Meningitis Surveillance Form - Epidemiology Unit
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3EPID/DS/MENINGITIS/2007
SURVEILLANCE OF MENINGITIS – CASE INVESTIGATION FORM
EPIDEMIOLOGY UNIT, MINISTRY OF HEALTH
The MOH should do the investigation personally. Necessary data should be obtained from the diagnosis card. Early
investigation and return are essential.
* Please write the Serial No given in the Infectious
Week Ending:
Serial No:
*
Disease Register (ID Register) in the MOH Office
of notification
d
d
m m
y
y
A. PARTICULARS OF PATIENT (Please (
) appropriate box where applicable)
1. Name of patient (BLOCK LETTERS) ..........................................................................
2. Residential Address: ...................................................................................................
/
/
3. Date of Birth :
(dd/mm/yyyy)
4. Age
5. Sex
6. Ethnic group
7. Occupation
8. DPDHS Division
9. MOH area
1. Male
/
1. Sinhalese
2. Female
................................
….................................
........................................
2. Tamil
/
y y
m m
9. Unknown
3. Moor
FOR OFFICE USE ONLY
4. Others
9. Unknown
B. PRESENT ILLNESS/OUTCOME
10. Date of onset of symptoms:
12. Was patient admitted to hospital
17. Date of discharge/ transfer or death:
1. yes
to Q.13
d d
m m
y y
d d
m m
y y
2. no
skip
11. Where did the patient first seek
18. If transferred to, name of hospital
3. not known
to Q.21
medical advice ?
..........................................................
1. government hospital
19. Was patient transferred from some
13. If yes, date of admission
other hospital?
2. private hospital
1. Yes
2. No
3. private practitioner
d
d
m
m
y
y
4. Ayurvedic institution
20. If “yes”, where was the patient
(public/private)
14. Name of hospital:
transferred from?
5. other (specify)
............................................
………………………………………..
...........................................
15. Ward: ..................
21. Outcome of the case
16. BHT No: ...........................
1. cured
3. transferred
2. died
4. not known
C. CLINICAL DATA
Surveillance case definition
Fever of acute onset with one or more of the following signs of meningeal irritation/inflammation: neck stiffness, poor sucking
(in infants), bulging fontanelles (in infants), altered consciousness, irritability, seizures, other signs of meningeal
irritation/inflammation
Case classification
1. Suspected: a case compatible with the surveillance case definition
2. Probable bacterial meningitis: a suspected case with a turbid (‘cloudy’) CSF or a CSF with an elevated protein (>100
3
mg/dl), decreased glucose (<40mg/dl) compared to the blood glucose level or leucocytosis (>100 WBC/mm
) with 80%
neutrophils
Probable viral meningitis: a suspected case with CSF findings including pleocytosis ( usually mononuclear, occasionally
polymorphonuclear in the early stage), increased protein, normal sugar and absence of other causative organisms.
3. Confirmed: a suspected or probable case which is laboratory confirmed by isolation of a causal organism by CSF and/or
blood culture and/or antigen detection.
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