Form CDC52.12 "Waterborne Disease Transmission - National Outbreak Reporting System"

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Download Form CDC52.12 "Waterborne Disease Transmission - National Outbreak Reporting System"

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General
National Outbreak Reporting System
Waterborne Disease Transmission
This form is used to report waterborne disease outbreaks. Pages 1-5 ask for the minimum or basic information about the outbreak investigation, epidemiological data, and clinical specimen and water test
results. These are followed by sections specific to the type of water exposure. Only 1 of the 5 water exposure sections should be completed.
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer,
1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (0920-0004) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESS
CDC USE ONLY
CDC ID
State ID
Form Approved
OMB No. 0920-0004
General Section
Primary Mode of Transmission
(Check one)
■ Food (Complete CDC 52.13)
■ Person-to-person (Complete CDC 52.13)
¨ Water (Complete the tabs for General, Water-General, Water-Etiology &
■ Environmental contamination other than food/water
(Complete CDC 52.13)
Lab, Water Samples and the type of water exposure)
■ Other/Unknown (Complete CDC 52.13)
■ Animal contact (Complete CDC 52.13)
Investigation Methods
(Check all that apply)
¨ Interviews only of ill persons
¨ Treated or untreated recreational water venue assessment
¨ Case-control study
¨ Investigation at factory/production/treatment plant
¨ Cohort study
¨ Investigation at original source (e.g., farm, water source, etc.)
¨ Food preparation review
¨ Food product or bottled water traceback
¨ Water system assessment: Drinking water
¨ Environment/food/water sample testing
¨ Water system assessment: Nonpotable water
¨ Other
Comments
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Dates
(mm/dd/yyyy)
Date first case became ill
____________________
Date last case became ill ____________________
(required)
Date of initial exposure ____________________
Date of last exposure ____________________
Date of report to CDC
(other than this form)
____________________
Date of notification to State/Territory or Local/Tribal Health Authorities _____________________
Geographic Location
Exposure state: ___________________________________________________________________________________________
¨ Exposure occurred in multiple states
¨ Exposure occurred in a single state, but cases resided in another state or multiple states
Other states: _______________________________________________________________________________________
(For multistate exposure or multistate residency outbreaks, enter the case count for each state)
Exposure county: _________________________________________________________________________________________
¨ Exposure occurred in multiple counties in exposure state
¨ Exposure occurred in a single county, but cases resided in another county or multiple counties
Other counties: _____________________________________________________________________________________
City/Town/Place of exposure: ____________________________________________________________________________
(Do not include proprietary or private facility names)
Primary Cases
Number of primary cases
Sex
(Number or percent of the primary cases)
Lab-confirmed primary cases
# Male
#
%
Probable primary cases
# Female
#
%
Estimated total primary cases
# Unknown
#
%
Total # of cases
for whom info is
Primary case outcomes
# Cases
available
Age
(Number or percent of the primary cases)
Died
#
#
<1 year
#
%
20–49 years
#
%
Hospitalized
#
#
1–4 years
#
%
50–74 years
#
%
Visited Emergency Room
#
#
5–9 years
#
%
> 75 years
#
%
Visited health care provider
#
# 10–19 years
#
%
Unknown
#
%
(excluding ER visits)
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
1
General
National Outbreak Reporting System
Waterborne Disease Transmission
This form is used to report waterborne disease outbreaks. Pages 1-5 ask for the minimum or basic information about the outbreak investigation, epidemiological data, and clinical specimen and water test
results. These are followed by sections specific to the type of water exposure. Only 1 of the 5 water exposure sections should be completed.
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer,
1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (0920-0004) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESS
CDC USE ONLY
CDC ID
State ID
Form Approved
OMB No. 0920-0004
General Section
Primary Mode of Transmission
(Check one)
■ Food (Complete CDC 52.13)
■ Person-to-person (Complete CDC 52.13)
¨ Water (Complete the tabs for General, Water-General, Water-Etiology &
■ Environmental contamination other than food/water
(Complete CDC 52.13)
Lab, Water Samples and the type of water exposure)
■ Other/Unknown (Complete CDC 52.13)
■ Animal contact (Complete CDC 52.13)
Investigation Methods
(Check all that apply)
¨ Interviews only of ill persons
¨ Treated or untreated recreational water venue assessment
¨ Case-control study
¨ Investigation at factory/production/treatment plant
¨ Cohort study
¨ Investigation at original source (e.g., farm, water source, etc.)
¨ Food preparation review
¨ Food product or bottled water traceback
¨ Water system assessment: Drinking water
¨ Environment/food/water sample testing
¨ Water system assessment: Nonpotable water
¨ Other
Comments
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Dates
(mm/dd/yyyy)
Date first case became ill
____________________
Date last case became ill ____________________
(required)
Date of initial exposure ____________________
Date of last exposure ____________________
Date of report to CDC
(other than this form)
____________________
Date of notification to State/Territory or Local/Tribal Health Authorities _____________________
Geographic Location
Exposure state: ___________________________________________________________________________________________
¨ Exposure occurred in multiple states
¨ Exposure occurred in a single state, but cases resided in another state or multiple states
Other states: _______________________________________________________________________________________
(For multistate exposure or multistate residency outbreaks, enter the case count for each state)
Exposure county: _________________________________________________________________________________________
¨ Exposure occurred in multiple counties in exposure state
¨ Exposure occurred in a single county, but cases resided in another county or multiple counties
Other counties: _____________________________________________________________________________________
City/Town/Place of exposure: ____________________________________________________________________________
(Do not include proprietary or private facility names)
Primary Cases
Number of primary cases
Sex
(Number or percent of the primary cases)
Lab-confirmed primary cases
# Male
#
%
Probable primary cases
# Female
#
%
Estimated total primary cases
# Unknown
#
%
Total # of cases
for whom info is
Primary case outcomes
# Cases
available
Age
(Number or percent of the primary cases)
Died
#
#
<1 year
#
%
20–49 years
#
%
Hospitalized
#
#
1–4 years
#
%
50–74 years
#
%
Visited Emergency Room
#
#
5–9 years
#
%
> 75 years
#
%
Visited health care provider
#
# 10–19 years
#
%
Unknown
#
%
(excluding ER visits)
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
1
General
Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases Only
Incubation Period
Duration of Illness
(Select appropriate units)
(Among recovered cases-select appropriate units)
Shortest
Min, Hours, Days
Shortest
Min, Hours, Days
Median
Min, Hours, Days
Median
Min, Hours, Days
Longest
Min, Hours, Days
Longest
Min, Hours, Days
Total # of cases for whom info is available
Total # of cases for whom info is available
¨ Unknown incubation period
¨ Unknown duration of illness
Signs or Symptoms
Sign or symptom
# Cases with signs or symptoms
Total # cases for whom info available
Vomiting
Diarrhea
Bloody stools
Fever
Abdominal cramps
HUS
Secondary Cases
Mode of secondary transmission
Number of secondary cases
(Check all that apply)
¨ Food
Lab-confirmed secondary cases
#
¨ Water
Probable secondary cases
#
¨ Animal contact
¨ Person-to-person
Estimated total secondary cases
#
¨ Environmental contamination other than food/water
¨ Other/Unknown
Estimated total cases (Primary + Secondary)
#
Other CDC System IDs
(If applicable)
NEARS ID:
1)________________________ 2)________________________ 3)________________________ 4)_______________________
OHHABS ID: 1)________________________ 2)________________________
Traceback
(For food and bottled water only, not public water)
¨ Please check if traceback conducted
Source name
Source type
Location of source
Traceback comments
(e.g. poultry farm, tomato
(if publicly available)
processing plant, bottled water factory)
State
Country
Recall
¨ Please check if any food or bottled water product was recalled
Type of item recalled: _________________________________________________________________________________________
Comments: _________________________________________________________________________________________________
Reporting Agency
Reporting site: ________________________________________
E-mail: __________________________________________
Agency name: _________________________________________
Phone #: _______________________________________
Contact name: ________________________________________
Fax #: __________________________________________
Contact title: _________________________________________
General Remarks
Briefly describe important aspects of the outbreak not covered above. Please indicate if any adverse outcomes occurred
in special populations (e.g., pregnant women, immunocompromised persons)
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
2
Water-General
Water - General Section
Type of Water Exposure
(Check ONE box)
¨ Treated recreational water (e.g., in manufactured venues such as pools, spas/whirlpools, hot tubs, spray pads, at-home kiddie pools)
¨ Untreated recreational water (e.g., water in natural venues such as freshwater lakes, hot springs, marine beaches/oceans)
¨ Drinking water in public or individual water systems (e.g., municipal system, private well, commercially-bottled water, water kiosk), regardless of the
exposure pathway (i.e., not limited to ingestion).
¨ Other water (e.g., cooling/industrial, water reuse, irrigation, occupational, decorative/display; includes water consumed from sources such as back-
country streams)
¨ Unknown water uses (i.e., the intended purpose or use of the water is unknown or the water exposure category could not be determined)
Epidemiologic Data
1. Estimated total number of persons with primary water exposure: ______________
2. Were data collected from comparison groups to estimate risk?
£ Yes (specify in table below)
£ No
£ Unknown
If NO or UNKNOWN, was water the common source
shared by persons who were ill?
£ Yes
£ No
£ Unknown
Exposure in epidemiologic investigation
Total #
# ill
Total
# ill not
Attack
Odds
Relative
p-Value
95%
(e.g., pool, waterpark, hot spring,
(provide
exposed
exposed
# not
exposed
rate (%)
ratio
risk
confidence
well water)
exact value)
(A)
(B)
exposed
(B/A)
interval
Attack rate for residents of reporting state: _________ %
Attack rate for non-residents of reporting state: _________ %
Geographic Location
Percent of ill persons (primary cases) living in reporting state: ______________%
Associated Events
Was exposure associated with a specific event or gathering?
£ Yes
£ No
£ Unknown
If YES, what type of event or gathering was involved?
_______________________________________________________________
If outbreak occurred during a defined event, dates of event:
Start date:________________ End date: ________________
(mm/dd/yyyy)
(mm/dd/yyyy)
Route of Entry
£ Ingestion
£ Contact
£ Inhalation
£ Other (specify in remarks)
£ Unknown
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
3
Water-Etiology & Lab
Outbreak Etiology
(Report the confirmed and/or suspected etiological agent(s) here, even if no clinical specimens were tested)
Confirmed as
Genus/Chemical/Toxin
Species
Serotype/Serogroup/
Genotype/
Detected
Total #
Total #
etiology?
Serovar
Subtype
in*
tested
positive
(list all
primary
primary
that apply)
cases
cases
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
¨ Confirmed
¨ Suspected
* 1-Clinical Specimens, 2-Water Samples, 3-Clinical Specimens & Water Samples, 4-Other (describe in the general remarks), 5-Unknown, 6-None
Outbreak Isolates
(Links data about molecular characterization across multiple systems. For each pathogen, provide a representative for each distinct molecular
designation)
Which CDC system contains this
CDC lab system outbreak #
State lab ID
Molecular
Molecular
(e.g., PulseNet tracking number)
(i.e., Lab tracking number)
isolate profile?
designation 1
designation 2
(e.g., PulseNet, CaliciNet)
Clinical Specimens
1. Were clinical diagnostic specimens taken from persons?
£ Yes
£ No
£ Unknown
If YES, from how many persons were specimens taken? _______________________________
Specimen type
Specimen subtype
Tested for
§
(list all that apply)
Specimen Type: 1- Autopsy Specimen (specify subtype), 2-Biopsy (specify subtype), 3-Blood, 4-Bronchial Alveolar Lavage (BAL), 5-Cerebrospinal Fluid (CSF), 6-Conjunctiva/Eye Swab, 7-Ear Swab, 8-Endotracheal
Aspirate, 9-Saliva, 10-Serum, 11-Skin Swab, 12-Sputum, 13-Stool, 14-Urine, 15-Vomitus, 16-Wound Swab, 17-Other (describe in the general remarks), 18-Unknown
Specimen Subtype: 1-Bladder, 2-Brain, 3-Dura, 4-Hair, 5-Intestine, 6-Kidney, 7-Liver, 8-Lung, 9-Nails, 10-Skin, 11-Stomach, 12-Wound, 13-Other, 14-Unknown
§
Tested for: 1-Bacteria, 2-Chemicals/Toxins, 3-Fungi, 4-Parasites, 5-Viruses, 6-Other (describe in general remarks), 7-Unknown
Testing Information
1. Test types
2. Was Antimicrobial Susceptibility Testing (AST) performed?
(select all test types used for clinical specimens)
£ Yes £ No £ Unknown
£ Chemical Testing
£ Serological/Immunological Test
If yes, where was AST performed?
£ Culture
(e.g., EIA, ELISA)
£ Clinical Lab £ Public Health Lab £ CDC-NARMS
£ DNA or RNA Amplication/Detection
£ Tissue culture infectivity assay
£ Other
£ Unknown
£ Other
(e.g. PCR, RT-PCR)
(specify in the general remarks)
If yes, were any antimicrobial resistant isolates associated with the
£ Microscopy (e.g., fluorescent, EM)
£ Unknown
outbreak? £ Yes £ No £ Unknown
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
4
Water Samples
Water Samples
(Provide representative data about water quality testing, chemical or pathogen testing. Additional sample data can be described in the remarks
or attached)
Was water tested?
£ Yes (specify in table below)
£ No
£ Unknown
Results
Sample number
1
2
3
4
5
Source of sample
(e.g., swimming pool, lake)
Additional description
(e.g., time of day, location
of sample collection)
Date
(mm/dd/yyyy)
Volume tested,
(number, unit)
Temperature
(number, unit)
Residual/Free disinfectant level -
number, unit (if total and combined disinfectant
levels given, total - combined = free)
Combined disinfectant level -
number, unit (if total and free disinfectant
levels given, total - free = combined)
pH
Turbidity (NTU)
Water Samples - Water Quality Indicators
(Might not be applicable for treated recreational water samples)
Sample
Type
Concentration
Unit
(e.g., fecal coliforms)
(numerical
value)
number
Water Samples - Microbiology or Chemical/Toxin Analysis
(Provide both positive and negative test results)
Sample
Genus/Chemical/Toxin
Species
Serotype/Serogroup/
Genotype/Subtype
PFGE pattern
number
Serovar
Sample
Test results positive?
Concentration
Unit
Test type*
Test method
(reference: National
(numerical value)
Environmental Methods Index: http://www.nemi.
number
gov)
£ Yes
£ No
£ Yes
£ No
£ Yes
£ No
£ Yes
£ No
£ Yes
£ No
£ Yes
£ No
* Test type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing, 6-Chemical Testing,
7-Tissue Culture Infectivity Assay, 8-Other (describe in the general remarks), 9-Unknown
CDC 52.12 Rev. 03 2017
National Outbreak Reporting System
CS262092-A
5