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INTRODUCTION

Urgency.

Depression of an infectious case rate is the major component of public health care and one of priority problems of a state policy. Virus hepatitises (VG) are to socially significant diseases of the person and serve one of the main reasons of chronic diseases of a liver.

According to the World organisation of public health services (CART) in the world is more than 500 million persons infected with a hepatitis virus In and about 150 million - a virus of a hepatitis With (Inf. Bjul. № 164, the CART, 2012). In the Russian Federation the number of patients with a chronic hepatitis In and carriers HBsAg makes about 5 million, number sick of a chronic hepatitis With and carriers of a virus of a hepatitis With - not less than 2 million persons (Zhdanov K.V with sovt. 2011; Rakhmanov A.G.s co-workers. 2011; Jushchuk N.D. from co-workers. 2012).

Thanks to introduction in a national calendar of inoculations of bacterination against VGV the number of cases OGV has essentially decreased and steadily decreases, number of new cases HGV (Baranov A.A. from co-workers. 2012, Pokrovsk Century And. 2013). Doubtless successes in treatment of chronic hepatitises, especially HGS are reached. Despite essential progress in diagnostics, treatment and preventive maintenance of a hepatotropic virus infection this problem is far from the decision (M.I.Mihajlov, 2004; Elisofon S.A., Jonas M.M. 2006; Sokal E.M., Paganelli M., Wirth S. et al. 2013).

The epidemiological situation in the Russian Federation on parenteral virus hepatitises remains to the extremely unsuccessful (ponomarenko T.N., 2009). Hepatitises on the social importance take a special place in infektologii. Urgency VG in pediatrics is bound to steady growth of a becoming infected of persons of genital age and risk perinatalnoj transfers of viruses with potential possibility of occurrence especially serious fulminantnyh or pervichnoyohronicheskih forms (Bajda K.J. 2005, Slowik M.K. 2005, Ignatova T.M., 2009, Ilunina L.M. 2011, Onakewhor J.U. et al. 2013, Prasad M.R. 2013)

Characteristic for GV and GS a variety of clinical forms, an adverse current and outcomes, also steady growth of number of patients with hepatitises of the admixed aetiology, cause necessity of the further studying, especially chronic forms of these infections at children (Rejzis the River of the River 2006, Uchajkin V. F. 2008, Kaganov A.P. 2013). Last years the steady augmentation of quantity of patients at which the hepatitis has the admixed aetiology is noted. Mikst - hepatitises differ from a mono-infection a fixing current, the long period of recover and larger frequency of synchronisation of process (Shahgildjan V. I. 2002, Strokova T.V. from co-workers. 2013). By present time the big clinical and experimental material specifying in ability of association patogenov cardinally to change the form and structure of infectious process is saved up: to lead to its manifestation or, on the contrary, to a latent condition to change a clinical picture of disease. Thus patterns of a current of a mikst-infection of virus hepatitises in many respects still remain obscure.

The special alarm is caused by data about early fibroticheskoj transformation and cirrhosis development at children's age, and that available schemes of treatment VG, including at children, are insufficiently perfect. Formation among born children of chronic carriers defines possibility of the further transmission of infection to following generation.

It is established, that 42 % of adult patients HG have disease sources at children's age (Uchajkin V. F. 2008, Chuelov S.B. 2010). Serious concern is caused by case rate indicators virus hepatitises in teenagers. The biggest augmentation of number of cases becomes perceptible at the age from 10 till 14 years. Teenagers are the most vulnerable group of the population concerning risk of a becoming infected parenteral virus infections owing to physiological and psychological features of this age (Zhevnerova N.S. 2005, Usanova E.P. 2009).

Prevalence of viruses of hepatitises In and With in territory of the Russian Federation is characterised by the expressed variegation, varying in the wide
Limits. Indicators of case rate HGV and HGS the general in population on 2011 in the Russian Federation have made 13 and 39,9 on 100000 population. At children till 14 years this indicator has made 1,35 and 2,1 on 100000 population accordingly. The highest indicator of a case rate of children and teenagers HG became perceptible in Dalne-east federal district (DVFO) - 7,03 on 100000 children in 2011. Yakutia concerns regions giperendemichnym on prevalence of the parenteral virus

B, With and D (Semenov I.S. 2007, Fedoseeva L.R. 2008, Savvin the River of Century 2008, Sleptsova

C. With. 2012). In RS (the indicator of a case rate of children and teenagers HG has made 4,75 on 100000 children in 20011году (Baranov A.A. from co-workers. 2012г). In the Arctic districts RS () frequency of detection HBsAg at children from 0 till 14 years makes 4,2 % (in the central zone of the Russian Federation - 2,7 %) (Jakovlev A.A. 2002; Semenov S.N. 2007).

Such negative epidemiological situation is bound, with climatic and mediko-social conditions of a life on the Far North. Among the radical and alien population Republics Sakhas (Yakutia) are devoted a problem of prevalence and factors of synchronisation of virus hepatitises only individual researches (Alekseeva M. N. 2008, Semenov S.N. 2007, Sleptsova S.S. 2013) in which it is shown, that level of prevalence of viruses of hepatitises In, With and D in territory Republics Sakhas (Yakutia) is high and demands serious additional clinico-epidemiological researches.

The data cited above testify that now a problem of parenteral virus hepatitises from the medical

It was transformed to the social. Thus, in connection with wide prevalence HG in all age groups which are available of regional, ethnic and social features, the problem of studying HG at children of teenagers in RS () is actual.

Research objective: to develop the program of the mediko-social help to children and teenagers with chronic virus hepatitises on the basis of research of the epidemiological, clinico-laboratory given patients with HG, living in giperendemichnom region taking into account ethnic and social factors.

Research problems:

1. To study features of epidemiological process HG at children and the teenagers living in giperendemichnom region, on an example Republics Sakhas (Yakutia).

2. To estimate social factors of risk of infection with virus hepatitises at teenagers of of Yakutsk.

3. To study clinico-laboratory implications HGV, HGS and mikst-hepatitises at children and the teenagers of a radical and not radical nationality living in giperendemichnom region, on an example Republics Sakhas (Yakutia).

4. To estimate efficiency of various schemes of antiviral therapy at HGV and HGS at children and teenagers.

5. To estimate quality of a life of children and teenagers with HG in Republic Sakha (Yakutia).

6. To develop and scientifically to prove the program of perfection of rendering of the mediko-social help to children with virus hepatitises.

Scientific novelty.

For the first time in territory Republics Sakhas (Yakutia) complex research of chronic virus hepatitises at children and teenagers by which results the program of perfection of rendering of the mediko-social help is developed is carried out.

For the first time studying of etiological structure HG at children and teenagers in RS () is spent. The HBV-infection leading part (67,1 %) is defined.

Influence of the ethnic factor on epidemic process HG at children and teenagers in RS () is taped. Among patients with HGV and mikst-hepatitises children of a radical nationality prevailed, they have made 77,7 % and 68,5 % accordingly. Whereas statistically significant differences to a national sign in group of patients with HGS it is taped. For the first time it is established differences in ways of a transmission of infection at children and teenagers with HG, depending on a nationality. At the patients concerning the small radical people of the north, the leader was family contact (63,3 %)

For the first time are studied a clinico-laboratory picture mono-and mikst-hepatitises at children and teenagers in RS (). Statistically significant differences are taped. At patients with mikst-hepatitises clinico-laboratory implications correspond to more serious current of disease. Clinical implications which are bound to a chronic intoxication most often became perceptible, that in turn influenced on physical development of children and teenagers. At all patients with HG high frequency of an anaemia is taped: at HGV in 43,8 % of cases, HGS - 42,2 %, mikst - hepatitises - 45,7 %.

For the first time absence of significant differences in clinical picture HGV at patients with HBsAg (+) and HBsAg is taped (-).

It is established, that at children and teenagers of a radical nationality the tendency to more serious current HG, without dependence from a process aetiology becomes perceptible. At representatives of a radical nationality complaints intoksikatsionnogo character and a painful syndrome were more often taped. Implications of a cytolytic syndrome, depression belkovoyosinteticheskoj functions of a liver and changes of a parenchyma of a liver according to ultrasonic were more significant.

For the first time in RS () the estimation of quality of a life of children and teenagers with HG is spent. It is taped, that in comparison with healthy children quality of a life is elderly as a whole is lowered, at what in younger age group in larger degree, than at senior children (on 20,9 %, on 5,8 %). Role functioning mainly suffers.

It is established, that efficiency of antiviral therapy by interferons of short action at children and teenagers with HGV does not depend, statistically significantly, from frequency rate of introduction of a preparation and fluctuates in limits from 45,5 % to 57,1 %.

As much as possible effective scheme of treatment HGS assumes application pegelirovannyh INF in a combination with ribavirinom (efficiency of 88,9 %).

Are defined positive prediktory efficiency PVT HG by means of a method logistical regressionnogo the analysis: in case of HGV and HGS
Them of steel IRI and T-limfotsity (CD8) and Russian nationality at HGS.

For the first time the analysis of a catamnesis of children and teenagers after PVT is carried out. By means of a method of the analysis of survival rate the factors influencing conservation of proof remission after PVT are taped. The general factor for HGV and HGS is the female, for HGV - a low virus load, for HGS - a high virus load and application pegelirovannyh INF.

On the basis of wide sociological research social and epidemiological risks of infection VG at teenagers in RS () which concern the early beginning of a sexual life, the alcohol use, a tobacco smoking and low knowledge of virus hepatitises are taped.

Problems in rendering of the qualitative mediko-social help to children, in system of the account of such patients are taped, disadvantages of operating system of prophylactic medical examination and the republican program taking into account taped epidemiological, clinico-laboratory and social features HG at children and teenagers in RS () is developed.

The practical importance of work.

The data obtained during research about features of a current of chronic hepatitises at children and teenagers RS () specify in necessity of creation of the program of perfection of rendering of the mediko-social help. Introduction of this program will allow to realise the system approach to the organisation of the mediko-social help to children and teenagers with HG.

Introduction in screening practice a-HBcor and a-HBs has allowed to tap group of sick children and teenagers with HGV at which it was not defined HBsAg.

Introduction in practice of the standard of treatment HGS including a combination pegelirovannogo ИНФа-2Ь and ribavirina, has allowed to reach peak efficiency of antiviral therapy.

The account prediktorov achievements SVO and conservations of proof remission has allowed to prognosticate more precisely efficiency PVT at children and teenagers with HGV and HGS.

Creation of the Republican centre of the mediko-social help to children and
To teenagers with HG will allow to raise level of primary, secondary and tertiary preventive maintenance of virus hepatitises; the continuity in a chain of structural sectionings (female consultation, maternity home, a children's out-patient department, an adult out-patient department), quality of medical aid to these patients, will make as much as possible accessible specialised medical aid to children and teenagers with chronic hepatitises in Republics Sakhas (Yakutia).

Introduction in practice of algorithm of conducting pregnant women, parturient women and newborns will allow to lower risk perinatalnoj transfers HBV - and HCV - infections.

Introduction in work KIZov of the report of a dispensary observation for patients HG, will allow to carry out as much as possible effectively observation over children and teenagers with the given pathology.

Use of results of dissertational research in creation of programs of continuous vocational training, will give the chance to raise level of knowledge of pediatrists, doctors-infektsionistov, doctors obshchevrachebnoj experts, medical workers of establishments of formation and Introduction of the received results in practice

Results of research are used by working out following zakonoyodatelnyh and is standard-methodical documents:

- The order of Ministry of Health RS (): «About a dispensary observation of patients with chronic virus hepatitises In, With and D» № 01-8/4­2166 from 12.12.2012 (the introduction certificate № 4-01-20/78 from 10.12. 2013).

- The order of Ministry of Health RS (): «About carrying out of III republican scientifically-practical conference« Pressing questions of an infectious pathology at children »№ 01-8/4-1764 from 10.09.2008. (The introduction certificate №4-01-20/78 from 10.12. 2013).

- The order of Ministry of Health RS (): «About carrying out of IV republican scientifically-practical conference« Pressing questions of an infectious pathology at children »№ 01-8/4-2056 from 1.10.2010. (The introduction certificate №4-01-20/78 from 10.12. 2013).

- The order of Ministry of Health RS (): «About carrying out of V republican scientifically-practical conference« Pressing questions of an infectious pathology at children »№ 01-8/4-1953 from 22.09.2012. (The introduction certificate №4-01-20/78 from 10.12. 2013).

- Methodical references of Ministry of Health RS () «Is passive-active preventive maintenance perinatalnoj transfers virus GV» № 01­8/4-523 from 25.04.2013 (the introduction certificate № 4-01-20/78 from 10.02. 2014).

- The information report of Management of public health services of of Yakutsk at MZ RS () «the Analysis of an infectious case rate of the children's population of of Yakutsk»; «the case rate Analysis intrahospital infections in children's hospitals of of Yakutsk» (the introduction certificate № 01-821 from 18.12.2013).

- The information report of Management of public health services of of Yakutsk at MZ RS () «the Analysis of an infectious case rate of the children's population of of Yakutsk»; «the case rate Analysis intrahospital infections in children's hospitals of of Yakutsk» (the introduction certificate № 01-821 from 18.12.2013).

Manuals «Propaedeutics of infectious diseases of children's age» and «Diagnostics of virus hepatitises at children», received signature stamp UMO by medical and pharmaceutical formation of high schools of Russia are developed and introduced in educational process of medical HIGH SCHOOLS, results of dissertational research are used in creation of a management for doctors «Diagnostics and treatment of a chronic hepatitis With at children and teenagers» under the editorship of Akad. Russian Academy of Sciences A.A. Baranova.

Work materials are used in educational process of medical institute FGAOU VPO «Northeast federal university of M.K.Ammosov - 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; educational program« Virus hepatitises in pediatric practice »internship programs on a speciality 060103"Pediatrics"on the basis of FGT.

Research materials are introduced in practical activities of infectious-diagnostic unit GBU RS () «the Children's city hospital №2» (the introduction certificate № 04-05/10-1007 from 10.12. 2013), Children's consulting out-patient department GBU RS () «Republican hospital №1-Национальный the medicine centre» (the introduction certificate № 04-02/154 from 13.01. 2014).

Work approbation.

On a dissertation theme are published printing works 74, including 12 articles in magazines from the list recommended VAK.

The basic results of the dissertation have been reported and discussed at session of Presidium of Academy of sciences Republics Sakhas (Yakutia) and at 22 republican Russian and international seminars, the congresses and conferences: the Japanese-Russian workshops on a medical exchange (Yakutsk, August, 2003, Niigata (Japan), August, 2004), the international workshop «Actual problems of pediatrics in the light of demonstrative medicine» (Dalian (the Peoples Republic of China), August, 2010); the All-Russia scientifically-practical conference with the international participation «Modern technologies of diagnostics, treatment and preventive maintenance in pediatrics» (Yakutsk, March, 2012); All-Russia nauchnoyoprakticheskaja conference with the international participation «Modern problems of pediatrics» (Yakutsk, March, 2011); I Pediatric forum «Innovative technologies in pediatrics: achievements and prospects» (Yakutsk, December, 2011); the Congress with the international participation «the Bionomics and health of the person in the north» (Yakutsk, 2007, 2013); Inter-regional scientifically-practical conference «Medical Assembly of the Union of cities of the Polar region and the Far North» (Yakutsk, September, 2002), inter-regional scientifically-practical conference «the Condition and prospects of development of pediatric service in system of municipal public health services: problems and decision ways» (Yakutsk, April, 2010); I congress of children's doctors RS () «the Organization of the mediko-social help to children and teenagers Republics Sakhas (Yakutia): problems, development prospects» (Yakutsk, April, 2010); republican scientifically-practical conference
«Pressing questions of an infectious pathology at children» (2003, 2005, 2006, 2008, 2010, 2012); V Regional scientifically-practical conference with the international participation «Pressing questions of an infectious pathology in the Far East the Russian Federation» (Khabarovsk) (2012г.), VIII annual nauchnoyoprakticheskaja conference «Perfection of pediatric practice. From simple to difficult» (Moscow) (2013г.), at sessions of the Society of pediatrists Republics Sakhas (Yakutia) (2000-2013).

The positions which are taken out on protection:

1. Epidemic process of virus hepatitises at children and teenagers in RS () is characterised by prevalence in structure of chronic hepatitises HBV - infections. Prevalence of representatives of radical nationalities among patients with HG and the leading part of family contact in structure of ways of a transmission of infection testify to value ethnic and social factors in disease occurrence. Chronic hepatitises concern to the disease which risk of development is directly bound to socially dangerous models of behaviour.

2. For chronic mono-hepatitises at children and teenagers characteristic is malosimptomnoe a current. Moderate expression of is mesenchymal-inflammatory and cytolytic syndromes, more often slabovyrazhennyj a fibrosis, speak as high regeneratornym in potential of a children's organism, and that children and teenagers cannot have the big experience of disease.

3. Disturbance of function of a liver, cytolytic process, immunologic shifts are more expressed at HGV. Clinico-laboratonye data of patients with HGV (HBsAg-) and HGS with low replikativnoj activity allows to survey them as HG with a low and moderate degree of activity. A clinical picture of mikst-hepatitises are characterised appreciable disturbance of state of health of the patients, proof implications of disturbance of belkovo-synthetic function of a liver and more significant cytolytic
Syndrome. The maximum expression these changes reach at ХГВ+Д. At children and teenagers of a radical nationality the tendency to more serious current HG becomes perceptible, the big frequency of complaints, painful and cytolytic syndromes, depressions of belkovo-synthetic function of a liver and changes of a parenchyma of a liver according to ultrasonic is taped.

4. Antiviral therapy HGV at children and teenagers at the present stage with use short INF and a preparation lamivudin is ineffective and should be spent under absolute indications. Antiviral therapy HGS should be spent pegelirovannym ИНФа-2Ь and ribavirinom. prediktorami SVO at carrying out of antiviral therapy, irrespective of the treatment scheme, in a case monoyogepatitov HGV and HGS immunologic indicators (IRI and CD8 +) are positive, besides at HGS - Russian nationality. To positive prediktoram conservations of proof remission at patients with HGV concern a female and a low virus load, at patients with HGS - a female, a high virus load and application pegelirovannogo ИНФа-2Ь.

5. Wide prevalence HG, malosimptomnoe a current at children's age and disadvantages of the organisation of the help of this category of patients in RS () have caused necessity of working out of the program of perfection of rendering of the mediko-social help. Realisation of this of directions of the program has allowed to carry out the system approach to the organisation of the mediko-social help to children and teenagers with HG, to raise quality of rendering of medical aid of the given category of patients at all levels, to provide availability of specialised and highly skilled medical aid, to raise level of preventive maintenance of virus hepatitises at children and teenagers in the conditions of Republics Sakhas (Yakutia).

The personal contribution of the author. The author had immediately been made a choice of a direction of research, formation of the program and its plan
Carrying out; the information collecting is carried out; epidemiological and clinical inspection of children and teenagers with chronic forms of virus hepatitises, sociological interrogation of children and parents is spent; statistical processing of the received data and their interpreting; the program of perfection of the mediko-social help to children and teenagers with HG is developed; the algorithm of references after preventive maintenance of a case rate of children and the analysis of its efficiency is developed. A share of participation of the author in material accumulation - 100 %, in statistical data processing - 80 %, in the analysis of the information and formation of results - 100 %.

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Scientific source Dmitriev Tatyana Gennadevna. CHRONIC VIRUS HEPATITISES At CHILDREN And TEENAGERS In REGION GIPERENDEMICHNOM. The PROGRAM of PERFECTION of RENDERING of the MEDIKO-SOCIAL HELP. The dissertation on competition of a scientific degree of the doctor of medical sciences. Yakutsk - 2014. 2014

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