Epidemiology method of research and his structure. Epidemiology diagnostics. Prognostication displays of epidemic process. Planning of prophylactic measures.

Antiepidemic measures in the focus of infections with a fecal-oral mechanism of transmissions (shigellosis, typhoid fever and paratyphoid, viral hepatitis A, cholera).

 

 

THE METHOD OF EPIDEMIOLOGY

 

A complex epidemiologic method is used to study the laws of infection spread among population. The method includes epidemiologic observation and experiment.

Epidemiologic observation, in turn, includes epidemiologic study of the focus of infection (incidental case) and outbursts; statistic analysis of morbidity; study and description of epidemic process on the whole within a given district or area.

Epidemiologic inspection of an infectious focus is necessary to reveal the source of infection and determine the mechanism of its transmission, to estimate the environmental factors and the living conditions that might promote the spread of the infection. Inspection includes analysis of the incidence of a given infection within its focus (residence, office, children’s institution) during 2-3 previous months.

In order to reveal the source of infection and the routes of its transmission, the patient and the surrounding people are inquired, and laboratory tests and experiments carried out. In accordance with the findings, concrete measures are taken to prevent further spread of the infection (see “Prevention of Infectious Diseases and Measures to Control Them”).

An epidemiologic examination of an outburst includes the study of morbidity before the outburst, the dynamics of morbidity during the outburst (by days and longer periods of time), the analysis of morbidity by its main signs, epidemiologic findings in separate foci, clinical course of the disease, the laboratory findings, examination of various objects, isolated strains of the causative agents, materials characterizing the sanitary and technical condition of food catering and other establishments. This complex examination gives information about the type of infection outburst (water-borne, food infection) and causes of its development, which facilitates conduction of rational measures to eradicate the infection outburst.

Analysis of morbidity on the basis of statistic findings is necessary for the study of epidemiology of infectious diseases by some indices during the course of a year, or several years. The infectious process is characterized by numerous indices. The most important of them are distribution of the incidence by age, sex, occupation, season, area, source of infection, nidality, etc.

Statistic data are usually absolute or relative figures, but they can also be presented in the form of tables, graphs, diagrams, and the like.

Primary material for a statistic presentation of an epidemic process is the material collected for each particular case of the disease which is entered into a chart of epidemiologic examination. Statistic analysis gives a summary in absolute indices, which are not, however, convenient for comparison of morbidity in various cities, areas or countries. In order to enable such comparison, absolute figures are converted into mean or relative values. Intensive and extensive indices are usually used in epidemiology.

Intensive indices characterize the distribution of a given infection. The coefficients are calculated from proportions reducing absolute figures to one base (1000, 10.000, 1.000.000 of population). Intensive indices include morbidity, mortality, and lethality.

Morbidity (incidence or sick rate) is the ratio of the diseased during a given period of time (e. g. a year) to the number of residents of a given city or country during the same period. Morbidity is expressed

by the following ratio:

sick persons

————-————— x 100.000

average population

Mortality (death rate) is the number of dead expressed by a coefficient per 100.000 of adult population, and 10.000 of children. The death rate is expressed by the ratio:

number of dead

            x 100.000

average population

Lethality is the percentage of the dead due to the given infection. Lethality index is expressed by the ratio:

number of dead

                   x 100

number of sick persons

Lethality index is used to estimate severity of infection and efficacy of treatment. Statistic analysis enables their comparison with the previous experience and thus to draw conclusions concerning the increase or reduction of morbidity, efficacy of therapeutic measures, and hence to plan further measures.

Description of an epidemic process within a confined area makes it possible to demonstrate the effect of separate elements of social conditions on morbidity.

Experiment includes microbiologic and serologic examinations, entomologic, physical and chemical studies, experiments on humans and animals. Microbiologic and serologic methods are used to study aetiology of infectious diseases, stability of causative agents in environment, inside the macroorganism and resistance to desin-fectants; experiment is also used to diagnose infectious disease, to assess treatment efficacy, to reveal acute and chronic carrier state. Microbiologic tests are used to detect pathogenic microbes in food and water. These tests are also used to locate accurately the source of infection, its transmission routes, time during which a sick person remains dangerous to the surrounding people, and to determine the immunologic structure of population.

Entomologic studies are concerned with ecology of the arthropods, the living carriers of the pathogenic microbes, multiplication of these microbes in the macroorganism in various environmental conditions, and establish the carrier type in a particular disease.

Chemical studies of water, food and other objects are necessary to solve disputable questions (e.g. in order to exclude chemical poisoning).

Single and mass-scale experiments can be carried out on animals and people. Experiments on animals are usually used for diagnostic purposes. Besides, they are used to assess harmlessness and efficacy of new vaccines, sera, immunoglobulins and therapeutic preparations.

New vaccines, sera, or immunoglobulins can be used in experiments on humans only after they have been tried in laboratory (experiments on animals included).

 

METHOD OF EPIDEMIOLOGY ANALYSIS

 

Tasks for independent work.

1. Conducting of epidemiological analysis on given material to present in  (theme XXI), and estimation of influence of different factors on epidemic process. Findings are in  tables and graphs.

2.  For implementation of this work groups should be made of 2-3 students and they should have set of the filled cards of epidemiology inspection on some infection, reflecting annual, half-year or quarterly morbidity.

3. The second conjuncture review is made on the basis of analysis of the prepared digital material, presented as tables.

4. On the basis of findings the plan of prophylactic  measures are made. At making of plan  feature of epidemic situation and  efficiency of the before conducted measures should be considered.

Purpose of epidemiology analysis is a study of character, level and dynamics of epidemic process, what is going in a certain territory (settlement, district, region, edge, republic) in the certain span of time (month, quarter, half-year, year, a few years )

Conducting an epidemiological analysis, an epidemiologist sets before itself the followings problems:

1) To expose conformities to the law of epidemic process and his feature at certain infectious diseases in concrete terms;

2) It is correct to define these conformities to the law, unseal their reasons;

3) It study efficiency conducted in the previous year (or years) of  and prophylactic measures;

4) To work out a plan of measures, directed on a decline or liquidation of separate infectious diseases, taking into account the features of epidemic process of one or another disease in the concrete terms of the proper area.

The study of these questions is needed for correct organization of measures of fight against one or another infection, choice of basic link of measures (directed on sources, ways of transmission or increase of immunity of population) implementation of which can result in the decline of infectious morbidity, and on occasion and to liquidation of it.

The comprehensive study of infectious morbidity of sanitary epidemiological centre conducts one time in a year. Such analysis as a conjuncture review refers in the proper higher organization: from district sanitary epidemiological centre  in city one (region, regional). Regional (regional sanitary epidemiological centre l)after the proper analysis of infectious morbidity on districts and cities of region (edges) makes the reviews of epidemiology’s on the whole on a region and sends in republican  sanitary epidemiological centre or Ministry of health protection of republic.

Except for annual infectious morbidity, the workers of sanitary epidemiological centre analyse morbidity and for more short interval of time (‘month, quarter or half-year), and also separate flashes of those or other infections.

Materials, necessary for an epidemiology analysis. For an epidemiology analysis the followings materials are needed:

1) description of district, cities, regions on the whole; state of dwelling fund, sewage system and cleaning of territory; presence of different objects, factories, factories, artels, food enterprises, markets, stations  etc

2) demographic information for a few years about number  and age composition of population, birth-rate, death rate, migration;

3) information about the social and professional structure of population;

4) Number and sanitary state of schools of nurseries, managers and scope by them  to child’s population;

5) sanitary state of schools, their number and quantity of schoolboys; 

6) state of medical service: and) material well-being by doctors and middle medical personnel;

  presence of number of beds, including infectious bunkers presence of bacteriological laboratories, infectious room of diseases, transport;  taking about immunization of population against separate infections, material well-being of district (cities) by bacterial preparations  state of disinfection business: full strength of the states, presence of transport, disinfectants;

7) information of individual registration of contagious diseases, cards of urgent notification and epidemiology inspection (forms ¹ 58 and 171);

8) magazines of registration of infectious diseases

9) forms ¹ 85-87-ëå÷ and sanitary epidemiological centre  and form;

10) information about a death rate and lethality;

11) information of laboratory researches of material from sick and healthy persons, inspected on the testimonies of epidemiology or according to plan;

12) at the analysis of morbidity zoonological information (quantity and morbidity of rodents, morbidity of wild and home animals by hydrophobia, brucellosis in the whole region , districts and on the inhabited areas

13) at the analysis of morbidity bloody and intestinal infections there is entomological information (quantity of mosquitoes, flies, their infection).

Except for the indicated materials needed:

1) reviews of epidemiological and statistical forms of account of infectious morbidity for a previous year.

2) plan of antiepidemiological work for current period.

A necessity in one or another materials at the epidemiology analysis of morbidity is determined character of the analysed infection. A doctor-epidemiologist must be engaged in the analysis of infectious morbidity. His helper can be attracted only for implementation of technical work (grouping of cards, calculation of indexes, graphic representation of data.).

The study of morbidity, its estimation and comparison of different indexes, must be conducted on the basis of information which can be compared between itself. For this purpose absolute values are little suitable. It is possible to use them only in those cases, when iumerical strength of population there is not any substantial difference and morbidity can be calculated on relatively equal number of persons.

As a rule, the analysis of infectious morbidity must be conducted not on the basis of absolute values, being in most cases uncomparable, and in relative indexes, calculated on the same number of persons.

Taking into account the study of infectious morbidity for greater exactness it is necessary to use relative sizes, expressed in intensive and extensive indexes.

If at the analysis of motion of morbidity on years on some reason it is impossible to calculate intensive indexes, it is possible to use conditional indexes. Thus the number of diseases of certain year is adopted after 100, and the index of morbidity of subsequent years is calculated in relation to the number of the first studied year. On the basis of such information (conditional index) it is possible to judge about direction of epidemic process, but not about its level. The number of population the quantity of which can substantially change for studied period is not quite taken into account thus.

A basic condition, providing high quality of epidemiological analysis, is presence on the areas of valuable document. This work must be executed in medical workers not only in the process of drafting of reports on morbidity but also during everyday work. In order that digital material was more evident, it is expedient to present him as the graphs and cartograms

Method of epidemiology analysis. An epidemiological analysis consists of a few sections. It begins from the detailed description of natural and economic features of territory. Geographical position, climatic terms, fauna, flora, soil, reservoirs of settlement, industrial objects, cultural  welfare and demographic data are cited, is described in this part.

The correctly conducted epidemiological analysis is instrumental in the concrete effective planning of measures on the nearest years on a fight against a certain infection.

The basic section of work is dedicated the detailed analysis of morbidity. It includes the followings information:

1) Dynamics of morbidity on years. It is necessary to analyse morbidity for a few years, because here direction of epidemic process comes to light more exactly. For the analysis of infectious morbidity in years it is necessary to use intensive indexes. Studying the level of epidemic process in a dynamics of years, it is necessary to make an effort to find out reasons of its increase or decline for studied period.

2) Study of distributing of infectious diseases on territory. To select the most staggered areas of city, settlements,burrows  etc and to analyse character of morbidity in them. It is necessary to select settlements (districts) with more high and more low morbidity, explaining reasons of its different level.

For evidence of study of morbidity on territory use the sketch-maps of the inhabited places with causing on them of morbidity. On small territories for the study of morbidity easily to use the sketch-map of district, on which morbidity is inflicted in certain points.

At the study of morbidity on one or another territory for the considerable span of time for greater evidence the making  of cartogram is recommended on the basis of intensive indexes of morbidity. On separate territories (settlements, districts, regions) with the different degree of staggered different strokes are inflicted depending on the level of morbidity, that gives the picture of character of epidemic process on different areas, in different districts, regions, republics both for current period and in different years (for example, morbidity is compared by some infection in 1950 and 1960 or 1940-1960 .). Such card illustrates intensity and scopes of  typhoid and other diseases). The task of epidemiologist consists not only in that, to study distributions of infection.

Analysis of monthly morbidity. At the analysis of morbidity a large value has a study of reasons of advancing morbidity in the certain months of year (seasonality). It is known that seasonality of infections can depend on climatic terms (tick encephalitis, malaria, fever of dengue when the value of reservoir of virus and carry of infection rises in distribution of diseases, and from production and economic activity of man (rabbit-fever, brucellosis.).

The degree of contagiousity can influence one or another infection and change of intercourse of people different periods of year (scarlatina, measles and other). At the row of communicable diseases seasonality can change depending on the terms of life of people and equipping with modern amenities of the inhabited places (dysentery distributing of morbidity on the months of year, but also main to define reasons of getting up of it in separate months. Studying them, it is possible to prevent the so-called seasonal getting up and the same to reduce annual morbidity on the size of this ‘getting up.

On the seasonal spreading of typhoid, dysentery and other intestinal infections the factor of transmission influences. However in every case the role of separate factors of passing to the infection (water, food products) can change. It is important in every concrete terms to define the stake of participation of one or another factor of transmission in the seasonal spread

For correct approach to the analysis of reasons of the seasonal spread of morbidity by infections, especially intestinal group, the careful epidemiology inspection of every case of disease and account of possibilities of spreading communicable diseases  carriers are needed, with water, by food and at a contact in the way of life.

Seasonality of infections can be studied on the basis of absolute numbers of morbidity on the months of year (information of forms ¹ 85-87-ëå÷. and cards of epidemiology inspection of one or another infection). Carefully analysing these materials, it is possible to exclude from the seasonal spread of diseases, related to the flashes or infection as a result of the use of the infected food product or water, and also cases diseases, related to the infection in other settlements.

Morbidity on the months of year can be studied on specific gravity of morbidity of every month in general annual morbidity. For example: in a settlement for a year by a dysentery 120 persons became ill. In January registered 5 cases, in February – 4, in March – 10 and etc the General number of morbidity for a year it is necessary to accept after 100 %, then there will be 4,1 on January %, on February—3,3 % etc

Such method of study of seasonality allows to define the general tendency of morbidity and character of seasonality. However much such method Enables to judge about the level of morbidity. In addition, created inconvenience at the study of monthly morbidity for a few years. Thus after 100 % different general annual morbidity is adopted. More expediently, taking into account the different number of days in a month (there is 31 day in January, and in February—28), to study seasonality (tendency to getting up in separate months) on average to the monthly figures. They are calculated by the division of morbidity in that or other month,íà amount of days in this month. For example, 38 cases of typhoid are incorporated in January. average a monthly index will be equal 1,22 (38:31).

For evidence  study of morbidity on the months of year it is necessary to make the graphs.

If the main task of epidemiologist is a study of character of seasonality, and analysis level of morbidity on the months of year, it is possible to take advantage of next method. There is a number of diseases for every month in the studied years and an average monthly number for a few years, and then — for every month in percents to the sum of all diseases, registered for analysed throughout the year. For example analysis  for 10 years 7000 cases of hepatitis are registered. In January for these throughout the year 250 persons became ill, in february 180 and etc the Common amount of the registered patients is adopted after 100%, and average of every month is calculated ‘(3,5% will make for January patients, after february—’2,5% and ò. of ä.).

Analysis of age morbidity. Analysing morbidity, an epidemiologist must define how the persons of different ages are often ill. The study of this question allows correctly to organize a fight on the decline of morbidity among the separate groups of ages from intensity of their defeat. We will suppose, analysing morbidity diphtheria, it is set that children are most often ill from this infection in age 8—9 years.

Morbidity on the groups of ages is studied usually in indexes on 10000 (or on 1000) population of the proper age. The absolute numbers of morbidity are not recommended for such analysis, similarly as extensive indexes. The analysis of age morbidity in extensive indexes allows to judge only about average of separate age group in annual morbidity on a settlement on the whole, but he caot show frequency of diseases on the different groups of ages.

For example, for a year in area of N 120 cases of diphtheria are registered. Thus in age 3—4 years 20 persons (16,6% to annual morbidity) became ill, on an age group 14 years and more senior there is 50 patients (41,6% to annual morbidity). At the first look there is the impression about more high staggered of the last age group on these numbers (14 years and more senior). Meantime children in age 3— of 4 years there was 100000 in a region, and persons in age 14 years and more senior — 1 200 000. An index of morbidity in the first age group (3—4) will be 2,0 on 10000 population of this age, while in an age group 14 years and more senior—0,41. Thus, at the calculation of intensive index the fact of more intensive staggered comes to light by diphtheria of children in age 3— of 4 years. The children of this age are ill diphtheria almost in 5 times more frequent, than persons in age 14 years and more senior. Such conclusion is pointed by idea about the necessity of careful prophylactic vaccination in the most struck age group, because a vaccination of children is the leading measure of warning of this disease.

At the analysis of age morbidity depending on character of the studied infection the groups of ages can change. So, at the analysis of morbidity diphtheria and whooping-cough more shallow groups of ages are recommended (from birth to 6 ìonths, 6 months— 1 year, 1, 2, 3, 4, á, 6, 7, 8—9, 10—’14, 14—20, 20—40, 40 years and more senior). It allows in more depth to understand age morbidity at these infections in every case. The same groups of ages can be used and at the study of morbidity intestinal infections, in particular by a dysentery.

At other infections it is possible to analyse age morbidity on more large groups of ages, taking into account the domestic features of life each of them (to 1 year, 1-3, 3-7, 7-14, 14-19, 20-40, 40-60 years and more senior). For development of age morbidity òàble is recommended students. 1 (appendix, page 271).

Note. Analysing morbidity a certain infection on the groups of ages, students must show most high and the most low morbidity in indexes on :10000 population of every age group. It is necessary to specify reasons of the most high morbidity, its declines in other groups of ages and lowest morbidity in certain ages. An analysis over of lethality is here brought. Thus, every table, besides the developed digital material, must be accompanied the detailed text analysis of its maintenance.

5. Analysis of morbidity on the professionally-domestic groups of population. The study of morbidity on professionally-domestic groups allows an epidemiologist to expose most staggered one or another infection of group of population and at planning and conducting of prophylactic and antiepidemiological measures for the decline of morbidity to pay the special attention to work among the most staggered contingents.

At the analysis of distributing of morbidity different infections on the professionally-domestic groups of epidemiologist can interest the different groups of population. So, analysing morbidity brucellosis, it is necessary to find out, what groups of rural or urban population are most staggered this infection (milkmaids, persons who tends cattle, shepherds, workers of creameries, meat-packing plants )

At the analysis of morbidity typhoid or dysentery it is necessary to pay the special attention to morbidity of workers in the food industry, workers of establishments of children’s and medical, and also on morbidity of children organized, unorganized, schoolboys and etc Analysing morbidity diphtheria and other infections of respiratory tracts, it is important to find out its level among children, visiting managers and schools of nurseries, among the schoolboys of ordinary schools, schools-boarding-schools  etc

Morbidity of persons of different professionally-domestic groups must be expressed in intensive indexes (on 10000 or on 1000 population of the proper group).

6. Analysis of sources and ways of passing to the infection. An exposure of sources is infections which resulted in appearance of new case of disease, and also determination of ways of transmission, instrumental in distribution of the contagious beginning, is an important section in work of epidemiologist. It should be remembered that a careful epidemiology inspection, and at some infections with the use of laboratory methods of research, allows in the large percent of cases to expose the sources of infection and define the ways of transmission of the contagious beginning. What below percent of obscure sources of infection at separate infectious diseases, so much the better quality of epidemiology inspection of hearths of communicable diseases and the the antiepidemiological measures conducted ‘in a hearth can appear more effective.

The source of infection can be sick with a typical and àtypical form of diseases, having zoonosis from different animals. At the epidemiology inspection of hearth of infectious disease doctors reflect character of the exposed source in cards (patient, transmitter.). At the end of year at development of cards on the basis of such records it is possible to draw conclusion about the value of certain sources of infection or factors of its transmission in spreading that or other communicable disease on the proper area. Analysis of material on sources and ways of transmission it is recommended to conduct. On this table material, touching the sources of infection, places of infection and factors of transmission, is developed.

Making all cards of epidemiology inspection, it is possible to define meaningfulness (average) of patients with a typical form diseases, which served the source of infection for patients, registered for current period. The value of patients is determined with a àtypical clinical picture, transmitters of the contagious beginning and also percent of infections in family, apartment, establishments of children’s and other places from the commoumber of the exposed places, where an infection could happen, Information on this table must be analysed in a next sequence.

In the percent of the exposed and unexposed sources of infection is the beginning determined, and also terms of infection from the common amount of the registered patients. Findings are estimated, and then materials are analysed about the exposed sources and terms of infection (in percent expression to the commoumber of patients with exposed the source of infection and terms of infection).

For example, it turns out at the analysis of materials of cards of epidemiology inspection, that at the epidemiology inspection of dysentery sources are exposed at 100 diseased (from 250), I.e. in 40% cases registered for certain period. Thus sick with a typical picture diseases served the source of infection 30 diseased, I.e. in 30% cases.

Detailed text description of this table (3), similarly as previous (1, 2) and subsequent (4, 5, 6, 7), for evidence it is recommended to accompany the graphs.

7. Study of efficiency of measures in regard to the source of infection (exposure, timeliness of diagnostics and quality of hospitalization) . The timely conducting of antiepidemiological measures in an infectious place (early exposure, timely diagnostics and hospitalization), as a rule, results in stopping of distribution of the contagious beginning on persons, surrounding a patient, localizations and liquidations of epidemic hearth. From importance of timeliness is here clear in conducting of these measures medical workers. The exposure of patients, rapid, exact diagnostics of diseases and their early hospitalization, infectious diseases must be conducted district doctors (mainly by internists and paediatricians). This work is under the permanent control of workers of center of epidemiology and sanitation the analysis of timeliness of antiepidimiological measures is for what conducted as monthly (information of analysis on areas understand at medical conferences) so for a year at the analysis of annual morbidity. Necessary information for development get out from the cards of epidemiology inspection. Thus both the day of address to the doctor and day of establishment of diagnosis and hospitalization of patient is calculated from the beginning of disease, instead of from the day of address to the doctor. The analysis of these data allows to judge a doctor about work, about the timeliness of medical service of infectious patients on an area, in a district or city.

Thus, information about that, how early from the beginning of disease patients appealed to the doctor, as a diagnosis was early set and as soon they were hospitalized at infectious diseases which obligatory hospitalization is certain to enable  estimate work of doctor and medical service of patients infectious diseases on areas.

These developments on days are calculated in percents : ‘to to. to the commoumber of patients. For example, from 150 patients in the 1th day of disease appealed a dysentery to the doctor 50 (33,3%), on 2—70 (46,6%). The diagnosis of dysentery in the 1th day of disease is set only at 25 (16,6%), on 2—ó 50 persons (33,3%) etc

Except for the analysis of digital material on turned, diagnostics and hospitalization of infectious patients must expose reasons of late hospitalization and study the consequences of late diagnostics and hospitalization. It is necessary to find out, in what late hospitalization resulted in sense of influencing both on weight, complications and duration of flow of illness and on further distribution her in an epidemic hearth.

It is necessary to set, what amount of the repeated cases in hearths is registered and the terms of their appearance are which. If information of table. 4 characterize the terms of diagnostics of disease, about quality and methods of diagnostics it is possible to judge on the basis of development. The analysis of these tables allows to draw conclusion about that, how often (in percents to the commoumber of patients by the proper infection) a primary diagnosis corresponded final, as often diagnosed other diseases. In addition, it is possible to judge and about the methods of diagnostics of the proper infectious diseases (typhoid and dysentery): whether diagnosed only on the basis of clinical picture (in percents to the commoumber of patients) or other methods of diagnostics were used (bacteriological, serological ,  rectomanoscopy .).

8. A study of efficiency of measures of fight is in the hearth of infectious disease. After an exposure and hospitalization of infectious patient at the row of diseases final disinfection is conducted, that must result in liquidation of possibility of distribution of the contagious beginning through the articles of everyday life (at intestinal infections, infections of outward covers, tuberculosis ).

Early treatment is with hospitalization of patient  in the first 3—6 hr after his apartment in permanent establishment considered most effective. However in a number of cases she can be late and quite often conducted through 1—2 or in more late terms. The analysis of timeliness of treatment of infectious diseases and efficiency of measures of fight on the break of mechanism of transmission in the hearth of infectious disease (terms of treatment of infection and its efficiency) allows to expose and remove shortages in work.

At development of materials about the terms of treatment of infection & it is important to find out not only the terms of their conducting after hospitalization of patient but also its efficiency, it is for what necessary to find out frequency of the repeated diseases in hearths depending on the terms of their treatment and number of the registered patients in hearths at their late treatment or then, when she was not conducted.

9. Estimation of efficiency of bacterial profile. At the row of infectious diseases (diphtheria, poliomyelitis.) the most effective mean of fight is vaccine prophylaxis. To judge about efficiency of this morbidity among correctly instiled, noninoculated and inoculated wrong. For the example of such analysis it is suggested to study efficiency  tips at diphtheria.

In description of settlement which is taken for conducting of epidemiology analysis of morbidity, the number of children, getting the complete course of inoculations, children to which was done only vaccination, children, with the skipped terms of inoculations, and also number of noninoculated, must be indicated.

On the cards of epidemiology inspection information is developed about morbidity of children depending on a term and quality of inoculations. It is necessary to calculate the intensive indexes of morbidity among the proper group of children depending on plenitude and timeliness of inoculations and to expect, in how many times morbidity by diphtheria among children correctly and in good time instiled below than morbidity of children of other groups: not vaccinated , only vaccinated more than 2 years back, revaccination  with the skipped terms of subsequent revaccination

In addition, it is possible to define the size of immune layer is a percent of the children valuably instiled to the commoumber in a settlement. For example, all the children 20000 (100%), valuably instiled 18000, an immune layer makes:

x= (20000-18000) /100=90%

As a result of analysis conclusions are drawn about character and features of epidemic process, the tasks of medical establishments are determined on a forthcoming year.

In this part short description of the basic exposed conformities to the law is given on territorial distribution of morbidity, on distributing of morbidity on years, months of year, basic conformities to the law of age morbidity and distributing of morbidity are briefly described on professionally-domestic groups. Short description of efficiency of the conducted antiepidemiological and prophylactic measures is given.

Coming from the exposed conformities to the law and shortages in work, it is necessary to develop the plan of measures on their removal.

Basic options to drafting of plan of antiepidemiological measure. At making of plan of antiepidimiological measures it is necessary to take into account some generals:

1. A plan of antiepidimiological measures must be. complex, I.e. for his realization participation of all prophylactic  network and row of economic establishments is needed, departments of local Advices of deputies of workers and other organizations.

2. The planned measures are developed local sanitary epidemiological centre  taking into account the features of regional epidemiology of infectious disease and steps settle accounts work during throughout the year. Annual plans divide by plans quarterlies and monthly.

3. Planning of measures is conducted to on to three to directions: 1) measures on rendering of source of infection harmless; 2) measures on destruction of mechanism of transmission and 3) measures on the increase of immunity of population. It is thus necessary to remember that depending on the feature of epidemiology at different infectious diseases these measures are not equivalent — one are more effective.

4. The planned measures on the maintenance must be concrete and at exposition of plan it is necessary to foresee the followings basic columns: «Name of measure», «Term  of execution», «Control of execution».

Measures, foreseen a plan, it is necessary to group in five sections:

1.Basic tasks of plan. In this section grounds, general pre-conditions, are given for drafting of plan, which follow from information, got at the analysis of infectious morbidity and analysis of sanitary situation in this district, city.

2. The joint meetings of epidemiology service and sanitary-epidemic advice, devoted fulfiling the plan of antiepidemiological measures and fight against infectious morbidity are foreseen, discussion on meetings of district executive committee of Advice of deputies workers.

3. Measures on the in-plant training and selection of shots. In this group of measures a subject and terms of business trips is planned into «working place», cycles of improvement, seminars and etc both doctors and middle medical workers (medical assistants, medical sisters, laboratory assistants and ò. of ä.).

4. Prophylactics , sanitary antiepidemiciological measures as it applies to separate infections. In this section measures are specified on rendering of sources of infection (an early exposure of patients, timely diagnostics, hospitalization, measures, measures on the interruption of mechanism of transmission (improvement of water-supply, cleaning, food supervision, to the mode in establishments of children’s, disinfection measures), to multiplying an immune layer (specific prophylaxis) and sanitary enlightening. Norms of calculations on the sanitary enlightening, given the amount of laboratory researches, number of beds, amount of inoculum and amount of disinfection facilities in the enclosed pointer of literature.

5. Financial providing of plan of measures. A section is very important, because all financial facilities, necessary for fulfiling the plan, are foreseen in him, for example, financial providing of number of beds , laboratory equipment, payment of additional regular units and etc As not only a department of health protection but also other departments of district executive committee and economic organizations participates in fulfiling the plan of antiepidemiological measures, providing certain financial funds is needed .

 

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 Europe and America. More than 75 millions of the people become ill by other acute viral diseases of the respiratory tract. Pandemic of grippe acquires character of the calamity and causes enormous economic detriment to all the countries. Every years multiple cases of streptococcous and staphylococcous infections, cholera, helminthiases, viral hepatitis, meningococcal infection and diseases caused by conditional pathogenic flora are registered in the world.

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 (3-5-8 years).

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.

Prevention

Doctor administering a typhoid vaccination at a school in San Augustine County, Texas

It has been suggested that Typhoid vaccine be merged into this article or section. (Discuss)

Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are therefore crucial to preventing typhoid.

There are two vaccines currently recommended by the World Health Organization for the prevention of typhoid:^[14] these are the live, oral Ty21a vaccine (sold as Vivotif Berna) and the injectable Typhoid polysaccharide vaccine (sold as Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline). Both are between 50 to 80% protective and are recommended for travelers to areas where typhoid is endemic. There exists an older killed whole-cell vaccine that is still used in countries where the newer preparations are not available, but this vaccine is no longer recommended for use, because it has a higher rate of side effects (mainly pain and inflammation at the site of the injection).^[14]

1939 conceptual illustration showing various ways that typhoid bacteria can contaminate a water well (center)

Transmission

Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Public education campaigns encouraging people to wash their hands after defecating and before handling food are an important component in controlling spread of the disease. According to statistics from the United States Center for Disease Control, the chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever in the U.S.

A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. According to the Centers for Disease Control approximately 5% of people who contract typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier was Mary Mallon (commonly known as “Typhoid Mary”), a young cook who was responsible for infecting at least 53 people with typhoid, three of whom died from the disease. Mallon was the first apparently perfectly healthy person known to be responsible for an “epidemic”.

Death rates for typhoid fever in the U.S. 1906–1960

Many carriers of typhoid were locked into an isolation ward never to be released in order to prevent further typhoid cases. These people often deteriorated mentally, driven mad by the conditions they lived in.^[15]

Epidemiology

With an estimated 16–33 million cases of annually resulting in 500,000 to 600,000 deaths in endemic areas, the World Health Organization identifies typhoid as a serious public health problem. Its incidence is highest in children and young adults between 5 and 19 years old.^[16]

Heterozygous advantage

It is thought that cystic fibrosis may have risen to its present levels (1 in 1600 in UK) due to the heterozygous advantage that it confers against typhoid fever.^[17] The CFTR protein is present in both the lungs and the intestinal epithelium, and the mutant cystic fibrosis form of the CFTR protein prevents entry of the typhoid bacterium into the body through the intestinal epithelium.

 

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.

Prevention of Shigellosis

Simple precautions can be taken to prevent getting Shigellosis: wash hands before handling food and thoroughly cook all food before eating.

In addition to improved sanitation and hygiene, several vaccine candidates for Shigella are in various stages of development. According to the World Health Organization, candidates include live attenudated, conjugate, ribosomal, and proteosome vaccines.^[3] There is promising results for a vaccine against serotype 1, which otherwise show large resistance against antibiotics.^[4]

Treatment of Shigellosis

Treatment consists mainly of replacing fluids and salts lost because of diarrhea. Oral replacement is satisfactory for most people, but some may need to receive fluids intravenously. In most cases, the disease resolves within 4 to 8 days without antibiotics. Severe infections may last 3 to 6 weeks. Antibiotics such as trimethoprim-sulfamethoxazole, norfloxacin, ciprofloxacin, or furazolidone may be given when the person is very young or very old, when the disease is severe, or when there is a high risk of the infection spreading to other people. The severity of the symptoms and the length of time the stool contains Shigella are reduced with antibiotics. Antidiarrheal drugs (such as diphenoxylate or loperamide) may prolong the infection and should not be used.

 

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.

Cholera is an acute intestinal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. It has a short incubation period, from less than one day to five days, and produces an enterotoxin that causes a copious, painless, watery diarrhoea that can quickly lead to severe dehydration and death if treatment is not promptly given. Vomiting also occurs in most patients.

More about cholera

Cholera: prevention and control

The current response to cholera outbreaks tends to be reactive, in the form of an emergency response. While this approach prevents many deaths, it fails to prevent cases of cholera. The importance of medium- and long-term prevention activities in cholera control should therefore be emphasized.

The capacity for disease prevention, epidemic preparedness, and emergency response varies greatly among countries. Regional strategies are needed to ensure that all countries have the capacity to deal with these issues. Among the priorities are:

·     the need to obtain better data and ensure greater information sharing;

·     the adoption of a coordinated multisectoral approach;

·     efforts to improve sanitation and sewage disposal;

·     the need to ensure political commitment and community involvement.

Case management

Cholera is a diarrhoeal disease caused by Vibrio cholerae. Children as well as adults can get infected. Among those infected, about 20% develop acute watery diarrhoea, of which 10-20% develop severe watery diarrhoea with vomiting. The mainstay of treatment is rehydration and up to 80% of cholera cases can be treated successfully using only oral rehydration salts.

Prompt and appropriate medical management of cases can significantly decrease mortality; when applied properly, case-fatality rate should be below 1%. In untreated cases the case fatality rate may reach 30-50%. These levels are often observed in crisis situations with overcrowding, limited access to health care, and precarious environmental management.

Treatment of cholera

Surveillance systems

Sensitive surveillance and prompt reporting contribute to the rapid containment of cholera epidemics. In many endemic countries, cholera is a seasonal disease, occurring every year usually during the rainy season. Surveillance systems can provide an early alert to outbreaks, which should lead to a coordinated response, and assist in the preparation of preparedness plans.

As part of an integrated surveillance system, an efficient cholera surveillance system can also improve the risk assessment for potential cholera outbreaks. Understanding the seasonality and location of outbreaks will provide guidance for improving cholera control activities for the most vulnerable. This will also contribute to developing indicators for appropriate use of oral cholera vaccines.

– Cholera surveillance and number of cases

Multisectoral approach

A multisectoral and coordinated approach is paramount in order to efficiently control a cholera outbreak. Key sectors to be involved are health, water and sanitation, fishery and agriculture, and education. A cholera coordination committee should be in place in countries where cholera outbreaks are recurrent. These committees should involve representatives of the different sectors as well as non-governmental organizations and international partners present in the country. Representatives from communication and information also play an important role.

Water supply and sanitation

Cholera is usually transmitted through faecally contaminated water or food. Outbreaks can occur sporadically in any part of the world where water supply, sanitation, food safety, and hygiene are inadequate. WHO recommends improvements in water supply and sanitation as the most sustainable approach for protecting against cholera and other waterborne epidemic diarrhoeal diseases. However, such an approach is unrealistic for the many impoverished populations most affected by cholera.

–      Acute diarrhoeal diseases in complex emergencies: critical steps

–      Cholera and other epidemic diarrhoeal disease control – Technical cards on environmental sanitation [pdf]

–      Environmental health in emergencies and disasters

Personal hygiene, food preparation and health education

Outbreaks can be mitigated and case-fatality rates reduced through several other measures, many of which are suitable for community participation. Human behaviours related to personal hygiene and food preparation contribute greatly to the occurrence and severity of outbreaks.

Health education aimed at behaviour change is thus an important component of cholera prevention and control.

Vaccines

WHO is evaluating the use of newer tools to complement traditionally recommended cholera control measures. Safe and effective oral cholera vaccines are available for use by individuals and health personnel, and work is under way to investigate the role of mass vaccination as a public health strategy for protecting at-risk populations. Issues include logistics, costs, timing, vaccine production capacity, and criteria for the use of mass vaccination to contain as well as prevent outbreaks.

– More on cholera vaccines

 

 

Hepatitis A

Electron micrograph of hepatitis A virions.
Virus classification
Group:	Group IV ((+)ssRNA)
Family:	Picornaviridae
Genus:	Hepatovirus
Species:	Hepatitis A virus

Hepatitis A (formerly known as infectious hepatitis) is an acute infectious disease of the liver caused by the hepatitis A virus (HAV),^[1] which is most commonly transmitted by the fecal-oral route via contaminated food or drinking water. Every year, approximately 10 million people worldwide are infected with the virus.^[2] The time between infection and the appearance of the symptoms, (the incubation period), is between two and six weeks and the average incubation period is 28 days.^[3]

In developing countries, and in regions with poor hygiene standards, the incidence of infection with this virus is high^[4] and the illness is usually contracted in early childhood. HAV has also been found in samples taken to study ocean water quality.^[5] Hepatitis A infection causes no clinical signs and symptoms in over 90% of infected children and since the infection confers lifelong immunity, the disease is of no special significance to the indigenous population. In Europe, the United States and other industrialized countries, on the other hand, the infection is contracted primarily by susceptible young adults, most of whom are infected with the virus during trips to countries with a high incidence of the disease.^[3]

Hepatitis A does not have a chronic stage, is not progressive, and does not cause permanent liver damage. Following infection, the immune system makes antibodies against HAV that confer

 

Prevention

For information about the vaccine, its properties, and its application, see Hepatitis A vaccine.

Hepatitis A can be prevented by vaccination, good hygiene and sanitation.^[1][13] Hepatitis A is also one of the main reasons not to surf or go in the ocean after rains in coastal areas that are known to have bad runoff.^[5]

The vaccine protects against HAV in more than 95% of cases for 10 years. It contains inactivated Hepatitis A virus providing active immunity against a future infection.^[14][15] The vaccine was first phased in 1996 for children in high-risk areas, and in 1999 it was spread to areas with elevating levels of infection.^[16]

The vaccine is given in two doses in the muscle of the upper arm. The first dose provides protection two to four weeks after initial vaccination; the second booster dose, given six to twelve months later, provides protection for up to twenty years.^[14][16]

Treatment

There is no specific treatment for hepatitis A. Sufferers are advised to rest, avoid fatty foods and alcohol (these may be poorly tolerated for some additional months during the recovery phase and cause minor relapses), eat a well-balanced diet, and stay hydrated. Approximately 6–10% of people diagnosed with hepatitis A may experience one or more symptomatic relapse(s) for up to 40 weeks after contracting this disease.^[17]

Prognosis

The United States Centers for Disease Control and Prevention (CDC) in 1991 reported a low mortality rate for hepatitis A of 4 deaths per 1000 cases for the general population but a higher rate of 17.5 per 1000 in those aged 50 and over. Death usually occurs when the patient contracts Hepatitis A while already suffering from another form of Hepatitis, such as Hepatitis B or Hepatitis C.^[18]

Young children who are infected with hepatitis A typically have a milder form of the disease, usually lasting from 1–3 weeks, whereas adults tend to experience a much more severe form of the disease.^[19]

Epidemiology

Prevalence

Hepatitis A Distribution 2005

HAV is found in the feces of infected persons and those who are at higher risk include travelers to developing countries where there is a higher incidence rate,^[20] and those having sexual contact or drug use with infected persons.^[21] There were 30,000 cases of Hepatitis A reported to the CDC in the U.S. in 1997. The agency estimates that there were as many as 270,000 cases each year from 1980 through 2000.^[22]

Transmission

The virus spreads by the fecal-oral route and infections often occur in conditions of poor sanitation and overcrowding. Hepatitis A can be transmitted by the parenteral route but very rarely by blood and blood products. Food-borne outbreaks are not uncommon,^[19] and ingestion of shellfish cultivated in polluted water is associated with a high risk of infection.^[23] Approximately 40% of all acute viral hepatitis is caused by HAV.^[10] Infected individuals are infectious prior to onset of symptoms, roughly 10 days following infection. The virus is resistant to detergent, acid (pH 1), solvents (e.g., ether, chloroform), drying, and temperatures up to 60^oC. It can survive for months in fresh and salt water. Common-source (e.g., water, restaurant) outbreaks are typical. Infection is common in children in developing countries, reaching 100% incidence, but following infection there is life-long immunity. HAV can be inactivated by: chlorine treatment (drinking water), formalin (0.35%, 37^oC, 72 hours), peracetic acid (2%, 4 hours), beta-propiolactone (0.25%, 1 hour), and UV radiation (2 μW/cm²/min).

Cases

The most widespread hepatitis A outbreak in the United States afflicted at least 640 people (killing four) iorth-eastern Ohio and south-western Pennsylvania in late 2003. The outbreak was blamed on tainted green onions at a restaurant in Monaca, Pennsylvania.^[24] In 1988, 300,000 people in Shanghai, China were infected with HAV after eating clams from a contaminated river.^[10]

 

 

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 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 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 7 days; bacteriological inspection of decretive groups. At leaving the patient in-home – the current disinfection, after hospitalization – final disinfection.
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 UFA.
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.
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