Invasive Listeriosis Questionnaire

Questionnaire Background for Interviewer

Please complete questionnaire for all invasive listeriosis cases that meet the following case definition:

Clinical Evidence: Invasive clinical illness is characterized by meningitis or bacteremia. Infection during pregnancy may result in fetal loss through miscarriage, stillbirth, neonatal meningitis or bacteremia.

Laboratory Criteria for Diagnosis: Laboratory confirmation of infection with symptoms:

· isolation of Listeria monocytogenes from a normally sterile site (e.g., blood, cerebral spinal fluid, joint, pleural or pericardial fluid),OR

· in the setting of miscarriage or stillbirth, isolation of L. monocytogenes from placental or fetal tissue (including amniotic fluid and meconium)

For cases of Listeria in pregnant women or infants ≤1 month of age the MOTHER is the case.

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

I. Case information

Case Name:

Proxy Name:

Street Address:

City/Town:

Postal Code:

Home phone:

Work phone:

Cell Phone:

Physician:

Physician Phone:

Invasive Listeriosis Questionnaire

Section 1: Case information

National ID: Provincial ID:	Provincial Lab ID:
Case Interviewed by:	Date of interview (dd/mm/yy):
Respondent was: ▢ Case ▢ Parent ▢ Spouse ▢ Caretaker ▢ Other, specify:
Age:	Sex: ▢ M ▢ F
Health Unit/Authority:	Province/Territory:

Section 2: Pregnancy associated cases

Is this case associated with pregnancy? (Illness in pregnant woman, fetus or neonate ≤ 1 month)

▢ Yes If yes, skip to section 4

▢ No If no, continue to Section 3

▢ Unknown If unknown, continue to section 3

Section 3: Clinical information (Non-pregnant adults and children > 1 month of age)

Positive specimen type(s): ▢ CSF ▢ Blood ▢ Urine ▢ Other:

PFGE patterns:

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

Date first positive specimen collected (dd/mm/yy):

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

When did symtoms resolve (recovery date)? (dd/mm/yy):

▢ Still ill ▢ Don’t Know

Type of Illness: ▢ Bacteremia/sepsis ▢ Meningitis

▢ UTI ▢ Other:

Symptoms :

Diarrhea* ▢ Y ▢ N ▢ DK Abdominal cramps ▢ Y ▢ N ▢ DK Stiff neck ▢ Y ▢ N ▢ DK

Headache ▢ Y ▢ N ▢ DK Muscle aches ▢ Y ▢ N ▢ DK Confusion ▢ Y ▢ N ▢ DK

Vomiting ▢ Y ▢ N ▢ DK Fever ▢ Y ▢ N ▢ DK Weakness ▢ Y ▢ N ▢ DK

Chills ▢ Y ▢ N ▢ DK Nausea ▢ Y ▢ N ▢ DK Asymptomatic ▢ Y ▢ N ▢ DK

*3 or more loos e stools in 24 hours Other (specify):

Hospitalization?

▢ Not admitted to hospital ▢ Admitted to hospital due to listeriosis

▢ Don’t know ▢ Admitted to hospital for another reason

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

Date of admission (dd/mm/yy):

Date of discharge (dd/mm/yy):

▢ Still hospitalized at time of interview

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

If yes, Listeria infection underlying/contributing cause of death? ▢ Y ▢ N ▢ DK

If yes, was determination based on death certificate? ▢ Y ▢ N ▢ DK

Underlying medical conditions and treatments? ▢ Y ▢ N ▢ DK If yes, specify:

▢ cancer ▢ organ transplant ▢ liver disease ▢ immunosuppressive medication

▢ heart disease ▢ kidney disease ▢ COPD ▢ other, specify:

Proceed to Section 5. Exposure Sources

Section 4. Clinical Information (Pregnant woman, fetus or neonate ≤ 1 month of age)

Positive specimen type(s): ▢ CSF (mother) ▢ Blood (mother)
▢ CSF (neonate) ▢ Blood (neonate) ▢Other: PFGE Patterns:

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

Date first positive specimen collected (dd/mm/yy):

Clinical information on MOTHER:

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

When did symptoms resolve (recovery date) (dd/mm/yy)?

▢ Still ill ▢ Don’t Know

Type of Illness: ▢ Bacteremia/sepsis ▢ Meningitis

▢ UTI ▢ None

▢ Other:

Symptoms :

Diarrhea* ▢ Y ▢ N ▢ DK Abdominal cramps ▢ Y ▢ N ▢ DK Stiff neck ▢ Y ▢ N ▢ DK

Headache ▢ Y ▢ N ▢ DK Muscle aches ▢ Y ▢ N ▢ DK Confusion ▢ Y ▢ N ▢ DK

Vomiting ▢ Y ▢ N ▢ DK Fever ▢ Y ▢ N ▢ DK Weakness ▢ Y ▢ N ▢ DK

Chills ▢ Y ▢ N ▢ DK Nausea ▢ Y ▢ N ▢ DK Asymptomatic ▢ Y ▢ N ▢ DK

*3 or more loos e stools in 24 hours Other (specify):

Hospitalization?

▢ Not admitted to hospital ▢ Admitted to hospital due to listeriosis

▢ Don’t know ▢ Admitted to hospital for another reason

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

Date of admission (dd/mm/yy):

Date of discharge (dd/mm/yy):

▢ Still hospitalized at time of interview

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

If yes, Listeria infection underlying/contributing cause of death? ▢ Y ▢ N ▢ DK

If yes, was determination based on death certificate? ▢ Y ▢ N ▢ DK

Underlying medical conditions and treatments? ▢ Y ▢ N ▢ DK If yes, specify:

▢ Cancer ▢ Organ transplant ▢ Liver disease ▢ Immunosuppressive medication

▢ Heart disease ▢ Kidney disease ▢ COPD ▢ Other (specify)?:

Outcome of pregnancy ▢ Still pregnant ▢ Fetal death (miscarriage/stillbirth) ▢ Induced abortion ▢ Live birth

No. weeks gestation: Date (dd/mm/yy):

Clinical information on NEONATE:

Age at onset of illness (days):

Date of onset of first symptom (dd/mm/yy):
When did symptoms resolve (recovery date)? (dd/mm/yy):
▢ Still ill ▢ Don’t Know

Type of Illness: ▢ None ▢ Bacteremia
▢ Meningitis ▢ Febrile Gastroenteritis
▢ Other:

Hospitalization?
▢ Not admitted to hospital ▢ Admitted to hospital due to listeriosis
▢ Don’t know ▢ Admitted to hospital for another reason

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

Date of admission (dd/mm/yy):

Date of discharge (dd/mm/yy):

▢ Still hospitalized at time of interview

Neonate deceased? ▢ Y ▢ N Date of death (dd/mm/yy):

If yes, Listeria infection underlying/contributing cause of death? ▢ Y ▢ N ▢ DK

If yes, was determination based on death certificate? ▢ Y ▢ N ▢ DK

Section 5: Exposure sources:

In the 4 weeks before onset of illness, did you/case:

Live in a residential institution ? ▢ Y ▢ N ▢ DK Institution type/name:

(e.g. Nursing home, long term care facility, hospital, convalescent care center, prison, boarding school, etc)

Travel? ▢ Y ▢ N ▢ DK

If, yes: ▢ Within Province/Territory ▢ Other Province/Territory ▢ Outside Canada

Travel Destination (country/town/resort):

Departure (dd/mm/yy):

Return (dd/mm/yy):

Section 6: Home Food Purchases – Please attach a separate sheet if necessary

Where did you/case purchase food for home consumption in the last 4 weeks (include grocery stores, farmers markets, specialty stores, ethnic markets, food banks etc)?

Store Name	Location/Address

Section 7: Eating places outside the home – Please attach a separate sheet if necessary

In the 4 weeks prior to illness onset did you/case eat at a restaurant, fast food outlet, coffee shop, cafeteria or social event? ▢ Y ▢ N ▢ DK

Eating Place Name	Location	Date

Section 8: Special Diets

Are you/case a vegetarian? ▢ Y ▢ N ▢ DK

Are you/ case allergic to any foods? ▢ Y ▢ N ▢ DK

If yes, specify which foods:

In the 4 weeks prior to illness, were you/case on a special or restricted diet? (e.g. diabetic diet, kosher, halal, etc) ▢ Y ▢ N ▢ DK

If yes, describe:

Section 9: Food History

Did you/case eat any of the following foods in the 4 weeks prior to illness onset?

Instructions for interviewer: For each food item that the case consumed, ask follow up questions regarding the brand, location of purchase. Please read all response options to case in each category. In the event of a fetal death/neonatal infection (<1 month of age), the MOTHER is the case; ask her about her food history during the 4 weeks before DELIVERY.

INSTRUCTIONS TO READ TO CASE:

I am interested in the foods you ate during the 4 weeks before your illness onset date. I will be asking you questions about 4 weeks before this date, that is, from (dd/mm/yy): through (dd/mm/yy): . 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. Please include foods eaten by themselves, as part of a sandwich, or as part of another food dish, including salads.

Prob (Probably Ate) = Case thinks he/she ate this food or case usually eats this food, but is unsure if eaten during time period in question

DK = Don’t know if it was eaten during the time period in question.

Deli Meats

	Response	Brand/Details	Where purchased or eaten:
Turkey deli meat ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Chicken deli meat ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Beef deli meat (e.g. roast beef) ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Ham deli meat ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Bologna ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Pastrami ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Salami ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Pepperoni ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Other deli meat (e.g. corned beef, kielbasa, prosciutto, mortadella) Specify type: ▢ prepackaged ▢ sliced at the deli counter	▢Y ▢P ▢N ▢DK
Prepackaged sandwiches/wraps (purchased from vending machine, cafeteria, gas station, grocery store etc.)	▢Y ▢P ▢N ▢DK

Other Meats

	Response	Brand/Details	Where purchased or eaten:
Pâté/meat spread (not canned)	▢Y ▢P ▢N ▢DK
Hot dogs If yes, heated before eating? ▢Y ▢N ▢DK	▢Y ▢P ▢N ▢DK
Cured or dried meats (e.g. jerky, pepperettes) ▢ prepackaged ▢ unpackaged at deli counter	▢Y ▢P ▢N ▢DK
Chicken eaten cold (e.g. chicken pieces or strips, rotisserie, leftover cooked chicken, cold chicken on salads) ▢ purchased cooked, ready to eat ▢ cooked at home & later ate it cold	▢Y ▢P ▢N ▢DK
Ham eaten cold (not deli meat) ▢ purchased cooked, ready to eat ▢ cooked at home & later ate it cold	▢Y ▢P ▢N ▢DK
Turkey eaten cold (e.g. turkey pieces or strips, leftover cooked turkey) ▢ purchased cooked, ready to eat ▢ cooked at home & later ate it cold	▢Y ▢P ▢N ▢DK
Sausage eaten cold (e.g. ham sausage, breakfast sausage, frankfurters, cured sausages, leftovers) ▢ purchased cooked, ready to eat ▢ cooked at home & later ate it cold	▢Y ▢P ▢N ▢DK
Ground Beef	▢Y ▢P ▢N ▢DK

Cheese

Exposure	Response	Brand/Details	Where purchased or eaten:
Brie	▢Y ▢P ▢N ▢DK
Camembert	▢Y ▢P ▢N ▢DK
Blue cheese (e.g. Roquefort, Gorgonzola,Stilton etc)	▢Y ▢P ▢N ▢DK
Feta	▢Y ▢P ▢N ▢DK
Goat cheese	▢Y ▢P ▢N ▢DK
Mexican- or Latin-style fresh cheese (e.g. queso fresco, queso blanco, queso panela etc.)	▢Y ▢P ▢N ▢DK
Other soft/semi-soft cheeses (e.g. Havarti, bocconcini) Specify type:	▢Y ▢P ▢N ▢DK
Other cheese, all types (e.g. cottage cheese,ricotta, gouda, cheese sold as a block, Halloumi cheese) Specify type:	▢Y ▢P ▢N ▢DK
Unpasteurized cheese Specify type:	▢Y ▢P ▢N ▢DK

Dairy

Exposure	Response	Brand/Details	Where purchased or eaten:
Unpasteurized (raw) milk	▢Y ▢P ▢N ▢DK
Pasteurized milk Specify (e.g. whole,skim,1%, 2%, flavoured):	▢Y ▢P ▢N ▢DK
Ice cream/Frozen Yogurt/Gelato (including milkshakes, frozen dairy bars and sandwiches, and other novelties) If yes, was it soft serve from a machine? ▢Y ▢N ▢DK	▢Y ▢P ▢N ▢DK
Other Dairy (e.g. butter, yogurt, sour cream, whipped cream) Specify:	▢Y ▢P ▢N ▢DK

Seafood

Exposure	Response	Brand/Details	Where purchased or eaten:
Raw fish (e.g. sushi, sashimi, tartar)	▢Y ▢P ▢N ▢DK
Smoked or cured fish (not from a can/retort pouch e.g smoked salmon, gravlax, jerky or lox)	▢Y ▢P ▢N ▢DK
Pre-cooked shrimp or prawns eaten cold (e.g. shrimp ring, shrimp cocktail, in a salad, leftovers eaten cold)	▢Y ▢P ▢N ▢DK
Pre-cooked crab eaten cold (including imitation crab meat)	▢Y ▢P ▢N ▢DK
Other ready to eat shellfish eaten cold (e.g. mussels, oysters, clams)	▢Y ▢P ▢N ▢DK

Salads and dips

Exposure	Response	Brand/Details	Where purchased or eaten:
Prepared green salad (e.g. garden, greek, caesar, purchased in a store, restaurant or cafeteria)	▢Y ▢P ▢N ▢DK
Potato salad ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK
Pasta salad ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK
Bean Salad ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK
Cole slaw ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK
Hummus ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK
Other salads/dips (e.g. chicken salad, egg salad, tuna salad, seafood salad, rice salad, tabouli) Specify type: ▢ homemade ▢ purchased	▢Y ▢P ▢N ▢DK

Fresh Vegetables (eaten raw, uncooked)

Exposure	Response	Brand/Details	Where purchased or eaten:
Alfalfa sprouts	▢Y ▢P ▢N ▢DK
Bean sprouts	▢Y ▢P ▢N ▢DK
Lettuce and/or salad purchased pre-packaged in a bag or plastic container	▢Y ▢P ▢N ▢DK
Whole lettuce	▢Y ▢P ▢N ▢DK
Spinach, purchased loose or in a package	▢Y ▢P ▢N ▢DK
Mushrooms (raw, uncooked)	▢Y ▢P ▢N ▢DK
Fresh Herbs (e.g. basil, cilantro, parsley)	▢Y ▢P ▢N ▢DK
Packaged pre-cut vegetables (e.g. in a platter or tray, diced onions, diced celery etc) Specify type:	▢Y ▢P ▢N ▢DK

Fresh Fruit

Exposure	Response	Brand/Details	Where purchased or eaten:
Honeydew melon ▢ whole, cut at home ▢ pre-cut	▢Y ▢P ▢N ▢DK
Cantaloupe ▢ whole, cut at home ▢ pre-cut	▢Y ▢P ▢N ▢DK
Watermelon ▢ whole, cut at home ▢ pre-cut	▢Y ▢P ▢N ▢DK
Packaged pre-cut fruit (e.g. in a platter or tray, apple slices, fruit salad etc)	▢Y ▢P ▢N ▢DK
Unpasteurized fruit/vegetable juice (eg fresh squeezed orange juice)	▢Y ▢P ▢N ▢DK

Local/Provincial/Territorial Comments (Attach additional pages if needed)

PHAC comments (Attach additional pages if needed)

Download the alternative format