Avian influenza outbreak investigation form – COMMERCIAL flocks Unique ID ____________________________ (one form per commercial unit investigated)
GENERAL INFORMATION Central request
Provincial request
District request
Repeat visit1
Reason for visit
Name of Investigator (cellphone number & email Title of Investigator Date of this visit
1: If a repeat visit use the original unique record number LOCATION Name of owner / manager Province District Sub District Village Sub Village Northing
GPS of commercial unit
Easting
BIRDS ON SITE (current numbers/ages, i.e. 1,000/26 weeks old) Layers
Broilers
Healthy Sick Dead due to illness Culled
Muscovy Ducks Healthy Sick Dead due to illness Culled
Geese
Native chickens
Ducks
DESCRIBE DISEASE EVENT (start approximately 2 weeks before first death/sign)
CLINICAL SIGNS CHECKLIST Body system Gastrointestinal
Nervous
Musculoskeletal
Feathers / comb / skin
Sudden death
Other
Presence
Duration
Describe
VACCINATION HISTORY Type
Manufacturer
e.g.AI
Medion
HOUSING SYSTEM Chickens
Ekor
Who vacc?
1,000
Owner
Age when vaccinated 1st
2nd
3rd
4th
10 days
16 weeks
20 weeks
46 weeks
Ducks
Other
Deep litter Cage system Bird proof nets Free range Other
Number of houses on site
Total
Affected
VENTILATION SYSTEM Chickens
Ducks
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist Controlled climate
SOURCE OF BIRDS Chickens Hatchery Rearer Dealer Other
Ducks
OTHERS
OTHER
5th
DIAGNOSTIC TESTS Number of tests
Number positive
Number negative
Carcass
Blood/serum
Cloacal swab
Oropharyngeal swab
Environmental swab
Other
HPAI PCR
Virus isolation
HPAI serology
Bacteriology
Anatomic pathology
Toxicology
Rapid antigen test result Type of rapid antigen test
Laboratory samples submitted
Laboratory tests requested
Date samples submitted Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (from approximately 7 days from first mortality) Risk factor Visit from poultry collectors Visit from egg collectors Birds received from markets Nearby rice field grazed by commercial ducks flocks Contact with village ducks Contact with village chickens Farm vehicles/equipment ? Feed delivered Infected premises <=1km (household or commercial) Vaccination team visit Veterinary/para-veterinary visit Large flocks of wild birds near village Visit by professional agriculture worker (vet, farm adviser etc) Other Other Other Other 1: ‘Y’ if applies, else leave blank
Risk existing1
High risk1
MAP OF FARM SITUATION (show key risk factors such as other infected places, markets, rivers, etc).
HUMAN CASES IN VILLAGE Age
Sex
Date of symptoms
Recovered (Y/N)
Date of death
Occupation
HIGH RISK TRACES ON (since 7 days before clinical signs) High risk trace on
Date
NO.
Source
HIGH RISK TRACES OFF (since clinical signs) High risk trace off
Date
NO.
Destination
Form Investigasi Wabah Avian Influenza (AI)
Informasi Umum Pusat
Provinsi
Kabupaten
Repeat visit1
Asal Informasi
Nama Investigator (HP & email) Title of Investigator Tanggal Kunjungan
1: If a repeat visit use the original unique record number LOKASI KEJADIAN Nama Pemilik Provinsi Kabupaten Kecamatan Desa Dusun/ RT/ RW Northing
GPS of commercial unit
Easting
BIRDS ON SITE (current numbers/ages, i.e. 1,000/26 weeks old) Layers
Broilers
Sehat Sakit Mati karena sakit Culled (dimatikan)
Muscovy Ducks Sehat Sakit Mati dikarenakan sakit Culled (dimatikan)
Geese
Ayam Kampung
Unggas Air
Gambaran Kejadian Penyakit (Dimulai 2 minggu sebelum kematian/ sakit pertama)
CLINICAL SIGNS CHECKLIST Sistem Gastrointestinal
Nervous
Musculoskeletal
Feathers / comb / skin
Sudden death
Other
Presence
Lama Kejadian
Gambaran
Sejarah Vaksinasi Type
Manufacturer
e.g.AI
Medion
Sistem Pemeliharaan Ayam
Ekor
Who vacc?
1,000
Owner
Age when vaccinated 1st
2nd
3rd
4th
10 days
16 weeks
20 weeks
46 weeks
Unggas Air
Lainnya
Deep litter Cage system Bird proof nets Free range Other
Number of houses on site
Total
Affected
VENTILATION SYSTEM Chickens
Ducks
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist Controlled climate
SOURCE OF BIRDS Chickens Hatchery Rearer Dealer Other
Ducks
OTHERS
OTHER
5th
DIAGNOSTIC TESTS Number of tests
Number positive
Number negative
Carcass
Blood/serum
Cloacal swab
Oropharyngeal swab
Environmental swab
Other
HPAI PCR
Virus isolation
HPAI serology
Bacteriology
Anatomic pathology
Toxicology
Rapid antigen test result Type of rapid antigen test
Laboratory samples submitted
Laboratory tests requested
Date samples submitted Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (7 hari sebelum kematian pertama) Risk factor Kunjungan pengepul ayam Kunjungan pengepul telur Datangnya ayam/ unggas air dari pasar Dekat dengan sawah yang ada unggas airnya Kontak dengan unggas air (entog) Kontak dengan ayam kampung sekitarnya Peralatan kandang Pengantar pakan Peternakan terinfeksi<=1km (backyard atau komersial) Kunjungan vaksinator Kunjungan dokter hewan dan paramedis Peternakan komersial yang dekat dengan kampung Kunjungan anak kandang Apakah letak peternakan dekat dengan sungai ? 1: ‘Y’ if applies, else leave blank
Risk existing1
High risk1
PETA SITUASI PETERNAKAN ( Daerah terinfeksi, pasar, sungai, dll).
Kejadian pada manusia di kampung disekitarnya Umur
Sex
Tanggal Kejadian
Recovered (Y/N)
Tanggal Kematian
Pekerjaan
HIGH RISK TRACES ON (since 7 days before clinical signs) High risk trace on
Date
NO.
Source
HIGH RISK TRACES OFF (since clinical signs) High risk trace off
Date
NO.
Destination
Form Investigasi Wabah Avian Influenza (AI) (Sektor III/ IV)
Informasi Umum Pusat
Provinsi
Kabupaten
Repeat visit1
Asal Informasi
Nama Investigator (HP & email) Title of Investigator Tanggal Kunjungan
1: If a repeat visit use the original unique record number LOKASI KEJADIAN Nama Pemilik Provinsi Kabupaten Kecamatan Desa Dusun/ RT/ RW Northing
GPS of commercial unit
Easting
BIRDS ON SITE (jumlahnya/ umur, contoh: 1,000/26 weeks old) Ayam Petelur Sehat Sakit Mati karena sakit Culled (dimatikan)
Muscovy Ducks Sehat Sakit Mati dikarenakan sakit Culled (dimatikan)
Geese
Broilers
Ayam Kampung
Unggas Air
Gambaran Kejadian Penyakit (Dimulai 2 minggu sebelum kematian/ sakit pertama)
CLINICAL SIGNS CHECKLIST Sistem Gastrointestinal
Nervous
Musculoskeletal
Feathers / comb / skin
Sudden death
Other
Presence
Lama Kejadian
Gambaran
Sejarah Vaksinasi Type
Manufacturer
e.g.AI
Medion
Sistem Pemeliharaan Ayam
Ekor
Who vacc?
1,000
Owner
Age when vaccinated 1st
2nd
3rd
4th
10 days
16 weeks
20 weeks
46 weeks
Unggas Air
Lainnya
Deep litter Cage system Bird proof nets Free range Other
Number of houses on site
Total
Affected
VENTILATION SYSTEM Chickens
Ducks
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist Controlled climate
SOURCE OF BIRDS Chickens Hatchery Rearer Dealer Other
Ducks
OTHERS
OTHER
5th
DIAGNOSTIC TESTS Number of tests
Number positive
Number negative
Carcass
Blood/serum
Cloacal swab
Oropharyngeal swab
Environmental swab
Other
HPAI PCR
Virus isolation
HPAI serology
Bacteriology
Anatomic pathology
Toxicology
Rapid antigen test result Type of rapid antigen test
Laboratory samples submitted
Laboratory tests requested
Date samples submitted Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (7 hari sebelum kematian pertama) Risk factor Kunjungan pengepul ayam Kunjungan pengepul telur Datangnya ayam/ unggas air dari pasar Dekat dengan sawah yang ada unggas airnya Kontak dengan unggas air (entog) Kontak dengan ayam kampung sekitarnya Peralatan kandang Pengantar pakan Peternakan terinfeksi<=1km (backyard atau komersial) Kunjungan vaksinator Kunjungan dokter hewan dan paramedis Peternakan komersial yang dekat dengan kampung Kunjungan anak kandang Apakah letak peternakan dekat dengan sungai ? 1: ‘Y’ if applies, else leave blank
Risk existing1
High risk1
PETA SITUASI PETERNAKAN ( Daerah terinfeksi, pasar, sungai, dll).
Kejadian pada manusia di kampung disekitarnya Umur
Sex
Tanggal Kejadian
Recovered (Y/N)
Tanggal Kematian
Pekerjaan
HIGH RISK TRACES ON (since 7 days before clinical signs) High risk trace on
Date
NO.
Source
HIGH RISK TRACES OFF (since clinical signs) High risk trace off
Date
NO.
Destination
