19 CSR 20-20.010 - Definitions Relating to Communicable, Environmental and Occupational Diseases

PURPOSE: This rule defines terminology used throughout this chapter and defines terms related to infectious waste.

(1) Administrator is the person in charge of an institution, such as the chief executive officer, chairperson of the board, administrator, clinician in charge, or any equivalent position.
(2) Adult respiratory distress syndrome (ARDS) is a syndrome with the following simultaneous characteristics:
(A) Hypoxemia due to intrapulmonary shunting of blood;
(B) Increased lung stiffness; and
(C) Chest x ray evidencing diffuse infiltration.
(3) Board is the State Board of Health.
(4) Carrier is a person who harbors a specific infectious agent in the absence of discernible clinical disease and serves as a potential source or reservoir of infection for man.
(5) Case, as distinct from a carrier, is a person in whose tissues the etiologic agent of a communicable disease is present and which usually produces signs or symptoms of disease. Evidence of the presence of a communicable disease also may be revealed by routine laboratory findings.
(6) Cluster is a group of individuals who manifest the same or similar signs and symptoms of disease.
(7) Communicable disease is an illness due to an infectious agent or its toxic products and transmitted, directly or indirectly, to a susceptible host from an infected person, animal or arthropod, or through the agency of an intermediate host or a vector, or through the inanimate environment.
(8) Contact is a person or animal that has been in association with an infected person or animal and through that association has had the opportunity to acquire the infection.
(9) Designated representative is any person or group of persons appointed by the director of the Department of Health and Senior Services to act on behalf of the director or the State Board of Health.
(10) Director is the state Department of Health and Senior Services director.
(11) Disinfection is the killing of pathogenic agents outside the body by chemical or physical means, directly applied.
(A) Concurrent disinfection is disinfection immediately after the discharge of infectious material from the body of an infected person or after the soiling of articles with the infectious discharges.
(B) Terminal disinfection is the process of rendering the personal clothing and immediate physical environment of a patient free from the possibility of conveying the infection to others after the patient has left the premises or after the patient has ceased to be a source of infection or after isolation practices have been discontinued.
(12) Environmental and occupational diseases are illnesses or adverse human health effects resulting from exposure to a chemical, radiological or physical agent.
(13) Exposure is defined as contact with, absorption, ingestion or inhalation of chemical, biologic, radiologic, or other physical agents by a human that results in biochemical, physiological or histological changes.
(14) Food is any raw, cooked or processed edible substance, ice, beverage or ingredient used or intended for use in whole or in part for human consumption.
(15) Heat exhaustion means a reaction to excessive heat marked by prostration, weakness and collapse resulting from dehydration.
(16) Heat stroke means a severe illness caused by exposure to excessively high temperatures and characterized by severe headache; high fever with a dry, hot skin; tachycardia; and in serious cases, collapse, coma or death.
(17) Hyperthermia means a physician-diagnosed case of heat exhaustion or heat stroke.
(18) Hypothermia means a physician-diagnosed case of cold injury associated with a fall of body temperature to less than ninety-four and one-tenth degrees Fahrenheit (94.1oF) and resulting from exposure to a cold environment.
(19) Immediately reportable diseases are those diseases or findings listed in 19 CSR 20-20.020(1)(A)-(C) and shall be reported at once, without delay and with a sense of urgency by means of rapid communication to the Missouri Department of Health and Senior Services or to the local public health agency, regardless of the day or hour.
(20) Immunization is a treatment which renders an individual less susceptible to the pathologic effects of a disease or provides a measure of protection against the disease.
(21) Infectious waste is waste capable of producing an infectious disease. For a waste to be infectious, it must contain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease. Infectious waste generated by small quantity generators shall include the following categories:
(A) Sharps-all discarded sharps including hypodermic needles, syringes and scalpel blades. Broken glass or other sharp items that have come in contact with material defined as infectious are included;
(B) Cultures and stocks of infectious agents and associated biologicals-included in this category are all cultures and stocks of infectious organisms as well as culture dishes and devices used to transfer, inoculate and mix cultures; and
(C) Other wastes-those wastes designated by the medical authority responsible (physician, podiatrist, dentist, veterinarian) for the care of the patient which may be capable of producing an infectious disease.
(22) Institution is any public or private hospital, nursing home, clinic, mental health facility, home health agency, or medical or professional corporation composed of health care workers.
(23) Invasive disease is caused by a pathogen that invades the bloodstream and/or normally sterile bodily fluids and has the potential to cause severe morbidity and/or mortality. Culturing organisms from blood, cerebrospinal fluid, joint fluid, or pleural fluid identifies invasive diseases. Examples of conditions caused by invasive organisms include:
(A) Haemophilus influenzae-meningitis, occult febrile bacteremia, epiglottitis, septic arthritis, pericarditis, abscesses, empyema, and osteomyelitis;
(B) Streptococcus pneumoniae-bacteremia, and meningitis;
(C) Neisseria meningitidis-meningitis with or without meningococcemia, septicemia (purpura fulminans), bacteremia, pericarditis, myocarditis, arthritis, and epididymitis;
(D) Streptococcus pyogenes (group A)- bacteremia associated with cutaneous infection, deep soft tissue infection (necrotizing fasciitis), meningitis, peritonitis, osteomyelitis, septic arthritis, postpartum sepsis, neonatal sepsis, and non-focal bacteremia.
(24) Isolation is the separation for the period of communicability of infected individuals and animals from other individuals and animals, in places and under conditions as will prevent the direct or indirect transmission of the infectious agent from infected individuals or animals to other individuals or animals who are susceptible or who may spread the agent to others.
(25) Laboratory means a facility for the biological, microbiological, serological, chemical, immuno-hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of a human. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Laboratory includes hand-held testing equipment. All testing laboratories must be certified under the Clinical Laboratories Improvement Amendment of 1988 (CLIA- 42 CFR part 493 ).
(26) Local health authority is the city or county health officer, director of an organized health department or of a local board of health within a given jurisdiction. In those counties where a local health authority does not exist, the health officer or administrator of the Department of Health and Senior Services district in which the county is located shall serve as a local health authority.
(27) Local public health agency is a legally constituted body provided by a city, county or group of counties to protect the public health of the city, county or group of counties.
(28) Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and nosocomial infection are:
(A) MRSA shall be defined as S. aureus strains that are resistant to oxacillin, nafcillin and methicillin; historically termed MRSA. These organisms are resistant to all [BETA]-lactam agents, including cephalosporins and carbapenems. (NOTE: MRSA isolates are often resistant to other multiple, commonly used classes of antimicrobial agents, including erythromycin, clindamycin, and tetracycline.)
(B) VRE shall be defined as enterococci that possess intrinsic or acquired resistance to vancomycin. Several genes, including vanA, vanB, vanC, vanD, and vanE, contribute to resistance to vancomycin in enterococci.
(C) Nosocomial infection shall be defined by the national Centers for Disease Control and Prevention and applied to infections within hospitals, ambulatory surgical centers, and other facilities.
(29) Outbreak or epidemic is the occurrence in a community or region of an illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source.
(30) Period of communicability is the period of time during which an etiologic agent may be transferred, directly or indirectly, from an infected person to another person or from an infected animal to a person.
(31) Person is any individual, partnership, corporation, association, institution, city, county, other political subdivision authority, state agency or institution or federal agency or institution.
(32) Pesticide poisoning means human disturbance of function, damage to structure or illness which results from the inhalation, absorption or ingestion of any pesticide.
(33) Poisoning means injury, illness or death caused by chemical means.
(34) Quarantine is a restriction of movement of persons or animals that have been exposed to a communicable disease, but have not yet developed disease. The period of quarantine will not be longer than the entire incubation period of the disease. The purpose of quarantine is to prevent effective contact with the general population.
(A) Complete quarantine is a limitation of freedom of movement of persons or animals exposed to a reportable disease, for a period of time not longer than the entire incubation period of the disease, in order to prevent effective contact with the general population.
(B) Modified quarantine is a selective, partial limitation of freedom of movement of persons or animals determined on the basis of differences in susceptibility or danger of disease transmission. Modified quarantine is designed to meet particular situations and includes, but is not limited to, the exclusion of children from school, the closure of schools and places of public or private assembly and the prohibition or restriction of those exposed to a communicable disease from engaging in a particular occupation.
(35) Reportable disease is any disease or condition for which an official report is required. Any unusual expression of illness in a group of individuals which may be of public health concern is reportable and shall be reported to the local health department, local health authority or the Department of Health and Senior Services by the quickest means.
(36) Small quantity generator of infectious waste is any person generating one hundred kilograms (100 kg) or less of infectious waste per month and as regulated in 10 CSR 80.
(37) Statewide pandemic is an outbreak of a particularly dangerous disease affecting a high proportion of the population, appearing in three (3) or more counties, as declared by the director of the Department of Health and Senior Services.
(38) Terrorist event is the unlawful use of force or violence committed by a group or individual against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives. Terrorist attacks are classified as chemical, biological, or radiological.
(A) Chemical means any weapon that is designed or intended to cause widespread death or serious bodily injury through the release, dissemination, or impact of toxic or poisonous chemicals or precursors of toxic or poisonous chemicals.
(B) Biological means any microorganism, virus, infectious substance, or biological product that may be engineered as a result of biotechnology, or any naturally occurring or bioengineered component of any such microorganism, virus, infectious substance, or biological product.
(C) Radiological means any weapon that is designed to release radiation or radioactivity at a level dangerous to human life.
(39) Toxic substance is any substance, including any raw materials, intermediate products, catalysts, final products or by-products of any manufacturing operation conducted in a commercial establishment that has the capacity through its physical, chemical or biological properties to pose a substantial risk of death or impairment, either immediately or later, to the normal functions of humans, aquatic organisms or any other animal.
(40) Unusual diseases-Examples include, but are not limited to, the following:
(A) Diseases uncommon to a geographic area, age group, or anatomic site;
(B) Cases of violent illness resulting in respiratory failure;
(C) Absence of a competent natural vector for a disease; or
(D) Occurrence of hemorrhagic illness.
(41) Unusual manifestation of illness-Examples include, but are not limited to, the following:
(A) Multiple persons presenting with a similar clinical syndrome at a steady or increasing rate;
(B) Large numbers of rapidly fatal cases, with or without recognizable signs and symptoms;
(C) Two (2) or more persons, without a previous medical history, presenting with convulsions;
(D) Persons presenting with grayish colored tissue damage; or
(E) Adults under the age of fifty (50) years, without previous medical history, presenting with adult respiratory distress syndrome (ARDS).
(42) Varicella (Chickenpox) severity of illness shall include the following categories:
(A) Mild-less than fifty (50) lesions (able to count lesions within thirty (30) seconds);
(B) Moderate-fifty to five hundred (50-500) lesions (anything in between mild and severe); and
(C) Severe-more than five hundred (500) lesions (difficult to see the skin) or lesions with complications.


19 CSR 20-20.010
AUTHORITY: sections 192.006 and 260.203, RSMo 2000 and 192.020, RSMo Supp. 2006.* This rule was previously filed as 13 CSR 50-101.010. Original rule filed July 15, 1948, effective Sept. 13, 1948. Rescinded and readopted: Filed Dec. 11 , 1981, effective May 13, 1982. Amended: Filed Aug. 16, 1988, effective Dec. 29, 1988. Amended: Filed Aug. 14, 1992, effective April 8, 1993. Amended: Filed Sept. 15, 1995, effective April 30, 1996. Emergency amendment filed June 1, 2000, effective June 15, 2000, expired Dec. 11 , 2000. Amended: Filed June 1, 2000, effective Nov. 30, 2000. Amended: Filed Oct. 1, 2004, effective April 30, 2005. Amended: Filed Feb. 15, 2006, effective Sept. 30, 2006. Emergency amendment filed June 15, 2007, effective July 6, 2007, expired Jan. 1, 2008. Amended: Filed June 15, 2007, effective Jan. 30, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995; 192.020, RSMo 1939, amended 1945, 1951, 2004; and 260.203, RSMo 1986, amended 1988, 1992, 1993.

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