CONFIDENTIAL
Follow up of confirmed
TOXIGENIC CORYNEBACTERIUM DIPHTHERIAE infections
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 7621
Fax: 020 8327 7404
CIDSC use only:
Number
Week of notification
Source of reporting
PERSONAL DETAILS
CORYNEBACTERIUM
RTOXIGENIC
eference Laboratory
Number:
PSEUDOTUBERCULOSIS infections
Date of Birth: __/__/__
Patient’s residence postcode:
Was the case notified? Yes ☐ No ☐ nk ☐
Date of statutory notification: __/__/__
CLINICAL INFORMATION
TOXIGENIC
PSEUDOTUBERCULOSIS
Did
the patient have CORYNEBACTERIUM
any symptoms?
Yes ☐ No ☐
nk ☐
infections
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 ☐
Other systemic complication ☐ please specify
Outcome:
Died ☐ Survived ☐ not known ☐
Duration of illness:
Circulatory collapse ☐
days
VACCINATION HISTORY
TOXIGENIC
CORYNEBACTERIUM
Has
the patient ever
been immunised?
PSEUDOTUBERCULOSIS
infections
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
TRAVEL DETAILS
TOXIGENIC
CORYNEBACTERIUM
PSEUDOTUBERCULOSIS
Did
the patient travel
outside the UK recently (ie. within
the last 3 months)?
Yes ☐ No ☐infections
nk ☐
If yes, please specify the country(ies) visitied
Date of return to the UK:
OR no 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 ☐
Last updated 14 July 2014
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Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)
MANAGEMENT OF CASE
Yes ☐ No ☐ nk ☐
Did the patient receive antibiotics?
Antibiotic (chronological order)
Duration (days)
Did the patient receive a booster dose of diphtheria vaccine?
Response (Yes/No)
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. diphtheriae?
Yes ☐ No ☐ nk ☐
If yes, please state how many persons were positive for C. diphtheriae?
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
Last updated 14 July 2014
Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)
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