Version 2015

Philippine Integrated Disease

Surveillance and Response Case Report Form
Acute Meningitis-Encephalitis Surveillance

VII. CASE CLASSIFICATION (*Case Classification will be filled out by Epidemiology and Surveillance Units)

A. For Acute Encephalitis Syndrome B. For Bacterial Meningitis

Case Classification: Case Classification:

 Suspected  Suspected Meningitis
 Laboratory confirmed JE AES other agent ______________________  Probable Bacterial Meningitis
 Probable JE  AES unknown   Confirmed Meningitis; if confirmed case, please state confirmatory test
_________________________________________________________________

Final Diagnosis:_______________________________________________
VIII. OUTCOME
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 Alive Date of Discharge: ____ / ____ /_____  Died Date of death: ____ / ____ / ____
MM DD YY MM DD YY

Recovered w/ sequelae  Yes  No

If yes, specify:__________________________________________  Home Against Medical Advice (HAMA) Date if HAMA: ____ / ____ / ____
MM DD YY

Transferred/ Referred To: ________________________________

CASE DEFINITION of Acute Meningitis-Encephalitis Surveillance

A combined case definition for AES and BM surveillance shall be used. Suspected cases will be captured through the standard case definition of Acute Meningitis-Encephalitis Surveillance System (includes meningitis,
encephalitis, and overlapping cases)

A case of suspected Acute Meningitis-Encephalitis is a person of any age, WITH a sudden onset of fever, plus one of:
 change in mental status (including altered consciousness, confusion, or inability to talk)
 new onset of seizures
 neck stiffness
 other meningeal sign