PPHSN Reporting Form Severe acute respiratory syndrome (SARS) outbreak

Transcription

1 ANNEX 2 PPHSN Reporting Form Severe acute respiratory syndrome (SARS) outbreak (updated )

2 PPHSN Reporting Form Severe acute respiratory syndrome (SARS) outbreak Report of suspected or probable cases This form is to be used for reporting suspected or probable cases of respiratory illness, which may be associated with the outbreaks of SRAS. The cases to be reported are those conforming to the case definitions adapted from the WHO and reproduced hereunder. Please return this form to PPHSN-CB Focal Point at SPC Fax: +(687) AND/OR WHO South Pacific Fax: +(679) PPHSN case definitions for hospital based surveillance Suspected case A person presenting to a health care facility after 1st November 2002 with a history of: High fever (>38 o C) AND: One or more respiratory symptoms (cough, shortness of breath, difficulty breathing) AND one or more of the following exposures during the 14 days prior the onset of the symptoms: Close contact* with a person who is a suspect or probable case of SARS. History of travel to an area with recent local transmission of SARS (see ANNEX 3B). Residing in an area with recent local transmission of SARS * Close contact means having cared for, having lived with, or having had direct contact with respiratory secretions, body fluids or excretion (e.g. faeces) of a suspect or probable case of SARS. Probable Case A suspect case with chest x-ray findings of pneumonia or Adult Respiratory Distress Syndrome OR A suspect case of SARS that is positive for SARS coronavirus by one or more assays. OR A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause. Note In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea. Exclusion criteria A case should be excluded if an alternative diagnosis can fully explain their illness. Reclassification of cases As SARS is currently a diagnosis of exclusion, the status of a reported case may change over time. A patient should always be managed as clinically appropriate, regardless of their case status. - A case initially classified as suspect or probable, for whom an alternative diagnosis can fully

3 explain the illness, should be discarded after carefully considering the possibility of co-infection. - A suspect case who, after investigation, fulfils the probable case definition should be reclassified as "probable". - A suspect case with a normal CXR should be treated, as deemed appropriate, and monitored for 7 days. Those cases in whom recovery is inadequate should be re-evaluated by CXR. - Those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as "suspect". - A suspect case who dies, on whom no autopsy is conducted, should remain classified as "suspect". However, if this case is identified as being part of a chain transmission of SARS, the case should be reclassified as "probable". - If an autopsy is conducted and no pathological evidence of RDS is found, the case should be "discarded".

4 Reporter details Name of person completing this form: _ Date of report to PPHSN / / _ Name of reporter: Position: _ Institution/Organisation: _ Country: _ Contact telephone number: _ _ Mobile phone number: Fax no. Patient details Name: Surname: Sex: Female Male Date of birth: / / Country of residence (If different from home address) _ Home address: _ City/town: _ Postcode: _ Country: _ Home telephone: _ Mobile phone:

5 Patient history In the last 14 days, has the patient been in contact with anyone who is a suspect or probable case of SARS? Yes No If yes: Type of contact: _ (e.g. family member, friend, etc) Name of the SARS contact: _ Place of the contact: Has the patient traveled since 1 November 2002 in one of the countries reported in the ANNEX 3B? If yes Yes No Country visited Length of the stay From To Date of return to (name country) / / Country of departure Airport of arrival in Country _

6 Clinical details Date of onset of illness / / Clinical diagnosis Pneumonia Fever 38 C Yes No ARDS Cough Yes No Other: _ Myalgia Yes No Current status: Fully recovered (symptom free) Shortness of breath/difficulty breathing Yes No Recovering Stable Getting worse Other, please specify: Severity of illness: Not very ill Moderately ill Severely ill Died / / Admitted to hospital? Yes No Admission status: Currently admitted Date of admission / / Hospital _ (Name and country) Transferred to other hospital Date of admission / / Hospital _ (Name and country) Discharged Date of discharge / /

7 Tests performed and laboratory results Chest X-ray Date / / Results: Normal Abnormal: Date / / Results: Normal Abnormal: Date / / Results: Normal Abnormal: Cell blood count Date (If performed) / / Result Normal Thrombocytopenic Leucocytopenic Date / / Result Normal Thrombocytopenic Leucocytopenic Date / / Result Normal Thrombocytopenic Leucocytopenic Additional Laboratory Tests requested: Results: