This is a behind-the-scenes look at how local health authorities are dealing with the worst measles outbreak in at least 20 years. Reporter Scott Yeoman spends time with the experts as they trace infections and attempt to prevent the spread. And he talks to people who have had their lives changed by this highly contagious and potentially deadly disease.
Dr Phil Shoemack is sitting in his office in central Tauranga when news of the latest measles case comes through the door.
A baby, with a Bay of Plenty link.
It's Wednesday midmorning and Shoemack hasn't yet managed to look at his emails. He's had four meetings already, the first at 8am with the Lakes District Health Board and the second half an hour later with the Bay of Plenty District Health Board. Then two more meetings, one to review active and pending cases and another with the incident management team. He has a radio interview to do in the next hour to raise awareness in the community.
And it's all to do with measles.
Shoemack, the on-call Medical Officer of Health at the Bay of Plenty's public health unit, Toi Te Ora, is this week leading the response to a measles outbreak in the region.
A couple of hundred kilometres away in Auckland, the situation is much worse: more than 800 confirmed cases this year.
The Big Smoke is the epicentre of the outbreak, and is only a few hours drive away.
Shoemack sits in silence as he listens to the brief about the baby. He learns the child has probably been in contact with a confirmed measles case in Auckland and has then travelled to Whakatāne to visit a person in hospital.
The baby arrived back at Whakatāne Hospital the next day with measles-like symptoms.
Lynne Dobbs, the staff member who walked into the room to share the news, is in charge of communicable disease administration at Toi Te Ora. She and her team receive notifications of new cases.
The baby was put into isolation the second time, but not during the initial visit to the hospital the previous day, she says.
Dobbs asks: "Do we need the details of the person they were visiting and all that sort of jazz?"
Shoemack replies: "That would be good. As much as you can get, basically, and then we can follow up with Whakatāne Hospital."
What comes next is what Shoemack, Dobbs and others at Toi Te Ora have all morning been calling "contact tracing".
The Bay of Plenty Times Weekend has been shadowing Shoemack for several hours by this stage, watching as he and his team respond to what is thought to be the worst measles outbreak in New Zealand in at least 20 years.
Measles is an airborne disease, spread by coughing and sneezing. What may look like simple cold-like symptoms to begin with can become coughing, rashes, a fever.
Read more: 'Welcome back to the dark ages': Our measles disaster explained
As of yesterday morning, the Bay of Plenty has had 38 confirmed cases of the highly infectious viral illness this year.
About 45 per cent (17) of those people required hospital treatment.
That is Shoemack's biggest concern about this outbreak.
"It's unlikely that anything's changed with the virus, but typically we say one out of 10 or so people who get measles will end up in hospital. Nationally so far it's been closer to three or four out of 10.
"So we're not sure what that's about or what's changed, but that's a concern – both in terms of the severity of the illness but also in terms of the workload for hospitals."
Shoemack says New Zealand is almost getting to a stage where it is a victim of its own success.
"Because our vaccines now are so effective, so safe … measles infection is much less common than it used to be. Most years there's very little measles in New Zealand. And so people forget. We get complacent and we think it's just another childhood illness."
But it isn't. Measles can kill.
Morva Leyden knows that.
The 81-year-old, who lives in Pāpāmoa Beach, this week revisited the tragic morning she lost her "gorgeous" young daughter Diana in April, 1978.
Leyden says an autopsy later showed the 7-and-a-half-year-old, who had Down syndrome, had been infected with measles, which had brought on pneumonia.
At the time, however, Diana's sudden death came as a complete shock. Leyden says she didn't know it was measles and it all happened in the space of a few days.
The family was living on a farm in the Waikato and it was a Saturday when Leyden first became aware Diana was unwell.
She says the young girl seemed to have a sore throat and "just wasn't her bright, bubbly self".
"And then she started to get the rash."
The rash was only on the inside of Diana's elbows and under her arms, Leyden says, and it hadn't spread far.
Leyden kept her at home, warm and dry. Kept an eye on her.
She phoned the family doctor on the Monday and some medication was sent over.
"Monday night I put her to bed fairly early because she was very tired. I gave her a quick bath and popped her into bed."
Leyden says her husband was out that night and he checked in on Diana when he returned at about 11pm and she was all right.
But when Leyden woke early the next morning, it was very quiet. Diana was always a noisy sleeper.
"I woke with an absolute start. I thought, 'Oh my God, she must be dead' and I went in and she was.
"She was cold."
She blamed herself for a long time and questioned whether she should have bathed Diana before bed that night.
"I think I was just in shock at the time, but I did wonder how it had happened so quickly. It didn't give us any time to do anything."
Leyden says she doesn't think Diana had the vaccine for measles, mumps, rubella (MMR).
"I didn't get around to it and it didn't seem terribly important at that time, I mean, we all had measles and we all cruised through it no problems."
But that changed after Diana's death. Leyden says if she knew then what she does now, she would have made sure Diana was vaccinated against measles.
That's her message amid the current outbreak: "Don't be complacent."
She says: "We must have the vaccinations, that's what's protecting us from it and stopping it being an epidemic."
Leyden says she's shocked that she's still reading about measles all these decades later.
She says she often thinks of Diana. She has a photo of her on the wall.
"She was absolutely delightful. We took Diana just about everywhere we went and we left it to her and she won people over."
Measles is a preventable disease. A safe and cost-effective vaccine is available.
Yet, according to the World Health Organisation (WHO), in 2017 there were 110,000 measles deaths globally.
Mostly among children under the age of 5.
Shoemack says like polio, measles could be eliminated, just as smallpox was.
Vaccination is the answer.
Before the introduction of a measles vaccine to the world in 1963 and widespread vaccination, major epidemics occurred about every two to three years and measles caused an estimated 2.6 million deaths each year.
Vaccination changed that, but the fight is not over.
The WHO has reported that the number of cases of measles around the world has quadrupled in the first three months of 2019 compared with the same time last year.
Shoemack says anyone aged between 5 and 50 should have had two doses of the MMR vaccine.
The vaccine was first introduced to New Zealand in 1969, first as one dose and then, from 1992, the recommendation changed to two doses.
He says anyone born before 1969, almost without exception, would have had measles and therefore would now be immune.
Anyone born after 1969 who isn't sure whether they've had zero, one or two doses, should get the vaccine anyway. It's free and getting an extra dose does no harm.
Babies generally receive their first MMR vaccine at 15 months old and then a second one after they turn 4.
Auckland has now brought the first one forward to 12 months and in some cases, if people are travelling overseas to a measles hotspot, it can be done as early as 6 months.
Shoemack is quietly spoken and calm when answering all these questions. He is measured; always looking to provide clear context and explanation.
He's never loose with words. The 63-year-old has been a doctor for 40 years and talks with authority.
Since 2005 New Zealand has had a national immunisation register, which records all children who are vaccinated, he says.
In the past 12 months, it shows roughly 88 per cent of children aged 5 in New Zealand have received both doses of the MMR vaccine.
Bay of Plenty is generally at or near the bottom of the list compared with other regions in New Zealand, but still has an MMR vaccine uptake of about 81 per cent.
Authorities don't have a firm fix on what proportion of the country's population older than 15, who were born before the register was introduced, are vaccinated.
Shoemack says concern about the current outbreak is justified. He says of the world's developed nations, New Zealand has got one of the lower MMR immunisation rates.
He says New Zealand currently has measles-free status from the WHO because any new cases it gets are clearly shown to have been brought into the country from overseas.
"However, it's possible that this outbreak will signal the end of our measles-free status.
"Measles is so infectious, if one person brings it in from wherever, comes to New Zealand, socialises, lives with other people, the other people who are not vaccinated have got a very high risk of getting it.
"What's putting that [the measles-free status] at risk is our less than adequate vaccination coverage. So if we've got, let's just say 15 per cent of our population that's not vaccinated, measles is so infectious that it will start being transmitted hither and yonder through all of those people."
And so the line between overseas source and New Zealand source starts to blur.
"Sure the outbreak was prompted earlier this year from someone coming from overseas, but if it's still going 12 months later, it's through transmission within New Zealand," Shoemack says.
He says there are a lot of things that can be done to respond to measles outbreaks but at the top of the list is always going to be improving vaccination rates.
"And then after that is primarily our job – following up the cases and doing what we can to limit the spread from the cases to other people."
Which brings us to the situation with the baby who travelled from Auckland to Whakatāne.
As Dobbs leaves the room, Shoemack explains further: "So, they've been confirmed as a case of measles now. We know that they would have been infectious for a few days prior to now, and obviously they didn't know that they had measles during that time. So, it's just a good example of what we've got to do – piece together where they've been and who with, during that period of being infectious."
At the case review meeting a little earlier in the morning the Times saw the complexity of that task firsthand.
In the boardroom were health protection officers, communicable disease nurses, analysts, a junior doctor and staff members looking after administration and communication. Shoemack sat at the end of the table.
The first measles case the team spoke about was a Rotorua man who had been confirmed positive on Monday evening.
He had visited three different waiting rooms and a pharmacy while infectious.
"So there's going to be lots of work contact tracing him," Lindsay Lowe, a communicable disease nurse, told the room. She said there could be as many as a hundred people that need to be tracked down to see if they have been vaccinated. If not, they would be put into protective isolation.
Another active measles case was a woman who was only confirmed positive the night before. She had just been overseas. She started feeling unwell when she got back and then got the measles rash several days later.
"I've sent her an email today to say she must stay in isolation until and including Friday," Lowe said.
"And I've sent her a timeline and I've asked her to fill in exactly where she's been and I've done that with the other case that we just talked about."
A back and forth conversation then took place as the Toi Te Ora team tried to clarify the woman's timeline to work out whether it was an imported case of measles from overseas to New Zealand, whether the woman took it overseas, and whether she was infectious while there and on the plane back (they later worked out she wasn't).
She also visited another area of New Zealand on her return and a GP practice twice, but luckily the waiting room was almost deserted both times.
Then there was her family – her sister had visited a doctor's waiting room in Tauranga and there was a possible 33 contacts there.
All these avenues of investigation and the branches that spread out from each possible contact were talked through for each active case. Then there were unconfirmed cases still under investigation (two new ones that morning). And then contact tracing still ongoing from previous active cases.
Another meeting followed straight after, with the incident management team.
It was all about logistics – staff numbers, who's doing what, what needs to be organised in the next 24 to 48 hours. An outbreak means extra workload for Toi Te Ora, on top of what they already do, and extra staff might need to be called in or redirected to help cover.
Questions were asked and jobs were delegated. Who's responding to queries from the public? Is the website displaying all the up-to-date information it needs to? Can someone help liaise with the AIMS Games team?
Both of these meetings are only held when there is an outbreak or an event that needs a public health response. For this measles outbreak, the meetings started early last week and are now being held every day.
Come Thursday's meeting, the new baby case will have been added to the list.
About 2km down the road from the office where these meetings are taking place is Tauranga Hospital, where Dr Justin Wilde is a paediatrician.
Wilde told the Times this week that he had seen three children who had been infected with measles this year. Before that, he had only ever seen one case in his 21-year career.
Wilde says they generally try not to hospitalise people with measles.
"Once people have measles, the only treatment options involve what is called supportive care – dealing with complications and giving fluids and that sort of thing. But there's no antibiotic or other medicine you can give to make measles go away."
He says children with measles become "inconsolable".
"It's really upsetting to watch and parents find it very, very distressing."
The children who are hospitalised with measles are the ones who have complications, including not being able to drink properly.
For the three cases he was involved with this year, all the children were very young, too young to have been vaccinated.
Wilde says if a mother is vaccinated against measles, some of her antibodies can cross the placenta during pregnancy, and so her newborn will have some immunity against measles for the first few months of their life, but that level of immunity can vary from baby to baby.
"That wanes quite quickly because those immune proteins don't last very long, they have a finite life-span. So a baby becomes increasingly vulnerable in the first few months of life," he says.
"Babies less than 12 months old are quite vulnerable because they're very much dependent on everyone else around them being vaccinated."
To be vaccinated against measles, patients need two doses of the MMR vaccine, given at least four weeks apart. The standard immunisation schedule is to immunise at 15 months, and again at 4 years. The first vaccine can be given earlier, from 12 months.
He also says if babies are vaccinated for MMR between 6 and 12 months, which they can be in certain circumstances, their immunity doesn't last so well.
"You would still then need to have another two doses once you're over 1. That is, you would still need to have the normal two doses."
He says it's also important to get the second MMR shot, usually given at 4 years old.
That is because the MMR vaccine is very effective, with the number of people who are immune after the first vaccine being about 95 per cent. But once the second dose is given, the immunity rate is very close to 100 per cent.
Wilde says measles is one of the most, if not the most, contagious infections there is.
It's also got a high complication rate – about one in 10 cases, "but we're probably seeing a bit higher than that locally in the cases we have seen so far".
"The rate of getting serious brain complications is about one in 1000, which is a number that people have difficulty getting their head around because it sounds rare, but that's actually really common."
New Zealand, for instance, has already had more than 1000 cases this year.
"So we're already seeing some serious complications from that," Wilde says.
He says measles is also a condition that can cause some long-term complications years later.
Stephanie Peeni, a mother of four who lives in Tauranga south, had her opinion on vaccines change this year when three of her children were hospitalised after being infected with measles.
First, about four weeks ago, her 3-year-old twins Carter and Valentina and then a couple of weeks later, her 7-month-old Manaia.
Peeni, who moved to New Zealand from Australia two years ago, says she and her husband are fully vaccinated and so is their 6-year-old daughter Marlee.
The twins received their first dose of the MMR vaccine while in Australia but are not due for their second dose until they are 4. Manaia was still too young for her first dose.
Peeni says in Australia there are much stricter rules around vaccinating children and so she didn't second guess it. Marlee was fully vaccinated and the twins got their first dose.
Once the family moved to New Zealand, however, and there was a bit more flexibility, she started to do some research online before Manaia got hers.
She says she read a lot about vaccinations, including what she realises now were anti-vaxx posts on social media, and found herself swayed against it.
"And I turned I guess anti-vaxx, you could say."
One day, when Manaia was only 1 or 2 months old, Peeni organised a nurse to come to the house to give her her first immunisations (not MMR), only to pull out at the very last minute.
She says the nurse was ready to begin when she suddenly told her to stop. She had begun to feel faint and took that as a sign that Manaia shouldn't get the vaccines.
"I said 'I'm sorry I just can't do it'."
Fast forward to today and Peeni has gone full circle.
"Definitely now after this experience I can say that my stance on vaccines has changed," she says.
"For whatever reason, the twins were just unfortunately in that 5 per cent of people that the first vaccine didn't cover. I 100 per cent believe that had they had that second dose, they would have been covered.
"My 6-year-old, fully vaccinated child did not get measles when her siblings did."
Peeni says she is "pro choice" and feels uneasy and unqualified to influence other parents' decisions, but with the rapid rise in measles cases this year, she also feels like she needs to encourage people to vaccinate their children.
"It's starting to become a huge concern and now it's not just about your own children, it's about those around you."
Sitting back in his office, Shoemack says that, yes, Bay of Plenty will get more cases of measles in the coming weeks.
The best defence, he reiterates again, is the vaccine.
"We know with measles that if we can get 95 or 96 per cent of the population covered, let's just say there's only four per cent who haven't been, those four per cent – they get significant protection against measles from the 96 per cent being protected because there's just not enough people in the community for the virus to carry on in," Shoemack says.
It's called "herd immunity".
He says New Zealand got very close to achieving 95 per cent for about six months several years ago, but then it slipped.
The number one priority, he says, is to get back to that point.
"We don't have to get 100 per cent of people vaccinated to get rid of measles but we need to get close to it."
So, what comes next?
Shoemack says he and his Toi Te Ora team will continue to trace the spread and do everything they can to prevent it.
He says both DHBs in the region are looking at ways to increase vaccination coverage at general practices, and are also looking at introducing pop-up vaccine clinics at pharmacies, schools, halls.
Asked when that should be introduced, Shoemack says: "Yesterday would be good."
He says Tauranga Hospital has started planning for a situation where they may have more people turning up with possible measles cases next week, just in case, with the city expecting an extra 20,000 people in town for the AIMS Games.
However, Shoemack is adamant the event does not need to be cancelled.
"There is a risk, as there is with any what we call mass gathering," he says.
But he says he can't imagine a scenario where Toi Te Ora advise an event like the AIMS not to go ahead.
It's about managing risk, Shoemack says.
He says this is not an epidemic, yet, that would only be if measles was a major issue throughout every part of New Zealand.
"We've got things under control here at the moment."
The numbers
There have been 38 confirmed cases of measles in the Bay of Plenty since January 1, 2019.
Confirmed cases by district:
• Western Bay: 29
• Eastern Bay: 0
• Rotorua: 3
• Taupō: 6
Other statistics:
• 17 of the confirmed cases in the Bay of Plenty required hospitalisation.
• A quarter of the cases were aged under 5 years old.
• A third of the cases were between ages 20-29.
• There were no cases reported over the age of 40.
The two primary transmission routes have been among members of unimmunised families/whānau or via contact with an infectious individual in a healthcare waiting room.
Note: This is the up-to-date data as of Friday morning.