ORGANIZATION OF PROPHYLAXIS AND ANTYEPIDEMIC MEASURES ON MEDICAL DISTRICT
Prevention of Infectious Diseases
and Measures to Control Them
Prevention and control of infectious diseases include the following:
(1) mass-scale measures aimed at improvement of public health, prevention and spread of infectious diseases;
(2) medical measures aimed at reduction of infectious morbidity and eradication of some diseases;
(3) health education and involvement of population in prevention or restriction of the spread of infectious diseases;
(4) prevention of import of infectious diseases from other countries.
Improvement of peoples’ well-being, adequate housing, medical aid, and health education should be adequately planned and carried out. Preventive sanitary supervision is also necessary. Industrial objects, residential houses, children’s and medical institutions should be constructed with strict adherence to the special sanitary requirements that are intended to improve labour and living conditions, prevention of onset and spread of infectious diseases.
Preventive measures aimed to control infectious diseases taken by medical personnel are divided into preventive and anti-epidemic. Preventive measures are carried out regardless of the presence or absence of infectious diseases at a given time and locality. These measures are aimed at prevention of infectious diseases.
Anti-epidemic measures are necessary when an infectious disease develops. It has already been said that the following three basic factors are necessary for development of an epidemic: the source of infection, transmission mechanism, and susceptibility of population. Exclusion of any of these factors terminates the spread of an epidemic process. Prophylactic and antiepidemic measures are therefore aimed at control of the source of infection, disruption of the route by which infection spreads, and strengthening of non-susceptibility of population.
Control of infection source. Patients with some infectious diseases, e. g. measles, pertussis, dysentery or cholera, liberate the pathogenic microorganisms into the environment during the last days of the incubation period or during the first day of the disease. Timely revealing of the sick is thus very important. Active detection of the sick is performed by medical personnel at hospitals, polyclinics, medical posts and the like. Health education of population by medical personnel promotes early attendance of the sick for medical aid and thus helps timely detection of infectious patients. Examination of population in outpatient conditions (in residential districts) is helpful in this respect.
An infectious disease is diagnosed on the basis of clinical findings, epidemiologic anamnesis and laboratory tests. All patients with the diagnosis of an infectious disease should be entered into a special record. The record should be made by a physician or a medical nurse. All cases of infectious diseases or suspected cases should be entered into the record, and higher epidemiologic authorities should be informed not later than within 24 hours. In cases of plague, cholera or other disease that requires quarantine measures, local medical personnel must inform higher authorities of the health system.
The infectious patients must be isolated in proper time. Patients with plague, cholera, viral hepatitis, typhoid and paratyphoid fever, diphtheria, and similar contagious diseases should be immediately hospitalized. The patients should be handled in special ambulance cars that should be disinfected after transportation of each patient (See Disinfection). The patient delivered to the hospital must be given appropriate sanitary treatment before placing in the appropriate ward or an isolated room, if the diagnosis is not clear, or infection is mixed by its character. Special measures should be taken in order to prevent spread of infection within the hospital. In order to remove the danger of spreading infection, the patient should be given appropriate therapy. Patients with scarlet fever, escherichiasis, dysentery and the like diseases can remain at home where they must be isolated from the other family. The family must be instructed how to prevent infection and to disinfect the household utensils. Observation of the patient by the medical personnel must be constant.
Persons cured from infectious diseases should be discharged from hospital after alleviation of all clinical symptoms, and examination for the carrier state, specific for each particular infection; for example, person who sustained diphtheria, can be discharged from hospital after a complete clinical cure and two negative bacteriological tests of the faucial and nasopharyngeal smears. Persons who recovered from typhoid fever, paratyphoid, salmonellosis, dysentery should be observed in outpatient conditions. The term of observation depends on each particular disease.
Carriers of infection should be revealed and isolated for medical examination and treatment. Since it is impossible to screen the entire population, only those who can be a danger for the surrounding people (personnel of children’s institutions, food catering, and the like establishments) should be inspected.
If the epidemiologic situation requires, the following groups of people should be examined for the carrier state: (a) persons who can be in contact with typhoid fever patients, patients with dysentery, paratyphoid, diphtheria, and meningococcal infection; (b) persons with a history of sustained typhoid fever, paratyphoid, and dysentery; (c) persons suspected for being a source of infection in the focus of infection. The carriers must be immediately withdrawn from their occupation at food catering or children’s institutions till they are completely cured and given multiple tests for the absence of the carrier state. Chronic carriers should be moved to other jobs that are not connected with food or children. Infection carriers must be regularly treated and observed according to special instructions.
If animals are the source of infection, measures differ. Veterinary measures should be taken with respect to domestic animals. Animals with brucellosis should be slaughtered. Horses with glanders should also be killed. Food and materials obtained from diseased animals must be given special treatment. Farms where infection is revealed, must be disinfected and quarantine established. Wild animals that are not the object of quarry must be destroyed, and measures for their isolation from man should be taken.
Disruption of infection transmission pathways. The pathways by which infection can be transmitted are disrupted by acting on the transmission factors. Since intestinal infections are transmitted by the faecal-oral route, all preventive measures are aimed to preclude contact of the infected material with water, food, or hands. General sanitary measures should be taken constantly and universally, regardless of the presence or absence of infection in a given locality.
Community hygiene is very important in prevention of infection spread. Layout of settlements, housing conditions, the presence or absence of water supply and sewage systems are important factors in this respect. Permanent control of water supply system, a correct selection of water body and the site of water intake, protection of the water intake zone, purification and decontamination of water are important preventive measures. Soil protection from contamination with domestic wastes and sewage and timely cleaning of settlements are decisive measures against flies.
Almost all intestinal infections can spread by ingestion of food. The anti-epidemic role of sanitary supervision over foods consists in prevention of contamination of food during all stages of its preparation, cooking, handling and storage, and during final dressing before serving. Neglected rules of cooking and storage of food at catering establishments, shops, and in food industry result in mass-scale spreading of salmonellosis, dysentery, typhoid fever, paratyphoid, etc.
Health education of population is decisive too.
Respiratory infections are easily transmitted from the source of infection to susceptible population. The main measure is prevention of overcrowding, adequate insolation and ventilation of enclosures, use of ultraviolet radiation for disinfection of air at medical and children’s institutions. Respirators are necessary in special cases.
In blood infections, the pathogenic agent resides in the blood supply system, in the lymphatic system and sometimes in various bodily organs. The pathogenic agent is transmitted to another susceptible macroorganism through bites of the blood-sucking arthropods. Besides, inoculation is possible during transfusion of blood from an infected person, through wounds during autopsy of the infected dead, during removing skin from infected rodents with valuable fur; transmission of infection is possible during medical manipulations that can be associated with damage to the blood vessels.
Most blood infections are characterized by natural nidality, except those transmitted by lice.
Irrigation of land, drying of swamps, cultivation of new soils and other measures taken in combination with medical ones have considerably decreased morbidity of tick-borne encephalitis, tularaemia, malaria and many other infections.
Control of arthropods (disinsection) is important for prevention of blood infection. Improved living, labour and leisure conditions of population and sanitary control at hairdressers’, etc. promote eradication of recurrent fever and louse-bome typhus.
In skin infections, each particular disease is characterized by specific routes of transmission of the causative agent which depend on the living and labour conditions. The transmission mechanism Can be broken by improving general health of population and the living and labour conditions. In addition to the mentioned general «anitary conditions, disinfection is another important factor for the disruption of the transmission pathways. Measures to break the transmission mechanism during wound infections include prevention of industrial injuries, traffic and domestic trauma.
Measures to increase non-susceptibility of population. Non-susceptibility of population is increased by improving general non-specific resistance of population by improving the living and labour conditions, nutrition, physical training, health envigorating measures and by creating specific immunity through preventive vaccination. The ancients noted that people who had sustained many infectious diseases became non-susceptible to repeated infection with the same disease. In the Orient (China, India) they believed that if a person could sustain a mild form of an infection, it could protect him from dangerous diseases during epidemic outbursts. They protected themselves from smallpox by rubbing the content of smallpox lesions into the skin or ingested crusts (variolation), or put contaminated underwear of smallpox patients on healthy children, etc.
In Europe, first attempts to create artificial non-susceptibility to infectious diseases were made in the 18th century. Variolation was practiced in England, Germany, Italy, France, Russia and some other countries. Samoilovich, for example, suggested that population could be immunized by the bubonic contents of plague patients.
The discovery of the English physician Edward Jenner has become a turn point in the teaching of artificial immunity. In 1796, Jenner developed a process of producing immunity to smallpox by inoculation with cowpox vaccine.
Louis Pasteur produced a live vaccine against anthrax by attenuating the causative agents at high temperature. His principle was used successfully by other investigators who also manufactured live vaccines. Virulence of tuberculosis bacteria has thus been decreased by multiple cultivation of the starting culture on bile-potato media.
Most effective proved the method of controlled variability of microbes and selection of low-virulence and highly immunogenic strains. Artificial active immunity is now induced by vaccines (from Latin vacca, cow and vaccina, cowpox); the method is known as vaccination.
The following preparations are used to prevent infectious diseases:
live vaccines prepared from attenuated non-pathogenic microorganisms or viruses; inactivated vaccines prepared from inactive cultures of pathogenic microorganisms causing infectious diseases; chemical vaccines (antigens), isolated from microorganisms by various chemical methods; toxoids, prepared by treating toxins (the poisons produced by microorganisms causing infectious diseases) with formaldehyde.
Vaccines can produce immunity against a given infectious disease or can be polyvalent, i. e., effective against several infectious diseases. Adsorbed vaccines are popular. Aluminium hydroxide is used as an adsorbent. Adsorbed vaccines induce active durable immunity in the vaccinated macroorganism by creating a depot at the site of administration of the antigen, which is slowly absorbed.
Live vaccines are used to create specific immunity against poliomyelitis, measles, influenza, tuberculosis, brucellosis, plague, tularaemia, anthrax, Q fever, skin leishmaniasis, epidemic parotitis, and some other diseases.
Live vaccines prepared from attenuated vaccine strains of microorganisms are more effective than inactivated chemical vaccines. Immunity induced by live vaccines is about the same as produced by normal infection. Live vaccines are given in a single dose intra-cutaneously, subcutaneously, per os, into the nose or by scarification. The disadvantage of live vaccines is that they should be stored and transported at a temperature not exceeding 4-8 °С.
Inactivated vaccines are prepared from highly virulent strains with adequate antigen properties. They are used to prevent typhoid fever, paratyphoid, cholera, influenza, pertussis, tick-borne encephalitis, and some other diseases. Depending on the microorganism species, various methods are used to inactivate them. The microorganisms can be treated with formaldehyde, acetone, alcohol, merthiolate, or at high temperature. Efficacy of inactivated vaccines is lower than that of live vaccines although there are some highly effective inactivated vaccines as well. Inactivated vaccines are injected subcutaneously. Adsorbed vaccines are given intramuscularly. Inactivated vaccines are more stable in storage. They can be kept at temperatures from 2 to 10 °С.
Chemical vaccines are more active immunologically. These are specific antigens extracted chemically from microbial cells. Adsorbed chemical vaccines are used for active immunization against typhoid fever, paratyphoid and other diseases.
Toxoids are formaldehyde-treated exotoxins of the microorganisms causing diphtheria, tetanus, cholera, botulism, and other diseases. Diphtheria and tetanus toxoid is used in the adsorbed form. Toxoids are highly efficacious. When administered into a macroorganism, the vaccine induces an active immunity against a particular infection. Live vaccines produce an immunity that lasts from 6 months to 5 years. Duration of immunity produced by inactivated vaccines is from a few months to a year.
Immune sera and their active fractions (mainly immunoglobulins) induce passive immunity. Immune sera and immunoglobulins are prepared from blood of hyperimmune animals and from people who have sustained a particular disease or have been immunized otherwise. Passive immunization is used for urgent prophylaxis of people who are infected or supposed to be infected, and also for treatment of the corresponding infectious disease. The effect of immune sera and immunoglobulins lasts from 3 to 4 weeks. They are given intramuscularly.
Bacteriophages are used to prevent and treat some infectious diseases. Bacteriophages are strictly specific toward separate species and even types of.bacteria.
The preparations can be given parenterally (percutaneously, intracutaneously, subcutaneously, intramuscularly, intravenously) or enterally (per os), intranasally or by inhalation (aerosols).
When giving vaccines parenterally, it is necessary to observe sterile conditions and to adhere to the rules specified for injection of a particular vaccine. Jet injections are widely used now: the preparations are administered into the skin, subcutaneously and intramuscularly using various syringes.
When given in the liquid state or in tablets, the vaccine should be taken together with water.
Live vaccines are usually given in a single dose, while inactivated vaccines are given in two or three doses at intervals from 7 to 10 or from 30 to 45 days.
Revaccination is used to maintain immunity induced by previous vaccination. The terms of revaccination depend on a particular disease and vary from several months to 5 years. Efficacy of immunization depends largely on regularity of revaccination performed in due time with adequate doses. Quality of the vaccine, and the condition of its storage and transportation are also important.
When selecting persons for immunization, contraindications should be considered. Individual contraindications depend on the route of vaccination, the presence of concurrent diseases, the stage of recovery, previous vaccinations, and the like.
Vaccination should be performed by a physician or secondary medical personnel after thorough examination of persons to be vaccinated in order to reveal possible contraindications, the presence of allergic reactions to medicines, food, etc.
The main contraindications to prophylactic vaccination are as follows: (1) acute fever; concurrent diseases attended by fever;
(2) recently sustained infections; (3) chronic diseases such as tuberculosis, heart diseases, severe diseases of the kidneys, liver, stomach or other internal organs; (4) second half of pregnancy; (5) first nursing period; (6) allergic diseases and states (bronchial asthma, hypersensitivity to some foods, and the like).
Vaccination can induce various reactions. These can be malaise, fever, nausea, vomiting, headache and other general symptoms; a local reaction can develop: inflammation at the site of injection (hyperaemia, oedema, infiltration, regional lymphadenitis). Pathology can also develop in response to vaccination; such pathologies are regarded as postvaccination complications. They are divided into the following groups: (1) complications developing secondary to vaccination; (2) complications due to aseptic conditions of vaccination; (3) exacerbation of a pre-existing disease.
Prevention of postvaccination complications includes: strict observation of aseptic vaccination conditions, adherence to the schedule of vaccination, timely treatment of pathological states (anaemia, rickets, skin diseases, etc.), timely revealing of contraindications to vaccination, and screening out the sick or asthenic persons. All cases with severe reactions to vaccination should be reported to higher authorities. If vaccination is performed by scarification, the results are not always positive, and the vaccine must therefore be tested. The results of vaccination should be assessed at various terms, depending on a particular disease against which a person is vaccinated. The result of vaccination against, e. g. anthrax, should be assessed in 2-3 days.
Vaccination should be performed according to a predetermined plan, or for special epidemiologic indications. Planned vaccination is performed against tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis, measles, epidemic parotitis, and against some other infections within the confinement of separate districts or population groups, regardless of the presence or absence of a given disease. Vaccination for special epidemiologic indications are performed in the presence of direct danger of spreading of a particular infection. Vaccination reports must be compiled and special entries made in histories.
The results of vaccination (efficacy of vaccination) are assessed by comparing morbidity rates among the vaccinated and non-vaccinated groups of population. The number of the diseased and severity of cases must be assessed (agglutination test, complement fixation test, test for allergy).
Sanitary and epidemiologic posts and stations must supervise the work of vaccination posts.
Complex prophylactic and anti-epidemic measures. In case of infectious outbreak it is necessary to take a complex of anti-epidemic measures aimed at eradication of the source of infection, disruption of the transmission mechanism, and increasing non-susceptibility of population. The main measure should be selected depending on the character of infection and a particular condition in a given area. Other measures are only secondary in importance, although their role is also great. For example, only systematic vaccination of the entire population has made it possible to eradicate smallpox all over the world. The main measure in louse-borne and recurrent typhus is control of the source of infection and eradication of pediculosis among population.
Anti-epidemic measures in the focus. The efficiency of anti-epidemic measures taken in the focus of infection depends largely on the time when the source of infection (patient) is revealed and isolated from the surrounding people.
Regardless of the character of the focus (family, community) measures should be taken toward the patient, the persons who were in contact with the diseased, and the surrounding objects. As the diseased person is revealed, the following measures should be taken:
the disease diagnosed, appropriate record made and the authorities informed, the patient hospitalized or isolated in out-patient conditions and given specific therapy.
The focus should be examined by an epidemiologist or a rural physician. The results of examination should be entered into a special chart (record). The purpose of the epidemiologic examination is to reveal the source and ways of infection transmission, to establish the boundaries of the focus, to determine the scope of disinfection and reveal contacts; a plan of immediate measures aimed to control and eradicate the focus should be made out.
Epidemiologic examination of the focus should begin with the study of morbidity at a given locality in the past (flat, hostel, institution, etc.), acquaintance with disease rate among animals and contamination of surrounding objects.
Questioning of the patient, the family and contacts helps reveal the source of infection. Questioning usually begins with asking the patient if he or she had contact with the diseased within his family, among the relatives or acquaintances. If a zoonotic focus is examined, possible contacts with the diseased people or animals must be established. Information about previous travels to other city or village, visits of relatives or acquaintances from other districts should be revealed. It is very important to establish occupation of the diseased, conditions of his labour, living and nutrition conditions.
The value of epidemiologic examination depends on the skill and form of questioning. It is recommended that the results of questioning should be recorded at the end of the talk. The physician must plan his questions beforehand.
Depending on a particular disease, the corresponding objects must be examined. For example, the source of water supply and rooms where food is cooked and stored should be examined in intestinal infections. If sewage is absent, waste receptacles should be examined. Places where refuse is collected must be examined as well. It is necessary to establish if flies were the transmitters of the infection. Cleaning of the surrounding territory must be inspected. Sanitation and hygiene of persons residing in the focus of infection should also be taken into consideration.
Material for microbiologic studies should be taken from the patient, his contacts, and, if necessary, animals and the surrounding objects (water, food, washings from equipment, various materials of animal origin, etc.).
Immunity tests, skin allergy tests, experimental inoculation of susceptible animals should be performed if necessary.
Persons who had contacts with the patient (in the family, house, institution) should undergo a thorough medical examination in order ; to reveal, as early as possible, new cases of the disease (Addition 1). The terms and , character of observation depend on a particular infection. For example, a typhoid fever focus is visited by medical personnel every day (during 25 days), the residents are questioned, examined, and their temperature taken. A viral hepatitis focus should be visited once a week (for 45 days). Stools must be examined in the focus of dysentery. If bacteria carriers, are found in the focus of infection, all contacts must be examined microbiologically to reveal possible carriers.
Workers and other personnel engaged in food catering and the like establishments (i.e., persons engaged in handling foods, their processing and cooking, maintenance of equipment used for food processing and cooking, staff of medical institutions dealing with nutrition of people, workers engaged in water supply and those responsible for storage of water), children at kindergartens and schools should be isolated for various terms depending on a particular infection. All persons who had contacts with plague or cholera patients should be isolated, observed, and given preventive treatment.
The room where the patient is kept before hospitalization should be disinfected. After taking the patient to hospital, or after his or her recovery from the disease (if the patient remained at home), the focus should be disinfected again. If the disease is transmitted by living transmitters (lice in louse-borne and recurrent fever, fleas in plague), disinsection must be carried out. Rodents must be exterminated in the focus of plague or tularaemia.
Health education of population must be carried out in the focus of infection. Medical personnel must acquaint population with the first signs of the disease, the measures that people must take if the signs of the disease develop, and preventive measures.
In order to stop the spread of infection and eradicate the focus of infection, specific preventive measures must be taken. Depending on indications, the entire population in a given region, or only separate persons who had contacts with the diseased must be vaccinated. For example, if there exists a danger of repeated cases of tularaemia, the entire population of a given area must be immunized.
DISINFECTION IN VARIOUS INFECTIOUS DISEASES
Intestinal infections. Final disinfection should be carried out in foci of typhoid fever, paratyphoid, salmonellosis, bacterial dysentery, gastroenteritis and colitis, infections caused by yersinia and escherichia, viral hepatitis, poliomyelitis and other enteroviral infections.
1. The following objects should be disinfected in foci of typhoid fever, paratyphoid, salmonellosis, dysentery, gastroenteritis and colitis, yersiniosis, escherichiasis and cholera:
patient’s excrements (faeces, urine, vomitus) should be treated with dry lime chloride taken in the ratio 1:2 (one part of the preparation per two parts of excrements). The time of exposure is 30 minutes. Ibis time should be doubled if the ratio of the disinfectant to excrement is 1:5. Thus treated excrements should be discarded to sewage. If the excrements contain little moisture, water should be added (1:4). Excrement containers (bed pans, pails, bottles and the like) should be treated in the following solutions: (a) 3 per cent chloramine solution (30 minutes), 3 per cent clarified lime chloride solution, 0.5 per cent activated chloramine solution; (b) 1 per cent clarified solution of chlorinated lime, 1 per cent solution of thermally stable chlorinated lime, 1 per cent chloramine solution (for an hour);
(c) 0.1 per cent sulphochlorantin solution (for 2 hours). After disinfection, the articles should be washed in water;
the walls at the patient’s bedside and in the lavatory (to the height of 1.5 m) should be sprayed with a disinfectant solution (25U-300 ml/sq.m) or rubbed with a cloth wetted in the disinfectant. The disinfectant solution should be removed in an hour after treatment with a 1 per cent chloramine solution, 1 per cent clarified chlorinated lime solution, 0.2 per cent sulphochlorantin solution; if a 3 per cent chloramine solution (0.5 per cent of activated chloramine), a 3 per cent clarified chlorinated lime solution is used, final treatment should be terminated in 30 minutes; polished pieces of furniture should be treated with vaseline oil or other suitable material;
doors, walls, and lavatory pans in toilet rooms should be treated with one of the mentioned disinfectant solutions (500 ml/sq.m) and, in 30 minutes, rubbed with cloth wetted with the disinfectant;
if the lavatory is situated out-of-doors, the surface of the receptacle pit should be treated with dry chlorinated lime (0.5 kg/sq.m); the walls and the floor should be sprayed with a 10 per cent solution of chlorinated lime;
dishes (cups and plates) should be boiled in a 1 per cent sodium hydroxide solution for 15 minutes or they can be placed for 60 minutes (after removing food traces) into one of the following solutions: 0.5 per cent chloramine solution, 0.5 per cent clarified chlorinated lime solution, 0.5 per cent of hydrogen peroxide, or (for 15 minutes) a 0.04 per cent DP-2 solution. Two litres of solution are necessary to treat one set of dishes (2 plates, a spoon, fork, knife, cup, and a saucer). The amount of the solution must be sufficient to cover the dishes. After disinfection, the articles should be washed in hot water,
food remnants should be boiled for 15 minutes or mixed with dry chlorinated lime taken in the ratio of 5:1 and allowed to stand for 30 minutes;
linen, towels, underwear and the like articles should first be laundered in disinfectant solution and then kept in one of the following solutions: 0.5 per cent chloramine solution, 0.5 per cent clarified chlorinated lime solution, 3 per cent lysol solution, 0.04 per cent DP-2 solution, or boiled in a 1 per cent soap-soda solution for 15 minutes. Underwear having no visible traces of contaminants should be boiled in a 1 per cent soda-soap solution for 15 minutes and then treated in a disinfectant solution;
toys (rubber, metal, plastic or wood) should be boiled for 15 minutes in a 2 per cent sodium hydrocarbonate solution or a solution of another detergent (except plastic articles), or kept for 30 minutes in one of the following solutions: 0.5 per cent chloramine solution, 0.5 per cent clarified chlorinated lime solution, 0.1 per cent sulphochlorantin, or for 15 minutes in a 0.04 per cent DP-2 solution;
pillows, blankets, mats, clothes and carpets should be treated with steam or formaldehyde vapour in special chambers, or cleaned with brushes wetted in disinfectant solution.
2. Final disinfection in hepatitis A, poliomyelitis and other enteroviral infections is the same as in intestinal infections, except that: dishes should be boiled in a 2 per cent sodium hydrocarbonate solution for 15 minutes, or, after removing food remnants, the dishes can be kept in one of the following solutions: (a) for an hour in: 0.5 per cent activated chloramine solution, 3 per cent chloramine solution, 3 per cent clarified chlorinated lime solution, 0.04 per cent DP-2 solution, 1.4 per cent hydrogen peroxide solution; (b) for 2 hours in: 1 per cent chloramine solution, 1 per cent clarified chlorinated lime solution, 1 per cent clarified sulphochlorantin solution;
linen, underwear, towels and other personal belongings should be boiled for 15 minutes in a solution of any detergent or in a 2 per cent soda-soap solution, or soaked for 30 minutes in a 0.5 per cent activated chloramine solution, 3 per cent chloramine solution, hot (50 °С) 3 per cent hydrogen peroxide solution containing 0.5 per cent detergent solution, or for 2 hours in a 0.04 per cent DP-2 solution. The rate of solution consumption is 4 litres per kg of dry material to be disinfected. Heavily soiled articles should first be laundered in any of the mentioned solutions and then soaked or boiled in this solution;
toys (rubber, metal, plastic, wood) should be boiled in a 2 per cent sodium hydrocarbonate solution for 15 minutes, or placed for 30 minutes in any of the following solutions: 3 per cent chloramine solution, 0.5 per cent activated chloramine solution, 3 per cent clarified chlorinated lime solution, or placed in a 0.04 per cent DP-2 solution for an hour;
hot-water or ice bottles, inflatable rubber cushions or other similar articles should be treated with a cloth wetted in a disinfectant solution or washed in a 2 per cent hot soda-soap solution and rinsed with hot water;
oil cloths, napkins should be treated in the same solutions as used for treatment of linen and underwear, and then washed in hot water;
pillows, mats, blankets, clothes and carpets should be treated with steam or formaldehyde vapour in special chambers.
Current disinfection should be carried out every day: the floor and utensils should be treated with cloths wetted in disinfectant solution. Patient’s excrements, the linen and other personal belongings should be disinfected as in final disinfection.
Respiratory infections. Obligatory final disinfection should be carried out in foci of diphtheria, meningococcal infection and ornitosis. The following objects should be treated:
dishes (free from food residue) should be boiled in a 2 per cent sodium hydroxide solution for 15 minutes or kept for an hour in one of the following solutions: 1 per cent chloramine solution, 1 per cent clarified chlorinated lime solution, 0.1 per cent sulphochlorantin solution, or for 15 minutes in a 0.1 per cent activated chloramine solution, or 0.04 per cent DP-2 solution;
dishes with residues of food on them should be boiled for 15 minutes in a 2 per cent sodium hydrocarbonate solution or kept for 2 hours in one of the mentioned solutions;
toys (plastic, rubber, wood or metal) should be boiled for 15 minutes in a 2 per cent sodium hydrocarbonate solution, or kept for an hour in one of the following disinfectant solutions: 1 per cent chloramine solution, 1 per cent clarified chlorinated lime solution, 0.2 per cent sulphochlorantin solution, or kept for 15 minutes in a 0.1 per cent activated chloramine solution, or a 0.04 per cent DP-2 solution;
underwear, linen, towels, etc. that are not soiled with excretions of the patient, should be boiled in a 2 per cent sodium hydrocarbonate solution for 15 minutes, or kept for an hour in one of the following solutions: 1 per cent chloramine solution, 1 per cent clarified chlorinated lime solution, 0.1 per cent sulphochlorantin solution, or for 15 minutes in a 0.1 per cent activated chloramine, or 0.04 per cent DP-2 solution;
linen and underwear of the patient soiled with patient’s excrements should be boiled for 15 minutes in a 2 per cent sodium hydrocarbonate solution or soaked in one of the mentioned disinfectant solutions for 2 hours with subsequent common laundry. The consumption of disinfectant solution is 4 litres per kg of dry linen.
Room where the petient is kept, utensils, and the adjacent rooms where the patient does his private hygienic procedures (lavatory and the like) should be sprayed with one of the following solutions: 0.5 per cent chloramine solution, 0.5 per cent clarified chlorinated lime solution, 2 per cent hydrogen peroxide solution with an additive of a 0.5 per cent of a detergent, 0.1 per cent sulphochlorantin solution. After a 1-hour exposure, the walls coated with an oil paint and all pieces of furniture should be treated with a cloth soaked in a disinfectant solution. The consumption of the disinfectant is 0.5 litre per square metre of the floor area.
Cloths and other materials, that were used for disinfection, should be boiled in a 2 per cent sodium hydrocarbonate solution for 15 minutes or soaked in one of the mentioned disinfectant solutions for 2 hours; later procedures are the same as those used for disinfection of the linen and underwear. Linen, clothes, textile toys and books should be treated in formaldehyde vapour chambers.In cases of an air-borne infection, the room should be treated with cloth wetted in one of the following disinfectant solutions: 0.5 per cent chloramine solution, 0.1 per cent sulphochlorantin solution. Dishes and toys should be boiled in a 2 per cent sodium hydrocarbonate solution or kept in one of the mentioned disinfectant solutions as described above.
Skin infections. Final disinfection in foci of anthrax should be carried out in the house (after hospitalization or death of the patient) or in enclosures where raw materials and products manufactured of the animals with anthrax were stored.
The floor, the walls, the ceiling, pieces of furniture, and utensils should be sprayed two times (at 30 minutes interval) with one of the following solutions: 5 per cent clarified chlorinated lime solution, or 4 per cent activated chloiinated lime or chloramine solution, hot (55-60 °С) 5 per cent solution of formaldehyde with an additive of a 5 per cent soap, 6 per cent hydrogen peroxide solution with a 0.5 per cent detergent solution.
Linen, underwear, overalls of the medical personnel, who take care of the patient, should be boiled in a 2 per cent sodium hydrocarbonate solution for an hour or kept in a 0.1 per cent sulphochlorantin solution for 90 minutes, or in a 1.2 per cent DP-2 solution for 30 minutes.
Garments, blankets, mats and the like articles should be disinfected in steam and formaldehyde chambers.
Dishes should be boiled in a 2 per cent solution of sodium hydrocarbonate for an hour, or kept in a 1 per cent activated chloramine or 6 per cent hydrogen peroxide solution containing 0.5 per cent detergent solution at a temperature of 50 °С, or in a 1.2 per cent DP-2 solution for an hour.
Food remnants should be boiled in a 2 per cent sodium hydrocarbonate solution for an hour, or mixed with dry chlorinated lime (200 g/1, or 1:5) and allowed to stand for 4 hours.
Patient’s excrements should be mixed with dry chlorinated lime (200 gm/1, or 5:1). Bed pans, urine receptacles, sputum receptacles should be cleaned and kept in a 20 per cent clarified solution of chlorinated lime for an hour. Excretions of the patient are taken in the ratio of 10:1 (100 gm/1) and allowed to stand for 4 hours after which they are discarded to sewage. Dressing material, wastes, and inexpensive articles should be burnt.
Final disinfection in a focus of plague should be performed by a disinfection brigade headed by a physician. Special antiplague overalls should be worn.All rooms and objects in them should be sprayed with ample 3 per cent chloramine solution or 10 per cent lysol solution (at 60 °С). Disinsection and deratization should be carried out in an hour, then disinfection is repeated in 4 hours and the house kept locked for 3-4 days.
TREATMENT OF INFECTIOUS PATIENTS
Complex therapy should be given along with specific treatment, that must be pathogenetically substantiated and individual for each particular patient, depend on the severity of the patient’s condition, and the period of the disease.
Specific therapy is used to eradicate or neutralize the infective agent and its metabolites, and to strengthen the defensive forces of the patient. Chemotherapy, serotherapy, and immunotherapy are indicated.
Chemotherapy. Chemical drugs that produce a specific action on the pathogenic agent can be synthetic or vegetable by their origin. Synthetic antibiotics are also used.
When a chemical drug is administered, it inhibits multiplication and vitality of the pathogenic microorganisms. Further eradication of the agent is ensured by the defense force of the patient.
Sulpha drugs include prolonged-action preparations such as sulphapyridazine, sulphadimethoxin, and other preparations. Limited use of these preparations is explained by development of resistant strains and the irritating effect on the gastric mucosa (nausea, vomiting, gastric hyposecretion). Allergic rash and stones in the kidneys are also possible. Taking great amount of alkaline drinks prevents formation of such stones.
Derivatives of 8-oxyquinoline (intestopan, mexaform, mexase, 5-NOK.) are used to treat intestinal infections. These preparations do not inhibit normal intestinal flora, decrease putrefactive and fermen-tative processes in the intestine. Prolonged use of 8-oxyquinolines can cause peripheral neuritis and impair vision.
Nitrofurans (furadonin, furacin, furazolidone, furagin) are effective against intestinal infections.
Antibiotics are efficacious in infectious patients. They shorten the course of the disease, prevent complications and decrease the mortality rate. When prescribing antibiotics, it is necessary to consider the type of causative agent, its sensitivity to a given antibiotic, duration of antibiotic therapy, the dose and route of administration (oral, intramuscular, intravenous), duration of treatent and toxicity of the antibiotic. Antibiotics give prompt therapeutic effect. The patient’s condition improves in 1-2 days (less frequently in 3 days) and the body temperature normalizes. In the absence of improvement, it is necessary to change the antibiotic.
Chloramphenicol has a broad spectrum of its action and is effective against intestinal infections (typhoid fever, paratyphus A and B), rickettsiosis, spirochaetosis.
Penicillins (salts of behzylpenicillin, bicillin, ampicillin) are highly effective against meningococcal infection and anthrax.
The tetracyclines (hydrochlorides of tetracycline and doxycycline, rondomycin) are effective against rickettsiosis, intestinal infections, tularaemia and plague.
Allergic and endotoxic complications, and also dysbacteriosis can develop following chemotherapy. Allergic reactions occur regardless of the dose or time during which a preparation is given. They manifest by capillarotoxicosis, catarrhs of the mucosa, oedema, skin rash, and shock (loss of consciousness, arterial hypotension, respiratory distress). The endotoxic reaction occurs after administration of priming doses of antibiotics and is explained by liberation of great amount of endotoxin from the dead microorganisms. Dysbacteriosis occurs mostly in treatment with chloramphenicol and the tetracyclines, which inhibits the normal intestinal microflora. Autoinfection develops due to multiplication of staphylococci and yeast-like fungi {Candida} which are a part of natural intestinal flora. Biosynthesis of vitamins, especially of vitamins B, is upset. Another disadvantage of antibacterial therapy is development of resistance of the infective agent to a given preparation.
In order to prevent the allergic response in the patient, a thoroughly collected history is important. Desensitizing preparations should be given whenever necessary (dimedrol, dimedryl, diazolin, diprazin, suprastin). In order to lessen endotoxic reactions, detoxicat-ing and antihistaminic preparations should be given together with antibiotics. Dysbacteriosis can be prevented by nystatin, biologically active bacterial preparations, e.g. colibacterin, lactobacterin, bificol, bifidobacterin.
Serotherapy. Serum of immune animals and people is used to treat infectious diseases. The preparations are classed as antitoxic (containing antitoxins) and antibacterial (containing bactericidal antibodies). Antitoxic sera are highly effective. They are prepared by hyperimmunization of animals (e. g. horses, bulls and other animals) with specific exotoxins. Antitoxic sera are used to treat diphtheria, botulism, tetanus, gaseous gangrene, etc. The serum should be administered as early as possible, before the toxins produce irreversible changes in the organs and tissues. Antitoxic serum should be given in various doses depending on severity of the disease. It can be administered intramuscular! у and, in exceptionally rare cases, intravenously.
Antibacterial sera are prepared by hyperimmunization of animals with bacterial vaccines. They are given in millilitres (50-100-150 mL) depending on severity of the disease.
Administration of heterologic serum can evoke various reactions. They can be immediate, early (developing in 4-6 days after administration), and late (in two and more weeks). Immediate complications can develop as specific anaphylactic shock characterized by a fall of arterial pressure (collapse), dyspnoea, convulsions, low body temperature, involuntary defaecation and urination; non-specific fever and chill; hyperaemia of the face, cramping, skin rash; local reaction (hyperaemia developing at the site of injection immediately or few hours following the injection, oedema, less frequently necrosis).
Early and late reactions are manifested by development of serum disease that is evoked by the administration of large doses of serum, especially in repeated injections. In 1-12 days after the injection, the patient develops rash in the form of erythema or urticaria, which is especially intensive at the site of injection, oedema of the face, diarrhoea, swollen and tender joints, enlarged lymph nodes, elevated body temperature.
The serum disease lasts from several days to 3 weeks. Treatment includes dimedrol (dimedryl) and calcium gluconate.
In order to prevent anaphylactic shock, individual sensitivity of the patient should first be determined by an intracutaneous test. To that end, a horse serum (diluted 1:100) is given intracutaneously in a dose of 0.1 ml. The test is considered negative if the diameter of the resultant papule does not exceed 0.9 cm in 20 minutes after the injection and erythema is limited. The horse serum can then be given without dilution in a dose of 0.1 ml. If the reaction is absent within 30-60 minutes, the whole dose of the serum can be injected intramuscularly or intravenously. If the skin test is positive, or anaphylactic reaction develops, the serum may be administered only for very important clinical indications. The dilute serum is injected three times at a 20-minute interval (doses: 0.5, 2 and 5 ml, respectively), then 0.1 ml of serum without dilution is injected. In the absence of reaction, the remaining dose is injected in 30 minutes. Human (homologous) serum almost never evokes anaphylaxis or serum disease.
In order to prevent allergic complications, it is necessary to find out if the serum was administered to the patient before or if the patient had allergic diseases (bronchial asthma, urticaria, eczema). If signs of anaphylactic shock develop, the administration of the serum should be discontinued, the patient placed in bed with his legs in the elevated position. Noradrenaline or ephedrine (or mesatone) should be given intravenously; atropine or glucocorticoids (prednisolone) should be given for bronchial spasm.
Immune globulins (polyglobulins, gamma-globulins) should be used to treat infectious patients. Gamma-globulins and polyglobulins are obtained from serum, placental blood, immunized donors (homologous) or animals (heterologous). No side reactions are evoked after administration of homologous gamma-globulin or polyglobulin. Heterologous gamma- and polyglobulins should be administered after an intracutaneous test. To that end, 0.1 ml of gamma-globulin (diluted 1:100) should be injected into the flexor surface of the forearm. If the test is negative, 0.1 ml of the solution diluted 1:10 is administered in 20 minutes, and then, in an hour, the whole dose, intramuscularly. If the test is positive, the preparation should not be injected, or it may be given in divided doses. Gamma-globulins are used for therapeutic and prophylactic purposes in influenza, pertussis, measles, seasonal encephalitis, anthrax, leptospirosis, staphylococcal infections. Treatment of infectious patients with immunoglobulins is often combined with chemical drugs.
Immunotherapy acts on the immune system of a patient. Specific and non-specific therapies are differentiated. Specific immunotherapy produces effect on the systems of cell and humoral immunity, intensifying formation of specific immunity to certain antigens. Biologic preparations such as vaccines, antigens, bacterial lipopolysaccharides, and anatoxins are used for this purpose. Autovaccines prepared from the causative agent isolated from the patient are most efficacious. Vaccine therapy should be combined with antibiotics, usually when acute manifestations of the disease decrease, in long-standing and chronic cases (tularaemia, brucellosis, dysentery). For therapeutic purposes, the vaccine is given intravenously, intramuscularly, subcutaneously, and intracutaneously. The vaccine therapy is contraindicated to patients with lesions of the cardiovascular system, of the kidneys or the liver.
Blood and its components, vitamins, pyrimidines or their derivatives (methyluracil, pentoxyl) are used for non-specific stimulation. Pyrimidines are component parts of nucleic acids that are involved in the biosynthesis of protein, both specific and non-specific, they stimulate cell and humoral mechanisms of immunity, and produce anti-inflammatory effect. Pyrimidines are used for complex treatment of typhoid fever, dysentery, brucellosis, and viral hepatitis. Non-specific immunotherapy also includes bacterial lipopolysaccharides (pyrogens), most popular of which are pyrogenal and levamidol. Other pyrogens that are isolated from various cells and tissues of macroorganism, are also used. Pyrogens intensify the activity of antibody-forming cells; they stimulate leucopoiesis and increase non-specific resistance of the body to toxins of bacteria and viruses.
Pathogenetic therapy includes many medical measures aimed at elimination of toxaemia by detoxicating or infusion-detoxicating therapy, and glucocorticosteroid therapy, depending on the clinical form of the disease; restoration of water-salt equilibrium by rehydration therapy; normalization of the cardiovascular and nervous function; and also increasing the impaired bodily functions by stimulation therapy.
Detoxicating therapy is given in mild and moderate forms of infectious diseases. It is sufficient to give the patient ample drinking:
juice, stewed fruits, mineral water, boiled water, tea, etc.
Patients with pronounced toxaemia are given infusion-detoxicating therapy directed at neutralization and elimination from the body of microbial toxins and metabolites. To that end, haemodez is given intravenously; polyglucin, rheopolyglucin, blood plasma, and 10 per cent albumin solution should be given for severe hypotension. A 5 per cent glucose solution and isotonic sodium chloride solution should also be administered. The solutions can be infused separately or, wherever possible, in mixtures (drip infusion).
Depending on the degree of toxaemia, from 500 to 1000 ml of fluid are infused. Infusions should be repeated 2-3 times a day with strict control of the infused volumes, body weight, and of the diuresis, that must ensure withdrawal of excess liquid from the body.
Glucocorticosteroid therapy is given to patients in septic shock and acute adrenal failure (meningococcal infection, influenza, haemorrhagic fever, poliomyelitis, typhoid fever, louse-borne typhus, salmonellosis, dysentery, diphtheria, plague, cholera).
Glucocorticosteroids (prednisolone, dexamethazone, triamcino-lone, cortisone, hydrocortisone) are given in large doses, better intravenously. For example, a daily dose of prednisolone is 120-300 mg and more; after recovery of the patient from shock, the daily dose of the preparation is decreased 2-4 times and is given intramuscularly or per os with control of arterial pressure.
Rehydration therapy is directed at restoration of the water-salt equilibrium and is used in gastrointestinal forms of intestinal infections attended by incoercible vomiting, frequent stools (profuse diarrhea), dehydration of the body and accordingly decreasing volume of circulating blood (hypovolaemia), and development of hypovolaemic shock.
The amount of repleted salts, their composition and the way of administration depend on the rate and degree of dehydration and the character of the water-salt disbalance. Four degrees of dehydration are differentiated.
Dehydration, degree I. The patient loses water in the amount of 1-3 per cent of body weight. The patient develops moderate thirst, dryness of the mucosa, and moderate fatigue; stools are semiliquid or watery, 3-10 times a day; vomiting is rare.
Dehydration, degree II. The loss of liquid is 4-6 per cent of body weight. Stools are ample, watery, or resembling rice water, 10-20 times a day; vomiting is frequent (5-Ю times). The patient develops thirst, the skin and mucosa are dry; the lips, fingers and feet are cyanotic; fatigue is marked. Muscular cramping in the calves, wrists, and feet; signs of blood thickening develop; tachycardia, hypotension and oliguria are seen.
Dehydration, degree III. The loss of liquid is 7-9 рьг cent of body weight. Stools are frequent and ample; vomiting and cramping of limb muscles are seen; the skin and mucosa are dry, washerwoman’s hands symptom develops, hypotension is pronounced; oliguria or even anuria develops.
Dehydration, degree IY (the algid form). The liquid loss is 10 per cent of body weight. The disease begins acutely. Diarrhoea and vomiting discontinue at the beginning of the disease. The body temperature falls to 35-35.5 °С, peripheral pulse and arterial pressure are absent; anuria and aphonia develop. Cyanosis is intensive, the muscles are cramping, the facies are pinched, the eyes and the cheeks are retracted.
In I and II degree dehydration the patient is given gastric lavage and then one of the following solutions (to drink in small portions):
glucose-salt mixture (3.5 g of sodium chloride, 2.5 g of sodium hydrocarbonate, 1.5 g of potassium chloride, and 20 g of glucose dissolved ex tempore in 1 litre of drinking water); a solution containing 4 g of sodium hydrocarbonate, 5 g of sodium chloride, and 1 g of potassium chloride; a solution containing 2.6 g of sodium acetate, 1 g of sodium hydrocarbonate, 6.2 g of sodium chloride, and 0.3 g of potassium chloride; or Locke-Ringer solution containing glucose or sweet tea. If vomiting continues, the liquid should be administered through a nasogastric tube.
In II and III degree dehydration, and especially degree IV, the patient should be given intravenously polyion buffer solutions preheated to 38-40 °С. In addition to the mentioned solutions, used also are solutions containing 2 g of sodium acetate, 5 g of sodium chloride, 1.0 g of potassium chloride, or a solution containing 3.6 g of sodium acetate, 4.75 g of sodium chloride, and 1.5 g of potassium chloride, or a solution containing 3.3 g of sodium lactate, 4.75 g of sodium chloride, and 1.5 g of potassium chloride. Treatment includes two states: primary rehydration (repletion of the liquid lost before rehydration therapy is started) and compensatory (replenishment of the liquid lost during treatment).
In III degree dehydration the solution is given intravenously at a rate of 100 ml/min. In IV degree dehydration, and if hypovolaemic shock develops, one of the specified solutions is infused at a rate of 100-120 mL/min, 5-7 litres during 60-90 minutes. After the patient’s condition is no longer critical, the second stage of treatment begins. The solution is now infused by drip at a rate of 100-150 drops per minute with a gradual reduction of the rate to 60 and then 20-10 drops per minute. Liquid infusion can be suspended depending on the degree of improvement of the patient’s condition and normalization of the water-salt metabolism. If necessary, the glucose-salt solutions are given per os, by small portions at short time intervals.
Salt solutions, especially their large volumes, should be administered under constant laboratory control of the water-electrolyte metabolism, blood counts, and diuresis.
Stimulating therapy is aimed at normalization and intensification of dysfunctioning organs and systems. Cardiovascular dysfunction develops due to the action of toxins liberated by the pathogenic agent on the myocardium and the vessels. Dehydration of the body causes thickening of the blood, evokes circulatory and haemostatic disorders. Cordiamine, caffeine, ephedrine, and norepinephrine are given to neutralize the action of toxins.
Vitamin therapy is useful from the very beginning of the disease;
especially important this therapy is in long-standing and chronic diseases and in the presence of complications. Vitamins given together with hormones and enzymes catalyze the metabolic processes.
Vitamin Bi facilitates correction of some nervous disturbances, vitamins А, С and Bi decrease the toxic effect of antibiotics, vitamins C, B, PP and P produce an anti-inflammatory and detoxicating action, vitamin P decreases brittleness and permeability of vessels, vitamin К promotes blood coagulation. Depending on the nature of a given disease, vitamin complexes are prescribed; the dose should 3-4 times exceed normal one; during the recovery phase, the dose should be 2-3 times higher thaormal. Vitamins are given per os or intravenously with glucose solutions (vitamin С as a 5 per cent solution of ascorbic acid; vitamin B as a 6 per cent solution).
Blood transfusion produces a neuroreflex effect on body reactivity, stimulates resistance to infections, and performs a haemostatic and replacement role in haemorrhages. Blood is transfused in protracted and chronic diseases, in the presence of complications (typhoid fever, scarier fever). Two or three transfusions at 3-4 day intervals are necessary.
Plasma can be infused instead of blood. Plasma is available in the dry form in ampoules. Before use, it is dissolved in distilled water. Plasma is infused intravenously in a dose of 50-100 mL to children with protracted and chronic dysentery and with other infections.
Autohaemotherapy, polyglobulin, and interferon (in viral infections) are also used.
Symptomatic therapy is aimed at elimination of separate symptoms that usually develop as a result of toxaemia: amidopyrin with phenacetin are given for headache, hypnotics are effective against insomnia.
PROPHYLAXIS OF INFECTIOUS DISEASES
At the last decades certain successes were achieved in fighting with infectious diseases, massive epidemics of most dangerous infectious diseases (epidemic typhus fever, plaque, smallpox, tick-borne relapsing fever and other). The struggle is realized successfully with diphtheria, poliomyelitis, measles, and many zoonozic infections. Undoubt success is achieved in malaria control. However, the deliverance of humanity from malaria requires time, considerable efforts and great expenses. More than billion cases of infectious diseases of gastrointestinal and respiratory tract are registered in the world every year. For example, grippe is registered in separate years in 10-15 % of population only of the countries of
Thus, prophylaxis of infectious diseases is actual question. The measures of prophylaxis of infectious diseases may be conditionally divided on 2 groups: general and special, measures. The general measures are state measures, directing on increase of material favorable condition, improvement medical service, and conditions of work and rest of the population, sanitary-technique, hydrotechnic measures and also international measures in attitude of quarantine infections.
It is known about 3 links for development of epidemic process: the source of infection, ways of the transmission and susceptibility of the organism. The absence or rupture either of this links leads to cessation of epidemic process.
There are 3 groups of prophylactic measures:
1. The measures directing on the source of infection, its elimination.
2. The measures, directing on the mechanism of the transmission of infection. Their purpose is rupture of the ways of transmission of infection.
3. The measures directing on increasing of unsusceptibility of population to infection.
Prophylactic measures, directing on the source of infection play an important role. It is known that when antroponozic infection the source of infection is a sick man or carrier of the agent. The source of infection is sick animal at zoonotic infections. Prophylactic measures of this group are diagnostic, isolative, medical and regimen-limitary measures. In some infectious diseases hospitalization into infectious hospital is obligatory (especially dangerous infections, typhoid fever, epidemic typhus, diphtheria, meningococcal disease). In other diseases isolation may be at home if epidemiological and clinical antividences are absent (shigellosis, escherihiosis, measles and others).
An important prophylactic measure is active revealing of carriers and their sanation. Revealing of carriers is performed in focuses of infection, among reconvalescents, and also among persons of food establishments, water pipe stations, and children’s establishments. It is necessary to perform their bacteriological examination and treatment.
Isolation of persons, contacting with patient is necessary in case of especially dangerous infections (plague, cholera). The duration of isolation depends on maximal incubation period: in plague – 6 days, in cholera – 5 days. This measure is named observation. Observation is one of the quarantine measures. The word “quarantine” was originated from Italian word quarantine (quaranta gieri – 40 days). At this historic period duration of incubation period was not known. Because isolation of patients with plague and some other infectious diseases was 40 days.
The measures about sanitary guard of borders have an important meaning. In 1969 on Universal Public Health Assembly “International medical-sanitary roles” have been accepted. Infections, having international meaning are divided on 2 groups:
Diseases, which are submitted to these roles (plague, cholera, yellow fever).
Diseases for international surveillance (epidemic typhoid fever, tick-borne relapsing fever, grippe, poliomyelitis and malaria).
All countries-members of World Health Organization should be done information about all cases of this diseases, and also perform corresponding antiepidemic measures. In zoonozic infections prophylactic measures have one’s own features. If the source of infection are domestic animals, that it is necessary to perform sanitary-veterinary measures about their health. If the source of infection mousses and rats it is necessary to perform are deratization.
In prophylaxis of infectious diseases an important measure is influence on mechanism of transmission of infection. Transmission of the agent from sick man to healthy man is realized with help of different factors (water, food, air, dust, soil and other). Prophylactic measures, directing on the second link of epidemic process are divided on 3 groups: sanitary-hygienic, disinfection and disinsection. The basic factors of transmission of the agent are food water, rarely-flies, dirty hands in case of intestinal infections with fecal-oral mechanism of transmission of infection (typhoid fever, cholera, shigellosis). In prophylaxis of these infectious diseases general sanitary and hygienic measures have the most important meaning.
Prophylactic measure, directing on the ways of transmission is disinfection, which is performed in the focuses of infectious diseases, public place (railroad station, transport, and public toilets).
At infections of the respiratory tract (measles, rubella, diphtheria, scarlet fever, meningococcal infection, grippe) preventive measures are sanation of air, application of respirators. Disinfection is performed only due to scarlet fever and diphtheria, because the agents of the majority infections of respiratory tract are nonresistant in environment.
At transismissive infections the method of disinsection has the great meaning, directed on distruction of insects.
The measures, directed on the third link of epidemic process are increasing general nonspecific resistance of the organism and also specific prophylaxis. Specific prophylaxis is directed on creation of artificial immunity (active or passive) against infectious diseases.
Specific prophylaxis is performed with help of vaccines, anatoxins serums, gammaglobulines. Vaccines and anatoxins create active immunity, serums and gammaglobulines – passive immunity. Vaccines are divided on living and killed vaccines.
Microorganisms with weakening of virulence are used for preparation of vaccines. In 1798 Edward Jenner proposed vaccine against smallpox, containing agent of cowpox. This agent has a little virulence for humans. Jenner called his new method of preventing smallpox “vaccination”, from the Leatin word “vacca”, that is “a cow”. In 1885 Paster proposed vaccine against rabies from weakening vaccine strain. Living vaccines are used for prophylaxis such infectious diseases, as tularemia, poliomyelitis, yellow fever, measles and other. These vaccines create tense and prolonged immunity (
Killed vaccines are divided on corpuscular and molecular (chemical). Killed vaccines are used for prophylaxis of intestinal infections. Efficiency of killed vaccines is less, than living vaccines. The duration of immunity is from 6 months till 12 months.
Anatoxins are also used for creation of artificial active immunity. Anatoxins have no toxic properties, but they preserve antigenic and immunogenic properties. At the present time anatoxins are used for prophylaxis of diphtheria, tetanus, botulism.
Artificial active immunity appears after injection of vaccine through few weeks. Artificial passive immunity develops more quickly. It is caused by injection of blood serum with ready antibodies (immune serums and immunoglobulines). There are preparations used for prophylaxis of tetanus, measles, tick-encephalitis and other infectious diseases.
TYPHOID FEVER AND PARATYPHOID
Control of Salmonella, typhi infection transmitted from person to person depends on high standards of personal hygiene, maintenance of a supply of uncontaminated water, proper sewage dispose and identification, treatment, and follow-up of chronic carriers. Hand washing is of paramount importance in controlling person – to person spread although hands of convalescent carriers are often contaminated after defecation detectable Salmonella are easily removed by washing the hands with soap and water.
Typhoid fever vaccine, a saline suspension of aceton or heat/phenol killed S.typhi enhances the resistance of human beings to infection with S.typhi under experimental and natural conditions. Vaccine efficacy ranges from 51 to 67 %.
There is also renewed interest in testing the capsular polysaccharide of S.typhi (Vi antigen) as a parenteral typhoid fever vaccine.
Typhoid fever vaccine should be considered for persons with intimate continuing exposure to a documented typhoid fever carrier and for persons traveling to areas where there is a recognized appreciable risk to exposure to typhoid fever.
SHIGELLOSIS
Prophylaxis of shigellosis includes complex of measures, directed to revelate the source of the infection, interrupt the ways of the transmission, increase of the organism resistance. Keeping the rules of personal hygiene and rules of food’s cooking plays the principal role in prophylaxis of the disease. Sanitary education of population has an important meaning in shigellosis prophylaxis too.
SALMONELLOSIS
The measures of prophylaxis are veterinary-surveillance upon animals and production of meat and dairy industry, laboratory control of food stuffs.
It is necessary to reveal carriers on milk farms, in foods, children’s and medical establishments. The maintenance of the rules of personal hygiene and rules of food’s cooking plays an important role in prophylaxis of Salmonellosis.
CHOLERA
The measures of prophylaxis depend on epidemic situation in the country. The information of world health organisation about cases of cholera in different countries has an important meaning.
The incidence of disease can be diminished by sanitary-hygienic measures, sanitary disposal of human feces, purification and protection of water supplies, pasteurization of milk and milk products, strict sanitary supervision of preparation and serring of flood exclusion of persons with diarrhea from handling food, organization of the work about diseases of gastrointestinal tract and their examination on cholera.
Specific prophylaxis of cholera is performed by corpuscular vaccine and cholerogen-anatoxin.
Parenterally inoculated killed complete cell vaccine has been available for years, this vaccine stimulates high titers of serum vibriocidal antibodies, but it does not induce antibodies to toxin. Protection by vaccine has been induced for approximately 1 years, with vaccine efficacy approximately 70 %. Local gastrointestinal tract immunity against the organism and against the toxin should provide a better, less reactogenic immunogen using recombinant DNA technology an “attenuated” V. Cholerae organism that lacks the genes for production of the A and B subunits of toxin was created. A plasmid containing the subunit gene was then constructed and inserted. Thus a candidate live V.cholera vaccine containing all the cell-was antigens necessary for adherence and the capacity to produce only the subunit of toxin has been engineered.
LEPTOSPIROSIS
The deratization and sanitation veterinary measures the essential part of the prevention. Deratization is for decreasing of the activity of the natural foci (wild rodents control) and the sanitation of the anthropurgias foci (the sinanthropos rodents control).
One of the directions of leptospirosis prevention is the actions which break the transmission of the disease by water in the natural foci (mechanization of me agricultural work, the supplying of workers with water-proof clothes, a ban to swim in the infected reservoirs and to use unboiled water). Vaccination is recommended for the people who permanently stay in the natural foci. The people who belong to a group of high risk infection (cattle-breeders, veterinary doctors, the meat packing plant personal, night-men, deratizators) should be vaccinated with inactivated vaccine.
ANTHRAX
Early in this century, as an example of health preventive intervention, a formaldehyde disinfecting station was built by the British government in
The resistance of the spore form of B. anthracis to physical and chemical agents is reflected in the persistence of the organism in the inanimate environment. Organisms have been demonstrated to persist for years in factories in which the environment became contaminated during the processing of contaminated imported materials of animal origin. Accordingly, they may serve as the source of infection for people who work in the area. Special efforts are required to decontaminate this environment; one method is to use paraformaldehyde vapor, which is successful in killing B. anthracis spores. In the laboratory, surfaces may be decontaminated with either 5 % hypochlorite or 5 % phenol (carbolic acid); instruments and other equipment may be autoclaved.
Employees should be educated about the disease and the recommendations for working in a contaminated environment and for reducing the risk of developing the disease. Medical consultation services should be available to the employees. Adequate cleanup facilities and clothes-changing areas should be available so that workers do not wear contaminated clothes home.
It should be noted that the risk of industrial infection has been reduced significantly as the use of imported animal products decreased because of changing business conditions, the increased use of synthetic materials, and the use of human vaccine.
Gastrointestinal anthrax can be prevented by forbidding the sale for consumption of meat from sick animals or animals that have died from disease. Depending on the circumstances, it may be important to alert individuals who may come in contact with contaminated meat about the disease and about the need to cook all meats thoroughly. Prophylactic penicillin may be used if contaminated food has been ingested.
Animals that graze in areas known as anthrax districts should be vaccinated annually with the animal vaccine. All animals suspected of dying from anthrax should be examined microbiologically: blood or tissue smears can be examined microscopically, and cultures can be set up from these same materials. Necropsies with spillage of contaminated blood with resultant sporulation of organisms should be avoided. All animals that have died with a confirmed diagnosis of anthrax should be thoroughly burned and the remaining bones and other materials buried deeply.
Control of the disease in humans ultimately depends on control of the disease in animals. Effective animal vaccines are available, and all cases should be reported to state veterinary authorities.
Both an attenuated live vaccine and a killed vaccine have been developed. However, the only human vaccine in current use in the
VIRAL HEPATITIS
If the patient is hospitalized, he should be placed in a private room with separate toilet facilities. The major reason for such isolation is to prevent the spread of type A hepatitis. Even with lax precautions, such spread is very rare; most patients with type A hepatitis are no longer excreting virus once they have become symptomatic. Nevertheless, there are exceptions, and isolation is prudent. Secretions and blood products should be handled with care gowns, masks, and gloves are not necessary, but a prominent sign reading “needle and blood precautions” is appropriate. Labeling of blood specimens from a patient with hepatitis, is a common practice. It should be stressed, however, that all blood from any patient should be handled as if potentially infectious.
If the patient with viral hepatitis is at home, the patient should be advised about care in personal hygiene – careful hand washing. Attention also should be paid to blood and blood products and the handling of cuts and lacerations.
Recommendations regarding the prevention of acute hepatitis are governed by the type of viral hepatitis that is being considered. In the case of acute type A hepatitis, all family members, and close personal contacts should receive immune serum globulin (ISG) at a dosage of 2-5 mL in as soon as possible after exposure. Office, factory, and school contacts do not need to be treated. Immune serum globulin can be given for up to 4 weeks after exposure, but it probably is only effective if given within 7-14 days.
In the case of acute type В hepatitis, prophylaxis only needs to be provided for “regular” sexual contacts. The best form of protection is argued Hepatitis В immune globulin (HBIG) at a dosage of 5 mL in as soon as possible and again 1 month later has been the conventional recommendation in this situation. However, the efficacy of HBIG in preventing the sexual spread of acute type В hepatitis has not been well proved. In addition, there is now evidence that postexposure immunization with HBV vaccine, can attentuate or prevent acute type В hepatitis. Vaccine should be given as soon as possible and then 1 month and 6 months later.
MENINGOCOCCAL INFECTION
Prophylactic measures, directional against the sources of meningococcal infection include early revelation of the patients, sanation of meningococcal carriers, isolation and treatment of the patients. Medical observation is provided in the focuses of the infection about contact persons during 10 days.
The measures, directional on the rupture of the mechanism of the transmission of the infection, consist of performance of sanitary and hygienic measures and disinfection. It is necessary to liquidate the congestion, especially in the closed establishments (children’s establishments, barracks’s and other). The humid cleaning with using of chlorcontaining disinfectants, frequent ventilation, ultra-violet radiation are performed at the lodgings.
The measures, directional on receptive contingents, include increase nonspecific resistance of the people (tempering, timely treatment of the diseases of respiratory tract, tonsils) and formation of specific protection from meningococcal infection. Active immunization is more perspective with help of meningococcal vaccines. There are several vaccines, for example, polysaccharide vaccines A and C.
Vaccine from meningococcus of the group B was also obtained. However, the group B capsular polysaccharide is not sufficiency immunogenic to produce a reliable antibody response in humans to be effective, several solutions to this problem are being studied, including the chemical alterations of the capsular B antigen to make it more immunogenic and the search for other cell wall antigens that are capable of eliciting bactericidal antibodies against B meningococci with a minimum of serious side effects. New vaccines against meningococcus are under development.
DIPHTHERIA
The major manifestations of diphtheria can be prevented in individual patients by immunization with formalin-inactivated toxin. Therefore, documentation of inadequate levels of antitoxin in large proportion of the adult population in
Recommendations from the Immunization Practices Advisory Committee, published by CDC in 1991 are as follows.
For children from 6 weeks to 7 years of age: three 0.5-mL intramuscular injections of (DPT) vaccine should be given at 4-8-week intervals, beginning at 6-8 weeks of age, followed by a fourth dose 6-12 months after the third.
For persons 7 years or more of age: 0.5 mL Td (toxoid—adult) is given twice at a 4-8-week interval, with a third dose 6-12 months later. Because the pertussis component of DPT is responsible for most of its side effects, and the risk of pertussis is much less after age 6, that component of the vaccine is omitted. Moreover, because subjects over age 7 have a higher incidence of local and systemic reactions to the concentration of diphtheria toxoid in pediatric DPT vaccine (7-25 limit flocculation [Lf] units) and because a lower dose of toxoid has been shown to induce protective levels of antitoxin, the Td formulation of vaccine contains a maximum concentration of 2 Lf units of diphtheria toxoid. If the recommended sequence of primary immunizations is interrupted, normal levels of immunity can be achieved simply by administering the remaining doses without need to restart the series.
Booster immunizations: children who have completed their primary immunization before age 4 should receive a booster dose of DPT at the time of school entry. Persons above 7 years of age should receive booster immunization with Td at 10-year intervals. As a help to memory, this should be done at decade or mid-decade intervals (e.g., ages 15, 25, 35, etc., or 20, 3О, 40, etc.). Travelers to areas where diphtheria is still endemic should be particularly careful to be sure their immunization is current. Although the recommended booster dose of 1.5-2.0 Lf units will increase antitoxin levels to above 0.01 IU in 90-100 % of previously immunized individuals, some authorities have recommended using 5 Lf units, because antitoxin levels remain above 0.01 lU/mL for a longer period than with 2 Lf units.
Patients should receive toxoid immunization in the convalescent stage of their disease because clinical infection does not always induce adequate levels of antitoxin. Close contacts whose immunization status is incomplete or unclear should promptly receive a dose of toxoid appropriate for their age, and complete the proper series of immunizations. In addition, they should receive prophylactic treatment with erythromycin or penicillin, pending the results of pretreatment cultures. Given these preventive measures, the prophylactic use of antitoxin is considered unwarranted.
RABIES
In rabies endemic areas, those at high risk of exposure to rabid animals should be given pre-exposure vaccination. These include veterinarians, health care personnel, laboratory workers, and dog catchers. In areas where animal rabies is highly prevalent, especially among domestic dogs, there may even be a case for including rabies vaccine in the expanded programs of immunization for children. In nonendemic areas those who come into contact with imported mammals in quarantine, who work with rabies virus in laboratories, or who intend to travel to rabies endemic areas should be vaccinated. Travelers at particular risk of exposure to rabies are zoologists and other field workers, foresters, cave explorers, and those whose work involves walking and cycling in urban and rural areas of
Postexposure Prophylaxis. Cleaning the wound as soon as possible after a bite or other contact with a rabid animal is essential first aid and is particularly effective for superficial wounds. The wound should be scrubbed with soap or detergent and generously rinsed under a running tap for at least 5 minutes. Foreign material and dead tissue should be removed under anesthesia. The wound should be irrigated with a viricidal agent such as soap solution, povidone iodine, 0.1 % aqueous iodine, or 40 to 70 % alcohol. Quaternary ammonium compounds, hydrogen peroxide, and mercurochrome are not recommended. Suturing may inoculate virus deeper into the tissues and so should be avoided or delayed when possible. The risk of other viral, bacterial, fungal, and protozoal infections must be considered after bites by animals and humans.
TETANUS
Tetanus is preventable in almost all patients, leading to its description as the “inexcusable disease.” A series of 3 monthly intramuscular injections of alum-adsorbed tetanus toxoid provides almost complete immunity for at least 5 years. Patients less than 7 years of age should receive combined diphtheria-tetanus-pertussis vaccine, and other patients combined diphtheria-tetanus vaccine. Routine booster injections are indicated every 10 years; more frequent administration may increase the risk of a reaction. Some patients with humoral immune deficiencies may not respond adequately to toxoid injection: such patients should receive passive immunization for tetanus-prone injuries regardless of the period since the last booster. Most young patients with human immunodeficiency virus (HIV) infection appear to retain antitetanus antibody production if their primary immunization series was completed prior to acquiring HIV. Vitamin A deficiency interferes with the response to tetanus toxoid. A recent report documented tetanus in babies of women immunized with toxoid later shown to be devoid of potency; this disconcerting report underscores the need for quality control in toxoid production.
Although any wound may be inoculated with tetanus spores. Some types of injury are more frequently associated with tetanus and are therefore deemed tetanus-prone. These include wounds that are contaminated with dirt, saliva, or feces; puncture wounds, including unsterile injections; missile injuries; burns; frostbite; avulsions; and crush injuries. Patients with these wounds who have not received adequate active immunization in the past 5 years, or in whom immunodeficiency is suspected should receive passive immunization with HTIG (250-500 IU intramuscularly) in addition to active immunization.
Mild reactions to tetanus toxoid (e.g. local tenderness, edema, low-grade fever) are common. More severe reactions are rare; some are actually due to hypersensitivity to the preservative thiomersal.
MALARIA
Because of increasing drug resistance, alternative measures such as reducing vector-human contact are progressively more (rather than less) important. Insecticide-impregnated bed nets (with permethrin or deltamethrin) markedly reduce intradomi-ciliary vector populations, and should offer significant protection against the risk of malaria. Alternatively, insect repellents such as N,N diethyltoluamide (DEET) may also reduce the risk of transmission and infection.
Because malaria does not produce immunity, there is no model of effective immunity to plasmodial infection, and no guarantee that numeral or cellular immune responses to specific antigens will protect against either infection or disease. In fact, one of the major unsolved questions is whether different mechanisms may be responsible for protection from infection vs. disease.
PLAGUE
Dispensary observation during 3 months it’s necessary for reconvalescense with obligatory bacteriological researching from mucosa of pharynx and sputum.
It is necessary to protect people from expansion of plague diseases. This work is carried out by workers of sanitation center, ambulatory – polyclinic network and antiplague establishments. Plague is the quarantine diseases, so on it the international medicosanitary rules (WOPH, 1969) there are distributed.
Workers of the general medical network observe health of the population with the purpose of early revealing the patients on plague. Each medical worker should know the basic attributes of disease, the rules of personal prophylaxis, be able to carry out initial antiepidemic actions.
At presence of epizootia among rats and diseases of camels vaccination of the population by local services under the control of antiplague establishment will be carried out. As active immunization use living plague vaccine (dose for epicutaneous indication for children till 7 years 1 billion, 7-10 years – 2 billion, adults 3 billion microbes bodies, at a hypodermic immunization 1/10 of epicutaneous doses). Immunity is kept during 6 months, then if it necessary will spend revaccination in one year.
At occurrence of a plague among the population the antiepidemic actions carry out wich is directed on localization and liquidation of epidemic pesthole. They include: revealing of patients and their hospitalization in special hospitals in isolation wards with severe antiepidemic regime; and establishment of territorial quarantine: revealing and isolation of all persons which was in contact with patients they must be isolated for 6 days and will carry out emergency prophylaxis by antibiotics – Streptomycinum 0.5 gm 2 times per day in muscle or Tetracyclinum on 0.5 gm 3 times per day inside during 6 days); revealing the patients with fever and their hospitalization in special departaments; final disinfection, and also disinfestation and deratization at territory of settlement and around it. Invaluable things are liable to destruction. The personnel should be work in antiplague costumes. For persons who need to leave zone of quarantine, will carry out an observation.
TULAREMIA
The prophylaxis includes the control over the natural foci, the interruption of the mechanism of the disease transmission, as well as the vaccination of the population in the epidemic foci. The planning and the fulfillment of this work in the tularemia foci are done by the sanitary-antiepidemic service with the participation of the medical workers of the medical institutions who perform the rounds in the houses and the vaccination of the population.
AQUIRED IMMUNODEFICIENCY SYNDROME
(AIDS/HIV infection)
Most infections occur as a result of repeated and close contact with a carrier of HIV, specifically mucous membrane contact with blood or body fluids of the carrier. Sexual relationships are the major source of such contacts, and people must be educated to modify sexual practices, to avoid sexual encounters with persons in high-risk groups, reduce the number and frequency of sexual contacts, avoid high-risk practices (eg, anal intercourse), and use protective devices such as condoms. Consistent use of condoms should reduce transmission of HIV by preventing exposure to semen and infected lymphocytes. Whether symptomatic or not, persons who know they carry the HIV virus should be counseled to avoid sexual contacts in which body fluids may be exchanged with uninfected persons.
Since HIV may be transmitted in utero or during or after birth, women carriers and those in high-risk groups should be counseled, and testing for antibody to HIV should be offered to women in high-risk groups. Women known to be HIV-positive should be advised to defer pregnancy.
Parenteral drug users need to be educated and counseled with regard to the risk of sharing needles with other drug users.
Testing for antibody to HIV should be offered on a confidential basis to anyone requesting it, but only in conjunction with pre- and post-test counseling by someone familiar with its significance. Confidentiality is necessary because the patient’s job, insurability, and social life can be jeopardized. Counseling is necessary because test results require sophisticated analysis; patients need to be well informed before the tests are performed, and the results must be fully explained afterward.
HIV carriers and persons belonging to a high-risk group (even if their HIV antibody test results are negative) should not donate their blood (or organs for transplantation), and should inform medical and dental professionals of their status. The latter should wear gloves when examining all patients if contact with mucous membranes may occur, and body fluids and tissue samples should be handled in the same manner as those from patients with hepatitis B.
Accidental needle sticks of health care personnel are remarkably common and special emphasis must be placed on teaching all health care students and professionals how to avoid these potentially very dangerous accidents. While the risk of HIV transmission appears to be much less than that of hepatitis B transmission, the potential consequences are much worse.
Patients with HIV infection generally need not be isolated in the hospital, except when their complicating infections (eg, suspected or proven TB) require that other patients and hospital personnel be protected. Surfaces contaminated by blood or other body fluids should be cleaned and disinfected; HIV is readily inactivated by heat and commonly used disinfecting agents, including peroxide, alcohols, phenolics, and hypochlorite. Although AIDS patients are not particularly contagious to other hospital personnel or patients, their body fluids and blood should be handled with extreme care, following the same procedures used with patients who carry hepatitis B virus.
INFECTIOUS DEPARTMENT AND HOSPITAL
Infectious departments and hospitals are intended for isolation of infectious patients for the time during which they remain dangerous to the surrounding people, and also for treatment of such patients after the diagnosis is established.
An infectious hospital has two major divisions: the diagnostic unit and the therapeutic department. An infectious hospital must be provided with units for intensive therapy and reanimation (resuscitation), a surgical department, laboratories for clinical, bacteriologic, serologic, virologic and biochemical studies, a pathologico-anatomic department and mortuary.
Each hospital must also have a unit where all medical tools and instruments can be sterilized.
The admittance unit must have separate cubicles, with their separate entrances and exits, for patients with different infectious diseases. Each cubicle should be provided with separate conveniences, such as cloak-room, showers, baths, etc.
During admittance to an infectious hospital, after establishing a tentative diagnosis, material should be taken from the patient for its laboratory examination. The ambulance car in which the patient was brought to the hospital and the cubicle should be disinfected with a 0.5-1 per cent chloramine solution.
Patients with mixed infections or dubious diagnosis, should be placed in isolated wards or rooms provided with all facilities and conveniences.
In order to prevent nosocomial infections, infectious patients of general hospitals should be kept in a separate building. (Patients with similar diseases should preferably be placed in separate buildings.) Rooms for critical patients should be provided. Medical and paramedical personnel should have all facilities separately from the patients (lavatories, canteens, etc.).
Rooms, where infectious patients are kept, should be regularly aired and treated with ultraviolet rays (3 times a day for 40 minutes).
Rooms should be cleaned with a 0.5 per cent chloramine solution at least three times a day. Lavatories should be cleaned at least 4 times a day with a 0.5 per cent solution of chlorinated lime. Soiled lavatory pans should be cleaned immediately.
Table dishes should be boiled in a 2 per cent sodium hydrocar-bonate solution for 15-30 minutes after each meal; chloramine solution can also be used, but after such treatment all dishes should be rinsed in hot (100 °С) water. Food residue should be treated with dry chlorinated lime.
Only rubber or plastic toys can be given to children since these are easy to disinfect. Medical personnel must see to it that the patients observe individual hygiene rules.
Critical patients should be given a separate nurse for 24-hour observation. A signal button must be provided at bedside of each patient in all wards.
A patient can be discharged from an infectious hospital only for special indications (favourable results of laboratory examinations, termination of therapeutic course, normal body temperature, etc.).
Before leaving a hospital, the patient takes bath or shower and puts on clean and disinfected clothes.
The room where the patient remained during his stay in the hospital should be given a final disinfection. Soiled linen should be sent in a special bag to the disinfection chamber. The concentration of chloramine solution by which the room is disinfected depends on a particular infection.
Hygiene requirements for medical personnel Medical and paramedical personnel of an infectious hospital must keep their clothes in separate boxes. The personnel must wear special overalls and keep them clean. Nails must be cut short.
Materials for laboratory examinations (blood, urine, faeces, vomitus, cerebrospinal fluid) should be taken and handled in conditions that exclude infection of the personnel or other patients.
After inspection and examination of the patient, or after any other manipulation associated wilh patient’s care, the personnel must wash their hands with a 0.5 per cent chloramine solution and then with warm water.
Prevention of nosocomial infection. A nosocomial infection is an infection that develops in a patient inside a hospital in a lapse of time that exceeds the duration of the incubation period of a given infection, or an infection that develops in a patient after his discharge from the hospital in a period of time that is shorter than the incubation period for a given infection.
Extrahospital infection implies cases of infection before hospital-ization (the patient is admitted to the hospital during the incubation period of a given infection). Among nosocomial infections, most common are air-borne infections, such as influenza and acute respiratory diseases, chickenpox, rubella, epidemic parotitis, scarlet fever, or measles.
Nosocomial infections result from admittance to the hospital of patients with unrevealed diseases.
Anti-epidemic measures should be taken in cases of development of nosocomial infections. These measures are aimed at prevention of infection spread. Quarantine should be established whenever necessary. During this period, only those patients can be admitted to the hospital who have already sustained this particular disease.
The first patient with a nosocomial infection should be isolated from the others or placed in a mixed-infection ward, while the room and objects that were used by this patient must be disinfected.
Other patients and personnel who had contacts with the nosocomial infection patient should be observed during the incubation period. Depending on the disease, they should be given immunoglobulin (prophylactic therapy) and tested for the carrier state.
Care and Nutrition of Infectious Patients
Proper care is an important curative and preventive factor. It is decisive in children and critical patients. Considerate care strengthens the patient’s belief in his recovery and restoration of the working capacity.
The medical and paramedical personnel should take care of patient’s hygiene and the condition of his bedding. The patient must be given a bath at least once a week. If the patient’s condition is critical, his body should every day be rubbed with a wet towel. Patient’s underwear and linen should be changed each week or, if necessary, every day or immediately. All patients must be washed in the morning. Children and critical patients should have their faces and handy washed with warm water.
To prevent bedsores, the skin of patients with severe diseases should be coated with vegetable oil or camphor alcohol at sites where bedsores are more likely to develop. The patient must be helped to turn from side to side; inflatable cushions should be placed under the patient, if necessary.
Body temperature should be taken twice a day. The configuration of the temperature curve is important diagnostically. Great temperature variations indicate complications or change in the course of the disease.
If symptoms of toxaemia develop (headache, delirium, high body temperature), ice should be applied to the patient’s forehead for 20 minutes (at 25-30 minute intervals).
If the patient complains of insomnia, he should be given a hypnotic an hour before night sleep. The condition of the patient must be constantly observed. His cardiovascular system should be controlled (pulse frequency and strength). The function of the respiratory system (frequency of respiratory excursions per minute, the character of respiration, the presence of cough, expectoration of sputum), of the alimentary system (inflation of the abdomen, constipation, diarrhea, vomiting), and of the urinary system (frequency of urination, the character of the urine, its colour and other properties) should be controlled.
Nutrition is an important curative factor. Patients and convalescents should be given at least 4 meals a day. Food must be adequate, i.e., contain all necessary nutrients, salts, vitamins; it must be caloric. The patient must be given fresh vegetables, fruits, berries, fruit juices.
When prescribing a diet, it is necessary to consider the pathogenesis and the course of the disease. For example, a patient with typhoid fever should be given a sparing diet because of the ulceration in the intestine. Food must be liquid or semiliquid. Meat broth, kissels, dried bread, curds, kefir, boiled steamed-cured chopped meat, porridge rubbed through a sieve, and fruit juices should be given. Dietary restrictions should be gradually removed in shigellosis and typhoid fever patients during the recovery phase; the caloric value of the diet should be increased. Food must be sparing mechanically. All dishes should be chopped or rubbed through a sieve. Dietary habits and the appetite of the patient must be considered as well. The appearance of food is also important.
Liquid must be given in adequate amount in order to ensure withdrawal of pathogenic microbe metabolites from the patient’s body. Patients must be given tea with lemon, stewed fruits and berries, and juices.
Addition 1
The incubation period of some infectional diseases
|
Disease |
Duration of the incubatory period |
||
|
minimal |
maximal |
average |
|
|
1 |
2 |
3 |
4 |
|
Food poisoning Botulism Salmonellosis Cholera Shigellosis Plague Anthrax Staphylococcus disease ARVI: Flu
Rhinovirus infection RS-infection paraflu adenovirus disease Meningococcus disease Enterovirus disease Aphthosa Rotavirus disease Diphtheria Gonococcus infection Esherihiosis Scarlet fever Tularemia Intestinal ersiniosis Pertussis and parapertussis Pseudotuberculosis Scabies Paratyphus B |
0,5 hours 6 hours 6 hours 12 hours 1 day 12 hours 12 hours
2 hours
12 hours
1 day 3 days 48 hours 4 days
2 days 2 days 2 days 2 days 2 days 1 day 3 days 1 day 1 day 1 day
2 days 3 days 2 days 2 days |
24 hours 10 days 3 days 5 days 7 days 6 days 8 days
7 days
3 days 168 hours 6 days 7 days 6 days 14 days
14 days 7 days 7 days 15 days 10 days 15 days 6 days 12 days 21 days 6 days
14 days 18 days 14 days 18 days |
1-12 hours 18 hours 24 hours 1-3 days 2-3 days 2-3 days 2-3 days
2-4 days
1-2 days
4-5 days 5-7 days 3-5 days 5-7 days
5-7 days 3-4 days 3-5 days 3-5 days 3-5 days 3-5 days 4-5 days 3-6 days 3-7 days 1-2 days
5-7 days 5-7 days 7 days 5-8 days |
|
Leptospirosis Tetanus Hemorrhagic fevers: Lass Abbol Crimea-Congo with renal syndrom Measles Poliomyelitis Tick encephalitis Puffing |
4 days 3 days
3 days 4 days 2 days 4 days 9 days 5 days
2 days |
14 days 1 month
17 days 16 days 14 days 49 days 17 days 35 days 21 days |
7-9 days 7-10 days
6-7 days 5-8 days 7-10 days 12-15 days 10 days 10-12 days 10-12 days 10-14 пор |
|
Rickettsiosis: north Asian Marseilles fever Epidemic typhus Q-fever Volynska fever Paratyphus A Typhoid fever Chicken pox Epidemic parotitis Rubella Brucellosis Syphilis Malaria: tropical three-days tachyform four-days bradyform Leishmaniosis: skin visceral Helminthiasis: trichinelliasis enterobiasis strongiloidosis opistorhosis trichocephaliasis ascariasis taeniorhynchus and teniasis echinococcosis and alveococcosis Amebiasis Tuberculosis Hepatites A Hepatites Е Hepatites C Hepatites B HIV – infection
Rabies |
4 days 3 days 6 days 3 days 7 days 3 days 7 days 11 days 11 days 11 days 7 days 8 days
8 days 10 days 21 days
7 days 21 days
2 days
Some months
7 days 14 days 2 weeks 1,5 months 2 weeks
7 days |
7 days 18 days 25 days 32 days 1 months 10 days 25 days 21 days 23 days 24 days 24 days 4 weeks
16 days 14 days 42 days
1,5 months. 1 year
28 days
Some years 4 months.
45 days 50 days 26 weeks 6 months 5-8 years and more |
4-6 days 5-7 days 10-12 days 10-14 days 10-15 days 8-10 days 10-15 days 13-17 days 15-19 days 16-20 days 14-21 days 21-30 days
10-14 days 10-20 days 1 months.
1 months 3-5 months
9-10 days 12-14 days 17-20 days 20-30 days 30-45 days days 56-70 days
20-40 days 20-60 days days 30-40 days 40-50 days 2-6 months 2-6 months 1-2 months
1-3 months |
Addition 2
MEASURES FOR THE PATIENTS WITH INFECTIOUS DISEASE AND PERSONS WHO WERE IN CONTACT WITH THEM
|
Disease |
Duration of the incubatory period |
||
|
minimal |
maximal |
average |
|
|
1 |
2 |
3 |
4 |
|
Food poisoning Botulism Salmonellosis Cholera Shigellosis Plague Anthrax Staphylococcus disease ARVI: Flu Rhinovirus infection RS-infection paraflu adenovirus disease Meningococcus disease Enterovirus disease Aphthosa Rotavirus disease Diphtheria Gonococcus infection Esherihiosis Scarlet fever Tularemia Intestinal ersiniosis Pertussis and parapertussis Pseudotuberculosis Scabies Paratyphus B |
0,5 hours 6 hours 6 hours 12 hours 1 day 12 hours 12 hours
2 hours
12 hours
1 day 3 days 48 hours
4 days 2 days 2 days 2 days 2 days 2 days 1 day 3 days 1 day 1 day 1 day 2 days 3 days 2 days 2 days |
24 hours 10 days 3 days 5 days 7 days 6 days 8 days
7 days
3 days 168 hours 6 days 7 days 6 days
14 days 14 days 7 days 7 days 15 days 10 days 15 days 6 days 12 days 21 days 6 days 14 days 18 days 14 days 18 days |
1-12 hours 18 hours 24 hours 1-3 days 2-3 days 2-3 days 2-3 days
2-4 days
1-2 days
4-5 days 5-7 days 3-5 days
5-7 days 5-7 days 3-4 days 3-5 days 3-5 days 3-5 days 3-5 days 4-5 days 3-6 days 3-7 days 1-2 days 5-7 days 5-7 days 7 days 5-8 days |
|
Leptospirosis Tetanus Hemorrhagic fevers: Lass Abbol Crimea-Congo with renal syndrom Measles Poliomyelitis Tick encephalitis Puffing |
4 days 3 days
3 days 4 days 2 days 4 days 9 days 5 days
2 days |
14 days 1 month
17 days 16 days 14 days 49 days 17 days 35 days 21 days |
7-9 days 7-10 days
6-7 days 5-8 days 7-10 days 12-15 days 10 days 10-12 days 10-12 days 10-14 days |
|
Rickettsiosis: north Asian Epidemic typhus Q-fever Volynska fever Paratyphus A Typhoid fever Chicken pox Epidemic parotitis Rubella Brucellosis Syphilis Malaria: tropical three-days tachyform four-days bradyform Leishmaniosis: skin visceral Helminthiasis: trichinelliasis enterobiasis strongiloidosis opistorhosis trichocephaliasis ascariasis taeniorhynchus and teniasis echinococcosis and alveococcosis Amebiasis Tuberculosis Hepatites A Hepatites Е Hepatites C Hepatites B HIV – infection Rabies |
4 days 3 days 6 days 3 days 7 days 3 days 7 days 11 days 11 days 11 days 7 days 8 days
8 days 10 days 21 days
7 days 21 days
2 days
Some months
7 days 14 days 2 weeks 1,5 months 2 weeks
7 days |
7 days 18 days 25 days 32 days 1 months 10 days 25 days 21 days 23 days 24 days 24 days 4 weeks
16 days 14 days 42 days
1,5 months. 1 year
28 days
Some years 4 months.
45 days 50 days 26 weeks 6 months 5-8 years and more |
4-6 days 5-7 days 10-12 days 10-14 days 10-15 days 8-10 days 10-15 days 13-17 days 15-19 days 16-20 days 14-21 days 21-30 days
10-14 days 10-20 days 1 months.
1 months 3-5 months
9-10 days 12-14 days 17-20 days 20-30 days 30-45 days days 56-70 days
20-40 days 20-60 days days 30-40 days 40-50 days 2-6 months 2-6 months 1-2 months
1-3 months |
Addition 3
MEASURES FOR THE PATIENTS WITH INFECTIOUS DISEASE AND PERSONS WHO WERE IN CONTACT WITH THEM
|
Disease |
Measures for the patient |
Measures for persons which are in touch with patients |
|
Typhoid fever and paratyphus A and B |
Hospitalization is obligatory. Sending out from a hospital not earlier than for 21-st day of normal temperature (if not applied antibiotics – on 14‑th) under condition of reception of 2 negative results of bacteriological analyses of stool and the urine takeot earlier of 5‑th day of normal temperature with a 5-day’s interval between them. |
Supervision during 21 days with daily thermometry (at paratyphus– 2 weeks). Unitary bacteriological research of stool and RSGA with cistein. At allocation of the agent from stool – repeated research of bile, urine and stool, at positive RSGA-at once. Fagoprophylactic three times with an interval 3-4 days. Final disinfection. |
|
Chicken-pox |
Isolation for 5 days from the last eruption. |
Children till 7 years which were not sick on windy smallpox, are subject to isolation for 21 day from the moment of contact. Disinfection will not carry out |
|
Hepatites A and Е |
Hospitalization in an infectious hospital. Sending out after disappearance of jaundice, normalization liver sizes, restoration of its functions (according to parameters of bilirubin , Аlat). Patients with age from 3 till 30 years with easy course can under the arrangement with the epidemiologist be treated in-home. |
Medical supervision during 35 days (thermometry, the examinatioot less often than 1 time for week, definition of the sizes of a liver, the control of color of urine and stool and etc). Laboratory inspection (the analysis on bile pigments, definition Аlat by micromethod). In children’s preschool establishment quarantine in group; introduction donor hammaglobulin to children till 14 years and to pregnant women; the termination(discontinuance) on 2 month scheduled inoculations, diagnostic remeasures, stomatologic inspections. |
|
Dysentery |
Obligatory hospitalization of decretive groups. Signing from a hospital after clinical recovery at presence of 2 negative results of bacteriological analyses of stool, carried out not earlier than in 2 days after ending of antimicrobal therapy. |
Medical supervision during |
|
Diphtheria |
Hospitalization is obligatory. Signing from a hospital after clinical recovery: at the located forms – after 3 week., toxic 1 degrees – not earlier than for 30-th day, toxic II-III degrees – 50-60-й day from the beginning of illness. Obligatory there are 2 negative results of bacteriological analyses on corynebacteruim of diphtheria from fauces and a nose. |
In the quarantine focus for 7 days, inspection (smear from fauces and a nose on the agent) all contact. Final disinfection of a room, boiling or chamber processing of things. For the revealed carriers of toxygenic strains – sanitation of a nasopharynx, their isolation to reception of 2 negative results of bacteriological analyses on corynebacteruim of diphtheria. Carriers of nontoxic strains the agent from collective do not deduce. At unsuccessful sanitation of carriers suppose in completely inoculated collectives not earlier than for 21-st day from the weekly bacteriological control. |
|
Measles |
Hospitalization for clinical and epidemiological indications. The termination of isolation in 4 days from the beginning of eruption, at complication by a pneumonia – in 10 days. |
Among inoculated against reproach and had been ill measures will not carry out(spend). Notinoculated contact persons at absence of contra-indications urgently inoculates weakened enter gammaglobulin. For notinoculated: isolation of organized children for 17 days; that accepted gammaglobulin, – for 21 day. Medical supervision with daily thermometry and the examination. Disinfection will not carry out |
|
Leptospirosis |
Obligatory hospitalization in infectious, for indications – in resuscitation branch. Signing out – after disappearance of the clinical phenomena and restoration of function of a liver and a kidneys. |
Isolations do not practice. In the focus – deratization. |
|
Meningococcal infection
|
Obligatory hospitalization for the patient with a purulent meningitis and meningococemia, at nasopharingitis at clinical and epidemiological indications. Signing out from a hospital after clinical recovery not later than for 21-st day from the beginning of illness. |
In the organized collectives of inspection contact on carriage twice with an interval of 3-7 days, in domestic focus – 1 time. Isolation for the period of inspection. In the closed collectives medical supervision during 10 days (daily thermometry, the examination of a nasopharynx and a skin), quarantine. At an adverse epidemiological situation of hammaglobulin introduction . Sanitation of carriers. Disinfection, in children’s establishments in addition |
|
Poliomyelitis |
Hospitalization. Signing out after disappearance of the sharp phenomena, but not earlier 40-th day from the beginning of illness, with additional isolation in-home during 12 days for organized children. |
Quarantine for 21 day, the daily medical examination with thermometry. Once immunization irrespective of the term and completeness of having inoculations. Disinfection. |
|
Salmonelosis |
Hospitalization. Signing out after clinical recovery with 1 control research of stool, carried out not earlier than in 2 days after the expiration of treatment; for foodworking and organized children – 2 bacteriological research of stool and urine. |
Medical supervision in the focus during 7 days, once bacteriological inspection on carriage (stool, urine). |
|
Scarlet fever |
Hospitalization for clinical and epidemiological indications. Isolation to clinical recovery, but is not less than for 10 days from the beginning of illness. For decretive groups: organized children till 8 years – additional isolation in domestic conditions for 12 days, adults – workers children’s and medical institutions, dairy kitchens – on such time going on another (epidemically safe) work. |
The patient with quinsy from the focus of a scarlet fever can’t go to children’s and medical institutions, on dairy kitchens during 22 days from the beginning of disease. Isolation for 7 days of children till 8 years which were not sick on a scarlet fever. For had been ill on a scarlet fever and grown-ups children, adults decretive groups – medical supervision during 7 days after isolation of the patient. In case of continuation of dialogue with patients during all illness the term prolong about 17 days from the beginning of contact. Disinfection. |
|
Epidemic typhus |
Provisory hospitalization of the patient with long-term fever, with the unstated diagnosis. Hospitalization of the patient on petechial typhus is obligatory. Signing out after clinical recovery not earlier than in 12 days of normal temperature. |
Medical supervision in the focus during 25 days – daily thermometry, Serological inspection in RCK, RUGA. The examination on pediculosis. Sanitary processing. Chamber disinfection. |
|
Cholera |
Obligatory hospitalization in hospital. Signing out from a hospital after full clinical recovery, realization of 3-single daily bacteriological research of stool on cholera vibrion which need to be beguot earlier as in 24-36 year after stopping of etiotropic therapy; in foodworkers in addition investigate portions In and From bile. |
Urgent isolation of contact. Medical supervision during 5 days, the examination of excrements. Revealing of signal-sorting attributes of a cholera (diarrhea, vomiting, stub) and hospitalization of the patient in provisory hospital. Bacteriological inspection stool inoculation on cholera vibrion). Urgent preventive maintenance by antibiotics. Final disinfection. |
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Epidemic parotitis |
Isolation for 9 days from the beginning of disease. |
Isolation of children under 10 years which were not ill on an epidemic parotitis, for 21 day. Disinfection will not carry out |
