Case-Control Study Questionnaire for Investigation of GB

PR- ____ ____ - ____

Case-Control Study Questionnaire for the Investigation of

Guillain-Barré Syndrome (GBS) in Relation to Arboviral Infections

Study ID Number PR- ____ ____ - ____ □ Case □ Control

The ID number begins with the 2 digit case number (for example PR01) followed by an “A” for the case patient, a “B” for the first control, and a “C” for the second control. For example, the second control subject matched for case number 8 would be labeled “PR-08-C.”

Interviewer: _______________________________ Date of Interview: __ __ /__ __ /______ MM DD YYYY

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

Insert onset date into questions 10 and 11.

This questionnaire was conducted on: □ Directly with case or control □ Indirectly

If indirectly, with whom?:_______________

T

Background and Demographics

he following questions are to be asked of cases AND controls during the interview.

1. Current Address: _____________________________________________/_________________________________

(Street) (Municipality)

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. a) Ethnicity: □ Hispanic or Latino □ Not Hispanic or Latino □ Decline to answer

b) Race (may select more than one): □ American Indian or Alaska Native □ Asian □ Black or African-American □ Native Hawaiian or other Pacific Islander □ White □ Decline to answer

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

7. What is your occupation? ________________________________________________

8. What form of health insurance do you have? □ Reforma/SSS □ Private □ Veteran’s □ Other □ None

Medical History

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 cholesterol

□ Stroke □ Kidney disease □ Liver disease □ Rheumatologic disease

□ Asthma □ Cancer □ Chronic obstructive pulmonary disease (COPD)

□ Surgery (within 2 months of date of symptom onset) □ Other neurologic illness:__________________________

9. Do you take any medication (e.g., prednisone) or have any condition that might impact your ability to fight infections (e.g., immunological disorder):

□ Yes □ No If yes, please list: ______________________________________________

10. a). In the 2 months prior to __ __ /__ __ / 2016 (neuro onset date for case), have YOU been sick at all?

MM DD YYYY

□ Yes □ No □ Unknown

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

MM DD YYYY

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

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

f.) If so, was any other bodily fluids tested? □ Yes □ No □ Unknown

If yes, which? □ Urine □ Saliva □ Other_______________

11. a.) In the 2 months prior to __ __ /__ __ / 2016 (neuro onset date for case), has anyone in your

MM DD YYYY HOUSEHOLD been sick at all?

□ Yes □ No □ Unknown

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

MM DD YYYY

c.) If so, what symptoms did this household member 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

12. I would like to ask you some questions about vaccination. Do you have a vaccination record available?

□ Yes and shown to interviewer □ Yes but not shown □ Information provided verbally

13. Which vaccinations have you received and when?

a.) In the last 2 months, did you receive the influenza vaccine? □ Yes □ No

If yes, when? ______________________________

b) Which other vaccinations have you received?

MM DD YYYY

i.) MMR __ __/__ __/______ Additional doses: ____________________

ii.) Polio __ __/__ __/______ ____________________

iii.) Yellow fever __ __/__ __/______ ____________________

iv.) BCG __ __/__ __/______ ____________________

v.) DTaP __ __/__ __/______ ____________________

vi.) HIB __ __/__ __/______ ____________________

vii.) Pneumococcal __ __/__ __/______ ____________________

viii.) Meningitis __ __/__ __/______ ____________________

ix.) Hep B __ __/__ __/______ ____________________

x.) Zoster/Shingles __ __/__ __/______ ____________________

x.) Other vaccines (e.g. rabies, Japanese encephalitis, etc.):

Which? ________________________________ __ __/__ __/______

Behavior and Environmental Exposures

For the remaining questions, I will ask about practices and behaviors over the past two months. Please think back over the past 2 months when answering to them.

14. What pets or other animals (e.g., farm animals) have lived in your house or on your property (check all that apply)?

□ Dogs □ Cats □ Mice/rats □ Pet birds □ Reptiles/amphibians

□ Goats □ Sheep □ Cows □ Chickens □ Pigs

□ Other __________________________________________

15. 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

16. 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

17. How often do you walk around barefoot outside?

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

18. Have you swam or waded in a freshwater river, stream, or pond?

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

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

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

20. Do you recall being bitten by a mosquito? □ Yes □ No □ Unknown

21. Do you normally wear insect repellant when outside?

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

22. 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

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

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

24. Does your home use any of the following for air conditioning?

□ Central air conditioning □ Local air conditioning (1–2 room) □ None

25. 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

26. Have you slaughtered animals and/or handled any dead animals?

□ Yes □ No □ Unknown

If yes, which? _________________­­­­­_______

27. 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

28. Did you eat any of the following foods raw or undercooked (check all that apply)?

□ Beef □ Lamb □ Chicken □ Shellfish □ Fish (including ceviche)

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