Appendix 17 Congenital Rubella Syndrome Case Report

Date of Report: hh hh hhhh 

Month Day Year

Date of last Evaluation of Infant: hh hh hhhh

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 Less than 1 Month Unknown

Date of Birth:

Month Day

Year

Birth Weight:

Grams

lbs. oz.

Unknown

Gestational Age:

Weeks

Sex:

M F

Unknown

Race:

American Indian or Alaska Native

 Asian or Pacific Islander

Black

White

 Other (specify)

Ethnicity:

Hispanic Origin

Not of Hispanic Origin

 Unknown

ll CLINICAL CHARACTERISTICS

Cataracts

Hearing Loss

Mental Retardation

Congenital Heart Disease 1. Patent Ductus Arteriosus

2. Peripheral Pulmonic Stenosis

3. Congenital Heart Disease

Type Unknown

4. Other (Specify)

Meningoencephalitis

Microcephaly

Purpura

Enlarged Spleen

Enlarged Liver

Long Bone Radiolucencies

Congenital Glaucoma

Pigmentary Retinopathy

Other Abnormalities: Yes No Unknown If Yes, specify

Is Child Living? Yes No Unknown

If No, Date of Death

If Child Died, Was Autopsy Performed?

Yes No Unknown

Causes of Death: (from death certificate)

Final Anatomical Diagnosis:

lIl MATERNAL HISTORY

 h h h 

Yes No Unk.

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 . . . . . . . . . . . . . . . . . . h h h

...................... h h h 

Yes No Unk.

 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h h h

.......................................................... h h h

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....................................................... h h h

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 ................................................ h h h

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h h

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h

h h h 

hh hh hhhh 

Month Day Year

h h h 

Mother’s Name:

Last First Middle

Age at Delivery:

 Years

Occupation at Time of Conception:

h Unemployed

h Unknown

Did Mother Attend Family 

Planning Clinic Prior to 

Conception?

Yes No Unknown

Number of Previous 

Live Births:

Unknown

Number of Previous

Pregnancies:

Unknown

Prenatal Care for this Pregnancy:

 Yes No Unknown

Date of First Visit:

Month Day Year 

Unknown

Was Prenatal Care Obtained in:

Public Sector

Private sector

Unknown

Rubella-Like Illness During Pregnancy:

Yes No Unknown

If Yes, Month of Pregnancy:

 Unknown

Was Rubella Diagnosed by a Physician 

at Time of Illness? Yes No Unknown

If not MD, by Whom?

Was Rubella Serologically Confirmed 

at Time of Illness?

Yes No Unknown

Location of Exposure:

Within the United States hYes h No h Unknown

Outside the United States hYes h No h Unknown

If Yes, specify country; also specify county and city, if known:

If Location of Exposure is Unknown, did 

Mother Travel Outside the U.S. During the

First Trimester of Pregnancy?

Yes No Unknown

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

if known:

Date of Travel:

Month Day Year

Unknown

Source of Exposure: Was the Mother Directly 

Exposed to a Known Rubella Case?

Yes No Unknown

If Yes, specify relationship:

Date of Exposure:

Month Day Year

Unknown

Number of Other Children Less than 18 Years of Age Living in Household During this Pregnancy:Were Any of the Children Immunized with Rubella Vaccine?

hYes h No h Unknown

h h h 

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h 

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h h h 

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h h h 

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1.

2.

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:

Rash Yes No Unknown

If Yes, Date of Onset:

Month Day Year

Fever Yes No Unknown

Lymphadenopathy Yes No Unknown

Arthralgia/Arthritis: Yes No Unknown

Other (specify)

Was Mother Immunized with Rubella Vaccine?

Yes No Unknown

If Yes, Date Vaccinated:

Month Day Year

If Yes, Source of Information:

Physician Mother Only

School Other (specify)

Public Sector Private Sector

Unknown

Did the Mother Have Serological Testing for 

Rubella Immunity Prior to Exposure?

 Yes No Unknown

If Yes, Date:

Month Day Year

If Yes, Interpretation of Test Results:

Susceptible Immune Unknown

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

 

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IV LABORATORY

Specimens for Viral Study Yes No

Mother Infant

(Check one) Type Specimen Date Collected Laboratory

Specific Test 

Methods Used 

(See below)*

Test Results

V APPRAISAL

 Confirmed Probable Possible Infection Only Not CRS Stillbirth Unknown Indigenous to U.S. Imported to U.S.

Investigator's Name (print):

Physician Responsible for Child’s Care: Telephone:

Source of Report:

 Private MD Death Record Birth Record 

Telephone: Date:

Laboratory Hospital Other

LAB TEST METHODS

a) Viral Cultures 

b) RIA 

c) IFA 

d) ELISA 

e) Hemagglutination Inhibition

f) Latex Agglutination

g) Passive Hemagglutination (PHIA)

h) Other (Specify)

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

DEFINITIONS

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.

CDC 71.17 (DRAFT) Rev. 02/2009, Page 2 of 2