Philippine Integrated Disease

Surveillance and Response Case Report Form

Hand, Foot and Mouth Disease and Severe Enteroviral Disease
Name of DRU:
Address: Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Gov’t Laboratory Private Laboratory Airport/Seaport

I. PATIENT INFORMATION
Patient Number Patient’s First Name Middle Name Last Name

Complete Address Date of Birth: Age Sex

mm/dd/yy ________
District:  Days  Male
ILHZ: ___/___/___  Months  Female
 Years
Patient admitted? Y N Date Admitted/ MM DD YY
Date Onset MM DD YY

Seen/Consult of Illness
MM DD YY Name of investigator/s: Contact Nos.:
Date of
Investigation:
II. CLINICAL INFORMATION
Fever: Y N Other signs/symptoms (please tick) Are there any complications?
Date onset: ____/____/____  Poor/loss of appetite Y N
Rash:  Y  N  Body malaise If YES, specify:
Date onset: ____/____/____  Sore throat ____________________________________
palms fingers  Nausea & vomiting
soles of feet Buttocks  Difficulty of breathing Working/Final Diagnosis
Mouth ulcers  Acute Flaccid Paralysis
Painful? Y N  Meningeal irritation
Characteristic: Others, specify:
 maculopapular  papulovesicular __________________________________

III. EXPOSURE HISTORY

Is there a history of travel within 12 weeks to an area with ongoing epidemic of HFMD or EV Disease?  Y  N
Are there other known cases in the community?  Y  N
Where did exposure probably occur?
Day care Community School Dormitory
Home HealthCare Facilities Others, specify ________________

IV. LABORATORY TESTS

Result:
Specify
Specimen If YES, Date sent to Date received Positive, Nega- Date of result
organism
Date Collected RITM at RITM tive , Not Done

Throat swab ___ /___ /____ ___ /___ /____ ___ /___ /____ ___ /___ /______

Vesicle swab ___ /___ /____ ___ /___ /____ ___ /___ /____ ___ /___ /______

Rectal swab ___ /___ /____ ___ /___ /____ ___ /___ /____ ___ /___ /______

 Stool ___ /___ /____ ___ /___ /____ ___ /___ /____ ___ /___ /______

V. CLASSIFICATION VI. OUTCOME

Suspected case of HFMD  Suspected case of Severe  Alive  Died

Enteroviral Disease
Probable case of HFMD Confirmed case of Severe Date died: ____/____/____
Enteroviral Disease
Confirmed case of HFMD
 Case Report Form
Hand, Foot and Mouth Disease and Severe Enterovirus Disease

CASE DEFINITION/CLASSIFICATION:

Suspected case of HFMD: Any individual, regardless of age, who develop acute febrile illness with papulovesicular or
maculopapular rash on palms and soles, with or without vesicular lesion/ulcers in the mouth.

Probable case of HFMD: A suspected case that has not been confirmed by a laboratory, but is geographically and tempo-
rally related to a laboratory-confirmed case.

Confirmed case of HFMD: A suspected case with positive laboratory result for Human Enteroviruses that cause HFMD.

Suspected case of Severe Enteroviral Disease: Any child less than ten (10) years of age: with fever plus any severe signs
and symptoms referable to central nervous system involvement, autonomic nervous system dysregulation or cardiopulmonary
failure;

OR a suspect or probable HFMD case with complications

OR who died < 48hours after presenting with fever and CNS involvement;

Confirmed case of Severe Enteroviral Disease: A suspected Severe Enteroviral Disease that has positive laboratory re-
sults for Enteroviruses

COMPLICATIONS ASSOCIATED WITH HFMD AND SEVERE ENTEROVIRUSDISEASE:

Aseptic Meningitis Febrile illness with headache, vomiting and meningism associated with of more
that 5-10 white cells per cubic millimeter in cerebrospinal (CSF) fluid, and nega-
tive results on CSF bacterial culture.

Brainstem encephalitis Myodonus, ataxia, nystagmus, oculomotor palsies, and bulberpalsy in various
combinations, with or without MRI. In resource –limited settings, the diagnosis of
brainstem encephalitis can be made in children with frequent myoclonic jerks
and CSF pleocytosis.

Encephalitis Impaired consciousness, including lethargy, drowsiness or coma, or seizures or

myoclonus.

Encephalomyelitis Acute onset of hyporeflexic flaccid muscle weakness with myoclonus, ataxia,
nystagmus, oculomotor palsies and bulbar palsy in various combinations.

Acute Flaccid Paralysis Acute onset of flaccid muscle weakness and lack of reflexes.

Autonomic Nervous System (ANS) Presence of cold sweating , mottled skin, tachycardia, tachypnea, and
dysregulation hypertension

Pulmonary oedema/haemorrhage Respiratory distress with tachycardia, tachypnea, rales, and pink frothy secre-
tion that develops after ANS dysregulation, together with a chest radiograph that
shows bilateral pulmonary infiltrates without cardiomegaly.

Cardiorespiratory failure Cardiorespiratory failure is defined by the presence of tachycardia, repiratory

distress, pulmonary oedema, poor peripheral perfusion requiring inotropes, pul-
monary congestion on chest radiography and reduced cardiac contractility on
echocardiography.