Hantavirus Pulmonary Syndrome
Enhanced Surveillance Report
NDR#
Please Print off completed form and FAX to AH Communicable Disease Control at 780-415-9609
SECTION 1: CASE INFORMATION
Birth Date:
Gender:
Age at onset:
Male
Female
Unknown
Municipality:
SECTION 2: CLINICAL INFORMATION
Onset Date:
Hospitalized?
Name of Hospital
1.
2.
3.
Fatal?
No
No
Unknown
Unknown
Yes
Date medical attention sought:
If Yes, number of times hospitalized:
Admit Date
Yes  Date of death:
 Died from disease?
Discharge Date
Yes
No
Unknown
Fever >38.3
O2 Sats ≤ 90% at any time during
illness?
Chest X-Ray shows bilateral
pulmonary infiltrates?
Respiratory compromise requiring
supplemental O2?
Intubated and mechanically
ventilated?
Treatment with Ribavirin?
No
 Was exam compatible with non-cardiogenic pulmonary
edema?
Yes
No
Unknown
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
 Date of initial intubation:
No
Unknown
Yes
Low platelet count (≤150,000)?
No
Unknown
Yes
 Date treatment started:
 Indicate lowest platelet count:
 Date of lowest platelet count:
Elevated hematocrit?
No
Unknown
Yes
Autopsy performed?
No
Unknown
Yes
 Date of CXR:
 Indicate highest hematocrit:
 Date of highest hematocrit:
History of underlying medical
No
Unknown
Yes Specify:
conditions?
Other possible explanations for acute illness (e.g. sepsis, burns, trauma)?
Other clinical comments:
SECTION 3: EXPOSURE HISTORY
Occupation:
Place of work (to nearest municipality):
In the 6 weeks prior to onset of illness was there exposure
WITHIN Alberta to rodents or their excretions?
Yes
Date of Exposure
Home/Recreation/Work?
Location of Exposure
(yyyy/mm/dd)
(e.g. at home)
(to nearest municipality)
Alberta Health, April 2014
© 2014 Government of Alberta
No
Unknown
Description of Exposure
(e.g. found mouse droppings while
cleaning garage)
Exposure to
(e.g., mice…)
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SECTION 4: TRAVEL HISTORY
In the 6 weeks prior to onset of illness did case travel outside of Alberta?
Yes
No
Unknown
If Yes, please provide travel dates and location:
Date Arrived at
Location
Date Left
Location
Resort Name/Destination Details
Municipality
Prov/Terr/State
Country
SECTION 5: LABORATORY TESTING
Specimen #
Report Date
Collection Date
Specimen Type
Test Performed
Test Result
(e.g. YYYY/MM/DD)
(e.g. YYYY/MM/DD)
(e.g. Blood, lung tissue)
(e.g. Hantavirus PCR)
(e.g. Positive)
SECTION 6: ADMINISTRATIVE INFORMATION
Date Report to Alberta Health:
Zone/Region reporting: Zone - Region
Reported by:
Telephone number:
-
ext
Comments:
Alberta Health, April 2014
© 2014 Government of Alberta
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