Legionellosis Case Report

1 $%$ t /BUJPOBM $FOUFS GPS *NNVOJ[BUJPO BOE 3 FTQJSBUPSZ %JTFBTFT-&(*0/&--04*4 $"4& 3&1035 (DISEASE CAUSED BY ANY legionella SPECIES) case No.: (CDC use only)1"5*&/5 */'03."5*0/1. State Health Dept. case No.:2. Reporting State: 3. County of Residence:4. State of Residence: 5. Occupation:6a. Date of Birth: 6b. Age: 7. Sex: 1 Days 2 Mos. 1 MaleMo. Day Year3 Years2 Female8. Ethnicity: 1 Hispanic/Latino2 Not Hispanic/Latino9. Race: (check all that apply) 1 Black or African American American Indian/ 1 Native Hawaiian or Alaska Native1 Other Pacific Islander1 Asian1 White1 the 10 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?)]

2 (check one) 1 Yes* 2 No 9 Unknown If yes, please complete the following DATES OF STAYACCOMMODATION NAMEADDRESSCITYSTATEZIPCOUNTRYNUMBERARRI VAL DEPARTURE*If yes, was this case reported to CDC at 1 Yes 2 No 9 the 10 days before onset, did the patient get in or spend time near a whirlpool spa ( , hot tub)?(check one) 1 Yes 2 No 9 Unknown If yes, describe where: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ If yes, list dates: _____Patient s Name: _____ Telephone Number: _____ Hospital: _____LAST / FIRST / MIAddress: _____ _____Patient Chart No.: _____NUMBER / STREET / APT NO / CITY / STATE ZIP CODEPATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDCForm Approved OMB No.

3 0920-0728 Department of Health & Human ServicesCenters for Disease Control and Prevention (CDC), Atlanta, Georgia, 30329-4027 case Report Page 1 of 2 IMPORTANT PLEASE COMPLETE THE BACK OF THIS FORM 10. Diagnosis: (check one)1 Legionnaires Disease (pneumonia, clinical or X-ray diagnosed)2 Pontiac Fever (fever and myalgia without pneumonia)8 Other ( , endocarditis, wound infection): _____11. Date of symptomonset of Legionellosis : Mo. Day Year13. Was the patient hospitalized during treatment for Legionellosis ? 1 Yes 2 No 9 UnknownHospital name: _____If yes, date of admission: Mo. Day YearCity, State: _____$-*/*$"- *--/&4412.

4 Date of first Report topublic health at any level: Mo. Day Year14. Outcome of illness:1 Survived2 Died9 Unknown3 Still ill9 the 10 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other respiratory therapy equipment for the treatment of sleepapnea, COPD, asthma or for any other reason?(check one) 1 Yes 2 No 9 Unknown If yes, does this device use a humidifier? 1 Yes 2 No 9 UnknownIf yes, what type of water is used in the device? (check all that apply) 1 Sterile 1 Distilled 1 Bottled 1 Tap 1 Other 1 the 10 days before onset, did the patient visit or stay in a healthcare setting ( , hospital, long term care/rehab/skilled nursing facility, clinic)?

5 (check one) 1 Yes 2 No 9 Unknown If yes, please complete the following */'03."5*0/IS THIS TYPE OF HEALTHCARE DATE OF VISIT / TYPE OF EXPOSURENAME OF FACILITY ALSO SETTING / FACILITYREASON FOR VISITCITYSTATEADMISSION(CHECK ONE)FACILITYA TRANSPLANT (CHECK ONE)CENTER?START DATE END DATE1 Hospital 1 Inpatient1 Yes 2 Long term care2 Outpatient2 No3 Clinic 3 Visitor or volunteer9 Unknown8 Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _4 Employee1 Hospital 1 Inpatient1 Yes 2 Long term care2 Outpatient2 No3 Clinic 3 Visitor or volunteer9 Unknown8 Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _4 EmployeePublic reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

6 An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address. While your response is voluntary your cooperation is necessary for the understanding and control of this case Report Page 2 of 2 Interviewer s Name:Affiliation:Telephone No.

7 :*/5&37*&8&3 *%&/5*'*$"5*0/Local Health Dept. Please submit this document to: State/DHD/SSS via your CD clerkState Health Dept. Return completed form to: Respiratory Diseases Branch, Mailstop H24-6 Office of Infectious DiseasesCenters for Disease Control and Prevention 1600 Clifton Rd. NE, Atlanta, GA 303293&1035*/( */4536$5*0/4-"#03"503: %"5"PLEASE CHECK ALL METHODS OF DIAGNOSIS WHICH APPLY:19. Was this case associated with a healthcare exposure: (check one)1 Definitely: Patient was hospitalized or a resident of a long term care facility3 Possibly: Patient had exposure to a healthcare facility for a portion for the entire 10 days prior to onsetof the 10 days prior to onset2 No: No exposure to a healthcare facility in the 10 days prior to onset8 Other (specify) _____ 9 the 10 days before onset, did the patient visit or stay in an assisted living facility or senior living facility?)

8 (check one) 1 Yes 2 No 9 UnknownDATE OF VISITTYPE OF FACILITYTYPE OF EXPOSURENAME OF FACILITYCITYSTATESTART DATEEND DATE1 Assisted Living1 Resident2 Visitor or Volunteer3 Employee2 Senior Living 1 Resident(Includes retirement 2 Visitor or Volunteerhomes without skilled 3 Employeenursing or personal care) this case associated with a known outbreak or possible cluster? (check one) 1 Yes 2 No 9 Unknown If yes, specify name of facility, city, and state of outbreak: _____State Health Dept. case No.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$ _____State Health Dept. Official who reviewed this Report : Title:Telephone No.

9 :1 $0/'* $"4&1 Urine Antigen Positive: If yes,Date Collected: Mo. Day Year2 Culture Positive: If yes,Date Collected: Mo. Day YearSite: 1 lung biopsy 2 respiratory secretions ( , sputum, BAL) 3 pleural fluid4 blood 8 other (specify) _____Species: _____ Serogroup: _____3 Fourfold rise in antibody titer toLegionella pneumophila serogroup 1: If yes,Initial (acute) titer: _____ Date Collected: Mo. Day YearConvalescent titer: _____ Date Collected: Mo. Day Year2 4641&$5 $"4&4 Fourfold rise in antibody titer OTHER THAN Legionellapneumophila serogroup 1 or to multiple species or serogroups of legionella using pooled antigen: If yes,Initial (acute) titer: _____ Date Collected: Mo.

10 Day YearConvalescent titer: _____ Date Collected: Mo. Day YearSpecies: _____ Serogroup: _____ 5 Direct Fluorescent Antibody (DFA) orImmunohistochemistry (IHC) Positive: If yes,Date Collected: : 1 lung biopsy 2 respiratory secretions ( , sputum, BAL) 3 pleural fluid4 blood 8 other (specify) _____Species: _____ Serogroup: _____ 6 Nucleic Acid Assay ( , PCR): If yes,Date Collected: Mo. Day YearSite: 1 lung biopsy 2 respiratory secretions ( , sputum, BAL) 3 pleural fluid4 blood 8 other (specify) _____Species: _____ Serogroup: _____