Chapter 7. The PROGRAM CONCEPT «CHRONIC HEPATITISES At CHILDREN And TEENAGERS»

In our research questions epidemiologii, clinics, diagnostics and treatments HG at children and teenagers in giperendemichnom region have been surveyed. The results received by us in many respects coincide with literary data, but there is a number of features characteristic for Republics Sakhas (Yakutia) (RS ().

There is a number of factors defining problems in rendering of the wraparound and qualitative mediko-social help to children and the teenagers suffering HG.

External factors concerns:

- Low motivation of the population of region (both adults in relation to children, and teenagers) on conservation of the health and adherence to a healthy way of life,

- Adverse condition of internal medium of development of children and teenagers (at level of a family and educational bodies).

Internal factors of system of public health services concern:

- Absence of the system approach to the organisation of the mediko-social help to children and teenagers with HVG;

- Unsatisfactory level of primary, secondary and tertiary preventive maintenance of virus hepatitises at children and teenagers;

- Level of preparation of doctors - of pediatrists inappropriate to the modern demand, neonatologov, teenage doctors, doctors obshchevrachebnoj experts, accoucheurs-gynecologists concerning diagnostics, treatment and preventive maintenance of virus hepatitises at children and teenagers;

- Underestimation by doctors-pediatrists, neonatologami, teenage doctors, doctors obshchevrachebnoj experts, accoucheurs-gynecologists of factors of social risk of threat of infection with virus hepatitises of children and teenagers;

- Absence of standards of screening on virus hepatitises and delnejshego profound inspection of patients;

- Low degree of quality of the mediko-social help, low availability of the specialised help to children and teenagers with HG;

- Deficiency of volume of financing of preventive actions and the concrete medical-diagnostic actions referred on early diagnostics and specific therapy of chronic hepatitises at children and teenagers;

- Disharmony of a fixed capital and material base to modern demands;

- Absence of the structurally-organizational standard of rendering medikoyosotsialnoj the help to children and teenagers with chronic hepatitises;

- Disbalans levels of rendering of the treatment-and-prophylactic help to children and teenagers with chronic hepatitises;

The unsatisfactory situation in the general pediatric practice on active revealing, treatment and prophylaxes of virus hepatitises became the basis for working out of the program of perfection of rendering medikoyosotsialnoj to the help to children and teenagers with chronic hepatitises.

The purpose of working out of the program is the decision of organizational, medical and social problems of system of rendering assistance to children and teenagers with chronic virus hepatitises and prophylaxes of virus hepatitises at children.

The developed program directions consider the decision of many problems of an infectious pathology at children and provide the account of regional features, conditions of medium of development, education, a social component of a state of health of children and teenagers, mediko-social requirements;
Working out and introduction of preventive actions of the most effective and accessible to concrete social and economic conditions; an estimation of productivity of the spent work.

Program problems are:

1. Formation of multilevel system of rendering of the mediko-social help to children and teenagers with chronically hepatitises;

2. Satisfaction of patients and their families quality of rendering medikoyosotsialnoj the help;

3. Working out of measures of primary, secondary and tertiary preventive maintenance of virus hepatitises at children and teenagers.

4. The analysis of prevalence of the facts of the risk, which dynamics of indicators reflects efficiency of preventive actions.

5. Case rate depression by virus hepatitises of children and teenagers, optimisation of rendering of the mediko-social help to children and teenagers with chronically hepatitises, reduction of terms of the regenerative period, stabilisation and depression of indicators of an invalidism by introduction in medical practice of modern technologies of preventive maintenance, diagnostics, treatment and aftertreatment.

6. Integration with republican and municipal organs of public health services and formation, scientists RS () under programs of health protection of mother and the child.

Program realisation provides:

1. Conservation of leading directions of pediatric service - preventive, medical and rehabilitational.

2. Introduction of an electron database sick of chronic virus hepatitises and members of their families.

3. Medicosanitary education, formation of requirement of teenagers in a healthy way of life, training of parents concerning education of healthy children.

4. Revision of programs of additional vocational training of doctors-pediatrists, neonatologov, teenage doctors, accoucheurs-gynecologists and doctors obshchevrachebnoj experts on purpose rising of their preparation in questions on preventive maintenance and struggle against virus hepatitises at children and teenagers.

5. Studying in municipal unions and as a whole in republic of public opinion concerning threat of diffusion of virus hepatitises among children and teenagers by carrying out of sociological interrogations not only among children and their parents, but also among medical workers.

Program directions.

1. The organizational direction includes working out and carrying out of a complex of the organizational-methodical actions, referred maintenance of availability and quality of highly skilled primary both specialised medical aid to children and teenagers with HG in RS ().

2. The medical direction includes control maintenance for HG at children and teenagers in RS (), early revealing, perfection and rising of efficiency of methods of diagnostics, treatment, a dispensary observation, preventive maintenance and aftertreatment HG at children and teenagers.

3. The information-communicative direction includes introduction of the modern integrated information technologies at all levels of public health services on the basis of compatibility of information structures.

4. The educational direction includes working out introduction of special educational programs for children, teenagers and their families covering problems virus hepatitises and maintenance of safe vital activity. Rising of preparation of experts of public health services on an infectious pathology at children, in general, and in particular on problem HG.

Organizational direction. The basic work on revealing, observation, treatment and prophylaxes of virus hepatitises at children and teenagers is spent on an out-patient link. Considering a number of features of virus hepatitises, especially chronic virus hepatitises, it is offered to reform existing model for the purpose of its adaptation to a problem it is long, latentno current infections, such as chronic virus hepatitises.

The short of offered changes consists in the following:

1. Creation of multilevel system of rendering of the mediko-social help to children to teenagers with chronic hepatitises.

2. System KIZ creation in children's out-patient departments and the Central regional hospitals (TSUB) taking into account regional conditions RS ().

3. Development vnebolnichnoj medical aid to children and teenagers with HG.

Uniform multilevel the system of rendering of the mediko-social help to children to teenagers with chronic hepatitises will allow to co-ordinate efforts of many medical, educational and social establishments. The structured and controllable work of all links of system will allow to carry out as much as possible effectively actions for prophylaxes, diagnostics, to treatment and aftertreatment VG at children and teenagers, to frame uniform lechebnoyoprofilaktichesky process in which each technological link has the functions excluding duplication at other levels and limits, limited to functional reserving and economic feasibility (the Appendix 3, fig. № 1).

The first level of system (the primary medicosanitary help) are the medical organisations where primary screening on MVG is spent: maternity homes and gynecologic hospitals, children's out-patient departments and female consultations, local hospitals and FAPy. For the purpose of perfection of methods of diagnostics and early revealing VG at children of teenagers it is offered to dilate screening, having included in frameworks of obligatory researches except HBsAg and a-HCV,
In addition a-HBcor and a-HBs; to make research MVG obligatory at medical inspections, at planned and at emergency hospitalisation in hospitals of a various profile.

The second level (specialised medical aid) is presented by an office of infectious diseases at a children's out-patient department. According to the order of Ministry of Health and social development of the Russian Federation from 5.10.2012 years №521н «About the statement of an order of rendering of medical aid to children with infectious diseases» in children's out-patient departments offices of infectious diseases (KIZ) should be framed. One doctor-infektsionist is included In the list of staff on 20000 attached children's population. In our program we offer a number of the actions allowing as much as possible to approach possibility of performance of positions of the order in the conditions of low population density.

The first and most obvious problem is the small population of republic, in particular the children's population. A condition for creation KIZ at a children's out-patient department (20000 attached children's population) vypolnimo only in two settlements RS () - in Yakutsk and nerjungri with adjoining settlements, in all other districts of republic number of the children's population more low. Besides, TSRB have possibility to carry out diagnostic researches in the extremely limited volume. Only in of Yakutsk, nerjungri, Peace, Lensk and Aldan the full spectrum of researches on MVG is spent. The definition technique genoma a virus (method PTSR) is spent only in the medical organisations of of Yakutsk. Creation interdistrict KIZov in the settlements having as much as possible convenient transport scheme Is offered. Such interdistrict offices are offered to be organised in with. Majja for zarechnoj groups of districts, nerjungri for Nerjungrinsky and Aladansky districts, with. Suntar for viljujskoj groups of districts, Mirninsky and Lensky districts, with. Ust-Nera for Tomponsky, Ojmjakonsky, Verhnekolymsky and Momsky districts. Patients from right-bank districts, Olekminsky district and the Arctic districts it is rational to refer Yakutsk in

(Rice 38).

Fig. 38. A card of interdistrict Offices of infectious diseases at

Children's out-patient departments.

As KIZ it is offered to include the collecting of Serums for serologicheskogo and molekuljarno-biological research and the delivery organisation in Yakutsk in the centralised laboratory. Such organisation of work will make accessible carrying out of necessary laboratory researches at modern level to all patients, irrespective of a residing place.

The Republican centre of the mediko-social help to children and teenagers with chronic virus hepatitises becomes the third level (highly skilled medical aid). Creation the Republican centre of the mediko-social help to children and teenagers with chronic virus hepatitises on the basis of the Republican children's infectious diseases hospital will be rational. It is the unique medical organisation in RS () which renders specialised medical aid to children with an infectious pathology.

Centre work will allow to realise following directions of the program.

Medical direction.

Working out of a complex of measures of primary, secondary and tertiary preventive maintenance of virus hepatitises at children and teenagers.

Primary preventive maintenance assumes the prevention of occurrence of illness, eliminating its reasons. As infection with viruses of parenteral virus hepatitises probably and fetally preventive actions should be spent as infektsionistami and pediatrists, and doctors by accoucheurs-gynecologists.

Preventive maintenance of virus hepatitises in pregnancy and sorts includes educational programs for future mums with HG; joint conducting the infected women infektsionistom and the gynecologist; monitoring of a current of an infection with research genoma a virus; at high replikativnoj activity appointment of adequate antiviral therapy; to avoid to (limit) prenatal methods of diagnostics.

Preventive maintenance of virus hepatitises during the period after sorts includes:
Educational programs for mothers on preventive maintenance postnatalnogo becomings infected a virus of a hepatitis with an explanation about necessity of early diagnostics; planning of the combined antiviral therapy of mother; a dispensary observation of the child at infektsionista; continuity in work infektsionist - the accoucheur - the gynecologist - neonatolog - the pediatrist - infektsionist (fig. 39 and 40).

Fig. 39. Algorithm of preventive maintenance antenatalnoj transfers VGS

Fig. 40. Algorithm of preventive maintenance antenatalnoj transfers VGV

Secondary preventive maintenance is spent at the newborn and children of the first and second year of a life and referred on early diagnostics and timely treatment which can lower frequency of synchronisation VG. Observation is spent for is conditional-healthy children from risk group on a vertical transmission of infection and for children with VG owing to a vertical transmission of infection. Inspection of the newborns born from women of patients acute (in III trimester of pregnancy), HG, and also with an asymptomatic infection of "carriage" in following terms: at a birth, in 3 and 6, 9, 12 months and further till 3th years 2 times a year. (Fig. 41)

Fig. 41. Algorithm of inspection of the newborns born from women sick acute hepatitis (in III trimester of pregnancy), HG, asymptomatic "carriage"

For revealing of patients HG in as much as possible early terms it is offered
To introduce expanded screening on markers VG at medical inspections, at planned hospitalisation and at emergency hospitalisation in hospitals of a various profile. Expanded screening means including in frameworks of obligatory researches except HBsAg and a-HCV, in addition a-HBcor and a - HBs. Revealing of children and teenagers with MVG a screening method will allow to spend further it high-grade inspection (fig. 42 and 43).

Fig. 42. Algorithm of diagnostics GV

The algorithm of diagnostics of mikst-hepatitis ХГВ+D assumes including in the program of observation over patients with HGV annual serologicheskoe
Research on a-HD IgG. In a case revealing of antibodies at a virus of a hepatitis the delta, the observation program joins research by method PTSR for allocation RNA HDV.

Fig. 43. Algorithm of diagnostics GS

The algorithm of diagnostics of mikst-hepatitis ХГВ+С assumes association
Two, resulted above schemes.

We develop the report of a dispensary observation of children and teenagers with HG in KIZe (the Appendix 3).

Tertiary preventive maintenance is referred on reduction of complications of disease after illness was showed. Thus, tertiary preventive maintenance HG will consist in timely antiviral therapy, treatment and prophylaxes of complications of a virus hepatitis.

It is offered to include a number of obligatory researches in standard PVT before and during therapy. The choice of scheme PVT should be defined taking into account the diagnosis, presence of indications and prospective efficiency of treatment (the Appendix 3. «The report of a dispensary observation of children and teenagers with HG»).

The information-communicative direction consists of two components:

- Creation of the computerised information network with a database about patients with virus hepatitises on a platform «Medical information system» (MIS). The subroutine «Medical information system», is developed and introduced within the limits of realisation of programs «Modernization of public health services Republics Sakhas (Yakutia) for 2011-2013». The given subroutine is intended for differentiation of contingents on groups with various level of health, revealing of the latent pathology and an estimation of dynamics of changes (including under the influence of medical-improving actions) during all life of the child within the limits of a continuum of transitive states of health. Creation within the limits of MIS the module on HG at children will allow to carry out effectively continuity in a chain of structural sectionings: female consultation, maternity home, a children's out-patient department, an adult out-patient department.

- Rendering of the advisory-methodical help to medical workers concerning diagnostics and treatment HG at children and teenagers. The advisory help is necessary for doctors-pediatrists, neonatologam, to teenage doctors, doctors obshchevrachebnoj experts, to accoucheurs-gynecologists,
To medical workers of children's educational institutions concerning diagnostics, treatment, prophylactic medical examination and aftertreatment HG at children and teenagers. High-grade work of the given direction will help to overcome one of the main problems of public health services of republic - inaccessibility of specialised medical aid. Reception of planned consultations by patients with chronic diseases is put, now, in dependence on financial possibilities of parents as only transport expenses on a trip to Yakutsk, at times exceed incomes of all family for some months. Besides the difficult transport scheme, during the periods of an impassability of roads, an ice drift and ledostava does such trip simply not possible.

Educational direction

- Working out of educational programs for children, teenagers and their families. Work of such programs will allow to receive to children and teenagers authentic data on a problem of virus hepatitises and maintenance of safe vital activity. Taking into account the raised risk of becoming infected VG at teenage age attraction to this work of such experts as children's gynecologist and psychologist is necessary. Within the limits of work of offices of medical preventive maintenance, the centres of formation ZOZH in children's out-patient departments should be organizovanny «hepatitis Schools» for families of patients. Working out of the informed companies for the population about measures, forms and ways of struggle with VG and methods of their preventive maintenance. Propagation of a healthy way of life with use of social advertising, lectures and conversations about VG and ways of their preventive maintenance together with youth, public organisations and mass media.

- The uchebno-methodical complex for lecture and a practical training on section «Virus hepatitises at children» within the limits of the basic educational program of discipline (module) С3 Б31 «Infectious diseases at children» a base part of the program on a speciality 060103 "Pediatrics" on the basis of FGOZ 3 is developed and introduced. Working out and introduction UMKD «Infectious diseases at children» within the limits of educational standard SVFU on

To basis FGOZ 3 + [Order Minobrnauki of Russia from November, 8th, 2010 №1122 «About the statement and introduction in action of the federal state educational standard of the higher vocational training in a preparation direction (to a speciality 060103 Pediatrics (qualification (degree)"expert")].

- Working out and educational program introduction «Virus hepatitises in pediatric practice» internship programs on a speciality 060103 "Pediatrics" on the basis of FGT [the Order of Ministry of Health and social development of the Russian Federation from December, 5th 2011г. №1475н «About the statement of federal state demands to structure of the basic educational program poslevuzovskogo vocational training in internship and internship»].

Within the limits of the program «Chronic hepatitises at children and teenagers» in Yakutsk have been realised by us following actions.

Organizational direction. Opening KIZ on the basis of the Children's city hospital №2 which work has allowed to carry out a full complex preventive, diagnostic and lechebnoyoreabilitatsionnyh the actions making the program of a dispensary observation for children and teenagers with HG. Introduction of expanded screening on MVG in the medical organisations of of Yakutsk (Clinic of pediatrics РБ№1-of the National centre of medicine and the Children's city hospital №2) has allowed to improve detectability of patients with HGV HBsAg-negative.

Medical direction. Carrying out of the actions provided in methodical references of Ministry of Health RS () «PassivnoYOaktivnaja preventive maintenance perinatalnoj transfers virus GV» № 01-8/4-523 from 25.04.2013, in obstetric hospitals of of Yakutsk on preventive maintenance of vertical transfer of viruses of a hepatitis has improved early diagnostics VG at children. On the dispensary account in KIZ at DGKB №2 of Yakutsk consist group of children born from seropositive women. To these children the necessary diagnostic actions referred on earlier revealing are carried out
Disease and an estimation of a state of health. Observation over this group of children has allowed to optimise indications for PVT to children, since 3-year-old age, i.e. in as much as possible early terms. We develop the report of a dispensary observation of children and teenagers with HG in KIZe. Introduction of the scheme of complex inspection of patients before appointment PVT has given the chance to prognosticate result of therapy and to minimise undesirable phenomena PVT.

Information direction. Creation within the limits of MIS the module on HG at children has allowed to carry out effectively dynamic observation over children and teenagers with the given pathology. The further work of the module will improve continuity in a chain of structural sectionings: female consultation, maternity home, a children's out-patient department, an adult out-patient department.

Now in DGKB №2 the Republican advisory centre (order KZ operates at meri of Yakutsk from 1.02.2005. «About optimisation of rendering of medical aid to children from districts of republic with an acute infectious pathology a pathology». Within the limits of work of this centre as doctor-infektsionistom KIZa in DGKB №2 correspondence consultations to doctors in districts of republic concerning virus hepatitises at children and monitoring of serious patients, with use of modern communication technologies are carried out.

Educational direction. «Hepatitis Schools» the program is developed for families of patients. Lectures for teenagers about measures, forms and ways of struggle with VG and methods of their preventive maintenance are developed and conducted. Days ZOZH are spent at schools of of Yakutsk.

Introduction in educational process of educational programs on a problem of virus hepatitises at children has raised efficiency of a professional training by continuous formation of students, interns and doctors at a stage poslevuzovskogo vocational training.

Experience of realisation of program directions in Yakutsk allows to recommend to extend the given actions to all territory RS ().

Successful realisation of the program «Chronic hepatitises at children and teenagers» is possible at active participation of republican and municipal governing bodies RS (), Northeast federal university, medical the organisations, a territorial organ

Rozdravnadzora on RS (), insurance medical the organisations, electron and printing mass-media, the population of republic (tab. 128).

Table 128

Participants of realisation of the program

Expected results and estimation of efficiency of the program «Chronic hepatitises at children and teenagers»

Results of realisation of the program becomes: creation within the limits of MIS the module on HG at children; rising of detectability of patients HG; introduction of actions on antenatalnoj to preventive maintenance VG at children; rising of availability of specialised medical aid to children and teenagers with HG; rising of efficiency PVT of patients HG; improvement of professional skill of doctors-pediatrists, teenage doctors, accoucheurs-gynecologists, neonatologov and doctors obshchevrachebnoj experts; rising of knowledge the population about problem HG at children and teenagers.

The estimation of efficiency of realisation of the republican program «Chronic a hepatitis at children and teenagers» is spent on the basis of following criteria:

Estimation of preventive work:

1. Inspection coverage on MVG pregnant women,

2. Inspection coverage on MVG newborns from seropositive women,

3. Completeness of coverage by preventive inoculations of children,

4. Completeness of coverage by routine inspections of children.

Estimation of quality of medical aid to children and teenagers with HG:

1. Quality of a dispensary observation of children (a specific gravity of children and teenagers with HG, consisting under a dispensary observation; a specific gravity of children who have been taken out from a dispensary observation on recover; dynamics of number of children-invalids),

2. Completeness of coverage by the treatment-and-prophylactic help of children consisting under a dispensary observation (a specific gravity of children, inspection in a planned order; a specific gravity of children who have received antiviral therapy, from the general number of children consisting under a dispensary observation and requiring antiviral therapy; validity of a prescription of medicines and observance of rules of an extract of prescriptions to patients, including having the right to reception of a set of social services).