Diphtheria Electronic Disease Surveillance System Division of Surveillance and Disease Control Infectious Disease Epidemiology Program : 304-558-5358 or 800-423-1271 in : 304-558-8736 Investigation Information * indicates required fields Investigation Status* Closed Open Regional Review State Review Superceded Unassigned Case Status* Confirmed Not a Case Probable Suspect Patient Information * indicates required fields Last Name* First Name* Middle Initial Street Address City County State Zip Is the patient's residence a: Correctional Facility (Specify) Shelter or Group Home (Specify) Home Long Term Care Facility (Specify) None of the above Report Date Parent / Guardian Information Last Name First Name Middle Initial Relationship to Patient Check if address is same as above; otherwise complete guardian contact information below Guardian Street Address City County State Zip Home Patient Demographic Information * indicates required fields Sex Male Female Transsexual Failure to report sex/missing sex (Specify) Date of Birth* Age Age Units Days Weeks Months Years
First Name Last Name Diphtheria 11/12/04 Page 2 Patient Demographic Information cont. Ethnicity Hispanic or Latino Not Hispanic or Latino Failure to report ethnicity/missing ethnicity Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Failure to report race/missing race Some Race Clinical Information Date of onset of symptoms Outcome and Clinical Information Date of diagnosis Was patient hospitalized for this disease? Name of Hospital Date of Admission Symptoms Symptoms Fatigue (specify): Sore Throat Difficulty swallowing Change in voice Shortness of breath Weakness If membrane present, sites Conjunctiva Hard Palate Larynx Nares Nasopharynx Skin Soft Palate Tonsils Signs Fever? Neck edema? Neck edema, if Yes If yes, temperature: (Degrees F) Soft tissue swelling? (Around membrane) Neck edema, if Yes Bilateral Left side only Right side only Submandibular Midway to clavicle To clavicle Below clavicle Wheezing Palatal weakness Tachycardia Description of Clinical Picture Stridor Membrane present? EKG abnormalities Outcome Outcome Recovered, No residue Recovered, Residue Died Complications Complications? Airway obstruction? If Yes, Date of onset Intubation required Myocarditis? If Yes, Date of onset (Poly)neuritis? If Yes, Date of onset Specimen for diphtheria culture obtained? If, Describe Laboratory Data If Yes, date specimen collected Result Date Culture result Positive Negative Not Done
First Name Last Name Diphtheria 11/12/04 Page 3 Specify lab performing culture: If culture positive, biotype: Laboratory Data cont. Belfanti Gravis Intermedius Mitis Specimen sent to CDC Diphtheria Lab for confirmation/molecular typing Yes No Will be Sent Serum Specimen for Diphtheria Antitoxin Antibodies Obtained? As an Outpatient Treated with Antibiotics Type of specimen If culture positive, results of toxigenicity testing Negative Positive Not Done Clinical swab Piece of membrane C. diptheriae isolate If Yes, Date initiated PCR Result: Not Done Duration of Therapy (days) Antibiotic Therapy given as Outpatient Erythromycin (incl. pediazole, ilosone) Amoxicillin/Ampicillin/Augmentin/Ceclor/Cefixme Cotrimoxazole (bactrim/septra) (specify): As an Inpatient Treated with Antibiotics Penicillin (Bicillin, Pfizerpen-AS, Wycillin) Clarithromycin/azithromycin Tetracycline/Doxycycline If Yes, Date initiated Duration of Therapy (days) Antibiotic Therapy given in Hospital Erythromycin (incl. pediazole, ilosone) Amoxicillin/Ampicillin/Augmentin/Ceclor/Cefixme Cotrimoxazole (bactrim/septra) (specify): Were Antibiotics given in the 24 hours before culture? Penicillin (Bicillin, Pfizerpen-AS, Wycillin) Clarithromycin/azithromycin Tetracycline/Doxycycline DAT Administered Yes No Amount of DAT Administered IU DAT Laboratory Name Number Address State: Zip: Last Name Reporting Source First Name Facility Address City State Zip E-mail
First Name Last Name Diphtheria 11/12/04 Page 4 Last Name Provider with Further Patient Information First Name Address City State Zip Public Health Investigation Name of Person Interviewed Relationship to Patient Date reported to public health Investigator Date public health investigation began Health Department Investigation ID Country of Residence US History of International Travel (2 weeks prior to onset) Part of an Outbreak? Outbreak Name If, Country Name Lost to follow-up? Yes No Date of U.S. Arrival Country Visited From To Select Country History of Interstate Travel (2 weeks prior to onset) State Visited From To Select State Known Exposure to Diphtheria Case or Carrier? Childhood Primary Series Known Exposure to International Travelers? History of Immunization against Diphtheria If < 18 years old, number of doses Boosters as Adult Known Exposure to Immigrants? Date of last Dose Date Dosed
First Name Last Name Diphtheria 11/12/04 Page 5 Name Physician Requesting D.A.T. Institution Street City State Zip Code Name of Investigator under IND (if different from requesting physician) Name Ship Drug To: Name Institution Street City State Zip Code Diphtheria Close Contacts Information If, number of lifetime doses Last Dose
First Name Last Name Diphtheria 11/12/04 Page 6 Diphtheria Close Contacts Information cont. If, number of lifetime doses Last Dose If, number of lifetime doses Last Dose If, number of lifetime doses Last Dose
First Name Last Name Diphtheria 11/12/04 Page 7 Diphtheria Close Contacts Information cont. If, number of lifetime doses Last Dose Describe Public Health Action Taken