Vaccination rates are dropping across the country as fewer families immunise their babies.
Now, in the midst of a measles epidemic, a Herald analysis of immunisation data finds just 77 per cent of 6-month-olds are now getting their vaccines on time.
While the debate has been centred around the impact of the anti-vaxx movement, the numbers paint a different picture.
Kirsty Johnston and Chris Knox report.
Plummeting vaccination rates are being driven largely by the failure to immunise babies born into poor or Māori families - not by parents deliberately opting out.
A Herald analysis of immunisation data from every neighbourhood in New Zealand found 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.
Coverage of at least 90 per cent is needed for herd immunity.
The drop has been most marked for Māori babies, falling 9.5 percentage points to 61 per cent vaccinated; and for babies living in deprivation, down 7 percentage points to 69 per cent.
Only around a quarter of the total decrease can be accounted for by parents who declined vaccines, documents showed, meaning the rest were going un-immunised for other reasons such as access to healthcare.
"I think people have got a bit carried away with the impact of anti-vaxx," said Dr Nikki Turner, the director of the Immunisation Advisory Centre.
"Vaccine hesitancy has always been with us in New Zealand. That isn't changing. What is changing is our society, how hard it is for families to access care, and the impact of poverty."
The Herald analysed vaccination rates for 6-month-olds - considered the most sensitive measure of whether the system was working in a timely manner. Infants receive three courses of vaccinations before 5 months of age.
Timeliness was particularly important for babies, Turner said. For example, babies whose whooping cough vaccines were delayed were two-to-four times more likely to end up in hospital.
ESR data showed as vaccination rates dropped, whooping cough rates skyrocketed, with an ongoing outbreak since 2017. In the year to January 2019, 165 babies were hospitalised with whooping cough.
"If you're leaving the vaccination longer, you're leaving children exposed to disease," Turner said.
The data analysed showed that as of March this year the "equity gap" between Māori or poor children and the general population was at its widest since 2012.
But health boards varied widely in coverage. For example, Canterbury had the highest rates, at 86 per cent, while Tairawhiti had the lowest at 61 per cent.
While all health boards were slower to vaccinate poor or Māori children, some had wider inequities - and those were typically the areas with a rapid drop in rates.
***Scroll down to see vaccination rates in your area***
Hauora Māori lecturer Esther Willing, from the University of Otago, said the pattern was predictable.
"Māori are like the canary in the mine for the health system," she said. "When things aren't working they drop first because barriers to accessing services are most profound for Māori families."
The researchers said increasing issues with access - such as a lack of transport; both parents working and being unable to meet practice opening hours, or transience - had been lost in the narrative about immunisation being a "choice".
The picture was also complicated because two groups were missing out - babies living in deprivation, and Māori babies - and while there was overlap between the two, they weren't always the same.
"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-vaxx. Anti-vaxxers are usually wealthy, well-educated people because they have the resource to question what the health system is telling them."
The Ministry of Health has recognised an "urgent need" to address vaccination rates. In March it launched a campaign aimed at Māori and Pacific families, and in April it wrote to Minister of Health David Clark saying it would investigate the issue.
In May it identified seven possible reasons Māori families were not vaccinating - including socioeconomic barriers; a lack of flexibility with the general practice model; greater workload for outreach services; and vaccine hesitancy - but did not know which was the strongest.
"The barriers to immunisation are complex and multifactorial ... and are likely part of a larger picture indicating a growing systemic issue with inequity in health services," it said.
The ministry had convened a project team to work with DHBS. It also wrote to all DHB chiefs with its expectations, commissioned Māori-led research and organised a hui.
It said it needed more innovative solutions, given most regions previously had little success in improving immunisation coverage.
Acting minister of health Julie Anne Genter said the Government was working to remove barriers to healthcare while lowering the price to see a GP, and improving access to public transport, but there was more to be done.
"We need to continue to find ways to deliver services in ways that meet the needs of families, such as setting up vaccination clinics in more accessible places and times."
Outreach nurses work to find families in hard-to-reach places
Anahera was a solo mum with two kids when she adopted a baby boy who was otherwise going to be taken from a family member by the state.
She'd just moved to Tauranga, choosing to take a housing placement there, after almost three years on the waitlist in Auckland, and had no car.
Getting to a doctor, with no spare money and no data on her phone to Google the route - let alone taking three kids on a bus - seemed impossible.
"I didn't know where anything was," she says. "I have no family in Tauranga. When I took the kids for vaccines in Auckland it was ok because my mum was there. But it's hard in a new place."
So when Sue Stevens, an outreach immunisation nurse for the Western Bay of Plenty Primary Health Organisation, called her, Anahera only felt relief.
"I was like, are you serious? You can come to me? I was so grateful. I was worried the baby was going to get sick. And Sue was so was lovely."
Stevens vaccinated the baby boy, and also did top-ups for the other children. She'll be back in about a month to complete the baby's first course of immunisations.
"We will immunise anywhere," Stevens says. "In family homes, or on the front terrace if they're not comfortable with us coming inside. I've done them in parks. We aren't judgmental."
Stevens is one of dozens of outreach nurses around the country, employed by PHOs, to track down children and vaccinate them when they miss their scheduled injections.
The nurses get referrals from a General Practitioner or the National Immunisation Register and then drive to the family's address.
"Most people say yes at the doorstep," Stevens says. "Some take longer to come around. I worked with one family for four years. The mum was hesitant. Now I've done all three of her children."
Nikki Turner, the head of the director of the Immunisation Advisory Centre, says nurses like Stevens are reporting their roles are getting harder.
While most families want to vaccinate, with both parents working and inflexible GP hours, more people were pushing vaccination down the priority list. Some struggle to enrol with a GP because the books are full, or don't want to return because they can't afford their debt.
And with poverty more entrenched, Turner said, families were struggling more and more insecure housing and transience, making it harder for nurses to find families and keep track of them.
DeArna Randell, an outreach nurse in the Waikato, said while some of her families were in rural areas - workers on dairy farms, for example - most were in the city.
"The majority are living in poverty, they're transient, they're living in a caravan park or a motel. I can't go to [social services] and say 'where are they' so I just have to try and find them from the last known address."
Randell said for those families, vaccination simply wasn't a priority. "All they can think about is eating, housing, warmth and looking after each other. That's urgent, and anything else was an afterthought."
Some also couldn't afford birth certificates, so couldn't enrol with a GP. Or they were unaware of how to access the healthcare system other than through the hospital.
She said when she visited families, she would have a cup of tea, and then help them with referrals for other services as well as doing the injections. Sometimes she would drive whanau to a clinic so they could enrol.
"They let me in but they're embarrassed. It's hard when you're trying but it's still not good enough," she said.
"What would really help is if we could address the underlying issues. If the root problem - poverty - was sorted so they can prioritise immunisation."
"We know that some groups don't enjoy the same good health or access"
In March, two of the largest district health boards (DHBs) - Waikato and Bay of Plenty - discussed vaccination rates before Parliament's health select committee.
Both brought up the anti-vaxx movement as an issue to be addressed, arguing there needed to be a national campaign to push back against concerns.
"The anti-vax people have done a really good job of raising concerns. I think it needs a national message, we actually need to be pushing it. There is some good science out there, we need to be using it," said Waikato DHB interim chief executive Derek Wright.
"I think that's something we need to look at nationally, how we're going to combat the negative effects of that," BOP DHB chair Sally Webb.
Those DHBs both had extremely strong correlations with poverty and ethnicity and their vaccination rates, and rapid drop-offs since 2016.
In fact, those health boards - Waikato and Bay of Plenty - alongside two other DHBs -Tairawhiti and Lakes - contributed half of the approximately 660 fewer fully vaccinated children by March 2019.
DHB Vaccination Rates
Click or tap on the sides of the graph switch between DHBs
Waikato's executive director of public health, Tanya Maloney, said it was aware it was "slightly" under the national immunisation rate.
"We know that some groups don't enjoy the same good health or access to health services as others in our region," Maloney said.
She said Waikato was one of the larger DHBs, with nearly half its population living in small rural communities. It also had more than 20 per cent of its people living in deprivation.
She said while deprivation was an issue, hesitancy was also an issue that could delay getting immunised on time.
"This is not always because they do not want to immunise their child, it could be that they believe their infant might be too young such at the 6 or 8-month range."
Maloney said the DHB had established a new team to focus on the enrolments of all newborns with a GP and had a free drop-in service offering immunisation at the Hospital.
Bay of Plenty DHB's Child and Youth manager, Tim Slow, said there were many factors impact low immunisation rates, including "high levels" of declines, which were impacted by anti-vaccination campaigns.
"This is now being discussed internationally with anti-vaxxers identified as being among the top 10 health risks worldwide. Social media coverage of risks for vaccination are also thought to promulgate fear and create a tendency for partial vaccination/hesitancy/decline and consideration of alternatives," he said.
Other factors were difficulties in finding or contacting parents, and maintaining training with staff who manage the immunisation conversation with parents.
He said the board was running an immunisation improvement project, which included liaison and training with other service staff such as Tamariki Ora.
