Neb. Admin. Code tit. 173 — Control of Communicable Diseases

Chapter 1 Reporting and Control of Communicable Diseases

Neb. Admin. Code tit. 173, ch. 1 Reporting and Control of Communicable Diseases {#sec-173-nac-1 omnilex-key=us-ne-regs-official--title-173--173 NAC 1}

1-001 SCOPE AND AUTHORITY : These regulations apply to the content, control, and reporting of communicable diseases, poisonings, and organisms pursuant to the provisions of Neb. Rev. Stat. §§ 71-501 to 71-514.05, 71-531 to 71-532, and 71-1626.

1-002 DEFINITIONS : When terms are used in 173 NAC 1, the following definitions apply:

Adult HIV Confidential Case Report Form means a CDC form for reporting HIV in adult patients to the Department. The form is available for download on the Department Website at http://dhhs.ne.gov/publichealth/epi/Pages/ReportableDiseases.aspx or by email request at dhhs.epi@nebraska.gov.

Advanced practice registered nurse (APRN) means a registered nurse who holds a current APRN license as a Certified Nurse Midwife, Certified Registered Nurse Anesthetist, Clinical Nurse Specialist, or Nurse Practitioner.

Antibiotic susceptibility registry is the secured online database of susceptibilities of bacterial isolates to antimicrobial drugs reported to the state electronically by laboratories and stored in NEDSS (see NEDSS definition below).

Case means an instance of a suspected or confirmed disease or condition in a person or animal.

CDC means the Centers for Disease Control and Prevention.

CMS means Centers for Medicare and Medicaid

Communicable disease, illness, or poisoning means an illness due to an infectious or malignant agent, which is capable of being transmitted directly or indirectly to a person from an infected person or animal through the agency of an intermediate animal, host, or vector, or through the inanimate environment.

Confirmed case means a case of reportable disease that meets the case definitions specified and published by the Council of State and Territorial Epidemiologists (CSTE) for each disease, and available at http://wwwn.cdc.gov/nndss/script/casedefDefault.aspx. Confirmed cases generally require a positive laboratory test for the given disease, together with some clinical or epidemiologic data consistent with the clinical signs and symptoms of that disease.

Contact means a person or animal that has been in close proximity/association with a communicable disease, illness, or poison for such a period that they have had an opportunity to become affected.

Department means the Department of Health and Human Services (DHHS).

Epidemic or outbreak means the occurrence of one or more than one case of an illness of similar nature in persons of a community, institution, region, or other geographically defined area which is clearly in excess of normal expectancy.

Healthcare Associated Infection (HAI) means an infection that occurs as a result of a medical treatment or residence in a healthcare facility. Nebraska DHHS accepts the definitions of specific Healthcare Associated Infections (HAIs) as published by the CDC for NHSN (see NHSN definition below).

Healthcare Facility means any facility licensed under the Health Care Facility Licensure Act, and such additional clinics or facilities not licensed under that act as may be identified in specific orders issued pursuant to 173 NAC.

Laboratory means any facility that receives, forwards, or analyzes specimens from the human body, or referred cultures of specimens from the human body, and reports the results to physicians and public health authorities.

Local public health department means a county, district, or city-county health department approved by the Department of Health and Human Services as a local full-time public health service.

NEDSS means the Nebraska Electronic Disease Surveillance System for electronic and manual online reporting.

NHSN means the National Healthcare Safety Network.

Pediatric HIV Confidential Case Report Form means a CDC form for reporting HIV in pediatric patients to the Department. The form is available for download on the Department Website at http://dhhs.ne.gov/publichealth/epi/Pages/ReportableDiseases.aspx or by email request at dhhs.epi@nebraska.gov.

Suspected case means a person or deceased person having a condition or illness in which the signs and symptoms resemble those of a recognizable disease.

1-003 WHO MUST REPORT

1-003.01 Healthcare Providers: Physicians and hospitals must make reports of communicable diseases and poisonings as described in 173 NAC 1-003, 1-004, and 1-005, unless a report is made under 173 NAC 1-003.01A or 1-003.01B.

1-003.01A Reporting by Physician Assistants and Advanced Practice Registered Nurses: A physician assistant or advanced practice registered nurse who in lieu of a physician attends to any patient suspected of having a reportable disease or poisoning must make the report as required by 173 NAC 1.

1-003.01B Reporting by Laboratories in lieu of Physicians: If a laboratory provides a report containing the required information to the department, the physician is not required to make the report to the department. Physicians remain obligated to report when such reports are not made by laboratories.

1-003.01C Reporting by Healthcare Facilities in lieu of Physicians for Healthcare Associated Infections (HAIs): Healthcare Associated Infections (HAIs) that are reported by healthcare facilities to CDC’s NHSN are reportable. If a healthcare facility provides access to NSHN Healthcare Associated Infection (HAI) data to the department and its local public health department and Healthcare Associated Infections (HAIs) are reported to NHSN on a quarterly basis aligning with the CMS Reporting Schedule, the physician is not required to make the Healthcare Associated Infection (HAI) report. Physicians remain obligated to report Healthcare Associated Infections (HAIs) when access to NHSN data is not provided to the department. In the event of an outbreak, the department has the authority to require Healthcare Associated Infection (HAI) data reports from facilities not currently reporting to NHSN.

1-003.02 Laboratories: Laboratories must make reports as described in 173 NAC 1-004, 1-005.02, and 1-006.

1-003.02A Electronic Ordering of Laboratory Tests: For all laboratory tests which may identify a reportable disease (e.g., microbiology tests, hepatitis tests, etc.) and which are ordered through submission of an electronic requisition or other automated electronic mechanism, healthcare providers must include the following information at the time the test order is placed to the laboratory so that the laboratory may fulfill reporting requirements:

1. Patient first and last name;

2. Patient address including street, city, and zip;

3. Patient date of birth;

4. Patient gender;

5. Date of specimen collection;

6. Specimen source;

7. Ordered test;

8. Submitting provider’s name;

9. Submitting provider’s address and telephone number;

10. Pregnancy status, if available and if applicable;

11. Race, if available; and

12. Ethnicity (Hispanic / Non-Hispanic), if available.

1-004 REPORTABLE DISEASES, POISONINGS, AND ORGANISMS: LISTS AND FREQUENCY OF REPORTS : The following diseases, poisonings, and organisms are declared to be communicable or dangerous or both to the public. Incidents of diseases, poisonings, and organisms must be reported as described in 173 NAC 1-004.01 through 1-004.03, 1-005, and 1-006.

1-004.01 Immediate Reports

1-004.01A The following diseases, poisonings, and organisms must be reported immediately:

Anthrax (Bacillus anthracis) *^

Botulism (Clostridium botulinum) *^

Brucellosis (Brucella abortus ^, B. melitensis ^, and B. suis ^* )

Carbapenamase-Resistant Enterobacteriaceae (suspected or confirmed) **^ (not to include Proteus or Providencia species or Morganella morganii)

Cholera (Vibrio cholerae) ^

Coccidiodomycosis (Coccidioides immitis/posodasii)

Diphtheria (Corynebacterium diphtheriae)

Eastern equine encephalitis (EEE virus) *^

Food poisoning, outbreak-associated

Glanders [Burkholderia (Pseudomonas) mallei *^

Haemophilus influenzae infection (invasive disease only) ^

Hantavirus pulmonary syndrome (Sin Nombre virus)

Hemolytic uremic syndrome (post-diarrheal illness)

Hepatitis A (IgM antibody-positive or clinically diagnosed during an outbreak)

Hepatitis B infection (positive surface antigen tests, e antigen tests, and all IgM core antibody tests, both positive and negative)

Hepatitis E

Influenza due to novel or pandemic strains (includes highly pathogenic avian influenza virus) *^

Measles (Rubeola)

Melioidosis [Burkholderia (Pseudomonas) pseudomallei] *

Meningitis (Haemophilus influenza or Neisseria meningitidis) ^

Meningococcal disease, invasive (Neisseria meningitidis) ^

Monkeypox virus infection *^

Middle East Respiratory Syndrome - suspected or confirmed cases ^

Pertussis [whooping cough] (Bordetella pertussis) ^

Plague (Yersinia pestis) *^

Poliomyelitis, paralytic

Q fever (Coxiella burnetii) ^*

Rabies (human and animal cases and suspects)

Ricin poisoning *^

Rubella and congenital rubella syndrome

Severe Acute Respiratory Syndrome [SARS] (SARS-associated coronavirus)

Smallpox *^

Staphylococcal enterotoxin B intoxication*

Staphylococcus aureus, vancomycin-intermediate/resistant suspected or confirmed as defined by the CDC

Tick-borne encephalitis, virus complexes (Central European Tick-borne encephalitis virus, Far Eastern Tick-borne encephalitis virus, Kyasanur

Forest disease virus, Omsk Hemorrhagic Fever virus, Russian Spring and Summer encephalitis virus)

Tularemia (Francisella tularensis) *^

Typhus Fever, louse-borne (Rickettsia prowazekii)*^ and flea-borne / endemic murine (Rickettsia typhi)

Venezuelan equine encephalitis *^

Viral hemorrhagic fever (including but not limited to Ebola virus, Marburg virus, Congo Crimean Fever) - suspected or confirmed cases *^

Yellow Fever

• Potential agents of bioterrorism (designated as select agents by CDC)

^ Laboratories must submit the isolate and/or specimen to the Nebraska Public Health Laboratory as specified in 173 NAC 1-007.03

** Resistance to imipenem, doripenem, ertapenem or meropenem as defined by the CDC.

1-004.01B Clusters, Outbreaks, or Unusual Events, Including Possible Bioterroristic Attacks*: Clusters, outbreaks, or epidemics of any health problem, infectious or other, both in the community and in healthcare settings, including food poisoning, healthcare-associated outbreaks or clusters, influenza, or possible bioterroristic attack; increased disease incidence beyond expectations; unexplained deaths possibly due to unidentified infectious causes; and any unusual disease or manifestations of illness must be reported immediately.

1-004.02 Reports Within Seven Days: The following diseases, poisonings, and organisms must be reported within seven days of detection or diagnosis:

Acinetobacter spp., all isolates (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Acquired Immunodeficiency Syndrome (AIDS), as described in 173 NAC 1-005.01C2

Adenovirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Aeromonas (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Amebae-associated infection (Acanthamoeba spp., Entamoeba histolytica, and Naegleria fowleri)

Arboviral infections (including, but not limited to, West Nile virus, St. Louis encephalitis virus, Western Equine Encephalitis virus, Chikunguyna virus, Rift Valley fever virus, and Dengue virus) ^

Astrovirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Babesiosis (Babesia species)

Campylobacteriosis (Campylobacter spp.)

Carbon monoxide poisoning (use breakpoint for non-smokers)

Chancroid (Haemophilus ducreyi)

Citrobacter spp. (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Chlamydophila (Chlamydia) pneumoniae (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Chlamydia trachomatis infections (nonspecific urethritis, cervicitis, salpingitis, neonatal conjunctivitis, pneumonia)

Clostridium difficile (antibiotic-associated colitis and pseudomembranous colitis)

Coronavirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Creutzfeldt-Jakob Disease (subacute spongiform encephalopathy [14-3-3 and Tau protein from CSF or any laboratory analysis of brain tissue suggestive of CJD])

Cryptosporidiosis (Cryptosporidium parvum) ^

Cyclosporiasis (Cyclospora cayetanensis) ^

Ehrlichiosis, human monocytic (Ehrlichia chaffeenis)

Ehrlichiosis, human granulocytic (Ehrlichia phagocytophila)

Encephalitis (caused by viral agents)

Entamoeba histolytica

Enterobacter spp. (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Enterococcus spp . (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Enterovirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Escherichia coli gastroenteritis (to include E. coli O157-H7^ and other Shigatoxin- positive E. coli from gastrointestinal infection, Enteroaggregative E. Coli,

Enteropathogenic E. coli, Enterotoxigenic E. coli, Shigella/Enteroinvasive E. coli) ^

Escherichia coli (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Giardiasis (Giardia lamblia)

Gonorrhea (Neisseria gonorrhoeae)

Hansen’s Disease (Leprosy [Mycobacterium leprae])

Hepatitis C infection (all positive screening tests [e.g. EIA, CIA, ELISA, etc.] to include signal-to-cutoff ratio [S:CO] are reportable; all confirmatory tests [e.g. RIBA and PCR for qualitative, quantitative, and genotype testing] are reportable regardless of result [i.e., both positive and negative tests])

Hepatitis D

Herpes simplex, primary genital infection

Histoplasmosis (Histoplasma capsulatum)

Human immunodeficiency virus infection, as described in 173 NAC 1-005.01C2, Type 1 and suspected cases of HIV Type 2

Human Metapneumovirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Human Rhinovirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Influenza deaths, pediatric (< 20 years of age)

Influenza, all tests positive and negative (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Influenza, rapid tests summary report only (laboratories only)

Kawasaki disease (mucocutaneous lymph node syndrome)

Klebsiella spp., (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Lead poisoning (all analytical values for blood lead analysis must be reported)

Legionellosis (Legionella species)

Leptospirosis (Leptospira interrogans)

Listeriosis (Listeria monocytogenes) ^

Lyme disease (Borrelia burgdorferi)

Lymphocytic choriomeningitis virus infection

Lymphogranuloma venereum (LGV [Chlamydia trachomatis])

Malaria (Plasmodium species)

Meningitis, including viral, bacterial, and fungal (all such cases must be reported within seven days except those caused by Haemophilus influenzae and Neisseria meningitidis, which must be reported immediately)

Methemoglobinemia / nitrate poisoning (methemoglobin greater than 5% of total hemoglobin)

Mumps

Mycobacterium spp. (including M. tuberculosis complex organisms ^{[for genotyping] and all “atypical” species, to include culture, nucleic acid tests, or positive histological evidence indicative of tuberculosis infection or disease)}

Mycoplasma pneumoniae (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Necrotizing fasciitis

Norovirus infection (laboratories only)

Parainfluenza (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Plesiomonas shigelloides (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Poisoning or illness due to exposure to agricultural chemicals (herbicides, pesticides, and fertilizers), industrial chemicals, heavy metals, or radiologic exposures

Psittacosis [Chlamydophila (Chlamydia) psiittaci]

Pseudomonas aeruginosa (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Respiratory syncytial virus infection, all tests positive and negative (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1- 005.02C) Retrovirus infections (other than HIV)

Rheumatic fever, acute (cases meeting the Jones criteria only)

Rocky Mountain Spotted Fever (Rickettsia rickettsii) ^

Rotavirus (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Salmonella spp., including typhoid fever (Salmonella serogroup) ^

Sapovirus (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C)

Shiga toxin-positive gastroenteritis (enterhemorrhagic E. coli and other shiga toxin-producing bacteria) ^

Shigella spp. (Shigella species) ^

Staphylococcus aureus (applies only to laboratories performing electronic lab reporting as specified in 1-005.02C)

Streptococcal disease (all invasive disease caused by Groups A and B streptococci)

Streptococcus pneumonia, all isolates (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Syphilis (Treponema pallidum) RPR reactive and any FTA or other confirmatory test result whether positive or negative; if an EIA is performed first then the follow-up RPR results either positive or negative must be reported.

Syphilis, congenital

Tetanus (Clostridium tetani)

Toxic shock syndrome

Toxoplasmosis, acute (Toxoplasma gondii)

Transmissible spongiform encephalopathies

Trichinosis (Trichinella spiralis)

Tuberculosis (see Mycobacterium)

Typhoid fever (see Salmonella)

Varicella zoster primary infections (chicken pox)

Varicella zoster death (all ages)

Vibrio spp. (applies only to laboratories performing electronic lab reporting as specified in 173 NAC 1-005.02C)

Yersiniosis (Yersinia species not Y. pestis)

^ Laboratories must submit the isolate and/or specimen to the Nebraska Public Health Laboratory as specified in 173 NAC 1-007.03

1-004.03 Reporting of Antimicrobial Susceptibility: All laboratories reporting via automated electronic laboratory reporting (ELR) must report all antimicrobial susceptibility results, including the minimal inhibitory concentration, if performed for bacterial, viral, and fungal isolates listed in 173 NAC 1-004.01 and 1-004.02.

1-004.04 New or Emerging Diseases and Other Syndromes and Exposures; Reporting and Submissions

1-004.04A Criteria: The Director of the Division of Public Health or the Chief Medical Officer may require reporting, or a change in method or frequency of reporting, of newly recognized or emerging diseases, syndromes suspected to be of infectious origin, or exposures of large numbers or specific groups of persons to known or suspected public health hazards if:

1. The disease, syndrome, or exposure can cause or is suspected to cause serious morbidity or mortality; and

2. Reporting of the disease, syndrome, or exposure is necessary to monitor, prevent, or control the disease, syndrome, or exposure and to protect public health.

1-004.04B Surveillance Mechanism: The Director of the Division of Public Health or the Chief Medical Officer may describe a specific mechanism for surveillance of the disease, syndrome, or exposure including persons and entities required to report, a time frame for reporting, and protocols for the submission of clinical specimens collected from cases, suspected cases, or exposed persons to referral laboratories designated by the DHHS Division of Public Health.

1-004.05 Sexually Transmitted Diseases: For the purpose of implementing Neb. Rev. Stat. § 71-502.01, sexually transmitted diseases include, but are not limited to, the following diseases:

1. Bacterial vaginosis;

2. Candidiasis;

3. Chancroid;

4. Chlamydia trachomatis infection;

5. Genital herpes infection;

6. Gonorrhea;

7. Granuloma inguinale;

8. Hepatitis B infection;

9. Human immunodeficiency virus (HIV) infection;

10. Human papilloma virus (HPV) infection;

11. Lymphogranuloma venereum;

12. Syphilis; and

13. Trichomoniasis.

1-004.06 Healthcare Associated Infections (HAIs): Healthcare Associated Infections (HAIs) that are reported by healthcare facilities to CDC’s NHSN are reportable. If a healthcare facility provides access to NSHN Healthcare Associated Infection (HAI) data to the department and its local public health department and Healthcare Associated Infections (HAIs) are reported to NHSN on a quarterly basis aligning with the CMS Reporting Schedule, the physician is not required to make the Healthcare Associated Infection (HAI) report. Physicians remain obligated to report Healthcare Associated Infections (HAIs) when access to NHSN data is not provided to the department. In the event of an outbreak, the department has the authority to require Healthcare Associated Infection (HAI) data reports from facilities not currently reporting to NHSN.

1-005 METHODS OF REPORTING

1-005.01 Healthcare Providers

1-005.01A Immediate Reports of Diseases, Poisonings and Organisms: Healthcare providers must report diseases, poisonings and organisms, listed in 173 NAC 1-004.01A, by telephone, facsimile or other secure electronic mail system within 24 hours of diagnosis or detection. Reports must include the information as specified in 1-005.01D. See 173 NAC 1-006, Where to Report.

1-005.01B Immediate Reports of Clusters, Outbreaks, or Unusual Events, Including Possible Bioterroristic Attacks: Healthcare providers must report by telephone, facsimile, or other secure electronic mail system, information relating to confirmed, diagnosed, detected, or suspected clusters, outbreaks, or epidemics of any health problem, infectious or other, both in the community and in healthcare settings, including food poisoning, influenza or possible bioterroristic attack; increased disease incidence beyond expectations; unexplained deaths possibly due to infectious causes; any unusual disease or manifestations of illness. Reports must include the information as specified in 1-005.01D. See 173 NAC 1-006, Where to Report.

1-005.01C Reports Within Seven Days: Healthcare providers must make reports of diseases, poisonings and organisms listed in 173 NAC 1-004.02, within seven days of diagnosis or detection.

1-005.01C1 Reports may be made by postal service, telephone, facsimile, electronic laboratory report, or other secure electronic mail system, and must include the information as specified in 1-005.01D.

1-005.01C2 AIDS and HIV disease reports may be made by postal service, telephone, facsimile, electronic laboratory report, or other secure electronic mail system, submitted on or including the same information as Attachment A.

Adult cases of AIDS and HIV disease (patients > 13 years of age at time of diagnosis) must be submitted on or include the same information in the Adult HIV Confidential Case Report Form as described in 173 NAC 1-002. Pediatric cases of AIDS and HIV disease (patients < 13 years of age at time of diagnosis) and perinatally exposed HIV cases must be submitted on or include the same information in the Pediatric HIV Confidential Case Report Form, described in 173 NAC 1-002. AIDS and HIV case reports are required from healthcare providers responsible for:

1. Treating or diagnosing a person with HIV-1 or HIV-2 disease, based on the laboratory tests listed in 173 NAC 1-005.02B3a1 as being definitive for HIV infection, or based on clinical criteria, as outlined in the CDC’s most recent case definition for HIV;

2. Treating or diagnosing a person with AIDS as outlined in CDC’s most recent case definition for AIDS;

3. Providing medical care to a pregnant woman with HIV disease;

4. Providing medical care to a baby under 19 months of age born to a woman with HIV disease (perinatally HIV exposed). The diagnosis of HIV infection or determination of no infection is determined by CDC’s most recent case definition for HIV; and

5. Treating or diagnosing potential cases of public health importance related to HIV infection including:

a. Unusual strains of HIV (HIV-2 or non-B subtype of HIV-1); and

b. Unusual modes of transmission (such as, but not limited to transplant or artificial insemination; transfusion of blood or blood components, child sexual abuse, occupational, household, or other unusual exposure).

1-005.01C3 Reporting of Tuberculosis: Healthcare providers must report positive tuberculosis diagnostic tests (culture and nucleic acid amplification) or positive histological evidence indicative of tuberculosis infection or disease.

1-005.01D Report Information: Reports made under 1-005.01 must contain the following information:

1. Patient first and last name;

2. Patient address including street, city, and zip;

3. Patient date of birth;

4. Patient gender;

5. Patient race and ethnicity (if available);

6. Patient occupation (if available);

7. Patient pregnancy status (if available);

8. Date of report;

9. Physician name;

10. Physician address and telephone number;

11. Name of hospital or clinic (if any)

12. Date and time of onset (if available);

13. Date of diagnosis (if available);

14. Mode of transmission (if available);

15. Date of specimen collection;

16. Specimen source;

17. If lead test, whether sample is a capillary or venous blood sample;

18. Ordered tests;

19. Laboratory findings or result;

20. Other information pertinent to the case as requested.

1-005.01E Reporting to Laboratories: For all laboratory tests which may identify a reportable disease (e.g. microbiology tests, hepatitis tests, etc.) and which are ordered through submission of an electronic requisition or other automated electronic mechanism, providers must include the information as specified in 173 NAC 1-005.02B4 (except laboratory findings or result) at the time the test order is placed to the laboratory so that the laboratory may fulfill reporting requirements.

1-005.02 Laboratories

1-005.02A Electronic Reporting: All laboratories performing clinical testing on Nebraska residents must electronically report laboratory test results for the diseases specified in 173 NAC 1-004 and the tests specified in 1-005.02. This may be accomplished either through manual online data entry into Nebraska’s electronic disease reporting system, or through automated electronic laboratory reporting. Paper reports will be accepted only when established electronic transmission methods are inoperable.

1-005.02B Laboratories Using NEDSS Manual Online Reporting

1-005.02B1 Immediate Reports of Diseases, Poisonings, and Organisms: Laboratories must make immediate reports of diseases, poisonings, and organisms listed in 173 NAC 1-004.01A, both by telephone to a live public health surveillance official within 24 hours of diagnosis or detection and by electronic reporting to NEDSS. Reports must include the information as specified in 1-005.02B4. See 173 NAC 1-006, Where to Report.

1-005.02B2 Immediate Reports of Clusters, Outbreaks, or Unusual Events, Including Possible Bioterroristic Attacks: Laboratories must make immediate reports by telephone to a live public health surveillance official within 24 hours of diagnosis or detection, information relating to diagnosed, detected, or suspected clusters, outbreaks, or epidemics of any health problem, infectious or other, both in the community and in healthcare settings, including food poisoning, influenza, or possible bioterroristic attack; increased disease incidence beyond expectations; unexplained deaths possibly due to infectious causes; and any unusual disease or manifestations of illness. Reports must include the information as specified in 1-005.02B4.

1-005.02B3 Reports Within Seven Days: Laboratories must make reports of diseases, poisonings, and organisms diagnosed or detected, listed in 173 NAC 1-004.02, collected during one calendar week. Reports must be submitted no later than the following Tuesday and must include the information as specified in 1-005.02B4.

1-005.02B3a For the purposes of reporting AIDS and HIV, the laboratory reporting requirement applies as follows:

1. Any FDA approved test or combination of tests indicative of HIV-1 or HIV-2 that has acceptable specificity and sensitivity to reliably detect HIV infection is reportable.

2. A laboratory analyzing samples for any of the tests as listed below must report all of the following results:

a. Any result (positive, negative or indeterminate) on a confirmatory test for HIV antibody, (e.g. Western blot or immunofluorescence antibody test), usually preceded by a positive screening test for HIV antibody, (e.g. repeatedly reactive enzyme immunoassay);

b. All quantitative HIV RNA PCR tests regardless of the result. Include the detailed name of the test, detection limits of test, and/or interpretation of results. (This applies only to laboratories performing ELR.);

c. All positive results on any of the following:

(1) Qualitative HIV nucleic acid (DNA or RNA) detection [e.g. DNA polymerase chain reaction];

(2) HIV p24 antigen test, including neutralization assay;

(3) HIV isolation (viral culture); and

d. All CD4 counts per microliter and all CD4 percentages.

1-005.02B4 Report Information: Reports made under 1-005.02B must contain the following information:

1. Patient first and last name;

2. Patient address including street, city, and zip;

3. Patient date of birth;

4. Patient gender;

5. Patient race and ethnicity (if available);

6. Patient pregnancy status (if available);

7. Date of specimen collection;

8. Specimen source;

9. If lead test, whether sample is a capillary or venous blood sample;

10. Ordered test;

11. Laboratory findings or result;

12. Physician name;

13. Physician address and telephone number.

1-005.02C Laboratories Using Automated Electronic Laboratory Reporting (ELR)

1-005.02C1 Required data fields include:

1. Patient first and last name;

2. Patient address including street, city, state, and zip;

3. Patient date of birth;

4. Patient sex;

5. Patient ID number;

6. Performing laboratory’s name, address, and phone number;

7. Date and time of specimen collection;

8. Date and time the test was performed;

9. Specimen source;

10. Type of test performed;

11. Test result;

12. Result units;

13. Date and time the test was verified;

14. Accession number;

15. Date of report; and

16. Submitting provider’s name, address, phone number, and office

name; and, if available,

17. Pregnancy status;

18. Race/Ethnicity (Hispanic / Non-Hispanic);

19. Code for ordered test;

20. Code for test result;

21. Result flag;

22. High and low result reference range;

23. Provider ID number;

24. Provider office ID number;

25. ELR report date; and

26. The following data elements stored in the PV1 segment of HL7:

Element Name Sequence

Patient Class 2

Assigned Patient Location 3

Admission Type 4

Prior Patient Location 6

Attending Doctor 7

Admit Source 14

Admitting Doctor 17

Patient Type 18

Discharge Disposition 36

Discharged to Location 37

Admit Date and Time 44

Discharge Date and Time 45

A laboratory’s test results must be screened via an automated computer algorithm no less than once every 24 hours, and a file or files meeting this reporting requirement must be forwarded electronically to the department no less than once every 24 hours. Automated computer screening algorithms must be validated initially and once each year to ensure the screening process will capture all reportable disease test results that may be generated by the reporting laboratory. Results of this validation must be documented and maintained on file for two years at the laboratory for review by the department.

Electronic reporting does not exempt the laboratory from reporting by telephone those diseases that must be reported immediately.

1-005.02C2 Reporting of Antibiotic Susceptibility Results: Laboratories with automated electronic reporting capability which perform antibiotic susceptibility testing (AST) for bacterial diseases listed under 173 NAC 1-004 must report antibiotic susceptibility results, including minimal inhibitory concentration, for these tests. This requirement includes traditional broth, agar, and newer automated methods of AST, as well as molecular-based methods that assay for the molecular determinants of antibiotic resistance. Reports must include the method used for AST. Clinical laboratories must report AST results to the DHHS Division of Public Health via automated ELR. When necessary for the protection of the public health, the DHHS Division of Public Health may request additional reporting of AST results on other infectious agents that have increased in either incidence or severity.

1-005.03 Healthcare Associated Infections (HAIs): Healthcare Associated Infection (HAI) reports made to NHSN need not be reported separately to state and local public health departments provided access to NHSN Healthcare Associated Infection (HAI) data has been given to state and local public health departments.

1-006 WHERE TO REPORT

1-006.01 Cases Reported by Healthcare Providers and Laboratories: Except as stated for AIDS and HIV reporting in 173 NAC 1-006.01A and except for reports made through NEDSS, reports must be made to the local public health department if the area is served by a local public health department as defined in Neb. Rev. Stat. § 71-1626, and where the health director of the local public health department has specified this method of reporting. In all other areas, the reports are to be made directly to the DHHS Division of Public Health.

1-006.01A HIV/AIDS Cases Reported by Healthcare Providers and Laboratories: To report an AIDS or HIV case in Douglas or Lancaster County, submit the appropriate case report form or contact the local public health department listed below, based upon the county in which the patient resides. In all other areas, the reports must be made to DHHS Division of Public Health.

Douglas County

Epidemiology

Douglas County Health Department

1111 South 41st St.

Omaha, NE 68105

402-444-7214

Lancaster County

Communicable Disease Coordinator

Lincoln-Lancaster County Health Department

3140 “N” Street

Lincoln, NE 68510-1514

402-441-8053

DHHS Division of Public Health

Office of Epidemiology

P.O. Box 95026

Lincoln, NE 68509-5026

402-471-0360

1-006.02 Duties of Local Public Health Departments to Report to DHHS: It is the duty of the local public health department to report all cases of reportable diseases, poisonings, and organisms in the time frames described below.

1-006.02A Immediate Reports: The local public health department must make immediate reports of diseases, poisonings, and organisms listed in 173 NAC 1-004.01 to the DHHS Division of Public Health. Reports must be made by the health director or authorized representative of the respective local public health department by telephone to a live state public health surveillance official within 24 hours of diagnosis or detection. Reports must include the information as specified in 173 NAC 1-005.01D and 1-005.02B4.

1-006.02B Reports Within Seven Days: The local public health department must make reports of diseases, poisonings, and organisms listed in 173 NAC 1-004.02 to the DHHS Division of Public Health. Reports must be made via NEDSS, or in the event NEDSS is not operational, by postal service, telephone, facsimile, or other secure electronic mail system within seven days of diagnosis or detection. Reports must be made by the health director or authorized representative of the respective local public health department, no later than Friday of each week. Reports must include the information as specified in 173 NAC 1-005.01D and 1-005.02B4.

1-007 CONTROL MEASURES FOR COMMUNICABLE DISEASES : For the information of the public, the latest editions of these publications are used as a reference by the DHHS Division of Public Health, local public health departments, and healthcare providers in the control of communicable diseases: "Control of Communicable Diseases Manual", published by the American Public Health Association, 800 I Street NW, Washington, D.C. 20001-3710 and disease-specific recommendations of the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, as published in the "Morbidity and Mortality Weekly Report.”

1-007.01 Public Health Interventions, Noncompliance, and Directed Health Measures

1-007.01A Public Health Interventions: The healthcare provider attending a case or suspected case of a disease requiring isolation, quarantine, or other public health interventions, must make reasonable efforts to prevent the spread of the disease to others and must report the case to the local public health department or the DHHS Division of Public Health.

1-007.01B Noncompliance: Healthcare providers must report immediately to the local public health department or the DHHS Division of Public Health, the name, address, and other pertinent information for all individuals with diseases requiring isolation, quarantine, or other public health interventions who refuse to comply with prescribed public health interventions.

1-007.01C Directed Health Measures: The DHHS Division of Public Health may order a directed health measure as provided in 173 NAC 6, or in the case of tuberculosis, advise the local county attorney for proceedings under the Tuberculosis Detection and Prevention Act.

1-007.02 Contact Notification in Reportable Communicable Disease and Poisoning Investigations

1-007.02A Notification of Possible Contacts: In order to protect the public’s health and to control the spread of disease, in cases of reportable communicable disease or poisonings other than those covered by 173 NAC 1-007.02B, the DHHS Division of Public Health may notify individuals who are determined to be possible contacts of the source of the disease or poisoning by any means reasonably necessary.

1-007.02B Partner Identification and Notification in STD Cases:

1-007.02B1 In order to protect the public’s health, when an individual is tested and found to have an STD as defined in 173 NAC 1-004.05, the DHHS Division of Public Health or local public health department will conduct partner notification and referral activities in cases of HIV disease and early syphilis, and may conduct these activities as appropriate for other STD’s. Other local health related agencies may conduct these activities if staff have received appropriate training as determined by DHHS.

1-007.02B2 “Partner” is defined as any individual, including a spouse, who has shared needles, syringes, or drug paraphernalia or who has had sexual contact with an individual infected with an STD as defined in 173 NAC 1-004.05. In the case of HIV disease, in accordance with the Ryan White HIV/AIDS Treatment Modernization Act, “spouse” is defined as any individual who is the marriage partner of that person at any time within the ten-year period prior to the diagnosis of HIV disease.

1-007.03 Responsibilities of Laboratories: All laboratories performing clinical testing on Nebraska residents:

1. Must forward to the Nebraska Public Health Laboratory isolates of special public health interest indicated in 173 NAC 1-004.01A and 1-004.02; contact a state or local public health department before shipping any isolates or specimens suspected of containing: Yersinia, Francisella, Brucella, Bordetella, Coxiella, or Bacillus species. Contact the receiving laboratory prior to shipping the isolate or specimen.

2. Which diagnose reportable diseases with non-culture diagnostic methods (e.g. E. coli gastroenteritis with a shiga toxin assay) and which do not isolate the actual organism must, if ordered by the department (pursuant to Neb. Rev. Stat. § 71-502 or 173 NAC), forward the clinical sample testing positive to the Nebraska Public Health Laboratory; and

3. Must forward if ordered by the department (pursuant to Neb. Rev. Stat § 71-502 or 173 NAC) isolates or specimens to the Nebraska Public Health Laboratory or the CDC laboratories.

1-007.04 Responsibilities of Schools: School nurses or those acting in the capacity of a school nurse must, in accordance with state and federal statutes:

1. Notify the local public health department or the DHHS Division of Public Health of cases or suspected cases of reportable diseases as indicated in 173 NAC 1-004.01 and 1-004.02, or outbreaks and suspected outbreaks of diseases as indicated in 173 NAC 1-004.01B affecting students and/or other school-affiliated personnel and which present a reasonable threat to the safety or health of a student and/or other school-affiliated personnel; and

2. Cooperate with public health authorities in obtaining information needed to facilitate the investigation of cases and suspected cases, or outbreaks and suspected outbreaks of diseases affecting students and/or other school-affiliated personnel.

All information disclosed to a public health authority is confidential and not to be released to outside parties as stipulated by Neb. Rev. Stat. § 71-503.01.

1-007.05 Significant Exposure of Emergency Medical Services personnel and Healthcare Workers to Infectious Diseases or Conditions: Neb. Rev. Stat. §§ 71-507 to 71-513 address the risk of significant exposure of emergency services providers to infectious diseases or conditions, and Neb. Rev. Stat. §§ 71-514.01 to 71-514.05 address the risk of significant exposure of healthcare providers to infectious diseases or conditions.

1-007.05A For the purpose of implementing these statutes, infectious disease or condition means:

1. Hepatitis B;

2. Hepatitis C;

3. Meningococcal meningitis;

4. Active pulmonary tuberculosis;

5. Human immunodeficiency virus infection;

6. Diphtheria;

7. Plague;

8. Hemorrhagic fevers;

9. Rabies;

10. Severe acute respiratory syndrome;

11. Middle East respiratory syndrome.

1-007.05B Significant Exposure Report Form for Emergency Services Providers: For the purpose of implementing Neb. Rev. Stat. § 71-508, the form to be used by the emergency services provider to document information necessary for notification of significant exposure to an infectious disease or condition is Attachment A, incorporated in these regulations by this reference. Emergency services providers are responsible for reproduction of the form for use in the notification procedure.

1-008 RABIES : Cases of human and animal rabies are reportable under 173 NAC 1-004.01. Rabies control is governed by Neb. Rev. Stat. §§ 71-4401 to 71-4412 and 173 NAC 5, Rabies Control Program. Copies of these rules and regulations are available from the DHHS Division of Public Health, Rabies Surveillance, and online at http://dhhs.ne.gov/Pages/reg_t173.aspx.

ATTACHMENTS

ATTACHMENT A Emergency Services Provider (ESP) or Public Safety Official (PSO)

Significant Exposure Report Form (PHA-14)

History

• Effective 2017-01-01

Chapter 2 Care of Clients with Tuberculosis

Neb. Admin. Code tit. 173, ch. 2 Care of Clients with Tuberculosis {#sec-173-nac-2 omnilex-key=us-ne-regs-official--title-173--173 NAC 2}

001. SCOPE AND AUTHORITY . These regulations are authorized by and implement the Tuberculosis and Detection and Prevention Act, Nebraska Revised Statutes (Neb. Rev. Stats.) §§ 71-3601 to 71-3614.

002. DEFINITIONS . The definitions set out in Neb. Rev. Stats. §§ 71-3601 to 71-3614 and the following apply to this chapter.

002.01 CLASS B TUBERCULOSIS DESIGNATION. A designation given by the Centers for Disease Control for a person who upon arrival to the United States was determined to have communicable tuberculosis.

002.02 CLIENT. An individual applying for or receiving assistance from the program.

002.03 COMPLETE APPLICATION. An application that contains all of the information requested on the application, with attestation to its truth and completeness, and submitted with all required documentation.

002.04 CONTACT. An individual who has had exposure from a client with active infectious tuberculosis.

002.05 EXPLANATION OF BENEFITS. An insurance company’s written explanation or remittance advice regarding a claim showing what is paid on a client’s behalf.

002.06 PATIENT. A person with or suspected to have communicable tuberculosis.

002.07 PROGRAM. The Nebraska Department of Health and Human Services Tuberculosis Program.

002.08 PROVIDER. A health care facility defined in Neb. Rev. Stat. § 71-419, a health care service defined in Neb. Rev. Stat. § 71-415, or a physician, physician assistant, advanced practice registered nurse, or doctor of osteopathic medicine.

002.09 THIRD PARTY PAYER. Any individual, firm, partnership, corporation, company, association or any other entity responsible for, or otherwise under an obligation to provide, the payment of all or part of the cost of the care, treatment or maintenance or of the transportation of a client; but such term shall not mean the client, a provider providing services to a client, or the program.

003. ELIGIBILITY . To be eligible for assistance from the Tuberculosis Program, a client must:

(A) Be diagnosed with communicable tuberculosis, be suspected to have communicable tuberculosis, be a contact, or have a Class B tuberculosis designation;

(B) Be residing in Nebraska;

(C) Meet income and resource requirements based on household size; and

(D) Meet all statutory requirements for receiving assistance from the program.

003.01 INCOME AND RESOURCE REQUIREMENTS. A client’s annual income for the household must be at or below two hundred and fifteen percent of the federal poverty level in order to participate in the program. The income level is adjusted based on household size. A client’s available resources may not exceed an estimated total of four thousand dollars. Available resources includes cash or other liquid assets or any type of real or personal property or interest in property that the client owns and may convert into cash to be used for support and maintenance. A resource which appears on record in the name of a client is deemed to belong to the client. Jointly owned resources other than in joint tenancy are to be given the proportionate share based on the number of owners of the resource available to each owner. Resources that are owned jointly, are to be given the proportionate share based on the number of owners of the resource available to each owner. Resources that are owned in joint tenancy are considered available in total to the client. If the encumbrances against the property equal or exceed the price for which the property could be sold, the property is not an available resource. The value of the property is determined after any the amount of debt secured by mortgages, liens, promissory notes, and judgements are subtracted from the gross value of the encumbered property. The following resources are excluded in making a determination of eligibility:

(A) Real property which is owned by the client or the client’s household and which the client occupies as a home. Lots adjacent to a home are considered an available resource if they can be sold separately;

(B) Household goods;

(C) Clothing;

(D) A motor vehicle if used for employment or medical transportation;

(E) A motor vehicle used as the client’s home;

(F) The cash value of life insurance policies;

(G) Irrevocable burial trusts;

(H) Burial spaces;

(I) Stocks, inventories, and supplies used in self-employment;

(J) U.S. savings bonds;

(K) Any unavailable employment related retirement account that is held by the employer; and

(L) Earned income from a child 18 years of age and younger.

003.02 APPLICATION. Application to the program is made by submission of a complete application to the Department. Prior to eligibility being determined, a client must also provide the following as requested by the Department:

(A) Documentation to verify income and resources;

(B) Documentation to verify household size;

(C) Documentation of health insurance or a sworn statement that the client does not have health insurance from any third party payer; and

(D) Documentation of meeting the requirement of 173 Nebraska Administrative Code (NAC) 2-003(A).

003.03 APPROVAL. An approved application establishes client eligibility for 12 months provided the client continues to meet the eligibility requirements in statue and this chapter. The service start date for a client may be set for when a client is identified as a contact, or a suspect, receives a Class B Tuberculosis designation, or receives a diagnosis of communicable tuberculosis.

003.04 DENIAL. When the Department determines a client does not meet the eligibility requirements or is in violation of any provision set out in this chapter the Department will send written notice to the client stating the reason for the denial.

003.05 MAINTENANCE OF CLIENT ELIGIBILITY. The client, or the client’s representative, is responsible for informing the program in writing, within thirty (30) days of the following changes:

(A) When the client’s annual income increases above the two hundred fifteen percent of the federal poverty level;

(B) When the client’s resources increases above four thousand dollars;

(C) In the number of individuals living in the household;

(D) In treatment status which includes:

(i) Is no longer receiving treatment for communicable tuberculosis;

(ii) Has died;

(iii) Has competed treatment; and

(E) Address or primary telephone number changes.

003.06 TERMINATION. When the Department determines a client meets the requirements for termination from participation in the program the Department will send written notice to the client stating the reason for the termination. Clients are ineligible for the program and may be terminated from it under the following circumstances:

(A) Misrepresentation by the client;

(B) The client does not meet eligibility requirement or violates a provision set out in this chapter;

(C) Fails to provide documentation upon request; or

(D) Death.

003.07 INACTIVITY. If there have been no payments processed on a client’s behalf in a state fiscal year the client’s participation in the program shall be terminated.

004. RIGHT TO A FAIR HEARING . If an individual is denied participation in the program or is terminated from participation in the program the individual may request a fair hearing. The request must be in writing and filed with the Department within thirty (30) days of the mailing date on the written notice from the Department. The request must:

(A) Include a brief summary of the Department’s action being challenged;

(B) Describe the reason for the challenge; and

(C) Be sent to the Director of the Department Division of Public Health.

004.01 HEARING PROCEDURE. The hearing is conducted in accordance with 184 (NAC) 1.

005. PAYMENT . The program assists in paying for services that are directly related to the care and treatment of communicable tuberculosis, that are ordered or prescribed by a licensed health care provider possessing appropriate specialized knowledge in the diagnosis and treatment of communicable tuberculosis, and which are authorized by the Department. Such services may include:

(A) Pharmaceutical products necessary for the treatment of communicable tuberculosis;

(B) Latent tuberculosis pharmaceutical products and the cost associated with the dispensing of these products;

(C) The initial evaluation and diagnosis of contacts of a client;

(D) Visiting nursing services as allowed under Neb. Rev. Stat. § 71-3613; and

(E) Services received by a client from providers participating in the program.

005.01 NON COVERED SERVICES. The program does not pay for:

(A) Any services denied by Medicare, Medicaid, or any other health insurance as not medically necessary for the client;

(B) Any service not related to the treatment of communicable tuberculosis; or

(C) Any service not authorized by the Department.

005.02 LIMITATIONS. The program is a payer of last resort. Third party payers must be invoiced first and have paid on a client’s behalf before an invoice is sent to the program for payment consideration. The program does not pay for services required by statute to be paid by a county. The total amount of payments by the program cannot exceed the amount allocated to the program by the Nebraska Legislature for that state fiscal year. The program makes payments on behalf of a client directly to a provider.

006. PROVIDER PAYMENT . The rate of reimbursement paid by the Department to a health care facility or a healthcare provider will not exceed the applicable rate set by Nebraska Medicaid for the services provided. Participating providers agree to accept as payment in full the amount paid according to the Department’s payment methodologies after all other sources have been exhausted. The provider shall not bill the client for services covered by the program. If the client agrees in advance in writing to pay for a non-covered service, the provider may bill the client for such service. It is not a violation for a provider to bill the client for services when it is determined the client received funds from a third party resource, such funds were designated to pay for covered services, and payment of the funds has not been submitted to the provider.

007. RECORDS . The medical records of a client shall be available whenever requested. A discharge summary of the period of hospitalization or other care for which the program is to be billed shall accompany, or shall have been submitted prior thereto, the request of the payment. A discharge summary of the period of hospitalization or other care for diagnosis or treatment of any client, regardless of the source of payment, shall be transmitted by a provider to the program within five days after his or her discharge.

008. LABORATORY REQUIREMENT . A provider or local public health department that receives a laboratory report of M. tuberculosis complex will have the laboratory submit, within 48 hours of a growth of such culture or subculture, a specimen from the culture for genotyping and identification as directed by the program.

009. PROVIDER PARTICIPATION AND PAYMENTS . To participate in the program, providers must be licensed by the Department or its equivalent in another state. Providers that do not meet these standards are not eligible to participate with the program.

009.01 PAYMENT PROCEDURES. Payments are made in accordance with the standards and payment procedures set out in this chapter. Claims may be approved for payment when all of the following conditions are met:

(A) The client was approved for participation in the program when the service was provided;

(B) The services provided are for program covered services as described in this chapter; and

(C) No more than 6 months have elapsed from the date of service and when the program is received the claim. If circumstances beyond the entity’s or individual’s control delayed submittal to the program the program may make payment. The determination of whether the circumstances were beyond the entities or individual’s control is at the program’s discretion and may be based on documentation submitted by the entity or individual or other information received by the program.

009.02 FAILURE TO COOPERATE IN SECURING THIRD PARTY PAYMENT. The program may deny payment of a claim if the entity or client fails to apply third-party payments to covered services, file necessary claims, or to cooperate in matters necessary to secure payments by insurance or other responsible third-parties.

009.03 REFUNDS. Whenever a provider or client receives a third-party payment after a claim has been paid by the program, the provider or client is to refund the program the full amount of the payment within thirty days. The refund is to be accompanied by a copy of the documentation from the third party-payer.

History

• Effective 2022-07-19

Chapter 3 School Health, Communicable Disease Control, and Immunization Standards

Neb. Admin. Code tit. 173, ch. 3 School Health, Communicable Disease Control, and Immunization Standards {#sec-173-nac-3 omnilex-key=us-ne-regs-official--title-173--173 NAC 3}

3-001 SCOPE AND AUTHORITY : These regulations are intended to implement Neb. Rev. Stat. §§ 79-217 to 79-223.

3-002 DEFINITIONS : For purposes of these regulations:

Booster dose means a dose of vaccine given after the initial series to enhance waning immunity to specific disease(s).

Child or children means any student or students enrolled in a public or private elementary or secondary school system in Nebraska.

Department means the Department of Health and Human Services.

Local health department means a county, district, or city-county health department approved by the Department of Health and Human Services as a local full-time public health service.

Reportable communicable disease means those diseases which are required by law to be reported pursuant to 173 NAC 1.

3-003 SYMPTOMS OF COMMUNICABLE DISEASE; EXCLUSION FROM SCHOOL : Children showing any signs or symptoms of a contagious or infectious disease are required by law to be sent to their homes immediately, or as soon as safe and proper conveyance can be found. Teachers are encouraged to observe each child carefully for signs of illness each time the child returns to school. This is particularly important when epidemic diseases are known to be present in the community.

The presence of one or more of the following signs or symptoms should make the teacher suspect a communicable disease:

Fever, flushed face, headache, aches in muscles or joints, unexplained tiredness or listlessness, loss of appetite, stomach ache, nausea or vomiting, diarrhea, convulsions, sore throat, nasal congestion or discharge, unexplained skin eruption, sore or inflamed eyes.

3-004 REPORTING

3-004.01 Suspected Contagious or Infectious Disease: When a child is sent home because of a suspected contagious or infectious disease, the law requires the proper school authority, school board, or board of education to be notified without delay.

3-004.02 Suspected Reportable Disease: When a school nurse or an individual acting in the capacity of a school nurse identifies a case or suspected case of a reportable disease, s/he must report that case to the local public health department or the DHHS Division of Public Health as provided in 173 NAC 1-007.04.

3-005 DURATION OF EXCLUSION PERIOD : Children excluded for a confirmed communicable disease should not be allowed to return to school until the minimum isolation period has elapsed, and all signs or symptoms of acute illness have disappeared. The period of exclusion should extend throughout the period when acute signs of illness are present, or until the student is fever-free for 24 hours without the use of fever-reducing medication.

Minimum isolation periods are shown in the table on Attachment 1, Contagious and Infectious Disease/Condition Chart, which is attached to 173 NAC 3 and incorporated by this reference. School boards and boards of education may observe these periods, or adopt and enforce their own exclusion regulations which may not be shorter or less restrictive than those contained in 173 NAC 3.

3-006 EXCLUSION OF HEALTH CONTACTS : With a few exceptions (which are shown in the table on Attachment 1) there are no restrictions placed upon the health contacts of communicable diseases by these regulations; consequently, they may attend school unless the local health department, board of health, school board or board of education has adopted rules and regulations to the contrary. If officials consider exclusion of health contacts necessary, it is suggested that whenever possible this be confined to the latter portion of the incubation period and enforced only for those children who are not known to be immune.

3-007 (RESERVED)

3-008 IMMUNIZATION STANDARDS : Each student must be protected by immunization against the following diseases, unless otherwise exempted from this requirement under the provisions of 173 NAC 3-010:

Measles Diphtheria Invasive pneumococcal disease Mumps Tetanus Rubella Pertussis Polio Haemophilus Influenzae type b (Hib) Hepatitis B Varicella

3-008.01 For the purposes of complying with the requirement of immunization against the diseases listed above:

3-008.01A Students 2-5 years of age enrolled in a school-based program not licensed as a child care provider are considered to be immunized if they have received:

3 doses of hepatitis B vaccine; 4 doses of DTaP, DTP, or DT vaccine; 3 doses of polio vaccine; 1 dose of MMR vaccine given no earlier than 4 days before the first birthday; 3 doses of hib vaccine or 1 dose of hib vaccine given at or after 15 months of age; 1 dose of varicella vaccine; and 4 doses of pneumococcal vaccine or 1 dose of pneumococcal vaccine given at or after 15 months.

3-008.01B Students enrolling for the first time (kindergarten or 1st grade, depending on the school district’s entering grade), enrolling in 7th grade, and all transfer students from outside the state regardless of the grade they are entering are considered immunized if they have received:

3 doses DTaP, DTP, DT, or Td vaccine with at least 1 dose given no earlier than 4 days before 4 years of age; 3 doses of polio vaccine; 2 doses of MMR vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days; 3 doses of pediatric hepatitis B vaccine, or, if the alternate hepatitis B vaccination schedule is used, 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age; and 2 doses of varicella vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.

Students enrolling in 7th grade must provide evidence of having 1 booster dose of a tetanus, diphtheria, and pertussis (Tdap) vaccine, given on or after 7 years of age.

3-008.01C All other students are considered immunized if they have received:

3 doses of DTaP, DTP, DT, or Td vaccine, with at least 1 dose given no earlier than 4 days before 4 years of age; 3 doses of polio vaccine; 2 doses of MMR vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days; 3 doses of hepatitis B vaccine; and 2 doses of varicella vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.

3-009 REQUIRED EVIDENCE OF IMMUNIZATION

3-009.01 For purposes of compliance with the immunization requirement, the board of education or school board or other governing authority, must require the presentation of an immunization history which includes the name of the vaccine and the month, day, and year of administration.

3-009.02 Laboratory evidence of circulating antibodies for measles, mumps, or rubella constitutes evidence of immunity against those diseases provided the following information is supplied: name of laboratory, date of test, name of test, test result, signature of laboratory technician performing the test or of the laboratory director, and date of signature. For purposes of compliance with this rule, clinical history of measles, mumps, or rubella without laboratory or epidemiologic confirmation does not constitute evidence of immunity.

3-009.03 Epidemiologic confirmation of a diagnosis means that the clinical history of measles, mumps, or rubella is corroborated by association with laboratory proven case(s) and that such epidemiologic case(s) have been reported to and counted by the Department.

3-009.04 A documented history of varicella disease from a parent or health care provider with the year of infection constitutes evidence of immunity to varicella. The documentation must include one of the following:

1. Signature of the parent or legal guardian and the date (year) of the child’s varicella illness, or
2. Signature of a health care provider and the date (year) of the child’s varicella illness, or
3. Laboratory evidence of a child’s varicella immunity, or
4. A clinical diagnosis of shingles.

3-010 MEDICAL AND RELIGIOUS EXEMPTION; PROVISIONAL ENROLLMENT : Each student must be protected against the diseases listed using the standards described in 173 NAC 3-008 and submit evidence of immunization as described in 173 NAC 3-009. Any student who does not comply with these requirements must not be permitted to enroll in school, except as provided in 173 NAC 3-010.01 through 3-010.03.

3-010.01 Immunization is not required for a student's enrollment in any school in this state if he or she submits to the admitting official either of the following:

3-010.01A A statement signed by a physician, physician assistant, or nurse practitioner stating that, in the health care provider's opinion, the specified immunization(s) required would be injurious to the health and well-being of the student or any member of the student's family or household; or

3-010.01B A notarized affidavit signed by the student or, if he or she is a minor, by a legally authorized representative of the student, stating that the immunization conflicts with the tenets and practice of a recognized religious denomination of which the student is an adherent or member or that immunization conflicts with the personally and sincerely followed religious beliefs of the student.

3-010.02 A student may be provisionally enrolled in a school in Nebraska if he or she has begun the immunizations against the specified diseases prior to enrollment and continues the necessary immunizations as rapidly as is medically feasible. For purposes of complying with these requirements:

3-010.02A A student is considered to have begun immunizations against polio, diphtheria, tetanus, pertussis, hepatitis B, measles, mumps, and rubella and varicella if he or she has had at least one dose of DTaP/DTP/DT/Td, one dose of hepatitis B, one dose of either trivalent OPV or one dose of IPV, either one dose of the combined measles, mumps, and rubella vaccine or one dose of each vaccine for measles, mumps, and rubella, and one dose of varicella vaccine.

3-010.02B Continuation of necessary immunizations as rapidly as is medically feasible must be documented by a written statement from the student's immunization provider which shows the scheduled dates to complete the required immunization series. Failure to receive the necessary immunizations as rapidly as is medically feasible will result in exclusion of the student from attending school until either documentation of immunization or a medical statement or religious affidavit is provided to the school. The time interval for the completion of the required immunization series must not exceed nine months.

3-010.03 A student may also be provisionally enrolled in a school in Nebraska if he or she is the child or legal ward of an officer or enlisted person, or the child or legal ward of the spouse of such officer or enlisted person on active duty in any branch of the military services of the United States, and said student is enrolling in a Nebraska school following residence in another state or in a foreign country.

3-010.03A As a condition for the provisional enrollment of a student under this Section, a parent or adult legal guardian of the student must provide the school with a signed written statement certifying that the student has completed the course of immunizations required by 173 NAC 3-008.

3-010.03B The provisional enrollment of a student qualified for such enrollment under 173 NAC 3-010.03 must not continue beyond 60 days from the date of such enrollment. At such time, the school must be provided, with regard to said student, written evidence of compliance with 173 NAC 3-008. The student must not be permitted to continue in school after such date until evidence of compliance is provided.

3-011 TIME OF COMPLIANCE : Each student must present documentation as outlined in 173 NAC 3-009 and 3-010 prior to enrollment.

3-012 REPORTING REQUIREMENTS : A report to the Department summarizing immunization status is required by November 15 of each year from the board of education or school board of each school district, or other governing authority of the school. The report must include the following information regarding those entering school for the first time (kindergarten or 1st grade), those entering the 7th grade, and all transfer students from outside the state (excluding the entering and 7th grades):

3-012.01 For children in the entering grade (kindergarten or 1st grade depending on the school district’s entering grade):

1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Diphtheria, tetanus, and pertussis (DTP/DTaP/DT/Td):

1. The number of students with 3 or more doses of DTP/DTaP/DT/Td, with at least one dose given at or after 4 years of age.
2. The number of students with medical exemptions on file for diphtheria, tetanus, and pertussis.
3. The number of students with religious exemptions on file for diphtheria, tetanus, and pertussis.
4. The number of students provisionally enrolled.

4. Polio (IPV/OPV):

1. The number of students with 3 or more doses of polio vaccine.
2. The number of students with medical exemptions on file for polio.
3. The number of students with religious exemptions on file for polio.
4. The number of students provisionally enrolled.

5. Measles, mumps, and rubella (MMR):

1. The number of students with 2 doses of MMR with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
2. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
3. The number of students with medical exemptions on file for MMR.
4. The number of students with religious exemptions on file for MMR.
5. The number of students provisionally enrolled.

6. Hepatitis B:

1. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
2. The number of students with medical exemptions on file for hepatitis B.
3. The number of students with religious exemptions on file for hepatitis B.
4. The number of students provisionally enrolled.

7. Varicella:

1. The number of students with 2 doses of varicella vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
2. The number of students with documented history of varicella disease on file.
3. The number of students with medical exemptions on file for varicella.
4. The number of students with religious exemptions on file for varicella.
5. The number of students provisionally enrolled.
6. The number of students with a documented clinical diagnosis of shingles.

3-012.02 For children entering 7th grade:

1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Measles, mumps, and rubella (MMR):

1. The number of students with 2 doses of MMR, with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
2. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
3. The number of students with medical exemptions on file for MMR.
4. The number of students with religious exemptions on file for MMR.
5. The number of students provisionally enrolled.

4. Hepatitis B:

1. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
2. The number of students with medical exemptions on file for hepatitis B.
3. The number of students with religious exemptions on file for hepatitis B.
4. The number of students provisionally enrolled.

5. Varicella:

1. The number of students with 2 doses of varicella vaccine with the first dose given no earlier than 4 days before the first birthday and the two doses separated by at least 28 days.
2. The number of students with documented history of varicella disease on file.
3. The number of students with medical exemptions on file for varicella.
4. The number of students with religious exemptions on file for varicella.
5. The number of students provisionally enrolled.
6. The number of students with a documented clinical diagnosis of shingles.

6. Beginning July 2010, and thereafter, one booster dose containing tetanus, diphtheria and pertussis (Tdap):

1. The number of students with 1 dose of Tdap (tetanus, diphtheria and pertussis).
2. The number with a medical exemptions on file for Tdap.
3. The number of students with religious exemptions on file for Tdap.
4. The number of students provisionally enrolled.

3-012.03 For transfer students from outside the state:

1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Measles, mumps, and rubella (MMR):

1. The number of students with 2 doses of MMR, with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
2. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
3. The number of students with medical exemptions on file for MMR.
4. The number of students with religious exemptions on file for MMR.
5. The number of students provisionally enrolled.

4. Hepatitis B:

1. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
2. The number of students with medical exemptions on file for hepatitis B.
3. The number of students with religious exemptions on file for hepatitis B.
4. The number of students provisionally enrolled.

5. Varicella:

1. The number of students with 2 doses of varicella vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
2. The number of students with documented history of varicella disease on file.
3. The number of students with medical exemptions on file for varicella.
4. The number of students with religious exemptions on file for varicella.
5. The number of students provisionally enrolled.
6. The number of students with a documented clinical diagnosis of shingles.

3-012.04 The abbreviated reporting requirements for entering 7th graders and transferring students do not exempt them from meeting the immunization standards outlined in 173 NAC 3-008.01B.

ATTACHMENT 1

CONTAGIOUS AND INFECTIOUS DISEASES/CONDITIONS

• Day of onset of specific symptom is counted as "day zero;" the day after onset is "day 1;" second day after onset is "day 2;" and etc.

NOTE: Careful handwashing is the most important thing that can be done to prevent the spread of most infectious diseases.

Questions about this chart may be directed to the DHHS Division of Public Health, Lifespan Health Services, Immunization Program (402-471-6423) or School Health Program (402-471-0160).

History

• Effective 2013-02-05

Chapter 4 Immunization in Licensed Child Care Programs

Neb. Admin. Code tit. 173, ch. 4 Immunization in Licensed Child Care Programs {#sec-173-nac-4 omnilex-key=us-ne-regs-official--title-173--173 NAC 4}

CHAPTER 4 IMMUNIZATION IN LICENSED CHILD CARE PROGRAMS

4-001 SCOPE AND AUTHORITY : These regulations implement Neb. Rev. Stat. §§ 71-1913.01 to 71-1913.03 of the Child Care Licensing Act by establishing levels of protection for those diseases preventable through immunization and the reporting by licensed child care programs of each child's immunization status.

4-002 DEFINITIONS : For purposes of these regulations:

Program means the provision of services in lieu of parental supervision for children under 13 years of age for compensation, either directly or indirectly, on the average of less than 12 hours per day, but more than 2 hours per week. Program includes any employer-sponsored child care, family child care home, child care center, school-age child care program, school-age services under Neb. Rev. Stat. § 79-1104, or preschool or nursery school. Program does not include casual care at irregular intervals, a recreation camp as defined in Neb. Rev. Stat. § 71-3101, classes or services provided by a religious organization other than child care or a preschool or nursery school, a preschool program conducted in a school approved under Neb. Rev. Stat. § 79-318, services provided only to school-age children during the summer and other extended breaks in the school year, or foster care as defined in Neb. Rev. Stat. § 71-1901.

DTP and DTaP means diphtheria, tetanus toxoid, and pertussis vaccine.

DT means diphtheria and tetanus toxoid vaccine pediatric preparation.

Hep B means hepatitis B vaccine.

Hib means haemophilus influenzae type B vaccine.

MMR means measles, mumps, and rubella vaccine.

MMRV means measles, mumps, rubella, and varicella vaccine.

PCV means pneumococcal vaccine.

Polio means polio vaccine, including oral polio (OPV) and/or injectable polio (IPV).

Td means diphtheria and tetanus toxoid vaccine adult preparation.

Tdap means diphtheria, tetanus, and pertussis vaccine (booster).

VZV means varicella (chickenpox) vaccine.

4-003 REQUIRED IMMUNIZATION INFORMATION; EXCLUSION FROM ATTENDANCE; NOTICE

4-003.01 Each program must require the parent or guardian of each child enrolled in such program to present within 30 days of enrollment and periodically thereafter:

1. Proof that the child is protected by age-appropriate immunization against measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, tetanus, haemophilus influenzae type B, hepatitis B, varicella, and invasive pneumococcal disease;
2. Certification by a physician, advanced practice registered nurse, or physician assistant that immunization is not appropriate for a stated medical reason;
3. A written statement that the parent or guardian does not wish to have the child so immunized and the reasons therefor; or
4. Parental or clinical documentation of disease with year of infection for varicella. The documentation must include one of the following:

1. Signature of the parent or legal guardian and the date (year) of the child’s varicella illness, or
2. Signature of a health care provider and the date (year) of the child’s varicella illness, or
3. Laboratory evidence of a child’s varicella immunity.

4-003.02 If one of the documents described in 173 NAC 4-003.01 is not presented within 30 days of enrollment, the program must exclude a child from attendance until such proof, certification, or written statement is provided.

4-003.03 At the time the parent or guardian is notified that such information is required, he or she must be notified in writing of his or her rights to submit a certification or a written statement as described in 173 NAC 4-003.01.

4-004 REQUIRED LEVELS OF PROTECTION : For the purposes of complying with the requirement of immunization against the diseases listed in 173 NAC 4-003 and in recognition of the fact that immunization needs vary depending on the age of the child, the required minimum number of doses of each vaccine is indicated in the Childhood Immunization Schedule, Attachment 1, which is incorporated in these regulations by this reference.

4-004.01 For purposes of compliance with the immunization requirement, the licensee of a child care program must require the presentation of an immunization history which contains:

1. Names of the vaccines;
2. Month and year of administration for DTaP, DTP, DT, Td, Tdap, polio, Hep B, Hib, and pneumococcal vaccine;
3. Day, month, and year of administration of MMR, MMRV, and/or varicella;
4. Name of the health practitioner or agency where the immunizations were obtained; and
5. Signature of the physician, parent, guardian or of other such person maintaining the immunization history of the child, verifying that the child has received these vaccines. Children with a reliable history of chickenpox (validated by written parental/clinical documentation including year of infection) can be assumed to be immune to varicella and therefore need not receive the varicella vaccination.

4-005 FREQUENCY OF REVIEW AND REPORTS; RECORDKEEPING

4-005.01 Each program must review the status of immunization for all children on entry. The immunization status of children under 20 months of age must be reviewed again in March and September to insure compliance with age-specific requirements. Records of children who are 20 months of age or older need not be reviewed again until kindergarten entry except as noted in 173 NAC 4-005.02.

4-005.02 Parents/guardians submitting written statements refusing immunizations for children are required to resubmit, sign, and date that statement on an annual basis.

4-005.03 Each program must keep as part of each child's file the immunization history, or the certification by the medical provider, or the written statement from the parent or guardian. These records must be available to the Department for inspection and review.

4-005.04 The licensee of each program must report to the Department by November 1 of each year the records of immunization for all children enrolled as of September 30 of that year. Children who have reached kindergarten age and who are enrolled in a public or private school need not be included in the report. Each report must consist of the following items:

1. The name, address, and telephone number of the licensee and the number of children enrolled on September 30;
2. For each child enrolled, a report of the name of the child, the child’s date of birth, and the child’s immunization record; and
3. Copy of refusal of immunization or medical certification if the child is not up to date.

The copy of the certification from the medical professional must state the medical reason(s) for not immunizing the child. The copy of the written statement from the parent or guardian must state the reason(s) why the parent or guardian does not wish to have the child immunized.

Attachment 1

CHILDHOOD IMMUNIZATION SCHEDULE

• First dose must be given no earlier than 4 days before the 1st birthday.

** Hib vaccine is recommended to be given in a multiple dose schedule beginning in infancy. However, any child who has received a single dose of Hib vaccine at or after 15 months of age is appropriately immunized.

*** Hib vaccine is not required after child reaches 5 years of age.

**** If a child is 7 months of age or older when they start the PCV series, they do not need all 4 doses of PCV. Unvaccinated children who begin the PCV series between 7-11 months of age should receive 2 doses 4 weeks apart with a booster at 12-15 months. Unvaccinated children who begin the PCV series between 12-23 months of age should receive 2 doses 8 weeks apart. Unvaccinated children 24-59 months of age need 1 dose of PCV. Children with high-risk conditions age 24-59 months should follow their physician’s advice.

History

• Effective 2008-02-06

Chapter 5 Rabies Control Program

Neb. Admin. Code tit. 173, ch. 5 Rabies Control Program {#sec-173-nac-5 omnilex-key=us-ne-regs-official--title-173--173 NAC 5}

001. SCOPE AND AUTHORITY . These regulations are intended to implement the law governing the control of rabies pursuant to Nebraska Revised Statute (Neb. Rev. Stat.) §§ 71-4401 to 71- 4412.

002. INITIAL AND BOOSTER RABIES VACCINATIONS . Young domestic and hybrid animals must be initially vaccinated against rabies commencing at three months of age and can be considered immunized within 28 days. Regardless of the age of the animal or product used at initial vaccination, a booster vaccination should be administered one year later. Subsequent booster vaccinations should then be given at intervals consistent with the vaccine labeling. A domestic animal is considered immunized immediately after any booster vaccination.

003. RABIES CONTROL . Rabies control requirements are as follows:

003.01 DOMESTIC ANIMALS THAT HAVE BITTEN A PERSON. Any domestic animal which is owned by a person and has bitten any person or caused an abrasion of the skin of any person must be seized by the rabies control authority for a period of not less than ten days if the animal is suspected of having rabies or is not vaccinated. If, after observation and examination by a veterinarian, at the end of the ten-day period the animal shows no clinical signs of rabies, the animal may be released to its owner.

003.02 VACCINATED ANIMALS THAT HAVE BITTEN A PERSON. Whenever any person has been bitten or has an abrasion of the skin caused by domestic animal owned by another person, which animal has been vaccinated in accordance with this chapter, the animal must be confined and observed by the owner or other responsible person, as required by the rabies control authority, for a period of at least ten days and must be examined by a veterinarian at the end of the ten-day period. If no clinical signs of rabies are found by the veterinarian, the animal may be released from confinement.

003.03 LAW ENFORCEMENT OR GOVERNMENT AGENCY ANIMALS THAT HAVE BITTEN A PERSON. A vaccinated domestic animal that bites or causes an abrasion of the skin of any person during training or the performance of the animal’s duties must be observed for a period of at least ten days, during which time the agency must maintain ownership, control, and supervision of the animal. Any animal showing any signs of illness during the ten days must be examined by a veterinarian.

003.04 UNOWNED ANIMALS THAT HAVE BITTEN A PERSON. Any domestic animal which has bitten a person or caused an abrasion of the skin of a person and the ownership of which cannot be determined within 72 hours of the time of the bite or abrasion or is a stray or unwanted, must be euthanized, and the head or entire brain, including the brainstem, must be submitted for testing. The 72-hour period includes holidays and weekends and must not be extended for any reason.

003.05 VACCINATION IN CONFINEMENT. Rabies vaccine must not be administered to any domestic animal during a 10-day observation period to avoid confusing rare adverse vaccine reactions with signs of rabies.

003.06 ILLNESS IN CONFINED ANIMALS. Any illness in a domestic animal being confined and observed for rabies must be reported immediately to the Department or local rabies control authority. Such animals must be evaluated by a veterinarian at the first sign of illness during confinement. If signs suggestive of rabies develop, the animal must be euthanized, and the head or entire brain, including the brainstem, must be submitted for testing unless the Department advises otherwise.

003.07 EXPOSURE TO RABIES BY OTHER ANIMALS. Other animals that might have exposed a person to rabies must be reported immediately to the local rabies control authority who may consult the Department. Management of such animals depends on the species as, the shedding period for rabies virus is undetermined for most species. Previous vaccination might not preclude the necessity for euthanasia and testing.

003.08 EXPOSURE BY RABID ANIMALS. In the case of domestic animals or livestock known to have been bitten by or exposed to a confirmed or suspect rabid animal, the following rules apply:

003.08(A) ANIMALS REGARDED AS RABID. Wild mammalian carnivores, skunks, and bats that are not available or suitable for testing must be regarded as rabid.

003.08(B) UNVACCINATED DOMESTIC ANIMALS AND LIVESTOCK. If the domestic animal has never been vaccinated in accordance with Section 002 or is unvaccinated livestock, it must be immediately destroyed unless the owner is willing to place the animal in strict quarantine under veterinary supervision for a period of not less than six months. If dogs or cats receive rabies vaccination within 96 hours of the exposure, at the time of entry into quarantine, the quarantine period may be reduced to 4 months. Strict quarantine in this context refers to confinement in an enclosure that precludes direct contact with people and other animals.

003.08(C) VACCINATED ANIMALS. Livestock current on rabies vaccination with a United States Department of Agriculture-licensed vaccine approved for that species or a domestic animal that has been vaccinated in accordance with Section 002 or is overdue for booster vaccination but has appropriate documentation of having received a United States Department of Agriculture-licensed rabies vaccine at least once previously, are subject to the following procedures:

(i) The animal must immediately receive veterinary medical care for assessment, wound cleansing, and booster rabies vaccination. The animal must be kept under the owner’s control and observed for 45 days;

(ii) If the animal is not revaccinated within 96 hours of the exposure, it must be confined in strict quarantine under the supervision of a veterinarian and managed as unvaccinated in accordance with Section 003.08(B); or

(iii) The animal must be destroyed if the owner does not comply with either item (i) or (ii) above.

003.08(D) ANIMALS OVERDUE FOR BOOSTER VACCINATION. If the animal is overdue for a booster vaccination and is without appropriate documentation of having received a United States Department of Agriculture-licensed rabies vaccine at least once previously, the animal must immediately receive veterinary medical care for assessment, wound cleansing, and be managed as directed by the Department.

(i) A domestic animal may be treated as unvaccinated, immediately given a booster vaccination, and placed in strict quarantine in accordance with Section 003.08(B); or

(ii) Prior to booster vaccination, the attending veterinarian will consult the Department in the possible use of prospective serologic monitoring and subsequent management of the domestic animal as the Department directs.

(iii) Livestock overdue for a booster vaccination must be evaluated on a case-by-case basis and managed as directed by the Department.

003.09 OTHER EXPOSED ANIMALS. All animals other than domestic animals or livestock, which are known to have been exposed to a confirmed rabid animal must be euthanized immediately unless the animal is managed on a case-by-case basis as directed by the Department.

004. APPROVED TESTS FOR RABIES DETECTION . The Direct Fluorescent Antibody (DFA) test is approved for rabies diagnosis and must be performed in accordance with the established national standardized protocol by a qualified laboratory that has been designated by the Department. Any test method other than Direct Fluorescent Antibody (DFA) may only be used if approved by the Department.

005. REPORT OF TESTS FOR IDENTIFYING ANIMALS AFFLICTED WITH RABIES . The laboratory must report the results of the test to the Department and rabies control authority which submitted the specimen for testing.

History

• Effective 2020-09-15

Chapter 6 Directed Health Measures to Prevent or Limit the Spread of Communicable Disease, Illness, or Poisoning

Neb. Admin. Code tit. 173, ch. 6 Directed Health Measures to Prevent or Limit the Spread of Communicable Disease, Illness, or Poisoning {#sec-173-nac-6 omnilex-key=us-ne-regs-official--title-173--173 NAC 6}

6-001 SCOPE AND AUTHORITY : These regulations are enacted pursuant to Neb. Rev. Stat. §§ 71-502, and 81-601 et seq. and apply to the exercise of authority by the Department to order Directed Health Measures necessary to prevent, limit, or slow the spread of communicable disease, illness, or poisoning. Nothing in these regulations precludes the Department from requesting voluntary compliance with beneficial health measures.

6-002 DEFINITIONS

Chief Medical Officer means the state Chief Medical Officer appointed pursuant to Neb. Rev. Stat. § 81-3201, if the Department Director is not a medical doctor.

Communicable disease, illness, or poisoning means an illness due to an infectious or malignant agent, which is capable of being transmitted directly or indirectly to a person from an infected person or animal through the agency of an intermediate animal, host, or vector, or through the inanimate environment.

Decontamination means the removal or neutralizing of contaminating material, such as radioactive materials, biological materials, or chemical agents, from a person or object to the extent necessary to preclude the occurrence of foreseeable adverse health effects. Decontamination includes remediation or destruction of sources of communicable disease or biological, chemical, radiological, or nuclear agents.

Department means the Department of Health and Human Services Regulation and Licensure or its successor.

Directed Health Measure means any measure, whether prophylactic or remedial, intended and directed to prevent or limit the spread of communicable disease or to prevent or limit public exposure to or spread of biological, chemical, radiological, or nuclear agents.

Director means the Director of Regulation and Licensure, or a person acting on behalf of the Director as his or her designee.

Health care facility means any facility licensed under the Health Care Facility Licensure Act, and such additional clinics or facilities not licensed under that act as may be identified in specific orders issued pursuant to 173 NAC 6.

Health care provider means any credentialed person regulated under the Advanced Practice Registered Nurse Act, the Emergency Medical Services Act, the Licensed Practical Nurse- Certified Act, the Nebraska Certified Nurse Midwifery Practice Act, the Nurse Practice Act, the Occupational Therapy Practice Act, the Uniform Licensing Law, or Neb. Rev. Stat. §§ 71-3702 to 71-3715.

Isolation means the separation of people who have a specific communicable disease, illness, or poisoning from healthy people and the restriction of their movement to stop the spread of that disease, illness, or poison. In circumstances where animals are agents of spread of communicable disease, illness, or poisoning, isolation may apply to such animals.

Local public health department means a local public health department as defined by Neb. Rev. Stat. § 71-1626 and its governing officials.

Municipality means any City of the Metropolitan class (see Neb. Rev. Stat. § 14-101), Primary class (§ 15-101), First class (§ 16-101), Second class (§ 17-101), and Village (§ 17-201) and its governing officials.

Personal protective equipment (PPE) means equipment ordered or used to protect an individual from communicable disease, illness, or poisoning.

Premises means land and any structures upon it.

Public health authority means any individual or entity charged by law with a duty or authority to enforce or carry out a public health function.

Quarantine directed to identified individuals or defined populations means the restriction of, or conditions upon, the movement and activities of people who are not yet ill, but who have been or may have been exposed to an agent of communicable disease, illness, or poisoning and are therefore potentially capable of communicating a disease, illness, or poison. The purpose is to prevent or limit the spread of communicable disease, illness, or poison. Quarantine of individuals or defined populations generally involves the separation of the quarantined from the general population. In circumstances where animals are agents of spread of communicable disease, illness, or poisoning, quarantine may apply to such animals.

Quarantine officer means the statutorily established quarantine officer for a municipality or county, usually the chief executive or top law enforcement officer.

Quarantine of premises means restriction of the movement of all people and animals upon, into, or out from those premises to prevent or limit the spread of communicable disease or illness or to prevent or limit public exposure to or spread of biological, chemical, radiological, or nuclear agents.

6-003 FINDINGS

6-003.01 Director Informed: When the Director receives information that a member or members of the public have been, or may have been exposed to a communicable disease, illness, or poisoning by biological, chemical, radiological, or nuclear agents, the Director will review all information under the following provisions to determine if any Directed Health Measure should be ordered. This information may come from:

1. The United States Department of Health and Human Services Centers for Disease Control and Prevention;

2. A Local Public Health Department;

3. Communicable disease surveillance conducted by the Department;

4. Treating health care providers or health care facilities; or

5. Other public health, security, or law enforcement authorities.

6-003.02 Director’s Findings: Before ordering a Directed Health Measure, the Director:

1. Must find both:

a. That a member or members of the public have been, or may have been exposed; and

b. That Directed Health Measures exist to effectively prevent, limit, or slow the spread of communicable disease or illness or to prevent, limit, or slow public exposure to or spread of biological, chemical, radiological, or nuclear agents; and

2. Must find one or more of the following:

a. That the exposure presents a risk of death or serious long-term disabilities to any person;

b. That the exposure is wide-spread and poses a significant risk of harm to people in the general population; or

c. That there is a particular subset of the population that is more vulnerable to the threat and thus at increased risk; and

3. May make further finding, in assessing the nature of the risk presented:

a. Whether the threat is from a novel or previously eradicated infectious agent or toxin;

b. Whether the threat is or may be a result of intentional attack, accidental release, or natural disaster; or

c. Whether any person(s) or agent(s) posing the risk of communicating the disease are non-compliant with any measures ordered by a health care provider.

6-003.03 Affirmative Findings: If affirmative findings are made pursuant to 173 NAC 6-003.02 and the Director further finds that a delay in the imposition of an effective Directed Health Measure would significantly jeopardize the ability to prevent or limit the transmission of a communicable disease, illness, or poisoning or pose unacceptable risks to any person or persons, the Director may impose any of the Directed Health Measures set out in 173 NAC 6-004.

6-004 DIRECTED HEALTH MEASURES

6-004.01 Directed Health Measures which may be ordered by the Director are:

6-004.01A Quarantine of:

1. Individuals;

2. Defined populations;

3. Buildings and premises, or of defined areas, public and private, or

4. Animals.

The methods of quarantine may require the individual or population to remain within or outside of defined areas (cordon sanitaire) or restricted to or from specified activities, which may include “work quarantine” restricting individuals or defined populations to their residence or workplace. In the event that the quarantine of affected premises posing an immediate threat to the public health and safety is determined to be incapable of effective enforcement, the Department may act alone or in concert with any local jurisdiction having condemnation or nuisance abatement authority, to carry out measures effective to remove the threat, including safe demolition of the premises.

6-004.01B Isolation of individuals:

1. At home;

2. In a health care facility; or

3. In another designated area.

6-004.01C Decontamination.

6-004.01D Such other protocols or measures as may be identified as effective against public health threats by the American Public Health Association and the United States Department of Health and Human Services Centers for Disease Control and Prevention or other similar public health authority.

6-004.02 Any of the Directed Health Measures may include, and are not limited to, any of the following:

1. Periodic monitoring and reporting of vital signs;

2. Use of PPE for the performance of specified tasks or at specified premises; or

3. Specific infection control measures including cleaning and disposal of specified materials.

6-004.03 Any Order of the Director may include temporary seizure or commandeering of personal or real property for public health purposes.

6-004.04 Directed Health Measures may be directed to an individual, group of individuals, or a population, or directed to the public at large with regard to identified premises or activities and may also include health care providers, health care facilities, health care authorities, and public and private property including animals.

6-005 PROCEDURES

6-005.01 In making the finding under 173 NAC 6-003 and determining the measures under 173 NAC 6-004, the Director will consult with the Chief Medical Officer, if the Director is not a medical doctor, or other medical and communicable disease control personnel of the Department. The Director may make use of the expertise and observations of any health care provider who has treated a person for whom a Directed Health Measure is being considered. The Director will also consider the directives and guidelines issued by the American Public Health Association and the United States Department of Health and Human Services Centers for Disease Control and Prevention or their successors, and may consider the directives and guidelines issued by similar public health authorities.

6-005.02 In determining the nature, scope, and duration of the Directed Health Measure ordered, the Director, based on the information available at the time of the determination, will:

1. Assess the situation and identify the least restrictive practical means of isolating, quarantining, or decontaminating an individual that effectively protects unexposed and susceptible individuals;

2. Select a place of isolation or quarantine that will allow the most freedom of movement and communication with family members and other contacts without allowing disease transmission to others and allow the appropriate level of medical care needed by isolated or quarantined individuals to the extent practicable;

3. For communicable diseases, order that the duration of the Directed Health Measure should be no longer than necessary to ensure that the affected individual or group no longer poses a public health threat;

4. Give consideration to separation of isolated individuals from quarantined individuals. However, if quarantine or isolation is possible in the home(s) of the affected individual(s), individuals may be isolated with quarantined individuals; and

5. Give consideration to providing for termination of the Order under the following circumstances:

a. If laboratory testing or examination is available to rule out a communicable condition, the Order may provide that proof of the negative result will be accepted to terminate a Directed Health Measure; or

b. If treatment is available to remedy a communicable condition, the Order may provide that proof of successful treatment will be accepted to terminate a Directed Health Measure.

6-006 ISSUANCE OF ORDERS

6-006.01 Upon a finding pursuant to 173 NAC 6-003 and determination pursuant to 173 NAC 6-004, the Director will issue an Order directed to the affected individual, individuals, entity, or entities.

6-006.02 Orders of the Director imposing Directed Health Measures are effective immediately.

6-006.03 Orders will contain the finding and determination and will order the affected person or persons to comply with the terms of the Order, and will also include the following:

6-006.03A Orders of Isolation will contain the following:

1. Name and identifying information of the individual(s) subject to the order;

2. Brief statement of the facts warranting the isolation;

3. Conditions for termination of the order;

4. Duration of isolation period;

5. The place of isolation;

6. Prohibition of contact with others except as approved by the Director or designee;

7. Required conditions to be met for treatment;

8. Required conditions to be met for visitation if allowed;

9. Instructions on the disinfecting or disposal of any personal property of the individual;

10. Required precautions to prevent the spread of the subject disease;

11. The individual’s right to an independent medical exam at their own expense;

12. Provisions to ensure and monitor compliance; and

13. Procedure to request a hearing.

6-006.03B Orders of Quarantine will contain the following:

1. Name, identifying information or other description of the individual, group of individuals, premises, or geographic location subject to the order;

2. Brief statement of the facts warranting the quarantine;

3. Conditions for termination of the order;

4. Specified duration of the quarantine;

5. The place or area of quarantine;

6. Prohibition of contact with others except as approved by the Director or designee;

7. Symptoms of the subject disease and a course of treatment;

8. Instructions on the disinfecting or disposal of any personal property;

9. Precautions to prevent the spread of the subject disease;

10. The individual’s right to an independent medical exam at their own expense,

11. Provisions to ensure and monitor compliance; and

12. Procedure to request a hearing.

6-006.03C Orders of Decontamination will contain the following:

1. Description of the individual, group of individuals, premises, or geographic location subject to the order;

2. Brief statement of the facts warranting the decontamination;

3. Instructions on the disinfecting or disposal of any personal property;

4. Precautions to prevent the spread of the subject disease; and

5. Procedure to request a hearing.

6-007 NOTICE OF ORDERS

6-007.01 Orders to Individuals: Orders directed to individuals will be delivered in a manner reasonably calculated to give the individual actual notice of the terms of the Order consistent with the threat of communicable disease, illness, or poisoning. Personal delivery may be attempted, except in cases when personal delivery would present a risk of spread of disease or exposure to agents that cannot be avoided by measures reasonably available. Electronic transmission by e-mail or telefacsimile will be sufficient, provided that any available means of determining and recording receipt of such notice will be made. If electronic transmission is impossible or unavailable under the circumstances, oral communication by telephone or direct transmission of voice will be sufficient, and such communication will be memorialized at the time it is delivered.

6-007.02 Orders to Groups: Orders directed to groups of individuals or populations may be disseminated by mass media.

6-007.03 Quarantine Orders Regarding Areas: Orders directing the quarantine of premises or geographic locations may be disseminated by mass media and will be posted at or near the premises or geographic location in order to be visible and effective to achieve the intended purpose. Copies of the Orders will be delivered to the owners or others in control of the premises, if known, in the same manner as Orders directed to individuals.

6-007.04 Notice to Elected Officials: Copies of all Orders will be provided if reasonably possible to the chief elected official(s) of the jurisdiction(s) in which the Order is implemented.

6-008 HEARING PROCESS

6-008.01 Request for Hearing: Any person subject to an Order under 173 NAC 6 may request a contested case hearing to contest the validity of the Order, in accord with the Department’s rules of practice and procedure adopted pursuant to the Administrative Procedure Act.

6-008.02 Scheduling of Hearing: Upon request, the Department will schedule a hearing to be held as soon as reasonably possible under the circumstances. Unless the person subject to an Order requests otherwise, the hearing will be scheduled no sooner than three days after the request is received by the Department. The hearing will be conducted in accord with the Department’s rules of practice and procedure adopted pursuant to the Administrative Procedure Act.

6-008.03 Parties to the Hearing: The parties to the hearing will be limited to the Department and the subject person unless:

1. One or more additional persons have requested contested case hearings on substantially identical issues;

2. The interests of administrative economy require that the matters be consolidated; and

3. No party would be prejudiced by consolidation.

The parties may be represented by counsel at their own expense.

6-008.04 Notice and Conduct of Hearing: Reasonable prior notice of the time and place for hearing will be given to the parties. The hearing may be conducted in whole or in part by telephone or videoconference.

6-008.05 Purpose and Decision: The purpose of the hearing is to determine if the factual bases for the Order exist and the reasonableness of the ordered measures. The Director may affirm, reverse or modify the Order by a written Findings of Fact, Conclusions of Law and Order to be issued as soon as reasonably possible after the hearing.

6-008.06 Appeal of Hearing Decision: An appeal to the District Court may be taken from the decision of the Director in accord with the Administrative Procedure Act.

6-009 ENFORCEMENT OF ORDERS

6-009.01 The Department may seek the assistance of the appropriate quarantine officer to enforce any Order.

6-009.02 Department personnel assigned to the enforcement of any Order will promote the need for the Directed Health Measure and encourage individuals to comply with all aspects of the Order.

6-009.03 Any individual subject to an Order may at any time present evidence to the Director to show that the Order should be modified or terminated. The Director may or may not modify or terminate the Order in his or her sole discretion.

6-009.04 In the event of noncompliance with the terms of a Department Order under 173 NAC 6-006, law enforcement and other Municipal and Local Public Health Department personnel will be required to aid the Department in enforcement of the Order, pursuant to 173 NAC 6 and Neb. Rev. Stat. § 71-502.

6-010 COOPERATION AND COORDINATION

6-010.01 The Department may assist or seek the assistance of quarantine officers, Local Public Health Departments, other public health authorities, and others authorized or required by law to carry out Directed Health Measures in carrying out those measures.

6-010.02 Treating Health Care Providers must follow and aid affected individuals and populations in compliance with ordered Directed Health Measures.

6-011 REPORTING OF NONCOMPLIANCE

Treating Health Care Providers, Health Care Facilities, and other persons must report any information known to them concerning any individual or entity subject to an Order of quarantine, isolation, decontamination, or other Directed Health Measure that is not in compliance with the Order. The report must be made to the Department and local law enforcement.

History

• Effective 2007-02-21

Chapter 7 School Health Screening, Physical Examination, and Visual Evaluation

Neb. Admin. Code tit. 173, ch. 7 School Health Screening, Physical Examination, and Visual Evaluation {#sec-173-nac-7 omnilex-key=us-ne-regs-official--title-173--173 NAC 7}

CHAPTER 7 SCHOOL HEALTH SCREENING, PHYSICAL EXAMINATION AND VISUAL EVALUATION

7-001 SCOPE AND AUTHORITY

7-001.01 Statutory Authority: This chapter is adopted pursuant to Neb. Rev. Stat. §§ 79-214, 79-220, and 79-248 to 79-253.

7-001.02 Scope: These regulations apply to every public school district in Nebraska and students under their jurisdiction. This includes children aged 3-5 years enrolled in early childhood education or early childhood special education programs as defined in Title 92 Nebraska Administrative Code, Chapters 11 and Chapter 51 respectively. These regulations become operative July 1, 2017.

7-001.03 Role of School Boards: Neb. Rev. Stat. § 79-251 states the boards of education and school boards of the school districts of the state shall enforce the provisions of Neb. Rev. Stat. §§ 79-248 to 79-253. Neb. Rev. Stat. § 79-252 states that school district boards of education or school boards may employ licensed physicians to conduct screening in lieu of conducting screening. Neb. Rev. Stat. § 79-214 states that the school board of any school district shall require evidence of a physical examination and visual evaluation for those students in applicable grades.

7-001.04 Role of the Department of Health and Human Services (DHHS)

7-001.04A Neb. Rev. Stat. § 79-248 identifies the prescriptive role of the Department of Health and Human Services in identifying conditions for which to screen the school-aged population. Neb. Rev. Stat. § 79-249 provides the statutory authority to the Department of Health and Human Services to promulgate these rules and regulations. DHHS is to prescribe the schedule for minimum required school health screenings, which shall be based on current medical and public health practice, and to define the qualifications of the person or persons authorized to conduct required screenings.

7-001.04B Pursuant to Neb. Rev. Stat. § 79-249, the School Health Program in the DHHS Division of Public Health provides the School Health Guidelines for Nebraska schools; makes available useful materials to assist schools to implement school health screening programs; and makes available methods for gathering, analyzing, and utilizing data obtained that do not violate any privacy laws.

7-001.05 Purpose of Screening: The purpose of screening is to identify those students needing further evaluation or assistance in the areas screened. A health screening or health inspection is not diagnostic.

7-001.06 Role of Schools: The role of the school in these regulations is to make available required health screening services and carry out compliance activities as described. It is not the role of the school to be a medical provider. Parents/guardians are to be notified of the screening result if the student is found to need further evaluation, as determined by a qualified screener and comparison of individual data with an objective standard. The cost of such evaluation shall be borne by the parent or guardian of the student.

7-002 DEFINITIONS

Health Inspection: Neb. Rev. Stat. §§ 79-248 through 79-253 refer to health inspections conducted at school. For the purposes of these regulations, the term “health screening” shall be used synonymously and interchangeably with the phrase “health inspection.”

Health Screening: Collection of individual-level basic subjective and objective data from observations and interviews. The task includes the recording and reporting of the collected data.

Health screening does include: inspection, accurate measurement, and comparison of individual measurement with an objective standard in order to identify the individual student whose parent is to be notified of the need for further evaluation.

Health screening does not include: assessment, judgment based on the knowledge base of a regulated health profession, diagnosis, evaluation, examination, investigation, interpretation, treatment, or management of any health condition.

Health screening is not a regulated act reserved for the licensed health professions.

7-003 WHO MUST BE SCREENED

7-003.01 Minimum Required School Health Screening Schedule: The Department prescribes a schedule for screenings based on current medical and public health practice. The schedule is incorporated in these regulations by this reference, as Attachment 1. Parents/guardians will be notified that screenings will take place.

7-003.02 Exception: A child is not required to submit to a school health screening set forth in 7-004 if the child’s parent or guardian provides school authorities with a written statement as follows:

7-003.02A For hearing, vision, and/or dental screenings: the statement must (1) attest that the child underwent the required screening within the last six months; and (2) be signed by a physician, physician assistant, or advanced practice registered nurse-nurse practitioner practicing under and in accordance with his or her respective credentialing act, or other qualified provider as identified in 7-005.01C2 of these regulations

7-003.02B For height and weight measurement: the statement must object to such screening, be signed and dated by the parent or guardian, and be submitted before the screening is conducted. A statement submitted under this section is valid for the school year in which it is submitted; a new statement must be submitted each time such screening is required by these regulations.

7-003.03 Children with Special Health Care Needs: The student with special health care needs who cannot be screened by usual methods at school must not be excluded or overlooked by the school health screening program.

7-004 SCREENINGS TO BE PERFORMED

7-004.01 Students in Nebraska schools must be screened periodically for vision, hearing, and dental health. In addition, the Department of Health and Human Services prescribes height and weight measurement for the purpose of monitoring weight/height status at intervals for all students. The DHHS Minimum Required Health Screening schedule is shown in Attachment 1. Attachments 2A through 2E, incorporated herein by reference, contain the Competencies for each required screening. Additional resources on school health screening topics are available from the DHHS School Health Program.

7-004.02 Distance vision screening shall be accomplished by measuring a child’s vision in each eye separately, using a chart viewed at 20 ft., vision screening machine or photo vision tester, or equivalent. Near vision screening shall be accomplished by using a chart viewed at 20 ft., both eyes together, using 2.5+ diopter lenses, vision screening machine, photo vision tester or equivalent.

7-004.03 Hearing screening shall be accomplished by measuring a child’s response to audible tones delivered at 20 decibels, to each ear separately, at 1000 Hz, 2000 Hz, and 4000 Hz.

7-004.04 Dental screening shall be accomplished by inspecting the inner and outer visible surfaces of the teeth for unexplained absence of teeth, obvious decay, holes or deterioration, or severe discoloration, of the surfaces of the teeth.

7-004.05 Height/weight status screening shall be accomplished by the measurement of height and weight.

7-005 QUALIFICATIONS OF PERSONS AUTHORIZED TO SCREEN

7-005.01 The qualified screener carries out the required screening activity, following the competencies for accurate, reliable measurement as described in 7-004 and found in Attachments 2A through 2E. The qualified screener meets one of the following descriptions:

7-005.01A The screener has been determined competent to perform the screening method by a licensed health care professional within the previous three years. Documentation in writing of such competency determination shall include:

7-005.01A1 The name of the individual who successfully completed the competency determination and the date the determination was conducted;

7-005.01A2 The type of screening with type(s) of equipment used in the competency determination for the respective screenings; and

7-005.01A3 The name and license number of the licensed health professional conducting the competency assessment; OR

7-005.01B The screener will receive direct supervision from a licensed health care professional while screening; OR

7-005.01C Screening is conducted by a licensed health care professional, as follows:

7-005.01C1 A Nebraska-credentialed health care professional registered nurse, licensed practical nurse, advanced practice registered nurse-nurse practitioner, physician assistant, or physician, are authorized to perform health screening at school.

7-005.01C2 Other licensed health professionals authorized to conduct specific screenings in addition to health professionals identified in 7-005.01C1 are:

Hearing: Audiologists and speech-language pathologists.

Vision: Optometrists.

Dental health: Dentists and dental hygienists.

7-005.02 Record of Persons Qualified to Screen: The school must keep on file for a minimum of three years the name, profession, license number, or written verification of competency in the screening method, for each screener permitted by the school to perform health screening.

7-006 NOTIFICATION OF PARENTS / GUARDIANS OF SCREENING RESULTS : Parents / guardians are to be notified in writing of findings in the school health screening indicating a need for further evaluation, and necessity of professional attendance for the child, in accordance with Neb. Rev. Stat. § 79-248.

7-007 TIMETABLE FOR PERFORMING SCREENING

7-007.01 Annual Screening: During each school year the school district must provide a health screening program for children in attendance as outlined in Attachment 1.

7-007.02 Screening for New Enrollees: As children enter school during the year, health screening must be confirmed upon their entrance to school. If prior screening results corresponding to the schedule in Attachment 1 are not available, the student must be screened as identified in the minimum required schedule.

7-008 ENFORCEMENT / PENALTIES

7-008.01 The boards of education and school boards of the school districts of the state are responsible under Neb. Rev. Stat. § 79-248 for enforcement of the provisions of the school health screening statutes and these regulations.

7-008.02 Any person violating any of the provisions of Neb. Rev. Stat. §§ 79-248 to 79-252 is guilty of a Class V misdemeanor, as provided in Neb. Rev. Stat. § 79-253.

7-009 PHYSICAL EXAMINATION AND VISUAL EVALUATION REQUIREMENTS FOR SCHOOL ENTRY In accordance with Neb. Rev. Stat. § 79-214, the school board of any school district, before admitting a child, shall require evidence of the following:

7-009.01 Physical Examination Required: Physical examination by a physician, physician assistant, or advanced practice registered nurse-nurse practitioner within the six months prior to the entrance of a child into the beginner grade and the seventh grade, or in the case of a transfer from out of state, to any other grade of the local school, is required. Either a completed, signed, and dated physical exam report, or a printed or typewritten form signed by a qualified examiner indicating that a physical examination was administered on a specific date within the previous six-month period on a specifically named individual, provided to the school by the parent/guardian, constitutes sufficient evidence of compliance.

7-009.02 Visual Evaluation Required: Visual evaluation by a physician, a physician assistant, an advanced practice registered nurse-nurse practitioner, or an optometrist within six months prior to the entrance of a child into the beginner grade or, in the case of transfer from out of state, to any other grade of the local school, is required. The visual evaluation must consist of testing for amblyopia, strabismus, and internal and external eye health, with testing sufficient to determine visual acuity. The visual evaluation report inclusive at a minimum of the specific tests named above, signed and dated by the qualified examiner, provided to the school by the parent/guardian constitutes sufficient evidence of compliance.

7-009.03 Notification of Right to Refuse Physical Examination or Visual Evaluation: At the time a parent/guardian is notified of the requirements for physical examination and visual evaluation for school entry, that parent/guardian must also be notified of his or her right to submit a written statement refusing such examination or evaluation.

7-009.04 Parent/Guardian Objection to Physical Examination or Visual Evaluation: No such physical examination or visual evaluation as described in 7-009.01 and 7-009.02 is required of the student whose parent/guardian submits a written statement of objection to the school.

ATTACHMENT 1: DHHS MINIMUM REQUIRED ANNUAL SCHOOL HEALTH SCREENINGS

ATTACHMENT 2A: HEARING SCREENING COMPETENCIES

HEARING SCREENING (PURETONE AUDIOMETRY) COMPETENCIES Essential Steps for Accurate Measurement

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

ATTACHMENT 2B: MYOPIA (DISTANT VISION) SCREENING COMPETENCIES

VISION SCREENING COMPETENCIES: MYOPIA (DISTANT VISION) Essential Steps for Accurate Measurement

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

ATTACHMENT 2C: MYOPIA (DISTANT VISION) AND HYPEROPIA (NEAR VISION) SCREENING COMPETENCIES USING A PHOTO VISION SCREENER

VISION SCREENING COMPETENCIES: MYOPIA (DISTANT VISION) AND HYPEROPIA (NEAR VISION) USING PHOTO VISION SCREENER Essential Steps for Accurate Measurement

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

ATTACHMENT 2D: HYPEROPIA (NEAR VISION) SCREENING COMPETENCIES

VISION SCREENING COMPETENCIES: NEAR VISION Essential Steps for Accurate Measurement

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

ATTACHMENT 2E: DENTAL SCREENING COMPETENCIES

DENTAL SCREENING COMPETENCIES Essential Steps for Accurate Measurement

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

ATTACHMENT 2F: WEIGHT/HEIGHT SCREENING COMPETENCY

Essential Steps for accurate measurement.

Additional information and resources are available from the DHHS School Health Program, 402-471-1373.

History

• Effective 2017-06-10

Chapter 8 Concerning the Establishment and Operation of the Nebraska State Immunization Information System

Neb. Admin. Code tit. 173, ch. 8 Concerning the Establishment and Operation of the Nebraska State Immunization Information System {#sec-173-nac-8 omnilex-key=us-ne-regs-official--title-173--173 NAC 8}

001. SCOPE AND AUTHORITY . The purpose of these regulations is to implement Nebraska Revised Statute (Neb. Rev. Stat.) §§ 71-539 to 71-544.

002. DEFINITIONS . When terms are used in 173 Nebraska Administrative Code (NAC) 8, the following definitions apply:

002.01 AUTHORIZED USER. Individuals and entities authorized to access immunization records in the Immunization Information System.

002.02 DATA ENCRYPTION. The electronic obfuscation of data within an electronic message using industry standard practices for encryption.

002.03 ELECTRONIC HEALTH RECORD (EHR) SYSTEM. Any computerized or electronic system used to capture and store patient identifying health information including immunization data.

002.04 HEALTH CARE FACILITY. Any facility licensed or exempt from licensure under the Health Care Facility Licensure Act.

002.05 HEALTH CARE PROFESSIONAL. Any person authorized by law to order or administer an immunization.

002.06 HEALTH DEPARTMENT OF OTHER STATES. Any state health department established to promote the health and well-being of all residents within its jurisdiction.

002.07 IMMUNIZATION INFORMATION SYSTEM. A central database of immunization information which can be accessed and used pursuant to these regulations.

002.08 IMMUNIZATION STANDARD MESSAGE. A standard electronic message meeting specifications as identified by current versions of the Immunization Information System Flat File Specifications or HL7 Specifications for Immunization available from the Department upon request.

002.09 LICENSED CHILD CARE FACILITY. Any facility or program licensed under the Child Care Licensing Act.

002.10 POSTSECONDARY EDUCATIONAL INSTITUTION. Any organization or business enterprise which offers courses or subjects for which tuition is charged, and at the place of business of which a course of instruction is available through classroom instruction, home study, or both to a person for the purpose of training, preparing, or improving the person for an occupation even though the organization’s or business enterprise principal efforts may not be exclusively educational in nature.

002.11 LOCAL PUBLIC HEALTH DEPARTMENT. Has the same meaning as in Neb. Rev. Stat. § 71-1626.

002.12 PUBLIC HEALTH AUTHORITY. An agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is responsible for public health matters as part of its official mandate.

002.13 REAL-TIME MESSAGE. The transmission of discrete standard electronic messages to the Department as they are generated by the Electronic Health Record (EHR) system.

002.14 RESTRICTED IMMUNIZATION INFORMATION. All information contained within an immunization record in the Immunization Information System is restricted by the patient or, if the patient is a minor, the patient’s parent or legal guardian, from access from everyone other than the professional or entity that provided the immunization(s).

002.15 SCHOOL. Any approved or accredited school under Neb. Rev. Stat. §§ 79-318 or 79-1601 offering courses of instruction to its students on the school’s premises.

002.16 SECURE MESSAGE TRANSPORT PROTOCOL. A method of sending electronic data to the Department in a way that prevents unauthorized access to the data as specified by the Department.

003. WHO MAY REPORT AND HOW TO REPORT . Any person who provides immunizations may submit immunization information to the Department as follows:

003.01 DATA SUBMISSION. Immunization data may be manually entered or electronically submitted using secure message transport protocols and data encryption.

003.02 ELECTRONIC DATA. Electronic data must be submitted as an Immunization Standard Message. Real-time messages must meet the Department’s HL7 specifications. File formats must be approved and agreed upon by the Department prior to submission of messages.

003.03 MINIMUM DATASET. The minimum dataset should be manually entered or electronically submitted within 14 calendar days of the date of immunization administration.

003.04 AUTHORIZED USERS. Authorized users may submit data directly to the Department or through a third party acting as their agent. Authorized users selecting this option are responsible for ensuring that all data specifications conform to the requirements of these regulations.

004. ACCESS TO IMMUNIZATION RECORDS . An authorized user may only access unrestricted information in the Immunization Information System as follows:

004.01 LEVEL OF ACCESS. An authorized user will be given a unique user identification, password, and system role which will determine the level of access to unrestricted immunization information on an individual who is presently under that authorized user’s care, or enrolled in the authorized user’s facility, school, post-secondary educational institution, program or health plan, except as otherwise provided by law.

004.02 LOCAL PUBLIC HEALTH AUTHORITY. An authorized user that is a state or local public health authority may, in addition to accessing unrestricted information described in subsection 173 NAC 8-005.01, access unrestricted information on an individual within the public health jurisdiction for assessment, evaluation, surveillance and outreach related to immunization promotion and vaccine-preventable disease prevention.

004.03 EVIDENCE OF CARE OR ENROLLMENT. The Department may require any authorized user who has accessed an individual’s record to provide evidence that such individual was under the care of the authorized user or enrolled in the authorized user’s facility, school, post-secondary educational institution, program or health plan at the time the individual’s record was accessed.

004.04 INDIVIDUALS, PARENTS, AND GUARDIANS ACCESS TO THEIR CHILD’S IMMUNIZATION RECORD. In order for individuals, parents, and guardians to access to their own or their child’s immunization record, the following requirements must be met:

(A) The first name, last name, date of birth, and social security number must be populated in the Immunization Information System in order for the record to be accessed.

(B) The individual, parent, or guardian must search for a record using the first name, last name, date of birth, and social security number of the individual for whom they are searching.

005. DATA CONFIDENTIALITY AND SECURITY . An authorized user shall not disclose information from the Immunization Information System except to another authorized user or as otherwise stated in these regulations. All authorized users shall abide by such security policies and procedures to safeguard information in the Immunization Information System deemed necessary by the Department. Such policies and procedures may include, but are not limited to, confidentiality agreements, the use of computer passwords, and user identification codes.

History

• Effective 2020-06-10

Chapter 9 Electronic Reporting of Electronic Health Record Data for Public Health Syndromic Surveillance

Neb. Admin. Code tit. 173, ch. 9 Electronic Reporting of Electronic Health Record Data for Public Health Syndromic Surveillance {#sec-173-nac-9 omnilex-key=us-ne-regs-official--title-173--173 NAC 9}

001. SCOPE AND AUTHORITY . This chapter establishes a syndromic surveillance program for the purposes of protecting public health and tracking the impact of disease prevention strategies, pursuant to Nebraska Revised Statute (Neb. Rev. Stat.) § 71-552.

002. DEFINITIONS . For purposes of this chapter, the following definitions apply:

002.01 ACUTE CARE ENCOUNTER. A patient seen in a hospital emergency department or urgent care facility.

002.02 BATCH MESSAGE FILE. The transmission of a file containing multiple discrete standard electronic messages to the Department from the hospital data system on a periodic basis less than real time.

002.03 DATA ENCRYPTION. The electronic obfuscation of data within an electronic message using industry standard practices for encryption.

002.04 DE-IDENTIFIED PATIENT DATA. Electronic health record information that does not identify an individual and to which there is no reasonable basis to believe that the information can be used to identify an individual.

002.05 ACUTE CARE ENCOUNTER STANDARD MESSAGE. A standard electronic message as specified in the most current version of the Syndromic Surveillance Event Detection of Nebraska (SSEDON) Emergency Department Syndromic Surveillance Health Level 7 Implementation Guide.

002.06 HEALTH CARE FACILITY. Any facility licensed under the Health Care Facility Licensure Act, and such additional clinics or facilities not licensed under that act, such as Federally Qualified Health Centers (FQHCs), primary care clinics, ambulatory care clinics, and outpatient surgical centers.

002.07 HOSPITAL. A hospital licensed by the Department pursuant to Neb. Rev. Stat. § 71-401 et seq., including critical access hospitals and general acute hospitals as defined by Neb. Rev. Stat. §§ 71-419, 71-409, and 71-412.

002.08 PUBLIC HEALTH AUTHORITY. An agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is responsible for public health matters as part of its official mandate.

002.09 REAL TIME MESSAGE. The transmission of discrete standard electronic messages to the Department as they are generated by the hospital data system.

002.10 SECURE MESSAGE TRANSPORT PROTOCOL. A method of sending electronic data to the Department in a way that prevents unauthorized access to the data as specified by the Department.

003. WHO MUST REPORT . Hospitals that treat patients in an emergency department or urgent care setting shall submit to the Department a minimum data set on all emergency department and urgent care encounters.

004. DATA STANDARDS AND SPECIFICATIONS . The data content and format for acute care encounters shall conform to the acute care encounter standard message; the minimum set of acute care data elements is listed in Attachment 1.

005. DATA EXCHANGE . Data exchange must employ industry standard secure message transport protocols and data encryption. Encounter data shall be submitted a minimum of once per day as a batch message file containing the previous day’s acute care encounters and updates.

006. SUBMISSION OF REPORTING PLAN FOR ACUTE CARE ENCOUNTERS . Beginning no later than six months after the effective date of this chapter, every hospital that treats patients in an emergency department or urgent care setting shall submit to the Department for approval an implementation plan that specifies how and when it will submit acute care encounter data to the Department in compliance with 173 Nebraska Administrative Code (NAC) 9-004 of this chapter. Amendments to a previously approved plan require Department approval. The plan shall include at a minimum:

(A) Timing of messages, either real time or batch; (B) Secure message transport protocols to be used when submitting data to the Department; (C) Proposed format of data if the hospital is not able to conform to the standard electronic message as specified in 173 NAC 9-005; (D) Proposed format code set domain values if the hospital is not able to conform to the code sets defined in standard electronic messages as specified in 173 NAC 9-005; (E) Hospital technical contact(s) and contact information for the Department to utilize in the event technical assistance or support is necessary; (F) Expected date to begin sending messages; and (G) If a change request, the reason for change.

007. SUBMISSION OF DATA THROUGH A THIRD PARTY . Hospitals may submit data directly to the Department or through a third party acting as their agent. Providers selecting this option are responsible for ensuring that all terms of this chapter are met by the third party.

008. RELEASE OF DE-IDENTIFIED PATIENT DATA AND PATIENT CONTACT . To safeguard the health of the citizens of Nebraska, the Director or the Director’s designee may authorize the collection of information as to enable contact with a patient, physician or provider based upon data authorized and submitted under this chapter.

009. REPORTING AND SUBMISSION OF HOSPITAL INPATIENT ENCOUNTER DATA BY HOSPITALS . Hospitals that treat patients in an inpatient setting may submit to the Department a data set on all hospital inpatient encounters. Such submissions shall conform pursuant to specifications as defined by the Department. The Director may require reporting of hospital inpatient encounter data by hospitals if deemed necessary to detect diseases, syndromes, or exposures that can cause or are suspected to cause serious morbidity or mortality and such other reporting as necessary to protect public health.

010. REPORTING AND DATA SUBMISSION BY PROVIDERS OTHER THAN HOSPITALS . Other health care facilities may submit electronic health record data to the Department. Such submissions shall conform pursuant to specifications as defined by the Department. The Director may require reporting of providers other than hospitals if deemed necessary to detect diseases, syndromes, or exposures that can cause or are suspected to cause serious morbidity or mortality and such other reporting as necessary to protect public health.

Syndromic Surveillance Event Detection of Nebraska (SSEDON)

Data Element List for Emergency Department Syndromic Surveillance

Document Version 1.1

July 2013

This data element list contains a description of the demographic and clinical elements contained in the inpatient data set to be sent from hospitals. These messages are sent to the Syndromic Surveillance Event Detection of Nebraska system as a part of the Nebraska Department of Health and Human Services for syndromic surveillance purposes.

Emergency Department Data Element List

History

• Effective 2021-08-10