COMMUNICABLE DISEASE REPORTING AND INVESTIGATIONS

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7.1 Summary

Mandatory communicable disease reporting assists public health officials in investigating communicable diseases and taking actions to protect the health of the community. Identification and reporting of communicable disease is a collaborative effort among physicians and other healthcare providers, veterinarians, hospitals and other health facilities, laboratories, and the local public health system. Timely reporting of the specific illness or condition, as well as any unusual manifestations of disease, will allow public health officials to determine if further action is necessary to protect public health, such as isolation or quarantine of an individual or group of individuals. Thus, communicable disease reporting and investigation is an integral part of public health emergency law.

Before action is taken, it is critical that officials have a thorough understanding of the disease in question, including issues such as mode of transmission (e.g., airborne or through contact with bodily fluids) and how long the disease incubates in an affected individual before they become contagious (the incubation period). Thus, District epidemiologists should be consulted before action is taken.

Today’s global nature of travel and commerce means that disease spreads quickly throughout the world, requiring increased vigilance for emerging and re-emerging infectious diseases. Examples of such diseases include Ebola, Zika, Middle Eastern Respiratory Syndrome (MERS), measles, Severe Acute Respiratory Syndrome (SARS), Coronavirus Disease 2019 (COVID-19). See section 16.0 of the Manual for more information about emerging and re-emerging diseases.

7.2 Communicable Diseases

A communicable disease is any disease listed as a notifiable disease under D.C. Official Code § 7-131, including any illness due to an infectious agent or its toxic product that is transmitted:

  • Directly or indirectly to a well person from an infected person, animal, or ectoparasite (e.g., lice, fleas);
  • Through the agency of an intermediate host or vector, or by exposure to chemical or radiological agents within the immediate environment; or
  • Occurring as an outbreak of illness or toxic conditions, regardless of causation, in an institution or other identifiable group of people.

D.C. Official Code § 7-132(2).

Chemical and radiological agents and other toxic conditions are included within the definition of a communicable disease. Accordingly, communicable disease reporting in the District is not limited to traditional infectious diseases, and diseases that have or could result from exposure of individuals to chemical or radiological agents or other toxic conditions must also be reported to the DC Health Director.

As many diseases are transmitted via animals and vectors (e.g., mosquitoes), see section 13.0 of the Manual.

7.3 Communicable Disease Reporting

See Appendix 5.0 for a chart of notifiable diseases and conditions developed by DC Health (last revised March 2018). To ensure that the information is the most current, visit: https://dchealth.dc.gov/service/infectious-diseases.

Occasionally the DC Health Division of Epidemiology-Disease Surveillance and Investigation (DE-DSI) will issue health notices providing important information and updates on diseases and issues of public health significance. For the most up to date information regarding communicable diseases, refer to the recent health notices posted at https://dchealth.dc.gov/page/health-notices. For example, in February 2019, a Health Notice was issued for reporting, control, and containment of Candida auris.

7.3.1    Notifiable Diseases 

  1. The following diseases must be reported immediately upon provisional diagnosis or the appearance of suspicious symptoms by submission in writing via an online case report within 24 hours:
  • Animal bites;
  • Hepatitis A;
  • Shiga toxin-producing Escherichia coli (STEC);
  • Staphylococcal infections in newborns (nosocomial); and
  • Vibriosis (non-cholera Vibrio species infections).

See List of Notifiable Diseases and Conditions in the District of Columbia.

  1. The following diseases must be reported by telephone to DC Health immediately upon provisional diagnosis or the appearance of suspicious symptoms, with written confirmation via an online case report within 24 hours:
  • Anthrax (Bacillus anthracis);
  • Botulism;
  • Cholera (Toxigenic Vibrio cholerae 01 or 0139);
  • Diphtheria;
  • Encephalitis, acute arboviral (e.g., Eastern Equine Encephalitis, St. Louis Encephalitis, Western Equine Encephalitis);
  • Hantavirus pulmonary syndrome (HPS);
  • Hemolytic uremic syndrome;
  • Influenza A, novel;
  • Influenza-associated mortality (patients less than eighteen (18) years of age);
  • Listeriosis;
  • Measles (Rubeola);
  • Meningitis (Neisseria meningitidis);
  • Meningococcal disease, invasive;
  • Middle East Respiratory Syndrome (MERS);
  • Mumps;
  • Pertussis (Whooping cough);
  • Plague (Yersinia pestis);
  • Poliovirus infection;
  • Rabies (animal or human);
  • Rubella (German measles), including congenital rubella syndrome;
  • Severe Acute Respiratory Syndrome (SARS);
  • Smallpox;
  • Tularemia;
  • Typhoid fever (Salmonella typhi);
  • Viral hemorrhagic fevers (Ebola or other);
  • Yellow fever;
  • An infection or outbreak that may be of public health concern (including healthcare associated and foodborne); and
  • An emerging infectious disease or an unusual occurrence of any disease.

See 22B DCMR § 201.1 and List of Notifiable Diseases and Conditions in the District of Columbia. 

A healthcare associated infection (HAI) is an infection that develops in a patient or resident in a healthcare facility that was not present or incubating at the time of admission. An HAI outbreak is the occurrence of more cases of infections than expected in a given healthcare facility area among a specific group of people over a particular period of time, or when the number of infections in a healthcare facility is higher than the baseline rate for that facility. 22B DCMR § 299.1.

A foodborne disease outbreak is an incident in which two or more persons experience a similar illness resulting from ingestion of a common food. 22B DCMR § 299.1.

  1. The following diseases must be reported to DC Health in writing via an online case report within 24 hours after provisional diagnosis or the appearance of suspicious symptoms:
  • Brucellosis;
  • Campylobacteriosis;
  • Chikungunya;
  • Dengue;
  • Haemophilus influenza, invasive disease;
  • Healthcare-associated infection, cluster or outbreak;
  • Lymphogranuloma venerium (LGV, including atypical LGV);
  • Meningitis, (aseptic or viral, fungal, and bacterial (other than N. meningitidis));
  • Psittacosis (Ornithosis);
  • Q Fever;
  • Streptococcal infection, invasive (Pneumococcal disease);
  • Tetanus; and
  • Zika virus disease (including congenital Zika virus infection).

See 22B DCMR § 201.2 and List of Notifiable Diseases and Conditions in the District of Columbia.

  1. The following diseases must be reported to DC Health in writing via an online case report within 24 hours after provisional diagnosis or the appearance of suspicious symptoms if there are 3 or more cases that occur within a 7-day period in a school or childcare facility:
    • Conjunctivitis (Pink Eye) outbreak;
    • Gastrointestinal illness outbreak;
    • Hand, foot, and mouth disease outbreak;
    • Head lice outbreak;
    • Impetigo outbreak;
    • Pinworm (Enterobiasis) outbreak;
    • Ringworm (Tinea) outbreak;
    • Scabies outbreak; and
    • Streptococcal non-invasive, Group A (Scarlet fever and strep throat) outbreak.

See 22B DCMR § 201.2(k) and List of Notifiable Diseases and Conditions in the District of Columbia.

  1. The following diseases must be reported to DC Health in writing via an online case report within 48 hours after diagnosis or the appearance of suspicious symptoms:
  • Babesiosis;
  • Chancroid;
  • Chickenpox (morbidity, pediatric mortality);
  • Chlamydia trachomatis infection (including PID, perinatal, and trachoma);
  • Coccidioidomycosis;
  • Cryptosporidiosis;
  • Cyclosporiasis;
  • Ehrlichiosis;
  • Giardiasis;
  • Gonococcal infection;
  • Granuloma inguinale;
  • Hepatitis (acute B, C);
  • Human immunodeficiency virus (HIV) infection, and pregnancies in HIV-infected women;
  • Kawasaki disease;
  • Legionellosis;
  • Leptospirosis;
  • Lyme Disease (Borrelia Burgdorferi);
  • Malaria;
  • Melioidosis;
  • Powassan virus;
  • Rickettsiosis, spotted fever (e.g., Rocky Mountain Spotted Fever);
  • Salmonellosis;
  • Shigellosis;
  • Syphilis (all stages congenital);
  • Toxic shock syndrome (Staphylococcal, Streptococcal, and other);
  • Trichinosis (Trichinellosis);
  • Tuberculosis;
  • Urethritis, atypical;
  • Vaccine adverse events; and
  • West Nile virus.

See 22B DCMR § 201.3 and List of Notifiable Diseases and Conditions in the District of Columbia.

Reporting for acute hepatitis B is currently mandated. However, DC Health is requesting case reports for chronic and perinatal hepatitis B, which will be mandated in forthcoming regulations. Reports are also requested for a pregnancy in a woman positive for hepatitis B or C. See Appendix 5.0 of the Manual.

  1. Acute care, ambulatory, long-term acute care, skilled nursing, and outpatient renal dialysis facilities should report the following conditions to the National Healthcare Safety Network (NHSN) and provide DC Health with access to these data:
  • Carbapenem-resistant enterobacteriacae - LabID event;
  • Catheter-associated urinary tract infections;
  • Central line-associated bloodstream infections;
  • Clostridium difficile (C. difficile)- LabID event;
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia- LabID event; and
  • Surgical site infection, abdominal hysterectomy; and
  • Surgical site infection, colon surgery.
  1. Lead poisoning in children must be reported to the District of Columbia Department of Energy & Environment (DOEE) immediately by telephone or fax if the results are greater than or equal to 10 µg/dL.

As a courtesy, all results greater than or equal to 5 µg/dL should also be reported immediately. Providers must report the case to DOEE by telephone within 72 hours of receiving notification from a laboratory or another provider/facility. Laboratories, including providers who utilize point-of-care testing, are required to report all test results less than 10 µg/dL within 1 week of analysis.

See List of Notifiable Diseases and Conditions in the District of Columbia.

7.3.2    Information to Be Reported 

When reporting diseases to the DC Health Director as indicated above, the report must be filed on a form approved by the DC Health Director, and must include the following:

  • Information regarding the person submitting the report, including:
    • First and last name;
    • Phone number;
    • Facility name;
    • Facility address;
    • Name of provider who saw patient; and
    • Date report was sent.
  • Information regarding the patient, including:
    • First and last name;
    • Date of birth;
    • Sex;
    • Home address;
    • Race or ethnicity;
    • Telephone number; and
    • School or place of occupation.
  • Disease, condition, or symptom information, including:
    • Name of suspected or confirmed disease;
    • Date of symptom onset;
    • Date of diagnosis;
    • Supporting laboratory documentation; and
    • Other epidemiologic information the DC Health Director may request.

22B DCMR § 202.9.

District law requires the use of an approved form in order to report infectious diseases. The most up-to-date forms for reporting various diseases can be found at https://dchealth.dc.gov/service/infectious-diseases.

Notifiable disease reporting requirements can change over time. For the most up-to-date information, please visit DC Health’s website https://dchealth.dc.gov/node/115052.

7.3.3    Mandated Reporters and Special Reporting Obligations 

  1. Physicians and Other Healthcare Providers – Physicians and other healthcare providers are required to report communicable disease cases as described above. In addition, physicians and other healthcare providers must report information regarding carriers or contacts to the DC Health Director. 22B DCMR § 202.3.

Physicians and other healthcare providers must advise the infected adult or the infected minor’s parent or guardian of the applicable requirements for isolation, quarantine, and restriction of movement. 22B DCMR § 202.4.

See section 8.0 of the Manual for more information about isolation, quarantine, and other types of detention.

Physicians who are treating or caring for a person with a communicable disease must immediately report the name, address, and other relevant information to the DC Health Director in the following circumstances:

  • When the person is delinquent in treatment;
  • When the person violates isolation or quarantine; and
  • When there is any change in location of the case (must be reported to the DC Health Director by phone or in writing within 24 hours of the change).

22B DCMR § 202.10, 202.12.

In addition to the duty to report the diseases described above, physicians and other licensed healthcare providers must report an HIV/AIDS (Acquired Immune Deficiency Syndrome) diagnosis, as well as a pregnancy in an HIV-infected woman, to the DC Health Director within 48 hours of diagnosis and furnish information the DC Health Director deems necessary to complete a confidential case report. 22B DCMR § 206.2. These reports must include the following information:

  • Patient’s name;
  • Address of residence, including city, state, and zip code;
  • Sex;
  • Race or ethnicity;
  • Mode of exposure;
  • Place or country of birth;
  • Date of birth;
  • Date of diagnosis of HIV or AIDS and opportunistic infections;
  • Name/telephone number of person making report; and
  • Name of entity providing health/medical services.

22B DCMR § 206.3.

Protected health information (PHI) which is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), may be disclosed for public health activities, including disease reporting and surveillance. See section 10.4.4 B of the Manual.

  1. Veterinarians – Veterinarians are required to report communicable disease cases as described above. In addition, veterinarians must report information regarding carriers or contacts to the DC Health Director. Such reports must include a statement of the instructions provided regarding isolation, quarantine, and restriction of movement. 22B DCMR § 202.1-202.3.

Veterinarians must advise the person in charge of the infected animal of the applicable requirements for isolation, quarantine, and restriction of movement. 22B DCMR § 202.4.

Veterinarians or other persons who have reason to suspect any of the following must make an immediate report to the DC Health Director by telephone, followed by an immediate written online report to the DC Health Director:

  • A dog or other animal is suffering from rabies;
  • A dog or other animal has been bitten by or exposed to a dog or other animal suffering with rabies; or
  • A person with potential rabies exposure as a result of having been bitten or exposed to a dog or other animal.

22B DCMR § 203.1.

The report made by the veterinarian must include the information listed in section 7.3.2 above, as well as the following information:

  • The name, contact information, and place of residence of the person owning or harboring the animal;
  • The location of the animal; and
  • The dog license number and rabies license number, if any.

22B DCMR § 203.3.

If a report is made to a member of the Metropolitan Police Department (MPD), DC Health Animal Services Animal Care and Control Fields Services Division, or a privately owned veterinary hospital or clinic of any of the foregoing events, such event must be immediately communicated to the DC Health Director, followed immediately by a written report to the DC Health Director.

For more information regarding animal bites and rabies, see section 13.5 of the Manual and the DC Health website: https://dchealth.dc.gov/node/115012, https://dchealth.dc.gov/service/dog-bites, and https://dchealth.dc.gov/service/rabies-and-animal-exposures.

  1. Schools Schools are required to inform the DC Health Director within two hours when any student has contracted the following diseases:
  • Measles;
  • Meningococcal meningitis;
  • Mumps;
  • Pertussis;
  • Rubella;
  • Tuberculosis; or
  • Hepatitis A or any other food-borne illness.

22B DCMR § 209.6.

The specific form for schools to report these infectious diseases can be found at https://dchealth.dc.gov/node/115022.

  1. Laboratories A laboratory that tests a communicable disease specimen must report its findings directly to the person who submitted the specimen. In addition, laboratory operators must report positive tests for syphilis to the DC Health Director in writing within 24 hours, including the name and address of the person requesting the test. 22B DCMR § 211.3. Laboratory operators must also report HIV positive tests, as well as tests that are indicative of an HIV diagnosis such as CD4 and viral load tests, to the DC Health Director or their designee in writing within 48 hours and include the following information:
  • The name of the subject of the test;
  • The name and address of the physician or provider requesting the test; and
  • The patient’s medical record number.

22B DCMR § 211.4.

  1. Blood Banks Physicians in charge of blood banks must report positive tests for syphilis to the DC Health Director in writing within 24 hours. Physicians in charge of blood banks must also report HIV positive tests to the DC Health Director in writing within 48 hours. 22B DCMR § 211.8.
     
  2. Child Care Facilities – Child care facilities must immediately report to the DC Health Director the presence of an individual who has or is reasonably suspected of having a notifiable communicable disease. 29 DCMR § 322.1.
     
  3. Acute Care, Ambulatory, Long-Term Acute Care, Skilled Nursing, and Outpatient Renal Dialysis Facilities – These facilities should report the conditions in 7.3.1 F to the NHSN and provide DC Health with access to these data.

22-B DCMR Chapter 2, amended in November 2016, is currently under review for additional revisions. Thus, it is important to consult the most recent version of this rule.

7.4 Communicable Disease Investigations

7.4.1    Disease Investigation Authority 

The DC Health Director is responsible for initiating an investigation upon receipt of a report of:

  • A case or suspected case of a communicable disease; or
  • A communicable disease contact or carrier.

22B DCMR § 210.1.

7.4.2    Purpose of Investigation 

The investigation should determine the source of the infection and determine if the proper management and control measures are in place. 22B DCMR § 210.1.

7.4.3    Extent of Investigation 

The DC Health Director may:

  • Enter and inspect public or private property in the District. 22B DCMR § 210.2;
  • Institute preventive measures to eradicate the vectors and sources of the communicable disease. 22B DCMR § 210.3;
  • Order an individual having or suspected of having a communicable disease, or of being a contact or carrier of a communicable disease, to submit to an examination. 22B DCMR § 210.4; and/or
  • Order an individual having or suspected of having a communicable disease, or of being a contact or carrier of a communicable disease, to submit specimens of body secretions, excretions, fluids, and discharges for laboratory examination. 22B DCMR § 210.5.

In addition to controlling and investigating communicable disease, District officials have the authority to control and investigate public nuisances. A public nuisance is an “an unreasonable interference with a right common to the general public.” Restatement (Second) of Torts, § 821B(1) (1979); B & W Management, Inc. v. Tasea Inv. Co., 451 A.2d 879 (D.C. 1982). In the public health context, public nuisances arise from actions that affect the health or safety of the community; the police powers of state government allow it to take action against the public nuisance. For example, failing to follow specific guidelines with regard to swimming pools and spas constitutes a public nuisance. 25-C64 DCMR § 6463.1(o). See section 13.0 of the Manual for specific nuisance powers with regard to vectors (e.g., mosquitoes, ticks) and rodents.

7.5 Reporting Deaths from Communicable Diseases

Physicians are required to immediately notify the DC Health Director by telephone when they issue a certificate of death due to:

  • Cholera;
  • Anthrax;
  • Diphtheria plague (bubonic and pneumonic);
  • Smallpox; or
  • Louse-borne typhus fever.

22B DCMR § 214.1.

Special rules apply to the bodies of persons who died from the diseases listed in section 7.5 to prevent the spread of these diseases. 22B DCMR § 214.2 – 214.4. See section 12.5.1 of the Manual.

Under D.C. Official Code § 5-1405(b)(6), deaths related to disease that may threaten public health are investigated by the Office of the Chief Medical Examiner (OCME).



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