The University of Mississippi Medical Center

MANAGEMENT OF MEDICAL/INFECTIOUS WASTE Revised 6/30/13 Summary/Purpose: The Medical Infectious Waste Policy details procedures and requirements to meet federal and state regulations for the collection and disposal of medical infectious waste. An Outline MANAGEMENT OF MEDICAL/INFECTIOUS WASTE I. Identify medical/infectious waste. II. Separate medical/infectious waste from other wastes and dispose or prepare for disposal. See appendix A for guidance. A. Liquid medical/infectious waste may be flushed down sewer system. B. Sharps must be placed in code approved sharps containers. C. Other medical/infectious waste must be put in red bags 1.5 mil thick and properly tied. D. Non-hazardous trace-chemotherapy contaminated waste must go in yellow sharps containers and/or properly labeled (yellow) biohazard containers. E. Pharmaceutical waste contact pharmacy. F. Store waste in department-designated storage areas awaiting pickup. III. The housekeeping service provider is responsible for the collection of medical/infectious waste from designated storage areas. IV. Medical/infectious waste collected by the housekeeping service provider is stored in a special trailer located in the courtyard area on the main UMMC campus. Only designated housekeeping service providers have access to this storage trailer. Clinics and other satellite facilities have designated weekly pick-up by the contracted medical waste disposal provider. V. Medical/infectious waste is transported off campus for destruction in accordance with applicable laws and regulations; this is done by contract. All containers for the transport of this waste must be properly labeled. ANY QUESTIONS CONCERNING MEDICAL/INFECTIOUS WASTE DISPOSAL SHOULD BE DIRECTED TO ENVIRONMENTAL HEALTH AND SAFETY (41980). Page 1 of 16

Preface Medical/infectious waste is subject to the legal and regulatory authority of a number of entities including the Mississippi State Department of Health, Mississippi Department of Environmental Quality, the Department of Transportation, The Occupational Safety and Health Administration, and The Joint Commission for the Accreditation of Health Care Organizations. At the University of Mississippi Medical Center (UMMC), The Department of Environmental Health and Safety (EHS) is the point of contact for any issues concerning this policy and procedures. Waste generated at UMMC may be divided into five categories: (1) general waste cardboard, paper, cans, plastic containers, household trash, demolition/construction waste, etc.; (2) hazardous/chemical waste solvents, oils, sludge, chemicals, PCB s, more than trace amounts of chemo, etc.; (3) radioactive waste as defined by the Mississippi State Department of Health(MSDH) and concerned federal regulatory agencies; (4) pharmaceutical waste; and (5) medical/infectious as defined herein below. Each is handled and disposed of differently. (If any doubt exists as to the type of waste involved, inquiry should be made to the Dept of EHS, x 41980). This publication is concerned primarily, if not exclusively, with medical/infectious waste. The appointed housekeeping services provider for the various areas is responsible for the collection of medical/infectious waste. However, all supervisory personnel and department heads are responsible for the proper management of medical/infectious waste generated in their areas of concern. UMMC s medical/infectious waste management plan includes the following elements: (1) designation of medical/infectious waste (see Medical/Infectious Waste: Identification section below); (2) handling of medical/infectious waste (segregation, packaging, storage); (3) destruction (transport, treatment, disposal); and (4) related matters such as staff training, etc. Questions and comments concerning UMMC medical/infectious waste may be directed to the Department of Environmental Health and Safety. MEDICAL/INFECTIOUS WASTE: IDENTIFICATION Definitions of medical/infectious waste may vary among concerned authorities, both individuals and institutions, however, at UMMC the characterization of medical/infectious waste will be based, insofar as possible, on the rules and regulations promulgated by the Mississippi State Department of Health (MSDH) in its Standards For The Regulation of Medical Waste, and O.S.H.A. s Bloodborne Pathogen Standard. To quote there from: Bloodborne Pathogen Standard. Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that could release blood or other potentially infectious Page 2 of 16

materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Other Potentially Infectious Materials (OPIM) means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids: (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. Mississippi State Department of Health Infectious medical wastes includes solid or liquid wastes which may contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host has been proven to result in an infectious disease. For purpose of this Regulation, the following wastes shall be considered to be infectious medical wastes: (1) Wastes resulting from the care of patients and animals who have Class I and (or) II diseases that are transmitted by blood and body fluid as defined in the rules and regulations governing reportable diseases. (See appendix B) as defined by the Mississippi State Department of Health; Note: This includes all disposable items contaminated with blood/body fluid from isolation patients. (2) Cultures and stocks of infectious agents; including specimen cultures collected from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, and mix cultures; Note: The Department of Transportation s (DOT) new regulation states: Infectious substance falling into Category A may not be categorized nor disposed of as Regulated Medical Waste. Category A Infectious Substances may be treated by the generating facility and disposed of as required by state and local regulation. See appendix C for a list of Category A materials. (3) Blood and blood products such as serum, plasma, and other blood components; (4) Pathological wastes, such as tissues, organs, body parts, and body fluids that are removed during surgery and autopsy; Page 3 of 16

Note: All pathological wastes must be segregated into special biohazard containers and labeled for incineration (yellow label on the outside of the red biohazard container supplied by the medical waste company). (5) Contaminated carcasses, body parts, and bedding of animals that were exposed to pathogens in medical research; Note: Must be labeled in a designated red biohazard container for incineration. (6) All discarded sharps (e.g., hypodermic needles, syringes, Pasteur pipettes, broken glass, scalpel blades) used in patient care or which have come into contact with infectious agents; (7) Other wastes determined infectious by the generator or so classified by the State Department of Health. Medical Waste means all waste generated in direct patient care or in diagnostic or research areas that is in non-infectious but aesthetically repugnant if found in the environment. Confusion over whether or not waste is medical/infectious or its disposal may be resolved by a call to EHS (x 41980). MEDICAL/INFECTIOUS WASTE: MANAGEMENT The purpose of medical/infectious waste management is, of course, to protect human health and the environment. MSDH requires all generators of medical/infectious waste to have a waste management plan that includes, but not limited to, the following: I. Storage and Containment of Infectious Medical Waste and Medical Waste. A. Containment of infectious medical waste and medical waste shall be in a manner and location which affords protection from animals, rain and wind, does not provide a breeding place or a food source for insects and rodents, and minimizes exposure to the public. B. Infectious medical waste shall be segregated from other waste at the point of origin in the producing facility. C. Unless approved by the Mississippi State Department of Health or treated and rendered non-infectious, infectious medical waste (except for sharps in approved containers) shall not be stored at a waste producing facility for more than seven days above a temperature of 6 C (38 F). Containment of infectious medical waste at the producing facility is permitted at or below a temperature of 0 C (32 F) for a period of not more than 90 days without specific approval of the Department of Health. D. Containment of infectious medical waste shall be separate from other wastes. Enclosures or containers used for containment of infectious medical waste shall be so secured so as to discourage access by unauthorized persons and Page 4 of 16

shall be marked with prominent warning signs on, or adjacent to, the exterior of entry doors, gates, or lids. Each container shall be prominently labeled with a sign using language to be determined by the Department and legible during daylight hours. E. Infectious medical waste, except for sharps capable of puncturing or cutting, shall be contained in double disposable plastic bags or single bags (1.5 mil thick) which are impervious to moisture and have a strength sufficient to preclude ripping, tearing, or bursting under normal conditions of usage. The bags shall be securely tied so as to prevent leakage or expulsion of solid or liquid waste during storage, handling, or transport. Note: UMMC utilizes single red bags 1.5 mil thick. F. All sharps shall be contained for disposal in leakproof, rigid, punctureresistent containers which are taped closed or tightly lidded to preclude loss of contents. G. All bags used for containment and disposal of infectious medical waste shall be of a distinctive color or display the Universal Symbol for infectious waste. Rigid containers of all sharps waste shall be properly labeled. Note: UMMC utilize red bags for its medical/infectious waste. The housekeeping services provider will require that suppliers furnish the required materials and will also insure that all containers are properly labeled before transported off campus. Red bag liners will be placed in the rigid containers by the housekeeping services provider before the empty containers are distributed to the collection sites. H. Compactors or grinders shall not be used to process infectious medical waste unless the waste has been rendered non-infectious. Sharps containers shall not be subject to compaction by any compacting device except in the institution itself and shall not be placed for storage or transport in a portable or mobile trash compactor. I. Infectious medical waste and medical waste contained in disposable containers as prescribed above, shall be placed for storage, handling, or transport in disposable or reusable pails, cartons, drums, or portable bins. The containment system shall be leakproof, have tight-fitting covers and be kept clean and in good repair. J. Reusable containers for infectious medical waste and medical waste shall be thoroughly washed and decontaminated each time they are emptied by a method specified by the Mississippi State Department of Health, unless the surfaces of the containers have been protected from contamination by disposable liners, bags, or other devices removed with the waste. Page 5 of 16

Approved methods of decontamination include, but are not limited to, agitation to remove visible soil combined with one or more of the following procedures: 1. Exposure to hot water at least 180 F for a minimum of 15 seconds. 2. Exposure to a chemical sanitizer by rinsing with or immersion in one of the following for a minimum of 3 minutes: a. Hypochlorite solution (500 ppm available chlorine). b. Phenolic solution (500 ppm active agent). c. Idoform solution (100 ppm available iodine). d. Quaternary ammonium solution (400 ppm active agent). Reusable pails, drums, or bins used for containment of infectious waste shall not be used for containment of waste to be disposed of as non-infectious waste or for other purposes except after being decontaminated by procedures as described in part (J) of this section. Note: The washing and decontamination described in J. above shall be performed by the entity which contracts with UMMC for the disposal of medical/infectious waste. The contractor may be expected to certify that the containers are decontaminated in accordance with MSDH requirements. K. Trash chutes shall not be used to transfer infectious medical waste. L. Once treated and rendered non-infectious, previously defined infectious medical waste will be classified as medical waste and may be landfilled in an approved landfill. At the present time, UMMC contracts for the pickup (on campus) and the destruction (off campus) of medical/infectious waste. The contractor is required by UMMC to: Be available for medical/infectious waste consultation; Establish and maintain a recordkeeping system (including, if requested, departmental barcoding) providing cradle to grave manifest and satisfactory certificates of destruction; Take title to the conforming medical/infectious waste products upon pickup on campus and agree to indemnify UMMC for any liability arising from the contractor s negligence or willful misconduct and to provide evidence of general insurance limits in excess of $5,000,000; Provide assurance that all transportation services provided conforms to Department of Transportation and/or other legal requirements; and Page 6 of 16

Provide evidence of holding all licenses required to process all medical/infectious waste and (trace amounts of) non-hazardous chemotherapy waste. Anything other than trace amounts of non-hazardous chemotherapy waste should be collected as hazardous waste and disposed according to UMMC s Hazardous Waste policies. Additionally, the contractor should be able to perform in-service training to staff members in the proper handling and packaging of medical/infectious waste. MEDICAL INFECTIOUS WASTE TREATMENT The MSDH states that treatment or disposal of infectious medical waste shall be by one of the following methods: A. By incineration in an approved incinerator which provides combustion of the waste to carbonized or mineralized ash. B. By sterilization by heating in a steam sterilizer, so as to render the waste noninfectious. Infectious medical waste so rendered non-infectious shall be disposable as medical waste. Operating procedures for steam sterilizers shall include, but not be limited to the following: 1. Adoption of standard written operating procedures for each steam sterilizer including time, temperature, pressure, type of waste, type of container(s), closure on container(s), pattern of loading, water content, and maximum load quantity. 2. Check or recording and/or indicating thermometers during each complete cycle to ensure the attainment of a temperature of 121 C (250 F) for onehalf hour or longer, depending on quantity and density of the load, in order to achieve sterilization of the entire load. Thermometers shall be checked for calibration at least annually. 3. Use of heat sensitive tape or other device for each container that is processed to indicate the attainment of adequate sterilization conditions. 4. Use of the biological indicator Bacillus stearothermophilus placed at the center of a load processed under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. 5. Maintenance of record of procedures specified in (1), (2), (3) and (4) above for period of not less than a year. Note: Steam sterilization is employed in various departments, sections and areas of UMMC and nothing herein should be interpreted as discouraging this activity. C. By discharge to the approved sewerage system if the waste is liquid or semiliquid, except as prohibited by the State Department of Health. Page 7 of 16

Note: If a question arises as to discharge into the sewer system, EHS should be contacted (x 41980). D. Recognizable human anatomical remains shall be disposed of by incineration or interment, unless burial at an approved landfill is specifically authorized by the Mississippi Department of Health. Note: Human anatomical remains at UMMC are incinerated or interned. Animal carcasses at UMMC are also required to be incinerated by the medical/infectious waste contract even if they are not known to be exposed to pathogens in medical research. These carcasses should be frozen and remain frozen until removal. Contaminated animal bedding will also be sent out with the medical/infectious waste for incineration. If animals associated with the animal bedding were not infected with human pathogens, then these waste materials are considered solid waste. Place the non-infected animal bedding in suitable trash bags and personally bring them to the nearest outdoor solid waste container or dumpster. All waste designated for incineration must be placed in properly labeled containers. E. Chemical sterilization shall use only those chemical sterilants recognized by the U.S. Environmental Protection Agency, Office of Pesticides and Toxic Substances. Ethylene oxide, glutaraldehyde, and hydrogen peroxide are examples of sterilants that, used in accordance with manufacturer recommendation, will render infectious waste non-infectious. Testing with Bacillus subtilis spores or other equivalent organisms shall be conducted quarterly to ensure the sterilization effectiveness of gas or steam treatment. Treatment and disposal of medical waste which is not infectious shall be by one of the following methods: A. By incineration in an incinerator which provides combustion of the waste to carbonized or mineralized ash. B. By sanitary landfill, in an approved landfill which shall mean a disposal facility or part of a facility where medical waste is placed in or on land, and which is not a treatment facility. All the requirements of these standards shall apply, without regard to the quantity of medical waste generated per month, to any generator of medical waste to include, but not be limited to, the following categories: hospitals, nursing facilities, ambulatory surgical facilities, home health agencies, birthing centers. ADDITIONAL REQUIREMENTS FOR THE MANAGEMENT OF MEDICAL/INFECTIOUS WASTE AT UMMC: Identification of medical/infectious waste Precisely defining medical waste on the basis of quantity and type of etiologic agents present is virtually impossible. The most practical approach to medical waste management is to identify wastes that represent a sufficient potential risk of causing Page 8 of 16

infection during handling and disposal and for which some precautions likely are prudent. UMMC adheres to the definitions of medical/infectious waste as established by the MSDH, and O.S.H.A. S Bloodborne Pathogen Standard. As a general rule, questionable waste should be treated as medical/infectious; however UMMC S Department of Environmental Health and Safety (x 41980) can make this determination if consulted. Separation of medical/infectious waste Medical/infectious waste, as defined above, --- under no circumstances --- should be disposed of with general waste (and general waste must not be commingled with medical/infectious waste. Do not use red bags for general waste.) Sharps must be put into code approved sharps containers provided for them. The housekeeping services staff will pick up these containers when they are ready for disposal. Sharps containers may not be left in hallways or other unrestricted or uncontrolled areas while awaiting pickup. Sharps containers shall be sealed and replaced once the contents have reached the marked FULL line. CAUTION: No attempt should be made to pack the containers or otherwise overload them. Other medical/infectious waste must be put in the 1.5 mil-thick red bags provided by the housekeeping service provider. The red bags are placed in containers located throughout the institution awaiting pickup by the housekeeping services provider. Each liner must be twisted and tied with an overhand knot when filled to prevent any liquid leaks and to meet DOT shipping requirements. Containers should not be overfilled to prevent securing of the lid. A secure area should be provided within each department for storage while awaiting pickup. The area shall be secured so as to discourage access by unauthorized persons and shall be marked with prominent warning signs on, or adjacent to, the exterior of entry door. Time is a factor of some importance and, depending on the quantities generated and storage facilities available; each department may have to develop its own pickup schedule with the housekeeping services provider. Special Procedures for Disposal of Creutzfeldt-Jakob Disease (CJD) Waste Materials contaminated with Creutzfeldt-Jakob disease (CJD) must be pre-treated by one of the following methods described and recommended by the World Health Organization before red bagged for incineration. See Infection Control Policy and Procedure Manual IC/C-14 for additional information. 1. Autoclave at 134 136 degrees Celsius for a period of 20 minutes. 2. Soaked in a Sodium Hydroxide Solution, 1 (one) mole per Liter for a period of 1 (one) degrees Celsius. 3. Soaked in a Sodium Hypochlorite Solution, 2% available Chlorine Minimum (Bleach) for 1 (one) hour at 20 degrees Celsius (68 degrees F). Page 9 of 16

Once these materials have been treated as required, they will need to be placed in the red bag, goose neck tied, and place into its own designate empty red biohazard container (lid sealed). Separate this container from other biohazard containers to prevent disposal with the regular medical/infectious waste. Contact the Department of Environmental Health and Safety (x41980) to provide the proper documentation that the waste has been pre-treated. EHS personnel will come to this site to properly label and process the container for disposal. CONCLUSION The success of UMMC s medical/infectious waste management program is dependent on the cooperation of all employees, faculty, staff, and students. Employment by UMMC imposes a duty to become familiar with the requirements of this waste management program and to adhere to its requirements. Your housekeeping services provider, University Hospital Administration, and the Department of Environmental Health and Safety are willing and able to assist with any issues or questions regarding this subject. Page 10 of 16

APPENDIX A A

WASTE MANAGEMENT Regular Waste: Black Bag Trash Paper, Wrappers Dressings* Chux* Diapers* Gloves* Empty Foley Bags and Other Drainage Bags Disposable Patient Items(empty bed pans, urinals)* Sanitary Napkins* Batteries (Alkaline only) *unless grossly contaminated with blood or OPIM: semen, vaginal secretions, cerebrospinal, synovial, pleural, pericardial, peritoneal, amniotic fluids. Biohazardous Waste: Red Bag Blood/blood products and OPIM (Other Potentially Infectious Material) Examples: All Disposable items saturated/caked with Blood or OPIM Blood Tubing/ Bags/Hemovacs/ Pleurevacs/Stryker drain/jackson Pratt drain Empty Suction Canisters/Liners or those with absorbent material. Dialyzers and tubing Microbiology specimens, tubes bottles, and devices Human and Animal pathological wastes (label for incineration) All Disposable Items Contaminated with Blood/Body Fluids from Isolation Patients No pharmaceutical waste. Sharps Disposal Containers All sharps (needles,,blades, scalpels, razors, pins, clips, staples, wires, broken contaminated glass, disposable suture sets, biopsy forceps, and lancets) All empty syringes (with or without needle), tubexes, carpujects. Trocars, introducers, guide wires, sharps from procedures, specimen devices in endoscopy etc. Specimen slides (Use large volume sharps container if needed) No pharmaceutical waste. Pharmaceutical Waste: Contact Pharmacy Glass Vials, ampules Syringes, tubexes, carpujects with residual (pour able) medication IV bags / tubing with residual medication Partially used/ residual prescription or over-thecounter medication Example:vials,tablets, capsules, powders,liquids, creams/lotions, eye drops suppositories, ½ tablet Residual or wasted narcotics per UMMC policy. Narcotic patches Unopened/Unused or Expired Medications: Return to Pharmacy Pharmaceuticals: Return to Pharmacy Examples: Inhalers with residual (if empty-regular trash), unused(pbkc) nicotine gum or patches(with rappers), nitroglycerine tablets, unused/residual acetone, coumadin, cough syrup with alcohol content greater than 24% Yellow Chemo Containers Trace Chemo: All supplies used to make and administer chemo medication Example: tubing, EMPTY bags/ bottles/ vials, syringes, gloves, pads, masks, gowns, wipes etc. Used Chemo spill Clean-up kits Return all unused Chemo to Pharmacy Hazardous Waste Radioactive: Call Radiation Safety Officer for disposal of all radioactive waste. Call Chemical Safety Officer for disposal of all chemical waste. All Non-Alkaline batteries Outdated/unused chemotherapy drugs (bulk, or partial dose) Empty P coded chemo containers Mercury-filled devices, batteries, thermometers, & blood pressure cuffs & gauges Used solvents, stains, paints, and thinner Containers with hazardous label Formaldehyde & formalin, acetone, toluene, mercury fixatives, barium, xylene, alcohol, disinfectants & chemical sterilizing agents CJD - Contact Infection Control/Safety Officer or his designee for proper disposal of CJD contaminated waste Rev. 6.13 No Category A Infectious Substances/Waste are to be placed in biohazard containe A

APPENDIX B B

Mississippi State Department of Health List of Reportable Diseases and Conditions Reporting Hotline: 1-800-556-0003 Monday - Friday, 8:00 am - 5:00 pm To report inside Jackson telephone area or for consultative services Monday - Friday, 8:00 am - 5:00 pm: (601) 576-7725 Phone Epidemiology (601) 576-7725 (601) 576-7497 STD/HIV (601) 576-7723 TB (601) 576-7700 Class 1 Conditions may be reported nights, weekends and holidays by calling: (601) 576-7400 Fax Class 1: Diseases of major public health importance which shall be reported directly to the Mississippi State Department of Health (MSDH) by telephone within 24 hours of first knowledge or suspicion. Class 1 diseases and conditions are dictated by requiring an immediate public health response. Laboratory directors have an obligation to report laboratory findings for selected diseases (refer to Appendix B of the Rules and Regulations Governing Reportable Diseases and Conditions). Any Suspected Outbreak (including foodborne and waterborne outbreaks) (Possible biological weapon agents appear in bold italics) Anthrax Arboviral infections including but not limited to those Encephalitis (human) Glanders Ricin intoxication (castor beans) Smallpox due to: Haemophilus influenzae Invasive Disease Staphylococcus aureus, California encephalitis virus Hemolytic uremic syndrome (HUS), post-diarrheal vancomycin resistant (VRSA) or Eastern equine encephalitis virus Hepatitis A vancomycin intermediate (VISA) LaCrosse virus HIV infection- including AIDS Syphilis (including congenital) Western equine encephalitis virus Influenza-associated pediatric mortality (<18 years of age) Tuberculosis St. Louis encephalitis virus Measles Tularemia West Nile virus Botulism (including foodborne, infant or wound) Melioidosis Neisseria meningitidis Invasive Disease Typhoid fever Typhus fever Brucellosis Pertussis Varicella infection, primary, in patients Chancroid Plague >15 years of age Cholera Poliomyelitis Viral hemorrhagic fevers (filoviruses [e.g., Creutzfeldt-Jakob disease, including new variant Psittacosis Ebola, Marburg] and arenaviruses [e.g., Diphtheria Q fever Lassa, Machupo]) Escherichia coli O157:H7 and any shiga toxin-producing Rabies (human or animal) Yellow fever E. coli (STEC) Any unusual disease or manifestation of illness, including but not limited to the appearance of a novel or previously controlled or eradicated infectious agent, or biological or chemical toxin. Class 2: Diseases or conditions of public health importance of which individual cases shall be reported by mail, telephone, fax or electronically, within 1 week of diagnosis. In outbreaks or other unusual circumstances they shall be reported the same as Class 1. Class 2 diseases and conditions are those for which an immediate public health response is not needed for individual cases. Chlamydia trachomatis, genital infection Dengue Ehrlichiosis Listeriosis Lyme disease Malaria Rubella (including congenital) Salmonellosis Shigellosis Enterococcus, invasive infection, vancomycin resistant Meningitis other than meningococcal or H. influenzae Spinal cord injuries Gonorrhea Hepatitis (acute, viral only) Note - Hepatitis A requires Mumps M. tuberculosis infection (positive TST or positive IGRA***) Streptococcus pneumoniae, invasive infection Class 1 Report Noncholera Vibrio disease Tetanus Hepatitis B infection in pregnancy Poisonings* (including elevated blood lead levels**) Trichinosis Legionellosis Rocky Mountain spotted fever Viral encephalitis in horses and ratites Usually presents as meningitis or septicemia, or less commonly as cellulitis, epiglottitis, osteomyelitis, pericarditis or septic arthritis. Specimen obtained from a normally sterile site. *Reports for poisonings shall be made to Mississippi Poison Control Center, UMMC 1-800-222-1222. **Elevated blood lead levels (as designated below) should be reported to the MSDH Lead Program at (601) 576-7447. Blood lead levels (venous) of >10 µg/dl ***TST- tuberculin skin test; IGRA- Interferon-Gamma Release Assay Except for rabies and equine encephalitis, diseases occurring in animals are not required to be reported to the MSDH. Class 3: Laboratory based surveillance. To be reported by laboratories only. Diseases or conditions of public health importance of which individual laboratory findings shall be reported by mail, telephone, fax or electronically within one week of completion of laboratory tests (refer to Appendix B of the Rules and Regulations Governing Reportable Diseases and Conditions). All blood lead test results CD4 count and HIV viral load* Hepatitis C infection Blastomycosis Chagas Disease (American Trypanosomiasis) Histoplasmosis Campylobacteriosis Cryptosporidiosis Nontuberculous mycobacterial disease Hansen disease (Leprosy) *HIV associated CD4 (T4) lymphocyte results of any value and HIV viral load results, both detectable and undetectable. Class 4: Diseases of public health importance for which immediate reporting is not necessary for surveillance or control efforts. Diseases and conditions in this category shall be reported to the Mississippi Cancer Registry within six months of the date of first contact for the reportable condition. The National Program of Cancer Registries at the Centers for Disease Control and Prevention requires the collection of certain diseases and conditions. A comprehensive reportable list including ICD9CM codes is available on the Mississippi Cancer Registry website, http://mcr.umc.edu/documents/reportablecases10-09andlater.pdf. Each record shall provide a minimum set of data items which meets the uniform standards required by the National Program of Cancer Registries and documented in the North American Association of Central Cancer Registries (NAACCR). For further information, please refer to the Mississippi State Department of Health s website at www.msdh.state.ms.us. Revision: February 11, 2013

Laboratory Results that must be Reported to the Mississippi State Department of Health Laboratories shall report these findings to the MSDH at least WEEKLY. Diseases in bold type shall be reported immediately by telephone. Isolates of organisms marked with a dagger ( ) should be sent to the MSDH Public Health Laboratory (PHL). All referring laboratories should call the PHL at (601) 576-7582 prior to shipping any isolate. Confirmatory tests for some of these results may be obtained by special arrangement through the Epidemiology Program at (601) 576-7725. Positive Bacterial Cultures or Direct Examinations Result Reportable Disease Any bacterial agent in CSF Bacterial meningitis Bacillus anthracis Anthrax Bordetella pertussis Pertussis Borrelia burgdorferi Lyme disease Brucella species Brucellosis Burkholderia mallei Glanders Burkholderia pseudomallei Melioidosis Campylobacter species Campylobacteriosis Chlamydia psittaci Psittacosis Chlamydia trachomatis Chlamydia trachomatis genital infection Clostridium botulinum ** Botulism Clostridium tetani Tetanus Corynebacterium diphtheriae Diphtheria Coxiella burnetii Q fever Enterococcus species,* vancomycin resistant Enterococcus infection, invasive vancomycin resistant Escherichia coli O157:H7 and any shiga toxin-producing E. coli (STEC) Escherichia coli O157:H7 and any shiga toxin-producing E. coli (STEC) Francisella tularensis Tularemia Grimontia hollisae Noncholera Vibrio disease Haemophilus ducreyi Chancroid Haemophilus influenzae * H. influenzae infection, invasive Legionella species Legionellosis Listeria monocytogenes Listeriosis Mycobacterium species Nontuberculous mycobacterial disease Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhea Gonorrhea Neisseria meningitidis * Meningococcal infection, invasive Photobacterium damselae Noncholera Vibrio disease Rickettsia prowazekii Typhus Fever Rickettsia rickettsii Rocky Mountain spotted fever Salmonella species, not S. typhi Salmonellosis Salmonella typhi Typhoid fever Shigella species Shigellosis Staphylococcus aureus, vancomycin resistant or vancomycin intermediate Staphylococcus aureus vancomycin resistant (VRSA) or vancomycin intermediate (VISA) Streptococcus pneumoniae* Streptococcus pneumoniae, invasive infection Vibrio cholerae 01 Cholera Vibrio species Noncholera Vibrio disease Yersinia pestis Plague Isolates of organism should be sent to the MSDH PHL. All referring laboratories should call the PHL at (601) 576-7582 prior to shipping any isolate. *Specimen obtained from a normally sterile site (usually blood or cerebrospinal fluid, or, less commonly, joint, pleural, or pericardial fluid). Do not report throat or sputum isolates. **Contact the MSDH Epidemiology Program at (601) 576-7725 or the PHL at (601) 576-7582 for appropriate tests when considering a diagnosis of botulism. Positive Serologic Tests For: Arboviral agents including but not limited to those due to: California encephalitis virus Dengue Ehrlichiosis M. tuberculosis infection Plague Eastern equine encephalitis virus Hepatitis A (anti-hav IgM) Poliomyelitis LaCrosse virus Hepatitis B (anti-hbc IgM) Psittacosis St. Louis encephalitis virus Hepatitis B (HBsAg) in pregnancy Rocky Mountain spotted fever Western equine encephalitis virus Hepatitis C Rubella West Nile virus Brucellosis HIV infection (refer to Subchapter 14) Legionellosis Syphilis (refer to Rule 1.17.15) Smallpox Chagas Disease (American Trypanosomiasis) Lyme disease Trichinosis Cholera Malaria Varicella infection, primary in patients >15 years of Chlamydia trachomatis genital infection Measles age Mumps Yellow fever Serologic confirmation of an acute case of legionellosis cannot be based on a single titer. There must be a four-fold rise in titer to >1:128 between acute and convalescent specimens. Positive Parasitic Cultures or Direct Examinations Result Reportable Disease Any parasite in CSF Parasitic meningitis Cryptosporidium parvum Cryptosporidiosis Trypanosoma cruzi Chagas Disease (American Trypanosomiasis) Plasmodium species Malaria Indicates the positive specimens may be submitted to the MSDH PHL for confirmation. Blood Chemistries ALL blood lead test results are reportable to the MSDH Lead Program at (601) 576-7447. Positive Fungal Cultures or Direct Examinations Result Any fungus in CSF Blastomyces dermatitidis Histoplasma capsulatum Positive Viral Cultures or Direct Examinations Result Any virus in CSF Arboviral agents including but not limited to those du e to: California encephalitis virus Eastern equine encephalitis virus LaCrosse virus St. Louis encephalitis virus Western equine encephalitis virus West Nile virus Arenaviruses Dengue virus, serotype 1, 2, 3 or 4 Filoviruses Poliovirus, type 1, 2 or 3 Varicella virus Variola virus Yellow fever virus Reportable Disease Fungal meningitis Blastomycosis Histoplasmosis Reportable Disease Viral meningitis California encephalitis Eastern equine encephalitis (EEE) LaCrosse encephalitis St. Louis encephalitis (SLE) Western equine encephalitis (WEE) West Nile encephalitis (WNV) Viral hemorrhagic fevers Dengue Viral hemorrhagic fevers Poliomyelitis Varicella infection, primary in patients >15 years of age Smallpox Yellow fever Positive Toxin Identification Ricin toxin from Ricinus communis (castor beans) Surgical Pathology results Creutzfeldt-Jakob Disease, including new variant Hansen disease (Mycobacterium leprae) Human rabies Malignant neoplasms Mycobacterial disease including Tuberculosis Trichinosis For further information, please refer to the Mississippi State Department of Health s website at www.msdh.state.ms.us. Revision: February 11, 2013

APPENDIX C C

Category A UN 2814 linfectious substances affecting humans Bacillus anthracis (cultures only) Brucella abortus (cultures only) Brucella melitensis (cultures only) The University of Mississippi Medical Center CATEGORY A MATERIALS AS IDENTIFIED BY DOT (not a complete list) Mycobacterium tuberculosis (cultures only). Nipah virus Omsk hemorrhagic fever virus Brucella suis (cultures only) Poliovirus (cultures only) Burkholderia mallei- - Pseudomonas mallei- -Glanders Rabies and other lyssa viruses (cultures only) (cultures only) Rickettsia prowazekii (cultures only) Burkholderia pseudomallei- Pseudomonas pseudomallei Rickettsia rickettsia (cultures only) (cultures only) Rift Valley fever virus (cultures only) Chlamydia psittaci- -avian strains (cultures only) Russian spring-summer encephalitis virus (cultures only) Clostridium botulinum (cultures only) Sabia virus Coccidioides immitis (cultures only) Shigella dysenteriae type l (cultures only) Coxiella burnetti (cultures only) Tick-borne encephalitis virus (cultures only) Crimean-Congo hemorrhagic fever virus Variola virus Dengue virus (cultures only) Venezuelan equine encephalitis virus (cultures only) Eastern equine encephalitis virus (cultures only) Vesicular stomatitis virus (cultures only) Escherichia coli, verotocigenic (cultures only) West Nile virus (cultures only) Ebola virus Yellow fever virus (cultures only) Flexal virus Yersinia pestia (cultures only) Francisella tularensis (cultures only) Guanarito virus Category A UN 2900- -Infectious substances affecting animals only. Hantaan virus African swine fever virus (cultures only) Hantaviruses causing hemorrhagic fever with renal syndrome Avian paramyxovirus Type 1- -Velogenic Newcastle disease virus Hendra virus (cultures only) Herpes B virus (cultures only) Classical swine fever virus (cultures only) Human immunodeficiency virus (cultures only) Foot and mouth disease virus (cultures only) Highly pathogenic avian influenza virus (cultures only) Lumpy skin disease virus (cultures only) Japanese Encephalitis virus (cultures only) Mycoplasma mycoides--contagious bovine pleuropneumonia (cultures only) Junin virus Peste des petits ruminants virus (cultures only) Kyasanur forest disease virus Rinderpest virus (cultures only) Lassa virus Sheep-pox virus (cultures only) Machupo virus Goatpox virus (cultures only) Marburg virus Swine vesicular disease virus (cultures only) Monkeypox virus Vesicular stomatitis virus C