Chapter 01. Communicable Diseases and Related Conditions of Public Health Importance

The Compendium of Animal Rabies Prevention and Control, 2016;

The Compendium of Measures to Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017; and

The Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017.

“Body fluid” means an excretion or fluid from a human body that contains visible blood and all other tissues, excretions or fluids including:

“Body fluid” does not include stool, nasal secretions, sputum, tears, urine, or vomitus.

An animal bite;

An adverse reaction to pertussis vaccine;

Harmful algal bloom related illness;

Pesticide related illness; or

Ricin toxin poisoning.

Laboratory evidence of Chlamydophila psittaci infection consisting of:

Clinical evidence of Chlamydophila psittaci infection consisting of an epidemiologic link to an avian case that has laboratory evidence of infection, and has:

“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.

“Child care facility” includes child care center, day care center, nursery, family day care home, and babysitter.

“Clinical material” means:

“Clinical material” includes, for Mycobacterium tuberculosis, one culture obtained from the primary isolate on which the diagnosis of tuberculosis was established.

Physicians;

Physician assistants;

Dentists;

Chiropractors;

Nurse practitioners;

Nurses;

Podiatrists;

Medical examiners;

Hospital administrators;

Clinic administrators;

Dispensary administrators;

Nursing home administrators; and

Any other licensed health care providers.

“Health care worker” means a paid or unpaid individual working in a health care setting who has the potential for exposure to:

“Health care worker” includes, but is not limited to:

A foodborne disease outbreak;

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;

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;

A situation designated by the Secretary as an outbreak; or

One case of:

“Pet animal” means a live animal sold or distributed to the public with or without charge for pleasure or companionship and not for utility.

“Pet animal” does not include domestic farm animals including, but not limited to:

“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.

“Pet store” includes but is not limited to 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.

“Skin-penetrating body adornment procedure” includes body-piercing and tattooing.

“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.

“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.

“Standard precautions” includes:

Any hepatitis C antibody results that are positive;

Any hepatitis C virus RNA results associated with the results in(a) of this footnote that are qualitative or quantitative, if the results are:

Any hepatitis C virus RNA results associated with the results in(a) of this footnote if the hepatitis C virus is:

Any treponemal or non-treponemal results that are qualitative or quantitative, if the results are:

Any negative or non-reactive results associated with the positive, reactive, or inconclusive results in(a) of this footnote.

A laboratory confirmed acid-fast bacillus on smear;

An abnormal chest radiograph suggestive of active tuberculosis;

A laboratory confirmed biopsy report consistent with active tuberculosis; or

Initiation of two or more anti-tuberculosis medications.

There is a positive result on an Interferon Gamma Release Assay, Tuberculin Skin Test, or any other test indicating tuberculosis infection; and

Active or suspected tuberculosis has been ruled out.

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:

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.

The director of a medical laboratory located outside of Maryland shall report to the Secretary.

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:

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:

In writing on a form provided by the Secretary; or

In a format approved by the Secretary, when electronic submittal is available.

Date of the report;

Patient's name including first and last names and middle initial;

Residence address of the patient including:

Telephone number including area code;

Date of birth;

Sex;

Race;

Ethnicity;

Pregnancy status if applicable; and

Other epidemiologic information as specified by the Secretary or the health officer.

The date of onset of symptoms;

The diagnosis;

For syphilis, gonococcal infection, and Chlamydia trachomatis infection, the treatment given; and

Any laboratory information supporting the diagnosis of the disease or condition, as requested.

Name, address, telephone number, and federal Clinical Laboratory Improvement Amendments (CLIA) certificate number of the laboratory performing the test;

Date the specimen was received by the laboratory;

Accession number or other unique identifier for the specimen;

Type of test performed and the results, including:

Date of specimen collection;

Type of specimen, for example, blood, urine, stool, or mucus, and the site of specimen collection, for example, cervix, eye;

Date of the laboratory result;

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;

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

For hepatitis C infection:

Shall communicate directly with an individual in person or by telephone; and

May not leave a message on an answering device.

Within 24 hours after receiving notice of a disease or condition listed in Regulation .03C of this chapter; or

Within a shorter amount of time than 24 hours as specified by the Secretary.

Within 24 hours after receiving notice of a disease or condition listed in Regulation .03C of this chapter; or

Within a shorter amount of time than 24 hours as specified by the Secretary.

The physician or other health care provider caring for a patient is not reasonably available; and

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:

Care of young children;

Care of the elderly;

Food handling; and

Patient care.

School; or

Child care facility.

The seriousness of the disease;

The route or routes of transmission of the disease;

The contagiousness of the disease;

The behavior, neurological development and condition, and physical condition of the carrier;

The susceptibility to the disease of those likely to be exposed to the carrier in the occupation or setting;

The precautions that may be taken to minimize or eliminate the danger of transmission; and

Precedents in the practice of public health.

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

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.

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;

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;

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;

Use only sterile instruments, equipment, and bandages;

Wash both hands using soap and running water and dry the hands using individual single-use towels before and after each procedure;

Wear single-use disposable latex or vinyl gloves for each procedure and discard the gloves after the procedure is completed;

Wear a gown and face shield, or goggles and a mask, if spattering of blood is likely to occur during the procedure;

Cleanse the client's skin before and after the procedure;

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;

Clean and sterilize before reuse any instruments or equipment designed for multiple use;

Provide written after-care instructions to the client;

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

Post the following notice in a prominent place:

Perform a procedure on skin or mucous membrane that has a rash, infection, or other lesion;

Perform a procedure when the person performing the procedure has an infected or bleeding lesion on the hands;

Use a styptic pencil or alum block to staunch bleeding; or

Reuse instruments or equipment intended for single use.

Attending a child care facility; or

Participating in an occupation involving:

Attend a child care facility; and

Participate in an occupation involving:

The case's fecal cultures are Campylobacter-free on two consecutive specimens collected:

The health officer determines that the likelihood of disease transmission is low.

Attends a child care facility; or

Participates in an occupation involving:

Not less than 24 hours apart; and

If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics.

Attending a child care facility; or

Participating in an occupation involving;

Attend a child care facility; and

Participate in an occupation involving:

The case's fecal cultures are Vibrio-free on two consecutive specimens collected:

The health officer determines that the likelihood of disease transmission is low.

Attends a child care facility; or

Participates in an occupation involving:

Not less than 24 hours apart; and

If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics.

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

A health officer approves readmission based on the low likelihood of disease transmission.

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

A health officer approves resumption of occupational duties based on the low likelihood of disease transmission.

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

A health officer approves readmission based on the low likelihood of disease transmission.

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

A health officer approves resumption of occupational duties based on the low likelihood of disease transmission.

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;

For a previously unvaccinated individual older than 40 years old, immune globulin is recommended and single antigen hepatitis A vaccine may be used if:

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.

Receive hepatitis B immune globulin and the first dose of hepatitis B vaccine within 12 hours of birth;

Receive the rest of the vaccination series; and

Are tested for hepatitis B surface antigen and hepatitis B surface antibody at 9 to 15 months old.

Sharing hypodermic needles and other injecting drug paraphernalia;

Sexual transmission;

Maternal-child transmission;

Parenteral or permucosal exposure to blood or other infectious body fluids;

Chronic hemodialysis;

Transfusion; and

Transplantation;

Nonimmune individuals for measles, in general, are people who:

A health officer or health care provider shall recommend that:

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.

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

Shall authorize readmission upon documented proof of immunity in the form of immunization record, serologic test, or the low likelihood of disease transmission.

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.

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.

Nonimmune individuals for mumps, in general, are people who:

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.

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

Shall authorize readmission upon documented proof of immunity in the form of:

For 21 days after last exposure; or

Until the case patients and contacts have received 5 days of appropriate antibiotics;

Nonimmune individuals for rubella, in general, are people who:

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.

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

Shall authorize readmission by documented proof of immunity in the form of an immunization record, serologic test, or the low likelihood of disease transmission.

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.

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.

Attending a child care facility; or

Participating in an occupation involving:

Attend a child care facility; and

Participate in an occupation involving:

The case’s fecal cultures are Salmonella-free on two consecutive specimens collected:

The health officer determines that the likelihood of disease transmission is low.

Attends a child care facility; or

Participates in an occupation involving:

Less than 24 hours apart; and

Sooner than 48 hours following discontinuation of antibiotics if antibiotics have been given.

Observation for diagnosis has been completed;

Syphilis or HIV, if present, has been reported to a health officer;

Individual with syphilis has had the treatment that is necessary for the protection of the public health; and

Individual with HIV has entered into HIV medical care.

Receiving or has received treatment for syphilis; or

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.

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;

Take such measures as may be deemed necessary for the protection of the public health; and

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.

Shall endeavor to bring an individual with whom the patient has had potentially infectious contact to examination and, as appropriate, prophylaxis by:

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

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.

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

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.

Within 1 week of notification, be examined to ascertain whether the individual has been infected with syphilis or HIV; and

Be treated with a regimen appropriate for the stage of syphilis to which the individual has been exposed.

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:

Render appropriate treatment within 1 week whenever syphilis, in any stage, is diagnosed; and

Report the case to a health officer immediately.

Evaluate the infant for possible congenital syphilis and render all indicated treatment; and

Report immediately to a health officer the following information:

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

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.

Instruct the person on the modes of transmission and the prevention of transmission;

Render any necessary treatment to the case; and

Advise the case to inform a sexual partner or partners of exposure and the need for examination and treatment.

A 1-percent silver nitrate solution provided in individual wax ampules for the prevention of gonococcal ophthalmia neonatorum;

Tetracycline ophthalmic ointment; or

Erythromycin ophthalmic ointment (USP).

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

A health officer approves readmission based on the low likelihood of disease transmission.

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

A health officer approves resumption of occupational duties based on the low likelihood of disease transmission.

Attends a child care facility; or

Whose occupation involves:

Is excreted by the patient; or

Can be isolated by culture in the case of multidrug resistant tuberculosis (MDR-TB) or extremely drug resistant tuberculosis (XDR-TB).

Less than 24 hours apart;

Sooner than 48 hours following discontinuation of antibiotics; and

Earlier than 1 month after onset or date of first positive culture if asymptomatic.

Monitor the location, occupation, and bacteriological status of a carrier of Salmonella Typhi or Paratyphi;

Keep a complete file of all pertinent data on the carrier;

Issue written instructions to the carrier concerning the restrictions upon and responsibilities of the carrier;

Notify the carrier of the availability of treatments that may eliminate carriage;

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;

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

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.

May not participate in occupations involving:

Shall abide by Regulation .06D and E; and

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.

Who attend a child care facility; or

Whose occupations involve:

Used for agricultural purposes;

Used for scientific purposes;

Used for educational purposes as certified by a health officer;

Used for public exhibitions; or

That the Secretary determines is not a threat to human health and safety.

A caution notice with the text as indicated in §C of this regulation is:

At the time of the sale of a reptile, the seller: