Fax completed form to: (204) Further inquiries: your CD Coordinator

Transcription

1 Population and Public Health Program Acute Hepatitis B Virus (HBV) Enhanced Surveillance Case Report Form Fax completed form to: (204) Further inquiries: your CD Coordinator PERSON REPORTING Last Name First Name Phone # Date Case Report Form Completed PATIENT INFORMATION PHIN Patient Legal Last Name Patient First Name Current Street Address Date of Birth: Sex: Male Female Transgender Unstable Housing* City/Municipality/ Reserve Postal Code Self-Identified Ethnicity (check one) Caucasian Aboriginal (specify) Black (i.e., African, Haitian, Jamaican, etc.) First Nation on Reserve Asian (i.e., Chinese, Filipino, Japanese, etc.) First Nation off Reserve South Asian (i.e., East Indian, Pakistani, Sri Lankan, etc.) Métis Arab/West Asian (i.e., Armenian, Egyptian, Iranian, etc.) Inuit Latin American Other (specify) Refused to answer Country of Birth (check one) Canada Other (specify) Year of arrival in Canada (YYYY) IMMUNIZATION HISTORY Previous hepatitis B immunization If yes, dates of each dose: 1: () 2: () 3: () If HBV immunization received, has protective antibody response been documented? () Definitions Date of symptom onset: refers to the earliest reported date of clinically relevant symptoms. Unstable Housing: refers to an individual who lacks a fixed, regular, and adequate nighttime place of abode. 1

2 CLINICAL INFORMATION Date of Symptom Onset Date of Clinical Diagnosis Specimen collection date Asymptomatic INTERVIEW PERIOD Interview period definition: 6 months prior to onset of symptoms to interview date or if asymptomatic, the date of onset is the date testing was done. RISK FACTORS* Travel or Residence (in the 6 months prior to onset of symptoms) If yes: Out of Region, in MB, please specify: Out of Province, in CA, please specify: Out of country, please specify: Sexual Partners sexual contact Sexual contact with: One Partner Multiple Partners Men Having Sex with Men Drug Use History (in the 6 months prior to onset of symptoms) Do you use drugs: : Crystal Meth Opioids* Oral route Crack Cocaine Other: Oral route Unknown Child of HBV positive mother Household Contact with Confirmed or Suspect Case Sexual Contact with Confirmed or Suspect Case Sexual Assault IDU Equipment Sharing symptoms have you shared IDU equipment: : Syringes Water Ties Cookers Filters Other: Razor or toothbrush sharing : Razor Toothbrush Other: Sex Trade Worker Had Sex with a Sex Trade Worker Non-IDU Equipment Sharing symptoms have you shared non-idu equipment: : Straws Pipes Other: Unknown 2

3 symptoms, where have you injected/snorted/smoked your drugs? Specify location: Another person s residence If yes, please specify neighbourhood(s): Is this person someone you know well? Outdoors If yes, please specify neighbourhood(s): At home or trusted partner s home symptoms, have you usually used alone or with others: Alone With Others Don t Know How do you prepare your drugs (in the last 6 months prior to onset of symptoms): History of Incarceration (in the 6 months prior to onset of symptoms) Were there any sexual relations or drug use while incarcerated in the 6 months prior to onset of symptoms? Incarceration Location (in the 6 months prior to onset of symptoms) Please provide name of institution(s) and dates incarcerated: History of Tattooing Less than 6 months ago Between 6 months and 1 year ago More than 1 year ago Unknown timeframe Tattoo Venue (in the 6 months prior to onset of symptoms) Professional setting (e.g., tattoo parlor ) Jail Other non-professional or unregulated setting History of Piercings Less than 6 months ago Between 6 months and 1 year ago More than 1 year ago Unknown timeframe Piercing Venue (in the 6 months prior to onset of symptoms) Professional setting Jail Other non-professional or unregulated setting 3

4 Blood/blood product recipient If yes, date: () Hemodialysis/peritoneal dialysis Onset year: (YYYY) Major surgery/clinical exposure If yes, date () Acupuncture/scarification If yes, date: () Previous blood/tissue donation If Yes, most recent date () Hospital or facility: Client is aware that if there is a history of blood transfusion, Manitoba Health and Healthy Living is required to notify Canadian Blood Services Needlestick/occupational exposure If yes, date: () Disease Reporting Information (check all that apply) As per MHHL protocol, individuals with Hepatitis B or C should be tested for associated bloodborne pathogens: Type Parallel BBP Tests Performed on Case HBV Refused N/A HCV Refused N/A HIV Refused N/A Definitions cont d Opioids: could include Fentanyl, Morphine, Hydromorphone, Oxycode/Oxycotin, Heroin etc. Water: Water is added to a drug (either in a cooker or directly in the syringe barrel) to dissolve the drug prior to injection. People who inject drugs may report using either sterile water or tap water. Cooker: The container used for mixing and heating a drug. For drugs sold as powder, rocks, or tablets, in order to be injected, they should be fully dissolved in water and cooking the drug facilitates this process. People who inject drugs may use sterile, single use aluminum containers or non-sterile cookers such as spoons, bottle caps, the bottom of drink cans, or syringe barrels. Filters: After dissolving a drug, the solution is drawn into a syringe through a filter in order to prevent any dissolved particles of the drug, other debris and/or bacteria from being drawn into the syringe and potentially injected into a vein. Common filters are small cotton balls or cigarette filters. Ties: Material used to provide pressure to increase the blood flow into the preferred vein and facilitate injection. People who inject drugs use a medical grade tourniquet, rope, shoelaces or belts. Alcohol swabs: Used to clean an injection site prior to injection and may be placed on the site post inject to stem bleeding. Syringes: Needle used to inject drugs into veins. May be referred to as rigs, works or gear. Straws: Mode of inhalation to facilitate absorption of powdered drug via mucous membranes in nasal passages. People who use drugs commonly use modified drink straws or rolled bills. Pipes: Used to inhale drug vapors after heating a drug to a high temperature. Often glass but may also be modified bottles or aluminum cans. (Definitions adapted from: Strike C, Hopkins S, Watson TM, Gohil H, Leece P, Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L, Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Zurba N. Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: Part 1. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada ) 4

5 CONTACTS Is there anyone you know who might benefit from HBV testing? (Household, sexual, needle/other drug equipment/toothbrush/razor sharing contacts from the last 6 months prior to onset of symptoms): Name Age/DOB Address Phone Number Type of Exposure Dates of Exposure Immunization Hx (HBV) HBV Serology 5