Case Report for Coccidioidomycosis

OMB approved

0920-xxxx

Case ID: ___________________________ xx/xx/xxxx

Case Report Form for Coccidioidomycosis (Valley Fever) Enhanced Surveillance

CASE AND INTERVIEW INFORMATION (This section is for interviewer use only – do not read)

1. Date case was reported to the state health department (MM/DD/YY): _____________________

2. Interview date (MM/DD/YY): _____________________

3. Interviewer initials:________

4. Interview conducted with:

□ Case

□ Other, specify relationship: _________________________

If interview was not conducted with case, why not?

□ Case unavailable

□ Case is < 18 years old

□ Case deceased

How did Valley Fever contribute to the case’s death?

□ Valley Fever was the primary cause of death

□ Valley Fever was a related cause of death

□ Death was unrelated to Valley Fever

□ Unknown

□ Other reason, specify: _____________________

DEMOGRAPHICS

First, I’m going to ask you some questions about yourself (Or name of case, if interview not conducted with case).

5. What is your (or name of case, if not interviewing case) date of birth? (MM/DD/YYYY): __________________

6. What is your gender: □ Male □ Female □ Refused

DIAGNOSIS, CLINICAL PRESENTATION, AND HEALTHCARE UTILIZATION

7. Before this phone call did you know about your positive test result for Valley Fever, which is also called coccidioidomycosis or “cocci”?

□ Yes □ No □ Don’t know

8. Was the test for Valley Fever part of routine blood work or a medical screening prior to a procedure?

□ Yes, describe:__________________________________________ □ No □ Don’t know

I’m going to be asking you some questions about dates. Do you have a calendar available that you could look at?

9. Did you have symptoms of Valley Fever? (if needed, you can prompt using the list in question 10)

□ Yes □ No (Skip to question 16) □ Don’t know

(If yes) On what date did your Valley Fever symptoms start?

MM/DD/YY:_____________________ □ Don’t know

10. Which of the following symptoms did you have? I’m going to read a list. (Check all that apply)

□ Fever □ Cough

□ Sore throat □ Coughing up blood

□ Chills □ Shortness of breath

□ Night sweats □ Wheezing

□ Chest pain □ Rash or other skin problem

□ Extreme tiredness □ Stiff neck

□ Headache □ Joint pain

□ Weight loss without trying □ Muscle pain

□ Other, specify: _________________________

11. On what date did you first seek medical care for your symptoms?

MM/DD/YY:_____________________ □ Don’t know

12. Where did you first get medical care for your symptoms?

□ Primary care doctor

□ Urgent care clinic

□ Emergency room

□ Other, specify: _________________________

13. What city and state was the doctor in that you went to when you first got care for your symptoms? ________________________________________________

14. Did you ever go to the emergency room for your Valley Fever symptoms?

□ Yes □ No □ Don’t know

14a. (If yes) In what city and state? ______________________________________

15. How many times total did you see a doctor for your symptoms before you were tested for Valley Fever?

_______ times □ Don’t know

16. Did you ask a doctor to test you for Valley Fever? □ Yes □ No □ Don’t know

17. Which type of doctor first tested you for Valley Fever? I’m going to read a list.

□ Primary care doctor or nurse

□ Urgent care doctor

□ Emergency room doctor

□ Infectious disease doctor

□ Pulmonologist (lung specialist)

□ Other, specify: _________________________

□ Unknown

18. What date did your doctor tell you that you had a positive test result for Valley Fever?

MM/DD/YY:_____________________ □ Don’t know □ Didn’t tell me I had Valley Fever; he/she told me I had:_____________________________________________

19. Did your doctor first diagnose you with something else before he/she tested you for Valley Fever?

□ Yes, specify: ________________________________________ □ No □ Don’t know

19a. (If yes) Did your doctor prescribe you antibiotics? By “antibiotics,” I mean medication to treat a bacterial infection, which doesn’t work for Valley Fever. □ Yes □ No □ Don’t know

20. Were you ever hospitalized overnight for your Valley Fever symptoms?

□ Yes □ No □ Don’t know

20a. (If yes) In what city and state? ______________________________________

20b. (If yes) How long were you hospitalized? (#)_______days

21. Did your doctor perform a chest x-ray when diagnosing your illness?

□ Yes □ No □ Don’t know

22. When your doctor told you that you had Valley Fever, which parts of the body did he or she say were involved? I’m going to read a list. (Check all that apply)

□ Lungs

□ Brain or spinal cord

□ Bones or joints

□ Whole body

□ Other (Specify):____________________________________

□ The test was positive, but no specific body part was involved

□ The doctor didn’t tell me / I don’t know

23. How many times total did you see a doctor for Valley Fever, including times you were admitted to the hospital? (#)_______times

TREATMENT AND OUTCOMES

24. Did your doctor prescribe you antifungal medication to treat Valley Fever?

□ Yes □ No □ Don’t know

24a. (If yes) What was the name of the medication or medications? I’m going to read a list. (Check all that apply)

□ Amphotericin B □ Voriconazole (VFEND)

□ Fluconazole (Diflucan) □ Other, specify______________________________

□ Itraconazole (Sporanox) □ Don’t know

□ Posaconazole

24b. How long were you taking antifungal medication(s) to treat Valley Fever?

(#)_______days (#)_______weeks (#)_______months □ Still on medication

25. In total, how long did your symptoms last?

(#)_______days (#)_______weeks (#)_______months

□ Not yet recovered (see below) □ Don’t know □ Not applicable; no symptoms

25a. (If not yet recovered) Which symptoms do you still have?

□ Fever □ Cough

□ Sore throat □ Coughing up blood

□ Chills □ Shortness of breath

□ Night sweats □ Wheezing

□ Chest pain □ Rash or other skin problem

□ Fatigue (extreme tiredness) □ Stiff neck

□ Headache □ Joint pain

□ Weight loss without trying □ Muscle pain

□ Other, specify: _________________________

26. Did you have a job or were you in school when you were diagnosed with Valley Fever (or during your illness, if it was not determined to be Valley Fever)?

□ Yes, a job , specify: _____________________________ □ Yes, in school □ No

26a. Did you miss any time from your job or school due to Valley Fever?

□ Yes, (#)_______days □ No □ Don’t know

27. Did Valley Fever interfere with your ability to perform your usual daily activities?

□ Yes □ No □ Don’t know

27a. (If yes) For how long? (#)_______days (#)_______weeks (#)_______months □ Don’t know

MEDICAL HISTORY

Now I’m going to ask you some questions about your overall health and any past medical problems you may have had.

28. Have you ever smoked cigarettes? □ Yes, currently □ Yes, in the past □ No □ Unknown

29. Did you have any of the following medical conditions when you were diagnosed with Valley Fever (or had a positive test for Valley Fever, if not diagnosed)? I’m going to read a list.

□ Asthma requiring an inhaler

□ COPD or emphysema

□ Other lung disease, specify: _________________________

□ Diabetes

□ HIV / AIDS

□ Heart disease, specify: _________________________

□ Cancer, specify: _________________________

□ Organ transplant or bone marrow transplant, specify: _________________________

□ Liver disease

□ Kidney disease

□ Pregnancy, specify trimester: _________________________

□ Other major illnesses, specify: _________________________

□ Unknown

30. Before you were diagnosed with (or had a positive test for) Valley Fever, were you taking any medications that affect your immune system? Examples are steroids such as prednisone or dexamethasone, interferon, chemotherapy medications, methotrexate, medications to prevent organ transplant rejection, or any TNF inhibitor such as Remicade, Enbrel, or Humira.

□ Yes □ No □ Don’t know

30a. (If yes) What medication(s): ___________________________________________________________

From _____________________(MM/YY) to _____________________(MM/YY) or □ still taking

31. Before this diagnosis of Valley Fever, had a doctor ever told you that you had Valley Fever in the past?

□ Yes □ No □ Don’t know

31a. (If yes) When? _________________________(approximate date)

RESIDENCE, TRAVEL, AND RISK FACTORS

My next set of questions is about where you live, places you may have traveled before you got Valley Fever, and your outdoor activities.

32. What city and state did you live in when you tested positive for Valley Fever? By lived in, I mean what city and state you were spending most of your time in when you were tested for Valley Fever, not places you may have been visiting.____________________________________________

32a. How long had you lived in (state named above) before you tested positive for Valley Fever?

(#)_______months (#)_______years

33. In the 4 months before you developed symptoms of Valley Fever (or tested positive, if asymptomatic), did you travel to any of the following places: Arizona, California, New Mexico, Nevada, Utah, Texas, Washington State, Mexico, or Central or South America?

□ Yes □ No □ Don’t know

33a. (If yes) Where did you go? (Fill in location) On what date did you leave and what day did you return? (Fill in departure and return dates. If not known, ask “How long were you there?” and fill in duration). What was the purpose of the trip, for example, vacation or work? (Fill in purpose of trip) Did travel to any other of the places I mentioned in the 4 months before you tested positive for Valley Fever? (If yes, fill out the next line in the table; if no, continue to question 33b.)

#	Location (city and state or country)	Dates or duration of trip	Purpose of trip
1		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months
2		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months
3		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months
4		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months
5		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months
6		Departure date:_____________ Return date: ____________ Or (#)______days (#)_______weeks (#)_______months

33b. On any of these trips, did someone else go with you who also got Valley Fever?

□ Yes □ No □ Don’t know

33b1. (If yes) Who?_______________________ (relationship) Which trip?_____(fill in trip # from table)

34. Have you EVER been to any of the places I mentioned? That’s Arizona, California, New Mexico, Nevada, Utah, Texas, Washington State, Mexico, or Central or South America.

□ Yes □ No □ Don’t know

34a. (If yes) Where and approximately when?_______________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

35. In the 4 months before you developed symptoms of Valley Fever (or tested positive, if asymptomatic), did your job expose you to dirt or dust, or did you participate in any activities for fun that exposed you to dirt or dust? (Examples include construction, gardening, four-wheeling, horseback riding, etc.)

□ Yes □ No □ Don’t know

35a. (If yes) Specify activity(ies) and location:___________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

36. Did you know about Valley Fever before you were diagnosed with it (or tested positive for it)?

□ Yes □ No □ Don’t know

36a. (If yes) Where did you first hear about it? (Check one)

□ Doctor □ Internet □ Family member, friend, or co-worker

□ Radio □ Television

□ Don’t know □ Other, specify: _________________________

37. How and where do you think that you got Valley Fever? __________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

I have a few more questions about yourself (or name of case, if not interviewing case):

38. Are you Hispanic or Latino? □ Yes □ No □ Refused

39. Which of the following best describes your race? I’m going to read a list, and you can pick more than one. (Check all that apply)

□ White

□ Black or African American

□ Asian

□ American Indian or Alaska Native

□ Native Hawaiian or Other Pacific Islander

□ Other, specify: _________________________

□ Refused

NOTE: Questions 40, 41, and 42 are recommended, but optional – states may choose whether they would like their interviewers to ask these questions.

INSURANCE, EDUCATION, AND INCOME

We’re almost done. Thanks for your patience. I just have a few more questions for you, which are about your health insurance and education.

40. When you got Valley Fever, did you have any form of medical or health insurance?

□ Yes □ No □ Don’t know

40a. If yes, What type of insurance did you have? Check all that apply.

□ Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)

□ Other private insurance

□ Medicare

□ Medicaid

□ Military

□ Don’t know

□ Refused

41. How far did you go in school? I’m going to read a list of choices.

□ No high school

□ Some high school

□ High school graduate / GED

□ Technical school

□ Some college / associate degree

□ College graduate

□ Post-graduate / professional

□ Don’t know

□ Refused

42. Because income can affect a person’s ability to receive healthcare, I’d like to ask you about your total yearly household income from all sources. Which income group best represents the total income for your household in the year that you had Valley Fever? I’m going to start reading a list, and you can stop me when I get to the right category.

□ Less than $15,000

□ Between $15,001 and $25,000

□ Between $25,001 and $35,000

□ Between $35,001 and $50,000

□ Over $50,000

□ Refused

That’s all the questions I have for you. Thank you very much for your time. Do you have any questions for me?

(See list of common questions and answers in interview manual; record any questions below) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you have any questions later, please give us a call back. I can give you a phone number if you’d like it: xxx-xxx-xxxx. Thank you.

Interviewer notes:____________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSIS OF COCCIDIOIDOMYCOSIS (This section is to be completed after the interview. Please record all coccidioidomycosis laboratory test results below.)

43. Which laboratory test(s) was ordered to diagnose coccidioidomycosis? (EIA = enzyme immunoassay, ID = immunodiffusion, CF = complement fixation, LA=latex agglutination. Indicate brand of serologic test, if known: IMMY, Meridian Biosciences, Gibson Biosciences, or other)

Serology – serum
□ EIA – IgM	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ EIA – IgG	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ ID – IDTP	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ ID – IDCF	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ CF – IgG	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ LA – IgM	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
Serology – cerebrospinal fluid (CSF)
□ EIA – IgM	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ EIA – IgG	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ ID – IDTP	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ ID – IDCF	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ CF – IgG	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________
□ LA – IgM	Result: □pos. □neg. □unk.	Collection date: __________________	Brand:______________

Other laboratory test types

□ Histopathologic evidence of Coccidioides Source:________________ Collection date: _______________

□ Molecular evidence of Coccidioides Source:________________ Collection date: _______________

Specify test type (e.g., PCR):___________________________________________

□ Culture evidence of Coccidioides Source:________________ Collection date: _______________

Method of culture confirmation (e.g., AccuProbe, visual confirmation):___________________________

Species: □C. immitis □C. posadasii □unknown

44. Which laboratory(ies) performed the test(s) used to diagnose coccidioidomycosis? _____________________

________________________________________________________________________________________

45. (Optional) Did the case have any other possible etiologies of illness identified?

□ Yes □ No □ Don’t know

45a. If yes, describe laboratory tests (e.g., fungal panel) and results:_________________________________

________________________________________________________________________________________________________________________________________________________________________________

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-xxxx).