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By E. Raid. Warren Wilson College.

Young children rarely have atitis A vaccinations for homosexual men at age symptoms order discount ayurslim on line, but adults usually do order ayurslim 60 caps. If someone does have antibodies discount 60caps ayurslim visa, these confer pro- Treatment tection against getting the infection again. A per- If someone does contract hepatitis A, a physician son who has a negative result on a blood test but usually recommends rest, fluids, and medication has good reason to suspect infection should repeat to counter nausea. In people with liver problems, hepati- interest is the fact that some individuals whose tis A can be very serious. In some cases, a person blood shows evidence of having had this disease in with hepatitis A does not recover strength com- the past were never aware that they contracted or pletely for several months. The blood test result can turn up negative if the Cause individual has recently been infected. A liver One way that hepatitis B is contracted is via sexual biopsy may be necessary to determine stage of intercourse, especially anal. A test that measures liver function can- transmitted by drug addicts’ sharing of needles, by not be used to rule out hepatitis infection. If a per- vertical transmission (mother to child), and in son proves to be a hepatitis B carrier, a blood test health care environments. The more sex partners a for hepatitis D (delta hepatitis) should be done, person has, the more likely she or he is to get hep- because this can only occur in someone who has atitis B. Also at higher risk are those who have a hepatitis B—and, together, the two can create a seri- sexually transmitted disease. A small percentage of sufferers have extensive Hepatitis B varies greatly, appearing in both mild liver damage that eventually results in death. Although it is usually symptom-free, hepatitis B Treatment can also make the infected person experience any Once a person has hepatitis B, no form of treat- one or a combination of a variety of symptoms: ment can eradicate it. Fortunately, though, some- tiredness, anorexia, nausea, vomiting, headache, times the body of a hepatitis B carrier eventually fever, jaundice, dark urine, and liver tenderness manages to clear the infection spontaneously. A person with hepatitis B may have As far as treatment goes, people with chronic yellow eyes and skin and brown urine, and symp- hepatitis B infection sometimes benefit from alpha- toms may be similar to those of very severe flu. Sometimes, oral medications appear about two to three months after contracting such as lamivudine or adefovir are used. Symptoms that do occur are often eral rule, those who have hepatitis B cannot drink severe and last about six weeks. Sometimes people who have hepatitis B feel In some people who turn out to be carriers, sick off and on for a long time, but most sufferers chronic active hepatitis, whereby the virus gradu- recover from the infection and cannot be rein- ally destroys the liver, leading to cirrhosis, or scar- fected. These are people seen much more often in those who have had hep- whose immune systems were not strong enough to atitis B than in the general population, can also rid them of the infection entirely. Of special infectious than carriers of the chronic active vari- hepatitis C 75 ety, and their disease is much less likely to proceed of sexually transmitted diseases, and a long-term to cancer or cirrhosis. Further, it is unlikely that The means of transmission of hepatitis B include casual contact or household exposure that is non- sexual contact and blood-to-blood contact. A In a long-term monogamous relationship, the risk needlestick injury and a transfusion with infected of transmitting this disease is considered less than blood or blood products are two other possibilities. If someone knows that his or her sexual partner Risk factors are men’s having sex with men, has hepatitis B, it is imperative to be immunized. Risk for transmission grows patients and people who receive blood products, with duration of exposure to an infected sex part- people who travel to countries with a high level of ner. Vertical transmission is rare, and breast-feed- hepatitis B, prostitutes, and prisoners. Condoms ing has not been shown to transmit the virus to the and barriers such as dental dams can help prevent infant. Symptoms hepatitis C Formerly known as non-A, non-B The incubation period is 15 to 160 days but aver- hepatitis, hepatitis C is a major health concern ages six to seven weeks. The usual symptoms are worldwide because it is a common cause of chronic fatigue, jaundice (yellowing of skin), diarrhea, liver disease. Early signs during acute infection are malaise, anorexia, and jaundice; typically, Cause these are not diagnosed as signs of hepatitis C. It was not until 1992 that screeners began of this illness are often mild, and even more com- checking the blood supplies for hepatitis C. According to Hospital Practice (January 15, Most people with hepatitis C infection do not 2000), known risk factors for hepatitis C are a know they have it because symptoms do not nonautologous blood transfusion before 1992, develop. For some, this comes as a shock care worker), long-term hemodialysis, birth to an because their high-risk behavior occurred in the infected mother, multiple sex partners or history distant past. Usu- ally, a blood test will yield a positive finding of hep- hepatitis D Also termed delta hepatitis, hepatitis atitis C about six weeks after infection, but it can D occurs only in those who have hepatitis B infec- take months longer than that. The individual test- simultaneously infected with hepatitis D and B or ing himself or herself uses a safety lancet to take a superinfected with D while carrying B.

All these data show convincingly that sodium intake is directly associated with blood pressure cheap ayurslim 60caps. An overview of observational data obtained from population studies suggested that a difference in sodium intake of 100 mmol per day was associated with average differences in systolic blood pressure of 5 mmHg at age 15--19 years and 10 mmHg at age 60--69 years (37) quality ayurslim 60 caps. Diastolic blood pressures are reduced by about half as much ayurslim 60 caps fast delivery, but the association increases with age and magnitude of the initial blood pressure. It was estimated that a universal reduction in dietary intake of sodium by 50 mmol per day would lead to a 50% reduction in the number of people requiring antihypertensive therapy, a 22% reduction in the number of deaths resulting from strokes and a 16% reduction in the number of deaths from coronary heart disease. The first prospective study using 24-hour urine collections for measuring sodium intake, which is the only reliable measure, demonstrated a positive relationship between an increased risk of acute coronary events, but not stroke events, and increased sodium excretion (38). Several clinical intervention trials, conducted to evaluate the effects of dietary salt reduction on blood pressure levels, have been systematically reviewed (39, 40). Based on an overview of 32 methodologically adequate trials, Cutler, Follmann & Allender (39) concluded that a daily reduction of sodium intake by 70--80 mmol was associated with a lowering of blood pressure both in hypertensive and normotensive individuals, with systolic and diastolic blood pressure reductions of 4. Clinical trials have also demonstrated the 85 sustainable blood pressure lowering effects of sodium restriction in infancy (41, 42), as well as in the elderly in whom it provides a useful non- pharmacological therapy (43). The results of a low-sodium diet trial (44) showed that low-sodium diets, with 24-hour sodium excretion levels around 70 mmol, are effective and safe. Two population studies, in China and in Portugal, have also revealed significant reductions in blood pressure in the intervention groups (45, 46). A meta-analysis of randomized controlled trials showed that potassium supplements reduced mean blood pressures (systolic/diastolic) by 1. Several large cohort studies have found an inverse association between potassium intake and risk of stroke (48, 49). The recommended levels of fruit and vegetable consumption assure an adequate intake of potassium. Numerous ecological and prospective studies have reported a significant protective association for coronary heart disease and stroke with consumption of fruits and vegetables (50--53). While the combination diet was more effective in lowering blood pressure, the fruit and vegetable diet also lowered blood pressure (by 2. Most, but not all, population studies have shown that fish consumption is associated with a reduced risk of coronary heart disease. A systematic review concluded that the discrepancy in the findings may be a result of differences in the populations studied, with only high-risk individuals benefiting from increasing their fish consumption (55). It was estimated that in high-risk populations, an optimum fish consumption of 40--60 g per day would lead to approximately a 50% reduction in death from coronary heart disease. In a diet and reinfarction trial, 2-year mortality was reduced by 29% in survivors of a first myocardial infarction in persons receiving advice to consume fatty fish at least twice a week (56). Several large epidemiological studies have demonstrated that frequent consumption of nuts was associated with decreased risk of coronary heart disease (58, 59). Most of these studies considered nuts as a group, combining many different types of nuts. Nuts are high in unsaturated fatty acids and low in saturated fats, and contribute to cholesterol lowering by altering the fatty acid profile of the diet as a whole. However, because of the high energy content of nuts, advice to include them in the diet must be tempered in accordance with the desired energy balance. Several trials indicate that soy has a beneficial effect on plasma lipids (60, 61). Soy is rich in isoflavones, compounds that are structurally and functionally similar to estrogen. Several animal experiments suggest that the intake of these isoflavones may provide protection against coronary heart disease, but human data on efficacy and safety are still awaited. There is convincing evidence that low to moderate alcohol consumption lowers the risk of coronary heart disease. In a systematic review of ecological, case--control and cohort studies in which specific associations were available between risk of coronary heart-disease and consumption of beer, wine and spirits, it was found that all alcoholic drinks are linked with lower risk (63). However, other cardiovascular and health risks associated with alcohol do not favour a general recommendation for its use. The amount of cafestol in the cup depends on the brewing method: it is zero for paper-filtered drip coffee, and high in the unfiltered coffee still widely drunk in, for example, in Greece, the Middle East and Turkey. Intake of large amounts of unfiltered coffee markedly raises serum cholesterol and has been associated with coronary heart disease in Norway (64). A shift from unfiltered, boiled coffee to filtered coffee has contributed significantly to the decline in serum cholesterol in Finland (65). Fats Dietary intake of fats strongly influences the risk of cardiovascular diseases such as coronary heart disease and stroke, through effects on 87 blood lipids, thrombosis, blood pressure, arterial (endothelial) function, arrythmogenesis and inflammation.

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Identification—An almost invariably fatal acute viral encephalomy- elitis; onset generally heralded by a sense of apprehension purchase ayurslim 60caps overnight delivery, headache buy ayurslim 60caps with visa, fever order ayurslim cheap online, malaise and indefinite sensory changes often referred to the site of a preceding animal bite. The disease progresses to paresis or paralysis; spasms of swallowing muscles leads to fear of water (hydrophobia); delirium and convulsions follow. Without medical intervention, the usual duration is 2–6 days, sometimes longer; death is often due to respiratory paralysis. All members of the genus are antigenically related, but use of monoclonal antibodies and nucleotide sequencing shows differences according to animal species or geographical location of origin. Rabies- related viruses in Africa (Mokola and Duvenhage) have been associated, rarely, with fatal rabies-like human illness. A new lyssavirus, first identified in 1996 in several species of flying foxes and bats in Australia, has been associated with 2 human deaths from rabies-like illnesses. This virus, provisionally named Australian bat lyssavirus, is closely related to, but not identical to classical rabies virus. Occurrence—Worldwide, with an estimated 65 000–87 000 deaths a year, almost all in developing countries, particularly Asia (an estimated 38 000 to 60 000 deaths) and Africa (estimated 27 000 deaths). Most human deaths follow dog bites for which adequate post-exposure prophy- laxis was not or could not be provided. During the past 10 years drastic decrease of the numbers of human deaths have also been reported by several Asian countries particularly China, Thailand and Viet Nam. Western, central and eastern Europe including the Russian Federation report less than 50 rabies deaths annually. The areas currently free of autochthonous rabies in the animal population (excluding bats) include most of Australasia and western Pacific, many countries in Western Europe (insular and continental), part of Latin America including the Caribbean. In western Europe, fox rabies, once widespread, has decreased considerably since oral rabies immunization of foxes began in the early 1990s. Since 1985 bat rabies cases have been reported in Denmark, Finland, France, Germany, Luxembourg, the Netherlands, Spain, Switzer- land and the United Kingdom. Reservoir—Wild and domestic Canidae, including dogs, foxes, coyotes, wolves and jackals; also skunks, racoons, mongooses and other biting mammals. Rabbits, opossums, squirrels, chipmunks, rats and mice are rarely infected: their bites rarely call for rabies prophylaxis. Mode of transmission—Virus-laden saliva of rabid animal intro- duced though a bite or scratch (very rarely into a fresh break in the skin or through intact mucous membranes). Person-to-person transmission is theoretically possible, but rare and not well documented. Airborne spread has been demonstrated in a cave where bats were roosting and in laboratory settings, but this occurs very rarely. Transmission from infected vampire bats to domestic animals is common in Latin America. Incubation period—Usually 3–8 weeks, rarely as short as 9 days or as long as 7 years; depends on wound severity, wound site in relation to nerve supply and distance from the brain, amount and strain of virus, protection provided by clothing and other factors. Period of communicability—In dogs and cats, usually for 3–7 days before onset of clinical signs (rarely over 4 days) and throughout the course of the disease. Longer periods of excretion before onset of clinical signs (14 days) have been observed with Ethiopian dog rabies strains. In one study, bats shed virus for 12 days before evidence of illness; in another, skunks shed virus for at least 8 days before onset of clinical signs. Susceptibility—All mammals are susceptible to varying degrees, which may be influenced by the virus strain. Humans are more resistant to infection than several animal species; a study in the Islamic Republic of Iran showed that, of those bitten by proven rabid animals and not treated, about 40% developed the disease. Preventive measures: Many preventive measures are possible at the level of the main animal main host(s) and transmitter(s) of rabies to humans. Educate pet owners and the public on the importance of restrictions for dogs and cats (e. Where dog control is sociologically impractical, repetitive total dog population immunization has been effective. Get physicians, veterinarians and animal control officials to obtain/sacrifice/test animals involved in human and domestic animal exposures. If the biting animal was infective at the time of bite, signs of rabies will usually follow within 4–7 days, with a change in behaviour and excitability or paralysis, followed by death. All wild mammals that have bitten a person must be sacrificed immediately and the brain examined for evidence of rabies. In the case of bites by a normally behaving valuable pet or zoo animal, it may be appropriate to consider postexposure prophylaxis for the human victim, and, instead of sacrificing the animal, hold it in quarantine for 3–12 weeks. If previously immunized, reimmunize and detain (leashing and confinement) for at least 45 days. If such focal depopulation is undertaken, it must be maintained to prevent repopulation from the periphery.

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The Consultation articulated a new platform buy cheap ayurslim 60 caps online, not just of dietary and nutrient targets generic 60caps ayurslim otc, but of a concept of the human organism’s subtle and complex relationship to its environment in relation to chronic diseases generic ayurslim 60caps with visa. The discussions took into account ecological, societal and behavioural aspects beyond causative mechanisms. The experts looked at diet within the context of the macroeconomic implications of public health recommendations on agriculture, and the global supply and demand for foodstuffs, both fresh and processed. Nutrition is coming to the fore as a major modifiable determinant of chronic disease, with scientific evidence increasingly supporting the view that alterations in diet have strong effects, both positive and negative, on health throughout life. Most importantly, dietary adjustments may not only influence present health, but may determine whether or not an individual will develop such diseases as cancer, cardiovascular disease and diabetes much later in life. In many developing countries, food policies remain focused only on undernutrition and are not addressing the prevention of chronic disease. This emphasis is consistent with the trend to consider physical activity alongside the complex of diet, nutrition and health. Energy expenditure through physical activity is an important part of the energy balance equation that determines body weight. A decrease in energy expenditure through decreased physical activity is likely to be one of the major factors contributing to the global epidemic of overweight and obesity. Physical activity has great influence on body composition --- on the amount of fat, muscle and bone tissue. To a large extent, physical activity and nutrients share the same metabolic pathways and can interact in various ways that influence the risk and pathogenesis of several chronic diseases. Cardiovascular fitness and physical activity have been shown to reduce significantly the effects of overweight and obesity on health. Physical activity and food intake are both specific and mutually interacting behaviours that are and can be influenced partly by the same measures and policies. Lack of physical activity is already a global health hazard and is a prevalent and rapidly increasing problem in both developed and developing countries, particularly among poor people in large cities. In order to achieve the best results in preventing chronic diseases, the strategies and policies that are applied must fully recognize the essential role of diet, nutrition and physical activity. This report calls for a shift in the conceptual framework for developing strategies for action, placing nutrition --- together with the other principal risk factors for chronic disease, namely, tobacco use and alcohol consumption --- at the forefront of public health policies and programmes. The latest scientific evidence on the nature and strength of the links between diet and chronic diseases is examined and discussed in detail in the following sections of this report. This section gives an overall view of the current situation and trends in chronic diseases at the global level. These include obesity, diabetes, cardio- vascular diseases, cancer, osteoporosis and dental diseases. It has been calculated that, in 2001, chronic diseases contributed approxi- mately 60% of the 56. Almost half of the total chronic disease deaths are attributable to cardiovascular diseases; obesity and diabetes are also showing worrying trends, not only because they already affect a large proportion of the population, but also because they have started to appear earlier in life. The chronic disease problem is far from being limited to the developed regions of the world. Contrary to widely held beliefs, developing countries are increasingly suffering from high levels of public health problems related to chronic diseases. It is clear that the earlier labelling of chronic diseases as ‘‘diseases of affluence’’ is increasingly a misnomer, as they emerge both in poorer countries and in the poorer population groups in richer countries. This shift in the pattern of disease is taking place at an accelerating rate; furthermore, it is occurring at a faster rate in developing countries than it did in the industrialized regions of the world half a century ago (3). This 4 rapid rate of change, together with the increasing burden of disease, is creating a major public health threat which demands immediate and effective action. The number of people in the developing world with diabetes will increase by more than 2. On a global basis, 60% of the burden of chronic diseases will occur in developing countries. Indeed, cardiovascular diseases are even now more numerous in India and China than in all the economically developed countries in the world put together (2). As for overweight and obesity, not only has the current prevalence already reached unprece- dented levels, but the rate at which it is annually increasing in most developing regions is substantial (3). The public health implications of this phenomenon are staggering, and are already becoming apparent. The rapidity of the changes in developing countries is such that a double burden of disease may often exist. India, for example, at present faces a combination of communicable diseases and chronic diseases, with the burden of chronic diseases just exceeding that of communicable diseases.

The latter is particularly effective in encouraging desquamation purchase ayurslim 60 caps, but may not be used on large body areas for any length of time generic 60 caps ayurslim free shipping, as salicylic acid preparations when applied to abnormal skin may cause salicylate intoxication (sal- icylism) purchase 60 caps ayurslim otc. The reason for this appears to be a pla- cental deficiency of the steroid sulphatase and a consequent failure of the usual splitting of circulating maternal oestrone sulphate in the last trimester of pregnancy. The free oestrone is thought to have a role in priming the uterus to oxytoxic stimuli. It is also more marked over the extensor aspects of the body surface, but does not always spare the flexures and often affects the sides of the neck and even the face. The scales are often quite large, particularly over the shins and have a dark-brownish discoloration. Patients with sex-linked ichthyosis may be signifi- cantly disabled by their disorder. In fact, 248 Non-bullous ichthyosiform erythroderma the carrier female may demonstrate patchy scaling that is consistent with the ‘ran- dom deletion’ (or Lyon) hypothesis. The disorder is quite uncommon, having a gene frequency of approximately 1 in 6000. Histologically, there is a minor degree of epidermal thickening and mild hyper- granulosis. Biochemically, affected male subjects show a steroid sulphatase defi- ciency, but for diagnostic purposes, fibroblast, lymphocyte or epidermal cell cultures are tested. The steroid sulphatase abnormality results in excess quantities of cholesterol sulphate in the stratum corneum with diminished free cholesterol. This has been used as the basis of a diagnostic test and has been suggested as the underlying basis for the abnormal scaling. He had had it since birth, although it didn’t start to be a problem until he reached the age of 11. He complained of itchiness – especially in the wintertime, when, in addition to the itch, the skin of his hands became sore and ‘cracked’ in places. He had a brother who was affected and his maternal grandfather also had the disease. It was clear that he had sex-linked ichthyosis, which could be expected to persist, but the symptoms of which should be helped by emollients. It is probably heterogeneous, as, although the skin abnormality is similar in all patients, there are associations with abnormalities in other organ systems in some groups of patients. Ectropion, deformities of the ears and sparsity of scalp hair are common accompaniments. The con- dition persists throughout life, although the erythema tends to decrease. Severely affected patients may benefit from the use of long-term oral retinoid drugs. The agent usually used is acitretin, but isotretinoin has been used for some patients. The disorder starts to improve after 2–4 weeks, but full improvement may not take place before 6 weeks. Although there is often considerable improve- ment, evidence of the underlying problem is always present, and the condition always relapses when treatment is stopped. The oral retinoids have major and minor toxicities (see page 140) and are markedly teratogenic, so that fertile women must use effective contraception. Patients must be regularly monitored for hepatotoxicity, hyperlipidaemia and bone toxicity. Most patients notice drying of the mucosae – of the lips particularly – and some an increase in the rate of hair loss. The condition is characterized by the tendency to blister or develop erosions at the sites of trauma (Figs 16. Scaling and hyperkeratosis are characteristically ridged or corrugated at flexures. Patients often present a pathetic picture because of their severe hyperkeratosis, which causes physical disability and discomfort as well as a socially unacceptable appearance. The pathognomonic histological feature of epidermolytic hyerkeratosis is a reticulate degenerative change in the epidermis (Fig. In recent years, mutations in certain keratin genes have been identified in this disorder. The oral retinoids may improve the appearance considerably, although the dose has to be Figure 16. Lamellar ichthyosis This is a rare, autosomal recessive disorder of keratinization, characterized by a striking degree of hyperkeratosis but not much erythema. As with the other severe disorders of keratinization, there may be marked ectropion and ear deformities (Fig.

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They must be based on scientific evidence on the ways in which people’s dietary and physical activity patterns have positive or adverse effects on health purchase ayurslim 60 caps overnight delivery. In practice buy ayurslim 60caps line, strategies are likely to include at least some of the following practical actions generic 60caps ayurslim free shipping. The data required for implementing effective policies need to be specific for age, sex and social group, and indicate changing trends over time. The ultimate goal of information and communication strategies is to assure availability and choice of better quality food, access to physical activity and a better- informed global community. Its work in the area of nutrition and labelling could be further strengthened to cover diet-related aspects of health. Governments could make it easier for consumers to exercise healthier choices, in accordance with the population nutrient intake goals given in this report by, for example, promoting the wider availability of food which is less processed and low in trans fatty acids, encouraging the use of vegetable oil for domestic consumers, and ensuring an adequate and sustainable supply of fish, fruits, vegetables and nuts in domestic markets. For example, consumers should be able to ascertain not only the amount of fat or oil in the meals they have chosen, but also whether they are high in saturated fat or trans fatty acids. They should involve alliances that encourage the effective implementation of national and local strategies for healthy diets and physical activity. Intersectoral initiatives should encourage the adequate production and domestic supply of fruits, vegetables and wholegrain cereals, at affordable prices to all segments of the population, opportunities for all to access them regularly, and individuals to undertake appropriate levels of physical activity. The social, economic, cultural and psychological determinants of dietary and physical activity choice should be included as integral elements of public health action. There is an urgent need to develop and strengthen existing training programmes to implement these actions successfully. These chronic diseases remain the main causes of premature death and disability in industrialized countries and in most developing countries. Developing countries are demonstrably increasingly at risk, as are the poorer populations of industrialized countries. In communities, districts and countries where widespread, integrated interventions have been implemented, dramatic decreases in risk factors have occurred. Successes have come about where the public has acknowledged that the unnecessary premature deaths that occur in their community are largely preventable and have empowered them- selves and their civic representatives to create health-supporting environments. This has been achieved most successfully by establishing a working relationship between communities and governments; through enabling legislation and local initiatives affecting schools and the workplace; by involving consumers’ associations; and by involving food producers and the food-processing industry. There is a need for data on current and changing trends in food consumption in developing countries, including research on what influences people’s eating behaviour and physical activity and what can be done to address this. There is also a need, on a continuing basis, to develop strategies to change people’s behaviour towards adopting healthy diets and lifestyles, including research on the supply and demand side related to this changing consumer behaviour. Beyond the rhetoric, this epidemic can be halted --- the demand for action must come from those affected. Acknowledgements Special acknowledgement was made by the Consultation to the following individuals who were instrumental in the preparation and proceedings of the meeting: Dr C. Uauy, London School of Hygiene and Tropical Medicine, London, England and Institute of Nutrition of the University of Chile, Santiago, Chile. The Consultation also thanked the authors of the background papers for the Consultation: Dr N. Prentice, Medical Research Council Human Nutrition Research, Cambridge, England; Professor K. The Consultation also recognized the valuable contributions made by the following individuals who provided comments on the background documents: Dr Franca Bianchini, Unit of Chemoprevention, International Agency for Research on Cancer, Lyon, France; Mr G. Ferro-Luzzi, National Institute for Food and Nutrition Research, Rome, Italy; Dr R. Francis, Freeman Hospital, Newcastle-upon-Tyne, England; Dr Ghafoor- unissa, Indian Council of Medical Research, New Delhi, India; Dr K. McMichael, Australian National University, Canberra, Australian Capital Territory, Australia; Professor S. O’Dea, Menzies School of Health Research, Alice Springs, Northern Territory, Australia; Professor D. Walker, South African Institute for Medical Research, Johannesburg, South Africa; Dr S. Acknowledgement was made by the Consultation to the following individuals for their continualguidance:DrD. Robertson for her valuable contribution to the preparation and running of the meeting, to Mrs A. This manual has been written with the aim of developing the knowledge, skills and attitudes of nurses and midwives regarding infections and infectious diseases and their prevention and control. A workbook is provided separately, with opportunities for self-assessment through learning activities. A completed workbook is also available for each module to give further guidance to readers. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. Any views expressed by named authors are solely the responsibility of those authors.