Sanitary and social prevention of tuberculosis

Sanitary prevention of tuberculosis

Sanitary prevention of tuberculosis - prevention of infection of healthy people with mycobacteria tuberculosis. Targets for sanitary prevention: source of mycobacteria isolation and ways of transmission of the tuberculosis pathogen.

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

The greatest epidemic danger is posed by bacteria excretors - people with active tuberculosis who excrete a significant amount of mycobacterium tuberculosis into the environment. During bacteriological examination of pathological material or biological substrates obtained from a bacteria excretor, a significant number of mycobacteria are detected.

The most dangerous source of tuberculosis infection is patients with respiratory disease and destruction of lung tissue in the area of tuberculosis inflammation. Such patients excrete a significant amount of tuberculosis pathogens with the smallest particles of sputum when coughing, sneezing, and talking loudly and emotionally. The air surrounding the bacteria excretor contains a significant amount of tuberculosis mycobacteria. Penetration of such air into the respiratory tract of a healthy person can lead to infection.

Among patients with extrapulmonary forms of tuberculosis, individuals who have tuberculosis mycobacteria detected in fistula discharge, urine, feces, menstrual blood and other secretions are considered to be excretors of bacteria. The epidemic danger of these patients is relatively low.

Patients whose puncture, biopsy or surgical material shows growth of mycobacteria are not counted as bacteria excretors.

All medical institutions that have information about a patient with tuberculosis exchange information. For each patient with a diagnosis of active tuberculosis established for the first time (including posthumously), the doctor fills out a "Notification of a patient with a diagnosis of active tuberculosis established for the first time" at the place of its detection. For a patient with established isolation of Mycobacterium tuberculosis, the doctor also fills out an additional emergency notification for the territorial Center for Hygiene and Epidemiology.

If the diagnosis of tuberculosis is confirmed, the PTD sends information about the identified patient to the district polyclinic, as well as to the patient's place of work or study, within three days. Information about the patient is reported to the district housing and maintenance department to prevent new residents from moving into the patient's apartment or tuberculosis patients from moving into communal apartments.

The veterinary service is notified of each case of newly diagnosed respiratory tuberculosis in a rural resident.

The veterinary service reports cases of positive tuberculin reactions in animals to the Center for Hygiene and Epidemiology. Zoonotic tuberculosis foci are examined jointly by specialists from the phthisiological, sanitary-epidemiological and veterinary services. If tuberculosis occurs in animals, the farm is declared unhealthy, quarantine is established and the necessary measures are taken to prevent the spread of the disease.

The risk of spreading tuberculosis infection depends on the material and living conditions, the level of culture of the population, the habits of the patient and people in contact with him. The object of sanitary prevention should be considered not only the immediate source of mycobacterium tuberculosis, but also the epidemic focus of tuberculosis infection forming around it.

The focus of tuberculosis infection is a conventional concept, including the location of the bacteria excretor and its environment. In the focus of infection, mycobacteria can be transmitted to healthy people with subsequent development of tuberculosis. The focus of infection has spatial and temporal boundaries.

The spatial boundaries of an anthroponotic infection focus are the patient's place of residence (apartment, house, dormitory, boarding school), the institution where he works, studies or is being brought up. The hospital where the patient is hospitalized is also considered a focus of tuberculosis infection. The family of a patient with tuberculosis and the groups of people with whom he communicates are considered part of the focus. A small settlement (village, settlement) with closely communicating residents, among whom a patient with an active form of tuberculosis is found, is also considered a focus of infection.

The time frame of a tuberculosis infection outbreak depends on the duration of contact with the bacteria carrier and the period of increased risk of disease in infected contacts.

Among the factors that allow us to determine the degree of danger of a tuberculosis infection outbreak, special attention should be paid to:

• localization of the tuberculosis process (patients with damage to the respiratory system pose the greatest danger);
• the quantity, viability, virulence and resistance to anti-tuberculosis therapy of Mycobacterium tuberculosis isolated by the patient;
• the presence in the outbreak of adolescents, pregnant women and other individuals with increased susceptibility to tuberculosis infection;
• the nature of the dwelling (dormitory, communal or separate apartment, private home, closed-type institution) and its sanitary and communal amenities;
• timeliness and quality of implementation of anti-epidemic measures;
• social status, level of culture, health literacy of the patient and the people around him.

The characteristics of the outbreak taking into account the above factors allow us to assess the degree of its epidemic danger and predict the risk of spreading tuberculosis infection. Based on the information obtained, the volume and tactics of preventive measures in the outbreak are determined.

Conventionally, there are 5 groups of tuberculosis infection foci

The first group consists of foci with the greatest epidemic danger. These include places of residence of patients with pulmonary tuberculosis, in whom the fact of bacterial excretion has been established - "territorial" foci of tuberculosis. The danger of the spread of tuberculosis in these foci is aggravated by many factors: the presence of children, adolescents and people with increased susceptibility to mycobacteria tuberculosis among family members, unsatisfactory living conditions, failure to comply with the anti-epidemic regime. Such "socially burdened" foci most often arise in dormitories, communal apartments, closed institutions in which it is impossible to allocate a separate room for the patient.

The second group includes more socially favorable foci. Patients with pulmonary tuberculosis, releasing mycobacteria, live in separate comfortable apartments without children and adolescents and observe sanitary and hygienic conditions.

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

The fourth group of foci are considered to be the places of residence of patients with active pulmonary tuberculosis, in whom the cessation of the excretion of mycobacteria tuberculosis has been established (conditional excretors). In these foci, among the persons in contact with the patient, there are no children, adolescents, or people with increased susceptibility to mycobacteria tuberculosis. Aggravating social factors are absent. The fourth group also includes foci in which the excretor previously lived (control group of foci).

The fifth group is foci of zoonotic origin.

The affiliation of a tuberculosis focus to a certain epidemic group is determined by the district phthisiologist with the participation of an epidemiologist. Changes in the characteristics of the focus that reduce or increase its danger require the focus to be transferred to another group.

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

• initial examination and implementation of early interventions;
• dynamic observation;
• preparation for deregistration and exclusion from the number of tuberculosis foci.

The objectives of preventive anti-epidemic work in the center of tuberculosis infection:

• preventing infection of healthy people;
• prevention of disease in persons infected with Mycobacterium tuberculosis;
• improving health literacy and general hygiene culture of the patient and those in contact with him.

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

A significant part of the anti-epidemic work is assigned to the TB service. Duties of the employees of the anti-tuberculosis dispensary:

• examination of the outbreak, assessment of the risk of infection, development of a plan of preventive measures, dynamic monitoring;
• organization of ongoing disinfection;
• hospitalization of the patient (or isolation within the outbreak area) and treatment;
• training the patient and persons in contact with him in sanitary and hygienic rules and disinfection methods;
• registration of documents for improving housing conditions:
• isolation of children;
• examination of persons who have been in contact with the patient (fluorography, Mantoux test with 2 TE, bacteriological examination);
• BCG revaccination of uninfected contacts. Chemoprophylaxis;
• determination of the conditions under which an outbreak can be removed from epidemiological records;
• maintaining a map of the outbreak's observations, reflecting its characteristics and a list of the measures taken.

Responsibilities of employees of the sanitary and epidemiological supervision authority:

• conducting a primary epidemiological survey of the outbreak, determining its boundaries and developing a plan of preventive measures (together with a phthisiatrician);
• maintaining the necessary documentation for epidemiological examination and monitoring of the tuberculosis outbreak;
• organization and implementation of anti-epidemic measures in the outbreak (together with a phthisiologist);
• dynamic monitoring of the outbreak, making additions and changes to the action plan;
• control over the timeliness and quality of the complex of anti-epidemic measures in the outbreak;
• epidemiological analysis of the situation in tuberculosis foci, assessment of the effectiveness of preventive work.

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

The first visit to the place of residence of a newly diagnosed patient with tuberculosis is made by the local phthisiatrician and epidemiologist within three days after the diagnosis is established. The patient and his family members are asked about their permanent residence address, information about the patient's profession, place of work (including part-time work), and study is collected. Persons who have been in contact with the patient are identified. Living conditions and the level of sanitary and hygienic skills of the patient and his family members are assessed in detail. The phthisiatrician and epidemiologist must pay attention to the well-being of persons in contact with the patient and inform them about the timing and content of the upcoming tuberculosis examination and the plan for health measures, focusing on anti-epidemic measures. During the initial epidemiological examination of the outbreak, a decision is made on the need for hospitalization or isolation of the patient at home (allocation of a separate room or part of it, separated by a screen, provision of an individual bed, towels, linen, dishes). When visiting a focus, a card for epidemiological examination and observation of a tuberculosis focus is filled out in a form that is uniform for anti-tuberculosis dispensaries and hygiene and epidemiology centers.

The sanitary and epidemiological surveillance service monitors the process of hospitalization of a patient excreting tuberculosis mycobacteria. Patients who, due to the nature of their professional activities, come into contact with large groups of people in conditions that allow rapid transmission of infection (employees of children's institutions, schools, vocational schools and other educational institutions, medical and preventive institutions, catering establishments, trade, public transport, library employees, service sector workers), as well as persons working or living in dormitories, boarding schools and communal apartments, are subject to hospitalization first of all.

A full primary examination of persons who have been in contact with the patient must be carried out within 2 weeks from the moment the patient with tuberculosis is identified. The examination includes an examination by a phthisiatrician, a Mantoux tuberculin test with 2 TE, chest fluorography, clinical blood and urine tests. If sputum, discharge from fistulas or other diagnostic material is present, it is tested for Mycobacterium tuberculosis. If extrapulmonary localization of tuberculosis is suspected, the necessary additional studies are carried out. The dispensary staff forwards information about the examined persons to the polyclinic and the health center (or medical unit) at the place of work or study of persons in contact with the patient with tuberculosis. Young persons with a negative reaction to the Mantoux test with 2 TE are revaccinated with BCG. Persons in contact with bacteria carriers are prescribed chemoprophylaxis.

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

A distinction is made between current and final disinfection. Current disinfection is organized by the anti-tuberculosis service and is carried out by the patient and his family members. Periodic quality control of the work is carried out by an epidemiologist. Final disinfection is carried out by employees of the Center for Hygiene and Epidemiology at the request of a phthisiatrician after hospitalization, departure or death of the patient or when he is removed from the register as a bacteria excretor.

Current disinfection in the outbreak is carried out immediately after the identification of an infectious patient. Current disinfection includes daily cleaning of the premises, ventilation, disinfection of dishes and food remains, personal items, as well as disinfection of biological material containing tuberculosis mycobacteria.

In the patient's room, the number of everyday items is limited; items that are easy to clean, wash and disinfect are used. Upholstered furniture is covered with covers.

When cleaning the room where the patient lives, when disinfecting dishes, food scraps, the patient's relatives should wear specially designated clothing (gown, headscarf, gloves). When changing bed linen, it is necessary to wear a mask made of four layers of gauze. Special clothing is collected in a separate tank with a tightly closed lid and disinfected.

The patient's apartment is cleaned daily with a rag soaked in a soap-soda or disinfectant solution; the doors and windows are opened during cleaning. Plumbing fixtures and door handles are disinfected by wiping twice with a disinfectant solution. The room is ventilated at least twice a day for 30 minutes. If there are insects in the room, disinfestation measures are carried out beforehand. Upholstered furniture is regularly cleaned with a vacuum cleaner.

After eating, the patient's dishes, cleaned of food residues, are first disinfected by boiling in a 2% solution of soda ash for 15 minutes (in water without adding soda - 30 minutes) or by immersion in one of the disinfectant solutions, and then washed in running water. Food waste is boiled 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 using disinfectant solutions, for this, food residues are mixed in a ratio of 1:5 with the available agent and disinfected for 2 hours.

Bed linen should be periodically beaten out through wet sheets, which should be boiled after cleaning. The patient's dirty linen is collected in a special container with a tightly closed lid, disinfection is carried out by soaking in a disinfectant solution (5 liters per 1 kg of dry linen) or boiling for 15 minutes in a 2% soda solution or for 30 minutes in water without adding soda. It is recommended to steam outerwear (suit, trousers) once a week. In summer, the patient's things should be kept in the open sun.

Patient care items and cleaning equipment are disinfected after each use with a disinfectant.

When a patient produces sputum, it is necessary to collect and disinfect it. For this purpose, the patient is given two special containers for collecting sputum ("spittoons"). The patient must collect sputum in one container, and disinfect the other, filled with sputum. The container with sputum is boiled for 15 minutes in a 2% soda solution or for 30 minutes in water without adding soda. Disinfection of sputum can also be done by immersing the container with sputum in a disinfectant solution. The exposure time varies from 2 to 12 hours, depending on the disinfectant used.

If mycobacteria are detected in the patient's secretions (urine, feces), they are also subjected to disinfection. For this, disinfectants are used, strictly following the instructions and observing the exposure time.

Final disinfection is carried out in all cases of the patient's departure from the outbreak. When changing the place of residence, disinfection is carried out before the patient moves (the apartment or room with things is treated) and again after the move (an empty room or apartment is treated). Extraordinary final disinfection is carried out before the return of women in labor from maternity hospitals, before the demolition of dilapidated buildings where tuberculosis patients lived, in the event of the death of a patient from tuberculosis at home and in cases where the deceased patient was not registered with the dispensary.

Final disinfection in educational institutions is carried out in the event of detection 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 when tuberculosis is detected in women in labor and in women in childbirth, as well as in medical workers and service personnel.

Hygienic education of patients and their family members is a necessary component of effective sanitary prevention in the center of tuberculosis infection. The staff of the anti-tuberculosis dispensary teach the patient the rules of personal hygiene, methods of current disinfection, rules for using containers for collecting sputum, improve his general sanitary and medical literacy and form a strong motivation for strict compliance with all rules and recommendations. Repeated conversations with the patient are necessary to correct possible errors and maintain the habit of observing hygiene standards. Similar work should be carried out with the family members of the patient.

In the conditions of a tense epidemiological situation, there is a high probability of hospitalization of tuberculosis patients in general profile institutions. This contributes to an increase in the proportion of tuberculosis among nosocomial infections. To prevent the formation of an epidemic tuberculosis focus in general profile institutions, the following measures are taken:

• outpatient examination of individuals from high-risk groups:
• examination for tuberculosis of all patients undergoing long-term treatment in general hospitals:
• timely isolation and transfer of the patient - the source of tuberculosis infection to medical institutions specializing in tuberculosis;
• annual medical examinations of employees of the network of general medical and preventive institutions, fluorography;
• dispensary observation of infected individuals and individuals with increased susceptibility to mycobacterium tuberculosis;
• monitoring compliance with the sanitary regime established for medical institutions.

In general medical and preventive institutions with long-term patient stays, in the event of an epidemic outbreak of tuberculosis, along with other anti-epidemic measures, a quarantine is established for at least 2 months.

Strict adherence to sanitary rules in anti-tuberculosis institutions is an important principle of tuberculosis prevention. Monitoring of compliance with the sanitary regime is carried out by employees of hygiene and epidemiology centers.

To prevent the spread of tuberculosis among health workers working with patients with active tuberculosis, the following measures are provided:

• anti-tuberculosis service institutions employ persons over 18 years of age with a mandatory preliminary medical examination, subsequent control examinations are performed every 6 months;
• Persons not infected with Mycobacterium tuberculosis, with a negative reaction to tuberculin, are subject to BCG vaccination; admission to work is possible only after the appearance of a post-vaccination allergic reaction and the formation of stable immunity;
• upon hiring (and then annually), the head physician (or head of department) conducts a briefing on the internal regulations for staff;
• the administration of tuberculosis dispensaries and hospitals, under the supervision of hygiene and epidemiology centers, carries out disinfection measures;
• Employees of anti-tuberculosis institutions are monitored at the anti-tuberculosis dispensary at the IVB State Duma and undergo regular examinations.

In zoonotic foci of tuberculosis infection, the sanitary and epidemiological service monitors the mandatory examination of livestock breeders for tuberculosis. Patients with tuberculosis are not allowed to service animals and birds. Persons not infected with mycobacterium tuberculosis are vaccinated against tuberculosis. Milk from animals from farms with unfavorable tuberculosis rates is pasteurized twice and is subject to control. Meat and other products are heat treated. Animals with tuberculosis are subject to euthanization. The veterinary and sanitary and epidemiological services carefully monitor the condition of slaughterhouses and carry out health measures in farms with unfavorable tuberculosis rates.

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

A tuberculosis specialist visits the first group foci at least once a quarter, a nurse - at least once a month, an epidemiologist - once every six months. A tuberculosis specialist visits the second group foci once every six months, a nurse - once a quarter, an epidemiologist - once a year. The minimal risk of infection in the third group foci allows a tuberculosis specialist and epidemiologist to visit these foci once a year. A nurse - once every six months. The fourth group of epidemic foci of tuberculosis infection after the initial examination are visited by specialists of the tuberculosis service and the Center for Hygiene and Epidemiology if there are special indications. Zoonotic foci (the fifth group) are visited by a tuberculosis specialist and an epidemiologist once a year. A dispensary nurse - if there are indications.

Dynamic observation ensures control over changes occurring in the outbreak and timely correction of anti-epidemic measures. The annually drawn up plan for recovery of the outbreak reflects the organizational form, duration, nature of treatment and its results, the quality of the ongoing disinfection and the timing of the final disinfection, the timeliness of examination of persons in contact with the patient, the regularity of preventive measures. The results of dynamic observation are recorded in the epidemiological card.

It is generally accepted that a patient with tuberculosis after an effective primary course of treatment does not pose an epidemic danger 12 months after the cessation of MBT excretion. The absence of bacterial excretion must be confirmed by two consecutive negative bacterioscopic and microbiological studies carried out with an interval of 2-3 months. It is necessary to obtain X-ray tomographic data on the closure of the decay cavity, if any. If aggravating factors are identified (poor living conditions, alcoholism, drug addiction and mental disorders, the presence of children, adolescents, pregnant women in the outbreak, failure of the patient to comply with hygiene rules), additional observation for 6-12 months is necessary to confirm the absence of MBT excretion.

Observation of persons who were in contact with the patient is carried out for the entire period of excretion of MBT by the patient. After the patient is cured (or leaves) and is removed from the register as a bacteria excretor, the previously formed focus of tuberculosis infection remains dangerous and requires monitoring for a year. In the event of a fatal outcome of the disease, observation of the focus continues for another two years.

Social prevention of tuberculosis

Social prevention involves the organization and widespread implementation of a wide range of health measures that help prevent not only tuberculosis, but also other diseases. Social prevention is a set of measures of a universal nature, but their importance in the prevention of tuberculosis is great. Preventive measures are aimed at improving the environmental situation, combating poverty, increasing the material well-being, general culture and social literacy of citizens. Socially oriented measures create the conditions necessary for strengthening health and promoting a healthy lifestyle. The implementation of these measures depends on the general 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 for the Population is based on the principles of preventive focus, state character, and free medical care. The concept is reflected in state regulatory documents - the Federal Law "On the Prevention of the Spread of Tuberculosis in the Russian Federation", the Resolution 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 state financing of the entire spectrum of medical and social measures necessary for the prevention of tuberculosis.

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