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Silent voices: Women with advanced (metastatic) breast cancer share their needs and preferences order 250mcg fluticasone with mastercard asthmatic bronchitis is it contagious. Older Women With Breast Cancer: Slow Progress purchase genuine fluticasone on line asthma treatment 9 month old, Great Opportunity order fluticasone line asthma definition ensure, Now Is the Time. These concerns, coupled with provider and parent attitudes and behaviors related to confidential care, could limit adolescent access to currently available services. Project Objectives/Outcomes The purpose of this project is to better understand provision of confidential sexual health services by pediatricians and family medicine providers to female and male adolescents 11-17 years of age. Specifically, the project will describe perspectives from three key populations—adolescents, providers, and parents. For each study population--parents, providers, and adolescents--indicate the specific research questions to be addressed and method(s) of data collection (quantitative and/or qualitative). It is likely that both quantitative and qualitative data collection components with providers will be used. Please justify the selection of data collection methods based on the proposed research questions. Provide details on each data collection component, including sampling and recruitment plans, target sample size with justification, survey modes (e. Target populations Describe and provide evidence of access to clinic-based populations, including each of the following: • Pediatric and family medicine providers • Female and male adolescents 11-17 years of age • Parents of female and male adolescents 11-17 years of age It is anticipated that sample sizes will vary depending on the proposed data collection methods. For example, a quantitative data collection component would likely occur with a relatively large sample (e. Similarly, it is expected that a qualitative component could be conducted with a sufficient sample (e. Collaboration/Partnerships 50 of 57 Collaboration/Partnerships Describe and provide evidence of collaboration/partnerships with organizations that will facilitate recruitment of providers, adolescents, and parents, including national professional organizations or other organizations/networks able to reach a diverse sample of pediatric and family practice providers and clinics that will yield diverse samples for each of the three target populations. Recruitment Plan Describe plans to recruit research participants as part of the study design and methods section. Recruitment plans for each data collection component should be addressed and ensure guardian consent is discussed when conducting research with minors (e. For each person, describe their demonstrated knowledge and experience relevant to the proposed study. Applicant is also to provide description and timeline for key activities for entire project period. Evaluation Plan/Performance measurement Provide an evaluation plan to assess project performance and progress. Dissemination and Translation plans Describe a plan for disseminating the results of this project to relevant stakeholders, including researchers, providers, parents and adolescents. Increasing receipt of preventive services, including behavioral counseling, can reduce risk behavior and improve sexual and reproductive health outcomes. The appendices should include materials that show evidence of the applicant’s ability to successfully conduct the proposed project and other evidence deemed necessary to support the contents of the proposal. Availability of Funds It is anticipated that approximately $800,000 is available to fund 1 Prevention Research Center for a 2-year project period. Applicants should provide a federal-wide assurance number for each performance site included in the project. Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U. Human papillomavirus vaccination and cervical cytology outcomes among urban low-income minority females. Does delivering preventive services in primary care reduce adolescent risky behavior? Sexually transmitted infection testing among adolescents and young adults in the United States. Confidentiality and adolescents’ willingness to consent to sexually transmitted infection testing. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Messages might be appropriate for delivery through communication campaigns (electronic or print) or embedded in other intervention approaches such as school or community-based curriculum, clinic-based programs, and/or health care provider or counselor communication. Project Objectives/Outcomes The specific objectives of this project are to: • Identify known barriers and facilitators for the target protective behaviors that are currently found in peer-reviewed literature. The study design should describe an approach to synthesizing the current state of the literature on known barriers and facilitators for the identified protective behaviors that can serve as a foundation for both message development and the qualitative research. The application is expected to include a description of suggested search terms, databases, coding and synthesis processes, and specific research questions to be addressed. The study design should also reflect how it will build on the factors identified in the literature to provide an in-depth description of youth perspectives on (1) the most influential barriers and facilitators for the target protective behaviors (allowing youth to reflect on barriers and facilitators that emerged in the literature as well as additional barriers and facilitators that may be important), (2) what type of content they want and/or need in messages related to the most influential barriers and facilitators, (3) who (e. The design is expected to include individual interviews or focus groups with youth. Methods should be selected based on appropriateness for each study question of interest and considerations of participant comfort and convenience. The application is expected to include a discussion of the basis for the selected data collection methods, the proposed number of participants, and study design based on the proposed study questions. The application is also expected to include a description of proposed plans for data collection including proposed approach and plans for consent processes and incentives (if applicable). For example, the applicant may propose quantitative processes to have a larger and diverse set of youth rank or weight identified barriers and facilitators or provide feedback to create or refine draft messages. If the applicant proposes an additional quantitative component to the study, the application should include a description of the rationale for the component and the proposed plans for data collection and analysis. Finally, the application should include a description of how the applicant plans to develop (1) a draft set of messages expected to resonate with youth that would feasibly lead to an increase in the target protective behaviors, and (2) a companion set of recommendations for who should deliver those messages (who are the recommended messengers? Messages might be appropriate for delivery through communication campaigns (electronic or print) or embedded in other intervention approaches such as school or community-based curriculum, clinic-based programs, and/or health care provider or counselor communication. The application should include a description of plans for engaging a diverse group of youth in the creation of draft messages and in engaging youth in creating recommendations for messengers and communication channels. The application should also provide a few examples of the type of messages, messengers, and channels that might be considered. Collaboration/Partnerships Applicants are expected to describe and provide evidence of collaboration/partnerships that will support the accomplishment of study goals and objectives. These include: • Organizations that have access to or serve diverse groups of youth • Organizations or individuals with substantial experience in communication research and communication message development and delivery Recruitment Plan Applicants are expected to describe plans to recruit youth for the study who are diverse in terms of age, racial and ethnic backgrounds, geographic location, urban/suburban/rural settings, sexual and/or gender identity, and extent of connection to sexual health services. Plans should reflect the ability to gather 55 of 57 information from each segment of the target population in a manner that will provide sufficient information for representation from all groups.

Examples a system of enzymes buy fluticasone 100 mcg low cost asthma x ray images, including glutathione per- of both are shown in Table 2 purchase fluticasone 100mcg on line asthma treatment medscape. Figure 3 shows some of the actions of these note that they also serve useful purposes in the human enzymes buy fluticasone 100 mcg without prescription asthma definition 99213. For example, free radicals play a role in the antioxidant enzymes which are important in the destruction of disease-causing microbes by specialised catalytic decomposition of the superoxide radical to blood cells called phagocytes. Some, such as glutathione, ubiquinol enzymes containing selenium which are important in and uric acid, are produced by normal metabolism. Several essential minerals including selenium, copper, Other small-molecular-weight antioxidants are found in manganese and zinc are involved in the structure or the diet, the best known being vitamin E, vitamin C and catalytic activity of these enzymes. Some foods also contain other antioxidant minerals is inadequate, enzymatic defences may be substances, as shown in Table 3. Although these substances have no known A second line of defence is small-molecular-weight nutritional function, they may be important to human compounds which act as antioxidants; that is, they react health because of their antioxidant potency. Enzymatic antioxidant defences different tocopherols and tocotrienols which share the (L = lipid) same biological activity. It is the major antioxidant in all cellular membranes, and it protects polyunsaturated fatty acids Superoxide dismutase against oxidation. It is believed to be the most important antioxidant in 2H2O2 O2 + 2H2O extracellular fluids, and it has many known intracellular Glutathione peroxidase activities as well. Figure 4 illustrates the concept of balance between pro- oxidant factors and antioxidant defences. The diagram Some foods that contain nonnutrient shows the normal situation, in which pro - o x i d a n t antioxidants factors are adequately counterbalanced by antioxidant defences. An increase either in the production of Product Antioxidants oxidants or in a deficiency in the defence system could Soybeans Isoflavones, phenolic acids disturb this balance, causing oxidative stress. Important dietary carotenoids include ß-carotene, α- c a ro t e n e , lycopene, lutein, zeaxanthin and ß-cryptoxanthin. J Am Diet Assoc 1993;93:284-296 6 Concise Monograph Series Food sources of antioxidant nutrients Interactions between antioxidants Table 4 lists the best food sources of each of the major In addition to their individual effects, antioxidants dietary antioxidants. As Table 4 indicates, two interact in synergistic ways and have "sparing effects" in categories of foods — fruits and vegetables — are which one antioxidant protects another against particularly important. They also the antioxidant effect of vitamin E by regenerating the contribute substantial amounts of vitamin E to the diet, active form of the vitamin after it has reacted with a free as well as nonnutrient antioxidants. This beneficial interaction has been several countries have recommended that everyone demonstrated in biological fluids as well as in model should consume at least five servings of fruits and systems. There is some evidence that ubiquinol, a fat- vegetables daily, since population studies have revealed soluble antioxidant produced in the human body, may a lower incidence of certain degenerative diseases, such also regenerate vitamin E. There are other types of as cardiovascular disease and some forms of cancer, in beneficial interactions as well. For instance, vitamin E subjects consuming larger amounts of fruits and can protect the ß-carotene molecule from oxidation and vegetables. Unfortunately, the diets typically consumed thus may have a sparing effect on this antioxidant. Mechanisms of action As a result of interactions such as these, combinations of Cancer is the end point of a multistep process involving antioxidants may be more effective than larg e r a sequence of events that occur over a period of years or quantities of any single antioxidant. Figure 6 summarises current scientific thinking about one possible mechanism by which normal cells may be transformed into cancer cells. Much of this damage is oxidative in are less likely to develop cancer than people who have nature. It has been estimated that a typical human cell low dietary intakes of these foods. Table 5 summarises the results of these accumulate with age, and so does the risk of cancer. Cells that whereas low intakes are associated with increased risks divide rapidly are more susceptible to carcinogenesis of cancers at most body sites except the prostate. The evidence is strongest for epithelial cancers, such as Oxidants and antioxidants may also play a role in the cancers of the lung, larynx and oesophagus, and less later stages of cancer development. There is increasing convincing for hormone-dependent cancers, such as evidence that oxidative processes contribute to the breast cancer. F ruits and vegetables are the principal sources of Antioxidants may be able to cause the regression of vitamin C and carotenoids, and it is believed that these premalignant lesions or inhibit their development into antioxidants are major contributors to the apparent cancer. Preliminary studies have indicated that some c a n c e r- p rotective effects of these foods. Fruits and antioxidants, particularly ß-carotene, may be of benefit vegetables also contain vitamin E as well as other in the treatment of precancerous conditions such as oral nutrients including folate (a B complex vitamin) and leukoplakia (which may be a precursor of oral cancer). All of these nutrients, and perhaps some Some antioxidant nutrients may protect against cancer nonnutrient components, may be involved in cancer t h rough mechanisms other than their antioxidant prevention. For example, carotenoids may both enhance immune function and increase gap junctional Tissue levels of antioxidants communication (a type of interaction between cells that inhibits cell proliferation); both of these actions may be Some epidemiologic studies have used biomarkers — relevant to cancer prevention. The most commonly used short-term biomarker is the concentration of an antioxidant in blood plasma. Fruit, Vegetables, and Cancer Prevention: A Review of the Epidemiological Evidence, Nutr Cancer 1992:18:1-29. For example, in a study conducted in Hawaii, high concept that antioxidants may be protective against dietary intakes of ß-carotene, α-carotene and lutein were c a n c e r. This study was conducted in 65 Chinese each associated with reduced risks of lung cancer. Blood samples were collected from 100 levels of total carotenoids, α- c a rotene, ß-caro t e n e , randomly selected residents of each county; samples cryptoxanthin and lycopene, but not lutein, were lower f rom members of the same community were then among women who later developed cervical cancer pooled for analysis. For a wide range of cancers, associations developed oral cancer than among controls. High ß- Vitamin E carotene levels were associated with a reduced risk of stomach cancer. The evidence linking vitamin E and cancer risk is less extensive than that for vitamin C and carotenoids. Instead, most researchers have tissue concentrations of vitamin E and ß-carotene and used blood vitamin E levels as a biomarker of vitamin E toenail concentrations of selenium as biomarkers of nutriture. These biomarkers were chosen inconsistent; some have shown an inverse association because they are believed to be an integrated measure of between vitamin E levels and cancer risk, whereas exposure over months rather than days. National Cancer Institute associated the use of will compare levels of these biomarkers in breast cancer vitamin E supplements with a 50% reduction in oral patients with those in otherwise similar women without cancer risk. Dietary vitamin E and multivitamins had no the disease who live in the same areas. This suggests Effects of individual carotenoids the possibility that vitamin E may show a "plateau In a few recent studies, epidemiologists have attempted effect", meaning that below a certain critical dose it may to distinguish effects of specific carotenoids, rather than not have a detectable inverse association with cancer focusing on total carotenoids or ß-carotene. The plateau dose is likely to be greater than that of these studies have suggested that several different which can be obtained through diet alone.

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Models & theories Were there any models order fluticasone online from canada asthma 4 year old boy, theories or frameworks identified in the review? Weaknesses • Existing evaluation principles are based on values; however as values are context specific and can vary greatly between cultures order fluticasone uk asthma treatment nursing, transferring standards from one culture/country to another may bring additional challenges within the European context [133] discount fluticasone online visa asthma red zone symptoms. Tools Did the review identify any tools that facilitate step by step practical application? Strengths A number of tools were identified in the review which included: • Svoronos and Mate: driver diagram tool [134]. Weaknesses Limited tools to assist researchers in the process of conducting evaluations in specific contexts, for example, within resource-limited countries [134]. Evidence What evidence was identified in the review and what was the quality of the evidence? Strengths Quality Evidence on health communication campaign evaluation for communicable diseases was identified and included: • systematic and exploratory reviews [138-143]; • European examples; and • a variety of individual study designs. Broad principles of campaign design, implementation and evaluation have been developed and are available to public health professionals and researchers [144-147]. Weaknesses Communication effects • The review highlighted inconsistency in the indicators used to evaluate health communication campaigns. Application What has been applied into practice in the area of campaign evaluation for the prevention and control of communicable diseases? Strengths European A wide range of examples of evaluation studies of health communication campaigns for prevention and control of communicable diseases in Europe have been developed and implemented. Others included: chlamydia, hepatitis C, food safety and diphtheria [140-143, 148-187]. Targeting including hard-to-reach populations • The identified European examples mainly targeted healthcare workers, the general public, and young adults. Targeting including hard-to-reach populations Only two examples explicitly stated that it targeted hard-to-reach groups [166, 185]. Health communication campaign evaluation with regard to the prevention and control of communicable diseases in Europe. Weaknesses • Blurred definitions, dispersed across various disciplines and an overlap between risk and crisis/emergency communication. Models & theories Were there any models, theories or frameworks identified in the review? Four theoretical models of risk communication [188]: • Risk perception model • Mental noise • Negative dominance • Trust determination. In addition, there are social constructionist approaches – emphasising social and cultural factors [189, 190]. Weaknesses • Few integrative risk communication theoretical frameworks that bridge diverse disciplinary traditions [191]. Tools Did the review identify any tools that facilitate step by step practical application? Weaknesses • Resources focus on crisis rather than strategic pre-crisis communication. Evidence What evidence was identified in the review and what is the quality of the evidence? Strengths Four review papers assist in bringing together the key guidance documents which have informed much of risk communication policy and application over the past two decades: • Jardine et al. Quality • A number of the same best practices elements of effective risk communication were identified in all of the first three review papers. Weaknesses Quality • The majority of the guidance documents were focused on emergency crisis situations and are of varying depth and quality. Weakness Communication effects • The review does not report any reference to assessment of public engagement in matters of risk. Behavioural and other changes There is a lack of evidence-informed evaluations of risk communication on communicable diseases in the literature [220]. Application What has been applied into practice in the area of risk communication for the prevention and control of communicable diseases? European Practical application of risk communication studies were mostly identified from Europe and North America, with some also from south-east Asia. Focus The greatest number of identified studies were found on the topics of: risk communication theories, guidelines and risk perceptions. Weaknesses • Focus is on emergency and outbreak situations rather than strategic risk communication. Targeting including hard-to-reach populations Studies show that during communicable disease outbreaks, minority populations are found to be disproportionally affected [217-219], however the review identified a paucity of studies addressing hard- to-reach groups. A literature review on effective risk communication for the prevention and control of communicable diseases in Europe. The references cited in this matrix table and upcoming tables are listed in Appendix 3. Strengths There are a range of communication theories that are applicable to the concept of pro-immunisation communication [233-238]. Weaknesses The review concluded that few interventions explicitly considered underlying conceptual assumptions of pro-immunisation communication. Models & theories Were there any models, theories or frameworks identified in the review? Weaknesses • Absence of explicitly stated theoretical underpinning in most interventions captured by the review. Tools Did the review identify any tools that facilitate step by step practical application? Strengths • A very wide range of mass communication and personalised promotional communication tools applied and evaluated across a diverse range of channels, materials and dissemination methods and agents were identified in the review [for example see 244-245, 256]. Weaknesses Many interventions combined tools but reported evaluations did not isolate and measure contribution of individual elements. Strengths The review included thirty three studies of promotional communication interventions for immunisation [239-250, 256-277]. The evidence pool provides evidence for a range of promotional communication practices that can improve knowledge of, attitudes towards, and uptake of immunisation [244-246, 256, 263-264, 266]. Quality • Fifteen of the thirty three evaluation studies captured in the review were rated as high-quality studies [244-245, 248-250, 259, 261-263, 265-267, 272-274] • Seven high-quality studies reported convincing evidence of positive effect [244-246, 256, 263-264, 266] Weaknesses Quality Limited conclusions can be drawn from the review on most effective practice. This is due to the heterogeneity of interventions and evaluation methods, and the small number of studies assessed as high quality and reporting convincing evidence of positive effect. Behavioural and other changes None of the studies included in the review provided data on the impact of promotional communication on health status of the target audience(s). Application What has been applied into practice in the area of national immunisation schedule promotional communication? Strengths Focus Of the thirty three studies included in the review, 22 reported on interventions to promote influenza immunisation [239,244-250, 257, 259, 261, 262-271], and 11 reported on interventions to promote immunisations for other vaccine-preventable diseases [240-243, 258, 260, 272-276]. Targeting including hard-to-reach populations The majority of studies included in the review targeted healthcare workers [239, 244 -250, 256-260, 262, 264, 267] and/or patient risk groups such as the elderly [244-245, 250, 259, 261, 263, 265-266, 268-269, 273].

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They apply to our interactions with each other purchase fluticasone 100mcg with mastercard asthma symptoms in 21 month old, with animals and with the environment generic fluticasone 250mcg line asthma symptoms for kids. A guiding value for researchers is integrity purchase genuine fluticasone on-line asthmatic bronchitis during pregnancy, which includes a commitment to the search for knowledge, the honest and ethical conduct of research and the dissemination and communication of results. Particular attention needs to be paid to ethics whenever human subjects are involved. More rigorous scrutiny is needed when an investigation is extended to include people who have not been ill, for example, as part of an epidemiological investigation that involves data collection from a participant in the control group or a population not expressing the disease characteristics. In the context of outbreak management, these principles translate into such requirements as informed consent, careful assessment of the risks and benefits of the investigation for participants and fair selection of subjects. Outbreak investigation will not usually require prior approval from a research ethics committee, provided that the investigation is being undertaken as an acute measure to address an immediate and serious threat to public health. If there is uncertainty about the need for ethics committee approval, it may be appropriate to discuss the study protocol with the chairperson(s) of the appropriate ethics committee(s). If cases of disease have been occurring in a community over a long period of time, there is generally less urgency and the investigation may be more appropriately viewed as research. In such cases, the usual ethical approval process for research proposals should be observed. Further information on guidelines for ethical behaviour can be found on the Health Research Council of New Zealand’s website, http://www. This code applies to all personal health information collected as part of outbreak management. The following rules in the Code have particular relevance for agencies responding to disease outbreaks. The exception is granted “for research purposes (for which approval by an ethics committee, if required, has been given) and will not be in a form which could reasonably be expected to identify the individual concerned”. Data disclosure policies All agencies involved in outbreak investigations should have in place policies for the disclosure of health data and, in particular, data identifying or potentially identifying individuals. These policies need to address what data may be exchanged between organisations taking into account the requirements of the Health Act 1956, the Privacy Act 1993, the Official Information Act 1982, and the Health Information Privacy Code 1994. Cultural competency in outbreak management The urgency of an outbreak investigation and response can encourage a strong focus on the source of the illness and actions to eliminate it. In such situations however it is essential to avoid marginalising the concerns and values of the people primarily affected by the outbreak. The authors of several New Zealand outbreak reports have emphasised the importance of considering the cultural 23 context of outbreaks and the advantages of cultural competency within the outbreak management 24 team. Cultural competency as part of outbreak preparation Build cultural competency within the outbreak management organisation. Cultural competency during the outbreak investigation and response Ensure that the outbreak investigation and response does not disempower communities. Cultural competency while implementing recommendations Develop culturally appropriate recommendations from the outbreak response. The Treaty of Waitangi in outbreak management The Treaty of Waitangi provides a framework for Māori and non-Māori to exercise control over their health and wellbeing, and therefore underpins all health protection work in New Zealand, including outbreak management. Treaty of Waitangi principles derived from the provisions are argued to reflect the spirit and original aims of the Treaty of Waitangi, and to enable contemporary applications. The three principles derived from these sources are partnership, participation and active protection. The provisions are: kawanatanga/ governance – emphasises Māori involvement in all aspects of society within Aotearoa (New Zealand). Outbreak management organisations should encourage meaningful involvement of Māori in outbreak planning, prioritisation, investigation and response tino rangatiratanga/ Māori control and self-determination – refers to on-going relationships between the Crown and Māori with the goal of actively supporting advancement of Māori health aspirations as determined by Māori. This would include the development of Māori capacity for responding to outbreaks directly affecting Māori. Disease outbreak management that improves Māori health outcomes should be prioritised. A framework defining roles and responsibilities in outbreak management in complex situations is described in Appendix 1. Overview of the outbreak management process The overriding goal of outbreak management is to minimise the public health impact of disease outbreaks. Although listed sequentially in the table, these outbreak management components are often not addressed in this order in practice. Control and communication activities are not necessarily preceded by components such as outbreak description and full investigation, and it is often advisable to immediately implement simple practical control measures, where reasonable, following outbreak confirmation. Table 1: Components of outbreak management Components Aims Preparation Optimal level of preparedness Surveillance Consistent and comprehensive collection and review of information on diseases with outbreak potential Confirmation and assessment Sensitive, specific and timely detection of potential outbreaks with public health impact Outbreak description, including Characterisation of outbreak to situational analysis and identify the immediate need for descriptive epidemiology control or hypotheses for further investigation Minimising the public health impact of Full investigation Identification of outbreak source, disease outbreaks transmission mechanisms, Analytic epidemiological contributing factors and control points investigation Environmental investigation Laboratory investigation Outbreak control Prevent further disease transmission Outbreak communication Public and relevant agencies appropriately informed and involved in outbreak management Outbreak documentation Optimal dissemination of recommendations Figure 2, at the end of this chapter, presents a framework showing the interrelationships among these elements. The processes involved in outbreak identification; description and investigation are examples of risk assessment activities, while control, communication and documentation activities represent risk management. The relationship between these two basic groups of activities is fluid, and differs according to the type and setting of each outbreak. The elements of the framework are expanded throughout the remainder of this manual. The following points may be useful in helping understand the framework at this stage: outbreak preparation (Chapter 2) includes the development of an organisational outbreak plan and maintaining general capacity to implement an outbreak investigation and response surveillance (Chapter 3) includes all flows of information that act as raw material to detect outbreaks. These information flows include self-reported outbreaks, notification data and sporadic self-reported illness confirmation and assessment (Chapter 4) includes the processes of verifying that a suspected outbreak is genuine, and assessing the relative needs for investigation and control, as well as overall prioritisation outbreak description (Chapter 5) plays a key role in outbreak investigation. This largely epidemiological function addresses the characterisation of the outbreak, including situational analysis and descriptive epidemiology, identifying its scale, identifying hypotheses and planning further investigation full investigation comprises three major components: analytic epidemiological (Chapters 6, 7 and 8), environmental (Chapter 9) and laboratory (Chapter 10) investigations. These components are not hierarchical in overall importance, nor do they occur in a particular sequence. The relative contribution that each could make to an investigation depends on the type of outbreak, but all should be given consideration outbreak control (Chapter 11) is self-explanatory. Note that outbreak control needs to be considered at all stages of the overall investigation, and may precede or obviate the need for further investigation outbreak communication (Chapter 12) includes communication within the organisation, with the public and media, and with other organisations. Communication is an on-going responsibility outbreak documentation (Chapter 13) refers to the early reporting of detected outbreaks and collation of final information in a permanent form. This information then feeds back into the preparatory stage to continuously improve outbreak management and to prevent further outbreaks. How to use this manual Chapters in the manual have been developed to correspond with the components of outbreak management presented in Table 1. The manual has been developed as a series of independent modules that can be read in the sequence dictated by the circumstances of the outbreak. Preparation Outbreaks seem to invariably arise late on Friday afternoons, during holidays, or when key personnel are already overburdened with other projects. Valuable time is often lost organising the people and materials necessary to investigate and respond to the outbreak while the trail is still warm. Unfortunately, the likelihood of identifying the source of an outbreak and interrupting further disease transmission decreases steadily with every day of delay.