Varicella Investigation Outcome Reporting Form

OMB Approved

Control # 0920-0900

Exp date: XX-XX-XXXX

Varicella OUTBREAK Enhanced Data Collection

Ship ____________________ Voyage #____________________

Isolation Practices*: Were all persons with suspected varicella isolated* appropriately?
Cases: Were all persons with suspected varicella medically evaluated?
Treatment†: How many persons with suspected varicella were treated with antiviral (acyclovir) treatment†?	Total number treated with antivirals: ______
Contacts: How many total contacts‡ were identified (i.e. for all cases)?
How many total susceptible contactsǁ were identified?
How many total high risk§ susceptible contacts§ were identified?
Prophylaxis**: How many asymptomatic susceptible contactsǁ were provided with varicella vaccination?	Susceptible contacts prophylaxed: _____
How many asymptomatic high risk susceptible contacts§ were provided varicella-zoster immune globulin (VZIG)?	High risk susceptible contacts prophylaxed:_____
Notifications: Were varicella notifications sent out to crew/passengers?	Crew: Passengers:
Morbidity & Mortality: Were any persons with suspected varicella hospitalized (ashore or at sea)?
Were there any fatalities due to suspected varicella?

* Persons with suspected varicella should remain isolated in their cabins or quarters until all lesions have crusted over or no new lesions appear within a 24-hour period (usually 5-7 days after rash onset).

† Antiviral (acyclovir) treatment is recommended for people who develop varicella and are > 12 years old or others at high-risk for complications.

‡ Varicella contacts on a cruise ship are considered to be a person who has had ≥5 minutes of face-to-face contact with a varicella case during the infectious period, from 1 to 2 days before rash onset until lesions are crusted (generally 5-7 days after rash onset) or direct contact with the fluid from skin lesions of patients with varicella or herpes zoster .

ǁ Susceptible contacts include those without any of the following: documentation of receipt of two doses of varicella-containing vaccine; serologic evidence of immunity or confirmed disease; birth in the United States before 1980; a history of varicella or herpes zoster verified by a health-care provider or the cruise ship clinician based on the patient’s description of the illness

§ High Risk Susceptible Contacts include those who are pregnant, immunocompromised with HIV infection, with a malignant condition affecting the bone marrow or lymphatic systems, or persons taking oral steroids or other immunosuppressant medications

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 0920-0900.

** A dose of varicella vaccine should be administered within 3 days of exposure (possibly up to 5 days) to all susceptible contacts who lack evidence of immunity except those who are pregnant or immunocompromised. Vaccination is still recommended beyond 5 days to prevent infection from future exposures and further spread of disease. Susceptible contacts with written documentation of receipt of one dose of varicella vaccine may be vaccinated with a second dose. High-risk susceptible contacts for whom varicella vaccine is contraindicated (i.e., pregnant women or immunocompromised persons) should be evaluated for administration of varicella zoster immune globulin. VZIG should be administered as soon as possible but may be effective if administered as late as 10 days after exposure.