Thirteen-month-old Cruz Cook lets out a piercing cry as clinical nurse Kim Wi jabs a needle into his thigh. But it's nothing compared to the fuss moments later when his older brother Cheyenne, 4, is hauled in.

Cheyenne knows what's coming. It is the second of three injections he'll need for immunity against meningococcal B, the infection which has killed hundreds and taken thousands of children to the brink since 1991. It is six weeks since Cheyenne's first vaccination but time has only heightened his fear. He cries and struggles and has to be held by mum while Wi administers the needle.

But mother Charlene Cook is unfazed. In six weeks, she'll haul them back to the Turuki Health Centre in Mangere for their final shots. She's also making sure her three older children are immunised at school.


For Charlene, 29, it's personal. She had meningitis at age 11 and can remember slipping in and out of consciousness.

"Everything was pretty much a blur but my parents told me they almost lost me. That scares me. It's a lot worse to lose a child than to get a jab."

It is seven weeks since the long-awaited campaign to immunise 90 per cent of New Zealanders under 20 kicked off in South Auckland. The area, with its high proportion of low-income Maori and Pacific Island families, has been hit hardest by the meningitis scourge.

Nationally, Maori are nearly four times and Pacific Islanders nearly seven times more likely than Europeans to contract the disease; socio-economic factors and larger households increase the risk. Children under 5 are the most vulnerable group of all.

But this blustery midweek morning, Cruz and Cheyenne Cook are among just a handful of preschoolers to visit Turuki, a Maori primary health organisation, for their free injections.

Only around 40 per cent of Maori preschoolers have received their first jab, a report to last weekend's national immunisation conference in Rotorua claimed. Participation by Pacific Island pre-schoolers is much higher at around 75 per cent. In schools, the overall rate is well above the 90 per cent pass mark needed for the campaign to succeed.

But with an estimated 150,000 children to receive two more doses at six week intervals before the school year ends, the campaign among Maori preschoolers is in trouble. There are also signs of a fall-off among those who had their first jab.

Yet the campaign began seven weeks ago amid a blaze of publicity and enormous public goodwill. The plight of Waiheke Island baby Charlotte Cleverley-Bisman, who lost most of her arms and legs, and Mangere nine-month-old Sakiusa "Junior" Uluvula, who died after several amputations, brought home the terrifying speed and brutality of the disease.

"We made a mistake in thinking those two terrible cases were going to be sufficient to tell people and make them aware of the dangers of meningococcal disease," says Turuki chief executive Syd Jackson.

"We thought we would be overwhelmed with huge numbers of people. That didn't really occur."

Another event last weekend gave cause for head-scratching among campaigners. In a two-car crash near Kerikeri, baby Henare Matene, sitting unrestrained on her mother's knee in the front seat, was among four killed. Her mother and father also died. The tragedy was the third crash in the Far North this year in which three or more people have died and, in each case, some of the victims were not wearing seatbelts.

The head-scratching came because authorities have not exactly been slack about the belt-up message. Northland has come in for particular attention because research, though limited, suggests disturbingly low rates of seatbelt usage by Maori, particularly in the Far North.

Responses have included monthly police checkpoints, education campaigns and carseat rental schemes. Comparatively poor participation by Maori comes as no surprise to health and safety researchers - the issue dogs health promotion campaigns from anti-smoking to obesity. Despite years of acceptance of the need to target programmes for different cultures and backgrounds, results are decidedly mixed.

Dr Marewa Glover, of Auckland University's school of population health, found in a study of smoking during pregnancy that promotional literature developed especially for Maori women made little difference. This was partly because health professionals rarely handed it out.

She says GPs routinely miss opportunities to screen and educate patients. And promotional material is often not pitched for the many Maori and Pacific Islanders who leave school early.

"There are people out there who live differently because they don't have the same level of education skills and resources that the rest of us take for granted. A lot of people don't even use a calendar or a diary so they are not going to keep appointments."

The healthcare system often takes it for granted that people have prerequisite knowledge, she says. "It's not 'what's wrong with these people that don't get the message'. It's 'what are we doing wrong that we don't catch them'. Written materials are not going to do it. It sometimes takes a community-based approach."

With meningitis, cultural issues and the anti-immunisation arguments cloud the issue. "There's a lot of mythology around immunisation. You need people seen as credible to the community to go in and undo that, but people can take a lot of convincing." And so it has proved in South Auckland, where the 40 per cent figure for Maori preschoolers is below even the disturbingly low rates for Wellchild vaccinations such as MMR and diphtheria.

An adviser to the campaign, Liane Penney of Massey University's Te Ropu Whariki research group, says difficulties with the preschool sector were predictable.

"It's system failure, not a problem of the victims," she says. "The fact that 95 per cent of school children have accepted the vaccine suggests to me that Maori families want their children protected from meningococcal disease. The system has created barriers to [preschool] people getting vaccinated."

While school children are a captive audience, getting to the under-5s raises issues about publicity, childcare and transport costs, particularly for low-income working families and rural parents. But rather than take the vaccinations into the community, the Counties Manukau District Health Board has tried to get families to come into their GP clinic.

Penney says access and communication barriers are well known. National immunisation guidelines encourage outreach programmes such as mobile caravans or temporary clinics "but it does seem Counties Manukau is reluctant to fund outreach services with immunisation."

One of the issues is clinical safety, says Counties Manukau primary care programme manager Danny Wu. The risk of a severe reaction to the vaccine means resuscitation equipment must be on hand and protocols observed. It's considered desirable that the same health professional deliver all three doses of the vaccine.

Wu tosses in another obstacle: "The experience of the kids themselves - we are talking needles here. It's not a little pill you can slip under the tongue."

So why are Pacific Islanders apparently enlisting more readily than Maori? Margie Fepuleai, the health board's manager of Pacific health, says the campaign so far has been in areas where Pacific populations are highly concentrated; Maori are more dispersed. Pacific populations can be easier to reach, through churches.

There are doubts about the reliability of the 40 per cent figure - many clinics with high Maori rolls lack the technology to tap into the new national immunisation register, a computer database supposed to help health authorities target problem areas. The actual vaccination rate for Maori under-5s may be closer to 60 per cent.

Whatever the figure, no one disputes it is well short of the target. And there's at least a suspicion that in the hype surrounding the arrival of the long-awaited vaccine, health officials forgot well-worn lessons about tailoring programmes for different audiences.

Hopefully, it's not too late for some remedial work in South Auckland. Bernard Te Paa, health board manager of Maori health, says taking the programme into the community was identified from the start as desirable. Contingency plans to vaccinate at kohanga reo and at street level are being examined.

"People will ask why we didn't do that sooner - it's a fair question. But we did have a couple of processes [including promotions at sports events] that we thought would bring the rates up but which were not as successful as we'd hoped."

At Turuki, as Cruz and Cheyenne regain their composure with lollipops, Charlene Cook wonders why more Maori aren't lining up. "It could be religion or because they are scared, it could be lots of things."

She says people are "quite informed" about the need for immunisation. Health nurses are visiting kohanga reo and whanau hui to push the message. All her friends are having their children immunised. "I just wish people would say yes."