PHAC Travel-acquired enteric illness questionnaire

Case ID:

Questionnaire Background for Interviewer:

This questionnaire is designed to collect information on possible risk factors for travel-acquired enteric illness. It may be used in cluster investigations or for sporadic illness.

Data captured: – Case demographics – Animal exposures – Risk factors

– Clinical information – Trip details – Water exposures

– All-inclusive resort exposures (ONLY for cases reporting travel to all-inclusive resorts)

Since this information may be shared with public health authorities in the destination countries, it is important to collect as much detail as possible. Demographic information plus detailed exposure information is generally necessary for public health action.

The questionnaire is estimated to take 10 to 15 minutes to complete.

Section 1. Interviewer Details:
Case Interviewed by:	Date of interview (dd-mm-yyyy): ______ / ______ / _______
Respondent was: o case o parent o spouse o caretaker o other, specify:

Section 2. Case Information:
Age:	Gender: o M o F o Another Gender o Not asked/Unknown
Province/Territory:	Health Unit:

Section 3. Clinical Information:
Pathogen: o Cholera o E. coli o Salmonella o Giardia o Cyclospora o Hep A o Other, specify:
Serotype/Genotype:					Whole genome sequencing cluster code (if applicable):
Positive specimen type(s): o Stool o Blood o Urine o Other:
Date onset first symptom (dd-mm-yyyy): ______ / ______ / _______ Approx. time of onset: ________ o am o noon o pm o midnight
Symptoms: Diarrhea^¥ o Y o N o DK Vomiting o Y o N o DK Fever o Y o N o DK Nausea o Y o N o DK Abdominal cramps o Y o N o DK Other: _____________________________________ ^¥3 or more loose stools in 24 hours
Admitted^¥ to hospital because of the illness? o Y o N o DK ^¥do not include individuals who visited an emergency room or an outpatient clinic					Date of admission(dd-mm-yyyy): ______ / ______ / _______ Date of discharge (dd-mm-yyyy): ______ / ______ / _______ o Still hospitalized
(Interviewer) Case deceased? o Y o N If yes, was infection 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
Underlying conditions or medications that suppress the immune system (e.g. pregnancy, diabetes, cancer, steroids)? o Y o N o DK If yes, specify:
Did you see a health care provider for health information before travel? o Y o N o DK

Section 4: Trip Overview:
Destination country/countries:
Departure date (dd-mm-yyyy): ______ / ______ / _______				Return date (dd-mm-yyyy): ______ / ______ / _______
Type of travel: o Tourism o Medical Tourism o Business o Missionary/volunteer/aid work o Visiting friends & relatives o Other, specify: o Student o Military
Did you travel with a group (for example, tour group, wedding, mission group)? o Y o N o DK If yes, specify name of group/organization:
What type of accommodation did you stay in? (NOTE TO INTERVIEWER: If the case stayed at an all-inclusive resort, please complete Section 5 below. All other cases should omit Section 5 and proceed to Section 6). o All-inclusive resort – If yes, specify name and location and complete Section 5: ______________________________________ o Hotel – If yes, specify name and location: _____________________________________________________________________ o With family/friends o Private rental (e.g., condo, house) o Cruise ship – If yes, specify: _____________________________ o Other, specify: ____________________________________

Section 5. All-inclusive resorts (to be completed ONLY for travelers to all-inclusive resorts):
Did you participate in any activities/excursions off-resort? oY oN oDK – If yes, please specify below
Excursion description		Date (dd-mm-yyyy)	Food or drink?			If yes, specify food/snack/drink
			oY oN oDK
			oY oN oDK
			oY oN oDK
			oY oN oDK
			oY oN oDK
Did you consume any other meals/snacks/drinks off-resort? o Y o N o DK – If yes, please specify below
Location		Date (dd-mm-yyyy)				Specify food/snack/drink






Section 6. Risk Factors (to be completed for ALL cases): During your trip did you have exposure to any of the following risk factors?
Did you consume any food from street vendors? o Y o N o DK If yes, specify: __________________________________________________
Did you consume any raw or undercooked (rare) meats and fish, including shellfish? o Y o N o DK If yes, specify: _____________________
Did you consume any salads or other items made with uncooked produce? o Y o N o DK If yes, specify: _____________________________
Did you consume any fruits that did not have a peel (e.g., berries) or that you did not peel yourself? o Y o N o DK If yes, specify: _________
Did you consume any unpasteurized dairy products or fruit juices? o Y o N o DK If yes, specify: ____________________________________
Did you consume (e.g., drink, brush your teeth, etc.) any of the following during your trip? Bottled water o Y o N o DK Other o Y o N o DK – If yes, specify: __________________________________________ Tap water o Y o N o DK
Did you consume drinks with ice? o Y o N o DK
Did you swim in a pool? oY oN oDK
Did you swim in an ocean/lake/river? oY oN oDK
Did you have any contact with animals/animal waste? oY oN oDK – If yes, please specify below
1	Type of animal: Where: __________________________________________________ When: ________________________________________
2	Type of animal: Where: __________________________________________________ When: ________________________________________

Is there anything else we haven’t talked about that you think might be important (for example pool closures, public vomiting, etc.)?

This is the end of the survey. Thank you for your time.

Do you mind if we call you back at a later date if we have additional questions? o Y o N

Please return completed questionnaire to your provincial/territorial representative. They in turn are asked to forward the questionnaire to the Public Health Agency of Canada by e-mail at enteric.outbreak-eclosion.enterique@phac-aspc.gc.ca. Thank you.

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