LEGIONELLOSIS INVESTIGATION FORM

BASIC DEMOGRAPHIC DATA

Last Name:______First Name:______Middle Name:______

DOB: __ __ / __ __ /______Age: ______years months Current Sex: Female Male Unknown

Is the patient deceased? No Unknown Yes Date of Death: __ __ / __ __ /______

Street Address 1:______Street Address 2:______

City:______State:______Zip Code:______County:______

Home Phone: (______) ‐ ______‐ ______Cell Phone: (______) ‐ ______‐ ______Work Phone: (______) ‐ ______‐ ______Ext. ______

Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown

Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Unknown

INVESTIGATION SUMMARY

Investigation Start Date: __ __ / __ __ /______Investigation Status: Open Closed Investigator:______

REPORTING SOURCE

Date of Report: __ __ / __ __ /______Reporting Source:______

CLINICAL

Physician’s Name:______Phone Number: (______) ‐ ______‐ ______Ext. ______

Was patient hospitalized for this illness? No Unknown Yes If yes: Hospital Name:______

Admission Date: __ __ / __ __ /______Discharge Date: __ __ / __ __ /______Duration of Stay ______day(s)

Diagnosis Date: __ __ / __ __ /______Illness Onset Date: __ __ / __ __ /______Illness End Date: __ __ / __ __ /______

Age at Onset: ______days hours minutes months unknown weeks years

Did the patient die from this illness? No Unknown Yes Date of Death: __ __ / __ __ /______EPIDEMIOLOGIC

Is this patient associated with a day care facility? No Unknown Yes Is this patient a food handler? No Unknown Yes

Is this case part of an outbreak? No Unknown Yes If yes, outbreak name:______

Case Status: Confirmed Not a Case Probable Suspect Unknown MMWR Week: ______MMWR Year:______

ADMINISTRATIVE

General Comments:______

______

______

PHA4 SUPERVISOR REVIEW

Date Due: __ __ / __ __ /______Investigation ready for supervisor review: Reviewed (Complete) Reviewed (Incomplete)

Date investigation ready for supervisor review: __ __ / __ __ /______Reviewed (Not a case) Yes

Review comments (completed by supervisor):______

ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 1/3 SOURCES OF EXPOSURE (in the two weeks before onset, did patient)

Travel or stay overnight somewhere other than usual residence: No Unknown Yes If yes, what was the purpose of travel? Business Migration (immigration to US) Tourism Visiting relatives/friends Other ______Please specify the destination(s):

Destination 1 Type: Domestic State/Territory: ______International Country: ______

Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______

Destination 2 Type: Domestic State/Territory: ______International Country: ______

Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______

Destination 3 Type: Domestic State/Territory: ______International Country: ______

Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______

If more than 3 destinations, specify details here: ______

Have dental work? No Unknown Yes If yes, name of dental office and address: ______Visit a hospital as an outpatient? No Unknown Yes If yes, name of hospital and address (visited): ______Works in a hospital? No Unknown Yes If yes, name of hospital and address (worked in): ______

HOSPITAL RELATED (Nosocomial related)

NOT Nosocomial (No inpatient or outpatient hospital visits in the 10 days prior to onset of symptoms): No Unknown Yes POSSIBLY Nosocomial (Patient hospitalized 2‐9 days before onset of infection): No Unknown Yes DEFINITELY Nosocomial (Patient hospitalized 2‐9 days before onset of legionella infection): No Unknown Yes Other (Specify Nosocomial): No Unknown Yes If yes, name: ______Unknown (Nosocomial): No Unknown Yes

SIGNS AND SYMPTOMS (Clinical and Laboratory Evidence)

Fever: No Unknown Yes Myalgia: No Unknown Yes Cough: No Unknown Yes

Clinical Classification: Diagnosis (check one) Laboratory Classification:

Legionnaires’ Disease (, X‐ray diagnosed) Species: ______

(Fever, myalgia without pneumonia) Serogroup: ______

Other (Specify): ______

Unknown UNDERLYING CONDITIONS

Did the patient have any of the following underlying conditions?

CSF leak Hodgkin’s disease IVDU

Alcohol abuse Atherosclerotic cardiovascular disease (ASCVD)/CAD

Burns Cerebral vascular accident (CVA) stroke Chronic GI illness/diarrhea

Cirrhosis/liver failure Cochlear implant Current smoker

Deaf/profound hearing loss Diabetes mellitus (insulin): No Unk Yes Emphysema/COPD

Gastric surgery (type): ______Heart failure Hematologic disease (type): ______

Immunodeficiency (type): ______Immunoglobulin deficiency Immunosuppressive therapy (steroids, chemotherapy)

Leukemia Multiple myeloma Nephrotic Syndrome

None Organ transplant (organ): ______Other liver disease (type): ______

Other malignancy (type): ______Other prior illness (type): ______Other renal disease (type): ______

Peptic ulcer Renal failure/dialysis Sickle cell anemia

Splenectomy/asplenia Systemic lupus erythematosus (SLE) Unknown

ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 2/3 RELATED CASES

Does the patient know of any similarly ill persons? No Unknown Yes

If yes, did the health department collect contact information about other similarly ill persons and investigate further: No Unknown Yes

Are the other cases related to this one? No, sporadic Unknown Yes, household Yes, not household Yes, outbreak Note: Please enter name and Case ID of epi‐linked case(s) in the ALNBS General Comments section.

CASE CLASSIFICATION

Legionnaires’ Disease: Did the patient have fever, myalgia, cough, and clinical or radiographic pneumonia; OR 1 No Unknown Yes Pontiac Fever (milder illness without pneumonia)?

 By culture: isolation of any Legionella organism from respiratory , lung tissue, pleural fluid, or other normally sterile fluid. OR 2  By detection of serogroup 1 in urine using validated reagents. No Unknown Yes OR  By seroconversion: fourfold or greater rise in specific serum titer to Legionella pneumophila serogroup 1 using validated reagents.

 By seroconversion: fourfold or greater rise in antibody titer to specific species or serogroups of Legionella other than L. pneumophila serogroup 1 (e.g., L. micdadei, L. pneumophila serogroup 6). OR  By seroconversion: fourfold or greater rise in antibody titer to multiple species of Legionella using pooled antigen and validated reagents. 3 OR No Unknown Yes  By the detection of specific Legionella antigen or staining of the organism in respiratory secretions, lung tissue, or pleural fluid by direct fluorescent antibody (DFA) staining, immunohistochemistry (IHC), or other similar method, using validated reagents. OR  By detection of Legionella species by a validated nucleic acid assay.

Travel‐associated: a case that has a history of spending at least one night away from home, either in the same

country of residence or abroad, in the ten days before onset of illness.

Confirmed: 1 & 2 Suspect: 1 & 3

ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 3/3