0920-0004 Human Infection with Novel Influenza A Virus Case Report

[NCIRD] National Disease Surveillance Program - II. Disease Summaries

Attachment K_Human Infection with Novel Influenza A Virus_CRF

Human Infection with Novel Influenza A Virus Case Report Form

OMB: 0920-0004

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Shape1 Shape2

Form Approved

Human Infection with Novel Influenza A Virus


Case Report Form

OMB No. 0920-0004


Shape3

State: Date reported to health department: / / (MM/DD/YYYY) Date interview completed: / / (MM/DD/YYYY) State Epi ID: State Lab ID:

Shape4 Shape5 Shape6 Shape7 Shape8 Shape9

_________

:_____________________

____________________

Household ID (CDC use only): CDC ID (CDC use only) Cluster ID (CDC use only):

  1. At the time of this report, is the case

Shape10 Shape11 Shape12 Shape13 Confirmed Probable Case under investigation (skip to Q.3) Not a case (skip to Q.3)

  1. What is the subtype? (If a variant subtype is selected, please complete the Human Infection with Novel Influenza A Variant Module. If an avian subtype is selected, please complete the Human Infection with Novel Influenza A Virus Avian Module).

Shape14 Shape15 Shape16 Shape17 Influenza A(H1N1) variant Influenza A(H1N2) variant Influenza A(H3N2) variant Influenza A(H5N1) avian

Shape18
Shape19

Demographic Information

Influenza A(H7N9) avian Other Unknown

  1. Date of birth: / / (MM/DD/YYYY)

  2. Country of usual residence: If usual resident of U.S., county of residence:

  3. Shape21 Shape22 Shape23 Shape20 Shape24 Race: (check all that apply) White Asian American Indian/Alaska Native Black

Native Hawaiian/Other Pacific Islander

  1. Shape25 Shape26 Ethnicity: Hispanic or Latino Not Hispanic or Latino

  2. Shape27 Sex: Male Female

  3. Shape28

    Symptoms, Clinical Course, Treatment, Testing, and Outcome

    Occupation

  4. What date did symptoms associated with this illness start? / / (MM/DD/YYYY)

  5. Shape29 Shape30 Shape31 Shape32 Shape33 Shape34 Shape35 Shape36 Shape37 Shape38 Shape39 Shape40 During this illness, did the patient experience any of the following?

    Symptom

    Symptom Present?

    Symptom

    Symptom Present?

    Fever (highest temp oF)

    Yes No Unk

    Shortness of breath

    Yes

    No

    Unk

    If fever present, date of onset


    /


    /

    (MM/DD/YYYY)

    Vomiting

    Yes

    No

    Unk

    Felt feverish

    Yes No Unk

    Diarrhea

    Yes

    No

    Unk

    If felt feverish, date of onset

    /


    /


    (MM/DD/YYYY)

    Eye infection/redness

    Yes

    No

    Unk

    Cough

    Yes No Unk

    Rash

    Yes

    No

    Unk

    Sore Throat

    Yes No Unk

    Fatigue

    Yes

    No

    Unk

    Muscle aches

    Yes No Unk

    Seizures

    Yes

    No

    Unk

    Headache

    Yes No Unk

    Other, specify

    Yes

    No

    Unk

  6. Shape41 Shape42 Shape43 Does the patient still have symptoms?

Shape44 Shape45 Shape46 Yes (skip to Q.13) No Unknown (skip to Q.13)

  1. When did the patient feel back to normal? / / (MM/DD/YYYY)

  2. Did the patient receive any medical care for the illness?

Shape47 Shape48 Shape49 Yes No (skip to Q.30) Unknown (skip to Q.30)

  1. Where and on what date did the patient seek care (check all that apply)?

Shape50 Shape51 Shape52 Doctor’s office date: / / (MM/DD/YYYY) Emergency room date: / / (MM/DD/YYYY) Urgent care clinic date: / / (MM/DD/YYYY) Health department date: / / (MM/DD/YYYY) Other date: / / (MM/DD/YYYY) Unknown

  1. Was the patient hospitalized for the illness?

Shape53 Shape54 Shape55 Yes No (skip to Q.24) Unknown (skip to Q.24)

  1. Date(s) of hospital admission? First admission date: / / (MM/DD/YYYY) Second admission date: / / (MM/DD/YYYY)

  2. Was the patient admitted to an intensive care unit (ICU)?

Shape56 Shape57 Shape58 Yes No (skip to Q.19) Unknown (skip to Q.19)

  1. Date of ICU admission: / / (MM/DD/YYYY) Date of ICU discharge: / / (MM/DD/YYYY)

  2. Shape59 Shape60 Shape61 Did the patient receive mechanical ventilation / have a breathing tube?

Yes No (skip to Q.21) Unknown (skip to Q.21)

  1. For how many days did the patient receive mechanical ventilation or have a breathing tube? days

  2. Was the patient discharged?

Shape62 Shape63 Shape64 Yes No (skip to Q.24) Unknown (skip to Q.24)

  1. Date(s) of hospital discharge? First discharge date: / / (MM/DD/YYYY) Second discharge date: / / (MM/DD/YYYY)

  2. Where was the patient discharged?

Shape65 Shape66 Shape67 Shape68 Shape69 Home Nursing facility/rehab Hospice Other Unknown

Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).


  1. Did the patient have a new abnormality on chest x-ray or CT scan?

Shape70 Shape71 Shape72 Shape73 No, x-ray or scan was normal Yes, x-ray or scan detected new abnormality No, chest x-ray or CT scan not performed Unknown

  1. Shape74 Shape75 Shape76 Did the patient receive a diagnosis of pneumonia? Yes No Unknown

  2. Shape77 Shape78 Shape79 Did the patient receive a diagnosis of ARDS? Yes No Unknown

  3. Shape80 Shape81 Shape82 Shape83 Did the patient have leukopenia (white blood cell count <5000 leukocytes/mm3) associated with this illness? Normal Abnormal Test not performed Unknown

  4. Shape84 Shape85 Shape86 Shape87 Did the patient have lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of WBC) associated with this illness? Normal Abnormal Test not performed Unknown

  5. Shape88 Shape89 Shape90 Shape91 Did the patient have thrombocytopenia (total platelets <150,000/mm3) associated with this illness? Normal Abnormal Test not performed Unknown

  6. Shape92 Shape93 Shape94 Did the patient experience any other complications as a result of this illness? Yes (please describe below) No Unknown



  1. Did the patient receive influenza antiviral medications prior to becoming ill (within 2 weeks) or after becoming ill? Yes, (please complete table below) No Unknown

    Drug

    Start date (MM/DD/YYYY)

    End date (MM/DD/YYYY)

    Total number of days receiving antivirals

    Dosage (if known)

    Oseltamivir (Tamiflu)




    mg

    Zanamivir (Relenza)




    mg

    Peramivir (Rapivab)




    mg

    Other influenza antiviral




    mg

  2. Shape97 Shape98 Shape99 Did the patient die as a result of this illness?

Shape100
Shape101 Shape102 Shape103

Influenza Testing

Yes, Date of death: / / (MM/DD/YYYY) No Unknown

  1. When was the specimen collected that indicated novel influenza A virus infection tested by Reverse Transcription-Polymerase Chain Reaction (RT-

PCR)? / / (MM/DD/YYYY)

  1. Shape104 Shape105 Shape106 Shape107 Shape108 Where was the specimen collected? Doctor’s office Hospital Emergency room Urgent care clinic Health department

Shape109 Shape110 Other Unknown

  1. Shape111 Shape112 Shape113 Was a rapid influenza diagnostic test (RIDT) used on any respiratory specimens collected?

Yes No (skip to Q.39) Unknown (skip to Q.39)

  1. When was the RIDT specimen collected? / / (MM/DD/YYYY)

  2. Shape114 Shape115 Shape116 Shape117 Shape118 What was the result? Influenza A Influenza B Influenza A/B (type not distinguished) Negative Other

  3. Shape119

    Medical History -- Past Medical History and Vaccination Status

    What brand of RIDT was used?

  4. Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.


a.

Asthma/reactive airway disease

Yes

No

Unknown


b.

Other chronic lung disease

Yes

No

Unknown

(If YES, specify)

c.

Chronic heart or circulatory disease

Yes

No

Unknown

(If YES, specify)

d.

Diabetes mellitus

Yes

No

Unknown

(If YES, specify)

e.

Kidney or renal disease

Yes

No

Unknown

(If YES, specify)

f.

Non-cancer immunosuppressive condition

Yes

No

Unknown

(If YES, specify)

g.

Cancer chemotherapy in past 12 months

Yes

No

Unknown

(If YES, specify)

h.

Neurologic/neurodevelopmental disorder

Yes

No

Unknown

(If YES, specify)

i.

Other chronic diseases

Yes

No

Unknown

(If YES, specify)

  1. Shape120 Shape121 Shape122 Shape123 Shape124 Shape125 Shape126 Shape127 Shape128 Shape129 Shape130 Shape131 Shape132 Shape133 Shape134 Shape135 Shape136 Shape137 Shape138 Shape139 Shape140 Shape141 Shape142 Shape143 Shape144 Shape145 Shape146 Does the patient frequently use a stroller or wheelchair? If yes, please describe.

Shape147 Shape148 Shape149 Yes No Unknown





  1. Was patient pregnant or ≤6 weeks postpartum at illness onset?

Shape150 Yes, pregnant (weeks pregnant at onset) Yes, postpartum (delivery date) / / (MM/DD/YYYY)

Shape152 Shape151 No Unknown


  1. Does the patient currently smoke?

Shape153 Shape154 Shape155 Yes No Unknown


  1. Shape156 Shape157 Shape158 Was the patient vaccinated against influenza in the past year? Yes No (skip to Q.46) Unknown (skip to Q.46)

  2. Month and year of influenza vaccination? Vaccination date 1: / (MM/YYYY) Vaccination date 2: / (MM/YYYY)

  3. Shape159
    Shape160 Shape161 Shape162

    Epidemiologic Risk Factors

    Type of influenza vaccine (check all that apply): Inactivated (injection) Live attenuated (nasal spray) Other _______________ Unknown


  1. In the 10 days prior to illness onset, did the patient travel outside of his/her usual area? Yes No (skip to Q.50) Unknown (skip to

Shape163 Shape164 Shape165 Q.50)

  1. When and where did the patient travel? Please describe details of the patient’s travel in the notes section at the end of the form.

Trip 1: Dates of travel: / / to / / Country State City/County

Trip 2: Dates of travel: / / to / / Country State City/County

  1. Did the patient travel in a group (check all that apply)?

Shape166 Shape167 Shape168 Shape169 No, travelled alone Yes, with household members Yes, with non-household members Unknown

  1. Please describe the details of the trip



  1. In the 10 days prior to illness onset, did the patient attend a public event where a large number of people were present (e.g., a sporting event, wedding, concert)? Yes No (skip to Q.52) Unknown (skip to Q.52)

  2. Shape172 Shape173 Shape174 Please describe the event (include date and location)



  1. In the 10 days prior to illness onset, or at any time after illness onset, did the patient travel by means of public conveyance where others were present (e.g., public bus or train)? Yes No (skip to Q.54) Unknown (skip to Q.54)

  2. Shape177 Shape178 Shape179 Please describe means and frequency of public travel


  1. In the 10 days prior to illness onset, did the patient have close contact with someone who travelled outside the United States? Yes No (skip to Q.56) Unknown (skip to Q.56)

  2. Shape181 Shape182 Shape183 Please describe individual (including travel location)

Shape184

Risk Factors – Animal and Animal Product Exposure


  1. In the 10 days before becoming ill, did the patient attend an agricultural fair or event (e.g. show or auction)?

Shape186 Shape187 Shape188 Yes (specify name, if >1 fair, please describe in the notes section ) No Unknown

  1. In the 10 days before becoming ill, did the patient attend a live animal market?

Shape189 Shape190 Shape191 Yes (specify name. If >1 market, please describe in the notes section ) No Unknown

(If the answers to Q.56 and Q.57 are both No or Unknown skip to Q.59.)

  1. Shape192 Shape193 Shape194 Shape195 In the 10 days before becoming ill, on what days did the patient attend an agricultural fair/event or live animal market (check all that apply)? on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset

4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset 8 days before illness onset 9 days before illness onset 10 days before illness onset

  1. In the 10 days before becoming ill, did the patient have direct contact with any animals? Direct contact is defined as: handling, touching, or petting an animal. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.

Shape196 Shape198 Shape197 Yes No (skip to Q.62) Unknown (skip to Q.62)

  1. What type(s) of animals did the patient have direct contact with (check all that apply)?

Shape200 Shape207 Shape201 Shape202 Shape203 Shape204 Shape205 Shape206 Horses Cows Poultry/wild birds Sheep Goats Pigs/hogs Other (1)

Other (2)

Other (3)

Other (4)


  1. Where did the direct contact occur (check all that apply)?

Shape208 Shape209 Shape210 Shape211 Shape212 Shape213 Home Work Agricultural fair or event Live animal market Petting zoo Slaughterhouse/rendering facility

Shape214 Other

  1. In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of) any animals?

Shape215 Shape216 Shape217 Yes No (skip to Q.65) Unknown (skip to Q.65)

  1. What type(s) of animals did the patient have this exposure to from Q.62 (e.g, touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of ) (check all that apply)?

Shape219 Shape220 Shape221 Shape222 Shape223 Shape224 Shape225 Shape218 Horses Cows Poultry/wild birds Sheep Goats Pigs/hogs Other (1)

Other (2)

Other (3)

Other (4)

  1. Where did this exposure occur (check all that apply)?

Shape228 Shape227 Shape226

Shape229 Shape230 Shape231 Home Work Agricultural fair or event Live animal market Petting zoo Other

  1. In the 10 days before becoming ill, did the patient have direct or any other contact with any animal exhibiting signs of illness?

Shape232 Shape233 Shape234 Yes (specify animal type and location ) No Unknown

  1. In the 10 days before becoming ill, did the patient have direct or any other contact with any animal confirmed to be influenza A positive?

Shape235 Shape236 Shape237 Yes (specify animal type and location ) No Unknown

Shape238 Shape239 Shape240 Yes (specify influenza subtype (if known) ) No Unknown

  1. Shape241 Shape242 Shape243 Does anyone in the household own, keep or care for livestock, poultry, or farm animals (either at home or in the workplace)?

Yes No (skip to Q.69) Unknown (skip to Q.69)

  1. What type(s) of animals are owned, kept, or cared for by household members (check all that apply)?

Shape244 Shape251 Shape245 Shape246 Shape247 Shape248 Shape249 Shape250 Horses Cows Poultry/wild birds Sheep Goats Pigs/hogs Other (1)

Other (2) Other (3) Other (4)

  1. In the 10 days before becoming ill, did the patient drink any raw or unpasteurized milk from a cow or other animal sources, including drinking milk on the farm where it was produced or drinking milk from the “bulk tank”?

Shape257 Shape256 Shape255

Shape254 Yes No Unknown Refused

(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)

    1. What type of milk (cow milk, goat milk, etc.), variety, and brand: ___________________________________ Unknown

    2. What was the first date of consumption in the 10 days before becoming ill (MM-DD-YYY): ______________ Unknown

    3. Where was the milk acquired (store name, farm name, herd share, etc.): __________________________ Unknown

    4. What was the address, city, and state of acquisition (if not case’s home):________________________________________ Unknown

    5. What was the product expiration/best by/best before date: __________________________________________ Unknown

    6. What was the product lot number or code on the packaging:________________________________________ Unknown

      Shape260 Shape259
    7. Shape258 Is there any remaining product? Yes No Unknown

  1. In the 10 days before becoming ill, did the patient consume any raw or unpasteurized milk products? (select all that apply):

Shape267 Shape268 Shape265 Shape266 Shape264 Shape263 Shape262 Shape261

Raw milk cheese Heavy raw cream Whole raw kefir Raw butter Raw yogurt Raw kefir pet food Raw milk pet food Other (specify):

Unknown Refused

(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)

    1. What was the type (cow milk, goat milk, etc.), variety, and brand: _____________________________________ Unknown

    2. What was the consumption date (MM-DD-YYY): Unknown

    3. Where was the milk product acquired (store name, farm name, herd share, etc.): __________________________ Unknown

    4. What was the address, city, and state of acquisition (if not case’s home):_________________________________________ Unknown

    5. What was the product expiration/best by/best before date: ____________________________________________ Unknown

    6. What was the product lot number or code on the packaging:__________________________________________ Unknown

      Shape269 Shape271
    7. Shape270 Is there any remaining product? Yes No Unknown



Shape272

Risk Factors – Household, Occupational, Nosocomial, and Secondary Spread




  1. Does the patient reside in an institutional or group setting (e.g. nursing home, boarding school, college dormitory)? Yes (skip to Q.73) No Unknown (skip to Q.73)

  2. How many people resided in the patient’s household(s) in the week before or after illness onset (excluding the patient)?

A household member is anyone with at least one overnight stay +/- 7 days from patient’s illness onset. The patient may have resided in >1 household during this time. Please complete the table below for each household member and continue in the notes section if more space is needed.


ID

Household (HH) [“A” should be the patient’s primary household]


Relation to patient (e.g. parent, brother, friend)


Sex (M/F)



Age

Was HH member ill (fever or any respiratory symptom)

+/– 7 days from case patient’s onset?

If Yes, HH member’s date of

illness onset

1

A B C




Y N U


2

A B C




Y N U


3

A B C




Y N U


4

A B C




Y N U


5

A B C




Y N U


6

A B C




Y N U



  1. In the 7 days before or after becoming ill, did the patient attend or work at a childcare facility?

Shape273 Shape274 Shape275 Shape276 Yes (before becoming ill) Yes (after becoming ill) No (skip to Q.75) Unknown (skip to Q.75)

  1. Approximately how many children are in the patient’s class or room at the childcare facility?

  2. In the 7 days before or after becoming ill, did the patient attend or work at a school?

Shape277 Shape278 Shape279 Shape280 Yes (before becoming ill) Yes (after becoming ill) No (skip to Q.77) Unknown (skip to Q.77)

  1. Approximately how many students are in the patient’s class at the school?

  2. Shape281 Shape282 Shape283 In the 7 days before or after the patient became ill, did anyone else in the patient’s household(s) work at or attend a childcare facility or school? Yes No (skip to Q.79) Unknown (skip to Q.79)

  3. List ID numbers from Q.72 (the table above) for household members working at or attending a childcare facility or school:


  1. Does the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting? Yes No Unknown

  2. Shape285 Shape286 Shape287 Shape288 Shape289 Shape290 In the 7 days before or after becoming ill, did the patient work in or volunteer at a healthcare facility or setting? Yes No (skip to Q.83) Unknown (skip to Q.83)

  3. Specify healthcare facility job/role:

Shape297 Shape296 Shape295 Shape294 Shape293 Shape292 Shape291 Physician Nurse Administration staff Housekeeping Patient transport Volunteer Other

  1. Shape298 Shape299 Shape300 Did the patient have direct patient contact while working or volunteering at a healthcare facility? Yes No Unknown

  2. Shape301 Shape302 Shape303 In the 7 days before becoming ill, was the patient in a hospital for any reason (i.e., visiting, working, or for treatment)? Yes No Unknown

If yes, what were the dates? / / , / / City/Town

  1. Shape304 Shape305 Shape306 In the 7 days before becoming ill, was the patient in a clinic or a doctor’s office for any reason? Yes No Unknown

If yes, what were the dates? / / , / / City/Town


Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia in the 7 days BEFORE the case patient’s illness onset?

Shape307 Shape308 Shape309

ID

Relationship to patient

Sex (M/F)

Age

Date of illness onset

Comments

1






2






3






4






Yes (please list those ill before the case patient in the table below) No Unknown









  1. Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia beginning AFTER the case patient’s illness onset?

Shape310 Shape311 Shape312 Yes (please list those ill after the case patient in the table below) No Unknown

ID

Relationship to patient

Sex (M/F)

Age

Date of illness onset

Comments

1






2






3






4






  1. Is the patient a contact of a confirmed or probable case of novel influenza A infection?

Shape313 Shape314 Shape315 Shape316 Shape317 Yes (please list patient’s confirmed or probable contacts in the table below) No Unknown


Relationship to patient


State Epi ID


State Lab ID


Case status

Sex (M/F)


Age

Date of illness onset (MM/DD/YYYY)




Confirmed

Probable







Confirmed

Probable







Confirmed

Probable







Confirmed

Probable




  1. Shape318 Shape319 Shape320 Shape321 Shape322 Shape323 Any additional comments or notes (e.g. travel details, names/dates of fairs or live markets attended by case patient, dates of household members fair attendance and location of fair, information about other ill contacts)?




















Variant Module – complete only if confirmed case with a variant influenza virus (i.e. H1N1v, H1N2v, H3N2v)

Shape338


  1. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle pigs or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of any pigs/hogs) to pigs (check all that apply)?

Shape339 Shape340 Shape341 Shape342 on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset 4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset 8 days before illness onset 9 days before illness onset 10 days before illness onset

  1. What was the total number of days the patient reported direct or any other pig exposure ? days.

  2. Shape343 Shape344 Shape345 Shape346 Shape347 Shape348 Shape349 Shape350 Shape351 Please describe animal exposure for all household members listed in Q.72 of the main Novel A Case Report Form (please use the same id for each person as in Q. 72 of the main form).




ID

If household (HH) member was ILL

If HH member was NOT ILL

Did HH member have any pig/hog exposure ≤10 days before illness onset?

Did HH member visit a live market or fair ≤10 days before illness onset?

Did HH member have any pig/hog exposure or visit a live market visit ≤10 days before the case-patient’s illness onset?

1

Y

N

U

Y

N

U

Y

N

U

2

Y

N

U

Y

N

U

Y

N

U

3

Y

N

U

Y

N

U

Y

N

U

4

Y

N

U

Y

N

U

Y

N

U

5

Y

N

U

Y

N

U

Y

N

U

6

Y

N

U

Y

N

U

Y

N

U


  1. Shape352 Shape353 Shape354 Shape355 Shape356 Shape357 Shape358 Shape359 Shape360 Shape361 Shape362 Shape363 Shape364 Shape365 Shape366 Shape367 Shape368 Shape369 Shape370 Shape371 Shape372 Shape373 Shape374 Shape375 Shape376 Shape377 Shape378 Shape379 Shape380 Shape381 Shape382 Shape383 Shape384 Shape385 Shape386 Shape387 Shape388 Shape389 Shape390 Shape391 Shape392 Shape393 Shape394 Shape395 Shape396 In the 10 days before becoming ill, did the patient have direct or any other exposure (e.g. caring for, speaking with, or touching) with anyone

other than a household member who routinely has exposure with pigs/hogs?

Shape397 Shape398 Shape399 Yes No Unknown

  1. Shape400 Shape401 Shape402 Please describe the pig/hog exposure and fair attendance for individuals listed in Q. 85 of the main Novel A Case Report Form.


ID

Any pig/hog exposure or fair attendance ≤10 days before his/her onset?


Comments

1

Y

N

U


2

Y

N

U


3

Y

N

U


4

Y

N

U



  1. Shape410 Shape411 Shape412 Shape413 Shape414 Shape415 Shape416 Shape417 Shape418 Shape419 Shape420 Shape421 Shape409 Shape408 Shape404 Shape405 Shape407 Shape403 Shape406 Please describe the pig/hog exposure and fair attendance of individuals listed in Q. 86 of the main Novel A Case Report Form.


ID

Any pig/hog exposure or fair attendance ≤10 days before his/her onset?


Comments

1

Y

N

U


2

Y

N

U


3

Y

N

U


4

Shape422

Y

N

Shape423

U



  1. Notes:






Avian Module – complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)

Shape424

  1. Has the patient ever received an influenza H5N1 vaccination?

Shape425 Shape426 Shape427 Yes (Date: / / ) No Unknown

  1. In the 10 days before becoming ill, did the patient have direct contact with poultry (chickens, turkeys, ducks, or geese, etc.)? Direct contact is defined as: handling, touching, or petting an animal. This could have been at the patient's home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.

Shape428 Shape429 Shape430 Yes No (skip to Q.100) Unknown (skip to Q.100)

  1. Where did the direct contact with poultry occur (check all that apply)?

Shape431 Shape432 Shape433 Shape434 Shape435 Home Commercial poultry farm Agricultural fair or event Live animal market Petting zoo

Shape436 Veterinary care Slaughterhouse/Rendering facility Other

  1. What type(s) of poultry did the patient have direct contact with (check all that apply)?

Shape437 Shape438 Shape439 Shape440 Shape441 Shape442 Shape443 Shape444 Chickens Turkeys Geese Pheasants Ducks Ostriches Emu Pigeons Other

  1. In the 10 days before becoming ill, did the patient have any other exposure (e.g., touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of) to poultry?

Shape445 Shape446 Shape447 Yes No (skip to Q.113) Unknown (skip to Q.113)

  1. Where did this exposure from Q.100 to poultry occur (check all that apply)?

Shape448 Shape449 Shape450 Shape451 Shape452 Home Commercial poultry farm Agricultural fair or event Live animal market Petting zoo

Shape454 Shape453 Veterinary care Slaughterhouse Other

  1. What type(s) of poultry did the patient have this exposure to (check all that apply)?

Shape455 Shape456 Shape457 Shape458 Shape459 Shape460 Shape461 Shape462 Chickens Turkeys Geese Pheasants Ducks Ostriches Emus Pigeons Other

  1. Shape463 Shape464 Shape465 Did the patient clean any poultry pens/houses in the 10 days before becoming ill?

Yes No Unknown

  1. Shape466 Shape467 Shape468 Did the patient feed or water any poultry in the 10 days before becoming ill?

Yes No Unknown

  1. Did the patient have direct contact with surfaces contaminated by bird or poultry feces or poultry parts (carcasses, internal organs, etc.) in the 10 days before becoming ill?

Shape469 Shape470 Shape471 Yes No Unknown

  1. Did the patient participate in the culling of any poultry flocks?

Shape472 Shape473 Shape474 Yes No (skip to Q.109) Unknown (skip to Q.109)

  1. What measures did the patient use to protect himself/herself during the culling (check all that apply)?

Shape476 Shape477 Shape478 Shape479 Shape480 Shape475 Shape481 Shape482 None Facemask Respirators Hand gloves Eye Protection Gowns Boots Unknown Other

  1. What percentage of time did the person participating in culling wear the items mentioned above while culling flocks (only ask about the items the exposed person mentioned in Q. 107)?

% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots

% Other

  1. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure with birds or poultry (check all that apply)?

Shape483 Shape484 Shape485 Shape486 on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset

4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset

8 days before illness onset 9 days before illness onset 10 days before illness onset

  1. From Q.109, what was the total number of different days the patient reported direct or any other bird or poultry exposure? days

  2. Did the patient report direct or any other exposure (direct or any other exposure or both) with any ill-appearing poultry in the 10 days before becoming ill?

Shape487 Shape488 Shape489 Yes, specify No Unknown

  1. Did the patient report direct or any other exposure (direct, or any other exposure, or both) with dead poultry in the 10 days before becoming ill?

Shape490 Shape492 Shape491 Yes, specify No Unknown








Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)


R isk Factors—Household bird and poultry practices

  1. Were poultry raised on the patient’s property?

Shape493 Shape494 Shape495 Yes No (skip to Q.121) Unknown (skip to Q.121)

  1. Where were the poultry kept (check all that apply)?

Shape496 Shape497 Shape498 In patient’s basement or garage Inside patient’s house/living space Open-air poultry pen or poultry house

Shape499 Enclosed poultry pen or poultry house Other enclosure/cage outside the patient’s house Other

  1. What type(s) of poultry did the patient raise (check all that apply)? Please estimate the number of each type raised.

Shape500 Shape501 Shape502 Shape503 Shape504 Shape505 Shape506 Shape507 Chickens # Turkeys # Geese # Pheasants # Ducks # Ostriches # Emus # Pigeons # Other #

  1. Shape508 Shape509 Shape510 Did the patient’s household have any recent (within the past 30 days) ill-appearing poultry? Yes No Unknown

  2. Did the patient’s household have any recent poultry die-offs?

Shape511 Shape512 Shape513 Yes No (skip to Q.121) Unknown (skip to Q.121)

  1. Please indicate the percent of the flock that died. %

  2. When did the die-off begin and end? Begin date: / / (MM/DD/YYYY) End date: / / (MM/DD/YYYY)

  3. Was the flock culled?

Shape514 Shape515 Shape516 Yes (date / / MM/DD/YY) No Unknown

  1. Shape517 Shape518 Shape519 Did the patient have exposure to any eggs from a private flock (i.e., not store bought or commercial) in the 10 days before becoming ill? Yes No Unknown

  2. Shape520 Shape521 Shape522 Did the patient consume raw or undercooked poultry in the 10 days before becoming ill? Yes No Unknown

  3. Does anyone else in the household own, keep or care for poultry in a location other than the patient’s property?

Shape524 Shape525 Shape523 Yes, specify No Unknown

  1. Shape526 Were there any recent reports of sick or dead poultry in the case patient’s area?

Shape528 Shape527 Yes, specify No Unknown



  1. Shape529 Were captive wild birds kept at the patient’s residence?

Shape530 Shape531 Shape532 Yes (describe) No Unknown

  1. Did the patient visit any areas where wild/migratory birds (e.g. herons, gulls, falcons, wild ducks, geese, or swans) are present?

Shape533 Shape534 Shape535 Yes, specify location No Unknown

  1. In the 10 days before illness onset, did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to wild/migratory birds?

Yes No (skip to Q.132) Unknown (skip to Q.132)

  1. In the 10 days before illness onset, did the patient have any direct contact (touch or handle) with any wild/migratory birds?

Shape536 Shape537 Shape538 Yes, specify type of bird(s) No Unknown

  1. In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) any wild/migratory birds?

Shape541 Shape540 Shape539 Yes, specify type of bird(s) No Unknown


  1. Shape542 Shape543 Were any of the wild/migratory birds that the patient had direct or any other contact with sick or dying?

Shape544 Yes, specify No Unknown


Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)


  1. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) with wild birds (check all that apply)?

Shape548 Shape547 Shape546 Shape545 on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset

Shape549 4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset

8 days before illness onset 9 days before illness onset 10 days before illness onset


  1. In the 10 days before becoming ill, did the patient have direct or any other exposure with birds other than poultry or wild/migratory birds?

Shape550 Shape551 Shape552 Yes, specify type of bird(s) No (skip to Q.135) Unknown (skip to Q135.)

  1. Were any of these birds that the patient had direct or any other exposure with sick or dying?

Shape553 Shape554 Shape555 Yes, specify No Unknown

  1. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure with these birds (check all that apply)?

Shape559 Shape558 Shape557 Shape556 on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset

Shape560 4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset

8 days before illness onset 9 days before illness onset 10 days before illness onset


Shape561



135. In the 10 days before becoming ill, did the patient have direct contact (touch or handle) with livestock (cattle, goats, sheep, pigs, etc.)?

Shape562 Shape563 Shape564 Yes No (skip to Q.138) Unknown (skip to Q.138)

136. Where did the direct contact with livestock occur (check all that apply)?

Shape570 Shape571 Shape567 Shape566 Shape565 Shape572 Shape569 Shape568 Home Commercial farm Agricultural fair or event Live animal market Petting zoo Veterinary care Slaughterhouse Other


137. What type(s) of livestock did the patient have direct contact with (check all that apply)?

Shape574 Shape575 Shape576 Shape573 Cattle Sheep Goats Other


138. In the 10 days before becoming ill, did the patient have any other exposure to (e.g., touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) livestock?

Shape577 Shape578 Shape579 Yes No (skip to Q.141) Unknown (skip to Q.141)


Shape580 139. Where did this exposure from Q.138 to livestock occur (check all that apply)?

Shape582 Shape583 Shape584 Shape585 Shape586 Shape581 Home Commercial farm Agricultural fair or event Live animal market Petting zoo Veterinary care Slaughterhouse/rendering facility Other


140. What type(s) of livestock did the patient have this exposure to from Q.138 (check all that apply)?

Shape588 Shape589 Shape590 Shape587 Cattle Sheep Goats Other


141. Did the patient conduct any of the following activities in the 10 days before becoming ill (check all that apply)?

Shape592 Shape591 Work at a farm or facility where live animals are present Touch, handle, or otherwise interact with ill livestock (cattle, goats, sheep)

Shape593 Shape594 Touch, handle, or otherwise interact with ill wild animals Drink or handle raw or unpasteurized milk

Shape596 Shape595 Consume or handle raw or unpasteurized milk products (cheese, cream, kefir, etc.) Work in a maternity or reproductive area of a farm

Shape598 Shape597 Handle or clean up animal stool or manure Use a pressure washer or broom in an area contaminated by animal manure or milk

Shape600 Shape599 Operate or clean automated milking equipment Perform manual milking of animals


Shape601 Shape602 Shape603 142. Did the patient clean any livestock pens in the 10 days before becoming ill?

Yes No Unknown


Shape604 Shape605 Shape606 143. Did the patient feed or water any livestock in the 10 days before becoming ill?

Yes No Unknown


144. Did the patient have direct contact with surfaces contaminated by livestock, livestock manure, livestock milk, or livestock parts (carcasses, internal organs, reproductive tissues, etc.) in the 10 days before becoming ill?

Shape607 Shape608 Shape609 Yes No Unknown


145. What measures did the patient use to protect himself/herself when exposed to livestock (check all that apply)?

Shape610 Shape611 Shape612 Shape613 Shape614 Shape615 Shape616 Shape617 None Facemask Respirators Hand gloves Eye Protection Gowns Boots Unknown

Other


146. What percentage of time did the person wear the items mentioned above while exposed to livestock (only ask about the items the exposed person mentioned in Q. 146)?

% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots

% Other


147. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to livestock (check all that apply)?

Shape618 Shape619 Shape620 Shape621 on the day of illness onset 1 day before illness onset 2 days before illness onset 3 days before illness onset

4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset

8 days before illness onset 9 days before illness onset 10 days before illness onset


148. Did the patient report direct or any other exposure to any livestock that appeared ill in the 10 days before becoming ill?

Shape622 Shape623 Shape624 Yes, specify No Unknown

149. Did the patient report direct or any other exposure to dead livestock in the 10 days before becoming ill?

Shape625 Shape626 Shape627 Yes, specify No Unknown




R isk Factors—Human exposures

  1. Please describe bird/poultry/livestock exposure for all household members listed in Q.72 of the main Novel A Case Report Form (please use the same ID as in Q.72).


ID

If HH member was ILL

If HH member was NOT ILL


Did HH member have any bird exposure ≤10 days before his/her onset?

Did HH member visit a live market ≤10 days before his/her onset?

Did HH member have any bird exposure or visit a live market visit ≤10 days before the case-patient’s illness onset?

1

Y

N

U

Y

N

U

Y

N

U

2

Y

N

U

Y

N

U

Y

N

U

3

Y

N

U

Y

N

U

Y

N

U

4

Y

N

U

Y

N

U

Y

N

U

5

Y

N

U

Y

N

U

Y

N

U

6

Y

N

U

Y

N

U

Y

N

U


  1. Shape628 Shape629 Shape630 Shape631 Shape632 Shape633 Shape634 Shape635 Shape636 Shape637 Shape638 Shape639 Shape640 Shape641 Shape642 Shape643 Shape644 Shape645 Shape646 Shape647 Shape648 Shape649 Shape650 Shape651 Shape652 Shape653 Shape654 Shape655 Shape656 Shape657 Shape658 Shape659 Shape660 Shape661 Shape662 Shape663 Shape664 Shape665 Shape666 Shape667 Shape668 Shape669 Shape670 Shape671 Shape672 Shape673 Shape674 Shape675 Shape676 Shape677 Shape678 Shape679 Shape680 Shape681 Shape682 Shape683 Shape684 Shape685 Shape686 Shape687 Please describe the bird exposure and live market visits for individuals listed in Q.72 of the main Novel A Case Report Form.

ID

Any bird exposure or live market visits ≤10 days before his/her onset?

Comments

1

Y N U


2

Y N U


3

Y N U


4

Y N U



  1. Shape688 Shape689 Shape690 Shape691 Shape692 Shape693 Shape694 Shape695 Shape696 Shape697 Shape698 Shape699 Please describe the bird exposure and live market visits of individuals listed in Q.72 of the main Novel A Case Report Form.

ID

Any bird exposure or live market visits ≤10 days before his/her onset?

Comments

1

Y N U


2

Y N U


3

Y N U


4

Y N U



  1. Shape700 Shape701 Shape702 Shape703 Shape704 Shape705 In the 7 days before becoming ill, did the patient have direct or other exposure (e.g., caring for, speaking with, or touching) with anyone other than a household member who routinely has exposure to birds?

Shape706 Shape707 Shape708 Yes No Unknown


  1. Notes:











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