Contact tracing failed and vaccination was too slow to stop last year's measles epidemic ripping through South Auckland, a new review has found.
More than 2000 people disease caught the disease nationally last year, most of them in South Auckland. About 750 people were hospitalised, most of them children under two.
New Zealand most likely exported the disease to Samoa when it became deadly
The new review, commissioned by the Ministry of Health, paints a picture of a stretched public health system - both regionally and nationally - with inexperienced staff and a lack of leadership.
Measles had been eliminated in New Zealand but arrived in Canterbury in February last year.
It then started to rapidly grow in South Auckland in June.
Though 40,000 vaccinations were available in July, only 9000 were distributed, the review found.
Vaccines later ran out and, as more arrived at the start of September, there was confusion and mixed messages from authorities about who should get vaccinated, the report said.
South Auckland GP Api Talemaitoga remembers the confusion.
"The DHBs were telling us "come on, we've got all these doses, you're not using them up' but it was a real, uncoordinated response," he said.
Although GPs were noticing the odd case here and there, it took a long time for the public health teams, who would have seen notifications about individuals, to alert the community to the fact there was a rapidly growing outbreak, he said.
By June, the Auckland Regional Public Health Service did not have enough resources to keep up with contact tracing of the highly infectious disease.
Immunisation Advisory Centre director Nikki Turner said it was an example of years of under resourcing of public health.
"We had enough for a small amount of measles but the moment the numbers got to big we were no longer able to contact trace," Turner said.
That happened just as the disease was taking off among Pacific communities and meant they did not get the benefit from it that other populations had, the review found.
Dr Talemaitoga said Pasifika doctors had learnt lessons from that for Covid-19, and mobilised when the outbreak hit to make sure they were the ones getting the messages out.
The review found the large gap in the number of people immune to measles was also a big factor.
Dr Turner said that should have been closed years ago.
"It was no surprise we got measles back ... if we'd moved earlier and put more resources and more effort into ensuring enough people were vaccinated in New Zealand ... we would not have had measles last year," she said.
A catch-up campaign was announced in July this year to vaccinate those that still need one.
Director-General of health Ashley Bloomfield said no-one was responsible for the measles outbreak but the ministry had learnt lessons for its Covid-19 response.
Another review released today also found problems with mixed messages and leadership when it came to the distribution of the flu vaccine earlier this year.
Dr Bloomfield said the ministry was also working to improve on that, and it would be important for a potential Covid-19 vaccine