Malaria case report - revised 040611.indd

State of California—Health and Human Services Agency Local ID Number ___________________________ California Department of Public Health Center for Infectious Diseases (Please use the same ID Number on the preliminary and fi nal reports to allow linkage to the same case.) Infectious Diseases BranchSurveillance and Statistics Section CASE REPORT
PATIENT INFORMATION
Primary LanguageEnglish Spanish Address Number & Street - Residence Hispanic/LatinoNon-Hispanic/Non-LatinoUnk Race* (check all that apply, race descriptions on page 6) If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy) Other: _______________________________ Other Electronic Contact Information Pacifi c Islander (check all that apply) If Yes, Est. Delivery Date (mm/dd/yyyy) If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy) *Comment: self-identity or self-reporting Occupation Setting (see list on page 6) The response to this item should be based on the patient’s self-identity or self-reporting. Therefore, patients should be offered the option of selecting CLINICAL INFORMATION
California Department of Public Health MALARIA CASE REPORT First three letters ofpatient’s last name: SIGNS AND SYMPTOMS
Date First Sought Medical Care (mm/dd/yyyy) Highest temperature (specify °F/°C) PAST MEDICAL HISTORY
Has the patient previously been diagnosed with malaria? Date of Previous Illness (mm/dd/yyyy) P. falciparum P. malariae Not DeterminedP. vivax Did the patient have a blood transfusion or transplant within the last 12 months? CLINICAL COMPLICATIONS FOR THIS ATTACK
HOSPITALIZATION
Did patient visit emergency room for illness? If Yes, how many total hospital nights? If there were any ER or hospital stays related to this illness, specify details below. HOSPITALIZATION - DETAILS
Discharge / Transfer Date (mm/dd/yyyy) Discharge / Transfer Date (mm/dd/yyyy) California Department of Public Health MALARIA CASE REPORT First three letters ofpatient’s last name: OUTCOME
Survived as of ________________________________(mm/dd/yyyy) TREATMENT / MANAGEMENT
MALARIA CHEMOPROPHYLAXIS
Was malaria chemoprophylaxis taken? Were all pills taken as prescribed? If doses were missed, what was the reason? No, missed more than a few, but less than half of the doses Other (specify):___________________________________ LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
P. falciparum P. vivax P. malariae P. ovale Not determined Unk P. falciparum P. vivax P. malariae P. ovale Not determined Unk P. falciparum P. vicax, malariae, or ovale Mixed infection (P. falciparum and P. vivax, malariae, or ovale) Specify RDTBinaxNOW TM Other (specify):____________ EPIDEMIOLOGIC INFORMATION
TRAVEL HISTORY
Did patient travel out of county of residence during the three months
If No, did patient travel out of county of residence during the three years
Yes No Unk Yes No Unk If Yes for one of these questions, answer the following two questions, and specify all locations and dates in the Travel History - Details table (see on page 4). Principal Reason for Travel from/to U.S. for Most Recent Trip Did patient reside in U.S. prior to most recent travel? Yes, for < 12 months Unk No, specify country:___________________ California Department of Public Health MALARIA CASE REPORT First three letters ofpatient’s last name: TRAVEL HISTORY - DETAILS
NOTES / REMARKS
REPORTING AGENCY
First Reported ByClinician Laboratory Other (specify):______________________ EPIDEMIOLOGICAL LINKAGE
DISEASE CASE CLASSIFICATION
Case Classifi cation (see case defi nition below)Confirmed Suspect STATE USE ONLY
State Case Classifi cationConfi rmed Suspect Not a case Need additional information CASE DEFINITION
MALARIA (2010)
CLINICAL DESCRIPTION
The fi rst symptoms of malaria (most often fever, chills, sweats, headaches, muscle pains, nausea, and vomiting) are often not specifi c and are also found in other diseases (such as infl uenza and other common viral infections). Likewise, the physical fi ndings are often not specifi c (elevated temperature, perspiration, tiredness). In severe malaria (caused by P. falciparum), clinical fi ndings (confusion, coma, neurologic focal signs, severe anemia, respiratory diffi culties) are more striking and may increase the suspicion index for malaria.
LABORATORY CRITERIA FOR DIAGNOSIS CASE
• Detection of circulating malaria-specifi c antigens using rapid diagnostic test (RDT), OR • Detection of species specifi c parasite DNA in a sample of peripheral blood using a Polymerase Chain Reaction test*, OR • Detection of malaria parasites in thick or thin peripheral blood fi lms. CASE CLASSIFICATION:
Suspected:
• Detection of Plasmodium species by rapid diagnostic antigen testing without confi rmation by microscopy or nucleic acid testing in any person (symptomatic
or asymptomatic) diagnosed in the United States, regardless of whether the person experienced previous episodes of malaria while outside the country.
California Department of Public Health MALARIA CASE REPORT CASE DEFINITION (continued)
Confi rmed:
• Detection and specifi c identifi cation of malaria parasites by microscopy on blood fi lms in a laboratory with appropriate expertise in any person (symptomatic
or asymptomatic) diagnosed in the United States, regardless of whether the person experienced previous episodes of malaria while outside the country, OR
• Detection of Plasmodium species by nucleic acid test* in any person (symptomatic or asymptomatic) diagnosed in the United States, regardless of whether
the person experienced previous episodes of malaria while outside the country.
* Laboratory-developed malaria PCR tests must fulfi ll CLIA requirements, including validation studies A subsequent attack experienced by the same person but caused by a different Plasmodium species is counted as an additional case. A subsequent attack experienced by the same person and caused by the same species in the United States may indicate a relapsing infection or treatment failure caused by drug resistance or a separate attack.
Blood smears from questionable cases should be referred to the CDC Division of Parasitic Diseases Diagnostic Laboratory for confi rmation of the diagnosis. Cases also are classifi ed according to the following World Health Organization categories: • Autochthonous: -Indigenous: malaria acquired by mosquito transmission in an area where malaria is a regular occurrence -Introduced: malaria acquired by mosquito transmission from an imported case in an area where malaria is not a regular occurrence • Imported: malaria acquired outside a specifi c area (e.g., the United States and its territories) • Induced: malaria acquired through artifi cial means (e.g., blood transfusion, common syringes, or malariotherapy) • Relapsing: renewed manifestation (i.e., of clinical symptoms and/or parasitemia) of malarial infection that is separated from previous manifestations of the same infection by an interval greater than any interval resulting from the normal periodicity of the paroxysms • Cryptic: an isolated case of malaria that cannot be epidemiologically linked to additional cases Source: http://www.cdc.gov/ncphi/disss/nndss/casedef/malaria_current.htm California Department of Public Health MALARIA CASE REPORT RACE DESCRIPTIONS
Description
Patient has origins in any of the original peoples of North and South America (including Central America).
Patient has origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
(e.g., including Bangladesh, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Nepal, Pakistan, the Philippine Islands, Thailand, and Vietnam).
Patient has origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacifi c Islander Patient has origins in any of the original peoples of Hawaii, Guam, American Samoa, or other Pacifi c Islands.
Patient has origins in any of the original peoples of Europe, the Middle East, or North Africa.
OCCUPATION SETTING
• Health Care - Long Term Care Facility OCCUPATION
• Agriculture - farmworker or laborer (crop, nursery, or greenhouse) • Medical - physician assistant or nurse practitioner • Agriculture - migratory/seasonal worker • Animal - farm worker or laborer (farm or ranch animals) • Animal - veterinarian or other animal health practitioner • Professional, technical, or related profession • Student - elementary or middle school • Dentist or other dental health worker • Teacher/employee - preschool or kindergarten • Teacher/employee - elementary or middle school • Food service - cook or food preparation worker • Teacher/instructor/employee - college or university • Teacher/instructor/employee - other/unknown • Laboratory technologist or technician • Laborer - private household or unskilled worker • Medical - emergency medical technician or paramedic

Source: http://pop.immunizelink.net/acd/Diseases/EpiForms/MalariaCaseRep-CDPH8657.pdf