Mylan May Have Been "The Shot Heard Round the World"

The Mylan EpiPen debacle may have inadvertently weakened the grip Big Pharma on U.S. lawmakers.  Last week, a bill proposed by Senator Bernie Sanders was narrowly rejected by a vote of 52-46.  Unexpectedly, 12 Republicans and 1 Independent voted with Senator Sanders in favor of allowing pharmacists and distributors to import cheaper prescription drugs from Canada and other foreign countries (something typically favored by Democrats.)  The winds of change are starting to blow in the bipartisan direction when it comes to the pharmaceutical industry.    

U.S. Healthcare needs a revolution ; ‘the shot heard round the world’ frequently refers to the opening shots of the American Revolution in 1775.  The Big Pharma lobby is holding the American people hostage with their exorbitant ransom demands.  Last summer, Mylan Pharmaceuticals, led by CEO Heather Bresch, overplayed their hand.  Mylan came under fire for a 400% price increase in the EpiPen two-pack.  This device is considered life-saving for children and adults with anaphylactic reactions to various food, insect, or environmental insults.  Ms. Bresch insisted the significant price increase ($600-$700 for a medication which costs pennies) was justified due to the more ergonomic appearance of the delivery device and improved safety profile.  “There was a lack of access to appreciating the role epinephrine plays in the role of severe reaction.”  Classic Big Pharma:  when encountering difficulty with access, by all means, hike the price of your device.  Her miscalculation seems to have indirectly incited the war on Big Pharma by angering the public, the media, and the government simultaneously. 

Ms. Bresch landed herself in front of the House Oversight and Government Reform Committee on September 21^st, in attempts to defend her bold decision, where she insisted the company only profited $100 on each two-pack.  Somehow despite a paltry profit margin, her salary ballooned from 2.5 million to almost 19 million between 2007 and 2015.  Later that same month, the Centers for Medicare and Medicaid Services (CMS) discovered the EpiPen had been misclassified as a generic drug, making it ineligible for the low rebates Mylan was paying back to Medicaid.  Essentially, Mylan overbilled Medicaid for its life-saving drug resulting in being saddled with a large settlement.

In December 2016, Ms. Bresch took full responsibility for marking up the price of EpiPen.  Her reasoning was “we realized there’s an underserved patient population” and “a lack of awareness of severe allergic reactions and how to treat them from physicians and parents.”  Seriously?  Not only is she lying about primary care physicians not understanding anaphylaxis,; she is trying to convince us that those who are underserved are helped by paying $600 for Mylans’ life-saving device.  She is using dishonesty to support bilking millions out of consumers. 

Ironically, CEO Heather Bresch is the daughter of U.S. Senator Joe Manchin (D-W.V.). Bresch has had ethical difficulties throughout her illustrious career starting when her father was a governor.  Every decision she makes seems to border on unscrupulous.  Laws in at least 11 states require schools to stock epinephrine, and keeping a stockpile is incentivized by federal law.  So Mylan started the EpiPen4Schools program, in 2012, which provided free EpiPen two-packs to more than 65,000 schools, in an effort to ‘help’ children access life-saving medication.  The EpiPen4Schools discounted price was $112.10; however, in order to qualify for that price, schools had to agree they would not purchase products from any EpiPen competitors during the next twelve months.  A Mylan spokesperson said this requirement is no longer part of its program as of July1, 2016.

As Inauguration Day came to a close, I found myself reflecting on the positives and negatives of the most recent Presidential campaign; it appears one noble outcome may be the ushering in of true bipartisanship to Washington.  Big Pharma has relied upon their strategic lobbying efforts and targeted donations to key political insiders to ensure someone in power was always looking after their interests.  It appears the direct tactical approach by Trump could redefine those battle lines.  His comments calling out the pharmaceutical industry on their predatory tactics, sent drug sector stocks into a tailspin.

The morning of the pharmaceutical bill vote, President-elect Donald Trump accused Big Pharma of “getting away with murder.”  He pointed out “there’s very little bidding on drugs,” blaming the harmful influence of the pharmaceutical lobby.  Currently, federal law prohibits our government from negotiating Medicare drug prices with the pharmaceutical companies.  Trump has called for dissolving this policy in the past, another virtue that tends to be favored by Democratic lawmakers.  Federal laws regulate much of healthcare delivery; why not Big Pharma? The tide may be turning; four more votes are all that are needed next time.  Rep. Peter Welch (D-Vt.) has introduced a bill that would allow Medicare negotiation on drug prices.  Prohibiting Medicare from the first right of refusal in regard to price negotiation and medication formulary exclusion absolutely must end.

The Pharmaceutical Research and Manufacturers of America (PhRMA), oppose Medicare negotiation and importation of foreign medications because they “will not ensure prescription drugs entering the U.S. from abroad are safe and effective.”  Who are they kidding?  Have you purchased medications outside the country before?  It is a veritable smorgasbord of brand name medications, all with labels printed in English.  It’s almost as if the medications walked across the border on their own accord.  Big Pharma keeps peddling fear and trepidation; however, the tight grip they have had over Washington is indeed loosening. 

Those who supported Senator Sanders’ bill should be commended for voting with their conscience instead of their pocketbooks.  The 13 courageous GOP and Independent Senators who voted with Sen. Bernie Sanders are: John Boozman (AR), Susan Collins (ME), Ted Cruz (TX), Jeff Flake (AZ), Charles Grassley (IA), Dean Heller (NV), John Kennedy (LA), Curtis King (ME), Mike Lee (UT), John McCain (AZ), Lisa Murkowski (AK), Rand Paul (KY), and John Thune (SD.) It is worthwhile to note, 13 Democratic Senators voted against this bill, however many, including my own Senator from Washington State, Patty Murray, had ties to the pharmaceutical industry.  She received 300K in funding from Big Pharma during her most recent re-election bid. 

The overconfidence of Mylan Pharmaceuticals in support of government and the public for restricting access to life-saving medications for children was “the shot heard round the world.”    In one sweeping move, their CEO violated the trust of the consumer, by bankrupting them, Wall Street, as evidenced by declining share price, the pharmaceutical industry, by exposing their profit-driven manifesto, and most importantly, the federal government and its lawmakers. 

Recently, CVS announced it would begin stocking a competitor of EpiPen, Adrenaclick, for $110, a textbook example of free market forces at work.  An epinephrine delivery device has become available for $10 to patients at the largest pharmacy retailer in the nation within 6 months of Mylans’ price misstep.  Most individuals with private insurance now qualify for a manufacturer’s coupon knocking $100 off the price which will be applied right at the register.  The public maelstrom started by the CEO of Mylan not only took a toll on their share price, which tumbled from $54 to $36, but lost the monopoly on schools, pharmacies, and patients at the same time. 

When President Ronald Reagan gave his infamous speech “Tear down this wall”, he noticed words of wisdom spray painted upon its structure; ‘This wall will fall. For it cannot withstand faith; it cannot withstand truth. The wall cannot withstand freedom’.  Walls of Big Pharma have begun to crumble and it is time to hold their feet to the fire.  Four more votes stand between consumers and the freedom to purchase medications in foreign countries for pennies on the dollar.  Mylan deserves credit for showing us the ‘true colors’ of the pharmaceutical industry and my sincere hope is they can no longer stand in the way of the acquisition of knowledge, truth, and freedom of individuals to manage health for themselves.    

Taking Our Seat at the Table: The Practicing Physicians of America

This is a call to action for all 860,000 physicians in the United States of America.  Can you remember a time when practicing physicians played a vital role in healthcare reform? No, because it’s never happened. We are a crucial piece of the puzzle, and our expertise is needed to find a way to deliver quality, affordable healthcare to the citizens of our great nation. Our current system is on the verge of collapse. If we cannot get the attention of our legislators, we have no way to save it. 

The voices of practicing physicians on the front lines of medicine have been silenced for too long.

We cannot afford to wait for others to confer power, voice, or authority upon us. History shows that authority is claimed, not conferred, and we must claim authority over our own field before pharmaceutical and insurance companies wrest it away from us. Practicing physicians must have a seat at the healthcare reform table.

The Practicing Physicians of America (PPA) will be hosting a town hall meeting at the Library of Congress in the Jefferson Room on February 2, 2017 at 8:30am. PPA is a consortium of grassroots physician-led groups that have been collaborating on the issue of patient-centric healthcare reform for years. This is a unique and historic moment for us to come together as physicians and speak on behalf of our profession and our patients.

We invite lawmakers, health policy experts, and representatives of the administration to join us for six brief presentations, followed by panel discussion with lawmaker participation. Presentation topics include: MOC reform, quality reporting pitfalls, reforming the mental health system, responsible public health, improving patient care by helping the healers, and the impact of social media on the current landscape. 

Given the short notice, we welcome lawmakers to stop in at the event or contact us if interested in our stopping by their office for a short meeting. This can include photo opportunities for us to promote National Womens' Physicians Day, February 3, 2017.

Physicians must stand up and be counted. Our time is now. Practicing physicians can deliver valuable insight and novel perspective on how to enact change. We must give the power to make healthcare decisions back to the patient and their doctor, rather than to the insurance and pharmaceutical industries.

The historical perspective of healthcare reform has never included the one occupation at its core: practicing physicians. We must organize, speak up, and take action. It is time to shine a light on the healers of America who want to heal our broken healthcare system. Contact your representative today and invite them to join Practicing Physicians of America at the Library of Congress on February 2, 2017. All questions and responses are directed to one of our fearless leaders, Marion Mass, MD at marion@practicingphysicians.org. #healthcare #MOCreform #ACA #PPA

A Bird's Eye View from the Penalty Box

The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program—also known as Meaningful Use (MU)—initially provided incentives to accelerate the adoption of electronic health records (EHRs) to meet certified program  requirements.  Many physicians were mandated to change over to electronic records at the cost of tens of thousands of dollars.  Electronic records have never been shown to improve patient care or outcomes with statistical significance, the criteria physicians routinely use when making care decisions.   

Physicians who failed to participate in MU would receive penalties in the form of reduced Medicare reimbursements automatically. To avoid a penalty, physicians had to implement certified electronic health records (CEHRT) and demonstrate MU of that technology through an attestation process at the end of each reporting period.  There were 10 data specifications. Approximately 209,000 physicians were facing penalties at the start of 2016, almost one-fourth of the U.S. physician workforce. 

By the end of 2015, CMS had stated it would broadly accept applications for hardship exemptions because of the delayed publication of the program regulations.  Applications for physicians were due by July 1, 2016.

A friend of mine opened a private practice in October 2015 and thought she was on the right path toward submitting data and meeting MU requirements.  One of the most challenging things about running a business is hiring excellent ancillary staff for support.  Employees should be smart, capable, and well, able to reliably submit data.  It is worthwhile to note physicians receive no business training in medical school, so the learning curve is steep for all physicians including my friend, who is a family practice doctor. 

There are mistakes and triumph along the way and my friends’ misstep was hiring an office manager who ultimately was not a good fit – unbeknownst to the physician, she did not submit ANY data.  The notification arrived in the mail that this practice did not meet all 10 MU program requirements. “We had recently acquired a new EHR (cost 6K) and were uncertain how to verify data had been submitted.  We were working on it.” She contacted CMS and they denied any opportunity for appeal.

Welcome to the penalty box, with no term limit. Every single visit, procedure, counseling session, or medical intervention will have 2% shaved off the top.  The average family physician receives about $100,000 a year in Medicare reimbursements, so a 2% penalty for 2017 will become  3% in 2018, and increase to 4% in 2019—a combined three-year total of $9,000.  

This total overlooks the increased costs and overhead of running a business. Staff members get raises; medical supplies cost more, and even medical license fees continue increasing --- all while the physicians’ income is decreasing with no end in sight. 

This young physician is working in her hometown somewhere in Middle America, a small community, with a population of 13,000.  She is there because her family and friends are nearby.  She loves her patients; 50% of them are insured by Medicare and Medicaid.  She provides high quality care; for which she will be paid less and less each year. 

This physician is neither lazy nor stupid.  She is just not a businesswoman, yet.  She opened her practice straight out of residency and was under the impression she did not need to submit data immediately while getting things settled.  Once she began “submitting” data, she trusted the office manager to do it, because she was otherwise engrossed in seeing patients, (a part of our profession likely to disappear in the near future.)   The art of practicing medicine will become an outdated and ridiculous notion at the rate we are going.  

My advice for every primary care physician in this country is to opt-out of Medicare and Medicaid so our businesses can survive.  This particular physician cannot do that as the hospital has guaranteed her salary for one year while she gets her practice started.  What a great deal for the hospital! The primary care physician is left to their own devices, to build a practice, and serve as a source of revenue feeding the specialists, who are employed by the hospital in this particular scenario.  The hospital did offer to employ her; however the wage was far below the industry standard. 

This family physician might reluctantly have to close her Medicaid and Medicare panels anyway. If her business begins failing due to the penalties being leveraged, she will opt out of both Medicare and Medicaid.  So will us all if this punitive payment structure continues unabated. 

This scenario is repeating itself over and over across the country every day.  Private practice physicians are stuck between a rock and hard place.  Indentured servitude is on one side and the freedom to independently practice medicine is on the other. 

Financial analyst John Graham at Forbes wrote in April of 2015 that MACRA was a “fiscally irresponsible approach to increasing the amount the federal government spends on Medicare’s physicians’ services.”  What should we do when working with a fiscally irresponsible person?  Do we jump on board and begin a business partnership?  No.  Then why are physicians acquiescing to this abuse?  MACRA penalties will begin in 2019 at 4% and increase to 9% by 2022.  Who can afford to stay in practice at the rate of decline in reimbursement?

In general, physicians tend to be compassionate and empathetic, they are rule followers, and do the ‘right’ thing; traveling on the straight and narrow should not bring us to the point where we cannot make more than we would working  in a fast food restaurant.  The answer is we must opt-out until changes are made.  Private practice physicians need to realize we are on our own.  The AMA, ACP, and CMS are working in direct opposition to independent physicians fighting hard to break the chains that bind us.  It is simply time to let go and walk away. 

Suneel Dhand recently wrote, “it’s not just the ace of spades that the doctor and patient are holding — but the entire deck.”  He is right.  It is time for us to become dealers.  And I want to play dealers’ choice. 

The Greatest Blessing

Thirteen years ago, I received a call from the mother of a college freshman who was concerned because her son had been diagnosed with mononucleosis during finals week.  She felt something was not quite right and asked me for advice.  “Trust your instinct, go get him, and bring him home.” She brought him to my clinic the following day.  He looked mildly ill.  His vitals were stable; he was fatigued, slightly dehydrated, and pale.  His tonsils were enlarged to the point they were “kissing,” though not causing airway obstruction.  I gave him a steroid injection, with strict orders to go home, rest, drink clear liquids, and return with his mother the next morning. 

On the second day, he walked in looking unequivocally worse.  He was complaining of neck pain, though not stiffness, and his tonsils were considerably more swollen.  I drew blood, sent it off, and recommended a lateral neck film to evaluate his airway.  The lab called within the hour for an unusual finding.  He had atypical lymphocytes (mono cells) and a few schistocytes (chewed up cells) on his smear, he had thrombocytopenia (low platelets), and his sedimentation rate (a marker of inflammation) was unexpectedly low, something I had not encountered before.  I pulled out the book to search for causes of low ESR and a particular one jumped out.  The test can be a marker for fibrinogen levels, which if abnormal, may indicate disseminated intravascular coagulation (DIC), a serious complication of infection.  I spoke with the lab and added a PT, PTT, fibrinogen and D-dimer levels (tests to help with diagnosis.) 

The radiologist called to say my patients’ airway was narrowed and as I was contemplating my next step, he and his mother returned.  I will never forget the look of fear in his mothers’ eyes as he assumed a “tripod” position with labored breathing in my waiting room.  I am certain distress was etched on my face as well.  I called an ambulance to take him to the nearest hospital.  His mother started sobbing and I held her hand while we waited for EMS to arrive.  I promised her he was going to be alright, not being certain whether or not that was the truth. Once on his way in the ambulance, I breathed a sigh of relief. 

The term glandular fever was first used in 1889 by German physicians who recognized a clinical syndrome with the classic triad of fever, pharyngitis, and lymphadenopathy. “The kissing disease” is transmitted via primarily oropharyngeal secretions. 50% of children are infected before age 5; approximately 12% of susceptible college-aged young adults seroconvert each year, some of whom experience severe complications. 

Patients with infectious mononucleosis present clinically with fatigue, which may be profound, but usually resolves over 3 months. Nausea, without vomiting, weight loss, and anorexia are common.  Mortality and morbidity due to uncomplicated EBV infectious mononucleosis infections are low. There is really no treatment for this condition except rest, hydration, and the tincture of time.  However, massive tonsillar enlargement may result in airway obstruction, for which steroids are indicated, which was present in this particular case.  Rarely, mononucleosis results in more severe complications, such as encephalitis, pancreatitis, myocarditis, and myositis. 

While I see mononucleosis often, I have not seen a case of DIC in the last 13 years.  He was admitted to the ICU that evening and remained there for 3 days on steroids and antibiotics.  D-dimers came back positive and the rest of his labs were consistent with DIC. He decided to take some time off from school to recover and was able to make up the finals he missed during the next semester.  Over the years, he moved on to his adult life elsewhere and we lost touch.   

About twice a year, patients from the past stop by for a ‘social call’ while passing through town.  ‘Visitors’ are always an unexpected blessing to my day.  I remember every single one by name, even after almost two decades in practice.  This visitor was the young man’s brother, who is just as special to me.  I hugged him and he handed me an envelope from his mother.  His older brother turned 31 recently and is doing well.  I opened the card to find these handwritten words:  

“Not a year goes by without conversations about you, and much gratitude for truly saving my son’s life when he had mononucleosis in 2003.  We have had our challenges, but all in all doing very well.”

“Every year at the beginning of December, we give extra thanks for you, your heart, your caring, and expertise.  Your efforts on our son’s behalf continue to be perhaps the greatest blessing we have experienced.  We hope it has been returned to you ten-fold! With much love…”

I often wonder who has been the greatest blessing to whom.  A physician bears witness to the direct impact we have on the lives of other human beings.  What a rare treasure to behold!  As physicians, our journey is riddled with successes and failures.  Yet, my love and dedication to this noble and rewarding profession is instantaneously revitalized when a young person wanders into my office and reminds me of a time when we overcame such insurmountable odds together. 

  

Let's Make Vaccines Great Again!

Robert Kennedy, Jr. is an activist, author, and attorney specializing in environmental law. He is the son of Robert "Bobby" Kennedy, a former U.S. Attorney General, and the nephew of former U.S. President John F. Kennedy.  Kennedy is President of the Board of Waterkeeper Alliance, a non-profit focused on protecting and enhancing waterways worldwide.  He has written a book about the damaging effects of vaccinations due to thimerosol, and to round out his extensive medical resume, he has written two children's books.  By all means, with this broad background, it is crystal clear why President-Elect Trump tapped him to head up the Vaccine Safety Commission. 

“They get the shot, that night they have a fever of a hundred and three … and three months later their brain is gone,” Kennedy said in 2015.  His comment, “This [giving vaccinations] is a holocaust,” is terribly offensive.  He later apologized, saying, “I employed the term during an impromptu speech as I struggled to… convey the catastrophic tragedy of autism.” At least he has passion!  I look forward to more ‘impromptu’ statements because it will definitely keep D.C. hopping.   

The bottom line is the POTUS and his appointees have NO place in healthcare decision-making.  They are not physicians; they do not have the decade plus of necessary education and training.  The government machine lacks the basic knowledge and skills to make healthcare better on their own, otherwise they would have accomplished it by now.  It is like asking an archaeologist for stock market investment advice.   Ideally, healthcare decisions should be between a patient and a physician.  Physicians and patients need to be in control.  After today’s surprising yet possibly fortuitous event, we could be well on our way to advancing our physician-patient-centric agenda.

Adding to the vaccination debate, Dr. Daniel Neides, MD, medical director and chief operating officer of the Cleveland Clinic Wellness Institute, ignited a firestorm when he published a blog post spewing anti-vaccine rhetoric.  Dr. Neides describes a “difficult” recovery after receiving an influenza immunization to add insult to injury.   I lost a healthy 12 year old girl to Influenza A last flu season, so I find his non-scientific propaganda rather offensive.  Most of us would agree the potential “damage” from vaccination is far more desirable than the death of a child. 

How far should a medical director of a large scientific institution be allowed to veer off the path of mainstream medical science?  A medical doctor employed at a large, prestigious medical institution has an obligation to his patients, his colleagues, and the general public at large.  At the very least, Dr. Neides represents the Cleveland Wellness Institute and should adhere to their evidence-based standards.  For him to continue spreading falsehoods about vaccinations, toxins, preservatives, and additional nonsense in the future would be appalling.  He should categorically be relieved of his position as medical director. 

These misrepresentations endorsed by both gentlemen can be easily countered using scientific evidence.  Research has absolutely refuted any link between vaccinations and autism.  While immunization effectiveness leaves some room to be desired, vaccinations remain one of the pinnacle achievements of 19^th, 20^th and 21^st century medicine.  Devastating diseases, such as Measles, Whooping Cough, Diphtheria, and Polio have almost disappeared.  The WHO certified the global eradication of smallpox, a virus with a mortality rate over 30%, in 1979 following extensive vaccination campaigns throughout the 19^th and 20th century. 

Genetic factors are the most likely cause for autism spectrum disorders. Twin studies have estimated the genetic heritability of autism to be as high as 60-90%.  In most cases, there is no family history of autism, so these de novo mutations probably occur spontaneously, leading many to search for external causes.  A crucial distinction in all scientific medical literature is the difference between correlation and causation.  Autism is not caused by vaccinations any more than it is by our water system (an area in which Mr. Kennedy should be familiar.)  The diagnosis of autism is correlated with many things:  over-supplementation with folic acid in pregnancy, advanced paternal and maternal age, contracting influenza during pregnancy, having back to back pregnancies, and low birth weight infants or a history of jaundice, however still may not be caused by any of these.

Vaccinations save lives.  In 1958, there were 763,000 cases of measles in the United States; after the introduction of the vaccine, the number of cases dropped to fewer than 150 per year.  These are indisputable scientific facts.  Anti-vaccine propaganda has led to reduced immunization compliance and occasional disease outbreaks, such as the Measles outbreak at Disneyland and the current multi-state Mumps outbreak, encompassing more than 8 states.

Neither of these two individuals has demonstrated they have the educational background nor the expertise to diagnose autism, weigh in on vaccine safety, or be in charge of healthcare decision making. It is alarming to watch them promote anti-vaccine agendas while attaining prominent positions in the mainstream healthcare system.  The silver lining might be that those of us interested in truth, science, and the sanctity of the physician-patient relationship are now on higher moral ground with quacks at the helm.  The brightest future for physicians involves being in charge of our practices, our patients’ health, and our lives.  The more non-scientific rubbish produced by influential “leaders” of medical institutions and government agencies, the closer physicians are to achieving those goals.

Mumps, Cheek Bumps, and Testicle Lumps

Mumps is a contagious disease caused by a virus. It starts with a few days of fever, headache, muscle aches, tiredness, and loss of appetite, which can be followed by swollen cheeks (salivary glands) or swollen testicles in teenage boys and men. You can help protect yourself and your family against mumps with vaccination.  The mumps vaccine is pretty effective; in general, one does of MMR prevents infection by 78%, and two doses up to 88%. 

Mumps is no longer very common in the United States, but sporadic outbreaks continue to occur, especially in places where people have had prolonged, close contact with a person who has mumps.  Before the U.S. mumps vaccination program started in 1967, about 186,000 cases were reported each year.  Since the pre-vaccine era, there has been a 99% decrease in mumps cases in the United States.  In 2012, there were 229 cases reported in the U.S.

We are kind of having an exciting year in regards to Mumps outbreaks; as of the end of December 2016, seven states have reported more than 100 cases: AR, IA, IN, IL, MA, NY, and OK.  Washington is about to join that list with approximately 30 confirmed cases in King County and over 70 that are probable cases.  Symptoms typically appear 16-18 days after infection, but there is a long incubation period ranging from 12-25 days after infection.  Most people with mumps recover completely in a few weeks.

Mumps can occasionally cause complications, especially in adults.  Complications include:  inflammation of the testicles (orchitis) in males who have reached puberty, inflammation of the brain (encephalitis) or covering of the brain (meningitis), and inflammation of the ovaries (less obvious than the men.)

Here is where it gets interesting:  the outbreak in Arkansas, Texas, and Washington State are predominately in Marshallese people, those individuals with heritage from the Marshall Islands.  If geography is not your favorite subject, this is a group of Islands in the Pacific Ocean.  66% of those infected in Arkansas are Marshallese.  83% of those infected in Washington State are Marshallese or have close connections with the Marshallese community.  Those with Mumps in Washington State are mostly school aged (5-18 years) and about 90% of that group is fully immunized.   

So what does this mean exactly?  Most likely the mumps portion of the MMR vaccine is less effective in the Marshallese population in particular due to some genetic difference in their immune response.  It is also possible this virus is “drifting” by changing a protein here or there or an H or N molecule as similar to the influenza virus.  So all in all, there are likely small changes in the natural mumps virus altering the landscape for everyone; however those with Marshallese background are naturally more susceptible. 

In closing, as you would expect, I still recommend and support vaccination for all with MMR, personally and professionally.  However, no vaccination is perfect and works 100% of the time.  I wanted to share some scientific information with you all about what is happening here in the Northwest right now, most of which was provided by the Washington State Department of Health.