Pediatric Death Case Report

Influenza-Associated Pediatric Deaths Case Report Form

Form approved

OMB No. 0920-0007

STATE USE ONLY – DO NOT SEND INFORMATION IN THIS SECTION TO CDC
Last Name:	___________________________________	First Name: ______________________	County: _____________________
Address:		City:	State, Zip:

Patient Demographics
1. State:			2. County:		3. State ID:		4. CDC ID:
5. Age: _____		О Days О Months О Years	6. Date of birth: _______/ _______/ ________ MM DD YYYY			7.Sex: О Male О Female О Unkown	8. Ethnicity:		О Hispanic or Latino О Not Hispanic or Latino О Unknown
9. Race:	 White  Black  Asian  Native Hawaiian or Other Pacific Islander  American Indian or Alaska Native  Unknown
Death Information
10. Date of illness onset: _______/ _______/ _______ MM DD YYYY				11. Date of death: _______/ _______/ _______ MM DD YYYY				12. Was an autopsy performed? О Yes О No О Unknown
13 a. Did cardiac/respiratory arrest occur outside the hospital? О Yes О No О Unknown 13 b. Location of death: О Outside the Hospital (e.g. home or in transit to hospital) О Emergency Dept (ED) О Inpatient ward О ICU О Other (specify): _______________ 13 c. If the death occurred in the hospital, what was the date of admission? _______/ _______/ _______ MM DD YYYY
CDC Laboratory Specimens
14 a. Were pathology specimens sent to CDC’s Infectious Diseases Pathology Branch? О Yes О No О Unknown Please provide the lab ID No. if known­­­­­­­___________ 14 b. Were influenza isolates or original clinical material sent to CDC’s Influenza Division? О Yes О No О Unknown Please provide the lab ID No. if known­­­­­­­___________ 14 c. Were Staph aureus isolates sent to CDC’s Division of Healthcare Quality Promotion? О Yes О No О Unknown Please provide the lab ID No. if known­­­­­­­___________

Influenza Testing (check all that were used)
Test Type	Result	Specimen Collection Date
15.  Commercial rapid diagnostic test	О Influenza A О Influenza B О Negative О Influenza A/B (Not Distinguished) О 2009 Influenza A (H1N1) О Influenza virus co-infection (specify)______________	_____/ _____/ _____
 Viral culture	О Influenza A (Subtyping Not Done) О Influenza B О Negative О Influenza A (Unable To Subtype) О Influenza A (H1) О Influenza A (H3) О 2009 Influenza A (H1N1) О Influenza virus co-infection (specify)______________	_____/ _____/ _____
 Fluorescent antibody (IFA or DFA)	О Influenza A (Subtyping Not Done) О Influenza B О Negative О Influenza A (Unable To Subtype) О Influenza A (H1) О Influenza A (H3) О 2009 Influenza A (H1N1) О Influenza virus co-infection (specify)______________	_____/ _____/ _____
 Enzyme immunoassay (EIA)	О Influenza A (Subtyping Not Done) О Influenza B О Negative О Influenza A (Unable To Subtype) О Influenza A (H1) О Influenza A (H3) О 2009 Influenza A (H1N1) О Influenza virus co-infection (specify)______________	_____/ _____/ _____
 RT-PCR	О Influenza A (Subtyping Not Done) О Influenza B О Negative О Influenza A (Unable To Subtype) О Influenza A (H1) О Influenza A (H3) О 2009 Influenza A (H1N1) О Influenza virus co-infection (specify)______________	_____/ _____/ _____
 Immunohistochemistry (IHC)	О Influenza A О Influenza B О Negative О Influenza virus co-infection (specify)______________	_____/ _____/ _____

Culture confirmation of bacterial pathogens from STERILE (Invasive) SITES
16 a. Was a specimen collected for bacterial culture from a normally sterile site (e.g., blood, cerebrospinal fluid [CSF], tissue, or pleural fluid			О Yes О No О Unknown
16 b. If yes, please indicate the site from which the specimen was obtained and the result. If more than one specimen type is positive and more than one organism is identified please indicate the organism cultured from each specimen type in the comments section. Specimen Type Collection Date Result  Blood Date __/__/__ О Positive О Negative О Unknown  Pleural fluid Date __/__/__ О Positive О Negative О Unknown  CSF Date __/__/__ О Positive О Negative О Unknown  Other ____________________ Date __/__/__ О Positive О Negative О Unknown  Unknown
16 c. If positive, please check the organism cultured.
 Streptococcus pneumoniae	 Staphylococcus aureus, methicillin sensitive (MSSA)	 Haemophilus influenzae not-type b
 Group A streptococcus	 Staphylococcus aureus, methicillin resistant (MRSA)	 Haemophilus influenzae type b
 Other bacteria: ________________________ (If reporting another viral co-infection please do so in section 19 Clinical Diagnosis and Complications)	 Staphylococcus aureus, sensitivity not done	 Pseudomonas aeruginosa

Culture confirmation of bacterial pathogens from NON-STERILE SITES
16 d. Were other respiratory specimens collected for bacterial culture (e.g., sputum, ET tube aspirate)?			О Yes О No О Unknown
16 e. If yes, please indicate the site from which the specimen was obtained and the result. If more than one specimen type is positive and more than one organism is identified please indicate the organism cultured from each specimen type in the comments section. Specimen Type Collection Date Result  Sputum Date __/__/__ О Positive О Negative О Unknown  ET tube Date __/__/__ О Positive О Negative О Unknown  Other ____________________ Date __/__/__ О Positive О Negative О Unknown  Unknown
16 f. If positive, please check the organism cultured.
 Streptococcus pneumoniae	 Staphylococcus aureus, methicillin sensitive (MSSA)	 Haemophilus influenzae not-type b
 Group A streptococcus	 Staphylococcus aureus, methicillin resistant (MRSA)	 Haemophilus influenzae type b
 Other bacteria: ________________________ (If reporting another viral co-infection please do so in section 19 Clinical Diagnosis and Complications)	 Staphylococcus aureus, sensitivity not done	 Pseudomonas aeruginosa

Pathology confirmation of bacterial pathogens
16 g. Was a specimen (e.g., fixed lung tissue) collected from an autopsy for testing of bacterial pathogens by a local or state pathologist? (If pathology results are available from CDC it is not necessary to input those results here, however please make sure to complete section 14 “CDC Laboratory Specimens”)	О Yes О No О Unknown
If yes please indicate the results of these tests in the comments section at the end of the form.

Medical Care
17. Did the patient require mechanical ventilation?	О Yes О No О Unknown

Clinical Diagnoses and Complications
18 a. Did complications occur during the acute illness? О Yes О No О Unknown 18 b. If yes, check all complications that occurred during the acute illness:
 Pneumonia (Chest X-Ray confirmed)		 Acute Respiratory Disease Syndrome (ARDS)			 Croup		 Seizures
 Bronchiolitis		 Encephalopathy/encephalitis			 Reye syndrome		 Shock  Sepsis
 Another viral co-infection: ___________________________				 Other: _________________________________________________
19 a. Did the child have any medical conditions that existed before the start of the acute illness? О Yes О No О Unknown 19 b. If yes, check all medical conditions that existed before the start of the acute illness:
 Moderate to severe developmental delay	 Hemoglobinopathy (e.g. sickle cell disease)					 Asthma/ reactive airway disease
 Diabetes mellitus	 History of febrile seizures		 Seizure disorder			 Cystic fibrosis
 Cardiac disease (specify) _____________			 Renal disease (specify) ___________			 Skin or soft tissue infection (SSTI)
 Chromosomal Abnormality (specify) _______________			 Mitochondrial Disorder (specify) ________________________
 Chronic pulmonary disease (specify) _____________			 Immunosuppressive condition (specify) ___________
 Metabolic disorder (specify) _______________			 Neuromuscular disorder (including cerebral palsy) (specify) ________________
 Pregnant (specify gestational age) _______ weeks			 Other (specify) ______________________

Medication and Therapy History
20 a. Was the patient receiving any of the following therapies in the 7 days prior to illness onset or after illness onset? (check all that apply)		20 b. Was the patient receiving any of the following therapies prior to illness onset? (check all that apply)
 Aspirin or aspirin-containing products	 NSAID or NSAID-containing products	Antiviral Prophylaxis	 Chemotherapy or radiation therapy	 Steroids by mouth or injection	 other immunosuppressive therapy:__________
20 c. Was the patient receiving any of the following therapies after illness onset? (Check all that apply)  Antibiotic therapy specify___________  Antiviral therapy specify___________

Influenza Vaccine History
21. Did the patient receive any seasonal influenza vaccine during the current season (before illness)								О Yes О No О Unknown
22. If YES*, please specify the seasonal influenza vaccine received before illness onset:					 Trivalent inactivated influenza vaccine (TIV) [injected]
					 Live-attenuated influenza vaccine (LAIV) [nasal spray]  Unknown
23. If YES for seasonal vaccine*, how many doses did the patient receive and what was the timing of each dose? (Enter vaccination dates if available)
О 1 dose ONLY	 <14 days prior to illness onset  >14 days prior to illness onset		Date dose given:_______/ _______/ ______ MM DD YYYY
О 2 doses	 2nd dose given <14 days prior to onset  2nd dose given >14 days prior to onset		Date of 1st dose: _______/ _______/______ MM DD YYYY							Date of 2nd dose: ______/ ______/ ______ MM DD YYYY
24 a. Did the patient receive any influenza vaccine in previous seasons?							О Yes О No О Unknown
24 b. If YES, and patient was ≤8 years of age at the time of death, did they receive 2 doses of vaccine during a previous season?							О Yes О No О Unknown
25. Did the patient receive any 2009 Influenza A (H1N1) vaccine during the current season (before illness)											О Yes О No О Unknown
26. If YES*, please specify the 2009 Influenza A (H1N1) vaccine received before illness onset:						 Trivalent inactivated influenza vaccine (TIV) [injected]
						 Live-attenuated influenza vaccine (LAIV) [nasal spray]  Unknown
27. If YES for 2009 Influenza A (H1N1) vaccine *, how many doses did the patient receive and what was the timing of each dose? (Enter vaccination dates if available)
О 1 dose ONLY		 <14 days prior to illness onset  >14 days prior to illness onset		Date dose given:_______/ _______/ ______ MM DD YYYY
О 2 doses		 2nd dose given <14 days prior to onset  2nd dose given >14 days prior to onset		Date of 1st dose: _______/ _______/______ MM DD YYYY					Date of 2nd dose: ______/ ______/ ______ MM DD YYYY
Submitted By: ____________________________________________________________ Date: _______/ _______/ _______ Phone No.: ( )___-______ MM DD YYYY E-mail Address: ____________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0007).

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