Appendix 17 Congenital Rubella Syndrome Case Report Date of Report: hh hh hhhh Date of last Evaluation of Infant: hh hh hhhh Month Day Year Month Day Year l PATIENT INFORMATION Child’s Name: Last First Middle Current Address: (County, State and Zip Code) Age Congenital Rubella Syndrome Diagnosed: Years Months h Less than 1 Month h Unknown Date of Birth: Birth Weight: Gestational Age: Sex: Race: Ethnicity: Grams Weeks h M h F h American Indian or Alaska Native h Hispanic Origin hh hh h Asian or Pacific Islander h Not of Hispanic Origin Month Day lbs. oz. h Unknown h Black h Unknown h Unknown hhhh h White Year h Other (specify) ll CLINICAL CHARACTERISTICS Yes No Unk. Yes No Unk. Cataracts .............................................................h h h Meningoencephalitis ...................................................h h h Hearing Loss..........................................................h h h Microcephaly..........................................................h h h Mental Retardation .....................................................h h h Purpura ..............................................................h h h Congenital Heart Disease 1. Patent Ductus Arteriosus ......................h h h Enlarged Spleen .......................................................h h h 2. Peripheral Pulmonic Stenosis ..................h h h Enlarged Liver.........................................................h h h 3. Congenital Heart Disease......................h h h Long Bone Radiolucencies ..............................................h h h Type Unknown Congenital Glaucoma...................................................h h h 4. Other (Specify) Pigmentary Retinopathy ................................................h h h Other Abnormalities: h Yes h No h Unknown If Yes, specify Is Child Living? h Yes h No h Unknown Causes of Death: (from death certificate) 1. If No, Date of Death hh hh hhhh Month Day Year 2. If Child Died, Was Autopsy Performed? Final Anatomical Diagnosis: h Yes h No h Unknown lIl MATERNAL HISTORY Mother’s Name: Age at Delivery: Occupation at Time of Conception: Last First Middle h Unemployed Years h Unknown Did Mother Attend Family Number of Previous Number of Previous Prenatal Care for this Pregnancy: Was Prenatal Care Obtained in: Planning Clinic Prior to Live Births: Pregnancies: h Yes h No h Unknown h Public Sector Conception? h Unknown h Unknown Date of First Visit: h Private sector h Yes h No h Unknown hh hh hhhh Month Day Year h Unknown h Unknown Rubella-Like Illness During Pregnancy: Was Rubella Diagnosed by a Physician Was Rubella Serologically Confirmed h Yes h No h Unknown at Time of Illness? h Yes h No h Unknown at Time of Illness? h Yes h No h Unknown If Yes, Month of Pregnancy: If not MD, by Whom? h Unknown Location of Exposure: If Location of Exposure is Unknown, did Source of Exposure: Was the Mother Directly Within the United States h Yes h No h Unknown Mother Travel Outside the U.S. During the Exposed to a Known Rubella Case? First Trimester of Pregnancy? Outside the United States h Yes h No h Unknown h Yes h No h Unknown h Yes h No h Unknown If Yes, specify relationship: If Yes, specify country; also specify county and city, If Yes, specify country; also specify county and city, if known: if known: Date of Exposure: hh hh hhhh Date of Travel: hh hh hhhh Month Day Year Month Day Year h Unknown h Unknown Number of Other Children Less than 18 Years of Age Living in House- Were Any of the Children Immunized with Rubella Vaccine? hold During this Pregnancy: h Yes h No h Unknown THIS IS A DRAFT FORM WITHOUT OMB APPROVAL. CDC 71.17 (DRAFT) Rev. 02/2009, Page 1 of 2 CS106190 Clinical Features of Maternal Illness: Was Mother Immunized with Rubella Vaccine? Did the Mother Have Serological Testing for Rash...............h Yes h No h Unknown h Yes h No h Unknown Rubella Immunity Prior to Exposure? If Yes, Date of Onset: If Yes, Date Vaccinated: h Yes h No h Unknown hh hh hhhh hh hh hhhh If Yes, Date: hh hh hhhh Month Day Year Month Day Year Month Day Year Fever ..............h Yes h No h Unknown If Yes, Source of Information: If Yes, Interpretation of Test Results: h Susceptible h Immune h Unknown Lymphadenopathy ...h Yes h No h Unknown h Physician h Mother Only h School h Other (specify) (If more than one serologic test, include dates and results for each time tested.) Arthralgia/Arthritis: h Yes h No h Unknown h Public Sector h Private Sector Other (specify) h Unknown IV LABORATORY Specimens for Viral Study h Yes h No Mother Infant Specific Test Type Specimen Date Collected Laboratory Methods Used Test Results (Check one) (See below)* h h / / h h / / h h / / h h / / h h / / h h / / h h / / h h / / V APPRAISAL h Confirmed h Probable h Possible h Infection Only h Not CRS h Stillbirth h Unknown h Indigenous to U.S. h Imported to U.S. Investigator's Name (print): Telephone: Date: Physician Responsible for Child’s Care: Telephone: Source of Report: h Private MD h Death Record h Birth Record h Laboratory h Hospital h Other LAB TEST METHODS a) Viral Cultures d) ELISA g) Passive Hemagglutination (PHIA) b) RIA e) Hemagglutination Inhibition h) Other (Specify) c) IFA f) Latex Agglutination *If antibody testing was performed, specify which Rubella-specific immunoglobin antibody (IgM or IgG) was used. DEFINITIONS Clinical Case Definition Case Classification An illness of newborns resulting from rubella infection in utero and characterized by Possible: A case with some compatible findings but not meeting the criteria for a signs and symptoms in the following categories: probable case. A Cataracts/congenital glaucoma, congenital heart disease (most commonly pat- ent ductus arteriosus, peripheral pulmonary artery stenosis), loss of hearing, Probable*: A case that is not laboratory-confirmed and that has any two complica- pigmentary retinopathy. tions listed in A above, or one complication A and one from B. B Purpura, splenomegaly, jaundice, microcephaly, mental retardation, meningoencephalitis, radiolucent bone disease. Confirmed: A clinically compatible case that is laboratory-confirmed. Infection Only: A case with laboratory evidence of infection, but without any clinical symptoms or signs. Clinical Description * In probable cases, either or both of the eye-related findings (cataracts and congenital glaucoma) The presence of any defects or laboratory data consistent with congenital rubella count as a single complication infection (as reported by a health professional). Imported to U.S. Laboratory Criteria for Diagnosis A case which has its source of exposure outside the United States. c Isolation of rubella virus, or c Demonstration of rubella-specific IgM antibody, or c An infant’s rubella antibody level that persists above and beyond that expected form Indigenous to U.S. passive transfer of maternal antibody (i.e., rubella titer that does not drop at the A case which cannot be proved to be imported. expected rate of twofold dilution per month). CDC 71.17 (DRAFT) Rev. 02/2009, Page 2 of 2 .