Influenza Associated Pediatric Mortality Case Report For

Influenza-Associated Pediatric Mortality Case Report Form
Form Approved
OMB No. 0920-0004

STATE USE ONLY – DO NOT SEND INFORMATION IN THIS SECTION TO CDC
Last Name:

___________________________________

Address:

First Name: ______________________

County: _____________________

City:

State, Zip:

Patient Demographics
1. Country of Usual Residence:
2a.. State:

2b. County:

3. State ID:

4. CDC ID:
7a. Is sex known?  Yes

5. Age: _____

О Days
О Months
О Years

8a. Is ethnicity known?  Yes

6. Date of birth: _______/ _______/ ________
MM
DD
YYYY

9b. Race:  White

7b. Sex:
О Male
О Female

 No

8b. Ethnicity: О Hispanic or Latino
9a. Is race known?  Yes

 No

О Not Hispanic or Latino

 No

 Black

 Asian

 Native Hawaiian or Other Pacific Islander

 American Indian or Alaska Native

Death Information
10. Date of illness onset: _______/ _______/ _______
MM
DD
YYYY

11. Date of death: _______/ _______/ _______
MM
DD
YYYY

13 a. Did cardiac/respiratory arrest occur outside the hospital?
13 b. Location of death:

О Yes

О No

О Outside the Hospital (e.g. home or in transit to hospital)
О Other (specify): _______________

12. Was an autopsy performed?
О Yes
О No О Unknown

О Unknown
О Emergency Dept (ED) О Inpatient ward

О ICU

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?
Please provide the lab ID No. if known___________

О Yes

О No

О Unknown

14 b. Were influenza isolates or original clinical material sent to CDC’s Influenza Division?
Please provide the lab ID No. if known___________

О Yes

О No

О Unknown

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

Influenza Testing (check all that were used)
Test Type

Specimen
Collection Date

Result

15.
 Commercial rapid diagnostic test

О Negative
О Influenza A
О Influenza B
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 A (H3N2)v
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 A (H3N2)v
О Influenza virus co-infection (specify)______________

_____/ _____/ _____

 Immunohistochemistry (IHC)

О Influenza A
О Influenza B
О Influenza virus co-infection (specify)______________

О Negative

_____/ _____/ _____

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? Specimens collected greater than 24 hours after death are not sterile.

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
 Blood
 Pleural fluid
 CSF
 Lung Tissue
 Other ____________________
 Unknown

Collection Date
Date __/__/__
Date __/__/__
Date __/__/__
Date __/__/__
Date __/__/__

Result
О Positive
О Positive
О Positive
О Positive
О Positive

О Negative
О Negative
О Negative
О Negative
О Negative

О Unknown
О Unknown
О Unknown
О Unknown
О 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 18 Clinical Diagnosis and Complications)

 Staphylococcus aureus, sensitivity not done

 Pseudomonas aeruginosa

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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

 Sputum
 ET tube
 Other ____________________
 Unknown

Date __/__/__
Date __/__/__
Date __/__/__

Result
О Positive О Negative О Unknown
О Positive О Negative О Unknown
О Positive О Negative О 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 coinfection please do so in section 18
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”)
If yes please indicate the results of these tests in the comments section at the end of the form.

Medical Care
17. Was the patient placed on mechanical ventilation?

О Yes

О No

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О Unknown

О Yes О No О Unknown

Clinical Diagnoses and Complications
О Yes

18 a. Did complications occur during the acute illness?

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

 Hemorrhagic pneumonia/pneumonitis

 Cardiomyopathy/myocarditis

 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

 Renal disease (specify) ___________

 Skin or soft tissue infection (SSTI)

 Cardiac disease/congenital heart disease (specify)
____________________________________
 Chromosomal Abnormality/Genetic Syndrome (specify)
____________________________________
 Chronic pulmonary disease (specify) _____________
 Cancer (diagnosis and/or treatment
began in previous 12 months)
(specify)______________________

 Mitochondrial Disorder (specify) ________________________
 Immunosuppressive condition (specify) ___________________

 Endocrine disorder (specify)
_______________

 Obesity

 Cerebral Palsy

 Premature at birth
(specify gestational age)
____ weeks

 Neuromuscular disorder (e.g. muscular dystrophy) (specify)
__________________________________

 Other Neurological disorder (specify) ____________________________

 Pregnant (specify gestational age) _______ weeks

 Other (specify) ______________________

Medication and Therapy History
20 a. Was the patient receiving any of the following therapies prior to illness onset?
(if yes, check all that apply)
 Yes

 No

 Unknown

Antiviral Prophylaxis

 Chronic aspirin
therapy

 Chemotherapy or radiation therapy

 Other immunosuppressive therapy:_________________

20 b. Did the patient receive any of the following after illness onset? (if yes, check all that apply)
 Yes

 No

 Unknown

 Antibiotic therapy specify___________

 Antiviral therapy specify___________

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 Steroids by mouth or injection

Influenza Vaccine History
21. Did the patient receive any influenza vaccine during the current season (before illness)
О Yes
О No О Unknown
22. If YES*, please specify the influenza vaccine received before illness
 Inactivated influenza vaccine (IIV3) [injected]
onset:
 Quadrivalent inactivated influenza vaccine (IIV4) [injected]
 Live-attenuated influenza vaccine (LAIV4) [nasal spray]
 Unknown
23. If YES*, 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

 2nd dose given <14 days prior to
Date of 1st dose: _______/ _______/______
Date of 2nd dose: ______/ ______/ ______
onset
nd
MM
DD
YYYY
MM
DD YYYY
 2 dose given >14 days prior to
onset
23b. IF the patient received two doses of influenza vaccine during the
 Inactivated influenza vaccine (IIV3) [injected]
current season, please specify the SECOND influenza vaccine received
 Quadrivalent inactivated influenza vaccine (IIV4) [injected]
before illness onset:
 Live-attenuated influenza vaccine (LAIV4) [nasal spray]
 Unknown
О 2 doses

24 . Did the patient receive any influenza vaccine in previous seasons?

О Yes

О No

О Unknown

24 a. 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

Submitted By: ____________________________________________________________Date: _______/ _______/ _______
Phone No.: (
)
MM
DD
YYYY
E-mail Address: ____________________________________________________________
Case Investigation Closed:  Yes

 No

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