Diphtheria

Case Investigation Form

Diphtheria (ICD 10 Code: A36)

Type:

RHU

CHO

Gov't Hospital

Private Hospital

Clinic

Gov't Laboratory

Private Laboratory

Airport/Seaport

Patient Admitted?:

Yes

Unknown

Date Admitted/Seen/Consult:

Name of Parent / Caregiver:

Date of Investigation:

Name of Investigators:

Diphtheria-containing vaccine doses:

Yes

If Yes, Number of total doses:

Zero

Unknown

Date of last vaccination:

Source of Information:

Card

recall

TCL

Known Exposure to:

Confirmed case

Probable case

Carrier

International traveler

School name, if applicable:

Any travel within 14 days before onset of illness

Yes

If yes where (in detail)

Check Signs/Symptoms which apply:

Fever

Cough

Sore throat

Difficulty of swallowing

Difficulty of breathing

Pseudomembrane

Others, specify

Outcome at discharge

clinically well

Referred to

Death (Date died)

Others, specify

Administered antibiotic therapy?

Yes

Unknown

If yes, Date

Administered Diphtheria Anti toxin (DAT) therapy:

Yes

Unknown

If yes, Date

Date of collection:Date of sample send:

Case Definition/Classification:

Suspect Case
A person presenting with illness of upper respiratory tract characterized by pharyngitis, nasopharyngitis, tonsillitis or laryngitis and adherent pseudomembrane of the tonsils, pharynx, larynx and/or nose.

Laboratory-Confirmed Case
A case is a person (regardless of a symptoms) with Corynebacterium spp. Isolated by culture and positive for toxin production.

Special consideration. Sometimes during outbreak investigation when household contacts are investigated, people will be identified with positive Corynebacterium cultures and evidence of toxigenicity, who do not meet the suspected case definition. These people should still be reported as laboratory-confirmed cases, as their treatment and public health response is the same as the other laboratory-confirmed cases.

Epidemiologically linked Case
A case that meets the definition of a suspected case and is linked epidemiological linkage is having intimate respiratory or physical contact with a laboratory-confirmed case within the 14 days prior to onset of sore throat in the laboratory-confirmed case.

Clinically Compatible Case
A case that meets the definition of a suspected case and lacks both a confirmatory laboratory test result and epidemiologic linkage to a laboratory-confirmed case.

Discarded Case
A suspect case with:

1. C. diphtheriae but negative ELEK test (nontoxigenic Corynebacterium); or

2. Negative PCR for the toxin gene

I. PATIENT INFORMATION
Patient Number:	EPI ID:	Patient's Last Name First Name: Middle Name:

Current Address: (Specify House/Lot #, Street/ Purok/ Subdivision, Barangay, Municipality/City, Province, Region	Sex: Male Female Pregnant? Yes No Undefined If Yes, weeks of pregnancy:	Civil Status: Date of Birth:	Age: Days Months Years
Permanent Address: (Specify House/Lot #, Street/ Purok/ Subdivision, Barangay, Municipality/City, Province, Region

Name of Parent / Caregiver:		Contact Nos.:
Date of Report:	Name of Reporter:	Contact Nos.:
Date of Investigation:	Name of Investigators:	Contact Nos.:
II. BACKGROUND INFORMATION
Diphtheria-containing vaccine doses: Yes No If Yes, Number of total doses: Zero 1 2 3 Unknown Date of last vaccination: Source of Information: Card recall TCL Known Exposure to: Confirmed case Probable case Carrier International traveler Other means of exposure: School name, if applicable: Any travel within 14 days before onset of illness Yes No If yes where (in detail)
III. CLINICAL DETAILS
Date onset of fever and / or sore throat:
Check Signs/Symptoms which apply: Fever Cough Sore throat Difficulty of swallowing Difficulty of breathing Pseudomembrane Others, specify Outcome at discharge clinically well Referred to Death (Date died) Others, specify
IV. TREATMENT INFORMATION: Administered antibiotic therapy? Yes No Unknown If yes, Date Administered Diphtheria Anti toxin (DAT) therapy: Yes No Unknown If yes, Date
*V. SPECIMEN COLLECTION for Corynebacterium diphtheriae:* Date of collection:Date of sample send:
Date of results: Check what applies: Positive Negative Undetermined Not processed If Positive Toxigenic Non-toxigenic
VI. FINAL CLASSIFICATION: Suspect Lab confirmed EPI linked Clinically compatible Discarded
To include linelist for close contacts Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient's incapacity, may constitute non-cooperation punishable under the Republic-Act No. 11332.
Case Definition/Classification: Suspect Case A person presenting with illness of upper respiratory tract characterized by pharyngitis, nasopharyngitis, tonsillitis or laryngitis and adherent pseudomembrane of the tonsils, pharynx, larynx and/or nose. Laboratory-Confirmed Case A case is a person (regardless of a symptoms) with Corynebacterium spp. Isolated by culture and positive for toxin production. Special consideration. Sometimes during outbreak investigation when household contacts are investigated, people will be identified with positive Corynebacterium cultures and evidence of toxigenicity, who do not meet the suspected case definition. These people should still be reported as laboratory-confirmed cases, as their treatment and public health response is the same as the other laboratory-confirmed cases. Epidemiologically linked Case A case that meets the definition of a suspected case and is linked epidemiological linkage is having intimate respiratory or physical contact with a laboratory-confirmed case within the 14 days prior to onset of sore throat in the laboratory-confirmed case. Clinically Compatible Case A case that meets the definition of a suspected case and lacks both a confirmatory laboratory test result and epidemiologic linkage to a laboratory-confirmed case. Discarded Case A suspect case with: 1. C. diphtheriae but negative ELEK test (nontoxigenic Corynebacterium); or 2. Negative PCR for the toxin gene