Please Return the Questionnaire by Fax 020 8327 7404 FOA Sarah Collins (Tel: 0208 327 7261)

CONFIDENTIAL

Last updated 14 July 2014Page 1 of 2

Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)

Responsible Centre:

Immunisation, Hepatitis, and Blood Safety Department

Centre for Infectious Disease Surveillance and Control

Public Health England

61 Colindale Avenue, London, NW9 5EQ

Telephone: 020 8327 7621Fax: 020 8327 7404

Reference Laboratory Number:

Date of Birth: __/__/__ Patient’s residence postcode:

Was the case notified?Yes ☐ No ☐ nk☐Date of statutory notification:__/__/__

Did the patient have any symptoms?Yes ☐ No ☐ nk☐

If yes, date of onset of first symptoms:__/__/__

Yes No nk Yes No nk

Sore throat☐ ☐ ☐ Fever ☐ ☐ ☐

Membrane☐ ☐ ☐ Swollen lymph nodes ☐ ☐ ☐

Stridor☐ ☐ ☐ Skin lesion(s) ☐ ☐ ☐

Other symptoms☐ ☐ ☐ If yes, please specify ......

Underlying immunosuppression☐ ☐ ☐ If yes, please specify

Other underlying conditions☐ ☐ ☐ If yes, please specify

Systemic complications☐ ☐ ☐

If yes, please specify: Mycocarditis☐ Motor paralysis☐ Renal insufficiency☐ Circulatory collapse☐

Other systemic complication☐please specify

Outcome:Died☐ Survived☐ not known☐ Duration of illness: days

Has the patient ever been immunised?Yes ☐ No ☐ nk☐

If yes, were they the usual childhood immunisations?Yes ☐ No ☐ nk☐

Has the patient ever had an adult diphtheria booster?Yes ☐ No ☐ nk☐Year

Did the patient travel outside the UK recently (ie. within the last 3 months)?Yes ☐ No ☐ nk☐

If yes, please specify the country(ies) visitied

Date of return to the UK: ORno of weeks between return and onset

Has the patient had close contact with individual(s)who have recently returned/arrived in the UK? Yes ☐ No ☐ nk☐

If yes, please specify the country(ies)

Type of contact with the patient:Household ☐non household ☐

Other Relevant Information

Has the patient a history ofYes No nk Yes No nk

Drinking raw milk☐☐☐Eating raw milk products ☐ ☐ ☐

Contact with cattle☐☐☐Other rural contact ☐ ☐ ☐

Contact with domestic pets☐☐☐

If yes to any of the above, please give details

Management of Case

Did the patient receive antibiotics?Yes ☐ No ☐ nk☐

Antibiotic (chronological order) / Duration (days) / Response (Yes/No)

Did the patient receive a booster doseof diphtheria vaccine?Yes ☐ No ☐ nk☐

Did the patient receive diphtheria antitoxin?Yes ☐ No ☐ nk☐I

f yes, please specify the dose IU Date:

Was pre-booster or pre-antitoxin serum collected? Yes ☐ No ☐ nk☐

If yes, please send a specimen to CPHL Respiratory & Systemic Infections Laboratory (RSIL), Colindale

Management of Contacts

How many household contacts were there?

Were there any other types of close contact apart from household?Yes ☐ No ☐ nk☐

If yes, please describe

Were swabs taken from the close contacts?All☐ Some☐ None☐ nk☐

If yes, tick which site(s) were swabbed: Nose ☐ Throat ☐ Other☐please specify

Were any swabs positive for C. ulcerans?Yes ☐ No ☐ nk☐

If yes, please state how many persons were positive forC. ulcerans?

Was chemoprophylaxis recommended for close contacts? All ☐Some ☐None ☐NK ☐

If yes, what was recommended? Erythromycin☐ IM Penicillin ☐ Other ☐

If other, please specify

Were close contacts offered diphtheria vaccine? All☐ Some☐ None☐ nk☐

Were close contacts under clinical surveillance? All☐ Some☐ None☐ nk☐

Have clearance swabs been taken? All☐ Some☐ None☐ nk☐

If yes, please give results

Were swabs taken from animal contacts? Yes ☐ No ☐ nk☐

If yes, please specify animal type(s)

If yes, tick which site(s) were swabbed:Nose ☐ Throat ☐ Other☐please specify

Were any animal swabs positive for C. ulcerans? Yes ☐ No ☐ nk☐

If yes, please state which animal(s) was positive forC. ulcerans?

Was chemoprophylaxis recommended for animal contacts?All☐ Some☐ None☐ nk☐

If yes, what was recommended?Spiramycin☐Enrofloxacin☐Other☐

If other, please specify

Last updated 14 July 2014Page 1 of 2 Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)