Report of Adverse Event (Reaction) Following Immunization

AEFI Case Report Form

Health care providers are required by law to report Adverse Events Following Immunization (AEFIs) to monitor vaccine safety. Reports should be made using the British Columbia AEFI Case Report Form and sent to the local health unit. After filling and printing the form, send/fax it to your local health unit office:

Where to submit an AEFI report

Data from the form are to be entered into Panorama or PARIS by public health staff. Criteria for reporting and management of adverse events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization.

Part 5 - Adverse Events Following Immunization

AEFI Data Entry Guidelines 

The following resource is intended for BC health care providers completing the AEFI case report form or the Panorama AEFI form: User Guide for Completion and Submission of Adverse Events Following Immunization (AEFI) Reports.

Worksheet for Events Managed as Anaphylaxis Following Immunization

Anaphylaxis Worksheet

Events managed as anaphylaxis following immunization may be recorded on this BCCDC worksheet. This worksheet should be completed by the immunizing health care professional that observed and treated the client who experienced the anaphylactic episode. Management guidelines for these events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization.

Part 3 - Management of Anaphylaxis in a Non-Hospital Setting

After filling and printing the form, please submit the form to the appropriate Medical Health Officer (MHO) for review. Please also complete a Panorama report on this adverse event.

Reporting Form 

Confirmed Creutzfeldt-Jakob Disease (CJD) became reportable in BC in March 2007. To facilitate reporting when a case of CJD is confirmed by the National CJD surveillance system (CJD-SS) they will enter case details into the form and send to the attending neurologist. The neurologist will complete additional details and fax to public health to notify medical Health Officer. Please enter the case details into iPHIS and fax the form to Communicable Diseases and Immunization Service, BCCDC at 604-707-2516.

Enteric Provincial Surveillance Form with Panorama Guidance

Amebiasis

• Follow-up Form
  

AIDS

Case Report Form

AIDS is a reportable disease in British Columbia. AIDS reporting is accomplished by submitting a BC AIDS Case Report Form to the BC Centre for Disease Control, Division of STI/HIV Prevention and Control. If an AIDS-defining illness is diagnosed in an HIV positive patient, please download this form, complete and return by mail to:

The BC Centre for Disease Control 
Division of STI/HIV Prevention and Control 
HIV/AIDS Surveillance Nurse 
655 West 12th Avenue
Vancouver, B.C. V5Z 4R4

Gonorrhea and Chlamydia

• HLTH208 - Confidential Notification of Sexually Transmitted Infection Case Report Form (see below)
  

Gonorrhea and chlamydia are reportable diseases in British Columbia.

If gonorrhea and/or chlamydia are diagnosed within Vancouver Coastal Health Authority, or Fraser Health Authority, please download the following form (H208 – BCCDC), complete and return to: 

Hepatitis B: Acute HBV

• Acute HBV Case Report Form

As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.      

Hepatitis C: Acute HCV

• Acute HCV Case Report Form

As of January 1, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis C, in accordance with the follow-up practices of each Health Authority.

Screening Program Form (HLTH 939)

Instructions for HLTH 939

Enterovirus D68

• Enterovirus D68 Case Report Form

• Neurologic Illness Associated with Enterovirus D68 Case Report Form

All lab-confirmed cases of enterovirus D68 (EV-D68) should be entered in an electronic data management system for communicable diseases (Panorama/PARIS). For EV-D68 cases associated with respiratory (non-neurologic) clinical presentation, please use the general ‘Enterovirus D68 Case Report Form’. For EV-D68 cases associated with neurologic illness, please use the ‘Neurologic Illness Associated with Enterovirus D68 Case Report Form’.  Case definitions can be found in the linked forms.

Hepatitis B: Acute HBV

• Acute HBV Case Report Form

As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.

Influenza

Influenza Severe Outcome Surveillance (SOS) Case Report Form

Severe cases of influenza can be reported in an electronic data management system for communicable diseases (Panorama/PARIS) at the discretion of regional Health Authorities. Refer to Case Report Form for influenza severe outcome surveillance (SOS) case definitions.

Influenza-like Illness

ILI Outbreak Report Form

All influenza-like illness (ILI) outbreaks occurring in schools, work sites, acute care facilities, residential institutions (e.g. long-term care facilities, seniors' residences), and other facilities of interest (e.g. correctional facilities) should be reported to BCCDC by the responsible health unit or authority. This form can be delivered by fax (604-707-2516) or email. ILI outbreaks are defined as follows: 

• Schools and work sites: greater than 10% absenteeism on any day, most likely due to ILI

• All other facilities: two or more cases of ILI within a seven-day period

Invasive Group A Streptococcus

Case Report Form

Complete this form for every case of invasive group A Streptococcal disease. Return completed forms to Communicable Diseases and Immunization Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Invasive Pneumococcal Disease

Case Report Form

Complete this form for every case of invasive pneumococcal disease AGED 0-16 YEARS. Return completed forms to Communicable Diseases and Immunization Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Measles, Mumps & Rubella 

Measles Case Report Form
Mumps Case Report Form
Rubella Case Report Form

Congenital Rubella 

Case Report Form

Complete a form for every case of measles, mumps or rubella disease. Return completed forms to Communicable Diseases and Immunization Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS).

Meningococcal

Case Report Form

Complete this form for every case of meningococcal disease. Return completed forms to Communicable Diseases and Immunization Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Pertussis

Minimum data elements for provincial reporting for all probable and confirmed cases of pertussis should be reported in an electronic data management system for communiable diseases (Panorama/PARIS). For VCH only, completed forms should be faxed to Communicable Diseases and Immunization Service, BCCDC, at 604-707-2516.

Case Report Form

Contact Management and Treatment forms are provided for use within Health Authorities. These forms do not need to be submitted to BCCDC.

Contact Management Form
Pertussis Forms
Treatment Form 

Other Vaccine Preventable Diseases

Case Report Form

Complete a form for every case of invasive Haemophilus influenzae type b, poliomyelitis, tetanus, and for every case and carrier of toxigenic diphtheria.  

Enter reportable cases into Panorama or PARIS.  If required, return completed forms to Communicable Diseases and Immunization Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).