Department Of Health And Human Services Plague Case Investigation Report Page 2
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Laboratory Evidence of Infection
Detection or Isolation
Serology:
Yersinia pestis cultured?
Yes
No
Unknown
None
Single positive titer
≥4-fold change in titer
Specimen source
Date specimen collected
Serum 1:
(e.g., blood, bubo aspirate)
Date drawn
mm/dd/yyyy
mm/dd/yyyy
Titer:
If not cultured, presence of Y. pestis detected?
Yes
No
Unknown
Specimen source
Date specimen collected
Serum 2:
Date drawn
mm/dd/yyyy
mm/dd/yyyy
Titer:
Test performed
(e.g., DFA or PCR)
Plague Case Status
Confirmed A clinically-compatible case with either Y. pestis cultured from a clinical specimen or ≥4-fold change in serum
antibody titer
A clinically-compatible case with either detection (not isolation) of Y. pestis in a clinical specimen or a single
Probable
positive antibody titer (or <4-fold change in titer)
Not a case
Epidemiologic Investigation
Was this illness epi-linked to any other plague cases?
Yes
No
Unknown Specify:
Most likely location of exposure: State:
County:
Likely exposure setting:
Around the person’s home
Recreational (away from home)
Possible routes of exposure: In the 2 weeks preceding illness, did the patient report:
Flea or insect bites?
Yes
No
Unknown
Animal contact?
Yes
No
Unknown
If yes, type of animal
Wild (specify:
)
Domestic pet (specify:
)
What was the nature of the contact?
Bitten
Scratched
Disposed/handled deceased animal
Cleaned carcass
Consumed hunted game meat
Person-to-person transmission from a known plague patient
Yes
No
Unknown
Other possible exposure type: specify
Evidence of Yersinia pestis infected animals or fleas in the likely exposure location?
Yes
No
Unknown (If yes, specify:
)
Additional comments:
CDC 56.37 (E), Revised May 2016, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2016
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