Form CDC 54.1 CDC 54.1 Malaria Case Surveillance Report

MALARIA CASE SURVEILLANCE REPORT

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

Division of Parasitic Diseases (MS F-22), 4770 Buford Highway, N.E. Atlanta, Georgia 30341

Part I

State Case No: ....................... CSID No................................ Case No: .........................

Patient name (last, first): Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____				Age: _______ yrs. mos. wks. days (circle units) Date of Birth: ____/ ____/ ________ Is patient pregnant? Yes No Height: __ ft. and __ in. Weight:____ lbs./kgs (circle units)							Sex: Male Female Unknown
Physician name (last, first): Telephone Number: ( ) _________ – ___________				Ethnicity: Hispanic or Latino Not Hispanic or Latino				Race (select one or more): American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Black or African American Asian White Unknown
Positive lab test result (check all that apply): Smear PCR RDT No test done/unknown Species (check all that apply): Vivax Falciparum Malariae Ovale Not Determined Other species (specify) __________________ Parasitemia (%): _______________________
				State/territory reporting this case: ___________________ County: ___________________ Patient admitted to hospital: Yes No Unknown Hospital: _______________________________________ Date: ____/ ____/ ________ Hospital record No.: ________
Laboratory name: Telephone Number: ( ) _________ – ___________				Specimens being sent to CDC? Yes No Unknown If yes: Smears Whole Blood Other: _______________
Has the patient traveled or lived outside the U.S. during the past 2 years? Yes No If yes, specify:
Country:		1. ________________				2. _________________			3. ___________________
Date returned/ arrived in U.S. (mm/dd/yyyy):		____/ ____/ ______				____/ ____/ ________			____/ ____/ ________
Duration in country yrs. mos. wks. days (circle units)		_________________				__________________			___________________
Did patient reside in U.S. prior to most recent travel?			Principal reason for travel from/ to U.S. for most recent trip:
Yes No, (specify country): _____________________ Unknown			Tourism Military Business Peace Corps				Visiting friends/relatives Airline/ship crew Missionary or dependent Refugee/immigrant			Student/teacher Other: ____________ Unknown
Was malaria chemoprophylaxis taken? Yes No Unknown If yes, which drugs were taken? Chloroquine Mefloquine Doxycycline Primaquine  Atovaquone/proguanil Other: ______________________________ Unknown
Was chemoprophylaxis taken as prescribed? Yes, missed no doses No, missed doses Unknown	If doses were missed, what was the reason? Forgot Didn’t think needed Had a side effect (specify): ________________ Was advised by others to stop Prematurely stopped taking once home Other (specify): _________________________ Unknown				History of malaria in last 12 months (prior to this report)? Yes No Unknown Date of previous illness: ____/ ____/ ________ If yes, species (check all that apply): Vivax Falciparum Malariae Ovale Not Determined Other (specify) _____________
Blood transfusion/organ transplant within last 12 months: Yes No Unknown If yes, date: ____/ ____/ ________
Clinical Cerebral malaria ARDS None Was illness fatal: Yes No Unknown Complications: Renal failure Severe anemia(Hb<7) Other : ____________ If yes, date of death : _____/____/_______ Therapy for this attack (check all that apply): Chloroquine Tetracycline Doxycycline Mefloquine Exchange transfusion Artesunate Artemether/lumefantrine Unknown Primaquine Quinine Quinidine Clindamycin Atovaquone/proguanil Other (specify): ____________________________ Person submitting report: Telephone No. : Affiliation: Date Submitted: __________/__________/_____________ For CDC Use Only. Classification Imported Induced Introduced Congenital Cryptic Public reporting burden of this collection of information is estimated to average 15 minutes per response. 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. Please 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 Rd., NE (MS D-24); Atlanta, GA 30333; ATTN: PRA (0920-0009).

Physicians and other health care providers with questions about diagnosis and treatment of malaria cases

can call CDC’s Malaria Hotline:

- Monday – Friday, 9:00 am to 5 pm, EST: call 770-488-7788 (Fax: 770-488-4206)

- Off-hours, weekends, and federal holidays: call 770-488-7100 and ask to have the malaria clinician on call paged.

Information on malaria risk, prevention, and treatment is available at:

CDC’s Malaria Web site http://www.cdc.gov/malaria

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Part II (to be complete 4 weeks after treatment)

Please list all prescription and over the counter medicines the patient had taken during the 2 weeks before starting their treatment for malaria. ______________________________________________________________________________________________________________
Please list all prescription and over the counter medicines the patient had taken during the 4 weeks after starting their treatment for malaria. ______________________________________________________________________________________________________________
Was the medicine for malaria treatment taken as prescribed? No, doses missed Yes, no doses missed Unknown
Did all signs or symptoms of malaria resolve without any additional malaria treatment within 7 days after treatment start? Yes No Unknown	If yes, did the patient experience a recurrence of signs or symptoms of malaria during the 4 weeks after starting malaria treatment? Yes No Unknown
Did the patient experience any adverse events within 4 weeks after receiving the malaria treatment? Yes No Unknown (If Yes): Event description Relationship Time to Fatal? Life- Other to treatment Onset since Threatening? Seriousness?** suspected* treatment start 1 ________________________________________ __________ 2 ________________________________________ __________ 3 ________________________________________ __________ 4 ________________________________________ __________ 5 ________________________________________ __________ * Suspected means that a causal relationship between the treatment and an adverse event is at least a reasonable possibility, i.e., the relationship cannot be ruled out. ** A serious adverse event is defined as an event which is fatal or life-threatening, results in persistent or significant disability/incapacity, constitutes a congenital anomaly/birth defect, is medically significant (i.e., jeopardizes the patient or may require medical or surgical intervention), or requires inpatient hospitalization or prolongation of existing hospitalization

CDC 54.1 XX/XXXX (Front) OMB 0920-0009

If sending specimens, please forward blood smears (thick and thin) with this report.