Form 0920- Chronic Q Fever Enhanced Surveillance

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Chronic Q Fever Enhanced Surveillance

Thank you for consulting with CDC; please complete the information below to help us learn more about the clinical
manifestations of chronic Q fever in the United States.

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX/XX/20XX

The following enhanced chronic Q fever clinical surveillance tool was developed to gather more detailed and specific
clinical data on chronic Q fever to better understand its presentation, management, and long-term outcomes. This
information will allow for better characterization of chronic Q fever in the United States.
Your participation in this survey is strictly voluntary and you may stop at any time. All information collected will
remain anonymous; we will not collect any personally identifiable information, such as your patient's name or contact
information. There are no negative consequences to you should you decline to participate or not complete the survey
in its entirety. You may continue to consult with CDC's Rickettsial Zoonoses Branch regardless of your participation in
enhanced surveillance.
This survey should take you approximately 20 minutes to complete.
If you have any questions or concerns about completing this survey, please contact: 404-639-1075 or
[email protected].
The Rickettsial Zoonoses Branch thanks you for your time and involvement.

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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA 0920-XXXX

Demographics
When was this patient first diagnosed with chronic Q
fever?

Patient's age at first diagnosis

Sex of patient

10/02/2019 11:39am

__________________________________
(YYYY; If unknown, leave blank.)

__________________________________
(in years)
Male

Female

Not specified

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State of Residence

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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
U.S. Virgin Islands
Guam
American Samoa
Northern Mariana Islands

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Race

Ethnicity

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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
(select all that apply)
Hispanic or Latino
Not Hispanic or Latino
Unknown

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Acute Q fever history
Was this patient previously diagnosed with acute Q
fever?

Yes

No

Is the date of acute Q fever diagnosis known?

Yes

No

Year of acute Q fever diagnosis.

How was the initial diagnosis made?

Unknown

__________________________________
(YYYY)
PCR
Paired Serology
Single serology
Other
Unknown
(Select all that apply.)

If other diagnostic used, specify.
__________________________________________
Was the patient treated for acute Q fever?
What medication(s) was/were used?

Pleas specify what other antibiotics were prescribed?

How long was the patient on the medication for
treatment of acute Q fever?

Yes

No

Unknown

Doxycycline
Trimethoprim/sulfamethoxazole
Other
Unknown
(Select all that apply.)

__________________________________
(Use the common name for the drug or chemical, not
trade name.)

__________________________________
(Number of days. )

Was this patient pregnant at the time of acute Q
fever diagnosis?

Yes

In which trimester did the symptoms begin?

1st (weeks 1-12)
2nd (weeks 13-28)
3rd (weeks 29-42)
Unknown

Was the patient treated during pregnancy?

Yes

At what week gestation did treatment begin?

Is the patient still receiving treatment?

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No

No

Unknown

Unknown

__________________________________
(Week number)
Yes

No

Unknown

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How long was the patient on medication before
treatment was discontinued?

What antibiotics are/were used?

__________________________________
(Number of weeks.)
Trimethoprim/sulfamethoxazole
Other
Unknown

If other antibiotic use, specify.
__________________________________________
(Use the common name for the drug or chemical, not
trade name.)
Did this patient develop placentitis?
Did this patient develop any of the following
complications of pregnancy?

Yes

No

Unknown

Intrauterine growth restriction (IUGR)
Stillbirth
Miscarriage
Premature delivery
Other
No complications
Unknown
(Select all that apply.)

If other complication of pregnancy, please specify.
__________________________________________
Where any of the following newborn complications
present?

Malformations
Hyperbilirubinemia
Kernicterus
Other
No complications
Unknown
(Select all that apply.)

If malformations, please specify types.
__________________________________________
What other newborn complications were present?
__________________________________________
What was the gestational age at birth?

What was the weight at birth?

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__________________________________
(Weeks)

__________________________________
(in pounds)

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Risk Factors
Did this patient have a history of any of the
following cardiovascular conditions?

No history of cardiovascular conditions
Rheumatic heart disease
Aortic valve stenosis
Aortic valve prolapse
Aortic valve regurgitation
Mitral valve stenosis
Mitral valve prolapse
Mitral valve regurgitation
Pulmonic valve stenosis
Pulmonic valve prolapse
Pulmonic valve regurgitation
Tricuspid valve stenosis
Tricuspid valve prolapse
Tricuspid valve regurgitation
Prosthetic valve
Aneurysm
Vascular graft/stent
Atrial septal defect
Patent ductus arteriosus
Ventricular septal defect
Tetralogy of Fallot
Other congenital heart defect
Other heart valve problem
Unknown
(Check all that apply.)

Which valve was replaced?

Aortic
Mitral
Pulmonic
Tricuspid
Unknown
(Select all that apply)

Year of most recent replacement.

What type of valve replacement did the patient
receive?

Please specify other valve replacement received.

History of >1 valve replacement?

__________________________________
(YYYY)
Manufactured mechanical valve
Human donor valve
Bioprosthetic - bovine
Bioprosthetic - porcine
Other
Unknown

__________________________________
Yes

No

Unknown

Please specify other congenital heart defect.
__________________________________________
Please specify other heart valve problem.
__________________________________________

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Clinical Findings
What clinical signs and symptoms has the patient
exhibited?

Please specify what other clinical signs and symptoms
the patient has exhibited.

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Relapsing fever
Chills
Weight loss
Night sweats
Fatigue
Shortness of breath
Hepatosplenomegaly
Other
Unknown
(Select all that apply.)

__________________________________________

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Endocarditis
Did this patient have culture negative endocarditis?

Yes

No

Unknown

Please specify affected valve(s)

Aortic valve
Mitral valve
Pulmonary valve
Tricuspid valve
Unknown
(Select all that apply.)

What imaging technologies were used to diagnose
endocarditis?

Transthoracic echocardiogram (TTE)
Transesophageal echocardiogram (TEE)
PET CT Scan
CT Scan
MRI
Other
Unknown
(Select all that apply.)

Please specify what other imaging was/were used to
diagnose endocarditis.
Was the infected valve removed?
Please specify the year of valve removal.

Was the valve tested for the presence of Coxiella
burnetii?

Which testing method was used on the valve sample?

What were the diagnostic results?

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__________________________________
Yes

No

Unknown

__________________________________
(YYYY)
Yes

No

Unknown

PCR
IHC
Culture
Unknown
(Select all that apply.)
Positive
Negative/undetermined
Unknown

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Vascular infection
Did this patient have a vascular infection (i.e.
infection of vascular graft, stent, or aneurysm)
caused by Coxiella burnetii?

Yes

Please specify which type of vascular infection.

Vascular graft
Stent
Aneurysm
Other
Unknown

Please specify what other type of vascular infection
was present.

Please specify location of infection.

Please specify the other location of infection.

What year was the now infected graft/stent originally
placed?

Was infected graft/stent removed or aneurysm
repaired?
Please specify the year of removal or repair surgery.

Was the vascular infection tested for presence of
Coxiella burnetii?
Which testing method was used to on the vascular
infection sample?

What were the diagnostic results?

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No

Unknown

__________________________________

Abdominal aorta
Thoracic aorta
Other
Unknown

__________________________________

__________________________________
(YYYY)
Yes

No

Unknown

__________________________________
(YYYY)
Yes

No

Unknown

PCR
IHC
Culture
Unknown
(Select all that apply.)
Positive
Negative/undetermined
Unknown

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Osteoarticular infection
Did this patient have an osteoarticular infection
(e.g. osteomyelitis or spondylodiscitis) caused by
Coxiella burnetii?

Yes

No

Unknown

Please specify location of osteoarticular infection.
__________________________________________
Was this a native joint?

Yes
No
Unknown
Not applicable

Was surgical debridement of the diseased tissue and
bone performed?

Yes

Specify the year of most recent debridement.

During the debridement, was any tissue tested for
presence of Coxiella burnetii?
Which testing method was used on the debrided tissue?

What were the diagnostic results?

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No

Unknown

__________________________________
(YYYY)
Yes

No

Unknown

PCR
IHC
Culture
Unknown
(Select all that apply. )
Positive
Negative/undetermined
Unknown

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Granulomatous hepatitis
Did this patient have evidence of granulomatous
hepatitis?

Yes

No

Unknown

Which liver function tests were elevated?

Alk Phos
ALT
AST
LDH
Bilirubin
Albumin
GGT
(Select all that apply. )

Which imaging techologies were used to diagnose
hepatitis?

Ultrasound
MRI
MRE (elastography)
CT
Other
No imaging performed
(Select all that apply)

What other imaging technology was used to diagnose
hepatitis?

Was a liver biopsy performed?
What year was the liver biopsy performed?

Was the biopsy tested for presence of Coxiella
burnetii?

Which testing method was used on the liver biopsy?

What were the diagnostic results?

10/02/2019 11:39am

__________________________________

Yes

No

Unknown

__________________________________
(YYYY)
Yes

No

Unknown

PCR
IHC
Culture
Unknown
(Select all that apply.)
Positive
Negative/undetermined
Unknown

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Lymphadenopathy
Did this patient develop lymphadenopathy?
Please specify location of lymphadenopathy(s)

If other location of lymphadenopathy, please specify.

Yes

No

Unknown

Cervical
Supraclavicular
Axillary
Perihilar
Mediastinal
Mesenteric
Inguinal
Popliteal
Other
(Select all that apply.)

__________________________________

Was a lymph node biopsy performed?

Yes

No

Unknown

Was the biopsy tested for presence of Coxiella
burnetii?

Yes

No

Unknown

Which testing method was used on the lymph node
biopsy?

What were the diagnostic results?

10/02/2019 11:39am

PCR
IHC
Culture
Unknown
(Select all that apply.)
Positive
Negative/Undetermined
Unknown

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Additional complications
Did this patient develop any of the following
complications?

Please specify the location of the other abscess.

Was medical intervention performed?
What interventions were performed?

Please specify what other intervention was performed.

What year was the intervention performed?

Was any material from the abscess or rupture tested
for Coxiella burnetii?

What was the method used to test material from the
abscess?

Psoas abscess
Cardiac abscess
Empyema or other pulmonary abscess
Other abscess
Ruptured aneurism
None of the above
Unknown
(Select all that apply.)

__________________________________
Yes

No

Unknown

Incision and drainage
Marsupialization
Indwelling drain
Other
Unknown
(Select all that apply.)

__________________________________

__________________________________
(YYYY)
Yes

No

Unknown

PCR
IHC
Culture
Unknown
(Select all that apply.)

What was the result of testing?

Positive
Negative/undetermined
Unknown

Did this patient develop an embolic stroke or
infarct?

Yes

Please specify the location of the embolic stroke or
infarct.
Was this patient admitted to the hospital for chronic
Q fever?
Please provide the number of times the patient was
hospitalized at least overnight for complications of
chronic Q fever since the initial chronic Q diagnosis

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No

Unknown

__________________________________
Yes

No

Unknown

__________________________________
(# of hospitalizations)

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Antibiotics
Which antibiotics did the patient receive?

Please specify what other antibiotics is/was the
patient on.

How many months has the patient been on antibiotic
therapy?

Has the patient completed antibiotic therapy?
Did the patient develop any of the following side
effects or complications from antibiotic therapy?

Please specify what other side effects or
complications the patient developed from antibiotic
therapy.

Was the patient taken off any antibiotic during
treatment due to side effects?
Which medication(s) were stopped?

What other antibiotic was stopped?

What were the side effects that led to the medication
being discontinued?

Please specify other side effects that led to
medication to medication being discontinued.

10/02/2019 11:39am

Doxycycline
Hydroxychloroquine
Other
None
Unknown
(Select all that apply)

__________________________________
(Use the common name for the drug or chemical, not
trade name.)

__________________________________
(Number of Months)
Yes

No

Unknown

Nausea/other GI upset
Retinal damage
QT prolongation
Photosensitivity
Irreversible skin pigmentation
Other
None
Unknown
(Select all that apply.)

__________________________________

Yes

No

Unknown

Doxycycline
Hydroxychloroquine
Other
(Select all that apply)

__________________________________
(Use the common name for the drug or chemical, not
trade name.)
Nausea/other GI upset
Retinal damage
QT prolongation
Photosensitivity
Irreversible skin pigmentation
Fatigue
Other
(Select all that apply.)

__________________________________

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Serology
On average, how frequently are/were Q fever
serologies collected from the patient?

What was the Phase 1 IgG serology titer value at the
initial chronic Q diagnosis?

What was the Phase 2 IgG serology titer value at the
initial chronic Q diagnosis?

What was the most recent Phase 1 IgG titer value
recorded?

What was the most recent Phase 2 IgG titer value
recorded?

How many weeks ago was the most recent serology
collected?

At any point during treatment, has a four-fold
reduction in Phase 1 titers been observed?

10/02/2019 11:39am

__________________________________
(Average months (#))

__________________________________
(Record the only reciprocal titer (e.g. 64, 128,
256))

__________________________________
(Record the only reciprocal titer (e.g. 64, 128,
256))

__________________________________
(Record the only reciprocal titer (e.g. 64, 128,
256))

__________________________________
(Record the only reciprocal titer (e.g. 64, 128,
256))

__________________________________
(Number of weeks)
Yes

No

Unknown

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Outcome
Did the patient die from complications of this
illness?
What was the cause of death per death certificate?

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Yes

No

Unknown

__________________________________

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