The Control of Communicable Diseases STATE OF MAINE Department of Health and Welfare Bureau of Health Augusta Rules and Regulations Approved by the Advisory Council of Health and Welfare 1943 COMMUNICABLE DISEASE CONTROL Maine Department of Health and Welfare Bureau of Health Periods of Incubation. In attempting to trace, control or prevent epi- demics, it is important to have in mind the time which usually passes after the infection is received into the system, until the first symptoms appear. This interval required for the multiplication and development of the in- fectious agent after it enters the body, called the period of incubation, is more or less constant for each disease. The following gives the period of incubation in the diseases named: Chickenpox, 14 to 21 days. Diphtheria, 2 to 5 days, maybe 7. Dysentery, usually about 3 days. German measles, 2 to 3 weeks. Measles, 10 to 14 days. Mumps, 14 to 21 days. Scarlet fever, 2 to 7 days. Septic sore throat, 1 to 4 days. Smallpox, 8 to 16 days. Typhoid fever, i.to 3 weeks. Whooping cough, 4 to 14 days. The foregoing is a statement of the usual periods of incubation to the first of the symptoms, and not to the appearance of the eruption in the eruptive diseases. In exceptional cases, the period of incubation may be more prolonged. REGULATIONS RELATING TO THE COMMUNICABLE DISEASES Regulation 1. Definitions. Unless specifically provided herein, the fol- lowing words and terms used in these rules and regulations are defined for the purpose thereof as follows: (1) The word “town” means and includes city, town, or organized plantation. (2) The term “local health officer” means the executive health officer appointed by the municipal officers as provided in Chapter 1, Section 87, P. L. 1933. Amended, Chapter 84, Sections 87, 112, P. L. 1935. 3 (3) The term “householder” means and includes the parents, guardians, care-takers, or other persons who have charge of children or minors, or of the household or of a number or group of persons who dwell together or have their lodging or board together, and to the keeper, superintendent, manager, or other person who has charge of an almshouse, work house, house of correction, jail, prison, hospital, or boarding school, camp or other institution; it also means and includes the master or other commanding officer of a ship or steamboat. (4) Quarantine. The word “quarantine” as used herein with reference to control of any of the diseases listed under Regulation 20 applies to limitation of freedom of movement of persons or animals who have been exposed to a case of communicable disease. When a person or a house, building or place has been put under quar- antine by the local health officer, no person quarantined or persons within the quarantined area shall leave it, and no person outside shall enter it (except under the provision of Regulation 7) nor shall they do anything in disobedience of the orders of the local health officer or regulations of the State Bureau of Health. (5) Isolation. The word “isolation” as used herein with reference to the control of any of the diseases listed under Regulation 20, means the complete separation of persons who have a communicable disease, and their attendants, from other persons, in a room or apartment screened against flies and mosquitoes when practicable, under such conditions as to prevent direct or indirect infection of susceptible persons. (6) Contacts. Persons intimately exposed to any case of communi- cable disease are designated as contacts and shall be subject to such quar- antine measures as are indicated under various diseases listed under Regu- lation 20. (7) Disinfection. This means the destruction, by chemical or physical means, of the vitality of micro-organisms which cause disease. (8) Concurrent disinfection means the use of disinfecting methods immediately after the discharge of infectious material from the body of an infected person, or after the soiling of articles with such discharges, before there is opportunity for any other contact with them. (9) Terminal disinfection means disinfection of everything that may have been infected by a patient, after the patient is no longer a source of infection, by reason of recovery or death or removal. 4 Regulation 2. Notifiable Diseases. The following diseases are declared to be notifiable diseases : Actinomycosis Anthrax Chickenpox Cholera, Asiatic Dengue Diphtheria (Membraneous croup) Dysentery (a) Amebic (b) Bacillary Encephalitis, epidemic (Lethargic encephalitis) German measles Glanders Inguinale infection, including Ophthalmia neonatorum Hookworm disease Influenza (Grippe) Leprosy venereum Malaria Measles Meningitis (a) Cerebrospinal, epidemic (b) Tuberculous Mumps Paratyphoid fever Pellagra Plague Pneumonia Poliomyelitis, acute infectious (Infantile paralysis) Psittacosis (Parrot fever) Rabies Rocky Mt. spotted fever (Tick fever) Scarlet fever Septic sore throat (Epidemic sore throat) Smallpox *Syphilis Tetanus Trachoma 5 Trichinosis Tuberculosis, all forms Tularemia Typhoid fever Typhus fever Undulant fever Vincent’s angina Whooping cough Yellow fever Industrial diseases, and those marked with a star (*) in the above list, must be reported direct to the State Bureau of Health, using the special report blanks which are supplied by the Bureau for that purpose. Statute: Physicians to Report Cases. When any physician, public health nurse, osteopath or other attendant, knows or has good reason to believe that any person on whom he has called or whom he visits, or who visits or consults him, is infected with any of the diseases in Regulation 2, such physician, public health nurse, osteopath, or other attendant shall forthwith give notice thereof to the local health officer of the town in which such person lives (except in those cases of disease noted in Regu- lation 2, to be reported direct to the State Bureau of Health). Such report shall be in writing or by telephone when practicable and shall include the full name, age, and address of the person afflicted, together with the name of the disease. Chapter 1, Section 100, P. L. 1933. Regulation 3. Physicians or other attendants shall arrange for such precautionary measures, agreeable to the Bureau regulations, as are neces- sary to prevent the spread of infection to other members of the household or community. Whenever a case of diphtheria, typhoid or paratyphoid fever, epidemic sore throat, dysentery, epidemic meningitis, poliomyelitis, tuberculosis, scarlet fever, smallpox, Vincent’s angina, or a carrier of any of the above diseases, is found on any farm or in any place producing or handling for sale milk, cream, ice cream, butter, cheese, or other foods likely to be con- sumed raw, it shall be the duty of the physician or other attendant to put in operation the procedures outlined in Regulation 14 and report at once the case and circumstances to the local health officer. Statute: Householders to Report Cases. Whenever any householder knows or has reason to believe that any person within his family or house- hold has any of the diseases listed in Regulation 2, he shall at once give notice thereof to the local health officer of the town in which he resides 6 (except those cases to be reported direct to the State Bureau of Health), and such report shall be by telephone or writing. Chapter I, Section 97, P. L. 1933. Regulation 4. Reports to State Bureau of Health. Every local health officer shall report promptly to the State Bureau of Health upon blanks fur- nished by the Bureau for that purpose, and at such times and in such manner as is provided by those blanks, all cases and outbreaks of the dis- eases which are enumerated in Regulation 2, as reportable to said Bureau. Regulation 5. Contacts and Suspects. Persons wdio have been exposed to an infectious or contagious disease, or who are suspected of having an in- fectious or contagious disease, or of being infectious or the carriers of infec- tion, may be placed under quarantine until the period of incubation has elapsed, or until the nature of the disease has been determined, or the period of infectiousness and danger to the public has ended; and said persons shall obey all orders and shall be guided by the instructions which may be given by the local health officer, or by an official of the State Bureau of Health. Regulation 6. Children. When the well children who remain in the same home with those who are sick under isolation, are permitted by the local health officer to play in their own yard, they shall be kept off the streets and from all places outside of their premises, and it shall be the duty of their parents, guardians, or other persons under whose charge they are, to keep said children within their own yards or on their own premises. Parents, teachers, or other guardians of children in other homes or other places shall not allow the children under their charge to enter houses, premises, or yards where persons are held under quarantine nor to play with children of families which are placed under quarantine. Regulation 7. Adults Need Not Always Be Quarantined. When a per- son affected with a communicable disease is properly isolated on the premises (except in cases of smallpox, plague, typhus fever, Asiatic cholera or psittacosis) the adult members of the family or household particularly the wage earners, who do not come in contact with the patient or with his secretions or excretions, unless forbidden by the local health officer, may continue their usual vocations, provided such vocations do not bring them in close contact or association with children; and provided further that they do not go into other persons’ homes or attend any public entertain- ments, clubs, lodges, church services, etc., without permission from the local health officer. 7 Regulation 8. Quarantine in Certain Emergencies. When any case of infectious disease is not or cannot be properly and suitably isolated on the premises, or cannot be removed to a hospital, it shall be the duty of the local health officer to forbid any member of the household from leaving the premises, except under such conditions as he may specify. Regulation 9. Disregard of Quarantine Rules. In case any of the general provisions for isolation or quarantine or any of the orders or regulations of the local or state health officials relating thereto are violated or disobeyed, the local health officer may enforce full isolation and quar- antine, when in the opinion of the said officer the public safety requires such action. Regulation 10. Milkmen, Grocerymen, etc. When milkmen deliver milk to persons, houses or premises which are under quarantine they shall empty the milk into covered containers placed outside the door of said house or premises, or shall deliver the milk in containers which shall not be used again, but shall be burned as soon as they are emptied. They shall not enter such premises nor remove milk bottles, nor take anything else therefrom until the household or premises have been released from quar- antine and disinfected, and the bottles have been sterilized by boiling. If bottles have been delivered, they shall not be taken from the house until the quarantine has been raised and the bottles have been sterilized in accordance with the instructions of the local health officer. Grocerymen and other persons delivering merchandise are forbidden to enter such premises or remove packages or other articles therefrom, until such articles have first been boiled or otherwise sterilized, under the instructions of the local health officer. Regulation 11. Infectious Books. Books or magazines which have been in infected homes or used by persons afflicted with a communicable disease shall not be again used except by permission of the local health officer. Statute: The Duty of Teachers. It shall be the duty of teachers and of principals of schools to note the condition or the symptoms of their pupils which are suggestive of the onset of a contagious or an infectious dis- ease; and teachers or principals shall immediately report to the local health officer the condition of such pupils and shall exclude them from the school room until the health officer issues a certificate of readmission. The teacher shall furthermore exclude from the school room children from houses in which there is, or recently has been, a contagious or infectious disease, until a certificate of readmission is received from the local health officer. Chapter 1, Section 107, P. L. 1933. 8 Regulation 12. The Duty of the Owners or Persons in Charge of Dairy Farms. When no physician is in attendance, it shall be the duty of the owner or persons in charge of any farm 0£ dairy, producing milk, cream, butter, cheese, or other food products likely to be consumed raw, to report immediately to the local health officer the name and address and all facts relating to the illness and physical condition of any person who is affected with any disease presumably infectious or contagious, and who is employed or resides on or in such farm or dairy, or comes in contact in any way there- with or with its products. Regulation 13. Special Reports to the State Bureau of Health. It shall be the duty of the local health officer to report immediately to the State Bureau of Health the existence of any of the diseases enumerated in Regu- lation 14, on any farm or in any dairy producing milk, cream, butter or other dairy products for sale, together with all facts as to the isolation of such cases, and giving the names of the localities to which such dairy products are delivered. Regulation 14. Danger of Infecting Foods. When a case of diphtheria, typhoid fever, or paratyphoid fever, or a person who is a carrier of any of these diseases, or when a case of epidemic or septic sore throat, dysen- tery, epidemic meningitis, poliomyelitis, tuberculosis, scarlet fever, small- pox, or Vincent’s angina exists on any farm or in any dairy, producing or handling milk, cream, ice cream, butter, cheese, or other foods likely to be consumed raw, or exists in any home or other place where such foods are produced, handled, or sold, no such foods shall be sold or delivered from such farm, dairy, or other place, except under the following conditions: (a) That such foods are not brought into the house where such case exists. (b) That all persons coming in contact with such foods eat, sleep, and work wholly outside such house. (c) That such persons do not come in contact in any way with such house or its inmates or contents. (d) That said inmates are properly isolated and separated from all other parts of said farm or dairy, and efficiently cared for. (e) That a permit be issued by the local health officer. Regulation 15. Household Pets. Householders and those who have the care of the sick shall not allow a cat, dog, or other pet in a room where there is a person affected with any communicable disease, and when any of 9 said diseases are present in a house or tenement, pets shall not be allowed to visit other homes. It shall be the duty of the local health officer to enforce this rule. Regulation 16, Disinfection. After death, removal, or recovery of a person who has been sick with any of the diseases for which isolation is required, the rooms which have been occupied by such person shall, together with their contents, be thoroughly cleansed and disinfected. All persons who have been under isolation or quarantine regulations shall have their clothing disinfected and shall take a disinfecting bath before they are released. All disinfection prescribed in this rule shall be done to the satisfaction of the local health officer and in accordance with the directions for such work which may be given from time to time by the State Bureau of Health. Regulation 17. Funerals. When any person has died of diphtheria, scarlet fever, poliomyelitis, bubonic plague or typhus fever, no public funeral shall be held either in any church, chapel or other public, place, or in a home, until the premises where the person has been ill have been thoroughly cleansed and disinfected, and the body embalmed; and in any case the members of the immediate family and contacts, being free of dis- ease at the time, may, by permission of the local health officer, appear at the funeral only in a room separate from the general public. In case of death from smallpox, psittacosis or pneumonic plague there shall be no public funeral. Regulation 18. Duty of Local Health Officers. It shall be the duty of local health officers to require that all state laws, rules and regulations of the State Bureau of Health, and local health ordinances, be strictly en- forced in their respective communities, subject to the direction and super- vision of the State Bureau of Health. Regulation 19. Carriers. Any persons proved to be a carrier of disease germs shall be subject to such rules and regulations of the State Bureau of Health as said Bureau may deem necessary, for the protection of the public health, in each individual case. 10 Disease Minimum Period of Isolation of Patient Minimum Period of Quarantine of Contacts Adults Immune Children Children not Immune Placard Actinomycosis None None None None No Anterior Poliomyelitis 2 weeks from onset of (Infantile Paralysis) disease and until acute symptoms have sub- sided. 14 days from last ex- posure if occupation brings them into con- tact with children, with food to be eaten uncooked. Otherwise none. Until 2 weeks have elapsed from last ex- posure. Until 2 weeks have elapsed from last exposure. Yes Anthrax Until lesions are healed. None None None No Asiatic Cholera Same as Typhoid Fever. 7 days from last ex- posure and until a neg- ative stool is obtained. Same Same Yes Chickenpox Until all crusts have disappeared, but not to exceed 14 days. None None None No Diphtheria 10 days from date of onset and thereafter until at least two suc- cessive negative cul- tures from both nose and throat taken at least 24 hours apart have been obtained, or if Klebs-Loeffler Bacilli are found, they show negative virulence by accepted tests. Same as children. If immune as shown by Schick test, none, provided they live away from home, or the case is in a hos- pital and if 2 consecu- tive negative cultures from both nose and throat taken not less than 24 hours apart have been obtained. 1 week when child lives away from home and cultures have been obtained as in case of other contacts and child continues to live away from home. Yes REGULATION 20-ISOLATION AND QUARANTINE REQUIREMENTS UNDER REGULATIONS OF THE MAINE DEPARTMENT OF HEALTH AND WELFARE Minimum Period of Minimum Period of Quarantine of Contacts Placard Disease Isolation of Patient Adults Immune Children Children not Immune Dysentery (Amebic) None except for food handlers who shall be kept from handling food until 3 successive neg- ative stool examina- tions at intervals of not less than 3 days apart shall have been obtained. Adult food handlers who are contacts shall be under same rules as the case. None None No Dysentery, Bacillary For 1 week after sub- sidence of clinical symptoms. Food handlers, as long as they continue to live in same house with a case. If living in another house, un- til 3 negative stools taken not less than 24 hours apart have been obtained. Same as Typhoid Fever. Same as Typhoid Fever. No Encephalitis, Infectious 1 week after onset in screened room free of insects. None None None No German Measles None None None None No Glanders Until lesions are healed. None None None No Hookworm Disease None None None None No Leprosy Until disease is arrested. None None None No Measles 5 days from appearance of rash. None if they have had disease. None 14 days from last exposure. No Minimum Period of Minimum Period of Quarantine of Contacts Placard Disease Isolation of Patient Adults Immune Children Children not Immune Meningitis (Meningococcus) 14 days from onset and thereafter acute symp- toms have subsided. None None None Yes Mumps Not less than 1 week and until the swelling of salivary glands has subsided. None None None No Paratyphoid Fever Same as Typhoid Fever Same as Typhoid Fever Same as Typhoid Fever Same as Typhoid Fever No Pink Eye Exclusion from school and public places until recovery. None None None No Plague 1 week after subsidence of symptoms. In Pneumonic form until 7 days have elapsed from last con- tact. Same Same Yes Pneumonia, lobar Until recovery None None None No Psittacosis Until recovery None None None No Rocky Mountain Spotted Fever None None None None No Scarlet Fever 3 weeks from onset, and thereafter until ab- normal discharges shall have ceased. Same basis as children If immune as shown by negative Dick test, or previous attack of the disease, none, provided they do not contact the case or attendant. Until child has lived away from home 1 week. Yes Disease Minimum. Period of Isolation of Patient Minimum Period of Quarantine of Contacts Adults Immune Children Children not Immune Placard Septic Sore Throat Until 1 week after on- set and acute symptoms have subsided. None, except milk handlers who shall be guided by Reg. 14. Same as adults Same as adults No Smallpox 3 weeks from onset of disease and until all crusts have disappeared and skin lesions healed. 3 weeks after last con- tact unless there is his- tory of previous attack or recent vaccination. Same as adults Same as adults Yes T rachoma Exclusion from school and public places dur- ing acute stage. None None None No Tularemia During acute stage. None None None No Typhoid Fever Until 1 week after clin- ical symptoms subside. Thereafter to be under supervision of local health officer until 3 negative stool and u- rine cultures secured at intervals of one week apart have been obtained. See Reg. 14 None, after one negative stool specimen has been obtained. No Typhus Fever In vermin free room until recovery. In presence of lice, until 14 days after last exposure. Same Same No Vincent’s Angina Until infective lesions are healed. None None None No Weil’s Disease Until recovery. (Infectious Jaundice) None None None No Disease Minimum Period of Isolation of Patient Minimum Period of Quarantine of Contacts Placard Adults Immune Children Children not Immune Whooping Cough 3 weeks from beginning of spasmodic cough. None None. Immunity may be assumed if record of previous attack on file with local health officer or on sworn statement of parent or guardian. Until 2 weeks from No last exposure. Yellow Fever In mosquito proof room for first 4 days of fever. None None None No Epidemic Kerato- conjunctivitis Until all acute symp- toms have subsided and lesions healed. None None None No T uberculosis (Pulmonary) If not in a hospital or Sanatorium patients with positive sputum must live in separate quarters from others in the family, and all uten- sils used by the pa- tient sterilized after each use. All unnecessary visit- ing by any persons is prohibited and patient shall not visit public places except by per- mission of local Health officer after consulta- tion with the State Dis- trict Health officer. None None None Yes, only if regulation not observ- ed by pa- tient SYPHILIS 1. Infectious Syphilis, Definition. For the purpose of this code a per- son shall be deemed to have infectious syphilis when (a) primary or sec- ondary lesions of the disease are demonstrable on the skin or mucous membranes; or (b) less than two years have elapsed since the disease was acquired and the person shall not have had an amount of treatment equivalent to twenty injections of arsphenamine and twenty injections of a heavy metal salt, or (c) such person is pregnant and is known to have had syphilis or has evidence of the disease either clinical or as demonstrated by a Wassermann or comparable blood test. 2. Treatment Required. A person with infectious syphilis must sub- mit to treatment by a’licensed physician until the equivalent of a minimum of twenty injections of an arsenical and twenty injections of insoluble Bismuth preparation has been administered.f GONORRHEA 1. Infectious Gonorrhea, Definition. A person shall be deemed to have infectious gonorrhea whenever the gonococcus is found to be present in the discharges from the genital tract or other areas where the organism may be present (i. e. as the eyes in gonorrhea ophthalmia). 2. Treatment Required. A person with gonorrheal infection shall be treated by a licensed physician using accepted methods. The modern treat- ment in most cases will include the administration of a sulfonamide— especially, sulfadiazine or sulfathiazole. 3. Criterion of Cure. A. Male: Cure may be assumed in absence of clinical symptoms when no gonococci can be demonstrated in discharges from the genitalia, particularly material obtained by prostatic massage after symptoms have subsided. This massage should produce negative smear (and cultures if available) on three alternate days. B. Female: The criteria of cure is more difficult to fulfill, but an at- tempt should be made to have three negative cultures and smears on alter- nate days immediately following a menstrual period. Attempts should be made to recover the organism from a cleansed cervical canal, the urethra; Skene’s ducts and Bartholin’s ducts. C. Ophthalmia: Cure is assumed in the absence of clinical symptoms and negative smears and cultures from eye secretions. CHANCROID *1. Definition. An infectious communicable disease caused by the B. hemophilus Ducrey. It is infectious as long as open lesions are present or drainage is obtained from suppurating buboes. 16 LYMPHOGRANULOMA VENEREUM *2. Definition. An infectious communicable disease caused by a filter- able virus. Infectious as long as open lesions are present, or when dis- charge is present from buboes or rectal strictures. GRANULOMA INGUINALE Generally considered to be a venereal disease, the exact cause is unknown. In every case, however, diagnosis can be confirmed by finding intra-cellular inclusion bodies (Donovan Bodies) in the cytoplasm of large monocytes. Material may be stained by Wright’s blood stain. The disease is most prevalent among members of the colored race. *1. Diagnosis may be aided by the use of skin tests with chancroid vaccine. *2. The Frei Test, using chick-embryo antigen or mouse brain antigen may be helpful here. CLASSIFICATION OF SYPHILIS f In the interest of uniformity in the reporting of syphilis, the following classification of the disease is recommended. This classification is based on the chronological sequence of events in cases of syphilis allowed to pursue its natural course without treatment: A. Early Syphilis: Includes all infections with syphilis in patients who present primary or secondary manifestations of the disease. (This stage will not usually exceed two years from the onset of the infection.) B. Latent Syphilis: All cases of acquired syphilis not included in “A” above in which the only manifestation of the disease is a positive serologic test for syphilis. 1. Early Latent Syphilis: This term arbitrarily includes all patients with syphilis in that state of the disease which follows “EARLY SYPHILIS” up to the time the infection is four years old. 2. Late Latent Syphilis: Four years after the date of onset the disease becomes “LATE LATENT” if there is no other evidence of syphilis other than a positive serologic test for syphilis. NOTE: To substantiate a diagnosis of “LATENT SYPHILIS” the spinal fluid must have been examined and found to be negative for syphilis by a standard complement fixation test. C. Late Syphilis: Into this group fall all the cases formerly referred to as tertiary syphilis, i. e., gumma, syphilitic cardiovascular disease 17 (including syphilitic aortitis), central nervous system syphilis (general paresis, tabes dorsalis, etc.), optic atrophy due to syphilis, etc. D. Asymptomatic Central Nervous System Syphilis: This includes a large group of patients who have positive spinal fluid evidence of a syphilitic infection without any clinical evidence referable to the central nervous system. If this complication is going to occur it will most likely be present by the end of the second year of the dis- ease. Hence, the necessity of doing a spinal tap on every case of “EARLY SYPHILIS” when treatment is completed and before probation; or of examining the spinal fluid before treatment is insti- tuted in all cases of “LATENT SYPHILIS.” E. Congenital Syphilis: This group of infections include those persons infected in utero through the maternal placenta. The mother must be infected. Subsequent classification is the same as above except the diagnosis is qualified by using “Congenital” preceding the above terms. 18