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Pertussis case track record
Immunization Division, Texas Department of Health 1100 West 49th St., Austin, TX 78756 (800) 252-9152 (512) 458-7544 fax Pertussis Case Track Record FINAL STATUS : NETSS CASE #:
Patient’s Name: ______________________________________________________
Reported By: ___________________________________________
Address: ___________________________________________________________
Agency: _______________________________________________
Phone:( )___________________________________________
City: ________________________ County: _______________ Zip: ____________
Region: _________ Phone:( ) ______________________________________
Parent/Guardian: _____________________________________________________
Report Given to: _______________________________________
Organization: ___________________________________________
Physician: _______________________________Phone:( ) _______________
Physician’s Address: __________________________________________________
Phone: ( ) __________________________________________
___________________________________________________________________
DEMOGRAPHICS: DATE OF BIRTH: _____/_____/_____ AGE: ______ SEX: o Male o Female o Unknown
RACE: o White o Black o Asian/Pacific Islander o Native American o Unknown o Other: _________________________
CLINICAL DATA: TREATMENT:
o Cough - Onset Date: ____/____/____ Final Cough Duration:______ # of Days
Were antibiotics given? o Yes o No
o Paroxysmal Cough - Onset Date: _______/________/_______
o Erythromycin: Date Started:_____/_____/_____for _____ Days
o Cotrimoxazole: Date Started:_____/____/_____for ______ Days
o Apnea (Exclude Cyanotic Episode) o Cyanosis after Paroxysm
o Azithromycin: Date Started:_____/_____/_____for _____ Days
o Pneumonia: Chest X-Ray o + o - o Seizures (Focal or Generalized)
o Tetracycline: Date Started:_____/_____/_____for _____ Days
Date Started:_____/_____/_____for _____ Days
Is patient still coughing at final interview? o Yes o No Date: ___/_____/____
o Other:_________ Date Started:____/____/____for ______ Days
o Hospitalized at: __________________________________________________
o Other:_________ Date Started:____/____/____for ______ Days
Admitted: _____/_____/_____ Discharged: _____/_____/_____ # Days_______
OUTCOME:o Survived o Died o Unknown Physician Diagnosis:_________________________________________________
If Deceased, Date of Death: ____/_____/_____Note: A Pertussis Death Worksheet must also be submitted to TDH. INFECTION TIMELINE: Enter onset of cough. Count backwards and forwards to enter dates for probable exposure and communicable periods.
P e r i o d o f C o m m u n i c a b i l i t y
VACCINATION HISTORY: VACCINATED:o Yes o No o Unknown
o 1 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________
o 2 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________
o 3 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________
o 4 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________
o 5 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________
If no, indicate reason: o Religious exemption o Medical Contraindication o Evidence of immunity o Previous Disease - Lab Confirmed
o Previous Disease - MD Diagnosed o Under Age o Parental Refusal o Unknown o Other: ____________________________
Name: ________________________________________
LABORATORY DATA:Was laboratory testing done? o Yes o No o Unknown LABORATORY: o TDH o Other: ________________________________________________ Phone:( ) ________________________
o Culture: Date specimen collected: _____/_____/_____ Result: ________________
o PCR: Date specimen collected: _____/_____/_____ Result: ________________
o DFA: Date specimen collected: _____/_____/_____ Result: ________________
o IgA o IgG: Date of acute specimen: _____/_____/_____ Result: ________________
Date of convalescent specimen: _____/_____/_____ Result: ________________
Note: A four-fold rise in titer level from acute specimen to convalescent sample may be considered positive serology for pertussis. Results from a single specimen are not accepted as laboratory confirmation of a suspected pertussis case.
Results called to local investigator: o Yes o No o Unknown
Person Contacted: Date Called: _____/_____/_____ Initials: _________
SOURCE OF INFECTION: o No exposure Identified o Close contact with a known or suspected case.
____________________________ ( )____________________ __________
o Is case epidemiologically linked to a culture-confirmed case? o Yes o No o Unknown
o Where did this case acquire pertussis?: o Day-care o School o College o Work o Home o Dr Office o Hospital ER o Hospital Inpatient o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: _____________ Name(s) of Setting:__________________________________________________________________________________________________
o Has any travel occurred within the exposure period? o Yes o No o Unknown If yes, list location: __________________________
o Importation Class: o Indigenous o International o Out-of-state o Unknown If imported, from what country/state:________________
o Is case traceable within 2 generations to international import? o Yes o No o Unknown
o Is case part of an outbreak?: o Yes o No o Unknown If yes, list outbreak name: _________________________________________
Total number of contacts in any settings recommended antibiotics: _________________ HOUSEHOLD CONTACTS: Were control activities initiated?: o Yes o No o Unknown If no, explain: __________________________ *Symptoms/Date of Onset
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
*Investigations must be completed on all contacts with symptoms POSSIBLE SPREAD CONTACT: Setting: o No Spread o Day -care o School o College o Work o Home o Dr. Office o Hospital ER o Hospital Inpatient o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: ___________________________ Name (s) of Settings: __________________________________________________________________________________________________ Name *Symptoms/Date of Onset
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
______________________ _______________ _____
______________ ______________________ ___________________________
*Investigations must be completed on all contacts with symptoms
Investigator's Name: _____________________________________________ Agency name: _________________________________________
Phone:( ) ______________________ Date Investigation Initiated: _____/_____/_____ Date Investigation Completed: ____/_____/____
COMMENTS:
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