Zika Virus Testing and Report Form - Los Angeles County, California

The California Department of Public Health has released this version of the "Zika Virus Testing and Report Form" on June 23, 2016.

This form may be used by all California residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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ZIKA VIRUS TESTING AND REPORT FORM
FAILURE TO COMPLETE REQUIRED FIELDS WILL RESULT IN
SPECIMEN REJECTION OR DELAYED TESTING
Acute Communicable Disease Control
313 N. Figueroa St., Rm. 212
Los Angeles, CA 90012
213-240-7941 (phone), 213-482-4856 (fax)
publichealth.lacounty.gov/acd/
Date of Request
REQUIRED SUBMITTER INFORMATION
Requesting Physician Name (Last, First)
Facility/Submitter Name and Address
Requesting Physician Pager or Phone No.
Facility Fax Number
Facility Phone Number
Contact Person for Specimen(s)
Requesting Physician Email
Contact Person Phone
REQUIRED EPIDEMIOLOGICAL INFORMATION
The patient:
1. Resides in
Los Angeles County
?
Yes
No
If No, Call appropriate HEALTH DEPARTMENT.
(click hyperlink to lookup address)
2. Has a history of travel to a
Zika affected country
?
Yes
No
(click hyperlink for list)
If Yes, Country? ___________________________
Dates of travel: From ____________ to ____________
3. Is what gender?
Male
Female
Other: ______
If Female, Pregnant?
Yes
No
If Yes, Estimated date of delivery: _______________
Ultrasound screening evidence of microcephaly &/or calcifications in a fetus?
Yes
No
Not done
Did the pregnant woman have unprotected sex with a male traveler who had symptoms w/in 14 days of his return?
Yes
No
If Yes, Male Partner Name _____________________________
Complete another testing form for symptomatic male.
4. Has any of the following symptoms?
Yes
No
If Yes, Specify symptoms and Onset Date: _________________
Acute onset of fever (measured or reported)
Maculopapular rash
Arthralgia
Conjunctivitis
5. Is a postpartum mother who has an infant with evidence of microcephaly?
Yes
No Delivery date: _____________
6. Has a Guillain-Barré Syndrome diagnosis?
Yes
No
If Yes, Specify Onset Date: ____________
REQUIRED ELIGIBILITY SCREEN FOR TESTING
Using the Epidemiological Information section above, check  which category the travelers fits in:
Symptomatic Pregnant Traveler
Onset of symptoms within 14 days of return OR
Onset during travel
Asymptomatic Pregnant Traveler - Within 12 weeks after return from travel
Pregnant Traveler – regardless of symptoms
Ultrasound screening evidence of microcephaly and/or calcifications in a fetus
OR
Fetal loss
Infant of a Recently Pregnant Traveler - Evidence of microcephaly in an infant
Provide Mother’s Name ________________________________ and Mother’s Date of Birth ____________________
Infant with no apparent defect AND the mother has laboratory evidence of Zika virus infection (See instructions.)
Symptomatic pregnant woman with NO travel history AND had unprotected sex with a symptomatic male traveler
Symptomatic Non-Pregnant Traveler (Male or Female) - Onset of symptoms within 14 days of return
Traveler with a Guillain-Barré Syndrome diagnosis
Patient does not fit into any of the above categories.
Contact Acute Communicable Disease Control at 213-240-7941 for consultation.
Patient Name (Last, First, Middle Initial)
Date of Birth
(mm/dd/yyyy)
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
Page 1 of 6
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
ZIKA VIRUS TESTING AND REPORT FORM
FAILURE TO COMPLETE REQUIRED FIELDS WILL RESULT IN
SPECIMEN REJECTION OR DELAYED TESTING
Acute Communicable Disease Control
313 N. Figueroa St., Rm. 212
Los Angeles, CA 90012
213-240-7941 (phone), 213-482-4856 (fax)
publichealth.lacounty.gov/acd/
Date of Request
REQUIRED SUBMITTER INFORMATION
Requesting Physician Name (Last, First)
Facility/Submitter Name and Address
Requesting Physician Pager or Phone No.
Facility Fax Number
Facility Phone Number
Contact Person for Specimen(s)
Requesting Physician Email
Contact Person Phone
REQUIRED EPIDEMIOLOGICAL INFORMATION
The patient:
1. Resides in
Los Angeles County
?
Yes
No
If No, Call appropriate HEALTH DEPARTMENT.
(click hyperlink to lookup address)
2. Has a history of travel to a
Zika affected country
?
Yes
No
(click hyperlink for list)
If Yes, Country? ___________________________
Dates of travel: From ____________ to ____________
3. Is what gender?
Male
Female
Other: ______
If Female, Pregnant?
Yes
No
If Yes, Estimated date of delivery: _______________
Ultrasound screening evidence of microcephaly &/or calcifications in a fetus?
Yes
No
Not done
Did the pregnant woman have unprotected sex with a male traveler who had symptoms w/in 14 days of his return?
Yes
No
If Yes, Male Partner Name _____________________________
Complete another testing form for symptomatic male.
4. Has any of the following symptoms?
Yes
No
If Yes, Specify symptoms and Onset Date: _________________
Acute onset of fever (measured or reported)
Maculopapular rash
Arthralgia
Conjunctivitis
5. Is a postpartum mother who has an infant with evidence of microcephaly?
Yes
No Delivery date: _____________
6. Has a Guillain-Barré Syndrome diagnosis?
Yes
No
If Yes, Specify Onset Date: ____________
REQUIRED ELIGIBILITY SCREEN FOR TESTING
Using the Epidemiological Information section above, check  which category the travelers fits in:
Symptomatic Pregnant Traveler
Onset of symptoms within 14 days of return OR
Onset during travel
Asymptomatic Pregnant Traveler - Within 12 weeks after return from travel
Pregnant Traveler – regardless of symptoms
Ultrasound screening evidence of microcephaly and/or calcifications in a fetus
OR
Fetal loss
Infant of a Recently Pregnant Traveler - Evidence of microcephaly in an infant
Provide Mother’s Name ________________________________ and Mother’s Date of Birth ____________________
Infant with no apparent defect AND the mother has laboratory evidence of Zika virus infection (See instructions.)
Symptomatic pregnant woman with NO travel history AND had unprotected sex with a symptomatic male traveler
Symptomatic Non-Pregnant Traveler (Male or Female) - Onset of symptoms within 14 days of return
Traveler with a Guillain-Barré Syndrome diagnosis
Patient does not fit into any of the above categories.
Contact Acute Communicable Disease Control at 213-240-7941 for consultation.
Patient Name (Last, First, Middle Initial)
Date of Birth
(mm/dd/yyyy)
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
Page 1 of 6
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
PUBLIC HEALTH LAB
COUNTY OF LOS ANGELES
USE ONLY
DEPARTMENT OF PUBLIC HEALTH
PUBLIC HEALTH LABORATORIES
12750 Erickson Avenue
California Certified Public Health Laboratory #335637
CLIA #05D1066369
Downey, CA 90242
Phone 562-658-1330/1300
Fax 562-401-5999
FAX 62 401 4999
ZIKA TEST REQUISITION
THIS PART OF THE FORM MUST BE ACCOMPANIED BY PAGE 1
A SEPARATE TEST REQUEST MUST BE COMPLETED FOR EACH SPECIMEN TYPE
ALL FIELDS ON THIS PART OF THE FORM MUST BE COMPLETED
FAILURE TO COMPLETE ALL FIELDS WILL RESULT IN SPECIMEN REJECTION OR DELAY
REQUIRED PATIENT INFORMATION
Patient Name (Last, First, Middle Initial)
Date of Birth
Sex
(mm/dd/yyyy)
Male
Female
Other
Patient Address- Number, Street, Apt #
City
State
ZIP Code
Patient Home Telephone Number
Patient Work Telephone Number
Patient Cell Number
MRN/Patient ID
Requesting Physician (Last, First)
Previous Vaccination?
Tick-borne Encephalitis
Yellow Fever
Japanese Equine Encephalitis
Previous Testing? Chikungunya
Pos
Neg
Pending
Not done
Dengue
Pos
Neg
Pending
Not done
REQUIRED – Test(s) Requested
REQUIRED - Specimen Source
Each specimen type requires a
separate test request form
Arbovirus serology panel (serum, cord blood, or CSF)
Serum
Includes Zika, Chikungunya, and Dengue
Urine
Cord Blood
Arbovirus RT-PCR (serum, cord blood, urine, body fluids, and fresh/frozen/fixed tissue)
Amniotic Fluid
Includes Zika, Chikungunya, and Dengue
Fetal tissue
(specify type): ______________________
Immunohistochemistry (fixed tissue or paraffin block)
Placenta
CSF (if collected for other purposes)
Histopathology (fixed tissue or paraffin block)
REQUIRED
Date specimen collected: _____________
Time: _____________
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
Page 2 of 6
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
INSTRUCTION FOR ZIKA TEST REQUESTS
Guidance Date: June 23, 2016
Recommendations may be frequently updated. Ensure that you check DPH website frequently for updated
guidance and instructions.
1. If a provider suspects a case of Zika virus and requires testing, the provider should obtain relevant patient
clinical history including previous Dengue/Chikungunya/West Nile Virus, patient travel history, Japanese
encephalitis virus/Yellow Fever/Tickborne Encephalitis vaccination history, and results of other relevant
diagnostic tests if performed (ex. ultrasound imaging, TORCH serology panel, West Nile virus serology,
Dengue serology, Chikungunya serology, etc.).
For an updated list of countries with Zika virus infection, visit the following websites:
http://www.cdc.gov/zika/geo/active-countries.html
2. Appropriate samples types and available tests are described in the tables below. In general, suspect acute
Zika patients, should receive both serology and PCR testing. If <7 days from onset of symptoms, submit
both urine and serum specimens. Asymptomatic patients with suspect Zika exposure should receive
serology testing. Note, requests for serology and PCR requires separate specimens.
3. Provider downloads and completes the ”Zika Virus Testing and Report” form from the Los Angeles County
Department of Public Health website. Separate testing forms (both pages 1 and 2) must accompany each
specimen type. See http://publichealth.lacounty.gov/acd/Diseases/EpiForms/ZikaInfoTestReq.pdf.
4. The ”Required Information for Zika Virus Testing” form indicates required information and must contain the
following:
(1) Facility/Submitter name, address, phone, and fax
(2) Requesting provider name (Last, First) and contact information to enable reporting of results.
(3) Patient name or unique patient identifier
(4) Patient sex
(5) Patient date of birth
(6) Test(s) to be performed
(7) Specimen source
(8) Date and time of specimen collection
5. Provider collects samples and sends to the Los Angeles County Public Health Laboratories.
If provider or patient is unable to obtain phlebotomy services, contact the Los Angeles Acute
Communicable Disease Control Program for assistance, approval, and referral to a Los Angeles County
Public Health Clinic.
6. Specimens must be labeled with the following information:
Patient name (Last, First)
Date of Birth
Collection Date and Collection Time
Samples must be sent to the Los Angeles County Public Health Laboratories as soon as possible and within
24 hours of collection. Each specimen type must come with its own test request form and packaged using
individual biohazard specimen transport bags. Leaking specimens will be rejected. Specimen transport
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
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CONFIDENTIAL – This material is subject to the Official Information Privilege Act
conditions must be followed or sample will be rejected. Proper storage and transport conditions preserve
analyte integrity within the sample. Samples submitted with incomplete intake information, incomplete
patient history, incomplete or discrepant patient sample identifiers and labelling information, or incomplete
test request form will not be tested.
7. For consultation regarding appropriate testing, provider should contact the Los Angeles County
Department of Public Health Acute Communicable Disease Control (ACDC). ACDC can be contacted by
calling 213-240-7941 during business hours. After hours, weekends, or holidays contact the County
Operator (option 8) and ask for the Public Health Physician on call at 213-974-1234.
8. For questions regarding specimen collection or laboratory interpretation, provider should contact the Los
Angeles County Public Health Laboratories. The laboratory can be contacted at 562-658-1330 during
business hours. After hours, weekends, or holidays contact the County Operator (option 8) and ask for the
Public Health Laboratories Director at 213-974-1234.
9. Laboratory samples should be sent to:
Los Angeles County Public Health Laboratories
12750 Erickson Avenue
Downey, CA 90242
Phone 562-658-1330
Fax 562-401-5999
At this time, laboratory samples for Zika testing should not be sent directly to the California State
Department of Public Health or Centers for Disease Control.
If provider does not have access to courier services, the Public Health Laboratories will assist to arrange
for sample pick up. Courier arrangements are made by calling Public Health Laboratories Central
Accessioning Unit at 562-658-1460.
10. Provider may be required to complete additional forms for receiving results by fax if not currently a client of
the Los Angeles County Public Health Laboratories. Note, convalescent serum or an additional serum
sample may be requested depending on laboratory results.
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
Page 4 of 6
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
ZIKA TESTING AND NOTIFICATION
2
IgM
RT-PCR
Call to Notify
1-
serology
(serum,
Public Health
Indications for Zika testing
(serum,
urine, or
of these
CSF)
other
special cases
sample
213-240-7941
types)
Pregnancy-associated
Symptomatic pregnant traveler (At least one of the
YES
YES
NO
following: acute onset of fever [measured or reported],
maculopapular rash, arthralgia, conjunctivitis)
3
Asymptomatic pregnant traveler
YES
NO
NO
Pregnant traveler with ultrasound evidence of fetal
YES
YES
YES
rd
microcephaly (occipitofrontal circumference <3
4
percentile for age and gender) and/or calcifications
5
OR fetal loss
7
Infant with microcephaly and/or calcifications and
YES
YES
YES
evidence of maternal Zika virus infection
6
Infant with no apparent defect and evidence of
YES
YES
YES
6
maternal Zika virus infection
Symptomatic pregnant woman without travel history
YES
YES
YES
who had unprotected sex with a symptomatic male
traveler from Zika affected area
In Non–Pregnant Patients
Symptomatic non-pregnant traveler (male or female)
YES
YES
NO
(At least one of the following: acute onset of fever
[measured or reported], maculopapular rash, arthralgia,
conjunctivitis)
Traveler with Guillain-Barré Syndrome diagnosis
YES
NO
YES
For those symptomatic, collect serum for IgM ≥4 days post symptom onset
1
2
If <7 days from onset of symptoms, submit both urine and serum specimens; urine should be collected within 14 days of symptom onset
to improve sensitivity of diagnosis, however urine specimens collected within 30 days will continue to be accepted.
3
Collect sample between 2-12 weeks of return
4
Consider testing amniotic fluid
5
Additional specimens will be requested: e.g. placenta, fetal tissues
6
Positive or inconclusive Zika virus serology
7
Additional specimens will be requested: e.g. cord blood, placenta/umbilical cord tissue, CSF
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
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CONFIDENTIAL – This material is subject to the Official Information Privilege Act

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