Form NAHMS-317 EHV-1 Study Questionnaire

USDA State FIPS code: _____

Use Only Assigned premises #: __________ Horse #: __________ Project: ______________

Form Approved

OMB Number 0579-0399

Expires XX/XXXX

EHV-1 Study

Animal and Plant Health

Inspection Service

Veterinary Services

Questionnaire

Please complete a separate Questionnaire for each EHV/EHM suspect or confirmed case or control horse identified in the outbreak.

Date questionnaire completed:

Owner name:

Trainer name:

Horse’s registered name:

Horse’s barn name:

Premises where horse resides:

Facility name:

City/State:

:

Is this horse part of an EHV/EHM outbreak? ₁ Yes ₃ No

IF YES, what is the likely place of exposure to EHV (including event name, location, city, and State)?

_________________________________________________________________________________

NAHMS-317

Mar 2013

If you have not read the instructions,
please do so before completing the survey.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0399. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected.

INSTRUCTIONS: Answer questions based on the horse’s status at the time of disease

DATE Survey Completed: _________ date

Section 1—Horse Information/Signalment

1. Gender: C100

₁ Gelding

₂ Stallion

₃ Nonpregnant mare

₄ Pregnant mare

2. Breed: [Check only one.]

₁ Appaloosa ₈ Standardbred

₂ Arabian ₉ Tennessee Walker

₃ Draft breed ₁₀ Thoroughbred

₄ Morgan ₁₁ Quarter horse

₅ Mustang ₁₂ Warmblood breed

₆ Paint ₁₃ Other registered breed (specify:__________________)

₇ Saddlebred ₁₄ Other non-registered breed (specify:______________)

3. Age (in years) C102 _____ yrs

4. What is the primary use of this horse? [Check only one.] C103

₁ Recreation/pleasure ₅ Racing

₂ Lessons/school ₆ Farm or ranch work

₃ Showing/competition ₇ Other (specify:

₄ Breeding ___________________________________________) C103OTH

5. In how many events did this horse compete in the 30 days prior to February 15, 2013? C104 _____ #
(e.g., show, race, western performance, organized trail ride.)

6. What was the average level of exercise¹ in the 30 days prior to February 15, 2013? [Check only one.] C106

₁ Light

₂ Moderate

₃ Heavy

₄ Very heavy

7. How was this horse typically housed/maintained in the 30 days prior to February 15, 2013?

[Check all that apply.]

 Stall C107

 Paddock/corral C108

 Pasture C109

 Other (specify: _____________________________________) C110OTH C110

8. Was this horse receiving supplements added to the regular feed ration in
the 30 days prior to February 15, 2013? C111 ₁ Yes ₃ No

If YES, provide the specific name(s) of the supplements given and amount(s)

given/day:

	Amount fed per feeding
Product Name	Amount	Unit type	Number of times per day	In months, time on product
Example: Platinum performance CJ	1	1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)	15 months
		1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)
		1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)
		1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)
		1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)
		1 Ounce(s) 2 Scoop(s) 3 IU(s) 4 ML(s) 5 Other (specify)	1 Once a day 2 Twice a day 3 Other (specify)

9. Did this horse commingle with other horses outside of
its herdmates between February 1 and February 15, 2013? ₁ Yes ₃ No

[If item 9 = No, skip to Section 2.]

10. List the name(s) and location(s) of event/show/trail ride, race, etc) where

horses commingled between February 1 and February 15, 2013:
_______________________________________________________________________________

11. Which of the following interactions when at events applied to this horse during the most recent event (e.g., show, race, competition, western, organized trail ride)? [Check all that apply.]

 Tied in barn outside of stall C350

 Used a shared water source C351

 Grazed on facility grounds C352

 Utilized a wash rack C353

 Had veterinary treatment or examination C354

 Was worked on by a farrier C355

 Other (specify: ______________________________________) C356OTH C356

Section 2—Clinical Information

1. Has this horse shown any clinical signs of illness, such as a
fever (temp >101.5°F) or neurologic signs, since February 15, 2013? ₁ Yes ₃ No

[If NO, skip to Section 3.]

2. What was the date of onset of illness? Cxx __________ date

3. Has this horse had a rectal temperature greater than 101.5°F
since February 15, 2013? C402 ₁ Yes ₃ No ₉ No temp taken

[If No or No Temperature Taken, skip to Item 7.]

4. What was the date of onset of fever? C403 __________ date

5. What was the highest temperature documented during

the course of disease? C404 __________ temp

6. What was the date of last fever? C405 __________ date

7. Has the horse exhibited neurologic signs since February 15, 2013? C406 ₁ Yes ₃ No

[If NO, skip to Item 10.]

8. What was the date of onset of neurologic signs? C407 __________ date

9 Of the following neurologic signs listed, check all that were observed
in this horse since February 15, 2013. [Check all that apply.]

 Incoordination/wobbly gait C500

 Dogsitting C501

 Down (unable to rise) C502

 Exaggerated limb movements, either when walking or while down C503

 Stumbling/falling C504

 Circling C505

 Disorientation C506

 Lethargic C507

 Urine dribbling C508

 Flaccid tail C509

 Other (specify: _____________________________________) C510OTH C510

10. Of the following clinical signs, check all that were observed
in this horse since February 15, 2013: [Check all that apply.]

 Nasal discharge C511

 Coughing C512

 Off feed C513

 Excessive sweating C514

 Colic C515

 Limb edema/stocking up C516

 Abortion C516a

 Other (specify: ______________________________________) C517OTH C517

11. On what date did this horse: (write in n/a if not applicable)

a. fully recover? __________ date

b. return to previous performance level? __________ date

c. died or was euthanized? __________ date

If the horse died or was euthanized, please attach a copy of the necropsy
report and any laboratory results.

Section 3—Travel Information

1. In the 30 days PRIOR to February 15, 2013, list the location or event and the number of
miles this horse was transported:

Location or event	Total miles (round trip)	Dates
C602	C608
C603	C609
C604	C610
C605	C611
C606	C612
C607	C613

2. When traveling by trailer/van, on average, how many hours does

the horse travel before resting/unloading? C614 _____ hrs

3. In general, which of the following best describes this horse’s response to

the stress of travel? [Check the most appropriate description.] C615

₁ Tends to get more stressed than the average horse

₂ About average for a horse

₃ Very tolerant of travel and does not appear stressed compared to other horses

Section 4—Vaccination Information

1. In the 12 months PRIOR to February 15, 2013, was this horse

vaccinated against equine herpesvirus 1 (EHV-1; also called Rhino)? C700 ₁ Yes ₃ No

If YES, list the dates, product code, and product name used to vaccinate this horse against EHV-1.

It is important to provide the specific product name or category of vaccine because

they vary in content and mechanism of action. [If you cannot remember specific product

names, please check with the horse’s veterinarian and provide at least the category of

vaccine used, i.e., modified live vaccine, killed EHV product labeled for prevention

of abortion/respiratory disease, killed product labeled for prevention of respiratory disease.]

Product names and codes can be found on the last 2 pages of this questionnaire.

Product code	Trade name	Date(s) given in last 12 months (mm/dd/yy)
Example 3	Calvenza eiv/ehv	5/14/2012 7/18/2012 ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________
		___________ ___________ ___________ ___________ ___________ ___________

Section 5—Treatment

[Please contact the horse’s veterinarian for assistance in completing this section.]

1. List all dates this horse was examined by a veterinarian since February 15, 2013:

date: _______C800 date: _______C800a date: _______C800b date: _______C800c date: _______C800d

2. In the 30 days PRIOR to February 15, 2013 and through today which of the following types of treatment(s) have been given?: [Check all that apply.]

			If YES, complete these columns
		Was this treatment given?	Date Started	Days Treated	Dose
	DMSO	1 Yes 3 No				var
	Corticosteroids	1 Yes 3 No
	Fluids	1 Yes 3 No
Nonsteroidal anti-inflam- matories	Flunixin meglumine (Banamine™) (include dose)	1 Yes 3 No
	Phenylbutazone (Bute™) (include dose)	1 Yes 3 No
	Specify other nonsteroidal anti-inflammatories (include dose)	1 Yes 3 No
	Antibiotics	1 Yes 3 No
Antiviral drugs	Valtrex/valcyclovir (include product/dose)	1 Yes 3 No
	Acyclovir (include dose)	1 Yes 3 No
	Specify other antiviral drugs (include dose)	1 Yes 3 No
Immuno-modulators	Zylexis (include dose)	1 Yes 3 No
	Equistim (include dose)	1 Yes 3 No
	Specify other immunomodulators (include dose)	1 Yes 3 No
	Diuretics	1 Yes 3 No
	Seizure medications	1 Yes 3 No
	Placement in a sling	1 Yes 3 No
	Aspirin)	1 Yes 3 No
	Lysine	1 Yes 3 No
	Other (specify: ________________ ____________________________)	1 Yes 3 No

Section 6—Diagnostic Testing Information

[Please contact the horse’s veterinarian for assistance in completing this section.]

1. Were samples collected from this horse for diagnostic testing for EHV-1? C900 ₁ Yes ₃ No

[If NO, skip to the bottom of this page to end the survey.]

Please fill in the following chart.

[Provide official laboratory reports via fax, scanned document, or hard copy if available.]

Date collected	Sample type (check 1 only)	Test performed (check only 1)	Specify laboratory	EHV-1 PCR result (check only 1)	Virus types performed (check all that apply) SEE BELOW for DEFINITIONS
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done
	1 Nasal swab 2 Whole blood 3 Serum 4 CSF	1 PCR 2 Virus isolation 3 Unknown 4 Other (specify)		1 Positive 1 Negative 1 Other (specify)	1 Neuropathogenic POS 2 Neuropathogenic NEG 3 Non-neuropath/wild type POS 4 Non-neuropath/wild type NEG 5 Virus typing not done

Use a separate sheet of paper if additional space is needed.

Complete Virus Types (for last column of PCR for EHV-1 testing)

• Neuropathogenic (DNA_pol [ORF30] variants carrying the D₇₅₂ marker)

• Non-neuropathogenic/wild type (DNA_pol [ORF30] strains carrying the N₇₅₂ marker)

• Virus typing not done

Thank you very much for your participation.
EHV-1 vaccine listing starts on the next page.

EHV-1 Trade Names – For Section 4, Item 1, enter the Code # and name.

Code	Trade Name(s)	Detailed Information	Manufacturer
1	Calvenza -03 EIV-EHV	Equine Rhinopneumonitis Vaccine, Killed Virus	Boehringer Ingelheim Vetmedica, Inc.
2	Calvenza EHV	Equine Rhinopneumonitis Vaccine, Killed Virus	Boehringer Ingelheim Vetmedica, Inc.
3	Calvenza EIV/EHV	Equine Rhinopneumonitis-Influenza Vaccine, Killed Virus	Boehringer Ingelheim Vetmedica, Inc.
4	EquiVac EHV-1/4	Equine Rhinopneumonitis Vaccine, Killed Virus	Fort Dodge Laboratories, Inc.
5	EquiVac Innovator EHV-1/4	Equine Rhinopneumonitis Vaccine, Killed Virus	Fort Dodge Laboratories, Inc.
6	Fluvac Innovator 5	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Fort Dodge Laboratories, Inc.
7	Fluvac Innovator 5 Plus	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Fort Dodge Laboratories, Inc.
8	Fluvac Innovator 6	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Fort Dodge Laboratories, Inc.
9	Fluvac Innovator 6 Plus	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Fort Dodge Laboratories, Inc.
10	Fluvac Innovator EHV-4/1	Equine Rhinopneumonitis-Influenza Vaccine, Killed Virus	Fort Dodge Laboratories, Inc.
11	Fluvac Innovator EHV-4/1 Plus	Equine Rhinopneumonitis-Influenza Vaccine, Killed Virus	Fort Dodge Laboratories, Inc.
12	Pneumabort-K+1b	Equine Rhinopneumonitis Vaccine, Killed Virus	Fort Dodge Laboratories, Inc.
13	Prestige	Equine Rhinopneumonitis Vaccine, Killed Virus	Intervet/Schering-Plough Animal Health
14	Prestige II	Equine Rhinopneumonitis-Influenza Vaccine, Killed Virus	Intervet/Schering-Plough Animal Health
15	Prestige IV	Encephalomyelitis-Rhinopneumonitis Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
16	Prestige V	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
17	Prestige V with Havlogen	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
Code	Trade Name(s)	True Name	Manufacturer
18	Prestige V+VEE	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
19	Prestige V+WNV	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
20	Prestige V+WVN with Havlogen	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western, Killed Virus, Killed Flavivirus Chimera, Tetanus Toxoid	Intervet/Schering-Plough Animal Health
21	Prodigy with Havlogen	Equine Rhinopneumonitis Vaccine, Killed Virus	Intervet/Schering-Plough Animal Health
22	Rhino-Flu	Equine Rhinopneumonitis-Influenza Vaccine, Modified Live & Killed Virus	Pfizer Animal Health
23	Rhinomune	Equine Rhinopneumonitis Vaccine, Modified Live Virus	Pfizer Animal Health
24	CODE NOT USED
25	--	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Boehringer Ingelheim Vetmedica, Inc.
26	--	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Boehringer Ingelheim Vetmedica, Inc.
27	--	Encephalomyelitis-Rhinopneumonitis-Influenza Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Hennessy Research Associates, LLC
28	--	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Boehringer Ingelheim Vetmedica, Inc.
29	--	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Boehringer Ingelheim Vetmedica, Inc.
30	--	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Hennessy Research Associates, LLC
31	--	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western, Killed Virus, Tetanus Toxoid	Hennessy Research Associates, LLC
32	--	Encephalomyelitis-Rhinopneumonitis-Influenza-West Nile Virus Vaccine, Eastern & Western & Venezuelan, Killed Virus, Tetanus Toxoid	Hennessy Research Associates, LLC

1 Light exercise is described as 1 to 3 hours/week of mostly walking and trotting. Many horses kept for recreational riding would be included in the light exercise category. Moderate exercise consists of 3 to 5 hours/week of mostly trotting with some walking, some cantering and possibly some jumping or other type of more difficult activity. Horses used for horse shows, ranch work and frequent recreational riding would fit into the moderate exercise category. Heavy exercise is described as 4 to 5 hours/week of trotting, cantering, galloping and some jumping, cattle work, etc. Horses engaged in three day eventing, polo, endurance racing, cutting, or other competitive events would be in this category. The very heavy exercise category includes racehorses and a few other horses that compete at the elite level of endurance or three day eventing.

2