Accessible Cyclosporiasis Hypothesis Generating Questionnaire

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Questionnaire Background for Interviewer

This questionnaire is designed to collect comprehensive information on possible risk factors for cyclosporiasis. It is designed for cluster/outbreak investigations where the source of infection is unknown, but the questionnaire could be applied to investigate sporadic cases. More details are collected on high risk foods (berries, herbs and leafy greens), but please ask the case about all food items listed. Text is included above each food section to explain what information we are trying to capture and prompts to remind cases to include garnishes. The questionnaire is estimated to take 30 minutes to complete.

Since outbreaks of cyclosporiasis are often linked back to contaminated food products, it is critical to collect as much detail as possible on food exposures. Please collect as much detail as possible for each item, including restaurant exposures. Also consider collecting receipts, purchase data, loyalty card numbers, and using a calendar to probe for dates of exposure.

Text is intended for information for the interviewer.

For local use only – please remove this page if sending to PHAC

I. Case information

Case Name:

Case ID:

National ID:

Proxy Name:

Health Card Number:

Street Address:

City/Town:

Postal Code:

Home phone:

Work phone:

Cell Phone:

Physician:

Physician Phone:

Occupation:

Place(s) of employment:

II. Symptoms

Date of first symptom onset (dd/mm/yy):                                                    Asymptomatic:  ▢ Y  ▢ N  ▢ DK

Symptoms:       Watery  Diarrhea*  ▢ Y  ▢ N  ▢ DK              Fever      ▢ Y  ▢ N  ▢ DK                 Abdominal cramps        ▢ Y  ▢ N  ▢ DK                                  

                            Fatigue                      ▢ Y  ▢ N  ▢ DK              Gas         ▢ Y  ▢ N  ▢ DK                 Nausea                              ▢ Y  ▢ N  ▢ DK

                            Vomiting                   ▢ Y  ▢ N  ▢ DK              Other:    ▢ Y  ▢ N  ▢ DK                 If other, please specify:

*3 or more loose stools in a 24 hour period

Underlying conditions or medications that suppress the immune system (e.g. pregnancy, diabetes, cancer, steroids)? ▢ Y ▢ N ▢ DK

If yes, please specify:



 

Cyclosporiasis Hypothesis Generating Questionnaire

Section 1: Case information

National ID:

Date of interview (dd/mm/yy):

Case Interviewed by:

Date reported to Health Unit/Authority(dd/mm/yy):

Health Unit/Authority:

Province/Territory:

Age:

Sex: ▢ M ▢ F

Respondent was: ▢ Case ▢ Parent ▢ Spouse ▢ Caretaker ▢ Other, specify:

Section 2: Clinical information

Positive specimen type(s):

▢ Stool ▢ Other, specify:

Date of first symptom onset (dd/mm/yy):

Asymptomatic? ▢ Y ▢ N ▢ DK

Date of first positive specimen collection (dd/mm/yy):

Date of diarrhea onset (dd/mm/yy):

Admitted* to hospital because of the illness? ▢ Y ▢ N ▢ DK

*Do not include individuals who visit an emergency room or outpatient clinic

Date of admission (dd/mm/yy):                                                         ▢ Still hospitalized

Date of discharge (dd/mm/yy):

Case deceased?    ▢ Y ▢ N                              Date of Death (dd/mm/yy):

Section 3: Travel information

In the 14 days before onset of illness, did (you/case) travel within or outside of Canada? ▢ Y ▢ N ▢ DK

If yes: ▢ Within Province/Territory ▢ Other Province(s)/Territory(ies) ▢ Outside Canada

Specify travel destination(s) (country/town/resort):

Departure (dd/mm/yy):                                                              Return (dd/mm/yy):

If case spent entire incubation period outside of Canada, then stop interview here. If case spent part of incubation period within Canada, then continue interview to capture domestic exposures only.

Section 4: Social Gatherings

Did (you/case) attend any social gatherings in the 14 days prior to illness onset? ▢ Y ▢ N ▢ DK

Include weddings, parties, potlucks, religious events, community events, conferences, etc.

If yes, complete the information below:

Event Name, Location, Description:

Date(s) of gathering

(dd/mm/yy to dd/mm/yy)

Are you aware of anyone else who became ill with diarrhea following the gathering?

   

▢ Y ▢ N ▢ DK

If yes, number ill?

   

▢ Y ▢ N ▢ DK

If yes, number ill?

   

▢ Y ▢ N ▢ DK

If yes, number ill?

Notes: 

Section 5: Food Establishments outside the home

In the 14 days prior to illness onset did (you/case) eat at any food establishments? (including food taken from a restaurant and eaten at home and samples eaten at establishments such as grocery stores)?

We will ask you about what you ate later in this questionnaire.

Name of Food Establishment Name(s) Date(s) (dd/mm/yy) Location(s) (as specific as possible)
       
       
       
       
       
       

Section 6: Home Food Purchases

Where did (you/case) purchase food or receive food for home consumption for the 7 days before illness onset? Please include grocery stores, websites, farmers markets, specialty stores, ethnic markets, food banks, etc. Do you have a loyalty or points card for any of these stores? We use these cards to confirm brand names, expiry dates, and product lots so we can perform product testing.

Loyalty cards may be available for the following stores: Costco, Extra foods, NoFrills, Superstore, Fortinos, Independent, Loblaws, Valu-Mart, Zehrs, Atlantic Superstore, Maxi, Provigo, Dominion, BloorStreetMarket, SaveEasy, Wholesale Club, Axep, Freshmart, Shop Easy foods, Super Valu, and L’Inter Marche. Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC.

Store, market, or website name: Location/Address

Loyalty card available? ▢ Y ▢ N ▢ DK

 

Loyalty card available? ▢ Y ▢ N ▢ DK

 

Loyalty card available? ▢ Y ▢ N ▢ DK

 

Loyalty card available? ▢ Y ▢ N ▢ DK

 

Loyalty card available? ▢ Y ▢ N ▢ DK

 
Willing to share purchase information from your loyalty card if needed?    ▢ Y  ▢ N

Section 7: Food Exposures

I am interested in the food you ate during the 14 days before your illness onset date. For each food item please give me your best guess as to whether you ate the food, you’re not sure but you probably ate the food, or you did not eat the food.

Berries

I have some questions about fresh berries, not canned, cooked, or frozen, you might have eaten during the 14 days before your illness began. You could have eaten these either in your home or away from home. I am only interested in fresh berries that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick. Please remember that berries are often served as garnishes on top of or on the sides of salads and desserts or in smoothies.

Product and consumption Details

Fresh strawberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh raspberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh blackberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada)                            ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other fresh berries
(e.g., mixed fruit platter)

▢Y ▢P ▢N ▢DK

Product details:

Herbs

I have questions about fresh herbs that you may have eaten during the 14 days before illness began. Remember, these could have been part of a dish such as pesto, salsa, sauces, etc. I am interested in fresh herbs, not dried or bottled herbs. I am also only interested in fresh herbs that were not grown at home. Please remember that fresh herbs are often served as garnishes on top of or on the sides of entrees and desserts. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Product and consumption Details

Fresh basil

▢Y ▢P ▢N ▢DK

Specify:

▢ Thai Basil (green leaves and purple stems)

▢ Other basil: 

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh cilantro/coriander

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh parsley

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other fresh herbs

▢Y ▢P ▢N ▢DK

Product details

Lettuce and leafy greens

I have some questions about lettuce and leafy greens you might have eaten raw or uncooked during the 14 days before your illness began. You could have eaten this either in your home or away from home. This does not include canned or frozen items, but these foods could have been eaten alone or as part of a dish. I am only interested in lettuce and leafy greens that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick. Please include lettuce or leafy greens you may have eaten on on sandwiches or burgers or as a garnish.

Product and location of consumption Details

Iceberg lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Romaine lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Spinach

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Mesclun lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Arugula

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Prepackaged salad mix

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada)   Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other lettuce/leafy greens

▢Y ▢P ▢N ▢DK

 Product details

Other fresh vegetables

Now I have some questions about other fresh vegetables, not grown at home, that you may have eaten in the 14 days before your illness began. This does not include canned items, but these foods could have been eaten alone or as part of a dish. I am only interested in vegetables that were not grown at home. As I read each food, please answer as yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Product and location of consumption Details

Peas

▢Y ▢P ▢N ▢DK

Specify:

Snow peas (flat pods containing tiny peas)
▢Y ▢P ▢N ▢DK

Snap peas (plump, crisp edible pods)
▢Y ▢P ▢N ▢DK

Other peas:
▢Y ▢P ▢N ▢DK

 

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ prepackaged in a bag ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Green onions

▢Y ▢P ▢N ▢DK

 

If purchased, how were they packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell  ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

 

Other foods

Now I have some questions about other products containing fresh fruits, vegetables or herbs. This does not include canned items. I am only interested in that were not grown at home. As I read each food, please answer as yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Fresh Salsa

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

 

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Guacamole

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

 

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Pesto

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

 

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Any other foods containing fresh berries or herbs (salad, dip or salad dressing)

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

 

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Other fresh fruit and vegetables

Now I have some questions about fresh fruits and vegetables, not canned, cooked, or frozen, you might have eaten during the 14 days before your illness began. You could have eaten these either in your home or away from home. I am only interested in fresh fruits that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Other fresh fruit:
Food item Eaten Product details

Melon

▢Y ▢P ▢N ▢DK

 

Peaches

▢Y ▢P ▢N ▢DK

 

Nectarines

▢Y ▢P ▢N ▢DK

 

Apricots

▢Y ▢P ▢N ▢DK

 

Plums

▢Y ▢P ▢N ▢DK

 

Cherries

▢Y ▢P ▢N ▢DK

 

Apples

▢Y ▢P ▢N ▢DK

 

Grapes

▢Y ▢P ▢N ▢DK

 

Mangos

▢Y ▢P ▢N ▢DK

 

Avocado

▢Y ▢P ▢N ▢DK

 

Coconut

▢Y ▢P ▢N ▢DK

 

Citrus Fruits

▢Y ▢P ▢N ▢DK

 

Other fresh fruits:

▢Y ▢P ▢N ▢DK

 

Unpasteruized Fruit juice/cider

▢Y ▢P ▢N ▢DK

 

 

Other fresh vegetables:
Food item Eaten Product details

Tomatoes

▢Y ▢P ▢N ▢DK

 

Cabbage

▢Y ▢P ▢N ▢DK

 

Sprouts

▢Y ▢P ▢N ▢DK

 

Cucumbers

▢Y ▢P ▢N ▢DK

 

Bell pepper

▢Y ▢P ▢N ▢DK

 

Hot pepper

▢Y ▢P ▢N ▢DK

 

Broccoli

▢Y ▢P ▢N ▢DK

 

Cauliflower

▢Y ▢P ▢N ▢DK

 

Celery

▢Y ▢P ▢N ▢DK

 

Carrot

▢Y ▢P ▢N ▢DK

 

Onions

▢Y ▢P ▢N ▢DK

 

Garlic

▢Y ▢P ▢N ▢DK

 

Other fresh vegetables

▢Y ▢P ▢N ▢DK

 

Notes/General Comments

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