Utah Public Health

Utah Public Health LHD name LHD address line 1 LHD address line 2 Phone: (801) xxx-xxxx Confidential fax: (801) xxx-xxxx Date finalized CYCLOSPORIASIS Confidential Case Report Please fill in the blanks or check the answer for each field DEMOGRAPHIC INFORMATION NETSS ID Last name Address County Date of birth Race Ethnicity White Hispanic Age Black/Af. Am Non-Hispanic Y N State Gender Unk U If yes, how long has the patient been in the USA? M Phone number(s) F Asian First / MI City   Native Hawaiian/Pacific Islander Parent/Contact Alaska Native Other Unk Zip  Amer. Indian Refugee or recent immigrant? CLINICAL INFORMATION Onset date: Date resolved: Y Seen by physician (including ED)? Hospitalized? Died? Pregnant? Treated? Immunocompromised? Co-infected? N/A N U Symptoms: ongoing none nausea vomiting abdominal pain diarrhea fever Details Physician/ED: Health facility: From: Date of death: Due date: Treatment: If yes, explain: If yes, disease: Start: End: Not finished Phone: Medical Record Number: To: Date: LABORATORY INFORMATION Lab name/phone: Lab result: pos neg pres. pos inconcl. pending Specimen source: Test type: stool O&P DFA other: Collection date: other: HIGH-RISK OCCUPATIONS / SETTINGS (EPIDEMIOLOGICAL) Occupation: Y Food handler? Healthcare worker? Group living? Day care association? Attend or work in a school? Pool employee (lifeguard, swim instructor)? If yes to any above, did patient work/attend while ill? Dates/notes: N U (check all that apply): child student volunteer unemployed retired If yes to any, list details for each: ▪ ▪ ▪ ▪ facility name(s) location(s) supervisor name(s) phone number(s) ICP contacted if appropriate REPORTING INFORMATION Reporter name: Date results reported to clinician: Received by whom at LHD: Phone: Date reported to public health: LHD open date: Reported by: hospital/ICP lab other: LHD Investigator: clinic/MD office CYCLOSPORIASIS Name ________________________________________________________ NETSS ID _________________________ EXPOSURE PERIOD Have patient answer questions on following pages for the exposure period only: Date 14 days before disease onset: Date 1 day before disease onset: ILL CONTACT MANAGEMENT Does case’s infection appear secondary to another person’s infection? Any contacts ill with similar symptoms?  Last name: Relationship to case: Contact info same as case? Food handler  Last name: Relationship to case: Contact info same as case? Food handler  Last name: Relationship to case: Contact info same as case? Food handler  Last name: Relationship to case: Contact info same as case? Food handler  Last name: Relationship to case: Contact info same as case? Food handler Healthcare Y N Address: Day care Pool employee Not high-risk Group living Healthcare Y N Address: Day care Pool employee First / MI: Onset date: Not high-risk Group living Healthcare Y N Address: Day care Pool employee First / MI: Onset date: Not high-risk Group living Healthcare Y N Address: Day care Pool employee First / MI: Onset date: Not high-risk Group living Healthcare Y N Address: Day care Pool employee First / MI: Onset date: Not high-risk Group living First / MI: Onset date: Y Y N N U U Name/ NETSS: & list below. If yes, list below. If no, skip to TRAVEL HISTORY. Age: New case initiated?  NETSS ID: Phone: If high-risk, follow-up done? Age: New case initiated?  NETSS ID: Phone: If high-risk, follow-up done? Age: New case initiated?  NETSS ID: Phone: If high-risk, follow-up done? Age: New case initiated?  NETSS ID: Phone: If high-risk, follow-up done? Age: New case initiated?  NETSS ID: Phone: If high-risk, follow-up done? Y N Y Sex: N M F Y Sex: N M F Y Sex: N M F Y Sex: N M F Sex: M F TRAVEL HISTORY ( 1-14 days before onset) Travel outside USA? Travel outside Utah, but inside USA? Travel outside county, but inside Utah? Y Y Y N N N U U U Did case have visitors from out of state or outside the USA? If yes, did visitors bring food to share? If yes, details: Y Y N N U U If case answered yes to any of above travel questions, then fill in boxes below. If no, skip to FOOD HISTORY. Travel Location: Mode of Travel: plane car cruise ship other: List other details including:  Flight number / other identifiers  Accommodations & dates  Sources of food / water while traveling  Other relevant details Travel Location: Mode of Travel: plane car cruise ship other: List other details including:  Flight number / other identifiers  Accommodations & dates  Sources of food / water while traveling  Other relevant details From: Others in group ill? Y N To: U From: Others in group ill? Y N To: U If yes, list above. If yes, list above. Skip to FOLLOW-UP ACTIONS on pg 4 if patient was outside the country for entire exposure period. -2- CYCLOSPORIASIS Name ________________________________________________________ NETSS ID _________________________ FOOD HISTORY ( 1-14 days before onset) (Enter restaurant, group event and grocery store data in the Epidemiological tab in UT -NEDSS) Eat at any restaurants during exposure period? R Establishment name: Address: List foods eaten: R Establishment name: Address: List foods eaten: R Establishment name: Address: List foods eaten: R Establishment name: Address: List foods eaten: Attend a group event? Y N U Y N U If yes, list below. If no, skip to GROUP EVENT section. Date of meal: Time of meal: Others ill? Date of meal: Y N U If yes, list in ill contacts Time of meal: Others ill? Date of meal: If yes, list in ill contacts Time of meal: Others ill? Date of meal: Y N U If yes, list in ill contacts Time of meal: Others ill? Y N U If yes, list in ill contacts Type: party camp family reunion other (specify): wedding funeral work party Y N U conference If no, skip to HIGH-RISK FOODS section. Contact information (if applicable): Location/address: List foods eaten/event details: High-risk foods consumed (during exposure period) Date of meal: Time of meal: Others ill? IMPORTANT: remember to check “no” or “none” if appropriate Y N U If yes, list in ill contacts If case ate any high-risk foods, have case identify where each was purchased (including food eaten at a restaurant). Fill in store name(s) and address(es) under “Grocery stores” below. Then enter the store or restaurant number (e.g. S1 or R1) under “Store/Rest’rt #” to the right of each food. Store/Rest’rt # Shellfish (oysters, mussels, shrimp), including ceviche preparation Other fish/seafood, including other seafood ceviche preparation Specify: yes, fully cooked yes, fully cooked yes, undercooked yes, undercooked berries: yes, raw yes, raw no no unk unk Fresh produce? (store-bought, home-grown) pre-pack’ged leafy greens: fresh herbs: sprouts green onions melon: other: unpackaged leafy greens: none Y Y N N U U Food from farmers’ markets/roadside stands/samples, etc? (specify): Any other raw/imported/unpasteurized/suspect foods? (specify): S Name/address: S Name/address: S Name/address: Grocery stores, farmers’ markets, roadside stands, friends/neighbors where high-risk food purchased/obtained Approx date of last trip: Approx date of last trip: Approx date of last trip: WATER EXPO SURE (1-14 days before onset) Source of drinking water at home: (check all that apply) (check all that apply) municipal/public water bottled commercial delivery (e.g. Mount Olympus) municipal/public water bottled commercial delivery (e.g. Mount Olympus) Y N U Specify dates/details: well other (specify): well other (specify): Source of drinking water at work/school: Have recent plumbing/construction work done on water system? well hose/sprinkler pool/water park none Drink from, swim/play in or have exposure to any of the following water sources: secondary/irrigation water (e.g. canal) fountain/splash pad/interactive water feature other (specify): natural water (e.g. river, lake, stream, pond, spring) water table/water play at a daycare If none, proceed to FOLLOW-UP ACTIONS. If yes, details of any water exposure (dates, locations, etc): -3- CYCLOSPORIASIS Name ________________________________________________________ NETSS ID _________________________ FOLLOW-UP ACTIONS Date Action Provide client education (see disease plan). Notify Epidemiology of any high-risk occupations/settings and/or exposures likely to cause additional illness. Restrict/exclude case in high-risk occupations/settings until diarrhea has resolved; notify case’s supervisor if necessary. Notify case’s ICP or Employee Health Nurse if appropriate (case does direct patient care). Consider restricting/excluding symptomatic contacts in high-risk occupations/settings. Release case/contacts back to high-risk occupations/settings if case/contacts have been restricted/excluded. Notify daycare as needed, to identify source or spread, if case is a child in daycare. Notify school nurse as needed, to identify source or spread, if case is a child in school. Notify Environmental Health if facility/restaurant inspection is warranted. Notify UDAF (or UDOH) if trace-back/food supplier investigation is warranted (store, dairy, etc). Notify UDOH if suspect exposure occurred outside health district or if potential cluster/outbreak situation exists. Complete CDC outbreak form, if appropriate. Other follow-up: ADMINISTRATIVE LHD status: Confirmed Probable Suspect Not a case Carrier Pending UDOH status: Confirmed Probable Suspect Not a case Carrier Pending Did this case occur as part of an outbreak? Y N U ( 2 cases of Cyclosporiasis associated by time & place) LHD interview date: Interviewed: Client Parent/Guardian Sig. oth. HC provider Unable to contact/interview LHD Reviewer: LHD closed date: Outbreak name: Friend Other: Date submitted to UDOH: -4-