Sunday, June 16, 2019
Home Health Vadim Pokrovsky, Academician of the Russian Academy of Sciences about nosocomial infection

Vadim Pokrovsky, Academician of the Russian Academy of Sciences about nosocomial infection

As “Kommersant” previously reported, in the Amur Oblast Clinical Hospital of Blagoveshchensk, children with oncological diagnoses were infected with hepatitis C. Vadim Pokrovsky.

Infection with the hepatitis C virus (HCV) is not considered to be especially dangerous or socially significant, as it is not as lethal as HIV. Nevertheless, in Europe, with the reduction in the number of deaths from HIV / AIDS due to the success in treatment, mortality from HCV infection has become noticeable. It grows with us. Rosstat reported 1576 deaths from hepatitis C in 2017, this is the third place among infections (HIV infection – 20,045 deaths in the same year, tuberculosis – 9,614 deaths).

The treachery of HCV is that the initial acute phase of the disease is rarely severe, can go unnoticed, but in 55–80% of infected people the virus does not disappear from the body, and after 20 years, life-threatening complications can develop: fibrosis and cirrhosis (replacement of normal cells with useless connective tissue), and liver cancer.

The case is not limited to the liver; other organs may also be affected. At the same time, an additional role is played by the type of virus, heredity, concomitant diseases, the use of alcohol and other substances. The final percentage of hepatitis C deaths in the first 20 years of life with HCV is not so large compared with HIV infection, in which, without treatment, over 20 years, 95% of those infected die. But after 20 years, the death rate from HCV is increasing.

There are more patients living with HCV in Russia than those infected with HIV: some estimates reach 5 million people.

In the future, an increase in HCV mortality is inevitable. Unless, of course, time will not be treated.

Previously, experts disagreed on whether patients with HCV should be treated if there were no obvious abnormalities in the liver, especially since previous interferon treatment was difficult for the patient and took about a year. It is now believed that HCV infection can and should be cured in all infected and thus completely stop the spread of the virus.

New "direct antiviral effects" drugs quickly cure most patients and are easily tolerated. The only problem is how to get them: while they are expensive.

However, experts believe that by 2021-2022, the prices for these medicines will drop to the generally accessible level, and then it will be possible to think about a complete victory over this infection. True, I think this strategy is not effective enough to eradicate HCV: for example, syphilis, we have long learned how to quickly heal, but it does not become less. In Europe and the United States, many cases of repeated HCV infections have been observed in people who have been cured several times. Therefore, first of all we need to think about preventing new infections.

Regarding the situation with Blagoveshchensk, they constantly consult me ​​on it, since I have experience in deciphering similar nosocomial outbreak of HIV infection that occurred in children's hospitals in Kalmykia in 1988. The only difference is that the children in Blagoveshchensk were infected with the hepatitis C virus. I can’t disclose the details yet, since the Rospotrebnadzor, the Investigation Committee, the Ministry of Health, and even the State Duma continue their investigations. True, the results of all checks will obviously be different: some want to find and punish the perpetrators, others disclaim responsibility, and others protect the honor of the uniform. When I was investigating the situation in Kalmykia, the RSFSR Ministry of Health did everything to prove that there was no nosocomial infection there. I was not allowed to work in Rostov and Volgograd, where there were similar problems; as a result, infection in hospitals lasted for several more months. Only a few years later, Academician Anatoly Potapov, who was then Minister of Health of the RSFSR, praised me for not having retreated under his pressure. But the USSR Minister of Health, Academician Yevgeny Chazov, immediately realized that HIV / AIDS was indeed a serious threat, and in 1989, without much discussion, issued an order to organize a system of centers for the prevention and fight of AIDS, which are still active today. This year is already 30 years old. In such cases, the main thing is not to look for the guilty, but to identify the reasons, to predict the development of the situation and take preventive measures.

But after Kalmykia there were also system errors. In particular, the wrong conclusion was made that HIV outbreak in Elista was due to the lack of disposable plastic syringes, which were then not produced in Russia. Entrepreneurs immediately rushed to build factories for the production of disposable syringes, which quickly displaced glass. But glass syringes can be boiled, but plastic – not. As a result, the subsequent epidemic of HIV infection and hepatitis B and C among drug addicts who inject drugs intravenously, was entirely due to the use of the most disposable syringes that drug addicts used repeatedly and could not boil even if they wanted to. That is, plastic disposable syringes did not solve the problem, and in some ways even aggravated it.

The situation in Blagoveshchensk revealed a systemic problem.

The global spread of HCV occurred in the twentieth century and is undoubtedly associated with the development of medical technology, although its primary origin is still unclear, probably borrowed from the animal world. HCV is easily transmitted only with blood in skin-related procedures. Significantly less infection than in HIV infection is infection of sexual partners with HCV, less frequently infection of HCV and children from the mother. Before HCV was identified, it successfully spread with donor blood during transfusion. Now the donor's blood is being checked, therefore, the main group that is infected with HCV are considered to be drug addicts who infect each other when they share needles and syringes. However, Russians infected with HCV who have never injected drugs intravenously are not much less. It is believed that many people contracted acupuncture, tattoo, piercing, manicure. It is less pleasant to assume that the infection occurred at the dentist or in the hospital.

An investigation in Blagoveshchensk shows that medical procedures, alas, may be of paramount importance.

Just when an HCV infection is detected in adults, the investigation is rarely completed. And if they suspect that HCV infection has occurred in a medical institution, then they are limited to the imposition of a fine or just a comment. No systemic conclusions have been made before, but they could lead to a significant reduction in the incidence. One of the reasons is that, until recently, chronic HCV infection was not considered dangerous, since there was no information about its distant sad outcomes yet.

After the publication of the results of the investigation of an outbreak of HIV in Kalmykia in the late 1980s, doctors so actively took up the safety of medical interventions that the number of new cases of hepatitis B and C in Russia decreased significantly. The next rise in the incidence began already in the 1990s due to an increase in the number of drug users. The main thing is that after Elista, the medical staff were strongly tightened in anti-epidemic terms. Then we have not seen cases of nosocomial HIV infection for a long time, despite the economic difficulties in healthcare. But for the last ten years they have been detected again, although not so big: from one to five victims.

In total, we recorded more than 50 episodes with suspected HIV transmission in hospitals across the country, which means that HCV is transmitted there.

It seems that over the past 30 years, medical staff has gradually changed in age, came less trained youthwhich began to make mistakes. Of course, plays a big role and lack of medical facilities: Complaints about the lack of cheap supplies, such as syringes and gloves, come from everywhere. Plays a role and low salary outflow. The remaining nurses work at several rates, and work for wear leads to a weakening of attention and attempts to simplify the procedures. It is clear that making three patients an injection with one syringe, taking medicine from one bottle, is faster and more “economical” than changing syringes three times, each time opening three new bottles of medicine. But, perhaps, the sisters do not even understand that they are violating or “elder comrades” could order them to do this: when I was in nursing practice 40 years ago, I was taught a lot, which could not be done from an anti-epidemic point of view. Thanks to these "teachers" I now know these violations.

In hospitals we fight a whole group of infections related to the provision of medical care. Not all germs are transmitted only with injections. Many are transferred to the hands of medical personnel. Hand towels that have not yet disappeared everywhere from practice are quickly contaminated with germs. And modern technology, such as devices for ventilation of the lungs, can also easily become reservoirs of infection.

In most cases, the infection of patients is due to "minor deviations" from the sanitary rules, which are not easily noticed.

To avoid these mistakes, the security mode should be worked out in detail in practice with the staff in each unit. When this work is done, the number of cases of infections associated with the provision of medical care, is sharply reduced. This is what the "hospital epidemiologists" should do. But the administration of the hospitals, to which they submit, often requires them only to create an appearance of order before the arrival of the inspection of the Federal Service for Supervision of Consumer Rights Protection and Human Rights Supervision. And the employees of Rospotrebnadzor, whose numbers are not enough, are usually limited to the formal part: they study the records in the reporting documentation, check for the presence of disinfectant solutions, garbage buckets … See how the staff actually manipulates, they don’t have enough time.

Of course, all victims in Blagoveshchensk should receive modern HCV drugs as a priority and free of charge. The question of responsibility is more complicated. The investigation will confirm the infection of children in the hospital, but it will not be easy to identify exactly the person who infected the particular child, and we do not have collective criminal liability. Formally, you can only attract a switchman, that is, a nurse. If they find the culprit, the court will determine the punishment, but for the article on which the punishment will be chosen, the prosecution will have to fight with the defense. Possible financial claims to the institution. Some of the bosses will incur administrative and moral responsibility. Although it is not obvious from the published statements that they have realized their mistakes.

There will be demonstrative actions. In Blagoveshchensk, they are already going to buy syringes and a disinfecting installation, which is not bad in itself. But the cause of the outbreak is not only in their absence. Raising wages to nurses, but not at the expense of increasing workload, would make their work more attractive and of higher quality. And their additional training in anti-epidemic technology will be the most effective event.

Populists in the State Duma have already raised the issue of toughening sentences, but this is their usual tactic: it looks cool, but does not require any costs.

So far, the protection of the population from infections is considered to be less important than the protection from external threats.

But our loss of life only from HIV / AIDS is up to 300 thousand people in 30 years. And this is basically the loss of people of working age. Therefore, it would be good for the State Duma to help Rospotrebnadzor in law, since its functions are now very limited, and would think harder when adopting a budget.

It is necessary that the Rospotrebnadzor propose a set of measures that will at once block the nosocomial pathway for hepatitis, HIV, and in the future for dozens of other pathogens, such as, for example, the viruses HTLV-1 and HTLV-2 (T-lymphotropic human virus “B”), which can cause leukemia, and for still unknown pathogens, the appearance of which is expected.

I have long been raising the question of the country completely switching to syringes, which are destroyed after a single use. This is not only a matter of preventing nosocomial infections, but also reducing the transmission of HIV and hepatitis viruses among drug users, which is mainly due to the repeated use of a disposable syringe. If the Duma adopted a law on the gradual, in a few years, transition to self-destructive syringes, the entrepreneurs would have managed to restructure the production base without significant losses.

In the meantime, there is no guarantee that a meeting with the HCV will occur.



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