Form F-44236 - Pertussis Case Report - 2004 Page 4
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4DPH 4236 (Rev. 05/04)
Page 4 of 4
Name of case __________________________________
Total number of contacts for whom antibiotics were recommended _______ or
Unknown
What are the Setting(s) outside the household of further documented spread from this Case?
1 Day Care
6 Hospital Outpatient Clinic
11 Military
2 School Work
7 >1 setting outside household
12 Correctional Facility
3 Doctor’s Office
8 Work
13 Church
4 Hospital Ward
9 Unknown
14 International Travel
5 Hospital Emergency Room
10 College
15 Other
16 No documented spread outside household
Is Case Epi-linked?
Is Case outbreak related?
If Yes, name of outbreak:
Yes
No
Unknown
Yes
No
Unknown
Was CDC clinical case definition met (calculation included in
Is Case laboratory
Date of this report:
NETSS program)?
confirmed?
Yes
No
Unknown
Yes
No
Unknown
Instructions:
·
Complete a Pertussis Case Report on all reported cases of pertussis and all contacts with suspect pertussis.
·
"Duration of cough at final interview" box: if the cough duration is <14 days at the final interview it is important to
re-contact the patient to establish whether the patient did cough for at least 14 days. Time of cough duration is measured from
the Catarrhal phase cough onset date to the final interview date.
·
For cases with a cough duration of < 14 days, complete and fax the front page of the Pertussis Case Report to your Regional
Immunization Advisor. Re-contact the patient to establish whether the patient did cough for at least 14 days and then fax the
completed form to your Regional Immunization Advisor.
Definitions:
·
Clinical case: A cough illness lasting > 2 weeks with one of the following: paroxysms of coughing, inspiratory "whoop" or
post -tussive vomiting, with no other apparent cause.
·
Confirmed case: 1) An illness in a person with an acute cough of any duration who is culture positive, or
2) A case that meets the clinical case definition and is confirmed by PCR, or
3) A case that meets the clinical case definition and is epidemiologically linked directly to a case confirmed by
either culture or PCR.
Note: Only probable and confirmed cases are reported to CDC. The information on this form, except names of the
case, source and spread, is submitted to CDC via the National Electronic Telecommunication System for Surveillance (NETSS).
·
Probable case: A case that meets the clinical case definition, is not laboratory-confirmed, and is not epidemiologically linked to
a laboratory-confirmed case.
·
Close contact: Direct face-to-face contact for a period (not defined) with a case patient who is symptomatic; shared confined
space in close proximity for a prolonged period of time (e.g., > one hour) with a symptomatic case patient; or direct contact with
respiratory, oral or nasal secretions from a symptomatic case patient.
·
Catarrhal: first stage (lasting 1-2 weeks) symptoms of pertussis including cold-like illness, runny nose, sneezing, mild cough.
·
Paroxysmal: follows the Catarrhal stage, includes explosive coughing fits with (or without) the whoop and post-tussive vomiting.
·
Apnea: Prolonged breathlessness, which may occur either after a coughing spasm or spontaneously in an infant.
INVESTIGATION LOG (attach extra pages as needed)
DATE:
COMMENTS:
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