New Jersey Department of Health

Vaccine Preventable Disease Program

PO Box 369, Trenton, NJ 08625-0369

PERTUSSIS INVESTIGATION RECORD	Case Status

Confirmed	Possible

Probable	Not a Case
CDRSS#

E#

PATIENT INFORMATION
Name of Patient (Last) (First)

Name of Parent/Guardian

Address

Telephone No.

( )
City

Zip Code

County

Name of School/Work/Child Care

Facility Contact Name

Address

Telephone No.

( )
REPORTING INFORMATION
Reporting Source

Treating Physician Name

Address of Physician

Telephone No.

( )
Date(s) Physician Saw

Date Reported to LHD

Name of Investigator

Telephone No.

( )
Hospital

Hospital Record #

Hospital Address

Telephone No.

( )
ADDITIONAL PATIENT INFORMATION
CDRSS #

County

State

Zip

Birth Date (Month/Day/Year)

__ __ / __ __ / __ __	Age (Unknown = 999)

__ __ __	Age Type

____	0 = 1-120 Years	2 = 0-52 Weeks	9 = Age Unknown

1 = 0-11 Months	3 = 0-28 Days
Race

____	N = Native Amer./Alaskan Native	W = White

A = Asian/Pacific Islander	O = Other

B = African American	U = Unknown	Ethnicity

____	H = Hispanic

N = Not Hispanic

U = Unknown	Sex

____	M = Male

F = Female

U = Unknown
Event Date (Month/Day/Year)

__ __ / __ __ / __ __	Event Type

____	1 = Onset Date	4 = Reported to County

2 = Diagnosis Date	5 = Reported to State as of MMWR Report Date

3 = Lab Test Done	6 = Unknown
Reported (Month/Day/Year)

__ __ / __ __ / __ __	Imported

____	1 = Indigenous	3 = Out of State

2 = International	9 = Unknown	Report Status

____	1 = Confirmed	4 = Not a Case

2 = Probable	9 = Unknown

3 = Possible
CLINICAL DATA
Any Cough?

____	Y = Yes N = No

U = Unknown	Cough Onset (Month/Day/Year)

__ __ / __ __ / __ __	Paroxysmal Cough?

____	Y = Yes N = No

U = Unknown
Whoop?

____	Y = Yes N = No

U = Unknown	Post-tussive Vomiting?

____	Y = Yes N = No

U = Unknown	Apnea?

____	Y = Yes N = No

U = Unknown
Final Interview Date (Month/Day/Year)

__ __ / __ __ / __ __	Cough at Final Interview?

____	Y = Yes N = No

U = Unknown	Duration of Cough at Final Interview?

____ Days
COMPLICATIONS
Chest X-Ray for Pneumonia?

____	P = Positive	X = Not Done

N = Negative	U = Unknown	Seizures Due to Pertussis?

____	Y = Yes N = No

U = Unknown	Acute Encephalopathy Due to Pertussis?

____	Y = Yes N = No

U = Unknown
Hospitalized?

____	Y = Yes N = No

U = Unknown	Days Hospitalized?

____	0 - 998

999 = Unknown	Died?

____	Y = Yes N = No

U = Unknown

TREATMENT
Were Antibiotics Given?

____	Y = Yes N = No

U = Unknown	First Antibiotic* Received (refer to list of choices)

____	Date Started First Antibiotic (Month/Day/Year)

__ __ / __ __ / __ __	Days First Antibiotic Actually Taken?

__ __	0 - 98

99 = Unknown
*List of Choices for Antibiotics:

1 = Erythromycin (incl. pediazole, ilosone)

2 = Cotrimoxazole (bactrim/septra)

3 = Clarithromycin/azithromycin

4 = Tetracycline/Doxycycline

5 = Amoxicillin/Penicillin/Ampicillin/Augmentin /Ceclor/Cefixime

6 = Other 9 = Unknown
Second Antibiotic* Received (refer to list of choices*)

____	Date Started Second Anti-biotic (Month/Day/Year)

__ __ / __ __ / __ __	Days Second Antibiotic Actually Taken?

__ __	0 - 98

99 = Unknown

FOR STATE

USE ONLY:	Date Surveillance Rec’d at State

Date Reviewed at State

Final Case Status by State	E-Number	Date Sent to CDC

LABORATORY
*Not recommended for Confirmation	Culture:	Result Code **

____	Date Specimen Taken (Month/Day/Year)

__ __ / __ __ / __ __
Was Laboratory Testing for Pertussis Done?

____	Y = Yes

N = No

U = Unknown
PCR:	Result Code **

____	Date Specimen Taken (Month/Day/Year)

__ __ / __ __ / __ __
*DFA:	Result Code **

____	Date Specimen Taken (Month/Day/Year)

__ __ / __ __ / __ __
** Result Codes:

P	=	Positive	X	=	Not Done

N	=	Negative	S	=	Parapertussis

E	=	Pending	U	=	Unknown

I	=	Indeterminate
*Serology 1:	Result Code **

____	Date Specimen Taken (Month/Day/Year)

__ __ / __ __ / __ __
*Serology 2:	Result Code **

____	Date Specimen Taken (Month/Day/Year)

__ __ / __ __ / __ __
VACCINE HISTORY
Vaccinated? (Received any doses of diphtheria,

tetanus, and/or pertussis-containing vaccines)?	____	Y = Yes N = No U = Unknown
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Vaccination Date (Month/Day/Year)

__ __ / __ __ / __ __	Vaccine Type ***

____	Vaccine Mfgr. ****

____	Lot Number

__ __ __ __ __ __ __ __ __ __
Record Vaccine Type and Vaccine Manufacturer for each dose (unlikely to be available if patient born before 1988).	*** Vaccine Type Codes

W	=	DTP Whole Cell	P	=	Pertussis Only

A	=	DTaP	N	=	TdaP

H	=	DTaP - Hib	R	=	DTaP - HepB - IPV

D	=	DT or Td	O	=	Other

T	=	DTP – Hib	U	=	Unknown	**** Vaccine Manufacturer Codes

C	=	Sanofi-Pasteur	I	=	Mich. Health Dept.

L	=	Lederle	N	=	North American Vaccine

S	=	GlaxoSmithKline	O	=	Other

M	=	Mass. Health Dept.	U	=	Unknown

Date of Last Pertussis-Containing Vaccine Prior to Illness Onset (Month/Day/Year)

__ __ / __ __ / __ __	Number of Doses of Pertussis-Containing Vaccine Prior to Illness Onset

____	0 - 6

9 = Unknown
Reason Not Vaccinated With >3 Doses of Pertussis Vaccine

____	1 = Religious Exemption	5 = Parental Refusal	7 = Other

2 = Medical Contraindication	6 = Age Less Than 7 Months	9 = Unknown

4 = Previous Pertussis Confirmed by Culture
EPIDEMIOLOGIC INFORMATION
Date First Reported to a Health Department (Month/Day/Year)

__ __ / __ __ / __ __	Date Case Investigation Started (Month/Day/Year)

__ __ / __ __ / __ __
Outbreak Related

____	Y = Yes N = No U = Unknown	Epi-Linked?

____	Y = Yes N = No U = Unknown
Transmission Setting (Where did this case acquire pertussis)?
____	1 = Day Care	6 = Hospital Outpatient Clinic	11 = Military

2 = School	7 = Home	12 = Correctional Facility

3 = Doctor’s Office	8 = Work	13 = Church

4 = Hospital Ward	9 = Unknown	14 = International Travel

5 = Hospital ER	10 = College	15 = Other
Setting (Outside Household) of Further Documented Spread From This Case	Number of Contacts in Any Setting Recommended Antibiotics

__ ____ __
____	1 = Day Care	7 = >1 Setting Outside	12 = Correctional Facility

2 = School	Household	13 = Church

3 = Doctor’s Office	8 = Work	14 = International Travel

4 = Hospital Ward	9 = Unknown	15 = Other

5 = Hospital ER	10 = College	16 = No Documented Spread

6 = Hospital Outpatient Clinic	11 = Military	Outside Household

EPIDEMIOLOGICAL INFORMATION

Index Case	Date of Onset of Cough
1.	IDENTIFICATION: An acute bacterial disease involving the tracheobronchial tree. The initial catarrhal stage has an insidious onset with an irritating cough which gradually becomes paroxysmal, usually within 1 to 2 weeks, and lasts for 1 to 2 months. Paroxysms are characterized by repeated violent cough; each series of paroxysms has many coughs without intervening inhalation, followed by a characteristic crowing or high pitched inspiratory whoop; paroxysms frequently end with the expulsion of clear, tenacious mucus. Young infants and adults often do not have the typical paroxysm.	2.	INCUBATION PERIOD: From 5 to 21 days; almost uniformly within 10 days.

3.	PERIOD OF COMMUNICABILITY: Communicability is the greatest in catarrhal stage before onset of paroxysms. The organism rarely can be recovered after the 4th week of the disease. The period of communicability may be much shorter in patients receiving certain antimicrobial drugs.
Contacts	Relation to Patient	Date of Exposure	Age	Sex	Phone	Name of School

or Workplace	Drug Therapy	No. of PCV’s*	Date

of Last

PCV *
Drug	Start	End
Comments:

* PCV = Pertussis-Containing Vaccine

PERTUSSIS INVESTIGATION RECORD

(Continued)

IMM-24

JUL 12	Page 2 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

IMM-24, Pertussis Investigation Record

IMM-24, IMM, Immunization, vaccine, pertussis, pertussis investigation record, vaccine-preventable diseases program

EWhite

2005-09-06

NJDOH