As New Zealand's borders continue to ease, health professionals are worried the incoming infectious illnesses from that, mixed with winter and falling childhood immunisation rates, pose the risk of a "perfect storm".
Among the concerns was that infectious diseases like measles and the flu could re-enter the country.
Dr Andrew Old, the Northern Region Health Coordination Centre's chief clinical officer, said illnesses had the potential to "create significant pressure for our health system in months to come".
"I hope it won't be a perfect storm, but it's certainly a risk," he told 1News in late March.
"There are a number of things conspiring against us: we have had two years where we really haven't had much in the way of circulating viruses over winter. So, the combination of borders opening and winter just around the corner certainly does create more risk."
One of the "biggest" tools to prevent a large outbreak was vaccination, as well as continuing mask use over winter, he said.
That was why Old was encouraging parents to check if their child was up to date on all their jabs and, in particular, their MMR (measles, mumps, rubella) injections.
READ MORE: Borders opening increases measles outbreak risk - Southern DHB
That call was echoed by the Director-General of Health.
Dr Ashley Bloomfield said the current MMR vaccination coverage was lower than it should be, particularly for Māori or Pacific children.
He said it was worrying given what the country has seen during the 2019 measles outbreak that led to "quite a number of children very sick in hospital".
When asked on Thursday if the health system was concerned about a "perfect storm", Bloomfield said health officials were concerned enough that they were putting together a plan for this winter.
He said that plan included making flu jabs available to more Kiwis and an MMR catch-up campaign for teens and adults who missed out as children.
READ MORE: Flu season will 'put pressure on the system' – Bloomfield
The MMR vaccine is given in two doses - one at 12 months and another three months later. The vaccine is safe and effective - more than 99% of people are protected from measles after two doses.
Ministry of Health statistics shows that of children of all ethnicities who had turned one-and-a-half years old in 2021, 71.5% had received all of their scheduled immunisations.
Broken down by ethnicity, those figures are 89.2% for Asian children, 77.2% for New Zealand European, 64.5% for Pasifika, and 50.8% for Māori.
"But, what I would say is our vaccination rates for other vaccines children get at six weeks, five months, and eight months are all high - over 90% in all ethnic groups," Bloomfield said.
"We just see this drop-off at the 12- and 15-month MMR vaccinations and that's where we really need to focus our efforts."
The Ministry of Health data showed a pronounced drop in childhood immunisation coverage from 2020, disproportionately among lower socio-economic groups and Māori.
Dr Nikki Turner, a GP and Immunisation Advisory Centre director, said New Zealand wasn't alone in seeing childhood jab rates "significantly drop" during the pandemic.
"You can imagine all the reasons around disruption with Covid and why it's hard for families to get into doctors on time," she said.
"So, internationally, we are expecting to see a rise in diseases, measles as the most transmissible one."
She said, even before Covid-19, one of the drivers of falling immunisation rates was many infants weren't registered with a GP at birth or during pregnancy.
"Then they don't necessarily get offered and followed-up."
For lower-income communities, unstable housing also meant kids could get "lost in the system", Turner said.
"The families are often under a lot of other stresses, so preventive health issues are not at the top of their minds. So, if services aren't finding them, reaching out to them, engaging with them, then they miss out.
"It's not really about being anti-vaccination - it's much more just all the other challenges for these people's lives, particularly with Covid on top of it, and just the system not working well for them."
Turner said the pace at which vaccination rates could return to pre-pandemic times would depend on how much support communities were provided, given the continued pressures they face.
“As yet, I haven’t seen that we’re doing very well. We’re going to see measles back in New Zealand, and I feel it’ll take that arriving before it really propels more action.”
That was the case after the 2019 measles outbreak. In July 2020, the Government started what was meant to be a year-long $40 million measles catch-up effort for 15 to 30-year-olds who weren't immune to measles, in the hopes of preventing a wider outbreak.
By March 2022, the Government had come under fire after revelations at least $4 million worth of expired MMR vaccines were destroyed in the month prior. And, while the catch-up programme had tried to get off the ground again in November last year, Omicron soon entered the community and continued to keep health services busy.
Previously, Health Minister Andrew Little said the effort required to get Covid-19 jabs out meant it couldn't be done at the same time as MMR.
Little said about 30,000 more doses of the MMR vaccine had been ordered recently, and that health providers continued to work to get those in people's arms.
Turner said it was disappointing that the campaign had lost traction, but that it was “absolutely understandable” given the “enormous strain” that the pandemic had placed on communities and health services.
“So, this is not about blaming what went wrong."
Northland trying to up its MMR vaccinations
Northland DHB has the lowest childhood immunisation rate of all district health boards among its five-year-olds. In 2021, it was estimated to be at just under 74%.
Northland DHB's Jeanette Wedding said increasing that rate had been a challenge for Northland and the rest of the country because of Covid-19.
Wedding said the decline in childhood immunisation rates had increased in the past five years. Between 2014 and 2015, the average decline was 6 percentage points. Now that was dropping between 10 to 12.
"There are various reasons for the decline - some families [and] whānau want to delay, some are vaccine-hesitant, some are opposed," Wedding said.
"Northland has a strong anti-vaccination movement. A few years ago this resulted in significant declines in Northland and this negative impact has continued.
"We are focused on strategies and activities to build confidence and trust in our communities that immunisations are safe, rather than strategies and activities to address the anti-vaxxers."
Among those strategies were DHB outreach services that visited families with children whose immunisations were due or imminent, if GPs couldn't reach them.
Meanwhile, staff at Te Hau Āwhiowhio ō Otangarei in Whangārei continued to offer the MMR vaccine alongside the Covid-19 vaccine.
“Our point was just to try and keep moving it forward, keep offering it to whānau, and not be distracted. We wanted to keep driving our other vaccination campaigns,” operations manager Janine Kaipo told Te Karere.
Is there a plan?
In the long-term, Turner said improving immunisation rates had to start with focused attention and support for pregnant people and their infants to be enrolled with a GP.
That way, if the parent and their infant were "well-engaged with a health service that they trust", they could be followed up if they did miss out on a vaccine, she said.
She said more funding and support were also needed for those health services.
"We saw that, with the Covid vaccine, when local communities are well-engaged with health services and those health services are well-resourced to reach out, you get high coverage."
But, Turner wasn't convinced there was an immediate plan as borders loosened.
Director of Public Health Dr Carole McElnay said health professionals still didn't "fully understand why" childhood immunisation rates had taken a tumble during the pandemic.
"It is something that we have seen in other parts of the world.
"Despite that, we need to get those rates back up… because that is a fundamental part of our public health protection."
She said a task force was needed within the Ministry of Health to provide advice about how that could be done and that it should involve various groups because "childhood immunisation is something that requires a lot of different perspectives".
McElnay said the ministry was "very aware" of the impact of a less restrictive border as measles only ever came into New Zealand from overseas.
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