# COMAR Title 10 — Maryland Department of Health ## Subtitle 06 — Diseases ### Chapter 01 — Communicable Diseases and Related Conditions of Public Health Importance **Authority:** Health-General Article, §§2-104(b), 18-102, 18-103, 18-105, 18-201, 18-201.1, 18-202, 18-205,18-208, 18-214.1, 18-307, 18-337, and 24-101—24-110, Annotated Code of Maryland **Administrative History:** Effective date: March 30, 1944 **Administrative History:** Amended April 1, 1966 **Administrative History:** Regulation .55 effective May 15, 1953 **Administrative History:** Regulation .56 effective October 18, 1951 **Administrative History:** Regulation .57 effective April 1, 1966 **Administrative History:** Regulation .58 effective December 20, 1971 **Administrative History:** Regulations .01—.54, .56, and .57 repealed and new Regulations .01—.22 adopted effective December 26, 1980 (7:26 Md. R. 2420) **Administrative History:** Regulations .02A and .03B amended as an emergency provision effective June 21, 1983 (10:14 Md. R. 1257); emergency status expired October 21, 1983 **Administrative History:** Regulations .02A and .03B amended effective October 24, 1983 (10:21 Md. R. 1901) **Administrative History:** Regulation .14D amended as an emergency provision effective March 17, 1981 (8:7 Md. R. 639); emergency status expired August 1, 1981; adopted permanently effective August 17, 1981 (8:16 Md. R. 1365) **Administrative History:** Regulation .31 adopted as an emergency provision effective September 2, 1980 (7:20 Md. R. 1872); adopted permanently effective February 6, 1981 (8:3 Md. R. 227) **Administrative History:** Regulations .01—.22, .31, .55, and .58 repealed effective August 7, 1989 (16:15 Md. R. 1650) **Administrative History:** Regulations .01—.17 and .19—.24 adopted effective August 7, 1989 (16:15 Md. R. 1650) **Administrative History:** Regulation .18 adopted effective February 19, 1990 (17:3 Md. R. 297) **Administrative History:** Chapter revised effective July 5, 1993 (20:13 Md. R. 1049) **Administrative History:** Regulation .02 amended and Regulation .06G adopted as an emergency provision effective December 3, 1996 (23:26 Md. R. 1856); amended permanently effective March 24, 1997 (24:6 Md. R. 484) **Administrative History:** Regulation .17D amended as an emergency provision effective December 5, 1997 (24:26 Md. R. 1751); amended permanently effective January 26, 1998 (25:2 Md. R. 76) **Administrative History:** Chapter revised effective January 20, 2003 (30:1 Md. R. 24) **Administrative History:** Regulation .01B amended as an emergency provision effective October 1, 2003 (30:22 Md. R. 1574); amended permanently effective March 1, 2004 (31:4 Md. R. 315) **Administrative History:** Regulation .02B amended as an emergency provision effective October 1, 2003 (30:22 Md. R. 1574); amended permanently effective March 1, 2004 (31:4 Md. R. 315) **Administrative History:** Regulation .02B amended as an emergency provision effective July 12, 2007 (34:17 Md. R. 1505); emergency status extended at 35:3 Md. R. 285; amended permanently effective January 14, 2008 (35:1 Md. R. 17) **Administrative History:** Regulation .02B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective March 24, 2008 (35:6 Md. R. 698) **Administrative History:** Regulation .03B amended as an emergency provision effective October 1, 2003 (30:22 Md. R. 1574); amended permanently effective March 1, 2004 (31:4 Md. R. 315) **Administrative History:** Regulation .03B amended effective March 13, 2006 (33:5 Md. R. 519) **Administrative History:** Regulation .03B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective March 24, 2008 (35:6 Md. R. 698) **Administrative History:** Regulation .04 amended effective March 13, 2006 (33:5 Md. R. 519) **Administrative History:** Regulation .07B amended as an emergency provision effective October 1, 2003 (30:22 Md. R. 1574); amended permanently effective March 1, 2004 (31:4 Md. R. 315) **Administrative History:** Regulation .08-2A, B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective March 24, 2008 (35:6 Md. R. 698) **Administrative History:** Regulation .17-1 adopted as an emergency provision effective July 12, 2007 (34:17 Md. R. 1505); emergency status extended at 35:3 Md. R. 285; adopted permanently effective January 14, 2008 (35:1 Md. R. 17) **Administrative History:** Chapter revised as an emergency provision effective October 1, 2008 (35:22 Md. R. 1946); emergency status extended at 36:10 Md. R. 714; revised permanently effective April 6, 2009 (36:7 Md. R. 522) **Administrative History:** Regulation .01 amended effective April 24, 2017 (44:8 Md. R. 403) **Administrative History:** Regulation .01-1 amended effective April 6, 2009 (36:7 Md. R. 522) **Administrative History:** Regulation .02B amended effective March 28, 2016 (43:6 Md. R. 406); April 24, 2017 (44:8 Md. R. 403) **Administrative History:** Regulation .03C amended effective April 23, 2018 (45:8 Md. R. 420) **Administrative History:** Regulation .17 amended effective April 24, 2017 (44:8 Md. R. 403) **Administrative History:** Regulation .17-1 repealed effective March 28, 2016 (43:6 Md. R. 406) **Administrative History:** Regulation .18 amended effective April 24, 2017 (44:8 Md. R. 403) **Administrative History:** Chapter revised effective May 18, 2020 (47:10 Md. R. 516) **Administrative History:** Regulation .01C amended effective July 12, 2021 (48:14 Md. R. 538) **Administrative History:** Regulation .01-1 amended effective July 12, 2021 (48:14 Md. R. 538) **Administrative History:** Regulation .13D amended effective July 12, 2021 (48:14 Md. R. 538) #### Regulation .01 Scope. *COMAR 10.06.01.01* A. This chapter does not apply to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) surveillance, reporting, record maintenance, or confidentiality, which are covered by COMAR 10.18.02 and 10.18.03. B. This chapter applies to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) control. C. This chapter provides regulations for coordinated control efforts for communicable diseases and related conditions by the Department, local health officers, medical laboratory directors, physicians, veterinarians, and other Maryland governmental agencies, as guided by policy statements such as: (1) Recommendations of the Centers for Disease Control and Prevention, such as those of the Advisory Committee on Immunization Practices and the Advisory Council for the Elimination of Tuberculosis; (2) Recommendations of the National Association of State Public Health Veterinarians, including: (a) The Compendium of Animal Rabies Prevention and Control, 2016; (b) The Compendium of Measures to Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017; and (c) The Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017. #### Regulation .01-1 Incorporation by Reference. *COMAR 10.06.01.01-1* In this chapter, the following documents are incorporated by reference: A. Control of Communicable Diseases Manual (American Public Health Association, Twentieth Edition, 2015); B. Compendium of Measures to Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017 (The Association of Avian Veterinarians, 2017); C. Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017 (The National Association of State Public Health Veterinarians, 2017); and D. Compendium of Animal Rabies Prevention and Control, 2016 (The National Association of State Public Health Veterinarians, 2016). #### Regulation .02 Definitions. *COMAR 10.06.01.02* A. The definitions of terms used in the Control of Communicable Diseases Manual are accepted as official and applicable to the control of diseases within this State under this chapter. B. Terms Defined. (1) Body Fluid. (a) “Body fluid” means an excretion or fluid from a human body that contains visible blood and all other tissues, excretions or fluids including: (i) Visible blood or any body fluid that is visibly contaminated with blood; (ii) Semen or vaginal secretions; (iii) Amniotic, cerebrospinal, pericardial, peritoneal, pleural, or synovial fluids; (iv) Saliva in dental procedures; and (v) All body fluids in situations where it is difficult or impossible to differentiate between body fluids. (b) “Body fluid” does not include stool, nasal secretions, sputum, tears, urine, or vomitus. (2) “Case” means an individual who has laboratory or clinical evidence of being infected by an infectious agent. (3) “Case of a condition” means an individual who suffers from a condition that is not caused by an infectious agent, including, but not limited to: (a) An animal bite; (b) An adverse reaction to pertussis vaccine; (c) Harmful algal bloom related illness; (d) Pesticide related illness; or (e) Ricin toxin poisoning. (4) “Case (or suspected case) of avian psittacosis” means that a bird has: (a) Laboratory evidence of Chlamydophila psittaci infection consisting of: (i) Culture isolation of Chlamydophila psittaci from a clinical specimen; (ii) A positive fluorescent antibody test for Chlamydophila psittaci on a clinical specimen; (iii) A fourfold, or greater, increase in Chlamydophila psittaci antibody in a serologic titer, in two serum specimens obtained at least 2 weeks apart and assayed simultaneously at the same laboratory; or (iv) Identification of Chlamydophila psittaci within macrophages in smears stained with Gimenez or Macchiavellos stain or sections of the bird's tissues; or (b) Clinical evidence of Chlamydophila psittaci infection consisting of an epidemiologic link to an avian case that has laboratory evidence of infection, and has: (i) Exhibited one or more signs of psittacosis; (ii) Died; (iii) Been clinically diagnosed as having psittacosis by a licensed veterinarian; or (iv) Had gross necropsy findings or histopathological evidence consistent with psittacosis as reported by a veterinary pathologist. (5) Child Care Facility. (a) “Child care facility” means a licensed, registered, or unlicensed facility, institution, establishment, or home where children receive care or supervision for which money is paid when the child's parent has given the child's care over to another on a regular basis for some portion of a 24-hour day as a supplement to the parent's primary care of the child. (b) “Child care facility” includes child care center, day care center, nursery, family day care home, and babysitter. (6) Clinical Material. (a) “Clinical material” means: (i) An organism isolated from a clinical specimen; (ii) Material derived or prepared from a clinical specimen in which evidence of a communicable disease has been identified or detected; or (iii) If the organism or material described in §B(6)(a)(i) and (ii) of this regulation is not available, material from an individual that has already been obtained by the medical laboratory, in the following order of preference: a patient specimen, microbial genetic material, or other laboratory material. (b) “Clinical material” includes, for Mycobacterium tuberculosis, one culture obtained from the primary isolate on which the diagnosis of tuberculosis was established. (7) “Colonization” means the proliferation of microorganisms on or within one or more body sites without detectable host immune response, cellular damage, or clinical expression. (8) “Commissioner” means the Commissioner of Health of the Baltimore City Health Department. (9) “Department” means the Maryland Department of Health. (10) “Foodborne disease outbreak” means two or more epidemiologically related cases of illness following consumption of a common food item or items, or one case of botulism, cholera, mushroom poisoning, trichinosis, or fish poisoning such as ciguatera poisoning, scombroid poisoning, paralytic shellfish poisoning, and other neurotoxic shellfish poisoning. (11) “Health care provider” includes, but is not limited to: (a) Physicians; (b) Physician assistants; (c) Dentists; (d) Chiropractors; (e) Nurse practitioners; (f) Nurses; (g) Podiatrists; (h) Medical examiners; (i) Hospital administrators; (j) Clinic administrators; (k) Dispensary administrators; (l) Nursing home administrators; and (m) Any other licensed health care providers. (12) Health Care Worker. (a) “Health care worker” means a paid or unpaid individual working in a health care setting who has the potential for exposure to: (i) Infectious materials, including body substances; (ii) Contaminated medical supplies and equipment; (iii) Contaminated environmental surfaces; or (iv) Contaminated air. (b) “Health care worker” includes, but is not limited to: (i) Emergency medical service personnel; (ii) Dental personnel; (iii) Laboratory personnel; (iv) Autopsy personnel; (v) Nurses; (vi) Nursing assistants; (vii) Physicians; (viii) Physician assistants; (ix) Technicians; (x) Therapists; (xi) Pharmacists; (xii) Students and trainees; (xiii) Contractual staff not employed by the health care facility; and (xiv) Individuals not directly involved in patient care but potentially exposed to infectious agents, for example, clerical, dietary, housekeeping, maintenance, and volunteer personnel. (13) “Health officer” means the health officer in each of the 23 counties and the Commissioner of Health in Baltimore City, or the duly designated representative of the health officer, or both. (14) “Infectious” means capable of being transmitted in a manner that can cause a disease or abnormal condition in an individual. (15) “Invasive disease” means a disease in which an organism is detected in a specimen taken from a normally sterile body site. (16) “Normally sterile body site” means a body site except for skin, external ear, oronasopharynx, gastrointestinal tract, urethral meatus, and vagina. (17) “Novel influenza A virus infection” means a human case of infection with an influenza A virus subtype that is suspected to be markedly different from currently circulating human influenza A viruses, including, but not limited to, H2, H5, H7, or H9 subtypes. (18) “Outbreak” means: (a) A foodborne disease outbreak; (b) Three or more cases of a disease or illness that is not a foodborne outbreak and that occurs in individuals who are not living in the same household, but who are epidemiologically linked; (c) An increase in the number of infections in a facility, such as a hospital, long-term care facility, assisted living facility, school, or child care center, over the baseline rate usually found in that facility; (d) A situation designated by the Secretary as an outbreak; or (e) One case of: (i) Anthrax; (ii) Botulism; (iii) Cholera (imported or seafood related); (iv) Ciguatera poisoning; (v) Mushroom poisoning; (vi) Paralytic shellfish poisoning and other neurotoxic shellfish poisoning; (vii) Plague; (viii) Rabies (human); (ix) Smallpox; (x) Scombroid poisoning; or (xi) Trichinosis. (19) Pet Animal. (a) “Pet animal” means a live animal sold or distributed to the public with or without charge for pleasure or companionship and not for utility. (b) “Pet animal” does not include domestic farm animals including, but not limited to: (i) Equids; (ii) Cattle; (iii) Goats; (iv) Sheep; and (v) Swine. (20) Pet Store. (a) “Pet store” means a facility that keeps, cares for, and houses animals classified as pet animals for the purpose of sale or distribution to the public. (b) “Pet store” includes but is not limited to a: (i) Commercial facility; (ii) Feed store; or (iii) Department store. (21) “Physician” means an individual licensed to practice osteopathy or medicine by the State, or the physician's designee working under the supervision of the physician. (22) “Reptile” means a cold blooded, air breathing vertebrate of the class Reptilia. (23) “Secretary” means the Secretary of Health or the Secretary's designee. (24) “Sell” means to sell, hold for sale, or offer for commercial or public distribution, a pet animal. (25) “Seller” means a person who sells, holds for sale, or offers for commercial or public distribution, a pet animal. (26) “Sexually transmitted infection” means an infection which may be spread by sexual intercourse, including oral, anal, or vaginal sexual contact with an infected individual. (27) Skin-Penetrating Body Adornment Procedure. (a) “Skin-penetrating body adornment procedure” means a process that involves piercing or entering the skin or the mucous membrane of an individual for the purpose of inserting pigmented patterns, jewelry, or other forms of body decoration. (b) “Skin-penetrating body adornment procedure” includes body-piercing and tattooing. (c) “Skin-penetrating body adornment procedure” does not include piercing of an earlobe using a properly disinfected ear-piercing gun and single-use sterile studs and clutches. (28) Standard Precautions. (a) “Standard precautions” means a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status, given that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. (b) “Standard precautions” includes: (i) Hand hygiene and use of gloves, gown, mask, eye protection, or face shield depending on anticipated exposure; and (ii) Handling equipment or items in the patient environment likely to have been contaminated with infectious fluids in a manner to prevent transmission of infectious agents. (29) “Turtle” means an animal commonly known as a turtle, tortoise, or terrapin. #### Regulation .03 Reportable Diseases, Conditions, Outbreaks, and Unusual Manifestations; Submitting Clinical Materials. *COMAR 10.06.01.03* A. A person, as set forth in Regulation .04 of this chapter, shall report the diseases or conditions listed in §C of this regulation, or any other condition as requested by the Secretary. B. Upon a positive laboratory finding for a disease or condition listed in §C of this regulation, or upon request of the Secretary, the director of a medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) shall: (1) Submit clinical material to the Department's public health laboratory; and (2) Include information about the clinical material on a form provided by the Secretary. C. List of Reportable Diseases and Conditions. 1. As required to report in Regulation .04A(1)—(3), (5), and (6) of this chapter. 2. The time frame for reporting is specified in Regulation .04C of this chapter. 3. Clinical material shall be submitted according to §B of this regulation. 4. Any grouping or clustering of patients having similar disease, symptoms, or syndromes that may indicate the presence of a disease outbreak. 5. Suspected hepatitis C as indicated by: (a) Any hepatitis C antibody results that are positive; (b) Any hepatitis C virus RNA results associated with the results in(a) of this footnote that are qualitative or quantitative, if the results are: (i) Positive; or (ii) Negative; and (c) Any hepatitis C virus RNA results associated with the results in(a) of this footnote if the hepatitis C virus is: (i) Detected; or (ii) Undetected. 6. Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV), including CD4+ lymphocyte count and viral load, are reportable under COMAR 10.18. 7. Suspected syphilis as indicated by: (a) Any treponemal or non-treponemal results that are qualitative or quantitative, if the results are: (i) Positive; (ii) Reactive; or (iii) Inconclusive; and (b) Any negative or non-reactive results associated with the positive, reactive, or inconclusive results in(a) of this footnote. 8. Tuberculosis confirmed by culture and suspected tuberculosis as indicated by: (a) A laboratory confirmed acid-fast bacillus on smear; (b) An abnormal chest radiograph suggestive of active tuberculosis; (c) A laboratory confirmed biopsy report consistent with active tuberculosis; or (d) Initiation of two or more anti-tuberculosis medications. 9. Latent tuberculosis infection as indicated when: (a) There is a positive result on an Interferon Gamma Release Assay, Tuberculin Skin Test, or any other test indicating tuberculosis infection; and (b) Active or suspected tuberculosis has been ruled out. 10. Vibriosis, non-cholera, identified in any specimen taken from teeth, gingival tissues, or oral mucosa is not reportable. #### Regulation .04 Reporting Procedures. *COMAR 10.06.01.04* A. Sources of Reports and to Whom to Report. (1) An institution, as specified in Health-General Article, §18-202, Annotated Code of Maryland, and a health care provider who knows of a case of a reportable disease, condition, outbreak, or unusual manifestation shall report it to a health officer. (2) A teacher at any public, private, or parochial school or a child care provider at any child care facility shall report an occurrence of a reportable disease or condition, an outbreak, or an unusual manifestation as set forth in Regulation .03 of this chapter to the principal, school nurse, or superintendent or assistant superintendent or designee, who shall transmit to a health officer a report of the name and address of a child who appears to have a reportable communicable disease or who has been exposed to a reportable communicable disease. (3) The master or person in charge of a vessel or aircraft within the territory of the State shall report to the Secretary or a health officer at the nearest port of landing or entry, all known facts relating to the illness and physical condition of an individual aboard the vessel or aircraft who may have a reportable disease or condition, an outbreak, or an unusual manifestation. (4) Directors of Medical Laboratories or Laboratories that Possess Biological Agents as Defined in COMAR 10.10.11.03B(8). (a) The director of a medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) shall report: (i) Laboratory evidence of a reportable condition as specified in Regulation .03C of this chapter from examination of a human specimen acquired from an individual in this State; and (ii) Evidence of any other condition as requested by the Secretary. (b) The director of a medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) located in a Maryland jurisdiction shall report to the health officer of that jurisdiction. (c) The director of a medical laboratory located outside of Maryland shall report to the Secretary. (d) If a medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) forwards clinical materials out of State for testing, the originating medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) shall comply with this subsection by: (i) Reporting the results and submitting the clinical materials; or (ii) Ensuring that the results are reported and materials submitted. (e) When more than one specimen is taken from a patient during one disease episode, the director of a medical laboratory or a laboratory that possesses a biological agent as defined in COMAR 10.10.11.03B(8) need not report every test result of a specimen that shows evidence of the same disease in that patient if: (i) At least one positive test result is reported; and (ii) A health officer has agreed that all test reports do not need to be reported. (5) Any individual having knowledge of an animal bite shall report the bite according to the requirements of COMAR 10.06.02. (6) The owner or operator of a food establishment as defined in Health-General Article, §21-301, Annotated Code of Maryland, shall report to a health officer an occurrence of a reportable disease or condition, an outbreak, or an unusual manifestation. B. Method and Content of Reports. (1) A person, as listed in §A(1)—(4) of this regulation, shall report: (a) In writing on a form provided by the Secretary; or (b) In a format approved by the Secretary, when electronic submittal is available. (2) The report shall include at a minimum the: (a) Date of the report; (b) Patient's name including first and last names and middle initial; (c) Residence address of the patient including: (i) House or apartment number; (ii) Street; (iii) City or town; (iv) State; and (v) Zip code; (d) Telephone number including area code; (e) Date of birth; (f) Sex; (g) Race; (h) Ethnicity; (i) Pregnancy status if applicable; and (j) Other epidemiologic information as specified by the Secretary or the health officer. (3) In addition to what is specified in §B(2) of this regulation, institutions and health care providers, school and child care facility personnel, and masters of vessels or aircraft as listed in §A(1)—(3) of this regulation shall report: (a) The date of onset of symptoms; (b) The diagnosis; (c) For syphilis, gonococcal infection, and Chlamydia trachomatis infection, the treatment given; and (d) Any laboratory information supporting the diagnosis of the disease or condition, as requested. (4) A director of a medical laboratory, in addition to what is specified in §B(2) of this regulation, shall report the: (a) Name, address, telephone number, and federal Clinical Laboratory Improvement Amendments (CLIA) certificate number of the laboratory performing the test; (b) Date the specimen was received by the laboratory; (c) Accession number or other unique identifier for the specimen; (d) Type of test performed and the results, including: (i) Reference range; (ii) Quantitative results; and (iii) Results of speciating, grouping, or typing of organisms; (e) Date of specimen collection; (f) Type of specimen, for example, blood, urine, stool, or mucus, and the site of specimen collection, for example, cervix, eye; (g) Date of the laboratory result; (h) Name, address including number and street, city, state, and zip code, and phone number including area code of the health care provider who ordered the test; (i) Name, address including number and street, city, state, and zip code, and phone number including area code of the facility that ordered the test; and (j) For hepatitis C infection: (i) Signal-to-cut-off ratios and critical values; (ii) Hepatitis A IgM results; and (iii) Hepatitis B IgM test results. C. Timing of Reports. (1) If the Secretary requires an immediate report, the person making the report: (a) Shall communicate directly with an individual in person or by telephone; and (b) May not leave a message on an answering device. (2) A health care provider and a director of a medical laboratory shall report according to the time frame in Regulation .03C of this chapter. (3) School and child care facility personnel, a master of a vessel or aircraft, and the owner or operator of a food establishment shall report immediately. (4) A health officer shall transmit to the Secretary, by mail or as otherwise specified by the Secretary, all information obtained: (a) Within 24 hours after receiving notice of a disease or condition listed in Regulation .03C of this chapter; or (b) Within a shorter amount of time than 24 hours as specified by the Secretary. (5) The Secretary shall transmit to the health officer of the jurisdiction where the patient resides, by mail or as otherwise specified by the Secretary, all information related to the notice of a reportable condition provided by a director of a medical laboratory located outside of Maryland: (a) Within 24 hours after receiving notice of a disease or condition listed in Regulation .03C of this chapter; or (b) Within a shorter amount of time than 24 hours as specified by the Secretary. #### Regulation .05 Record Maintenance and Confidentiality. *COMAR 10.06.01.05* A. The custodian of a report identifying an individual that was filed by a reporting source (Regulation .04A) in compliance with the provisions of Health-General Article, §§18-201, 18-202, and 18-205, Annotated Code of Maryland: (1) Shall keep the report and record confidential; (2) May not open a report or record to public inspection; (3) Shall release a report or record or respond to a subpoena for a report or record in criminal or civil proceeding only pursuant to court order sealing the record; and (4) Shall make a record or report available to a governmental agency performing its lawful duties as authorized by an act of the Maryland General Assembly or the United States Congress when the Secretary determines that the release of information is necessary to protect the public health or to prevent the spread of an infectious or contagious disease. B. A report identifying an individual that was filed by a reporting source, as set forth under Regulation .04A of this chapter, in compliance with the provisions of Health-General Article, §§18-201, 18-202, and 18-205, Annotated Code of Maryland, and all information collected in connection with a report, are not medical records under Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland. C. Communication with a Health Care Provider or Patient. (1) The Secretary or a health officer may discuss a laboratory report with the attending physician or other health care provider caring for a patient. (2) The Secretary or a health officer may communicate with a patient directly to discuss a laboratory report if: (a) The physician or other health care provider caring for a patient is not reasonably available; and (b) The Secretary or health officer records the date and time of the efforts to contact the physician or other health care provider caring for the patient and documents the: (i) Name of the individual with whom a message was left; or (ii) Identification given by the answering machine, if a message was left on an answering machine. #### Regulation .06 General Control Measures. *COMAR 10.06.01.06* A. Necessary Action. The Secretary or health officer shall: (1) Take any action or measure necessary to prevent the spread of communicable disease or to control a reportable disease and condition; and (2) Issue, when necessary, special instructions for control of a disease or condition. B. Epidemiologic Investigations. (1) A health officer shall respond to each reported outbreak or suspected outbreak of disease within the health officer's jurisdiction in order to collect data to assist in establishing adequate control measures. (2) A health officer shall investigate a reported case or suspect case of a condition as requested by the Secretary. (3) The Secretary may, in conjunction with the health officers, conduct the epidemiologic investigation for each reported case or suspected case in an outbreak involving two or more jurisdictions or states. (4) An individual, a business, a facility, or an agency, including a health care provider, school or child care facility personnel, a master of a vessel or aircraft, or a medical laboratory director, shall make available to the Secretary or a health officer all records and information necessary to the epidemiologic response or investigation. C. A health officer or the Secretary shall order cessation of operation of a business or facility determined or suspected to be a threat to public health until the public health threat is determined by the health officer to have ceased. D. Carrier Approval. (1) A health officer shall grant or deny approval to a carrier of an infectious agent to work in any of the following occupations involving: (a) Care of young children; (b) Care of the elderly; (c) Food handling; and (d) Patient care. (2) A health officer shall grant or deny approval to a carrier of an infectious agent to attend a: (a) School; or (b) Child care facility. (3) A health officer shall consider the following when granting or denying approval to a carrier of an infectious agent to work in occupations or to attend settings listed under §D(1) and (2) of this regulation: (a) The seriousness of the disease; (b) The route or routes of transmission of the disease; (c) The contagiousness of the disease; (d) The behavior, neurological development and condition, and physical condition of the carrier; (e) The susceptibility to the disease of those likely to be exposed to the carrier in the occupation or setting; (f) The precautions that may be taken to minimize or eliminate the danger of transmission; and (g) Precedents in the practice of public health. E. Control of Food Handlers. A case with any of the following diseases may not serve or handle, in any manner whatsoever, food intended for public consumption: (1) Disease causing diarrhea, unless physician-certified as noninfectious; (2) Cholera; (3) Escherichia coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC), as discussed in Regulation .08-3 of this chapter; (4) Hepatitis A, as discussed in Regulation .10 of this chapter; (5) Salmonellosis, as discussed in Regulation .16 of this chapter; (6) Shigellosis, as discussed in Regulation .19 of this chapter; and (7) Typhoid or Paratyphoid fever or carrier of Salmonella Typhi or Paratyphi, as discussed in Regulation .21 of this chapter. F. Control of Communicable Diseases in Schools and Child Care Facilities. (1) A health officer shall: (a) Maintain the right to make physical inspections of pupils, teachers, or other persons attending, employed, or volunteering in schools or child care facilities whenever, in the judgment of the health officer, the inspections are necessary to investigate a suspected communicable disease; and (b) Determine whether enrollees, pupils, or other individuals attending schools or child care facilities have received the immunizations required under COMAR 10.06.04, 13A.15.03.02, or 13A.16.03.04. (2) The principal or other person in charge of any school or child care facility shall comply with a measure or special instruction issued by the Secretary or a health officer under Regulation .06A of this chapter. G. Use of Sterile Instruments or Equipment. An individual who performs a procedure that penetrates the skin or mucous membrane of another individual shall: (1) Utilize only sterile instruments or equipment for the procedure; (2) Discard, after a single use, in accordance with COMAR 10.06.06, 26.13.11, and 26.13.12, any instruments or equipment designed for single use; and (3) Clean and sterilize before reuse any instruments or equipment designed for multiple use. H. Skin-Penetrating Body Adornment Procedures — Infection Control. (1) An individual who performs a skin-penetrating body adornment procedure shall: (a) Disclose the risks of the procedure, obtain the client's written consent for the performance of the procedure or, in the case of a minor, the consent of the parent or guardian, and retain the consent on file for a period of 3 years and make it available to the health officer, if requested; (b) Maintain records of the name of the customer, the date and type of procedure performed, and the technician performing the procedure for a period of 3 years and make these records available to the health officer, if requested; (c) Perform the procedure in a separate, enclosed room that has adequate lighting, and floors, walls, and a ceiling that are constructed to be smooth, impervious, and washable; (d) Use only sterile instruments, equipment, and bandages; (e) Wash both hands using soap and running water and dry the hands using individual single-use towels before and after each procedure; (f) Wear single-use disposable latex or vinyl gloves for each procedure and discard the gloves after the procedure is completed; (g) Wear a gown and face shield, or goggles and a mask, if spattering of blood is likely to occur during the procedure; (h) Cleanse the client's skin before and after the procedure; (i) Discard, after a single use, in accordance with COMAR 10.06.06, 26.13.11, and 26.13.12, any instruments or equipment designed for single use or any blood-soiled article; (j) Clean and sterilize before reuse any instruments or equipment designed for multiple use; (k) Provide written after-care instructions to the client; (l) Use standard precautions in all situations where exposure to blood or body fluids may occur and comply with all applicable State and federal laws and regulations regarding worker protection; and (m) Post the following notice in a prominent place: (2) An individual who performs a procedure that penetrates the skin or mucous membrane may not: (a) Perform a procedure on skin or mucous membrane that has a rash, infection, or other lesion; (b) Perform a procedure when the person performing the procedure has an infected or bleeding lesion on the hands; (c) Use a styptic pencil or alum block to staunch bleeding; or (d) Reuse instruments or equipment intended for single use. (3) A health officer may investigate complaints received regarding compliance with this section. #### Regulation .07 Minimum Control Measures for Specific Diseases or Conditions. *COMAR 10.06.01.07* A. The definitions of terms used in the text and the recommendations for control included in the Control of Communicable Diseases Manual are accepted as official and applicable to the control of disease within this State under the regulations of the Secretary, except in those instances in which the recommendations may be in conflict with Regulation .06A or Regulations .08—.21 of this chapter, in which case the regulations of the Secretary or special instructions of the Secretary or a health officer shall take precedence. B. The diseases and conditions described in Regulations .08—.21 of this chapter are subject to specific requirements and control procedures as specified. #### Regulation .08 Amebiasis. *COMAR 10.06.01.08* A. Control of a Case. A case may not participate in an occupation involving patient care, care of young children or the elderly, and food handling until chemotherapy is completed and 24 hours after diarrhea has ceased. B. Control of Contacts. (1) A health officer shall investigate household and close contacts whose occupations involve food handling, patient care, and care of young children or the elderly. (2) A contact who has diarrhea shall submit three fecal specimens for examination. If a specimen is positive for Entamoeba histolytica, the contact becomes a case, and the control measures specified in §A of this regulation apply. C. Infection Control. Health care providers shall practice standard precautions. #### Regulation .08-1 Campylobacteriosis. *COMAR 10.06.01.08-1* A. Control of a Case. (1) For a case with diarrhea due to or presumed due to campylobacteriosis, a health officer shall restrict or exclude a case from: (a) Attending a child care facility; or (b) Participating in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) For a case who has been without diarrhea for at least 24 hours, unless a health officer otherwise restricts or excludes the case based on Regulation .06D of this chapter, the case may: (a) Attend a child care facility; and (b) Participate in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (3) If a health officer has restricted or excluded a case under §A(1) of this regulation or Regulation .06D of this chapter, the health officer shall approve resumption of child care attendance or occupational duties when: (a) The case's fecal cultures are Campylobacter-free on two consecutive specimens collected: (i) Not less than 24 hours apart; and (ii) If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or (b) The health officer determines that the likelihood of disease transmission is low. B. Control of Contacts at Increased Risk of Transmitting Campylobacteriosis. (1) A health officer shall restrict or exclude a contact who has diarrhea from child care or an occupational setting until at least 24 hours after diarrhea ceases if the contact is in the household of a case or is a close contact who: (a) Attends a child care facility; or (b) Participates in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) If an individual is a contact of a case as specified in §B(1) of this regulation, and that individual has diarrhea at the time of the health department's investigation of the case, then the contact shall submit for examination two fecal specimens taken: (a) Not less than 24 hours apart; and (b) If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics. (3) If either of the specimens referred to in §B(2) of this regulation is positive for Campylobacter, a health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation apply. C. Infection Control. A health care provider shall practice standard precautions. D. Control of Carriers. A health care provider shall apply the control measures specified in §A of this regulation to carriers in addition to cases. #### Regulation .08-2 Cholera (Vibrio cholera O1 or O139). *COMAR 10.06.01.08-2* A. Control of a Case. (1) For a case with diarrhea due to or presumed due to cholera, a health officer shall restrict or exclude a case from: (a) Attending a child care facility; or (b) Participating in an occupation involving; (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) For a case who has been without diarrhea for at least 48 hours, unless a health officer otherwise restricts or excludes the case based on Regulation .06D of this chapter, the case may: (a) Attend a child care facility; and (b) Participate in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (3) If a health officer has restricted or excluded a case under §A(1) of this regulation or Regulation .06D of this chapter, the health officer shall approve resumption of child care attendance or occupational duties when: (a) The case's fecal cultures are Vibrio-free on two consecutive specimens collected: (i) Not less than 24 hours apart; and (ii) If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or (b) The health officer determines that the likelihood of disease transmission is low. B. Control of Contacts at Increased Risk of Transmitting Cholera. (1) A health officer shall restrict or exclude from child care or an occupational setting a contact who has diarrhea, until at least 48 hours after diarrhea ceases, if the contact is in the household of a case or is a close contact who: (a) Attends a child care facility; or (b) Participates in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) If an individual is a contact of a case as specified in §B(1) of this regulation, and that individual has diarrhea at the time of the health department's investigation of the case, then the contact shall submit for examination two fecal specimens taken at: (a) Not less than 24 hours apart; and (b) If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics. (3) If either of the specimens referred to in §B(2) of this regulation is positive for Vibrio cholera, a health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation apply. #### Regulation .08-3 Escherichia coli O157:H7 and Other Shiga-Like Toxin Producing Escherichia coli (STEC). *COMAR 10.06.01.08-3* A. Control of a Case. (1) A case may not attend a child care facility until: (a) The case’s fecal cultures or stool Shiga-like toxin tests are free of E. coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC) on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves readmission based on the low likelihood of disease transmission. (2) A case, with or without diarrhea, may not participate in occupations involving food handling, patient care, or care of young children or the elderly until: (a) The case’s fecal cultures or stool Shiga-like toxin tests are free of E. coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC) on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves resumption of occupational duties based on the low likelihood of disease transmission. B. Control of Contacts. (1) A health officer shall require a culture of feces or stool Shiga-like toxin test only from a household member or other close contact who attends a child care facility or whose occupation involves food handling, patient care, or care of young children or the elderly. (2) A household member or other close contact shall submit for examination two fecal specimens taken at an interval of not less than 24 hours apart. (3) If either of the specimens submitted pursuant to §B(2) of this regulation is positive for E. coli O157:H7, other Shiga-Like Toxin Producing Escherichia coli (STEC), or Shiga-like toxin, a health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation apply. (4) A household member or other close contact who currently has diarrhea or who has had an onset of diarrhea in the past 3 weeks may not attend a child care facility until: (a) The household member or other close contact is without diarrhea for at least 24 hours and fecal cultures or Shiga-like toxin tests are free of E. coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC) on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves readmission based on the low likelihood of disease transmission. (5) A contact who currently has diarrhea or who has had an onset of diarrhea within the past week may not participate in occupations involving food handling, patient care, or care of young children or the elderly until: (a) The contact is without diarrhea for at least 24 hours and fecal cultures or Shiga-like toxin tests are free of E. coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC) on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves resumption of occupational duties based on the low likelihood of disease transmission. C. Infection Control. A health care provider shall practice standard precautions. #### Regulation .09 Foodborne and Waterborne Diseases. *COMAR 10.06.01.09* A. Control of a Case or Contacts. If one of the following diseases is identified, a health officer shall follow the procedures detailed in this chapter for the specific disease: (1) Campylobacteriosis; (2) Cholera; (3) Escherichia coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC); (4) Hepatitis, viral type A; (5) Salmonellosis; (6) Shigellosis; and (7) Typhoid fever (Salmonella Typhi) or paratyphoid fever (Salmonella Paratyphi A, Salmonella Paratyphi B tartrate negative, and Salmonella Paratyphi C). B. Investigation and Control Measures. (1) A food establishment as defined in Health-General Article, §21-301, Annotated Code of Maryland, shall provide to a health officer the information the health officer or the Secretary determines to be necessary and pertinent to the investigation. (2) A health officer or the Secretary shall investigate the source, inspect food establishments, and collect samples of suspected foods and clinical specimens from food service workers and cases or contacts in an effort to determine the cause of a foodborne illness. (3) A health officer or the Secretary shall submit all samples for laboratory examination. (4) A health officer or the Secretary may detain a food item, issue a public notice requiring the recall or return of a food item, or prohibit the serving of food at a food service facility, until it is determined whether the food item or the facility is implicated as a source of illness. #### Regulation .10 Hepatitis, Viral Type A. *COMAR 10.06.01.10* A. Control of a Case. A case may not participate in an occupation involving food handling, patient care, or care of young children or the elderly for 1 week after onset of jaundice, or for 2 weeks after the onset of illness, if not jaundiced. B. Control of Contacts. For an individual who previously has not received hepatitis A vaccine, the physician in attendance or a health officer shall offer a single dose of single antigen hepatitis A vaccine or immune globulin to contacts for prophylaxis: (1) As soon as possible, but within 2 weeks of exposure to household, sexual, child care, or other contacts as determined by a health officer; and (2) According to the following recommendations: (a) For a previously unvaccinated healthy individual 12 months old to 40 years old, single antigen hepatitis A vaccine at the age appropriate dose is recommended; (b) For a previously unvaccinated individual older than 40 years old, immune globulin is recommended and single antigen hepatitis A vaccine may be used if: (i) Immune globulin is not available; and (ii) The individual is healthy; or (c) For a previously unvaccinated child younger than 12 months old, an immunocompromised individual, an individual with chronic liver disease, or an individual for whom vaccine is contraindicated, immune globulin is recommended. C. Infection Control. Health care providers shall practice standard precautions. #### Regulation .11 Hepatitis, Viral Type B. *COMAR 10.06.01.11* A. Control of a Case. A physician in attendance upon a case having viral hepatitis type B shall educate that case on the: (1) Risks of sexual transmission, household contact transmission, maternal-infant transmission, and transmission by the sharing of hypodermic needles and other drug paraphernalia; (2) Availability of hepatitis B vaccine and hepatitis B immune globulin for contacts who have had sexual contact with a case of hepatitis B within the preceding 14 days, contacts who have percutaneous exposures to hepatitis B, and infants born to case mothers who carry hepatitis B virus at delivery, and the need for referring those contacts to health care providers for preventive treatment; (3) Importance of vaccination for viral hepatitis type A if the case is not already immune by reason of prior infection or prior vaccination; and (4) Importance of testing pregnant women for hepatitis B surface antigen at each pregnancy. B. Control of Contacts. A physician or health officer in attendance upon a contact of viral hepatitis type B shall: (1) Educate that contact about the availability of vaccine and hepatitis B immune globulin for contacts with exposure to the case’s blood or other infectious body fluids; (2) Recommend preventive treatment consistent with current Centers for Disease Control and Prevention guidelines based on type of exposure; and (3) Require that infants born to hepatitis B surface antigen positive mothers: (a) Receive hepatitis B immune globulin and the first dose of hepatitis B vaccine within 12 hours of birth; (b) Receive the rest of the vaccination series; and (c) Are tested for hepatitis B surface antigen and hepatitis B surface antibody at 9 to 15 months old. C. Infection Control. Health care providers shall practice standard precautions. #### Regulation .11-1 Hepatitis, Viral Type C. *COMAR 10.06.01.11-1* A. Control of a Case. A physician in attendance upon a case of viral hepatitis type C shall educate that case on: (1) The risks of transmission of viral hepatitis type C by: (a) Sharing hypodermic needles and other injecting drug paraphernalia; (b) Sexual transmission; (c) Maternal-child transmission; (d) Parenteral or permucosal exposure to blood or other infectious body fluids; (e) Chronic hemodialysis; (f) Transfusion; and (g) Transplantation; (2) How to reduce the risk of transmission of viral hepatitis type C to other individuals; (3) The importance of an individual health evaluation to determine if treatment should be recommended; (4) The importance of vaccination for viral hepatitis types A and B if the case is not already immune by reason of prior infection or prior vaccination; and (5) The prevention of further liver injury or more serious liver disease or liver failure. B. Control of Contacts. A physician or health officer in attendance upon a contact of viral hepatitis type C shall educate the contact about: (1) Any risk factors and signs of infection due to viral hepatitis type C; (2) Testing that is available to determine whether an infection due to viral hepatitis type C is present, and facilitate that testing if medically appropriate or if requested by the contact; and (3) How to reduce the contact's risk of receiving viral hepatitis type C from others. C. Infection Control. A health care provider shall: (1) Practice standard precautions; and (2) Implement and maintain, in hemodialysis centers and other settings where viral hepatitis type C transmission is known to be an increased risk, additional infection control measures based upon the Centers for Disease Control and Prevention recommendations for prevention and control of hepatitis C infection and HCV-related chronic disease, as directed by the Secretary to reduce disease transmission. D. Education. The Secretary, with the assistance of the health officer, shall provide professional and public education and informational materials on viral hepatitis type C, modes of transmission, and prevention of viral hepatitis type C. #### Regulation .12 Measles (Rubeola). *COMAR 10.06.01.12* A. Control of a Case. A health officer or health care provider shall recommend that a case may not attend a school, workplace, or child care facility from the onset of the illness at least through the 4th day after the rash appears. B. Control of Contacts. (1) Nonimmune Contacts. (a) Nonimmune individuals for measles, in general, are people who: (i) Have not received two doses of measles containing vaccine on or after the first birthday; (ii) Have no documentation of immunity or disease; or (iii) Were born in or after 1957. (b) A health officer or health care provider shall recommend that: (i) Nonimmune contacts receive measles vaccine within 72 hours of exposure if not medically contraindicated; and (ii) Nonimmune household or other close contacts, particularly contacts younger than 1 year old, pregnant women, persons with immunodeficiencies, or those for whom the vaccine is contraindicated, be given immune globulin within 6 days of exposure. (c) A health officer shall restrict or exclude a nonimmune contact from attending a school, health care facility, child care facility, or workplace until 21 days after the onset of rash in the last case of measles. (2) A health officer: (a) May require all nonimmune individuals to be excluded from a school, workplace, or child care facility when a case of measles is diagnosed or suspected in a student, employee, or volunteer of the school or facility; and (b) Shall authorize readmission upon documented proof of immunity in the form of immunization record, serologic test, or the low likelihood of disease transmission. C. Infection Control. Health care providers shall practice airborne precautions from the onset of illness at least through the 4th day after the rash appears. D. Proof of Immunity for Health Care Workers. (1) A worker born in or after 1957 working at least 20 hours each week who is newly retained as medical staff, a direct or contractual employee, or a volunteer of a hospital classified as a “general hospital” under Health-General Article, §19-307, Annotated Code of Maryland, shall have documentation of receipt of two doses of live measles virus vaccine after becoming 1 year old or proof of immunity by blood test for antibody to rubeola. The hospital shall keep the measles vaccination or immunity status of each worker on file. (2) Exemptions. (a) A hospital shall grant a medical exemption for any worker who presents a written statement from a licensed physician or a health officer indicating that immunization against measles is medically contraindicated or detrimental to the worker's health. The statement shall indicate whether the exemption should be permanent or temporary. If the exemption is temporary, the statement shall indicate the date on which the worker is to receive the immunization. A hospital shall withdraw a temporary medical exemption on the day following that date. If the exemption is permanent, the hospital shall maintain a record of the worker's measles antibody test results. (b) If a worker objects to an immunization upon the grounds that it conflicts with the worker's bona fide religious beliefs and practices, the hospital shall grant a religious exemption to the worker for the immunization. The hospital shall maintain a record of the worker's measles antibody test results. #### Regulation .12-1 Mumps. *COMAR 10.06.01.12-1* A. Control of a Case. A health officer or health care provider shall recommend that a case may not attend a school, workplace, or child care facility from the onset of illness through the 5th day after onset of parotitis. B. Control of Contacts. (1) Nonimmune Individuals. (a) Nonimmune individuals for mumps, in general, are people who: (i) Have not received two doses of mumps containing vaccine on or after the first birthday; (ii) Have no documentation of immunity or disease; or (iii) Were born in or after 1957. (b) A health officer shall restrict or exclude a nonimmune contact from attending a school, health care facility, child care facility, or workplace until 25 days after the onset of parotitis in the last case of mumps. (2) A health officer: (a) May require all nonimmune individuals to be excluded from a school, workplace, or child care facility when a case of mumps is diagnosed or suspected in a student, employee, or volunteer of the school or facility; and (b) Shall authorize readmission upon documented proof of immunity in the form of: (i) An immunization record; (ii) A serologic test; or (iii) The low likelihood of disease transmission. C. Infection Control. A health care provider shall practice droplet precautions for 5 days after onset of parotitis. #### Regulation .12-2 Pertussis. *COMAR 10.06.01.12-2* A. Control of a Case. (1) A health officer or health care provider shall recommend that a case may not attend school, a workplace, or a child care facility until the patient has received at least 5 days of appropriate antibiotics. (2) If a case does not receive antibiotics, a health officer shall restrict or exclude the case from attending a school, health care facility, child care facility, or workplace for 3 weeks after onset of cough. B. Control of Contacts. A health officer may: (1) Require all inadequately immunized household contacts younger than 7 years old to be excluded from schools, child care facilities, and public gatherings: (a) For 21 days after last exposure; or (b) Until the case patients and contacts have received 5 days of appropriate antibiotics; (2) Require all contacts to verify immunization status and be brought up to date if not adequately immunized to protect against subsequent exposure; and (3) Require antibiotic prophylaxis for contacts of cases. C. Infection Control. A health care provider shall practice droplet precautions for the shorter of: (1) 21 days after onset of cough; or (2) When a case has been on appropriate antibiotics for 5 days. #### Regulation .13 Psittacosis. *COMAR 10.06.01.13* A. There is no control of a human case or contacts. B. Infection Control. A health care provider shall practice appropriate disinfection and disposal of respiratory discharges. C. The sale and distribution of exotic birds and handling of exotic birds which are cases or suspected cases of avian psittacosis are subject to Health-General Article, §§24-101—24-110, Annotated Code of Maryland. D. The Department recommends that the Compendium of Measures To Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017, by the National Association of State Public Health Veterinarians, be followed for ill birds and birds that carry psittacosis. #### Regulation .14 Rabies. *COMAR 10.06.01.14* A. Control of a Case (Human). A health care provider shall apply contact isolation to the case for the period of communicability. B. Control of Contacts. A health officer or health care provider shall evaluate individually a close contact or hospital contact to determine the need for post-exposure rabies prophylaxis. A health care provider shall warn an immediate attendant of the hazard of infection. C. Infection Control. A health care provider shall practice contact isolation. D. Confinement or Examination of Animals. A health officer or the Maryland Public Health Veterinarian shall direct the quarantine, examination, control, and disposition of any animal that bites or otherwise potentially exposes a human to rabies, according to COMAR 10.06.02. #### Regulation .15 Rubella (German Measles). *COMAR 10.06.01.15* A. Control of a Case. A health officer or health care provider shall recommend that a case: (1) Be isolated from a woman of childbearing age who is not immune or is of unknown immunity, from the onset of illness through the 7th day after appearance of the rash; and (2) May not attend a school, workplace, or child care facility from the onset of the illness through the 7th day after the appearance of the rash. B. Control of Contacts. (1) Nonimmune Contacts. (a) Nonimmune individuals for rubella, in general, are people who: (i) Have not received at least one dose of rubella containing vaccine on or after the first birthday; (ii) Have no documentation of immunity or disease; or (iii) Were born in or after 1957. (b) A health officer shall restrict or exclude a nonimmune contact from attending a school, health care facility, child care facility, or workplace until 21 days after the onset of rash in the last case of rubella. (2) A health officer: (a) May require all nonimmune individuals to be excluded from a school, workplace, or child care facility when a case of rubella is diagnosed or suspected in a student, employee, or volunteer of the school or facility; and (b) Shall authorize readmission by documented proof of immunity in the form of an immunization record, serologic test, or the low likelihood of disease transmission. C. Infection Control. A health care provider shall practice droplet precaution for 7 days after onset of the rash. D. Proof of Immunity for Health Care Workers. (1) A worker born in or after 1957 working at least 20 hours each week who is newly retained as medical staff, a direct or contractual employee, or a volunteer of a hospital classified as a “general hospital” under Health-General Article, §19-307, Annotated Code of Maryland, shall have documentation of receipt of either one dose of live rubella virus vaccination on or after becoming 1 year old or proof of immunity by blood test for antibody to rubella. The hospital shall keep the vaccine or immunity status of each worker on file. (2) Exemptions. (a) A hospital shall grant a medical exemption for any worker who presents a written statement from a licensed physician or a health officer indicating that immunization against rubella is medically contraindicated or detrimental to the worker's health. The statement shall indicate whether the exemption should be permanent or temporary. If the exemption is temporary, the statement shall indicate the date on which the worker is to receive the immunization. A hospital shall withdraw a temporary medical exemption on the day following that date. If the exemption is permanent, the hospital shall maintain a record of the worker's rubella antibody test results. (b) If a worker objects to an immunization upon the grounds that it conflicts with the worker's bona fide religious beliefs and practices, the hospital shall grant a religious exemption to the worker for the immunization. The hospital shall maintain a record of the worker's rubella antibody test results. #### Regulation .16 Salmonellosis. *COMAR 10.06.01.16* A. Control of a Case. (1) For a case with diarrhea due to or presumed due to salmonellosis, a health officer shall restrict or exclude a case from: (a) Attending a child care facility; or (b) Participating in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) For a case who has been without diarrhea for at least 24 hours, unless a health officer otherwise restricts or excludes the case based on Regulation .06D of this chapter, the case may: (a) Attend a child care facility; and (b) Participate in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (3) If a health officer has restricted or excluded a case under §A(1) of this regulation or Regulation .06D of this chapter, the health officer shall approve resumption of child care attendance or occupational duties when: (a) The case’s fecal cultures are Salmonella-free on two consecutive specimens collected: (i) Not less than 24 hours apart; and (ii) If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or (b) The health officer determines that the likelihood of disease transmission is low. B. Control of Contacts at Increased Risk of Transmitting Salmonellosis. (1) A health officer shall restrict or exclude from child care or an occupational setting a contact who has diarrhea, until at least 24 hours after diarrhea ceases, if the contact is in the household of a case or is a close contact who: (a) Attends a child care facility; or (b) Participates in an occupation involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) If an individual is a contact of a case as specified in §B(1) of this regulation, and that individual has diarrhea at the time of the health department's investigation of the case, then the contact shall submit for examination two fecal specimens taken not: (a) Less than 24 hours apart; and (b) Sooner than 48 hours following discontinuation of antibiotics if antibiotics have been given. (3) If either of the specimens referred to in §B(2) of this regulation is positive for Salmonella, a health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation apply. C. Infection Control. A health care provider shall practice standard precautions. D. Control of Carriers. A health care provider shall apply the same control measures to carriers as to cases. #### Regulation .17 Syphilis and HIV. *COMAR 10.06.01.17* A. Control of a Case. (1) For an individual who appears to have or who has syphilis in a stage which is or may become communicable, or HIV, a physician shall instruct the individual in the use of any measure and render any treatment which may be necessary to prevent the spread of the disease. (2) An individual under medical observation for diagnosis of syphilis or HIV shall remain under medical supervision until the: (a) Observation for diagnosis has been completed; (b) Syphilis or HIV, if present, has been reported to a health officer; (c) Individual with syphilis has had the treatment that is necessary for the protection of the public health; and (d) Individual with HIV has entered into HIV medical care. (3) A physician shall report to a health officer within 1 working day and in writing the name and address of an individual who is: (a) Receiving or has received treatment for syphilis; or (b) Under medical observation for diagnosis or treatment of syphilis in an infectious or potentially infectious stage, who fails to return for observation or treatment within 1 week of the date of a missed appointment, and is not known to the attending physician to be under medical observation or treatment elsewhere for this infection. (4) A health officer shall: (a) Investigate an individual reported to the health officer under the provisions of §A(3) of this regulation or Health-General Article, §18-201.1, Annotated Code of Maryland, who is within the health officer’s territorial jurisdiction; (b) Take such measures as may be deemed necessary for the protection of the public health; and (c) Forward to the Secretary immediately a report of an individual reported under the provisions of §A(3) of this regulation or Health-General Article, §18-201.1, Annotated Code of Maryland, who is outside the health officer’s territorial jurisdiction for referral to the health officer of the proper jurisdiction. B. Control of Contacts. (1) A physician in attendance upon a patient having syphilis or HIV: (a) Shall endeavor to bring an individual with whom the patient has had potentially infectious contact to examination and, as appropriate, prophylaxis by: (i) Requesting a health officer to conduct a contact investigation of any case of syphilis or HIV; or (ii) Interviewing the patient in order to ascertain the names, descriptions, addresses, telephone numbers, and email addresses of those with whom the patient has had potentially infectious contact; (b) Shall report immediately to a health officer an individual identified as having had potentially infectious contact with a patient having syphilis reported under the provisions of §A(3) of this regulation; and (c) May report to a health officer an individual identified as having had potentially infectious contact with a patient having HIV reported under Health-General Article, §18-201.1, Annotated Code of Maryland, if a patient that has been informed of the patient’s HIV positive status refuses to notify the patient’s sexual and needle-sharing partners. (2) A health officer shall: (a) Investigate and notify immediately an individual reported under the provisions of §B(1)(b) of this regulation, who is within the health officer’s jurisdiction, of the individual’s exposure and advise the individual to undergo a medical examination to ascertain whether the individual is infected with syphilis or HIV; and (b) Forward immediately to the Secretary all reports of individuals who are outside the health officer’s territorial jurisdiction for referral to the health officer of the proper jurisdiction. (3) A reported individual shall: (a) Within 1 week of notification, be examined to ascertain whether the individual has been infected with syphilis or HIV; and (b) Be treated with a regimen appropriate for the stage of syphilis to which the individual has been exposed. C. Infection Control. A health care provider shall practice standard precautions. D. Congenital Syphilis. (1) A physician in attendance upon a pregnant woman shall: (a) Serologically test her for syphilis in accordance with Health-General Article, §18-307, Annotated Code of Maryland, by taking a blood sample and assuring the test is completed: (i) At the time the physician first examines the woman, either at the first prenatal visit or at the time of delivery if the woman has had no prenatal care; (ii) In the third trimester at the prenatal visit at 28 weeks of gestation or the first prenatal visit after 28 weeks of gestation; and (iii) At delivery, for high prevalence communities or high risk individuals; (b) Render appropriate treatment within 1 week whenever syphilis, in any stage, is diagnosed; and (c) Report the case to a health officer immediately. (2) A physician in attendance upon an infant born to an untreated woman who has a positive serological test for syphilis shall: (a) Evaluate the infant for possible congenital syphilis and render all indicated treatment; and (b) Report immediately to a health officer the following information: (i) The name, address, and telephone number of the mother; (ii) The results of the serological testing, including titers; and (iii) The results of the medical evaluation for congenital syphilis for the infant. (3) A health officer shall: (a) Investigate immediately an individual reported to the health officer under the provisions of §D(1)(c) and (2)(b) of this regulation, who is within the health officer's jurisdiction; and (b) Forward immediately to the Secretary a report of an individual reported under the provisions of §D(1)(c) and (2)(b) of this regulation, who is outside the health officer's jurisdiction for referral to a health officer of the proper jurisdiction. #### Regulation .18 Other Sexually Transmitted Infections. *COMAR 10.06.01.18* A. Control of a Case. (1) Hepatitis, viral type B, as discussed in Regulation .11 of this chapter. (2) A physician in attendance upon a person who appears to have, or who has a sexually transmissible disease in a stage which is or may become communicable, shall: (a) Instruct the person on the modes of transmission and the prevention of transmission; (b) Render any necessary treatment to the case; and (c) Advise the case to inform a sexual partner or partners of exposure and the need for examination and treatment. B. Control of Contacts. (1) Hepatitis, viral type B as discussed in Regulation .11 of this chapter (2) A physician in attendance upon an individual who is a sexual contact of a case of a sexually transmitted infection shall perform a medical examination and render indicated treatment. C. Prevention of Gonococcal Ophthalmia Neonatorum. (1) A birth-attending physician or certified nurse-midwife shall apply to both eyes of a newborn one of the following prophylactic agents: (a) A 1-percent silver nitrate solution provided in individual wax ampules for the prevention of gonococcal ophthalmia neonatorum; (b) Tetracycline ophthalmic ointment; or (c) Erythromycin ophthalmic ointment (USP). (2) A birth-attending physician or certified nurse-midwife shall document in a newborn's medical record the application of the prophylactic agent, the name of the agent used, and dose strength. #### Regulation .19 Shigellosis. *COMAR 10.06.01.19* A. Control of a Case. (1) A case may not attend a child care facility until: (a) The case's fecal cultures are Shigella-free on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves readmission based on the low likelihood of disease transmission. (2) A case, with or without diarrhea, may not participate in occupations involving food handling, patient care, or care of young children or the elderly until: (a) The case's fecal cultures are Shigella-free on two consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, if antibiotics have been given; or (b) A health officer approves resumption of occupational duties based on the low likelihood of disease transmission. B. Control of Contacts. (1) A health officer shall require a culture of feces only from a household member or close contact who: (a) Attends a child care facility; or (b) Whose occupation involves: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly. (2) A contact shall submit for examination two fecal specimens taken at an interval of not less than 24 hours apart. (3) If either of the specimens collected under §B(2) of this regulation is positive for Shigella, the health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation shall apply. C. Infection Control. A health care provider shall practice standard precautions. #### Regulation .20 Tuberculosis. *COMAR 10.06.01.20* A. Control of a Case and Suspected Case. (1) A health care provider shall immediately send notification that they have a patient who is suspected of being in a communicable stage to the local health officer of the jurisdiction in which the patient is currently located. (2) A health care provider may not discharge a patient who is suspected of being in a communicable stage until the local health department of the jurisdiction in which the patient is located has been informed of and concurs with the planned discharge or release of the individual. (3) A health officer or health care provider shall isolate a patient who is in a communicable stage as long as the specific microorganism: (a) Is excreted by the patient; or (b) Can be isolated by culture in the case of multidrug resistant tuberculosis (MDR-TB) or extremely drug resistant tuberculosis (XDR-TB). (4) A patient fulfills the requirements of isolation as long as the patient receives adequate chemotherapy, is under medical supervision, and observes instructions for isolation issued by a health officer. (5) A health care provider shall place individuals with tuberculosis and suspected tuberculosis on a tuberculosis treatment regimen that is in accordance with current national and State standards of care, and that provide for direct observation by a trained health care worker of ingestion of each dose of medication. (6) A health officer or health care provider treating an individual with tuberculosis or suspected tuberculosis shall provide human immunodeficiency virus testing and counseling. (7) A health officer shall monitor the treatment of individuals with tuberculosis and suspected tuberculosis to determine if the treatment is appropriate. (8) A health officer may impose limitations on travel and place restrictions on hospital discharge for an individual with tuberculosis or suspected tuberculosis. (9) A health officer may remove the limitations and restrictions set forth in §A(8) of this regulation when appropriate and consistent with the individual's tuberculosis treatment plan. (10) A health officer or the Secretary shall manage tuberculosis patients who are noncompliant with tuberculosis treatment in accordance with Health-General Article, §§18-324 and 18-325, Annotated Code of Maryland. (11) A health officer may require an individual having tuberculosis in a noncommunicable stage to be under medical supervision, which may include physical isolation from others, if the individual refuses to receive adequate chemotherapy. B. Control of Contacts. A health officer shall: (1) Direct that testing for tuberculosis infection using a Centers for Disease Control and Prevention approved method be performed on contacts of cases of tuberculosis in a communicable stage; (2) Recommend appropriate treatment for latent tuberculosis infection; and (3) Provide for the supervised presumptive treatment of latent tuberculosis infection for a child younger than 5 years old identified as a close contact to a confirmed case or suspected case of active pulmonary tuberculosis. #### Regulation .21 Typhoid Fever (Salmonella Typhi) and Paratyphoid Fever (Salmonella Paratyphi A, Salmonella Paratyphi B tartrate negative, and Salmonella Paratyphi C). *COMAR 10.06.01.21* A. Control of a Case. (1) A case may not attend a child care facility until fecal specimens are Salmonella-free on three consecutive specimens collected not less than 24 hours apart and not sooner than 48 hours following discontinuation of antibiotics, or until a health officer approves readmission based on the low likelihood of transmission. (2) A case may not participate in occupations involving food handling, patient care, or care of young children or the elderly until fecal specimens are Salmonella-free on three consecutive specimens collected not less than 24 hours apart, and not sooner than 48 hours after discontinuation of antibiotics. (3) A health officer shall supervise a case and release a case from supervision only after fecal specimens are culture negative for Salmonella Typhi or Paratyphi on three consecutive specimens collected not: (a) Less than 24 hours apart; (b) Sooner than 48 hours following discontinuation of antibiotics; and (c) Earlier than 1 month after onset or date of first positive culture if asymptomatic. (4) If any one of the specimens required in §A(3) of this regulation is positive, at least three consecutive negative cultures of feces at intervals of 1 month within the 12 months following onset shall be required for release from supervision. (5) If a person continues to excrete Salmonella Typhi or Paratyphi at 12 months, the requirements of §D of this regulation apply. B. Control of Contacts of a Case. Household, sexual, and other close contacts of a case may not attend a child care facility or participate in occupations involving food handling, patient care, or care of young children or the elderly until two consecutive cultures of feces taken at least 24 hours apart are negative for Salmonella Typhi or Paratyphi. C. Infection Control. A health care provider shall practice standard precautions. D. Control of Carriers. (1) A health officer shall: (a) Monitor the location, occupation, and bacteriological status of a carrier of Salmonella Typhi or Paratyphi; (b) Keep a complete file of all pertinent data on the carrier; (c) Issue written instructions to the carrier concerning the restrictions upon and responsibilities of the carrier; (d) Notify the carrier of the availability of treatments that may eliminate carriage; (e) Contact each carrier in the health officer's jurisdiction at intervals of not more than 1 year to check on the carrier's occupation and address and to determine if all instructions are being followed; (f) Release a carrier from supervision only after there have been three consecutive negative cultures of feces, taken 1 month apart at least 48 hours after antibiotic treatment; and (g) Forward immediately to the Secretary a report of a carrier who has relocated outside the health officer's territorial jurisdiction for referral to the health officer of the proper jurisdiction. (2) A case or a case's physician shall submit the fecal specimens to the State Laboratory for the release of a carrier. (3) A carrier: (a) May not participate in occupations involving: (i) Food handling; (ii) Patient care; or (iii) Care of young children or the elderly; (b) Shall abide by Regulation .06D and E; and (c) Shall keep a health officer informed at all times of the carrier's address and occupation, and shall notify the health officer at once of any change in address or occupation. E. Control of Contacts of a Carrier. (1) A health officer shall require culture of feces of those household and close contacts: (a) Who attend a child care facility; or (b) Whose occupations involve: (i) Food handling; or (ii) Care of patients, young children, or the elderly. (2) A contact shall submit for examination two fecal specimens taken at an interval of not less than 24 hours apart. (3) If either of the specimens required in §E(2) of this regulation is positive for Salmonella Typhi or Paratyphi, then the health officer shall consider the contact to be a case, and the control measures specified in §A of this regulation apply. #### Regulation .22 Sale and Distribution of Reptiles. *COMAR 10.06.01.22* A. Scope. (1) Pursuant to the authority conferred upon the Secretary by Health-General Article, §18-219, Annotated Code of Maryland, the Secretary has determined that reptiles and reptile eggs are dangerous to human health and safety in that human contact with reptiles and reptile eggs may spread disease to humans. (2) The Secretary prohibits the sale or public distribution of turtles with a carapace length of less than 4 inches and viable reptile eggs. (3) The Secretary may permit the sale and public distribution of reptiles in accordance with specific requirements and conditions as stated in §B of this regulation. (4) This regulation does not apply to a turtle: (a) Used for agricultural purposes; (b) Used for scientific purposes; (c) Used for educational purposes as certified by a health officer; (d) Used for public exhibitions; or (e) That the Secretary determines is not a threat to human health and safety. (5) The requirements of this regulation are in addition to any requirement imposed by Natural Resources Article, Title 10, Subtitle 9, Annotated Code of Maryland, and regulations adopted under it. (6) The giving away of reptiles is subject to the crimes and punishments set forth in Criminal Law Article, §10-610, Annotated Code of Maryland. B. Reptile Sales. (1) A person may not sell in Maryland viable reptile eggs or live turtles with a carapace length of less than 4 inches, except as otherwise provided in §A(4) of this regulation. (2) A person may sell turtles with a carapace length of 4 inches or more and other live reptiles in Maryland if: (a) A caution notice with the text as indicated in §C of this regulation is: (i) Posted by the person selling reptiles; (ii) Posted within 3 feet of each display of reptiles; and (iii) A minimum of 8 x 11 inches in size; and (b) At the time of the sale of a reptile, the seller: (i) Furnishes the buyer with a copy of the caution notice; or (ii) Has the buyer sign a log or statement that the buyer has read the caution notice. C. Caution Notice. A person who sells reptiles shall post a caution notice that: (1) Is in 4 parts, each separated by a horizontal 4-point rule; (2) In part 1 has the word “Caution” set in 100-point Times Roman Bold; (3) In part 2 has the following paragraph set in 30-point Times Roman: “Reptiles and other pets may carry and transmit germs (including Salmonella) to humans. It is important to wash your hands thoroughly after handling reptiles and other pets or coming in contact with their water, food, housing material, or container. Do not allow pet water, food, or housing material to come in contact with your food or areas where food is prepared.”; (4) In part 3 has the following sentence set in 42-point Times Roman Bold: “Provide your reptiles and other pets with a clean home, a suitable diet, and other proper care.”; and (5) In part 4 has the following sentence set in 30-point Times Roman: “If you or any member of your family is prone to or has serious health problems or is pregnant or your family includes a child younger than 5 years old, you should consult your physician before purchase.” D. Penalties and Seizure of Contraband Reptiles. (1) Pursuant to Health-General Article, §§18-219 and 18-222, Annotated Code of Maryland, a person who imports, transports, sells, transfers, breeds, raises, keeps, or possesses any live turtle with a carapace length of less than 4 inches, other reptiles, or reptile eggs in violation of §§A—C of this regulation is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $500, or imprisonment not exceeding 1 year, or both. (2) An authorized law enforcement officer may seize a turtle with a carapace length of less than 4 inches, viable turtle and other reptile eggs, and other reptiles, which are considered a nuisance and a contraband pursuant to Health-General Article, §18-222, Annotated Code of Maryland, and §A of this regulation. #### Regulation .23 Communicable Disease Information Provided With Sale and Distribution of Pet Animals. *COMAR 10.06.01.23* To help prevent the spread of a communicable disease, a seller or a group of sellers who prepares or causes to be prepared a pamphlet, flyer, or other printed information on the handling of one or more pet animals and who distributes the pamphlet, flyer, or other printed information, shall ensure that the pamphlet, flyer, or other printed information stresses the: A. Importance of handwashing after contact with a reptile or other pet animals or its surroundings; and B. Need to consult a physician if one or more of the following individuals live in the household for which a pet animal is purchased: (1) A child younger than 5 years old; (2) A pregnant woman; or (3) An immunocompromised individual. #### Regulation .24 Control of Communicable Diseases in Pet Stores. *COMAR 10.06.01.24* A. A pet store shall utilize procedures to ensure prevention and control of diseases common to and shared among humans and animals. B. To ensure prevention and control of diseases common to and shared among humans and animals, the Department recommends that pet stores utilize the Compendium of Animal Rabies Prevention and Control, the Compendium of Measures To Control Chlamydophila psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), and the Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, issued by the National Association of State Public Health Veterinarians. C. A health officer shall annually inspect a pet store to determine compliance with §A of this regulation. D. A health officer: (1) May delegate the authority to conduct annual pet store inspections to another specified agency such as, but not limited to, local animal control; and (2) Shall execute and keep on file a written agreement with the delegated inspection agency. E. Enforcement. An authorized law enforcement officer or local animal control authority shall promptly enforce a written order of a health officer or the Maryland Public Health Veterinarian issued pursuant to COMAR 10.06.02. F. Penalty. The owner of a pet store refusing or failing to comply with the provisions of this regulation is subject to the penalties set forth in Health-General Article, §§18-222, 18-604, and 24-110, Annotated Code of Maryland. ### Chapter 02 — Communicable Diseases — Rabies **Authority:** Health-General Article, §§18-102, 18-312—18-320, and 18-604, Annotated Code of Maryland **Administrative History:** Effective date: April 27, 1977 (4:9 Md. R. 714) **Administrative History:** Preface and Regulation .01 recodified to Regulation .01 and Regulation .01-1, respectively, in July 1994 **Administrative History:** Regulation .09A, B amended effective February 14, 1994 (21:3 Md. R. 193) **Administrative History:** Regulations .01—.14 repealed and new Regulations .01—.14 adopted effective November 16, 1998 (25:23 Md. R. 1696) **Administrative History:** Regulation .01 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .02B amended as an emergency provision effective January 1, 2008 (35:3 Md. R. 286); emergency status extended at 35:9 Md. R. 892; amended permanently effective March 24, 2008 (35:6 Md. R. 698) **Administrative History:** Regulation .02B amended effective February 15, 2016 (43:3 Md. R. 272); February 27, 2017 (44:4 Md. R. 253) **Administrative History:** Regulation .03C, D amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .03D amended effective May 20, 2019 (46:10 Md. R. 485) **Administrative History:** Regulation .03E repealed effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .04 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .04B, D amended effective February 27, 2017 (44:4 Md. R. 253) **Administrative History:** Regulation .06E amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .07 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .09 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .10 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .10B amended as an emergency provision effective January 1, 2008 (35:3 Md. R. 286); emergency status extended at 35:9 Md. R. 892; amended permanently effective March 24, 2008 (35:6 Md. R. 698) **Administrative History:** Regulation .11 amended effective September 14, 2015 (42:18 Md. R. 1174) **Administrative History:** Regulation .13B amended effective September 14, 2015 (42:18 Md. R. 1174); February 27, 2017 (44:4 Md. R. 253) #### Regulation .01 Scope. *COMAR 10.06.02.01* This chapter provides for cooperative rabies control efforts by the Department, local health officers, physicians, veterinarians, and other Maryland government agencies as guided by policy statements such as the Compendium of Animal Rabies Prevention and Control, issued annually by the National Association of State Public Health Veterinarians. #### Regulation .02 Definitions. *COMAR 10.06.02.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Adequately vaccinated” means a graduate veterinarian at a public antirabies clinic or a licensed veterinarian has: (a) Immunized an animal against rabies in accordance with the current year's recommendations as circulated by the Department; and (b) Documented the rabies immunization by issuing a valid rabies certificate. (2) “Animal” means a nonhuman species of mammal. (3) “Animal exposed to a rabid animal” means an animal that is known or is suspected to have had a bite from or non-bite contact with another animal that is known or suspected to be infected with rabies. (4) “Apparently healthy” means an: (a) Animal shows no signs of illness suggestive of rabies; and (b) Investigation by the local health officer or the health officer’s designee shows that: (i) The animal has not had a change in health or behavior in the past 30 calendar days, including but not limited to lethargy, lameness, weakness, slowness of movement or gait, paralysis, or loss of appetite; or (ii) A licensed veterinarian, having examined the animal more than 30 days before the bite or non-bite contact, has identified and documented that behavior or health changes were caused by a condition unrelated to rabies. (5) “Area quarantine” means a geographic region designated by the Public Health Veterinarian within which animals of a species designated by the Public Health Veterinarian are subject to the restrictions specified in this chapter. (6) “Bite contact” means penetration of the skin by the teeth of an animal, regardless of whether blood is visible. (7) “Cat” means Felis catus. (8) “Custodian” means a caretaker or keeper of an animal, or the local animal control authority who has responsibility for an unclaimed animal. (9) “Department” means the Department of Health. (10) “Department-approved facility” means a facility that has prior written approval of the Department to quarantine rabies suspect animals. (11) “Dog” means Canis familiaris, not including canine hybrids. (12) “Domestic animal” means a species of mammal that is accustomed to living in or about the habitation of man and is dependent on man for food or shelter, including but not limited to dogs, cats, ferrets, and livestock. (13) “Feral dog or cat” means a dog or cat that: (a) Shows no evidence, such as a collar, tag, or grooming, of being owned; and (b) Exhibits savage or wild behavior or is living in the wild. (14) “Ferret” means Mustela putorius furo. (15) “Livestock” means domestic farm animals, including but not limited to cattle, horses and other equines, swine, sheep, and goats. (16) “Local animal control authority” means that agency or individual appointed by the governing body of a county or the city of Baltimore to oversee animal control. (17) “Local health department” means a county health department under the direction of a local health officer or the Baltimore City Health Department under the direction of the Baltimore City Commissioner of Health. (18) “Local health officer” means the local health officer of a county or the Baltimore City Commissioner of Health, or the designee of the local health officer or the Commissioner of Health. (19) Non-Bite Contact. (a) “Non-bite contact” means a scratch or contamination of an abrasion, open wound, or mucous membrane with saliva or other potentially infectious material from an animal. (b) “Non-bite contact” does not include exposure to non-infectious material such as dried saliva. (20) “Person” means an individual, receiver, trustee, guardian, personal representative, fiduciary, or representative of any kind, and any partnership, firm, association, corporation, or other entity. (21) “Provoked” means that bite or non-bite contact from an animal resulted from human activity, such as an individual attempting to play with, pet, feed, handle, hold, harm, or redirect an animal’s actions. (22) “Public Health Veterinarian” means the veterinarian designated by the Secretary as responsible for the Veterinary Public Health Program of the Department or the designee of the Public Health Veterinarian. (23) “Quarantine” means, pursuant to an order of the Public Health Veterinarian or local health officer and on the private premises of the owner or custodian of the animal or at a Department-approved facility, confinement of an animal by leash, an escape-proof enclosure, or another manner, approved in writing by the Public Health Veterinarian or local health officer, that ensures protection of the public health. (24) “Rabies” means an acute viral disease in humans and animals produced by a rhabdovirus belonging to the genus Lyssavirus. (25) “Risk assessment” means the evaluation of the circumstances surrounding a bite or non-bite contact to determine the likelihood that an individual has been exposed to material potentially infectious with rabies. (26) “Secretary” means the Secretary of Health. (27) “Serologic monitoring” means monitoring of a dog or cat that was previously vaccinated against rabies to see if the animal demonstrates sufficient evidence of an immune response within seven days of being vaccinated against rabies. (28) “State Epidemiologist” means the person designated as the State Epidemiologist by the Secretary or the designee of the State Epidemiologist. (29) “Strict quarantine” means that: (a) An animal is confined in an escape-proof enclosure that precludes direct contact with people and other animals; (b) The animal is not removed from the enclosure at any time except for transport in a manner, approved in writing by the local health officer, that will safeguard the public health; (c) Human contact with the animal is restricted to one adult caring for the animal or not allowed at all by the local health officer or Public Health Veterinarian; and (d) The owner or custodian of the animal has signed an agreement with the local health department or animal control authority that the owner or custodian has met and agrees to meet the requirements specified in §B(28)(a)—(c) of this regulation. (30) “Unclaimed stray animal” means a domestic animal that is: (a) Not a feral dog or cat; and (b) Unclaimed by an owner after being held by the local animal control authority at least 72 hours for an owner to claim it. (31) “Wild animal” means a member of a mammalian species that is: (a) Not a domestic animal; (b) A feral dog or cat; or (c) An unclaimed stray animal. #### Regulation .03 Human Rabies. *COMAR 10.06.02.03* A. Reporting. (1) A physician, medical authority, or another person having knowledge of or suspicion of a case of human rabies shall immediately report the facts to the local health officer. (2) A local health officer who has received a report of a case or suspected case of human rabies shall immediately notify, by telephone or other immediate communication medium, the State Epidemiologist or the Public Health Veterinarian of the case or suspected case. B. Isolation. A physician or administrator of a health care facility providing medical care to an individual who is suspected of having been infected with rabies shall isolate the individual in accordance with the order of a local health officer or the State Epidemiologist. C. Immunization; Preexposure. (1) The Department shall provide rabies vaccine free of charge and the local health officer shall provide for the administration of preexposure immunization against rabies for any employee of the Department, a local health department, or another individual who provides rabies control services at the request of the Department. (2) The local health officer may provide rabies preexposure immunization to other individuals who are determined by the Public Health Veterinarian to have a high risk of exposure to rabies infection. (3) The local health officer shall: (a) Report to the Public Health Veterinarian at least every 3 months, the number of preexposure immunizations administered; and (b) Maintain records of the name, address, age, sex, county of residence, occupation, and the results of any blood tests administered in conjunction with rabies preexposure immunization for each individual immunized. (4) The Public Health Veterinarian and the State Epidemiologist shall make and distribute to local health officers recommendations on the dose and schedule of administration of rabies vaccine for the purpose of preexposure immunization of individuals. (5) The local health officer shall administer rabies preexposure immunizations according to the recommendations developed by the Public Health Veterinarian and the State Epidemiologist. D. Treatment; Postexposure. (1) The Public Health Veterinarian and the State Epidemiologist shall jointly issue and distribute to local health departments, physicians, hospitals, and other medical authorities, rabies postexposure treatment guidelines. (2) A local health officer shall report to the Public Health Veterinarian: (a) At least every 3 months, the number of postexposure treatments administered; (b) At the completion of treatment, for each individual administered treatment, the individual’s: (i) Name; (ii) Address; (iii) Age; (iv) Sex; (v) County of residence; and (vi) Occupation; and (c) Other information as directed by the Public Health Veterinarian. (3) The Department shall ensure no one is denied rabies postexposure treatment due to the inability to pay when the treatment is provided in accordance with the guidelines issued by the Public Health Veterinarian and the State Epidemiologist and recommended by a licensed health care provider. (4) The local health officer of the jurisdiction where the resident resides shall ensure access to rabies postexposure treatment provided in accordance with the guidelines issued by the Public Health Veterinarian and the State Epidemiologist. (5) When rabies postexposure treatment is provided in accordance with the guidelines issued by the Public Health Veterinarian and the State Epidemiologist, the Department shall pay the charge of the rabies biologics for persons unable to pay for them: (a) Based on the current ability-to-pay schedule of the Department; and (b) Only after all available benefits and discounts are applied. #### Regulation .04 Animal Rabies. *COMAR 10.06.02.04* A. Reporting. An individual shall report immediately by telephone or in person to the local police, sheriff’s department, or local animal control authority if they know of an animal that: (1) Has rabies; (2) Is suspected of having rabies; or (3) Has had a bite from or non-bite contact with an animal known to have or suspected of having rabies. B. Disposition of a Suspected Rabid Animal — No Bite or Non-Bite Human Contact. (1) Dogs, Cats, and Ferrets. (a) Except as provided in §B(3) of this regulation, the director of a Department-approved facility shall hold in strict quarantine, in a manner and place as established by the local health officer or the Public Health Veterinarian, any dog, cat, or ferret suspected of having rabies that has not had bite or non-bite contact with an individual in the preceding 10 days. (b) Except as provided in §B(3) of this regulation, unless otherwise specified by the Public Health Veterinarian, the director of a Department-approved facility shall continue the strict quarantine of the suspected rabid animal for at least 10 days and maintain proper, humane care of the animal during the period of strict quarantine, after which the animal may be humanely killed or released to its owner or custodian or for adoption. (c) At any time during the strict quarantine period, the local health officer, the Public Health Veterinarian, the owner, or the custodian of the animal may direct that the animal suspected of having rabies be humanely killed for the purpose of rabies testing. (d) At any time during the strict quarantine period, the owner or custodian of the animal may direct that the animal be humanely killed. (e) Rabies testing is not required if there is no human contact or contact with another animal. (2) Livestock. (a) Except as provided in §B(3) of this regulation, the Public Health Veterinarian shall direct the owner or custodian of livestock that has not had bite or non-bite contact with an individual and is suspected of having rabies to hold the livestock in strict quarantine for at least 10 days and shall designate the place and manner in which the strict quarantine is to be carried out, after which the livestock may be humanely killed or released to the owner or custodian. (b) At any time during the strict quarantine period, the local health officer, the Public Health Veterinarian, the owner, or the custodian of the animal may direct that the animal be humanely killed for the purpose of rabies testing. (c) At any time during the strict quarantine period, the owner or custodian of the animal may direct that the animal be humanely killed. (d) Rabies testing is not required if there is no human contact or contact with another animal. (3) Wild Animals. (a) The local health officer or Public Health Veterinarian may order a wild animal that is suspected of having rabies to be humanely killed if there is no evidence that the animal has an individual owner. (b) If there is evidence of ownership, the Public Health Veterinarian, local health officer, or local animal control authority may order the humane killing of the animal if the owner or custodian does not appear within 24 hours to claim the animal or if there is imminent threat to human health or safety. For unclaimed stray animals, the 24-hour period is included within the period required under Regulation .02B(29) of this chapter. (c) If an owner or custodian of the wild animal claims the animal within 24 hours, the Public Health Veterinarian may order the owner to hold the animal in strict quarantine in a place and manner determined by the Public Health Veterinarian for at least 30 days, after which it may be released to the owner or custodian if the animal has not developed rabies. (d) At any time during the strict quarantine period, the local health officer, the Public Health Veterinarian, or the owner or custodian of the animal may direct that the animal be humanely killed for the purpose of rabies testing. C. Examination of Animals Suspected of Having Rabies. (1) The Public Health Veterinarian or the local health officer may order a veterinary examination at any time of an animal suspected of having rabies. (2) The examining veterinarian shall report the results of the examination to the local health officer immediately. (3) The owner or custodian of the animal shall bear the expense of the examination. D. Disposition of an Animal Exposed to a Rabid Animal or to an Animal Suspected of Having Rabies. (1) If the owner or custodian of a domestic animal that has been exposed to a rabid animal, or to an animal suspected of having rabies, is able to provide a current or expired rabies vaccination certificate for the animal, the owner or custodian shall: (a) Have the animal re-vaccinated against rabies immediately; and (b) Keep the animal under the owner or custodian’s control and observed for 45 calendar days or for such time as specified by the Public Health Veterinarian. (2) If the owner or custodian of a domestic animal that has been exposed to a rabid animal, or to an animal suspected of having rabies, is unable to provide a current or expired rabies vaccination certificate: (a) The owner or custodian shall: (i) Have the animal humanely killed; or (ii) Have the animal vaccinated against rabies immediately, and hold dogs and cats in strict quarantine for a minimum of 4 months and other animals in strict quarantine for a minimum of 6 months in a facility and a manner approved by the Public Health Veterinarian; or (b) The local health officer or animal control authority may consult with the Public Health Veterinarian to determine if serologic monitoring can be used to keep a dog or cat under the owner or custodian’s control and observed for 45 calendar days rather than under strict quarantine for 4 months if the owner or custodian of a dog or cat states that the dog or cat was previously vaccinated. (3) The owner or custodian of a domestic animal that is being held in strict quarantine is responsible for all costs related to strict quarantine of the animal. (4) The local health officer, the Public Health Veterinarian, or the local animal control authority may make inspections of the site where an animal is being held in strict quarantine to assure that the animal is being held in strict quarantine under the terms specified in this chapter. (5) The local health officer or the Public Health Veterinarian may order the humane killing for rabies testing of an animal exposed to a rabid animal or to an animal suspected of having rabies if: (a) The strict quarantine agreement defined in Regulation .02B(28) of this chapter is violated; (b) The animal shows signs of having developed rabies; (c) A bite or non-bite contact to a human occurs; (d) A bite or non-bite contact to another animal occurs; (e) The animal is a wild animal; or (f) The exposed animal poses an imminent threat to human health or safety. #### Regulation .05 Reporting Bite or Non-Bite Contacts to Humans. *COMAR 10.06.02.05* A. A person having knowledge of an individual's having a bite from or non-bite contact with an animal shall report the facts of the contact immediately by telephone or in person to the local police or sheriff's department, except in Frederick County, where the person shall report the facts to the animal control center of Frederick County. B. Except as provided at §C of this regulation, upon receipt of a report, the local police or sheriff's department or animal control personnel shall: (1) Complete the Maryland Animal-Bite Report and Rabies Quarantine Agreement Form supplied by the Department, or an equivalent form developed by the local health department; (2) Make the report available within 24 hours to the local health officer and, on request, to the Public Health Veterinarian; and (3) Enforce all orders of the local health officer and the Public Health Veterinarian pursuant to this regulation. C. The local health officer shall report the number of animal bite and non-bite contacts to the Public Health Veterinarian monthly as specified in COMAR 10.06.01. #### Regulation .06 Risk Assessment Following Bite or Non-Bite Contact to Humans. *COMAR 10.06.02.06* Following the report of a bite or non-bite contact to a human, the local health officer shall conduct a risk assessment that includes a determination of: A. The species of animal that made the contact; B. Whether the animal is apparently healthy; C. Whether the animal is adequately vaccinated appropriate to its age; D. The type of contact; E. Whether the bite or non-bite contact was provoked and what human activity may have provoked the bite or non-bite; and F. The reasonable likelihood that the contact animal may have rabies or may have been exposed to rabies within the past 6 months, including information about unsupervised out-of-doors escape episodes, injuries, and other potential contacts of the animal to wild animals or bats. #### Regulation .07 Disposition of Animals Following Bite or Non-Bite Contact to Humans. *COMAR 10.06.02.07* A. When the local health officer has determined that quarantine of the exposing animal is allowable based on the findings of the risk assessment, the animal shall be quarantined. B. Quarantine Period. (1) Dogs, Cats, and Ferrets, Including Unclaimed Stray Animals. Except as provided in §B(3) and (4) of this regulation, the owner or custodian of a dog, cat, or ferret that was involved in bite or non-bite contact with a human shall quarantine the animal in a place and manner approved by the local health officer or the Public Health Veterinarian for at least 10 days after the date of the bite or contact. (2) Livestock Including Unclaimed Stray Animals. Except as provided in §B(3) and (4) of this regulation, the owner or custodian of livestock that has been involved in bite or non-bite contact with an individual shall quarantine the livestock in a place and manner approved by the Public Health Veterinarian in consultation with the Maryland Department of Agriculture for at least 10 days after the date of the bite or contact or a time period specified by the Public Health Veterinarian. (3) Wild Animals. (a) Except in situations in which the local health officer or the Public Health Veterinarian determines that an animal poses an imminent threat to public health or safety and must be killed immediately, the Public Health Veterinarian may order a wild animal involved in bite or non-bite contact with an individual to be placed in quarantine for at least 24 hours. (b) If the animal is not claimed by an owner or custodian within that 24-hour period, the Public Health Veterinarian may order the animal to be humanely killed and its head submitted to the laboratory designated by the Department for rabies testing. (c) For unclaimed stray animals, the 24-hour period is included within the period required under Regulation .02B(29) of this chapter. (4) Wild Animal with a Legal Owner. When a legally owned wild animal has been involved in bite or a non-bite contact with a human, the local health officer, in consultation with the Public Health Veterinarian, shall determine the disposition of the wild animal based on its individual risk assessment. C. Conditions of Quarantine. (1) The Public Health Veterinarian or the local health officer may order the owner or custodian of an animal under quarantine that has had bite or non-bite contact with a human to have the animal examined by a Maryland-licensed veterinarian at any time during the quarantine period. (2) The owner or custodian of an animal under quarantine shall pay for the cost of the veterinary examination and other associated costs. (3) If a Maryland-licensed veterinarian determines that a quarantined animal has possible rabies manifestations, the veterinarian may humanely kill the animal and submit its head promptly through the local health officer or local animal control authority to the laboratory designated by the Department for testing for rabies. D. Limitation on Movement During Quarantine. A person may not move an animal under quarantine from the place of quarantine without the written permission of the local health officer or the Public Health Veterinarian. E. Humane Killing of an Animal for Rabies Testing. The local health officer or the Public Health Veterinarian may order in writing the humane killing of an animal that has had bite or non-bite contact with a human for the purpose of rabies testing if: (1) The local health officer has determined that the contact animal is reasonably likely to have rabies based on the risk assessment; (2) The owner or custodian requests humane destruction during the quarantine; (3) The animal is a wild animal unclaimed for at least 24 hours by an owner or custodian, with, for unclaimed stray animals, the 24-hour period included within the period required under Regulation .02B(29) of this chapter; or (4) The animal is inhumanely suffering. F. Surrender of Animals. A person may not fail or refuse to surrender a dead or live animal for quarantine, humane killing, or rabies testing as required in this chapter when demand is made by written order of the local health officer or the Public Health Veterinarian. G. The police, sheriff, or animal control authority staff shall enforce all written orders of the local health officer or Public Health Veterinarian issued pursuant to this regulation. #### Regulation .08 Area Quarantine. *COMAR 10.06.02.08* A. If rabies is known to exist within an area, the Public Health Veterinarian, in conjunction with the Maryland Department of Agriculture, may establish an area quarantine for rabies, define the boundaries of the quarantine area, and specify the species of animal or animals subject to the quarantine. B. The owner or custodian of an animal subject to the area quarantine shall keep the animal in quarantine on the premises of the owner or custodian at all times until the area quarantine is terminated in writing by the Public Health Veterinarian, in conjunction with the Maryland Department of Agriculture. C. A person may not bring an animal subject to an area quarantine into or out of the quarantine area without the written permission of the Public Health Veterinarian and the Department of Agriculture. #### Regulation .09 Laboratory Testing. *COMAR 10.06.02.09* A. A local health officer or local animal control authority shall submit rabies specimens for laboratory testing. B. The director of the rabies testing laboratory shall promptly forward a copy of the results of a rabies examination to the: (1) Local health officer; (2) Individual that originally submitted the specimen to the laboratory from the local animal control authority; and (3) Public Health Veterinarian. C. The director of the rabies testing laboratory shall promptly report by telephone to the local health officer a positive rabies finding on a specimen from an animal that has been involved in bite or non-bite contact with an individual. D. After receiving results of a positive finding of rabies, the local health officer shall notify the attending physician or attending veterinarian by telephone. #### Regulation .10 Vaccination of Animals. *COMAR 10.06.02.10* A. An owner or custodian of a dog, cat, or ferret shall have that animal adequately vaccinated against rabies by the time the dog, cat, or ferret is 4 months old. B. Vaccination Documentation. (1) Except for a local animal control authority, an owner or custodian of an animal required to be licensed or registered shall have the animal adequately vaccinated and shall obtain a valid rabies vaccination certificate on the form specified by the Department. The certificate shall be completed and signed by a Maryland-licensed veterinarian or, in the case of public antirabies clinics, the certificate may be issued under the authority of the Public Health Veterinarian, documenting that the animal has been adequately vaccinated against rabies for the period of time covered by the rabies vaccination. (2) Except for a kennel licensed by the local animal control authority as a boarding kennel, an owner or operator of a kennel shall present, upon the request of the local health officer, Public Health Veterinarian, or local animal control authority, a valid rabies vaccination certificate for each dog, cat, or ferret: (a) Owned or kept by the kennel; and (b) That is 4 months old or older. (3) The Public Health Veterinarian may delay temporarily or indefinitely the rabies vaccination requirement for certain dogs, cats, or ferrets in the interest of public safety or for medical determinations or research. C. Unless the Public Health Veterinarian has authorized a delay in vaccination, a local animal control authority may not license or register a dog, cat, or ferret without verifying the rabies vaccination status as documented by a current rabies vaccination certificate. D. Vaccination Certificates. (1) A vaccine manufacturer shall issue the official National Association of State Public Health Veterinarians (NASPHV) Form 51, Rabies Vaccination Certificate, or an equivalent form. (2) A veterinarian shall administer rabies vaccine to an animal in accordance with the specifications on the vaccine and recommendations for immunization procedures, such as the current Compendium of Animal Rabies Prevention and Control. (3) The veterinarian administering rabies vaccine to an animal shall: (a) Complete the NASPHV Form 51, or an equivalent form, containing the: (i) Vaccine manufacturer and lot or serial number; (ii) Date the vaccine was given; (iii) Date the next vaccination is due by; (iv) Signature of the veterinarian and the date the rabies certificate was signed; (v) Veterinarian’s name, address, telephone number, and veterinary license number legibly stamped, typed, or printed; (vi) Owner’s name, address, and telephone number; (vii) Rabies tag number; and (viii) Animal’s species, age, weight, predominant breed, and color; and (4) When vaccine is administered at public antirabies clinics, the local clinic staff shall complete the NASPHV Form 51, or an equivalent form, as directed by the Public Health Veterinarian and provide a copy to the local health officer and the animal owner. (5) A veterinarian administering rabies vaccine shall maintain copies of vaccination certificates by tag number for a minimum of 5 years following the vaccination of an animal. (6) An owner or custodian may use the vaccination certificate as proof of vaccination and shall provide it to police, the animal control authority, or health officials upon request. E. Vaccination Procedures. (1) A licensed veterinarian may select a rabies vaccine of the veterinarian’s choice and use procedures for administering it that are consistent with the recommendations of NASPHV, the United States Department of Agriculture, and the Compendium of Animal Rabies Prevention and Control. (2) The Public Health Veterinarian shall select the vaccine or vaccines to be used in public clinics according to Department procedures. (3) The Public Health Veterinarian may require specified lots of vaccine to be tested for potency, safety, and contamination as a prerequisite to their use. (4) Except for veterinary staffing, the public antirabies clinics and the local health officer shall determine all administrative procedures for public antirabies clinics in keeping with the requirements of this chapter. (5) A vendor of rabies vaccine for animal use shall supply vaccine only to a veterinary biologic supply firm, a Maryland-licensed veterinarian, or the Public Health Veterinarian. F. Rabies Tags. (1) The Public Health Veterinarian shall specify annually the size, shape, and color of the rabies tag to be issued by veterinarians and public antirabies clinics. (2) Public antirabies clinics and veterinarians who provide rabies vaccination services to dogs, cats, and ferrets shall promptly issue to the owner of each vaccinated animal a rabies certificate, tag, and s-shaped metal link for attaching the tag on the animal's collar. (3) The local health officer shall order rabies tags through the Public Health Veterinarian for use in public antirabies clinics. G. Antirabies Clinics. (1) In conjunction with the Department, each local health department shall provide for low-cost, self-financing, antirabies clinics for animals in each county and Baltimore City. (2) The Department shall assure that at least two clinics are offered annually with at least one to be held between April 1 and July 1 at dates and locations determined by the local health department. (3) The Public Health Veterinarian shall establish in writing the vaccination procedures to be used at the clinics and distribute these procedures to the local health officers. (4) The local health departments may establish fees sufficient to cover the costs of operating the clinics. (5) The local health officer shall report, in the manner specified by the Public Health Veterinarian, data concerning animals vaccinated at each clinic and the related costs. #### Regulation .11 Importation of Animals. *COMAR 10.06.02.11* A. Except as provided in §§B and I of this regulation, the owner or custodian of a dog, cat, or ferret 4 months old or older to be imported into the State for any purpose shall forward a certificate, issued by a licensed veterinarian, to the Public Health Veterinarian, within 10 days of the animal's arrival in the State, that: (1) Describes the dog, cat, or ferret, documenting that it was vaccinated against rabies; (2) Lists the manufacturer or brand of vaccine used; (3) Lists the date or dates the vaccine was given; (4) Documents that the animal is adequately vaccinated; and (5) Documents that the most recent dose of vaccine was given more than 30 days before the date the animal arrived in the State. B. Except as provided in §I of this regulation, the owner or custodian of a dog, cat, or ferret brought into the State for a period of less than 30 days is exempt from the requirement to forward a certificate to the Public Health Veterinarian as specified in §A of this regulation, if a copy of a certificate signed by a licensed veterinarian can be presented to the local health officer immediately when requested. C. The local animal control authority may accept the certificate specified in §A of this regulation as proof of vaccination for licensing or registration purposes for the period specified on the certificate or 12 months, whichever period is shorter. D. The Public Health Veterinarian or the local health officer may order the owner or custodian of a dog, cat, or ferret brought into Maryland in violation of the provisions of this regulation to return the animal immediately to its point of origin at the owner's expense. E. If the local animal control authority is unable to locate an individual who will assume fiscal responsibility for an animal under an order to be returned to the point of origin within 48 hours of the issuance of the order, the authority may deem the animal abandoned and humanely kill it or place it for adoption. F. Research facilities and licensed dealers, as defined in 7 U.S.C. §2132 and 9 CFR 1.1 and 2.7, are exempt from §§D and E of this regulation when importing dogs, cats, and ferrets. G. The Secretary shall establish, in consultation with the Maryland Department of Agriculture, rabies control requirements for the importing and keeping of animals other than dogs, cats, and ferrets, such as livestock, wildlife, zoo animals, and exotic animals. H. The Secretary, with the agreement of the Secretary of Agriculture and the Secretary of Natural Resources, shall prohibit the importation of certain animals or species of animals from areas inside or outside the United States that are known to have a high prevalence of rabies and the animals subject to the ban are judged to present an unacceptable risk of rabies infection in humans or animals. I. The Public Health Veterinarian may waive the requirements of §§A and B of this regulation if the importation of the animal poses no risk to the public health or safety. #### Regulation .12 Permits Required for Keeping Certain Animals. *COMAR 10.06.02.12* The Secretary shall require a person to obtain from the Public Health Veterinarian a permit for keeping certain animals or species of animals if the Secretary has determined that these animals or species of animals represent a substantial threat of rabies to humans. #### Regulation .13 Disposition of Animals by Animal Shelters, Pounds, or Veterinarians. *COMAR 10.06.02.13* A. The owner or custodian of an animal who surrenders the animal to an animal shelter, pound, or veterinarian for the purpose of having the animal humanely killed or for the purpose of offering the animal for adoption shall certify in writing, under penalty of perjury, that the animal: (1) If a dog, cat, ferret, or livestock, has not had bite or non-bite contact with an individual within the previous 10 days; or (2) If a wild animal, has not had bite or non-bite contact with an individual within the previous 30 days. B. Except as provided in §C of this regulation, if the animal has had bite or non-bite contact with an individual within the time periods specified in §A of this regulation, the animal shelter, pound, or veterinarian shall: (1) If the animal is a dog, cat, ferret, or livestock, offer the owner or custodian, the option of: (a) Quarantining the animal for 10 calendar days at the owner’s or custodian’s expense; or (b) Humanely killing the animal and submitting the head for rabies testing; or (2) If the animal is a wild animal, immediately humanely kill the animal and submit its head for rabies testing. C. The Public Health Veterinarian may waive the requirements of §B of this regulation if it is determined that the public health is not threatened. #### Regulation .14 Penalty. *COMAR 10.06.02.14* A person refusing or failing to comply with the provisions of this chapter, or with the orders or directives of the local health officer, the State Epidemiologist, or the Public Health Veterinarian as provided by this chapter, shall be guilty of a misdemeanor and, upon conviction, subject to a fine of not more than $500 for each offense. ### Chapter 03 — ImmuNet **Authority:** Health-General Article, §18-109; Health Occupations Article, §12-508; Annotated Code of Maryland **Administrative History:** Effective date: April 27, 2015 (42:8 Md. R. 607) #### Regulation .01 Scope. *COMAR 10.06.03.01* This chapter governs ImmuNet, a computer-based registry of immunizations, as established in Health-General Article, §18-109, Annotated Code of Maryland. #### Regulation .02 Definitions. *COMAR 10.06.03.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Authorized user” means: (a) A child care facility; (b) A health care provider; (c) A health insurer; (d) A health maintenance organization; (e) An institution of higher learning; (f) A local health department; (g) A long-term care facility; (h) A managed care organization; (i) A nonprofit health service plan; (j) A patient; (k) A pharmacist authorized to administer vaccinations in accordance with Health Occupations Article, §12-508, Annotated Code of Maryland; (l) A school; (m) A school-based health center; (n) In the case of a minor child, a parent or guardian; and (o) Any other authorized user designated by the Secretary. (2) “Department” means the Maryland Department of Health. (3) “ImmuNet” means a computerized information and reminder system to: (a) Improve the timely and appropriate delivery of immunizations; (b) Provide a coordinated network for reminder notices when immunizations are due; (c) Provide and collect information to be shared by authorized users; and (d) Provide a quality indicator for the insurers’ health care provider practices and public health purposes. (4) “Refusal to permit disclosure of information” means the right of an individual or the parent or guardian of a minor to prevent disclosure to authorized users of individual identifiable information that was reported to ImmuNet. (5) Regional Registry. (a) “Regional registry” means a database that contains immunization information for individuals residing in an area of Maryland. (b) “Regional registry” includes an immunization database or registry maintained and operated by a local health department. (6) “Secretary” means the Secretary of Health. (7) “Vaccine information statement (VIS)” means a document that: (a) Is created and updated by the U.S. Centers for Disease Control and Prevention; and (b) Relates: (i) The purpose of specific vaccines; (ii) Schedules of administration; and (iii) Possible adverse reactions to specific vaccines. #### Regulation .03 Administration of ImmuNet. *COMAR 10.06.03.03* A. The Department shall support and administer ImmuNet. B. The Department may enter or edit information contained in ImmuNet. C. ImmuNet is subject to the security and reliability standards set forth in Regulation .09 of this chapter. D. The Department shall make available to authorized users and to the general public all forms relevant to ImmuNet, such as the: (1) User agreement; (2) Refusal to Permit Disclosure of Information form; and (3) Statement of Reactivation of Participation in ImmuNet form. #### Regulation .04 Information Reported to ImmuNet. *COMAR 10.06.03.04* A. The Department shall enter the following information from each birth certificate registered in Maryland: (1) Child’s: (a) First, middle, and last name; (b) Date of birth; (c) Sex; and (d) Current or last known address; and (2) Child’s mother’s: (a) First and middle names; (b) Maiden Name if applicable; and (c) Current last name. B. Following the administration of a vaccine to an individual residing in Maryland, the health care provider who administered the vaccine may enter the following information to ImmuNet: (1) Patient’s: (a) First, middle, and last name; (b) Date of birth; (c) Sex; (d) Birth state and country; (e) Current or last known address; (f) If the patient is a minor, the name of the parent or guardian; (g) Last four digits of Social Security number, if available; and (h) Medicaid number, if available and applicable; (2) Patient’s mother’s: (a) First and middle names; (b) Maiden name, if applicable; and (c) Current last name; (3) For each vaccine administered: (a) Antigen type; (b) Manufacturer; (c) Expiration date; (d) Lot number; (e) Date VIS provided to patient; (f) VIS date; and (g) Date of administration; (4) Contraindication, adverse event, and exemption information for the patient, including: (a) A medical contraindication or adverse event to the administration of one or more vaccines; (b) Whether the contraindication is permanent or temporary and, if temporary, the date after which the contraindication will no longer exist or needs to be reassessed; and (c) An objection to immunization based on a bona fide religious belief and practice; (5) Other medical information pertaining to vaccine-preventable diseases, including serologic test results; (6) Other information designated by the U.S. Centers for Disease Control and Prevention as Immunization Information System Required Core Data Elements; and (7) Other information designated by the Secretary. C. Correction of Inaccurate Information. A patient or a parent or a guardian of a minor patient whose immunization information is entered into ImmuNet may contact the Department to: (1) View the information; and (2) Provide information to correct any inaccuracies. #### Regulation .05 User Agreement. *COMAR 10.06.03.05* A. An authorized user who wishes to obtain information from ImmuNet shall enter into a user agreement with the Department for the purpose of protecting the confidentiality and security of ImmuNet information. B. The user agreement shall include but not be limited to the: (1) Functions that may be performed by an authorized user of ImmuNet; (2) Authorized uses of ImmuNet information as set forth in Health-General Article, §18-109(c), Annotated Code of Maryland; (3) Prohibitive uses of ImmuNet information as set forth in Health-General Article, §18-109(f), Annotated Code of Maryland; and (4) Basic practices for safeguarding confidential information. C. Authorized users shall request the renewal of the user agreement on an annual basis. D. Authorized User Functions. (1) An authorized user who has signed a user agreement may obtain the following information about an individual from ImmuNet: (a) First, middle, and last name; (b) Date of birth; (c) Address; (d) Telephone number; (e) In the case of a minor child, the name of the parent or guardian; (f) Immunizations given; (g) Immunization dates; (h) Contraindication, adverse event, and exemption information; and (i) Other medical information pertaining to vaccine-preventable diseases, including serologic test results. (2) An authorized user that is a health care provider, local health department, long-term care facility, or school-based health center that administers immunizations may: (a) Enter information into ImmuNet directly from medical records that are in the authorized user’s possession; and (b) Edit information the authorized user has entered into ImmuNet. (3) An authorized user who is a patient or a parent or guardian of a minor may view the patient’s or the minor patient’s ImmuNet information without signing a user agreement by requesting the information from the patient’s or minor’s immunization provider or the Department. (4) With approval from the Department, the following authorized users may enter information into ImmuNet: (a) A child care facility; (b) A health insurer; (c) A health maintenance organization; (d) An institution of higher learning; (e) A managed care organization; (f) A nonprofit health service plan; and (g) A school. #### Regulation .06 Refusal and Reactivation. *COMAR 10.06.03.06* A. An individual or a parent or guardian of a minor child who has received an immunization may at any time prohibit information in ImmuNet from being disclosed to authorized users by providing to the Department a signed and dated Refusal to Permit Disclosure of Information form. B. An individual or a parent or guardian of a minor who has submitted a Refusal to Permit Disclosure of Information form may allow information in ImmuNet to be disclosed by submitting to the Department a signed and dated written Statement of Reactivation of Participation in ImmuNet form. #### Regulation .07 Permissible Use of ImmuNet Information. *COMAR 10.06.03.07* Information in ImmuNet may be used by authorized users for the following purposes: A. To provide coordinated immunization services, including sending reminder notices to individuals who need immunizations; B. To obtain an individual immunization history; C. To identify geographic areas or population groups who are underimmunized; D. To compile aggregate information and distribute statistical reports on the status of immunizations in geographic areas and population groups; E. To assist in the management of State and local immunization programs; F. To monitor the safety of vaccines; G. To assess compliance with immunization requirements by monitoring admissions to: (1) Schools; (2) Institutions of higher learning; and (3) Child care facilities; and H. For any other purpose that the Secretary deems necessary to prevent the spread of communicable diseases or assess the safety or effectiveness of vaccines in accordance with Health-General Article, §18-109(c), Annotated Code of Maryland. #### Regulation .08 Regional and Other State Immunization Registries. *COMAR 10.06.03.08* A. A regional registry shall submit to ImmuNet all immunization information on Maryland residents within 14 calendar days of receipt of the information. B. If the confidentiality of records of Maryland citizens is protected, the Department may enter into a collaborative agreement with other states for the purpose of sharing immunization information. #### Regulation .09 Security and Reliability Standards. *COMAR 10.06.03.09* A. The Department shall maintain ImmuNet in accordance with system security requirements for federal information processing systems, including National Institute of Standards and Technology (NIST) 800-53 Special Publication, and prevailing agency information technology security policy standards and requirements. B. ImmuNet Security. (1) The Department shall: (a) Maintain ImmuNet information on a server protected by a firewall; and (b) Encrypt information traveling to and from authorized users. (2) The Department shall maintain encryption keys in a secure location. ### Chapter 04 — School Health Services and Required Immunizations Before Entry into School **Authority:** Education Article, §7-403 and Health-General Article, §18-102(a), Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulation .01 amended as an emergency provision effective May 10, 1977 (4:11 Md. R. 865); emergency status extended at 4:22 Md. R. 1667 and 4:27 Md. R. 2095 (Emergency provisions are temporary and not printed in COMAR) **Administrative History:** Regulation .01 amended effective December 16, 1977 (4:26 Md. R. 2024) and May 18, 1979 (6:10 Md. R. 842) **Administrative History:** Regulation .01A amended and C adopted effective February 11, 1985 (12:3 Md. R. 245) **Administrative History:** Regulation .03 amended effective January 2, 1984 (10:26 Md. R. 2340) **Administrative History:** Annotation: COMAR 10.06.04.03 cited in Davis v. State, 294 Md. 370 (1982), in which the court held that “membership in a recognized religious group cannot be required as a condition of exemption from vaccination”. The religious exemption was held to contravene the Establishment Clause of the First Amendment and was therefore invalid. The immunization requirement itself was found to be severable and remains in force. **Administrative History:** Chapter revised effective March 30, 1992 (19:6 Md. R. 672) **Administrative History:** Regulation .03 amended effective April 22, 1996 (23:8 Md. R. 605); May 19, 1997 (24:10 Md. R. 710) **Administrative History:** Regulations .01—.10 repealed and new Regulations .01—.10 adopted effective November 24, 2005 (32:23 Md. R. 1826) **Administrative History:** Regulation .03 amended effective November 12, 2012 (39:22 Md. R. 1428) **Administrative History:** Regulation .03E amended as an emergency provision effective July 1, 2006 (33:15 Md. R. 1273); amended permanently effective September 25, 2006 (33:19 Md. R. 1560) **Administrative History:** Regulation .03F adopted as an emergency provision effective March 20, 2007 (34:8 Md. R. 766); emergency provision expired #### Regulation .01 School Health Services. *COMAR 10.06.04.01* The local health department shall cooperate with the local school system in implementing the School Health Services regulations found in COMAR 13A.05.05.05—15. #### Regulation .02 Definitions. *COMAR 10.06.04.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Health officer” means the health officer in each of the 23 counties of Maryland and the Commissioner of Health in Baltimore City, the designated representative of the health officer, or both. (2) “Preschool program” means a program that enrolls children in an educational program below the level of kindergarten. (3) “Regulated child care program” means: (a) A family day care provider registered pursuant to COMAR 07.04.01; (b) The operator of a child care center licensed pursuant to COMAR 07.04.02; or (c) The operator of a child care facility issued a letter of compliance pursuant to COMAR 07.04.05. (4) “Secretary” means the Secretary of Health or the Secretary's designee. #### Regulation .03 Required Immunizations. *COMAR 10.06.04.03* A. Except as provided in Regulations .04—.06 of this chapter, a preschool or school principal or other person in charge of a preschool or school, public or private, may not knowingly admit a student to or retain a student in a: (1) Preschool program unless the student's parent or guardian has furnished evidence of age-appropriate immunity against Haemophilus influenzae, type b, and pneumococcal disease; (2) Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has furnished evidence of age-appropriate immunity against pertussis; and (3) Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles (rubeola); (e) Mumps; (f) Rubella; (g) Hepatitis B; (h) Varicella; (i) Meningitis; and (j) Tetanus-diphtheria-acellular pertussis acquired through a Tetanus-diphtheria-acellular pertussis (Tdap) vaccine. B. Except as provided in Regulations .04—.06 of this chapter, a parent or guardian shall provide evidence of age-appropriate immunity to the preschool or school authority on a form provided by the Secretary or on a printed or computer-generated form that lists the following: (1) Name of the student; (2) Date of birth; (3) Name and address of parent or guardian; (4) Complete history of vaccines received with month, day, and year of each vaccine dose; and (5) Signature, title, and date of the physician, health official, school official, or regulated child care program providing the information on the form. C. Except as provided in Regulations .04—.06 of this chapter and §A(3) of this regulation, a student shall obtain immunizations in accordance with the schedule of immunizations recommended by the Medical and Chirurgical Faculty of Maryland and the Secretary, as set forth in §D of this regulation and as required to be implemented in §§E and F of this regulation. D. Schedule of Immunizations. (1) Student in Preschool. In order for the immunization status of a student enrolled in a preschool to be complete, the student's parent or guardian shall provide proof of the following doses of immunizations: (2) Student in Kindergarten Through 12th Grade. (a) In order for the immunization status of a student enrolled in kindergarten through 12th grade to be complete, the student's parent or guardian shall provide proof of the immunizations or immunity as outlined in §D(2)(b)—(l) of this regulation. (b) Diphtheria. (i) Four doses of diphtheria immunization vaccine are required for a student younger than 7 years old; and (ii) Three doses of diphtheria immunization vaccine are required for a student 7 years old or older. (c) Tetanus. (i) Four doses of tetanus immunization vaccine are required for a student younger than 7 years old; and (ii) Three doses of tetanus immunization vaccine are required for a student 7 years old or older. (d) Pertussis. Four doses of pertussis immunization vaccine are required for a student younger than 7 years old. (e) Poliomyelitis (Oral or Injectable). (i) Three doses of poliomyelitis immunization vaccine are required for a student younger than 18 years old; or (ii) Proof of immunity from poliomyelitis by blood test is required for a student younger than 18 years old. (f) Rubella. (i) Two doses of live rubella virus vaccine are required when the student is 1 year old or older; or (ii) Proof of immunity from rubella by blood test is required when the student is 1 year old or older. (g) Measles (rubeola). (i) Two doses of live measles (rubeola) virus vaccine are required when the student is 1 year old or older; or (ii) Proof of immunity from rubeola by blood test is required when the student is 1 year old or older. (h) Mumps. (i) Two doses of live mumps virus vaccine are required when the student is 1 year old or older; or (ii) Proof of immunity from mumps by blood test is required when the student is 1 year old or older. (i) Hepatitis B. (i) Three doses of hepatitis B vaccine are required; or (ii) Proof of immunity from hepatitis B by blood test is required. (j) Varicella. (i) All doses of varicella vaccine shall be given when the student is 1 year old or older. (ii) Per the schedule of implementation in §E(1) of this regulation and except as provided in §D(2)(j)(iii) of this regulation, one dose of live varicella vaccine is required for a student younger than 13 years old, or two doses of live varicella vaccine are required for a student 13 years old or older, if the student does not have proof of vaccination against varicella at an age younger than 13 years old. (iii) Proof of immunity from varicella by blood test or by medical diagnosis indicated by month and year of diagnosis may be provided instead of meeting the requirements of §D(2)(j)(ii) or (iv) of this regulation. (iv) Per the schedule of implementation in §E(2) of this regulation and except as provided in §D(2)(j)(iii) of this regulation, two doses of live varicella vaccine are required. (k) Meningococcal. One dose of meningococcal vaccine is required per the schedule of implementation in §F of this regulation. (l) Tetanus-diphtheria-acellular pertussis (Tdap). One dose of Tetanus-diphtheria-acellular pertussis (Tdap) immunization vaccine is required per the schedule of implementation in §F of this regulation. (3) Record Review for Student in Preschool Through 12th Grade. A preschool or school, public or private, may count as valid, vaccine doses administered less than or equal to 4 days before the minimum interval or age. E. Schedule of Implementation: Varicella Effective Immunization Dates for a Student in Kindergarten Through 12th Grade. (1) As set forth in §E(2) of this regulation, by the date listed in Column 1, the parent or guardian of a student entering the grade listed in Column 2 shall provide proof to the school that the student: (a) Has received age appropriate vaccination with varicella vaccine; or (b) Is immune to varicella by providing the results of a blood test or a medical diagnosis indicated by month and year of diagnosis. (2) One-Dose Requirement Immunization Dates for a Student in Kindergarten Through 12th Grade. (3) As set forth in §E(4) of this regulation, by the date listed in Column 1, the parent or guardian of a student entering the grade listed in Column 2 shall provide proof to the kindergarten or school that the student: (a) Has received two doses of varicella vaccine; or (b) Is immune to varicella by providing the results of a blood test or a medical diagnosis indicated by month and year of diagnosis. (4) Two-Dose Requirement Immunization Dates for a Student in Kindergarten Through 12th Grade. F. Schedule of Implementation: Meningococcal and Tetanus-diphtheria-acellular pertussis (Tdap) Effective Immunization Dates for a Student in Preschool Through 12th Grade. (1) As set forth in §F(2) of this regulation, by the date listed in Column 1, the parent or guardian of a student entering the grade listed in Column 2 shall provide proof to the preschool or school that the student has received one dose of: (a) Meningococcal immunization vaccine; and (b) Tetanus-diphtheria-acellular pertussis (Tdap) immunization vaccine. (2) Immunization Dates for a Student in 7th Through 12th Grade. #### Regulation .04 Medical Contraindications. *COMAR 10.06.04.04* A. The requirements of Regulation .03 of this chapter do not apply to a student who presents a licensed physician's or health officer's written statement that the student's immunization against a disease in Regulation .03 of this chapter is medically contraindicated. B. The physician or health officer shall indicate in the statement presented under §A of this regulation whether the contraindication is: (1) Permanent; or (2) Temporary. C. If the contraindication is temporary: (1) The physician or health officer shall provide in the statement presented under §A of this regulation an estimate of when the immunization may be obtained by the student; and (2) The student's parent or guardian shall furnish to the preschool or school evidence of the completion of the immunization in accordance with the estimate. D. A preschool or school, public or private, shall maintain a current list of all students enrolled who have an exemption to immunizations on medical grounds. E. Annually, by November 15, a preschool or school, public or private, shall report to the Secretary of Health the number of students with a medical exemption enrolled in all grades. #### Regulation .05 Religious Exemption. *COMAR 10.06.04.05* A. Using the form provided by the Maryland Department of Health, a student whose parent or guardian objects to immunization on the ground that the immunization conflicts with the parent's or guardian's bona fide religious beliefs and practices is exempt from the requirement to present a physician's certificate of immunization in order that the student be admitted to school. B. The exemption allowed under §A of this regulation does not apply when the Secretary declares an emergency or epidemic of disease. C. A preschool or school, public or private, shall maintain a current list of all students enrolled who have an exemption to immunizations on religious grounds. D. Annually, by November 15th, a preschool or school, public or private, shall report to the Secretary of Health the number of students with a religious exemption enrolled in all grades. #### Regulation .06 Temporary Admission or Retention. *COMAR 10.06.04.06* A. Subject to the provisions of §B of this regulation, a preschool or school, public or private, shall temporarily admit a student to or retain a student in a preschool or school if: (1) The student is homeless; or (2) The student's parent or guardian is unable to provide proof of immunization pursuant to the requirements of Regulation .03 of this chapter. B. In order for a student to be temporarily admitted to or retained in a preschool or school, the student's parent or guardian shall present evidence of the student's appointment with a health care provider or local health department to: (1) Receive a required immunization; (2) Reconstruct a lost record; or (3) Acquire evidence of age-appropriate immunity on a form provided by the Department. C. The date of the appointment pursuant to §B of this regulation may not be later than 20 calendar days following the date the student was temporarily admitted or retained. D. A preschool or school, public or private, shall exclude from school a student who has been temporarily admitted or retained on the next school day following the appointment date if the student's parent or guardian fails to provide evidence of required immunizations. #### Regulation .07 Vaccine Provision. *COMAR 10.06.04.07* A. A student may have an immunization administered by the student's personal physician. B. If a parent or guardian cannot obtain the service of a private physician, the parent or guardian of the student may take the student to the local health department for the immunizations. C. A local health department shall provide the immunization referenced in §B of this regulation. #### Regulation .08 Record Review. *COMAR 10.06.04.08* A preschool or school, public or private, shall make immunization records of students available for review by a health officer as needed to assure compliance with regulations or to ascertain the immunization status of students. #### Regulation .09 Report on New Students. *COMAR 10.06.04.09* Annually, by November 15, on a form provided by the Department, a preschool or school, public or private, shall provide the health officer of the jurisdiction where the school is located with an immunization report of students in preschool through 12th grade who are new to the school. #### Regulation .10 Responsible Agencies. *COMAR 10.06.04.10* The local superintendents of schools and the local health officers shall be responsible for carrying out the provisions of this chapter. ### Chapter 05 — Meningococcal Vaccination Requirements for Students in Institutions of Higher Education **Authority:** Health-General Article, §18-102(b), Annotated Code of Maryland **Administrative History:** Effective date: November 12, 2001 (28:22 Md. R. 1937) #### Regulation .01 Scope. *COMAR 10.06.05.01* This chapter applies to meningococcal vaccination of individuals enrolled in institutions of higher education who are living in on-campus student housing. #### Regulation .02 Definitions. *COMAR 10.06.05.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Enrolled” means having registered for a credit or noncredit course. (2) “Institution of higher education” means a school of post-secondary education that generally limits enrollment to graduates of secondary schools and awards degrees at the associate, baccalaureate, or graduate level. (3) “Meningococcal vaccination” means receipt of the vaccine protecting against at least the four serogroups of A, C, Y, and W-135 of meningococcal disease within the preceding 5 years before the individual moves into on-campus student housing. (4) “On-campus student housing” means housing provided to individuals, regardless of the fee, that is owned, rented, or contracted for and operated by an institution of higher education, or through written agreement, with an agent of the institution of higher education. #### Regulation .03 Required Meningococcal Vaccination. *COMAR 10.06.05.03* Except as provided in Regulation .05 of this chapter, an individual enrolled in an institution of higher education living in on-campus student housing shall: A. Obtain a meningococcal vaccination; and B. Submit written documentation to the institution of higher education from a health care professional or clinic of receipt of a meningococcal vaccination. #### Regulation .04 Notification of Required Meningococcal Vaccination. *COMAR 10.06.05.04* An institution of higher education shall: A. Inform an individual or the parent or guardian of an individual younger than 18 years old of the requirement for meningococcal vaccination at the time the individual: (1) Is accepted for admission to an institution of higher education; or (2) Registers for classes, if the individual is not required to apply for admission before registering for courses; B. Include notice of the requirement for meningococcal vaccination in: (1) Admission acceptance information; (2) Student health-related information and materials; (3) Resident life information and materials; (4) The student handbook; and (5) The college catalog; and C. Provide detailed information to an individual who resides or may reside in on-campus student housing or the parent or guardian of an individual younger than 18 years old who resides or may reside in on-campus student housing concerning: (1) The risks associated with meningococcal disease; and (2) The availability and effectiveness of meningococcal vaccine. #### Regulation .05 Exemption from Meningococcal Vaccination Requirement. *COMAR 10.06.05.05* A. An individual 18 years old or older is exempt from the meningococcal vaccination requirement set forth at Regulation .03 of this chapter if the individual presents to the institution of higher education a signed written waiver as set forth in Regulation .06A of this chapter stating that the individual has: (1) Received and reviewed the information specified in Regulation .04C of this chapter; and (2) Chosen not to obtain the meningococcal vaccination. B. An individual younger than 18 years old is exempt from the meningococcal vaccination requirement set forth at Regulation .03 of this chapter if a signed written waiver as set forth in Regulation .06B of this chapter is presented to the institution of higher education on behalf of the individual stating that a parent or guardian of the individual has: (1) Received and reviewed the information specified in Regulation .04C of this chapter; and (2) Chosen not to have the individual obtain the meningococcal vaccination. #### Regulation .06 Waiver Form. *COMAR 10.06.05.06* A. A waiver form for an individual 18 years old or older shall: (1) State that the individual: (a) Is 18 years old or older; (b) Has received and reviewed the information provided by the institution of higher education on the risk of meningococcal disease and the availability and effectiveness of meningococcal vaccine; and (c) Chooses to waive the receipt of meningococcal vaccine; and (2) Provide spaces for the: (a) Printed name of the individual; (b) Signature of the individual; and (c) Date. B. A waiver form for an individual younger than 18 years old shall: (1) State that: (a) The individual is younger than 18 years old; (b) The parent or guardian of the individual has received and reviewed the information provided by the institution of higher education on the risk of meningococcal disease and the availability and effectiveness of meningococcal vaccine; and (c) The parent or guardian of the individual chooses to waive the receipt of meningococcal vaccine for the individual; and (2) Provide spaces for the: (a) Printed name of the individual; (b) Printed name of the parent or guardian; (c) Signature of the parent or guardian; and (d) Date. #### Regulation .07 Payment for Meningococcal Vaccination. *COMAR 10.06.05.07* Nothing in this chapter shall be construed to require an institution of higher education or a local public health agency to provide or pay for a meningococcal vaccination. ### Chapter 06 — Communicable Disease Prevention — Handling, Treatment, and Disposal of Special Medical Waste **Authority:** Health-General Article, §18-102, Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulations .01—.08 adopted as an emergency provision effective September 30, 1988 (15:22 Md. R. 2547); emergency status expired March 29, 1989; adopted permanently effective May 1, 1989 (16:8 Md. R. 909) **Administrative History:** Regulation .02B amended effective December 20, 1993 (20:25 Md. R. 1947) **Administrative History:** Regulation .04B amended effective December 20, 1993 (20:25 Md. R. 1947) **Administrative History:** Regulation .06B amended effective December 20, 1993 (20:25 Md. R. 1947) **Administrative History:** Regulation .07C amended effective December 20, 1993 (20:25 Md. R. 1947) **Administrative History:** Regulations .01—.07 repealed and new Regulations .01—.07 adopted effective September 1, 2004 (31:16 Md. R. 1254) **Administrative History:** Regulation .02B amended effective November 6, 2006 (33:22 Md. R. 1732) **Administrative History:** Regulation .04 amended effective November 6, 2006 (33:22 Md. R. 1732) **Administrative History:** Regulation .06A amended effective November 6, 2006 (33:22 Md. R. 1732) **Administrative History:** Regulation .07 amended effective November 6, 2006 (33:22 Md. R. 1732) #### Regulation .01 Scope and Purpose. *COMAR 10.06.06.01* A. Scope. (1) Regulations .01—.03 apply to a person who generates and handles special medical waste or sharps. (2) Regulations .01—.07 apply to a person who treats and disposes of special medical waste. (3) This chapter does not apply to: (a) Waste generated from veterinary practices that is governed by COMAR 15.14.03.02; (b) Radioactive medical waste that is governed by COMAR 26.12.01.01; (c) Remains of a dead human; and (d) Fetuses and placentas that are released to a funeral director or a parent. B. Purpose. The purpose of this chapter is to minimize the possibility of disease transmission by establishing requirements for the handling, treatment, and disposal of special medical waste. #### Regulation .02 Definitions. *COMAR 10.06.06.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Anatomical material” means human or animal body parts, including tissues and organs. (2) “Autoclaving” means a process by which an article is subjected to steam under pressure for documented periods of time, temperature, and pressure that render the article incapable of transmitting disease to humans. (3) “Blood” means human blood, human blood components, and products made from human blood. (4) Bloodborne Pathogens. (a) “Bloodborne pathogens” means pathogenic microorganisms that: (i) Are present in human blood; and (ii) Can cause disease in humans. (b) “Bloodborne pathogens” includes, but is not limited to: (i) Human immunodeficiency virus; (ii) Hepatitis B virus; and (iii) Hepatitis C virus. (5) “Chemical disinfection” means the application of a chemical agent to an article, so that the article is rendered incapable of transmitting disease to humans. (6) “Contaminated” means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. (7) “Cremation” means the incineration of human or animal remains. (8) “Decontamination” means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on an article to render the article incapable of transmitting disease to humans. (9) “Department” means the Maryland Department of Health. (10) “Disinfection” means a method that inactivates: (a) Vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites, and mycobacteria at a 6 log reduction or greater; and (b) Bacillus stearothermophilus spores and Bacillus subtilis spores at a 4 log reduction or greater. (11) “Encapsulation” means a process by which: (a) An article is sealed in a material that renders the article no longer recognizable or capable of transmitting disease to humans; and (b) The sealed material: (i) Is decontaminated or disinfected during the encapsulation process; and (ii) Remains sealed under physical stress. (12) “Incineration” means a process during which an article is burned: (a) In an incinerator that meets the requirements of the Department of the Environment as set forth in COMAR 26.11.08; (b) To carbonized or mineralized ash that is capable of disposal as solid waste; and (c) So the article is rendered incapable of transmitting disease to humans. (13) “Infectious agent” means an organism, including viral, rickettsial, bacterial, fungal, protozoal, or helminthic, that is capable of producing infection or infectious disease in humans. (14) “Interment” means burial in a location, other than a landfill, that is approved for that purpose under applicable law. (15) “Mechanical destruction” means a physical process that renders an article no longer recognizable as the original article. (16) “Microbiological laboratory waste” means waste from a microbiological laboratory that: (a) Contains an infectious agent; and (b) Includes cultures and stocks of infectious agents and associated biologicals. (17) “Occupational exposure” means skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials, that results from the performance of an employee's duties. (18) “Other potentially infectious material” means: (a) The following human body fluids: (i) Amniotic fluid; (ii) A body fluid that is visibly contaminated with blood; (iii) A body fluid that cannot be readily identified; (iv) Cerebrospinal fluid; (v) Pericardial fluid; (vi) Peritoneal fluid; (vii) Pleural fluid; (viii) Saliva only when dental procedures are performed; (ix) Semen; (x) Synovial fluid; and (xi) Vaginal secretions; (b) A tissue or organ from a living or dead human, not including intact skin, that has not been preserved by a chemical additive or preservative; (c) The following human immunodeficiency virus, hepatitis B virus, or hepatitis C virus related items: (i) HIV containing cell, tissue, or organ cultures; (ii) HIV, Hepatitis B, or Hepatitis C containing media or other solutions; and (iii) Blood, organs, or other tissues; and (d) Microbiological laboratory waste. (19) “Person” means an individual, receiver, trustee, guardian, personal representative, fiduciary, or representative of any kind and any partnership, firm, association, corporation, or other entity. (20) “Sanitary sewer” means: (a) A liquid waste piping network leading to a sewerage system permitted under Environment Article, §9-204, Annotated Code of Maryland; or (b) An on-site sewerage system permitted under Environment Article, §9-204, Annotated Code of Maryland. (21) “Sharps” means an object contaminated by blood or other potentially infectious material that can cut or penetrate the skin, including but not limited to: (a) A broken capillary tube; (b) Broken glass; (c) An exposed end of dental wire; (d) A needle; (e) A surgical instrument; and (f) A syringe with an attached sharp. (22) “Special medical waste” means: (a) Liquid or semiliquid blood or another potentially infectious material; (b) A contaminated article that releases liquid or semiliquid blood or another potentially infectious material if compressed; (c) An article that contains dried blood or another potentially infectious material and is capable of releasing the blood or material during handling; (d) Pathological and microbiological waste containing blood or another potentially infectious material; (e) Contaminated sharps; and (f) Anatomical material. #### Regulation .03 Handling of Special Medical Waste. *COMAR 10.06.06.03* A person shall handle special medical waste in accordance with the requirements of: A. 29 CFR §1910.1030(d)(4)(iii)(A) and (B), which is incorporated by reference at COMAR 09.12.31; and B. COMAR 26.13.12.05 and 26.13.13. #### Regulation .04 Treatment of Special Medical Waste, Excluding Sharps, Before Disposal. *COMAR 10.06.06.04* A. Except as provided in §B of this regulation, a person shall: (1) Treat special medical waste, excluding sharps, before disposal; and (2) Use one of the following treatment methods: (a) Autoclaving; (b) Chemical disinfection; (c) Cremation; (d) Disinfection; (e) Mechanical destruction after decontamination; (f) Incineration; or (g) An alternative method that meets the criteria of Regulation .06 of this chapter. B. A person may discharge certain special medical waste directly into a sewerage system, without treatment, in accordance with Regulation.07B of this chapter. #### Regulation .05 Treatment of Sharps Before Disposal. *COMAR 10.06.06.05* A person shall treat sharps: A. Before disposal; and B. By one of the following methods: (1) Encapsulation; (2) Incineration; (3) Mechanical destruction after decontamination; or (4) An alternative method that meets the criteria of Regulation .06 of this chapter. #### Regulation .06 Alternative Treatment Systems. *COMAR 10.06.06.06* A. Except as provided in §B of this regulation, a person may not use a method for treatment of special medical waste other than those set forth at Regulations .04A(2) and .05B of this chapter. B. Criteria for Alternative Treatment System. A person may use a method for treatment of special medical waste that complies with the following standards for treatment and microbial test procedures: (1) The method inactivates vegetative bacteria, fungi, parasites, lipophilic or hydrophilic viruses, and mycobacteria at a 6 log reduction or greater; (2) The method inactivates bacterial spores at a 4 log reduction or greater; and (3) The tests have been performed on a representative from each of the following microbial groups: (a) Staphylococcus aureus (ATCC 6538) or Pseudomonas aeruginosa (ATCC 15422); (b) Candida albicans (ATCC 18804) or Penicillium chrysogenum (ATCC 24791); (c) Polio 2 or Polio 3 or MS-2 Bacteriophage, (ATCC 15597-B1); (d) Cryptosporidium spp. oocysts or Giardia spp. cysts; (e) Mycobacterium terrae, Mycobacterium phlei, or Mycobacterium bovis (BCG) (ATCC 35743); and (f) Bacillus stearothermophilus (ATCC 7953) or Bacillus subtilis (ATCC 19659). C. A person may not use a method for treating of special medical waste that: (1) Creates a threat to health or safety; or (2) Violates applicable federal and State environmental laws or regulations. #### Regulation .07 Disposal of Special Medical Waste. *COMAR 10.06.06.07* A. Subject to §§B and C of this regulation, a person shall dispose of special medical waste after treatment by one of the following methods: (1) Interment; (2) Depositing in a facility approved to accept the type of solid waste being disposed in accordance with §C of this regulation; or (3) Incineration. B. A person may discharge a special medical waste that is liquid, semiliquid, or anatomical material that has been mechanically destroyed into a sewerage system, if the discharge is allowed under: (1) Local ordinance or regulation; and (2) Environment Article, Title 9, Annotated Code of Maryland. C. A person shall dispose of special medical waste in accordance with: (1) State laws and regulations pertaining to solid waste disposal including Environment Article, Title 9, Annotated Code of Maryland; and (2) Local ordinances and regulations to the extent that the local requirements are not preempted by or in conflict with State law. #### Regulation .08 Enforcement. *COMAR 10.06.06.08* A. The Secretary may enter the property of any person who generates, handles, treats, or disposes of special medical waste to investigate a complaint the Secretary receives regarding the handling, treatment, or disposal of special medical waste. B. Criminal Penalties. (1) A person who violates these regulations is guilty of a misdemeanor, and on conviction is subject to a fine not exceeding $500. (2) Each day that a violation exists shall constitute a separate offense. C. In addition to any penalty under §B, if a person violates these regulations, the Secretary may suspend or revoke any license, permit, or certificate issued to the person under the Health-General Article, Annotated Code of Maryland. ### Chapter 07 — Sexually Transmitted Infections — Expedited Partner Therapy for Chlamydia, Gonorrhea, and Trichomoniasis **Authority:** Health-General Article, §§2-104(b), 18-102, 18-201, 18-202, and 18-214.1, Annotated Code of Maryland **Administrative History:** Effective date: March 28, 2016 (43:6 Md. R. 406) **Administrative History:** Regulation .01A amended effective March 26, 2018 (45:6 Md. R. 318) **Administrative History:** Regulation .02B amended effective March 26, 2018 (45:6 Md. R. 318) **Administrative History:** Regulation .04-1 adopted effective March 26, 2018 (45:6 Md. R. 318) **Administrative History:** Regulation .05A, B amended effective March 26, 2018 (45:6 Md. R. 318) **Administrative History:** Regulation .06C amended effective March 26, 2018 (45:6 Md. R. 318) #### Regulation .01 Purpose and Scope. *COMAR 10.06.07.01* A. The purpose of expedited partner therapy in Maryland is to: (1) Provide antibiotic therapy to any partner of a patient diagnosed with chlamydia, gonorrhea, or trichomoniasis without a personal physical assessment of the partner, and without having a previous provider-patient relationship with the partner; (2) Contain and stop the further spread of chlamydia, gonorrhea, and trichomoniasis; and (3) Reduce the likelihood of reinfection in the diagnosed patient. B. This chapter applies to the provision of expedited partner therapy, as described in §A of this regulation, in public and private health care settings. #### Regulation .02 Definitions. *COMAR 10.06.07.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Antibiotic therapy” means the oral antibiotic treatment regimens: (a) Currently recommended by the Centers for Disease Control and Prevention for the treatment of chlamydia and gonorrhea through expedited partner therapy; and (b) For the treatment of trichomoniasis through expedited partner therapy: (i) In accordance with Regulation .05A of this chapter; and (ii) As authorized by Health-General Article, §18-214.1, Annotated Code of Maryland. (2) “Department” means the Maryland Department of Health. (3) “Expedited partner therapy (EPT)” means the prescribing or dispensing of antibiotic therapy to any partner of a patient diagnosed with chlamydia, gonorrhea, or trichomoniasis by certain health care providers without making a personal physical assessment of the partner, and without having a previous provider-patient relationship with the partner, in order to contain and stop the further spread of the infection and reduce the likelihood of reinfection in the diagnosed patient. (4) “Health officer” means the health officer in each of the 23 counties and the Commissioner of Health in Baltimore City, or the duly designated representative of the health officer, or both. (5) “Partner” means an individual with whom one has, or has had, oral, anal or vaginal sexual contact. #### Regulation .03 Partners Eligible for EPT. *COMAR 10.06.07.03* Partners eligible for EPT are: A. Any partner within 60 calendar days of the patient’s diagnosis; or B. The most recent partner of a patient if the patient has not had sex in the 60 days before diagnosis. #### Regulation .04 Health Care Providers Authorized to Prescribe and Dispense EPT. *COMAR 10.06.07.04* Notwithstanding any other provision of law, and only in accordance with their current scope of practice, EPT may be prescribed or dispensed by the following health care providers: A. A physician licensed under Health Occupations Article, Title 14, Annotated Code of Maryland; B. An authorized physician assistant licensed under Health Occupations Article, Title 15, Annotated Code of Maryland, acting in accordance with Health Occupations Article, §15-302.2, Annotated Code of Maryland; C. An advanced practice registered nurse with prescriptive authority licensed under Health Occupations Article, Title 8, Annotated Code of Maryland, acting in accordance with Health Occupations Article, §8–508, Annotated Code of Maryland; and D. A registered nurse employed by a local health department who complies with: (1) The formulary developed and approved under Health-General Article, §3-403(b), Annotated Code of Maryland; and (2) The requirements established under Health Occupations Article, §8-512, Annotated Code of Maryland. #### Regulation .04-1 Pharmacists Authorized to Dispense EPT. *COMAR 10.06.07.04-1* Notwithstanding any other provision of law, a pharmacist licensed under Health Occupations Article, Title 12, Annotated Code of Maryland, may dispense antibiotic therapy for EPT prescribed in accordance with Regulation .04 of this chapter. #### Regulation .05 Prescribing and Dispensing EPT Medications. *COMAR 10.06.07.05* A. Antibiotic therapy prescribed or dispensed for EPT shall be in accordance with treatment recommendations from the Centers for Disease Control and Prevention. B. Prescribing. (1) A separate prescription shall be issued for each partner. (2) The designation “EPT” or “Expedited Partner Therapy” shall be included on the face of the prescription for each prescription issued. (3) If the partner’s name is known, the prescription shall be issued in the partner’s name. (4) If the partner’s name is unknown, the written designation “EPT” or “expedited partner therapy” shall be sufficient for the pharmacist to fill the prescription. (5) An EPT prescription may not be refilled. C. Dispensing. Each EPT medication label shall: (1) Include: (a) The designation “EPT” or “Expedited Partner Therapy”; and (b) The partner’s name, if known; and (2) Comply with Health Occupations Article, §12-505, Annotated Code of Maryland. #### Regulation .06 Counseling and Educational Information Requirements. *COMAR 10.06.07.06* A. A health care provider prescribing or dispensing EPT to a patient shall: (1) Counsel the patient to encourage each partner to seek a personal physical assessment; and (2) Provide the patient with educational information for each partner, in accordance with §C of this regulation. B. A pharmacist dispensing EPT shall provide educational information for each partner, in accordance with §C of this regulation. C. The educational information, that is available or comparable to that available on the Department’s website, shall include: (1) Advice for the partner to seek a medical evaluation; (2) Information about chlamydia, gonorrhea, and trichomoniasis; (3) Medication instructions; (4) Warnings about adverse drug or allergic reactions; and (5) Advice to abstain from sexual activity as required during treatment. #### Regulation .07 Documenting EPT in a Medical Chart. *COMAR 10.06.07.07* A. A health care provider prescribing or dispensing EPT shall document the provision of EPT in the patient’s chart. B. Documentation shall include the: (1) Number of EPT prescriptions or medications provided to the patient for each partner; and (2) Medication and dosage being provided to the patient for each partner. #### Regulation .08 Reporting of Chlamydia and Gonorrhea by a Health Care Provider or Institution. *COMAR 10.06.07.08* A. This chapter may not affect the obligation of a health care provider or institution to report to a health officer cases of chlamydia and gonorrhea and the treatment provided to those cases in accordance with COMAR 10.06.01.04. B. When reporting a case of chlamydia or gonorrhea for which EPT was prescribed or dispensed, a health care provider or institution shall report the number of partners for whom: (1) Prescriptions were provided; and (2) Medications were dispensed.