Download PROPHYLAXIS OF TUBERCULOSIS

PROPHYLAXIS OF
TUBERCULOSIS
Prophylactic principle
• of health protection generally and, as far as
tuberculosis is concerned, in particular
should be a priority. Prophyaxis of
tuberculosis consists of a complex of
various measures. Social, sanitary, specific
(inoculation and revaccination) and
chemoprophylaxis are discriminated.
Social prophylaxis
• is carried out by means of performing prophylactic
measures of social-economic character of the
national scale. The social prophylaxis is aimed at
organizing the people’s healthy way of life by
improving the environmental conditions,
increasing the population’s material well-being,
strengthening its health through the development
of mass physical culture, sports, rest homes,
sanatoriums, improvement of nourishment and
home living conditions, as well as fighting
alcoholism and other harmful habits.
Sanitary prophylaxis
• is a systematic organization and performance of a
system of sanitary-hygienic and prophylactic
measures, aimed at warning healthy people against
infecting and catching tuberculosis. It is aimed at
the improvement of sanitary conditions of the nidi
of tuberculous infection, performance of sanitary –
educative work, veterinary control, early and
timely detection as well as treatment of
tuberculosis patients. Sanitary prophylaxis is
generally performed in the centre of tuberculous
infection.
An epidemiologic nidus of
tuberculosis
• is meant as a tuberculosis patient, who excretes
mycobacteria, his dwelling and the people sharing
it with him. To antiepidemic measures in the
cenrte of tuberculous infection belong
disinfection, contacts investigation, their
chemoprophylaxis, isolation of children from the
bacteriocarrier, sanitary-hygienic education of a
patient and the members of his family, improving
the living conditions as well as the patient’s
treatment.
The prophylactic work
• is realized in the centre according to its
epidemiological danger defined jointly by a
phthisiologist and an epidemiologist, taking
into account the following factors: 1) the
volume of bacterial excretion; 2) presence
of children and teenagers in the family; 3)
sanitary conditions under which a patient
and his family live.
The criteria of epidemiological
danger
• of a nidus of tuberculous infection are the
mass scale and continuity of MBT excretion
by a patient, his family life conditions,
behaviour, general culture and sanitary
enlightenment of the patient and his
surrounding.
Depending on the mass scale and the
term of bacterial excretion, it is
discriminated as:
• A.massive, when over 100 colonies of MBT
are revealed at a simple bacterioscopy or by
a sowing method;
• B.moderate, if 20-100 colonies are
revealed;
C. scanty (meagre), if MBT are revealed
only by bacteriological research, not more
than 20 colonies;
D. conditioned (formal):
• at firstly diagnosed tuberculosis, when the
cessation of bacterial excretion is reached as a
result of treatment and is confirmed by double
negative result of bacterioscopic and cultural
methods with 2-3 months intervals (during 10-12
months from the moment of the examination
negative result); 2) at chronic pulmonary
tuberculosis, when the cessation of bacterial
excretion as a result of treatment is confirmed by
repeated examinations with bacterioscopic and
cultural methods with 2-3 months intervals during
1,5-2 years from the moment of the first negative
result.
The nidi of tuberculous infection are
divided into 3 groups
• To the first, the most dangerous, group belong
nidi, where patients with abundant or meagre
bacterial excretion live, but there are children and
teenagers in the family or aggravating
circumstances exist: poor living conditions,
violation of hygienic rules, abuse of alcohol. An
epidemiologist and a district phthisiologist should
visit such a nidus once a quarter, a district nurse –
not less than once a month.
• To the second group, epidemiologically
less dangerous, belong nidi of tuberculous
infection, in which patients with meagre
bacterial excretion live and the
unfavourable factors, enumerated above, or
patients, considered to be conditional
bacterial excretors, are absent, but there are
children and teenagers in the family or there
exists at least one of the aggravating factors
mentioned above. A doctor pays a visit to
these nidi once half a year, and a medical
nurse once every two months.
• To the third group belong the nidi, where
only adults live and the patients are formal
bacterial excretors and any aggravating
circumstances are absent. To this group
belong families in whose private farms
there is cattle injured with tuberculosis. A
doctor visits these nidi once a year, a
medical nurse – once half a year.
The complex of prophylactic measures
• in a centre of tuberculous infection includes
performing a current and conclusive disinfection,
isolation of children from the bacterial excretor by
means of his hospitalization or sending the
children to specialized children’s institutions,
vaccinization of newly borns and revaccinization
of noninfected contactual with BCG vaccine,
regular examination of contactuals, performing
chemoprophylaxis for them, sanitary-hygienic
education of patients and the members of their
families, improving their living conditions,
intensive treatment of a patient in a clinic,
followed by controlled chemotherapy at the
dispensary stage.
The conclusive disinfection
• is made in all cases of the patient’s temporary or
constant departing (hospitalization, change of the
dwelling place, after death at home). Objects of
small value are desirable to be burnt. The ceiling,
the walls, the floor, the furniture (except polished
one) are irrigated with 5 % solution of chloramine
and the lodging is tightly closed for 2 hours.
Afterwards it is aired and tidied. An effective
method of disinfestation of lodgings is ultraviolet
radiation. This pertains, first and foremost, to
expensive objects, which are easily spoilt with
disinfectant solutions; they are radiated with
bactericidal lamps.
Before a patient’s hospitalization or when he stays at
home for various reasons, current disinfection is
systematically done by the patient himself or by
the members of his family which consists in the
following:
1) Daily airing and wet tiding of the lodging and
objects of home use. The bacterial excretor should
use only his personal table utensils, towels,
bedding which are systematically disinfestated.
2) Sputum collection into an individual sputum flask,
which is filled to a quarter of the volume with 5 %
chloramine solution and its disinfestation, as is
done with the table utensils and meal remnants.
3) Collection, putting into sacks, isolated keeping
of used underclothes and its future disinfestation
Antituberculous vaccination
and revaccination.
The most efficient method of specific prophylaxis of
tuberculosis is vaccination and revaccination with
BCG vaccine or vaccinoprophylaxis.
In 1923 the Hygienic Committee of the Nations
League took a decision as to the wide use of the
BCG vaccine for vaccination against tuberculosis
in all the countries of the world.
A tuberculous vaccine
(BCG) are live mycobacteria of vaccine
strain, lyophilicly dried in 1,5 % solution of
sodium glutaminate. It is manufactured in
ampullas of 1 mg of vaccine, which
contains 20 doses, each of 0,05 mg of the
preparation.
BCG vaccine
is used intracutaneously in a dose of 0,05
mg in the volume of 0,1 ml. The primary
vaccination is done to healthy, delivered at
the right time newly borns on the 3-5th day
of their life
BCG-M vaccine
is manufactured in a half dose (0,5 mg in an
ampulla, which contains 20 doses, each of
0,025 mg of the preparation), which is
meant for vaccinating prematurely newly
borns and children who were not
immunised at birth in connection with
contraindications.
At the proper technic a whitish papule of 5-6
mm in diameter is formed, which resolves
in 15-20 minutes. In 3-4 weeks a small
infiltration is formed in the site of the
injection – a nodule of cyanotic colour, in
which in 50 % of cases a small fistula with
cereous secretion is formed. Later on a crust
of brown colour is formed, which drops off
in 2-4 months and a pink seam (of 4-10 mm
in diameter) appears, which gradually
undergoes depigmentation.
Contraindications for BCG vaccination are:
1) a prematurely born child, when the body mass at
birth is less than 2000 g;
2) intrauterine infection;
3) purulent-septic illnesses;
4) hemolytic disease of newly-borns (moderate and
severeforms);
5) severe puerperal traumas with neurologic
symptomatics;
6) generalized skin wounds;
7) any acute illnesses;
8) generalized BCG infection of other children in
the family
Children (babies), not immunised at a
maternity home, in connection with
contraindications are vaccinated after recovery
at a children’s polyclinic or hospital-assistant’s
health station with BCG-M vaccine during 1-6
months. However, if a baby has reached a 2months age and more, the Mantoux test with 2 TU
should be done before inoculation. Children with
negative tuberculine reaction are vaccinated. The
interval between Mantoux test and vaccination
must be not less than 3 days and not more than 2
weeks.
The immunity after vaccination develops in
6-8 weeks, therefore vaccinated children
from the family of tuberculosis patient are
isolated from bacterial excretor for the
period of the immunity formation, i.e. not
less than 2 months.
In children BCG vaccinated at birth the
immunity is preserved during 5-7 years.
Only healthy persons with negative
Mantoux test are revaccinated. Vaccination
and revaccination of BCG is an effective
means of prophylaxis and it allows to
prevent the illness five times more, and if it
develops, then its course is much milder and
has a restricted character.
Contraindications for revaccination of children and
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teenagers:
1) tuberculosis infestation or previously suffered
tuberculosis;
2) acute and chronic illnesses in the aggravation
period;
3) complication to previous BCG vaccine
injection;
4) allergic illnesses in the aggravation stage;
5) malignant blood diseases and neoplasms;
6) immunodeficite states, treatment with
immunodepressors;
7) HIV-infestated children.
• Postvaccine seam and a positive tuberculin
reaction are the criteria of vaccination
quality and formation of antituberculous
immunity. A local pediatrician does the
observation for the development of local
postvaccinal reaction and writes it down in
the medical documentation in 1, 3 and 12
months after inoculation. The postvaccinal
seam being absent and at negative
tuberculin reaction the immunisation is
considered to be ineffective.
The WHO International Union of Fighting
Tuberculosis classifies postvaccinal
complications according to 4 categories:
• 1 category – local skin lesions (cold
abscesses, ulcers, keloid seams, regional
lymphadenites);
• 2 category – persisting and disseminated
BCG – infection without a lethal result
(lupus, ostites etc.);
• 3 category – disseminated BCG – infection,
generalized lesions with a lethal result,
which are noticed at a marked
immunodeficiency;
• 4 category – post-BCG-syndrome (an
illness, that arises immediately after BCG
vaccination, mainly of allergic character,
nodal fever, eruption, keloid seams).
• The most frequently observed are:
subcutaneous cold abscesses, surface ulcers
of 10 mm and more in diametre on the spot
of intracutaneous injection of BCG vaccine;
lymphadenites of regional lymphatic nodes
(groin, neck, supra- and subclavian), the
size of 1,5 cm and more; keloid seams of 10
mm and more in diametre.
Chemoprophylaxis.
• Specific prophylaxis is aimed not only to
the increase of the body resistance to
tuberculous infection by means of active
immunisation (vaccination, revaccination),
but also by using antimycobacterial means
(chemoprophylaxis).
• Chemoprophylaxis is viewed as an urgent
prophylaxis of tuberculosis, as its
preventive action develops from the first
hours after taking an antimycobacterial
drug. Chemoprophylaxis is recognized to
be the most efficient of all methods of
tuberculosis prophylaxis.
The primary and the secondary
chemoprophylaxis are discriminated.
• The primary chemoprophylaxis is performed to
noninfected persons, who react negatively to
tuberculin.
• The secondary chemoprophylaxis is performed
with a view to prevent the development of
tuberculosis of persons infestated earlier, the ones
who react positively to tuberculin and in whom
active clinico-roentgenological manifestations of
tuberculosis are absent.
Persons undergoing
chemoprophylaxis:
• 1) clinically healthly children, teenagers and
persons of young age up to 30, who are firstly
MBT infestated;
• 2) persons with stable hyperergic reactions to
tuberculin or their 6 mm and more increase
comparing to the previous results;
• 3) children, teenagers and adults, who are in
contact with epidemiologically dangerous
tuberculosis patients;
• 4) persons, who have nonactive tuberculous
changes, pregnancy or unfavou-rable factors being
present (acute illnesses, operations, traumas),
capable of provoking tuberculosis relapse;
• 5) persons with traces of previously suffered
tuberculosis, their illnesses being present
(bronchial
asthma,
collagenose,
sarcoidosis,stomach ulcer), which are treated with
various drugs, including corticosteroid hormones,
which may provoke complications or tuberculosis
relapse.
• Chemoprophylaxis is performed with
isoniazidum or phtivasidum during 2-3
months, and, at the preservation of
epidemiological danger, it is repeated
twice a year. For adults and teenagers a
daily dose of isoniazidum, when used every
day, is 0,3 g, for children – 8-10 mg/kg of
a body mass. A complex of vitamins is
administered in 30 minutes after the intake
of the drug with an obligatory inclusion of
vitamin B6 (30-50 mg daily) and vitamin C.