Please Return the Questionnaire by Fax 020 8327 7404 FOA Sarah Collins (Tel: 0208 327 7261)

CONFIDENTIAL

Last updated 14 July 2014 Page 1 of 2

Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)

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

Reference Laboratory Number:

Date of Birth: __/__/__ Patient’s residence postcode:

Was the case notified? Yes ☐ No ☐ nk ☐ Date of statutory notification: __/__/__

Did the patient have any symptoms? Yes ☐ No ☐ nk ☐

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 ☐ Circulatory collapse ☐

Other systemic complication ☐ please specify

Outcome: Died ☐ Survived ☐ not known ☐ Duration of illness: days

Has the patient ever been immunised? 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

Did the patient travel outside the UK recently (ie. within the last 3 months)? Yes ☐ No ☐ 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 ☐

Management of Case

Did the patient receive antibiotics? Yes ☐ No ☐ nk ☐

Antibiotic (chronological order) / Duration (days) / Response (Yes/No)

Did the patient receive a booster dose of diphtheria vaccine? 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 Page 2 of 2 Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7261)