6 CCR 1009-1
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 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 April 17, 2019. Effective June 14, 2019. Regulation 1. Reportable Diseases For the purpose of these regulations, the diseases named in the Reportable Diseases Table (Appendix A) are declared to be potentially dangerous to public health and shall be reportable in accordance with these regulations. In addition, any language specifying “(the) Department” refers to the Colorado Department of Public Health and Environment.
The 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, animal to person, or from person to person; 2) cases of a newly recognized entity, including novel influenza; 3) those related to a healthcare 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 healthcare provider determines or suspects may be caused by or related to a bioterrorist agent or incident must be reported immediately by telephone to the Department or county, district, or municipal public health agency by the healthcare provider and the hospital, emergency department, clinic, healthcare 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 healthcare 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 healthcare 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. In addition, for sexually transmitted infections, the patient’s sex at birth, gender identity and relevant treatment shall be reported. For reports from a publicly funded anonymous testing site, as provided in § 25-4-411, C.R.S, the patient’s name and address are not required.
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 Department, Laboratory Services Division.
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 healthcare providers and hospitals. When hospitals and laboratories transmit disease reports electronically using systems and protocols developed by the Department or Federal agencies 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 Department (or their designees), persons in charge of schools (including school nursing staff), licensed day care centers, or any other person providing testing and/or counseling to a person with a sexually transmitted infection.
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, or by an outpatient clinic that performs laboratory testing on site, 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 Department, 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. Laboratories should make an effort to report all test results electronically, whenever possible. 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 healthcare settings. The tuberculosis statute (§ 25-4-501, et seq., C.R.S.) 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 Department or county, district, or municipal public health agency within 1 working day by physicians, healthcare 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, healthcare providers, and healthcare facilities shall report within 7 calendar days the following tuberculin skin test (TST) or Interferon-Gamma Release Assay (IGRA) result if it occurs in a healthcare worker, correctional facility worker, or detention facility worker; a positive TST (defined as = or > 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 1 working day any result diagnostic of or highly correlated with active tuberculosis disease, including culture positive and nucleic acid amplification tests (NAAT) positives 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. When a laboratory performs a culture that is positive for Mycobacterium tuberculosis, the laboratory shall submit a sample of the isolate to the Department, Laboratory Services Division no later than one working day after the observation of positive findings.
F. The Department or county, district, or municipal public health agency 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 antimicrobial susceptibility test results are finalized. The Department or county, district, or municipal public health agency shall provide the laboratory and hospital the results of its evaluation, including comparison of the laboratory indices to norms for other similar laboratories.
G. The Board of Health determines that to prevent the emergence of multi drug-resistant tuberculosis (MDR-TB), it is necessary, appropriate and good medical practice for persons with active tuberculosis disease to receive directly observed therapy (DOT) for their disease. All healthcare providers and healthcare organizations are required to provide DOT 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 Department or Denver Public Health. DOT 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 § 25-4-506(3), C.R.S. Healthcare providers and healthcare organizations shall report to the Department or county, district, or municipal public health agency within 7 calendar days the name of any patient on DOT who has missed one dose. When requested by healthcare providers and healthcare organizations, the county, district, or municipal public health agency will ensure the provision of DOT to outpatients with active tuberculosis disease and this shall fulfill the requirement for the healthcare providers and healthcare organizations.
H. All healthcare providers within jails, prisons, and other incarceration facilities and hospitals and healthcare facilities providing inpatient treatment to persons with active tuberculosis disease shall notify the Department or county, district, or municipal public health agency of their intent to discharge a patient and involve the Department or county, district, or municipal public health agency in the discharge planning process prior to discharging the patient from the facility. The intention of the notification and involvement in discharge planning is to discuss the treatment plan for the patient and to assure adequate follow-up and coordination among healthcare providers and public health so that continuity of care and the DOT standard are met.
I. All licensed hospitals and nursing home facilities shall maintain a registry of the TST and/or IGRA test results of healthcare 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 § 25-4-508, C.R.S., authorized personnel of the Department 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.
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 Department or county, district, or municipal public health agencies. Such investigations may include, but are not limited to:
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;
B. Performing follow-up interview(s) with the case or persons knowledgeable about the case to collect information pertinent and relevant to the cause(s) of or risk factors for the reportable condition;
C. Medical examination and testing of persons with the explicit consent of such persons;
D. Obtaining from public or private businesses or institutions the lists of persons with a similar or common potential exposure to a reported case; such exposure may be current or have occurred in the past;
E. Interviewing or administering questionnaire surveys confidentially to any resident of a community or any agent, owner, operator, employer, employee of a public or private business or institution, that is either epidemiologically associated with a reported case or has had a similar exposure as a reported case;
F. Collecting and analyzing samples or measurements of items that may be related to the cause of the outbreak or reportable disease;
G. Taking photographs or videos related to the purpose of the investigation; If the photographs/videos are taken in a business, the employer shall have the opportunity to review the photographs/videos taken or obtained for the purpose of identifying those which contain or might reveal a trade secret;
H. Entering a public or private entity, such as a business or school, 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; such investigations shall be conducted during regular working hours or at other reasonable times and with such notice as is reasonable under the circumstances.
I. Review of workers' compensation claims;
J. Review of toxic tort or product liability claims filed with state or federal courts within the state; and K. Review of previously conducted environmental or product sampling data that may be related to the cause of the outbreak or reportable disease.
Regulation 6. Information Sharing Whenever a county, district, or municipal public health agency learns of a case of a reportable disease or an epidemic or communicable disease exposure potentially threatening to public health, it shall notify the Department in a timely manner, usually within the timeframe for reporting in Regulation 1. The Department shall, in turn, notify the appropriate county, district, or municipal public health 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 to public health.
These requirements shall not apply if the Department and county, district, or municipal public health agencies mutually agree not to share information on reported cases. Sharing of medical information on persons with reportable diseases between authorized personnel of the Department and county, district, or municipal public health agencies shall be restricted to information necessary for the treatment, control, investigation, and prevention of epidemic and communicable diseases dangerous to 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 Department. 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 public health such as rabies, anthrax, plague, tularemia, encephalitis, bovine spongiform encephalopathy, etc., shall promptly report the facts to the Department or county, district, or municipal public health agency.
B. Pursuant to § 25-4-607 (2), C.R.S., 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:
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 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 Board of Veterinary Medicine. Regulation 9. Confidentiality All personal medical records and reports held or viewed by the Department or county, district, or municipal public health agency in compliance with these regulations shall be confidential information subject to §§ 25-1-122(4) and 25-4-406(1), C.R.S. Reasonable efforts shall be made by the Department to consult with the responsible physician, other healthcare providers, or the medical facility caring for the patient prior to any further follow-up by Department or county, district, or municipal public health agencies. This information is to be used by the public health agencies as source material for necessary disease control efforts and the development of prevention programs. 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 § 12-29.5-111, C.R.S., which states 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 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 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 The Board of Health recognizes that non-sexual transmission may occur for some infections, and in individual cases, based on clinical and epidemiologic information, the responsible physician or other healthcare provider may conclude the patient’s infection was not sexually acquired. Information concerning testing, treatment, causes, or the prevention of sexually transmitted infections shall be shared, to the minimum extent necessary to achieve the public health purpose, between the appropriate county, district, or municipal public health agency, contracted agency, Ryan White Comprehensive AIDS Resources Emergency Act-funded agency, other health agency or person providing direct services related to sexually transmitted infections and the Department, as provided by § 25-4-406(1)(b), C.R.S.
With respect to Regulation 5, investigations related to sexually transmitted infections will be limited to the information necessary to confirm the diagnosis, treatment, source of infection, and identification of measures that may be used to prevent additional sexually transmitted infections. The Department shall destroy personal identifying information of all persons with CD4 or viral load results if the investigation subsequent to the report finds no evidence of a sexually transmitted infection. Section 25-4-411 (1)(a), C.R.S., requires the Department to conduct an anonymous counseling and testing program for persons considered to be at high risk for infection with human immunodeficiency virus (HIV). The provision of confidential counseling and testing for HIV is the preferred screening service for detection of HIV infection. Local boards of health who provide HIV counseling and testing through a contractual agreement with the Department shall consider the need for an anonymous HIV testing option in their jurisdiction, upon petition. The consideration of this option must provide an opportunity for public comment in a public forum, including anonymous testimony presented in writing or through an organization. Local boards of health electing to provide confidential HIV testing with an anonymous option must do so in conjunction with publicly-funded HIV testing and counseling projects. Operational Standards A. All persons providing HIV testing and counseling at a publicly funded HIV testing and counseling project in a non-health-care setting will have completed an HIV testing and counseling course approved by the Department.
B. All persons performing partner services will have completed courses concerning introduction to sexually transmitted disease interviewing and partner notification, and other related courses as specified by the Department.
C. Of all HIV tests performed at a publicly funded HIV testing and counseling project, 99% of those persons testing HIV positive will receive test results and appropriate post-test counseling related to those test results. Publicly funded HIV testing sites shall make a good faith effort to inform all persons of their test results and shall provide pertinent HIV prevention counseling and referrals.
D. All persons newly diagnosed with HIV will be referred for partner services. A minimum of 75% of those offered partner services will receive an interview and appropriate referrals. Partner services standards will be determined by the best practices guidance and code of conduct standards for sexually transmitted infection prevention providers developed by the Department. These standards shall be made publicly accessible.
E. Operational and evaluation standards for HIV testing and counseling sites will be determined by the best practices guidance developed by the Department.
F. In accordance with § 25-4-404(2), C.R.S., the Department shall create and maintain guidelines, subject to approval by the Board of Health, concerning the public health procedures described in §§ 25-4-412 and 25-4-413, C.R.S. These guidelines will include code of conduct standards for the delivery of partner services and clients’ rights, responsibilities and protections. Appendix A. Reportable Disease Table Carbapenem-resistant Acinetobacter Acinetobacter baumannii, baumannii (including Acinetobacter 4 days L All Required carbapenem-resistant (CRAB)5 baumannii complex and Acinetobacter baumannii-calcoaceticus complex)
Acute flaccid myelitis 4 days P Upon Request Animal bites by dogs, cats, bats, skunks, foxes, raccoons, coyotes, 24 hrs P Not Applicable or other wild carnivores 6,7 Animal bites by mammals not listed 4 days P Not Applicable above6 Anthrax6 Bacillus anthracis Immed L & P All Required Eastern equine encephalitis, Japanese encephalitis, LaCrosse encephalitis virus, California encephalitis serogroup, Arboviral Disease 4 days L All Upon Request Powassan virus, St. Louis encephalitis virus and Western equine encephalitis virus Botulism6 Clostridium botulinum Immed L & P All Upon Request Brucellosis6 Brucella species 4 days L & P All Required Campylobacteriosis Campylobacter species 4 days L & P All Upon Request Candida auris8 Candida auris, Candida haemulonii Immed L & P All Required Candidemia4-Metro Candida species 30 days L Blood Upon Request Catheter-associated urinary tract Per Any P Urine Not Applicable infection (CAUTI)9 CMS9 Chancroid Haemophilus ducreyi 4 days L & P All Upon Request Chikungunya Chikungunya virus 4 days L All Upon Request Chlamydia Chlamydia trachomatis 4 days L & P All Upon Request Cholera6 Vibrio cholerae Immed L & P All Required CJD and other transmissible 4 days P Upon Request spongiform encephalopathies (TSEs)6 Clostridium difficile infection4-Metro Clostridium difficile 30 days L All Upon Request Colorado tick fever Colorado tick fever virus 4 days L All Upon Request Cryptosporidiosis Cryptosporidium species 4 days L & P All Upon Request Cyclosporiasis Cyclospora species 4 days L & P All Upon Request Dengue Dengue virus 4 days L All Upon Request Diphtheria6 Corynebacterium diphtheriae Immed L & P All Required Encephalitis6 4 days P All Upon Request Carbapenem-resistant Escherichia coli, Klebsiella species, Enterobacter species Citrobacter species, Serratia species, Enterobacteriaceae, carbapenem- Raoultella species, Providencia species, 4 days L All Required resistant (CRE)11 Proteus species, Morganella species, and any carbapenemase-producing Enterobacteriaceae of any genus and species Enterobacteriaceae, extended- spectrum beta-lactamase (ESBL)4- Escherichia coli and Klebsiella species 4 days L All Upon Request Boulder, 12 Escherichia coli O157:H7 and Shiga Shiga toxin-producing Escherichia coli13 4 days L & P All Required toxin-producing Escherichia coli13 Giardiasis Giardia lamblia 4 days L & P All Upon Request Gonorrhea, any site Neisseria gonorrhoeae 4 days L & P All Upon Request Gram-negative bacteria (excludes Proteus, Providencia, Morganella, Gram-negative bacteria resistant to Serratia, Burkholderia, Neisseria, 4 days L All Required colistin### Chromobacterium, Edwardsiella, and Brucella)
Group A streptococci14, 4-Metro Streptococcus pyogenes 4 days L Sterile only Required Group B streptococci 4-Metro Streptococcus agalactiae 30 days L Sterile only Required Haemophilus influenzae Haemophilus influenzae working L & P Sterile only Required day Hantavirus disease6 Hantavirus 4 days L & P All Upon Request Healthcare-associated infections16 4 days P Not Applicable Hemolytic uremic syndrome if < 18 4 days P Upon Request years6 Hepatitis A6 Hepatitis A virus (+IgM anti-HAV ) working L & P All Upon Request day Hepatitis B virus (+HBsAg, +IgM anti- Hepatitis B 4 days L & P All Upon Request HBc, +HBeAg, or +HBV DNA)
Hepatitis C# Hepatitis C virus (- confirmatory assays) 4 days L All Upon Request Hepatitis, other viral 4 days P Upon Request Human immunodeficiency virus L & P Human immunodeficiency virus (HIV)/ CD4 counts (any value) L & P acquired immunodeficiency syndrome 4 days All Upon Request HIV viral load (any value) L & P (AIDS)
Outbreaks - known or suspected of all types - including those transmitted from Immed L & P Upon Request food, water, person-to-person, and related to a healthcare setting6 Pertussis (whooping cough)6 Bordatella pertussis working L & P All Upon Request day Plague6 Yersinia pestis Immed L & P All Required Poliomyelitis6 Poliovirus Immed L & P All Upon Request Pseudomonas, carbapenem- Pseudomonas aeruginosa 4 days L All Upon Request resistant17 Psittacosis Chlamydia psittaci 4 days L & P All Upon Request Q fever6 Coxiella burnetii 4 days L & P All Upon Request Rabies: human (suspected)6 Rabies virus (Lyssavirus) Immed L & P All Upon Request Respiratory Syncytial Virus-associated Respiratory Synctial Virus 4 DAYS L & P All Upon Request hospitalizations4-Metro Rickettsia species, including Rocky Mtn Rickettsiosis 4 days L & P All Upon Request spotted fever and typhus groups Rubella (acute infection)6 Rubella virus working L & P All Upon Request day Rubella (congenital)6 Rubella virus 4 days L & P All Upon Request Salmonellosis Salmonella species 4 days L & P All Required Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East Severe or novel coronavirus Immed L & P All Upon Request respiratory syndrome coronavirus (MERS-CoV)
Shigellosis Shigella species 4 days L & P All Required Smallpox6 Variola virus (Orthopox virus) Immed L & P All Upon Request Staphylococcus aureus, Vancomycin- Vancomycin non-susceptible 4 days L All Required non-susceptible## Staphylococcus aureus Streptococcal toxic shock syndrome Streptococcus pyogenes 4 days P All Required15 Streptococcus pneumoniae Streptococcus pneumoniae 4 days L Sterile only Required15 Syphilis6 Treponema pallidum working L & P All Upon Request day Tetanus6 Clostridium tetani 4 days P All Upon Request Tick-borne relapsing fever6 Borrelia species 4 days L & P All Upon Request Toxic shock syndrome (non- 4 days P Upon Request streptococcal)
Trichinosis6 Trichinella species 4 days P All Upon Request Tuberculosis disease (active)6 Mycobacterium tuberculosis18 working L & P All Required day Tuberculosis infection (LTBI) Mycobacterium Tuberculosis19 4 days L All Not Required Tularemia6 Francisella tularensis working L & P All Required day Typhoid fever6 Salmonella Typhi working L & P All Required day Varicella (chicken pox)6 Varicella virus 4 days L & P All Upon Request Vibriosis Vibrio species, non-cholera 4 days L All Required Crimean-Congo hemorrhagic virus, Ebola virus , Lassa fever virus, Lujo Viral hemorrhagic fever Immed L & P All Required virus, Marburg virus, Guanarito virus, Junin virus, Machupo virus, Sabia virus West Nile virus (acute infection, IgM+) West Nile virus 4 days L All Upon Request Yellow fever Yellow fever virus 4 days L All Upon Request Yersiniosis4-Seven Yersinia non-pestis species 4 days L All Required Zika virus Zika virus 4 days L All Upon Request 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 healthcare 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. *Time: 1) “Immed” = by phone, within 4 hours of suspected diagnosis. 2) Unless the term “working day” is specified, “days” refers to calendar days.
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 = healthcare 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 the Department (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, cerebrospinal fluid (CSF), pleural fluid (includes chest fluid, thoracentesis 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 Department, Laboratory Services Division. The isolate or clinical material shall be received at the Department, Laboratory Services Division no later than one working day after the observation of positive findings. 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 healthcare provider; (c) Name of disease or condition; and (d) Laboratory information - test name, collection date and specimen type.
4 Condition reportable only among residents of a specific catchment area. 4-Metro Condition reportable only among residents of Denver Metropolitan Area (Adams, Arapahoe, Denver, Douglas and Jefferson Counties).
6 Report shall be based on the diagnosis or suspected diagnosis of the attending physician or other healthcare 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 healthcare provider Reporter.
8 Candida auris identified, or any suspected Candida auris (e.g., Candida haemulonii identified by a laboratory instrument not equipped to detect Candida auris). 9 Reporting requirement is fulfilled through the Department’s access to the National Healthcare Safety Network (NHSN) for those healthcare facilities that are required to report catheter- associated urinary tract infection (CAUTI) and/or methicillin-resistant Staphylococcus aureus
10 [Footnote reserved.] 11 Escherichia coli, Klebsiella species, Enterobacter species, Citrobacter species, Serratia species, and Raoultella species that are resistant to at least one carbapenem (including imipenem, meropenem, doripenem, or ertapenem); or Providencia species, Proteus species, Morganella species that are resistant to at least one carbapenem (including meropenem, doripenem, or ertapenem); but not including imipenem); or Enterobacteriaceae of any genus and species that test positive for production of carbapenemase (e.g., KPC, NDM, VIM, IMP, OXA-48) demonstrated by a recognized test (e.g., modified carbapenem inactivation method [mCIM], polymerase chain reaction [PCR], nucleic acid amplification test [NAAT], metallo-beta-lactamase test, modified-hodge test [MHT], carba-NP).
12 Escherichia coli and Klebsiella species resistant to at least one extended-spectrum cephalosporin (ceftazidime, cefotaxime or ceftriaxone) or Escherichia coli and Klebsiella species that test positive for production of an extended-spectrum beta-lactamase (ESBL) demonstrated by a recognized test (e.g., broth microdilution, disk diffusion). 13 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.
14 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.
15 Clinical material shall be submitted from laboratories when the material is from residents of the 5- county metro area (Adams, Arapahoe, Denver, Douglas and Jefferson counties). 16 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.
17 Pseudomonas aeruginosa resistant to at least one of the following carbapenems: imipenem, meropenem, or doripenem; OR Pseudomonas aeruginosa that tests positive for production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA).
18 Including (+) AFB sputum smear, culture (regardless of specimen site) and nucleic acid amplification tests (NAAT). See regulation 4 F.
19. All positive Interferon Gamma Release Assays (IGRAs) will be reported by lab. # All associated results, including negative (nonreactive) and positive (reactive) HCV confirmatory assays from persons who have been diagnosed with or who have laboratory evidence of HCV infection are reportable (e.g., antigen or nucleic acid amplification for HCV RNA [including qualitative, quantitative or genotype testing]).
## Staphylococcus aureus that are non-susceptible to vancomycin, which include isolates with a minimum inhibitory concentration (MIC) of ≥4 mcg/ml.
### Any Gram-negative bacteria (excludes Proteus, Providencia, Morganella, Serratia, Burkholderia, Neisseria, Chromobacterium, Edwardsiella, and Brucella) resistant to colistin or a minimum inhibitory concentration (MIC) of ≥4 mcg/ml.
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:
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. Entire rule eff. 05/15/2017.
Entire rule eff. 07/15/2018.
Regulations 1, 4, 8.B, 9, 10 paragraph 1, 11, 11.F, Appendix A eff. 06/14/2019.