Sanitary and social prevention of tuberculosis

Sanitary prevention of tuberculosis

Sanitary prophylaxis of tuberculosis - prevention of infection with mycobacteria tuberculosis of healthy people. Targets for sanitary prophylaxis: the source of mycobacterial secretion and the route of transmission of the causative agent of tuberculosis.

Sources of infection are people with tuberculosis (anthroponous tuberculosis), and sick animals (zoonotic tuberculosis).

The greatest epidemiological danger is caused by bacterial excreta - people with active tuberculosis who emit a significant amount of mycobacterium tuberculosis into the environment. When bacteriological examination of a pathological material or biological substrates obtained from a bacteriocardicide, a significant amount of mycobacteria is detected.

The most dangerous source of tuberculosis infection is patients with respiratory damage and destructive pulmonary tissue in the area of tuberculous inflammation. Such patients excrete a significant number of tuberculosis pathogens with tiny particles of sputum when coughing, sneezing, loud emotional conversation. The air surrounding the bacteriocardium contains a significant amount of mycobacterium tuberculosis. Penetration of such air into the respiratory tract of a healthy person can lead to infection.

Out of the number of patients with extrapulmonary forms of tuberculosis, those who have tuberculosis mycobacteria in fistula, urine, feces, menstrual blood and other secretions are classified as bacterial survivors. The epidemic risk of these patients is relatively low.

Patients, when sowing puncture, biopsy or surgical material of which the growth of mycobacteria is detected, as bacterial scavengers are not taken into account.

All medical institutions that have information about a patient with tuberculosis are exchanging information. For each patient with a diagnosis of active tuberculosis for the first time (including posthumous) at the place of his detection, the doctor fills in the "Notice of the patient with the first diagnosis of active tuberculosis". On the patient with the established allocation of mycobacterium tuberculosis, the doctor also fills in an additional emergency notification for the territorial Center for Hygiene and Epidemiology.

When confirming the diagnosis of tuberculosis, PDD within three days passes information about the identified patient to the district clinic, as well as at the place of work or study of the patient. Information about the patient is reported to the district housing maintenance department to exclude the introduction of sick new residents in the apartment or to place sick tuberculosis in communal apartments.

Each case of newly diagnosed tuberculosis of respiratory organs in a rural resident is notified to the veterinary service.

On the cases of detection of positive reactions to tuberculin in animals, the Veterinary Service reports to the Hygiene and Epidemiology Center. The centers of zoonotic tuberculosis are examined jointly by specialists from phthisiology, sanitary-epidemiological and veterinary services. If a tuberculosis occurs in animals, the farm (farm) is declared unfit, establish quarantine and carry out the necessary measures to prevent the spread of the disease.

The risk of spreading a tuberculosis infection depends on the material and living conditions, the level of culture of the population, the habits of the patient and the people in contact with it. The object of sanitary prevention is not only the immediate source of mycobacteria of tuberculosis, but also the epidemic center of tuberculosis infection that is forming around it.

The focus of tuberculosis infection is a conditional concept, including the location of the bacteriovirus and its surroundings. In the focus of infection, transmission of mycobacteria to healthy people is possible, followed by the development of tuberculosis. The focus of infection has spatial and temporal boundaries.

The spatial boundaries of the anthroponotic focus of infection are the place of residence of the patient (apartment, house, dormitory, boarding school), the institution in which he works, studies or is in education. The hospital in which the patient is hospitalized is also treated as a hotbed of tuberculosis infection. As part of the focus, the family of a patient with tuberculosis and the groups of people with whom he communicates are treated. A small settlement (village, village) with closely communicating residents, among whom a patient with active tuberculosis is found, is also considered a hotbed of infection.

The timing of the focus of tuberculosis infection depends on the duration of contact with the bacteriovirus and the timing of an increased risk of infection of infected contacts.

Among the factors that make it possible to establish the degree of danger of the outbreak of tuberculosis infection, special attention should be paid to:

• localization of the tuberculosis process (the greatest danger is represented by patients with the defeat of the respiratory system);
• number, viability, virulence and resistance to anti-tuberculosis therapy for tuberculosis of mycobacteria;
• presence in the focus of adolescents, pregnant women and others with increased susceptibility to tuberculosis infection;
• character of the dwelling (hostel, communal or separate apartment, private house, closed type institution) and its sanitary and communal landscaping;
• timeliness and quality of antiepidemic measures;
• social status, level of culture, sanitary literacy of the patient and those around him.

The characteristics of the focus, taking into account the above factors, allows one to assess the degree of its epidemic danger and to predict the risk of spreading a tuberculosis infection. On the basis of the received information determine the scope and tactics of preventive measures in the outbreak.

There are 5 groups of foci of tuberculosis infection

The first group is formed by centers with the greatest epidemic danger. These include the place of residence of patients with pulmonary tuberculosis, who have established the fact of bacterial excretion - "territorial" foci of tuberculosis. The danger of the spread of tuberculosis in these centers is aggravated by many factors: the presence among the family members of children, adolescents and people with increased susceptibility to mycobacteria of tuberculosis, unsatisfactory living conditions, and non-compliance with the anti-epidemic regime. Such "socially burdened" foci often appear in dormitories. Communal apartments, closed institutions, where it is impossible to allocate a separate room for the patient.

The second group includes more prosperous in the social plan foci. Patients with pulmonary tuberculosis, which secrete mycobacteria, live in separate comfortable apartments without children and adolescents and observe a sanitary and hygienic regime.

The third group includes foci in which patients with active pulmonary tuberculosis live without the established allocation of mycobacteria, but in contact with the patient are children and adolescents or persons with increased susceptibility. This group also includes foci of infection in which patients with extrapulmonary forms of tuberculosis live.

Foci of the fourth group is considered the place of residence of patients with active pulmonary tuberculosis, which have established a cessation of allocation of mycobacterium tuberculosis (conditional bacterial discharge). In these outbreaks, there are no children, adolescents and people with increased susceptibility to tuberculosis mycobacteria among those who are in contact with the sick person. Aggravating social factors are absent. The fourth group also includes foci in which the bacterial survivor previously lived (the control group of the foci).

The fifth group is the centers of zoonotic origin.

The local tubing specialist, with the participation of an epidemiologist, determines the belonging of a tuberculosis center to a certain epidemic group. Changes in the characteristics of the focus, reducing or increasing its risk, require the transfer of the focus to another group.

Work in the focus of tuberculosis infection consists of three stages:

• initial examination and early activities;
• dynamic observation;
• preparation for removal from the register and exclusion from the number of foci of tuberculosis.

Problems of preventive antiepidemic work in the focus of tuberculosis infection:

• preventing the infection of healthy people;
• prevention of diseases of people infected with Mycobacterium tuberculosis;
• increase sanitary literacy and general hygienic culture of the patient and those in contact with him.

Anti-epidemic work in the outbreaks is carried out by anti-tuberculosis dispensaries together with the centers of hygiene and epidemiology. The results of monitoring the outbreak of tuberculosis infection and data on the conduct of antiepidemic measures are reflected in a special epidemiological survey map.

A significant part of the anti-epidemic work is entrusted to the phthisiatric service. Obligations of employees of the TB dispensary:

• examination of the outbreak, assessment of the risk of infection, development of a plan for preventive measures, dynamic observation;
• organization of current disinfection;
• hospitalization of the patient (or isolation within the hearth) and treatment;
• training of the patient and the persons in contact with him with sanitary and hygienic rules and methods of disinfection;
• registration of documents for the improvement of living conditions:
• isolation of children;
• examination of persons. Contact with the patient (fluorography, Mantoux test with 2 TE bacteriological examination);
• revaccination of BCG of uninfected contact persons. Chemoprophylaxis;
• determination of the conditions under which the focus can be removed from epidemiological accounts;
• keeping a map of the outbreak, reflecting its characteristics and a list of activities carried out.

Responsibilities of the staff of the sanitary and epidemiological supervision body:

• conducting a primary epidemiological survey of the outbreak, defining its boundaries and developing a plan for preventive measures (in conjunction with the phthisiatrist);
• maintenance of necessary documentation of epidemiological examination and monitoring of the focus of tuberculosis;
• organization and conduct of anti-epidemic measures in the outbreak (together with a phthisiatrist);
• dynamic observation of the hearth, making additions and changes to the plan of measures;
• control of timeliness and quality of a complex of antiepidemic measures in the outbreak;
• epidemiological analysis of the situation in the outbreaks of tuberculosis, evaluation of the effectiveness of preventive work.

In small settlements that are significantly removed from the territorial TB dispensaries, all anti-epidemic measures should be performed by specialists of the general outpatient and polyclinic network with the methodological assistance of a phthisiatrician and epidemiologist.

The first visit to the place of residence of the newly diagnosed tuberculosis patient is carried out by the local phthisiatrician and epidemiologist within three days after the diagnosis is established. The patient and his family members specify the address of the permanent place of residence, collect information about the patient's profession, place of work (including part-time jobs), and studies. Identify those who have been in contact with the sick person. In detail assess the living conditions, the level of sanitary and hygienic skills of the patient, his family members. The phthisiatrician and epidemiologist should pay attention to the state of health of persons who are in contact with the patient and inform them about the timing and content of the forthcoming screening for tuberculosis and the plan of recreational activities, focusing on anti-epidemic measures. In the course of the primary epidemiological survey, the focus is on the need to hospitalize or isolate the patient at home (allocate a separate room or part of it, fenced off with a screen, provide an individual bed, towels, linens, dishes). When you visit the center, fill the epidemiological survey card and observe the tuberculosis center in a uniform form for anti-tuberculosis dispensaries and hygiene and epidemiology centers.

The Service of Sanitary and Epidemiological Supervision supervises the process of hospitalization of a patient who secretes mycobacterium tuberculosis. In the first place hospitalization is subject to patients who, in the nature of their professional activities, come into contact with large groups of people in conditions that allow for rapid transmission of infection (workers of children's institutions, schools, vocational schools and other educational institutions, medical and preventive institutions, public catering establishments, trade, urban transport, library staff, service workers), as well as persons who work or reside in dormitories, boarding schools and communal apartments rah.

A full primary examination of persons in contact with the patient should be conducted within 2 weeks from the time the patient was diagnosed with tuberculosis. The examination includes an examination of the phthisiatrician, a Mantoux tuberculin test with 2 TE, fluorography of the chest, clinical blood and urine tests. In the presence of sputum, separated from the fistula or other diagnostic material, his study is made on mycobacterium tuberculosis. If there is a suspicion of extrapulmonary localization of tuberculosis, the necessary additional studies are carried out. Information about the examined persons is sent to the clinic and to the health center (or medical unit) at the place of work or study of persons who are in contact with a sick tuberculosis. Young people with a negative reaction to a Mantoux test with 2 TE are given a BCG revaccination. Persons who are in contact with bacterioviruses are prescribed chemoprophylaxis.

Disinfection of tuberculosis infection is a necessary component of sanitary prevention of tuberculosis in the outbreak. When it is carried out, it is important to take into account the high resistance of mycobacteria tuberculosis to environmental factors. The most effective effect on mycobacteria with the help of ultraviolet radiation and chlorine-containing disinfectants. For disinfection in the foci of tuberculosis infection apply: 5% solution of chloramine; 0.5% solution of activated chloramine; 0.5% solution of activated chloric lime. If the patient does not have the opportunity to use disinfectants, it is recommended to use boiling, especially with the addition of soda ash.

Distinguish the current and final disinfection. Current disinfection is organized by the anti-tuberculosis service, and the patient and his family members carry out the disinfection. Periodic quality control is carried out by an epidemiologist. The final disinfection is performed by the staff of the Center for Hygiene and Epidemiology at the request of the phthisiatrician after hospitalization, departure or death of the patient or when taking it off as a bacterial excretor.

Current disinfection in the outbreak is carried out immediately after the infectious patient is identified. In the current disinfection, daily cleaning of the premises, ventilation, disinfection of dishes and food rests, personal items, as well as disinfection of biological material containing mycobacterium tuberculosis.

The patient's room is limited by the number of items of daily use, uses things that are easy to clean, wash and disinfect. Upholstered furniture is covered with covers.

When cleaning the room where the patient lives, when disinfecting dishes, food residues, the relatives of the patient should wear specially selected clothing (robe, scarf, gloves) for this purpose. When changing bed linen, you must wear a mask of four layers of gauze. The overalls are collected in a separate tank with a tightly closed lid and disinfected.

The patient's apartment is cleaned daily with rags soaked in a soap-soda or disinfectant solution, at the time of cleaning, doors and windows are opened. Items of sanitary ware, door handles are decontaminated by double wiping with disinfectant solution. The room is ventilated at least twice a day for 30 minutes. In the presence of insects in the room, preliminary disinsection measures are carried out. Upholstered furniture is regularly vacuumed.

After eating, the dishes of the patient, cleared of food residues, are first disinfected by boiling in a 2% solution of soda ash for 15 minutes (in water without the addition of soda - 30 minutes) or immersion in one of the disinfecting solutions, and then washed in running water. Food waste is subjected to boiling for 30 minutes in water or for 15 minutes in a 2% solution of soda ash. Disinfection of food waste can also be carried out with the help of disinfectant solutions, for this purpose, the food residues are mixed in a ratio of 1: 5 with the available product and disinfected for 2 hours.

Bedding should be periodically ejected through wet sheets, which after cooking should be boiled. Dirty linen of the patient is collected in a special tank with a tightly closed lid, disinfection is carried out by soaking in a disinfectant solution (5 liters per 1 kg of dry laundry) or boiling for 15 minutes in a 2% solution of soda or for 30 minutes in water without adding soda. It is recommended to steam the outer clothing (suit, trousers) once a week. In summer, the patient's things should be kept under the open rays of the sun.

The patient care items and cleaning equipment are disinfected after each use by a disinfectant.

When isolating a sputum from the patient, it is necessary to ensure its collection and disinfection. For this, the patient is given two special containers for sputum collection (spittoons). In one container the patient should collect phlegm, and another, filled with sputum, disinfect. The container with sputum is boiled for 15 minutes in a 2% solution of soda or for 30 minutes in water without the addition of soda. Disinfection of sputum can also be carried out by immersing the container with sputum in a disinfectant solution. Exposure time varies from 2 to 12 hours, depending on the disinfectant used.

When detecting mycobacteria in the discharge of the patient (urine, faeces), they are also subjected to disinfection. To do this, use disinfectants, strictly following the instructions of the instructions and observing the exposure time.

The final disinfection is carried out in all cases of departure of the patient from the source. When the place of residence is changed, disinfection is carried out before the patient moves (they process an apartment or a room with things) and again after moving (processing an empty room or apartment). Extra final disinfection is carried out before the return of the puerperas from the maternity hospitals, before the demolition of the dilapidated buildings where the tuberculosis patients lived, in case of death of the patient from tuberculosis at home and in cases when the deceased patient was not registered in the dispensary.

The final disinfection in the educational institutions is carried out in case of identification of a patient with an active form of tuberculosis among children and adolescents, as well as among employees of preschool institutions, schools and other educational institutions. Disinfection is mandatory in maternity hospitals and other medical institutions for the detection of tuberculosis in parturients and puerperas, as well as with medical personnel and attendants.

Hygienic education of patients and their families is an essential component of effective sanitary prevention in the focus of tuberculosis infection. Employees of the TB dispensary train the patient with the rules of personal hygiene, methods of current disinfection, the rules for using containers for sputum collection, improve his overall health and medical literacy and form a strong motivation for strict implementation of all rules and recommendations. Repeated conversations with the patient are necessary to correct possible mistakes and preserve the habit of observing hygiene norms. Similar work should be conducted with family members of the patient.

In conditions of a strained epidemiological situation, there is a high probability of hospitalization of tuberculosis patients in institutions of general profile. This contributes to an increase in the proportion of tuberculosis among nosocomial infections. To prevent the formation of an epidemic TB center in general institutions, the following activities are carried out:

• outpatient examination of persons from high-risk groups:
• examination for tuberculosis of all patients with long-term treatment in general hospitals:
• timely isolation and transfer of a patient - a source of tuberculosis infection to TB hospitals;
• annual medical examinations of employees of the network of general treatment and prophylactic institutions, conducting fluorography;
• dispensary observation of infected persons and persons with increased susceptibility to mycobacteria of tuberculosis;
• control over the observance of the sanitary regime established for medical institutions.

In treatment and prevention institutions of general profile with a long stay of patients with an epidemic outbreak of tuberculosis, along with other antiepidemic measures, quarantine is established for at least 2 months.

Strict implementation of sanitary rules in anti-tuberculosis institutions is an important principle of tuberculosis prevention. Control over compliance with the sanitary regime is carried out by the staff of the centers of hygiene and epidemiology.

To prevent the spread of tuberculosis among medical personnel working with patients with active tuberculosis, the following measures are envisaged:

• in the institutions of the anti-tuberculosis service employ persons over 18 years of age with mandatory preliminary medical examination, subsequent follow-up examinations are performed every 6 months;
• persons not infected with mycobacteria tuberculosis, with a negative reaction to tuberculin are subject to vaccination BCG; admission to work is possible only after the emergence of postvaccinal allergic reaction and the formation of stable immunity;
• when applying for a job (subsequently every year), the head physician (or the head of the department) conducts the instruction according to the internal regulations for the personnel;
• the administration of TB dispensaries and hospitals under the supervision of the centers of hygiene and epidemiology carries out disinfection measures;
• workers of anti-tuberculosis institutions are observed in the TB dispensary in the IVB of the State Duma, they are regularly examined.

In zoonotic foci of tuberculosis infection, the passage by livestock keepers of mandatory tests for tuberculosis is controlled by the sanitary and epidemiological service. TB patients are not allowed to service animals and birds. Persons who are not infected with mycobacteria of tuberculosis are given anti-tuberculosis vaccination. Milk of animals from unfavorable farms with tuberculosis incidence is subjected to double pasteurization and is subject to control. Meat and other products are subjected to heat treatment. Tuberculosis-infected animals are subject to killing. The veterinary and sanitary-epidemiological services carefully monitor the condition of the slaughter sites and carry out health-improving measures in unfavorable farms with regard to the incidence of tuberculosis.

Dynamic monitoring of foci of tuberculosis infection is carried out taking into account their epidemic danger.

The TB doctor visits the foci of the first group at least once a quarter, the nurse - at least once a month, the epidemiologist - once every six months. Foci of the second group the TB doctor visits once in six months, the nurse - once a quarter, the epidemiologist - once a year. The minimal risk of infection in the outbreaks of the third group allows the TB doctor and epidemiologist to visit these outbreaks once a year. Nurse - once every six months. The fourth group of epidemic focuses of tuberculosis infection after a primary examination specialists of the TB services and the Center for Hygiene and Epidemiology visit if there are special indications. Zoonotic foci (the fifth group), the TB doctor and epidemiologist visit once a year. The nurse of the dispensary - if there is evidence.

Dynamic monitoring provides control over the changes occurring in the focus and timely correction of anti-epidemic measures. An annual plan for the recovery of the outbreak reflects the organizational form, duration, nature of the treatment and its results, the quality of ongoing disinfection and the timing of the final disinfection, the timeliness of the examination of individuals. Contact with the patient, the regularity of preventive measures. The results of dynamic observation are recorded in the epidemiological chart.

It is considered that a patient with tuberculosis after an effective main course of treatment 12 months after the termination of isolation does not pose an epidemic danger. The absence of bacterial isolation must be confirmed by two successive negative bacterioscopic and microbiological studies conducted at intervals of 2-3 months. It is necessary to obtain x-ray tomographic data on the closure of the decay cavity, if available. When revealing aggravating factors (unsatisfactory living conditions, alcoholism, drug addiction and mental disorders, the presence of children, adolescents, pregnant women in the outbreak, and non-observance of hygiene rules by patients), additional monitoring is necessary for 6-12 months to confirm the absence of an MBT.

Monitoring of persons in contact with the patient is carried out during the entire period of allocation to patients with ILT. After curing (or leaving) the patient and taking it off, taking into account the bacteriovirus, the previously formed focus of tuberculosis infection remains dangerous and requires control for a year. In the case of a lethal outcome of the disease, the surveillance of the outbreak continues for another two years.

Social prevention of tuberculosis

Social prevention presupposes the organization and ubiquitous implementation of a wide range of recreational activities that help prevent not only tuberculosis, but also other diseases. Social prevention is a complex of measures of a universal nature, but their importance in the prevention of tuberculosis is great. Preventive measures are aimed at improving the ecological situation, combating poverty, improving the material well-being, general culture and social literacy of citizens. Measures of social orientation create the conditions necessary to promote health and promote healthy lifestyles. The implementation of these measures depends on the overall socio-economic situation in the country, the political structure of the state and its ideology.

The fight against tuberculosis in Russia is a matter of national importance. The National concept of anti-tuberculosis care is based on the principles of preventive orientation, state character, and free medical care. The concept was reflected in the state regulatory documents - the Federal Law "On the Prevention of the Spread of Tuberculosis in the Russian Federation", the Decree of the Government of the Russian Federation, the order of the Ministry of Health and Social Development of Russia "On the improvement of anti-tuberculosis measures in the Russian Federation". These documents are the legislative basis for the social prevention of tuberculosis, they guarantee public funding for the full range of medical and social activities needed to prevent tuberculosis.

Social prevention of tuberculosis affects all parts of the epidemic process. It creates the foundation necessary for the implementation of preventive measures of another level, and largely determines their overall effectiveness.