These are not mutually exclusive stages, and although they are in order of action, several events can be carried out at the same time.

Excess cases, unusual deaths, exceeding the epidemic threshold or an unexpected clustering of cases will be indicators that an outbreak of a new or known epidemic disease is taking place. The cause will need to be identified and an estimate made of the magnitude and distribution of cases. Field investigations are organized and active surveillance set up to find any new cases. The disease can be confirmed by using an agreed case definition, specific laboratory test or sero-epidemiological technique. The disease must be notified as soon as possible, both nationally and possibly internationally (see Chapter 6). Judgement needs to be used in spending time on making an accurate diagnosis, or starting treatment with the information that is available. There will be great pressure to treat cases, which is a necessary humanitarian action, but until transmission is interrupted more cases will occur. Once the disease is under control, methods must be implemented to prevent recurrence. Finally, the outbreak is analysed and written up. A surveillance system is on the look-out for the first indications of the communicable disease starting again. These stages will be considered in more detail.

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