Samoan children hospitalised with measles died after catching antibiotic-resistant superbugs that threaten patients and life-saving treatments in New Zealand.
Documents obtained by the Weekend Herald reveal disturbing details about the measles epidemic that swept Samoa last year, after an outbreak in New Zealand that was likely the source, and before the worldwide spread of Covid-19.
A major Samoan hospital was scrubbed after high levels of multi-drug-resistant germs infected patients. New Zealand DHBs are increasingly worried about such micro-organisms, which are spreading globally.
• 'A different terror': Tracing Samoa's measles pain back to NZ
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• 'Illness, disability and death': Auckland DHB warns about superbugs in confidential report
The Ministry of Foreign Affairs and Trade (Mfat) briefings track the terror as measles overwhelmed Samoa's health system and killed dozens of babies and children; vulnerability that remains with the threat of Covid-19. Details include:
• Chronic overcrowding in one hospital meant highly-infectious measles victims were treated alongside women giving birth, with children sleeping on the floor. Blood banks ran out and intensive-care oxygen supplies failed as fatigued and traumatised nurses worked 14-hour shifts.
• Human error meant New Zealand sent five times the number of vaccines as planned (the extra supplies were gratefully received). Later, The Whakaari/White Island explosion meant a request for ongoing ICU staffing support was declined.
• Vaccination teams found people who likely died from measles, after apparent confusion about the extent of stay-at-home orders, during an unprecedented "door-to-door" mass vaccination campaign.
• Officials noted rising negative sentiment about New Zealand after an Otago Daily Times cartoon made light of the measles catastrophe, and Mfat officials monitored social media comments about a front-page Samoa Observer story on Jacinda Ardern's "dodging" of a question about whether measles came from New Zealand.
Samoa declared a measles epidemic in mid-October. Unlike Pacific neighbours, it had very low immunisation rates (about 13 per cent of under 5s) - fertile conditions for a disease that is the world's most contagious, with a single case able to infect a further 12-18 people, on average.
By mid-November, there were 10 confirmed deaths, and hospitals were well over capacity. Kiwi medics and officials visited Leulumoega Rural District Hospital, which usually has eight beds but was treating 19 measles cases, 17 of whom were children and infants.
"There was chronic overcrowding with measles cases alongside an active birthing unit," an Mfat situation report noted. "Potentially unvaccinated siblings of the admitted children are staying with their family in the hospital and are exposed to risk.
"Facilities are basic with not enough beds...children are sleeping on the floor. The second clinic five kilometres away is dealing with non-measles cases and is reverting to locking the gates to keep suspected measles cases and adults seeking vaccination out."
Three days later, Apia's main hospital was out of blood. Nurses worked 14-hour shifts, and soon there was one mother and six pregnant women with measles in the hospital's maternity ward. "There is a major need for immunoglobulin (antibodies) to support babies born from mothers with measles," a November 22 briefing warned.
That same document provided suggested lines to answer any media questions about whether New Zealand could have done more to help, and if the measles outbreak came from Aotearoa: "Where we have been asked we have responded quickly and positively...Samoa has reported that the first case came from a New Zealander."
By November 24 the country recorded 253 new cases in 24 hours. Twenty four of the 25 dead were aged under 3. The Tupua Tamasese Meaole (TTM) Hospital in Apia had 129 children with measles, about three-quarters of whom had pneumonia (a complication of measles and a common cause of death from measles in young children). Stocks of immunoglobulin ran out.
"[Australian] medical practitioners are calling this a pneumonia crisis...oxygen shortage is a very real risk. Oxygen supply to the ICU has failed twice, for approximately 15 minutes each, in the last 24 hours," Mfat noted in briefings.
"The ICU at TTM has extended into theatre space and is dealing with a large number of critical cases. Measles cases are increasing in complexity, with the leading cause of death being pneumonia complicated by secondary methicillin-resistant staphylococcus infections (MRSA)."
Such bacteria are resistant to certain antibiotics and can pose a fatal risk in hospitals.
An internal report produced by Auckland DHB shortly before the measles outbreak warned antibiotic-resistant germs were endemic in some hospitals in the Pacific Islands, and travel and patient transfer could hasten the spread to New Zealand. Babies, people in intensive care and those with very reduced immune systems are most vulnerable.
Work by Nelson-based infectious disease specialist and microbiologist Dr Richard Everts has found staphylococcus aureus (which mostly causes skin and wound infection) grown from New Zealand patient samples in 2017 showed about 13 per cent was methicillin-resistant. That proportion was 52 per cent in Samoa.
Antibiotic resistance has been a health issue for more than 50 years but has grown to the extent that scientists have warned of an "antibiotic apocalypse" that will mean common infections become untreatable.
Globally, about 700,000 people die each year because of drug-resistant infections. The WHO estimates that could reach 10 million by 2050 if current trends continue. Resistance happens naturally but has been turbo-charged by incorrect and overuse of antibiotics in humans and animals.
Properly used, antibiotics destroy disease-causing bacteria. But if taken for a viral infection like a cold, drugs won't attack viruses causing sickness and instead destroy a wide variety of other bacteria. Those that survive this onslaught can multiply and spread, and share drug-resistant traits with other bacteria. Poor sanitation and infection control can help the spread.
University of Auckland microbiologist Dr Siouxsie Wiles, author of Antibiotic Resistance: the end of modern medicine?, said the development of new antibiotics was too slow, and she worried Covid-19 could make this worse.
"It is heartbreaking, though not surprising, to hear that antibiotic-resistant superbugs complicated Samoa's measles outbreak and resulted in the deaths of so many children. It's a powerful reminder of the future we all face, as the medicines we have become so reliant on become effectively useless."
The Mfat briefings show health infrastructure failed alongside antibiotics; oxygen shortages continued, and patients slept on mattresses on the floor at Apia's TTM hospital.
Exhausted hospital workers witnessing death and suffering asked for psychological support. An Australian medical assistance team reported at least 15 seriously unwell children "have been signed out against medical advice and taken home".
A catch-up campaign had vaccinated nearly 60,000 people by early December. New Zealand funded 100,000 vaccines and arrangements were made to send 3000 MMR (measles, mumps, rubella) doses from our own stocks.
A "clerical error" meant 15,000 doses were actually sent, documents show: "The Samoan Government is grateful for the additional contribution...there will be no immediate impact on New Zealand's domestic MMR vaccine supply."
A door-to-door mass vaccination campaign began on December 5, with non-essential services across the country shut.
"Mobile vaccination teams have found measles-infected people, including people who likely died from measles," a later Mfat briefing recorded. "It appears some people in the community thought the nationwide shutdown precluded travel even for medical purposes (it does not...)."
About 90 per cent of the population were now vaccinated against measles. More than one in every five Samoans aged 6-11 months had caught measles.
New Zealand declined a request to keep two ICU nurses in Samoa over Christmas/New Year because of the pressure put on rosters back home following the Whakaari/White Island explosion and the influx of victims to intensive care units.
The national hospital still had upwards of 100 measles patients, and "infection prevention and thorough cleaning of wards is being conducted in response to high levels of multi-drug-resistant superbugs present in the hospital".
Mfat's media lines advised that "while we have not been provided with any evidence, it is highly likely that New Zealand is the main source for the outbreak...the WHO (World Health Organisation) is reporting a threefold increase globally in measles in the last year. Any country that does not have herd immunity is vulnerable."
A January 3 Mfat briefing noted only three new cases in the past 24 hours. The death of a 3-month-old and adult brought the death toll to 83.
The Weekend Herald travelled to Samoa the next month and met families who lost children to the disease, including from a village, Toamua, where 10 babies or children succumbed.
That pain can be linked to New Zealand. Ministry of Health documents show measles outbreaks that put Kiwi kids in intensive care could have been avoided had the Government acted on expert advice to close gaping immunity gaps here. It's likely the disease then spread with travellers to Samoa.
In February and soon after the Weekend Herald's investigation was published Associate Health Minister Julie Anne Genter announced $23 million to offer free vaccinations to hundreds of thousands of young people not fully protected against measles.
The funding included a business case to rebuild the national immunisation register, and outreach efforts would be led by DHBs and make immunisation easier to get, including at schools, workplaces, pharmacies and marae.
The campaign - which will have a focus on Māori and Pasifika - was paused because of Covid-19 but will start from July, with extra doses of the MMR vaccine due to arrive between June and August.
The August 2019 ministry report warned if measles wasn't controlled it could threaten the Pacific and recommended consideration of "measures to ensure that travellers into and out of New Zealand are vaccinated".
Measles subsequently reached and ravaged Samoa, where vaccination rates were among the lowest in the developed world, partly because of the deaths of two toddlers in 2018. It was later confirmed those cases were because of human error when nurses (subsequently jailed for manslaughter) incorrectly prepared vaccines with expired anaesthetic. Fear spread among parents, fanned by anti-vaxxers.
Samoa ended its emergency response to measles after immunisation rates approached levels needed for "herd immunity" that can contain the disease.
The country has so far avoided an outbreak of Covid-19. In mid-March and with six confirmed cases in New Zealand, Prime Minister Jacinda Ardern announced strict border exit measures for people travelling to the Pacific, including no travel for people outside of New Zealand in the past 14 days and health assessments including temperature checks.
"We take very seriously our duty of care," she said.
Samoa and New Zealand shut their respective borders to foreigners only days later.
Ardern and her Australian counterpart, Scott Morrison, have announced they'll ease transtasman travel restrictions as soon as it's safe to do so. The Pacific - heavily reliant on tourism - would be next to join any "bubble".
"It wasn't that long ago that we had a terrible outbreak of measles in Samoa, and so we want to make sure that whatever we do that there is really support and agreement from our Pacific neighbours," Ardern said on Monday. "Because no one wants to carry the burden of Covid going into areas which at the moment are Covid-free."