Meningococcal Disease

Case Investigation Form

Meningococcal Disease

(ICD 10 Code: A39)

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:	EPI ID:	Patient's Last Name First Name: Middle Name:

Current Address: Permanent Address: Civil Status:	Sex: Male Female Indigenous people? Yes No Unknown If Yes, specify:	Date of Birth:	Age: Days Months Years
Current Address: Permanent Address: Civil Status:

Occupation:

Name of Workplace:

Address of Workplace:

If Student:

Name of School

Address of School:

II. CLINICAL INFORMATION

Admitted?:

Yes

Unknown

Date Admitted/Seen/Consult:

Date Onset of Illness

Signs and Symptoms

Clinical Presentation

Meningitis

Septicemia

Both

Case Classification

Suspected Case

Probable Case

Confirmed Case

Outcome:

Alive

Died

Date Died:

III. CASE MANAGEMENT

Were blood/CSF extracted before the first dose of antibiotics was given to the patient?

Yes

Unknown

Administered antibiotic therepy?

Yes

If Yes, Date

IV. LABORATORY TESTS:

Specimen	Type of Laboratory test done	Result
CSF	Culture	Positive for:
	Latex agglutination	Positive for:
	Gram stain	Positive for:
Blood	Culture	Positive for:
Blood	PCR	Positive for:

VI. PAST HISTORY

Did the PATIENT or CLOSE CONTACT/S interact with a suspected or confirmed meningococcal case within 2 weeks before onset of illness?

Yes, the patient

Yes, close contact/s (name/s)

If yes, what was the name of the suspected or confirmed meningococcal case?:

Wha tis the address of the suspected or confirmed meningococcal case?

Where did the patient or close contact/s interact with the meningococcal case?

When

Number of Days?

Did the PATIENT travel within 2 weeks prior to illness?

Yes

Unknown

If Yes, where?

Did a CLOSE CONTACTIS of the patient travel within 2 weeks prior to illness?

Yes

Unknown

If yes, who and where?

Did the PATIENT attend any social gathering within 2 weeks prior to illness?

Yes

Unknown

If yes, who and where?

Did the PATIENT have upper respiratory tract infection within 2 weeks prior to illness?

Yes

Unknown

Did a CLOSE CONTACT/S have upper respiratory tract infection within 2 weeks prior to the patient's illness?

Yes

Unknown

If Yes, who?

Case Definition/Classification:

Suspected case: Clinical purpura fulminans in the absence of a positive blood culture; or Gram-negative diplococci, not yet identified, isolated from a normally sterile body site (e.g., blood or CSF)

Probable case: Detection of N. meningitidis antigenin formulin-fixed tissue by immunohistochemistry (IHC); or in CSF by latex agglutination

Confirmed case: A suspected or probable case plus: *Isolation of meningitidis from a sterile site (CSF, blood) or Positive test for meningitides from a sterile site (CSF, blood)

LABORATORY CONFIRMATION:

Positive cerebrospinal fluid (CSF) antigen detection or culture.
Positive blood culture.
Positive PCR test

Attach File

Patient ID	Patient Name	Gender	Blood Group	Age