The total surface area of the United Kingdom is 244,820 sq km with 241,590 sq km of land. The UK population is estimated at 60,441,457 with about 50.1 million living in England . For the last three years, the population average growth has been 0.4 per cent per year. The annual growth rate between 1991 and 2003 was 0.3 per cent.

The UK has an ageing population with a declining proportion of the population aged under 16 and an increasing proportion 65 and over. Since the late 1990s, net international migration into the UK has become an increasingly important factor in population change.

There is also an enormous amount of travel in and out of London and the Country in general. Heathrow International Airport (LHR), one of London's three airports, is the world's busiest airport. Ninety airlines fly into Heathrow from 180 + destinations in over 90 countries. A fifth terminal now under construction will be able to accommodate more traffic. Gatwick International Airport (LGW), London 's second airport, is the busiest single runway airport in the world, the second largest airport in the United Kingdom and the seventh busiest international airport in the world. Around 90 airlines operate from Gatwick's two terminals, serving around 200 destinations. Stansted (STN) is the third busiest passenger airport in the U.K with over 22 million passengers a year. Forty four scheduled and charter airlines serving 145 destinations in 32 countries are based at London 's third airport.

Iowa became the 29th State in 1846. It is 56,275 sq. mi. (145,753 sq. km.) and is bordered by the Mississippi to the east and the Missouri to the west.

Des Moines is Iowa 's capital city. According to the U.S. department of Transportation,

Des Moines International Airport (DSM) was the Nation's 91 st “most active” airport during calendar year 2005.

According to the most recent U.S. Census Bureau figures, Iowa 's estimated population is 2,966,334, ranking Iowa 30th in population. The state's population increased by 5.4% during the nineties compared to 13.1% nationally. In 2000, children under 5 were 6.4% of the state's population (vs. 6.8% for the US ), individuals under 18 were 25.1% (vs. 25.7 % in the US ) and persons 65 years or older 14.9% (vs. 12.4% for the U.S. ).

The “ Hawkeye State ” is an agricultural hub ranking first in the nation in corn, pork and egg production and second in soybean and red meat production. Iowa 's total cash receipts for farm commodities in 2003 totaled $12.6 billion – the third highest in the country. About 89 percent of the land area in the state is in farms.

Iowa 's education system has consistently earned high marks including a 6th place ranking overall for getting a quality education. The state's public school graduation rate was 90.4% in 2004, way above the national average.

Because of its central location, its highly educated, dedicated and productive work force and its pro-business government, Iowa has attracted and welcomed many successful ventures in the fields of bio-science, financial services and information solutions.

The state was part of the Lewis and Clark expedition and the site of many historic events.

The famous Iowa Caucuses are pivotal during election years.

Quick Summary

Iowa 's official state web site features the welcoming slogan “Come Home to Iowa ” followed by the simple statement “ Iowa is a great place to live and travel”.

That is unquestionably true, although it may be a good idea to wait on the travel part for a few weeks, unless you've had mumps.

No one exactly knows what happened in 2006, but by March 28, there were already 219 mumps cases statewide. William Bellini of the Centers for Disease Control and Prevention (CDC) was still puzzled on April 13 when he wondered “Why Iowa, and why now? We really don't know. There are a lot of unknowns." ( Washington Post)

For the last 20 years, Iowa has averaged five cases of mumps annually. In the last 5 years the whole U.S. has averaged 265 reported cases a year.

So here we are in 2006, in the middle of the United States of America and we are suddenly facing the largest U.S. mumps epidemic in almost twenty years - in a state with consistently superior vaccination rates. According to the CDC, 97% of children entering Iowa schools in September 2004 had received 2 doses of MMR vaccine.

Of those first 219 patients, forty eight percent were 17-25 years old and about a third were college students. Of the 133 patients with investigated vaccine history, 87 (65%) had documentation of receiving 2 doses of vaccine, 19 (14%) had received one dose, and eight (6%) no doses. The vaccination status of the remaining 19 (14%) patients could not be determined.

The Iowa Department of Public Health (IDPH) did everything right. It immediately called the CDC and it kept everyone, citizens and health professionals alike, informed with complete details of the outbreak and how to contain it. It also issued successive press releases as the situation changed. The first, on March 17, 2006 , started “ Iowa 's public health community continues to investigate an unusual outbreak of mumps statewide, with over 70 cases reported so far this year, the most since a large Iowa outbreak in 1987. Cases have been reported in 15 different counties.”

IDPH issued three press releases in April:

4/13/2006 : “With 605 reported, probable, confirmed and suspect cases of mumps in Iowa , the Iowa Department of Public Health (IDPH) and local Iowa public health agencies, with assistance from the University of Iowa Hygienic Laboratory and the Centers for Disease Control and Prevention (CDC) continue to address the current mumps situation in the state.”

4/20/2006 : “With the highest number of Iowa mumps cases occurring in the young adult (18 through 22 years old) population, the Iowa Department of Public Health, and its local public health partners have announced a statewide campaign to vaccinate those at high risk of mumps. Iowa has seen 975 cases of the illness this year .”

4/28/2006 : “With the highest number of Iowa mumps cases occurring in a young adult (18 through 25 years old) population, the Iowa Department of Public Health, and its local public health partners have announced the second phase to vaccinate those at high risk of mumps has expanded to include 25 year olds. The previous campaign had targeted 18 through 22 year olds. Iowa has seen over 12-hundred cases of the illness this year. This expansion covers three additional years that also have close relationships to the original targeted group because they may still be in college or socialize with the previously targeted group.”

By May 8, 2006 , there were 1609 confirmed, probable or suspect cases of mumps reported to IDPH. In other words, cases of mumps in Iowa increased by almost 2200% (70 to 1,609) in 7 ½ weeks.

The “epidemic” peaked in week 13, the week ending April 8, with 309 cases. There were only 48 cases in the week ending May 6 (week 18) just one case more than week 10, the week ending March 11, 2006 .

CDC Director Gerberding suggested that mumps had spread quickly because of the dense concentration of students in affected areas and because “the vaccine is not perfect. It has about an 80 percent efficacy rate for people who have been inoculated with one dose, and a rate of about 90 percent for people who have received the recommended two doses.”

She added “We have absolutely no information to suggest that there's a problem with the vaccine …What's going on here is basically a number of people who haven't received both doses, coupled together with people who have received the vaccine but are susceptible anyway, living in crowded conditions like college dormitories or mixing up with other students at spring break or during holidays, and setting up a cascade of transmission that's going to take a while to curtail.” http://tinyurl.com/memq6

In the same April 19 report, state epidemiologist Patricia Quinlisk MD said that half of the cases in Iowa involved college-age students, “most of whom have been vaccinated”. She candidly summarized the situation with the reassurance: “…It's hard to say what comes next. When mumps was around, it tended to be a winter and spring disease, and it tended to go down in the summer. We'll be waiting to see if Mother Nature gives us a little help.”

[Pat Quinlisk has to be the World's most honest and candid public health official. Talking about the spread to mumps to neighboring states, she told Infectious Diseases in Children “ We are definitely spreading it, unfortunately” (see below)]

The CDC and IDPH made generous quantities of MMR vaccine available to all and very promptly. IDPH also provided information to the public. One of its correct statements was that individuals who did not respond to the first two doses will probably not respond to a third. Some other pronouncements were unfortunately not 100% scientifically defensible e.g. it is safe to give a third dose of MMR vaccine if an individual cannot provide documentation and it takes 10-14 days to mount a response to a vaccine's first dose and approximately seven days after the second dose.

It has certainly not been “proven” that it is absolutely safe to give a third dose of MMR to an adult who received already two but does not have a little paper saying so. It is also widely accepted that it takes 2-4 weeks for full immunity to develop after vaccination.

In the middle of its difficulties, IDPH found a way to “plug” two other vaccines: “ The mumps vaccine (part of the MMR vaccine) is about 95% effective. This means out of every 100 people vaccinated, 95 will be protected. However, the vaccine will not "take" in 5 people, and these people will remain susceptible to the disease. By comparison, the measles vaccine (also part of the MMR vaccine) is about 98% effective and the annual influenza vaccine is about 70-85% effective.”

The reference to the measles vs. mumps antibodies does not agree with Merck's statement on page 1 of the MMR II product insert that states that a single injection of MMR induced measles hemagglutination-inhibition (HI) antibodies in 95%, mumps HI antibodies in 96% and rubella HI antibodies in 98% of vaccinated subjects. As to the influenza vaccine, the 70-85% effectiveness quoted by IDPH is wishful thinking by the CDC and the vaccine manufacturer. Patients of all ages are yet to see such results and in fact, to quote Jefferson of the Cochrane Collaboration who reviewed the World literature “according to reliable evidence, the usefulness of vaccines in the community is modest.”

The IDPH presented the two following examples to explain the outbreak in Iowa in the presence of impressive vaccination rates:

“ Example 1:

In a community of 100 people, 100% have been vaccinated. Everyone is exposed to mumps. What happens?

Example 2:

In a community of 100, 98% have been vaccinated (a similar rate to what is being seen today in Iowa 's K-12 schools and some colleges.) Thus 98 people are vaccinated and 2 people are not. Everyone is exposed to mumps. What happens?

Thus a large percent of the people with mumps have been vaccinated. This is expected in a highly vaccinated population when dealing with a vaccine that is 95% effective and a contagious disease like mumps. This does not mean that the vaccine is not working; in fact the mumps vaccine is working as expected.” (End of quote)

* * *

In an effort to vaccinate young adults in the state as promptly as possible, the CDC air-lifted thousands of doses of MMR to Iowa and the IDPH, the local city and towns health departments and medical services at colleges and universities statewide made a major effort to vaccinate anyone and everyone willing to show up to receive the vaccine.

Surprisingly, the joint campaign failed to take off.

As of May 4, 2006 “Thousands of doses of mumps vaccine remain in health-clinic refrigerators across the state, because relatively few college-age students showed up for shots last week” according to Tony Leys of the Des Moines Register.

All of the above is possible …but unlikely. I have trouble believing that young intelligent educated men would worry more about a term paper than their testicles, their hearing and the possibility of developing neurological complications – should they contract mumps. I believe that in Iowa , a state where childhood vaccination rates are very high, vaccination requirements to enter college are quite comprehensive and frequently updated. It is almost certain that arriving freshmen carefully fulfill those requirements. It is therefore more likely that Iowa college students simply realized that just as many vaccinated and unvaccinated individuals were coming down with the disease and that everyone had recovered nicely.

One day the CDC and IDPH will have to just bite the bullet and concede that the MMR is not 100% effective: Period. From Finland to Toronto to Luxembourg to Cape Town to Anchorage Alaska , one can find reports of local outbreaks of measles and mumps among highly vaccinated populations.

When the mumps figures for England and Wales provided by the U.K. Health Protection Agency are reviewed, it is apparent that the disease has been overly diagnosed clinically. (See attached table) < http://www.hpa.org.uk/infections/topics_az/mumps/data_quarter.htm >

In 2003, the number of “uncorrected notified cases of mumps” was 4,265. It increased to 16,494 in 2004 and to 18,565 in 2005, when the populations of England and Wales were around fifty million and three million respectively.

The average percentage of laboratory–confirmed mumps cases was 39% of the tested cases in 2005 which means that of the 18,565 reported cases possibly as few as 7,240 cases were actually mumps. This number would be equivalent to around 410 cases in Iowa with its 3 million inhabitants.

We do know that there were 1,539 (1609 minus 70) cases of mumps recorded in Iowa between March 17 and May 8, 2006 . Regardless of the margin of error in the above calculations, it is evident that Iowa with its superior vaccination rate had proportionately many more cases of mumps during that period than the U.K in 2005.

* * *

In the U.K. the present mumps outbreak is blamed on poor MMR vaccination rates. This in turn has been attributed ad nauseam to a February 1998 publication by Andrew J. Wakefield in which he describes a possible link between MMR vaccination and autism in a small number of children. Wakefield 's enemies have even blamed him for the death of a child who could NOT receive the vaccine because he was immuno-compromised and for no other reason .

Most mumps cases in the U.K. have been reported among young adults.

This is not surprising when one notes that:

The medical authorities in the United Kingdom should

* * *

It is quite evident that Iowa , a state with superlative vaccination rates has had, in the last four months, proportionately more mumps cases than the U.K.

This can ONLY mean that maximal MMR vaccination rates will NOT guarantee that outbreaks of one of the three diseases will NEVER happen. It is of primordial importance to realize that – once and for all - whether or not we call the occurrence a vaccine failure or not.

There are now several small outbreaks of mumps in the neighboring states of Illinois , Kansas , Minnesota , Missouri , Nebraska and Wisconsin . The author of an article in the May issue of Infectious Diseases in Children stated that Iowa Health officials did not know the origin of the infection. She also quoted Patricia Quinlisk (see above) who said that IDPH was not focusing on that, but just concentrating on slowing and stopping transmission of the disease.

Midwesterners are calm people and there does not appear to be any feeling of impending doom in the area. Whether the disease spreads to the Atlantic and Pacific oceans is anyone's guess. If it does, it is not going to be the end of the world.

* * *

It is unfortunate that no one in the CDC - or the involved state health departments in the Midwest simply stated that two doses of MMR are not enough to guarantee immunity in everyone - forever. They lost a good chance to be candid …first.

Under the title Two doses of MMR 'may not protect from mumps', Sam Lister described the findings of a new study published in the Journal of Epidemiology and Infection in The TimesonLine – Britain on May 11, 2006 :

“The study analyzed serum samples from 3,445 patients aged from 1 to 69. In children born between 1986 and 1990, who would be expected to have received one dose of MMR as part of routine vaccination, 34 per cent were found to have low levels of mumps antibodies — indicating potential lack of protection. Of those born between 1991 and 1995, who should have had two doses, 15 per cent were found to have low antibody levels.” http://tinyurl.com/nhgdl

* * *

Does history repeat itself?

J Pediatr.1991 Aug;119(2):187-93

Mumps outbreak in a highly vaccinated population by
Hersh BS , Fine PE , Kent WK , Cochi SL , Kahn LH , Zell ER , Hays PL , Wood CL .
[From the Division of Immunization, Centers for Disease Control, Atlanta , Georgia ]

From October 1988 to April 1989, a large mumps outbreak occurred in Douglas County, Kansas. Of the 269 cases, 208 (77.3%) occurred among primary and secondary school students, of whom 203 (97.6%) had documentation of mumps vaccination. Attack rates were highest for students attending junior high school (8.0%), followed by high school (2.0%) and elementary school (0.7%). A retrospective cohort study conducted at one junior high school with an attack rate of 12.9% did not find age at vaccination or type of vaccine received (single or combined antigen) to be risk factors for vaccine failure. Students vaccinated more than 4 years before the outbreak appeared to have a higher attack rate than those vaccinated more recently (relative risk (RR) = 4.3; 95% confidence interval (CI) = 0.6, 30.0); however, this association did not exist when risk was evaluated based on number of vaccine doses received. Students who had documentation of receiving only one dose of vaccine were at greater risk than those who had received two doses (RR = 5.2; 95% CI = 1.0, 206.2). Overall, vaccine effectiveness among Douglas County junior high school students was estimated to be 83% (95% CI = 57%, 94%). These data suggest that mumps vaccine failure and the failure to vaccinate have contributed to the relative resurgence of mumps observed in the United States since 1986. The recent change in immunization policy to recommend a two-dose schedule of measles-mumps-rubella vaccine should help reduce the occurrence of mumps outbreaks in highly vaccinated populations.

PMID: 1861205 [PubMed - indexed for MEDLINE]

So 15 years ago, we had an outbreak of mumps among a highly vaccinated cohort of school children in the rural Midwest and the CDC investigators thought it was due in part to vaccine failure. The exact same thing seems to be happening again now among college students: Why doesn't anyone just concede that it is vaccine failure…again?

* * *

Good People of the U.K.

•  You have an outbreak of mumps and so do we

•  You have had mumps outbreaks for centuries and so did we

•  Children who contract mumps will have a stronger immunity than those you vaccinate

•  Two doses of MMR vaccine do not guarantee lifetime immunity

•  The MMR vaccine should be offered to those who wish to use it

•  Single vaccines should be re-introduced to improve vaccination rates and increase chances to curtail measles, mumps and rubella. By the way, single vaccines are available in the U.S. and the rest of the world.

•  One dose of Mumpsvax® at age ten is the most logical and economical way to protect nations against mumps

•  Summer will soon be here and Mother Nature will do her thing.

Mumps notifications (confirmed cases), England and Wales , 1995 - 2005* by quarter

http://www.hpa.org.uk/infections/topics_az/mumps/data_quarter.htm