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					                                                       LHJ Use     ID ______________________                   Outbreak-related
                                                         Reported to DOH       Date ___/___/___
                                                       LHJ Classification         Confirmed                    LHJ Cluster#_________
                                                                                  Probable                    LHJ Cluster

Rubella                                                   By:      Lab      Clinical
                                                                   Epi Link: _________________
                                                                                                            Name: ____________________

County                                                                                                      DOH Outbreak # ___________
REPORT SOURCE
LHJ notification date ___/___/___    Investigation     Reporter name ____________________________________________________
Reporter (check all that apply)      start date:
                                                       Reporter phone ____________________________________________________
  Lab       Hospital      HCP        ___/___/___
  Public health agency         Other                   Primary HCP name _________________________________________________
OK to talk to case?     Yes     No     Don’t know      Primary HCP phone _________________________________________________
PATIENT INFORMATION
Name (last, first) _________________________________________________________                   Birth date ___/___/___ Age _______
Address ____________________________________________________                    Homeless       Gender       F    M    Other   Unk

City/State/Zip ___________________________________________________________                     Ethnicity     Hispanic or Latino
Phone(s)/Email _________________________________________________________                                     Not Hispanic or Latino
Alt. contact   Parent/guardian     Spouse      Other    Name ____________________              Race (check all that apply)
Zip code (school or occupation): _________________ Phone ___________________                      Amer Ind/AK Native       Asian
Occupation/grade ________________________________________________________                         Native HI/other PI       Black/Afr Amer
Employer/worksite __________________ School/child care name _________________                     White                    Other
CLINICAL INFORMATION
Onset date: ___/___/___       Derived         Diagnosis date: ___/___/___         Illness duration: _____ days
Signs and Symptoms                                                     Y N DK NA
   Y N DK NA                                                                             Hospitalized at least overnight for this illness
                                                        o
               Fever Highest measured temp: _____ F                 Hospital name ___________________________________
               Type:    Oral     Rectal   Other: ______  Unk        Admit date ___/___/___ Discharge date ___/___/___
               Runny nose (coryza)
                                                                       Y N DK NA
               Rash (maculopapular) Onset date: ___/___/___
                                                                                         Died from illness       Death date ___/___/___
               Duration: ____ days
                                                                                         Autopsy       Place of death _________________
               Describe rash progression: __________________
               ________________________________________             Vaccination
               Does the rash itch?         Yes__ No__                  Y N DK NA
               Headache                                                                    Ever received rubella containing vaccine
               Malaise                                                          Dose 1     Type: _________ Date received: ___/___/___
                                                                                Dose 2     Type: _________ Date received: ___/___/___
Clinical Findings
                                                                                Dose 3     Type: _________ Date received: ___/___/___
   Y N DK NA
               Conjunctivitis                                                             Vaccine up to date for rubella
                                                                                                                    st
               Lymphadenopathy Onset date: ___/___/___                                   Number doses on or after 1 birthday:___________
                                                                                         Vaccine series not up to date reason:
                 Cervical               Suboccipital
                                                                                           Religious exemption       Medical contraindication
                  Postauricular        Other: ________________
                                                                                           Philosophical exemption
               Arthritis or arthralgia
                                                                                           Previous infection confirmed by laboratory
               Rash observed by health care provider
                                                                                           Previous infection confirmed by physician
               Rash distribution: _________________________
                                                                                           Parental refusal     Other: __________        Unk
                 Generalized Localized         On palms and soles
                 Petechial        Macular        Papular            Laboratory                             P = Positive     O = Other
                                                                                                           N = Negative     NT = Not Tested
                 Pustular        Vesicular      Bullous             Collection date ___/___/___            I = Indeterminate
                 Other: ________________________________            Source ________________
               Congenital Rubella Syndrome (CRS)                    P N     I    O NT
               Hemorrhagic signs                                                        Rubella virus culture (clinical specimen)
               Pneumonia or pneumonitis                                                 Rubella IgG with significant rise (acute and
               Encephalitis or encephalomyelitis                                        convalescent serum pair)
               Leukopenia                                                               Rubella IgM
               Thrombocytopenia                                                         Rubella virus nucleic acid detection (PCR)
               Complications                                                            Tests to rule out other agents
               Specify: _______________________________                                 Agent/results: ___________ Date: ___/___/___
                                                                                        Agent/results: ___________ Date: ___/___/___
Case defining variables are in bold. Answers are: Yes, No, Unknown to case, Not asked /Not answered                   DOH 210-073 (Rev. 2/17/10)
Washington State Department of Health                                                    Case Name: _________________________
INFECTION TIMELINE
Enter onset date (first                       Exposure period            o                   Contagious period
sx) in heavy box.             Days from                                  n
Count forward and              onset:         -23           -12          s             7 days before to 7 days after rash onset *
backward to figure                                                       e
probable exposure and                                                    t
contagious periods        Calendar dates:                                               * Infants born with congenital rubella
                                                                                       syndrome may shed for months after birth

EXPOSURE (Refer to dates above)
  Y N DK NA                                                             Y N DK NA
               Travel out of the state, out of the country, or                       Congregate living
               outside of usual routine                                                 Barracks        Corrections      Long term care
               Out of:     County        State      Country                             Dormitory       Boarding school      Camp
               Destinations/Dates: ______________________                               Shelter         Other: ____________________
               ______________________________________                                Visited health care setting 1 - 3 weeks preceding
               Contact with recent foreign arrival                                   onset     Facility name: ____________________
               Specify country: _________________________                            Number of visits: _______ Date(s): ___/___/___
               Foreign arrival (e.g. immigrant, refugee, adoptee,                    Exposure setting identified:
               visitor)    Specify country: _________________                           Child care       School       Doctor’s office
               Does the case know anyone else with similar                              Hospital ward       Hospital ER
               symptoms or illness                                                      Hospital outpatient clinic      Home
               Epidemiologic link to a confirmed or probable                            College       Work      Military
               case                                                                     Correction facility     Church
                                                                                        International travel
                                                                                        Other, specify: ___________         Unknown

Where did exposure probably occur?           In WA (County: ___________________)             US but not WA          Not in US       Unk
Exposure details: ___________________________________________________________________________________________
  No risk factors or exposures could be identified
  Patient could not be interviewed
PUBLIC HEALTH ISSUES                                                  PUBLIC HEALTH ACTIONS
  Y N DK NA
               If female, is case pregnant Weeks gestation: ____        Exclude exposed susceptibles from work/school for incubation
               Previous rubella titer                                   period
                   Pos     Neg      DK      NA      Year: ________      Evaluate immune status of close contacts
               Any contact with pregnant woman                          Assess possibility of pregnancy in female contacts
               Attends child care or preschool
               Employed in child care or preschool
               Do any household members work at or attend
               child care or preschool
               Documented transmission from this case
                   Child care       School      Doctor's office
                   Hospital ward        Hospital ER
                   Hospital outpatient clinic      Home
                   College      Work       Military
                   Correction facility    Church
                   International travel     Other: _______      Unk

NOTES




Investigator ________________________ Phone/email: _______________________                 Investigation complete date ___/___/___

Local health jurisdiction _________________________________________________                         Record complete date ___/___/___

Rubella: case defining variables are in bold. Answers are: Yes, No, Unknown to case, Not asked /Not answered

				
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posted:1/27/2011
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