Pertussis case track record

Immunization Division, Texas Department of Health
1100 West 49th St., Austin, TX 78756
(800) 252-9152 (512) 458-7544 fax
Pertussis Case Track Record
FINAL STATUS : NETSS CASE #:
Patient’s Name: ______________________________________________________ Reported By: ___________________________________________ Address: ___________________________________________________________ Agency: _______________________________________________ Phone:( )___________________________________________ City: ________________________ County: _______________ Zip: ____________ Region: _________ Phone:( ) ______________________________________ Parent/Guardian: _____________________________________________________ Report Given to: _______________________________________ Organization: ___________________________________________ Physician: _______________________________Phone:( ) _______________ Physician’s Address: __________________________________________________ Phone: ( ) __________________________________________ ___________________________________________________________________ DEMOGRAPHICS:
DATE OF BIRTH: _____/_____/_____ AGE: ______ SEX: o Male o Female o Unknown RACE: o White o Black o Asian/Pacific Islander o Native American o Unknown o Other: _________________________ CLINICAL DATA:
TREATMENT:
o Cough - Onset Date: ____/____/____ Final Cough Duration:______ # of Days Were antibiotics given? o Yes o No o Paroxysmal Cough - Onset Date: _______/________/_______ o Erythromycin: Date Started:_____/_____/_____for _____ Days o Cotrimoxazole: Date Started:_____/____/_____for ______ Days o Apnea (Exclude Cyanotic Episode) o Cyanosis after Paroxysm o Azithromycin: Date Started:_____/_____/_____for _____ Days o Pneumonia: Chest X-Ray o + o - o Seizures (Focal or Generalized) o Tetracycline: Date Started:_____/_____/_____for _____ Days Date Started:_____/_____/_____for _____ Days Is patient still coughing at final interview? o Yes o No Date: ___/_____/____
o Other:_________ Date Started:____/____/____for ______ Days o Hospitalized at: __________________________________________________ o Other:_________ Date Started:____/____/____for ______ Days Admitted: _____/_____/_____ Discharged: _____/_____/_____ # Days_______ OUTCOME: o Survived o Died o Unknown
Physician Diagnosis:_________________________________________________
If Deceased, Date of Death: ____/_____/_____ Note: A Pertussis
Death Worksheet must also be submitted to TDH.
INFECTION TIMELINE: Enter onset of cough. Count backwards and forwards to enter dates for probable exposure and communicable periods.
P e r i o d o f C o m m u n i c a b i l i t y VACCINATION HISTORY:
VACCINATED: o Yes o No o Unknown
o 1 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 2 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 3 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 4 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 5 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ If no, indicate reason: o Religious exemption o Medical Contraindication o Evidence of immunity o Previous Disease - Lab Confirmed
o Previous Disease - MD Diagnosed o Under Age o Parental Refusal o Unknown o Other: ____________________________ Name: ________________________________________ LABORATORY DATA: Was laboratory testing done? o Yes o No o Unknown
LABORATORY: o TDH o Other: ________________________________________________ Phone:( ) ________________________ o Culture: Date specimen collected: _____/_____/_____ Result: ________________ o PCR: Date specimen collected: _____/_____/_____ Result: ________________ o DFA: Date specimen collected: _____/_____/_____ Result: ________________ o IgA o IgG: Date of acute specimen: _____/_____/_____ Result: ________________ Date of convalescent specimen: _____/_____/_____ Result: ________________ Note: A four-fold rise in titer level from acute specimen to convalescent sample may be considered positive serology for pertussis. Results from a
single specimen are not accepted as laboratory confirmation of a suspected pertussis case.
Results called to local investigator: o Yes o No o Unknown Person Contacted: Date Called: _____/_____/_____ Initials: _________ SOURCE OF INFECTION: o No exposure Identified o Close contact with a known or suspected case.
____________________________ ( )____________________ __________ o Is case epidemiologically linked to a culture-confirmed case? o Yes o No o Unknown o Where did this case acquire pertussis?: o Day-care o School o College o Work o Home o Dr Office o Hospital ER o Hospital Inpatient o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: _____________ Name(s) of Setting:__________________________________________________________________________________________________ o Has any travel occurred within the exposure period? o Yes o No o Unknown If yes, list location: __________________________ o Importation Class: o Indigenous o International o Out-of-state o Unknown If imported, from what country/state:________________ o Is case traceable within 2 generations to international import? o Yes o No o Unknown o Is case part of an outbreak?: o Yes o No o Unknown If yes, list outbreak name: _________________________________________ Total number of contacts in any settings recommended antibiotics: _________________
HOUSEHOLD CONTACTS: Were control activities initiated?: o Yes o No o Unknown If no, explain: __________________________
*Symptoms/Date of Onset
______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ *Investigations must be completed on all contacts with symptoms
POSSIBLE SPREAD CONTACT:
Setting: o No Spread o Day -care o School o College o Work o Home o Dr. Office o Hospital ER o Hospital Inpatient
o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: ___________________________
Name (s) of Settings: __________________________________________________________________________________________________
Name
*Symptoms/Date of Onset
______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ *Investigations must be completed on all contacts with symptoms
Investigator's Name: _____________________________________________ Agency name: _________________________________________ Phone:( ) ______________________ Date Investigation Initiated: _____/_____/_____ Date Investigation Completed: ____/_____/____ COMMENTS:

Source: http://acchd.us/PDFs/diseasereporting/PERTUSSIS.pdf