing issues with access for Māori.
"Māori have additional barriers, like appropriateness of service, on top of other access issues," Willing said. "Maybe they have had a bad experience and don't want to go back."
Equally, if parents were already stressed for money and time, and they heard messages like "vaccines are dangerous", it was understandable they could become hesitant, she said.
"But traditionally, these families are not anti-vax. Anti-vaxxers are usually wealthy, well-educated people because they have the resource to question what the health system is telling them."
What needs to change?
Experts interviewed said a lot more needed to be done to make sure all New Zealand children were protected from these diseases. This included:
• Ensure all babies are enrolled into the health system and are signed up to the National Immunisation Register.
• Create better awareness for pregnant mums to get the pertussis vaccine - which starts with GPs and midwives passing on that knowledge.
• Collect data on the number of New Zealanders born in the 1990s who have been vaccinated.
• Funding for the meningococcal vaccines so all Kiwis have free access.