Zika Virus Disease Enhanced Surveillance – Hospitalizati

Zika Virus Enhanced Surveillance of Selected Populations

Att. 5 - Enhanced surveillance - Hospitalized

Zika Virus Disease Enhanced Surveillance – Hospitalization associated with Zika virus disease

OMB: 0920-1192

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Form Approved

OMB Control No. 0920-XXXX

Exp. date: XX/XX/XXXX

Attachment 5: Zika Virus Disease Enhanced Surveillance – Hospitalization associated with Zika virus disease

Demographic Information

Case ID (ArboNET):_____________________ Control for Case ID:____________________

State of residence:_____________________ County of residence:___________________

Age: ______ Years Months Days Sex: Male Female

Pregnant: Yes No Unknown Est Date Delivery: ____/____/____ OR Last Menstrual Period: ____/____/____

Race (Select all appropriate): American Indian or Alaska Native Asian Black or African American

Native Hawaiian or Other Pacific Islander White Other Unknown

Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown

Imported From: Not Imported Acquired Out of State Acquired Out of Country Unknown

Country of Origin:________________________________ Travel dates:____________________________

State of Origin:__________________________________ Travel dates: ____________________________

Other possible exposures: Sexual Breastfeeding Blood products Organs

Past Medical History

Hypertension

Yes No Unk

Heart disease

Yes No Unk

Diabetes mellitus

Yes No Unk

Asthma/respiratory disease

Yes No Unk Specify:_________________________________________

COPD

Yes No Unk

Autoimmune disorder

Yes No Unk

Cancer

Yes No Unk

Other immune deficiency

Yes No Unk

Liver/hepatic disease

Yes No Unk

Kidney/renal disease

Yes No Unk

Thyroid disease

Yes No Unk

Seizure disorder

Yes No Unk

Other neurologic disease

Yes No Unk Specify:_________________________________________

Tobacco use

Yes No Unk If yes: Current Past

Alcoholism

Yes No Unk

Intravenous drug use

Yes No Unk If yes: Current Past

Other medically important condition

Yes No Unk Specify:_________________________________________

Pre-existing Medications and Treatments

Medications to treat hypertension

Yes No Unk

Medications to treat coronary heart disease

Yes No Unk

Medications to treat congestive heart failure

Yes No Unk

Chemotherapy

Yes No Unk

Other treatments for cancer

Yes No Unk

Medications that suppress the immune system

Yes No Unk

Insulin or other meds to treat diabetes

Yes No Unk

Hemodialysis

Yes No Unk

Other treatments for kidney disease

Yes No Unk

Oral or injected steroids

Yes No Unk

Clinical Information

Illness onset date: _____/_____/_____

Clinical syndrome: Febrile illness Encephalitis/meningoencephalitis Meningitis Acute flaccid paralysis

Guillain-Barré syndrome Other neuroinvasive presentation Other clinical

Case Status (ArboNET): Confirmed Probable

Fever

Yes No Unk Subjective Measured (Max temperature: __________)

Chills/Rigors

Yes No Unk

Rash

Yes No Unk Type: Maculopapular Petechial Purpuric

Other:____________________________________________

Pruritic: Yes No Unk

Distribution:­­­­­­­_______________________________________________

Headache

Yes No Unk

Retro-orbital pain

Yes No Unk

Conjunctivitis

Yes No Unk

Oral ulcers

Yes No Unk

Nausea/Vomiting

Yes No Unk

Diarrhea

Yes No Unk

Arthralgia

Yes No Unk

Arthritis

Yes No Unk

Myalgia

Yes No Unk

Paresis/Paralysis

Yes No Unk

Stiff Neck

Yes No Unk

Ataxia

Yes No Unk

Altered mental status

Yes No Unk

Seizures

Yes No Unk

Sore throat

Yes No Unk

Cough

Yes No Unk

Lymphadenopathy

Yes No Unk

Paresthesia

Yes No Unk

Abdominal pain

Yes No Unk

Edema

Yes No Unk Specify:__________________________________________________

Other

Yes No Unk Specify:__________________________________________________

Outcomes

Emergency department

Yes No Unk

Hospitalized

Yes No Unk

Admission: ____/____/____ Discharge:____/____/____

Days hospitalized:______________

Multiple admissions: Yes No Unk Number:__________

ICU

Yes No Unk

Admission: ____/____/____ Discharge:____/____/____

Days in intensive care:____________

Intubation: Yes No Unk

Admission diagnoses

Primary diagnosis or ICD 10:________________________________________________________

Additional diagnoses:_____________________________________________________________

Outcomes (continued)

Discharge diagnoses

Primary diagnosis or ICD 10:________________________________________________________

Additional diagnoses:_____________________________________________________________

Died

Yes No Unk

Date of Death:_____/_____/_____

Causes of death: 1.________________________________________

2.________________________________________

3.________________________________________

Discharged to rehab

Yes No Unk

Treatments Administered During Hospitalization

Antimicrobials

Yes No Unk Specify:________________________________________

Steroids/other immune modulating

Yes No Unk Specify:________________________________________

Blood products

Yes No Unk Specify:________________________________________

Zika Virus Test Results

Dengue Virus Test Results

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial

Specimen collected: _____/_____/_____

Specimen Type: Serum CSF Urine

Test: IgM PRNT PCR/NAT IHC

Result: Positive Negative Equivocal

Performing Lab: CDC State PH Commercial


Laboratory Tests

CBC performed Yes No Unk


Leukopenia (<4,500)

Thrombocytopenia (<150,000)

Leukocytosis (>11,000)

Yes No Unk

Yes No Unk

Yes No Unk

Nadir:_____ ; Date:__­­­­__/___/____

Nadir:_____ ; Date:__­­­­__/___/____

Max:______ ; Date:__­­­­__/___/____

Abnormal liver enzymes

AST: Yes No Unk Max:_______; Date:__­­­­__/____/____

ALT: Yes No Unk Max:_______; Date:__­­­­__/____/____

LP performed

Yes No Unk


Date:___/____/____

WBC:_____________

RBC:______________

Protein:___________

Glucose:___________

Date:___/____/____

WBC:_____________

RBC:_____________

Protein:___________

Glucose:__________

Date:___/____/____

WBC:_____________

RBC:_____________

Protein:___________

Glucose:__________

MRI

Yes No Unk

Date:___/____/____

Abnormal results: Yes No Unk

If yes, describe:________________________

_____________________________________

CT

Yes No Unk

Date:___/____/____

Abnormal results: Yes No Unk

If yes, describe:________________________

_____________________________________

EMG/NCS

Yes No Unk

Date:___/____/____

Abnormal results: Yes No Unk

If yes, describe:________________________

_____________________________________

Other test

Yes No Unk

Date:___/____/____

Abnormal results: Yes No Unk

If yes, describe:________________________

_____________________________________





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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSamuel, Lee (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-22

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