GBS_Columbia Case Control Investigation Questionnaire -

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission— Colombia, 2016

Case Control Investigation Questionnaire

Investigation ID Number COL- ____ ____ - ____ □ Case □ Control

The ID number begins with the 2 digit case number (for example COL01) followed by an “A” for the case patient, a “B” for the first control, a “C” for the second control, and a”D” for the third control. For example, the second control subject matched for case number 8 would be labeled “COL-08-C.”

Interviewer: ___________________________ Date of Interview: __ __ /__ __ /__ __ DD MM YYYY

Neuro Symptom Onset Date for Case __ __ /__ __ /__ __ DD MM YYYY

The following questions are to be asked of cases AND controls during the interview:

1. Current Address: ________________________________/__________________/__________________/___________

(Street) (Town) (Province) (District)

2. Onset Address: _________________________________/__________________/__________________/___________

(for cases only if different from above; where cases spent most nights in the 2 months prior to neuro onset)

3. GPS Coordinates (Onset for cases; current for controls): __ __. __ __ __ __ __ S, __ __ __. __ __ __ __ __ E

4. Sex: □ Male □ Female

5. Race: □ White □ Brown □ Indigenous □ Black/African decent □ Yellow □ Other:_____________

6. Age when cases developed first neuro symptoms (or equivalent date for controls): ______ Years

7. What is your occupation? ________________________________________________

8. Have you ever been told by a clinician that you have any of the following medical conditions?

□ Diabetes □ High blood pressure □ Heart disease □ High colesterol

□ Stroke □ Kidney disease □ Liver disease □ Rheumatologic disease

□ Asthma □ COPD □ Cancer □ Surgery (within 2 months of

symptom onset)

□ Other neurologic illness:______________________________

□ Take any medication or have any condition that might impact your ability to fight infections (e.g. prednisone):

__________________________________________________

9. a. In the 2 months prior to __ __ /__ __ /__ __ (neuro onset date for case), have YOU been sick at all?

□ Yes □No □ Unknown

b. If so, when did you first feel sick? __ __ /__ __ /__ __

c. If so, what symptoms did you have (check all that apply)?

□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Abnormally red eyes

□ Headache □ Pain behind eyes □ Stiff neck □ Confusion

□ Abdominal pain □ Coughing □ Runny nose □ Sore throat □ Calf pain

□ Pruritus

d. If so, did you see a doctor or go to the hospital for this illness?

□ Yes □ No □ Unknown

Which doctor? ________________________ Which hospital? _____________________________

e. If so, did they draw any blood for testing? □ Yes □ No □ Unknown

10. a. In the 2 months prior to __ __ /__ __ /__ __ (neuro onset date for case), has anyone in your HOUSEHOLD been sick at all?

□ Yes □ No □ Unknown

b. If so, when did the first household member become sick? __ __ /__ __ /__ __

c. If so, what symptoms did any household members have (check all that apply)?

□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Abnormally red eyes

□ Headache □ Pain behind eyes □ Stiff neck □ Confusion

□ Abdominal pain □ Coughing □ Runny nose □ Sore throat □ Calf pain

□ Pruritus

11. Which vaccinations have you received and when?

□ Information verified on vaccine card □ Information provided verbally

Vaccine Number of doses Date of final dose

a. Hep B _____ __ __ /__ __ /__ __

b. HPV _____ __ __ /__ __ /__ __

c. Yellow fever _____ __ __ /__ __ /__ __

d. MMR _____ __ __ /__ __ /__ __

e. DT _____ __ __ /__ __ /__ __

f. DtaP _____ __ __ /__ __ /__ __

g. Influenza _____ __ __ /__ __ /__ __

h. Other vaccines (e.g. rabies, 23-pneumo, Japanese encephalitis, etc.):

__________ _____ __ __ /__ __ /__ __

__________ _____ __ __ /__ __ /__ __

12. Since October 2015, what pets, farm, or other animals have lived in your house or on your property (check all that apply)?

□ Dogs □ Cats □ Mice/rats □ Pet birds □ Pet lizards /turtles

□ Goats □ Sheep □ Cows □ Chickens □ Pigs □ Other ____________

13. Since October 2015, how often have you gotten your drinking water from the tap?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

If ever, was the water boiled or treated? □Yes □No □Unknown

14. Since October 2015, how often have you gotten your drinking water from a well or river/stream/pond?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

If ever, was the water boiled or treated? □Yes □No □Unknown

15. In 2015, how often do you walk around barefoot outside?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

16. In 2015, have you swam or waded in a freshwater river, stream, or pond?

□Daily □Weekly □Monthly □Rarely (<once per month) □Never

17. In 2015, do you recall being bitten by a mosquito? □Yes □No □Unknown

18. How much time do you spend outdoors each day?

□<1 hour □1-4 hours □5-8 hours □>8 hours

19. Do you normally wear insect repellant?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

20. Do you leave the windows open at your house?

□Yes, during the day □Yes, at night □Yes, all times □Windows are not left open at this house

21. How many of your windows or doors have intact screens?

□All of them □Some of them □None of them

22. Does your home use any of the following for air conditioning (check all that apply)?

□Local air conditioning (at least 1 room) □Fans □None

23. How often do you have sources of standing water around the outside of your house (e.g. buckets, water storage/cistern, septic tank, pond)?

□Daily □2-3 times/week □Once/week □Every other week □Never

24. Since October 2015, have you slaughtered any animals? □Yes □No □Unknown

Which? _________________­­­­­_______

25. Since October 2015, have you handled any dead animals? □Yes □No □Unknown

Which? _________________­­­­­_______

26. In 2016, have you eaten or drunk any of the following foods at least once per week (check all that apply)?

□ Beef □ Lamb □ Chicken □ Fish □ Shellfish

□ Milk □ Cheese □ Yogurt □ Fresh salad / uncooked greens

27. In 2016, did you eat any of the following foods raw or undercooked (check all that apply)?

□ Beef □ Lamb □ Chicken □ Fish □ Shellfish

28. Hughes Disability Score: (Date recorded __ __ /__ __ /__ __)

Hughes Disability Score (0 to 6): _______ □ Unknown

[0 = Complete recovery; no sequelae, 1 = Minor symptoms and capable of running, 2 = Able to walk 10 metres or more without assistance but unable to run, 3 = Able to walk 10 metres with help, 4 = Bedridden or chairbound (unable to walk 10 meters with help), 5 = Requiring assisted ventilation for at least part of the day, 6 = Dead]

Public reporting burden of this collection of information is estimated to average 15 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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)