1.5.1. Bacterination

One of priority methods of struggle against a tubercular infection javljayoetsja bacterination. Now bacterination BTSZH is carried out in 64 strayonah and officially recommended in 118 countries of the world [295].

Efficiency of bacterination BTSZH

The most inconsistent aspect of vaccine BTSZH is it effektivyonost.

Unfortunately, in modern conditions are absent objective unifitsiyorovannye criteria of an estimation of a condition of postvaccinal immunity. EdinstYOvennymi indicators of an individual and population solvency proyovedennoj bacterinations remain the size of a dermal sign and tuberkulinovye assays though they do not reflect true immunity to a tuberculosis, especially in cases of absence of a postvaccinal scar and a negative Mantoux reaction [71, 72, 73, 75, 191]. Protective action of a vaccine is estimated by criterion sniyozhenija a case rate and risk of development disseminirovannyh processes.

Clinical efficiency BTSZH in various researches estimate from low to the high. The researches spent to the Great Britain, have shown protective effect BTSZH within 60 %-80 %, in the USA - at level of 14 %, as has induced the USA to refuse introduction of mass immunization BTSZH [130, 180,
193, 305]. However it is recognised, that vaccine BTSZH possesses the greatest effektivnoyostju concerning the development prevention disseminirovannogo a tuberculosis and a tubercular meningitis within 75-86 % in this connection vaccine BTSZH has been included in the expanded programme of immunization at children, spent the CART in 1974г. [150, 151, 22, 295].

Risk of development disseminirovannoj BTSZH-INFECTIONS at a HIV-infected of children.

Tubercular vaccine BTSZH - a preparation from live culture of micobacteria of the vaccine strain, therefore possibility of occurrence of complications always exists. Mainly there are local (local) complications in viyode a hypodermic cold abscess, an ulcer, regionarnogo a lymphadenitis, but can arise and the complications bound to a dissimination of the BTSZH-INFECTION: ostites, geyoneralizovannaja the BTSZH-INFECTION. The vaccine is considered safe at practically healthy children, frequency of occurrence disseminirovannoj all over the world makes BTSZH-INFECTIONS less than 5 on 1 000 000 vaccinated [130,193]. DisseminirovanYOnaja the BTSZH-INFECTION is potentially lethal complication and projavyoljaetsja only in an organism with the weakened immunity [275].

Data on immunization of children with a HIV-infection vaccine BTSZH very much mayolo and they are inconsistent.

It is known, what even at practically healthy children bacterination BTSZH podavyoljaet development of T-lymphocytes till 2 months [176, 237]. According to some avyotorov, reduction of quantity of T-lymphocytes can cause sharp progresyosirovanie immunodefitsitnogo conditions at children with a HIV-infection at vvedeyonii vaccines BTSZH and raise risk of development of secondary infections, including a generalised BTSZH-INFECTION [271]. However there is also other opinion: primeneyonie BTSZH at children with a HIV-infection during the period novorozhdennosti coherently with otnosiyotelno low frequency of complications as supressii immunyonoj systems it is necessary for development of several months [287].

In the research spent to Haiti, it has been shown, that the risk oslozhneyony after introduction BTSZH has made 9,6 % at the thoracal children born zhenshchinayo
mi, not infected HIV, 13,3 % at the thoracal children born from sick HIV - by an infection of mothers, but not infected HIV, 30,8 % - at children from a HIV - an infection.

However risk levels in connection with the BTSZH-VACCINE at a HIV-infected deyotej are not defined, and it is possible to find in the literature raznorechivye data about voznikyonovenii BTSZH-INFECTION generalisations [194, 201, 270].

Data which have been received in Southern Africa (32 cases disseminiyorovannoj BTSZH-INFECTIONS for the 3-year-old period of observation) and later in ArgentiYOne (4 cases from 310 vaccinated), testified that the risk voznikyonovenija disseminirovannoj BTSZH-INFECTIONS considerably raises at children even from an asymptomatic HIV-infection [194, 225, 302].

Large kogortnye researches among the African populations in Zimbabwe, Malawi and to Ruanda have not fixed others any case disseminirovanyonoj BTSZH-INFECTIONS among children from the HIV vaccinated BTSZH (559 died from 1147 children with a HIV-infection) [207, 237, 326].v frameworks Brazilian kogortnogo researches among 66 HIV-infected of children for the 7-year-old period nabljudeyonija cases disseminirovannoj BTSZH-INFECTIONS also has not been taped.

In review A.C.Hesseling (2006 [176] settlement risk disseminirovannoj forms BTSZH, counted up on each year of observation, fluctuated in a range 110-417 on 100 000 vaccinated HIV-infected of children. In later isyosledovanijah in the West cape province of Southern Africa it is spoken about fakticheyoskom level of total risk - 992 on 100 000 (at 95 % of Dee 567-1495) vaktsiniyorovannyh children with a HIV-infection (32 cases disseminirovannoj to the BTSZH-INFECTION

42 for 3 summer period). Presumably, if the risk disseminirovannoj at a HIV-infected of children makes forms BTSZH 992/100000, disseminirovannaja the BTSZH-INFECTION form will annually arise at 4000 children [224].

Some authors consider what to lower risk of development BTSZH-BOUND zayobolevanija the wound begun art as the CART recommends naznacheyonie art to all children with a HIV-infection aged less than 12 months irrespective of their clinical or immunologic status [207] will allow. Besides, appointment art at an early stage, most likely, can reduce not only risk razyovitija disseminirovannoj BTSZH-INFECTIONS, but also to lower risk of occurrence at them an active tuberculosis and is possible, to raise clinical efficiency BTSZH [177, 192, 231, 273].

Regionarnye complications after introduction BTSZH are observed both at infitsiyorovannyh, and at not infected HIV of children, which total frequency soyostavila 6 % [163, 175, 177, 192, 270].

The integrated analysis of safety of application of vaccine BTSZH at children with a HIV-infection suffices it is resulted in system review P. Azzopardi and co-workers, (2009 [180]. The analysis included the review of articles in English from 1950 till April 2009гг. (215 publications from more 1000) are selected.

In total, in frameworks observatsionnyh researches it was a question of 49 cases disseminirovannoj BTSZH-INFECTIONS (confirmed mikrobiologicheyoski), 47 of which fall to a HIV-infected of babies and two cases - on children with other implications of an immunodeficiency, and the majority (41/47) children lived in the West cape province of Southern Africa. avtorayomi it is taped: mediannyj the age of offensive disseminirovannoj BTSZH - infections has made 8 months (in a range from 3 till 35 months). From 36 patients with a known outcome have died 29 (81 %). The period before a lethal outcome from the moment of diagnosis statement disseminirovannoj BTSZH-INFECTIONS fluctuated in limits from several days till 18 months.

P. Azzopardi and co-authors on the basis of the spent system review deyolajut a conclusion, that a HIV-infected children accept bacterination BTSZH.

However the problem is covered in much more numerous group of children, rozhyodennyh from sick HIV-infections of mothers, but not infected HIV for which introduction BTSZH is shown in endemichnyh on a tuberculosis regions, poyoskolku the delay of bacterination BTSZH before specification of the status of a HIV-infection at rebenyoka raises risk of transition of becoming infected MBT in disease. In this case early diagnostics of a HIV-infection and art at an early stage will promote depression of risk of development disseminirovannoj to the BTSZH-INFECTION at children of the sick HIV-infections which have received vaccine BTSZH.

In 2007, taking into account the saved up data, on bacterination of newborns with a HIV-infection (in particular, data about a high mortality from disseminiroyovannoj the BTSZH-INFECTION vaccinated in Southern Africa), the CART has declared, that the risk from BTSZH can exceed advantage of bacterination of a HIV-infected of children [219] and did not recommend introduction of vaccine BTSZH a HIV-infected mladenyotsam even if they do not have any symptoms [220].

In the Russian Federation the preventive direction of medicine naiboyolee is brightly expressed in the field of struggle against a tuberculosis where in the general system profiyolakticheskih measures the leading place is occupied with bacterination BTSZH of newborns.

In domestic publications, since 60th years and to the present vreyomeni, authors of the spent researches do not call in question effektivyonost antituberculous bacterination. Authors of numerous researches notice efficiency BTSZH concerning risk depression infitsirovannosti and case rates, changes of structure of a case rate in the parties of augmentation of "small" forms of a tuberculosis and reduction disseminirovannogo a tuberculosis and tuyoberkuleznogo a meningitis, that basically will be compounded from research of foreign authors [3, 4,5, 75, 121, 122].

Complications on bacterination BTSZH, as well as all over the world, remain a bacterination problem. Thus all complications have basically local character, on frequency in structure of complications prevailed regionarnye lymphadenites: from 54,5 % to 77,1 % from all complications [29, 45, 67, 78, 80].

The account of complications of bacterination BTSZH has allowed to ascertain, that for poyoslednie 7 years (since 2004 on 2011) in the Russian Federation of the morses bound to generalisation of the BTSZH-INFECTION are not registered (78).

Last years according to a national calendar profilaktiyocheskih inoculations of bacterination of BTSZH TH in a maternity home children are subject, rozhdenyonye a HIV-infected mothers and received three etapnuju himioprofiyolaktiku transfers of a HIV from mother to the child (during pregnancy, sorts and in peyoriode novorozhdennosti), children with a bacterination HIV-infection are not subject [102].

The first data in the domestic literature on bacterination BTSZH of children, royozhdennyh from women with a HIV-infection, appeared as about casual vaktsiniroyovannyh in a maternity home or right after extracts from the maternity home, vaccinated "casually" as at mothers the HIV-status was not known. All authors otmeyochali safety of bacterination of these children as the complications bound to vaccine BTSZH, it has not been taped [84, 86, 91, 108, 117] are described edinichyonye cases vaccinated BTSZH children with a HIV-infection, and.

Experience of purposeful bacterination of children born from bolyonyh a HIV-infection of women is interesting. In Sverdlovsk area, considering neblagopoluchyonuju a situation on a HIV-infection among women and progressive growth of number deyotej, mothers who have born from a HIV-infected, immunization of children born from sick HIV-infections of mothers and children, born from women with doubtful result immunoblota on a HIV was spent protivotuberyokuleznaja. During the period for 2004-2010 it is vaccinated by a vaccine of BTSZH TH 615 children, rozhdenyonyh from sick HIV-infections of mothers. The risk of development of complications at children with a HIV-infection did not exceed that at children without a HIV-infection [145,154,155]. Authors note efficiency of bacterination in respect of risk depression infitsiroyovanija micobacteria of a tuberculosis and disease by a tuberculosis of children, rozhdenyonyh from women with a HIV-infection.

Similar experience of bacterination BTSZH of children born by a HIV - by infected women, is described in Irkutsk area: on the beginning of 2009 in Irkutsk area 3572 children from sick HIV-infections mA - have been born

45 terej, more than 40 % of children, sick HIV-infections have been inoculated by vaccine BTSZH - M, thus complication in a kind regionarnogo a lymphadenitis is noted at one reyobenka [20].

Thus, the literature review on a problem of bacterination against tuberkuyoleza with a HIV-infection has shown children, that saved up not only Russian, but also world experience while insufficiently and there is common opinion in the relation vakyotsinatsii no children born from sick HIV-infections of women, including inyofitsirovannyh a HIV as data raznorechivy, data on risk BTSZH - bacterinations at children with a HIV-infection are limited. Thus uroyoven clinical vigilance in the relation disseminirovannoj BTSZH - infections it is low, as this complication traditionally is considered rare, that boyolee that clinical implications disseminirovannoj BTSZH-INFECTION forms anayologichny to a picture disseminirovannogo a tuberculosis. It is not defined effektivyonost bacterinations BTSZH at children with a HIV-infection as researches proyovedeny on the limited quantity of children, and value in development of a tuberculosis in children with a HIV-infection plays set of factors, including rasprostranenyonost infections MBT in populations, probability of contact to the patient tuberkuleyozom, age, a stage of a HIV-infection and degree immunosupressii, carrying out preyoventivnogo treatments.