Antiviral-Resistant Influenza Infection Case Report

Antiviral-Resistant Influenza Infection Case Report Form
Form Approved
OMB No. 0920-0004
FAX COMPLETED FORM TO: 404-639-3866

CDC ID (CDC use only): _______________

I. Specimen Information
State Lab Specimen ID
Specimen Collection State
Patient County of residence
Patient State of residence
Oseltamivir resistance
Zanamivir resistance

_______________
_______________
_______________
_______________
 Yes  No  Unk
 Yes  No  Unk

Reason for Antiviral Resistance Test:
 Requested for Clinical Indication
 Surveillance
 Other _________________
Date of Specimen Collection:
__ __/ __ __/ __ __ __ __

Influenza type/subtype:
 Influenza A
 H1N1
 H3N2
 Influenza B
 Unknown

II. Basic Information If information is from patient interview please READ:: I’m going to ask you for some information about yourself
(your child) and your (the child’s) illness. To help you remember, I am going to tell you the date that your nose/ throat swab was taken
to test for flu (use specimen collection date in section I). Please feel free to look at a calendar to help you remember dates. I can wait
until you find one.
Age: __ __  yrs  months
Sex:  Male  Female
Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino
 Unknown

Race:
 American Indian/ Alaska Native
 Asian or Pacific Islander
 Black or African American
 White
 Other __________
 Unknown

Illness History:
Date of illness onset:
__ __/ __ __/ __ __ __ __
Hospitalized for illness?
Yes
No
Unknown

Patient Outcome:
 At Home
 At Extended Care Facility
 Currently Hospitalized
 Dead (Was it influenzarelated?
Yes  No 
Unknown)
 Unknown

III. Pre-existing Medical Conditions
Did a doctor ever tell you that you (your child) had any of
the following conditions? (Check all that apply)
 No underlying conditions
 Diabetes Mellitus
 Chronic kidney disease
 Asthma
 Chronic lung disease (non-asthma), specify_______
 Neurologic/neuromuscular disease

 Immunosuppressive condition (complete section below)
 Chronic Heart Disease, specify: ___________________
 Chronic Liver Disease, specify: ___________________
 Morbid obesity: Height _______ Weight _______
 Other Condition, specify: ___________________
If female aged >16 years, were you pregnant at time of specimen
collection:  Yes  No  Unknown Trimester ______

Immunosuppression Details (check all that apply)

Specify type(s)

 Solid Tumor
Malignancy:

 Hematologic
Malignancy:

 Receipt of Stem
Cell Transplant

 Receipt of Solid
Organ Transplant

 Autoimmune
Disorder











 Other condition (Lupus, Rheumatoid Arthritis, Crohns, etc) Specify Type (s):

 HIV/AIDS

IV. Hospitalized Patient Information (skip to section V if patients is not hospitalized)
Date of hospital admission: __ __/ __ __/ __ __ __ __
Date of hospital discharge: __ __/ __ __/ __ __ __ __
Reason for Hospital Admission:  Respiratory Illness

Where was the patient discharged to?
 Other hospital  Home  Hospice  Rehabilitation facility
 Long term care facility  Other
 Other, specify:

During hospitalization, was patient in Intensive Care Unit?  Yes  No  Unknown

Public reporting burden of this collection of information is estimated to average 30 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).

V. Influenza Antiviral Medication History
Received influenza antiviral medications including oseltamivir (Tamiflu®) or zanamivir (Relenza®)?
 Yes  No (skip to section VI)  Unknown (skip to section VI)
If yes, Please check all below that apply:
 Oseltamivir (Tamiflu)
Dose:
 75mg  Other _______ Frequency:  QD  BID  Other _____
Location:
 Outpatient  Inpatient Start Date: __ __/ __ __/ __ __ __ __

 Zanamivir (Relenza)
Dose:
 10mg
 Other _______
Indication:  Treatment  Prevention
Start Date: __ __/ __ __/ __ __ __ __

Route:  Inhaled  IV (experimental)
Location:
 Outpatient  Inpatient
End Date: __ __/ __ __/ __ __ __ __

 Additional/other Agent
Name:
_______________________
Dose:
_______________________
Indication:  Treatment  Prevention
Start Date: __ __/ __ __/ __ __ __ __

Route:
Location:
End Date:

Indication:
End Date:

 Treatment  Prevention
__ __/ __ __/ __ __ __ __

Frequency:  QD  BID  Other _____

 Oral  IV  Inhaled
 Outpatient  Inpatient
__ __/ __ __/ __ __ __ __

Frequency:  BID

 Other _______

 Yes  No  Unknown

Patient finished all of the pills (or suspension)?

Information on antiviral treatment is from (check all that apply)
 inpatient medical record  outpatient medical record  dispensing pharmacy  self-report
Comments about antiviral therapy: (e.g. other courses of antiviral treatment, reasons for poor compliance, etc.)
VI. Influenza Vaccine History
Did you (your child) receive the influenza vaccine this year?

 Yes  No  Unknown

VII. Clinical Illness [Read to patient: I am going to ask you some questions about your (your child’s) illness. Please feel free to look at
the calendar to help you remember.]
1. Did you (your child) have a fever or feel feverish when you (he/she) had flu?
 Yes
 No (skip to Q2)
 DK (skip to Q2)
1a. How many days did you (your child) have fever?
______ day(s)
1b. Did you take your (your child’s) temperature?
 Yes
 No (skip to Q2)  DK (skip to Q2)
1c. What was the highest temperature that you recorded? __________
6. On what date did you first seek medical care for the flu illness? __ __ / __ __ / __ __ __ __
VIII. Transmission History [Read to patient: I’m going to ask some questions about others in your home who may have been ill and
travel.]
 Single Family House (1 housing unit in building)
 Multi-Family Housing ( > 1 unit in building)
 Facility (hospital, long term care, nursing home, jail, etc)

1.

At the time you (your child) became ill, where did you reside?
 University Dorm or boarding school
 Other, specify: _____________________________

2.

During the week before illness, did anyone else in the household have flu or a respiratory illness?
If Yes, Did anyone else other than you in the household get a diagnosis of flu?

 Yes  No  Unknown
If yes, how many? ________
 Yes  No  Unknown
If yes, how many? ________

 Yes (  for treatment  for prevention)
 No  Unknown
 Tamiflu Relenza Unknown Other specify______

3.

During the week before illness, did anyone else in the
household receive any antiviral medications?
If yes, What was the name of the antiviral agent?

4.

Did you travel outside of your typical residence area during the 7 days prior to illness?

 Yes

 No

 Unknown

If yes, Where did you travel to? Country__________ state______ city/town_____________
Dates of travel? __ __/ __ __/ __ __ __ __ to __ __/ __ __/__ __ __ __
If the patient is a child, university student or living in a facility (e.g. LTCF), ask the following questions, if not, skip to the next
section.
5. Were others at your (your child’s) school/residency also sick at the same time as your (the child’s) flu illness?

 Yes

 No

 DK

If yes, where do you (your child) go to school/ reside?

________________________________

IX. Additional Comments

Sender Information
First Name:
Institution Name:

Last Name:

Date of Survey Completion: __ __/ __ __/ __ __ __ __
Email Address:

Telephone Number: