GENERIC MMG Pertussis Surveillance Worksheet Pertussis MMG Appendix 11-3 

NAME (Last, First) Hospital Record No.

Address (Street and No.) City PID-11.3 County PID-11.9 Zip PID-11.5 Phone

Reporting Physician/Nurse/Hospital/Clinic/LabPhone 48766-0 Address Phone

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CDC NETSSid County PID-11.9 State PID-11.4 Zip PID-11.5

Birth Date PID-7

 

month day year 

Age 77998-3

 

Unk=999

Age Type OBX-6 for 77998-3

 0 = 0-120 years 3 = 0-28 days 

 1 = 0-11months 9 = Age Unknown 

 2 = 0-52 weeks

Race PID-10

 N = Native American/Alaskan W = White

 A = Asian/Pacific Islander O = Other 32624-9

 B = AfricanAmerican U = Unknown

Ethnicity PID-22

 H = Hispanic

 N = Not Hispanic

 U = Unknown

Sex PID-8 M = Male 

 F = Female

 U = Unknown

Event Date

 

month day year

Event Type 

 1 = Onset date 11368-8 4 = Reported to County 77972-8

 2 = Diagnosis date 5 = Reported to State or MMMWR report date

 3 = Lab test done 9 = Unknown

Outbreak 

Associated

 77980-1

999 = Unknown

Reported 77995-9

 

month day year 

Report Status

 1 = Confirmed 3 = Suspect

 2 = Probable 9 = Unknown 

77990-0

CLINICAL DATA

Any Cough? 

 Y = Yes N = NoINV919 U = Unknown 49727002 

Cough Onset 85932-2

 

 Month Day Year

Paroxysmal Cough? 

 Y = Yes 43025008 N = No

 U = Unknown 

Whoop? 

 Y = Yes N = No

 U = Unknown

COMPLICATIONS

Chest X-ray for Pneumonia P = Positive X = Not Done

 N = Negative U = Unknown

Seizures Due to Pertussis Y = Yes 67187-5 

 N = No INV920 

 U = Unknown

Posttussive Vomiting? Y = Yes 424580008 N = No

 U = Unknown 

Apnea? 

 Y = Yes N = No

 U = Unknown 

Final Interview Date INV555

 

Month Day Year

Acute Encephalopathy Due to Pertussis 67187-5 Y = Yes

 N = No INV920 U = Unknown 

Cough at Final Interview? PRT008 Y = Yes N = No

 U = Unknown 

Duration of Cough at Final 85933-0

Interview 0-160

 Days 999 = Unknown 

Hospitalized? Days Hospitalized?

 Y = Yes 77974-4 0-998 78033-8 N = No 999 = Unknown

 U = Unknown

Died? 77978-5

 Y = Yes

 N = No

 U = Unknown

TREAETMENT

Were Antibiotics Given? 29303-5 Y = Yes INV559 1 = Erythromycin (incl.pediazole, liosome) 6 = Other

 N = No 2 = Cotrimoxazole (bactrim/septra) 9 = Unknown

 U = Unknown 3 = Clarithromycin/azithromycin

 4 = Tetracycline/Doxycycline

 5 = Amoxicillin/Penicillin/Ampicillin/Augmentin/Cector/Cefixime 

Date Started First Antibiotic Days First Antibiotic Actually Taken

 86948-7 0-998 67453-1 month day year 999 = Unknown

LABORATORY

Was Laboratory Testing for Pertussis Done? LAB630

 Y = Yes

 N = No Result Date Specimen Taken 68963-8

 U = Unknown INV291 Month Day Year

 549-6 Culture 

 

 550-4 DFA

 

 Serology 1

 

 Serology 2

 23826-1 PCR

Second Antibiotic Received

 See choices for first antibiotic given

 29303-5 

Date Started Second Antibiotic Days Second Antibiotic Actually Taken

 86948-7 0-998 67453-1 999 = Unknown

 month day year 

VACCINE HISTORY

Vaccinated? (Received any doses of diphtheria, VAC126 

tetanus, and/or pertussis-containing vaccines) 

EPIDEMIOLOGIC INFORMATION

Date First Reported to a 

Health Department 77970-2

 

 N

 U

 

 

 Month Day Year

Date Case Investigation 

Started 77979-3

Month Day Year

Vaccination Date 30956-7 Vaccine Vaccine Lot Number

 Month Day Year Type Manuf 30959-1

 Outbreak Related? 77980-1

 Y = Yes

 N = No

 U = Unknown

Epi-Linked? INV927

 Y = Yes

 = No

 = Unknown

Outbreak Name (Name of outbreak this case is associated with)

 77981-9

If Patient <12 months old: 

 What was the mother’s age at infant’s birth? 85724-3

 What was the weight of the Infant at birth? 56056-5

OBX-6 for 56056-5 _______ lb _______ oz OR _______ kg _______ g

Transmission Setting (Where did this patient acquire pertussis)? 1 = Day Care 6 = Hosp. Outpatient Clinic 11 = Military

2 = School 7 = Home 12 = Correctional Facility

3 = Doctor’s Office 8 = Work 13 = Church

4 = Hospital Ward 9 = Unknown 14 = International Travel

5 = Hospital ER 10 = College 15 = Other Date of Last Pertussis-Containing 

Vaccine Pior to Illness Onset VAC142

 Month Day Year

Number of Doses of PertussisContaining Vaccine Prior to Illness 

Onset 0 – 6 82745-1 

 9 = Unknown 

Setting (Outside Household) of Further Documented 

Spread From This Case INV561

 Use same codes as for Transmission Settings, except: 

 7 = >1 Setting Outside Household Reason Not Vaccinated With ≥ 3 Doses of Pertussis Vaccine VAC149 16 = No Documented Spread Outside Household

 1 = Religious Exemption 5 = Parental Refusal

 2 = Medical Contraindication 6 = Age <7 months

 3 = Philosophical Exemption 7 = Other 

 4 = Previous Pertussis Confirmed by Culture or MD 9 = Unknown

Number of Contacts in Any Setting Recommended 

Antibiotics INV562 0-998 

 999 = Unknown

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 RESULT CODES

P = Positive E = Pending X = Not Done U = Unknown

N = Negative I = Indeterminate S = Parapertussis 

Y = Yes

N = No

U = Unknown

Vaccine Type Series W = DPT Whole Cell V = DTap-IPV-Hep B

A = DTaP N = DTap-IPV-Hib

H = DTap-Hib K = DTap –IPV 

D = DT o Td O = Other 

T = DTP-Hib U = Unknown 

P = Pertussis Only

X = Tdap

Vaccine Manufacturer Codes

C = Sanofi Pasteur

L = Wyeth

S = GlaxoSmithKline

M = Massachusetts Health Department

I = Michigan Health Department

N = North American Vaccine

O = Other U = Unknown

INV923

60537006

1023001

81267-7

30952-6 30957-5

77997-5

77975-1

OBX-19

77973-6
 

 

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The information below is epidemiologically important,

but not included on NETSS screens.

Setting In which setting was pertussis acquired?

(Please specify) In which setting was there secondary spread?

(Please specify)

Day care

School

Doctor’s Office

Hospital

(Ward/Outpatient/Clinic)

Home

Travel

(International/Domestic)

Other

Unknown

Name of Contact Birthdate

Relation to 

CasePatientCase? Case ID # 

Case Onset 

Date 

(if present)

Number 

of 

PCVs*

Date of Last 

PCV

Parents’ Name and 

Phone Number

(if applicable)

PRT077 PRT088

 

 *PCV=Pertussis-Containing Vaccine

 Comments

 77999-1

 Age PRT074 Age Type OBX_6 for PRT074 

Age of the person from whom this patient contracted pertussis 0 = 0 – 120 years 3 = 0 – 28 days

 999 = Unknown 1 = 0 – 11 months 9 = Age unknown

 2 = 0 - 52 weeks 
Clinical Case Definition*:

A cough illness lasting ≥ 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop”, or posttussive vomiting, without apparent cause

Case Classification*: 

Probable: A case that meets the clinical case definition is not laboratory confirmed, and is not epidemiologically linked to a laboratory-confirmed case. 

Confirmed: 1) A case that is culture positive, and in which an acute illness of any duration is present, or 

2) a case that meets the clinical case definition and is confirmed by PCR, or 

3) a case that meets the clinical case definition and is epidemiologically linked directly to a case confirmed by either culture or PCR.

*CDC Case Definitions for Infectious Conditions Under Public Health Surveillance. MMWR 1997;46 (No. RR-10):39

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