Appendix 17-4

Congenital Rubella Syndrome Case Report

 

________________________________________________________________________________________________ 

 : 

 Month Day Year 85734-2 Month Day Year 

 

Child’s Name Last First Middle

 

Current Address: (County PID-11.9, State PID-11.4, and Zip Code PID-11.5) Age Congenital Rubella Syndrome Diagnosed: 63932-8

_____ Years _____ Months 

 

 

 

 

 

 

 

 

 

 

 

 

Less than 1 Month Unknown

Date of Birth: PID-7

Month Day

 Year

Birth Weight: 8339-4

_____ Grams 

OBX-6 for 8339-4

_____ lbs _____ oz

 Unknown

Gestational Age:

18185-9 

_____ Weeks

Sex: PID-8

 M F 

Unknown

RACE: PID-10

 American Indian or Alaskan Native

 Asian or Pacific Islander

 Black

 White

 Other (specify) ___________________

Ethnicity: PID-22

 Hispanic Origin

 Not of Hispanic Origin

 Unknown

II CLINICAL CHARACTERISTICS

 67187-5 INV920 Yes No Unk INV920 Yes No Unk 

Cataracts ................................................................................ Meningoencephalitis ............................

Hearing Loss .......................................................................... Microcephaly .......................................

Mental Retardation .................................................................. Purpura .............................................

Congenital Heart Disease 1. Patent Ductus Arteriosus ........................ Enlarged Spleen .................................

 2. Peripheral Pulmonic Stenosis ................... Enlarged Liver ....................................

 3. Congenital Heart Disease ........................ Type Unknown

 4. Other (Specify) __________________________________

Long Bone Radiolucencies ..................

Congenital Glaucoma ..........................

Pigmentary Retinopathy ......................

Other Abnormalities: ________________________________________________________ 

 ___________________________________________________________________________________________

 

 

Yes No Unknown If Yes, specify 67187-5 

Is Child Living? Yes No Unknown

If No, Date of Death 

 PID-29 Month Day Year

Causes of Death: (from death certificate)

1. _____________________________________________________________________________________INV337

2. _____________________________________________________________________________________INV338

If Child Died, Was Autopsy Performed?

 __________________________________________________________________ Yes No Unknown

Final Anatomical Diagnosis:

__________________________________________________________________

III MATERNAL HISTORY

Mother’s Name:

 Last First Middle

__________________________________________

Age at Delivery:

85724-3 

_____ Years OBX-6 

Occupation at Time of Conception: 85658-3

______________________________ 

Did Mother Attend Family

Planning Clinic Prior to

Conception? 85723-5 

 

 

 

 

 

 

 

 

 

 

 

Yes No Unknown

Number of Previous

Live Births: 75202-2

______ Unknown

Number of Previous

Pregnancies: 75201-4 

______ Unknown

Prenatal Care for this Pregnancy:

Yes No Unknown 75204-8

Date of First Visit: 75200-6 

 Month Day Year

 Unknown

Was Prenatal Care Obtained in:

Public Sector 85718-5

Private Sector

Unknown

Rubella-like Illness During Pregnancy:

 

 

 

 

Yes No Unknown 85716-9

If Yes, Month of Pregnancy: 85715-1

_________ Unknown

Was Rubella Diagnosed by a Physician MTH124

At the Time of Illness? Yes No Unknown 

If not MD, by Whom? MTH125

________________________________________________________

Was Rubella Serologically Confirmed

At the Time of Illness? 85711-0

Yes No Unknown

Location of Exposure: 85710-2

Within the United States 

 

Yes No Unknown 

Outside the United States Yes No Unknown

If Yes, specify country 77984-3; also specify county 77987-6 and

city 77986-8 , if known:

________________________________________________________

________________________________________________________

 

If Location of Exposure is Unknown, did

Mother Travel Outside of U.S. During the 

First Trimester of Pregnancy? 85709-4

 Yes No Unknown

If Yes, specify country; also specify county and city, 

if known: 82764-2 

__________________________________

Date of Travel:

 82752-7 Month Day Year

 

 

Unknown

Source of Exposure: Was the Mother Directly 

Exposed to a Known Rubella Case? 85708-6

Yes No Unknown

If yes, specify Relationship: 85707-8

_______________________________________

Date of Exposure: 

 85706-0 Month Day Year

 Unknown

Number of Other Children Less than 18 Years of Age Living in Household During this Pregnancy: 85722-7 _______Were Any of the Children Immunized with Rubella Vaccine? 85721-9

Yes No Unknown

 022009 Page 1 of 2

 

Date of Report: Date of last Evaluation of Infant

I PATIENT INFORMATION

 Unemployed

 Unknown

 OBX-6 for 63932-8

77995-9
Clinical Features of Maternal Illness:

Rash ......85733-4 

 

 

 

 

 

 

 

 

 

 

 

 I

Yes No Unknown

If Yes, Date of Onset: 85732-6

 Month Day Year 

Fever ......85730-0..... Yes No Unknown 

Lymphadenopathy 85727-6 Yes No Unknown

Arthralgia/Arthritis 85794-6 Yes No Unknown

Other (specify) 85726-8 ______________________________

Was Mother Immunized with Rubella Vaccine?

Yes No Unknown 85702-9 

If Yes, Date Vaccinated: 30952-6

 Month Day Year

If Yes, Source of Information: 48766-0

Physician Mother Only

School Other (specify) __________________

Public Sector Private Sector

Unknown

Did the Mother Have Serological Testing for 

Rubella Immunity Prior to Exposure? 85717-7 

Yes No Unknown 

If Yes, Date: 

85674-0 Month Day Year

If Yes, Interpretation of Test Results: 85675-7

Susceptible mmune Unknown

(If more than one serologic test, include dates and results for each time tested.)

IV LABORATORY

Specimens for Viral Study Yes No LAB630 

Mother 85793-8 Infant

(check one) Type Specimen 66746-9 

Date Collected 68963-8 Laboratory

82771-7 

Specific Test Methods Used 

INV290 (See below)*

Test Results

INV291 LAB628

 / /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

V APPRAISAL

 Confirmed Probable Possible nfection Only Not CRS Stillbirth Unknown I INV935 Indigenous to U.S . Imported to U.S. INV516

Investigator’s Name (print): ____________________________________________________________________Telephone:

_____________________________________________

Date:

____________________________________

Physician Responsible for Child’s Care

________________________________________________________________________________________________________________________

Date:

____________________________________

Source of Report 48766-0 Private MD Death Record Birth Record Laboratory Hospital Other 

LAB TEST METHODS

a) Viral Cultures d) ELISA g) Passive Hemagglutination (PHA)

b) RIA e) Hemagglutination Inhibition h) Other ______________________________________________________

c) IFA f) Latex Agglutination

*If antibody testing was performed, specify which Rubella-specific immunoglobin antibody (IgM or IgG) was used.

Clinical Case Definition 

 An illness of newborns resulting from rubella infection in utero and characterized by signs and 

symptoms in the following categories:

 A Cataracts/congenital glaucoma, congenital heart disease (most commonly patent ductus 

arteriosus, peripheral pulmonary artery stenosis), loss of hearing, pigmentary retinopathy.

 B Purpura, splenomegaly, jaundice, microcephaly, mental retardation, meningoencephalitis, 

radiolucent bone disease.

Clinical Description 

 The presence of any defects or laboratory data consistent with congenital rubella infection (as 

reported by a health professional).

Laboratory Criteria for Diagnosis 

 ▪ Isolation of rubella virus, or 

 ▪ Demonstration of rubella-specific IgM antibody, or 

 ▪ An infant’s rubella antibody level that persists above and beyond that expected form passive 

transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of twofold 

dilution per month).

Case Classification

 Possible: A case with some compatible findings but not meeting the criteria for a probable case.

 

 Probable*: A case that is not laboratory-confirmed and that has any two complications listed in A 

above, or one complication A and one from B.

 

 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.

* In probable cases, either or both of the eye-related findings (cataracts and congenital glaucoma) count as a single complication

Imported to U.S.

 A case which has its source of exposure outside the United States.

Indigenous to U.S.

 A case which cannot be proved to be imported.

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