Brucellosis Case Report Form

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Department of Health and Human Services Centers for Disease Control and Prevention Atlanta, GA 30033

Brucellosis Case Report Form

OMB number

Brucellosis Case Report Form General Instructions

Please complete as much of the form as possible. The instructions below explain each variable.

If you have questions, please contact Bacterial Special Pathogens Branch at (404) 639-1711.

Send the completed form with all personal identifiers removed to:

Mail:	Centers for Disease Control & Prevention ATTN: Bacterial Special Pathogens Branch Mailstop C09 1600 Clifton Rd NE Atlanta, GA 30333
Fax:	(404) 639-7080

Patient identifier information (NOT transmitted to CDC)

Patient Name	Patient’s full name
Phone	Patient’s phone number
Patient Chart Number	Medical chart number for patient
Address	Patient’s address including street and city
State, Zip	Patient’s state of residence and zip code
Hospital Name	Name of the hospital where the patient is admitted or seen

Information obtained for confirmed and probable brucellosis cases

Patient & Physician Information
State Case ID		Unique identifier given by the state health department.
Investigator		State health department investigator name.
Date Reported		Date the case was reported to state.
Physician		Primary health care provider name.
Phone		Primary health care provider phone number and/or pager.
NETSS Number		If case submitted to NETSS, include the NETSS-generated Case ID number.
Demographics
State of Residence		Use the 2 letter postal abbreviation (e.g., NY) of patient’s state of residence.
County of Residence		Patient’s county of residence.
Age		Age of patient at time of diagnosis; indicate age unit as months or years.
Sex		Genetic sex of patient (i.e., male or female).
Pregnant		Pregnancy status at time of diagnosis.
Country of Birth		Indicate original country of birth, including U.S. born. If unknown, please enter “Unknown”.
Ethnicity		Indicate ethnicity of patient.
Race		Race of patient as noted in the chart or reported by physician or infection control personnel (ICP). Multiple boxes may be checked. Do not make assumptions based on name or native language. If race is unknown, please check “Unknown”.
Occupation		Indicate occupation at time of disease onset. Specify past occupation(s) if relevant.
Clinical Information And Treatment
Disease Presentation		Disease presentation- a date determined by duration from onset of symptoms to date of diagnosis.
Symptoms and Associated Diagnoses		Select patient-described symptoms. Enter date of onset if known. If approximate date is known, enter rounded date (e.g., fever two weeks prior to seeking medical care on 9/17—enter 9/1).
Signs and Associated Diagnoses		Select signs identified upon examination. Enter date of diagnosis where known. Enter an approximate date if a precise date is unknown.
Hospitalized?		Indicate whether the patient was admitted to a hospital due to this illness. Enter admission and discharge date, if applicable.
Deceased?		Indicate if the patient died of this illness. Enter date if applicable.
Treatment and Duration		Select whether the patient has completed their treatment. Select the prescribed antimicrobial agents, amount, and duration for each. If prescribed other antimicrobials, enter the generic name, amount, and duration, if known. NOTE: If an agent is taken twice daily, enter the total prescribed mg/day (e.g., 100 mg BID- enter 200 mg/day).
Risk Factors
Travel			Select whether the patient traveled out of state or country in the past six months, and where and when if applicable.
Animal Contact			Select which animals and type of contact, if any, the patient had in the past 6 months.
Unpasteurized Dairy			Select if the patient consumed unpasteurized (raw) dairy in the past six months. Choose type of animal, owner of the animal the dairy came from, what products were eaten, and location of product.
Confirmed Case			Select if the patient is linked to a confirmed case. If yes, select the relationship to the patient.
Similar Illness			Select if the patient is aware of a contact having a similar illness. If yes, select the relationship to the patient.
Risk Status			If the patient had a known exposure to Brucella, indicate the exposure source and the location of exposure. Also indicate the assessed risk status of the exposure. Finally, if exposed to a Brucella vaccine, indicate to which vaccine the case was exposed. The CDC exposure guidelines are available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5702a3.htm. If a laboratory exposure did occur, review these assessment, monitoring, and prophylaxis recommendations. For assistance, contact CDC at the phone number listed on page one.
Received Post-Exposure Prophylaxis (PEP)			If the patient was exposed to Brucella, indicate if the patient took PEP, or reasons for not taking PEP.
Completed PEP			If exposed, indicate if the patient completed the entire course of PEP as prescribed. CDC recommended PEP regimen is doxycycline 100 mg orally twice a day plus rifampin 600 mg orally once a day for 21 days.
Laboratory Data
NOTE: Complete a new Laboratory Data section for each laboratory receiving and processing patient samples. Leave the test field blank for each test not performed.
Case Status	Indicate case classification. Confirmed and Probable cases must be reported to NETSS by the next regularly scheduled transmission cycle. CDC must be notified of multiple cases which are temporal/spatial clusters within 24 hours of the cases meeting the notification criteria (CSTE Position Statement 09-SI-04).
Laboratory Name	Enter the laboratory name and address which processed the sample. For each laboratory that processed the sample, start a new laboratory section. Submit a copy of page four for each laboratory involved in testing.
Received From	Enter the name, city, and state of the laboratory from which the specimen is received; include date of receipt.
Paired Serologic Tests	If a paired agglutination test was done, enter results in this table. If known, enter the agglutination test (SAT, BMAT, Tube AT). Indicate which titers were run- total antibody (complete) and/or IgG (reduced). Enter in the acute and convalescent titers. Indicate if one, both, or paired titers are positive. Enter the testing laboratory’s positive cut-off value for the test. If a single titer was done, enter as an acute titer. For ELISA, indicate if IgG, IgM, or both titers were run. Enter in the acute and convalescent titers and if one, both, or paired titers are positive. Enter the testing laboratory’s positive cut-off value for the test.
Date Collected	Enter the dates the acute and convalescent samples were collected.
Other Serologic Tests	Enter the value or titer in the row of the test completed, and whether the test was considered positive. If the test used is not listed, enter name and results in “Other”. Indicate the laboratory’s positive cut-off value for the test.
Other Tests	Select whether PCR and/or culture was attempted. Indicate the source of specimen used for the specified test. Enter the date of specimen collection, if the test was positive, and the species identified (e.g.: abortus, canis, melitensis, suis, other).
Specimen Cultured	Indicate if the specimen for culture was collected prior to administration of antimicrobial therapy.
Isolate Reported to CDC	Indicate if a culture-positive result of a select agent was reported to CDC, as required by regulation. Reporting requirements and forms are available at http://www.selectagents.gov/.
Laboratory Exposure	Select if laboratory workers were possibly exposed during specimen processing. The CDC exposure guidelines are available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5702a3.htm. If a laboratory exposure did occur, review these assessment, monitoring, and prophylaxis recommendations. For assistance, contact CDC at the phone number listed on page one.
Exposure Reported to CDC	If a laboratory exposure occurred, indicate if the “release” of a select agent was reported to CDC, as required by regulation. Reporting requirements and forms are available at http://www.selectagents.gov/.
Specimens to CDC	Indicate if the specimen was sent to CDC for testing.
Specimen available	Indicate if the specimen is still available, if needed for future testing.

-Brucellosis Case Report Form-

Case Name

Phone

Medical Chart No.

Address

State, ZIP

Hospital Name

R emove case identifier information prior to transmission to CDC.

Department of Health and Human Services Centers for Disease Control and Prevention Atlanta, GA 30033

Brucellosis Case Report Form

Form Approved OMB No. 0920-0004 Exp. Date 6/30/2013

- CASE & PHYSICIAN INFORMATION -

State Case ID

Physician

Phone Number

Investigator

NETSS ID No (if notified):

__ __ __ __ __ __--__ __ __--- __ __ CASE ID SITE STATE

Date Reported

___/___/_______

- DEMOGRAPHICS -

State of Residence

_____

County of Residence

__________________

Age

____  mo  yrs

Sex

 Male  Female  Unknown

Pregnant

 Yes  No  Unknown

Country of Birth

_____________________

Ethnicity

 Hispanic  Non-Hispanic  Unknown

Race  American Indian/ Alaskan Native  Asian/Pacific Islander  Black  White  Unknown Other:___________________

Occupation  Animal research  Medical research  Dairy  Laboratory  Wildlife  Rancher  Slaughterhouse  Tannery/rendering  Veterinarian/Vet Tech  Lives with person of above occupation  Other ___________________________

- CLINICAL INFORMATION AND TREATMENT -

Disease Presentation

 Acute (0-8 weeks)  Subacute (8 weeks - <1 yr)  Chronic (1 yr+)  Unknown

Symptoms, Signs, and Associated Diagnoses (indicate date of onset or diagnosis):

Yes

No

Unk

Symptom

Date Onset

Yes

No

Unk

Symptom/Sign

Date Diagnosis

Yes

No

Unk

Signs

Date of Diagnosis







Fever

_ _ / _ _ / _ _ _ _







Anorexia

_ _ / _ _ / _ _ _ _







Hepatomegaly

_ _ / _ _ / _ _ _ _

Max temp:______

(circle) °F or °C







Myalgia

_ _ / _ _ / _ _ _ _







Splenomegaly

_ _ / _ _ / _ _ _ _







Night sweats

_ _ / _ _ / _ _ _ _







Weight loss

_ _ / _ _ / _ _ _ _







Arthritis

_ _ / _ _ / _ _ _ _







Arthralgia

_ _ / _ _ / _ _ _ _







Endocarditis

_ _ / _ _ / _ _ _ _







Meningitis

_ _ / _ _ / _ _ _ _







Headache

_ _ / _ _ / _ _ _ _







Orchitis

_ _ / _ _ / _ _ _ _







Spondylitis

_ _ / _ _ / _ _ _ _







Fatigue

_ _ / _ _ / _ _ _ _







Epididymitis

_ _ / _ _ / _ _ _ _







Other:___________

_ _ / _ _ / _ _ _ _

Was the case hospitalized because of this illness?

 Yes  No  Unknown

If yes, admission date:

_ _ / _ _ / _ _ _ _

If applicable, discharge date:

_ _ / _ _ / _ _ _ _

Is the case deceased?

 Yes  No  Unknown

If yes, date of death:

_ _ / _ _ / _ _ _ _

Treatment and Duration (check all that apply):  Currently under treatment  Completed treatment  Not treated

 Doxycycline

mg/day

days

 Other:

mg/day

days

 Rifampin

mg/day

days

 Other:

mg/day

days

 Streptomycin

mg/day

days

 Other:

mg/day

days

- RISK FACTORS -

In the 6 months prior to illness onset, did the case:

Travel outside state of residence?  Yes  No  Unknown

If Yes, where? _____________________________________

Dates of travel ___/___/_______ to ___/___/_______

If Yes, where? _____________________________________

Dates of travel ___/___/_______ to ___/___/_______

Have contact with animals?  Yes  No  Unknown

Who owns the animal(s)?

Type of contact

Cattle

Pig

Goat

Sheep

Dog

Deer

Bison

Elk

Other

Case

Private

Wild

Commercial

Unknown

Birthing/animal products

















 ________











Skinning/slaughter

















 ________











Hunting

















 ________











Other:______________

















 ________











Consume unpasteurized dairy or undercooked meat?  Yes  No  Unknown

In what country was the product acquired?

Type of food product

Cattle

Pig

Goat

Sheep

Dog

Deer

Bison

Elk

Other

U.S.

Other

Other

Milk

















 ________



 ______________

 ______________

Fresh/soft cheese

















 ________



 ______________

 ______________

Undercooked meat

















 ________



 ______________

 ______________

Other: _____________

















 ________



 ______________

 ______________

Have a link to a confirmed case?  Yes  No  Unknown

Who?

 Household  Neighbor  Coworker  Other:_________________________

Know of similar illness in contact?  Yes  No  Unknown

Have an exposure to a Brucella?

 Clinical specimen  Isolate  Vaccine  Unknown

Where did the exposure occur?

 Clinical setting  Laboratory  Farm/Ranch  Surgery  Unknown  Other:_________________

Exposure Risk Status:

 High  Low  Unknown

If exposed to vaccine, Indicate which:

 S19  RB51  Rev1  Other

Receive post-exposure prophylaxis (PEP)?

 Yes  No  Unknown

If no, why not?

 Unaware of exposure  Unavailable  Allergic  Pregnant  Unknown  Other: ____________________________

If yes, did case complete course?

 Yes  No  Unknown  Partial explain:_____________________________________________

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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).

-CASE DEFINITION (2010) -

Confirmed: A clinically compatible illness with definitive laboratory evidence (i.e.: culture and identification of Brucella spp. from clinical specimens OR serological evidence of a fourfold rise in Brucella antibody titer in paired acute and convalescent serum specimens greater than or equal to 2 weeks apart). Probable: A clinically compatible illness epidemiologically linked to a documented Brucella case OR has presumptive laboratory evidence (i.e.: Brucella total antibody titer of greater than or equal to 160 by standard tube agglutination test (SAT) or Brucella microagglutination test (BMAT) in one or more serum specimens obtained after onset of symptoms OR detection of Brucella DNA in a clinical specimen by PCR assay).

- LABORATORY DATA -

NOTE: Complete a new Laboratory Data section for each laboratory receiving and processing case samples. Print extra copies if necessary. Leave the test field blank for each test not performed.

Case Status  Culture confirmed  Serologically confirmed  Probable

Laboratory Name:

City:

State:

Zip:

Received From:

City:

State:

Date Received:

_ _ / _ _ / _ _ _ _

Below, indicate Yes or No only if the test or procedure was performed. Lack of selection indicates that the test was not performed.

Paired Serologic Tests

Titers

Acute Titer

Convalescent Titer

Positive?

Positive Cut-off:

Agglutination Test:______________

 Total antibody  IgG

__:_____ __:_____

__:_____ __:_____

 Yes  No  Unknown  Yes  No  Unknown

ELISA: ___________

 IgG  IgM

__:_____ __:_____

__:_____ __:_____

 Yes  No  Unknown  Yes  No  Unknown

Date Sample Collected:

Acute: _ _ / _ _ / _ _ _ _

Convalescent: _ _ / _ _ / _ _ _ _

Other Serologic Tests

Titer or Value

Positive?

Positive Cut-off

Rose Bengal

__:_____

 Yes  No  Unknown

Coombs IgG

__:_____

 Yes  No  Unknown

Other: ___________________

__:_____

 Yes  No  Unknown

Other: ___________________

( _ _ _ _ )

 Yes  No  Unknown

Other Tests

Source of Specimen

Date Collected

Positive?

Species

PCR

 Blood  Abscess/wound  Bone Marrow  CSF  Other: ___________

_ _ / _ _ / _ _ _ _

 Yes  No  Unknown

Culture

 Blood  Abscess/wound  Bone Marrow  CSF  Other: ___________

_ _ / _ _ / _ _ _ _

 Yes  No  Unknown

Was the specimen for culture collected prior to antimicrobial therapy?

 Yes  No  Unknown

If culture positive, was the identification of a select agent reported to CDC?

 Yes  No  Unknown

Did a possible laboratory exposure occur?

 Yes  No  Unknown

If yes, was it reported to CDC?

 Yes  No  Unknown

Were specimens sent to CDC for testing?

 Yes  No  Unknown

Is the specimen still available?

 Yes  No  Unknown