Utah Public Health s2

IMMEDIATELY NOTIFIABLE Utah Public Health LHD name INFANT BOTULISM LHD address line 1 LHD address line 2 Phone: (801) xxx-xxxx Confidential fax: (801) xxx-xxxx Confidential Case Report Date finalized Please fill in the blanks or check the answer for each field DEMOGRAPHIC INFORMATION UT-NEDSS ID Last name First / MI Address City Zip County State Phone number(s)    Date of birth Age Gender M F Parent/Contact Race White Black/Af. Am Amer. Indian Asian Alaska Native Native Hawaiian/Pacific Islander Other Unk Ethnicity Hispanic Non-Hispanic Unk Interviewee mother father both chart other: Refugee or recent immigrant? Y N U If yes, how long has the patient been in the USA?

CLINICAL INFORMATION Y N U Details Seen by physician (including ED)? Physician/ED: Phone: Date: Health facility: Medical Record Number: Hospitalized? From: To: Died? Date of death: Was Botulism the cause of death? Y N U Immunocompromised? If yes, explain: Co-infected? If yes, disease:

Onset date: Date resolved: ongoing SIGNS / SYMPTOMS / PHYSICAL EXAM FINDINGS Check here if discharge summary or hospital chart is attached: constipation progressive weakness other: poor feeding impaired respiration failure to thrive Was antitoxin (BabyBIG) administered? Y N U If yes, date administered:

LABORATORY / PROCEDURES INFORMATION

Lab name/phone: Collection date: Laboratory tests performed: Y N U If yes, complete questions below: Specimen source: stool other: Toxin assay Lab result: positive negative presumptive positive inconclusive pending If positive, toxin type: A B C D E F G not done Specimen source: stool other: Culture Lab result: positive negative presumptive positive inconclusive pending If positive, toxin type: A B C D E F G not done

REPORTING INFORMATION Reported by: Reporter name: Phone: hospital/ICP clinic/MD office Date results reported to clinician: Date reported to public health: lab other: Received by whom at LHD: LHD open date: LHD Investigator:

EXPOSURE PERIOD Have patient answer questions on following pages for the exposure period only: Date 30 days before disease onset: Date 3 days before disease onset: INFANT BOTULISM Name ______UT-NEDSS ID ______

TRAVEL HISTORY (3-30 days before onset) Travel outside USA? Y N U Did case have visitors from out of state or outside the USA? Y N U Travel outside Utah, but inside USA? Y N U If yes, did visitors bring food to share? Y N U Travel outside county, but inside Utah? Y N U If yes, details: If case answered yes to any of above travel questions, then fill in boxes below. If no, skip to FOOD HISTORY.

Travel Location: From: To: Mode of Travel: plane car cruise ship other: List other details, including: . Flight # . Sources of food / water . Accommodations, dates . Other relevant details

FOOD HISTORY (3-30 days before onset) High-risk foods consumed (during exposure period) IMPORTANT: remember to check “no” or “none” if appropriate Store/Rest’rt If case ate any high-risk foods, have case identify where each was purchased (including food eaten at a restaurant). Fill in store name(s) and # address(es) under “Grocery stores” below. Then enter the store or restaurant number (e.g. S1 or R1) under “Store/Rest’rt #” to the right of each food. Was infant ever breastfed? Y N U How many weeks? Was infant ever formula-fed? Y N U How many weeks? breastfed formula-fed equally Was infant primarily (>50%)… other: Consumed: Date(s): Available for testing: Formula Y N U Y N U Type: Home-canned/home-bottled food Y N U Y N U Type: Commercially-canned food Y N U Y N U Type:

Baby foods Y N U Y N U Type: Unpasteurized products (milk, juice, cheese, etc) Y N U Y N U Type: Syrup (karo/corn/maple) Y N U Y N U Type: Honey Y N U Y N U Fermented/smoked/salted/dried fish or fish products (eggs, heads, etc) Y N U Y N U Type: Other fermented animal products (seal, whale, beaver) Y N U Y N U Type: Garlic/herbs/chilies stored in oil/any infused oil Y N U Y N U Smoked/dehydrated/jerky meat Y N U Y N U Non-refrigerated perishable food stored in an airtight container Y N U Y N U Improperly cooked/reheated baked potatoes wrapped and stored in foil Y N U Y N U Any improperly cooked/reheated soup/stew Y N U Y N U Any homeopathic products/medicinal herbs or plants Y N U Y N U Type: Did patient ever use a pacifier? Y N U syrup honey Ever dipped in: other: Y N U Other suspect food, e.g. vacuum packed Y N U Y N U Specify: Y N Anything else by mouth, including teething products? U Y N U Specify:

- 2 - INFANT BOTULISM Name ______UT-NEDSS ID ______

Source of high-risk food (grocery stores, farmers’ markets, roadside stands, Meals on Wheels, friends, neighbors): (Enter grocery store data, etc, in the Epidemiological tab in UT-NEDSS) S1 Name/address: Approx date of last trip: S2 Name/address: Approx date of last trip: S3 Name/address: Approx date of last trip: S4 Name/address: Approx date of last trip:

ENVIRONMENTAL HISTORY (3-30 days before onset) Y N Was there any construction near the home? U Approx dates: to Describe:

Was there any excessive dust or environmental change in/near the home? Y N U Approx dates: to Describe:

Y N Were the parents involved in gardening work? U Approx dates: to Describe:

MISCELLANEOUS EXPOSURES (3-30 days before onset) Did patient sustain a wound or trauma? Y N U Date sustained: Type of wound/trauma: puncture fracture laceration Site of wound/trauma: Was wound/trauma contaminated? Y N U Has infant had surgical alterations of GI Y N U Date(s) of procedure(s): tract? Type(s) of procedure(s):

ILL CONTACT MANAGEMENT Know of any other infants ill with similar symptoms? Y N If yes, list details below. If no, proceed to FOLLOW-UP ACTIONS. U Details (name, age, gender, contact information):

FOLLOW-UP ACTIONS

- 3 - INFANT BOTULISM Name ______UT-NEDSS ID ______Date Action Provide client education (see disease plan). Notify Epidemiology of any high-risk exposures likely to cause additional illness. Notify UDAF if trace-back/food supplier investigation is warranted (store, dairy, etc). Notify UDOH if suspect exposure occurred outside health district or if potential cluster/outbreak situation exists. Complete CDC outbreak form, if appropriate. As needed, provide contact information to clinician for obtaining BabyBIG. BabyBIG can be obtained from the California Department of Health Services Infant Botulism Treatment and Prevention Program: 24/7 telephone (510) 231-7600. If case is determined to be non-intestinal, complete follow-up actions on Foodborne, Wound or Intestinal Botulism Confidential Case Report Form. Other follow-up:

ADMINISTRATIVE LHD status: Confirmed Probable Suspect Not a case Pending UDOH status: Confirmed Probable Suspect Not a case Pending Did this case occur as part of an outbreak? Y N U ( 2 cases of Infant Botulism associated by time & place) Outbreak name: LHD interview date: Interviewed: Client Parent/Guardian Sig. oth. HC provider Friend Other: Unable to contact/interview LHD Reviewer: LHD closed date: Date submitted to UDOH: