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RABIES HUMAN

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					     North Carolina Department of Health and Human Services                                                                  AttENtIoN PHySICIANS/HoSPItAlS:
         Division of Public Health • Epidemiology Section                                                                    Return this form to your local health department.
                  Communicable Disease Branch




                                        RABIES, HUMAN
      Confidential Communicable Disease Report—Part 2
                  NC DISEASE CoDE: 33
    Patient’s First Name                             Middle              Last                     Suffix            Maiden/Other              Alias                    Birthdate (mm/dd/yyyy)
                                                                                                                                                                                /        /
                                                                                                                                                                       SSN


   Medical provider completing clinical component of surveillance form:                                           lHD CD nurse/designee completing form for submission to DPH:
   name/Title: ________________________________________________________                                           name/Title (print): ___________________________________________________
   Telephone: (______) ______ - ___________ Fax: (______) ______ - ___________                                    Telephone: (______) ______ - ___________ Date completed _____/_____/ _____
   Date completed _____/_____/_____                                                                               LHD CD nurse/designee signature ______________________________________

   PERIOD OF INTEREST                                                      LOCAL HEALTH DEPARTMENT USE ONLY                                  TREATMENT
7 years prior to the onset of illness                                    Check one:                                                        Was rabies post-exposure prophylaxis
(usually 3–8 weeks)                                                        Case definition is met.                                          recommended? ............................... Y        n       u
                                                                           (Complete Part 1 and Part 2 and submit to state)                 by whom:
   GENERAL DIAGNOSTIC INFORMATION                                                                                                               Public health veterinarian
                                                                           Case definition is not met.
Is/was patient symptomatic?............                     Y   n    u     (Complete Part 2 only and submit to state)                           Public health physician
Date of illness onset (mm/dd/yyyy):____/____/ ____                                                                                              Public health nurse
Diagnosis by health care                                                                                                                        Private healthcare provider
 provider or lHD (mm/dd/yyyy):____/____/ _______                           PREDISPOSING CONDITIONS                                              Other
Patient’s health care provider for                                                                                                              unknown
                                                                         Any immunosuppressive conditions? .                 Y   n   u     Was rabies post-exposure prophylaxis
  this illness ________________________________
                                                                          Specify ___________________________________                       (PEP) given? .................................... Y   n       u
Name of provider’s practice or facility
                                                                            _________________________________________                       Date PEP initiated (mm/dd/yyyy):____/____/____
___________________________________________
                                                                         Injury/Wound/Break in skin .............. Y n u                   Patient previously vaccinated .......... Y  n                  u
telephone number for health care
                                                                         Recent/Acute injury(ies) or wound(s) .... Y n u                    Date vaccinated (mm/dd/yyyy):____/____/____
  provider (_______) _________________________
                                                                          Date (mm/dd/yyyy):____/____/____                                  Specify type of PEP:
   CLINICAL FINDINGS                                                      Anatomic site_______________________________                           Human rabies immune globulin (RIG)
                                                                                                                                                 and 5 vaccines
Fever ...................................................   Y   n    u    Circumstances _____________________________
                                                                                                                                                 2 vaccines (booster)
   Yes, subjective                      no                                 _________________________________________                             unknown
   Yes, measured                        unknown                           Principal wound type:                                            Continuing vaccinations begun in
  How was temperature taken? __________________                               Animal bite                                                   another county/state?..................... Y            n     u
                                                                              Other (e.g. with cancer)                                     Who supplied PEP? (check all that apply)
  Highest measured temperature _________________                              unknown                                                          State HD
  Date of highest measured temperature: ____/____/____                                                                                         LHD
  Fever onset date (mm/dd/yyyy):____/____/____                             REASON FOR TESTING                                                  Private mD
Fatigue or malaise or weakness ...... Y                          n   u   Why was the patient tested for this condition?                        Other
Altered mental status ........................ Y                 n   u      Symptomatic of disease                                             unknown
  Patient displayed:                                                        Screening of asymptomatic person with                          Who administered PEP? (check all that apply)
      Confusion                                    Agitation                reported risk factor(s)                                            LHD
      Delirium                                      Combativeness           Exposed to organism causing this disease                           Private mD
      Coma                                          Excitability            (asymptomatic)                                                     Other
      Anxiety/apprehension                          Hallucinations          Household / close contact to a person reported                     unknown
Headache............................................ Y           n   u      with this disease                                              Did patient sign a consent/declination form
Encephalitis ....................................... Y           n   u      Other, specify________________________                          for rabies PEP? ............................... Y       n     u
Seizures/convulsions ........................ Y                  n   u      unknown                                                        Did the patient receive medical care
Ataxia .................................................. Y      n   u                                                                      for this illness?...................................  Y   n       u
Autonomic instability ........................ Y                 n   u    HOSPITALIZATION INFORMATION                                       Specify level(s) of care (check all that apply):
Pain/sensory changes around location                                     Was patient hospitalized for                                            Outpatient
  of animal bite ................................... Y           n   u    this illness >24 hours? ................... Y n u                      Emergency department
Insomnia ............................................. Y         n   u    Hospital name: _____________________________                           Inpatient
Hypersalivation .................................. Y             n   u    City, State: _________________________________                         ICu
Aversion to water (hydrophobia) ....... Y                        n   u                                                                           Other
                                                                          Hospital contact name: _______________________
Aversion to air on face (aerophobia)                       Y     n   u                                                                           unknown
Cranial nerve or bulbar weakness                                          Telephone: (______) ______ - ___________                         Did the patient require supplemental
  or paralysis ...................................... Y          n   u    Admit date (mm/dd/yyyy): ____/____/____                           oxygen? ........................................... Y   n     u
Difficulty swallowing (dysphagia) ..... Y                        n   u                                                                     Did the patient require mechanical
                                                                          Discharge date (mm/dd/yyyy):____/____/____
Muscle weakness (paresis) ............... Y                      n   u                                                                      ventilation? ...................................... Y   n     u
Muscle paralysis ................................ Y              n   u    ICu admission? .................................   Y   n    u
Nausea ................................................ Y        n   u
Vomiting ............................................. Y         n   u
Priapism (persistent erection)............. Y                    n   u

DHHS/EPI #33 (DRAFT)                                                                                                                                                                       RAbIES, HumAn
APRIL 2008                                                                                                                                                                                    PAGE 1 OF 4
   Patient’s First Name                 Middle                    Last                Suffix        Maiden/Other                   Alias                  Birthdate (mm/dd/yyyy)
                                                                                                                                                                   /        /
                                                                                                                                                          SSN


 CLINICAL OUTCOMES                                                  HEALTH CARE FACILITY AND                                    BEHAVIORAL RISK & CONGREGATE LIVING
 Discharge/Final diagnosis: ____________________                    BLOOD & BODY FLUID EXPOSURE RISKS                          In what setting was the patient most likely exposed?
                                                                  During the 3-8 weeks prior to onset has the patient              Restaurant                   Place of Worship
 ___________________________________________                      had any blood or body fluid exposures?                           Home                         Outdoors, including
 Survived? ........................................... Y    n u     Emergency Department (not hospitalized)                        Work                         woods or wilderness
 Died?................................................... Y n u                                                                    Child Care                   Athletics
                                                                   Visit/admit date (mm/dd/yyyy): ____/____/____
 Died from this illness? ...................... Y           n u                                                                    School                       Farm
                                                                   Facility name _______________________________
 Date of death (mm/dd/yyyy):_____/_____/_____                                                                                      university/College           Pool or spa
                                                                   Was facility notified regarding
 Autopsy performed? ......................... Y n            u                                                                     Camp                         Pond, lake, river or
                                                                    ill patient? ............................. Y n u n/A
  Facility where autopsy was performed                                                                                             Doctor’s office/             other body of water
                                                                    Hospitalized
                                                                                                                                   Outpatient clinic            Hotel / motel
   _________________________________________                       Visit/admit date (mm/dd/yyyy): ____/____/____                   Hospital In-patient          Social gathering, other
  Patient autopsied in nC? .................. Y n u                Has patient been discharged? .......... Y   n       u           Hospital Emergency           than listed above
   County of autopsy:______________________                        Facility name _______________________________                   Department                   Travel conveyance
  Source of death information:                                     Was facility notified regarding                                 Laboratory                   (airplane, ship, etc.)
      Death certificate                                             ill patient? ............................. Y n u n/A           Long-term care facility      International
     Autopsy report final conclusion                                long term care facility - resident (e.g. nursing               /Rest Home                   Community
      Hospital/physician discharge                                home, rest home, rehab)                                          military                     Other (specify)
      Other                                                                                                                        Prison/Jail/Detention        _________________
                                                                   Visit/admit date (mm/dd/yyyy): ____/____/____
  Date of death (mm/dd/yyyy):____/____/____                                                                                        Center                       unknown
                                                                   Has patient been discharged? .......... Y   n       u
   NOTE: The death certificate, autopsy report,
   hospital/physician discharge summary, and/or other              Facility name _______________________________                  OTHER EXPOSURE INFORMATION
   documentation should be attached.                               City__________________________State ________                Does the patient know anyone else with
                                                                   Country ___________________________________                  similar symptoms? ......................... Y         n       u
                                                                   Was facility notified regarding                              Specify ___________________________________
                                                                    ill patient? ............................. Y n u   n/A     Has the patient ever served in
                                                                    outpatient facility - patient (e.g. urgent care, clinic,
                                                                                                                                the U.S. military? ............................. Y n u
                                                                  physician office)
                                                                                                                                If yes, dates of service:
 TRAVEL & IMMIGRATION                                              Visit/admit date (mm/dd/yyyy): ____/____/____
                                                                                                                                  From _________________ to_________________
the patient is:                                                    Facility name _______________________________
    Resident of nC
    Resident of another state or uS territory                      City__________________________State ________                 OUTDOOR ACTIVITIES
    none of the above                                              Country ___________________________________                 During the 3-8 weeks prior to onset, did the
Did patient have a travel history during the                       Was facility notified regarding                              patient participate in any
 3-8 weeks prior to onset? ............... Y  n             u       ill patient? ............................. Y n u n/A        outdoor activities? ............................. Y       n       u
                                                                    transplant recipient (tissue / organ / bone / bone          If yes, specify and give details:
  List travel dates and destinations:                             marrow)
  From _____/_____/_____ to _____/_____/_____                      Date received (mm/dd/yyyy):____/____/____
   _________________________________________                       Type of donation / transplant ___________________
   _________________________________________                       Provider name ______________________________
Does patient know anyone else with similar                                                                                     Was patient exposed to wild animals? ..           Y        n       u
symptom(s) who had the same or similar                             Contact name at facility _______________________
                                                                                                                                If yes, specify and give details:
travel history? .................................... Y n u         Facility name _______________________________
  List persons and contact information:                            City__________________________State ________
   _________________________________________                       Country ___________________________________
   _________________________________________                        Visitor to health care setting
   _________________________________________                       Visit/admit date (mm/dd/yyyy): ____/____/____
                                                                                                                               Did patient sleep outside in open? ..         Y        n       u
                                                                   until date: ____/____/____                                   If yes, specify and give details:
                                                                   Frequency
                                                                        Once
                                                                        multiple times within this time period
                                                                        Daily
                                                                   Facility name _______________________________
                                                                   City__________________________State ________
                                                                                                                               Did patient sleep in tent or cabin? ...       Y        n       u
                                                                   Country ___________________________________                  If yes, specify and give details:
                                                                   Was facility notified regarding
                                                                    ill patient? ............................. Y n u n/A
                                                                    Worked or volunteered in health care or
                                                                    clinical setting
                                                                    No
                                                                    Unknown




DHHS/EPI #33 (DRAFT)                                                                                                                                                         RAbIES, HumAn
APRIL 2008                                                                                                                                                                      PAGE 2 OF 4
   Patient’s First Name                Middle                    Last               Suffix        Maiden/Other                Alias                  Birthdate (mm/dd/yyyy)
                                                                                                                                                              /        /
                                                                                                                                                     SSN


   ANIMALS                                                                                                                 RABIES
 During the 3-8 weeks prior to onset, did the patient            Did the patient work at or visit a fair with              During the 3-8 weeks prior to onset, was the patient
  have exposure to animals (includes animal tissues,              livestock or a petting zoo? ................ Y    n  u     known to be or potentially exposed to a
  animal products, or animal excreta)? ...          Y n u           Visited or worked?                                       rabid animal? ................................... Y n u
 Household pets? .................................. Y n u                Visited     Worked                                If yes, type of exposure
  Specify pet(s) ______________________________                     Specify contact/exposure to agricultural livestock          bite (any penetration of the skin by teeth)
  Was pet vaccinated for rabies? ............            Y n u           Cattle               Sheep                             non-bite (contamination of open wound, abrasion,
  Was pet sick? .......................................  Y n u           Horses               Swine                             mucous membrane or scratch with saliva or other
  Was pet free-ranging? ..........................       Y n u           Goats                Other_______________              potentially infectious material, such as
 Did patient own, work at, or visit a pet store, animal            Fair/petting zoo name __________________________             nervous tissue)
  shelter, and/or animal breeder/wholesaler/                       Street address________________________________               Cryptic / presumed (no known exposure to saliva;
  distributor? ......................................... Y n u                                                                  i.e. bat found in house, bat found in sleeping area,
                                                                   City ________________________________________
   Specify:                                                                                                                     aerosol exposure such as caves)
        Owned                                                      State____________________Zip code ____________
                                                                                                                                unknown
        Worked                                                     County______________________________________              On (mm/dd/yyyy):____/____/____
        Visited                                     Telephone (______) ___________________________                           until (mm/dd/yyyy):____/____/____
    business name _______________________________ Did the patient work at or visit a zoo,                                    Frequency
    Street address________________________________ zoological park, or aquarium? ..........  Y      n    u                        Once
                                                    Visited or worked?                                                            multiple times within this time period
    City ________________________________________
                                                         Visited                                                                  Daily
    State____________________Zip code ____________       Worked
                                                                                                                            Circumstances of exposure ____________________
    Exposed on (mm/dd/yyyy):____/____/____          Specify contact/exposure to any agricultural livestock
                                                      present at facility:                                                   _________________________________________
    until (mm/dd/yyyy):____/____/____
                                                         Cattle                Sheep                                       location of wound on body (anatomic site: hand,
    Frequency
         Once                                            Horses                Swine                                        arm, leg, etc.) ______________________________
         multiple times within this time period          Goats                 Other                                       Was wound cleaned? ........................ Y n u
        Daily                                                      Zoo or Aquarium name _________________________          Seek medical attention & treatment? . Y       n u
  Did the patient handle any animals? ....      Y    n      u      Street address________________________________          Exposure location (where exposure occurred)
   Species: ____________________________________                                                                               In north Carolina
                                                                   City ________________________________________
   Did it/they appear sick?......................      Y n u                                                                   County _________________________________
                                                                   State____________________Zip code ____________
 Did patient work with animal                                                                                                  Outside north Carolina, but in uS
  importation? ....................................... Y n u       County______________________________________
                                                                                                                               State ___________________________________
    business address _____________________________                  Telephone (______) ___________________________             Outside uS
                                                                 Did patient work in a veterinary practice or animal
    City ________________________________________                 laboratory, animal research setting,                        Country _________________________________
    State_____________________Zip code ___________                biomedical laboratory, or an animal                      Was the animal wild? ........................ Y n u
    Species _____________________________________                 diagnostic laboratory? ...................... Y n  u      Specify animal ______________________________
                                                                    Which type of work setting?                                  unknown animal species
    Country of origin ______________________________
                                                                        Animal diagnostic (pathology) laboratory            Was the animal captured for testing? ... Y     n u
   Shipping port of origin (if known) _________________                 Animal laboratory/animal research                    If yes, DFA result
 Did patient / household contact work at, live on,                      biomedical laboratory                                     Positive      negative      Inconclusive
  or visit a farm, ranch, or dairy? ........ Y  n    u                  Research involving animals
   Specify:                                                             Veterinary medical practice                         Laboratory name ____________________________
        Worked                                                                                                              Street address ______________________________
                                                                   name of facility _______________________________
        Lived on
                                                                   Street address________________________________           City______________________State ____________
        Lived with someone who worked/visited
        Visited                                                    City ________________________________________            Zip code __________________________________
    Farm/ranch/dairy name _________________________                State____________________Zip code ____________           Telephone (______) _________________________
                                                                                                                           Was the animal a domestic animal
    Street address________________________________                 County______________________________________             or pet? .............................................. Y n u
    City ________________________________________                  Telephone (______) ___________________________           Specify animal ______________________________
    State____________________Zip code ____________                Specify species:__________________________               Was the animal vaccinated? ............. Y n u
   County______________________________________ Did patient work with vaccines for                                          Date of animals last rabies vaccine: ____/____/____
                                                                zoonotic agents?................................ Y n u
   Telephone (______) ___________________________                                                                            Total number of doses ________________________
                                                                  Specify vaccine(s):
   Exposed on (mm/dd/yyyy): ____/____/____                            brucella vaccine (parenteral or mucous membrane)     Is animal undergoing 10-day
   until (mm/dd/yyyy): ____/____/____                                 Other                                                  confinement?................................... Y n u
   Frequency                                                   Did patient necropsy animals? ...........         Y n u      Date entered 10-day confinement: ____/____/____
        Once                                                      Specify species:__________________________                Is 10-day confinement complete? ..... Y    n    u
        multiple times within this time period                 Did patient work with zoonotic agents?            Y n u
        Daily                                                                                                                Date completed 10-day confinement: ____/____/____
 Was patient exposed to animals associated with                   Specify agent(s):__________________________              Was animal dead or alive at time of exposure?
  agriculture or aviculture (domestic/semi-domestic                                                                             Status unknown            Dead             Alive
  animals)? ............................................ Y n u                                                             Did the animal appear sick or exhibit
                                                                                                                             abnormal behavior? ........................ Y       n u
  Specify animal(s): ___________________________                                                                               Describe behavior(s)
   _________________________________________                                                                                       Lethargic
  Exposed on (mm/dd/yyyy):____/____/____                                                                                           Aggressive
  until (mm/dd/yyyy):____/____/____                                                                                                Salivating
  Frequency:                                                                                                                       Staggering or have abnormal gait
       Once                                                                                                                Did animal attack animal(s)
       multiple times within this time period                                                                                or person(s)? ................................... Y n u
       Daily                                                                                                               If yes, was the animal provoked? ........ Y           n u
                                                                                                                           Animal-related notes:




DHHS/EPI #33 (DRAFT)                                                                                                                                                   RAbIES, HumAn
APRIL 2008                                                                                                                                                                PAGE 3 OF 4
    Patient’s First Name                        Middle                Last                     Suffix         Maiden/Other               Alias                  Birthdate (mm/dd/yyyy)
                                                                                                                                                                         /        /
                                                                                                                                                                SSN


   CASE INTERVIEWS/INVESTIGATIONS                                          GEOGRAPHICAL SITE OF EXPOSURE                              VACCINE
 Was the patient interviewed? ...........              Y   n    u         In what geographic location was the patient                Has patient/contact ever received vaccine
                                                                            MoSt lIKEly exposed?                                      for this disease?.............................. Y   n   u
  Date of interview (mm/dd/yyyy):_____/_____/_____
 Were interviews conducted                                                 Specify location:                                             Known vaccine type,
  with others? ..................................... Y n u                    In nC                                                      specify _________________________________
  Who was interviewed?                                                      City _____________________________________                   unknown vaccine type
                                                                            County___________________________________                    Rabies Immune Globulin (RIG)
 Were health care providers
  consulted? .......................................   Y   n    u             Outside nC, but within uS                               number of doses received? ___________________
  Who was consulted?                                                        City _____________________________________                Date(s) of doses: ____________________________
                                                                                                                                     How many days prior to illness onset was
 Medical records reviewed (including telephone review                       State ____________________________________
                                                                                                                                      vaccine received?
 with provider/office staff)? ............... Y n u                         County___________________________________                    Fewer than 14 days      14 days or more
 Specify reason if medical records were not reviewed:                         Outside uS                                             Prescribing healthcare
                                                                            City _____________________________________                provider name ______________________________
                                                                            Country __________________________________               Prescribing healthcare
 Notes on medical record verification:                                         unknown                                                provider telephone (______) ___________________
                                                                          Is the patient suspected of being part of a                Was vaccination pre-exposure or post-exposure?
                                                                            common source outbreak? ............ Y         n    u        Pre-exposure         Post-exposure
                                                                                                                                     Source of vaccine information:
                                                                          Notes:
                                                                                                                                         Patient’s or Parent’s verbal report
                                                                                                                                         Physician
                                                                                                                                         medical record (Note: Any vaccine on a medical
                                                                                                                                         record should be recorded in the NCIR)
                                                                                                                                         Certificate of immunization record (Note: Any
                                                                                                                                         vaccine on a certificate of immunization should be
                                                                                                                                         recorded in the NCIR)
                                                                                                                                         Patient vaccine record
                                                                                                                                         School record
                                                                                                                                         Other, specify:________________________
                                                                                                                                         unknown




     DIAGNOSTIC TESTING
 Give details below.
    Collection Date                Result Date             type of test            Specimen             Results (include   Reference Range                  lab Name/City/State
                                                                                    Source              serogroup/type)
           /       /                   /       /
           /       /                   /       /
           /       /                   /       /


   1997 CDC/CSTE CASE DEFINITION
   ClINICAl DESCRIPtIoN: Rabies is an acute encephalomyelitis that almost always progresses to coma or death within 10 days after the first symptom.
   lABoRAtoRy CRItERIA FoR DIAgNoSIS: Detection by direct fluorescent antibody of viral antigens in a clinical specimen (preferably the brain or the nerves surrounding
   hair follicles in the nape of the neck), or isolation (in cell culture or in a laboratory animal) of rabies virus from saliva, cerebrospinal fluid (CSF), or central nervous system
   tissue, or identification of a rabies-neutralizing antibody titer greater than or equal to 5 (complete neutralization) in the serum or CSF of an unvaccinated person.
   CASE ClASSIFICAtIoN: Confirmed: a clinically compatible case that is laboratory confirmed
DHHS/EPI #33 (DRAFT)                                                                                                                                                              RAbIES, HumAn
APRIL 2008                                                                                                                                                                           PAGE 4 OF 4