Hand, Foot and Mouth Disease and Severe Enteroviral Disease

Case Report Form

Hand, Foot and Mouth Disease and Severe Enteroviral Disease

Name of DRU:

Address:

Type:

RHU

CHO

Gov't Hospital

Private Hospital

Clinic

Gov't Laboratory

Private Laboratory

Airport/Seaport

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

Current Address: Permanent Address:	Sex: Male Female	Date of Birth:	Age: Days Months Years

Patient Admitted?:

Yes

No

Date Admitted/Seen/Consult:

Date Onset of Illness

Date of Investigation:

Name of Investigators:

Contact Nos.:

II. CLINICAL INFORMATION

III. EXPOSURE HISTORY

Is there a history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EV Disease?

Yes

No

Are there other known cases in the community?

Yes

No

Where did exposure probably occur?

Day care

Community

School

Dormitory

Home

HealthCare Facilities

Other, specify

III. LABORATORY TESTS

Specimen	If YES, Date Collected	Date Sent to RITM	Date recieved at RITM	Result	Specify organism	Date of Result
Throat swab
Vesicle swab
Rectal swab
Stool

V. CLASSIFICATION			VI. OUTCOME
Suspected case of HFMD Suspected case of Severe Enteroviral Disease Probable case of HFMD Confirmed case of Severe Enteroviral Disease Confirmed case of HFMD			Alive Died Date Died:

CASEDEFINITION/CLASSIFICATION: Suspected case of HFMD: Any individual, regardless of age, who develop acute febrile illness with papulovesicular or maculopapular rash on palms and soles, with or without vesicular lesion/ulcers in the mouth. Probable case of HFMD: A suspected case that has not been confirmed by a laboratory, but is geographically and tempo-rally related to a laboratory-confirmed case. Confirmed case of HFMD: A suspected case with positive laboratory result for Human Enteroviruses that cause HFMD. Suspected case of Severe Enteroviral Disease: Any child less than ten (10) years of age: with fever plus any severe signs and symptoms referable to central nervous system involvement, autonomic nervous system dysregulation or cardiopulmonary failure; OR a suspect or probable HFMD case with complications OR who died < 48hours after presenting with fever and CNS involvement; Confirmed case of Severe Enteroviral Disease: A suspected Severe Enteroviral Disease that has positive laboratory re-sults for Enteroviruses Confirmed Case: A suspect case that is laboratory confirmed or epidemiologically linked to a laboratory-confirmed case Laboratory criteria for diagnosis: Isolation of Bordetella pertussis from clinical specimen
COMPLICATIONS ASSOCIATED WITH HFMD AND SEVERE ENTEROVIRUSDISEASE:
Aseptic Meningitis	Febrile illness with headache, vomiting and meningism associated with of more that 5-10 white cells per cubic millimeter in cerebrospinal (CSF) fluid, and negative results on CSF bacterial culture.
Brainstem encephalitis	Myodonus, ataxia, nystagmus, oculomotor palsies, and bulberpalsy in various combinations, with or without MRI. In resource –limited settings, the diagnosis of brainstem encephalitis can be made in children with frequent myoclonic jerks and CSF pleocytosis.
Encephalitis	Impaired consciousness, including lethargy, drowsiness or coma, or seizures or myoclonus.
Encephalomyelitis	Acute onset of hyporeflexic flaccid muscle weakness with myoclonus, ataxia, nystagmus, oculomotor palsies and bulbar palsy in various combinations.
Acute Flaccid Paralysis	Acute onset of flaccid muscle weakness and lack of reflexes.
Autonomic Nervous System (ANS) dysregulation	Presence of cold sweating , mottled skin, tachycardia, tachypnea, and hypertension
Pulmonary oedema/haemorrhage	Respiratory distress with tachycardia, tachypnea, rales, and pink frothy secre-tion that develops after ANS dysregulation, together with a chest radiograph that shows bilateral pulmonary infiltrates without cardiomegaly.
Cardiorespiratory failure	Cardiorespiratory failure is defined by the presence of tachycardia, repiratory distress, pulmonary oedema, poor peripheral perfusion requiring inotropes, pul-monary congestion on chest radiography and reduced cardiac contractility on echocardiography.

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Patient ID	Patient Name	Gender	Blood Group	Age