Primary and secondary prevention of opportunistic infections in HIV-infected people. What methods are used to prevent HIV infection Individual HIV prevention in the medical environment
Specific immunoprophylaxis for HIV infection has not been developed. WHO (according to documents) indicates 4 main areas of prevention:
^prevention of sexual transmission of HIV through medical and moral education of the population, including high school students;
2) preventing the transmission of HIV through blood by ensuring the safety of blood products, aseptic conditions during invasive therapy (surgical and dental procedures that violate the integrity of the skin);
3) preventing perinatal transmission of HIV by disseminating information on methods of preventing perinatal transmission of HIV during family planning, as well as providing medical care (including counseling) to women infected with HIV;
4) organization of medical care and social support for HIV patients, their families and others.
Unfortunately, as can be seen from the introductory remarks to the chapter, it turned out to be impossible to achieve 100% effectiveness of each of the directions, and by the mid-90s, WHO recognized the presence of an HIV pandemic in a number of regions of the world. Without touching on the reasons for this, we will only point out that (in the second direction) so far only serological examinations of blood donors are carried out. “False-negative” results of such an examination can be caused not only by technical errors, but also by the fact that the donor is in the “seronegative” period of the disease. PCR testing with donor blood is not yet performed in any country in the world. From the above it follows that an important link in the prevention of the transmission of HIV (as well as cytomegaly virus, hepatitis, etc.) with blood and its preparations is a sharp limitation of indications for blood transfusions. With regard to perinatal transmission, an HIV-infected woman must decide for herself whether to prevent or terminate a pregnancy, and forced termination of pregnancy is unacceptable, as this violates human rights.
Specific prevention of HIV infection in a child born from an HIV-infected mother is outlined in our textbook “Neonatology” [M.: MEDpress, 2004].
Prevention of infection in medical institutions is ensured by strict adherence to the sanitary and epidemic regime. It is necessary to remember:
The greatest danger of spreading HIV is blood and saliva.
The maximum risk is the penetration of infected material through damaged skin and mucous membranes. In this regard, it is necessary to carefully avoid accidental damage to the skin with sharp instruments.
Medical workers carry out all manipulations with patients, as well as work with biological materials from patients, wearing disposable rubber gloves and masks. In addition, it is necessary to observe all precautions provided when working with patients with viral hepatitis B.
All healthcare workers who have contact with HIV-infected patients should be vaccinated against hepatitis B.
If the skin is damaged, you must immediately treat the gloves (70% alcohol, 3% chloramine, alcohol solution of chlorhexidine) and remove them, squeeze the blood out of the wound, then wash your hands thoroughly under running water with soap, treat them with 70% alcohol and lubricate the wound with 5% iodine solution. If your hands become contaminated with blood, you should immediately treat them with a swab moistened with a 3% chloramine solution or 70% alcohol, wash them twice with running water and soap, and wipe dry with a disposable towel. You should immediately consult with an HIV specialist and decide on chemoprophylaxis (Table 299).
Prevention of HIV infection at risk of parenteral infection (Rakhmanova A. G., 2000)
Table 299
|
* The HIV status of the patient with whose blood there was contact is taken into account:
In case of trauma from an asymptomatic patient with a high level of CD4+ T-helper cells and a low viral load (the number of HIV RNA copies in 1 ml of blood plasma), type 3 chemotherapy is administered;
In case of an advanced clinical picture of the disease, the level of CD4+ T-helper cells is below 500 in 1 μl and/or viral load, type 1 chemoprophylaxis is carried out.
* * If the patient does not have positive serology before contact and there is no data on his negative serological test, a rapid test is preferable, since its results will be known within 1 hour. Standard serological tests can take from 3 to 7 days, but a negative ELISA usually available within 24-48 hours. If the patient has an acute HIV infection syndrome, testing should also include measurement of HIV RNA and HIV DNA levels.
If blood gets on the mucous membranes of the eyes, they should be immediately washed with water or a 1% boric acid solution.
If the patient’s blood or saliva gets on the nasal mucosa, it is necessary to treat it with a 1% protargol solution; on the oral mucosa - rinse your mouth with a 70% alcohol solution or a 0.05% potassium permanganate solution or a 1% boric acid solution.
Health care workers with wounds on the hands, exudative skin lesions, or weeping dermatitis are temporarily excluded from caring for HIV-infected patients and contact with care items.
Be sure to thoroughly wash your hands after removing gloves and personal clothing before leaving the room where you are working with potentially infected material.
Hospitalization of patients with AIDS and HIV-infected patients should be carried out in such a way as to prevent the spread of infections, as well as taking into account the requirements for maintaining patients with altered behavior due to damage to the central nervous system.
When treating children with HIV infection, it is necessary to use only disposable equipment and syringes.
If household items, bedding, or environmental objects are contaminated with the patient's secretions, it is necessary to treat with disinfectants (5.25% sodium hyposulfite solution, 0.2% sodium hypochloride solution, ethyl alcohol).
Necessary measures to combat infection include timely recognition and hospitalization of infected patients in specialized institutions. However, as the number of HIV-infected people increases, their hospitalization for any intercurrent diseases only in specialized hospitals becomes unrealistic. As long as basic precautions are followed, communication with HIV-infected people and even AIDS patients is safe. HIV-infected children and even sick people can attend childcare centers and school during the period of remission. The family itself must decide who to talk about the child’s diagnosis. Many families are afraid of what will become known about their children and themselves being HIV-infected. It is important to discuss with them who should know about the diagnosis. Hospital medical personnel must carefully maintain confidentiality. It can be beneficial for a child if a teacher who sympathizes with him and knows about the diagnosis pays increased attention to him in the event of falling behind or missing school due to illness. Some families want no one to know about the diagnosis, and a conflict with the doctor about this can lead to the parents completely refusing the hospital's help. Medical care for the child in case of deterioration of the child’s condition is the most important, and the parents themselves will later come to the conclusion about the need to disclose the diagnosis to a certain circle of people. Parents also tend to be concerned about information that may be contained on a child's record being submitted to school, where confidentiality may not be maintained. Parents always face the problem of when to tell their child about his illness. There are no clear answers to all these complex questions, and in each specific case the solution is individual. These parents can be helped by connecting them with families in similar situations.
Primary prevention is carried out to prevent the occurrence of the first episode of infection. Secondary prevention is carried out to prevent the occurrence of a repeat episode of infection after an infection.
Distinguish nonspecific prophylaxis, immunoprophylaxis, and drug prevention and treatment of opportunistic infections.
Nonspecific prevention of infections.
Children and/or their caregivers should receive recommendations from a doctor for nonspecific prevention of opportunistic infections, that is, recommendations for developing hygiene skills and avoiding risky behavior, based on data on the epidemiology of opportunistic infections and the possibility of a particular child becoming infected with them.
Recommendations for nonspecific prevention of zoonotic infections:
|
pathogen |
source |
||
| Toxoplasma gondii | cats (stale excrement and soil and food contaminated with it), raw animal meat and fish | avoid contact with stale cat excrement, feed the cat with ready-made dry cat food or well-cooked meat; consume meat and seafood in heat-treated form, do not taste raw minced meat, wash your hands thoroughly after contact with raw meat; work with soil (in the garden, home gardening, contact with sand) only with gloves, wash vegetables and fruits thoroughly |
|
| Cryptosporidium spp. | cats, dogs, other domestic and agricultural animals | Avoid direct contact with pet feces, wash hands after manually picking up feces; carry out mandatory examination of animals with prolonged diarrhea by a veterinarian; consume thermally processed meat, offal and eggs |
|
| Salmonella spp. | dogs, cats, farm animals | ||
| Cryptococcus neoformans | poultry (especially pigeons) | Avoid cages, perches, and other bird habitats contaminated with feces where inhalation of aerosols containing fungal spores is possible. | |
| M. avium | poultry (chickens) | isolation and treatment of birds with tuberculosis infection clinic | |
| M. marinum | fish | aquarium hygiene, wear gloves when cleaning aquariums | |
Immunoprophylaxis of infections in HIV-exposed and HIV-infected children.
HIV-infected children are at high risk of infectious diseases, which increases as their immunodeficiency worsens. Therefore, vaccination of HIV-infected children, including children in the AIDS stage, should be carried out especially carefully.
A. Vaccination of HIV-exposed children and HIV-infected children without pronounced signs of immunodeficiency (clinical categories 1-3 according to the 2006 WHO classification and CD4 >15%) is carried out according to the national calendar of preventive vaccinations in accordance with the order of the Ministry of Health of the Republic of Belarus No. 913 dated December 5, 2006 “On improving the organization of preventive vaccinations”, taking into account the following:
- in the presence of clinical manifestations of acute infections, vaccination is carried out during a period of remission, lasting at least 0.5-1 month;
- the use of live vaccines is limited: children are vaccinated against tuberculosis with the BCG-M vaccine; Vaccination of children, as well as other persons living with them (family contact), against polio is carried out with inactivated polio vaccine (IPV), but not with live oral vaccine (OPV).
B. Vaccination of HIV-infected children with severe immunodeficiency (clinical category 4 according to the 2006 WHO classification or CD4<15%) должна проводится всеми анатоксинами, убитыми и рекомбинантными вакцинами. Из живых вакцин показано введение только коревой вакцины. Для пассивной иммунопрофилактики у ВИЧ-инфицированных детей с выраженным иммунодефицитом по клиническим показаниям применяется внутривенный нормальный человеческий иммуноглобулин.
Approaches to drug prevention
Primary drug prevention is prescribed to patients who are at risk of opportunistic infection (begins when the CD4 count decreases or other infections occur).
Treatment is carried out with clinical and laboratory confirmation of the presence of an active opportunistic infection.
Secondary prevention is carried out for patients who are at risk of developing recurrent opportunistic infections. Secondary prevention begins immediately after completion of the course of treatment for the infection.
Indications for the use of prophylaxis against opportunistic infections are formulated in national protocols for the treatment of HIV/AIDS.
A quick look at the main drugs for prevention:
|
indications for prophylaxis |
a drug |
|
| Tuberculosis | contact with a patient with active tuberculosis or hyperergy / tuberculin test deviation | isoniazid, etc. |
| Pneumocystis pneumonia | CD4<15% (<200 клеток/мкл) или длительная немотивированная лихорадка с одышкой | Biseptol |
| Toxoplasmosis | the presence of IgG to Toxoplasma and severe immunosuppression (CD4<100 клеток/мкл) | pyrimethamine, biseptol |
| Fungal infections | Only secondary prevention is recommended | fluconazole |
| Invasive bacterial infections | hypogammaglobulinemia IgG<4 г/л | intravenous human immunoglobulin |
There are no uniform recommendations for stopping primary and secondary prevention of opportunistic infections in children. It should be remembered that the prophylaxis regimen can only be discontinued in a child receiving effective ART, provided that a stable (registered for at least 6 months) increase in CD4 lymphocyte level >15% of the age norm is achieved, as well as in the absence of clinical symptoms in the child. laboratory manifestations of this opportunistic infection.
In an era when ART was not yet available, only the introduction of high-quality drug prevention of opportunistic infections made it possible to reduce AIDS mortality several times.
Biseptoloprophylaxis in HIV-exposed and HIV-infected children.
Pneumocystis pneumonia in HIV-infected children can develop quite early (sometimes even before the diagnosis of HIV infection is confirmed) and is usually characterized by a rapid course with a rapid increase in respiratory failure. Pneumocystis pneumonia is the leading cause of death in HIV-infected children in the first year of life. Therefore, prevention of Pneumocystis pneumonia in all children born to HIV-infected mothers is mandatory.
Prevention is carried out with the combined chemotherapy drug trimethoprim/sulfamethoxazole (Biseptol).
Biseptal prophylaxis in HIV-exposed children should begin from the moment of discontinuation of drug ARV prophylaxis (4-6 weeks of life) or, if for some reason the newborn is not started on drug ARV prophylaxis, from the 5th day of life.
Regimen: trimethoprim/sulfamethoxazole (Biseptol) 150/750 mg/m2 (or 5/25 mg/kg) per day orally in 2 divided doses daily.
Biseptoloprophylaxis in HIV-exposed children is stopped at the age of 6 months, provided there are no clinical signs of initial immunodeficiency (normal physical and psychomotor development, absence of lymphadenopathy, splenomegaly, hematological manifestations and clinical symptoms of damage to barrier organs - frequent recurrent infections of the respiratory, urinary tract and skin). HIV-exposed children aged 6-12 months are recommended to prescribe Biseptol for each episode of respiratory infection during its acute manifestations.
Biseptoloprophylaxis is stopped immediately after the diagnosis of HIV infection is excluded in the child, no matter what age this occurs.
Biseptoloprophylaxis in HIV-infected children is carried out in accordance with current regulatory documents.
There are no specific methods for preventing HIV infection. Infection can only be prevented by eliminating the possibility of the virus that causes AIDS entering the body.
Acquired immunodeficiency syndrome AIDS is an infectious disease that can lead to the death of the patient. AIDS develops quickly and within a few years the patient may die from concomitant diseases. Since there are no specific treatments, HIV prevention remains important to prevent the spread of the disease.
The human immunodeficiency virus is a retrovirus and its effect on the body is to suppress human cellular immunity. By affecting CD4 receptors, which are located on the surface of T-lymphocytes, macrophages and dendritic cells, the virus reduces the body's immune defense. This suppresses the immune system and increases the risk of developing infectious diseases and cancer, which ultimately lead to the death of the patient.
The virus constantly undergoes changes, this causes differences in the course of the disease, and is the reason that there are no specific prevention methods (vaccines) against it. Nonspecific prevention of HIV infections is aimed at preventing infection. Awareness of the population about the routes of HIV transmission plays an important role in this. Measures taken by the media and medical institutions have helped reduce the spread of HIV.
How can you get infected?
Infection occurs if the virus enters the internal environment of the human body. The source of infection is a patient or a carrier of the virus. Moreover, there are quite a lot of seropositive HIV carriers. Not everyone infected develops AIDS, as some have resistance to the virus at the genetic level.
The infectious agent may be present in biological fluids, such as:
- blood;
- sperm;
- vaginal mucus;
- breast milk.
Other biological fluids may also contain it (urine, saliva, sweat), but its concentration in them is so low that it cannot cause the development of infection in a healthy person. Based on this, infection prevention measures have been developed, the observance of which allows one to avoid such a serious disease as AIDS.
Transmission routes can be divided into several groups:
- contact infection or sexual intercourse;
- vertical path or from mother to child;
- artificial infection (medical, cosmetic procedures).
Prevention methods in adults
The most common route of transmission of infection in adults is the penetration of the virus into the body during sexual intercourse, and the semen and vaginal mucus of a patient or virus carrier contain HIV in high concentrations.
But the risk of infection is high among drug addicts and during various manipulations associated with damage to the skin. There is no data on the possibility of the virus entering through contact through everyday life through a kiss, handshake, food, water, or through the bites of blood-sucking insects.
Prevention during sexual intercourse
Infection during sex can occur even during interrupted sexual intercourse, since the infectious agent is also found in pre-ejaculatory fluid. The risk of contracting HIV increases many times with an increase in the number of sexual partners and the use of unprotected sex.
The risk of infection is especially high among young people, teenagers, since during this period there is a sexual surge in the body, which reduces the feeling of danger. And even awareness of the risks of unprotected sex does not always stop.
Using condoms during sexual intercourse reduces the risk of infection by almost 95-98%, but they must be used correctly.
- Choose condoms from large manufacturers, preferably in opaque packaging.
- Use condoms without various aromatic lubricants, as they can cause irritation and allergies, which means that the likelihood of microdamage to the mucous membrane increases.
- Do not use creams or Vaseline for lubrication, they can damage the latex.
- Check the expiration date of the condom.
- Storage conditions play an important role, so it is better to purchase them in pharmacies.
- Condoms should not be stored for a long time in the light or at elevated temperatures, for example, in pockets, as this leads to damage to their integrity.
- You cannot put one condom on top of another; the likelihood of damage increases due to friction.
- You should not be embarrassed to offer your partner protected sex; this does not indicate mistrust, but indicates awareness, concern for your own and his health.
Sanitary education work to raise public awareness begins at school. Teenagers are introduced to the ways of transmission of HIV and methods of preventing diseases such as AIDS. In some countries, schoolchildren are given free condoms and warned that the best prevention measure is to abstain from promiscuous sexual intercourse and test partners for HIV before marriage.
Prevention for drug addicts
Another problem inherent in the youth environment is drug addiction. Injecting drugs with one syringe can lead to infection. Educational work about the dangers of drug addiction with different age groups, compulsory treatment and the fight against the production and distribution of drugs are measures to prevent acquired immunodeficiency syndrome.
Prevention during medical and cosmetic procedures
There is a risk of infection during medical and cosmetic procedures. You can become infected by shaving, doing nails, or getting tattoos. Compliance with personal hygiene rules and careful sterilization of instruments in beauty salons can reduce it.
Regarding medical interventions and procedures, the use of sterile or disposable instruments prevents infection. Compliance with the standards for their processing is carried out at several levels in each medical institution.
There have been cases where HIV infection occurred as a result of transfusion of infected blood products. This led to the development of rules for manufacturing, processing and proper use, which significantly reduced the risk of infection.
Health care workers are also at risk, since while providing care to patients there is a risk of infection through contaminated blood from cuts and injuries. In such cases, they undergo emergency medical post-exposure prophylaxis, which consists of providing first aid (wound treatment) and prescribing antiretroviral drugs.
Prevention methods in newborns
AIDS infection of a child can occur in early pregnancy, during childbirth and during breastfeeding. Pregnant women infected with HIV are prescribed antiviral drugs. Childbirth is often performed by caesarean section to shorten its duration. To prevent infection when feeding a child, they are transferred to artificial nutrition.
HIV prevention is necessary to prevent the development of AIDS and virus carriage. Every person should understand that AIDS is a serious disease with a high mortality rate, and its prevention is the only way to preserve the health of yourself and your loved ones.
RUSSIAN FEDERATION
FEDERAL STATE BUDGETARY INSTITUTION "RUSSIAN CENTER OF FORENSIC MEDICAL EXAMINATION"
"APPROVED"
chief freelance specialist
in forensic medical examination
Russian Ministry of Health,
Director of the Federal State Budgetary Institution "RCSME"
Russian Ministry of Health,
Doctor of Medical Sciences
____________A.V. Kovalev
"___"___________ 2013
PREVENTION OF HIV INFECTION IN STATE
^ FORENSIC MEDICAL INSTITUTIONS
Moscow
Methodological recommendations were developed by Doctor of Medical Sciences V.N. Bolekhan, Candidate of Medical Sciences P.G. Dzhuvalyakov, Candidate of Medical Sciences, Associate Professor D.G. Zigalenko, Doctor of Medical Sciences D.S. Kadochnikov, Doctor of Medical Sciences, Professor E.M. Kildushov, Doctor of Medical Sciences A.V. Kovalev (chief freelance specialist in forensic medical examination of the Ministry of Health of Russia), Candidate of Medical Sciences A.L. Kochoyan, Candidate of Medical Sciences E.S. Orlova, Doctor of Medical Sciences, Professor A.I. Mazus (chief freelance specialist on the problems of treatment and diagnosis of HIV infection of the Russian Ministry of Health), resident P.V. Minaeva.
Bolekhan V.N., Dzhuvalyakov P.G., Zigalenko D.G., Kadochnikov D.S., Kildyushov E.M., Kovalev A.V., Kochoyan A.L., Orlova E.S., Mazus A. .I., Minaeva P.V. Prevention of HIV infection in state forensic medical institutions: methodological recommendations. – M., 2013. – 38 p.
The methodological recommendations present the system for the prevention of HIV infection in the state forensic medical expert institution (SSMEU), issues of organizing sectional and laboratory work with HIV-infected material, risk factors for infection, accident rates during medical procedures and injuries to medical workers, and recommendations for post-exposure prevention against the risk of occupational infection.
The methodological recommendations are intended for heads of state forensic medical expert institutions (GSMEU), as well as forensic medical experts (forensic experts), mid-level and junior medical staff of GSMEU, students, residents, graduate students and teachers of state educational institutions of higher and additional professional education.
INTRODUCTION
The HIV epidemic in Russia is characterized by a further increase in the number of new cases of infection. In recent years, there has been an increase in the mortality rate among HIV-infected people. A manifestation of the current epidemic situation is an increase in the frequency of detection of cases of HIV infection in medical organizations of various profiles, as well as an increase in the number of sectional studies of HIV-infected people. This indicates a growing threat of HIV infection being introduced into state forensic medical institutions (SFMEI) and, accordingly, the risk of infection of employees of these institutions as a result of professional activities.
At SSMEU, employees of thanatology departments have the greatest risk of infection, since they are in direct contact with corpses. An analysis of injuries during sectional studies showed that annually up to 65% of forensic experts and support staff have a risk of contracting HIV, blood-borne hepatitis viruses as a result of infected blood getting on damaged skin and mucous membranes during the section. In addition, at the time of an emergency, less than 1% of the examined corpses are accompanied by intravital medical documentation about HIV status and viral liver pathology.
Informing employees about the risks associated with their activities and preventive measures is a basic component of the preventive work of health services. If health care workers do not feel supported when they are at risk of exposure to HIV, it will be extremely difficult for them to do their jobs with the confidence they need. Therefore, the most important task of medical science and practice is the development and creation of safe working conditions for medical personnel.
In this regard, primary importance in the State Medical and Medical Regulations should be given to the issues of training and protection of medical personnel in the event of a risk of occupational infection with HIV and other infections through parenteral transmission.
^ 1. RISK FACTORS OF INFECTION
MEDICAL WORKERS
Currently, HIV infection is an incurable infectious disease. Despite prevention efforts, the number of new cases of HIV infection increases every year. The epidemic of this infectious disease has become an additional factor creating an excessive burden on healthcare.
Risk factors for infection include multiple, frequent parenteral interventions, associated with the risk of infectious complications in the patient and injuries to medical personnel, especially those carried out in violation of anti-epidemic rules. The likelihood of a medical worker becoming infected with infections through parenteral transmission as a result of his or her professional duties consists of three components:
the emergence of conditions for transmission of infection (emergency or injury);
the presence of a risk of pathogen transmission (the contagiousness of the pathogen and the dose of infected material are taken into account);
determination of the potential infectiousness of the material with which contact has occurred.
In HIV-infected persons, markers of parenteral viral hepatitis are detected in 66% of cases. In this regard, medical workers also have a higher risk of contracting hepatitis B and C than with HIV infection. The incidence rate of hepatitis B and C among medical workers in clinical specialties with these infections exceeds the incidence rate of the population of Russia by 1.5-6.5 times, and for the staff of the State Medical University of Medical Sciences this figure increases by 20-50. In this regard, parenteral viral hepatitis in medical workers should be considered occupational diseases, especially if a direct cause-and-effect relationship with their occurrence and professional activity is proven (Order of the Ministry of Health and Social Development of Russia dated April 27, 2012 No. 417n “On approval of the list of occupational diseases”).
The frequency of detection of markers of viral hepatitis B and C among medical workers of various specialties varies significantly. This allows us to talk about groups of different levels of occupational risk of infection. These include employees of the departments of laboratory diagnostics, surgery, intensive care, dentistry, gynecology, and thanatology departments of the State Medical University. Infection with viral hepatitis B can currently be prevented by specific prophylaxis - vaccination, followed by regular determination of the titer of protective antibodies. There are currently no specific preventive measures against HIV infection and viral hepatitis C.
Transmission factors for infections with a parenteral transmission mechanism are blood and objects contaminated with it. With viral hepatitis B, 1 ml of blood can contain from 1.5 to 150 million infectious doses, with viral hepatitis C - from 1 to 100 thousand, with HIV infection - from 10 to 1 thousand. According to a number of researchers, the probability of a health worker becoming infected when performing manipulations on a patient with HIV infection with a single puncture of the skin varies from 0.1-0.2% to 0.3-0.5%, and when performing manipulations on a patient with viral hepatitis B and C - 30-43% and 1.8-2%, respectively.
^ 2. ACCIDENTS DURING MEDICAL MANIPULATIONS
AND INJURIES TO MEDICAL WORKERS
A detailed analysis of the frequency of injuries and accidents associated with the risk of occupational HIV infection is complicated by the system of their registration. Every month, 65% of medical workers receive microtrauma to the skin, but no more than 10% of injuries and emergencies are officially registered. Based on registration data, the frequency of injuries from sharp medical instruments has been established, which ranges from 0.75 to 5.15 per year per employee, and it is also possible for blood to enter the skin and mucous membranes. Of the emergency situations during sectional examinations, the most common are cuts and “scratching” of the skin - 63.5%, needle pricks - 18%. Less often, blood gets on the skin - 12.5% and the mucous membrane of the eyes - 6%.
One study found that the injury rate for nursing staff was 0.61 per 1000 people per day (equivalent to 22.3 per 100 people per year), with only 4.3% of nurses and 3.9% of doctors reporting injuries occurring. Nearly a third of all health care workers had at least one needlestick injury within a 12-month period. The smallest number of injuries is described in pediatrics - 18.7%, and the largest - in surgery - 46.9%.
The ratio of the frequency of emergency situations among medical personnel in surgical and therapeutic hospitals is 3:1. It is generally accepted that the frequency of safety violations during surgery and microtraumatization of hands among surgeons during the year is 10-30%.
The risk of HIV infection in a healthcare worker directly depends on the conditions of injury and the nature of the injury itself. Thus, injections are more dangerous than incised wounds due to the fact that bleeding from an open incised wound greatly reduces the risk of infection. In addition to damage from sharp objects, contamination of damaged skin (abrasions, eczema, etc.) and mucous membranes with biological material contaminated with HIV poses a minor danger.
The first case of a healthcare worker becoming infected with HIV as a result of a needle stick was described in 1984. Currently, 344 cases of professional infection of health workers with HIV infection have been described in the world. Among them, 106 are classified as proven cases, and 238 are cases in which professional contact as the cause of infection is suspected. The largest number of cases of HIV infection (48.2%) was observed among nurses, in second place (39.3%) were employees of clinical laboratories, in third (12.5%) were doctors of surgical specialties (surgeons, obstetricians-gynecologists, etc.) .d.) .
^ 3. GENERAL ISSUES IN HIV PREVENTION
AT THE RISK OF OCCUPATIONAL CONTAMINATION
The main way to prevent occupational infection is to follow standard precautions when working with blood and biological material. According to WHO recommendations, these are:
maximum prevention of the possibility of contamination of the skin and mucous membranes with blood and biological fluids as a result of the use of personal protective equipment (overalls, gloves, goggles, screens, shields);
compliance with sterilization, disinfection regimes and algorithms for performing invasive procedures.
Using latex gloves reduces the risk of infection several times.
However, a study by Danish scientists showed that 28% of accidents could not be prevented using universal precautions. In the USA, 20% of emergencies were associated with unexpected, difficult to predict events, the rest were the result of insufficient implementation of anti-epidemic measures. Only 13.2% of all injuries could have been prevented through organizational measures, and 34% through the use of safer tools.
In the event of an emergency involving a risk of HIV infection, medical personnel should reduce the likelihood of infection by reducing the infectious dose entering the body (for example, by allowing blood to flow freely from a wound or by carefully rinsing the wound or mucous membranes with water, treating the injury site with disinfectants), and by influencing the pathogen with post-exposure chemoprophylaxis.
In accordance with the recommendations set out in the clinical protocol of the WHO European Office (2006), and in a number of other methodological documents, all workplaces for performing invasive procedures should be provided with first aid kits for partial sanitization in the event of an accident or injury (Anti-AIDS first aid kit ""). Wounds and skin areas after contact with blood or other biological fluids must be washed with soap and water, and mucous membranes should be rinsed with water. The use of antiseptics for wound treatment does not significantly reduce the risk of HIV transmission. However, the use of antiseptics is recommended by most guidelines for emergency chemoprophylaxis of HIV infection. An HIV-infected patient is prescribed to perform invasive manipulation in the presence of a second specialist, who, in the event of an emergency or injury, will be able to continue performing it, and the injured medical worker will receive first aid.
When a patient with HIV infection is hospitalized in a medical organization, medical workers, in most cases, do not know about the patient’s HIV status. Therefore, in the event of an emergency, rapid tests must be used to quickly determine the patient’s HIV status. In the event of an emergency, a GSMEU medical worker is also advised to conduct an HIV test on the blood of a corpse, regardless of the presence or absence of intravital medical documentation.
Data on the development of the initial stage of HIV infection indicate that full-scale general infection does not develop immediately, leaving a chance for antiviral measures to be taken after dangerous contact (up to 36 hours!), which may affect viral replication. Experimental work on animals and humans has provided direct and indirect evidence of the effectiveness of antiretroviral drugs as means of emergency post-exposure prevention of HIV infection.
Currently, three classes of drugs can be used for post-exposure emergency chemoprophylaxis: nucleoside (nucleotide) reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs).
The scope of post-exposure emergency prophylaxis, that is, the prescription of antiretroviral drugs, is determined by an infectious disease doctor, taking into account the nature of the traumatic effect, the amount of biological fluid that has entered the wound or on the mucous membranes, and the possible amount of HIV in a given substrate. In accordance with the methodological recommendations of the Ministry of Health and Social Development of Russia (2007) for emergency post-exposure prophylaxis of HIV infection, during prophylactic use of antiretroviral drugs it is necessary to monitor toxicity at the start of the course and two weeks after its start. At a minimum, it should include a general clinical blood test with determination of its formula, as well as a study of biochemical blood parameters.
A number of methodological documents of the Ministry of Health and Social Development of Russia and the Ministry of Labor of Russia require mandatory recording and investigation of emergency situations and injuries among medical workers performing professional duties. For each case associated with the risk of nosocomial infection of a medical worker with HIV infection in the workplace, based on the explanations of the victim and eyewitnesses, an entry is immediately made in the log of injuries and accidents among medical workers (Appendix 2) and a medical injury report is drawn up ("Act about an accident at work" - Appendix 5).
The fact of HIV infection, as well as the cause of infection, its connection with the performance of official duties by a medical worker is established by a specialized medical organization of the state or municipal health care system dealing with the prevention of HIV infection, together with the territorial center of state sanitary and epidemiological surveillance.
If HIV infection is detected in workers of certain professions, industries, enterprises, institutions and organizations, the list of which is approved by the Government of the Russian Federation, these workers are subject, in accordance with the legislation of the Russian Federation, to transfer to another job that excludes conditions for the spread of HIV infection.
^ 4. HIV PREVENTION SYSTEM IN SSMEU
The system for preventing HIV infection in the State Medical University includes a set of sanitary and anti-epidemic (preventive) measures and the totality of the forces and means of the institution for its implementation. Activities within the system are carried out in the following areas: ensuring sanitary and epidemiological well-being in SSMEU, organizing and conducting laboratory diagnostics of HIV infection, ensuring the sanitary and anti-epidemic regime (SAER), improving the professional training of medical personnel on the problem of HIV infection.
^ 4.1. Ensuring sanitary and epidemiological
well-being on HIV infection in SSMEU
The organization of work on the prevention of HIV infection in the SSMEU provides for: constant monitoring and identification of risks of occupational infection in the workplace, determination of priority tasks and the nature of preventive measures taking into account emerging risks of infection, application of safety standards when performing medical procedures, ensuring optimal workload for personnel, analysis of cases of occupational injuries, carrying out emergency prevention of HIV infection in the event of a risk of occupational infection, training medical staff in safety rules when handling traumatic instruments and infectious substrates, including their disinfection and disposal.
There are two main areas of sanitary and anti-epidemic (preventive) measures to ensure sanitary and epidemiological well-being regarding HIV infection in the State Medical and Medical Inspectorate:
prevention of the occurrence and localization of foci of HIV infection among medical workers,
prevention of the “uncontrolled removal” of HIV infection outside the State Medical and Medical Institution.
^ Prevention of the occurrence and localization of foci of HIV infection among medical workers is ensured by strict compliance with the requirements of the PERM, and is also achieved by carrying out the following groups of measures: restrictive, disinfection, laboratory tests, including the use of rapid tests for examining corpses with unknown HIV status; emergency post-exposure chemoprophylaxis at risk of infection of medical workers. Medical staff are provided with methodological work and special training on HIV prevention issues.
When a corpse with unknown HIV status is admitted to the State Medical Examiner's Office recommended perform a laboratory express test of his blood for HIV infection by the forensic biological department in the following cases:
murders and suspected murders;
suicides of persons under 40 years of age;
suspected death from drug poisoning;
death from various causes of persons who previously used drugs;
availability of data on lifetime HIV infection or suspicion of it;
death of persons aged 18 to 50 years from tuberculosis, pneumonia, hepatitis, cirrhosis of the liver;
violent and non-violent death of asocial persons (homeless people, etc.).
If HIV infection is detected in cadaveric material, the result of the study must be entered into the “Register of Hospital Infections” (form. 060-U). If epidemiological signs of possible infection and clinical manifestations of HIV infection are identified during a forensic medical examination of living persons, they should be sent for consultation to the territorial Center for the Prevention and Control of AIDS and Infectious Diseases.
^ Preventing the “uncontrolled spread” of HIV infection outside the State Medical and Medical Institution can be ensured by the timely transfer of information about the detection of HIV infection in a corpse to the territorial center of the State Sanitary and Epidemiological Supervision, the Center for the Prevention and Control of AIDS and Infectious Diseases (city, regional) and the relatives of the deceased.
^ 4.2. Ensuring sanitary and anti-epidemic
regime in GSMEU
The heads of forensic medical examination bureaus (centers), full-time and non-staff epidemiologists, medical personnel of the State Sanitary and Epidemiological Supervision Authority, the logistics service of the State Sanitary and Epidemiological Supervision Center, etc. take part in ensuring the sanitary and anti-epidemic regime (SER) in the State Medical and Epidemiological Agency.
Responsibility for organizing the SPER in SSMEU rests with the head of the institution. The head of the forensic medical examination bureau (center) organizes the implementation of the requirements of the legislation of the Russian Federation in the field of ensuring the sanitary and epidemiological well-being of personnel. The deputy head of the bureau (center) of forensic medical examination for organizational and methodological work provides general guidance on the organization of the forensic medical examination and preventive measures. Heads of departments organize the fulfillment of the requirements of the EDMS by staff, collect, record and analyze cases of detection of HIV infection and viral hepatitis B and C among employees, among living examined persons and deceased persons admitted for forensic medical examination, conduct training for medical personnel on the prevention of parenteral infections, take part in the investigation of cases of injuries and accidents among medical workers, and provide measures for their prevention. The chief (senior) nurse of the bureau (center) of the forensic medical examination directly organizes the implementation and is personally responsible for compliance with the PER. Nursing and junior medical personnel are required to perform PERM in their daily work.
Heads of SSMEU departments provide briefings on the requirements of the sanitary and anti-epidemic regime, the need to maintain medical confidentiality and responsibility for disclosing information signed by a medical worker in a special journal.
^ 4.3. Improving the professional training of medical personnel on the problem of HIV infection
Increasing the professional competence of SSMEU medical workers on current issues of epidemiology, clinical presentation, diagnosis and prevention of HIV infection is carried out within the framework of special training. To assess the level of knowledge of medical workers on the problem of HIV/AIDS in SSMEU, it is necessary to have control tests, according to which personnel should be periodically tested to assess their readiness to work in conditions of professional contact with HIV-infected corpses. Such testing objectively reflects the level of professional knowledge of SSMEU medical specialists and allows for proper planning of work to improve it.
^ 5. ORGANIZATION OF SECTIONAL WORK WITH
HIV-INFECTED MATERIAL
5.1. Ensuring safety during sectional examinations
HIV-infected cadaver studies and activities
in case of an accident
The working conditions of forensic medical experts (forensic experts), the procedure for organizing and conducting forensic medical examinations (forensic examinations) in the State Medical Examiner's Office, the requirements for ensuring safety when working with HIV-infected material are regulated by the legislation of the Russian Federation.
In order to protect the expert from HIV infection during a sectional examination of a corpse, it is necessary to use protective clothing: a gown, a cap, a disposable surgical mask, goggles or a face shield, two pairs of rubber anatomical gloves, disposable oversleeves and an apron. The protective clothing set can be supplemented with rubber shoes or boots. If there are microtraumas, scratches, or cuts on your hands, you should pre-glue the damaged areas with adhesive tape or cover them with a fingertip.
All instruments and materials used in laboratory and sectional studies and which have had contact with HIV-infected material must be disinfected.
The sectional instruments used in the study of a corpse infected with HIV are placed in a special hermetically sealed container, and objects contaminated with blood are placed in a plastic bag.
GSMEU waste is epidemiologically hazardous and is classified as medical waste of class “B”. Containers and bags for collecting waste in these institutions must be yellow or have a yellow marking “Waste. Class B." If sectional material, instruments or objects have had contact with pathogens of pathogenicity groups 1-2 or tuberculosis, then they pose an extreme epidemiological danger and should, like medical waste, be collected in appropriate red containers or be marked red “Waste. Class B."
Methods and methods for collecting, neutralizing (disinfecting), transporting and disposing of medical waste of classes “B” and “C” are described in the relevant sanitary standards and regulations.
Referral forms, jars or other containers with sectioned HIV material sent for research are marked in red in the form of a triangle, as for hepatitis B. The diagnosis of HIV infection in all medical documents is indicated with the code “B.23”.
Upon completion of work with material containing HIV and after removing protective clothing, all medical personnel thoroughly wash their hands with soap and treat them with an antiseptic.
If an emergency occurs and blood or other biological fluids (substrates) get on the surface of objects, it is necessary to wipe the contaminated surface twice (immediately and at intervals of 15 minutes) with a rag, cotton or gauze swab, generously moistened with a disinfectant solution. All work should be done with gloves. It is undesirable to use chlorine-based compositions as disinfectants, since formaldehyde is often present in the premises of the State Sanitary Inspectorate, which with hypochlorite forms a strong carcinogen - bis (chloromethyl) ether. Used rags and tampons are discarded into a container with a disinfectant solution or into a tank for subsequent autoclaving.
If parts of the body of medical personnel unprotected by a gown and gloves come into contact with blood or other biological material from a corpse infected with HIV, the contaminated surface is quickly treated with a disinfectant solution. Before removing, the apron is thoroughly wiped with a gauze cloth soaked in a disinfectant, after which it is removed and folded with the outer side inward. Use separate napkins, generously moistened with a disinfectant solution, to wipe oversleeves and rubber gloves.
Used and contaminated during the examination of a corpse infected with HIV, the gown and cap are placed in a waterproof sealed bag and sent for autoclaving, or soaked in a container with disinfectant directly in the section room. After the recommended exposure specified in the instructions for the disinfectant, the soaked elements of the protective suit are washed with running water and washed. Shoes are treated by wiping them twice with a rag soaked in a solution of one of the disinfectants. The skin of the hands and other parts of the body under contaminated clothing is wiped with a 70% ethyl alcohol solution.
^ 5.2. Nonspecific prevention measures
HIV infection
Any equipment or linen contaminated with cadaveric secretions should be considered potentially contaminated with HIV. It should be handled in such a way as to avoid contact of skin and mucous membranes. If such contact does occur, it is necessary to carry out partial sanitization (Appendix 1):
if such potentially infectious material comes into contact with the skin: treat with a 70% ethyl alcohol solution, wash thoroughly with soap and water and re-treat with a 70% ethyl alcohol solution;
if such potentially infected material comes into contact with the mucous membrane of the eyes, nose and oral cavity: rinse the oral cavity with plenty of water and rinse with a 70% solution of ethyl alcohol, the mucous membrane of the nose and eyes is washed generously with water.
If the skin is damaged (cut, injection), you must: immediately remove gloves, wash your hands with soap and running water, treat your hands with a 70% ethyl alcohol solution and a 5% alcohol solution of iodine.
All cases of possible infection of employees as a result of accidents or injuries in the workplace must be immediately reported to the head of the department and the epidemiologist or the person responsible for the prevention of HIV infection, as well as the head of the State Medical Inspectorate. Data about the examined corpse and injured medical worker are entered into a log of injuries and accidents among medical workers, which is stored in a place established by a special order for the State Medical Inspectorate. The registration form is given in Appendix 2.
If an accident occurs, as a result of which a medical worker is injured, the head of the department ensures that this emergency is recorded and investigated (makes an entry in the log of injuries and accidents for medical workers - see Appendix 2). For each case associated with the risk of occupational infection of a medical worker with HIV infection, it is necessary to issue an injury report (“Workplace Accident Report”, see Appendix 5). An injury (accident) report must be drawn up in the department immediately after the injury (accident) has occurred, based on the explanations of the victim and eyewitnesses. The act is signed by the head of the unit, the person responsible for labor protection in the institution and the safety of personnel (at night, weekends and holidays - by the administrator on duty), and eyewitnesses from among medical workers.
^ 6. RAPID DIAGNOSTICS OF HIV INFECTION IN GSMEU AT THE RISK OF INFECTION OF MEDICAL WORKERS
In the absence of data on the HIV status of the corpse, it is necessary to perform an express study of its blood, based on the results of which a decision will be made to carry out emergency post-exposure prophylaxis of HIV infection to a medical worker and organize anti-epidemic measures in a potential source of HIV infection.
Cadaveric blood is taken from the heart before the brain is removed. To do this, it is necessary to make a midline incision on the anterior surface of the body and separate the musculocutaneous flap. The surface of the sternum should be wiped with gauze moistened with 70% ethyl alcohol and cauterized with a hot spatula. Then the sternum and pericardium are dissected, the anterior surface of the right ventricle of the heart is cauterized with a spatula, through which a sterile syringe needle is inserted into the cavity. At least 5-10 ml of blood should be drawn into the syringe. If blood is clotted or absent in the cavity of the heart, it should be taken under the same conditions from the vena cava, femoral or jugular veins.
To conduct rapid testing for HIV infection, the SSMEU must have appropriate diagnostic enzyme-linked immunosorbent test systems. The result of the express study will be known within 1 hour, which will ensure timely administration of emergency chemoprophylaxis to the injured medical worker. The result of the study must be entered into the log of injuries and accidents among medical workers.
A referral form with a negative result of a rapid test for HIV infection from the State Medical Examiner's Office must be submitted to the unit where the medical worker's injury occurred and attached to the autopsy report.
In the event of a positive result of a rapid test for HIV infection, in order to assess the risk of occupational infection and determine indications for prescribing emergency post-exposure prophylaxis for HIV infection of the appropriate volume, the injured medical worker with an injury (accident) report and the result of rapid diagnostics must be sent to the doctor on duty -infectious disease specialist of a medical organization. When choosing such a medical organization, it is advisable to proceed from the principle of its maximum proximity to SSMEU.
In the absence of the possibility of express testing for HIV by the State Medical Examiner's Office, blood taken from a corpse (a probable source of HIV infection) with a direction and a report of a medical injury (accident) should be sent to the nearest medical organization that has a diagnostic laboratory that performs express tests on HIV.
However, a rapid test does not replace testing for HIV infection in a standard test, which has greater specificity. Such a study is carried out in the above-mentioned laboratory of a medical organization, where a blood sample from a corpse must be received within the first 24 hours after the risk of infection of a medical worker arises. Obtaining a negative result in a standard test (after 1-3 days) will allow you to cancel the emergency chemoprophylaxis that has been started and stop further anti-epidemic measures to localize the epidemic focus of HIV infection.
It should be noted that the average cost of one rapid test is approximately 13 times higher than a standard serological test, but 11 times cheaper than a weekly course of emergency post-exposure chemoprophylaxis with only one antiretroviral drug (for example, azidothymidine) prescribed before obtaining the result of a serological test for HIV, and approximately 27 times cheaper than a weekly course of extended-regimen antiretroviral therapy prescribed for injuries with a high risk of infection.
Consequently, organizing and conducting express diagnostics of HIV infection at the State Medical University for the Risk of Occupational Infection is an economically feasible measure. This allows, in the case of a positive result for HIV infection, to promptly begin emergency chemoprophylaxis of HIV infection for a health worker, and in the case of a negative result, to avoid the unreasonable use of toxic antiretroviral drugs and relieve psycho-emotional stress in an injured medical worker.
^ 7. ORGANIZATION OF SPECIFIC PREVENTION OF HIV INFECTION AT THE RISK OF OCCUPATIONAL INFECTION
Each medical organization, including State Medical and Medical Institutions, should be provided with or have access, if necessary, to rapid HIV tests and antiretroviral drugs. A stock of antiretroviral drugs should be stored in any medical organization at the discretion of the health authorities of the constituent entities of the Russian Federation, but in such a way that examination and treatment can be organized within 2 hours after an emergency.
After performing nonspecific prophylaxis measures and rapid testing of cadaveric blood from a probable source of infection, indications for emergency (specific) chemoprophylaxis should be determined for a person who received damage to the skin and/or mucous membranes during the examination of a corpse or in the process of working with contaminated biological material.
Emergency post-exposure chemoprophylaxis for HIV infection should be prescribed to a healthcare worker in the first 2 hours after the injury (accident). The effectiveness of prevention started later than 36 hours from the moment of the accident is sharply reduced, and after 72 hours it is considered inappropriate.
An epidemiologist, based on a positive result of a laboratory test of the blood of a corpse and studying the circumstances of the injury, determines the risk of infection, and an infectious disease specialist, if indicated, prescribes emergency chemoprophylaxis for occupational HIV infection of the appropriate amount (Table 1.)
Table 1
Indications for emergency chemoprophylaxis of HIV infection
| № | Risk of infection | Indications |
| 1 | High: deep wounds, mucous membrane contact or other cases of contact with large volumes of blood that contains significant amounts of virus | Recommended |
| 2 | Short: contact of the mucous membrane or damaged skin with blood or other liquids containing a small amount of the virus | Recommended |
| 3 | Minimum(no risk): contact with liquid in which there is no visible sign of blood | Not offered |
Before starting emergency prophylaxis, an infectious disease doctor consults a medical worker who has been injured with a risk of contracting HIV infection, informs the victim that he has the right to refuse chemoprophylaxis, and provides objective information about possible complications. An infectious disease doctor must obtain voluntary informed consent from a medical worker to carry out emergency prophylaxis (Appendix 4). Then he must make recommendations regarding the need to: prevent pregnancy, breastfeed a child, donate blood, tissue or sperm; use of condoms during sexual intercourse during the period of dispensary observation; compliance with standard precautions in the workplace if there is a risk of occupational exposure, clinical and laboratory monitoring, strict adherence to the regimen for taking antiretroviral drugs.
damage treatment
1. Cotton and gauze swabs – 5 pieces each (treatment of skin, mucous membranes).
2. 70% ethyl alcohol solution – 100 ml (skin treatment, rinsing the mouth).
3. 5% alcohol solution of iodine – 1 bottle (treatment of the wound surface).
4. Antiseptic adhesive plaster – 1 package (covering microtraumas).
5. Finger pads – 5 pieces (covering microtraumas).
6. Metal scissors.
7. Glass pipettes – 5 pieces.
Note:
The first aid kit should be stored in a labeled metal box. Responsibilities for monitoring the storage and replenishment of the mini-pack are assigned to the chief (senior) nurse of the SSMEU and the person responsible for the prevention of HIV infection.
accidents among medical workers
Date ___/___/____/, time _____ hours _____ minutes.
FULL NAME. health worker _______________________________________________
Position of health worker _____________________________________________________
Manipulation performed _________________________________________________
Nature of injuries received ___________________________________
Brief description of the circumstances of the emergency ____________________
__________________________________________________________________
Measures taken________________________________________________
Manager's signature division _____________________________________________
Signature of the person responsible for HIV prevention ________________
Signature of the head (senior) nurse _________________________________
Zidovudine (azidothymidine) 2 (or its analogs) – 54 caps. 100 mg each
Lamivudine (or its analogues) – 18 caps. 150 mg each
Lopinavir/ritonavir (kaletra) 2 (or its analogues) – 36 tablets. 200/50 mg each
Lamivudine + Zidovudine (combivir) 2 (or its analogues) – 18 caps.
Note:
1 – use strictly as prescribed by an infectious disease specialist;
2 – installation is designed for 3 emergency cases and taking medications for 3 days;
3 – drugs included in the packing can be replaced with their analogues from the same pharmacological groups.
I, _______________________________________________________, born 19 ____,
(last name, first name, patronymic in full)
I hereby confirm my voluntary consent to carry out chemoprophylaxis of HIV infection and/or chemoprophylaxis of secondary diseases for me (the person represented) with the following drugs:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
^ I confirm, that I (the person being represented) have been given full and comprehensive explanations:
That the treatment prescribed to me (the person represented) is aimed at suppressing the reproduction of the human immunodeficiency virus (HIV) in the body and preventing the development of secondary diseases associated with HIV infection; that therapy will not lead to a complete cure for HIV infection and will not completely prevent the possibility of me infecting others;
Why therapy is necessary, the effect of the drugs prescribed to me (the person being represented) and the adverse reactions that they can cause are explained;
I have been given a contact phone number by which, if necessary, I can contact the attending physician or his substitute (tel.: ____________________).
^ I put (put) inform the attending physician about all health-related problems, including allergic manifestations or individual intolerance to medications, about all diseases I (the person represented) have suffered, and about medications taken. I reported (reported) truthful information about heredity, as well as about the use of alcohol, narcotic and toxic drugs.
^ I undertake (I give my voluntary consent to the person represented) strictly in accordance with the instructions of the attending physician or his substitute:
Undergo the necessary diagnostic tests: general and biochemical blood tests, blood tests to determine viral load and immune status, viral hepatitis, X-ray, ultrasound and endoscopic studies;
Take prescribed medications; Do not take, without consulting your doctor, any medications not prescribed by him (even if they are prescribed by another doctor not on an emergency basis). If taking these medications is unavoidable (for example, in emergency cases), inform your doctor as soon as possible;
Report immediately (within 24 hours) to the attending physician about all changes in the state of my (represented) health during treatment, if I believe that these changes are related to taking the medications prescribed to me (represented).
^ I am familiar (acquainted) that refusal of treatment, non-compliance with the medication regimen, the regimen established in a given medical institution, uncontrolled self-medication can complicate the treatment process and negatively affect health; The treatment prescribed to me may be terminated at my own request or the decision of the attending physician, including due to my failure to comply with the medication regimen or examination. If I fail to comply with the doctor’s orders and recommendations, as well as other disagreements regarding my (represented) treatment, a decision may be made to transfer me (represented) for dispensary observation and treatment to another attending physician.
^ I am familiar (acquainted) and I agree (agree) with all points of this document, the provisions of which were explained to me, I understand and voluntarily give my consent to examination and treatment to the extent proposed.
I allow, if necessary, provide information about my diagnosis, severity and nature of the disease to my relatives, legal representatives, citizens:
__________________________________________________________________________________________________________________________________________________________
(last name, first name, patronymic in full, passport details/place of registration, date of birth)
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Additional Information:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date of completion: “____”________________20___.
Signature ________________________________
(signature)
Signed in my presence:
________________________________
Doctor __________________________________ (signature)
(position, full name)
Appendix 5
^
Form N-1
(approved by the Decree of the Ministry of Labor of the Russian Federation
From October 24, 2002 No. 73)
One copy is sent
the victim or his authorized representative
I approve
____________________________________
(signature, full name of employer)
ACT No. ____
^
about an accident at work
Date and time of the accident______________________________________________
(day, month, year and time, number of full hours from the start of work)
Organization (employer) of which the victim is (was) an employee
_____________________________________________________________________________ (name, location, legal address, departmental and industry affiliation (OKONH main activity))
(last name, initials of the employer – individual)
Name of structural unit ________________________________________________
The organization that sent the employee ________________________________________
_______________________________________________________________________________
(name, location, legal address, industry affiliation)
Person who conducted the accident investigation: __________________________
(surname, initials, position and place of work)
Information about the victim:
Full Name ________________________________________________________
______________________________________________________________________________
Gender (male, female)
Date of Birth __________________________________________________________________
professional status ________________________________________________________________
profession (position) __________________________________________________________
length of work during which the accident occurred _________________
(number of complete years and months)
including in this organization ________________________________________________
(number of complete years and months)
Information on briefings and training on labor protection
Introductory briefing / initial, repeated _____________________________________________
(day month Year)
Instruction at the workplace (unscheduled, targeted / underline as necessary) in the profession or type of work during which the accident occurred, if not carried out, indicate ____________________________________________________________
(day month Year)
Internship: from "_____" _________________20___ to "_____"____________20___.
(if not carried out, indicate)
Labor safety training in the profession or type of work during which the accident occurred: from "___"___________20___ to "___"___________20___.
(if not carried out, indicate)
Testing knowledge of labor protection in the profession or type of work during which the accident occurred ___________________________________________
(day, month, year, protocol number)
Brief description of the place (object) where the accident occurred
(brief description of the scene of the incident indicating dangerous and (or) harmful production
______________________________________________________________________________
equipment the use of which led to an accident
(name, type, brand, year of manufacture, manufacturer organization)
8. Circumstances of the accident _____________________________________________
(brief summary of the circumstances preceding the accident, description of events
and actions of the victim and other persons related to the accident, availability of funds
Defense, other information established during the investigation)
8. 1. Type of incident__________________________________________________________
______________________________________________________________________________
(puncture wound, superficial or deep abrasion, puncture with a contaminated needle, contamination of damaged skin and mucous membrane with infected blood or other biological fluids, etc.)
8. 2. The nature of the injuries received and the organ damaged, a medical report on the severity of the damage to health
______________________________________________________________________________
3. The victim is under the influence of alcohol or drugs_________________________________________________________________
4. Eyewitnesses of the accident _____________________________________________
______________________________________________________________________________
(last name, initials, permanent place of residence, home telephone)
Causes of the accident _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(indicate the main and accompanying causes of the accident with references to the violated requirements of legislative and other regulatory legal acts, local regulations)
Persons who violated labor protection requirements: _________________________
______________________________________________________________________________
(surname, initials, position (profession) indicating the requirements of legislative, other regulatory, legal and local regulations providing for liability for violations that were the causes of the accident specified in paragraph 9 of this act, when establishing the fact of gross negligence of the victim, indicate the degree of his guilt in percentage)
Organization (employer) whose employees are these persons_______
__________________________________________________________________
_____________________________________________________________________________
(name, address)
Measures to eliminate the causes of the accident, timing
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signatures of the persons who carried out
Accident investigation
_____________________________________________________________________________
"______"______ 20____
Dear readers! HIV infection is not often discussed in the media these days. But this does not mean that the problem does not exist. The incidence of HIV infection is growing every year, and so is the mortality rate. The worry is that a more dangerous strain of the virus has emerged. The Asian strain, which was detected in migrants from Asian countries, mixed with the Russian one, and as a result of the “mixing,” a more dangerous type of virus, A63, appeared. This strain has a low infectious dose, is more resistant to modern antiviral drugs and contributes to a more rapid development of immunodeficiency and death of patients.
I cannot help but touch on the morbidity statistics. The numbers make us think about the size of the epidemic. According to data from the Ministry of Health of the Russian Federation, in 2016 the number of newly diagnosed cases increased significantly. In terms of the rate of growth of new cases, our country is ahead of many countries in the world, including such as Uganda, Zimbabwe, Kenya and Tanzania.
The total number of HIV-infected people in Russia as of January 1, 2017. amounted to 1,501,574 people (more than 1.5 million people plus more than 100 thousand temporarily living foreigners infected with HIV), of which 240 thousand people died from AIDS (in the world, in general, 50 million died from AIDS). As stated by the head of Rospotrebnadzor Anna Popova, at the beginning of 2016, every fifth HIV-infected person died in Russia, not necessarily from AIDS, but including other causes of death: drug overdose, suicide, accident, etc.
Experts believe that the main reasons for such a rapid increase in HIV-infected people are:
- Uncontrolled distribution of synthetic drugs, spice, which lead to persistent addiction, uncontrolled sexual activity, and insanity.
- Derogation of the moral foundations of family and society, propaganda on television and the Internet of sexual promiscuity and multiple sexual partners.
- Insufficient work of regulatory authorities responsible for preventing infection among the population.
The tragedy of the situation is that the young working population between the ages of 30 and 35 is dying. And if earlier it was believed that the incidence of the disease had a concentrated stage (mainly drug addicts, homosexuals, prostitutes were ill), now the incidence has gone beyond this scope. Socially prosperous people are already getting sick. Here is the chain: a drug addict husband infected his wife, who does not belong to any asocial group. A pregnant wife infects her child in utero. And so on…
HIV infection - epidemiology
The causative agent is an RNA virus belonging to the retrovirus family. The virus enters a cell, produces its own kind, multiplies and causes the death of these cells. It affects T-lymphocytes (T-4) cells - helpers (defenders), which are responsible for the state of immunity. These cells become fewer and fewer, and the protective immune system weakens. When entering an organism with a weakened immune system, various viruses, bacteria, and fungi cause the development of opportunistic infections. The patient dies not so much from the action of the HIV virus, but from a complex of diseases due to reduced immunity and death of central nervous system cells.
The HIV virus is relatively unstable in the external environment, so at a temperature of 60º it dies within half an hour. At temperatures down to -10º (with rapid freezing) it dies within 7-10 days, at -70º it can persist for years. Disinfectants in viral mode die within 15-60 minutes.
However, on the biological fluids of an infected person, it retains its viability and virulence for a long time. The virus survives in the dried blood of used syringes for a week (at a temperature of 27-37º), in corpses and organs - up to half a month.
High risk of infection and a high concentration of the virus is noted:
- in blood and blood products,
- in seminal fluid
- in vaginal secretions,
- in any biological fluid where there is blood,
- in breast milk.
Low risk of infection and the minimum number of viruses is contained:
- in saliva,
- in tears,
- in urine,
- in feces,
- in sweat fluid.
Transmission routes
In medical practice, a distinction is made between natural and artificial transmission routes.
Natural:
- Sexual – during sexual contacts. Non-traditional sexual contacts are the most dangerous in terms of virus transmission, as there is a lot of trauma and the presence of blood;
- From woman to fetus: transplacental (vertical) during pregnancy and childbirth;
- During breastfeeding with milk or if there are cracks in the nipples.
Artificial:
- When administering drugs intravenously using a single syringe or needle;
- When transfusing untested blood;
- During parenteral interventions, when they work with insufficient or unprocessed medical instruments.
At present, airborne transmission of the virus and through insect bites has not been proven. During a sexual kiss, transmission of the virus is possible only if the mucous membranes of both partners are injured. It is not possible to transmit the pathogen through a friendly kiss or when swimming in the same body of water, through the air, when coughing or sneezing, or when shaking hands.
Symptoms and duration of stages of the disease
The clinical course of the disease is divided into 4 stages.
- The incubation period lasts from 3 weeks to 6 months, in children - up to 1 year. The virus is rapidly multiplying. Since antibodies to the virus appear in the blood only 2-3 weeks after infection, this period is very dangerous in terms of further spread of the infection.
- Stage of primary manifestations (pre-AIDS). The virus itself is impacting. In 70%, acute HIV infection develops, and in the remaining 30%, primary manifestations may be absent. This stage of the disease is manifested by fever, enlarged lymph nodes, skin rashes, enlarged liver and spleen, and dyspeptic disorders. Lasts from several weeks to 6-8-10 years.
- Stage of secondary manifestations (AIDS stage). The duration varies depending on the state of the immune system - from 1.5 years or more. Manifested by various fungal infections of different localization and frequency: herpes zoster, esophageal candidiasis, herpes, Pneumocystis pneumonia (queen of AIDS), cytomegalovirus infection, hairy leukoplagia of the tongue, secondary lymphadenopathy, pyoderma, eczema, warty candidiasis, spontaneous abscesses caused by the introduction of fungi. Kaposi's sarcoma, a malignant neoplasm of the skin, develops, as well as other tumors - brain lymphoma, lung and stomach cancer. Tuberculosis is very common. All these are AIDS-associated infections.
- Terminal stage. The patient cannot cope with the infection and dies, since there are still no means of specific and etiotropic therapy.
What can be said about preventing HIV infection? If you have read this publication carefully, then you probably already understand what preventive measures exist. Therefore, it is very important to lead a correct lifestyle, avoiding all those moments that can lead to infection.
It is necessary to be more attentive to various medical procedures; do not hesitate to ask what instrument is used to perform the procedure on you, whether it has undergone pre-sterilization cleaning and sterilization, make sure that in the treatment rooms disposable instruments are opened before your eyes.
If there is a drug addiction, then the addict is unlikely to refuse the next dose, then let him inject drugs with at least disposable syringes and needles.
Prevention of unprotected sexual intercourse
During sexual intercourse, use a condom if you are not completely sure that your partner is healthy. But there are situations when sexual contact occurred with a stranger or there was rape. What to do in such a situation?
In such a situation, you need to see a doctor as soon as possible, but no later than 2 days. The doctor will prescribe medications for post-exposure prophylaxis. It is important to know that medications should be taken no later than the 2nd day after contact, strictly according to the regimen recommended by the doctor.
At the first visit, the doctor will write a referral for a blood test for HIV antibodies. This is necessary in order to exclude an existing infection.
Since antibodies in the blood are not produced immediately, but some time after infection, it will be necessary to donate blood for antibodies to HIV after another 6 weeks. But even this negative result does not give a 100% guarantee that infection has not occurred, so to be completely sure, you will have to donate blood again after 3 months.
If there is HIV in the family - infected
No need to panic! What happened, happened. However, know that the HIV virus is not very stable in the external environment and is practically not transmitted in everyday life. You cannot become infected through bedding, dishes, washcloths or soap. For infection, contact between the biological fluids of a healthy and sick person is necessary.
However, precautions must be taken. Therefore, try not to share razors, toothbrushes, manicure accessories, etc.
And to be more sure, it is best to get checked periodically at the AIDS center.
Dear readers, today you learned a little more about what HIV infection is, how it is contracted and prevention measures. I hope that this danger will pass you by.