Page 1 of 3

Philippine Integrated Disease

Surveillance and Response Case Investigation Form

Severe Acute Respiratory Infection (SARI)

(ICD 10 Code: J22)
Name of DRU: Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address: Gov’t Lab. Private Lab. Airport/Seaport Others_________

Source:  Surveillance  Outbreak

I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:

Complete Address: MM DD YY Age:

Days
Male Date of
Sex: Months
Female Birth:
Years

Occupation: Name of Workplace:

Address of Workplace:

II. HISTORY OF ILLNESS, PHYSICAL EXAMINATION AND PRE-EXISTING CONDITIONS

Admitted? MM DD YY MM DD YY
Date Admitted/ Date Onset of
Yes No Unknown Seen/Consult Illness
Did you take any of the following medication(s) Are there any influenza-like-illness during
prior to consultation? the week in your:
Did you received Anti-influenza
 Ranitidine (e.g. Flumadine)
Household Vaccination in the past year
 Amantidine  Yes  No  Unknown
 Zanamivir  Yes  No  Unknown
 Oseltamivir (e.g. Tamiflu) School/Daycare
 Others: (Please specify) ________________  Yes  No  Unknown
History of exposure to any of the ff:
History of travel: Chest X-ray
 Bats  Poultry/Migratory Birds  Done  Not Done
 Camels  Pigs  Yes (specify country) ____________ Result: _________________
 Horses  Others:____________________  No
2. IMCI criteria for severe pneumo-
SARI Suspect Case for Patients < 5 years
Temperature at consultation:___ C old and
0 EITHER ONE of the two IMCI criteria nia
for pneumonia
 Any child 2 months to 5 years
 Fever/ Feverish of age with cough or difficult
Duration:_____ days/weeks 1. IMCI Criteria for pneumonia:
breathing
 Headache
 Cough  Any 2 months to 5 years of age with With any of the following danger
Signs and  Sore throat cough or difficult breathing signs:
Symptoms:  Difficulty of breathing  Breathing faster than 60 breaths/min
(infants < 2 months)  Unable to drink or breastfeed
 Others: (Please specify)
_____________________  Breathing faster than 50 breaths/min (2-  Vomits everything
12 months)
 Convulsions
 Breathing faster than 40 breaths/min (1-
5 years old)
 Lethargic or unconscious
 Requires hospital admission.  Chest indrawing or stridor in a
calm child
 Requires hospital admission.
 Asthma  Chronic renal disease Clinical Impression:
 Chronic cardiac disease  Diabetes
  Influenza-like-illness (ILI)
Pre-existing  Chronic liver disease Haematologic disorders
Conditions  Chronic neurological or neuro-  Immunodeficiency diseases  SARI
muscular disease  Pregnancy  Others, specify:
III. LABORATORY TESTS:
Specify If YES, date tak- Type of laboratory Results
Date result
Specimen en test done N=Negative; I=Indeterminate; U-Unknown
MM DD YY MM DD YY
Positive for: N I U
MM DD YY MM DD YY
Positive for: N I U

DOH-EB-PIDSR-SARICIF-REV0
 Page 2 of 3

Case Investigation Form

Severe Acute Respiratory Infection (SARI)

IV. CLINICAL MANAGEMENT AND OUTCOME

 Yes  No  Unknown  Yes  No  Unknown
Antibiotics If Yes, please specify Bacterial Testing If Yes, please specify
_______________ _______________
 Yes  No  Unknown  Yes  No  Unknown
If Yes, please specify Other Therapeutic
Antivirals If Yes, please specify
_______________ Procedures
_______________
 Yes  No  Unknown
Fluid Therapy If Yes, please specify Final Diagnosis
_______________
 Yes  No  Unknown  Alive  HAMA  Died
Oxygen If Yes, please specify Outcome at Discharge  Others (specify) __________
_______________

 Yes  No  Unknown
Intubation If Yes, please specify Date of discharge
_______________

Others

CASE DEFINITION/CLASSIFICATION:

INFLUENZA- LIKE-ILLNESS (ILI)

Suspected case: A person with acute respiratory infection, with measured fever of ≥38°C and cough with onset within the last
10 days.
Probable case: Not applicable
Confirmed case: A suspected case that is laboratory-confirmed (used mainly in epidemiological investigation rather than
surveillance).

SEVERE ACUTE RESPIRATORY INFECTION (SARI)

SARI Suspect Case for Persons > 5 years old:

An acute respiratory infection with:
-history of fever or measured fever of ≥ 38 C°;
-and cough;
-with onset within the last 10 days;
-and requires hospitalization
-WITH difficulty of breathing; OR
-A suspect case of severe undiagnosed pneumonia, Acute Respiratory Distress Syndrome, Severe Respiratory Disease
due to Novel Respiratory Pathogens

DOH-EB-PIDSR-SARICIF-REV0
 Page 3 of 3

Case Investigation Form

Severe Acute Respiratory Infection (SARI)

CASE DEFINITION/CLASSIFICATION: (Continued)

SARI Suspect Case for Patients < 5 years old:

EITHER:

IMCI criteria for pneumonia

Any child 2 months to 5 years of age with cough or difficult breathing, AND:
Breathing faster than 60 breaths/min (infants < 2 months)
Breathing faster than 50 breaths/min (2-12 months)
Breathing faster than 40 breaths/min (1-5 years old)
OR:

IMCI criteria for severe pneumonia

Any child 2 months to 5 years of age with cough or difficult breathing and any of the following danger signs:
Unable to drink or breastfeed
Vomits everything
Convulsions
Lethargic or unconscious
Chest indrawing or stridor in a calm child

AND
Requires hospital admission.

Notes:

 The requirement of “hospital admission” is meant to imply that in the judgment of a treating clinician the patient has an ill-
ness that is severe enough to require inpatient medical care.
 “Shortness of breath or difficulty breathing” is intended to capture dyspnea or air hunger. This does not refer to nasal con-
gestion or other upper airway obstruction.
 “History of fever” does not require a history of documented fever and may include a patient’s subjective report of having a
fever or feeling “feverish”.
 SARI may reflect a new illness superimposed on an underlying condition or older illness
 SARI is not equivalent to classic pneumonia and would not always present as pneumonia. It is expected that much of
the severe respiratory disease associated with influenza would be due to exacerbations of chronic lung disease or heart
disease, for example, and would not include an admitting diagnosis of pneumonia.

PROBABLE CASE

A person fitting the definition above of a “Suspect Case” with clinical, radiological, or histopathological evidence of pulmonary
parenchyma disease (e.g. pneumonia or ARDS) but no possibility of laboratory confirmation either because the patient or
samples are not available or there is no testing available for other respiratory infections, AND

Close contact with a laboratory confirmed case, AND

Condition not already explained by any other infection or etiology, including all clinically indicated tests for community-
acquired pneumonia according to local management guidelines.

CONFIRMED CASE: A suspected case that is laboratory-confirmed.

DOH-EB-PIDSR-SARICIF-REV0