Infectious Diseases and Circumstances Relevant to 

Notication of Emergency Response Employees: 

Implementation of Sec. 2695 of the Ryan White HIV/AIDS 

Treatment Extension Act of 2009
2

Infectious Diseases and Circumstances Relevant to 

Notification of Emergency Response Employees: 

Implementation of Sec. 2695 of the Ryan White

 HIV/AIDS Treatment Extension Act of 2009

ii
3

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Suggested Citation

NIOSH [2020]. Infectious diseases and circumstances relevant to notification of emergency response employees: 

implementation of Sec. 2695 of the Ryan White HIV/AIDS Treatment Extension Act of 2009. Atlanta, GA: U.S. Department 

of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, DHHS (NIOSH) Publication No. 2020-119, https://doi.org/10.26616/NIOSHPUB2020119.

DHHS (NIOSH) Publication No. 2020-119

DOI: https://doi.org/10.26616/NIOSHPUB2020119

March 2020

This document is in the public domain domain and may be freely copied or reprinted.

iii
4

Preface

NIOSH originally published this document, Implementation of Section 2695 (42 U.S.C. 300ff–131) Public Law 

111–87: Infectious Diseases and Circumstances Relevant to Notification Requirements, in a Federal Register 

notice on November 2, 2011 (see 76 Fed Reg 67736). It has two purposes: (1) to identify those potentially lifethreatening infectious diseases to which emergency response employees (EREs) may be exposed in responding 

to emergencies, and (2) describe the steps that medical facilities should follow to notify EREs to allow for the 

timely diagnosis and post-exposure medical treatment of those exposures. 

Medical facilities may notify EREs about potential exposures without violating the Health Insurance Portability 

and Accountability Act (HIPAA) of 1996 (Pub. L. No. 104-191). Pursuant to HIPAA, if a law requires the 

disclosure of individually identifiable health information, a covered entity (such as a medical facility) may 

comply with such statute provided that the disclosure complies with and is limited to the relevant requirements 

of such law.

Under Section 2695, if the determination is that an ERE has been exposed, the medical facility must provide the 

name of the infectious disease involved and the date on which the victim of the emergency was transported by 

ERE to the facility. Other than this information, Section 2695 does not authorize medical facilities to disclose 

identifying information with respect to either a victim of an emergency or an ERE. Thus, a medical facility would 

not violate HIPAA by complying with this requirement of the PHS Act.

The list of potentially life-threatening infectious disease to which EREs may be exposed and accompanying 

guidelines are republished here from the original 2011 Federal Register notice. This document includes the 

following updates:

- addition of COVID-19, the disease caused by the virus SARS-CoV-2

- addition of “emergency response employee” definition

- renumbering of footnotes

- confirmation and correction of web links 

- removal of list of Select Agents from footnote 15

1
Implementation of Section 2695 (42 U.S.C. 300ff–131) Public Law 111–87: Infectious 

Diseases and Circumstances Relevant to Notification Requirements

The Ryan White HIV/AIDS Treatment Extension Act of 20091 (Pub. L. 111–87) amended the Public Health Service Act (PHS 

Act, 42 U.S.C. § 201–300ii) and addresses notification procedures and requirements for medical facilities and state public 

health officers and their designated officers regarding exposure of emergency response employees (EREs) to potentially 

life-threatening infectious diseases.2 (See Title XXVI, Part G of the PHS Act, codified as amended at 42 U.S.C. §§ 300ff–131 

to 300ff–140). This document sets forth the final list of diseases to which these provisions apply; final guidelines describing 

circumstances under which exposure to listed diseases may occur, and final guidelines for determining whether an exposure 

to the listed diseases has occurred, as required by the Act. The final list of diseases and guidelines incorporate comments 

received by CDC on a draft list and guidelines (75 Fed. Reg. 77642, December 13, 2010).

Contents

Part I. List of Potentially Life-Threatening Infectious Diseases to Which Emergency Response Employees May Be Exposed.

Part II. Guidelines Describing the Circumstances in Which Emergency Response Employees May Be Exposed to Such 

Diseases.

Part III. Guidelines Describing the Manner in Which Medical Facilities Should Make Determinations for Purposes of 

Section 2695B(d) [42 U.S.C. § 300ff–133(d)].

Definitions

The following definitions are used in the list of diseases and guidelines: 

Aerosol means tiny particles or droplets suspended in air. These range in diameter from about 0.001 to 100 μm.3

Aerosolized transmission means person-to-person transmission of an infectious agent through the air by an aerosol. See 

“aerosolized airborne transmission” and “aerosolized droplet transmission.”

Aerosolized airborne transmission means person-to-person transmission of an infectious agent by an aerosol of small 

particles able to remain airborne for long periods of time. These are able to transmit diseases on air currents over long 

distances, to cause prolonged airspace contamination, and to be inhaled into the trachea and lung.4

Aerosolized droplet transmission means person-to-person transmission of an infectious agent by large particles only 

able to remain airborne for short periods of time. These generally transmit diseases through the air over short distances 

(approximately 6 feet), do not cause prolonged airspace contamination, and are too large to be inhaled into the trachea and 

lung.5

Contact or body fluid transmission means person-to-person transmission of an infectious agent through direct or indirect 

contact with an infected person’s blood or other body fluids.6

Emergency response employee (ERE) means firefighters, law enforcement officers, paramedics, emergency medical 

technicians, funeral service practitioners, and other individuals (including employees of legally organized and recognized 

volunteer organizations, without regard to whether such employees receive nominal compensation) who, in the course of 

professional duties, respond to emergencies in the geographic area involved.

Exposed means to be in circumstances in which there is recognized risk for transmission of an infectious agent from a 

human source to an ERE7 or, in the case of a Select Agent, from a surface or environment contaminated by the agent to an 

ERE.

Potentially life-threatening infectious disease means an infectious disease to which EREs may be exposed and that has 

reasonable potential to cause death or fetal mortality in either healthy EREs or in EREs who are able to work but take 

medications or are living with conditions that might impair host defense mechanisms.

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Part I. List of Potentially Life-Threatening Infectious Diseases to Which Emergency 

Response Employees May Be Exposed

The List of Potentially Life-Threatening Infectious Diseases to Which Emergency Response Employees May Be Exposed is 

divided into four sections: Diseases routinely transmitted by contact or body fluid exposures, those routinely transmitted 

through aerosolized airborne means, those routinely transmitted through aerosolized droplet means, and those caused 

by agents potentially used for bioterrorism or biological warfare. Diseases often have multiple transmission pathways. 

However, for purposes of this classification, diseases routinely transmitted via the aerosol airborne or aerosol droplet routes 

are so classified, even if other routes, such as contact transmission, also occur. CDC will continue to monitor the scientific 

literature on these and other infectious diseases. In the event that CDC determines that a newly emerged infectious disease 

fits criteria for inclusion in the list of potentially life-threatening infectious diseases required by the Ryan White HIV/AIDS 

Treatment Extension Act of 2009, CDC will amend the list and add the disease.

A. Potentially Life-Threatening Infectious Diseases: Routinely Transmitted by Contact or Body Fluid Exposures

• Anthrax, cutaneous (Bacillus anthracis)

• Hepatitis B (HBV)

• Hepatitis C (HCV)

• Human immunodeficiency virus (HIV)

• Rabies (Rabies virus)

• Vaccinia (Vaccinia virus)

• Viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, and other viruses yet to be identified)8

B. Potentially Life-Threatening Infectious Diseases: Routinely Transmitted Through Aerosolized Airborne Means

These diseases are included within “those infectious diseases on the list that are routinely transmitted through airborne or 

aerosolized means.”9

• Measles (Rubeola virus)

• Tuberculosis (Mycobacterium tuberculosis)—infectious pulmonary or laryngeal disease; or extrapulmonary (draining 

lesion)

• Varicella disease (Varicella zoster virus)—chickenpox, disseminated zoster

C. Potentially Life-Threatening Infectious Diseases: Routinely Transmitted Through Aerosolized Droplet Means

These diseases are included within “those infectious diseases on the list that are routinely transmitted through airborne or 

aerosolized means.”10

• Diphtheria (Corynebacterium diphtheriae)

• Novel influenza A viruses as defined by the Council of State and Territorial Epidemiologists (CSTE)11

• Meningococcal disease (Neisseria meningitidis)

• Mumps (Mumps virus)

• Pertussis (Bordetella pertussis)

• Plague, pneumonic (Yersinia pestis)

• Rubella (German measles; Rubella virus)

• SARS-CoV

• COVID-19 (the disease caused by SARS-CoV-2)

D. Potentially Life-Threatening Infectious Diseases Caused by Agents Potentially Used for Bioterrorism or Biological Warfare

These diseases include those caused by any transmissible agent included in the HHS Select Agents List.12 Many are not 

routinely transmitted human to human but may be transmitted via exposure to contaminated environments. (See the 

special note in Part II.C for further explanation.) The HHS Select Agents List is updated regularly and can be found on the 

National Select Agent Registry Web site: http://www.selectagents.gov/.

36
Part II. Guidelines Describing the Circumstances in Which Emergency Response 

Employees May Be Exposed to Such Diseases

A. Exposure to Diseases Routinely Transmitted Through Contact or Body Fluid Exposures 

Contact transmission is divided into two subgroups: Direct and indirect. Direct transmission occurs when microorganisms 

are transferred from an infected person to another person without a contaminated intermediate object or person. Indirect 

transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. 

Contact with blood and other body fluids may transmit the bloodborne pathogens HIV, HBV, and HCV. When EREs 

have contact circumstances in which differentiation between fluid types is difficult, if not impossible, all body fluids are 

considered potentially hazardous. In the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens 

Standard, an exposure incident is defined as a “specific eye, mouth, other mucous membrane, non-intact skin, or parenteral 

contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.”13

Occupational exposure to cutaneous anthrax would include exposure of an ERE’s nonintact skin or mucous membrane 

to drainage from a cutaneous anthrax lesion; percutaneous injuries with sharp instruments potentially contaminated 

with lesion drainage should also be considered exposures. Contact with blood or other bodily fluids is not thought to 

pose a significant risk for anthrax transmission. Occupational exposure to rabies would include exposure of an ERE’s 

wound, nonintact skin, or mucous membrane to saliva, nerve tissue, or cerebral spinal fluid from an infected individual. 

Percutaneous injuries with contaminated sharp instruments should be considered exposures because of potential contact 

with infected nervous tissue. Intact skin contact with infectious materials or contact only with blood, urine, or feces is not 

thought to pose a significant risk for rabies transmission. Occupational exposures of concern to vaccinia would include 

contact of mucous membranes (eyes, nose, mouth, etc.) or non-intact skin with drainage from a vaccinia vaccination site 

or other mucopurulent lesion caused by vaccinia infection.

B. Exposure to Diseases Routinely Transmitted Through Airborne or Aerosolized Means

Occupational exposure to pathogens routinely transmitted through aerosolized airborne transmission may occur when 

an ERE shares air space with a contagious individual who has an infectious disease caused by these pathogens. Such an 

individual can expel small droplets into the air through activities such as coughing, sneezing and talking. After water evaporates from the airborne droplets, the dried out remnants can remain airborne as droplet nuclei. Occupational exposure to 

pathogens routinely transmitted through aerosolized droplet transmission may occur when an ERE comes within about 6 

feet of a contagious individual who has an infectious disease caused by these pathogens and who creates large respiratory 

droplets through activities such as sneezing, coughing, and talking. 

C. Special Note on Exposure to Diseases Transmitted by Agents Potentially Used for Bioterrorism or Biological Warfare

The Select Agents list14 maintained by HHS, lists biological agents and toxins that have the potential to pose a severe threat 

to human health and that may be used for or adapted for bioterrorist attacks. There are special reporting requirements 

for Select Agents, as detailed in 42 CFR part 73. Those agents included on the HHS Select Agents List that are routinely 

transmitted person to person and for which natural transmission remains a significant concern are categorized in the “List 

of Potentially Life-Threatening Infectious Diseases to Which Emergency Response Employees May be Exposed,” Part I 

above, according to their modes of transmission. The remaining agents on the Select Agent List would not typically exhibit 

human-to-human transmission or be considered contemporary contagious threats. However, in the setting of potential 

intentional modification to artificially increase transmissibility and/or lethality (“weaponization”) and deployment as 

bio-weapons (potentially in quantities far greater than would naturally be encountered), atypical pathways of transmission 

may occur. In this case, EREs may be exposed by entering contaminated environments to care for victims and by exposure 

to contaminated individuals from those environments.

47
Part III. Guidelines Describing the Manner in Which Medical Facilities Should Make 

Determinations for Purposes of Section 2695B(d) [42 U.S.C. § 300ff–133(d)]

Section 2695B(d) [42 U.S.C. § 300ff–133(d)] specifies that medical facilities must respond to appropriate requests by 

making determinations about whether EREs have been exposed to infectious diseases included on the list issued pursuant 

to sec. 2695(a)(1) [42 U.S.C. § 300ff–131(a)(1)]. A medical facility has access to two types of information related to a 

potential exposure incident to use in making a determination. First, the request submitted to the medical facility contains 

a “statement of the facts collected” about the ERE’s potential exposure incident.15 Information about infectious disease 

transmission provided in relevant CDC guidance documents16 or in current medical literature should be considered in 

assessing whether there is a realistic possibility that the exposure incident described in the statement of the facts could 

potentially transmit an infectious disease included on the list issued pursuant to sec. 2695(a)(1) [42 U.S.C. § 300ff–131(a)

(1)]. 

Second, the medical facility possesses medical information about the victim of an emergency transported and/or treated 

by the ERE. This is the medical information that the medical facility would normally obtain according to its usual 

standards of care to diagnose or treat the victim, since the Act does not require special testing in response to a request 

for a determination. As stated in sec. 2695G(b) [42 U.S.C. § 300ff–138(b)], “this part may not, with respect to victims of 

emergencies, be construed to authorize or require a medical facility to test any such victim for any infectious disease.”

Information about the potential exposure incident and medical information about the victim should be used in the 

following manner to make one of the four possible determinations as required by sec. 2695B(d) [42 U.S.C. §300ff–133(d)]:

(1) The ERE involved has been exposed to an infectious disease included on the list: 

—Facts provided in the request document a realistic possibility that an exposure incident occurred with potential for 

transmitting a listed infectious disease from the victim of an emergency to the involved ERE; and

—The medical facility possesses sufficient medical information allowing it to determine that the victim of an emergency 

treated and/or transported by the involved ERE had a listed infectious disease that was possibly contagious at the time of 

the potential exposure incident.

(2) The ERE involved has not been exposed to an infectious disease included on the list: 

—Facts provided in the request rule out a realistic possibility that an exposure incident occurred with potential for 

transmitting a listed infectious disease from the victim of an emergency to the involved ERE; or

—The medical facility possesses sufficient medical information allowing it to determine that the victim of an emergency 

treated and/or transported by the involved ERE did not have a listed infectious disease that was possibly contagious at the 

time of the potential exposure incident.

(3) The medical facility possesses no information on whether the victim involved has an infectious disease included on the list:

—The medical facility lacks sufficient medical information allowing it to determine whether the victim of an emergency 

treated and/or transported by the involved ERE had, or did not have, a listed infectious disease at the time of the potential 

exposure incident.

—If the medical facility subsequently acquires sufficient medical information allowing it to determine that the victim of an 

emergency treated and/or transported by the involved ERE had a listed infectious disease that was possibly contagious at 

the time of the potential exposure incident, then it should revise its determination to reflect the new information.

(4) The facts submitted in the request are insufficient to make the determination about whether the ERE was exposed to an 

infectious disease included on the list:

—Facts provided in the request insufficiently document the exposure incident, making it impossible to determine if there 

was a realistic possibility that an exposure incident occurred with potential for transmitting an infectious disease included 

on the list issued pursuant to Section 2695(a)(1) [42 U.S.C. § 300ff–131(a)(1)] from the victim of an emergency to the 

involved ERE.

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Footnotes

1The Ryan White Act (Pub. L. 111–87) amended the Public Health Service Act (PHS Act, 42 U.S.C. § 201–300ii), including the addition 

of a Part G to Title XXVI.

2See Title XXVI, Part G of the PHS Act, codified as amended at 42 U.S.C. §§ 300ff–131 to 300ff–140.

3Baron P. Generation and Behavior of Airborne Particles (Aerosols). PowerPoint Presentation. U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Applied Technology. http://www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdf. Accessed January 15, 2019. Baron PA, Willeke K, eds. Aerosol 

measurement: Principles, Techniques, and Applications. Second edition. New York: John Wiley & Sons, Inc. 2001.

4Baron P. Generation and Behavior of Airborne Particles (Aerosols). PowerPoint Presentation. U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Applied Technology. http://www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdf. Accessed January 15, 2019.Siegel JD, Rhinehart E, Jackson M, 

Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing 

Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed January 

15, 2019.

5Baron P. Generation and Behavior of Airborne Particles (Aerosols). PowerPoint Presentation. U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Applied 

Technology. http://www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdf. Accessed January 15, 2019. Siegel JD, Rhinehart E, 

Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: 

Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. 

Access January 15, 2019

6Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline 

for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/

isolation/Isolation2007.pdf. Accessed January 15, 2019.

7Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline 

for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/

isolation/Isolation2007.pdf. Accessed January 15, 2019.

8For most viral hemorrhagic fevers (VHFs), routine transmission is limited to transmission from a zoonotic reservoir or direct contact 

with an infected person (e.g. Ebola virus, Marburg virus) or through arthropod-borne transmission (Rift Valley fever, Crimean-Congo 

hemorrhagic fever). For a small number of VHF viruses, transmission may occur through droplet transmission (e.g. Nipah virus), 

however prolonged close contact is likely necessary. Aerosol transmission does not occur in natural (non-laboratory) settings.

9Section 2695(b) [42 U.S.C. § 300ff–131(b)].

10Section 2695(b) [42 U.S.C. § 300ff–131(b)].

11Council of State and Territorial Epidemiologists, Position Statement Number 13–ID–14. Available at https://www.cste.org/page/

PositionStatements. Accessed March 25, 2020.

1242 C.F.R. §§ 73.3, 73.4.

1329 C.F.R. § 1910.1030.

14Notwithstanding any notification procedures specified here, all reporting requirements that are required under 42 C.F.R. part 73 remain applicable. The HHS Select Agents list is updated regularly and can be found on the National Select Agent Registry website: http://

www.selectagents.gov. Accessed March 25, 2020.

15Section 2695B [42 U.S.C. § 300ff–133].

16For example: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. CDC. Updated U.S. 

Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure 

Prophylaxis. MMWR 2005;54 (No. RR–9):1–17.

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DHHS (NIOSH) Publication No. 2020-119 

DOI: https://doi.org/10.26616/NIOSHPUB2020119