Primary Three Drug Class Antiretroviral-Resistant HIV (3DCR HIV) 

The following information is adapted from the City of New York Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention.

Background

On February 11, 2005, the New York City Department of Health and Mental Hygiene (DOHMH) announced that a person in New York City had been diagnosed with a strain of HIV that is highly resistant to current therapies.  The strain is being called "primary three drug class antiretroviral-resistant HIV,” or “3DCR HIV.” 

In addition to drug resistance, this one patient appeared to have rapidly progressed from HIV infection to AIDS. Usually, AIDS occurs about 8 to 10 years after infection with HIV, but in this case, the onset of AIDS appears to have occurred less than two years after HIV infection based on his last negative test. 

Much is yet unknown about this patient.  Some people have low CD4 counts for a period of time soon after initial infection with HIV; their CD4 counts usually return to normal or near normal several months later.  This situation is called “acute retroviral syndrome.”  This case had symptoms consistent with acute retroviral syndrome in the fall of 2004.  At this time it is unclear whether he has AIDS or a prolonged acute retroviral syndrome.  

This patient is a gay man who reported multiple male sex partners and unprotected anal intercourse, often while using crystal methamphetamine (“crystal meth”). He was first diagnosed with HIV in December 2004, with the diagnosis of 3DCR HIV made shortly thereafter. 

Q. This patient’s HIV is being called “Three Drug Class Antiretroviral-Resistant HIV.” What is that? 

A strain of HIV virus that is resistant to treatment by three classes of antiretroviral drugs (not three individual drugs) is called “Three Drug Class Antiretroviral-Resistant HIV.” These strains of HIV are highly resistant to most of the currently used antiretroviral therapies, which are taken by people living with HIV to slow damage to the immune system caused by HIV.  Because 3DCR HIV strains do not respond to the most commonly used antiretroviral drugs, treatment can be difficult. 

Drug resistance is becoming more common among people with HIV who are getting drug treatment.  Being infected with a strain of HIV that is already drug-resistant before any attempts at drug treatment is less common, although not rare.  According to studies in the US and Europe 8-20% of new infections are resistant to one class of HIV drugs and 1-4% are multi-drug resistant.  It is, however, extremely rare to be infected with a strain of HIV that is resistant to three (out of 4) of the most commonly used classes of antiretroviral drugs.  CDC has a surveillance system in six states (not including Maine) that gathers resistance information on new HIV infections. Data from that surveillance system estimate only 0.6% of 1,800 new infections had 3DCR strains of HIV.  None of these strains were identical to the New York case’s strain. 

In addition, Canadian investigators reported two separate instances of transmission of highly resistant strains of HIV; both these cases also appeared to progress rapidly.  The strains from these two cases have been compared to the New York virus and are different from it. 

Q. What does it mean that this strain of HIV rapidly progresses to AIDS? 

A strain of HIV that rapidly progresses to AIDS causes severe suppression of the immune system and makes the patient vulnerable to opportunistic infections.  Usually it takes about 8-10 years after infection for HIV to progress to AIDS.  However, there are many cases where people progress to AIDS within 2 years. 

Rapid progression can be caused by a highly infectious virus, the condition of the infected person’s immune system, or some combination of the two.  In the New York City case, AIDS was diagnosed within 3 to 20 months after HIV was diagnosed.  It’s not clear yet what caused the rapid progression in this case. 

Q. Why is this different from other strains of HIV? 

This strain has the ability to bind two different places on T-cells (the target cells for HIV infection). Thus it may deplete the T-cell population more rapidly than usual. At the same time, its resistance to most drugs in three of the four most commonly used antiretroviral drug classes limits treatment options. 

The combination of rare 3-class drug resistance and the rapid immune system damage makes this New York City case unique.  Around the world, experts are studying it.  Because it’s so unique, it’s getting a lot of attention.  Many questions about it haven’t yet been answered.  

Q. Is the New York City case a new and deadly strain of HIV?  Is this the start of a new epidemic? 

We don’t know yet.  Some of the questions we’re waiting to have answered are:

• Are there are other individuals who had sex with the NYC case that are also HIV infected and have the same strain of virus?

• Was the rapid progression linked to the virus itself and not because of the man’s genetics or already weakened immune system?

• Can the virus from this man be easily transmitted?

 Q.  To which anti-viral drugs is this HIV strain resistant? 

The New York case’s strain of HIV is resistant to most available antiretroviral drugs in the following classes: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors. 

Q.  What kind of treatment is this person receiving? 

The patient’s virus showed susceptibility to a recently approved drug in a new class of antiretroviral medications called “fusion inhibitors.” The patient is being treated with a fusion inhibitor in combination with other anti-HIV medications to which the strain may be partially susceptible.  

Q.  How can clinicians identify this particular strain of HIV? 

Clinicians should consider testing for drug resistance in persons with newly diagnosed HIV and in HIV-infected persons who are responding poorly to treatment.  Two types of drug resistance tests are available.  Genotypic assays detect resistance-conferring mutations.  Phenotypic assays directly measure resistance of the patient’s HIV strain to specific individual drugs. 

Q.  How can people protect themselves against this strain of HIV? 

The usual ways of reducing risk should work against this particular strain of HIV. The only way to completely avoid HIV is by not having sex and not sharing needles and drug works.  

People who are sexually active should use a latex or polyurethane condom every time they have sex (vaginal, anal, and oral).  Risk can also be reduced by avoiding drugs (such as methamphetamine or crack cocaine) and alcohol that impair judgment while having sex. 

All people at risk for HIV should be tested regularly, especially sexually active men who have sex with men and their sex partners; injection drug users and their sex partners; sex workers and their sex partners; anyone diagnosed with a sexually transmitted infection; and persons with multiple sex partners. 

Q.  Can people who are already HIV-infected, become infected with the 3DCR HIV strain? 

Yes, there have been rare reports of HIV-infected patients who become infected with another strain of HIV.

Contributed by: Bob Woods
bob.woods@maine.gov

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Influenza Surveillance--Maine 2004-2005 Season Report  

During the 2004-2005 influenza season, the Maine Bureau of Health conducted influenza surveillance in collaboration with multiple public and private agencies with the intent of using the data to inform influenza prevention and control policy.  Maine sentinel providers observed a total of 116,297 patients; 1,157 (1.0%) of which sought care for influenza-like illness.  Sentinel schools reported an average of 5.3% students absent each day.  A total of 316 (2.3%) of 13,983 hospital admissions from sentinel emergency departments were due to respiratory illness.  The Maine Health and Environmental Testing Laboratory reported 150 (32.0%) of 469 respiratory specimens submitted for viral testing were confirmed as influenza; 104 (69.3%) of 150 were characterized as influenza A (H3), 12 (8.0%) were influenza A not subtyped, and 34 (22.7%) were influenza B.  Thirty-six outbreaks of influenza-like illness in long-term care facilities and three nosocomial outbreaks of influenza-like illness in acute care facilities were reported during the 2004-2005 influenza season.  A total of 210 (10.3%) of 2,040 deaths reported by three city vital records offices were attributable to pneumonia and influenza.  Two influenza-associated pediatric deaths were reported in Maine during the 2004-2005 influenza season. 

 The 2004-2005 Maine Influenza Surveillance Season Report will be available June 17 at the Bureau of Health website (www.mainepublichealth.gov) and will include a full summary of 2004-2005 influenza surveillance indicators (as mentioned above), information on year-round surveillance activities, and anticipated composition of the 2005-2006 influenza vaccine.  For more information, contact Anne Redmond, Influenza Surveillance Coordinator, at (207) 287-7273 or Anne.Redmond@maine.gov

Contributed by: Anne Redmond
anne.redmond@maine.gov

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Interim guidelines for evaluation and management of CA MRSA in Maine   

The Maine Bureau of Health will publish interim guidelines to assist clinicians in the evaluation and management of community-associated methicillin-resistant Staphylococcus aureus (CA MRSA) in July 2005. This document is intended to provide interim clinical guidance for management of Staphylococcus aureus skin and soft tissue infections (SSTI) in outpatients in the setting of increasing levels of CA MRSA until more definitive guidelines are available from the Centers for Disease Control and Prevention and/or medical professional organizations.  The Maine Infectious Disease Work Group and Bureau of Health is developing the guidelines collaboratively, using two state guidelines as models.

In 2004, approximately 60 cases of MRSA were confirmed as community-associated; 20% of these cases were among persons incarcerated.  Clinicians should have a high index of suspicion for CA-MRSA in individuals who are currently or have recently been incarcerated, drug users, persons living with HIV infection, and persons not responding to conventional antibiotic treatment.  

Contributed by: Anne Redmond
anne.redmond@maine.gov

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Tattooing and Body Piercing: Public Health Updates

Background 

In Maine, tattooing is defined as “the insertion of pigment under the skin of a human being by pricking with a needle or otherwise, so as to produce an indelible mark or figure visible through the skin .”¹  Body piercing is defined as “the creation of an opening in the body of a human being for the purpose of inserting jewelry or other decoration.”²   The popularity of these forms of body art continues to grow in the state. The Bureau of Health's Eating and Lodging Program, began licensing tattooists and tattooing facilities in 1978.  In 1998, body piercing became a licensed industry as well.  In 2005, the state-established guidelines for safe practice of tattooing and body piercing were updated to ensure current infection control practice and continued safety for these forms of adornment.  The Eating and Lodging Program now licenses 202 tattooists and 99 body piercers.  The program website provides contact information for these artists and facilities. (Please see links at end of article.)

Safe Practice Guidelines Whenever the skin is punctured, abraded or cut, the risk of skin, soft tissue or blood-borne infection exists.  Use of pigment, metal, plastic jewelry and latex products can also result in allergic reactions. These risks exist for consumer and practitioner alike.  The perception of these risks has changed over the years with advancing understanding of disease transmission and allergy sensitization, and with changing tattooing and body piercing techniques.  The risk of infection and allergic reaction is greatly reduced by adherence to Code of Maine Rules for safe practice. 3  These guidelines, originally written in 1978, were revised in the 1990's to respond to bloodborne viruses like HIV and hepatitis B and to reflect current national trends in safe industry practice. To keep up with the growth in the body adornment industry, and promote safe and healthy practice in 2005, the new rules were further adapted and went into effect on March 18, 2005. *

* Note:  Micro pigmentation and ear piercing, with an ear-piercing gun, are not licensed under these rules.

 The following is a synopsis of the current guidelines: 

• All tattooing and body piercing is to be performed only by a licensed practitioner, and only in the facility where his or her license is approved.

• In the state of Maine, no one under the age of 18 may receive a tattoo, regardless of parental or guardian consent.

• In the state of Maine, no one under the age of 18 may get a body piercing without first obtaining consent from an adult parent or guardian.

• Tattoo and body piercing practitioners are to apply tattoos and jewelry only in the facilities for which they are licensed or at approved trade shows.

• Tattooing and body piercing in dwellings, or at home tattoo parties,“tat parties,” is illegal.

• Practitioners are required to provide and review an initial medical questionnaire, for each client, to establish the client’s health history.

• Practitioners of tattooing and body piercing are required to take bloodborne pathogen classes for certification.  They are required to give proper after care instructions and are required to report any signs of infection from tattoos or piercings to the BOH.

• The tattoo facility owner is required to maintain records, for a minimum of two years, of all clients’ identification and demographics, consent forms, health history, procedure documentation and any adverse outcomes.

• All tattoos or body piercings with signs of infection shall be reported by the practitioner to the BOH, and the client referred to a health care provider for medical follow up.

Unlicensed operation of an establishment or practice not adhering to licensing guidelines is illegal and punishable by a fine, for body piercing, and by a fine and/or imprisonment for tattooing.   Illegally-acquired tattoos have been identified on several recent occasions in Maine due to associated staphylococcal skin infections that required medical attention. Unlicensed practitioners, “scratchers,” have been arrested and prosecuted by law enforcement agencies. In these cases, the illegal operators had been applying tattoos with inadequate sterilization and hygiene, and were using improper equipment.

Infection Risk

Bloodborne Pathogens 

The Centers for Disease Control and Prevention (CDC) warns of the risk of acquiring HIV, Hepatitis B (HBV) and Hepatitis C (HCV) infections when blood-contaminated instruments are improperly sterilized and equipment improperly used between tattoo and body piercing clients. While the incidence level of bloodborne pathogen infections related to unsafe tattooing practices is not clear, CDC continues to study that association. Hepatitis C surveillance data over the last 20 years indicates that tattoos were unlikely to have been a major contributing cause to that epidemic, as fewer than 1% of persons with newly-acquired HCV infection reported having received a tattoo⁴. Some independent researchers claim that there is a more significant association between tattooing, body piercing, and bloodborne infections. Whether or not tattooing causes very large numbers of infections, it is clear that the practice of unregulated tattooing is a risk for bloodborne infection, and it is of special concern in settings such as correctional facilities, where the rates of HIV, HBV, and HCV infections may be high. 

Other Infections

The emergence of Community-Associated Methicillin Resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections, has underscored the importance of proper technique and infection control precautions.  

Although there are no formal recommendations at this time, reports of endocarditis associated with tongue and nasal piercing have raised concern that those at risk for endocarditis from dental procedures may also require antibiotic prophylaxis for oral piercings.⁵  Persons interested in obtaining a body piercing or tattoo, particularly those with know medical conditions, should consult their health care providers. 

What to Look for in a Body Art Facility When Considering a Tattoo or Piercing: 

• A license from the Maine Eating and Lodging Program prominently displayed.

• The establishment listed on the Maine Eating and Lodging website as licensed and inspected.

• A clean, well lit establishment with partitioned work space, adequate water, sewage, and an available bathroom.

• No animals present.

• No use of alcoholic beverages, chemicals, tobacco or consumption of food by clients or practitioners.

• New equipment used for each new client.

• Clean, gloved hands applying tattoo or piercing.

• Use of germicidal soap and alcohol rinse before and after application or piercing.

• Clean and sterilized equipment in individual sealed packages.

• Use of autoclave and ultrasonic cleaner for sterilization of equipment that is not disposable.

• No defective equipment.

• New containers of ink used for each new client.

• New gloves used by operator and gloves changed when a nonsterile surface is touched.

• For body piercing: sterile, disposable needles used. Not a gun.

• Medical history taken. Caution conveyed to diabetics and those with history of skin infections.

• Written and verbal aftercare instructions provided.

• Records kept.

• All questions answered.

All healthcare providers, clients and body artists are encouraged to contact the Maine Bureau of Health, Division of Health Engineering, Eating and Lodging Program at 207-287-5671 or by email at dhe.sanitarian@maine.gov if they suspect a tattoo or body piercing has been illegally performed, or if a facility is not following proper procedures. To report infections from tattoos or body piercings, or for questions regarding body art infections please contact the Bureau of Health, Division of Disease Control, Infectious Disease Epidemiology Program at 1-800-821-5821. 

For additional information please see the following links:

• www.maine.gov/dhs/eng/el/attooist.pdf

• http://www.maine.gov/dhhs/eng/el/index.html

• http://mainegov-images.informe.org/dhhs/eng/el/Tattoo%20Rules.pdf

• http://mainegov-images.informe.org/dhhs/eng/el/Body%20Piercing%20Rules.pdf

• www.niehs.nih.gov/external/faq/tattoo.htm

• www.cdc.gov/ncidod/EID/vol8no8/01-0458.htm

• http://www.cfsan.fda.gov/~dms/cos-204.html

• http://www.safe-tattoos.com/

• http://www.safepiercing.org/index.html

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Rabies – Close Encounters of the Furry Kind

Introduction

Rabies is endemic throughout the continental United States, including Maine.  Although this disease is rare in humans in the U.S., it is considered fatal once symptoms develop, and requires careful consideration when a potential exposure occurs. Rabies post-exposure prophylaxis (PEP) is not only expensive, but its biologic components are in limited supply, and although proven to be very safe, the administration of biologic materials is never risk-free.  Thus, the timely and accurate assessment of a person’s potential exposure to rabies is of the utmost importance in both preventing human rabies and avoiding unwarranted PEP.

Background

Any mammal can carry rabies. Transmission of rabies virus is by introduction of saliva containing the rabies virus into a bite wound. It can also be transmitted when saliva or central nervous system tissue from a rabid animal contacts a fresh wound or mucous membrane lining. Human cases have occurred in recipients of infected cornea/organ transplants; most recently, four U.S. recipients last summer and three German recipients early this year died from rabies contracted from infective organ/tissue transplants. Aerosolized rabies virus is considered transmissible, but only under very rare circumstances, such as may occur in a research/testing laboratory.

When the virus is introduced into a wound or mucous membrane it first replicates at the site of entry and then is taken up by the peripheral nervous system. From the peripheral nervous system, rabies virus is transported to the central nervous system until it reaches the brain; once cerebral infection occurs, the symptoms of rabies develop.

Discussion

The following situations are considered potential rabies exposures:

• A visible bite or significant scratch penetrating the skin from a confirmed, suspected, or potentially rabid animal;
• A non-bite exposure with direct contact of a wound or mucous membrane with potentially infectious material such as saliva or central nervous system tissue (i.e. brain or spinal cord) from a confirmed, suspected, or potentially rabid animal;
• Eating of any part of a confirmed or suspected rabid animal;
• Aerosolized rabies virus is thought to have caused disease and is considered exposure in very rare circumstances (i.e., in a research/testing lab);
• Physical contact with a bat where a bite cannot be positively ruled out is considered an exposure, as are certain situations where a bat is discovered in the presence of a person who cannot positively determine or communicate that a bite has occurred (the person was sleeping, a child, debilitated, or under the influence of medications or alcohol).

Evaluations of patients with potential rabies exposures are rarely clear-cut. Other factors that need to be considered include: the type of exposure, the extent/severity of exposure, the type of animal involved, vaccination status of the animal involved, circumstances (provoked vs. unprovoked) around the potential exposure, availability of the animal for quarantine or testing, and the presence of rabies in the region. A “Rabies Exposure Assessment Algorithm for Humans” is available in the 2005 Maine Rabies Management Guidelines on page 18.

PEP may be appropriate even in the absence of a demonstrable bat bite, scratch, or mucous membrane exposure, particularly in situations in which there is reasonable probability that such exposure to a bat may have occurred. Some examples are: a sleeping individual awakes to find a bat in the room, or an adult witnesses a bat in the room with a previously unattended child, mentally challenged person, or intoxicated individual.  Rabies PEP is recommended for all persons with bite, scratch, or mucous membrane exposure to a bat, unless the bat tests negative for rabies.

Contributed by: Donna Guppy
donna.guppy@maine.gov

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DDC Monthly Disease Summary

 Infectious diseases of public health importance are reportable by law in Maine by health care providers, laboratories, and health care facilities.  To monitor trends, the Division of Disease Control publishes a monthly graph of reportable diseases in Maine (please see graph).  The graph displays the Year-To-Date (YTD) totals for the current year against the median YTD totals for the previous five-year period.  By comparing the current year with the previous five years, we can determine if the incidence of a disease differs from the historical baseline.

Diseases of high incidence are displayed in the horizontal bar chart; diseases of low incidence are displayed in the table.  Chlamydia is the most commonly reported disease in Maine.  The numbers for chlamydia in the bar chart should be multiplied by a factor of 10.  Due to space limitations, not all notifiable conditions are displayed on the graph.  The complete list of notifiable conditions is available at: http://www.maine.gov/dhhs/boh/ddc/diseasereporting.htm 

Data presented in the graph should be considered preliminary as the numbers may be revised as additional reports are received.  Disease reports can be made by calling 1-800-821-5821.  Questions or comments about the graph can be directed to Andrew Pelletier, MD, MPH at 287-4326.a

contributed by Andrew Pelletier
andrew.pelletier@maine.gov

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Thimerosal:  What and Why 

Brief History of Thimerosal

Thimerosal is a preservative containing almost 50% ethylmercury.  Although it has been used for about 70 years and found in many vaccines and pharmaceuticals such as ophthalmic and nasal products, its use in childhood vaccines was highlighted in 1999 when the Food and Drug Administration listed it as a source of mercury exposure for our young children.  

Assuring non-contamination from bacteria, thimerosal was used in over 30 non-live vaccines, including most childhood vaccines.  Routine infant vaccinations in the United States in 1999 commonly resulted in infants being exposed to 188 micrograms of ethylmercury.  U.S. manufacturers moved to remove thimerosal in 1999, and now, routine vaccinations may expose infants to only trace amounts of ethylmercury, resulting in an estimated <3 micrograms.  

Mercury

Mercury is a heavy metal, similar in some ways to lead.  It can bind to proteins, particularly those in the nervous system and kidneys.  Because of children’s low body weight and developing nervous systems, they are most susceptible to mercury’s toxicity.  

Mercury comes in different forms – elemental, inorganic, and organic.  All of these differ in toxicity and toxicokinetics.  Elemental mercury was commonly found in thermometers, barometers, and dental amalgam.  Well absorbed if inhaled, it is poorly absorbed if ingested or handled.  Elemental mercury is also released from smokestack precipitates, and eventually is converted to methylmercury, a type of organic mercury, once in watersheds.   

Methylmercury, is thus commonly found in fish, and is associated with neurodevelopmental effects in people.  It is readily absorbed when ingested, and crosses the blood-brain barrier.  One can of white tuna ingested per week can result in 6-8 micrograms of methylmercury per day (half of this for light tuna).  Fish consumption advisories, especially for pregnant women and young children, emanate from methylmercury.     

Ethylmercury, found in thimerosal, is another type of organic mercury.  Although there is very limited toxicological data on ethylmercury, some data suggest it is removed more quickly from the blood and body of infants than methylmercury, and may be less toxic.   

Concerns About Thimerosal

Concerns about thimerosal were fueled by some widely publicized studies suggesting a linkage between childhood vaccines and autism.  As a result, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to study the thimerosal-autism issue in 2001 and again in 2004.  Their review of the studies that reportedly found associations between autism and vaccines were found to be methodologically flawed.  Five other epidemiological studies examining thimerosal-containing vaccines and autism consistently provided evidence of no association, despite the fact that they used different methods and examined different populations (Sweden, Denmark, U.S., and U.K.). 

The 2004 IOM report summarized, “The committee concludes that the evidence favors rejection of a casual relationship between thimerosal-containing vaccines and autism.”   

It should be noted that separate concerns arose about a possible linkage between MMR vaccine (Measles, Mumps, Rubella) and autism.  However, since MMR is a live virus vaccine, and therefore never contained thimerosal, these concerns arose separately from the thimerosal-autism concerns.  The IOM studied these concerns as well, and also found no evidence of an association between the MMR vaccine and autism. 

Maine’s Response

The Maine Bureau of Health moved quickly in 1999 to assure that the childhood vaccine it provides has a minimal amount of thimerosal.  All childhood vaccines provided by the Bureau of Health are now considered free of thimerosal except for trace amounts in three of them.  DTaP, pediatric Influenza, and occasionally Hepatitis B can contain a trace of thimerosal (less than 1 microgram each ethylmercury) that is left over from the manufacturing process.  Additionally, there may be a thimerosal-free, preservative-free pediatric Influenza vaccine available for 2005-2006.  

The only vaccines currently provided by the Bureau of Health with thimerosal (more than a trace) are:

• Adult Influenza vaccine, primarily for those age 9 and over;
• Tetanus/Diphtheria vaccine (DT and Td) for those who have had severe reactions to the Pertussis component of the DPT vaccine and for persons receiving a booster every 10 years.

Each of these contains 25 micrograms of ethylmercury per 0.5 ml, meaning that children receiving a half dose of the adult Influenza vaccine would receive 12.5 micrograms of ethylmercury.  There are currently no thimerosal-free alternatives for these vaccines. 

In 2003, out of nearly 430,000 childhood vaccines distributed by the Maine Bureau of Health, 0.2% (941 doses) contained thimerosal (more than a trace).

Summary

Parents expressing concerns about thimerosal can be given the following advice:

• There are no known long-term risks of thimerosal when given in vaccines.
• There are known risks of non-immunization. 
• Thimerosal use has greatly diminished since 1999, with ethylmercury exposure being reduced from 188 micrograms to <3 from routine infant immunizations.

The Centers for Disease Control and Prevention has recently said they plan on adding information on thimerosal to the Vaccine Information Statements. 

Contributed by:
Dora A. Mills
dora.a.mills@maine.gov

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