Tuberculosis in Russia
Organization of fight against tuberculosis in Russia
1. The history of development of phthisiatric service, ethical and legal bases of fight against tuberculosis in Russia
In Russia till 1917, the state policy in relation to tuberculosis, in general, was practically absent and existed on charitable forms. After the October revolution (1917) the organization of struggle against tuberculosis were transferred from charity to state basis. At the Ministry of health of the USSR (Union of Soviet Socalist Republics), a section against the struggle of tuberculosis was organised. Gradually a new medical specialty known as phthisiatry was developed. As a result of social evolutions and wide conduction of anti-tuberculosis campaigns by the end of 1930’s, the incidence and mortality from tuberculosis were decreased sharply in the country.
During the World War II (1941-1945), incidence of tuberculosis grew considerably due to massive evacuation of the population from occupied territories. The measures, taken up by the state, were directed on the struggle against tuberculosis and mobilization of the doctors – phthisiatrists into the army. In 1943, the government law: «About measures of struggle against tuberculosis» was accepted, in which the development concerning new tuberculosis hospitals, night sanatoriums at the enterprises, children's sanatorium gardens and forest schools was sanctioned.
In post war years, anti-tuberculosis service in the country continued to improve. Already at the beginning of 1948, the number of anti-tuberculosis establishments in the country has exceeded pre-war (1941) level. The tuberculosis patients received not only prolonged free treatment, but also housing and other privileges.
The decrease of incidence, mortality, degree of infectiousness proceeded until ninetieth of the last century testifies that the method of anti-tuberculosis struggle in USSR was theoretically and practically improved.
Social and economic evolutions in the beginning of 1990’s in Russian Federation were accompanied by insufficient finance of public health services, compelling migration and deterioration of social protection of the population. The named factors acting together have caused the growth of all epidemiological parameters of tuberculosis and they became the same as in 1960. It once again testifies that tuberculosis is not simply an infectious disease, but a complex socio-biological phenomenon which is under negative influence of deep economic recession, poor standards of living, local military conflicts, deprivation of the people of social guarantees.
At the same time, the presences of organized phthysiatric service in Russia, even with insufficient finance, under all adverse conditions, have limited the spread of tuberculosis
2. Ethical and legal bases of fight against tuberculosis
In Russian Federation several basic normative documents act on regulating the relationship between the tuberculosis patient and the state. The following are related to the documents:
1. Constitution of Russian Federation.
2. Basis of the legislation of Russian Federation about protection of health of the citizens (№ 5487-1 from 22.07.1993).
3. Law of RSFSR «About sanitary-epidemiological well-being of the population (1991).
4. Law of Russian Federation «About prevention of spread of tuberculosis in Russian Federation» from June 18, 2001 № 77-FL.
The law of RF «About prevention of tuberculosis spread in Russian Federation» № 77 from 2001 establishes legal bases of state policy realization in the field of tuberculosis and prevention in the Russian Federation with the aim of citizens health protection and maintenance of sanitary-epidemiological well-being of the population.
As the law defines, anti-tuberculosis help includes joint medical, sanitary-hygienic and anti-epidemiological measures directed on revealing, examination and treatment, including obligatory examinations and treatment, dispensary supervision and rehabilitation of the tuberculosis patients.
The regulations of the law are applied to the citizens of Russian Federation with the aim to provide them with anti-tuberculosis treatment. The law is applied to the legal and physical persons rendering anti-tuberculosis help in territory of the Russian Federation. The foreign citizens and persons without citizenship also receive anti-tuberculosis treatment according to this law.
The providing of anti-tuberculosis help to tuberculosis patient is guaranteed by the state and is carried out based on the principles of legality including maintenance of the rights of the man and citizen, free of charge, general accessibility.
Anti-tuberculosis help is provided to the citizens at their voluntary will or their consent. At the same time, dispensary supervision of the tuberculosis patients is established irrespective of the consent of such patients or their lawful representatives.
The patients with infectious forms of tuberculosis (discharging mycobacterium tuberculosis), repeatedly breaking sanitary-epidemiological regime, deliberately avoiding examinations for tuberculosis or do not follow tuberculosis treatment, based on court decisions could be hospitalized in specialized medical anti-tuberculosis establishments for compulsory examinations and treatment.
The supervisors of medical organizations and citizens engaged in private medical activity are obliged to inform the appropriate organizations on the tuberculous patients revealed within the jurisdiction territories, and about everyone suffering from tuberculosis exempted from prison.
The tuberculosis patients requiring anti-tuberculosis help receive such help from medical tuberculosis organizations having the appropriate licenses.
Tuberculosis patients supervised by dispensary, with the aim to obtain anti-tuberculosis help have the right to:
1) valid and humane relation;
2) receive information about their rights and duties of tuberculosis patients, about character of disease which they have and methods of treatment given;
3) preservation of medical privacy;
4) diagnostics and treatment;
5) sanatorium and health resort treatment;
6) stay in anti-tuberculosis in-patient medical organizations, during the time necessary for examination and (or) treatment.
The persons who are registered in connection with tuberculosis in dispensary, are obliged to:
1) perform prescribed medical treatment and sanitary measures;
2) follow the internal hospital rules during the stay at these anti-tuberculosus organizations;
3) carry out sanitary-hygienic rules established for the tuberculous patients in public places.
For citizens who have temporarily lost working capacity due to tuberculosis, the place of work (post) is reserved for them as established by the law of Russian Federation.
From the time the patient is unemployed due to tuberculosis the patient is provided the welfare payment of state social insurance, according to the law of Russian Federation.
The patients, who are under tuberculosis dispensary supervision in connection with tuberculosis, are provided with free-of-charge drugs for tuberculosis treatment. The patient with infectious forms of tuberculosis, have the right to improve their housing conditions, in view to reduce epidemiological danger in the surrounding and eventually the inhabited area, according to the law of Russian Federation.
Medical, veterinary and other workers directly participating in rendering of anti-tuberculosis help, have the right to:
1) additional paid leave;
2) reduction of working hours;
3) extra pay in connection with harmful working conditions (danger of MBT infection);
4) ensuring in the prime order by the permits for sanatorium-resort treatment in case of development of tuberculosis as a result of execution of the official duties.
Violation of the rules of the Russian Federation law concerning tuberculosis control, attract disciplinary, civil law, administrative and criminal responsibility according to the legislation.
2. The anti-tuberculosis dispensaries
The activity of anti-tuberculosis (phthisiatric) service is determined by the official documents (orders, methodical indications, instructions etc.) approved by the Ministry of Public Health of Russian Federation. Such documents are elaborated on the basis of the existing laws of the Russian Federation, thereby defining concrete activity of anti-tuberculosis service providing medical care to tuberculous patients, within the framework of the existing laws.
The phthisiatric system consists of a network of state, specialized, independent medical establishments, whose basic task is the struggle against tuberculosis. Anti-tuberculosis dispensary is the leading establishment of this net- work.
The anti-tuberculosis dispensary supervises all branches of medical and prophylactic measures directed to struggle against tuberculosis. Dispensaries are organized according to the territorial principle. In small cities, there is one dispensary. In large cities, one dispensary serves one or two areas with the population of 200 000 – 400 000 inhabitants. Dispensary provides treatment-diagnostic help to the inhabitants of the given area, and also to all workers and employees of the enterprises, establishments and educational institutions located in the dispensary territory.
The basic aim of the dispensary – systematic decrease in the incidence, morbidity, infectiousness and mortality from tuberculosis among the population of given area.
To achieve this aim, the medical staff of the dispensary should study well the territory, the sanitary and socio-economic relations and have close contact to all treatment-prophylactic and sanitary establishments.
Every anti-tuberculosis dispensary in the territory of its authority provides the functioning of the centralized control system based on two principles:
1) unification of measures on revealing, diagnosis and treatment of tuberculosis according to the instruction of the dispensary organization, dispensary observation and registration of the contingent of anti-tuberculosis establishments;
2) differentiation of the specified measures allowing to develop individual plan of observation of each patient in urban and rural territories depending on geographical and economic features, condition of communication, way of life and other social conditions and the character of tuberculous process in the patient etc.
The basic tasks of dispensary are:
1.
Organization and realization of prophylactic measures:1.1. Anti-tuberculosis BCG vaccination and revaccination.
1.2. Improvement of the tuberculosis infection pesthole (focus / place) in time and prolonged hospitalization of bacillary expectorators.
1.3. Improvement of housing conditions of the patients presenting epidemiological danger to the surrounding.
1.4. Organization of chemoprophylaxis, in the foci of tubercular infection.
1.5. Admission of infected children to sanitary establishments (tubercular sanatorium).
1.6. Sanitary-awareness of the population.
2. Revealing patients with early symptoms of tuberculosis illness.
3. Organization and realization of qualified and successive treatment of the tuberculosis patients in outpatient and stationary conditions, for achievement of clinical treatment.
4. propagation of knowledge about tuberculosis among the doctors and paramedical personal of the treatment-prophylactic establishments of the area.
Structure of the dispensary. Dispensary should have following departments and cabinets:
1. Therapeutic departments (out-door patient and in-door-patient) for treatment of the adult tuberculosis patients.
2. Pediatric department, in which children from 3 to 15 years are treated.
3. Cabinet for patients with tuberculosis of bones and joints.
4. Cabinet of bronchologic investigations.
5. X-ray room.
6. Laboratories: clinical and microbiological.
7. Procedure cabinet.
8. Stomatologic unit (in large dispensaries).
9. Fluorography room.
10. Daytime tuberculosis in-patient facility.
In large dispensaries, it is recommended to organize consultations by urologists, gynecologists, dermatologists, and oculists.
The pulmonary surgical help in Russian Federation is provided in large-scale tuberculosis hospitals, where the pulmonary surgical departments are accordingly equipped.
In every dispensary, where there is an in-patient department, it is recommended to organize labor workshops, in which the patients undergo rehabilitation and are able to perform simple work under the supervision of an instructor or get a new profession, corresponding to their physical conditions.
Organization of medical service. Direct admission is not present in the dispensary. The patient, if suspected of tuberculosis, is referred to the dispensary from the regional polyclinic by the physician, surgeon, neuropathologist, pediatrician, school doctor or medical assistant of the medical center.
Fluorography is a way of massive, rapid and cheap examination of thoracic organs among the large groups of the population. Patients are directed to the dispensary for diagnosis if changes are detected in the lungs during fluorography. The early recognition of disease is possible only during prophylactic investigation of healthy people wit-hout exception.
3. The dispensary groups of tuberculosis patients
When the patient is diagnosed with tuberculosis, he is admitted to the dispensary for treatment:
– on reversibility of tuberculosis till clinical cure;
– on irreversibility of tuberculosis till the end of life.
The grouping of dispensary contingents are based on the treatment and epidemiological principles and allow the local doctor-phthisisatrist to:
1) correctly form groups of supervision;
2) call for investigation in time;
3) define medical tactics;
4) carry out rehabilitative and preventive measures;
5) withdraw patients from dispensary supervision.
The concrete grouping of dispensary contingents is constantly reconsidered and affirmed by the Ministry of health of Russian Federation.
Group zero – (0). In the zero group are observed:
1) individuals with unspecified activity of tuberculous process;
2) individuals requiring differential diagnosis with the aim to establish the diagnosis of tuberculosis of any localization.
3) individuals in whom the activity of tuberculous changes is necessary to be established are included in zero A-subgroup (O-A);
4) individuals for differential diagnosis of tuberculosis and other diseases in zero – B – subgroup (0-B).
First group (I).
In the first group, the patients with active forms of tuberculosis of any localization are observed.
Group (I) is divided into 2 subgroups:
First (I – А) – the patients with disease manifested for the first time;
First (I – B) – patients with relapse of tuberculosis.
In both subgroups, patients are subdivided:
– with MBT expectoration (I-А – МБТ +, I-Б – МБТ +);
– without MBT expectoration (I-А – МБТ-, I-Б – МБТ-).
Furthermore, the patients (I-В) are subdivided into those who have interrupted treatment or were not examined after completion of treatment (the result of their treatment is unknown).
Second group (II).
In the second group, patients with active forms of tuberculosis of any localization with chronic course of tuberculosis are observed. This group includes two subgroups:
Second (II-A) – patients in whom intensive treatment can achieve clinical recovery.
Second (II-B) – patients with far advanced process in whom treatment can not be achieved by any methods as well as patients who require supporting, symptomatic treatment and periodic (at occurrence of the indications) anti-tuberculosis therapy.
Third group (III). The third group (control group) registers individuals with cured tuberculosis of any localization.
Fourth group (IV). In the fourth group, the patients who are in contact with the sources of tuberculosis infection are under supervision.
The group (IV) is subdivided into two subgroups:
- (IV-A) for persons who are in household and industrial contact with the source of tuberculosis infection;
- (IV-B) for persons who are in professional contact with the source of tuberculosis infection.
The ndices and criteria of dispensaries surveillance and registration
Tuberculosis of doubtful activity.
By this concept the tuberculous changes in lungs and other organs are indicated, but the activity of the changes is unclear. The 0 (zero) subgroup of dispensary observation is intended to establish the activity of the tubercular process and to conduct the complex of diagnostic measures.
The basic complex of diagnostic measures is carried out within 2-3 weeks.
The patients of the zero groups can be moved into the first group or referred to public health establishments.
Active tuberculosis is a specific inflammatory process caused by MBT and determined by a complex clinical, laboratory and X-ray features.
The patients with active form of tuberculosis require medical, diagnostic, anti-epidemiological, rehabilitative and social help.
All patients with active tuberculosis revealed for the first time or with tuberculosis relapse are enlisted only in the 1st group of dispensary monitoring.
Chronic course of the active tuberculosis forms.
Long term (more than 2 years), including wavy (interchange of subsidizing and exacerbation) course of the disease, during which clinical, x-ray and bacteriological features of active tuberculosis process are preserved.
The chronic course of active form of tuberculosis as a result of late recognition of the disease, inadequate and non-systematic treatment, condition of the immune status of the organism or presence of concomitant diseases complicating the course of tuberculosis.
Clinical cure. Disappearance of all signs of active tuberculous process occurs as result of basic course of complex treatment.
Verification of clinical cure of tuberculosis and moment of completion of the effective course of complex therapy is determined by the absence of signs of aggravation of tuberculous process within 2-3 months.
Time of observation of the first group should not exceed 24 months, including the six months after effective surgical treatment.
Persons discharging MBT. The patients with active form of tuberculosis, in whom MBT are revealed in the biological fluids of the organism and/or in the pathological material.
Among the patients with non-pulmonary forms of tuberculosis, to persons discharging MBT are referred those in whom MBT were revealed in contents of secreting fistulas, urine, menstrual blood or excretions of other organs.
Patients in whom MBT revealed only by bacterial inoculation of puncture aspiration, biopsy or operational materials are not taken into account as persons discharging MBT.
In an effort to reveal MBT expectoration in each tuberculosis patient, before starting the treatment, thorough examination of sputum (bronchial fluids) and other pathological secretions by bacterioscopy and culture methods must be carried out not less than three times.
This investigation must be repeated in the course of monthly treatment till the disappearance of MBT which should later be confirmed by at least two consecutive examinations (including cultural) with intervals of 2-3 months.
Discontinuance of MBT expectoration. (synonym - abacillation) – disappearance of MBT in biological fluids and pathological secretions from organs of the patient, discharged into the external environment. Abacillation is proved by two negative consecutive bacteriologic and cultural examinations with an interval of 2-3 months after the first negative analysis.
Residual post-tuberculosis changes. To residual changes refer dense calcified foci and nidus of various size, fibrous and cirrhotic changes (including residual sanitized cavities), and pleural depositions, post-operational changes in lungs, in pleura and in other organs and tissues and also functional disturbances after clinical cure.
Isolated (up to 3 cm) fine (1 cm), dense and calcified foci, limited fibrosis (within the limits of 2 segments) is regarded as small residual changes.
All the other residual changes are regarded as considerable.
Destructive tuberculosis is the active form of tuberculosis process with the presence of tissue disintegration determined by complex of radiographic examinations.
X-ray examinations (general view X-ray films and tomograms) are basic methods for showing destructive changes in organs and tissues.
The closure (healing) of a cavity of disintegration considered as its disappearance, confirmed by the methods of radiographic diagnosis.
Exacerbations (grow progressively worse) of tuberculosis is the appearance of new signs of active tuberculosis process after the period of improvement or the reinforcement of the signs of the disease before the diagnosis of clinical cure.
Appearances of the exacerbations testify ineffective treatment and demand its correction.
Relapse. Appearance of the signs of active tuberculosis among individuals, previously suffered from tuberculosis and cured, being supervised in III dispensary group or withdrawn from it due to recovery.
Occurrence of signs of active tuberculosis is regarded as a new disease in spontaneously recovered persons earlier who were not registered in anti-tuberculosis dispensaries.
The formulation of the diagnosis at assignment or at case of inclusion to
another dispensary registration group
At inclusion of a patient into the I group of dispensary registration.
Example:
1. Infiltrative tuberculosis of the superior lobe of the right lung (S1, S2) in the phase of disintegration and dissemination, MBT+.
2. Tuberculosis spondylitis of thoracic vertebra with destruction of the thoracic vertebrae bodies 8-9, MBT-.
3. Cavernous tuberculosis of the right kidney, MBT+.
When the patient is moved into II group (with chronic course of tuberculosis) the clinical picture which takes place at the present moment of tuberculosis is specified.
During the moment of the registration, there was an infiltrative form of tuberculosis. Due to unfavorable progression of the disease, fibro-cavernous lung tuberculosis developed (or large tuberculoma remained with or without disintegration). During the transition, the diagnosis of fibro-cavernous lung tuberculosis (or tuberculoma) should be indicated in the epicrisis.
The diagnosis is formulated according to the following principle during the transition of the patient into control group (III): clinical cure of either form of tuberculosis (the most severe diagnosis during the disease is brought forward) with presence of residual post tuberculosis changes (large and small), the character and prevalence of residual changes should be specified.
Examples of formulation of diagnosis at transition of the patient to the control group III of the dispensary registration.
1. Clinical cure of focal lung tuberculosis with presence of small residual post-tuberculosis changes, in the form of fine, isolated, dense foci and limited fibrosis in the superior lobe of the left lung.
2. Clinical cure of the disseminated lung tuberculosis with presence of large residual post-tuberculosis changes in the form of multiple dense fine foci and spread of fibrosis in the superior lobes of the lungs.
3. Clinical cure of lung tuberculoma with presence of the large residual changes in the form of scars and pleural thickenings after small resection (S1, S2) of the right lung.
For the patients with non-pulmonary tuberculosis, the diagnosis is formulated using the same principles as for the patients with lung tuberculosis.
Examples.
1. Clinical cure of tuberculous coxitis on the right with partial infringement of joint function.
2. Clinical cure of tuberculous gonitis on the left resulting into anchylosis.
3. Clinical cure of tuberculous gonitis on the right with residual changes after operation – anchylosis of the joint.
4. The Day tuberculosis inpatient facility (DTIF)
With the aim to improve medical help for tuberculosis patients, since 1993 at tuberculosis dispensary, day tuberculosis inpatient facilities are organized.
Tasks of the Day tuberculosis inpatient facility:
1) implementation of controlled chemotherapy for the tuberculosis patients undergoing main course of treatment;
2) controlled diagnostic investigation;
3) performing anti-relapse and preventive treatment.
The DTIF with the aim to maintain epidemio-logical regime must be organized into separate blocks or in isolated part of the main inpatient building.
Patients not demanding medical supervision in the evening and night time could admit in the DTIF if they satisfy the following criteria:
1. Clinical indications:
1.1. the newly diagnosed patients with limited forms of tuberculosis of lungs and not expectorating MBT;
1.2. the patients after an effective course of chemotherapy, as a result of which the expectoration of MBT have been terminated.
2. The epidemiological indications are necessarily combinations with the following conditions:
2.1. good housing conditions comparable to tubercular focus III groups (see section 7.6):
2.2. the patient residing near the tubercular stationary (absence of negative influence on health due to trips from and back home);
2.3. morale boosting of the patient with the firm motivation for treatment, and the assurance that he adheres to measures of personal and public epidemiological safety.
5. Specific prevention of tuberculosis. Vaccination. Chemoprophylaxis
Methods of tuberculosis specific prevention include the following BCG (Bacilles-Calmette-Guerin) vaccination, revaccination and chemoprophylaxis.
The BCG strain is used for vaccination and revaccination. This strain has the following properties: it is harmless, has specificity, immunogeniccity, keeps residual virulence, has limited multiplication in vaccinated organism, being in lymphatic nodes. For immunization in Russian Federation a dry BCG vaccine is applied as most stable, and capable for considerable time to keep required quantity alive MBT.
The duration and stability of post-vaccinated immunity is determined by character of immuno-morphological changes and vegetation of BCG in inoculated organism. BCG strain introduced in organism, multiply within the cells, and stimulates the development of anti-tuberculosis immunity.
After two weeks of vaccination BCG strain begin to transform into L-forms. In such situation MBT of BCG strain can exist in organism for a long time, maintaining anti-tuberculosis immunity.
The efficiency of BCG vaccinations is shown by the fact that among vaccinated and revaccinated children, teenagers and adults incidence of new tuberculosis cases and mortality is lower, than among not vaccinated.
The duration of post-vaccination immunity is maintained minimum up to 5-7 years after intra dermal BCG vaccination.
Method of administration of BCG vaccine and its dose. In the territory of Russian Federation intradermal BCG vaccination is used as the most effective and economic method of vaccination.
BCG vaccination of newborn is carried out on 4-7-th day of life without preliminary tuberculin test.
BCG revaccination or repeated inoculation against tuberculosis will be carried out in decreed (approved) periods at presence of negative reaction on Mantoux test with 2 TU PPD-L.
The first revaccination is carried out at the age of 7 years (1-st school class), second at 11-12 years (5-th school class), third – 16-17 years (10-th school class).
Subsequent revaccinations will be carried out with an interval 5-7 years up to 30-years of age. Method of revaccination is the same as the vaccination.
Chemoprophylaxis
The term chemoprophylaxis has been applied to two distinct types of preventive therapy of tuberculosis.
1. Primary chemoprophylaxis where the drug is given to individuals who have not been infected (with negative tuberculin test) in order to prevent development of disease (e.g. infant being breastfed, being in contact with bacillary patient).
2. Secondary chemoprophylaxis where the anti-tuberculosis drugs is used to prevent deve-lopment of disease in people who have already been infected but being in condition of repeated infection or relapse of tuberculosis.
The groups of populations eligible for chemoprophylaxis
Chemoprophylaxis is carried out for the prevention of tuberculosis in the following groups of population:
1) children, teenagers and adults who are being in constant contact with tuberculous patients;
2) healthy children without clinical signs, teenagers and persons of young age till 30 years of age who for the first time are MBT infected;
3) persons with constant hyper allergic reactions to tuberculin;
4) newborn (BCG vaccinated in the maternity hospital), born from tuberculosis suffering mother;
5) people with newly positive tuberculin reactions;
6) the persons with the signs of earlier transferred tuberculosis and now in the presence of the adverse factors (acute forms of diseases, operation, traumas, pregnancy etc.). capable to cause an aggravation of tuberculosis, and also in persons who were earlier treated from tuberculosis but with large residual changes in lungs, being in a dangerous environment;
7) the persons with signs of old tuberculosis but at present having concomitant diseases capable to activate tuberculosis (diabetes, collagenosis, silicosis, sarcoidosis, ulcer of stomach, stomach resection etc.).
Among the persons who had undergone chemoprophylaxis, the number of incidence of tuberculosis is 5-7 times less in comparison with the appropriate groups of the persons without chemoprophylaxis.
Drugs. For chemoprophylaxis isoniazid or ftivaside are used for 3 months, and if epidemic danger remains, chemoprophylaxis is repeated 2 times per year for 2 months. For the persons with hypersensitivity to tuberculin test, prophylaxis is recommended with two preparations – isoniazid and pirazinamide (ethambutol).
Doses. For adults and teenagers the daily doze of isoniazid for daily administration is 0,3 g, for children 8-10 mg/kg. If intolerance to isoniazid occurs, it is possible to do chemoprophylaxis with ftivasid. Ftivasid prescribed for the adult is 0,5 g 2 times per day, children 20-30 mg/kg. Both adults, and children should necessarily take vitamin B6 and С.
The application of secondary chemoprophylaxis is most justified by seasonal courses (in a autumn-spring season) for 2-3 month 2 times per year.
6. Social and sanitary prevention of tuberculosis
The basic principles of carrying out tuberculosis control are based on state struggle against tuberculosis as a social disease. The organization concerned with the fight against tuberculosis includes establishments of public health services together with specialized anti-tuberculosis system.
The purpose of anti-tuberculosis
measures:
1) to prevent MBT infection of healthy people;
2) to limit and to assure safety of contacts
of active tuberculous patient (especially MBT sputum positive) with the healthy people living together or at work.
Major component of sanitary prevention is the realization of social, epidemiological and medical measures in family and in the residence (infection focal point) of tuberculous patient.
The realization of preventive measures in the infection focal point begins with its visit by phthisiatrist, epidemiologist and medical nurse of the local dispensary immediately from the moment of detecting MB in the sputum of patient or detection of destructive tuberculosis in lung. Depending on the results of the examination of the infection focal point the plan of its improvement (sanitation) is made.
The plan should reflect:
1) disinfection of the focal point;
2) treatment of the patient;
3) isolation of children;
4) registration of the inhabitants in dispensary;
5) frequency and extent of regular investigation of all members of a family, realization of chemotherapy prevention, supply of disinfectants.
The criteria of epidemic danger of the place of tuberculous patients’s residence (tuberculous focus) are:
1) massive and constant expectoration of MBT by the patient;
2) patient’s life style;
3) behavior, general standards of cultural habits and sanitary awareness of the patient as well as persons surrounding him.
On the basis of these criteria the tuberculous focuses depending on degree of epidemic danger are divided into three groups. According to this grouping volume and contents of preventive measures in the tuberculous focus are defined.
The I group of tuberculous focus – most unfavourable:
1) the patient with chronic destructive tuberculosis living in bad housing conditions constantly expectorates MBT;
2) in family of the patient there are children, teenagers, pregnant women;
3) the patient and the people around him do not observe hygienic rules.
The II group of the tuberculous focus – relatively unsuccessful:
1) the patient has poor bacterial expectoration, stable tuberculous process, lives in satisfactory housing conditions;
2) in family of the patient there are only adult persons, adverse factors are absent;
3) the patient and the persons around him do not observe hygienic rules.
The III group of the tuberculous focus – potentially dangerous:
1) the patient is conditional MBT expectorator;
2) in family of the patient there are only adults;
3) the patient and the persons, around him, carry out all necessary sanitary – hygienic mea-sures of tuberculosis prevention.
Realization of preventive measures in the focus of infection
The important section of the plan is educating the patient and members of his family about sanitary – hygienic skills.
The room of the patient is to be cleaned and disinfected every day.
When the patient is going from the house for treatment in a hospital, in a sanatorium or in case of his death, a final sanitary – epidemiological service should be carried out.
Attention paid for training the patient to be careful with sputum, plates and dishes, subjects of personal use that practically makes him safe for persons around him.
The MBT expectorator should have spittoon for sputum collection, which content must be boiled, with the purpose of MBT elimination; it is possible to use chloride of lime.
The clothings of the patient and especially handkerchiefs, towels should be collected in a separate bag, before washing the linen is soaked in 5 % of chloramin solution over night and boil in 2 % solution of soda during 30 minutes.
Plates and dishes of the patient are washed and are wiped by a separate towel.
The clothes of the tuberculous patient should be exposed to the sun often, weekly ironed and disinfected not less than 2 times per year in steam or in steam-formalin chambers. The cleaning of clothes should be done outside the inhabited room.
The floor cleaning must be conducted with a damp cloth dipped in 2 % soda solution.
All these measures forming part of the concept of the current disinfection, which is carried out by the patient or adult members of his family under the management and control of the medical nurse of tuberculosis dispensary.
Measures on tuberculosis prevention among persons, being in contact
with the tuberculous patients and working in tuberculosis establishments
In anti-tuberculosis establishments the personnel communicate with the tuberculous patients, including those who are secreting bacteria. These contacts take place in out-patient reception of the patients, at service in clinics and in the apartments, where the transmission of the infection is possible through dust, contact, drops and alimentary ways.
Incidence of tuberculosis among medical staff of anti-tuberculosis establishments is 8-10 times higher, than in all population.
In every anti-tuberculosis establishment, there are rules with the purpose to minimize the danger of infection by tuberculosis and to create the most favorable working conditions for the personnel. These rules should be strictly observed.
Individual means of protection of respiratory organs
The general regulations. Individual means of respiratory organ protection (respirators, gauze bandages) serve for medical workers as "last boundary of defense" against concomitant MBT distribution.
Respirator’s use is limited in places of high risk, namely:
1) in boxes of the tuberculous patients or MDR-TB;
2) at stimulation of sputum expectoration or other procedures causing cough;
3) at bronсhoscopy;
4) at section halls;
5) at spirometry;
6) during emergency surgery on the potentially infectious tuberculous patients.
Surgical masks. Between a surgery mask and respirator there are important differences. Surgical masks for example (made of cloth or of paper):
1) really provide prevention of distribution of microorganisms from their source (for example, tuberculous patient) to other persons by retention of large particles separated near nose and mouth;
2) do not provide protection of the user (for example, medical worker, patient, member of fa-mily) from inhalation of the infectious agent in air droplets.
Means and methods of disinfection
Means of disinfection. Now there is a wide spectrum of disinfectants. However at application it is necessary to check their activity to disinfect contaminated MBT material. From these preparations chloride of lime and chloramin are most widely used in Russian Federation.
1. Chloride of lime – white powder contai-ning 28, 0-35, 0 % of active chlorine.
2. Chloramin B and XB – powder of cream color, contents of active chlorine 27,0-28,0 %.
For preparation of 5 % chloramin disinfectant solutions 500 g. of chloramin powder dissolve in 10,0 liters of water.
Disinfection of objects of personal and public use
Spittoons. Plates and dishes with remains of food. The remains of food. Wash basin, urinals, lavatory pans, taps. Subjects of patient’s care: bedpans, urinals, tips for clysters.
Methods of disinfection.
1. Boiling in soda solution.
2. Immersing in a pan with a cover containing chloramin solution.
3. Autoclaving.
4. To cover with chloride of lime.
Service rooms (wall, floor, doors, furniture) in wards, in procedure units, in places of common usage.
Methods of disinfection.
1. Wiping with tatters moistened in the activated solutions of chloramin.
2. Washing with hot soap-soda solution.
3. Immersing in a vessel with a cover contai-ning solution of chloramin.
4. To cover with chloride of lime.
Linen (bed, from dining rooms, underwear, furniture cases, gauze masks, respirators, handkerchiefs, personal linen and bed cloths).
Methods of disinfection.
1. Boiling in soda solution.
2. Ironing by a hot iron.
3. Disinfection in gas-chamber.
Soft furniture. Fine objects of use, toy (metal, rubber, wooden, plastic), books, notes, paper etc.
Methods of disinfection.
1. Immerse in disinfection solutions and disinfect according to regimes.
2. The objects of little value are burnt, and valuable ones are disinfected in gas chamber.
3. Cleaned by a brush moistened in one of disinfectant solutions.
In anti-tuberculosis hospitals at reception of the patients, and then regularly sanitary – educational work with the patients should be carried out. With the purposes of protection of the personnel from infection, special attention should be paid to the rules of behavior, obligatory for the patients.
When discharged, the patient must receive explanations about the rules of his behavior at his place of living and in public places, warning him about the spread of tuberculosis infection to the surrounding.
Sanitary education is part of preventive work in dispensary. In the plan epidemiological measures directed on struggle against tuberculosis, anti-tuberculosis propagation should play an important role. The sanitary – educational work is necessary for carrying out first of all among the tuberculous patients.
The propagation of knowledge about the origin of tuberculosis, its sources, and distribution is the important part of struggle with this illness. The knowledge of methods of personal and public preventive measures of tuberculosis has the practical importance for the population.
Anti-tuberculosis activity of general medical establishment’s network
Prevention of tuberculosis and detection of the patients with tuberculosis in a population is the function of treatment-preventive establishments of a general medical network. This work is carried out under organized and methodical management of the tuberculosis dispensary and organs of sanitarian-epidemiological surveillance.
The basic tasks of general medical establishment of polyclinic type are to perform proper investigations in the patient in whom tuberculosis is suspected and to send him to tuberculosis dispensary.
The polyclinics of common profile carry out, after investigation of the tuberculosis suspects, a clinical minimum: lung fluorography, sputum examination for MBT, tuberculin test, analysis of blood and urine.
Measures of sanitary and epidemiological surveillance of the
Russian Federation in prevention and revealing of tuberculosis
The work of committee of sanitarian and epidemiological surveillance and its divisions on prevention of tuberculosis in territory of their responsibility includes the following:
1) specific prevention and early detection of tuberculosis, improvement of bacteriological service for strengthening of the effectiveness of epidemiological situation on tuberculosis;
2) to controll sanitary situation of the industrial enterprises, children's and teenage establishments, epidemiological regime in anti-tuberculosis establishments and in the focuses of tuberculosis infection;
3) to carry out retrospective epidemiological forecast and participation in planning of anti-tuberculosis measures.
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