Lecture 1 Lecture 1Stomat Determination of tuberculosis as a scientific and practical problem. History of development of phthisiology. Epidemiology of.

Lecture 1Lecture 1Stomat Stomat

Determination of tuberculosis as Determination of tuberculosis as a scientific and practical a scientific and practical

problem. problem. History of development of History of development of

phthisiology. Epidemiology of phthisiology. Epidemiology of tuberculosis. tuberculosis.

Description of exciter. Description of exciter. Pathogenic of tuberculosis. Pathogenic of tuberculosis.

Organization of fight against Organization of fight against tuberculosis in Ukraine. tuberculosis in Ukraine.

Prof. Prof. L.A. HryshchukL.A. Hryshchuk 2013 2013

The World Health Organization (WHO) The World Health Organization (WHO) proclaimed tuberculosis to be the global proclaimed tuberculosis to be the global danger. According to its forecasts there will be danger. According to its forecasts there will be 90 million new tuberulosis cases in the world 90 million new tuberulosis cases in the world during the decade. Of those who will fall ill during the decade. Of those who will fall ill approximately 30 million people may die in the approximately 30 million people may die in the current decade unless the reaction to this global current decade unless the reaction to this global problem radicallyproblem radically improves.improves.

Nowadays the world scientists distinguish Nowadays the world scientists distinguish threeunion tuberculosis epidemic: the first is threeunion tuberculosis epidemic: the first is the epidemic of typical tuberculosis that is the epidemic of typical tuberculosis that is treated well; the second is the epidemic of treated well; the second is the epidemic of chemioresistant tuberculosis and the third one chemioresistant tuberculosis and the third one is the epidemic of tuberculosis and the AIDS.is the epidemic of tuberculosis and the AIDS.

Source: Global TB control report, 2011

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The incidence of TB has slowly The incidence of TB has slowly declined during the past years, declined during the past years, reaching 48 (confidence intervals 44-reaching 48 (confidence intervals 44-50) per 100 000 population in 2009. 50) per 100 000 population in 2009.

However there is a big discrepancy However there is a big discrepancy between east and west.between east and west.

The TB prevalence decreased from 96 The TB prevalence decreased from 96 (confidence intervals 70-130) to 63 (confidence intervals 70-130) to 63 (confidence intervals 49-81) per 100 (confidence intervals 49-81) per 100 000 population between 1990 and 000 population between 1990 and 2009 against a target of below the 2009 against a target of below the prevalence of 48 set out in the target prevalence of 48 set out in the target for 2015.for 2015.

Mortality from TB must further Mortality from TB must further decline, from 6.9 (confidence intervals decline, from 6.9 (confidence intervals 5.7-8.3) per 100 000 persons in 2009 5.7-8.3) per 100 000 persons in 2009 to 6 by 2015. to 6 by 2015.

TB incidence

TB/HIV incidence, 2010, 2010

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We will start with the patient since they are typically the source of infection. This slide shows a violent sneeze caught on film by high speed photography showing large liquid droplets.

Most of these large, visible droplets will fall to the ground. However, the small droplet nuclei that can reach the deep lung are not visible and are 1:5 micro meters in size.

According to the WHO criteria from 1995 tuberculosis epidemic has been registered in Ukraine in so far as tuberculosis patients comprise over 1 % of the total number of the population.

The statistics of sickness in all the forms of tuberculosis in 2009 was 72,7 persons per 100 thousand of the population.

Alarming is the fact that tuberculosis “has turned younger”, its number among children, able-bodied and reproductive ages increases.

HISTORICAL REVIEW 

Tuberculosis, as an illness, is known since ancient times.

The principal clinical manifestations of tuberculosis are described still by Hippocrate, Gallen, Avizenna.

The fact that tuberculosis is infectious was confirmed by Fracastoro in the 16th century.

It was Morton who published the first monograph “Phthisiology or a treatise on the phthisis” ( R. Morton, 1689) and named a science of tuberculosis “phthisiology” (from the Greek word “phthisis” – which means exhaustio. In the 17th century the French anatomist Sylviy, describing the hurt lungs of patients who had died of phthisis, used the word “hump” (tuberculum).

However, it was only in the 19th century in France that pathologists and therapeutists G. Bayle, and then R. Laennec proved the hump and caseous necrosis to be specific morphological substratum of tuberculosis. In 1865 the French physician B. Villemin experimentally proved the infectious nature of tuberculosis, though he could not reveal the pathogene.

In 1882 the German bacteriologist Robert Koch (fig. 1) discovered the pathogene of tuberculosis, which was named bacillus of Koch (BK). He was also the first who obtained tuberculin with the hope to successful treatment of tuberculosis patients. These expectations of the scientist did not come true, nevertheless for the purpose of diagnostics tuberculine has been used for over 100 years.

 Fig. 1. R.Koch (1843-1910)

M.I. Pyrohov studied clinico-morphological properties of tuberculosis of various localization and for the first time described typhoid form of miliar tuberculosis, histologic structure of tuberculous granuloma. Further study of pathomorphological alterations at lungs tuberculosis was proceeded by A.I. Abrykosov and A.I. Strukov.

In 1887 R. Philip in Edinburgh (Scotland) founded the world first antituberculosis dispansery. This new institution offered the patients not only medical but also social help, which later on laid the foundation of the organization of antituberculosis service also in this country.

In 1882 in Rome C. Forlanini offered artificial pneumothorax for treating lung tuberculosis patients.

In 1895 Wilhelm Kondrat Roentgen discovered X-rays, which have been widely used in medicine up to today. Actually, it’s known well enough that X-rays were discovered by Ukrainian scientist Ivan Pulyuy (1845-1918) from Halichina 17 years earlier. However, he made his announcement about the discovery 7 days after Mr. Roentgen had made his one, thus the preference was given to Mr. Roentgen who received Nobel Prize.

An important achievement of the start of the 20th century was the creation by the French scientists Calmette and Guerin (1919) of the antituberculosis vaccine BCG (Bacilles Calmette, Guerin). Since 1935 mass vaccination began. At the same time in 1924 Abre in Brazile introduced the method of fluorographic observation of the population for active revealing lung tuberculosis patients.

THE WORLD TUBERCULOSIS EPIDEMIOLOGICAL SITUATION

 More than 6 billion people live on our planet now. More

than 2 billion of them suffer from various diseases. Every fifth earthman lives in extreme need and poverty, which has become the main death reason in the world. Today tuberculosis is the most widely spread infectious disease which ranks first as to the deathrate among the people from infectious pathology. Moreover, new misfortunes are added. In 2007 A.D. there are 30-40 million carriers of the human immunodeficite virus in the world and 10 million AIDS patients, who increase the number of tuberculosis patients considerably.

According to the data of the World Health Organization half of the globe population is infected with tuberculosis mycobacteria. In some countries infectiousness of the population with tuberculosis reaches 80-90 %. This is also true about Ukraine. Every year each tuberculosis patient can infect 10-15 and more persons of which 5-10 % will catch the disease.

Every year 7-10 million people fall ill with tuberculosis all over the world, including 4-4,5 mln. – with bacterial secretion and about 3 mln. adults die of it (of these 97 % – in the developing countries) and approximately 300 thousand children. The total number of tuberculosis patients reaches 50-60 mln.Nowadays tuberculosis is the most menacing illness for the whole mankind. It kills more patients worldwide than all the infectious and parasitic illnesses taken together. Present tuberculosis epidemic has acquired the global scales. In many parts of the world tuberculosis epidemic is beyond the control.

The highest tuberculosis statistics of sickness is noted in African and Asian regions, in the countries of the Pacific Ocean coast. Tuberculosis epidemic situation got worse in the countries of Europe too, especially in the countries of the former Socialist community.

In 2007 the lowest tuberculosis index was registered in the highly developed countries, such as Malta (4,2), Sweden (5), Norway (5,5), Iceland (6,2), Italy (8,4 per 100000 of the population), the highest – in Romania (114,6), in the former Soviet Union, as in Kirgistan (127,8), Kazakhstan (126,4), Georgia (124,4), Turkmenistan (86,1 per 100.000 of the population) (fig.3).

TUBERCULOSIS EPIDEMIOLOGICAL SITUATION IN UKRAINE

 If one looks into the past, he will see that from 1965 to

1990 the morbidity of all clinical forms of tuberculosis decreased 3,6-fold or from 115,4 per 100 thousand population to 32,0 per 100 thousand population; the death-rate for these years decreased 3,3-fold or from 27,1 per 100 thousand population to 8,1 per 100 thousand population. However, starting from 1990 a crucial moment occurred in tuberculosis epidemiological situation, it started to grow, which is vividly reflected in epidemiological indices.

Morbility on tuberculosisMorbility on tuberculosis and HIV and HIV in Ukraine in Ukraine The statistics of morbidity in all forms of tuberculosis in

Ukraine from 1990 to 2011 increased from 32 to 68,4 per 100 thousand population/

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ВІЛ Туберкульоз

The pathogenesis of The pathogenesis of tuberculosistuberculosisInfection with Infection with

Mycobacterium Mycobacterium tuberculosistuberculosis, the , the

causative agent, follows a causative agent, follows a relatively well-defined relatively well-defined

sequence of events. The sequence of events. The infectious bacilli are infectious bacilli are

inhaled as droplets from inhaled as droplets from the atmosphere. In the the atmosphere. In the lung, the bacteria are lung, the bacteria are

phagocytosed by alveolar phagocytosed by alveolar macrophages and induce macrophages and induce

a localized a localized proinflammatory proinflammatory

response thatresponse that leads to leads to

recruitment of recruitment of mononuclear cells from mononuclear cells from

neighbouring blood neighbouring blood vessels. These cells are vessels. These cells are the building blocks for the building blocks for

the granuloma, or the granuloma, or tubercle, that defines the tubercle, that defines the

diseasedisease. .

The granuloma consists of a kernel of infected The granuloma consists of a kernel of infected macrophages, surrounded by macrophages, surrounded by FOAMY GIANT CELLSFOAMY GIANT CELLS and macrophages with a mantle of and macrophages with a mantle of LYMPHOCYTESLYMPHOCYTES delineating the periphery of the structure. delineating the periphery of the structure.

This tissue response typifies the 'containment' This tissue response typifies the 'containment' phase of the infection, during which there are no phase of the infection, during which there are no overt signs of disease and the host does not overt signs of disease and the host does not transmit the infection to others. Containment transmit the infection to others. Containment fails after a change in the immune status of the fails after a change in the immune status of the host, which is usually a consequence of old age, host, which is usually a consequence of old age, malnutrition, or HIV-co-infection.malnutrition, or HIV-co-infection.

Under such circumstances, the centre of the Under such circumstances, the centre of the granuloma undergoes caseation and spills viable, granuloma undergoes caseation and spills viable, infectious bacilli into the airways. This leads to infectious bacilli into the airways. This leads to development of a productive cough that development of a productive cough that facilitates aerosol spread of infectious bacilli.facilitates aerosol spread of infectious bacilli.

Pathogenesis of Pathogenesis of TuberculosisTuberculosis

Infection with Infection with Mycobacterium tuberculosisMycobacterium tuberculosis, the , the causative agent, follows a relatively well-causative agent, follows a relatively well-defined sequence of events. The infectious defined sequence of events. The infectious bacilli are inhaled as droplets from the bacilli are inhaled as droplets from the atmosphere. In the lung, the bacteria are atmosphere. In the lung, the bacteria are phagocytosed by alveolar macrophages and phagocytosed by alveolar macrophages and induce a localized proinflammatory response induce a localized proinflammatory response that leads to recruitment of mononuclear cells that leads to recruitment of mononuclear cells from neighbouring blood vessels. These cells from neighbouring blood vessels. These cells are the building blocks for the granuloma, or are the building blocks for the granuloma, or tubercle, that defines the disease. The tubercle, that defines the disease. The granuloma consists of a kernel of infected granuloma consists of a kernel of infected macrophages, surrounded by FOAMY GIANT macrophages, surrounded by FOAMY GIANT CELLS and macrophages with a mantle of CELLS and macrophages with a mantle of LYMPHOCYTES delineating the periphery of the LYMPHOCYTES delineating the periphery of the structurestructure

This tissue response typifies the This tissue response typifies the 'containment' phase of the 'containment' phase of the infection, during which there are infection, during which there are no overt signs of disease and the no overt signs of disease and the host does not transmit the host does not transmit the infection to others. Containment infection to others. Containment fails after a change in the immune fails after a change in the immune status of the host, which is usually status of the host, which is usually a consequence of old age, a consequence of old age, malnutrition, or HIV-co-infection. malnutrition, or HIV-co-infection.

Under such circumstances, the Under such circumstances, the centre of the granuloma undergoes centre of the granuloma undergoes caseation and spills viable, caseation and spills viable, infectious bacilli into the airways. infectious bacilli into the airways. This leads to development of a This leads to development of a productive cough that facilitates productive cough that facilitates aerosol spread of infectious bacilli.aerosol spread of infectious bacilli.

Thin section transmission electron micrograph of Thin section transmission electron micrograph of Mycobacterium tuberculosisMycobacterium tuberculosis

ORGANIZATION OF ANTITUBERCULOUS ORGANIZATION OF ANTITUBERCULOUS ACTIVITY IN THE PERIOD OF ACTIVITY IN THE PERIOD OF

TUBERCULOSIS EPIDEMYTUBERCULOSIS EPIDEMY Tuberculosis is a social disease and is a mirror of social-Tuberculosis is a social disease and is a mirror of social-

economic prosperity of the state and the well-being of its economic prosperity of the state and the well-being of its people, therefore antituberculous measures under present people, therefore antituberculous measures under present conditions must be taken on the national level by the conditions must be taken on the national level by the government of the country.government of the country.

At present time, the principal task in fighting tuberculosis At present time, the principal task in fighting tuberculosis in Ukraine is to take the epidemy of the illness under in Ukraine is to take the epidemy of the illness under control (I stage), to stabilize the epidemiological indices control (I stage), to stabilize the epidemiological indices (infestation, morbidity, sickliness and death rate) of (infestation, morbidity, sickliness and death rate) of tuberculosis (2 stage), and then their gradual decrease (3 tuberculosis (2 stage), and then their gradual decrease (3 stage).stage).

For the successful organization of antituberculous For the successful organization of antituberculous measures close cooperation of the medical system, measures close cooperation of the medical system, sanitary-epidemiological service and the organs of the sanitary-epidemiological service and the organs of the state power is necessary. The general organization and state power is necessary. The general organization and methodological guidance of antituberculosis activity in methodological guidance of antituberculosis activity in this country is realized by the Ministry of Health this country is realized by the Ministry of Health Protection of Ukraine and Acad. F.G.Yanovsky Ukrainian Protection of Ukraine and Acad. F.G.Yanovsky Ukrainian phthisiology and pulmonology research institutephthisiology and pulmonology research institute (scheme (scheme 1)1)..

STRUCTURE OF ANTITUBERCULOSIS SERVICESTRUCTURE OF ANTITUBERCULOSIS SERVICEIN UKRAINIANIN UKRAINIAN

TThe Ministry of Health Protection he Ministry of Health Protection         Acad. F.G.Yanovsky Ukrainian phthisiology and Acad. F.G.Yanovsky Ukrainian phthisiology and

pulmonology research institutepulmonology research institute         Regional of aRegional of antituberculous dispensaryntituberculous dispensary         Distric(townDistric(town) ) of of antituberculous dispensarantituberculous dispensarieies s        TubcabinetTubcabinet   At child’s policlinicAt child’s policlinic At policlinicAt policlinic At medical partsAt medical parts

Antituberculous dispensaryAntituberculous dispensary (Engl. dispensation (Engl. dispensation – distribution) – distribution) is a specialized medicative-is a specialized medicative-prophylactic institution, which work is aimed at prophylactic institution, which work is aimed at lowering morbidity, sikliness, infestation with lowering morbidity, sikliness, infestation with tuberculosis and death rate caused by it as tuberculosis and death rate caused by it as well as at conducting a complex of well as at conducting a complex of organizational and methodical, prophylactic organizational and methodical, prophylactic antituberculous measures among the district antituberculous measures among the district population.population.

The main tasks of an antituberculous The main tasks of an antituberculous dispensary are:dispensary are:

1) prophylaxis;1) prophylaxis; 2) early revealing;2) early revealing; 3) treatment of tuberculosis patients;3) treatment of tuberculosis patients; 4) registration of groups of tuberculosis 4) registration of groups of tuberculosis

patients and contingents of persons patients and contingents of persons

DISPENSARY DISPENSARY CATEGORYCATEGORY

Contingents of antitubercular dispensaries Contingents of antitubercular dispensaries are divided into are divided into categoriecategories, which enables s, which enables to examine them differentially, define the to examine them differentially, define the treatment tactics, perform prophylactic treatment tactics, perform prophylactic and rehabilitation actions.and rehabilitation actions.

Contingents of adult persons,Contingents of adult persons, children and children and teenagersteenagers due to being observed at an due to being observed at an antitubercular dispensary, are divided into antitubercular dispensary, are divided into 5 5 dispensary categoriesdispensary categories: : 1, 2, 3, 4 and 51, 2, 3, 4 and 5..

To 5 categories (Cat 5) are referred To 5 categories (Cat 5) are referred dispensary contingents of risk to disease dispensary contingents of risk to disease to a tuberculosis and its relapse.to a tuberculosis and its relapse.

CLINICAL CLASSIFICATION OF CLINICAL CLASSIFICATION OF TUBERCULOSISTUBERCULOSIS

I. TYPE OF TUBERCULOUS I. TYPE OF TUBERCULOUS PROCESSPROCESS

1. First diagnosed tuberculosis – FDT1. First diagnosed tuberculosis – FDTB B (date of its ascertainment)(date of its ascertainment)

2. Tuberculosis relapse – T2. Tuberculosis relapse – TBBR (date of R (date of its ascertainment)its ascertainment)

3. 3. Chronic tuberculosis – CTChronic tuberculosis – CTB B (date of (date of its ascertainment)its ascertainment)

II. II. CLINICAL FORMSCLINICAL FORMS OF OF TUBERCULOSISTUBERCULOSIS

A 15.-A 16. – Lung tuberculosis (LTB) (from a A 15.-A 16. – Lung tuberculosis (LTB) (from a facultative designation of the form of injury)facultative designation of the form of injury)

A 15A 15..-16.-16.- - Primary tuberculous complexPrimary tuberculous complex A 19.A 19.- part - part Disseminated lung tuberculosisDisseminated lung tuberculosis A 15-16.A 15-16.-- Nidus lung tuberculosisNidus lung tuberculosis A 15-16.A 15-16.-- Infiltrative lung tuberculosisInfiltrative lung tuberculosis A 15-16.A 15-16.-- Caseous pneumoniaCaseous pneumonia A 15-16.A 15-16.-- Lung tuberculomaLung tuberculoma A 15-16.A 15-16.-- Lung fibrous-cavernous Lung fibrous-cavernous

tuberculosistuberculosis A 15-16.A 15-16.-- Lung cirrhotic tuberculosisLung cirrhotic tuberculosis A 15-16.A 15-16./J65 /J65 Tuberculosis of respiratory Tuberculosis of respiratory

organs combined with dust professional lung organs combined with dust professional lung diseases (coniotuberculosis)diseases (coniotuberculosis)

III. CHARACTERISTIC OF III. CHARACTERISTIC OF TUBERCULOUS PROCESSTUBERCULOUS PROCESS

1. Localization of defect1. Localization of defect Localization Localization of defect of defect in lungs according to in lungs according to

the numbers (names) of segments, names the numbers (names) of segments, names of lung sections, and in other organs and of lung sections, and in other organs and systems – according to anatomical names of systems – according to anatomical names of localization of a localization of a failurefailure..

2. 2. Presence of destructionPresence of destruction (Destr +) destruction is present (Destr +) destruction is present (Destr -) destruction is not present (Destr -) destruction is not present

facultatively it is necessary to specify a facultatively it is necessary to specify a phase of tubercular processphase of tubercular process::

infiltration, decay infiltration, decay (Destr +)(Destr +), sowing;, sowing; suction, condensation, scarring, calcination.suction, condensation, scarring, calcination.

3. 3. Etiologic confirmation of tuberculosis Etiologic confirmation of tuberculosis diagnosisdiagnosis

(MBT +) it is confirmed by the results of bacteriological analysis (code A 15), (MBT +) it is confirmed by the results of bacteriological analysis (code A 15), in this case to specify:in this case to specify:

(M +) (M +) positive result of sputum analysis on acid-resisting bacteria (ARB);positive result of sputum analysis on acid-resisting bacteria (ARB); (C 0)(C 0) cultural analysis was not done;cultural analysis was not done; (C -) (C -) negative result of cultural analyses;negative result of cultural analyses; (C +) (C +) positive result of cultural analyses, in that case to specify:positive result of cultural analyses, in that case to specify: (Resist 0) MBT resistance to preparations of I line was not analysed;(Resist 0) MBT resistance to preparations of I line was not analysed; (Resist -) resistance to preparations of I line has not been established;(Resist -) resistance to preparations of I line has not been established; (Resist +) ( abbreviation of antitubercular preparations of I line) resistance (Resist +) ( abbreviation of antitubercular preparations of I line) resistance

ММBBТТ to preparations of I line has been established (in brackets to list all the to preparations of I line has been established (in brackets to list all the preparations of I line to which resistance has been determined). preparations of I line to which resistance has been determined).

(Resist II0) MBT resistance to preparations of II line was not analysed;(Resist II0) MBT resistance to preparations of II line was not analysed; (Resist II-) resistance to preparations of II line has not been established;(Resist II-) resistance to preparations of II line has not been established; (Resist II+) ( abbreviation of antitubercular preparations of II line) (Resist II+) ( abbreviation of antitubercular preparations of II line)

resistance resistance ММBBТТ to preparations of I line has been established (in brackets to to preparations of I line has been established (in brackets to list all the preparations of I line to which resistance has been determined). list all the preparations of I line to which resistance has been determined).

( ( ММBBТТ-) is not confirmed by the results of bacteriological analysis (the code -) is not confirmed by the results of bacteriological analysis (the code A16), in this case to specify:A16), in this case to specify:

(S 0) sputum was not investigated;(S 0) sputum was not investigated; (S -) negative result of sputum analysis on acid-resisting bacteria (ARB);(S -) negative result of sputum analysis on acid-resisting bacteria (ARB); (C 0) cultural analysis was not done;(C 0) cultural analysis was not done; (C- ) negative result of cultural analysis;(C- ) negative result of cultural analysis; (Hist 0) histologic analysis was not carried out;(Hist 0) histologic analysis was not carried out; (Hist -) is not confirmed by the results of histologic analysis (the code A 16);(Hist -) is not confirmed by the results of histologic analysis (the code A 16); (Hist +) it is confirmed by the results of histologic analysis (the code A 15).(Hist +) it is confirmed by the results of histologic analysis (the code A 15).

IV. IV. COMPLICATIONSCOMPLICATIONS OF OF TUBERCULOSISTUBERCULOSIS

Complications of lung tComplications of lung tuberculosisuberculosis (LTB):(LTB): haemoptysis, lung haemorrhage, haemoptysis, lung haemorrhage, spontaneous pneumothorax, lung spontaneous pneumothorax, lung insufficiency, chronic lung heart, atelectasis, insufficiency, chronic lung heart, atelectasis, amyloid diseaseamyloid disease etc etc..

Complications of extrapulmonary Complications of extrapulmonary tuberculosistuberculosis (EpTB) (EpTB):: bronchus stenosis, bronchus stenosis, pleura empiema, fistulae (bronchial, thoracic), pleura empiema, fistulae (bronchial, thoracic), renal renal (adrenal) (adrenal) insufficiency, sterilityinsufficiency, sterility, , commissure, ankylosis, commissure, ankylosis, amyloid disease etc.amyloid disease etc.

V. CLINICAL AND DISPENSARY V. CLINICAL AND DISPENSARY CATEGORY OF THE REGISTRATION CATEGORY OF THE REGISTRATION

PATIENTPATIENT Category 1 (Cat 1)Category 1 (Cat 1) First diagnosed First diagnosed

tuberculosis with bacterial excretion (FDTB tuberculosis with bacterial excretion (FDTB ММBBТТ +), and also other grave and wide-spread +), and also other grave and wide-spread forms of the disease without bacterial forms of the disease without bacterial excretion (FDTB excretion (FDTB ММBBТТ-)-)

Category 2 (Cat 2)Category 2 (Cat 2) Relapses of Relapses of tuberculosis (Rtuberculosis (RТТB B ММBBТТ +) and (R +) and (RТТB B ММBBТТ-) and -) and first diagnosed tuberculosis inefficiently first diagnosed tuberculosis inefficiently treated ( FDTB IT treated ( FDTB IT ММBBТТ +) and (FDTB IT +) and (FDTB IT ММBBТТ-)-)

Category 3 (Cat 3)Category 3 (Cat 3) First diagnosed First diagnosed tuberculosis with the limited process, without tuberculosis with the limited process, without bacterial excretion (FDTB bacterial excretion (FDTB ММBBТТ-) and -) and tuberculosis of unstated localization in children tuberculosis of unstated localization in children (tubintoxication) (tubintoxication)

Category 4 (Cat 4)Category 4 (Cat 4) Chronic tuberculosis (C Chronic tuberculosis (CТТ) ) of various localizations of various localizations ММBBТТ + and + and ММBBТТ--

Category 5 (Cat 5)Category 5 (Cat 5) Risk groups to Risk groups to tuberculosis or its reactivationtuberculosis or its reactivation

Group 5.1Group 5.1 residual changes of cured residual changes of cured tuberculosis,tuberculosis,

Group 5.2Group 5.2 contact persons, contact persons, Group 5.3Group 5.3 adults, tuberculosis patients of adults, tuberculosis patients of

doubtful localization,doubtful localization, Group 5.4Group 5.4 children and teenagers with latent children and teenagers with latent

tubinfection, persons from risk group, and also tubinfection, persons from risk group, and also children who were not vaccinated in the children who were not vaccinated in the neonative period and with postvaccinal neonative period and with postvaccinal complications.complications.

Group 5.5Group 5.5 children and teenagers whose children and teenagers whose etiology of sensitivity to tuberculin it is etiology of sensitivity to tuberculin it is necessary to specify, or character of changes in necessary to specify, or character of changes in the lungs with the purpose of difdiagnosis.the lungs with the purpose of difdiagnosis.

VII.VII. TUBERCULOSIS TUBERCULOSIS CONSEQUENCESCONSEQUENCES

Residual changes after healed Residual changes after healed lung lung tuberculosis:tuberculosis:fibrous, fibrous-nidus, bullous-dystrophic, fibrous, fibrous-nidus, bullous-dystrophic, calcinates in lungs and lymphatic nodes, calcinates in lungs and lymphatic nodes, pleuropneumosclerosis, cirrhosis, consequences pleuropneumosclerosis, cirrhosis, consequences of surgical intervention (of surgical intervention (with the indication of with the indication of the type and the date of an operationthe type and the date of an operation), etc.), etc.

Residual changes after healed tuberculosisResidual changes after healed tuberculosis of extrapulmonary localisationof extrapulmonary localisation: : cicatricial cicatricial changes in various organs and their changes in various organs and their consequences, calcinosis, consequences of consequences, calcinosis, consequences of surgical intervention (with the indication of the surgical intervention (with the indication of the type and the date of an operation).type and the date of an operation).

ORGANIZATION OF ANTITUBERCULOUS ORGANIZATION OF ANTITUBERCULOUS ACTIVITY IN THE PERIOD OF ACTIVITY IN THE PERIOD OF

TUBERCULOSIS EPIDEMYTUBERCULOSIS EPIDEMY Tuberculosis is a social disease and is a mirror of social-Tuberculosis is a social disease and is a mirror of social-

economic prosperity of the state and the well-being of its economic prosperity of the state and the well-being of its people, therefore antituberculous measures under present people, therefore antituberculous measures under present conditions must be taken on the national level by the conditions must be taken on the national level by the government of the country.government of the country.

At present time, the principal task in fighting tuberculosis At present time, the principal task in fighting tuberculosis in Ukraine is to take the epidemy of the illness under in Ukraine is to take the epidemy of the illness under control (I stage), to stabilize the epidemiological indices control (I stage), to stabilize the epidemiological indices (infestation, morbidity, sickliness and death rate) of (infestation, morbidity, sickliness and death rate) of tuberculosis (2 stage), and then their gradual decrease (3 tuberculosis (2 stage), and then their gradual decrease (3 stage).stage).

For the successful organization of antituberculous For the successful organization of antituberculous measures close cooperation of the medical system, measures close cooperation of the medical system, sanitary-epidemiological service and the organs of the sanitary-epidemiological service and the organs of the state power is necessary. The general organization and state power is necessary. The general organization and methodological guidance of antituberculosis activity in methodological guidance of antituberculosis activity in this country is realized by the Ministry of Health this country is realized by the Ministry of Health Protection of Ukraine and Acad. F.G.Yanovsky Ukrainian Protection of Ukraine and Acad. F.G.Yanovsky Ukrainian phthisiology and pulmonology research institutephthisiology and pulmonology research institute (scheme (scheme 1)1)..

STRUCTURE OF ANTITUBERCULOSIS SERVICESTRUCTURE OF ANTITUBERCULOSIS SERVICEIN UKRAINIANIN UKRAINIAN

TThe Ministry of Health Protection he Ministry of Health Protection         Acad. F.G.Yanovsky Ukrainian phthisiology and Acad. F.G.Yanovsky Ukrainian phthisiology and

pulmonology research institutepulmonology research institute         Regional of aRegional of antituberculous dispensaryntituberculous dispensary         Distric(townDistric(town) ) of of antituberculous dispensarantituberculous dispensarieies s        TubcabinetTubcabinet   At child’s policlinicAt child’s policlinic At policlinicAt policlinic At medical partsAt medical parts

Antituberculous dispensaryAntituberculous dispensary (Engl. dispensation (Engl. dispensation – distribution) – distribution) is a specialized medicative-is a specialized medicative-prophylactic institution, which work is aimed at prophylactic institution, which work is aimed at lowering morbidity, sikliness, infestation with lowering morbidity, sikliness, infestation with tuberculosis and death rate caused by it as tuberculosis and death rate caused by it as well as at conducting a complex of well as at conducting a complex of organizational and methodical, prophylactic organizational and methodical, prophylactic antituberculous measures among the district antituberculous measures among the district population.population.

The main tasks of an antituberculous The main tasks of an antituberculous dispensary are:dispensary are:

1) prophylaxis;1) prophylaxis; 2) early revealing;2) early revealing; 3) treatment of tuberculosis patients;3) treatment of tuberculosis patients; 4) registration of groups of tuberculosis 4) registration of groups of tuberculosis

patients and contingents of persons patients and contingents of persons

Other very important tasks of an Other very important tasks of an antituberculous dispensary are revealing, antituberculous dispensary are revealing, registration and treating tuberculosis patients. registration and treating tuberculosis patients. The results of treating tuberculosis patients to a The results of treating tuberculosis patients to a considerable degree depend on the disease considerable degree depend on the disease being timely revealed. In this connection, being timely revealed. In this connection, firsty firsty diagnozed tuberculosis patients are divided into diagnozed tuberculosis patients are divided into three groups: timely, untimely and lately three groups: timely, untimely and lately revealed.revealed. For children and teenagers the fourth For children and teenagers the fourth group is separated – group is separated – early revealing.early revealing.

The main criteria of dividing patients into The main criteria of dividing patients into groups are the character of a specific process, groups are the character of a specific process, the presence or absence of destruction (cavern) the presence or absence of destruction (cavern) and bacterial excretion, peculiarities of the and bacterial excretion, peculiarities of the prognosis at treatment, the degree of a prognosis at treatment, the degree of a patient’s danger for healthy persons.patient’s danger for healthy persons.

Children and teenagers, in whom the Children and teenagers, in whom the following factors are diagnosed, following factors are diagnosed, compose compose a group of early revealeda group of early revealed::

1) tuberculin test range;1) tuberculin test range; 2) primary tubinfestation;2) primary tubinfestation; 3) hyperergic Mantoux test;3) hyperergic Mantoux test; 4) tuberculous intoxication.4) tuberculous intoxication.

DISPENSARY DISPENSARY CATEGORYCATEGORY

Contingents of antitubercular dispensaries Contingents of antitubercular dispensaries are divided into are divided into categoriecategories, which enables s, which enables to examine them differentially, define the to examine them differentially, define the treatment tactics, perform prophylactic treatment tactics, perform prophylactic and rehabilitation actions.and rehabilitation actions.

Contingents of adult persons,Contingents of adult persons, children and children and teenagersteenagers due to being observed at an due to being observed at an antitubercular dispensary, are divided into antitubercular dispensary, are divided into 5 5 dispensary categoriesdispensary categories: : 1, 2, 3, 4 and 51, 2, 3, 4 and 5..

To 5 categories (Cat 5) are referred To 5 categories (Cat 5) are referred dispensary contingents of risk to disease dispensary contingents of risk to disease to a tuberculosis and its relapse.to a tuberculosis and its relapse.