DHHS 2124 (Revised 7/03) EPIDEMIOLOGY. Hemorrhagic Fever (68)] Causative Organism: [Encephalitis, arboviral (9), Other Foodborne Disease (13), Viral

Transcription

1 Reporters should indicate in the "COMMENTS" section the source of infection, if known, particularly for foodborne diseases. This area of the card is used by State or local health department staff to identify cases associated with a particular outbreak. Particularly important for respiratory and enteric diseases. To be completed by LHD. LHD should obtain surveillance forms when required (see other side) and ensure completeness and accuracy of information. Additional information to be supplied for specific diseases noted here and by * on other side. Local Health Director s Signature or Stamp Clinic No. Address Surveillance Form Case Investigation No. Local Health Department (LHD) should notify LHD in county where acquired so an investigation can be initiated and control measures given. Enter Age in months if less than 12 mos. and in years if 12 mos. or greater. Not necessary to figure months if over one year. / / Years OR Months Public Private Indicate where infection was acquired if somewhere other than county of residence. If acquired in county of residence, mark "SAME". Patient's Address: Street or RFD No. Was this Hospitalized Enter Number for disease reported from reverse side of card. FOR STD ONLY: VOL. EPI. SCREEN N.C. Department of Health and Human Services Division of Public Health Mark both sections. Enter yes only if the Social Security Number No need to reported disease was create a number for use here. the primary cause of death. Completed cards should be sent to the local health department INSTRUCTIONS COMMUNICABLE DISEASE REPORT CARD (FRONT OF CARD)

2 INSTRUCTIONS COMMUNICABLE DISEASE REPORT CARD (BACK OF CARD) Report cards for all shaded diseases should be accompanied by a properly completed surveillance form. The local health department should note on reverse side if surveillance form is complete or not required. Additional information, (site of infection, causative organism, serotype) should be entered on reverse side of card. PLEASE NUMBER IN BLOCK ON FRONT OF CARD CDC BIOTERRORISM - CATEGORY A (continued) SEXUALLY TRANSMITTED DISEASES REPORT IMMEDIATELY TO LOCAL HEALTH DEPARTMENT PLAGUE 29 SMALLPOX 69 TULAREMIA 43 VIRAL HEMORRHAGIC FEVER *68 BRUCELLOSIS 5 TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES (CJD/vCJD) 66 DENGUE 7 DIPHTHERIA 8 E. COLI, SHIGA TOXIN- PRODUCING INFECTION EHRLICHIOSIS, MONOCYTIC (E.chaffeensis) 572 ENCEPHALITIS, ARBOVIRAL (CAL, EEE, WNV, OTHER) *9 STAPHYLOCOCCAL 12 OTHER or UNKNOWN *13 HANTAVIRUS INFECTION 67 SYNDROME 59 HEMOPHILUS INFLUENZAE, HEPATITIS A 14 HEPATITIS B, ACUTE 15 HEPATITIS B CARRIER 115 HIV INFECTION 900 SHIGELLOSIS 39 MALARIA 21 TUBERCULOSIS *TB MUMPS 28 POLIO, PARALYTIC 30 TYPHOID CARRIER 144 OPHTHALMIA NEONATORUM 345 RABIES, HUMAN 33 VIBRIO INFECTION, OTHER *55 ROCKY MOUNTAIN SPOTTED FEVER 35 VIBRIO VULNIFICUS *54 RUBELLA 36 RUBELLA CONGENITAL SYNDROME 37 HEPATITIS B, PERINATAL 116 SALMONELLOSIS *38 YELLOW FEVER 48 WHOOPING COUGH (PERTUSSIS) 47 NONGONOCOCCAL URETHRITIS (NGU) 400 PELVIC INFLAMMATORY DISEASE 490

3 PLEASE NUMBER IN BLOCK ON FRONT OF CARD CDC BIOTERRORISM - CATEGORY A (continued) SEXUALLY TRANSMITTED DISEASES REPORT IMMEDIATELY E. COLI, SHIGA TOXIN- TO LOCAL HEALTH DEPARTMENT PRODUCING INFECTION HIV INFECTION 900 SHIGELLOSIS 39 PLAGUE 29 EHRLICHIOSIS, MONOCYTIC SMALLPOX 69 (E.chaffeensis) 572 TULAREMIA 43 ENCEPHALITIS, ARBOVIRAL VIRAL HEMORRHAGIC FEVER *68 (CAL, EEE, WNV, OTHER) *9 MALARIA 21 TUBERCULOSIS *TB BRUCELLOSIS 5 STAPHYLOCOCCAL 12 OTHER or UNKNOWN *13 MUMPS 28 HANTAVIRUS INFECTION 67 POLIO, PARALYTIC 30 TYPHOID CARRIER 144 OPHTHALMIA NEONATORUM 345 TRANSMISSIBLE SPONGIFORM SYNDROME 59 ENCEPHALOPATHIES (CJD/vCJD) 66 HEMOPHILUS INFLUENZAE, RABIES, HUMAN 33 VIBRIO INFECTION, OTHER *55 HEPATITIS A 14 ROCKY MOUNTAIN SPOTTED FEVER 35 VIBRIO VULNIFICUS *54 HEPATITIS B, ACUTE 15 RUBELLA 36 WHOOPING COUGH DENGUE 7 HEPATITIS B CARRIER 115 RUBELLA CONGENITAL SYNDROME 37 (PERTUSSIS) 47 NONGONOCOCCAL URETHRITIS (NGU) 400 DIPHTHERIA 8 HEPATITIS B, PERINATAL 116 SALMONELLOSIS *38 YELLOW FEVER 48 PELVIC INFLAMMATORY DISEASE 490 PLEASE NUMBER IN BLOCK ON FRONT OF CARD CDC BIOTERRORISM - CATEGORY A (continued) SEXUALLY TRANSMITTED DISEASES REPORT IMMEDIATELY E. COLI, SHIGA TOXIN- TO LOCAL HEALTH DEPARTMENT PRODUCING INFECTION HIV INFECTION 900 SHIGELLOSIS 39 PLAGUE 29 EHRLICHIOSIS, MONOCYTIC SMALLPOX 69 (E.chaffeensis) 572 TULAREMIA 43 ENCEPHALITIS, ARBOVIRAL VIRAL HEMORRHAGIC FEVER *68 (CAL, EEE, WNV, OTHER) *9 MALARIA 21 TUBERCULOSIS *TB BRUCELLOSIS 5 STAPHYLOCOCCAL 12 OTHER or UNKNOWN *13 MUMPS 28 HANTAVIRUS INFECTION 67 POLIO, PARALYTIC 30 TYPHOID CARRIER 144 OPHTHALMIA NEONATORUM 345 TRANSMISSIBLE SPONGIFORM SYNDROME 59 ENCEPHALOPATHIES (CJD/vCJD) 66 HEMOPHILUS INFLUENZAE, RABIES, HUMAN 33 VIBRIO INFECTION, OTHER *55 HEPATITIS A 14 ROCKY MOUNTAIN SPOTTED FEVER 35 VIBRIO VULNIFICUS *54 HEPATITIS B, ACUTE 15 RUBELLA 36 WHOOPING COUGH DENGUE 7 HEPATITIS B CARRIER 115 RUBELLA CONGENITAL SYNDROME 37 (PERTUSSIS) 47 NONGONOCOCCAL URETHRITIS (NGU) 400 DIPHTHERIA 8 HEPATITIS B, PERINATAL 116 SALMONELLOSIS *38 YELLOW FEVER 48 PELVIC INFLAMMATORY DISEASE 490

4 FOR STD ONLY: VOL. EPI. SCREEN N.C. Department of Health and Human Services Division of Public Health Was this Hospitalized Patient's Address: Street or RFD No. / / Years OR Months Public Private Address Surveillance Form Local Health Director s Signature or Stamp Case Investigation No. Clinic No. FOR STD ONLY: VOL. EPI. SCREEN N.C. Department of Health and Human Services Division of Public Health Was this Hospitalized Patient's Address: Street or RFD No. / / Years OR Months Public Private Address Surveillance Form Local Health Director s Signature or Stamp Case Investigation No. Clinic No.

5 REPORTABLE IN NORTH CAROLINA The Division of Public Health, Department of Health and Human Services, is authorized by law (G.S. 130A-133 through 130A-143) to collect reports of cases of communicable diseases listed below. G.S. 130A-135 requires licensed physicians to report cases and suspected cases of reportable communicable diseases and conditions in persons who have consulted them professionally. AIDS Anthrax Botulism* Brucellosis Campylobacter Infection* Chancroid Chlamydia Cholera* Cryptosporidiosis* Cyclosporiasis* Dengue Diphtheria E. coli, Shiga Toxinproducing Infection (including E.coli O157:H7)* Ehrlichiosis, granulocytic Ehrlichiosis, monocytic (E. chaffeensis) Encephalitis, Arboviral (CAL, EEE, WNV, other) Enterococci, Vancomycinresistant ( VRE ), from normally sterile site Foodborne Disease:* - C. perfringens - Staphylococcal - Other/Unknown Gonorrhea, all sites Granuloma Inguinale Hantavirus Infection Hemolytic Uremic Syndrome Hemophilus influenzae, Invasive Disease Hepatitis A* Hepatitis B, Acute Hepatitis B Carrier Hepatitis B, Perinatal Hepatitis C, Acute HIV Infection Legionellosis Leptospirosis Listeriosis Lyme Disease Lymphogranuloma Venereum Malaria Measles Meningitis, Pneumococcal Meningococcal Disease Monkeypox Mumps Nongonococcal Urethritis (NGU), other than labconfirmed Chlamydia Plague Pelvic Inflammatory Disease Polio, paralytic Psittacosis Q Fever Rabies, Human Rocky Mountain Spotted Fever Rubella Rubella, Congenital Syndrome Salmonellosis* S.A.R.S. (Coronavirus Infection) Shigellosis* Smallpox Streptococcal Infection, Group A, Invasive Disease Syphilis, all stages Tetanus Toxic Shock Syndrome Toxic Shock Syndrome, Streptococcal Toxoplasmosis, Congenital Transmissible Spongiform Encephalopathies (CJD/vCJD) Trichinosis* Tuberculosis Tularemia Typhoid, Acute* Typhoid Carrier* Typhus, Epidemic (louse-borne) Vaccinia Vibrio Infection, Other* Vibrio vulnificus* Viral Hemorrhagic Fever Whooping Cough (Pertussis) Yellow Fever Bioterrorism Potential: Diseases underlined in the above list (ANTHRAX, BOTULISM, PLAGUE, SMALLPOX, TULAREMIA and VIRAL HEMORRHAGIC FEVER) have been identified by the U.S. Centers for Disease Control and Prevention as having high potential for use as bioweapons. IMMEDIATELY report any suspected or confirmed case to the Local Health Department, or to the General Communicable Disease Control Branch 24-hour number with pager link after hours at Report diseases in Bold Italics within 24 hours (by phone and card), and other diseases within 7 days (by card). PLEASE NOTE: Diseases reportable within 24 hours (in bold italic letters) have potential for epidemic spread or require rapid action. An immediate telephone report to the local health department is required as well as completion of the communicable disease report card and a surveillance form (for selected diseases) within 7 days. *Diseases listed with an asterisk: Restaurants and other food or drink establishments are required to report all outbreaks or suspected outbreaks of foodborne illness in customers or employees. Procedure for Reporting: Cases should be reported on the communicable disease report card (DHHS 2124) available from local health departments. If unsuccessful, as a last resort, please call the Surveillance Unit of the General Communicable Disease Control Branch at Surveillance forms required for some diseases (indicated by shading on the back of the communicable disease report card) are also available from the same sources. Physicians should forward case reports to their local health department, which will then forward the report to the Communicable Disease and Epidemiology Section. Telephone Reports: Please report the following occurrences to the local health department: 1. All diseases that are required to be reported within 24 hours; 2. Disease occurrences of unusual significance, incidence, or concentration which may merit an epidemiologic evaluation, including nosocomial outbreaks, diarrheal disease, rash illness, day care outbreaks, etc.; and 3. Foodborne and waterborne outbreaks suspected common source outbreaks. Telephone reports should include the following information: a. Disease (diagnosed or suspected) b. Date of onset and symptoms c. Patient name, other identifying info. d. Patient s address e. Source, if known f. Patient s age, sex, and race/ethnicity g. Laboratory confirmed (yes or no) h. Patient s physician i. Name and phone number of person making report For further information or assistance regarding communicable diseases, physicians should first contact their local health department. Local health department staff may contact the General Communicable Disease Control Branch at Rev.4/6/04