Epidemiology
Table of Contents North Carolina Communicable Disease A. Lead, elevated blood levels 2 North Carolina Case Definition 2 Reporting Criteria 2 Time frame 2 Method 2 Agency 2 Reporting Information Required 2 Reporting follow up information 2 Reporting form 2 B. Hepatitis C 2 Case Definition 2 Reporting Criteria 2 Time frame 2 Method 2 Agency 2 Reporting Information Required 2 Reporting follow up information 2 Reporting form 2 C. Measles 2 Case Definition 2 Reporting Criteria 2 Time frame 2 Method 2 Agency 2 Reporting Information Required 2 Reporting follow up information 2 Reporting form 2 D. Animal Bites/Rabies 2 Case Definition 3 Reporting Criteria Animal Bites/Rabies 4 Time Frame & Responsible Reporter 5 Method of Reporting: 5 NC Electronic Disease Surveillance Report Part 1 (DHHS 2124) 7 NC Electronic Disease Surveillance Report Part 2 (DHHS/EPI #33) 9
Lead, elevated blood levels
North Carolina Case Definition
Reporting Criteria
Time frame
Method
Agency
Reporting Information Required
Reporting follow up information
Reporting form
Hepatitis C
Case Definition
Reporting Criteria
Time frame
Method
Agency
Reporting Information Required
Reporting follow up information
Reporting form
Measles
Case Definition
Reporting Criteria
Time frame
Method
Agency
Reporting Information Required
Reporting follow up information
Reporting form
Animal Bites/Rabies
Case Definition
North Carolina Case Definition (2011): Rabies, Human[footnoteRef:1] [1: NC-DHHS (February 2011), NC Communicable Disease Manual/Case Definitions: Rabies, Human, NC-DHHS Dep. of Public Health , Feb. 2011, https://epi.dph.ncdhhs.gov/cd/lhds/manuals/cd/casedefs/RABIES_HUMAN_CD.pdf ]
Clinical evidence
Rabies is an acute encephalomyelitis that almost always progresses to coma or death within 10 days after the first symptom.
Laboratory evidence
I. detection of Lyssavirus antigens in a clinical specimen (preferably the brain or the nerves surrounding hair follicles in the nape of the neck) by direct fluorescent antibody test, or
II. isolation (in cell culture or in a laboratory animal) of a Lyssavirus from saliva or central nervous system tissue, or
III. identification of Lyssavirus specific antibody (i.e. by indirect fluorescent antibody (IFA) test or complete rabies virus neutralization at 1:5 dilution) in the CSF, or
IV. identification of Lyssavirus specific antibody (i.e. by indirect fluorescent antibody (IFA) test or complete rabies virus neutralization at 1:5 dilution) in the serum of an unvaccinated person, or
V. detection of Lyssavirus viral RNA (using reverse transcriptase-polymerase chain reaction [RT-PCR]) in saliva, CSF, or tissue.
Case classification
Confirmed: a clinically compatible case that is laboratory confirmed by testing at a state or federal public health laboratory.
Suspect: Not Classified
Probable: Not Classified
Comment
Laboratory confirmation by all of the above methods is strongly recomme
Reporting Criteria Animal Bites/Rabies[footnoteRef:2] [2: ,3 NC-DHHS. (2013, February). Responsibility for Rabies Control in North Carolina: Retrieved December 1, 2019, from https://epi.dph.ncdhhs.gov/cd/lhds/manuals/rabies/docs/roles.pdf.]
Whenever an animal required to be vaccinated against rabies bites a person, the bite and all identifying information must be reported (NC-DHHS, 2013, P.1). All animal bites attended to by a physician requires reporting as well as all suspected or confirmed cases of Rabies.
Agency to Report Incident :
Required reporting begins at the county level by contacting the Local Health Department’s (LHD) communicable disease Health Director or Communicable Disease (CD) nurse.[footnoteRef:3] Local health departments can be found for each county on North Carolina’s Department of Health & Human Services- Public Health Division Website[footnoteRef:4] https://www.ncdhhs.gov/divisions/public-health/county-health-departments. If there is no available contact information then the required contact would be the North Carolina's Communicable Disease Branch Public Health Department in Raleigh, North Carolina.[footnoteRef:5] [3: ] [4: NC-DHHS. Public Health Departments. Retrieved December 1, 2019, from https://www.ncdhhs.gov/divisions/public- health/county-health-departments.] [5: CDC - State and Local Consultation Contacts - Rabies. (2019, August 7). Retrieved December 1, 2019, from https://www.cdc.gov/rabies/resources/contacts.html.]
During Business Hours Call 919-733-3419 (ask for the rabies person-on-call)
After Business Hours Call 919-733-3419, (press 7).
For all suspected and confirmed cases of Rabies reporting is required to the N.C. Division of Public Health, Communicable Disease Branch.[footnoteRef:6]8 [6: 8 NC-DHHS (2019) NC Communicable Disease Manual/NC Reportable Diseases and Conditions LHD Disease Investigation Steps: Rabies, human Retrieved December 1, 2019 from https://epi.dph.ncdhhs.gov/cd/lhds/manuals/cd/invest/RABIES_LHD_STEPS_0419.pdf ]
Reporting Time Frame & Responsible Reporter
For Animal Bites from Domesticated Animals
Reporting is required Immediately by the person bitten or by the animal’s owner or person in control of the animal and within 24 hours by local health care providers[footnoteRef:7]. [7: NC-DHHS. (2013, February). Responsibility for Rabies Control in North Carolina: Retrieved December 1, 2019, from https://epi.dph.ncdhhs.gov/cd/lhds/manuals/rabies/docs/roles.pdf.]
Local health care providers are required to complete “Communicable Disease Report 1” (DHHS 2124) within 7 days and submit it electronically to their local health department.
For Bites from Animals Known as Potential Carriers of Rabies.
Same reporting guidelines as above
For Suspect or Actual Human Rabies Cases
Same reporting guidelines as above
& within 24 hours of diagnosis to N.C. Division of Public Health, Communicable Disease Branch (919-733-3419) by the local health department. In addition
a “Communicable Disease Report 2” (DHHS/EPI # 33) is completed within 7 days and submitted into North Carolina Electronic Disease Surveillance System (NC EDSS) by local health departments[footnoteRef:8]7’[footnoteRef:9]8. [8: ] [9: ]
Method of Reporting:
Animal Bites from Domesticated Animals
Initial report is made to the local health care department by phone call and a written report (DHHS 21 2 4) is made by a health care provider which is electronically sent to their local health department.
For Bites from Animals Known as Potential Carriers of Rabies.
Same reporting guidelines as above .
Suspect or Actual Human Rabies Cases
Same reporting guidelines as above
& the local healthcare department contacts The N.C. Division of Public Health (919-733-3419) by telephone and completes Report 2 (DHHS/EPI # 33) which is submitted to (NC EDSS) Electronically by LDH.
NC Electronic Disease Surveillance Report Part 1 (DHHS 2124)
Part 1: NC Confidential Communicable Disease Report (DHHS 2124)
NC Electronic Disease Surveillance Report Part 2 (DHHS/EPI #33)
Part 2: NC Confidential Communicable Disease Report Rabies, Humans NC Code: 33
ATTENTION HEALTH CARE PROVIDERS: Please report relevant clinical findings about this
disease event to the local health department.
North Carolina Department of Health and Human Services Division of Public Health • Epidemiology Section
Communicable Disease Branch
Birthdate (mm/dd/yyyy) / / SSN
Patient’s Last Name First Middle Suffix Maiden/Other Alias
NC Electronic Disease Surveillance System NC EDSS EVENT ID# ____________________
Instructions for completing the Communicable Disease Report Form can be found in the NC Public Health Communicable Disease Manual online at: www.epi.state.nc.us/epi/gcdc/manual/toc.html.
Questions? Concerns? Contact the NC EDSS Helpdesk: Phone: ...................................................... (919) 715-5548 Toll Free: ................................................... (877) 625-9259 Email: [email protected]
NC EDSS LAB RESULTS
Verify if lab results for this event are in NC EDSS. If not present, enter results.
Patient’s Last Name First Middle Suffix Maiden/Other Alias
Birthdate (mm/dd/yyyy)
Age Age Type Years Months Weeks Days
Race (check all that apply): White
Black/African American American Indian/Alaska Native
Asian Other Unknown
Ethnic Origin Hispanic Non-Hispanic
Sex M F Trans.
Parent or Guardian (of minors) Medical Record Number
Patient is associated with (check all that apply): Child Care (child, household contact, or worker in child care) School (student or worker) College/University (student or worker) Food Service (food worker) Health Care (health care worker)
Correctional Facility (inmate or worker) Long Term Care Facility (resident or worker) Military (active military, dependent, or recent retiree) Travel (outside continental United States in last 30 days)
Is the patient part of an outbreak of this disease? Yes No
Outbreak setting: Household/Community (specify index case):______________________________ Restaurant/Retail Child Care Long term care Healthcare setting Adult care home
In what geographic location was the patient MOST LIKELY exposed? In patient’s county of residence Outside county, but within NC - County: ________________________ Out of state - State/Territory: _________________________________ Out of USA - Country: _______________________________________ Unknown
Did patient die from this disease?
Yes No
Is the patient pregnant?
Yes No
Was patient hospitalized for this disease? (>24 hours)
Yes No
Initial Date of Report to Public Health:____/____/_______ Initial Source of Report to Public Health:
Health Care Provider (specify): Hospital Private clinic/practice Health Department Correctional facility
Laboratory Other
Specimen Date
Specimen # Specimen Source
Type of Test Test Result(s)
Description (comments) Result Date Lab Name — City/State
/ / / / / / / / / / / /
Is/was patient symptomatic for this disease? .................................. Y N U If yes, symptom onset date (mm/dd/yyyy): / / SPECIFY SYMPTOMS:
If a sexually transmitted disease, give specific treatment details 1. Date patient treated:(mm/dd/yyyy) ____________
Medication ______________________________ Dosage _________________________________ Duration ________________________________
DHHS 2124 (Revised January 2016) EPIDEMIOLOGY
Patient’s Street Address City State ZIP County Phone
(_____) _____-_______
Confidential Communicable Disease Report — Part 1
CLINICAL INFORMATION
NAME OF DISEASE / CONDITION
LOCAL HEALTH DEPARTMENT USE ONLY
Health Care Provider for this disease (if not reporting physician): ____________________________________________________________ Contact Person/Title: ___________________________________________
Phone: (______) ______– ________ Fax: (______) ______– __________
Reporting Physician/Practice: ____________________________________________________________ Contact Person/Title: ___________________________________________ Phone: (_____) _____–_________ Fax:(_____) _____– _______________
2. Date patient treated:(mm/dd/yyyy) ____________ Medication ______________________________ Dosage _________________________________ Duration ________________________________
DIAGNOSTIC TESTING Provide lab information below and fax copy of lab results and other pertinent records to local health department.
Date / /
Assisted living facility Adult day care School Prison
Name of facility___________________________ Address of facility_________________________ ________________________________________
Native Hawaiian or Pacific Islander
DISEASE/CONDITION A-G
ANTHRAX ............................................................................................... BOTULISM, FOODBORNE .................................................................... BOTULISM, INTESTINAL (INFANT) ...................................................... BOTULISM, WOUND .............................................................................. Campylobacter infection .......................................................................... Chancroid ................................................................................................
Cholera .................................................................................................... Cryptosporidiosis ..................................................................................... Cyclosporiasis ......................................................................................... Diphtheria ................................................................................................ E. coli infection, shiga toxin-producing ..................................................... Foodborne disease: Clostridium perfringens ............................................. Foodborne: staphylococcal...................................................................... Foodborne disease: other/unknown ........................................................ Foodborne poisoning: ciguatera .............................................................. Foodborne poisoning: mushroom ............................................................ Foodborne poisoning: scombroid fish...................................................... Gonorrhea ............................................................................................... Granuloma inguinale ...............................................................................
H-N Haemophilus influenzae,
invasive disease .................................................................................... Hemolytic-uremic syndrome (HUS) ......................................................... HEMORRHAGIC FEVER VIRUS INFECTION ............................................................................................. Hepatitis A................................................................................................ Hepatitis B, acute .................................................................................... HIV/AIDS
HIV......................................................................................................... AIDS ......................................................................................................
Influenza virus infection causing death .................................................... Listeriosis................................................................................................. Measles (rubeola) .................................................................................... Meningococcal disease, invasive ............................................................
Monkeypox .............................................................................................. NOVEL INFLUENZA VIRUS INFECTION ...............................................
O-U Ophthalmia neonatorum .......................................................................... Pertussis (Whooping Cough)................................................................... PLAGUE .................................................................................................. Poliomyelitis, paralytic ............................................................................. Rabies, human ........................................................................................ Rubella .................................................................................................... Salmonellosis .......................................................................................... S. aureus with reduced susceptibility to vancomycin .............................. SARS coronavirus infection .................................................................. Shigellosis ............................................................................................... SMALLPOX ............................................................................................. Syphilis
primary................................................................................................... secondary .............................................................................................. early latent ............................................................................................. late latent ............................................................................................... late with clinical manifestations .............................................................. congenital ..............................................................................................
Tuberculosis ............................................................................................ TULAREMIA ........................................................................................... Typhoid Fever, acute ...............................................................................
V-Z Vaccinia ................................................................................................... Vibrio infection, other than cholera & vulnificus ....................................... Vibrio vulnificus ....................................................................................... Zika..........................................................................................................
DISEASE/CONDITION A-G
Brucellosis ................................................................................................ Chlamydial infection — laboratory confirmed ............................................ Creutzfeldt-Jakob Disease ....................................................................... Dengue ..................................................................................................... Ehrlichiosis, HGA (human granulocytic anaplasmosis) ............................ Ehrlichiosis, HME (human monocytic or e. chaffeensis) .......................... Ehrlichiosis, unspecified ........................................................................... Encephalitis, arboviral, WNV .................................................................... Encephalitis, arboviral, LAC ..................................................................... Encephalitis, arboviral, EEE ..................................................................... Encephalitis, arboviral, other ....................................................................
H-N Hantavirus infection .................................................................................. Hepatitis B, carriage ................................................................................. Hepatitis B, perinatally acquired ............................................................... Hepatitis C, acute ..................................................................................... Legionellosis ............................................................................................. Leprosy .................................................................................................... Leptospirosis ............................................................................................ Lyme disease ........................................................................................... Lymphogranuloma venereum ................................................................... Malaria ...................................................................................................... Meningitis, pneumococcal ........................................................................ Mumps ...................................................................................................... Non-gonococcal urethritis .........................................................................
O-Z Pelvic inflammatory disease...................................................................... Psittacosis ................................................................................................ Q fever ...................................................................................................... Rocky Mountain Spotted Fever ................................................................ Rubella, congenital syndrome .................................................................. Streptococcal infection, Group A, invasive ............................................... Tetanus ..................................................................................................... Toxic shock syndrome, non-streptococcal ................................................ Toxic shock syndrome, streptococcal ....................................................... Trichinosis ................................................................................................ Typhoid, carriage (Salmonella typhi) ........................................................ Yellow fever ..............................................................................................
Reportable to Local Health Department Within 7 Days
Reportable to Local Health Department Within 24 Hours
:
DHHS 2124 (Revised January 2016) EPIDEMIOLOGY
Diseases in BOLD ITALICS should be reported immediately to local health department.
Chikungunya ............................................................................................
Middle East respiratory syndrome (MERS) .............................................
North Carolina General Statute: §130A-135. Physicians to report. A physician licensed to practice medicine who has reason to suspect that a person about whom the physician has been consulted professionally has a communicable disease or communicable condition declared by the Commission to be reported, shall report information required by the Commission to the local health director of the county or district in which the physician is consulted.
North Carolina Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions (a) The following named diseases and conditions are declared to be dangerous to the public health and are hereby made reportable within the time period specified after the disease or condition is reasonably suspected to exist:
Physicians must report these diseases and conditions to the county local health department, according to the North Carolina Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions (see below). Contact information for local health departments can be accessed at www.ncalhd.org/directors. If you are unable to contact your local health department, call the 24/7 pager for N.C. Communicable Disease Branch (919) 733-3419.
For diseases and conditions required to be reported within 24 hours, the initial report shall be made by telephone to the local health department, and the written disease report be made within 7 days. The reporting rules and disease report forms can be accessed at: http://epi.publichealth.nc.gov/cd/report.html
You may be contacted by the local health department for additional information about this case. Medical record information relevant to the investigation and/or control of a communicable disease is exempt from the HIPAA Privacy Rule (see 45 CFR 164.512(a) ) and is permitted as an exception to confidentiality of records in NC State Law GS § 130 A-130.
Diseases and Conditions Reportable in North Carolina
DISEASE/CONDITION A-G
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V-Z 9DFFLQLD���������������������������������������������������������������������������������������������������� 9LEULR�LQIHFWLRQ��RWKHU�WKDQ�FKROHUD� �YXOQL¿FXV���������������������������������������� 9LEULR�YXOQL¿FXV���������������������������������������������������������������������������������������� =LND����������������������������������������������������������������������������������������������������������
DISEASE/CONDITION A-G
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Reportable to Local Health Department Within 24 Hours
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DHHS/EPI #33 AUGUST 2011
rAbIES, HUmAn PAGE 4 OF 5
Has patient/contact ever received rabies vaccine ............................................ Y n U
Known vaccine type, specify _________________________________ Unknown vaccine type rabies Immune Globulin (rIG)
number of doses received? ___________________ Date(s) of doses: ____________________________
How many days prior to illness onset was vaccine received?
Fewer than 14 days 14 days or more Prescribing healthcare
provider name ______________________________ Prescribing healthcare
provider telephone (______) ___________________ Was vaccination pre-exposure or post-exposure?
Pre-exposure Post-exposure Source of vaccine information:
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
Was the patient interviewed? ........... Y n U Date of interview (mm/dd/yyyy):_____/_____/_____
Were interviews conducted with others? ..................................... Y n U Who was interviewed?
Were health care providers consulted? ....................................... Y n U Who was consulted?
Medical records reviewed (including telephone review with provider/office staff)? ............... Y n U Specify reason if medical records were not reviewed:
Notes on medical record verification:
CASE INTERVIEWS/INVESTIGATIONS In what geographic location was the patient
MoST LIKELY exposed? Specify location:
In nC City _____________________________________ County___________________________________ Outside nC, but within US
City _____________________________________ State ____________________________________ County___________________________________ Outside US
City _____________________________________ Country __________________________________ Unknown
Is the patient part of an outbreak of this disease? ................................... Y n
Notes:
GEOGRAPHICAL SITE OF EXPOSURE VACCINE
Patient’s Last Name First Middle Suffix Maiden/Other Alias Birthdate (mm/dd/yyyy) / / SSN
DHHS/EPI #33 AUGUST 2011
rAbIES, HUmAn PAGE 3 OF 5
ANIMAL EXPOSURE During the 3-8 weeks prior to onset of symptoms,
did the patient have exposure to animals (includes animal tissues, animal products, or animal excreta)? .............................................. Y n U
Household pets? .................................. Y n U Specify pet(s) ______________________________ Was pet vaccinated for rabies? ............ Y n U Was pet sick? ....................................... Y n U Was pet free-ranging? .......................... Y n U
Did patient own, work at, or visit a pet store, animal shelter, and/or animal breeder/wholesaler/ distributor? ......................................... Y n U
Specify: Owned Worked Visited
business name _______________________________ Street address________________________________ City ________________________________________ State____________________Zip code ____________ Exposed on (mm/dd/yyyy):____/____/____ Until (mm/dd/yyyy):____/____/____ Frequency
Once multiple times within this time period Daily
Did the patient handle any animals? .... Y n U Species: ____________________________________ Did it/they appear sick?...................... Y n U
Did patient work with animal importation? ....................................... Y n U
business address _____________________________ City ________________________________________ State_____________________Zip code ___________ Species _____________________________________ Country of origin ______________________________ Shipping port of origin (if known) _________________
Did patient / household contact work at, live on, or visit a farm, ranch, or dairy? ........ Y n U
Specify: Worked Lived on Lived with someone who worked/visited Visited
Farm/ranch/dairy name _________________________ Street address________________________________ City ________________________________________ State____________________Zip code ____________ County______________________________________ Telephone (______) ___________________________ Exposed on (mm/dd/yyyy): ____/____/____ Until (mm/dd/yyyy): ____/____/____ Frequency
Once multiple times within this time period Daily
Was patient exposed to animals associated with agriculture (domestic/semi-domestic animals)? ............................................ Y n U Specify animal(s): ___________________________ _________________________________________ Exposed on (mm/dd/yyyy):____/____/____ Until (mm/dd/yyyy):____/____/____ Frequency:
Once multiple times within this time period Daily
During the 3-8 weeks prior to onset of symptoms, was the patient known to be or potentially exposed to a rabid animal? .............................. Y n U If yes, type of exposure
bite (any penetration of the skin by teeth) non-bite (contamination of open wound, abrasion,
mucous membrane or scratch with saliva or other potentially infectious material, such as nervous tissue)
Cryptic / presumed (no known exposure to saliva; i.e. bat found in house, bat found in sleeping area, aerosol exposure such as caves)
Unknown On (mm/dd/yyyy):____/____/____ Until (mm/dd/yyyy):____/____/____ Frequency
Once multiple times within this time period Daily
Circumstances of exposure ____________________ _________________________________________
Location of wound on body (anatomic site: hand, arm, leg, etc.) ______________________________
Was wound cleaned? ........................ Y n U Sought medical attention &
treatment?......................................... Y n U Exposure location (where exposure occurred)
In north Carolina County _________________________________ Outside north Carolina, but in US State ___________________________________ Outside US Country _________________________________
Was the animal wild? ........................ Y n U Specify animal ______________________________
Unknown animal species Was the animal captured for testing? ... Y n U
If yes, DFA result Positive negative Inconclusive
Laboratory name ____________________________ Street address ______________________________ City______________________State ____________ Zip code __________________________________ Telephone (______) _________________________
Was the animal a domestic animal or pet? .............................................. Y n U Specify animal ______________________________
Was the animal vaccinated? ............. Y n U Date of animals last rabies vaccine: ____/____/____ Total number of doses ________________________
Is animal undergoing 10-day confinement? ................................... Y n U Date entered 10-day confinement: ____/____/____ Is 10-day confinement complete? ..... Y n U Date completed 10-day confinement: ____/____/____
Was animal dead or alive at time of exposure? Status unknown Dead Alive
Did the animal appear sick or exhibit abnormal behavior? ........................ Y n U
Describe behavior(s) Lethargic Aggressive Salivating Staggering or have abnormal gait
Did animal attack animal(s) or person(s)? ................................... Y n U
If yes, was the animal provoked? ........ Y n U Animal-related notes:
Did the patient work at or visit a fair with livestock or a petting zoo? ................ Y n U
Visited or worked? Visited Worked
Specify contact/exposure to agricultural livestock Cattle Sheep Horses Swine Goats Other_______________
Fair/petting zoo name __________________________ Street address________________________________ City ________________________________________ State____________________Zip code ____________ County______________________________________ Telephone (______) ___________________________
Did the patient work at or visit a zoo, zoological park, or aquarium? .......... Y n U
Visited or worked? Visited Worked
Specify contact/exposure to any agricultural livestock present at facility:
Cattle Sheep Horses Swine Goats Other
Zoo or Aquarium name _________________________ Street address________________________________ City ________________________________________ State____________________Zip code ____________ County______________________________________ Telephone (______) ___________________________
Did patient work in a veterinary practice or animal laboratory, animal research setting, biomedical laboratory, or an animal diagnostic laboratory? ...................... Y n U
Which type of work setting? Animal diagnostic (pathology) laboratory Animal laboratory/animal research biomedical laboratory research involving animals Veterinary medical practice
name of facility _______________________________ Street address________________________________ City ________________________________________ State____________________Zip code ____________ County______________________________________ Telephone (______) ___________________________ Specify species:__________________________
Did patient work with rabies vaccine production? ........................................ Y n U Did patient necropsy animals? ........... Y n U
Specify species:__________________________
RABIES EXPOSURE
Patient’s Last Name First Middle Suffix Maiden/Other Alias Birthdate (mm/dd/yyyy) / / SSN
DHHS/EPI #33 AUGUST 2011
rAbIES, HUmAn PAGE 2 OF 5
HEALTH CARE FACILITY AND BLOOD & BODY FLUID EXPOSURE RISKS
During the 3-8 weeks prior to onset of symptoms, did the patient have blood or body fluid exposures? ........................................... Y n U
Transplant recipient (tissue / organ / bone / bone marrow)
Date received (mm/dd/yyyy):____/____/____ Type of donation / transplant ___________________ Provider name ______________________________ Contact name at facility _______________________ Facility name _______________________________ City__________________________State ________ Country ___________________________________
During the 3-8 weeks prior to onset of symptoms, did the patient participate in any
outdoor activities? ............................. Y n U If yes, specify and give details:
Was patient exposed to wild animals? .. Y n U If yes, specify and give details:
Did patient sleep outside in open? .. Y n U If yes, specify and give details:
Did patient sleep in tent or cabin? ... Y n U If yes, specify and give details:
OUTDOOR EXPOSURE
Patient’s Last Name First Middle Suffix Maiden/Other Alias Birthdate (mm/dd/yyyy) / / SSN
The patient is: resident of nC resident of another state or US territory none of the above
Did patient have a travel history during the 3-8 weeks prior to onset of symptoms? ........................................... Y n U
List travel dates and destinations: From _____/_____/_____ to _____/_____/_____ _________________________________________ _________________________________________
Does patient know anyone else with similar symptom(s) who had the same or similar travel history? .................................... Y n U
List persons and contact information: _________________________________________ _________________________________________
TRAVEL & IMMIGRATION Does the patient know anyone else with
similar symptoms? ......................... Y n U Specify ___________________________________
Has the patient ever served in the U.S. military? ............................. Y n U If yes, dates of service:
From _________________ to_________________
OTHER EXPOSURE INFORMATION Was rabies post-exposure prophylaxis
recommended? ............................... Y n U by whom:
Public health veterinarian Public health physician Public health nurse Private healthcare provider Other Unknown
Was rabies post-exposure prophylaxis (PEP) given? .................................... Y n U Date PEP initiated (mm/dd/yyyy):____/____/____
Patient previously vaccinated .......... Y n U Date vaccinated (mm/dd/yyyy):____/____/____ Specify type of PEP:
Human rabies immune globulin (rIG) and 5 vaccines 2 vaccines (booster) Unknown
Continuing vaccinations begun in another county/state? ..................... Y n U
Who supplied PEP? (check all that apply) State HD LHD Private mD Other Unknown
Who administered PEP? (check all that apply) LHD Private mD Other Unknown
Did patient sign a consent/declination form for rabies PEP? ............................... Y n U
Did the patient receive medical care for this illness? ................................... Y n U Specify level(s) of care (check all that apply):
Outpatient Emergency department Inpatient ICU Other Unknown
Did the patient require supplemental oxygen? ........................................... Y n U
Did the patient require mechanical ventilation? ...................................... Y n U
TREATMENT
DHHS/EPI #33 AUGUST 2011
rAbIES, HUmAn PAGE 1 OF 5
ATTENTION HEALTH CARE PROVIDERS: Please report relevant clinical findings about this
disease event to the local health department.
North Carolina Department of Health and Human Services Division of Public Health • Epidemiology Section
Communicable Disease Branch
Birthdate (mm/dd/yyyy) / / SSN
Patient’s Last Name First Middle Suffix Maiden/Other Alias
NC Electronic Disease Surveillance System NC EDSS EVENT ID# ____________________
ATTENTION Local Health Department Staff: There is no Part 2 Wizard for this disease. Enter all information from this form into the NC EDSS question packages.
If sending this form to the Health Care Provider, remember to attach a cover letter from your agency indicating the part(s) of the form the provider should complete.
NC EDSS LAB RESULTS
Verify if lab results for this event are in NC EDSS. If not present, enter results.
RABIES, HUMAN Confidential Communicable Disease Report — Part 2
NC DISEASE CoDE: 33
Any immunosuppressive conditions? ...................................... Y n U
Specify:___________________________________ Injury/Wound/Break in skin .............. Y n U Recent/Acute injury(ies) or wound(s) .... Y n U
Date (mm/dd/yyyy):____/____/____ Anatomic site _______________________________ Circumstances _____________________________ _________________________________________ Principal wound type:
Animal bite Other (e.g. with cancer) Unknown
PREDISPOSING CONDITIONS Is/was patient symptomatic for this disease? .................................. Y n U If yes, symptom onset date (mm/dd/yyyy): __/__/____ Fever ................................................... Y n U
Yes, subjective no Yes, measured Unknown
How was temperature taken? __________________ Highest measured temperature _________________ Date of highest measured temperature: ____/____/____ Fever onset date (mm/dd/yyyy):____/____/____
Fatigue or malaise or weakness ...... Y n U Altered mental status ........................ Y n U
Patient displayed: Confusion Agitation Delirium Combativeness Coma Excitability Anxiety/apprehension Hallucinations
Headache............................................ Y n U Encephalitis ....................................... Y n U Seizures/convulsions ........................ Y n U Ataxia .................................................. Y n U Autonomic instability ........................ Y n U Pain/sensory changes around location
of animal bite ................................... Y n U Insomnia ............................................. Y n U Hypersalivation .................................. Y n U Aversion to water (hydrophobia) ....... Y n U Aversion to air on face (aerophobia) Y n U Cranial nerve or bulbar weakness
or paralysis ...................................... Y n U Difficulty swallowing (dysphagia) ..... Y n U Muscle weakness (paresis) ............... Y n U Muscle paralysis ................................ Y n U Nausea ................................................ Y n U Vomiting ............................................. Y n U Priapism (persistent erection)............. Y n U
CLINICAL FINDINGS
Was patient hospitalized for this illness >24 hours? ................... Y n U Hospital name: _____________________________
City, State: _________________________________
Hospital contact name: _______________________
Telephone: (______) ______ - ___________ Admit date (mm/dd/yyyy): ____/____/____ Discharge date (mm/dd/yyyy):____/____/____
HOSPITALIZATION INFORMATION
Specimen Date
Specimen # Specimen Source
Type of Test Test Result(s)
Description (comments) Result Date Lab Name — City/State
/ / / /
/ / / /
/ / / /
Discharge/Final diagnosis: ____________________ ___________________________________________ Survived? ........................................... Y n U Died? ................................................... Y n U Died from this illness? ...................... Y n U Date of death (mm/dd/yyyy):_____/_____/_____ Autopsy performed? ......................... Y n U
Facility where autopsy was performed _________________________________________ Patient autopsied in nC? .................. Y n U
County of autopsy:______________________ Source of death information:
Death certificate Autopsy report final conclusion Hospital/physician discharge Other
Date of death (mm/dd/yyyy):____/____/____ NOTE: The death certificate, autopsy report, hospital/physician discharge summary, and/or other documentation should be attached.
CLINICAL OUTCOMES