Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form Page 2
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4Hospitalization, Death, & Severe Respiratory Illness (SRI) Case Report Form
*Please fax completed form to your Regional Communicable Disease Control Nurse*
TO BE COMPLETED BY PHAC:
Provincial/Territorial Case ID: __________________________
Date received by PHAC ____/____/________ (dd /mm/yyyy)
PHAC ID: ___________________________
SECTION 1: CASE DEFINITION
Severe Respiratory Illness (SRI) case
(A) SRI case
A person admitted to hospital with:
V.
Respiratory symptoms, i.e.:
Fever (over 38 degrees Celsius)
•
AND
New onset of (or exacerbation of chronic) cough or breathing difficulty
•
AND
VI.
Evidence of severe illness progression, i.e.:
Radiographic evidence of infiltrates consistent with pneumonia
•
OR
Diagnosis of acute respiratory distress syndrome (ARDS)
•
OR
Severe ILI, which may also include complications such as encephalitis or other severe and life threatening complications
•
AND
Admission to the ICU/other area of the hospital where critically ill patients are cared for
•
OR
Mechanical ventilation
•
AND
VII.
No alternate diagnosis within the first 72 hours of hospitalisation, i.e.:
Results of preliminary clinical and/or laboratory investigations, within the first 72 hours of hospitalisation, cannot ascertain a
•
diagnosis that reasonably explains the illness.
AND
VIII.
One or more of the following exposures/conditions, i.e.:
Residence, recent travel or visit to an affected area where a novel influenza virus or other emerging or re-emerging respiratory
•
virus has been identified (including Pandemic (H1N1) 2009) [refer to table of currently affected areas/sites:
aspc.gc.ca/h5n1/index.html.]
Close contact (including health care providers) of an ill person who has been to an affected area/site within the 10 days prior to
•
onset of symptoms.
Exposure to settings in which there had been mass die offs or illness in domestic poultry or swine in the previous six weeks.
•
Occupational exposure involving direct health care, laboratory or animal exposure, i.e.:
•
Health care exposure involving primary care providers exposed to patients linked to an ongoing outbreak
o
investigation or sick/dying animals;
OR
Laboratory exposure in a person who works directly with emerging or re-emerging pathogens;
o
OR
Animal exposure in a person employed as one of the following:
o
ƒ
domestic poultry/swine farm worker;
ƒ
domestic poultry processing plant worker;
ƒ
domestic poultry culler (catching, bagging, or transporting birds, disposing of dead birds/swine);
ƒ
worker in live animal market
ƒ
dealer or trader of pet birds or other potentially affected animals
chef working with live or recently killed domestic poultry or other potentially affected animals
ƒ
(B) SRI death
A deceased person with:
V.
A history of respiratory symptoms, i.e.:
History of unexplained acute respiratory illness (including fever, and new onset of (or exacerbation of chronic) cough or
•
breathing difficulty) resulting in death
AND
VI.
Autopsy performed with findings consistent with SRI, i.e.:
autopsy findings consistent with the pathology of ARDS without an identifiable cause
•
AND
VII.
No alternate diagnosis that reasonably explains the illness
AND
VIII.
One or more of exposures/conditions, as listed above.
Revised November 12, 2009
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