Page 1 of 2

Philippine Integrated Disease Case Investigation Form

Surveillance and Response
Meningococcal Disease
(ICD 10 Code: A39)

Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address:
Gov’t Laboratory Private Laboratory Airport/Seaport

I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:

Complete Address: MM DD YY Age: Days

Male Date of
Sex:
Birth:  Months
Female
Years
Occupation: Name Workplace:

Address of Workplace:

Name of School: Address of School:

If student:

II. CLINICAL Admitted? Date Admitted/

MM DD YY
Date Onset
MM DD YY
INFORMATION: Yes No Unknown Seen/Consult of Illness
Fever Seizure Malaise
Headache Stiff neck Cough
Maculopapular rash Vomiting Sore throat
Signs and
Symptoms: Petechia Change of sensorium Runny nose
Purpura Drowsiness Dyspnea
Other lesions: Other signs / symptoms:
Clinical Presentation: Case Classification: Outcome:
Meningitis Suspected Case Alive
Septicemia Probable Case Died, Date Died _____/_____/_____
Both Confirmed Case Unknown
III. CASE Were blood/CSF extracted before the first dose of antibiotics was given to the patient?
MANAGEMENT:
Yes No Unknown
What antibiotics were given in the hospital?

IV. LABORATORY TESTS:

If YES, date Type of laboratory Results
Specimen Date result
taken test done N=Negative; I=Indeterminate; U-Unknown; ND= Not Done
MM DD YY MM DD YY
Culture Positive for: N I U ND
MM DD YY MM DD YY
CSF Latex agglutination Positive for: N I U ND
MM DD YY MM DD YY
Gram stain Positive for: N I U ND
MM DD YY MM DD YY
Blood Culture Positive for: N I U ND
 Page 2 of 2

Case Investigation Form

Meningococcal Disease

V. PAST HISTORY: Did the PATIENT or CLOSE CONTACT/S interact with a suspected or confirmed meningococcal case
within 2 weeks before onset of illness?
Yes, the patient Yes, close contact/s (name/s) __________________________________________

If yes, what was the name of the suspected or confirmed meningococcal case?

What is the address of the suspected or confirmed meningococcal case?

Where did the patient or close contact/s interact with the meningococcal case? When? MM/DD/YY Number of Days?

Did the PATIENT travel within 2 weeks prior to illness? If yes, where?
Yes No Unknown
Did a CLOSE CONTACT/S of the patient travel within 2 weeks prior to illness? If yes, who and where?
Yes No Unknown
Did the PATIENT attend any social gathering within 2 weeks prior to illness? If yes, where?
Yes No Unknown

Did the PATIENT have upper respiratory tract infection within 2 weeks prior to illness? Yes No Unknown
Did a CLOSE CONTACT/S have upper respiratory tract infection within 2 weeks prior to the patient’s illness?
Yes No Unknown, If Yes, who?

CASE DEFINITION/CLASSIFICATION:
 Suspected case: A person with sudden onset of fever (>38.5°C rectal or >38.0°C axillary) and one or more
of the following:
 neck stiffness
 altered consciousness
 other meningeal signs
 petechial or purpural rash

Note: In patients <1 year, suspect meningitis when fever is accompanied by bulging fontanels

 Probable case: A suspected case as defined above AND with Turbid cerebrospinal fluid (with or without
positive Gram stain) OR ongoing epidemic and epidemiological link to a confirmed case.

 Confirmed case: A suspected OR probable case with laboratory confirmation.

LABORATORY CONFIRMATION:
 Positive cerebrospinal fluid (CSF) antigen detection or culture.
 Positive blood culture.