Plummeting rates of vaccination against preventable diseases among Māori and Pacific children are creating the conditions for another potential public health crisis, according to documents obtained by the Herald.
While New Zealand races to vaccinate its population against Covid-19, health officials have grown increasingly concerned about a stark drop-off in some communities of routine immunisations that protect children from infectious diseases such as measles and whooping cough.
In July, officials warned in a confidential briefing to Health Minister Andrew Little that immunisation rates for Māori children in most district health boards were below the level of 85 per cent required to achieve "herd immunity" against many infectious diseases.
Rates for Pacific children had also dropped "for the first time in many years", according to the briefing memo, which was obtained by the Herald along with numerous other internal government and DHB documents.
Doctors and scientists warn that falling vaccine coverage increases the risk of a major outbreak in communities that are already vulnerable, which could result in preventable deaths and put enormous strain on a health system already stretched to the limit by Covid-19.
"What it directly means for Māori… is that Māori will attend more tangi," said Dr Owen Sinclair, at the Waitematā DHB, who is one of seven Māori paediatricians in the country.
"People talk about it in medical terms, but it's not. It's grief and sorrow and harm.
"Some of these children could be the best and the brightest and it's tragic."
The confidential briefing to Little blamed the decline partly on missed immunisations, which officials said could be a sign of "access issues". Vaccinations for children have also been affected by health authorities diverting staff and resources into the response to Covid-19.
The ministry has ordered health authorities across the country to take "immediate action" to address the declines in coverage.
The falling vaccination rates are a stark illustration of deep-rooted inequities that have led to Māori and Pacific peoples having lower life expectancy and poorer health across a range of measures than Pākehā.
Those gaps have been exposed by Covid, with Māori disproportionately affected by the virus but with vaccination rates that lag the wider population.
In New Zealand, children are immunised for a range of diseases, including pertussis (whooping cough), pneumococcal disease, and measles between six weeks and four years old, with further immunisations at 11 or 12 years.
Māori have long had lower rates of childhood immunisation than other groups and there have been numerous attempts by governments and health authorities over the years to address this gap. Government data shows the coverage is getting worse.
In the briefing to Little, officials said vaccine coverage had decreased across "each of the three milestones for all ethnic groups" in the latest quarter ending March 31. Rates for Māori children at 8 months of age had fallen to 75.7 per cent, compared to 90.4 per cent for New Zealand European children.
Dr Rawiri McKree Jansen, co-leader of Te Rōpū Whakakaupapa Urutā (National Māori Pandemic Group), said the prospect of a Covid-19 outbreak coinciding with an outbreak of pertussis, measles or RSV is chilling.
"We notice that high rates of immunisation for non-Māori, non-Pacific and concerning 15-percentage point gap for Māori, that is an inequity," Jansen said. "Covid has taken resources away from traditional care models, but that will also be done unequally."
He called the inequity "unfair, unjust and remedial". It does not have to be that way, he said, citing the achievements of Papakura Marae Health Clinic as an example.
"We achieved the health to all of the national health targets continuously for 18 months. We had 95 per cent of kids immunised at 8 months and at 24 months, we had the smoking cessation work done, we had the cardiovascular disease risk assessments done and we achieved cervical smears to the target. And that's hard work, but the point is, it can be done. My assertion is that primary care needs some very clear messaging that not only can it be done, it must be done."
Since the memo to Little was written in July, more recent data has been released showing at rates at 8 months for all ethnic groups declined again in the quarter ending June 2021.
The Ministry of Health put in place an action plan, sent to Little and the director general of health, Dr Ashley Bloomfield, which included establishing a cross-ministry team focused on childhood immunisations and an Immunisation Steering Group, chaired by the deputy director general for population health and prevention, Deborah Woodley.
Other actions included working with the ministry's primary care team and DHBs to address barriers to enrolment; commissioning "whānau-led insights" to understand why families weren't immunising their children; working to increase the capacity and capability of the Māori health and disability workforce; and building on the positive outcomes of the 2020 Māori Influenza Vaccination Programme to include Pacific providers and all immunisation events, including childhood.
The ministry wrote to 18 DHBs whose vaccination rates were too low, warning about the risks of future outbreaks when the country eases the public health restrictions put in place to prevent the spread of Covid.
"These [diseases] are only a plane ride away and present increased risk once our borders reopen to more countries," the ministry said in the letter.
"We must act now to lift coverage and close the equity gap to reduce the risk of outbreaks and long-term health implications for our tamariki."
In other documents obtained by the Herald, DHBs told ministry officials that immunisation rates had been impacted by the pressure that primary care services were under, with some GPs closing their books and patients waiting several weeks in some cases for appointments.
Referrals to DHB outreach immunisation services, which deliver immunisations to children under 5 who had not received them through primary care, had increased significantly and providers didn't have the capacity to meet need, the authorities said.
Covid-19 had "saturated the workforce". Staff such as data analysts and nurses had been moved to the pandemic response. Vaccinator assessors were reported to be at full capacity, slowing the authorisation of newly trained vaccinators.
Sinclair said the childhood immunisation system had collapsed under the pressure of the Covid-19 response, which exacerbated existing issues.
"It's hard, in the face of a global pandemic, not to argue that that was a good thing to do. But it meant, as you've seen in the latest data, [immunisation rates have] fallen off a cliff, specifically for Māori."
Other experts shared Sinclair's concern that New Zealand faced another outbreak of a disease we vaccinated against if rates weren't increased and more children didn't receive their vital vaccinations on time.
Vaccinologist Dr Helen Petousis-Harris said it was vital children are immunised on time as a number of the diseases were most dangerous at certain times in life, such as whooping cough, with the very youngest most likely to get critically ill or die from it.
Petousis-Harris said it was an almost "foregone conclusion" that New Zealand would have another problem with measles.
"It's completely predictable, you can model it. We have not attended to the problem sufficiently that we already had. Once we open up our borders, we're at horrible risk of various things, including measles."
University of Otago Associate Professor Tony Walls said declining trends in infant immunisations were worrying and meant it was likely more children would present with the severe diseases we vaccinate against in coming years, like invasive meningococcal disease (meningitis and pneumonia).
Accessing immunisation services is a problem for many people who are unable to get to a clinic between business hours while facing other costs associated with getting there, such as taking time off work or requiring a vehicle.
Waikato DHB's chief executive, Dr Kevin Snee, wrote to the Ministry of Health in August saying it had redirected significant resources that were routinely dedicated to childhood immunisation to meet the needs of the national Covid-19 vaccine campaign.
"Sustainable and alternative measures" would be needed in future if health authorities are to manage both Covid-19 and the existing childhood immunisation programme," Snee said.
The DHB's draft plan outlined many measures to address declines, including: reducing barriers to newborn enrolments with GPs; improving access to immunisation services, including by upping the availability of after-hours services and adding more convenient locations with high-foot traffic; ensuring kaupapa Māori and Pasifika providers were appropriately resourced for outreach servicing; and working with the ministry to address vaccine hesitancy.