Appendix 12.1

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:

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:

10. Sex: 

11. Race: 

12.Ethnicity:

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.

• 

• 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:

15. Pertussis Laboratory Results—General Instructions:

• 

• 
Appendix 12.2

• 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]).
Appendix 12.3

• 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.
Appendix 12.4

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.

APPENDIX 1: Antibiotics- Alphabetized by Generic Name

Generic Name Brand Name

AMIKACIN AMIKACIN

AMOX/CLAVULANATE AUGMENTIN

AMOXICILLIN AMOXICILLIN

AMOXICILLIN AMOXIL

AMOXICILLIN TRIMOX

AMPICILLIN AMPICILLIN SODIUM

AMPICILLIN PRINCIPEN

AMPICILLIN/SULBACTAM UNASYN

AZITHROMYCIN AZITHROMYCIN

AZITHROMYCIN ZITHROMAX 

AZITHROMYCIN ZITHROMAX Z-PAK

AZTREONAM AZACTAM

CARBENICILLIN GEOCILLIN

CEFACLOR CECLOR

CEFACLOR CEFACLOR 

CEFADROXIL CEFADROXIL

CEFADROXIL DURICEF

CEFADROXIL KEFLEX 

CEFADROXIL KEFTAB

CEFAZOLIN CEFAZOLIN SODIUM

CEFDINIR OMNICEF

CEFDITOREN SPECTRACEF

CEFEPIME MAXIPIME

CEFIXIME SUPRAX

CEFOTAXIME CEFOTAXIME SODIUM

CEFOTAXIME CLAFORAN

CEFOTETAN CEFOTETAN DISODIUM

CEFOXITIN CEFOXITIN SODIUM

CEFPOXODIME VANTIN

CEFPROZIL CEFPROZIL

CEFPROZIL CEFZIL

CEFTAZIDIME CEFTAZIDIME PENTAHYDRATE

CEFTIBUTEN CEDAX
Appendix 12.5

APPENDIX 1: Antibiotics- Alphabetized by Generic Name

Generic Name Brand Name

CEFTIZOXIME CEFIZOX

CEFTRIAXONE CEFTRIAXONE SODIUM

CEFTRIAXONE ROCEPHIN

CEFUROXIME CEFTIN

CEFUROXIME CEFUROXIME

CEPHALEXIN CEPHALEXIN

CHLORAMPHENICOL CHLOROMYCETIN

CIPROFLOXACIN CIPRO

CIPROFLOXACIN CIPROFLOXACIN

CLARITHROMYCIN BIAXIN

CLARITHROMYCIN CLARITHROMYCIN

CLINDAMYCIN CLEOCIN 

CLINDAMYCIN CLINDAMYCIN 

COLESTIMETHATE COLY-MYCIN

COLISTIN COLY-MYCIN

DAPTOMYCIN CUBICIN

DEMECLOCYCLINE DEMECLOCYCLINE HCL

DICLOXACILLIN DICLOXACILLIN

DIRITHROMYCIN DYNABAC 

DORIPENEM DORIBAX

DOXYCYCLINE ADOXA

DOXYCYCLINE DORYX EC

DOXYCYCLINE DOXYCYCLINE

DOXYCYCLINE MONODOX

DOXYCYCLINE VIBRAMYCIN

ERTAPENEM INVANZ

ERYTHROMYCIN ERY E-SUCC/SULFISOXAZOLE

ERYTHROMYCIN ERYPED

ERYTHROMYCIN ERY-TAB EC

ERYTHROMYCIN ERYTHROCIN

ERYTHROMYCIN ERYTHROMYCIN 

ERYTHROMYCIN PCE 

GATIFLOXACIN TEQUIN

GEMIFLOXACIN FACTIVE

GENTAMICIN GENTAMICIN SULFATE

IMIPENEM IMIPENEM/CILASTATIN SODIUM

IMIPENEM PRIMAXIN

IMIPENEM/CILASTIN PRIMAXIN I.V.

KANAMYCIN KANAMYCIN SULFATE

LEVOFLOXACIN LEVAQUIN

LEVOFLOXACIN LEVOFLOXACIN

LINCOMYCIN LINOCIN

LINEZOLID LINEZOLID
Appendix 12.6

APPENDIX 1: Antibiotics- Alphabetized by Generic Name

Generic Name Brand Name

LINEZOLID ZYVOX 

LORACARBEF LORABID

MEROPENEM MERREM

METHENAMINE HIPREX

METHENAMINE UREX

METRONIDAZOLE FLAGYL

METRONIDAZOLE METRONIDAZOLE

MINOCYCLINE DYNACIN

MINOCYCLINE MINOCIN PELLETIZED

MINOCYCLINE MINOCYCLINE

MOXIFLOXACIN AVELOX

MOXIFLOXACIN MOXIFLOXACIN HCL

NAFCILLIN NAFCILLIN SODIUM

NITROFURANTOIN FURADANTIN

NITROFURANTOIN MACROBID

NITROFURANTOIN MACRODANTIN

NITROFURANTOIN NITROFURANTOIN 

NORFLOXACIN NOROXIN

OXACILLIN FLOXIN

OXACILLIN OXACILLIN

PENICILLIN PEN G BENZ/PEN G PROCAINE

PENICILLIN PENICILLIN

PENICILLIN PENICILLIN VK

PENICILLIN VEETIDS

PIPERACILLIN PIPERACIL

PIPERACILLIN PIPERACILLIN SODIUM

PIPERACILLin/TAZOBACTAM PIPERACILLIN/TAZOBACTAM SODIUM

PIPERACILLin/TAZOBACTAM ZOSYN

POLYMYXIN B POLYMYXIN B SULFATE

QUINUPRISTIN/DALFOPRISTIN QUINUPRISTIN/DALFOPRISTIN

QUINUPRISTIN/DALFOPRISTIN SYNERCID

RIFAMPICIN RIFADIN

RIFAMPIN RIFADIN

SMX/TMP BACTRIM DS 

SMX/TMP SEPTRA DS

SMX/TMP SULFAMETHOXAZOLE W/TMP

SMX/TMP SULFAMETHOXAZOLE/TRIMETHOPRIM

SMX/TMP SULFATRIM

STREPTOMYCIN STREPTOMYCIN

SULFACETAMIDE SULFACETAMIDE SODIUM

SULFADIAZINE SULFADIAZINE

SULFAMETHOXAZOLE/TRIMETHOPRIM CO-TRIMOXAZOLE

SULFASALAZINE AZULFIDINE
Appendix 12.7

APPENDIX 1: Antibiotics- Alphabetized by Generic Name

Generic Name Brand Name

SULFASALAZINE SULFASALAZINE

SULFISOXAZOLE SULFISOXAZOLE

TELITHROMYCIN KETEK

TETRACYCLINE ACHROMYCIN V

TETRACYCLINE SUMYCIN 

TETRACYCLINE TETRACYCLINE

TICARCILLIN TICARCILLIN

TICARCILLIN/CLAVULANATE TICARCILLIN/K CLAVULANATE

TICARCILLIN/CLAVULANATE TIMENTIN

TIGECYCLINE TYGACIL

TOBRAMYCIN TOBI

TOBRAMYCIN TOBRAMYCIN SULFATE

TRIMETHOPRIM TRIMETHOPRIM

VANCOMYCIN VANCOCIN

APPENDIX 2: Underlying Health Issues

AIDS or CD4 count <200 This includes patients 1) diagnosed with AIDS and 2) those who are HIV+ 

and whose CD4 count was ever <200, even if AIDS is not a diagnosis 

noted in the chart.

The CD4 count from the current illness/admission being investigated may 

be used to determine if the person has AIDS and is most often listed in the 

admission history and physical or discharge summary; prior charts do not 

need to be reviewed.

The lowest CD4 count is often listed in the admission history and physical 

or discharge summary. If “AIDS” is checked, “HIV Infection” should also 

be checked, but if HIV is present, AIDS should only be checked if it is the 

diagnosed in the chart of if the CD4 count is <200.

Alcohol abuse Current: abuse of alcohol within the past 12 months or timing unknown.

Past: abuse of alcohol beyond 12 months or clearly noted as “former” in 

the chart.

Includes ETOHA (ethanol abuse).

Aspiration, history of Aspiration is the inhalation of oropharyngeal or gastric contents into the 

lower airways, and can lead to aspiration pneumonia or pneumonitis.

Persons at risk for aspiration and aspiration pneumonia are those with 

altered consciousness (anything that reduces the gag reflex) neurologic 

problems and swallowing dysfunction.

This should only be checked if patient’s past medical history notes a 

history of ‘aspiration’ or ‘aspiration pneumonia’.

Asthma Chronic lung disease in which the airways become narrowed and inflamed.

Note on “Reactive airway disease”. RAD is a term used in young children 

who have had several episodes of wheezing; it’s a precursor to asthma, 

but not all persons with RAD with have asthma. Unless “asthma” is stated 

in the chart, RAD alone would not count as asthma (and would also not 

count as emphysema or COPD. If a history RAD reported in chart, check 

the box for RAD.

Atherosclerotic cardiovascular disease 

(ASCVD)/CAD

This is also described as Arteriosclerotic Heart Disease, CAD (coronary 

artery disease), and CHD (coronary heart disease). Also includes heart 

attacks and myocardial infarctions.

Bone Marrow Transplant May be indicated as ‘bone marrow transplant’, ‘BMT’ ‘hematopoietic stem 

cell transplantation’ or ‘HSCT’, ‘peripheral blood stem cell transplantation’ 

or ‘PBSCT’.
Appendix 12.8

APPENDIX 2: Underlying Health Issues

Bronchopulmonary Dysplasia (BPD) A chronic lung disease in premature infants, generally resulting from 

treatment of respiratory distress syndrome with mechanical ventilation.

Also called Chronic Lung Disease (CLD), however this is a specific term 

applied to CLD of infancy. This should not be applied to persons noted to 

have a chronic lung disease such as COPD or asthma.

Cerebral Vascular Accident (CVA)/Stroke Includes any history of CVA or stroke. This does not include a history of 

a TIA (transient ischemic attack).

Chronic kidney disease Chronic renal disease; a progressive loss in renal function over time. 

Does not include decedents with acute renal failure. Also, not all persons 

with CKD will be on dialysis. 

Cirrhosis/Liver failure This does not include hepatitis A, hepatitis B, or hepatitis C infection 

without liver failure and does not include acute liver failure.

Complement deficiency Complement deficiencies are a group of disorders in which there is a 

reduced level of specific proteins that are needed for a normal immune 

response (“complement”).

Examples of specific complement deficiencies are: C1 qrs deficiency, 

C3 deficiency, C2-C4 deficiency, C5-9 deficiency.

Congenital heart disease Includes: Ebstein’s anomaly, Hypoplastic left heart (HLH), Pulmonary 

atresia, Tetralogy of Fallot (TOF), Total anomalous pulmonary venous 

return (TAPVR), Transposition of the great vessels, Tricuspid atresia, 

Truncus arteriosus, Aortic stenosis, Atrial septal defect (ASD), 

Atrioventricular canal (endocardial cushion defect), Coarctation of the 

aorta (“coarc”), Patent ductus arteriosus (PDA), Pulmonic stenosis, 

Ventricular septa defect (VSD)

Current chronic dialysis Dialysis is a treatment that does some of the things done by healthy 

kidneys. It is needed when a person’s kidneys can no longer take care of 

the body’s needs. 

For this question, the interest is in whether a patient was on “chronic 

dialysis” before their pertussis infection They may have received “chronic 

dialysis” either as in inpatient or outpatient. They may have received either 

“hemodialysis” or “peritoneal dialysis”. 

If the patient was placed on dialysis as a result of their infection,DO NOT 

check this box. 

NOTE: “Chronic kidney disease” and “current chronic dialysis” are 

overlapping variables (either or both may be checked). Indicate whatever 

is noted in the chart based on the instructions provided.

Cystic Fibrosis An inherited disease of the secretory glands, including the lungs

Dementia Significant loss of brain and/or cognitive function that interferes with daily 

function.

Includes Alzheimer’s, multi-infarct dementia, and senile dementia. Does 

not include persons with diminished capacity and/or considered mentally 

challenged.

Diabetes mellitus Includes either type I or type II (both “insulin-dependent” and “adult-onset”). 

Also includes glucose intolerance and new-onset diabetes. Do NOT include 

decedents noted as “pre-diabetic” or those with gestational diabetes. It is 

not necessary to look at the results of glucose tolerance test in laboratory 

results section of the chart for an indication of diabetes. 

Common abbreviations: DM, AODM, IDDM, NIDDM.

Emphysema/COPD COPD=chronic obstructive pulmonary disease. Includes chronic 

bronchitis.

Heart failure/CHF Congestive heart failure, including cardiomyopathy

HIV Infection Not everyone who develops an HIV infection will have AIDS.

If “AIDS” is checked, “HIV Infection” should also be checked.

Hodgkin’s Disease/lymphoma This cancer of the lymph system results in “immunocompromised for life” 

so should be marked if any history.
Appendix 12.9

APPENDIX 2: Underlying Health Issues

Immunoglobulin deficiency Includes syndromes such as SCID (severe combined immunodeficiency), 

agammaglobulinemia, Ig, IgM, or IgG deficiencies, Wiskott-Aldrich 

Syndrome.

Immunosuppressive therapy 

(Steroids, Chemotherapy, Radiation)

Treatment with agents, such as X-rays, corticosteroids, or cytotoxic 

chemicals that suppress a person’s immune response to antigen(s). 

Immunosuppressive drugs are most commonly used to prevent rejection 

of organs and tissues after transplant and to treat autoimmune diseases 

(such as multiple sclerosis, systemic lupus erythematosus, multiple 

myeloma, inflammatory bowel disease (i.e., Crohn’s and Ulcerative Colitis), 

rheumatoid arthritis, psoriasis, etc.) and other inflammatory diseases 

(i.e., sarcoidosis—note sarcoidosis is not an underlying condition for an 

ABCs infection). 

This should be checked if the chemotherapy is ongoing, if patient is 

between cycles, or if within 2 weeks of completion. 

Use of steroids is considered an underlying disease or condition only 

if they are long-term systemic steroids (this does NOT include topical 

creams, steroids used only for short course treatment such as one week, 

and inhaled steroids used for asthma).

There are numerous brand and generic drug names for 

immunosuppressive agents. Understanding which conditions persons 

may be prescribed may help identify the agents. Please see Appendix 4 

for further guidance on specific drug names. 

If you are uncertain after review of the list of agents listed in Table 8 

whether the drug should be considered an immunosuppressive agent, 

especially if the person has one of the conditions listed previously, please 

contact CDC.

IV drug use Any intravenous drug. 

Current: any intravenous drug use within the past 12 months or timing 

unknown.

Past: any intravenous drug use beyond 12 months or clearly noted as 

“former” in the chart.

Leukemia A cancer of the hematopoietic system (bone marrow and other bloodforming organs). 

This results in an “immunocompromised” condition and includes CML 

(chronic myelogenous leukemia), CLL (chronic lymphocytic leukemia), 

AML (acute myelogenous leukemia), ALL (acute lymphocytic leukemia).

Multiple Myeloma This cancer of the hematopoietic system results in "immunocompromised 

for life" so should be marked if any history.

Multiple Sclerosis Chronic autoimmune disease that affects the brain and spinal cord; the 

body’s immune system attacks myelin. 

Nephrotic syndrome Kidney disorder characterized by excessive loss of protein in urine. 

Neuromuscular disorder Disorder of the nerves that control voluntary muscles. 

Includes muscular dystrophy (MD), myasthenia gravis, and amyotrophic 

lateral sclerosis (ALS), cerebral palsy (CP), reflex sympathetic dystrophy 

(RSD). 

Obesity The condition of being significantly overweight. Obesity has been defined 

by the National Institutes of Health (the NIH) as a BMI of 30 and above.

The obesity variable should not be checked in the underlying conditions 

section if there is no mention of obesity in the chart. (Calculating an 

obese BMI value using the height and weight data should not be used to 

complete this variable.)
Appendix 12.10

APPENDIX 2: Underlying Health Issues

Other drug use Any illicit drug use other than intravenous drug use. 

Current: any illicit drug use within the past 12 months or timing unknown.

Past: any illicit drug use beyond 12 months or clearly noted as “former” 

in the chart.

Please include decedents treated with or noted to have used “medical 

marijuana” or methadone in this group. 

Parkinson’s disease Degenerative disorder of the central nervous system due to insufficient 

dopamine.

Peripheral neuropathy Dysfunction of the peripheral nerves.

Includes Charcot-Marie-Tooth Syndrome, Guillain-Barre Syndrome

Plegias/paralysis Paralysis of extremities.

Includes quadraplegias (paralysis of all four limbs), paraplegias 

(paralysis of legs) and hemiplegia (paralysis of one side of the body). 

Pulmonary hypertension Pulmonary hypertension occurs when the blood pressure in the 

pulmonary arteries is higher than normal.

This is not the same diagnosis as the systemic form of hypertension 

(‘high blood pressure’, HTN).

Reactive Airway Disease (RAD) Sometimes, particularly in infants, their medical chart will read “6 month 

old male with one prior history of wheezing”. This may not be specifically 

stated to be Reactive Airway Disease, but should be included.

Seizure/Seizure disorder Uncontrolled electrical activity of the brain.

Includes epilepsy. Does NOT include febrile seizures. 

Sickle Cell Anemia Includes persons with HbSS, HbSC or HbS-beta thalassemia. Common 

abbreviations: SCD, SS disease, SC disease.

Smoking Current: smoked within the past 12 months or timing unknown.

Past: last smoked >12 months or clearly noted as “former” in the chart.

Includes a smoker of cigarettes or cigars, but does not include smoking 

crack or other illicit drugs. Smoking crack or other illicit drugs should be 

listed under “other drug use”. (If a person quit smoking within the past 

12 months, consider this person a current smoker.)

Does NOT include those being treated with or noted to have used 

“medical marijuana”.

Solid organ malignancy Malignancy of a solid organ such as liver, kidney, pancreas, heart, lung, 

or of other organs such as colon, bladder, and skim melanoma (excludes 

non-melanomatous skin cancer and in situ cervical carcinoma).

Splenectomy/Asplenia Absence of spleen or absence of spleen function.

Systemic Lupus Erythematosus (SLE) Includes SLE or lupus.

Other chronic lung conditions Includes chronic lung diseases OTHER THAN asthma, COPD, cystic 

fibrosis, bronchopulmonary dysplasia (BPD), pulmonary hypertension, 

and aspiration pneumonia. 

Examples of chronic lung diseases in this category are chronic bronchitis, 

bronchiectasis, alveolitis, post inflammatory pulmonary fibrosis, 

chronic airway obstruction, pneumoconiosis, ventilator-dependent, 

tracheamalacia, hituberculosis, emphysema thoracis, bronchiolitis 

obliterans, and interstitial lung disease. 
Appendix 12.11

APPENDIX 3: Pertussis Vaccines

Vaccine Types Brand Names Manufacturers

DTaP

DTaP-Hib

DTaP-IPV-Hib

DTaP-IPV

DTP (Whole Cell)

DTP-Hib

DT or Td

Tdap

Infanrix

Pediarix

Kinrix

Boostrix

Daptacel

Pentacel

Tripedia

Adacel

TriHIBit

Acel-Immune

Sanofi

GSK

Wyeth

Aventis

Connaught

North American Vaccine