DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT RULES AND REGULATIONS PERTAINING TO EPIDEMIC AND COMMUNICABLE DISEASE CONTROL 6 CCR 1009-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Adopted by the Board of Health on September 16, 2015; Regulation 10 Repealed by the Board of Health on September 16, 2015; Regulation 10 Subsequently Adopted by the Executive Director on September 16, 2015.

Regulation 1. Reportable Diseases For the purpose of these regulations, the diseases named in the Reportable Diseases Table (Appendix A) are declared to be dangerous to the public health and shall be reportable in accordance with the provisions of these regulations.

The Colorado Board of Health also requires the reporting of any unusual illness, or outbreak, or epidemic of illnesses, which may be of public concern whether or not known to be, or suspected of being, communicable. Such illnesses, outbreaks, or epidemics include, but are not limited to: 1) those which may be a risk to the public and which may affect large numbers of persons such as illnesses transmitted through food, water, or from person to person; 2) cases of a newly recognized entity, including novel influenza; 3) those related to a health care setting or contaminated medical devices or products; and 4) those related to environmental contamination by any infectious agent or toxic product of such an agent. The occurrence of a single case of any unusual disease or manifestation of illness which the health care provider determines or suspects may be caused by or related to a bioterrorist agent or incident must be reported immediately by telephone to the state or local health department by the health care provider and the hospital, emergency department, clinic, health care center, and laboratory in which the person is examined, tested, and/or treated. The same immediate reporting is required for any unusual cluster of illnesses that may be caused by or related to a bioterrorist agent or incident. Bioterrorist agents include, but are not limited to, anthrax, plague, smallpox, tularemia, botulism, viral hemorrhagic fever and brucellosis.

Manner of Reporting All cases are to be reported with patient’s name, date of birth, sex, race, ethnicity, and address (including city and county) and name and address of responsible physician or other health care provider; and such other information as is needed to locate the patient for follow up. In addition, all laboratory information reported shall include specimen accession number. For animal bites by dogs, cats, bats, skunks, foxes, raccoons, coyotes, and other wild carnivores, the name and locating information of the owner of the biting animal shall be reported, if known, by the health care provider. For healthcare-associated infections, except as provided in § 25-3-601, C.R.S., facilities choosing to voluntarily participate in applied public health projects on a project by project basis shall make medical records available for review by the Department upon request within a reasonable time frame. See Appendix A, Reportable Diseases Table and Footnotes to determine time frame for reporting (from diagnosis or test result), who shall report, the reporting area, whether laboratory information is required for a report, and whether an isolate or clinical material must be sent to the State Laboratory. Reports on hospitalized patients may be made part of a report by the hospital as a whole. The Department shall develop systems and forms for reporting for physicians, other health care providers and hospitals. When hospitals and laboratories transmit disease reports electronically using systems and protocols developed by the department that ensure protection of confidentiality, such reporting is acceptable and is considered good faith reporting.

Regulation 2. Reporting by Individuals Where Reporter = ‘P’ in the Appendix A Reportable Diseases Table, cases of diseases shall be reported by the physician or other health care provider and by other persons either treating or having knowledge of a reportable disease, including, but not limited to coroners, persons in charge of hospitals or other institutions licensed by the Colorado Department of Public Health and Environment, (or their designees), persons in charge of schools (including school nursing staff) and licensed day care centers. Regulation 3. Laboratory Reporting Where Reporter = ‘L’ in the Appendix A Reportable Diseases Table, cases of diseases shall be reported with the information required in Regulation 1 by the laboratory that performs the test, whether or not associated with a hospital. The following laboratories shall also report: 1) out of state laboratories that maintain an office or collection facility in Colorado or arrange for collection of specimens in Colorado; and 2) in-state laboratories that send specimens to out-of-state referral laboratories. The case shall be reported by a laboratory when a result diagnostic of or highly correlated with clinical illness is found. Laboratory assays which demonstrate only immunity should not be reported (for example, a single elevated rubella antibody titer obtained during routine prenatal screening should not be reported). For organisms so noted in Appendix A, Reportable Diseases Table, testing laboratories shall routinely submit bacterial culture isolates or patient clinical material that yields positive findings to the CDPHE Laboratory Services Division. Clinical material is defined as: (i) A culture isolate containing the infectious organism for which submission of material is required, or (ii) If an isolate is not available, material containing the infectious organism for which submission of material is required, in the following order of preference: (A) a patient specimen; (B) nucleic acid; or (C) other laboratory material. All specimens shall be accompanied by the following information: (a) Patient's name, date of birth, sex, race, ethnicity, and address (b) Name and address of responsible physician or other health care provider (c) Name of disease or condition (d) Laboratory information - test name, collection date and specimen type.

Regulation 4 Treatment and Control of Tuberculosis The emergence of multiple drug-resistant tuberculosis in this country and state dictates a coherent and consistent strategy in order to protect the public health from this grave threat. The underlying principles of disease control expressed in the following rules are as follows: use of the most rapid and modern diagnostic methods by laboratories, rapid reporting, full patient compliance with medical treatment, and prevention of spread of tuberculosis in health care settings. The tuberculosis statute (C.R.S. 25-4-501 et seq) covers subject matters not included in these regulations.

A. All confirmed or suspected cases of active tuberculosis disease, regardless of whether confirmed by laboratory tests, shall be reported to the state or local health department or health agency within 24 hours by physicians, health care providers, hospitals, other similar private or public institutions, or any other person providing treatment to the confirmed or suspected case. The reports shall include the following information: the patient’s name, date of birth, sex, race, ethnicity, address (including city and county), name and address of the reporting physician or agency; and such other information as is needed to locate the patient for follow-up. If reported by a physician, the physician shall also give the evidence upon which the diagnosis of tuberculosis was made, the part of the body affected, and the stage of disease.

B. Physicians, health care providers, and health care facilities shall report within 7 days the following tuberculin skin test (TST) or Interferon-Gamma Release Assay (IGRA) result if it occurs in a health care worker, correctional facility worker, or detention facility worker: a positive TST (defined as = 5 mm induration) or positive IGRA test (based on manufacturer’s interpretation criteria) if the worker has had prolonged or frequent face-to-face contact with an infectious tuberculosis case.

C. Laboratories shall report within 24 hours any result diagnostic of or highly correlated with active tuberculosis disease, including cultures positive for Mycobacterium tuberculosis and sputum smears positive for acid fast bacilli, and shall report the results of tests for antimicrobial susceptibility performed on positive cultures for tuberculosis.

D. Results must be reported by the laboratory which performs the test, but an in-state laboratory which sends specimens to an out-of-state referral laboratory is also responsible for reporting the results.

E. A laboratory may fulfill its requirement to report (in parts C and D of this regulation) by submitting a sputum specimen from the patient to either the State Public Health Laboratory, or for facilities located in Boulder, Broomfield, Denver, Adams, Douglas, Arapahoe, and Jefferson counties, to the Denver Public Health laboratory. The reporting requirement is not fulfilled if the laboratory submits an isolate from a culture to either of the public health laboratories or if the laboratory delays sending the sputum specimen for more than 2 days after collection of the specimen.

F. When a laboratory performs a culture that is positive for Mycobacterium tuberculosis, the laboratory shall store the isolate until it receives a request from the state or local health department for the isolate. In lieu of such storage, the laboratory may fulfill this requirement by submitting the isolate to the state public health laboratory.

G. The State or local health department is authorized to perform evaluations of the timeliness of laboratory diagnostic processes. The data collected in an evaluation may include the mean, median, and range for the following indices: the length of time from specimen collection to isolation; the length of time from isolation of an organism to identification of the organism as Mycobacterium tuberculosis; and the length of time from isolation until susceptibility test results are finalized. The state or local health department shall provide the laboratory and hospital the results of its evaluation, including comparison of the laboratory indices to norms for other similar laboratories.

H. The Board of Health determines that to prevent the emergence of multiple drug- resistant tuberculosis, it is necessary and appropriate and good medical practice that persons with active tuberculosis disease receive directly observed treatment for their disease. All medical providers and health care organizations are required to provide directly observed therapy for patients with active tuberculosis disease for the full course of therapy, unless a variance for a particular patient from this requirement is approved by the tuberculosis control program of the State Department of Public Health and Environment or Denver Public Health. Directly observed therapy is not required for patients with extrapulmonary tuberculosis disease provided that the presence of pulmonary tuberculosis has been investigated and excluded. In applicable situations, a variance shall be granted in accordance with C.R.S. 25-4-506(3).

1. Medical providers and health care organizations shall report to the state or local health department within seven days the name of any patient on directly observed therapy who has missed one dose. When requested by medical providers and health care organizations, the state or local health department shall provide directly observed treatment to outpatients with active tuberculosis disease and this shall fulfill the requirement for the medical providers and health care organizations.

I. All hospitals and health care facilities providing in-patient treatment to persons with active tuberculosis disease shall notify the state or local health department immediately after plans are made to discharge the patient from the facility. The notification is intended to discuss the treatment plan for the patient and to assure adequate follow-up and coordination among providers so that the standard of directly observed treatment is met.

J. All licensed hospitals and nursing home facilities shall maintain a register of the TST and/or IGRA test results of health care workers in their facility, including physicians and physician extenders who are not employees of the facility but provide care to or have face-to-face contact with patients in the facility. The facility shall maintain such TST and IGRA test results as confidential medical information. Pursuant to C.R.S. 25-4-508, authorized personnel of the department of public health and environment may inspect and have access to such register in the course of an investigation intended to identify sources and contacts of a case of active tuberculosis disease and to control tuberculosis.

K.

1. (1) With respect to tuberculosis treatment and control, the chief medical health officer of a local health agency must be a physician licensed to practice medicine in the State of Colorado. The chief medical health officer of a local health agency may design a program, consistent with good medical practice, of required screening for latent TB infection. The objective of the program must be to target persons who are at high risk of such infection based on recent local, state, national, or international epidemiologic data concerning the incidence of and risk factors for tuberculosis. The programs shall be limited to screening persons who participate in activities or who work in occupations and job categories that have a reasonably large proportion of persons at increased risk of tuberculosis. The programs should be designed so that the initial step in screening is the determination of whether a person has recognized risk factors for tuberculosis and if yes, then said person should undergo a TST or IGRA test and clinical evaluation. If free of signs and symptoms of tuberculosis, subsequent testing would be dependent on the results of the TST or IGRA test.
   1. (2) The chief medical health officer of a local health agency, with the prior approval of the local board of health and pursuant to the requirements of subparagraph 3 of this paragraph K may require screening be performed for a particular group or population that has been identified as high risk based on the criteria set forth in this paragraph K, but each individual shall be informed of his or her right to be exempt from the screening because of medical or religious reasons. The local health agency should provide at least 30 days notice to potentially affected persons, groups, and businesses prior to consideration of the proposed program by the local board of health.
   2. (3) Except as provided in subparagraph 6 of this paragraph K, no program approved by a local board of health shall be implemented without the approval of the State Board of Health. Within 30 days of a program having been approved by a local board of health, the local health agency shall submit a copy of the proposed program to the State Board of Health. When considering a proposed local health agency program, the State Board of Health shall provide notice to all parties on its mailing list at least 20 days prior to the hearing.
   3. (4) If an individual has signs and symptoms compatible with tuberculosis in the infectious stages, the chief medical health officer may require examination pursuant to 25-4- 506,C.R.S. The screening may be performed by an institution, organization, or agency acting at the direction of the local health agency. The results of screening shall be given in writing to the person screened. Any person who is found to have latent TB infection without evidence of active disease shall be counseled and offered appropriate treatment by the agency performing the screening, but the person is not required to take such treatment.
   4. (5) Locally required screening programs shall be evaluated and reviewed by the local board of health every three years.
   5. (6) Nothing in this rule shall prohibit the State Health Department or the local health agency from developing voluntary screening programs, from investigating and screening contacts of suspected or confirmed cases of tuberculosis in a contagious form, or from responding to potential outbreaks of tuberculosis in a community.

Regulation 5. Investigations to Confirm the Diagnosis, Treatment, and Causes of Epidemic and Communicable Diseases and to Determine Appropriate Methods of Epidemic and Communicable Disease Control Investigations may be conducted to confirm the diagnosis, treatment, and causes of reportable conditions and shall be considered official duties of the health department or health agency. Such investigations may include, but are not limited to:

1. (a) review of pertinent, relevant medical records by authorized personnel, if necessary to confirm the diagnosis; to investigate causes; to identify other cases related to the outbreak or the reported communicable disease in a region, community, or workplace; to determine if a patient with a reportable disease has received adequate treatment to render him/her non-infectious or a person exposed to a case has received prophylaxis, if appropriate. Such review of records may occur without patient consent and shall be conducted at reasonable times and with such notice as is reasonable under the circumstances. Where feasible, facilities are encouraged to provide remote electronic access to authorized health department staff for this purpose;
   1. (b) performing follow-up interview(s) with the case or persons knowledgeable about the case to collect pertinent and relevant information about the cause(s) of or risk factors for the reportable condition;
   2. (c) medical examination and testing of persons with the explicit consent of such persons;
   3. (d) obtaining from public or private businesses or institutions the identities and locating information of persons, travelers, passengers, or transportation crews with a similar or common potential exposure to the infectious agent as a reported case; such exposure may be current or have occurred in the past;
   4. (e) interviewing or administering questionnaire surveys confidentially to any resident of a community or any agent, owner, operator, employer, employee, or client of a public or private business or institution, that is either epidemiologically associated with the outbreak or with the reported communicable disease case or has had a similar exposure as a reported case;
   5. (f) collecting environmental samples of substances or measurements of physical agents that may be related to the cause of an outbreak or reportable communicable disease;
   6. (g) taking photographs related to the purpose of the investigation; If the photographs are taken in a business, the employer shall have the opportunity to review the photographs taken or obtained for the purpose of identifying those which contain or might reveal a trade secret;
   7. (h) entering a place of employment for the purpose of conducting investigations of those processes, conditions, structures, machines, apparatus, devices, equipment, records, and materials within the place of employment which are relevant, pertinent, and necessary to the investigation of the outbreak or reportable communicable disease; such investigations shall be conducted during regular working hours or at other reasonable times and with such notice as is reasonable under the circumstances. Regulation 6. Information Sharing Whenever a local health department or health agency learns of a case of a reportable disease or an epidemic or communicable disease exposure potentially threatening the public health, it shall notify the State Department of Health in a timely manner, usually within the timeframe for reporting in regulation 1. The State Department of Health shall, in turn, notify the appropriate local health department or agency in a timely manner, usually within the timeframe for reporting in Regulation 1, whenever it learns of a case of a reportable disease or it learns of an epidemic or communicable disease exposure potentially threatening the public health.

These requirements shall not apply if the State and local health agencies mutually agree not to share information on reported cases.

Sharing of medical information on persons with reportable diseases between authorized personnel of State and local health departments shall be restricted to information necessary for the treatment, control, investigation, and prevention of epidemic and communicable diseases dangerous to the public health. Regulation 7. Food Handling and Infected Persons No person, while infected with a disease in a communicable form which can be transmitted by foods or who is afflicted by a boil, or an infected wound,shall work in a food processing, milk producing, milk processing or food service setting in any capacity in which there is a likelihood of such person contaminating food or food contact surfaces with pathogenic organisms or transmitting diseases to other persons. The employer is responsible for ensuring the absence from work of an employee with an infectious disease for which there is evidence of transmission to persons in a food service, food processing, milk producing, or milk processing setting, as determined by the State Department of Health. Regulation 8. Reporting of Diseases Among Animals and Waiver Process for Rabies Inoculation A. Every veterinarian, livestock owner, veterinary diagnostic laboratory director, or other person having the care of, or knowledge of, the existence of animals having or suspected of having any disease which may endanger the public health such as rabies, anthrax, plague, tularemia, encephalitis, bovine spongioform encephalopathy, etc., shall promptly report the facts to the local health department or health agency or the State Department of Health.

B. Pursuant to C.R.S. § 25-4-607 (2), a veterinarian licensed in Colorado may issue a written waiver as provided in this section exempting an animal from a rabies vaccination order if the veterinarian, in his or her professional opinion, determines the rabies inoculation is contraindicated due to the animal’s medical condition. The terms “waiver” and “exemption” as used in this section are interchangeable. A veterinarian may issue a waiver if:

1. 1. The animal to be exempted has a medical condition defined as “a disease, illness, or other pathological state” for which, in the opinion of the exempting veterinarian, a rabies inoculation is contraindicated;
   1. 2. A valid veterinary-client-patient relationship, as defined under C.R.S. § 12-64-103 (15.5), has been established between the veterinarian, owner and animal to be exempted from rabies inoculation;
   2. 3. The veterinarian completes and signs the veterinary section of the Exemption from Rabies Vaccination form provided by the Department;
   3. 4. The animal owner signs the informed consent section of the Exemption from Rabies Vaccination form;
   4. 5. The veterinarian maintains the signed exemption as part of the animal’s medical record and provides a copy to the owner;
   5. 6. The exemption issued is limited to the anticipated duration of the animal’s medical condition that precludes inoculation; and 7. The veterinarian provides a copy of the exemption form to the Department, the local health department or animal control agency when requested.

C. A waiver may not exceed a period of three years from the date of issuance. If the medical condition persists beyond a three year period and, in the professional opinion of a veterinarian licensed in the State of Colorado, the exemption continues to be appropriate, a new waiver may be issued.

D. Upon receiving a complaint regarding the validity of a rabies inoculation exemption, the executive director or his/her designee(s) may review Exemption from Rabies Vaccination forms and examine the veterinary records pertaining to the medical condition to determine if the medical condition legitimately contraindicates rabies inoculation. if appropriate, the executive director or his/her designee(s) may refer the case to the State Board of Veterinary Medicine. Regulation 9. Confidentiality All personal medical records and reports held or viewed by the state or local health department in compliance with these regulations shall be confidential information subject to C.R.S. 25-1-122(4). Reasonable efforts shall be made by the department to consult with the attending physician or medical facility caring for the patient prior to any further follow-up by State or local health departments or health agencies Regulation 10. Use of Sterile Needles, and Cleaning and Disinfection of Other Instruments, Probes, and Devices Used by Practitioners of Acupuncture and Adjunctive Therapies (promulgated by the Executive Director)

This regulation is promulgated pursuant to C.R.S. Section 12-29.5-111, which states that the Department shall promulgate rules relating to the proper cleaning and sterilization of needles used in the practice of acupuncture and the sanitation of acupuncture offices.

All parts of the premises of an acupuncture establishment shall be kept in a clean, sanitary, neat, and orderly condition at all times. All surfaces (e.g., tables, counters, chairs) used in connection with procedures involving equipment items shall be cleaned and disinfected with a disinfectant registered by the U.S. Environmental Protection Agency for use in health care settings according to labeled instructions. Equipment items shall be defined as any needle, instrument, probe, or device utilized by practitioners of acupuncture that punctures the skin or enters tissue of any patient/client. Prior to and after each treatment of acupuncture, the practitioner shall perform hand hygiene by either washing his/her hands with soap and water or using an alcohol-based hand sanitizer. Needles and other equipment items that puncture the skin or enter the tissues of any patient/client shall be disposable single-use items that are appropriately discarded immediately after use in an appropriate sharps container, and shall never be used on more than one patient. Equipment items that are vehicles for needles and other puncturing devices shall either be disposable, single-use items (preferred), or thoroughly cleaned and disinfected between each patient use according to the manufacturers’ instructions. If there are no manufacturers’ instructions for how to clean and disinfect the device, the device shall not be used on more than one patient.

Regulation 11. Sexually Transmitted Infections In addition to all manifestations of chlamydia, syphilis and gonorrhea, the Colorado Board of Health finds that the following diseases are contagious, are sexually transmissible, are dangerous to the public health, and pursuant to C.R.S. 25-4-401(1) are determined to be sexually transmitted infections. The Board recognizes that non-sexual transmission may occur for some of these diseases, and that in individual cases, based on clinical and epidemiologic information, the attending physician may conclude the patient’s disease was not sexually acquired:

1. Chancroid Genital herpes simplex infection Granuloma inguinale Lymphogranuloma venereum Urethritis in males caused by C. trachomatis, U. urealyticum, M. genitalium,T. vaginalis, and Herpes simplex virus Mucopurulent cervicitis in females caused by C. trachomatis or N. gonorrhoeae Trichomoniasis Pelvic inflammatory disease caused by C. trachomatis or N. gonorrhoeae Epididymitis caused by C. trachomatis, N. gonorrhoeae, or E. coli Human papillomavirus infection, including genital or anal warts Hepatitis A Hepatitis B Hepatitis C Pediculosis pubis Acute proctitis caused by C. trachomatis, N. gonorrhoeae, T. pallidum, or Herpes simplex virus Appendix A. Reportable Diseases Table Limited Specimen Send Clinical Reporting Disease/Event Pathogen/Organism Time Reporter1 Source(s)2 Material3 area4 Acinetobacter Carbapenem-resistant 30 L Sterile sites, Metro baumannii, carbapenem- Acinetobacter baumannii days urine resistant (CRAB)5 (including Acinetobacter baumannii complex and Acinetobacter baumannii- calcoaceticus complex)

   Acute flaccid myelitis 7 days P Animal bites by dogs, 24 P cats, bats, skunks, hours foxes, raccoons, coyotes, or other wild carnivores 6,7 Animal bites by mammals not listed 7 days P above6 Anthrax6 Bacillus anthracis L & P All Required hours Botulism6 Clostridium botulinum L & P All hours Brucellosis6 Brucella species 7 days L & P All Required California/LaCrosse LaCrosse encephalitis 7 days L All serogroup virus diseases virus, California encephalitis serogroup virus, etc.

   Campylobacteriosis Campylobacter species 7 days L & P All Chancroid Haemophilus ducreyi 7 days L & P All Chikungunya Chikungunya virus 7 days L All Chlamydia Chlamydia trachomatis 7 days L & P All Cholera6 Vibrio cholerae L & P All Required hours CJD and other 7 days P transmissible spongiform encephalopathies (TSEs)6 Clostridium difficile 30 Clostridium difficile L All Requested8 Metro infection days Colorado tick fever Colorado tick fever virus 7 days L All Cryptosporidiosis Cryptosporidium species 7 days L & P All Cyclosporiasis Cyclospora species 7 days L & P All Required Dengue Dengue virus 7 days L All Corynebacterium 24 Diphtheria6 L & P All Required diphtheriae hours Eastern equine Eastern equine encephalitis 7 days L All encephalitis virus Encephalitis6 7 days P All Enterobacteriaceae, Carbapenem-resistant 7 days L All Requested8 carbapenem-resistant Escherichia coli, Klebsiella (CRE)9 species, Enterobacter species Limited Specimen Send Clinical Reporting Disease/Event Pathogen/Organism Time Reporter1 Source(s)2 Material3 area4 Escherichia coli Shiga toxin-producing 7 days L & P All Required O157:H7 and Shiga Escherichia coli10 toxin-producing Escherichia coli10 Giardiasis Giardia lamblia 7 days L & P All Gonorrhea, any site Neisseria gonorrhoeae 7 days L & P All Group A streptococci11 Streptococcus pyogenes 7 days L Sterile only Required12 Metro Group B streptococci Streptococcus agalactiae 7 days L Sterile only Required12 Metro Haemophilus influenzae6 Haemophilus influenzae L & P Sterile only Required hours Hantavirus disease6 Hantavirus 7 days L & P All Healthcare-associated 7 days P infections13 Hemolytic uremic 7 days P syndrome if ≤ 18 years6 Hepatitis A virus (+IgM 24 Hepatitis A L & P All anti-HAV ) hours Hepatitis B Hepatitis B virus (+HBsAg, 7 days L & P All +IgM anti-HBc, +HBeAg, or +HBV DNA)

   Hepatitis C Hepatitis C virus (+ serum 7 days L & P All antibody titer, including signal to cut-off ratio, or more specific + tests)

   Hepatitis, other viral 7 days P Influenza-associated 7 days P death if < 18 years Influenza-associated 7 days P hospitalization Japanese Encephalitis Japanese encephalitis 7 days L All virus Legionellosis6 Legionella species 7 days L & P All Leprosy (Hansen's 7 days P Disease)

   Listeriosis Listeria monocytogenes 7 days L & P All Required Lyme disease Borrelia burgdorferi 7 days L & P All Lymphogranuloma Chlamydia trachomatis 7 days L & P All venereum (LGV)

   Malaria6 Plasmodium species 7 days L & P All Measles (rubeola)6 Measles virus L & P All hours Neisseria meningitidis or 24 Meningococcal Disease6 L & P Sterile only Required gram-negative diplococci hours Mumps virus (acute Mumps6 7 days L & P All infection)

   Outbreaks - known or 24 P suspected of all types hours including those transmitted from food, water, person-to-person, and related to a health care setting6 Pertussis (whooping 24 Bordatella pertussis L & P All Requested8 cough)6 hours Plague6 Yersinia pestis L & P All Required hours Poliomyelitis6 Poliovirus L & P All hours Powassan virus disease Powassan virus 7 days L All Pseudomonas, Pseudomonas aeruginosa 7 days L All Requested8 carbapenem-resistant14 Psittacosis Chlamydia psittaci 7 days L & P All Q fever6 Coxiella burnetii 7 days L & P All Limited Specimen Send Clinical Reporting Disease/Event Pathogen/Organism Time Reporter1 Source(s)2 Material3 area4 Rabies: human 24 Rabies virus (Lyssavirus) L & P All (suspected)6 hours Spotted fever Rickettsia species 7 days L & P All rickettsiosis Rubella (acute infection) Rubella virus L & P All hours Rubella, congenital6 Rubella virus 7 days L & P All Salmonellosis Salmonella species 7 days L & P All Required Severe or novel Severe acute respiratory 24 L & P All coronavirus syndrome coronavirus hours (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV)

   Shigellosis Shigella species 7 days L & P All Required Variola virus (Orthopox 24 Smallpox6 L & P All virus) hours St. Louis encephalitis St. Louis encephalitis virus 7 days L All Staphylococcus aureus, Vancomycin-resistant 7 days L All Required Vancomycin-resistant Staphylococcus aureus Streptococcal toxic Streptococcus pyogenes 7 days P All Required12 shock syndrome Streptococcus Streptococcus pneumoniae 7 days L Sterile only Required12 pneumoniae Syphilis (1°, 2°, or early 24 Treponema pallidum L & P All latent) 6 hours Tetanus6 Clostridium tetani 7 days P All Tick-borne relapsing Borrelia species 7 days L & P All fever6 Toxic shock syndrome 7 days P (non-streptococcal)

   Trichinosis6 Trichinella species 7 days P All Tuberculosis disease Mycobacterium 24 L & P All See Reg 4F (active)6 tuberculosis15 hours Tularemia6 Francisella tularensis L & P All Required hours Typhoid fever6 Salmonella Typhi L & P All Required hours Varicella (chicken pox)6 Varicella virus 7 days L & P All Vibriosis Vibrio species, non-cholera 7 days L All Required Viral hemorrhagic fever Crimean-Congo 24 L & P All Required hemorrhagic virus, Ebola hours virus , Lassa fever virus, Lujo virus, Marburg virus, Guanarito virus, Junin virus, Machupo virus, Sabia virus West Nile virus (acute West Nile virus 7 days L All infection, IgM+)

   Western equine Western equine 7 days L All encephalitis encephalitis virus Yellow fever Yellow fever virus 7 days L All Yersiniosis Yersinia non-pestis species 7 days L All Required Seven All cases are to be reported with patient's name, date of birth, sex, race, ethnicity, and address (including city and county) and name and address of responsible physician or other health care provider; and such other information as is needed in order to locate the patient for follow up. In addition, all laboratory information reported shall include specimen accession number. 1 Reporter: The party responsible for reporting is indicated by one of the following: L = Laboratory (whether or not associated with a hospital; by out-of-state laboratories that maintain an office or collection facility in Colorado; and by in-state laboratories which send specimens to an out-of- state laboratory referral laboratory), P = health care provider or other person knowing of or suspecting a case (including but not limited to coroners, persons in charge of hospitals or other institutions licensed by CDPHE (or their designees), persons in charge of schools (including nursing staff) and licensed day care centers), L & P = Both 2 Specimen sources: A condition is reportable when the pathogen is isolated or detected from any specimen source unless where otherwise indicated. A normally “sterile site” is defined as blood, CSF, pleural fluid (includes chest fluid, thoracocententesis fluid), peritoneal fluid (includes abdominal fluid, ascites), pericardial fluid, bone (includes bone marrow), joint or synovial fluid, needle aspirate or culture of any specific joint, internal body sites (sterilely obtained from biopsy/tissue/abscess/aspirate/fluid/swab from lymph node, brain, heart, liver, spleen, vitreous fluid, kidney, pancreas, vascular tissue, or ovary). Skin and skin abscesses are not considered sterile sites.

3 Testing laboratories shall routinely submit bacterial culture isolates or patient clinical material that yields positive findings to the CDPHE Laboratory Services Division. Clinical material is defined as:

1. (i) A culture isolate containing the infectious organism for which submission of material is required, or (ii) If an isolate is not available, material containing the infectious organism for which submission of material is required, in the following order of preference: (A) a patient specimen; (B) nucleic acid; or (C) other laboratory material. All specimens shall be accompanied by the following information: (a) Patient's name, date of birth, sex, race, ethnicity, and address (b) Name and address of responsible physician or other health care provider (c) Name of disease or condition (d) Laboratory information - test name, collection date and specimen type.

4 Condition reportable only among residents of a specific catchment area. Metro = Denver Metropolitan Area (Adams, Arapahoe, Denver, Douglas and Jefferson Counties); Seven = Seven- county Denver Metropolitan Area (Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson Counties). If not specified, condition reportable in all Colorado counties. 5 Acinetobacter baumannii (including Acinetobacter baumannii complex and Acinetobacter baumannii-calcoaceticus complex) that are intermediate or resistant to at least one carbapenem (including imipenem, meropenem, doripenem, or ertapenem) isolated from a normally sterile site or urine.

6 Report shall be based on the diagnosis or suspected diagnosis of the attending physician or other health care provider, whether or not supporting laboratory data are available. 7 For animal bites by dogs, cats, bats, skunks, foxes, raccoons, coyotes, and other wild carnivores, the name and locating information of the owner of the biting animal shall be reported, if known, by the health care provider Reporter.

8 Clinical material is requested from selected laboratories. 9 Escherichia coli, Klebsiella species, and Enterobacter species that are intermediate or resistant to at least one carbapenem (including imipenem, meropenem, doripenem, or ertapenem) AND resistant to all third-generation cephalosporins tested (ceftriaxone, cefotaxime, and ceftazidime); OR Escherichia coli, Klebsiella species, and Enterobacter species that test positive for carbapenemase production (by any method, including the Modified Hodge Test, disk diffusion, or

1. PCR) production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA-48) demonstrated by a recognized test (e.g., polymerase chain reaction, metallo-ß-lactamase test, modified-Hodge test, Carb-NP).

10 This includes any shiga-toxin test or O157 antigen test that is positive, even if no culture is performed. If the laboratory does not have the capacity to perform H (flagellar) antigen tests, then Escherichia coli O157 should be reported.

11 If Group A streptococci is isolated from a wound or surgical tissue/specimen and is accompanied by necrotizing fasciitis or streptococcal toxic shock syndrome, the case shall be reported and the isolate shall be submitted.

12 Clinical material shall be submitted from laboratories located in the seven-county Denver Metropolitan Area (Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, and Jefferson Counties) when the material is from residents of the Metro Area (Adams, Arapahoe, Denver, Douglas and Jefferson counties).

13 Reportable only by facilities that are voluntarily participating in applied public health projects. Appendix B includes a definition of healthcare-associated infections, a list of included infections, and a list of included health facility types 14 Pseudomonas species that are resistant to at least one of the following carbapenems: imipenem, meropenem, or doripenem; OR Pseudomonas species that test positive for production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA)

15 Including (+) AFB sputum smear Appendix B. Healthcare-Associated Infections Definition of a healthcare-associated infection: a localized or systemic condition that results from an adverse reaction to the presence of an infectious agent or its toxins that was not present or incubating at the time of admission to the health facility.

Healthcare-associated infections include:

1. Bloodstream infections Bone and joint infections Cardiovascular system infections Central nervous system infections Eye, ear, nose, throat, or mouth infections Gastrointestinal system infections Lower respiratory tract infections other than pneumonia Pneumonia Reproductive tract infections Skin and soft tissue infections Surgical site infections Systemic infections Urinary tract infections Health facility types include:
   1. Ambulatory surgical centers Birth centers Convalescent centers Dialysis treatment clinics/End-stage renal disease facilities Hospices Hospitals (general, psychiatric, rehabilitation, maternity, and long-term care) Long-term care facilities Outpatient clinics (community clinics; community clinics with emergency centers; rural health clinics; outpatient rehabilitation facilities; outpatient physical therapy, occupational therapy or speech pathology services; and private physician offices) _________________________________________________________________________ Editor’s Notes History Regulations 1, 3 eff. 05/30/2007.

Regulation 3 eff. 03/30/2008.

Regulation 8 eff. 03/02/2010.

Regulations 1, 3, 11 eff. 04/14/2010.

Regulations 1, 3, Appendix A eff. 12/30/2010.

Regulations 1, 3 eff. 11/30/2012.

Regulations 1-3, 5, 9 eff. 10/15/2014.

Regulations 1-4, 8, 10, Appendices A-B eff. 11/14/2015.