08 July 2009
Guidelines for Australian Public Health Units
Version 4.1; Last updated 8 July, 2pm AEST, NSW section added 6 August 09
These Guidelines have been modified to reflect a period where there is now increasing community transmission of H1N1 influenza 09 infection (previously known as Human Swine Influenza) in many areas, with some areas still remaining relatively unaffected. It is noted that the relative application of measures for case and contact ascertainment and management may vary between jurisdictions, based on local epidemiology and resources.
The focus of the PROTECT phase is on identifying the people who are most vulnerable for severe disease and to provide medical care and interventions to reduce the incidence of poor outcomes. Information for health care providers on the clinical management of H1N1 influenza 09 cases is described in the Protect Phase Annex to the Australian Health Management Plan for Pandemic Influenza available at (www.healthemergency.gov.au )
Public health priority
- Low - for individual cases
- High - for outbreaks in 'closed' facilities or high-risk settings such as health care facilities, special schools, residential care facilities, cruise ships and indigenous communities.
- Cases will be managed directly by their health care providers with a focus on patients with influenza like illness (ILI) who are in vulnerable groups, or who have moderate to severe disease.
- Public health action will focus on outbreaks in care facilities with vulnerable contacts.
- None routinely, except in specific 'closed' facilities or high-risk settings.
- Remind health care providers to be mindful of appropriate management of close contacts who are in vulnerable groups, including to provide instruction for early presentation for testing and treatment should they develop symptoms.
2. The disease
H1N1 influenza 09 is a novel influenza A virus infecting humans. Influenza viruses are composed of an RNA core surrounded by an envelope containing two surface glycoproteins — haemagglutinin and neuraminidase. These antigens have the ability to rapidly mutate and produce minor or major changes to the antigenic structure, known as antigenic drift and antigenic shift respectively. Although all influenza strains were originally avian in origin, the H1N1 influenza 09 virus appears to be most closely related to North American and Eurasian swine influenza lineages, against which humans have little or no immunity.
Mode of transmission
Definitive information regarding the mode of transmission of H1N1 influenza 09 is not yet available, however, it seems likely that it shares the same transmission dynamics as seasonal influenza, i.e. it is most commonly spread from person-to-person by inhalation of infectious droplets produced while talking, coughing and sneezing. Transmission may also occur through direct and indirect (fomite) contact. The virus may persist on hard surfaces for 1-2 days, particularly in cold or low humidity conditions. The virus may remain viable on hands for 5 minutes.
While the maximum incubation period could be 7 days, a shorter median incubation period of 3-4 days seems typical. This may change as more information concerning characteristics of the H1N1 influenza 09 virus becomes available.
Patients may shed influenza virus for up to 24 hours (1 day) before onset of symptoms until 7 days after the onset of symptoms. Viral shedding is reduced to very low levels by 5 days. Presence of fever is correlated with viral shedding.
It is possible that some groups, especially children, might be contagious for longer periods. However the ability to transmit infection is also likely related to the presence of respiratory symptoms.
Anti-influenza medicines will reduce the amount of virus shed by the patient within 1 to 3 days.
Patients are considered no longer infectious 24 hours after resolution of the fever, provided either they have received 72 hours of anti-influenza medicine or 7 days have elapsed since onset of respiratory symptoms.
Seasonal influenza typically commences with symptoms of fever, cough, fatigue, sore throat, headache, myalgia, arthralgia and rigors or chills. Studies of confirmed cases of H1N1 influenza 09 infection suggest a similar profile, with diarrhoea and/or vomiting also being reported by around 25% of cases. In one series, 95% of confirmed H1N1 influenza 09 cases reported fever, plus cough and/or sore throat.
Pneumonia may develop directly from influenza infection (primary influenza pneumonia) or from secondary bacterial infection. Symptoms of pneumonia may include breathing difficulty, productive cough, bloody sputum, and pain when breathing. Chest X-rays may show pneumonia. Acute respiratory distress syndrome (ARDS) may develop several days after disease onset.
In a recent review of 567 confirmed H1N1 influenza 09 hospitalizations in New York, 80% of cases had at least one known risk factor for severe illness or complications due to influenza. These included: asthma (41%), pregnancy (noted in 28% of the 142 women of childbearing age), age less than 2 years (12%), diabetes (11%), weakened immunity (9%), and cardiovascular disease (9%).
3. Risk assessment
Routine prevention activities
Hand hygiene and cough etiquette are thought to dampen transmission of influenza. No specific vaccine is currently available for H1N1 influenza 09 and data indicate that available seasonal vaccines are unlikely to provide protection. Voluntary home isolation may have significant impact on reducing disease transmission.
Threat and vulnerability
As H1N1 influenza 09 has not been seen in human populations before, the Australian community is thought to be generally susceptible to infection. However, studies suggest that protective antibodies may be present in a minority of elderly people.
The following groups appear to be at increased risk of severe H1N1 influenza 09 disease:
- Persons with chronic respiratory conditions - including asthma requiring routine preventive medication and chronic obstructive pulmonary disease (COPD)
- Pregnant women - particularly in the second and third trimesters
- Persons with morbid obesity
- Persons with other conditions predisposing to severe influenza such as:
- cardiac disease (excluding simple hypertension)
- diabetes mellitus
- chronic metabolic diseases
- chronic renal or liver disease
- immunosuppression (including, cancers, HIV/AIDS infection, drugs)
- chronic neurological conditions
- Indigenous people (because of a high prevalence of risk factors in this group, it is important to carefully assess indigenous patients for risk).
- Patients with a moderate to severe disease with rapid deterioration
Others groups which may be at higher risk than the general population include:
- People with obstructive sleep apnoea
- Children under the age of 2 years
- Pregnant women in the first trimester.
Health care workers
Health care workers, defined as those workers providing clinical care, are considered to be a group of special interest asH1N1 influenza 09 disease in a health care worker in the hospital setting can expose vulnerable patients to infection. Additionally reduction in health care worker numbers due to illness will adversely affect the care of vulnerable patients.
In the PROTECT phase, risk management focuses on protecting vulnerable groups from severe disease by:
- Public messages encouraging:
- early treatment for people at risk for severe disease
- symptomatic people to not attend school, child care, work or public gatherings while ill
- School closure, and exposure-related school exclusions are not generally recommended, with emphasis placed on children with ILIs staying home, and sending home children who present unwell at school
- Provision of early treatment for people with ILIs who are at increased risk of severe disease, through health care providers (such as GPs, hospitals and influenza clinics)
- Voluntary home isolation for those who are sick
- A focus on control of outbreaks in 'closed' facilities and high-risk settings.
4. Surveillance objectives
- To monitor the incidence of H1N1 influenza 09 by time, place and person, including the introduction of infection into unaffected areas
- To identify risk factors for severe disease (e.g. hospitalisations, deaths)
- To monitor and detect any changes in the antigenic characteristics and antiviral drug sensitivity of the H1N1 influenza 09 virus
- To identify outbreaks in closed and high risk settings to allow for the implementation of control measures
- To monitor the relative incidence of H1N1 influenza 09 and seasonal influenza
Note. Surveillance during the PROTECT phase will also be strengthened by enhanced sentinel surveillance of influenza through established general practice and other sentinel surveillance schemes.
5. Data management
- Only confirmed cases of H1N1 influenza 09 should be entered on NetEpi or other compatible database, including data on risk factors, hospitalisation and deaths
- Confirmed case details should be entered into a NetEpi-compatible database by the jurisdiction managing the case, even if the case is a resident of another jurisdiction.
- Positive H1N1 influenza 09 laboratory results should be reported to the State/Territory disease control office or PHU in a timely fashion
- Public Health Units to inform their State/Territory disease control office when notified of an outbreak of H1N1 influenza 09 in a 'closed' facility or high-risk setting, or in an area with few previously reported cases
- Where a confirmed case is being managed by a jurisdiction other than that of the case's usual residence, the managing jurisdiction will notify the jurisdiction of residence.
7. Case definition
A confirmed case of H1N1 09 virus is defined as a person with H1N1 influenza 09 virus infection identified by one or more of the following tests:
- H1N1 viral sequencing
- H1N1 09 specific-PCR
- H1N1 09 virus culture.
In addition to the confirmed case definition, the following clinical case criteria have been developed to guide clinical management and treatment of individuals:
An influenza like illness characterised by:
- Fever (>=38oC or a good history of fever) AND
- Cough and/or sore throat.
8. Laboratory testing
During the PROTECT phase of the response to H1N1 influenza 09, laboratory testing of all potential cases is neither required nor desirable. This is because:
- confirmation is no longer required to inform decisions about isolation and quarantine in the community setting, or use of anti-influenza medicines
- the majority of cases, to date, have experienced mild clinical illness
- consumption of laboratory reagent stocks and pressure on laboratory human resources are not sustainable in the face of high levels of laboratory testing.
For clinicians, laboratory testing is only recommended in limited circumstances. Testing should be prioritised for people with influenza like illness who are hospitalised or who die, and is not routinely required for others unless it guides clinical management.
Laboratory testing is recommended for:
- Patients who meet the clinical case criteria in areas where the disease is newly introduced, to allow control measures to be instituted if appropriate
- A representative sample of ILI patients from sentinel surveillance systems
- Cases or outbreaks in 'closed' facilities or high-risk settings where individuals are at increased risk for severe influenza. The number of ill people needing testing to determine the cause of an outbreak is generally low (this will depend on the clinical situation, but five samples should suffice)
- Health care workers.
9. Case investigation
- Jurisdictions should follow up hospitalised confirmed cases and deaths in confirmed cases to ascertain epidemiological data detailed in the NetEpi case investigation form
- Public health action should focus on outbreaks in 'closed' facilities and high-risk settings (see Part 12. Special situations).
Health care providers should provide free anti-influenza medicine as soon as possible and within 48 hours of symptom onset to patients who meet the clinical case criteria AND who are at risk for more severe disease (see section 3), who are healthcare workers (where indicated, see section 12), or who have moderate or severe illness.
Anti-influenza medications have shown to attenuate disease in cases of seasonal influenza if give early in the course if the illness (within 48 hours of developing symptoms).
- The health care provider should provide the patient with information on the disease, the use of anti-influenza medications (if indicated), hygiene and infection control practices and precautions (see website links in Part 13 for fact sheets)
- Health care providers should urge patients with ILI to ask close contacts who are at risk of severe disease to present early for treatment should ILI symptoms develop.
- Health care providers should counsel patients who have ILI to stay at home and keep away from work, school and crowded areas or public gatherings until symptoms have resolved. They should be advised to wear a surgical mask when seeking medical attention or when in close company of vulnerable people. Cases in home isolation should maintain a distance of 1 metre from other persons and sleep in a separate room, wherever possible
- A vulnerable household member should wear a surgical mask if they need to come within 1 metre of an ill person who is not able to wear a mask
- Health care workers with ILI should stay at home while infectious (see section 2)
- People with ILI who work with pigs or poultry should not return to work while infectious (see section 2)
- People hospitalised with ILI should be nursed in a single room where possible. Where this is not possible, they should be cohorted with other patients with ILI, maintaining at least 1 m spacing between patients at all times. Care should be taken with infection control precautions to minimise the risk of patients with seasonal influenza becoming co-infected with H1N1 influenza 09, and vice versa. Patients at risk of severe disease should not be co-located with other patients with ILI. Confirmed H1N1 influenza 09 cases should not be cohorted with confirmed seasonal influenza cases.
10. Control of environment
If hospital, residential care facility- or multi-purpose service-acquired infection is suspected, infection control experts should review the facility's infection control procedures. Staff conducting the review must have a thorough understanding of infection control practices, be competent in using PPE and ideally should have been vaccinated with the current seasonal influenza vaccine.
Cleaning H1N1 Influenza 09 In-Patient Rooms
- Daily and on discharge - clean with a neutral detergent. The room can be used immediately following cleaning
- Management of laundry and utensils should be performed in accordance with procedures followed for seasonal influenza
- Treat waste as general medical waste
- Used tissues are disposed of in general waste
11. Contact management
No public health action routinely required except in closed facilities and high risk settings (see section 12).
12. Special situations
12.1 Schools and Childcare settings
- Children and staff with influenza-like illnesses (ILI) should not attend school or child care. If a child or staff member becomes sick with an ILI at school they should be sent home
In regular schools and child care settings if an outbreak is reported:
- PHU should assess
- Based on the assessment the PHU may issue a letter for the school highlighting the outbreak, reinforcing control measures (stay away if sick, hygiene, etc), and urging children and staff at high risk of complications to see their doctor early for treatment if sick.
In boarding schools - because of the close nature of the students, outbreaks may spread more rapidly, and special control measures may be required, including:
- PHU should assess
- Based on the assessment the PHU may issue a letter for the school highlighting the outbreak, reinforcing control measures (stay away or isolate if sick, hygiene, etc) and urging children and staff at high risk of complications to see their doctor early for treatment if sick
- Sick children in boarding schools should be sent home where feasible, and the remainder (e.g., those who live far away) should be isolated or cohorted where practicable
- Prophylactic anti-influenza medicine should be considered to control outbreaks in dormitories where an outbreak is detected early, but may be less useful where disease is widespread, in which case prophylaxis should be considered for vulnerable students and staff.
In special schools - because there may be large numbers of students with chronic illnesses at risk of severe complications from influenza, special control measures may be required including:
- PHU should assess
- Based on the assessment the PHU may issue a letter for the school highlighting the outbreak, reinforcing control measures (stay away if sick, hygiene, etc), and urging children and staff at high risk of complications to see their doctor early for treatment if sick
- Consider use of prophylactic anti-influenza medicine to control outbreaks in specific classes at risk.
- School closures are not generally recommended on public health grounds, although it is recognised that they may be considered on logistical grounds by the school.
12.2 Outbreaks in Residential Care Facilities
12.3 Health Care Workers
HCWs with ILI require special consideration because an infectious HCW can expose vulnerable patients to infection and/or be a reflection of a broader outbreak in a healthcare setting. Patient care may also be adversely impacted by a reduction in health care worker numbers.
- Prevention of transmission of ILI between patients and HCWs requires an approach consistent with the PROTECT phase, including:
- raised awareness among staff, patients and visitors in health care settings about prevention, early detection and exclusion policies, through measures such as education and prominent signage
- good infection control practices, including use of appropriate personal protective equipment and hand hygiene
- early identification and isolation of potentially infectious patients
- early identification and exclusion of potentially infectious staff and visitors from patient contact
- potential reassignment of vulnerable staff away from areas where contact with influenza patients is most likely
- in limited high risk settings, contact tracing of vulnerable patients and staff who were exposed to infectious cases, and provision of early treatment, or rarely, post exposure prophylaxis
- HCWs managing patients with ILI symptoms must ensure that the patient is wearing a surgical mask when not in isolation
- HCWs should routinely wear a surgical mask, protective eyewear and disposable gloves if they are undertaking an examination of an individual with an ILI that may lead to coughing (e.g. collecting nose and/or throat swabs), or where the HCW is within a metre of the patient and the patient is not able to use a surgical mask appropriately
- HCWs who are at increased risk of complications from H1N1 Influenza 09 and who are likely to be in direct contact with patients whom have ILI which may be H1N1 influenza 09 should be considered for redeployment to lower risk activities or environments. Where this is not practical, these HCW must ensure that they use appropriate PPE when examining and managing patients with ILI.
- If redeployment is not possible, managers must ensure that health care workers who are potentially at increased risk of complications from H1N1 Influenza 09 should not participate in procedures which may generate small particles or aerosols of respiratory secretions in patients with confirmed or suspected H1N1 influenza 09, and should not be in the room when such procedures are undertaken. HCWs must be advised of their responsibility to identify themselves if they believe they are in an 'increased risk' group and take appropriate action to protect themselves and others.
Management of Ill Health Care Workers - Health care facilities should ensure HCWs are aware to:
- Be alert for symptoms
- Exclude themselves from work immediately if they develop a fever of >=38 degrees C with either a cough or sore throat, and report the illness to their supervisor
- Be assessed for influenza (by an influenza clinic, their GP or occupational health clinic)
- If influenza is diagnosed on clinical grounds:
- where it is important to facilitate early return to work in areas with critical staffing levels, then swabs should be collected for priority testing for H1N1 influenza 09 and the HCW should receive anti-influenza medicine (see note below).
- where the HCW worked while infectious in a setting with vulnerable patients swabs should be collected for priority testing for H1N1 influenza 09. Contact tracing may be recommended in these settings (see Post exposure prophylaxis in specialised settings to protect vulnerable patients below).
- The HCW should be excluded from work while infectious (see section 2)
- Where clinically appropriate, a negative test result may allow the HCW to return to work earlier.
- Contact tracing is not routinely required following diagnosis of an ILI in a HCW.
Post exposure prophylaxis in specialised settings to protect vulnerable patients.
- Contact tracing should be considered where a HCW worked, or a patient was cared for, while infectious with confirmed H1N1 influenza 09 in a setting with high risk patients (such as hospital wards specifically for people who are immunosuppressed or neonatal wards, but not EDs, general wards, theatres or outpatient settings).
- In these cases, H1N1 influenza 09 test results should be prioritised.
- Close contacts are defined as patients and co-workers who were exposed to the HCW within 1 metre for >15 minutes without a mask.
- Vulnerable patients who are close contacts should be advised of their risk and, if indicated, in consultation with their health care provider, should be offered early treatment should symptoms develop. Prophylaxis should only be considered where the patient is assessed to have a very high risk of severe disease.
- Clinical staff who are close contacts and who are expected to be working on an ongoing basis with high risk patients should be offered prophylaxis and advised to absent themselves from work if symptoms develop within the next week in order to protect vulnerable patients.
- Health Care Workers in specific specialised settings, caring for high risk patients, who have been within 1 metre for 15 minutes of a confirmed case without using appropriate PPE, should be offered post exposure prophylaxis and advised to absent themselves from work if symptoms develop within the next week in order to protect vulnerable patients.
Outbreaks in Health Care Facilities - If an outbreak occurs in a health care facility, an outbreak management team should be convened, including a senior facility manager, an infection control practitioner and appropriate clinical staff, in consultation with PHU staff as required. Control measures may include:
- Case finding and treatment
- Prophylaxis for vulnerable patients and staff
- Epidemiological studies to determine risks for infection
- Distribution of information letters and fact sheets.
12.4 Outbreaks in Indigenous Communities
In the remote indigenous community or "town camp" setting (where conditions are very similar), key factors to be considered are:
- The high level of people with "risk medical conditions" for severe H1N1 influenza 09 disease (approximately 40% of the population is likely to have one or more risk conditions).
- If present in these settings, overcrowding, poor hygiene and other environmental conditions can increase disease transmission and raise attack rates
- Access to health care is often reduced. Most primary care services have limited service and staff capacity.
- Many ill people tend to present late.
- Many communities may be sufficiently isolated to delay entry of the virus, and testing of sentinel ILI cases to detect initial entry is important.
The clinical and public health response to suspected or confirmed H1N1 influenza 09 outbreaks in the remote community or "town camp" setting should aim to:
- Encourage early presentation and identification of all ILI cases, particularly in vulnerable community members*.
- Test and treat ILI cases who fit the clinical case criteria and have been in areas where there is likely to be community transmission in order to detect early incursion of the virus and to inform management of vulnerable community members*.
- Test and treat ILI cases who fit the clinical case criteria and are identified as vulnerable community members* or who have moderate to severe disease, to enable prompt and appropriate management to reduce the risk of severe complications.
- Consider providing anti-influenza prophylaxis for vulnerable community members who were close household contacts of an ILI case while infectious. Broader use of anti-influenza prophylaxis in a community setting should be only done in consultation with the communicable disease control area within the relevant State or Territory Health Department.
* Note - during outbreaks in indigenous communities it is recommended that the identification of vulnerable community members should include all individuals with risk factors referred to in Part 3, including individuals who fall into one or more of the "Other groups which may be at higher risk than the general population". Children who fall into the "failure to thrive" category should also be considered as vulnerable to severe complications of H1N1 influenza 09 infection.
12.5 Outbreaks on Cruise Ships or other Passenger Vessels
- Passengers and crew members who are ill with ILI prior to commencement of the voyage should be advised not to join the vessel until their symptoms have resolved. In regard to this, informal pre- embarkation screening for ILI is important.
- Cruise ships are recommended to:
- provide frequent messages to passengers and crew about hand hygiene and cough etiquette, and seeking (ideally free) medical assessment and treatment if they develop respiratory symptoms and fever
- provide ready access to hand hygiene measures throughout the ship (including alcohol-based hand rub and soap and running water)
- During the voyage, crew should encourage staff and passengers to immediately report ILI. New passengers and local support staff in places visited should not board if they have ILI.
- Passengers and crew who meet the clinical case criteria for H1N1 influenza 09 during the voyage should be offered anti-influenza medicine, be isolated and cared for in single cabins, and be kept separated from other passengers while infectious (see section 2).
- Passengers and staff who are in vulnerable groups need to reconsider their attendance on a cruise ship as contact with large numbers of people increases the risk that they come into contact with respiratory viruses.
- On leaving the ship, passengers with ILI should voluntarily isolate themselves from others while infectious, and seek medical advice if required. No restrictions are placed upon well contacts.
13. Additional sources of information
Department of Health and Ageing:
State and Territory Health Departments:
NSW Department of Health - Human Swine Influenza Investigation
Victorian Government - Swine Influenza - Influenza A (H1N1) virus
Queensland Swine Flu Response
Western Australian Department of Health - Human Swine influenza
SA Department of Health - Human Swine Influenza
NT Government Department of Health and Families - Swine Influenza Outbreaks
Tasmanian Government - H1N1Influenza09 pandemic information
ACT Health - H1N1 Flu (Swine Flu)
14. Jurisdictional specific issues (NSW)
14.1 Testing of health care workers
In NSW testing of health care workers with an ILI is not required routinely and should only be done where:
- it will change the clinical management of the HCW, or
- the HCW is admitted to hospital, or
- the HCW worked in a high risk hospital area and highly vulnerable patients or co-workers are being considered for prophylaxis (see section 12.3).
14.2 Data entry
PHUs receive laboratory reports of confirmed cases from their local laboratory.
Cases who are resident in its Area Health Service (AHS)
For cases who are resident in its AHS, the PHU should enter case details into NetEpi. Check if the case has already been entered onto NetEpi. If not, create a new NetEpi case form, and enter details from the laboratory report including:
- laboratory name
- case's demographic data
- type of provider who took the specimen (GP, ED, etc.)
- date of sample collection
- date of laboratory result
- check the influenza A subtyping box positive for H1N1
- Public Health Unit office managing the case.
Where the laboratory report indicates the test was taken in an emergency department, hospital outpatients or hospital ward, then follow up the patient (directly or by checking the local Patient Administration System [PAS]) to determine whether or not the patient was admitted to a local hospital and enter this information into NetEpi.
Cases who are resident in another AHS
For cases who are resident in another AHS, where the PHU receiving the notification has sufficient resources, the PHU should check if the case has already been entered onto NetEpi. If not, create a new NetEpi case form, and enter details from the laboratory report including:
- laboratory name
- case's demographic data
- type of provider who took the specimen (GP, ED, etc.)
- date of sample collection
- date of laboratory result
- check the influenza A subtyping box positive for H1N1
- Public Health Unit office managing the case.
Where the laboratory report indicates the test was taken in a local emergency department, hospital outpatients or hospital ward, then check the local Patient Administration System (PAS) to determine whether or not the patient was admitted to a local hospital and enter this information into NetEpi.
Write on the laboratory report the NetEpi number and send the report to the PHU of residence (by mail or fax, as agreed with that PHU). For swabs taken in local hospitals also indicate whether PAS has been checked.
If the receiving PHU does not have resources to undertake data entry or PAS checking then fax the report as soon as possible (same day) to the PHU of residence.
14.3 Follow up of cases admitted to hospital
For cases admitted to hospital, collect and enter risk factors into NetEpi according to the enhanced surveillance form. Discharge date should be determine either by reviewing local data bases or where these are not available, calling the hospital 7 days after admission to determine discharge date.
Where known, note if the case has been admitted to ICU. Details of cases admitted to ICU should not be collected directly from the ICU, but should be extracted from the ANZICS dataset into NetEpi (see below).
ICU data collection
To streamline and simplify data collection on ICU patients with H1N1 influenza 09, NSW Health has funded the Australia and New Zealand Intensive Care Research Centre to assist in capturing the fields required for national H1N1 influenza surveillance.
This database includes demographic details, daily clinical information (ventilation, ECMO), date of onset, date of hospitalisation and admission to ICU, date of ICU discharge, and several risk factors (pregnancy, diabetes, cardiovascular or respiratory disease and morbid obesity). The remainder of risk factors are not specified, but are indicated as present or not.
Paediatric data collection
Case admitted to any of the three tertiary paediatric hospitals (located at Westmead, Randwick, Hunter) will be investigated by special surveillance staff employed at those hospitals, and entered directly onto NetEpi. Where a child is a confirmed case tested in a hospital setting, check to see whether the case has already been admitted to a tertiary hospital. If so, no further follow up is required. If not, then investigate as above.
Where the public health unit become aware that a case of confirmed H1N1 has died alert the Communicable Disease Branch by email or phone of the death including whether (or when) the clinicians caring for the patient told the family of the diagnosis, and complete the case's details in NetEpi on the same (or within one) working day.