Download (location of symptom onset) 4. Laborato

MERS Reporting Form v2
Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Interim Case Summary Form for rapid reporting
of probable and confirmed cases of MERS-CoV infection to WHO v2
v2 May 2017
Reason for update: v2 has been updated taking into consideration knowledge of potential and
suspected risk factors for infection and severe disease
Confidential
This rapid reporting form and information contained therein are confidential.
1.
Reporter information
Form completed by (name) _______________________________
Contact information of interviewer (mobile number)
_________________________
Email:______________________
Date of interview (dd/mm/yyyy) ___/____/______
2.
Patient Information
Unique Case ID (Used in country) ___________________________________________________
WHO Case ID (International)____________________________________________
Status of Case
Probable Case
Confirmed Case
Sex
Male
Female
Age (in years if over 1 year old, in months if <1 year old) ___________ years _______ months (if under 1)
Occupation of the patient: _________________________________________________________
Nationality or ethnicity of the patient: _________________________________________________________
Date of symptom onset (dd/mm/yyyy) ___/____/______
Tick box for no symptoms at time of reporting
Date of first admission to hospital (dd/mm/yyyy) ___/____/______
Tick box for not admitted to a hospital at the
time of reporting
Date of isolation (dd/mm/yyyy) ___/____/______
Date of death (dd/mm/yyyy) ___/____/______ OR
3.
Date of discharge (dd/mm/yyyy) ___/____/______
Geographic information (location of symptom onset)
Country_________________________________
Administrative Level 1___________________________________
Province/State or equivalent_________________________________
Administrative Level 2___________________________________
4.
Laboratory Tests
MERS-CoV PCR Testing
Date of specimen collection
Specimen type
Results
Targets
(dd/mm/yyyy)
(NP/OP swab, sputum, aspirate, etc)
(Positive or negative)
(upE, ORF1a, ORF1b)
1st collection
___/____/______
_____________________
pos
neg
upE
ORF1a
ORF1b
2nd collection
___/____/______
_____________________
pos
neg
upE
ORF1a
ORF1b
3rd collection
___/____/______
_____________________
pos
neg
upE
ORF1a
ORF1b
4th collection
___/____/______
_____________________
pos
neg
upE
ORF1a
ORF1b
Comments: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1
Unique Case ID __________________________
MERS Reporting Form v2
MERS-CoV Serologic Testing
Single Sample
Paired Sampling
Date of first serum sampling (dd/mm/yyyy) ___/____/______
Serologic Assay Used:____________________________________
Result:________________________________________ Titre:______________________________
Date of second serum sampling (dd/mm/yyyy) ___/____/______
Serologic Assay Used:____________________________________
Result:________________________________________ Titre:______________________________
MERS-CoV Sequencing
Yes
Other respiratory virus testing
Contact with MERS case
5.
No
Unknown
Influenza A
Influenza B
RSV
Other_____________________
Exposures in the 14 days prior to symptom onset (prior to reporting if asymptomatic)
Has the patient had contact with a confirmed case?
Relationship with confirmed case?
Yes
No
Relative
Unknown
Co-worker
other (please specify) _______________________
Has the patient visited a health care facility in the 14 days prior to symptom onset?
Yes
No
Unknown
Recent health care visits
If yes, where and when where the health care visit(s)?
Health Care Facility Name
Inpatient or Outpatient
Date admitted
Date released
1 ___________________________
In
Out
___/____/______
___/____/______
2 ___________________________
In
Out
___/____/______
___/____/______
3 ___________________________
In
Out
___/____/______
___/____/______
4 ___________________________
In
Out
___/____/______
___/____/______
Where (hospital name and city)____________________________________________________
Has the patient had contact with dromedary camels in the 14 days prior to symptom onset?
Was the contact direct (touched the camel)?
Yes
No
Yes
No
Unknown
Unknown
Contact with dromedaries
Was the contact indirect (visited a farm, market, race track without direct contact)?
Visited a camel market
Yes
No
Unknown
Visited a camel farm
Yes
No
Unknown
Visited a camel race track
Yes
No
Unknown
Other ____________________________
Yes
No
Unknown
Has the patient had any contact with raw camel materials?
Yes
No
Unknown
If yes, which materials (check all that apply):
handled/consumed unpasteurized camel milk
handled/consumed camel urine
handled/consumed camel blood
handled/consumed uncooked camel meat or organs
Other, please specify _______________________________________________
Recent travel
Has the patient travelled in the 14 days prior to symptom onset?
Yes
No
Unknown
If yes, where and when was the travel?
Location 1 _________________________
Dates (from when to when): ___________________________
Location 2 _________________________
Dates (from when to when): ___________________________
Location 3 _________________________
Dates (from when to when): ___________________________
Has the patient been to any mass gatherings in the 14 days prior to symptom onset (check all that apply)?
Mass sporting event
2
Hajj
Umrah
Family celebration
Other_________________
Unique Case ID __________________________
MERS Reporting Form v2
6. Signs/Symptoms/Complications present at initial presentation
Respiratory symptoms
Yes
No
Date first recognized ____/____/______
Fever
Yes
No
Date first recognized ____/____/______
Gastrointestinal symptoms
Yes
No
Date first recognized ____/____/______
Pneumonia
Yes
No
Date first recognized ____/____/______
ARDS (Acute Respiratory Distress Syndrome)
Yes
No
Date first recognized ____/____/______
Acute renal failure
Yes
No
Date first recognized ____/____/______
Cardiac failure
Yes
No
Date first recognized ____/____/______
Consumptive coagulopathy
Yes
No
Date first recognized ____/____/______
Other: _____________________________
Yes
No
Date first recognized ____/____/______
What is the current status (at the time of reporting) of the patient? _____________________
home isolation
7.
admitted to ward, in isolation
In ICU
Other:______________________________
Underlying conditions
Does the patient have any underlying medical conditions?
Yes
No
Unknown
Diabetes
Yes
No
Unknown
Heart Disease, including hypertension
Yes
No
Unknown
Renal Disease
Yes
No
Unknown
If yes, which conditions?
Weakened immune system (from cancer, chemotherapy, radiation therapy, immunosuppressive medications,
Yes
No
Unknown
Obesity
Yes
No
Unknown
Asthma
Yes
No
Unknown
Chronic lung disease, including COPD
Yes
No
Unknown
Liver disease
Yes
No
Unknown
HIV, organ transplant, or inherited immunodeficiency)
Other, please specify _______________________________________________________________
If female, is the patient pregnant?
8.
Yes
No
Unknown
Other Observations and comments
Contact tracing initiated
Household
Yes
No
Unknown
Date initiated ____/____/______
HCW
Yes
No
Unknown
Date initiated ____/____/______
Co-workers
Yes
No
Unknown
Date initiated ____/____/______
If applicable, contact made with Ministry of Agriculture for dromedary testing
Yes
No
Unknown
Date initiated ____/____/______
Other Comments
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3
Unique Case ID __________________________