Organization of detection of patients with tuberculosis

Identification of patients with tuberculosis is a systematic, definitely organized and backed up by regulatory documents activity of health care institutions, aimed at the identification of persons with suspected tuberculosis, followed by their examination to confirm or exclude this diagnosis.

[1], [2], [3],

Identification of patients when treatment

One of the priorities in the system of anti-tuberculosis measures in modern conditions is the detection of tuberculosis in health facilities of various profiles among those who applied for medical care. The identification of patients with tuberculosis among those seeking medical care in the institutions of the general treatment network is carried out by employees of these institutions.

Patients are subject to examination:

• with symptoms of inflammatory bronchopulmonary disease (respiratory symptoms):
  • the presence of a prolonged cough (more than 2-3 weeks) with sputum discharge:
  • hemoptysis and pulmonary hemorrhage;
  • chest pain associated with breathing;
• with persistent more than 2-3 weeks of intoxication symptoms:
  • increased body temperature;
  • weakness;
  • increased sweating, especially at night;
  • loss of body weight.

In the conditions of establishment of public health services of any profile, all persons with symptoms of respiratory diseases are treated:

• clinical examination: examine complaints, anamnesis, conduct physical examination;
• laboratory study: three times the sputum is examined under a microscope (if available) for acid-fasting mycobacteria, using Tsiol-Nelsen staining;
• X-ray examination of chest organs in an accessible volume for the institution (the best option is the use of digital fluorography). Most patients with infectious forms of tuberculosis have symptoms of the disease. Therefore, microscopic examination of sputum in people who go to medical institutions with suspicious complaints of tuberculosis is the fastest way to identify epidemically dangerous ballpoints. The first and second samples of sputum are taken in the presence of a medical worker on the day of the patient's treatment (with an interval of 1.5-2 hours), then he is given a dish for collecting morning phlegm before the second visit to the doctor.

If the patient lives far from a medical institution or is in an unsatisfactory condition, he is hospitalized for 2-3 days for examination.

In remote settlements it is necessary to train paramedics or other medical workers in the technique of collecting and preserving sputum. In the therapeutic, pulmonological and other hospitals of health facilities of any profile, where patients with acute and chronic inflammatory diseases of the respiratory system come in, the microscopy of smears of sputum stained according to Tsilyu-Nelsen is an obligatory component of the survey. The collected sputum should be delivered as soon as possible to the laboratory. If this is not possible, the material is stored in the refrigerator at an air temperature of 4-10 C. If the laboratory is located at a distance from the health care institution, the delivery of material for research is carried out 1 or 2 times a week.

In the absence of acid-fast mycobacteria in all three sputum smears examined, but the presence of clinical and radiologic signs of inflammation in the lungs, it is possible to perform a test therapy of up to 2 weeks with broad-spectrum antibiotics. In this case, do not use drugs that have anti-tuberculosis activity (streptomycin, kanamycin, amikacin, capreomycin, rifampicin, rifabutin, a group of fluoroquinolones, etc.). If the antibiotic therapy is ineffective, the patient should be referred to an anti-tuberculosis institution.

If the necessary equipment is available in health facilities of any profile, primarily in therapeutic and pulmonological hospitals, instrumental research methods should be used for morphological, cytological and microbiological confirmation of the diagnosis of tuberculosis. Invasive examinations are performed in a hospital or, if possible, in a hospital of one day. Day hospital or other stationary substitution conditions

The scope of examination of a patient with suspected tuberculosis is determined by the need to obtain reliable confirmation or exclusion of the diagnosis of tuberculosis. If it is impossible in this institution to ensure that the necessary research is carried out, the patient should be referred to a health facility where such an opportunity exists.

At feldsher-midwifery stations, outpatient clinics, district hospitals, polyclinics, complaints and anamnesis should be collected and analyzed, sputum smear microscopy with Tsiol-Nelsen coloring should be performed three times to detect acid-fast mycobacteria, general blood and urine tests are done, and in children and adolescents - Mantoux tuberculin test.

At the level of the municipal hospital, X-ray (fluorography) examination of the patient and necessary consultations with extrapulmonary pathology specialists should be added to these studies in the presence of indications (neurologist, urologist, orthopedic surgeon, gynecologist, ophthalmologist, etc.).

In regional, regional, national and federal institutions, the survey can be supplemented with high-tech methods of radiation diagnosis (CT, magnetic resonance imaging, positron emission tomography), endoscopic studies, immunological and special examination methods in extrapulmonary pathology, cytological and histological study of biopsy specimens. In large hospitals and clinics of the therapeutic, pulmonological and surgical profile, molecular genetic methods of detection of mycobacteria of tuberculosis, high-tech invasive methods of surgical diagnosis can also be used as indicated.

With positive or questionable results of the examination in health facilities of any profile, the patient is sent to an anti-tuberculosis institution to confirm or exclude the diagnosis of tuberculosis and take the patient on the record.

To assess the level of organization of timely detection of tuberculosis patients, the following indicators and criteria are used:

• coverage of the population by screening inspections (should be 60-70% of the number of people living in the territory);
• the proportion of patients with active tuberculosis, revealed during check-ups among all first-time registered (70-75%);
• the proportion of actively detected patients by sputum smear microscopy among all newly diagnosed TB patients with respiratory organs-untimely detection (no more than 10%);
• the proportion of patients with fibrous-cavernous tuberculosis among newly diagnosed patients (not more than 1-1.5%);
• the proportion of patients who died of tuberculosis in the first year of follow-up, among all those who died from tuberculosis;
• the proportion of patients with posthumously established diagnosis among all those who died of tuberculosis (5%) and among all first-time registered (1%).

Active detection of tuberculosis patients

Under the active detection of tuberculosis in Russia, it is customary to understand the identification of patients in surveys conducted regardless of the presence or absence of signs of tuberculosis. Active detection of tuberculosis is carried out at mass screening (screening) surveys (traditionally called "preventive"), when examining risk groups or when examining people who have applied to a medical institution for any disease and complaining that are not related to the tuberculosis process.

Responsibility for the work on timely active detection of tuberculosis patients is borne by the heads of medical institutions. Heads of municipal health authorities and Rospotrebnadzor supervise the detection of tuberculosis patients. Organizational and methodological assistance is provided by workers of anti-tuberculosis institutions.

For many years, the basis for the active detection of tuberculosis of respiratory organs in adults in Russia was the fluorographic method of investigation, conducted by the entire population every 1-2 years. Mass x-ray examinations covered the majority of the population and made it possible to identify patients with respiratory tuberculosis at relatively early stages of the disease, mainly with limited processes, little or no clinical manifestations of the disease.

The system of active detection of tuberculosis patients is currently undergoing a period of modernization and transition to new organizational technologies and research methods.

In modern conditions, the active detection of tuberculosis among those groups of the population most often diagnosed with tuberculosis is recognized as the priority in so-called high-risk groups for tuberculosis. In this case, all available methods for detecting tuberculosis can be used.

Three methods are used to actively identify tuberculosis patients:

• ray (mainly fluorographic method, preferably using digital X-ray equipment). This method is used to detect tuberculosis in the adult population and adolescents;
• microbiological examination of sputum and urine in people with symptoms of respiratory and renal disease. Applied for examination of adults, adolescents and less often children;
• tuberculin diagnostics. Used as a screening method for examining children and, in part, adolescents.

The main thing in detecting tuberculosis is the fluorographic method of examination. When testing fluorographic examinations, pulmonary forms of tuberculosis are detected in the early stages, when the symptoms of the disease (subjective and objective) are absent or little expressed. The microbiological method of sputum examination is a very important additional method for identifying patients with infectious forms of tuberculosis.

The following population groups are subject to the survey 2 times a year:

• military servicemen undergoing military service on conscription;
• employees of maternity hospitals (departments);
• persons who are in close domestic or professional contact with sources of tuberculosis infection;
• Persons removed from dispensary records in treatment-and-prophylactic specialized anti-tuberculosis institutions in connection with recovery - within the first 3 years after being withdrawn;
• persons who have suffered from tuberculosis and who have residual changes in the lungs - within the first 3 years from the time the disease is detected;
• HIV-infected;
• patients who are on dispensary registration in narcological and psychiatric institutions;
• persons released from pre-trial detention centers and correctional facilities - during the first 2 years after release;
• prisoners under investigation, detained in pre-trial detention centers, and convicts held in correctional facilities.

The following population groups are subject to the survey once a year:

• patients with chronic nonspecific diseases of the respiratory system, gastrointestinal tract, genitourinary system;
• patients with diabetes mellitus:
• persons receiving corticosteroid, radiation and cytostatic therapy;
• Persons belonging to social groups at high risk of tuberculosis:
  • without a specific place of residence;
  • migrants, refugees, internally displaced persons;
  • living in in-patient social care institutions and social care institutions for people without a specific place of residence and occupation;
• persons working:
  • in social services for children and adolescents;
  • in medical-prophylactic, sanatorium-resort, educational, improving and sports establishments for children and teenagers.

Extraordinary medical examinations in order to detect tuberculosis are subject to:

• persons living together with pregnant women and newborns;
• citizens recruited for military service or entering the military service under a contract;
• Persons whose HIV infection is diagnosed for the first time.

When analyzing the coverage of the population by examinations and the proportion of newly diagnosed patients with active tuberculosis, it is necessary to compare these indicators with the level of the incidence of tuberculosis.

Reducing the coverage of the population by screening examinations and reducing the quality of these examinations created the illusion of well-being, which did not allow the timely development of appropriate measures to improve the detection of tuberculosis patients.

In 2005, 51594 patients with active tuberculosis were diagnosed during the screening tests.

Thus, without the use of the fluorographic method, about half of the newly diagnosed tuberculosis patients (49.5%) would remain unknown, and treatment and prophylactic measures against them and those around them would not have been carried out. Analysis of the results of bacteriological research methods for active detection of tuberculosis patients testifies to their inadequate application and the need to improve work in this direction.

The effectiveness of fluorographic examinations depends on:

• full accounting of persons subject to survey and planning of their survey;
• organization of examination in fluorography cabinets;
• organization of a survey of persons with identified changes.

Planning of surveys, organization and reporting is provided by the heads of medical-prophylactic institutions according to the individual population records according to the territorial or territorial-production principle. Surveys are carried out in the fluorographic offices of polyclinics, hospitals, TB dispensaries at the place of residence, at the place of work, when seeking medical help. It is very important to consider all the data on the scale of the territory for statistical and medical processing, which is possible if there is a single information system. The system should be available for medical institutions in case of repeated examinations of patients. The introduction of such a system will allow:

• reduce the radiation burden on patients;
• exclude duplication of surveys;
• use the possibility of retrospective study of X-ray studies of past years. Reduce the time of diagnosis and, as a consequence, start at an earlier time adequate therapy;
• identify the tuberculosis process in the early stages of development, which will increase the effectiveness of treatment and lead to a reduction in mortality;
• create a data bank for scientific analysis of trends in the development of the tuberculosis process and the exchange of information.

At checkup fluorographic examinations, in addition to tuberculosis, posttuberculosis changes, lung cancer, metastatic lung lesions, benign tumors, sarcoidosis are revealed. Pneumoconiosis. Emphysema of the lungs, pneumofibrosis. Pleural adhesions, adhesions, calcifications, mediastinal pathology, cardiac pathology, spine scoliosis, development options and pathological changes of ribs, etc.

Rapid development of digital technologies in X-ray diagnostics over the past 10 years has allowed to reduce the dose of the patient many times and take advantage of computer image processing. The active introduction to practical healthcare of digital radiographic techniques dramatically changed the attitude towards the status of fluorographic examinations and increased the diagnostic capabilities of the method for detecting tuberculosis and other lung diseases. It is encouraging to note that the domestic industry today can provide the country with digital fluorography of good quality. At the same time, their cost is 4-5 times lower than the cost of foreign analogues.

A new step in the development of digital technologies in X-ray diagnostics is the creation of low-dose digital devices of the next generation with high resolution (from 2.3 pairs of lines per 1 mm and higher), which allow not only to detect changes in the lungs, but also to diagnose tuberculosis in the early stages.

[4], [5], [6], [7], [8], [9], [10],

Detection of tuberculosis in children and adolescents

A characteristic feature of tuberculosis in children is the involvement in the pathological process of the entire lymphatic system, predominantly of the intrathoracic lymph nodes, and the slow involution of specific changes in them. Localization of the causative agent of the disease in the lymphatic system is one of the reasons limiting the possibility of bacteriological confirmation of the diagnosis (at least 90% of children and 50% of adolescents with newly diagnosed tuberculosis of the lungs and intrathoracic lymph nodes are not bacterial). In these cases, the diagnosis of tuberculosis is based on a combination of history data, the results of tuberculin diagnostics, clinical radiology data, and laboratory test results.

The choice of methods for conducting research determines the biological age characteristics of the juvenile-juvenile contingent and. As a consequence, features of the course of tuberculosis infection in the child. The tasks of general medical and preventive network doctors at the site, in children's institutions (nursery school, school), general practitioners, family doctors include mass tuberculin diagnostics, anti-tuberculosis vaccination of newborns not vaccinated in the maternity hospital, and BCG revaccination.

[11], [12],

Detection of tuberculosis when seeking medical help

When seeking medical help, tuberculosis is detected in 40-60% of older children and adolescents, in the overwhelming majority of children of the first year of life. In this case, as a rule, the most common and severe forms are found. Almost all infants with tuberculosis come first to general medical departments with such diagnoses as: pneumonia, acute respiratory viral infection, meningitis. In the absence of positive dynamics, a suspicion of tuberculosis arises in the treatment, after which the children are hospitalized in specialized children's tuberculosis departments.

Adolescents (students in secondary specialized educational institutions, working, unorganized) should be examined using the X-ray (fluorographic) method in the following cases:

• at any reference to the doctor, if the fluorography was not carried out in the current year;
• when referring to a doctor with symptoms that make it possible to suspect tuberculosis (pulmonary diseases of protracted course (more than 14 days), exudative pleurisy, subacute and chronic lymphadenitis, erythema nodosum, chronic diseases of the eyes, urinary tract, etc.);
• before the appointment of physiotherapeutic treatment;
• before the appointment of corticosteroid therapy;
• often and long-term ill adolescents are examined during an exacerbation, regardless of the timing of the previous fluorography.

[13], [14], [15],

Detection of tuberculosis during preventive examinations

Mass tuberculin diagnostics is carried out using the Mantoux reaction with 2 tuberculin units (TE) to children and adolescents vaccinated against tuberculosis. The sample is done once a year from the age of one year. Children and adolescents not vaccinated against tuberculosis are tested once every 6 months from the age of 6 months before receiving the vaccination.

Fluorography is given to adolescents at work or school. Working in small businesses and unorganized - in polyclinics and PDD.

Fluorography is carried out by adolescents from 15 to 17 years annually, and in the future according to the scheme of examination of the adult population - at least 1 time in 2 years. Adolescents who come to educational institutions from other regions of Russia and CIS countries are given fluorography if it has not been provided or has been more than 6 months since its inception.

Before the birth of the child in the first 6 months of pregnancy, fluorography is carried out by all persons who will live with the child in the same apartment.

Bacteriological tests for the diagnosis of tuberculosis are carried out if the child has:

• chronic respiratory diseases (examine sputum);
• chronic diseases of the urinary system (urine);
• meningitis (examine the cerebrospinal fluid on mycobacterium tuberculosis, fibrin film).

Detection during the examination by contact. If any case of an active form of tuberculosis (sick person, sick animal) is detected, the children and adolescents who are in contact with him are sent for consultation to the TB specialist and observed in the tuberculosis dispensary in the State Dispensary Department IV. Possible contacts:

• household (family, related);
• living in the same apartment;
• living on one staircase;
• stay on the territory of a tuberculosis institution;
• living in families of livestock keepers, who have sick farm animals or who work in tuberculosis farms that are not endemic.

The pediatrician of the general outpatient medical network should be able to identify children belonging to the risk groups for tuberculosis development, carry out the necessary diagnostic and treatment and preventive measures for children of these groups, correctly and systematically apply methods for detecting tuberculosis infection and preventing the development of the disease in childhood.

[16], [17], [18], [19],

Identification of tuberculosis in institutions of general medical network

In institutions of the general medical network, primary differential diagnosis of tuberculosis with diseases of non-tubercular etiology is carried out. For this:

• collect an anamnesis of susceptibility to tuberculin in previous years and information on immunization with BCG vaccine;
• conduct individual tuberculin diagnostics.
• children and adolescents are advised by the phthisiatrist;
• on the recommendation of the phthisiatrician conduct clinical tuberculin diagnostics, X-ray examination, etc.

Detection of tuberculosis in TB dispensaries

One of the tasks of the PDD is the organization of a primary clinical examination of children and adolescents at risk for tuberculosis (GDU 0, IV and VI). The mandatory diagnostic minimum for surveys conducted under PDD conditions includes:

• familiarity with anamnesis and physical examination of children and adolescents from risk groups for the development of the disease;
• individual tuberculin diagnostics;
• laboratory diagnostics (blood and urine tests);
• bacteriological diagnostics: luminescent microscopy and culture of urine, sputum or smear from the throat on mycobacterium tuberculosis (three times);
• X-ray and (or) tomographic examination.

[20], [21], [22],

Dispensary supervision

One of the most important activities of anti-tuberculosis institutions is dispensary observation of patients. The forms and methods of dispensary work have changed over the years of the existence of anti-tuberculosis institutions. The principle of long-term (2-4 years) control over the durability of cure after the completion of complex therapy is based on all the existing dispensary groupings (1938, 1948, 1962, 1973, 1988, 1995).

In connection with a decrease in the effectiveness of treatment of tuberculosis patients, an increase in the number of bacterioviruses (threefold in the last 15 years), the principles of dispensary observation of contingents of anti-tuberculosis institutions have been modified. The Federal Law "On Prevention of the Spread of Tuberculosis in the Russian Federation", the Governmental Decree on the implementation of this Law No. 892 of December 25, 2001, has issued the regulatory and legal basis for a new system of dispensary surveillance and accounting of contingents of anti-tuberculosis institutions. Order No. 109 of the Ministry of Health of Russia dated 02 March 2003. Based on them, the principles of dispensary observation of contingents of anti-tuberculosis institutions were revised, the number of contingents registered , TB specialists and focus on patients in need of treatment. The following principles are based on the new dispensary group:

• validity of determining the activity of the tuberculosis process and conducting differential diagnosis;
• validity and timeliness of solving the issue of clinical cure of tuberculosis;
• confirmation of the persistence of the cure in the observation of patients in control groups;
• conducting anti-relapse treatment courses according to indications.

[23], [24], [25], [26], [27], [28],

Groups of dispensary observation and registration of adults

There are several groups of dispensary observation (GDN) and the account (GDU) of adult contingents of anti-tuberculosis institutions.

The group of dispensary observation 0 (GDM 0)

This group includes individuals. Requiring the diagnosis of tuberculosis process activity (GDN 0A) and in differential diagnosis (GDN OB). Diagnosis of the disease is carried out both in patients who first applied to an anti-tuberculosis institution, and in previously registered patients. The duration of the diagnostic period and the follow-up periods in the HDU 0 should be 2-3 weeks and not more than 3 months for the test therapy.

After the diagnostic period is over, when determining the active form of tuberculosis, the patient is transferred to GDU I. If a non-tuberculosis disease or inactive tuberculosis is detected, the patient is removed from the register and sent to the clinic with appropriate recommendations. Persons registered in the GDU III, IV, who had the need to determine the activity of the existing changes, are not transferred to the GDN 0. These issues are resolved by examining and monitoring such patients in the same treatment group.

The dispensary observation group I (PHD I)

In GDU I include patients with active forms of tuberculosis: in the subgroup IA-with a newly diagnosed disease, in IB-with relapse of tuberculosis. Both subgroups are subdivided by 2 more depending on the presence of bacterial release in the patient: IA (MBT +), IA (MBT-), IB (MBT +) and IB (MBT-). In addition, in this group, the subgroup IB is isolated for patients who spontaneously interrupted treatment or who were not timely examined at the end of the course of treatment (ie, the result of treatment remained unknown). The group of patients with tuberculosis of respiratory organs is designated as IA TOD, a group of patients with tuberculosis with extrapulmonary and localization-IA TVL.

The issue of registering newly diagnosed tuberculosis patients and withdrawing from this account is decided by the CEAC or the KEK on the presentation of a phthisiatrician or an appropriate specialist in an anti-tuberculosis institution (tuberculosis department). The duration of follow-up in GDU I is determined by the timing of the disappearance of signs of active tuberculosis of the respiratory system, but it should not exceed 24 months from the date of registration. After the disappearance of signs of active tuberculosis treatment is considered complete and effective, and the patient as a clinically healed is transferred to the GDU III for the subsequent control of the persistence of the cure and the justification for its transfer to group III.

The dispensary observation group II (GDN II TOD, GDN II TVL)

In GDU II, patients with active forms of tuberculosis with a chronic course of the disease are observed, mainly with bacterial excretion and destructive changes. The group includes 2 subgroups. In subgroup IIA, patients who need intensive treatment are observed, with the help of which it is possible to achieve clinical cure and to transfer the patient to GDN III. In the subgroup PB include patients with a long-gone process, requiring general restorative, symptomatic treatment and periodic (if there is evidence) anti-tuberculosis therapy. The observation time in GDU II is not limited.

The chronic course of active forms of tuberculosis is a long (more than 2 years) wave-like (remission, exacerbation) of the course of the disease, in which clinical, roentgenological and bacteriological signs of tuberculosis activity remain. Chronic course of active forms of tuberculosis occurs due to late detection of the disease, inadequate and unsystematic treatment, features of the immune state of the organism or the presence of concomitant diseases complicating the course of tuberculosis.

It is not allowed to transfer from GDU I to GDN II patients who completed the course of treatment, without destructive changes and bacterial excretion. To confirm the durability of the cure. This is the fundamental difference between the GDN II new observation system and the former.

The group of the dispensary registration III (GDU III TOD GDU III TVL)

In GDU III (control), people who are cured of tuberculosis are considered with large and small residual changes or without them. GDU III is a group at increased risk of recurrence of tuberculosis. In this group, the persistence of clinical cure and the validity of this diagnosis are monitored after completion of observation in GDU I and II.

The time of observation depends on the magnitude of residual changes and aggravating factors, including comorbidity. The duration of observation of individuals with large residual changes in the presence of aggravating factors is 3 years, with small residual changes without aggravating factors - 2 years, without residual changes - 1 year.

In recent years, there has been an increase in reactivation of tuberculosis in patients with GDU III. The increase in the number of relapses occurs, on the one hand, due to an incorrect evaluation of the activity of the process (cure) when transferred to GDU III, on the other - because of the actual reactivation of the disease. In this regard, it is advisable to increase the time of observation in the GDU III to 5 years.

Group of the dispensary account IV (ГДУ IV)

In the GDU IV include people in contact with patients with tuberculosis. There are 2 subgroups in the group. In the IVA subgroup, persons are considered. (family, relative, apartment) with a patient with active tuberculosis with established and unidentified bacterial release. The duration of observation in this group is limited to one year after the end of effective treatment of the patient with tuberculosis, stay in the outbreak or after the death of the patient from tuberculosis. These people undergo two courses of chemoprophylaxis for 3 months for 1 year after the source of the infection is identified. A comprehensive examination of persons who are in contact with a sick tuberculosis is carried out 2 times a year.

In the IVB subgroup, persons who have professional and productive contact with tuberculosis patients and animals, as well as all individuals, are considered. Who have contact with bakteriovydelitelyami in place of work. The length of stay in the State Tax Administration of IVB is determined by the period of work in the conditions of occupational hazards and production contact plus 1 year after its termination. The control complex examination is conducted at least once a year. Persons who are members of this GDH are recommended general health activities (preferably in a sanatorium, rest homes). Chemoprophylaxis of tuberculosis is carried out according to indications.

Groups of dispensary observation and registration of children

This grouping is unified for children of early, older age and adolescents. The contingents of children and adolescents to be registered with the dispensary are divided into 5 main groups.

Zero group (0)

In the zero group, children and adolescents are observed to clarify the nature of positive sensitivity to tuberculin and (or) to carry out differential diagnostic activities in order to confirm or exclude tuberculosis of any localization.

The first group (I)

In group I patients with active forms of tuberculosis of any localization are observed. In the group there are 2 subgroups:

• subgroup IA. It includes patients with advanced and complicated tuberculosis;
• subgroup IB, including patients with small and uncomplicated forms of tuberculosis.

The second group (II)

In group II patients with active forms of tuberculosis of any localization and chronic course of the disease are observed. Patients can be observed in this group with continued treatment (including individual) and more than 24 months.

The third group (III)

In group III, children and adolescents with a risk of recurrence of tuberculosis of any site are considered. It includes 2 subgroups:

• subgroup IIIA. It includes newly diagnosed patients with residual post-tuberculosis changes;
• subgroup IIIB, which includes persons transferred from groups I and II. As well as subgroup IIIA.

The fourth group (IV)

In the fourth group, children and adolescents in contact with sources of tuberculosis infection are considered. In the group there are 2 subgroups:

• subgroup IVA. It includes persons who are family, relative and apartment contacts with bacilli generators, as well as in contacts with bacterial divisors in children's and adolescent institutions; children and adolescents living in the territory of tuberculosis institutions:
• subgroup IVB. It includes persons who are in contact with patients with active tuberculosis without bacterial excretion; Living in families of livestock keepers who work in dysfunctional farms on tuberculosis, as well as in families containing sick animals with tuberculosis.

The fifth group (V)

In the fifth group, children and adolescents with complications after antituberculous vaccinations are observed. There are 3 subgroups:

• subgroup VA, uniting patients with generalized and common lesions;
• subgroup VB, which includes patients with local and limited lesions;
• subgroup VB. It includes people with inactive local complications, both newly identified and transferred from subgroups VA and VB.

Sixth group (VI)

In the sixth group, people with an increased risk of developing local tuberculosis are observed. It includes 3 subgroups:

• subgroup VIA, which includes cases "and adolescents in the early period of primary tuberculosis infection (the turn of tuberculin reactions):
• subgroup VIB. It includes previously infected children and adolescents with a hyperergic reaction to tuberculin;
• subgroup VIB. Which includes children and adolescents with increasing tuberculin sensitivity.

Definitions used for dispensary observation and taking into account the activity of the tuberculosis process

Tuberculosis of doubtful activity. This term refers to tuberculosis changes in the lungs and other organs, the activity of which is unclear.

Active tuberculosis. Active form of tuberculosis is a specific inflammatory process caused by mycobacteria of tuberculosis and determined by clinical, laboratory and radiological (x-ray) signs. Patients with active tuberculosis need to conduct therapeutic, diagnostic, anti-epidemic, rehabilitation and social activities.

The issue of registering newly diagnosed tuberculosis patients and withdrawing from this account is decided by the CEC at the presentation of a phthisiatrician or an appropriate specialist in an anti-tuberculosis institution (tuberculosis department). About taking under the dispensary observation and on stopping the observation of the patient notifies the anti-tuberculosis institution in writing with filling out the notice. The notification dates are recorded in a special journal.

Clinical cure is the disappearance of all signs of an active tuberculosis process as a result of the main course of comprehensive treatment. Criteria for the effectiveness of treatment of patients with tuberculosis:

• disappearance of clinical and laboratory signs of tuberculous inflammation;
• persistent cessation of bacterial excretion, confirmed by microscopic and culture studies;
• regression of residual radiographic manifestations of tuberculosis on the background of adequate therapy during the last 2 months.

Multidrug resistance of the pathogen - resistance of mycobacterium tuberculosis to any two or more antituberculosis drugs, except for simultaneous resistance to isoniazid and rifampicin.

Multiple drug resistance of the causative agent is the resistance of mycobacteria tuberculosis to action and isoniazid and rifampicin, regardless of the presence or absence of resistance to any other anti-tuberculosis drugs.

Monoresistance of the causative agent is the resistance of mycobacterium tuberculosis to one (any) anti-tuberculosis drug.

An epidemic focus (the focus of a contagious disease) is the location of the source of the infection and the surrounding area within which dissemination of the infectious agent is possible. People who come into contact with the source of infection are those who come into contact with bacteriovirus. The epidemic focus is taken into account at the place of actual residence of the patient. Anti-TB facilities (offices, offices) are also considered a hotbed of tuberculosis infection. On this basis, workers of anti-tuberculosis institutions are referred to persons who are in contact with bacterial excretors and are accounted for by the GDU IVB.

Bacteriovideliteli - patients with an active form of tuberculosis, in which biological bacteria and / or pathological material released into the external environment were found mycobacterium tuberculosis. Patients with extrapulmonary forms of tuberculosis are considered to be bacilli if they have mycobacterium tuberculosis in fistula, urine, menstrual blood, or secretions of other organs. Such patients are considered bacteriologically dangerous for others. Patients who have received the growth of mycobacterium tuberculosis when sowing puncture, biopsy or surgical material, as bacilli are not considered.

Patients are taken as bacterial excretors in the following cases:

• in the presence of clinical and roentgenological data, indicative of the activity of the tuberculosis process. In this case, the patient is taken into account even with a single detection of mycobacteria tuberculosis:
• at 2-fold detection of mycobacterium tuberculosis by any method of microbiological examination in the absence of clinical and radiographic signs of active tuberculosis. In this case, the source of bacterial release may be endobronchitis, the breakthrough of the caseous lymph node into the bronchus lumen or the disintegration of a small foci that is difficult to determine by the roentgenological method,

One-time detection of mycobacterium tuberculosis in patients with GDU III in the absence of clinical and radiological symptoms confirming the reactivation of tuberculosis requires the use of in-depth clinical, radiation, laboratory and instrumental methods of in-patient examination to determine the source of bacterial release and the presence or absence of tuberculosis recurrence.

Every patient with tuberculosis should be carefully examined sputum (washing water of bronchial tubes) and other pathological detachable at least 3 times by bacterioscopy and sowing before starting treatment. Control microbiological and radiological examinations are carried out within a month from the beginning of treatment and repeat 1 time in 2-3 months until the end of the observation in GDM I.

Termination of bacterial excretion (abacillation) - the disappearance of mycobacteria tuberculosis from secreted into the external environment of biological fluids and pathological separable from the patient's organs, confirmed by two negative consecutive (bacterioscopic and cultural) studies at intervals of 2-3 months after the first negative analysis.

At the end of destructive tuberculosis in the filled or sanitized cavities (including after thoracoplasty and cavernotomy), patients are removed from the epidemiological register after 1 year from the moment of bacterial excretion.

The issue of setting patients on the registration of bacterioviruses and removing them from this account is decided by the CEC at the presentation of the attending physician with the direction of the corresponding notification to the center of Rospotrebnadzor.

Residual post-tuberculosis changes - dense calcified foci and foci of different sizes, fibrous-cicatricial and cirrhotic changes (including residual residuals), pleural layers, postoperative changes in the lungs, pleura and other organs and tissues, functional abnormalities determined after clinical cure.

Small residual changes - single (up to 3 cm), small (up to 1 cm), dense and calcified foci, limited fibrosis (within 2 segments). Large residual changes are all other residual changes.

Destructive tuberculosis is an active form of the tuberculosis process with the presence of tissue disintegration, determined with the help of radiation research methods. The main method for detecting destructive changes in organs and tissues is radiation study (X-ray: overview X-rays in the direct and lateral projections, various types of tomography, etc.). In addition, with tuberculosis of the genitourinary organs, ultrasound (ultrasound) is of great importance. Closure (healing) of the cavity of decay is called its disappearance, confirmed by tomographic and other methods of radiation diagnosis.

Progression - the emergence of new signs of active tuberculosis process after a period of improvement or enhancement of the existing signs of the disease when observed in GDU I and II before the diagnosis of clinical cure. With the exacerbation and progression of tuberculosis, patients are observed in the same groups of dispensary records in which they were (GDN I, II). The onset of an exacerbation or progression indicates an unsuccessful treatment and requires its correction.

Relapse - the appearance of signs of active tuberculosis in individuals. Who had previously undergone this disease and were cured of it when observed in the State Children's Clinical Hospital III or taken out of account in connection with recovery. These patients are not considered among the newly diagnosed tuberculosis patients. Reactivation of tuberculosis, which occurred in persons who have spontaneously recovered and who were not previously registered in TB dispensaries, is regarded as a new case of the disease.

The main course of treatment for tuberculosis patients is a complex of therapeutic measures, including intensive and supporting phases and aimed at achieving clinical cure of the active tuberculosis process. The main method of treatment is combined drug therapy with anti-tuberculosis drugs: simultaneous administration of several anti-tuberculosis drugs to the patient according to the approved standard schemes and individual correction. If there are indications, surgical methods of treatment should be used.

Aggravating factors are factors contributing to a decrease in resistance to tuberculosis infection, weighting of the course of the tuberculosis process and slowing of the cure. To the burdens include:

• medical factors: non-tubercular diseases, pathological conditions, bad habits;
• social factors: stress, income below the subsistence minimum, poor housing conditions, increased production load;
• professional factors: constant contact with sources of tuberculosis infection.

Aggravating factors are taken into account when observing patients in treatment groups, when choosing the form of treatment organization and carrying out preventive measures:

Formulation of diagnoses. When the patient is registered with active tuberculosis (GDN I), the diagnosis is formulated as follows: called a disease (tuberculosis), indicate the clinical form, localization, phase, the presence of bacterial excretion. For example:

• tuberculosis, infiltrative, upper lobe of right lung (S1, S2) in the phase of decay and seeding, MBT +;
• tubercular spondylitis of the thoracic spine with destruction of vertebral bodies TVIII-IX, MBT-;
• tuberculosis of the right kidney, cavernous, MBT +.

When transferring the patient to GDU II (patients with chronic tuberculosis), the clinical form of tuberculosis is indicated by the one that is observed at the time of transfer. For example, if the registration was infiltrative form of tuberculosis. And in case of an unfavorable course of the disease, fibro-cavernous pulmonary tuberculosis (or large tuberculoma with or without decay) is formed, the fibrocus-cavernous form of pulmonary tuberculosis (or tuberculosis) should be indicated in the translation epicrisis.

When transferring a patient to a control group (GDU III), the diagnosis is formulated as follows: "Clinical cure of a form of tuberculosis (the most severe diagnosis is made during the period of the disease) with the presence of (large, small) residual post-tuberculous changes in the form (indicate the nature and prevalence changes) ». For example:

• clinical treatment of disseminated pulmonary tuberculosis with the presence of large residual posttuberculous changes in the form of numerous dense small foci and widespread fibrosis in the upper lobes of the lungs;
• clinical cure of pulmonary tuberculosis with the presence of large residual changes in the form of a state after the economical resection of the upper lobe (S1, S2) of the right lung.

For patients with extrapulmonary forms of tuberculosis, diagnoses are formulated according to the same principle. For example:

• clinical cure of tubercular coxitis on the right with partial disruption of joint function;
• clinical cure of cavernous tuberculosis of the right kidney.

[29], [30], [31],