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Prophylaxis of tuberculosis

Social Prevention
Social prevention includes social and economic
measures on the state level directed at the increase of the quality of life of the population. Such measures include provision of food, satisfactory conditions at work and home, development of physical culture and sports, health resorts, protection of environment and water storage reservoirs from pollution; all these measures are also aimed at supporting the health of the population, and thus at putting an end to the spread of tuberculosis. Especially important is improving the living conditions of bac-terioexcretion patients by means of providing such patients with separate apartments or living area expansion.

Infection control is the prevention of Mycobacterium

tuberculosis spread, of healthy persons infection, and of infected individuals superinfection. There are the following ways of infection control: 1) administrative control (reasonable location of departments in an antituberculous institution; isolation of bacteria excreting pa tients until the termination of the spread of the disease, which is ver ified by means of microscopy; regulation of patients' admittance); 2) construction control (ventilation system, sterilization with ultraviolet lamps); 3) personal protection (hygiene of patients' cough, wearing of surgical masks by persons discharging bacteria, wearing of respirators with hepafilters by medical staff contacting Tb seeding patients).

Sanitary Prevention
Sanitary prevention is the sanitizing of tubercular
infection foci, sanitary and veterinary inspection, community health work, early case finding and treatment of new cases of tuberculosis. Sanitary prevention is in most cases performed in the focus of tubercular infection. The place of residence of a patient with active tuberculosis, who is also a person discharging bacteria (verified at least once by means of any evaluation method), is considered a focus of tubercular infection. Tubercular infection foci are divided into three groups depending on their danger.

The criteria for the danger of a focus are: massiveness of bacterioexcretion; presence of children and teenagers in the focus of tubercu

lar infection; living and sanitary and hygienic conditions in the focus of tubercular infection. Bacterioexcretion might be: massive, when Tb are found by means of light microscope bacterioscopy or with culture (more than 20 colonies); scarce, when Tb are only found with bacteriology (no more than 20 colonies); formal (conditional), when bacterioexcretion has stopped, but the patient is still registered in the epidemiological registry. Classification of tubercular infection foci:

Group 1 (the most dangerous epidemiological^):

found in patients residing in the focus: A) massive (permanent or periodical) bacterioexcretion; B) scarce bacterioexcretion if children and teenagers live in the focus or when complicating factors are present, such as inade quate living conditions, not following sanitary and hygienic rules, alcohol abuse. Group 2 (less dangerous epidemiological^) is found at: scarce bacterioexcretion when only adults live in the focus, without complicating factors; formal bacterioexcretion, if children and teenagers or at least one complicating factor are present in the focus of tubercular infection.

Group 3 (with potential epidemiologic danger): the

patient has formal bacterioexcretion, only adults reside in the focus and no complicating factors are present. The first measures in the focus of tubercular infection are as follows: hospitalization of the patient and intensive treatment in hospital followed with controlled chemotherapy; current and complete disinfection (conducted by a sanitaryand-epidemiologic station); isolation of children from the person discharging bacteria (hospitalization of patients or placement of children in child care institutions); vaccination of newborns or re-vaccination of uninfected with BCG; regular examination of contacts and their chemoprophylaxis; improvement of living conditions

In the focus of tubercular infection it is mandatory

to provide current and complete disinfection, because timely destruction of Tb in the environment disrupts the chain of infection. Current disinfection is performed regularly during the habitation of a patient discharging bacteria (or members of his/her family) in the focus. Special attention must be paid to the disinfection of sputum and contaminated things. Patients have to strictly follow the rules for coughing up, to avoid sputum contamination of hands, household items, soil, and food. Persons discharging bacteria should use individual tableware, towels, bed linen, and have a separate room.

Tuberculous patients producing sputum should be

provided with two pocket containers filled with 5 % chloramine solution by about one fourth. The container should be placed in an easily washable bag. After washing the bag should be boiled and dried. Large TB medical establishments have special machines for sputum disinfection. For practical reasons most of patients do not use pocket containers outside a medical facility. Thus, they should be recommended to have an additional insert pocket with handkerchiefs. At night these insert pockets should be removed from pockets and soaked in 5 % chloramine solution in an enamel bowl. In 6 hours the solution can be discarded into the sewerage, and the insert pockets are washed with soap or boiled during 15-20 min and ironed, after this they can be reused.

After mechanical treatment dishware should be

disinfected by boiling during 15-20 min or sterilized. Food debris are left for 4 hours mixed with the same volume of 10 % bleach and then discarded into sewerage. Disinfection of handkerchiefs, underwear, linen, and household items is advisable to do by way of boiling after being soaked with 2 % sodium hydrocarbonate. Underwear may be disinfected chemically by way of soaking in 1 % chloramine during 2-4 hours (1 kg of dry underwear per 5 1 of the solution). Each item of underwear should be soaked in solution separately and unfolded. After that underwear can be washed or rinsed in running water. Mattresses, pillows, blankets, and clothing are disinfected in formaldehyde gas chambers. Items, which cannot be disinfected thermally or chemically, should be thoroughly cleaned from dust and dirt out-of-doors away from living spaces, and then dried in the sun.

Persons involved in all disinfection procedures, such as

collection of underwear, cleaning of clothing, carpets, mattresses, carrying them to disinfection chambers, should wear 4-layer face masks and special clothing, which is also disinfected after work. An antituberculous facility should be well ventilated, insolated and disinfected with bactericidal lamps. Wet cleaning should be done 2-3 times a day. Shared facilities should be cleaned especially thoroughly, as well as the patient's bed, bedside table, and all items situated within 2 m around the bed. All the items used for cleaning should be also disinfected in 5 % chloramine. Current disinfection is conducted by antituberculous facilities, and when these are absent, by outpatient departments.

Completing disinfection
Completing disinfection is conducted in the apartment after
the hospitalization of the patient, change of residence or death. Workers of sanitary-and-epidemiologic institutions and disinfection stations do complete disinfection. The ceiling, walls and furniture (except for polished furniture) are thoroughly washed with 5 % chloramine from the hydraulic sprayer. The windows, doors, and ventilation ducts are closed for 2 hours. After that the place of residence is ventilated, cleaned and dried. Using an ultraviolet lamp is an effective method of disinfection. Valuables, which might be damaged by disinfection solution, should be thoroughly cleaned and irradiated with bactericidal lamps. Not valuable items are incinerated. Refurbishment is advisable after complete disinfection. It is important to avoid the infection of people with milk, eggs or meat from diseased animals. These measures are conducted together with veterinary service. Animals with tuberculosis or those suspected of having tuberculosis must be killed.

Specific Prevention
Specific primary prophylaxis of tuberculosis is vaccination
(BCG, BCG-M), revaccination, and chemoprophylaxis. Vaccination and revaccination are carried out to build antituberculous immunity in non-infected individuals. For this purpose BCG vaccine is used. Studies, conducted in many countries, show that BCG vaccination decreases morbidity, mortality, primary infection amongst the vaccinators and prevents the development of miliary tuberculosis, caseation pneumonia, meningeal tuberculosis (BCG blocks the hematogenous spread of Tb in the host). BCG vaccine, named after Frenchmen Calmette and Guerin, was first received in 1919. Beginning from 1906 the scientists cultured virulent strains of Mycobacterium bovis every 2 weeks during 13 years (thus 230 passages were done). It was shown that the obtained strain had evident immunological properties against tubercular infection.

The first vaccination with BCG vaccine was carried out in

1921 in a newborn in France. In 1962 intradermal vaccination was introduced by A. Vallgren. Dry BCG vaccine for intradermal injection is used for active specific prophylaxis of tuberculosis. It consists of alive Mycobacteria of BCG-1 vaccine strain lyophilized in 1.5 % solution of sodium glutamate. BCG-M is used for sparing vaccination (half a dose of BCG). The vaccine is available in ampoules sealed under vacuum and containing 1.0 mg of dry BCG vaccine or 0.5 mg of BCGM. 1 mg of the vaccine contains 8 million bacilli (0.05 mg contains 400 thousand bacilli). Biological activity of BCG is associated with residual virulence allowing the strain to survive in the host, multiply mainly in the lymphatic system and result in specific morphological alteration with their dissolution, and retain increased tissue resistance to tubercular infection.

BCG vaccine is stored in a specially designated room in a


refrigerator. In this room the vaccine is dissolved and collected into an individual syringe for earch child. Primary vaccination is carried out to healthy full-term newborns on the 3-rd-5th day of life (in the morning, in a hospital room, after examination by a pediatrician). 0,05mg of BCG or 0,025mg of BCG-M in 0,1ml of solution is injected strictly intradermally in the area between the upper and medial thirds of the external surface of the left shoulder.The content of the ampoule with the vaccine is dissolved in 2ml of sterile isotonic solution of sodium chloride collected with a sterile syring with a long needle to get the desired dose. With correct technique the injection should be followed by a whitish papule 6-8mm in diameter(5-6mm in newborns), which disappears in 15-20min.

In newborns a specific reaction of a 5-10mm papule

and a small nodule at its center develops at the site of injection after 4-6 weeks; after revaccination reaction may appear already during the first week. Sometimes infiltrate may turn into a small cyanotic nodule or pustule. The latter dries and dissolves or leaves a crust. In some cases small ulceration might appear (no more than 8 mm in diameter) with seropurulent discharge, which later heals spontaneously. Local reaction heals in 2-4 months, but for some children it may take longer than that. A 2-10 mm scar develops at the site of vaccination, which signifies the presence of matured immunity. Immunological rebuilding of the body due to BCG is associated with positive Mantoux skin test with 2 IU PPD-L.

Vaccination of newborns is contraindicated at: body weight of premature infants being less than 2,000 g; intrauterine infection; a birth trauma with neurological deficits; acute diseases; purulent infections; hemolytic disorders; generalized skin lesions; generalized BCG infection in other children in the family. BCG-M vaccine is used in the following cases: premature infants with body weight of 2,000 g and more; vaccination of children who had contraindications at birth. It is carried out in 1-6 months after suspension of contraindications in an outpatient pediatric department (before vaccination at the age of 2 months and older Mantoux skin test is done with 2 IU PPD-L); vaccination of children living in territories polluted with radionuclides (III-IV zone).

Revaccination is done at 7 and 14 years in children

and teenagers with a negative reaction to Mantoux test with 2 IU PPD-L. The interval between 2 IU PPD-L and revaccination should be no less than 3 days and no more than 2 weeks. Revaccination is contraindicated in the following cases: children and teenagers were infected with tuberculosis in the past; reaction to Mantoux skin test with 2 IU PPD-L is doubtful; complications of vaccination at birth; allergy exacerbation; recovery from acute diseases; exacerbation of chronic diseases; blood cancers; tumors; immunodeficiency and long-term immunosuppressive therapy.

It is important to remember that BCG vaccination and

revaccination do not prevent the host from contracting infection and develop ing the disease of tuberculosis. Besides, BCG vaccination might lead to complications.

Usually these are local and are rarely observed, in about 0.02 % cases. The complications are: cold subcutaneous abscess, superficial ulceration at the site of injection (10 mm and larger), lymphadenitis of regional lymphatic nodes, keloid cicatrices (10 mm and larger at the site of healed vaccination reaction). At all these complications antimycobacterial therapy is indicated. Cold subcutaneous abscess is associated with a defect of intradermal injection technique and vaccine appearance under the skin. Cold subcutaneous abscess is painless, it may first appear in 1-8 months after vaccination or revaccination. It dissolves without treatment in 2-3 months or softens with fluctuation or, sometimes, a fistula. Healing might result in a stellar scar.

The treatment consists of: hydrocortisone ointment bandages; aspiration of caseation masses with a syringe and introduc

tion of 5 % saluzid into the cold abscess (dosage is calculated ac cording to body weight); when conservative treatment is ineffective, cold abscess is surgically removed in 2-3 months with a capsule. Superficial ulceration may appear in 3-4 weeks after vaccination or revaccination at the site of vaccination. Ulceration affects surface layers of skin. The treatment consists of dry isoniazid application. Post vaccination lymphadenitis of regional lymph nodes in the site of vaccination is observed in newborns in 2-3 months after vaccination with a normal local reaction. Asymptomatic beginning is characteristic of the disease as well as lymphadenopathy. The clinical signs depend on the phase of the disease (infiltration, abscess, calcination). Sometimes a lymph node may develop softening and a fistula discharging odour-free pus. Healing follows spontaneous emptying of lymphadenitis. If abscess lymphadenitis does not heal, local treatment with antimycobacterial drugs is prescribed for 3-6 months plus:

lymph node puncture with its contents aspiration and 5 %

saluzid injection; " application of rifampicin solution (0.45 g of rifampicin is diluted in 100 ml of 20 % diniexid); removal of calcifications sized 1 cm and larger together with the capsule. A keloid scar at the site of healed post-vaccination reaction is a tumor-like scar consisting of connective tissue (10 mm and more), which is raised over the skin, it is whitish and very firm by touch. Most often this complication is observed in revaccinated prepubertal girls and teenagers with allergic predisposition or in cases of a too high injection into the shoulder area. Usually postvaccination keloid does not grow. Large keloids (more than 1 cm) have a tendency to grow. Large keloids should be treated with injection of 0.5 % solution of hydrocortisone emulsion on 0.5 % of novo-caine. Injections are given once a week with tuberculin needles in 5-6 sites into keloid per se. When ineffective, pyrogenal and lidase with hydrocortisone could be used as well.

Chemoprophylaxis
Chemoprophylaxis (secondary prevention) is the prescription
of antimycobacterial drugs to: increase the resistance of healthy persons with high risk of

avoid exacerbation or relapse of tuberculosis. Chemoprophylaxis is considered the most effective method of tuberculosis prevention. Antimycobacterial drugs are used for chemoprophylaxis. Chemoprophylaxis can be primary and secondary. Primary chemoprophylaxis is prescribed to uninfected individuals in tl-e focus of infection. The purpose is the prevention of infection with Tb and tuberculosis symptoms. This chemoprophylaxis is used in: children, teenagers and healthy adults contacting a person discharging bacteria or a patient with active tuberculosis.These individuals receive 0,45mg of isoniasid twice a year for 3 months during the whole period of contact and for 2 years after ceasing of contact;

tuberculosis infection;

newborns vaccinated with BCG vaccine born from women

with a late diagnosis of tuberculosis. These newborns receive isoniazid (10mg/kg) once a year for 3 months over the period of 2 years. Secondary chemoprophylaxis is done for the prevention of: 1.Disease: - infected for the first time (children and teenagers with tuberculosis test virage); children and teenagers with hyperergic Mantoux skin test with 2 TU PPD-L; infected persons contacting a person discharging bacteria or a patient with active tuberculosis. Secondary chemoprophylaxis is prescribed to the firsttime infected before the age of 30: continuing isoniazid during 2-3 months; to persons with hyperergic Mantoux skin test: isoniazid during 2-3 months twice a year; infected contacts: isoniazid during 2-3 months twice a year and during 2 years after ceasing of the contact.

2. Relapse of tuberculosis in persons with tuberculosis



and: concomitant unfavorable diseases; large residual changes; concomitant severe disorders; HIV with hyperergic reactions to tuberculin. Secondary chemoprophylaxis is prescribed for 2-3 months twice a year with isoniazid and another drug (0.8-1.2 g ethambu-tol, 0.45-0.6 g rifampicin).