0920-0004 Cholera and Other Vibrio Illnesses 52.79

..............................

TEL.:

PATIENT'S NAME:

Home

Work

ADDRESS:
TEL.:

PHYSICIAN'S NAME:

.....................................................................................................................................................................................................................................................................
– PATIENT IDENTIFIERS NOT TRANSMITTED TO CDC

SEND COMPLETED REPORT TO STATE INFECTION CONTROL
State will Centers for Disease Control
forward to: and Prevention
Enteric Diseases Epidemiology
Branch, MS A38
1600 Clifton Road
Atlanta, GA 30333, Fax 404-639-2205

CHOLERA AND OTHER VIBRIO ILLNESS
SURVEILLANCE REPORT
I. DEMOGRAPHIC AND ISOLATE INFORMATION

OMB 0920-0322 Exp. Date 02/28/2006

REPORTING HEALTH DEPARTMENT

1. First three letters
of patient's last name:

State:

City:

County/Parish: (16-26)

(6-15)

(4-5)

State Epi No.:

(1-3)

(27-37)

State Lab Isolate ID:(38-49) CDC USE ONLY

FDA No.: (61-69)
(50-60)

2. Date of birth:
Mo.

Day

3. Age:
Yr.

Years

(70-75)

4. Sex: (80)

5. Ethnicity: (81)
Hispanic or Latino
Origin?

M (1)

Mos.

(76-79)

F (2)

Yes (1)

Unk.(9)

No (2)

Black or African
American (2)

6. Race: (70)

Unk

7. Occupation:(71-81)

American Indian/
Alaska Native (5)

Native Hawaiian or
other Pacific Islander (6)

Asian (4)

White (1)

(9)

Unk. (9)

8. Vibrio species isolated (check one or more):

Date specimen collected
Source of specimen(s) collected from patient (If more than one specify earliest date)

Species

Stool

Blood

Wound

Other

Mo.

Day

If wound or other, specify site :

Yr.

V. alginolyticus ......................................

(85)

(86-91)

(92-103)

V. cholerae O1 ......................................

(107)

(108-113)

(114-125)

V. cholerae O139 ..................................

(129)

(130-135)

(136-147)

V. cholerae non-O1, non-O139 ...........

(151)

(152-157)

(158-169)

V. cincinnatiensis ..................................

(173)

(174-179)

(180-191)

V. damsela ............................................

(195)

(196-201)

(202-213)

V. fluvialis ..............................................

(217)

(218-223)

(224-235)

V. furnissii .............................................

(239)

(240-245)

(246-257)

V. hollisae .............................................

(261)

(262-267)

(268-279)

V. metschnikovii ....................................

(283)

(284-289)

(290-301)

V. mimicus ............................................

(305)

(306-311)

(312-323)

V. parahaemolyticus .............................

(327)

(328-333)

(334-345)

V. vulnificus ...........................................

(349)

(350-355)

(356-367)

Vibrio species - not identified ................

(371)

(372-377)

(378-389)

Other (specify):___________________

(409)

(410-415)

(416-427)

(390-405)

9. Were other organisms isolated from the same
specimen that yielded Vibrio?

Yes (1)

No (2)

Unk. (9)
(428)

Specify organism(s): ____________________________________________________________

10. Was the identification of the
species of Vibrio (e.g., vulnificus,
fluvialis) confirmed at the State
Public Health Laboratory?

Yes (1)

No (2)

Unk. (9)
(451)

_______________________________________________________________________ (429-450)
11. Complete the following information if the isolate is Vibrio cholerae O1 or O139:
Serotype (452) (check one)

Biotype

(453) (check

one)

Inaba (1)

Not Done (4)

El Tor (1)

Not Done (3)

Ogawa (2)

Unk. (9)

Classical (2)

Unk. (9)

Hikojima (3)

Toxigenic? (454) (check one) If YES, toxin positive by: (check all, that apply)
Yes (1)

No (2)

Unk. (9)

ELISA (455)
Latex agglutination (456)
Other (specify): _____________________________
_____________________________________ (457-471)

CDC 52.79 REV. 01/2006 (Page 1 of 4)
CHOLERA AND OTHER VIBRIO ILLNESS SURVEILLANCE REPORT
(CDC Adobe Acrobat 7.0 Electronic Version, 4/2006)

Name of Hospital:
Address:

State:

Age:

II. CLINICAL INFORMATION

Sex:

1. Date and time of onset
of first symptoms:

2. Symptoms
Yes
F (1) (1)
and signs: max.
C (2)
temp.
Fever .................................................................
•

Day

Yr.

(472-7)

Hour

Min.

(478-9)

No (2)

(days)

Unk.(9)

(550-552)

(1)

No
(2)

Unk.

(2)

(9)

(497)

Nausea .............................................................

(490)

Muscle pain ..

(498)

Vomiting ............................................................

(491)

Cellulitis

.......

(499)

Site: _________________________

Diarrhea ............................................................

(492)

Bullae ............

(515)

Site: _________________________

Shock ............

(531)

Other .............

(532)

(486) (487) (488)

Visible blood in stools ......................................

(495)

Abdominal cramps ...........................................

(496)

Admission
date:

Mo.

Day

(500-514)
(516-530)

(554559)
(560565)

(specify): ______________________
(533-549)

5. Any sequelae? (e.g., amputation, skin graft)
If YES, describe:

Yr.

Discharge
date:

6. Did patient die?

(566)

Yes (1)

Yes (1)

No (2)

No (2)

Unk.(9)

(636)

If YES, date of death:
Mo.

Day

Yr.

Unk.(9)

(637-642)

(567-635)

7. Did patient take an
antibiotic as treatment
for this illness? (643) 1.
Yes

No

(1)

(systolic BP <90)

(482)

Yes (1)

Yes

(9)

Headache .....

4. Admitted to a hospital for this illness? (553)

3. Total
duration
of illness:

Unk.

(max. no. stools/24 hours: _____ ) (493-494)

am (1)
pm (2)

(480-1)

(2)

(489)

(483-5)

Mo.

No

Vibrio species: __________________________________

Date began antibiotic:

If YES, name(s) of antibiotic(s):

Mo.

8. Pre-existing
conditions?

Date ended antibiotic:

Yr.

Mo.

Day

Yr.

(644-646)

(647-652)

(653-658)

2.

(659-661)

(662-667)

(668-673)

3.

(674-676)

(677-682)

(683-688)

Unk.
(9)

Day

Yes
(1)

No
(2)

9. Was the patient receiving any of the following treatments or taking any of
the following medications in the 30 days before this Vibrio illness began?

Unk.
(9)

Yes

No

Unk.

Alcoholism ...............

(689)

Diabetes ..................

(690)

Peptic ulcer .............

(692)

Gastric surgery ........

(693)

type: _________________________________

Heart disease ..........

(710)

Heart failure?

Hematologic disease

(712)

type: _________________________________

(713-728)

Immunodeficiency ...

(729)

type: _________________________________

(730-745)

Liver disease ...........

(746)

type: _________________________________

(747-762)

Malignancy ..............

(763)

type: _________________________________

(764-779)

Renal disease .........

(780)

type: _________________________________

(781-796)

Other .......................
.......................

(797)

specify: _______________________________ (798-810)

(1)

(2)

(9)

on insulin?

Yes
(1)

(691)

(694-709)

(711)

No
(2)

Unk. If YES, specify treatment and dates:
(9)

Antibiotics ................

(811)

Chemotherapy .........

(831)

Radiotherapy ...........

(851)

Systemic steroids ..

(871)

Immunosuppressants

(891)

Antacids ...................
H2-Blocker or other
ulcer medication .......

(911)

(812-830)
(832-850)
(852-870)
(872-890)
(892-910)
(912-930)
(931)

(e.g., Tagamet, Zantac, Omeprazole)

(932-950)

III. EPIDEMIOLOGIC INFORMATION
1. Did this case occur as part of an outbreak? Yes (1) No (2) Unk. (9)
(Two or more cases of Vibrio infection )
(951)

If YES, describe:
(952-970)

2. Did the patient travel outside his/her home
state in the 7 days before illness began?
Yes
(1)

No
(2)

Unk.
(9)

(973)

Patient home state:

(971-972)

Mo.

City/State/Country

1.

If YES, list 2.
destination(s)
and dates:
3.

Date Entered
Day

Yr.

Mo.

Date Left
Day

(974-1004)

(1005-1010)

(1011-1016)

(1017-1047)

(1048-1053)

(1054-1059)

(1060-1090)

(1091-1096)

(1097-1102)

3. Please specify which of the following seafoods were eaten by the patient in the 7 days before illness began: (If multiple times, most recent meal)
Type of
Type of
Any eaten raw?
Mo.
Day
Yr.
seafood
Yes No Unk.
seafood
Mo.
Day
Yr.
Yes No Unk.
Yes No Unk.
(1)

(2)

(9)

(1)

(2)

(1)

(9)

Clams .....

(1103)

(1104-1109)

(1110)

Crab ........

(1111)

(1112-1117)

(1118)

Lobster ...

(1119)

(1120-1125)

(1126)

Mussels ..

(1127)

(1128-1133)

(1134)

Oysters ..

(1135)

(1136-1141)

(1142)

Yr.

(2)

(9)

Any eaten raw?

Yes
(1)

No
(2)

(9)

Shrimp .......

(1143)

(1144-1149)

(1150)

Crawfish ....

(1151)

(1152-1157)

(1158)

Other
shellfish .....

(1159)

(1160-1165)

(1166)

(specify): ______________________________________________________
Fish ...........

CDC 52.79 REV. 07/2000
(Page 2 of 4)
(CDC Adobe Acrobat 5.0 Electronic Version, 4/2006)

Unk.

(1192)

(1193-1198)

(specify): ______________________________________________________

CHOLERA AND OTHER VIBRIO ILLNESS SURVEILLANCE REPORT

(1167-1191)

(1199)
(1200-1225)

State:

Age:

III. EPIDEMIOLOGIC INFORMATION (CONT.)

Sex:

4. In the 7 days before illness began, was patient’s
skin exposed to any of the following?
Yes No
(1)

(2)

Unk.
(9)

A body of water (fresh, salt, or brackish water) ..

(1226)

Drippings from raw or live seafood .....................

(1227)

Other contact with marine or freshwater life ......

(1228)

Mo.

Day

Hour

Time of
exposure:

(1256-7)

If YES, specify body
of water location:

Yr.

Date of
exposure:

am (1)
pm (2)

(1258-9)

(1229-1242)

Yes
If YES to any of the
(1)
above, answer each:
Handling/cleaning seafood ..

No
(2)

Unk.

Yes

(9)

Swimming/diving/wading .....
Walking on beach/shore/
fell on rocks/shells ...............

(1250-5)

Min.

Vibrio species: _______________________________

Boating/skiing/surfing ...........

(1)

No
(2)

Unk.
(9)

(1243)

Construction/repairs .........

(1247)

(1244)

Bitten/stung .......................

(1248)

(1245)

Other: (specify) .................

(1249)

(1246)

____________________________________
(1261-1275)

(1260)

...........................................................................................................................................................................................................................................................

• If skin was exposed to water, indicate type:

Additional comments:

(1276)

Salt (1)

Brackish (3)

Unk. (9)

Fresh (2)

Other (8)
(specify): _______________________________________

(1277-1284)

(1285-1290)
...........................................................................................................................................................................................................................................................

• If skin was exposed, did the patient sustain a wound during this exposure, or have a pre-existing wound? (choose one): (1291)
YES, had a pre-existing wound. (2)

YES, sustained a wound. (1)

YES, uncertain if wound new or old. (3)

NO. (4)

Unk . (9)

If YES, describe how wound occurred and site on body :
(Note: Skin bullae that appear as part of the acute illness should be recorded in section II, Clinical Information, only).
(1292-1320)

If isolate is Vibrio cholerae O1or O139 please answer questions 5 - 8.
5. If patient was infected with V. cholerae O1 or O139, to which of the
following risks was the patient exposed in the 4 days before illness began:
Yes
(1)

No
(2)

Unk.
(9)

Yes
(1)

No
(2)

Unk.
(9)

Other person(s) with cholera or cholera-like illness ...............

(1324)

Raw seafood ................

(1321)

Street-vended food ................................................................

(1325)

Cooked seafood ..........

(1322)

Other ......................................................................................

(1326)

Foreign travel ...............

(1323)

(specify):
(1327-1350)

6. If answered “yes” to foreign travel (question III. 5),
had the patient been educated in cholera prevention measures before travel? ....................................................

Yes
(1)

No
(2)

Unk.
(9)

(1351)

If YES, check all source(s) of information received:
Pre-travel clinic (1352)

Friends (1355)

Travel agency (1358)

Airport (departure gate) (1353)

Private physician (1356)

CDC travelers’ hotline (1359)

Newspaper (1354)

Health department (1357)

Other (specify): (1360)
(1361-1400)

Yes (1)

7. If answered “yes” to foreign travel (question III. 5),
what was the patient’s reason for travel? (check all that apply)
To visit relatives/friends (1401)
Business (1402)
Tourism (1403)

No (2)

8. Has patient ever received a
cholera vaccine? ....................

Unk. (9)
(1428)

( If YES, specify type most recently received):

Other (specify): (1405) _____________________________

Oral (1429)

____________________________________________
(1406-1426)

Mo.

Unk. (1427)

Day

Parenteral (1430)
Yr.

Most recent
date:

Military (1404)

(1431-1436)

If domestically acquired illness due to any Vibrio species is suspected to be related to seafood
consumption, please complete section IV (Seafood Investigation).
ADDITIONAL INFORMATION or COMMENTS
CDC Use Only
Comment: (1444-1454)

Mo.

Person completing
section I - III:

Date:

Title/Agency:

Tel.:

Day

Source: (1443)

Syndrome: (1455)

Yr.
(1437-1442)

CDC Isolate No.

(1456-1463)

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0322). Do not send the completed form to this address.

CDC 52.79 REV. 07/2000 (Page 3 of 4)
CHOLERA AND OTHER VIBRIO ILLNESS SURVEILLANCE REPORT
(CDC Adobe Acrobat 5.0 Electronic Version, 4/2006)

(OVER)

State:

Age:

IV. SEAFOOD INVESTIGATION SECTION

Sex:

Vibrio species: _______________________________

For each seafood ingestion investigated, please complete as many of the following questions as possible.
(Include additional pages section IV if more than one seafood type was ingested and investigated.)
1. Type of seafood (e.g., clams):

Mo.

Date
consumed:

Day

Yr.

(1464-1480)

Time
consumed:

(1481-1486)

Hour

Min.

(1487-8)

(1489-90)

Amount
consumed:

am (1)
pm (2)
(1491)

(1492-1512)

If patient ate multiple seafoods in the 7 days before onset of illness, please note why this seafood was investigated (e.g.,consumed raw, implicated in outbreak investigation):

2. How was this fish or seafood prepared?
Raw (1)

Baked (2)

(1513)

Boiled (3)

Broiled (4)

Fried (5)

Steamed (6)

Unk. (9)

Other (8) (specify):_________________________________________
(1514-1530)

Yes (1)

3. Was seafood imported from another country?

No (2)

Unk. (9)

If YES, specify
exporting country if known: ______________________________________________________

(1531)

(1532-1554)

4. Was this fish or shellfish harvested by the patient or a friend of the patient?

Yes (1)

Unk. (9)
(1555)

(If YES, go to question 12.)

6. Name of restaurant, oyster bar, or food store:

5. Where was this seafood obtained? (1556) (Check one)
Oyster bar or restaurant (1)

Seafood market (4)

Truck or roadside vendor (2)

Other (8)
(specify): ______________________________________

Food store (3)

No (2)

Tel.:

Unk. (9)
Address:

(1557-1590)

7. If oysters, clams, or mussels were eaten, how were they distributed to the retail outlet? (1591)
Shellstock (sold in the shell) (1)

Shucked (2)

8. Date restaurant or food
outlet received seafood:

Mo.

Day

Unk. (9)

Other (8) (specify): _____________________________________________________________ (1592-1610)
9. Was this restaurant or
food outlet inspected as
part of this investigation?

Yr.
(1611-1616)

10. Are shipping tags available
from the suspect lot? (1618)

Yes
(1)

No
(2)

Unk.

Yes (1)

No (2)

Unk. (9)
(1617)

11. Shippers who handled suspected seafood: (please include certification numbers if on tags)

(9)

(Attach copies if available)
12. Source(s) of seafood:

13. Harvest site:

Date:

Mo.

Day

Status:

Yr.

(1640-1645)

(1619-1639)

(1688-1693)

(1667-1687)

(1646)

(1694)

Approved (1)

Conditional (3)

Prohibited (2)

Other (8) (specify): __________________________

Approved (1)

Conditional (3)

Prohibited (2)

Other (8) (specify): __________________________

(1647-1666)

(1695-1714)

14. Physical characteristics of harvest area as
close as possible to harvest date:
Maximum ambient temp. ........................(1715-1718)
Surface water temp. ...............................(1726-1727)

Date Measured
Mo.
Day
Yr.

Result

F (1)
C (2)

(1720-1725)

F (1)
C (2)

(1729-1734)

(1719)

(1728)

Salinity (ppt) ...........................................(1735-1736)

(1737-1742)

Total rainfall (inches in prev. 5 days) .....(1743-1744)

(1745-1750)

Fecal coliform count ...............................(1751-1755)

(1756-1761)

Yes (1)

No (2)

Unk. (9)

15. Was there evidence of improper storage, cross-contamination, or holding temperature at any point?

Person completing section IV:

(Attach copy of coliform data)

(1762)

Date:

If YES, specify deficiencies:

Mo.

Day

Yr.
(1763-1768)

Title/Agency:

Tel.:

CDC 52.79 REV. 07/2000
(Page 4 of 4)
CHOLERA AND OTHER VIBRIO ILLNESS SURVEILLANCE REPORT
(CDC Adobe Acrobat 5.0 Electronic Version, 4/2006)