Human Infection with Novel Influenza A Virus Severe Outc

Human Infection with Novel Influenza A Virus
Severe Outcomes

Form Approved
OMB No. 0920-0004

This form is intended to be used as a supplement to the Novel Influenza A Case Report Form for patients with severe outcomes
(hospitalization or death). Please complete all sections of this form for each patient with a severe outcome in addition to the Novel
Influenza A Case Report Form. Once this form is complete, please submit it as an email attachment to CaseReportForms@cdc.gov
or fax the completed form to 404-471-8119.

I. Reporter Information
State/Territory _____
State/Territory Epi Case ID ________________________
State/Territory Lab ID _______________________
Date form completed: ____/____/_____
CDC Case ID ______________________
Person completing form: First Name:______________ Last Name:_____________ Phone: ____________ Email:___________________
What are the source(s) of data for this
 Medical chart
 Death certificate
 Case report form
 Other________________
report? (check all that apply)

II. Patient Information and Medical Care
1. Patient Date of birth: ____/____/______ (mm/dd/yyyy)
 Yes, date: ____/____/______
2. Did the patient have an outpatient or ER
(if multiple, list most recent)
medical care encounter during this illness?
3. Was the patient admitted to the hospital for this  Yes, date: ____/____/______
Time: ____:____  AM  PM
illness?
4. Was patient hospitalized previously at another facility during this illness?
Admission date: ____/_____/______

Discharge date: ____/_____/______

 No

 Unknown

 No

 Unknown

 Yes

 No

 Unknown

Was discharge from prior hospital a transfer?

 Yes

 No

Please note initial vital signs at hospital admission/ER presentation.
Date taken: ____/____/______ (mm/dd/yyyy)
5. Body Mass
 Inches  Height
 Lbs.
________
6. Height ________
7. Weight: _________
 Weight Unknown
Index:
 Cm
Unknown
 Kg
8. Blood Pressure ____ /_____ 9. Respiratory Rate ______ per min 10. Heart Rate ___________ beats/min Temperature: ______ °C °F
13. Using:  O2 mask  room air  ventilator
11. O2 Sat ______%
12. Fraction of inspired oxygen ______  %  L
Specify O2 mask type:___________________________

III. Illness Signs and Symptoms
Date of initial symptom onset: ____/____/______
14. Please mark all signs and symptoms experienced or listed in the admission note.
 Fever (measured) highest temp. ______ °C °F
Date of fever onset ____/____/______ (mm/dd/yyyy)
 Feverishness (temperature not measured)
 Wheezing
 Altered mental status
 Cough
 Chills
 Red or draining eyes (conjunctivitis)
 With sputum (i.e., productive)
 Headache
 Abdominal pain
 Hemoptysis or bloody sputum
 Excessive crying/fussiness (< 5 years old)
 Vomiting
 Sore throat
 Fatigue/weakness
 Diarrhea
 Runny nose (rhinorrhea)
 Muscle pain/myalgia
 Rash, location _______________________
 Dyspnea/difficulty breathing
Location ________________________  Other_______________________________
 Chest pain
 Seizure
_____________________________________

IV. Patient Medical History
15. Does the patient have any of the following pre-existing medical conditions? Check all that apply.

15a.  Asthma/Reactive Airway Disease

15c.  Chronic Metabolic Disease
 Diabetes
Insulin dependent  Yes  No  Unknown
 Other:___________________________________

15h.  Immunocompromising Condition
 HIV infection
 AIDS or CD4 count < 200
 Stem cell transplant (e.g., bone marrow transplant)
 Organ transplant
 Cancer diagnosis within last 12 months (excluding nonmelanoma skin cancer) Type:_________________________
 Chemotherapy within last 12 months
 Primary immune deficiency
 Chronic steroid therapy (within 2 weeks of admission)
 Other: __________________________________________

15d.  Blood disorders/Hemoglobinopathy

15i.  Renal Disease

15b.  Chronic Lung Disease
 Emphysema/COPD
 Other:___________________________________

Public reporting burden of this collection of information is estimated to average 90 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. 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/ATSDR Information Collection 
Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0004).

Human Infection with Novel Influenza A Virus
Severe Outcomes
 Sickle cell disease
 Splenectomy/Asplenia
 Other:___________________________________

 Chronic kidney disease/chronic renal insufficiency
 End stage renal disease
 Dialysis
 Nephrotic syndrome
 Other:__________________________________________

15e.  Cardiovascular Disease (excluding hypertension)
 Atherosclerotic cardiovascular disease
 Cerebral vascular incident/Stroke
With disability  Yes  No  Unknown
 Congenital heart disease
 Coronary artery disease (CAD)
 Heart failure/Congestive heart failure
 Other:___________________________________

15j.  Other
 Liver disease
 Scoliosis
 Obese or BMI ≥ 30
 Morbidly obese or BMI ≥ 40
 Down syndrome
 Pregnant, gestational age in weeks: _____  Unknown
 Post-partum (≤ 6 weeks)
 Current smoker
 Drug abuse
 Alcohol abuse
 Other:___________________________________________
____________________________________________________
____________________________________________________

15f.  Neuromuscular or Neurologic disorder
 Muscular dystrophy
 Multiple sclerosis
 Mitochondrial disorder
 Myasthenia gravis
 Cerebral palsy
 Dementia
 Severe developmental delay
 Plegias/Paralysis
 Epilepsy/Seizure disorder
 Other:_________________________________
15g.  History of Guillain-Barré Syndrome

PEDIATRIC CASES ONLY (<18 years old)
 Yes
 No
 Unknown
Abnormality of upper airway
 Yes
 No
 Unknown
History of febrile seizures
 Yes
 No
 Unknown
Premature
(gestational age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestation age at birth in weeks: ________
 Unknown gestational age at birth

V. Hematology and Serum Chemistries
16. Were any hematology or serum chemistries performed at hospital
 Yes
 No (skip to Q. 35)  Unknown (skip to Q. 35)
admission/presentation to care?
Please note initial values at admission/presentation to care. Date values were taken: ____/____/______ (mm/dd/yyyy)
17. White blood cell count (WBC)
cells/mm3 19. Hematocrit (Hct)
% 24. Serum creatinine
mg/dL
18. Differential: Neutrophils
% 20. Platelets (Plt)
103/mm3 25. Serum glucose
mg/dL
Bands
% 21. Sodium (Na)
U/L 26. SGPT/ALT
U/L
Lymphocytes
% 21. Potassium (K)
U/L 27. SGOT/AST
U/L
Eosinophils
% 22. Bicarbonate (HCO3)
U/L 28. Total bilirubin
mg/dL
23. Serum albumin
g/dL 29. C-reactive protein (CRP)
mg/dL
Please describe other significant lab findings (e.g., CSF, protein).
Type of test
Specimen type
Date (mm/dd/yyyy)
Result
_____/_____/________
31.
_____/_____/________
32.
_____/_____/________
33.
_____/_____/________
34.

VI. Bacterial Pathogens – Sterile or respiratory site only
 Yes
35. Was a pneumococcal urinary antigen test performed?
 Positive
 Negative
If yes, result:
 Yes
35. Was a Legionella urinary antigen test performed?
 Positive
 Negative
If yes, result:

 No
 Unknown
 Unknown
 No
 Unknown
 Unknown
 Unknown (skip to Q.41)
 No (skip to Q.41)
35. Were any bacterial culture tests performed (regardless of result)?  Yes

Blood

Cerebrospinal
fluid
(CSF)

Bronchoalveolar
lavage (BAL)
36. Indicate sites from which specimens
were collected (check all that apply):
 Sputum
 Pleural fluid
 Endotracheal aspirate  Other:_____________________
 Yes
 No (skip to Q.41)
 Unknown (skip to Q.41)
37. Was there culture confirmation of any bacterial infection?
38b. Specimen type:  Blood  Cerebrospinal fluid (CSF)  Bronchoalveolar lavage (BAL)
38a. Positive Culture 1 collection date:
_____/_____/________ (mm/dd/yyyy)
 Sputum  Pleural fluid  Endotracheal aspirate  Other:__________________________
38c. Pathogen(s) identified:  S. aureus  S. pyogenes  S. pneumoniae  H. influenzae  Other:_____________________________
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
38d. If Staphylococcus aureus, specify:

2

Human Infection with Novel Influenza A Virus
Severe Outcomes
39b. Specimen type:  Blood  Cerebrospinal fluid (CSF)  Bronchoalveolar lavage (BAL)
 Sputum  Pleural fluid  Endotracheal aspirate  Other:__________________________
39c. Pathogen(s) identified:  S. aureus  S. pyogenes  S. pneumoniae  H. influenzae  Other:_____________________________
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
39d. If Staphylococcus aureus, specify:
40b. Specimen type:  Blood  Cerebrospinal fluid (CSF)  Bronchoalveolar lavage (BAL)
40a. Positive Culture 3 collection date:
_____/_____/________ (mm/dd/yyyy)
 Sputum  Pleural fluid  Endotracheal aspirate  Other:__________________________
40c. Pathogen(s) identified:  S. aureus  S. pyogenes  S. pneumoniae  H. influenzae Other:_______________________________
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
40d. If Staphylococcus aureus, specify:
39a. Positive Culture 2 collection date:
_____/_____/________ (mm/dd/yyyy)

VII. Respiratory Viral Pathogens
 No (skip to Q.42)
 Unknown (skip to Q.42)
41. Was the patient tested for any other viral pathogens?  Yes
Positive Negative Not Tested/Unknown
Collection Date
Specimen Type
a. Respiratory syncytial virus/RSV
____/____/______
___________________________



b. Adenovirus
____/____/______
___________________________



c. Parainfluenza 1
____/____/______
___________________________



d. Parainfluenza 2
____/____/______
___________________________



e. Parainfluenza 3
____/____/______
___________________________



f. Human metapneumovirus
____/____/______
___________________________



g. Rhinovirus
____/____/______
___________________________



h. Coronavirus
____/____/______
___________________________



i. Other, specify: ________________
____/____/______
___________________________



j. Other, specify: ________________
____/____/______
___________________________




VIII. Medications
42. Did the patient receive influenza antiviral medications during illness?
 Yes
 No
 Unknown
Date started
Date stopped
Frequency
Dose
Oseltamivir (Tamiflu)
 PO  IV  Inhaled ____/____/_______ ____/____/_______  QD  BID  TID
Zanamivir (Relenza)
 PO  IV  Inhaled ____/____/_______ ____/____/_______  QD  BID  TID
Peramivir
 PO  IV  Inhaled ____/____/_______ ____/____/_______  QD  BID  TID
Other influenza antiviral:___________  PO  IV  Inhaled ____/____/_______ ____/____/_______  QD  BID  TID
Other influenza antiviral:___________  PO  IV  Inhaled ____/____/_______ ____/____/_______  QD  BID  TID
43. Did the patient receive antibiotics during the illness?
 Yes
 No
 Unknown
If yes, name
Date started
Date stopped
Dose
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
44. Did the patient receive steroids (excluding inhaled steroids or one time injections) or other
 Yes
 No
 Unknown
immune modulating treatment specifically for this illness?
If yes, name
Date started
Date stopped
Dose
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
____/____/_______
____/____/_______
 PO  IV  IM
45. Additional treatment comments:

IX. Chest Radiograph – Based on final impression/conclusion of the radiology report
Please include a copy of the radiology report with the form.
46. Did the patient have a chest x-ray within 3 days of
 Yes, date ____/____/_______  No (skip to Q.52)
admission?
 Yes, date ____/____/_______  No (skip to Q.52)
47. If yes, was the chest x-ray abnormal?
48. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Final impression/conclusion:

3

 Unknown (skip to Q.52)
 Unknown (skip to Q.52)

Human Infection with Novel Influenza A Virus
Severe Outcomes

 Single lobar infiltrate
 Multi-lobar infiltrate (unilateral)
 Multi-lobar infiltrate (bilateral)
 Lobar or segmental collapse
 Cavitation/Abscess/Necrosis
 Round pneumonia
 Alveolar (air space) disease
 Interstitial disease
 Mixed (airspace and interstitial) disease
 Other Infiltrate: 
 Unilateral
 Bilateral
 Pleural Effusion: 
 Complicated
 Uncomplicated
 Bronchiolitis: 
 Air leak/Pneumothorax
 Lymphadenopathy
 Chest wall invasion
 Other: 
 Specify:________________
49. Did the patient have another chest x-ray within 3
 Yes, date ____/____/_______  No (skip to Q.52)  Unknown (skip to Q.52)
days of admission?
 Yes, date ____/____/_______  No (skip to Q.52)  Unknown (skip to Q.52)
50. If yes, was the chest x-ray abnormal?
51. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
 Consolidation: 

Final impression/conclusion:

 Consolidation: 
 Other Infiltrate: 
 Pleural Effusion: 
 Bronchiolitis: 
 Other: 

 Single lobar infiltrate
 Lobar or segmental collapse
 Alveolar (air space) disease
 Unilateral
 Complicated
 Air leak/Pneumothorax
 Specify:________________

 Multi-lobar infiltrate (unilateral)
 Cavitation/Abscess/Necrosis
 Interstitial disease
 Bilateral
 Uncomplicated
 Lymphadenopathy

 Multi-lobar infiltrate (bilateral)
 Round pneumonia
 Mixed (airspace and interstitial) disease

 Chest wall invasion

X. Chest CT or MRI – Based on final impression/conclusion of the radiology report
please include a copy of the radiology report with the form.
52. Did the patient have a chest CT/MRI scan within
 Yes, date ____/____/_______
 No (skip to Q.56)  Unknown (skip to Q.56)
3 days of admission?
 CT: contrast
 CT: non-contrast
 MRI
52. If yes, please select one:
 Yes, date ____/____/_______
 No (skip to Q.56)  Unknown (skip to Q.56)
54. If yes, was the CT/MRI abnormal?
55. For abnormal chest CT/ MRI, please check all that apply and please transcribe the final impression/conclusion:
Final impression/conclusion:

 Consolidation: 
 Other Infiltrate: 
 Pleural Effusion: 
 Bronchiolitis: 
 Other: 

 Single lobar infiltrate
 Lobar or segmental collapse
 Alveolar (air space) disease
 Unilateral
 Complicated
 Air leak/Pneumothorax
 Specify:________________

 Multi-lobar infiltrate (unilateral)
 Cavitation/Abscess/Necrosis
 Interstitial disease
 Bilateral
 Uncomplicated
 Lymphadenopathy

 Multi-lobar infiltrate (bilateral)
 Round pneumonia
 Mixed (airspace and interstitial) disease

 Chest wall invasion

XI. Clinical Course and Severity of Illness
56. At any time during the current illness, did the patient require or have the diagnosis of :
 Yes
 No
 Unknown
a. Admission to intensive care unit (ICU)
Admission date:
____/____/_______
Discharge date:
____/____/_______
If multiple admissions, 2nd ICU admission date:
____/____/_______ 2nd ICU discharge date:
____/____/_______
If more than 2 ICU admissions, please provide dates in the comments section (Q.66)
 Yes
 No
 Unknown
b. Supplemental oxygen
Date started: ____/____/_______
Date stopped ____/____/_______
 Yes
 No
 Unknown
c. Ventilatory support

4

Human Infection with Novel Influenza A Virus
Severe Outcomes
Check all that apply:

 Intubation
 ECMO
 CPAP
 BiPAP

Date started:
Date started:
Date started:
Date started:

____/____/______
____/____/______
____/____/______
____/____/______

d. Vasopressor medications (e.g. dopamine, epinephrine)
Date started: ____/____/_______
e. Dialysis (Acute)
Date started: ____/____/_______
 Yes, date started:___/___/_____
f. Resuscitation, CPR
 Yes, date started:___/___/_____
g. Acute respiratory distress syndrome (ARDS)
 Yes, date started:___/___/_____
h. Disseminated intravascular coagulopathy (DIC)
 Yes, date started:___/___/_____
i. Hemophagocytic syndrome
 Yes, date started:___/___/_____
j. Bronchiolitis
 Yes, date started:___/___/_____
k. Pneumonia
 Yes, date started:___/___/_____
l. Stroke (Acute)
 Yes, date started:___/___/_____
m. Sepsis
 Yes, date started:___/___/_____
n. Shock
Type:  hypovolemic
 cardiogenic
 septic
 toxic
 Yes, date started:___/___/_____
o. Acute myocarditis
 Yes, date started:___/___/_____
p. Acute myocardial dysfunction
 Yes, date started:___/___/_____
q. Acute myocardial infarction
 Yes, date started:___/___/_____
r. Seizures
 Yes, date started:___/___/_____
s. Reye’s syndrome
 Yes, date started:___/___/_____
t. Acute encephalitis / encephalopathy
 Yes, date started:___/___/_____
u. Guillain-Barre syndrome
 Yes, date started:___/___/_____
v. Rhabdomyolysis
 Yes, date started:___/___/_____
w. Acute liver impairment
 Yes, date started:___/___/_____
x. Acute renal failure
y. Other, specify: ____________________________  Yes, date started:___/___/_____
z. Other, specify: ____________________________  Yes, date started:___/___/_____

Date stopped:
Date stopped:
Date stopped:
Date stopped:

____/____/_______
____/____/_______
____/____/_______
____/____/_______

 Yes
 No
 Unknown
Date stopped ____/____/_______
 Yes
 No
 Unknown
Date stopped ____/____/_______
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____  No
 Unknown
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____
stopped: ___/___/_____

 No
 No
 No
 No
 No
 No
 No
 No
 No
 No

 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown

XII. Outcomes
 Yes, date ____/____/_______
 No (skip to Q.62)
 Unknown (skip to Q.62)
57. Did the patient die during this illness?
 Home
 Hospital  ER
 Hospice
 Other, specify__________________________
58. What was the location of death?
 Yes
 No
 Unknown
59. Did the patient have a DNR (do not resuscitate) order?
 Yes (please attach a copy of the autopsy form to this report if available)
 No
 Unknown
60. Was an autopsy performed?
61. What were the causes of death (immediate and underlying) in order of appearance on the death certificate or medical record?
1.

4.

7.

2.

5.

8.

3.

6.

9.

 Yes, date ____/_____/______  No
 Unknown
62. Has the patient been discharged from the hospital?
 Home
 Other hospital
 Hospice
 Rehabilitation Facility
63. If yes, please indicate to where:
 Other long-term care facility
 Other, specify: ______________________
 Hospitalized on ward
 Hospitalized in ICU  Died
63. If no, please indicate status:
64. If patient was pregnant, please indicate pregnancy status at discharge or final update:
 Still
 Uncomplicated labor/delivery  Complicated labor/delivery
pregnant
Describe ______________________________________________
64. If pregnancy resulted in delivery, please indicate neonatal outcome: Birth date: ____/_____/______
 Healthy newborn

 Ill newborn, describe: _______________________________

XIII. Additional Comments
66. Additional Comments:

5

 Fetal loss
Date ____/____/_____

 Newborn died: Date ____/____/______

65. Additional notes regarding discharge:

 Unknown

 Unknown

Human Infection with Novel Influenza A Virus
Severe Outcomes

6