Neonatal Tetanus

Case Investigation Form

Neonatal Tetanus

(ICD 10 Code: A33)

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:

District:

Permanent Address:

LHZ

Sex:

Male

Female

Date of Birth:

Age in days:

Patient Admitted?:

Yes

Unknown

Date Admitted/Seen/Consult:

Date Onset of Illness

Date of Report:

Date of Investigaion:

Mother's Full Name:

Contact Number:

IV. CLASSIFICATION AND OUTCOME:
CLASSFICATION	OUTCOME
Suspect Case Confirmed Case	Alive Died Unknown Date Died:

Case Definition/Classification:

Suspected Case: Any neonate who would suck and cry normally during the first two days of life and develop tetanus-like illness or death between 3 and 28 days of age and not investigated

Clinically-Confirmed Case: Any suspected case found to have ail three of the following: normal ability to suck and cry during the first 2 days of life AND could not suck normally between 3 and 28 days of age AND developed muscle stiffness and/or spasms which may include jerking, trismus, clenched fists or feet, continuously pursed lips, and/or curved back (opisthotonus).

OR A neonate from 3 to 28 days of age diagnosed as a case of tetanus by a physician.

NOTE: Neonatal tetanus case classification is based solely on clinical criteria. Any neonatal death occurring in

babies 3-28 days old with no apparent cause should be suspected as NT and evaluated according to the above criteria. In calculating age, the day of birth is considered the first day of life (i.e., the baby is 1 day old on the day he/she was born).

Protection at Birth (PAB) is defined as any of the following:

Regardless of interval:

2 TDV doses during the pregnancywith the youngest child, or
1 TDV dose during the pregnancy with the youngest child plus 2 doses prior to the pregnancy, or
3 TDV doses prior to the pregnancy with the youngest child

III. MOTHER'S INFORMATION
Prenatal Care No. of total pregnancies: Live births: Living children: How many prenatal care visits did the mother make to a health facility during her pregnancy? When was the first prenatal visit? Is the prenatal care history reported by: Card Recall Both Unknown State reason for no or late prenatal care:	Immunization Status How many doses of Tetanus containing vaccine has the mother received? doses unknown Date last dose given: If she received, 2 doses, were they .given during this pregnancy? Yes No Unknown Is the immunization status reported by: Card Recall Both Unknown	If she has a card, copy the dates of all Tetanus containing immunizations recorded on the card: TD1: TD2: TD3: TD4: TD5: Is the child protected at birth? Yes No Unknown

II. CLINICAL DATA
In the first 2 days of life, check which applies: did the baby suck and cry normally? Yes No Unknown From 3 to 28 days of life was the baby unable to suck and cry normally? Yes No Unknown	From 3 to 28 days of life does the baby have convulsions or muscles stiffness or fits, trismus? Yes No Unknown Was the umbilical stump infected? (bad smell, pus) Yes No Unknown