Results from ingestion of preformed neurotoxin in food or drink.Symptoms may initially include vomiting and/or diarrhea and can be followed by ptosis (drooping eyelids), fixed and dilated pupils, visual disturbance, dysphagia (difficulty swallowing), dry mouth and dysphonia (difficulty speaking). Constipation is common later in presentation.Symptoms may extend to a descending symmetrical flaccid paralysis in an alert afebrile person.
Intestinal: (infant botulism and adult colonization)
Results from ingestion of spores that germinate in the intestine, rather than by ingestion of preformed toxin. Affects infants under the age of one almost exclusively, but can affect adults who have altered gastrointestinal anatomy and microflora (i.e., intestinal surgery, inflammatory bowel disease, exposure to antimicrobial agents). Clinical symptoms in infants start with constipation and may include loss of appetite, generalized weakness, weak cry, weak suck, ptosis, drooling and significant loss of head control.
Wound:
Results when a wound, boil, abscess or inoculation site becomes infected with C. botulinum and toxin is produced.Infection associated with the injection or sniffing of illicit drugs is also classified as wound botulism. Symptoms are similar to foodborne botulism (except usually without vomiting and/or diarrhea).
This questionnaire is designed to collect comprehensive information on possible risk factors for botulism. It is intended to investigate cases where the source of infection is unknown.
Data captured: – Case demographics – Food exposures
– Clinical information – Other risk factors
– Laboratory information
This questionnaire has both an open ended food history followed by a detailed check list of food items; this may seem repetitive but is used to ensure all possible food exposures are captured. Please collect as much details as possible for each item, including restaurant exposures. Also consider using a calendar to probe and collect receipts, purchase data or loyalty cards if available. The questionnaire is estimated to take 45 – 60 minutes to complete
FOR LOCAL USE ONLY – PLEASE REMOVE THIS PAGE IF SENDING TO PHAC
Case Information:
Case Name:
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:
Ill Contacts:
Did (you/case) know of anyone else ill with similar symptoms? o Y o N o DK If yes, can you tell me who?
Name:___________________________________________ Sex: o M o F Phone Number: ___________________________ Relationship to (you/case):________________________________ Age: ________ Date of onset: d____ / m____ / y______
Name:___________________________________________ Sex: o M o F Phone Number: ___________________________ Relationship to (you/case):________________________________ Age: ________ Date of onset: d____ / m____ / y______
Name:___________________________________________ Sex: o M o F Phone Number: ___________________________ Relationship to (you/case):________________________________ Age: ________ Date of onset: d____ / m____ / y______
Section 1. Case Information:
Case Interviewed by: v
Date of interview: d____ / m____ / y______
Health Unit/Authority:
Date reported to Health Unit/Authority: d____ / m____ / y______
Province/Territory:
Respondent was: o Case o Parent o Spouse o Caretaker o Other, specify: ______________________________
Date of birth: d_______ / m_______ / y________ Age: _______
Admitted* to hospital because of the illness? o Y o N o DK *Do not include individuals who visit an emergency room or outpatient clinic
Date of admission: d______ / m______ / y______ Date of discharge: d______ / m______ / y______ o Still hospitalized
Was antitoxin administered? o Y o N o DK If yes, date antitoxin given: d____ / m____ / y______ If yes, number of vials given: _______
Does the case have underlying gastrointestinal co-morbidities (e.g. GI surgery, IBD, Chrohn’s Disease, diabetes)? o Y o N o DK If yes, specify: _____________________________________________________________________________________________________________
To be filed out by interviewer
Case deceased: Date of Death: d____ / m____ / y______ If yes, was C. botulinum infection the underlying/contributing cause of death? o Y o N o DK If yes, was determination based on death certificate? o Y o N o DK
Section 3: Travel Information
In the 3 days before onset of illness, that is from d____/m_____/y_____ through d____/m____/y____, did (you/case) travel within or outside of Canada? o Y o N o DK
If yes: o Within Province/Territory o Other Province(s)/Territory(ies) o Outside Canada
Are (you/case) a vegetarian? o Y o N o DK If yes, do (you/case) ever eat: Eggs o Y o N o DK Dairy o Y o N o DK Fish o Y o N o DK Poultry o Y o N o DK Red meat o Y o N o DK Other Meat o Y o N o DK If yes, specify: ________________
Are (you/case) allergic to any foods ? o Y o N o DK If yes, specify which foods:
Are there any foods/food groups that (you/case) never eat? o Y o N o DK If yes, describe:
In the 3 days prior to illness, were (you/case): On a special or restricted diet? (e.g. raw food diet, vegan, diabetic diet, kosher, halal) o Y o N o DK If yes, describe: ____________________________________________________________________________ Taking a dietary or nutritional supplement? (e.g. meal replacements, protein powder, vitamins, herbs) o Y o N o DK If yes, describe: ____________________________________________________________________________
Section 5. Social Gatherings:
Did (you/case) attend any social gatherings in the 3 days prior to illness onset? o Y o N o DK (Note, social gatherings include weddings, parties, potlucks, religious events, community events, conferences, etc) If yes, complete information below:
Event names/location/description:
Date of gathering(s)
Are you aware of anyone else who became ill with diarrhea following the gathering?
In the 3 days prior to illness onset did (you/case) eat at any of the following 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.
Food Establishment
Name(s)
Date(s)
Location(s)
Restaurant or Bar
oY oN oDK
Fast Food chain restaurant
oY oN oDK
Coffee Shop or Bakery
oY oN oDK
Cafeteria or food served at an institution (University, hospital, workplace etc.)
oY oN oDK
Street Vendor / Concession Stand
oY oN oDK
Ready to eat from Gas Stations/Convenience Stores
oY oN oDK
Ready to eat from Grocery Store (including samples)
oY oN oDK
Other If yes, specify: ___________
oY oN oDK
Section 7. Home Food Purchases:
Where did (you/case) usually purchase food for home consumption (include grocery stores, farmers markets, specialty stores, ethnic markets, food banks etc)? Interviewer note: *Consent form for collecting loyalty card information is available from your provincial/territorial health authourity or PHAC
Store Name
Location/Address
A
Loyalty card? o Y o N o DK Loyalty card #: ____________________________
B
Loyalty card? o Y o N o DK Loyalty card #: ____________________________
C
Loyalty card? o Y o N o DK Loyalty card #: ____________________________
D
Loyalty card? o Y o N o DK Loyalty card #: ____________________________
E
Loyalty card? o Y o N o DK Loyalty card #: ____________________________
Section 7A. Online Food Purchases:
In the 3 days prior to illness onset did (you/case) consume food/supplements purchased over the internet: o Yes o No If yes please provide details:
Type / Variety / Brand
Specify store name/website
Section 8: Three Day Food History
I’d like to talk to you about the foods/drinks (you/case) consumed before (you/case) got sick. Starting with the day (you/case) were first developed symptoms: (Interviewer note: please probe regarding where foods were eaten and how prepared, e.g. prepared and eaten at home, eaten at a restaurant, take-out, ready-to-eat meal, frozen dinner, etc)
Day of illness d____ / m____ / y______ o M o T o W o Th o F o Sat o Sun
Breakfast
Lunch
Dinner
Snacks
1 day before illness d____ / m____ / y______ o M o T o W o Th o F o Sat o Sun
Breakfast
Lunch
Dinner
Snacks
2 days before illness d____ / m____ / y______ o M o T o W o Th o F o Sat o Sun
Breakfast
Lunch
Dinner
Snacks
3 days before illness d____ / m____ / y______ o M o T o W o Th o F o Sat o Sun
Breakfast
Lunch
Dinner
Snacks
Additonal Exposures for infants (less than 1 year) ONLY: In the 4 weeks before illness, did the baby have any of the following exposures:
Breast milk
oY
oP
oN
oDK
Formula
oY
oP
oN
oDK
Cow’s milk
oY
oP
oN
oDK
Dry infant cereal
oY
oP
oN
oDK
Honey
oY
oP
oN
oDK
Jarred baby food
oY
oP
oN
oDK
Home-prepared baby food
oY
oP
oN
oDK
Cookies/biscuits
oY
oP
oN
oDK
Camomile or other herbal remedies (e.g. homeopathic teething remedies)
oY
oP
oN
oDK
Other If yes, specify:___________
oY
oP
oN
oDK
Section 9: Food Exposures
INSTRUCTIONS TO READ TO CASE I am interested in the food (you/case) ate during the 3 days before (your/case) illness onset date; that is from d____/m_____/y_____ through d____/m____/y____. For each food item please give me your best guess as to whether (you/case) ate the food, you’re not sure but you probably ate the food, or you did not eat the food. Please include food eaten on their own, or as part of a salad, sandwich, or dish. INSTRUCTIONS FOR INTERVIEWER For each food item that the case consumed ask follow up questions regarding the brand, location of purchase. Please select an answer for each question or indicate if question not asked
Yes
Prob
No
DK
IMPORTANT: Please complete in as much detail as possibleType/Variety/Brand
Where purchased or eatenSpecify grocery store or restaurant name
Canned Goods
Any homemade canned food If yes, please specify type(s) below
oY
oP
oN
oDK
Meat If yes, specify:___________________
oY
oP
oN
oDK
Vegetable If yes, specify:___________________
oY
oP
oN
oDK
Fruit If yes, specify:___________________
oY
oP
oN
oDK
Sauce/soup If yes, specify:___________________
oY
oP
oN
oDK
Any flavoured oil (e.g. garlic oil) If yes, specify:___________________
oY
oP
oN
oDK
Any commercially canned food If yes, please specify type(s) below
oY
oP
oN
oDK
Meat If yes, specify:___________________
oY
oP
oN
oDK
Vegetable If yes, specify:___________________
oY
oP
oN
oDK
Fruit If yes, specify:___________________
oY
oP
oN
oDK
Sauce/soup If yes, specify:___________________
oY
oP
oN
oDK
Any flavoured oil (e.g. garlic oil) If yes, specify:___________________
oY
oP
oN
oDK
Other food from a can or jar
oY
oP
oN
oDK
Meat/Seafood
Marine mammal If yes, specify:___________________
oY
oP
oN
oDK
Yes
Prob
No
DK
IMPORTANT: Please complete in as much detail as possibleType/Variety/Brand
Where purchased or eatenSpecify grocery store or restaurant name
Any smoked meat or fish If yes, specify:___________________
oY
oP
oN
oDK
Any fermented meat or fish (including fish eggs) If yes, specify:___________________
oY
oP
oN
oDK
Other meat/seafood If yes, specify:___________________
oY
oP
oN
oDK
Other Foods
Foil wrapped baked potatoes
oY
oP
oN
oDK
Peanut butter
oY
oP
oN
oDK
Nut puree, paste, butter or spread (other than peanut butter e.g. almond butter, hazelnut spread, etc.) If yes, specify:__________________
oY
oP
oN
oDK
Section 10. Risk Factors:
In the 3 days before onset of illness did (you/case):
Have contact with soil (e.g. gardening, etc.)?
o Y oN o DK
Specify:
Have any skin infections or wounds?
o Y oN o DK
Specify:
Inject drugs?
o Y o N o DK
Specify:
Share injection drug use (IDU) equipment?
o Y o N o DK
Specify:
Did you take antibiotics in the month prior to onset?
o Y o N o DK
Specify:
Infants (less than 1 year) ONLY: In the 4 weeks before illness, did the baby have the following exposures:
Home renovations
o Y oN o DK
Specify:
Construction around the home (e.g. house is dusty from construction)
o Y oN o DK
Specify:
Close proximity to farms where soil is being disturbed (e.g. house is dusty from land being disturbed)
o Y oN o DK
Specify:
Exposure to reptiles/turtles
o Y oN o DK
Specify:
Section 11. Food Sampes:
Were any food samples collected as part of the case investigation? o Y oN o DK If yes please provide details: