Health Board Logo. Post SARS Outbreak Surveillance. Report of possible or probable cases (Form version 1) February 11 th 2004

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1 Post SARS Outbreak Surveillance Report of possible or probable cases (Form version 1) February 11 th 2004 This form is to be used for persons who fit the surveillance case definition of possible or probable SARS when there is no evidence of SARS transmission (person-to-person) globally. The cases to be reported are those conforming to the case definitions provided by the WHO/EU in the absence of SARS transmission (person-to-person) globally, which are reproduced at the bottom of this form. Date of report: ame of reporter: Position: Institution/organisation Telephone/Fax/ PATIET DETAILS ame of patient: Sex Date of birth Home address M F Telephone Country of Residence (If different from home address) Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 1 of 13

2 Occupation & place of work Date when last at work GP ame Address Telephone/Fax/ HOSPITAL ADMISSIO Admitted to hospital? If yes, give name of hospital. Currently admitted? If yes, date of admission Transferred to other hospital If yes, name of hospital Date of transfer Date of Discharge CLIICAL DETAILS Current Health Status If the patient died Date of Onset of Illness Recovering Moderately ill Severely ill Ventilated Died Date of Death Autopsy Documented or reported fever History of fever (not documented) Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 2 of 13

3 Symptoms High fever (>38 0 c) Cough Myalgia Dyspnoea/difficulty breathing Diarrhoea Other If other please specify: Clinical diagnosis Pneumonia ARDS Other If other please give details Severity of Illness ot very ill Moderately ill Severely ill RISK FACTORS Is the Patient a Healthcare Worker? If es, where is their place of employment? Were other possible SARS Cases /cases of unexplained pneumonia associated with the healthcare facility Have close contacts of case been diagnosed with unexplained pneumonia If ES in either/both of the two above, please give details Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 3 of 13

4 History of recent travel? Close contact* with a possible or probable SARS Case or close contact with ill person who returned from zone of reemergence in the last 10 days. If yes, please give details in terms of dates, place and nature of exposure to case. Definition of close contact is outlined on Page 8 Does the person work in a laboratory which undertakes work/research on SARS If yes, give details IVESTIGATIOS General Investigations Chest X-Ray Date of CXR / / Result ormal Abnormal FBC Date of FBC / / Thrombocytopenia Leucopenia Serology (to be sent to ational Virus Reference Laboratory for analysis) Acute Serum (if symptomatic at time of assessment) Result Date serum obtained / / Convalescent Serum (taken 14 days after acute serum or 14 days after onset of illness) Result Date convalescent serum taken / / Bacteriology Serology for atypical pneumonia (Mycoplasma, Chlamydia etc.) Result Blood Culture Result Sputum (if available) Result Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 4 of 13

5 Urinary Antigen for Legionella Result Virology Serum Result asopharyngeal Aspirate Result Viral Throat Swab Result Oral Washings Result PLACE OF POTETIAL EXPOSURE Has the patient travelled outside of Ireland since August ? If yes complete following section Country /area visited Date of Return to Ireland Country of Departure Airport of arrival in Ireland Was person symptomatic on the flight 1. Dates of visit: from to 2. Dates of visit: from to 3. Dates of visit: from to 4. Dates of visit: from to Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 5 of 13

6 Airflight Details Other comments Carrier Airline Flight umbers Outbound Inbound Date and time of Arrival at Destination Date: / / Time:. am/pm Date and time of Departure from Destination Date: / / Time:. am/pm Accomadation Details Includes apartments, campsites, cruise ships etc. Country Town Hotel Room umber if available From / / to / / Country Town Hotel Room umber if available From / / to / / Additional Comments Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 6 of 13

7 PLEASE LEAVE BLAK (For Public Health Department Purposes Only) Final Diagnosis (as per Case Definitions) Confirmed SARS Probable SARS Possible SARS Laboratory Acquired SARS Other Please specify Please return this form by fax to Dr., Director of Public Health, Fax: Tel: Reporting Form Post SARS Outbreak Version 1.0 February 04 Page 7 of 13

8 SARS: Details of contacts (from 10 days prior to onset) Patient ame: Patient Address: Tel: Form completed by: Position: Date: ame, address, tel number D.O.B Relationship to patient ature of contact (e.g. healthcare facility, household, work, social). Total hours of contact with case in previous 10 days GP name, address, tel number Contact tracing form completed Status of Contact i.e. Possible, Probable Confirmed Case Reporting Form Post SARS OB Version 1.0 February 2004 Page 8 of 13

9 Reporting Form Post SARS OB Version 1.0 February 2004 Page 9 of 13

10 The following case definitions apply to the surveillance of SARS in the absence of known transmission (person-to person) worldwide. 1 Clinical Case Definition of SARS The following case definition of SARS is consistent with the WHO clinical case definition and has been developed for public health purposes. The respiratory illness usually will be severe enough to warrant hospitalisation and include a history of: Fever of 38 C (documented or reported) AD One or more symptoms of lower respiratory tract illness (cough, difficulty breathing, shortness of breath) AD Radiographic evidence of lung infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) or autopsy findings consistent with the pathology of pneumonia or RDS without an identifiable cause. AD o alternative diagnosis to fully explain the illness. It is important that clinicians obtain a detailed travel history from patients with symptoms and signs consistent with clinical SARS as well as ascertain whether other family members and/or close contacts (particularly within the hospital setting) have had a similar illness within the 10 days prior to the patient s onset of illness. 2 Possible Case a) Individual Case A person fulfilling the clinical case definition of SARS (see 1) Reporting Form Post SARS OB Version 1.0 February 2004 Page 10 of 13

11 AD within ten days of onset of illness, a history of travel to an area classified by WHO as a potential zone of re-emergence of SARS (this includes an area identified as the source of the ovember 2002 outbreak and/or an area with increased likelihood of animal to human transmission of SARS-CoV infection). b) Health Care Worker (HCW) Cluster Two or more HCWs in the same health care facility fulfilling the clinical case definition of SARS (see above) and with onset of illness within the same 10- day period. The definition of the health care unit in which the cluster occurs will depend on the local situation. Unit size may range from an entire health care facility if small, to a single department or ward of a large tertiary hospital. This constitutes SARS Alert c) Other Hospital Cluster Hospital acquired illness in three or more persons (health care workers and/or other hospital staff and/or patients and/or visitors) in (or linked to) the same health care unit fulfilling the clinical case definition of SARS (see above) and with onset of illness within the same 10-day period. This constitutes SARS Alert In order to detect a cluster of SARS in the healthcare setting, clinicians are asked to notify cases of unexplained pneumonia in healthcare workers to the Medical Officer of Health (Director of Public Health). All healthcare workers should be asked to inform the Occupational Health Physician/Department if they develop signs of severe pneumonia that requires hospital admission. 3 Probable Case An individual with symptoms and signs consistent with clinical SARS (Possible Case) AD with preliminary laboratory evidence of SARS-CoV based on the following: Either Single positive antibody test for SARS-CoV Or Positive PCR for SARS-CoV on a single clinical specimen and assay Reporting Form Post SARS OB Version 1.0 February 2004 Page 11 of 13

12 .4 Laboratory acquired probable case An ill person who has developed the symptoms reported below in the 10 days following working with or having been in contact with a laboratory activity involved with SARS-CoV manipulation: Fever (>38 C) One or more respiratory symptoms including cough, difficulty breathing, shortness of breath And Radiographic evidence of lung infiltrates consistent with pneumonia or respiratory distress syndrome. This person should be considered as a SARS probable case and managed accordingly until the contrary is proven. 5 Confirmed Case An individual with symptoms and signs consistent with clinical SARS (Possible Case) AD with laboratory evidence of SARS-CoV infection based on one or more of the following: a) PCR positive for SARS-CoV using a validated method from: OR At least two different clinical specimens (e.g. nasopharyngeal and stool) The same clinical specimen collected on two or more occasions during the course of the illness (e.g. sequential nasopharyngeal aspirates) OR Two different assays or repeat PCR using a new RA extract from the original clinical sample on each occasion of testing. b) Seroconversion by ELISA or IFA egative antibody test on acute serum followed by positive antibody test on convalescent phase serum tested in parallel OR Fourfold or greater rise in antibody titre between acute and convalescent phase sera tested in parallel. Reporting Form Post SARS OB Version 1.0 February 2004 Page 12 of 13

13 c) Virus isolation Isolation in cell culture of SARS-CoV from any specimen AD PCR confirmation using a validated method. Testing should only be undertaken in a national or regional reference laboratory as per WHO recommendations (Use of laboratory methods for SARS diagnosis). 6 Denotified Case A case is denotified when 1. An alternative laboratory diagnosis is made which can fully explain the illness OR 2. The patient has a negative convalescent serology result (ote: negative PCR result does not result in the declassification of a possible case). Reporting Form Post SARS OB Version 1.0 February 2004 Page 13 of 13