# Pertussis Death Worksheet Instructions

1. **Decedent State of Residence**: State of decedent’s residence at time of cough onset.

2. **State Surveillance ID**: State-assigned, unique identifier assigned to pertussis case-patients. If the decedent did not meet the CSTE pertussis case definition for reporting, this field should be left blank. 

3. **County of Residence**: County of decedent’s residence at time of cough onset.

4. **State Where Death Occurred**: State where the decedent expired, which may differ from the state of residence if the decedent was treated or hospitalized away from home.

5. **Date of Birth**: Birth date of the decedent in MM/DD/YYYY format.

6. **Country of Birth**: Country where the decedent was born.

7. **Gestational age at birth**: For decedents < 1 year of age at time of cough onset, record the number of completed weeks of gestation at birth.  This data element should be left blank for case-patients ≥ 1 year of age.

8. **Cough Onset Date**: Date on which the decedent experienced first cough during the course of illness in MM/DD/YYYY format.

9. **Date of Death**: Date on which the decedent expired in MM/DD/YYYY format.

10. **Sex**: Indicate whether decedent is Male or Female.

11. **Race**: Decedent’s race reported by next of kin or recorded from medical records/death certificate; more than one option may be recorded.

12. **Ethnicity**: Decedent’s ethnicity reported by next of kin or recorded from medical records/death certificate. 

13. **Clinical Symptoms – General Instructions**: Select all of the clinical symptoms that the decedent experienced during the course of illness preceding their death. 

· **Cough**: Cough of any duration.

· **Apnea**: Prolonged failure to take a breath, possibly after a coughing spasm, or without prior coughing in an infant.  Apnea may occur with or without cyanosis.  *Next of kin report is sufficient to confirm the presence of apnea*.

· **Paroxysms**: Sudden, uncontrollable bursts or spells of coughing where one cough follows the next without a break for breath.

· **Post-tussive Vomiting**: Vomiting immediately following a paroxysm.

· **Whoop: A** high-pitched noise heard on inhalation after paroxysms of cough.

· **Cyanosis:** A bluish or purplish tinge to the skin or mucous membranes during the course of illness. *Next of kin report is sufficient to confirm the presence of cyanosis.*

· **Fever:** Only select if decedent experienced a temperature of ≥ 100.4 degrees Fahrenheit that is documented in their medical chart. This data element should be left blank for decedents who did not experience fever.

· **Rhinorrhea:** Watery discharge from the nose.

· **Other**: List any other symptoms experienced by the decedent that you feel are pertinent to their pertussis infection.

14. **Cough Duration**: The total number of days the decedent coughed from the date of cough onset to the date of death.   If decedent stopped coughing prior to the date of death but the last date of cough is unavailable, duration of cough should be calculated using the latest date at which cough was recorded by a clinician. For example, if the decedent began coughing on January 1, was recorded as coughing on January 8th  and died on January 27th (but had ceased coughing at an unknown date prior to death) the cough duration should be recorded as 7 days (i.e., January 8 – January 1.)  

15. **Pertussis Laboratory Results – General Instructions**: Select all of the pertussis-positive types of laboratory results associated with the decedent during the course of illness preceding their death.

· **Culture**: Isolation of *Bordetella pertussis* via bacterial culture.

· **PCR**: Detection of *Bordetella pertussis* or unspecified *Bordetella* species DNA via Polymerase Chain Reaction (PCR).

· **Serology**: Select if any positive pertussis serology results are available for the decedent; if multiple serologic test results are generated and results are discordant, any positive result should be noted here.

· **Respiratory****Panel**: If a multi-pathogen respiratory panel assay was used to diagnose pertussis, provide the panel name/manufacturer (e.g., BioFire/FilmArray).

· **Other**: Provide the type/name of any other positive pertussis test result associated with the decedent’s course of illness preceding their death.

16. **Complications Experienced – General Instructions**: Select all of the complications the decedent experienced during the course of illness preceding their death.

· **Pneumonia**: Pneumonia should be reported only if diagnosed by a healthcare provider and should not be based on report by next of kin.

· **Encephalopathy**: Acute illness of the brain manifesting as decreased level of consciousness (excluding  altered consciousness following an unrelated seizure) and reduced level of nervous system functioning.  Encephalopathy almost always results in hospitalization and requires extensive evaluation.  Acute encephalopathy should be reported only if diagnosed by a healthcare provider and should not be based on report by next of kin.

· **Seizures**: Select if the decedent ever experienced any seizures *not*associated with another diagnosis.  Next of kin report is sufficient to confirm the presence of seizures.

· **Lymphocytosis**: Select if the decedent was diagnosed with an elevated white blood cell count. Lymphocytosis should only be reported if diagnosed by a healthcare provider and documented in the medical chart or death certificate.

· **Other**: List any other documented complications that the decedent experienced during the course of illness preceding their death.

17. **Was Decedent Hospitalized**: Indicate whether the decedent was hospitalized at any time during the course of illness preceding their death. Hospitalization typically refers to admission into an in-patient care facility; however, a decedent also would be considered hospitalized if admitted for 24 or more hours in an observation unit or ER.  A decedent would not be considered hospitalized if admitted for a <24-hour observation period only. Be sure to include first admission date associated with decedent’s pertussis illness, as well as either the final date of discharge or date of death, where appropriate. If decedent was transferred between hospitals during their period of hospitalization, record only the first date of admission and last date of discharge.

18. **Treatments/Interventions – General Instructions**: Select all of the treatments or interventions the decedent received as a result of the illness that preceded their death; include the date the treatment or intervention was started.

· **Antibiotics**: Record any antibiotic treatment provided to the decedent during the course of illness preceding their death. *Refer to Appendix 1 for a complete list of antibiotic generic and brand names.*

· **Intubation**:  Record if decedent required placement of an endotracheal tube and mechanical ventilation during the course of illness preceding their death.  

Notes: 

· Mechanical ventilation is referred to as conventional ventilation (CV) or conventional mechanical ventilation (CMV).  Mechanical ventilation settings include A/C (assist control), IMV (intermittent mandatory ventilation), SIMV (synchronized IMV), PSV (pressure support ventilation).

· Include decedents on high frequency ventilation**:**Includes high frequency positive pressure ventilation (HPPV), high frequency percussive ventilation (HFPV), includes volumetric diffusive ventilation or (VDR), high frequency jet ventilation (HFJV, or “jet”), high frequency oscillatory ventilation (HFOV, or “oscillator”), and high frequency flow interrupter (HFFI).  

· Do not include decedents that only required supplemental oxygen (O2) without intubation (includes patients on nasal cannula [NC] or non-invasive positive pressure ventilation, such as CPAP [continuous positive airway pressure] and bilevel positive airway pressure [BiPAP or BPAP]).

· **ECMO:**Select if the decedent underwent Extracorporeal Membrane Oxygenation (ECMO) during the course of illness preceding their death.

Note: ECMO is a procedure that uses a machine to take over the work of the lungs (Veno-veno; VV) or the heart and lungs (Veno-arterial; VA).  It is sometimes used in pertussis patients with severe pulmonary hypertension. Evidence shows reductions in WBC count in ECMO-treated patients who present with very high WBC.

· **Other**: List any other treatments or interventions provided to the decedent during the course of illness preceding their death.

19. **Epi-linked to a Lab-Confirmed Case**: Indicate whether the decedent was epidemiologically-linked to another laboratory-confirmed case of pertussis, which was identified by either culture or PCR.

20. **Family History of Cough**: Indicate whether anyone in the decedent’s family or immediate household experienced acute cough illness within the 21 days prior to the decedent’s own cough onset.

21. **Underlying Health Issues – General Instructions**: Select any of the underlying health issues listed on the worksheet that the decedent experienced prior to or during the course of illness preceding their death. *Refer to Appendix 2 for a complete description of each option.*

22. **Co-Infections and Other Diagnoses – General Instructions**: Select any of the diseases listed on the worksheet diagnosed via laboratory testing that were identified during the decedent’s course of illness preceding their death.

23. **Decedent Pertussis Vaccination History – General Instructions**: Provide all documented doses of pertussis-containing vaccines administered to the decedent at least two weeks prior to their cough onset. Include each of the pieces of information listed below.  vaccine type, date of vaccine administration, and vaccine manufacturer and/or lot number, where available. *Refer to Appendix 3 for a complete list of vaccine types, names and manufacturers.*

· **Vaccine (Type or Name)**: For each documented dose of vaccine, record the type and/or brand name.

· **Date Administered**: For each *documented* dose of vaccine, please list the date of administration in MM/DD/YYYY format.  If only month and year are available, fill in ‘15’ for the day portion of the date.

· **Manufacturer and/or Lot Number**: Record the manufacturer and or lot number associated with the dose of vaccine.

24. **Maternal Tdap History – General Instructions:**For decedents < 12 months of age, provide all documented doses of Tdap administered to the decedent’s biological mother, either prior to, during, or following her pregnancy with the decedent. For each documented dose of Tdap administered to the decedent’s biological mother, include each of the pieces of information listed, below. *Refer to Appendix 3 for a complete list of vaccine types, names and manufacturers.*

· **Date Administered**: For each *documented* dose of Tdap, please list the date of administration in MM/DD/YYYY format.  If only month and year are available, fill in ‘15’ for the day portion of the date.

· **Pregnancy Status at Administration**: Indicate whether decedent’s biological mother was Pregnant, Post-Partum (within the 30 days following birth), or Neither at the time of Tdap administration.

· **Week of Pregnancy**: If decedent’s biological mother was pregnant with the decedent at the time of Tdap administration, record the number of weeks of pregnancy she had *completed* on the date of administration.

· **Delivery Date/Expected Delivery Date**: If decedent’s biological mother was pregnant with the decedent at the time of Tdap administration, record the mother’s delivery date or expected delivery date in MM/DD/YYYY FORMAT.

· **Manufacturer and/or Lot Number**: Record the manufacturer and or lot number associated with the dose of Tdap.

25. **Post Mortem Examination and Death Certificate Information**

· **Was Post-Mortem Exam Done**: Indicate whether a post-mortem examination was completed for the decedent. 

· **Is Death Certificate Available**: Indicate whether the decedent’s death certificate was available when completing the pertussis death worksheet.

· **Causes of Death/ICD-10 Codes**: Using the decedent’s death certificate, list all of the causes of death, including complete ICD-10 codes; be sure to include all decimal points where applicable.

· **Contributing Conditions/ICD-10 Codes**: Using the decedent’s death certificate, list all of the contributing conditions, including complete ICD-10 codes; be sure to include all decimal points where applicable.

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