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Case Investigation Form

Philippine Integrated Disease

Surveillance and Response

Anthrax
(ICD 10 Code: A22)
Name of DRU:

Type: RHU

Address:

CHO Govt Hospital

Govt Laboratory

I. PATIENT
INFORMATION:

Patient Number:

Patients First Name

Complete Address:
Sex:
Occupation:

Private Hospital

Private Laboratory

Middle Name

Male
Female

Last Name

MM

Date of
Birth:

Clinic

Airport/Seaport

DD

YY

Age:

Days
Months
Years

Name Workplace:
Address of Workplace:

II. CLINICAL
INFORMATION:

Signs and
Symptoms:

Admitted?
Yes No Unknown

Fever
Upset stomach (nausea)
Headache
Dry cough
Sore throat
Trouble swallowing
Trouble breathing

Date Admitted/
Seen/Consult

MM

DD

Stomach pain
Vomiting blood
Bloody diarrhea
Sweating excessively
Extreme tiredness
Pain or tightness in the chest
Sore muscles

YY

Date Onset of
Illness

MM

DD

YY

Neck pain
Itchy skin
Black scab on skin
Skin lesions
Describe lesion: ____________
_________________________

Other (list): ________________

_________________________

III. POTENTIAL RISK FACTORS IN THE 15-60 DAYS PRIOR TO ONSET OF SIGNS/SYMPTOMS
Y N U

Is the patients occupation associated with animals or agriculture?

Y N U

Has the patient been exposed to Anthrax Vaccine or to anthrax-vaccinated animals?

Y N U

Does the patient have occupational or other exposure to hides, wool, furs, bone meal or other animal products?

Y N U

Contact with live or dead animals? (cattle, sheep, goats, horses, pigs and other herbivores both livestock and wildlife)

Y N U

Does the patient have a history of travel beyond his/her usual place of residence/surroundings?

Y N U

Does the patient work in a laboratory?

Y N U

Have any household members experienced similar symptoms recently?

Y N U

Has the patient eaten undercooked meat? (cattle, sheep, goats, horses, pigs and other herbivores both livestock and wildlife)

Y N U

Did the patient receive unusual letters or packages? (e.g. containing threats or unusual messages)

Y N U

Has the patient opened mails for others?

Y N U

Was the patient present or nearby when an envelope that contained any form of powder was opened?

IV. CLINICAL FORMS, CLASSIFICATION AND OUTCOME:

CLINICAL FORMS

CASE CLASSIFICATION

OUTCOME

Cutaneous
Gastrointestinal

Suspected Case

Alive

Pulmonary

Probable Case

Died,

Confirmed Case

Unknown

Meningeal
Unknown

Date died: ____/____/____

V. LABORATORY TESTS:
Specify
Specimen

If YES, date
taken
MM

MM

DD

DD

Type of laboratory
test done

Results
N=Negative; I=Indeterminate; U-Unknown

YY

Positive for:

N I U

Positive for:

N I U

YY

Date result
MM

DD

YY

MM

DD

YY

Page 2 of 2

Case Investigation Form

Anthrax

CASE DEFINITION/CLASSIFICATION:

Suspected case: A person with acute onset of illness characterized by several clinical forms as follows:
a. localized form:
1. cutaneous: skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed
black eschar invariably accompanied by edema that may be mild to extensive;
b. systemic forms:
1. gastro-intestinal: abdominal distress characterized by nausea, vomiting, anorexia and followed by fever;
2. pulmonary (inhalation): brief prodrome resembling acute viral respiratory illness, followed by rapid onset of
hypoxia, dyspnea and high temperature, with X-ray evidence of mediastinal widening;
3. meningeal: acute onset of high fever possibly with convulsions, loss of consciousness, meningeal signs and
symptoms; commonly noted in all systemic infections;

AND has an epidemiological link to a suspected or confirmed animal cases or contaminated animal products;

Probable case: A suspected case that has a positive reaction to allergic skin test (in non-vaccinated individuals);

Confirmed case: A suspected case that is laboratory-confirmed.

LABORATORY CONFIRMATION:

Isolation of Bacillus anthracis from a clinical specimen (e.g., blood, lesions, discharges)

Demonstration of B. anthracis in a clinical specimen by microscopic examination of stained smears (vesicular fluid,
blood, cerebrospinal fluid, pleural fluid, stools)

Positive serology (ELISA, Western blot, toxin detection, chromatographic assay, fluorescent antibody test (FAT))