0920-1353 Initial Outbreak Report Form

Outbreak Summary Report Form

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

CDC Use Only

CDC unique identifier (created for initial report)

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Reporting Agency

Reporting jurisdiction
Contact name (person completing form)
Contact phone number (xxx-xxx-xxxx)
Contact email address
Additional contact name(s) (if applicable)
Additional contact phone number(s) (xxx-xxx-xxxx)
Additional contact email address(es)
Date of report submission (MM/DD/YYYY)
Reporting Period	Select one □ Year 1 □ Year 2 □ Year 3 □ Year 4 □ Year 5

• By the end of each Reporting Period, submit an Outbreak Summary Report Form for each outbreak that was reported via the Initial Outbreak Report Form that year.

  • If an outbreak is closed prior to the end of the Reporting Period, the Outbreak Summary Report Form may be submitted at the time of close out rather than waiting until the end of the Reporting Period.

  • If an outbreak is ongoing at the end of the Reporting Period, an interim Outbreak Summary Report Form should be submitted based on data available at the end of the year Reporting Period. An updated, final Outbreak Summary Report Form should be submitted once the outbreak is closed.

• Complete this form with available information as of the date of report submission.

Outbreak

Outbreak status

Select one □ Outbreak, over □ Outbreak, ongoing □ Not an outbreak

NOTE: Stop here if “Not an outbreak” selected

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Jurisdiction-assigned outbreak ID1
Date outbreak was confirmed (MM/DD/YYYY)
Date outbreak was closed, if applicable (MM/DD/YYYY)
Outbreak type (select all that apply)	□ Hepatitis A, community/person-to-person □ Hepatitis A, foodborne — associated with an infected food handler □ Hepatitis A, foodborne — associated with contaminated food □ Hepatitis A, foodborne — undetermined whether associated with an infected food handler or contaminated food □ Hepatitis A, waterborne □ Hepatitis A, source not identified □ Hepatitis B, community/person-to-person □ Hepatitis B, healthcare-associated □ Hepatitis B, source not identified □ Hepatitis C, community/person-to-person □ Hepatitis C, healthcare-associated □ Hepatitis C, source not identified □ Other, specify:

¹ A jurisdiction-assigned unique name or identifier for an identified outbreak. For jurisdictions reporting via HL7, this is PHIN variable code=INV151 and data element identifier=77981-9.

Geographic Location

Was this a multistate outbreak?	Select one □ Yes □ No □ Unknown
Specify the geographic area(s) in your jurisdiction affected by the outbreak (i.e., areas where outbreak-associated cases are residents)	County name(s): City name(s):

Outbreak Case Characteristics

Number of outbreak-associated cases2
Earliest symptom onset date3 (MM/DD/YYYY)
Most recent symptom onset date3 (MM/DD/YYYY)

² Outbreak case definitions are developed by the outbreak investigation team for each outbreak and specify case definition criteria in person, place, and time for cases that are included in the outbreak. Cases meeting the outbreak case definition often also meet the surveillance case definition; however, there are many exceptions.

³ If the symptom onset date is unknown, then the date that the patient first tested positive (i.e., specimen collection date) for the hepatitis virus being reported on this form can be used as a proxy for symptom onset date.

		Number of cases for which information is available
Median age (years)
Age range (years)	Lower age limit: Upper age limit:

Gender (number) Total should equal number of outbreak-associated cases	Female: Male: Other gender identity: Unknown/missing:
Race (number) Check all that apply	American Indian/Alaska Native: Asian: Black/African American: Native Hawaiian/Other Pacific Islander: White: Unknown/missing:
Ethnicity (number) Total should equal number of outbreak-associated cases	Hispanic/Latino: Not Hispanic/Latino: Unknown/missing:

	Number	Number of cases for which information is available
Patients with symptoms
Patients with jaundice

	Number	Number of cases for which information is available
Patients hospitalized4
Patients deceased5

⁴ Patients should be considered hospitalized if their hospitalization was due to the viral hepatitis infection that resulted from this outbreak. For reporting purposes, ‘hospitalized’ includes patients having evidence of an inpatient hospital admission, evidence of an admission order from an emergency department physician for those patients who left against medical advice, or evidence of >24 hours observation at a medical facility. Patients who were evaluated in an outpatient clinic, those discharged to home from the emergency department with a duration of stay ≤24 hours, or whose hospitalization status was unknown should not be considered hospitalized for the purposes of reporting on this form.

⁵ For reporting purposes, patients should be reported as deceased if their case was reported as outbreak-associated and their death was due to the viral hepatitis infection that resulted from the outbreak or to complications from their outbreak-associated viral hepatitis illness.

Healthcare-associated hepatitis B and C outbreaks

NOTE: Complete the following two questions for healthcare-associated hepatitis B and C outbreaks only. If the outbreak being reported on this form is not a healthcare-associated hepatitis B or C outbreak, enter “N/A.”

Estimated number of potentially exposed individuals
Number of potentially exposed individuals screened to date

Outbreak Characteristics

Specify outbreak RISK FACTORS identified by time of report (select all that apply)

□ Drug use, injection □ Drug use, non-injection □ Homelessness or unstable housing □ Incarceration □ Sexual activity (MSM, multiple sex partners, STDs) □ Contact with viral hepatitis (household) □ Contact with viral hepatitis (healthcare worker) □ Contact with viral hepatitis (other), specify6: □ Contaminated pharmaceutical product, specify: □ Healthcare exposure (healthcare worker, employee) □ Healthcare exposure (patient) □ Hemodialysis □ Tissue or organ transplantation □ Tattoo receipt □ International travel, specify: □ Other, specify: □ Unknown

⁶ e.g., drug use partner, sexual partner

Specify outbreak SETTINGS identified by time of report (select all that apply)

□ Community □ Household □ Restaurant or restaurant chain □ Grocery store or chain □ Homeless shelter □ Correctional facility □ Drug treatment/rehab facility □ Healthcare facility (medical, inpatient) □ Healthcare facility (medical, outpatient) □ Healthcare facility (medical, emergency department) □ Healthcare facility (medical, surgery center) □ Healthcare facility (dental) □ Nursing home or assisted living facility □ Dialysis center □ Other, specify7: □ Unknown

⁷ e.g., hepatitis A in daycare/childcare, hepatitis B in a group home

Use this space if needed to provide additional information about settings, risk factors, or modes of transmission

Public Health Interventions

Which public health interventions did you implement in response to the outbreak? (select all that apply)

□ Collected food specimens or traceback information □ Performed an environmental health inspection (e.g., restaurant, grocery store) □ Closed a facility □ Issued notification, limited (e.g., letter to potentially exposed patients, shopper alert issued to consumers who purchased a specific food product) □ Issued notification, public (e.g., press release, Epi-X) □ Performed an infection prevention and control assessment □ Recommended screening of potentially exposed individuals □ Provided screening of potentially exposed individuals □ Recommended postexposure prophylaxis □ Provided postexposure prophylaxis □ Performed targeted preexposure prophylaxis (hepatitis A vaccination) outreach for populations at increased risk of infection or adverse consequences of infection □ Expanded access to sterile injection paraphernalia among populations affected by the outbreak □ Expanded access to medication for opioid use disorder among populations affected by the outbreak □ Expanded access to testing for HBV, HCV, and HIV among populations affected by the outbreak □ Expanded access to hepatitis A and hepatitis B vaccination among populations affected by the outbreak □ Expanded access to treatment among populations affected by the outbreak □ Other, specify:

Use this space if needed to provide additional information about your completed and/or planned interventions

Other remarks

Use this space if needed to provide additional information about any aspect(s) of the outbreak not covered above

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