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. This chapter applies to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) control. 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: 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; Recommendations of the National Association of State Public Health Veterinarians, including: 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. In this chapter, the following documents are incorporated by reference: Control of Communicable Diseases Manual (American Public Health Association, Twentieth Edition, 2015); Compendium of Measures to Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017 (The Association of Avian Veterinarians, 2017); Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017 (The National Association of State Public Health Veterinarians, 2017); and Compendium of Animal Rabies Prevention and Control, 2016 (The National Association of State Public Health Veterinarians, 2016). 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. Terms Defined. Body Fluid. “Body fluid” means an excretion or fluid from a human body that contains visible blood and all other tissues, excretions or fluids including: Visible blood or any body fluid that is visibly contaminated with blood; Semen or vaginal secretions; Amniotic, cerebrospinal, pericardial, peritoneal, pleural, or synovial fluids; Saliva in dental procedures; and All body fluids in situations where it is difficult or impossible to differentiate between body fluids. “Body fluid” does not include stool, nasal secretions, sputum, tears, urine, or vomitus. “Case” means an individual who has laboratory or clinical evidence of being infected by an infectious agent. “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: An animal bite; An adverse reaction to pertussis vaccine; Harmful algal bloom related illness; Pesticide related illness; or Ricin toxin poisoning. “Case (or suspected case) of avian psittacosis” means that a bird has: Laboratory evidence of Chlamydophila psittaci infection consisting of: Culture isolation of Chlamydophila psittaci from a clinical specimen; A positive fluorescent antibody test for Chlamydophila psittaci on a clinical specimen; 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 Identification of Chlamydophila psittaci within macrophages in smears stained with Gimenez or Macchiavellos stain or sections of the bird's tissues; or Clinical evidence of Chlamydophila psittaci infection consisting of an epidemiologic link to an avian case that has laboratory evidence of infection, and has: Exhibited one or more signs of psittacosis; Died; Been clinically diagnosed as having psittacosis by a licensed veterinarian; or Had gross necropsy findings or histopathological evidence consistent with psittacosis as reported by a veterinary pathologist. Child Care Facility. “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. “Clinical material” means: An organism isolated from a clinical specimen; Material derived or prepared from a clinical specimen in which evidence of a communicable disease has been identified or detected; or 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. “Clinical material” includes, for Mycobacterium tuberculosis, one culture obtained from the primary isolate on which the diagnosis of tuberculosis was established. “Colonization” means the proliferation of microorganisms on or within one or more body sites without detectable host immune response, cellular damage, or clinical expression. “Commissioner” means the Commissioner of Health of the Baltimore City Health Department. “Department” means the Maryland Department of Health. “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. “Health care provider” includes, but is not limited to: 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. “Health care worker” means a paid or unpaid individual working in a health care setting who has the potential for exposure to: Infectious materials, including body substances; Contaminated medical supplies and equipment; Contaminated environmental surfaces; or Contaminated air. “Health care worker” includes, but is not limited to: Emergency medical service personnel; Dental personnel; Laboratory personnel; Autopsy personnel; Nurses; Nursing assistants; Physicians; Physician assistants; Technicians; Therapists; Pharmacists; Students and trainees; Contractual staff not employed by the health care facility; and Individuals not directly involved in patient care but potentially exposed to infectious agents, for example, clerical, dietary, housekeeping, maintenance, and volunteer personnel. “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. “Infectious” means capable of being transmitted in a manner that can cause a disease or abnormal condition in an individual. “Invasive disease” means a disease in which an organism is detected in a specimen taken from a normally sterile body site. “Normally sterile body site” means a body site except for skin, external ear, oronasopharynx, gastrointestinal tract, urethral meatus, and vagina. “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. “Outbreak” means: 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: Anthrax; Botulism; Cholera (imported or seafood related); Ciguatera poisoning; Mushroom poisoning; Paralytic shellfish poisoning and other neurotoxic shellfish poisoning; Plague; Rabies (human); Smallpox; Scombroid poisoning; or Trichinosis. Pet Animal. “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: Equids; Cattle; Goats; Sheep; and Swine. Pet Store. “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: Commercial facility; Feed store; or Department store. “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. “Reptile” means a cold blooded, air breathing vertebrate of the class Reptilia. “Secretary” means the Secretary of Health or the Secretary's designee. “Sell” means to sell, hold for sale, or offer for commercial or public distribution, a pet animal. “Seller” means a person who sells, holds for sale, or offers for commercial or public distribution, a pet animal. “Sexually transmitted infection” means an infection which may be spread by sexual intercourse, including oral, anal, or vaginal sexual contact with an infected individual. Skin-Penetrating Body Adornment Procedure. “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. “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: Hand hygiene and use of gloves, gown, mask, eye protection, or face shield depending on anticipated exposure; and 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. “Turtle” means an animal commonly known as a turtle, tortoise, or terrapin. 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. 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: Submit clinical material to the Department's public health laboratory; and Include information about the clinical material on a form provided by the Secretary. List of Reportable Diseases and Conditions. As required to report in Regulation .04A(1)—(3), (5), and (6) of this chapter. The time frame for reporting is specified in Regulation .04C of this chapter. Clinical material shall be submitted according to §B of this regulation. Any grouping or clustering of patients having similar disease, symptoms, or syndromes that may indicate the presence of a disease outbreak. Suspected hepatitis C as indicated by: 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: Positive; or Negative; and Any hepatitis C virus RNA results associated with the results in(a) of this footnote if the hepatitis C virus is: Detected; or Undetected. Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV), including CD4+ lymphocyte count and viral load, are reportable under COMAR 10.18. Suspected syphilis as indicated by: Any treponemal or non-treponemal results that are qualitative or quantitative, if the results are: Positive; Reactive; or Inconclusive; and Any negative or non-reactive results associated with the positive, reactive, or inconclusive results in(a) of this footnote. Tuberculosis confirmed by culture and suspected tuberculosis as indicated by: 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. Latent tuberculosis infection as indicated when: 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. Vibriosis, non-cholera, identified in any specimen taken from teeth, gingival tissues, or oral mucosa is not reportable. Sources of Reports and to Whom to Report. 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. 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. 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. Directors of Medical Laboratories or Laboratories that Possess Biological Agents as Defined in COMAR 10.10.11.03B(8). 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: 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 Evidence of any other condition as requested by 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) 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: Reporting the results and submitting the clinical materials; or Ensuring that the results are reported and materials submitted. 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: At least one positive test result is reported; and A health officer has agreed that all test reports do not need to be reported. Any individual having knowledge of an animal bite shall report the bite according to the requirements of COMAR 10.06.02. 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. Method and Content of Reports. A person, as listed in §A(1)—(4) of this regulation, shall report: In writing on a form provided by the Secretary; or In a format approved by the Secretary, when electronic submittal is available. The report shall include at a minimum the: Date of the report; Patient's name including first and last names and middle initial; Residence address of the patient including: House or apartment number; Street; City or town; State; and Zip code; 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. 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: 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. A director of a medical laboratory, in addition to what is specified in §B(2) of this regulation, shall report the: 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: Reference range; Quantitative results; and Results of speciating, grouping, or typing of organisms; 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: Signal-to-cut-off ratios and critical values; Hepatitis A IgM results; and Hepatitis B IgM test results. Timing of Reports. If the Secretary requires an immediate report, the person making the report: Shall communicate directly with an individual in person or by telephone; and May not leave a message on an answering device. A health care provider and a director of a medical laboratory shall report according to the time frame in Regulation .03C of this chapter. 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. A health officer shall transmit to the Secretary, by mail or as otherwise specified by the Secretary, all information obtained: 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 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: 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 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: Shall keep the report and record confidential; May not open a report or record to public inspection; 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 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. 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. Communication with a Health Care Provider or Patient. The Secretary or a health officer may discuss a laboratory report with the attending physician or other health care provider caring for a patient. The Secretary or a health officer may communicate with a patient directly to discuss a laboratory report if: 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: Name of the individual with whom a message was left; or Identification given by the answering machine, if a message was left on an answering machine. Necessary Action. The Secretary or health officer shall: Take any action or measure necessary to prevent the spread of communicable disease or to control a reportable disease and condition; and Issue, when necessary, special instructions for control of a disease or condition. Epidemiologic Investigations. 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. A health officer shall investigate a reported case or suspect case of a condition as requested by the Secretary. 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. 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. 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. Carrier Approval. A health officer shall grant or deny approval to a carrier of an infectious agent to work in any of the following occupations involving: Care of young children; Care of the elderly; Food handling; and Patient care. A health officer shall grant or deny approval to a carrier of an infectious agent to attend a: School; or Child care facility. 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: 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. 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: Disease causing diarrhea, unless physician-certified as noninfectious; Cholera; Escherichia coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC), as discussed in Regulation .08-3 of this chapter; Hepatitis A, as discussed in Regulation .10 of this chapter; Salmonellosis, as discussed in Regulation .16 of this chapter; Shigellosis, as discussed in Regulation .19 of this chapter; and Typhoid or Paratyphoid fever or carrier of Salmonella Typhi or Paratyphi, as discussed in Regulation .21 of this chapter. Control of Communicable Diseases in Schools and Child Care Facilities. A health officer shall: 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. 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. Use of Sterile Instruments or Equipment. An individual who performs a procedure that penetrates the skin or mucous membrane of another individual shall: Utilize only sterile instruments or equipment for 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; and Clean and sterilize before reuse any instruments or equipment designed for multiple use. Skin-Penetrating Body Adornment Procedures — Infection Control. An individual who performs a skin-penetrating body adornment procedure shall: 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: An individual who performs a procedure that penetrates the skin or mucous membrane may not: 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. A health officer may investigate complaints received regarding compliance with this section. 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. The diseases and conditions described in Regulations .08—.21 of this chapter are subject to specific requirements and control procedures as specified. 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. Control of Contacts. A health officer shall investigate household and close contacts whose occupations involve food handling, patient care, and care of young children or the elderly. 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. Infection Control. Health care providers shall practice standard precautions. Control of a Case. For a case with diarrhea due to or presumed due to campylobacteriosis, a health officer shall restrict or exclude a case from: Attending a child care facility; or Participating in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: Attend a child care facility; and Participate in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: The case's fecal cultures are Campylobacter-free on two consecutive specimens collected: Not less than 24 hours apart; and If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or The health officer determines that the likelihood of disease transmission is low. Control of Contacts at Increased Risk of Transmitting Campylobacteriosis. 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: Attends a child care facility; or Participates in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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 less than 24 hours apart; and If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics. 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. Infection Control. A health care provider shall practice standard precautions. Control of Carriers. A health care provider shall apply the control measures specified in §A of this regulation to carriers in addition to cases. Control of a Case. For a case with diarrhea due to or presumed due to cholera, a health officer shall restrict or exclude a case from: Attending a child care facility; or Participating in an occupation involving; Food handling; Patient care; or Care of young children or the elderly. 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: Attend a child care facility; and Participate in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: The case's fecal cultures are Vibrio-free on two consecutive specimens collected: Not less than 24 hours apart; and If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or The health officer determines that the likelihood of disease transmission is low. Control of Contacts at Increased Risk of Transmitting Cholera. 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: Attends a child care facility; or Participates in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: Not less than 24 hours apart; and If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics. 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. Control of a Case. A case may not attend a child care facility until: 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. 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: 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. Control of Contacts. 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. 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. 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. 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: 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. 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: 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. Infection Control. A health care provider shall practice standard precautions. 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: Campylobacteriosis; Cholera; Escherichia coli O157:H7 and other Shiga-Like Toxin Producing Escherichia coli (STEC); Hepatitis, viral type A; Salmonellosis; Shigellosis; and Typhoid fever (Salmonella Typhi) or paratyphoid fever (Salmonella Paratyphi A, Salmonella Paratyphi B tartrate negative, and Salmonella Paratyphi C). Investigation and Control Measures. 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. 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. A health officer or the Secretary shall submit all samples for laboratory examination. 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. 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. 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: 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 According to the following recommendations: 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: Immune globulin is not available; and The individual is healthy; or 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. Infection Control. Health care providers shall practice standard precautions. Control of a Case. A physician in attendance upon a case having viral hepatitis type B shall educate that case on the: Risks of sexual transmission, household contact transmission, maternal-infant transmission, and transmission by the sharing of hypodermic needles and other drug paraphernalia; 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; Importance of vaccination for viral hepatitis type A if the case is not already immune by reason of prior infection or prior vaccination; and Importance of testing pregnant women for hepatitis B surface antigen at each pregnancy. Control of Contacts. A physician or health officer in attendance upon a contact of viral hepatitis type B shall: 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; Recommend preventive treatment consistent with current Centers for Disease Control and Prevention guidelines based on type of exposure; and Require that infants born to hepatitis B surface antigen positive mothers: 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. Infection Control. Health care providers shall practice standard precautions. Control of a Case. A physician in attendance upon a case of viral hepatitis type C shall educate that case on: The risks of transmission of viral hepatitis type C by: 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; How to reduce the risk of transmission of viral hepatitis type C to other individuals; The importance of an individual health evaluation to determine if treatment should be recommended; 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 The prevention of further liver injury or more serious liver disease or liver failure. Control of Contacts. A physician or health officer in attendance upon a contact of viral hepatitis type C shall educate the contact about: Any risk factors and signs of infection due to viral hepatitis type C; 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 How to reduce the contact's risk of receiving viral hepatitis type C from others. Infection Control. A health care provider shall: Practice standard precautions; and 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. 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. 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. Control of Contacts. Nonimmune Contacts. Nonimmune individuals for measles, in general, are people who: Have not received two doses of measles containing vaccine on or after the first birthday; Have no documentation of immunity or disease; or Were born in or after 1957. A health officer or health care provider shall recommend that: Nonimmune contacts receive measles vaccine within 72 hours of exposure if not medically contraindicated; and 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. 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. A health officer: 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. Infection Control. Health care providers shall practice airborne precautions from the onset of illness at least through the 4th day after the rash appears. Proof of Immunity for Health Care Workers. 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. Exemptions. 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. 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. Control of Contacts. Nonimmune Individuals. Nonimmune individuals for mumps, in general, are people who: Have not received two doses of mumps containing vaccine on or after the first birthday; Have no documentation of immunity or disease; or Were born in or after 1957. 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. A health officer: 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: An immunization record; A serologic test; or The low likelihood of disease transmission. Infection Control. A health care provider shall practice droplet precautions for 5 days after onset of parotitis. Control of a Case. 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. 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. Control of Contacts. A health officer may: Require all inadequately immunized household contacts younger than 7 years old to be excluded from schools, child care facilities, and public gatherings: For 21 days after last exposure; or Until the case patients and contacts have received 5 days of appropriate antibiotics; Require all contacts to verify immunization status and be brought up to date if not adequately immunized to protect against subsequent exposure; and Require antibiotic prophylaxis for contacts of cases. Infection Control. A health care provider shall practice droplet precautions for the shorter of: 21 days after onset of cough; or When a case has been on appropriate antibiotics for 5 days. There is no control of a human case or contacts. Infection Control. A health care provider shall practice appropriate disinfection and disposal of respiratory discharges. 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. 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. Control of a Case (Human). A health care provider shall apply contact isolation to the case for the period of communicability. 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. Infection Control. A health care provider shall practice contact isolation. 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. Control of a Case. A health officer or health care provider shall recommend that a case: 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 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. Control of Contacts. Nonimmune Contacts. Nonimmune individuals for rubella, in general, are people who: Have not received at least one dose of rubella containing vaccine on or after the first birthday; Have no documentation of immunity or disease; or Were born in or after 1957. 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. A health officer: 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. Infection Control. A health care provider shall practice droplet precaution for 7 days after onset of the rash. Proof of Immunity for Health Care Workers. 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. Exemptions. 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. Control of a Case. For a case with diarrhea due to or presumed due to salmonellosis, a health officer shall restrict or exclude a case from: Attending a child care facility; or Participating in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: Attend a child care facility; and Participate in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: The case’s fecal cultures are Salmonella-free on two consecutive specimens collected: Not less than 24 hours apart; and If antibiotics have been given, not sooner than 48 hours following discontinuation of antibiotics; or The health officer determines that the likelihood of disease transmission is low. Control of Contacts at Increased Risk of Transmitting Salmonellosis. 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: Attends a child care facility; or Participates in an occupation involving: Food handling; Patient care; or Care of young children or the elderly. 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: Less than 24 hours apart; and Sooner than 48 hours following discontinuation of antibiotics if antibiotics have been given. 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. Infection Control. A health care provider shall practice standard precautions. Control of Carriers. A health care provider shall apply the same control measures to carriers as to cases. Control of a Case. 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. An individual under medical observation for diagnosis of syphilis or HIV shall remain under medical supervision until the: 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. A physician shall report to a health officer within 1 working day and in writing the name and address of an individual who is: 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. A health officer shall: 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. Control of Contacts. A physician in attendance upon a patient having syphilis or HIV: Shall endeavor to bring an individual with whom the patient has had potentially infectious contact to examination and, as appropriate, prophylaxis by: Requesting a health officer to conduct a contact investigation of any case of syphilis or HIV; or 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; 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. A health officer shall: 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. A reported individual shall: 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. Infection Control. A health care provider shall practice standard precautions. Congenital Syphilis. A physician in attendance upon a pregnant woman shall: 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: 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; In the third trimester at the prenatal visit at 28 weeks of gestation or the first prenatal visit after 28 weeks of gestation; and At delivery, for high prevalence communities or high risk individuals; Render appropriate treatment within 1 week whenever syphilis, in any stage, is diagnosed; and Report the case to a health officer immediately. A physician in attendance upon an infant born to an untreated woman who has a positive serological test for syphilis shall: Evaluate the infant for possible congenital syphilis and render all indicated treatment; and Report immediately to a health officer the following information: The name, address, and telephone number of the mother; The results of the serological testing, including titers; and The results of the medical evaluation for congenital syphilis for the infant. A health officer shall: 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. Control of a Case. Hepatitis, viral type B, as discussed in Regulation .11 of this chapter. 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: 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. Control of Contacts. Hepatitis, viral type B as discussed in Regulation .11 of this chapter 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. Prevention of Gonococcal Ophthalmia Neonatorum. A birth-attending physician or certified nurse-midwife shall apply to both eyes of a newborn one of the following prophylactic agents: 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). 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. Control of a Case. A case may not attend a child care facility until: 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. 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: 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. Control of Contacts. A health officer shall require a culture of feces only from a household member or close contact who: Attends a child care facility; or Whose occupation involves: Food handling; Patient care; or Care of young children or the elderly. A contact shall submit for examination two fecal specimens taken at an interval of not less than 24 hours apart. 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. Infection Control. A health care provider shall practice standard precautions. Control of a Case and Suspected Case. 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. 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. A health officer or health care provider shall isolate a patient who is in a communicable stage as long as the specific microorganism: 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). 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. 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. A health officer or health care provider treating an individual with tuberculosis or suspected tuberculosis shall provide human immunodeficiency virus testing and counseling. A health officer shall monitor the treatment of individuals with tuberculosis and suspected tuberculosis to determine if the treatment is appropriate. A health officer may impose limitations on travel and place restrictions on hospital discharge for an individual with tuberculosis or suspected tuberculosis. 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. 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. 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. Control of Contacts. A health officer shall: 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; Recommend appropriate treatment for latent tuberculosis infection; and 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. Control of a Case. 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. 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. 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: 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. 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. If a person continues to excrete Salmonella Typhi or Paratyphi at 12 months, the requirements of §D of this regulation apply. 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. Infection Control. A health care provider shall practice standard precautions. Control of Carriers. A health officer shall: 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. A case or a case's physician shall submit the fecal specimens to the State Laboratory for the release of a carrier. A carrier: May not participate in occupations involving: Food handling; Patient care; or Care of young children or the elderly; 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. Control of Contacts of a Carrier. A health officer shall require culture of feces of those household and close contacts: Who attend a child care facility; or Whose occupations involve: Food handling; or Care of patients, young children, or the elderly. A contact shall submit for examination two fecal specimens taken at an interval of not less than 24 hours apart. 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. Scope. 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. The Secretary prohibits the sale or public distribution of turtles with a carapace length of less than 4 inches and viable reptile eggs. 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. This regulation does not apply to a turtle: 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. 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. The giving away of reptiles is subject to the crimes and punishments set forth in Criminal Law Article, §10-610, Annotated Code of Maryland. Reptile Sales. 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. A person may sell turtles with a carapace length of 4 inches or more and other live reptiles in Maryland if: A caution notice with the text as indicated in §C of this regulation is: Posted by the person selling reptiles; Posted within 3 feet of each display of reptiles; and A minimum of 8 x 11 inches in size; and At the time of the sale of a reptile, the seller: Furnishes the buyer with a copy of the caution notice; or Has the buyer sign a log or statement that the buyer has read the caution notice. Caution Notice. A person who sells reptiles shall post a caution notice that: Is in 4 parts, each separated by a horizontal 4-point rule; In part 1 has the word “Caution” set in 100-point Times Roman Bold; 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.”; 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 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.” Penalties and Seizure of Contraband Reptiles. 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. 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. 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: Importance of handwashing after contact with a reptile or other pet animals or its surroundings; and Need to consult a physician if one or more of the following individuals live in the household for which a pet animal is purchased: A child younger than 5 years old; A pregnant woman; or An immunocompromised individual. A pet store shall utilize procedures to ensure prevention and control of diseases common to and shared among humans and animals. 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. A health officer shall annually inspect a pet store to determine compliance with §A of this regulation. A health officer: May delegate the authority to conduct annual pet store inspections to another specified agency such as, but not limited to, local animal control; and Shall execute and keep on file a written agreement with the delegated inspection agency. 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. 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. 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 Effective date: March 30, 1944 Amended April 1, 1966 Regulation .55 effective May 15, 1953 Regulation .56 effective October 18, 1951 Regulation .57 effective April 1, 1966 Regulation .58 effective December 20, 1971 Regulations .01—.54, .56, and .57 repealed and new Regulations .01—.22 adopted effective December 26, 1980 (7:26 Md. R. 2420) Regulations .02A and .03B amended as an emergency provision effective June 21, 1983 (10:14 Md. R. 1257); emergency status expired October 21, 1983 Regulations .02A and .03B amended effective October 24, 1983 (10:21 Md. R. 1901) 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) 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) Regulations .01—.22, .31, .55, and .58 repealed effective August 7, 1989 (16:15 Md. R. 1650) Regulations .01—.17 and .19—.24 adopted effective August 7, 1989 (16:15 Md. R. 1650) Regulation .18 adopted effective February 19, 1990 (17:3 Md. R. 297) Chapter revised effective July 5, 1993 (20:13 Md. R. 1049) 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) 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) Chapter revised effective January 20, 2003 (30:1 Md. R. 24) 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) 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) 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) 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) 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) Regulation .03B amended effective March 13, 2006 (33:5 Md. R. 519) 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) Regulation .04 amended effective March 13, 2006 (33:5 Md. R. 519) 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) 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) 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) 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) Regulation .01 amended effective April 24, 2017 (44:8 Md. R. 403) Regulation .01-1 amended effective April 6, 2009 (36:7 Md. R. 522) Regulation .02B amended effective March 28, 2016 (43:6 Md. R. 406); April 24, 2017 (44:8 Md. R. 403) Regulation .03C amended effective April 23, 2018 (45:8 Md. R. 420) Regulation .17 amended effective April 24, 2017 (44:8 Md. R. 403) Regulation .17-1 repealed effective March 28, 2016 (43:6 Md. R. 406) Regulation .18 amended effective April 24, 2017 (44:8 Md. R. 403) Chapter revised effective May 18, 2020 (47:10 Md. R. 516) Regulation .01C amended effective July 12, 2021 (48:14 Md. R. 538) Regulation .01-1 amended effective July 12, 2021 (48:14 Md. R. 538) Regulation .13D amended effective July 12, 2021 (48:14 Md. R. 538)