DRAFT COPY
DRAFT COPY
U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES
PUBLIC HEALTH SERVICE
CDC
VIRAL HEPATITIS CASE REPORT
Centers for Disease Control
and Prevention
Hepatitis Branch, (G37)
Atlanta, Georgia 30333
The following questions should be asked for every case of viral hepatitis
Prefix: (Mr. Mrs. Miss Ms. etc) ______
Last: ______________________________
Preferred Name (nickname): _________________________________
First: _________________________
Middle: _________________
Maiden: _________________________________________________________
Address: Street: ________________________________________________________________________________________________________________
City: ________________________________________________
Phone: (
) -
Zip Code: ___ ___ ___ ___ ___ -- ___ ___ ___ ___
SSN # (optional) ___ ___ __ - ___ ___ - ___ ___ ___ ___
Only data from lower portion of form will be transmitted to CDC
State: _______________
County: ______________________________________________ Date of Public Health Report__ __ / __ __ / __ __ __ __
Was this record submitted to CDC through the NETSS system?
Yes
No
If yes, please enter NETSS ID NO.
If no, please enter STATE CASE NO.
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8
DEMOGRAPHIC
INFORMATION
RACE (check all that apply):
Amer Indian or Alaska Native
Asian
SEX:
Male
Female
Black or African American
Native Hawaiian or Pacific Islander
Unk
White
Other Race, specify: ___________
PLACE OF BIRTH:
USA
Other:____________
ETHNICITY:
Hispanic ....................
Non-hispanic .............
Other/Unknown .........
__ __
__ Y
__ __
__
AGE: ___ ___ (years)
( 00= <1yr , 99= Unk )
DATE OF BIRTH: __
M __
M/D
D /Y
YY
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8
CLINICAL & DIAGNOSTIC DATA
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REASON FOR TESTING: (Check all that apply)
Symptoms of acute hepatitis
Screening of asymptomatic patient with reported risk factors
Screening of asymptomatic patient with no risk factors (e.g., patient requested )
Prenatal screening
Unknown
CLINICAL DATA:
Diagnosis date:
DIAGNOSTIC TESTS: CHECK ALL THAT APPLY
__ M
__
M
/ __
__ / Y
__ Y
__ Y
__ Y
__
DD
Yes
No
Unk
Is patient symptomatic? ...........................................
if yes, onset date: M
__ M
__ / __
__ / Y
__ Y
__ __
__
DD
YY
Was the patient
Jaundiced? ...............................................................
Hospitalized for hepatitis? ....................................
Was the patient pregnant ? .......................................
due date :
M
__ M
__ / D
__ D
__
LIVER ENZYME LEVELS AT TIME OF DIAGNOSIS
Yes
No
Unk
Total antibody to hepatitis B core antigen [total anti-HBc] .....
IgM antibody to hepatitis B core antigen [IgM anti-HBc] .........
Antibody to hepatitis C virus [anti-HCV] ...................................
anti-HCV signal to cut-off ratio __________
Supplemental anti-HCV assay [e.g., RIBA] ..............................
HCV RNA [e.g., PCR] .....................................................................
Antibody to hepatitis D virus [anti-HDV] ...................................
Antibody to hepatitis E virus [anti-HEV] ...................................
If this case has a diagnosis of hepatitis A that has not been
Upper limit normal_______
serologically confirmed, is there an epidemiologic link between
AST [SGOT] Result ______
Upper limit normal_______
this patient and a laboratory-confirmed hepatitis A case? ............
Date of AST result
Unk
Hepatitis B surface antigen [HBsAg] .............................................
ALT [SGPT] Result ______
Date of ALT result
Neg
IgM antibody to hepatitis A virus [IgM anti-HAV] .....................
Pos
Total antibody to hepatitis A virus [total anti-HAV] ................
Y __
Y __
Y __
Y
/ __
Did the patient die from hepatitis? ..........................
__ M
__ / D
__ D__ / __
__
Date of death: M
Y __
Y __
YY
Evaluation of elevated liver enzymes
Blood / organ donor screening
Follow-up testing for previous marker of viral hepatitis
Other: specify: ____________
M
M / __
D D__ /Y
Y __
Y __
Y
__ __
__ __
M
M / __
D D__ /Y
Y __
Y __
Y
__ __
__ __
DIAGNOSIS: (Check all that apply)
Acute hepatitis A
Acute hepatitis B
Chronic HBV infection
Acute hepatitis C
HCV infection (chronic or resolved)
Acute hepatitis E
Acute non-ABCD hepatitis
Perinatal HBV infection
1
C:\My Documents\Projects\Hepatitis\VHSPW.p65
Hepatitis Delta (co- or super-infection)
DRAFT COPY
Patient History- Acute Hepatitis A
NETSS ID NO.
STATE CASE NO. _________________________________________
During the 2-6 weeks prior to onset of symptomsYes
Was the patient a contact of a person with confirmed or suspected
hepatitis A virus infection? .................................................................................................
If yes, was the contact (check one)
household member (non-sexual) ...................................................................................
a child or employee in a day care center, nursery, or preschool ? ..........................
No
Unk
sex partner ......................................................................................................................
child cared for by this patient .......................................................................................
babysitter of this patient ...............................................................................................
playmate ..........................................................................................................................
other _____________________________________
Was the patient
a household contact of a child or employee in a
day care center, nursery or preschool ? ....................................................................
If yes for either of these, was there an identified hepatitis A case
in the child care facility? ............................................................................................
Please ask both of the following questions regardless of the patients gender.
0 1
2-5
In the 2- 6 weeks before symptom onset how many
male sex partners did the patient have? ....................................................
Unk
female sex partners did the patient have? ................................................
In the 2- 6 weeks before symptom onset
Yes
Did the patient inject drugs not prescribed by a doctor? .............................................
Did the patient use street drugs but not inject? ............................................................
Did the patient travel outside of the U.S.A. or Canada .............................................
If yes, where?
1) _________________ 2) _________________
(Country)
3) _________________
In the 3 months prior to symptom onset
Did anyone in the patients household travel outside of the U.S. A. or Canada?
If yes, where? 1) _________________ 2) _________________
(Country)
3) _________________
Is the patient suspected as being part of a common-source outbreak? ..........................
If yes, was the outbreak
Foodborne- associated with an infected food handler ................................................
Foodborne - NOT associated with an infected food handler ....................................
specify
food item
_____________________________________
Waterborne ......................................................................................................................
Source not identified .......................................................................................................
Was the patient employed as a food handler during the TWO WEEKS
prior to onset of symptoms or while ill? ..............................................................................
VACCINATION HISTORY
Yes
No
Unk
Has the patient ever received the hepatitis A vaccine ?
1
If yes, how many doses? ................................................
In what year was the last dose received? ..................
Y Y
Yes
Y Y
No
Unk
Has the patient ever received immune globulin ? ...........
>5
If yes, when was the last dose received? ...................... ______ / _____
mo
yr
No
Unk
DRAFT COPY
STATE CASE NO. _________________________________________
NETSS ID NO.
Patient History- Acute Hepatitis B
During the
6 weeks- 6 months prior to onset of symptoms
was the patient a contact of a person with confirmed or
suspected acute or chronic hepatitis B virus infection? Yes
Ask both of the following questions regardless of the patients gender.
0 1 2-5 >5 Unk
In the 6 months before symptom onset how many
No
Unk
If yes, type of contact
Sexual .........................................................................
male sex partners did the patient have? ...............
female sex partners did the patient have? ...........
Was the patient EVER treated for a sexually-
Household [Non-sexual] ..........................................
Other: _______________________________
6 weeks- 6 months
prior to onset of symptoms
Yes
Did the patient undergo hemodialysis? ...................................................
have an accidental stick or puncture with a needle
or other object contaminated with blood? ...............
receive blood or blood products [transfusion] ............
if yes, when? M M / D D / Y Y Y Y
No
Unk
have other exposure to someone elses blood ............
specify: ____________________________________
During the 6 weeks- 6 months prior to onset of symptoms
Did the patient have any part of their body pierced
(other than ear)?
where was the piercing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
Yes No Unk
Did the patient have dental work or oral surgery? .............
Did the patient have surgery ? (other than oral surgery) ..
Was the patient- Check all that apply
6 weeks - 6 months prior to onset of symptoms
Was the patient employed in a medical or dental field
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ..........................
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent
Yes
1
incarcerated for longer than 24 hours ? ..........................
incarcerated for longer than 6 months ? ...........................
Did the patient receive a tattoo? ...................................
In what year was the last shot received? ..................
a resident of a long term care facility ? ...........................
During his/her lifetime, was the patient EVER
No
2
If yes,
YY
__Y__
__
what year was the most recent incarceration ? ....................__ Y
where was the tattooing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
hospitalized ? .............................
if yes, what type of facility (check all that apply)
prison ..............................................................
jail ....................................................................
juvenile facility ..............................................
Was the patient employed as a public safety worker
Did the patient ever receive hepatitis B vaccine?
If yes, how many shots? ...........................................
6 weeks- 6 months prior to onset of symptoms
use street drugs but not inject? .......................................
involving direct contact with human blood ? ...............
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent
Unk
inject drugs not prescribed by a doctor? ........................
receive any IV infusions and/or injections in the outpatient setting...
During the
No
YY
If yes, in what year was the most recent treatment ? __
__ Y
__Y
__
During the
During the
Yes
transmitted disease? ...............................................................
for how long ? ..................................................................... __ __ __ mos
Unk
Was the patient tested for antibody to HBsAg
3+ (anti-HBs) within 1-2 months after the last dose? .......
If yes, was the serum anti-HBs 10mIU/ml? ....................
(answer yes if the laboratory result was reported as .....
Y
positive or reactive)
Yes
No
Unk
DRAFT COPY
Perinatal Hepatitis B Virus Infection
NETSS ID NO.
STATE CASE NO. _________________________________________
RACE OF MOTHER:
Amer Ind or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Unknown
Other Race, specify: ______________
Yes
No
Unk
Was Mother born outside of United States? .................................................................
If yes, what country?___________________
Was the Mother confirmed HBsAg positive prior to or at time of delivery ? ...
If no, was the mother confirmed HBsAg positive after delivery? ....................
Date of HBsAg positive test result ....................................................................................
MM/DD/YYYY
How many doses of hepatitis B vaccine did the child receive ? .................................. 0
No
Unk
When?
MM/DD/YYYY
MM/DD/YYYY
Dose 3- M M / D D / Y Y Y Y
Dose 1Dose 2-
Yes
Did the child receive hepatitis B immune globulin (HBIG)? .......................................
If yes, on what date did the child receive HBIG? .................................................
ETHNICITY OF MOTHER:
Hispanic ....................
Non-hispanic .............
Other/Unknown .........
MM/DD/YYYY
DRAFT COPY
NETSS ID NO.
Patient History- Acute Hepatitis C
During the
STATE CASE NO. _________________________________________
2 weeks- 6 months prior to onset of symptoms
Ask both of the following questions regardless of the patients gender.
1
2-5 >5 Unk
In the 6 months before symptom onset how many 0
was the patient a contact of a person with confirmed or
suspected acute or chronic hepatitis C virus infection?
Yes
No
Unk
If yes, type of contact
Sexual .........................................................................
2 weeks- 6 months
prior to onset of symptoms
Yes
inject drugs not prescribed by a doctor? ........................
use street drugs but not inject? .......................................
During the
No
Unk
have other exposure to someone elses blood ............
specify: ____________________________________
Was the patient employed in a medical or dental field
prior to onset of symptoms
Did the patient have dental work or oral surgery? .............
Did the patient have surgery ? (other than oral surgery) ..
Was the patient- Check all that apply
2 weeks - 6 months prior to onset of symptoms
2 weeks- 6 months
Did the patient have any part of their body pierced
(other than ear)?
where was the piercing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
Yes No Unk
involving direct contact with human blood ? ...............
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent
hospitalized ? .............................
a resident of a long term care facility ? ...........................
incarcerated for longer than 24 hours ? ..........................
if yes, what type of facility (check all that apply)
prison ..............................................................
jail ....................................................................
juvenile facility ..............................................
Was the patient employed as a public safety worker
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ..........................
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent
No Unk
Y __
YY
If yes, in what year was the most recent treatment ? __
__ Y
__
During the 2 weeks- 6 months prior to onset of symptoms
receive any IV infusions and/or injections in the outpatient setting...
During the
Yes
transmitted disease? ....................................................................
Did the patient undergo hemodialysis? ...................................................
have an accidental stick or puncture with a needle
or other object contaminated with blood? ...............
receive blood or blood products [transfusion] ............
if yes, when? M M / D D / Y Y Y Y
female sex partners did the patient have? ...........
Was the patient EVER treated for a sexually
Household [Non-sexual] ..........................................
Other: _______________________________
During the
male sex partners did the patient have? ...............
During his/her lifetime, was the patient EVER
incarcerated for longer than 6 months ? ...........................
Did the patient receive a tattoo? ...................................
If yes,
YY
__Y__
__
what year was the most recent incarceration ? ....................__ Y
where was the tattooing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
for how long ? ..................................................................... __ __ __ mos
DRAFT COPY
NETSS ID NO.
Patient History- Hepatitis C Virus Infection (chronic or resolved)
STATE CASE NO. _ ________________________________________
The following questions are provided as a guide for the investigation of lifetime risk factors for HCV infection. Routine collection of risk factor
information for persons who test HCV positive is not required. However, collection of risk factor information for such persons may provide useful
information for the development and evaluation of programs to identify and counsel HCV-infected persons.
Yes
Did the patient receive a blood transfusion prior to 1992? ...................
Did the patient receive an organ transplant prior to 1992? .............................
Did the patient receive clotting factor concentrates produced prior to 1987?
No
Was the patient ever on long-term hemodialysis? ..........................................
Has the patient ever injected drugs not prescribed by a doctor
even if only once or a few times? ............................................................
How many sex partners has the patient had (approximate lifetime) ? _________
Was the patient ever incarcerated? .............................................................
Was the patient ever treated for a sexually transmitted disease? .............
Was the patient ever a contact of a person who had hepatitis ? ..........
If yes, type of contact
Sexual .........................................................................................................
Household [Non-sexual] ............................................................................
Other: ____________________________________
Unk
Yes
No
Was the patient ever employed in a medical or
dental field involving direct contact with human
blood? ....................................................................
Unk
