Case Investigation Form
Measles/Rubella
(ICD 10 Code: B05; B06)
Name of DRU:
DRU Complete Address
Type:
RHU
CHO
Gov't Hospital
Private Hospital
Clinic
Gov't Laboratory
Private Laboratory
Airport/Seaport
I. PATIENT INFORMATION
Find
Patient Number:
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
Unknown
If Yes, weeks of pregnancy
Date of Birth:
Age:
Days
Months
Years
Permanent Address: (Specify House/Lot #, Street/ Purok/ Subdivision, Barangay, Municipality/City, Province, Region
Patient Admitted?:
Yes
No
Date Admitted/Seen/Consult:
Date Onset of Illness
Is the case a member of Indigenous Group?:
Yes
No
If Yes, specify:
Name of Parent/Caregiver:
Contact Nos.:
Date of Report:
Name of Reporter:
Contact Nos.:
Date of Investigation:
Name of Investigators:
Contact Nos.:
II. CLINICAL DATA
Fever:
Yes
No
Date onset:
Rash:
Yes
No
Date onset:
Cough:
Yes
No
Koplik sign:
Yes
No
Runny nose/coryza:
Yes
No
Red eyes/conjunctivitis:
Yes
No
Arthralgia/Arthritis:
Yes
No
Swollen lymphatic nodules:
Yes
No
If Yes, specify location:
cervical
post-auricular
others, specify
sub-occipital
Are there any complications?:
Yes
No
If YES, specify:
Other symptoms:
Working/Final Diagnosis:
III. VACCINATION HISTORY AND VITAMIN A SUPPLEMENTATION
Patient received measles-containing vaccine (MVC)?
Yes
No
If YES, include the number of doses which is applicable:
MV:
MR:
MMR:
Date last dose received MCV:
Measles vaccine received validated through:
Vaccination Card
Logsheet
By recall
(others, specify)
Was vaccination received during special campaigns?
Yes
No
If patient did not received any MVC, state reason/s
Mother was busy
Against belief
Medical contraindication
Fear of side effects
Child was sick
No vaccine available
Vaccinator not available
Not eligible for vaccination
Forgot schedule
Other reasons, specify
Was the patient given Vitamin A during the illness?
Yes
No
IV. EXPOSURE HISTORY
With history of travel with 23 days prior to onset of rash:
Yes
No
If YES, specify place and timing:
place of travel:
Date of travel:
< 7 days from rash onset
7 - 23 days from rash onset
*Was there contact with a confined Measles case 7-23 days prior to rash onset :
No
Unknown
Yes
*Was there contact with a confined Rubella case 7-23 days prior to rash onset :
No
Unknown
Yes
If Yes, name of contact:
Place of residence:
Date of contact:
Tick the type of place where exposure probably occur:
Daycare
Health care facility
Barangay
Dormitory
Home
Others, specify:
School
*Are there other known cases with fever and rash (regardless of presence of 3 C's) in the community?
Yes
No
Unknown
V. LABORATORY TEST
Specimen collected
If YES, Date Collected
Date sent to RITM
Date received in RITM
(to be filled up by RITM)
Measles IgM Result
Rubella IgM Result
Virus
Isolation Result
PCR
RESULT
Serum
Dried Blood Spot
Oropharyngeal/
Nasopharyngeal swab?
VI. FINAL CLASSIFICATION
VII. SOURCE OF INFECTION
Laboratory Confirmed Measles
Epi-linked Confirmed Measles
Measles Compatible
Laboratory Confirmed Rubella
Epi-linked Confirmed Rubella
Discarded Non Measles/Rubella
Endemic
Imported
Import-related
Unknown
VIII. OUTCOME
Alive
Died
Final Diagnosis
Date Died
CASE DEFINITION AND CLASSIFICATION
CASE DEFINITION
Suspected case:
Any individual, regardless of age, with the following signs and symptoms:
fever (38
°C or more)
or hot to touch; and
Maculo-papular rash (non-vesicular) AND
at least one of the following: cough, coryza (runny nose), or conjunctivitis (red eyes)
CASE CLASSIFICATION
Laboratory-confirmed Measles:
a suspected measles case that has been confirmed by a proficient laboratory as positive for Measles IgM and antibodies and/or positive for measles virus isolation or Polymerase Chain Reaction (PCR)
Epidemiologically Linked Confirmed Measles:
a suspected measles case that has not been confirmed by a laboratory but was geographically and temporary related with dates of rash onset occurring between 7 and 23 days apart from a laboratory-confirmed case or another epidemiologically confirmed measles case
Clinically Compatible Measles:
a suspected measles case, for which no adequate clinical specimen was taken and the case has not been linked to a laboratory-confirmed case of measles or other communicable disease OR laboratory confirmation is still pending
Laboratory-confirmed Rubella:
a suspected rubella case with a positive laboratory test results for rubella-specific IgM antibodies or other laboratory test method
Epidemiologically Linked Confirmed Rubella
a suspected case who has direct contact with another laboratory confirmed rubella case with rash onset occured 12-23 days before the present case
Non-Measles/Rubella Discarded Case:
a suspected case that has been investigated and discarded as non-measles (and non-rubella) when any of the following is true:
negative laboratory testing in a proficient laboratory on an adequate specimen collected during the proper time period after rash onset
epidemiological linkage to a laboratory confirmed outbreak of other communicable disease that is not measles/rubella
confirmation of other etiology
SOURCE OF INFECTION
Endemic:
a confirmed measles case acquired the infection within the country wherein the chain of measles virus transmission is continuous for
≥ 12 months
Imported:
a returning traveler or visitor exposed to measles outside the country during 7 - 23 days prior to rash onset and supported by epidemiological or virological evidence
Import-related
a locally acquired infection that occurs as part of a chain of transmission originating from an imported case as supported by epidemiological or virological evidence
Unknown:
a confirmed case for which no epidemiological or virological link to importation or endemic transmission cam be established after a thorough investigation
LABORATORY CONFIRMATION
Positive serologic test for anti-measles IgM antibodies
Fourfold rise in anti-measles igG antibodies in acute and convalescent serum
Isolation of measles virus
Dot Immunobinding assay
Polymerase chain reaction (PCR) testing for measles nucleic acid
LABORATORY CONFIRMATION
50,000 IU for children < 6months old
100,000 IU for children 6 to 11months old
200,000 IU for children 12 to 71months old
Note:
The therapeutic dosage of Vitamin A for measles cases should be given upon diagnosis regardless of when the last dose of vitamin A capsule was given.
Deliberately providing false or misleading, personal information on the part of the patient, or the next kin in case of patient's incapacity, may constitute non-cooperation punishable under Republic Act No. 11332.
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