Novel Human Influenza A Case

Novel Human Influenza A Virus Infection Case Report Form

Reported by:

State: ______________ County: _________________

Date reported to state/local health department State/Local Case ID

__/__/__ ________________

Name of Person Reporting to CDC: Last Name: ___________ First Name: ___________

Phone Number :( )___-_______ Fax Number :( )___-_______ E-Mail: ____________

Patient Demographic Data

Date of Birth: ___/___/___

Race:  American Indian/Alaska Native White

 Asian  Black

 Native Hawaiian/Other Pacific Islander

Ethnicity:  Hispanic  Non-Hispanic

Sex:  Male  Female

Is the patient pregnant?  Yes  No  Unknown

Clinical and Diagnostic Data:

Date of symptom onset: ___/___/___

Signs and symptoms: (check all that apply)

 Fever >38 C (100.4 F) ___________T max  Sore throat

 Feverish but temperature not taken  Conjunctivitis

 Cough  Shortness of breath

 Headache  Diarrhea

 Seizures  Other, specify _______________

Was the patient vaccinated against human influenza in the past year?

 Yes  No  Unknown

If yes, date of vaccination ____/____/____

Type of vaccine:  Inactivated  Live attenuated  Unknown

Did the patient receive antiviral medications?

 Yes  No  Unknown

If yes, complete table below

Drug	Date Initiated	Date Discontinued	Dosage (if known)
Oseltamivir
Zanamivir
Rimantidine
Amantadine
Other ____________

Laboratory Findings:

Leukopenia (white blood cell count <5,000 leukocytes/mm3)

 Yes  No  Unknown

Lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of total WBC)

 Yes  No  Unknown

Thrombocytopenia (total platelets <150,000/mm3)

 Yes  No  Unknown

Does the patient have any underlying medical conditions?

 Yes  No  Unknown

If yes, please specify __________________ __________________ _________________

Does the patient have compromised immune function such as HIV infection, cancer, chronic corticosteroid therapy, diabetes, or organ transplant recipient?

 Yes  No  Unknown

If yes to compromised immune function, specify:

_________________________________________________

Was the patient hospitalized?  Yes  No  Unknown

Did the patient require mechanical ventilation?

 Yes  No  Unknown

Did the patient have a chest x-ray or CAT scan performed?

 Normal  Abnormal  Test not performed  Unknown

If abnormal:

Was there evidence of pneumonia?

 Yes  No  Unknown

Did this patient have acute respiratory distress syndrome?

 Yes  No  Unknown

Did the patient die as a result of this illness?  Yes  No  Unknown

Diagnostic tests:

Test 1

Specimen type:

 NP swab  NP aspirate  Nasal aspirate  Sputum

 Oropharyngeal swab  Endotracheal aspirate  Chest tube fluid

 Broncheoalveolar lavage specimen (BAL) Serology

 Other

Date collected: __/__/__

Test type:

 RT-PCR  Direct fluorescent antibody (DFA)

 Viral culture  Rapid antigen test

Test result:

 Influenza A  Influenza B  Influenza type unknown

 Negative  Pending

Test 2

Specimen type:

 NP swab  NP aspirate  Nasal aspirate  Sputum

 Oropharyngeal swab  Endotracheal aspirate  Chest tube fluid

 Broncheoalveolar lavage specimen (BAL)  Serology

 Other

Date collected: __/__/__

Test type:

 RT-PCR  Direct fluorescent antibody (DFA)

 Viral culture  Rapid antigen test

Test result:

 Influenza A  Influenza B  Influenza type unknown

 Negative  Pending

Indicate when and what type of specimens (including sera) were sent to CDC

__/__/__ Specimen type ___________________________

__/__/__ Specimen type ___________________________

__/__/__ Specimen type ___________________________

Epidemiologic Risk Factors

In the 10 days prior to illness onset, did the patient travel?

 Yes  No  Unknown

If yes, please fill in the arrival and departure dates for all countries visited.

Country____________ Arrival_________________ Departure______________

Country____________ Arrival_________________ Departure______________

Country____________ Arrival_________________ Departure______________

Country____________ Arrival_________________ Departure______________

Country____________ Arrival_________________ Departure______________

The following questions concern the 10 days prior to illness onset…

Did the patient have close contact (within 1 meter (3 feet)) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable or confirmed novel human influenza A case?

 Yes  No  Unknown

Did the patient touch (handle, slaughter, butcher, prepare for consumption) animals (including poultry, wild birds, or swine) or their remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Was the patient exposed to animal (including poultry, wild birds, or swine) remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Was the patient exposed to environments contaminated by to animal feces (including poultry, wild birds, or swine) in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Did the patient consume raw or undercooked animals (including poultry, wild birds, or swine products) in an area where influenza infections in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Did the patient have any animal contact?

 Yes  No  Unknown

If yes, please specify contact with dogs, cats, horses, wild birds, poultry or swine.

_______________________________________________________

_______________________________________________________________________________________________________________________________________________

Did the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting?

 Yes  No  Unknown

Does the patient work in a health care facility or setting?

 Yes  No  Unknown

Did the patient visit or stay in the same household with any one with pneumonia or severe influenza-like illness?

 Yes  No  Unknown

Did the patient visit or stay in the same household with anyone who died following the visit?

 Yes  No  Unknown

Did the patient visit an agricultural event, farm, petting zoo or place where pigs live or were exhibited (state or county fair) in the last month?

 Yes  No  Unknown

Did the patient have direct contact with pigs at an agricultural event, farm, petting zoo or place where pigs were exhibited (state or county fair) in the last month?

 Yes  No  Unknown

If this patient has a diagnosis of novel influenza A virus infection that has not been serologically confirmed, is there an epidemiologic link between this patient and a laboratory-confirmed or probable novel influenza A case?

 Yes  No  Unknown

Novel Human Influenza A Case Definition

Clinical presentation: Illness compatible with influenza virus infection.

Laboratory evidence: A novel human influenza virus is defined as a influenza A virus substantially different from currently circulating human influenza H1 and H3 strains such that it cannot be subtyped using standard methods and reagents. This would include influenza A H1 and H3 viruses of animal origin (e.g. swine and avian H1 and H3 viruses) and non-H1 or H3 subtype influenza A viruses (e.g. H2, H5, H7, and H9 subtypes). Novel influenza A viruses will be identified as unsubtypable with methods available for detection of currently circulating human influenza viruses at state public health laboratories (e.g., real-time RT-PCR).

Confirmation of an influenza A virus as a novel virus will be performed

by CDC’s influenza laboratory. Criteria for epidemiologic linkage: a) the patient has had contact with one or more persons who either have/had the disease and b) transmission of the agent by the usual modes of transmission is plausible. A case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed.

Confirmed case: A case of human infection with a novel influenza A virus

confirmed by CDC’s influenza laboratory.

Probable case: A case meeting the clinical criteria and epidemiologically linked to

a confirmed case, but for which no laboratory testing for influenza virus infection

has been performed.

Suspected case: A case meeting the clinical criteria, pending laboratory

confirmation. Any case of human infection with an influenza A virus that is

different from currently circulating human influenza H1 and H3 viruses is

classified as a suspected case until the confirmation process is complete.