1. family and parenting
2. children

Центрально-Азиатский научно-практический журнал по общественному здравоохранению
UDC: 616-053.2(4)-056.4
Zh. A. Kalmatayeva, E.K. Bekbotayev, A.B. Skakov, A.E. Omarova, B.E. Aryspayev
School of Public Health of the Ministry of Healthcare of the RK, Almaty
QUALITYOF LIFE ASSESSMENT OF THE 5 AND 6 YEAR OLD CHILDREN WITH
CHRONIC DISABILITIES IN ALMATY AND KYZYLORDA REGIONS
Keywords: children population, chronic disability diseases, quality of life, regional indicators.
Summary. For the first time in the Republic of Kazakhstan a study was done on the quality of
life of 5-6 years old children with chronic disability according to the international methodological standards. Quality of life comparison was done for the children living in urban and rural areas in Almaty and Kyzylorda regions. Health Related Quality of Life (HR QoL) study will allow
to get a more comprehensive picture of patient’s health, because it takes into consideration his
subjective opinion about own physical, psychological and social welfare.
The aim of this study was to identify the quality of life indicators of 5-6 year old children with
chronic disability.
The subjects of the study were 5-6 year old children in Almaty and Kyzylorda regions with
chronic disability diseases. As a study tool we have used the Russian version of the generic quality of life questionnaire (PedsQL™ 4.0 GenericCoreScales)for 5-7 year old children (parents’
form).
Therewereatotalof205 parents/guardianssurveyed: among them in Almaty region–
64,4±3,34% and in Kyzylorda region– 35,6±5,60% respondents. Out of total number of
respondents, there were 44,4±5,21% of boys’ parents/guardians and 55,6± 4,65% of girls’. In
the nosology and disease groups structure, children with congenital anomalies (development
pathologies) of the central nerveous system (CNS), cardio-vascular system (CVS), other
congenital pathologies, bronchial asthma as well as trauma consequences take dominant
position – 89,8±2,11%.
In general it can be noted that chronic disability diseases significantly decrease the QL of 5-6
year old children in both regions. Statistically the differences in the QL indicators of the
diseased and relatively healthy children differ with a high confidence interval (р<0,01). At the
same time it was noticed that QL of the rural area population is lower than urban population on
all scales except for RF. The indicator of the psychosocial function in gamong urban children
was higher by 7,7 points and in general or sum scale it was higher by 8,7 points. Depending on
children’s gender higher parameters of QL were seen in girls(in summary scale by 2,6 points),
mainly due to the difference in the physical functioning scale (physical functioning in boys was
worse more than in girls). It is necessary to notea different degree of adverse in fluence from
various diseases on the QLof5-6 year old children: of all nosologies and disease groups included
in the study, QL was lower among 5-6 year olds with congenital CNS pathologies, especially
physical (39,9 points) and social (52,8 points) functioning and with other congenital pathologies
–role functioning (49,4 points).
Therefore the studied disability conditionslower the QL of 5-6 year olds with high
confidence(р<0,01). QL indicators of children in ruralarea are lower than those of urban
children with high certainty (р<0.01). 5-6 year old girls with chronic disability conditions had
certainly higher QL indicators on all scales than boys. In both studied regions QL suffered the
most in 5-6 year olds with congenital pathologies of CNS (especially physical and social functioning). Fur ther more it was lower in those living in Kyzylorda region than of their peers in
Almaty region with high confidence.
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Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Introduction
According to the definition of international center for quality of life studies (Russia),quality of life (QL) is an integral character is ticofphysical, psychological, emotional
and social function in gof the patient, based
on his subjective perception[1]. Until present time mostly objective data of laboratory
an dinstrumental studies were taken into accountin assessment of patient’s state, where
as QL criteria gave an opportunity to learn
the person’s subjective opinion about own
physical health, psychological state, own
role in the society and create a full and holistic picture of health. Common in QL studies is application of standardized question
naires to assess quality of life and symptoms, tested in research and clinical practice,
which have satisfactory psychometric properties (reliability, validity, sensitivity) [2, 3].
One of the most common lyused international questionnaires in pediatrics is Pediatric Quality of Life Inventory (PedsQL™
4.0), the purpose of which is to assess the
QL of relatively healthy as well assick children. The questionnaire has parent and children forms, it consists of 21-23questions,
which are grouped in the following scales:
physical functioning – FF (8 questions),
emotional functioning – EF (5 questions),
social functioning – SF (5 questions), life in
school or pre-school – LS (3-5questions depending on age)[4].
The aim of the present study was to identify quality of life of 5-6 year old children
with chronic disability diseases.
Materials and methods
Subjects of our research were children
aged 5-6 in Almaty and Kyzylorda regions
with the follow in gnosologies and disease
groups:bronchial asthma; cysticfibrosis; ce-
liac syndrome; acuteleukemia, histiocytosis,
aplasticanemia,
haemophilia;
obstructiveuropathy; congenital pathologies of respiratory organs, gastric organs, circulatory
system and heart, genitourinary and central
nervous systems; retinopathy in premature
infants; traumas; other congenital pathologies (congenital pathologies of osteoarticular
system and tissues,such as: congenital hip
dislocation, clubfoot etc.). As an instrument
for study (after obtaining the permission
from the International institute of the quality
of life study – MAPI, France) Russian version of the international QL questionnaire
was used – PedsQL™ 4.0 Generic Core
Scales for children aged 5-7 years (parent
form).The survey was done in their presence, on a voluntary basis, after the informed consent form was signed.
After the survey with the help of guidelines, scaling of the questionnaires was
done. According to the guidelines answers
on all scales were transformed into points:
«never» - 100 points, «almost never» - 75
points, «sometimes» - 50 points, «often» 25 points and «almost always» - 0 points.
Therefore mean values were identified in all
scales and average psychosocial functioning
scales were identified– PSF (according to
the scales EF, SF, RF) and their sum– SS
(average point on all scales).
Results
Inordertoassessthe quality of life of 5-6
year olds with chronic disability diseases
205 surveys of parents/guardians were done
(picture 1). Among the min Almaty region –
132 respondents (64,4±3,34%), in Kyzylorda region – 73 respondents (35,6±5,60%).
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Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Picture 1 – Share of the respondents of 5-6 year olds by region and gender, in %
Of the total number of the respondents
boys’ parents/guardiens were 91 people
(44,4±5,21%), girls’ – 114 people (55,6±
4,65%).
Picture 2 presents the distribution of the
respondents by location type. Total number
of the respondents living in urban area exceeded rural area by 3,7 times (78,5%, vs.
21,5%), among them in Almaty region by
3,3 times and in Kyzylorda region 4,6 times.
Picture 2 – Distribution of urban and rural area respondents aged5-6 years, in %
In the nosology and diseases groups
structure
children
with
congenital
pathologies of the CNS, CVS, other
congenital pathologies, bronchial asthms, as
well as trauma consequences take the
dominating place (table 1).
Their summary share among children of
this age group is 89,8±2,11%. With a big
gap to the other groups the first place is taken by the congenital pathologies of the cen-
tral nervous system (29,3±3,18%);then almost with equal share come traumas
(17,5±2,65%), congenital pathologies of the
circulatory system and heart (17,1±2,63%)
and
other
congenital
pathologies
(16,6±2,60%). Children suffering from
bronchial asthma have taken the 5th place
in ranking (9,3±2,03%).
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Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Table 1 – Distribution of the respondents by region and diagnosis
Diagnosis
Region and patients number
Almaty region
Kyzylorda region Total
Abs. ratio,
Abs. ratio,
Abs.
ratio,
No. in %
No. in %
No.
in %
Bronchial asthma
8
6,1±2,08
11
15,1±4,19 19
9,3±2,03
Congenitalpathologiesofcirculatorysystemandheart
19
14,4±3,06 16
21,9±4,84 35
17,1±2,63
CongenitalpathologiesoftheCNS 44
33,3±4,10 16
21,9±4,84 60
29,3±3,18
Trauma, accidents.
31
23,5±3,69 5
6,9±2,97
36
17,5±2,65
Other congenital pathologies
17
12,9±2,92 17
23,3±4,95 34
16,6±2,60
Other
13
9,8±2,59
8
10,9±3,65 21
10,2±2,11
Total
132 100,0
73
100,0
205
100,0
latory system and heart with the ratio of
Among urban and rural area population
18,2±5,82%. Children with traumas shared
the first place by frequency is taken by conthe 3rd and 4 th places in frequency with othgenital pathologies of CNS, urban –
er congenital pathologies (по 11,4±4,79%).
27,3±3,51%, rural area – 36,3±7,25% reThe fifth place in dominating pathologies is
spectively (table 2). Amongurbanpopulataken by bronchial asthma, both is urban
tionthesecondplaceistakenbythetrau(10,0±2,36%), and rural (6,8±3,80%) popumaswiththeratioof19,3±3,11%, and among
lation.
rural area population the second place is
taken by the congenital pathologies of circuTable 2 – Distribution by location type and diagnosis
Diagnosis
Location type and patient number
Urban
Rural
Total
Abs. ratio,
Abs.
ratio,
Abs.
ratio,
No. in %
No.
in %
No.
in %
Bronchial asthma
16
10,0±2,36 3
6,8±3,80 19
9,3±2,03
Congenitalpathologiesofcirculato18,2±5,8
rysystemandheart
27
16,8±2,95 8
2
35
17,1±2,63
CongenitalpathologiesoftheCNS
36,3±7,2
44
27,3±3,51 16
5
60
29,3±3,18
Trauma, accidents.
11,4±4,7
31
19,3±3,11 5
9
36
17,5±2,65
Other congenital pathologies
11,4±4,7
29
18,0±3,03 5
9
34
16,6±2,60
Other
15,9±5,5
14
8,6±2,21
7
1
21
10,2±2,11
Total
161 100,0
44
100,0
205
100,0
system and heart – 18,7±4,09%, 3rd and 4th
As for gender structure among 5-6 year
place is shared by traumas and other
olds with chronic disability diseases
congenital pathologies (each 13,2±3,55%).
congenital pathologies of CNS were seen
Among girls second place is taken by
most often, is boys – 32,9±4,93%, in girls –
traumas (21,0±3,81%), third – by congenital
26,3±4,12% respectively, and more rarely
pathologies (19,3±3,70%), 4th – by
bronchial asthma, in boys– 9,9±3,13%, and
congenital pathologies of circulatory system
girls – 8,8±2,65%respectively (table 3).
and heart (15,8±3,42%).
Among boys second ranking was taken
by congenital pathologies of circulatory
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Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Table 3 – Distribution of the respondents by gender and diagnosis
Diagnosis
Gender and number of patients
Boys
Girls
Total
Abs.
ratio,
Abs.
ratio,
Abs.
ratio,
No.
in %
No.
in %
No.
in %
Bronchial asthma
9
9,9±3,13
10
8,8±2,65
19
9,3±2,03
Congenitalpathologiesofcirculatorysystemandheart
17
18,7±4,09 18
15,8±3,42
35
17,1±2,63
CongenitalpathologiesoftheCNS
30
32,9±4,93 30
26,3±4,12
60
29,3±3,18
Trauma, accidents.
12
13,2±3,55 24
21,0±3,81
36
17,5±2,65
Other congenital pathologies
12
13,2±3,55 22
19,3±3,70
34
16,6±2,60
Other
11
12,1±3,42 10
8,8±2,65
21
10,2±2,11
Total
91
100,0
114
100,0
205
100,0
functioning of both regions are similar.
In pictures 3 and 4 there are QL
There is a significant difference in the scale
parameters of the children in Almaty and
of physical functioning– FF indicator (52,8)
Kyzylorda regions in comparison with
of the Kyzylorda region children is lower by
regional population norms in the form of
8,8 points. However, confidence interval of
vector diagrams. At the same time QL
the QL differences among Almaty and
indicators of 5-6 year olds with chronic
Kyzylorda region children is statistically
disability diseases across the regions on the
insignificant (р>0.05).
scales of emotional, social and role
Almaty region
Normative values
FF
82,5
SS 86,8
66,9
65,5
66,7
PSF88,2
89,4 EF
61,6
72,4
60,9
94,1
SF
81,0
RF
Picture 3 – Profile of QL of 5-6 year old children with chronic disability diseases in Almaty
region with regional population norms in points
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Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Kyzylorda region
Normative values
FF
76,5
SS 82,4
63,4
67,7
66,9
PSF 84,4
85,1 EF
52,8
72,1
60,9
88,4 SF
79,7
RF
Picture 4 – Profile of QL of 5-6 year old children with chronic disability diseases in Kyzylorda
region with regional population norms in points
In general it can be noted that chronic
disability diseases significantly decrease the
QL of 5-6 year old children in both regions.
Statistically the differences in the QL indicators among diseased and relatively healthy
children are confirmed by a high degree of
certainty (р<0,01).
In table 4 there are QL indicators of 5-6
year old children with chronic disability diseases depending on their location and gender. According to the location of the re-
spondents it can be noted that QL of rural
population is lower than in urban population
on all scales except for RF. Psychosocial
functioning scale indicator of urban population is 7,7 points higher and on the total or
summary scale it is even by 8.7 points. The
differences of QL of rural and urban population are statistically significant with high
confidence (р<0.01).
Table 4 – QLindicatorsofurbanandruralchildrenaged5-6 years with chronic disability diseases,
in points
Location type, gender FF
EF
SF
RF
PSF
SS
Bylocationtype
Urban
60,9
69,3
75,1
60,9
68,4
66,6
Rural
49,5
59,3
62,0
60,9
60,7
57,9
By gender
Male
54,8
66,7
71,4
60,2
66,1
63,3
Female
61,4
67,6
73,0
61,5
67,4
65,9
shown
(table
5),
that
the
points
of
children
Depending on the gender of children,
with bronchial asthma in summary scale difhigher QL indicators are seen in girls (by the
fer insignificantly in population of both resummary scale by 2,6 points), mainly due to
gions. At the same time PSF indicator is
the difference in physical functioning score
slightly higher in Kyzylorda region children:
(among boys the physical state is worse
75,8 points vs. 74,2 –in Almaty region.
more than among girls). ThesegenderdifferPoints on all scales in children with conencesof the QL indicators are confidently
genital
pathologies of circulatory system and
significant (р<0.05).
heart are compatible in both regions. HowAnalysis of QL indicators of children
ever, the reliability of the differences of QL
aged 5-6 according to the nosologies and
indicator in children, suffering from brondisease groups in the studied regions has
chial asthma and congenital circulatory sys6
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
tem and heart diseases of the studied regions
is statistically insignificant (р>0.05).
Table 5 – QL indicators of the 5-6 year old children with bronchial asthma across the regions
in points
Region
FF
EF
SF
RF
PSF
SS
Bronchial asthma
Almaty region
61,3
73,1
82,5
67,0
74,2
71,0
Kyzylorda region
59,1
70,9
83,2
73,3
75,8
71,6
Congenitalpathologiesof the circulatory system and heart
Almaty region
65,0
69,2
82,9
63,6
71,9
70,2
Kyzylorda region
67,6
67,8
84,4
65,0
72,4
71,2
CongenitalpathologiesofCNS
Almaty region
46,5
58,6
56,3
56,0
57,0
54,4
Kyzylorda region
21,9
58,8
43,4
46,7
49,6
42,7
Trauma
Almaty region
69,1
71,8
81,5
68,5
73,9
72,7
Kyzylorda region
71,9
68,0
82,0
45,0
65,0
66,7
Other congenital pathologies
Almaty region
83,6
77,4
87,1
56,0
73,5
76,0
Kyzylorda region
47,8
64,4
71,5
41,3
59,1
56,3
of the children in the studied regions, who
Among the studied nosologiesand disease
have suffered from trauma (р>0,05).
groups the lowest indicators of the QL were
Among children suffering from other
seen in all scales among 5-6 year old chilcongenital pathologies(along with children
dren with congenital pathologies of CNS. It
with congenital CNS pathologies) there is
should be noted that except foremotional
the greatest difference in QL indicators in
functioning scale, indicators on all scales are
the regions. Kyzylorda children have low
lower among Kyzylorda region children:
QL indicators in all scales compared to Alaccording to the PSF scale by 7,4 points and
maty region. In PSF scale this difference is
according to the summary scale by 11,7
14,4 points and in summary scale 19,7
points. Especially low indicator has been
points. Reliability of the QL indicators difidentified according to the scale of physical
ferences among Kyzylorda and Almaty refunctioning of children in Kyzylorda region
gion children in this disease group is very
- 21,9 points, which is more than 2 times
high (р<0,01).
lower than in Almaty region. Differences in
Average QL indicators of the total numthe QL indicators of the children with conber of 5-6 year old children for the given
genital pathologies of CNS in the studied
nosologies are shown in table 8.
regions are statistically significant (р<0,05).
The refore , different exten to fad verse in
It was noted that in children with traufluenceon QL can be noted for various dismas living in Kyzylorda region role funceasesin 5-6 year old children: of all nosolotioning was worse to the greater extent
giesand disease groups included in the
(41,3). In Almaty region the indicators of
study, the QL of 5-6 year olds is the lowest
psychosocial functioning were higher than
for children with congenital CNS patholoin Kyzylorda region by 8,9 points and on
gies, especially physical(39,9 points) and
summary scale by 6,0 points. However, stasocial (52,8 points) functioning and other
tistical calculations have reliably shown incongenital pathologies –role functioning
signi ficance of differences in quality of life
(49,4 points).
7
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Table 8 – QLparametersofthechildren age 5-6 by nosologies in points
FF
EF
SF
RF
Nosology
PSF
SS
Bronchial asthma
60,0
71,8
82,9
69,4
74,7
71,0
Congenital pathologies of CVS
66,2
68,6
83,6
64,2
72,1
70,7
Congenital pathologies of CNS
39,9
58,7
52,8
54,4
55,3
51,5
Traumas
69,4
71,3
81,5
65,3
72,7
71,9
Other congenital pathologies
65,7
70,9
79,3
49,4
66,5
66,3
Discussion
We have identified the quality of life of
5-6 year old children with chronic disability
diseases in Kyzylorda and Almaty regions.
We have analyzed the results of a range of
QL studies for children ages5-7 years usingPedsQL™ 4.0 GenericCoreScalesfor
children ages5-7 years, conducted in Russia.
Specifically, during the study conducted
in2007-2009 in Orenburg region [5], negative in fluence of chronic diseases and low
resistance of the organism on the QL was
proven for children of 5-7 years old. There
is a QL study of children with recurrent respiratory conditions in Sakha republic[6], in
which the researchers also reached the conclusion that QL of 5-7 year olds with this
pathology group is lower than in relatively
healthy children. In some studies the authors
have established the in fluence of social determinantson QL of pre-school children, and
it was identified that QL of children ages5-7
from low-income families is lower than that
of children from wealthy families [7].
The last decade demonstrated increased
global interest in the studies with use of QL
approach. The search in PubMed database of
the key phrase «qualityoflife» returns about
205000 results, among them more than
135000 done in the last 10 years. Atthesametimeabout15000 works in the last 10
years are devoted to studying children QL.
Similar studies are an ewand perspective
direction for Kazakhstan, especially during
the development and implementation of the
comprehensive treatment and rehabilitation
programs efficiency assessment.
Conclusions
As a result of the study it was established
that all chronic disability conditions decrease the QL of children of with high confidence (р<0,01). At the same time, QL indicators of the rural population is lower than
those of urban population (р<0.01).
Girlsaged5-6 years with chronic disability
diseases had higher QL indicators on all
scales than boys. In both regions QL suffers
the most in children ages 5–6 years old with
congenital pathologies of CNS (especially
physical and social functioning). Quality of
life of children ages 5-6 with congenital pathologies of CNS and other congenital pathologies living in Kyzylorda region is lower
than that of their peers from Almaty region.
References
1. NovikA.A.,
IonovaT.I.
Guidelinesonqualityoflifestudiesinmedicine/Edited
by Yu.L. Shevchenko. - М.: RANS, 2012. –
528 p.
2. BowlingA., EbrahimS. Handbookofhealthresearchmethods.
Maidenhead:
OpenUniversityPress, 2005.
3. FayersP., HaysR. AssessingQualityofLifeinClinicalTrials: MethodsandPractice.
OxforduniversityPress:
Oxford,
NewYork, 2005.
4. NovikA.A., IonovaT.I. Quality of
life studies in pediatrics /Edited by Yu.L.
Shevchenko. - М.: RANS, 2008. – 108 p.
5. VinyarskayaI.V.,
PavlenkoT.N.,
MurzinaYu.M.Quality of life of children age
5-7, living in Orenburg city // Collection of
the materials of the XIIIPediatricians congress of Russia «Topical problems of pediat-
8
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
rics» with international participation. – М.,
2010. – P. 155.
6. UarovaA.V.,
SavvinaN.V.Modern
approaches to the recurrent sinusitis and
bronchitis among frequently ill children//
Materials of the Icongress of pediatricians of
the Far East «Topical issues of maternity
and childhood protection on the modern
stage». – Khabarovsk, 2010. – P. 310-312.
7. VolginaS.Ya., KurmayevaE.A. Quality of life of pre-school children from poor
families // Kazan medical journal. – Kazan,
2010. №1. – P. 91-94.
Ziad A. Memish, Nischay Mishra, Kevin J. Olival, Shamsudeen F. Fagbo, Vishal Kapoor, Jonathan H. Epstein, RafatAlHakeem, Abdulkareem Durosinloun, Mushabab Al Asmari, Ariful Islam, AmitKapoor, Thomas Briese, Peter Daszak, Abdullah A. Al Rabeeah, and W. Ian LipkinComments to Author
Ministry of Health, Riyadh, Saudi Arabia (Z.A. Memish, S.F. Fagbo, R. AlHakeem, A. Durosinloun, A.A. Al
Rabeeah); Columbia University, New York, New York, USA (N. Mishra, V. Kapoor, A. Kapoor, T. Briese, W.I.
Lipkin); EcoHealth Alliance, New York (K.J. Olival, J.H. Epstein, P. Daszak); Ministry of Health, Bisha, Saudi
Arabia (M. Al Asmari); EcoHealth Alliance, Dhaka, Bangladesh (A. Islam)
MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS IN BATS,
SAUDI ARABIA
Key words: knitting factories, women, working conditions, job performance, dynamics of the
functional state of cardiovascular system, increased air temperature, noise.
Summary. The source of human infection with Middle East respiratory syndrome coronavirus
remains unknown. Molecular investigation indicated that bats in Saudi Arabia are infected with
several alphacoronaviruses and betacoronaviruses. Virus from 1 bat showed 100% nucleotide
identity to virus from the human index case-patient. Bats might play a role in human infection.
Introduction
The knitting industry is one of the most
promising and rapidly developing sectors of
Uzbekistan’s economy. Currently, there are
more than 40 factories and small businesses
where cotton fiber is processed into fabric.
The complexity and diversity of the process,
the scale of production resulted in a large
number of workers, predominantly women,
being employed in the field. Therefore, improvement of working conditions in the knitting industry, the promotion of occupational
health, the development and implementation
of measures aimed at the prevention of occupational hazards – are the main priorities.
Reaching those goals will ensure the wellbeing and improve job performance of a
large number of women employed in the
industry.
In the recent years the economy of Uzbekistan enjoyed the establishment of joint
factories supplied by the newest equipment,
which created more work opportunities for
women. The modern technologies have been
introduced which led to the change of the
working conditions in the knitting factories,
increased work intensity, neuroemotional
strain and increased intellectual work.
However, occupational health of women
working at the modern knitting factories in
the republic has not been studied extensively. The influence of many harmful factors
on the physiological processes of various
body systems in working women has not
been identified. It is particularly important
to study the industrial effect on worker’s
cardiovascular system, which supports all
organs and systems and, therefore, maintains
performance, regulates responses to the var-
9
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
ious processes in the body. Moreover, climatic conditions of Uzbekistan with its hot
dry climate put additional burden on the
human body, its thermoregulatory system,
which is controlled by changes in vascular
tonus and entire cardiovascular system.
Some data suggests that morbidity rates
among women working at the textile factories located in hot areas are significantly
higher than in other places [1].
Goal and objectives of the study
To identify the impact of working conditions on the functional state of cardiovascular system and the job performance of the
operators of the knitting machines and develop recommendations to improve their
working conditions.
Methods
Traditional hygienic methods have been
used to study the working conditions of
women working at the knitting factories.
Some of the measurements have been done
using a psychrometer, anemometer, sound
level meter, aspirator, light meter, in accordance with the methodological requirements.
The functional state of cardiovascular
system has been studied based on hemodynamic parameters. The pulse rate was determined by the palpation of the radial artery; Korotkov sound method was used to
measure blood pressure; mathematical calculations were performed to determine the
following: the systolic end-volume and cardiac output based on the Starr’s formula;
average-dynamic pressure and peripheral
vascular resistance based on the Chikem’s
formula [2].
Measurements were taken at the workplace in the beginning of the workday, before the lunch break and at the end of the
first shift, during the most favorable spring
season (to determine the effect of working
conditions) and during the hottest period of
the year when the air temperature was at its
highest. The level of job performance was
assessed based on the time needed to remove the break, and the change of this pa-
rameter throughout the working day based
on the chronometric measurements [3].
The study was conducted on the basis of
the knitting factories in Tashkent that produce cotton fabric and knitwear. The study
included healthy women aged 10 to 40 years
old with work experience from 1 year to 20
years.
Results
The working process of the operator of a
knitting machine includes the following:
tucking of the bobbin into the spinning machine (56-109 items depending on the machine brand); regulating the mode of work
of the knitting machine depending on the
type of the linen; sticking the end of the
thread of each bobbin to the end of the yarn;
turning the machine on and controlling its
working process; removing the break, and
producing the fabric. If the needle is damaged, the operator stops the machine, calls
the mechanic to replace the needle, then inserts the thread back into the needle and
continues the work. The knitting process
also results in the production of cotton dust,
which lands on the equipment, as well as the
skin of working women. Cotton dust concentrations at the workshops were ranging
from 0,8 to 5,2 mg/m3, with mean concentration of 4,2 ± 0,2 mg/m3. Taking into account that the maximum acceptable concentration of cotton dust is 4.0 mg / m ³, it is
possible to assume that the dust content of
surrounding air at the working sites of the
knitting factories is insignificant; however,
given the potential of fibrogenic cotton dust
to cause allergic reactions, close contact
with the dust throughout the work shift for
prolonged periods could have an adverse
effect on the women’s organism.
During the cold season of the year the air
inside the factories had the following characteristics: the average temperature of the
air during the shift was 16,4 ± 1,4ºC ; relative humidity was 56,4 ± 3,4% and velocity
was 3,5 ± 0,4 m/sec (increased level of air
velocity depends on the power of fans that
are installed into the upper part of the knitting machine to remove the remaining cotton
10
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
dust from the junction and decrease the possibility of the thread breakage). During the
warm season of the year the average air
temperature was 34,0 ± 1,6ºC, with the relative humidity of 37,4 ± 2,8% and velocity of
3,5 ± 0,1 m/sec.
The knitting machines generate noise, the
level of which depends on the brand of a
knitting machine: such brands as “Terrot”,
“Pajlon”, “Pai Lunj” make the noise that
measures at 82 dBA; others, like “Wellknit”,
make the noise up to 86 dB, knitting machines of the model “Terrot”, that produce
knitted fabric of 32 diameter, can make the
noise up to 106 dBA, the noise has high
frequency, with the maximum frequency of
8000 Hrz. Interesting to note that as the
number of spins of the knitting machine increase, the noise level at the working places
also increases.
The level of lightning of working spaces
was uneven and insufficient, varying from
70 to 660 lx.
The working process of operators of the
knitting equipment differs based on intensity, monotony and sensory load. Moreover,
the operators have to be concentrated 75%
of the shift time.
The study performed suggests that working conditions of the knitters working at the
modern knitting factories can be classified
as the third class, third degree of harmfulness which indicates the occupational health
risk for the working women.
The results of chronometry of time needed for removal of one break - the leading
manufacturing procedure performed by the
operators of knitting machinery - showed
that the time spent to remove a break by the
operators of the knitting machines during the
shift period increases (p<0.01). During the
first hour of work, the average time it took
for operators to remove the break was 12.4
sec; during the second hour that time decreased down to 10,8 sec (this was likely
due to increased repetition); by the lunch
break the time increased up to 12,5 sec
(15.7% increase), and by the end of the work
day up to 14,3 sec (32.4% increase), which
indicates the reduction in work efficiency
due to work fatigue [3]. We have identified
a significant correlation between reduced
performance and increased noise level at the
workplace. In addition, a correlation between reduced job performance and increased noise levels was noted (r=0.63).
Table 1 presents data on the state of operators’ cardiovascular system.
Table 1 – Cardiovascular system characteristics of the operators of knitting machines during
the spring season
Hemodynamic characBeginning of
Lunch break
End of workday Significance
teristics
workday
M±m
M±m
M±m
t
P<2-4
1
2
3
4
5
6
Pulse (b/min)
72,8± 2,5
78,5± 3,7
84,0± 2,2
3,39 0,01
Arterial blood pressure (mm Hg)
maximum
102,0± 1,8
126,0± 3,7
132,0± 1,8
7,8 0,001
minimum
70,0± 2,7
76,0± 3,7
82,0± 1,8
3,7 0,01
Pulse pressure
32,0± 1,8
50,0± 2,4
50,0± 1,2
4,4 0,001
Average-dynamic pres- 83,9± 3,0
92,6± 3,7
98,6± 1,8
6,1 0,001
sure
End-systolic volume
61,2± 3,3
61,6± 2,8
58,0± 2,8
0,7 (ml)
Cardiac output (ml)
4459,3± 290,4
4824,1± 116,9 4871,0± 232,7
2,2 0,05
Peripheral vascular re1539,0± 130,0
1438,7± 164,2 1547,6± 182,8
1,02 sistance (dyne)
11
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Study materials show that from the start
to the end of the workday the heart rate of
the knitters increased. In the beginning of
the workday the average heart rate was 72.8
±2,5 b/min; during the first half of the work
day the rate increased up to 78.8 ±3.7 b/min,
and during the second half – up to 84.0 ± 2.2
b/min (p<0,01). Maximum arterial blood
pressure increased from 102.0 ± 1.8 mm Hg
in the beginning of the workday up to 126.0
± 8.7 mm Hg by lunchtime and up to 132.0
± 1.8 mm Hg by the end of workday
(p<0,001). Minimum arterial blood pressure
in the beginning of the workday was, on average, 70.0 ± 2.7 mm Hg, increasing up to
76.0 ± 3.7 mm Hg by lunchtime, and up to
82.0 ± 1.8 mm Hg by the end of the workday (р<0,001). Throughout the day the pulse
and average-dynamic pressure tended to in-
crease, while end-systolic heart volume
tended to decrease. Cardiac output increased
due to increases in pulse frequency. Peripheral vascular resistance remained unchanged.
Thus, from the beginning till the end of
the workday during the spring season, when
the climatic conditions are the most favorable, the changes in hemodynamic parameters
indicate compensatory strain of hypertensive
nature, which is likely to happen due to the
weakening of the functional reserves of the
cardiovascular system.
During the hot season of the year when
the impact of cumulative factors on the knitters’ body exacerbated by high temperature
levels (34 - 35 ° C), cardiovascular characteristics are adversely affected as well (Table 2).
Table 2 – Cardiovascular system characteristics of the operators of knitting machines during
the hot (summer) season
Hemodynamic
Beginning of
Lunch break
End of workday Significance
characteristics
workday
M±m
M±m
M±m
t
P<2-4
1
2
Pulse (b/min)
70,4± 1,9
Arterial blood pressure (mm Hg)
maximum
115,2± 2,3
minimum
60,3± 1,4
Pulse pressure
54,9± 1,8
Average-dynamic
78,6± 3,4
pressure
End-systolic volume 61,6± 3,6
(ml)
Cardiac output (ml)
4336,6± 48,4
Peripheral vascular
resistance (dyne)
1449,6± 21,7
From the beginning till the end of the
workday, women’s heart rate significantly
increased; maximum pressure lowered, minimum pressure increased, pulse pressure, as
well as average-dynamic arterial pressure
increased. End- systolic volume and cardiac
output decreased, in spite of increased heart
rate and peripheral vascular resistance
(p<0.05-0.001). According to the previously
published data [4], hemodynamic changes
3
76,2± 1,4
4
84,8± 2,1
5
5,08
6
0,001
110,4± 2,4
62,5± 1,7
47,9± 1,6
78,4± 2,8
102,0± 1,4
70,4± 1,6
32,2± 2,3
81,1± 2,2
4,68
4,76
7,77
2,5
0,001
0,001
0,001
0,05
56,8± 2,7
44,2± 1,7
4,37
0,001
4328,1± 37,2
3753,2± 42,4
9,06
0,001
1448,7± 32,4
1728,2± 38,6
6,29
0,001
described here indicate significant decrease
in functional reserves of the cardio-vascular
system, which could potentially result in
other pathological changes.
Discussion
The study results are consistent with
those of other authors and prove that intensive industrial noise acts as a stress factor
and results in changes in central nervous
12
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
system, disorders of internal organs and systems, including the cardiovascular system
[5-7]. The study results have been used in
the development of national work and rest
schedules of the operators of knitting machines, as well as recommendations to improve the working conditions, implementation of which has yielded positive results by
reducing the tedium of the working process
and improving hemodynamic parameters.
Conclusion
1. The working conditions and nature of
the working process of the operators of knitting machines affect their performance and
strain the functional state of the cardiovascular system, bearing a compensatory nature.
2. In the hot season, the impact of working conditions on the functional state of the
cardiovascular system is aggravated by exposure to elevated temperatures, which leads
to a significant weakening of the functional
reserve of the cardiovascular system.
3. The data obtained indicate the need
for revising the work and rest regimen and
implementation of measures to improve the
working conditions in the knitting factories.
References
1. Singh M.B., Fotedar R., Lakshminarayana J. Occupational morbidities and their
association with nutrition and environmental
factors among textile workers of desert areas
of Rajasthan, India. Desert medicine Research Сentre (ICMR), Jodhpur, India.
mbsgh@yahoo.com J.Occup Health, 2005,
Vol. 47(5):P.371-377.
2. Lichnitskaya I.I. Evaluation of the
functional systems in determining of the
work performance.-Leningrad, 1962.
3. Rosenblat V.V. The problem of fatigue.-Moscow: Medicina, 1975.
4. Umidova Z.I., Glezer G.A., Yanbaeva Kh., I., Korol G.P. Essays on cardiology
of the hot climate -Tashkent, 1975.
5. Izmerov N.F. Manual Book on occupational health.-Moscow:Medicina, 1987.
6. Izmeov N.F. Physical facors, ecological-hygienic assessment and control.Moscow: Medicina, 1999. - Vol.2. –P. 6.
7. Izmerov N.F., Suvorov G.A., Prokopenko L.V. The human and noise.Moscow: Medicina. – 381 p.
UDC: 614.2-614.88
1
1
U.S. Samarova , D.S. Mussina , Zh.M. Tentekpayev2
1
State medical university of Semey, Kazakhstan.
2
Municipal state public enterprise (MSPE) «Polyclinic №1» of the Pavlodar city, Kazakhstan
IMPROVEMENT OF A PRIMARY HEALTH CARE FACILITY
Key words: primary medical health care, screening, demographic indicators, hospitalization,
driving component to per capita funding.
Summary. Development of primary medical care is a key direction for increasing accessibility, quality and efficiency of the health care system. General accessibility level and quality of
medical care is largely defined on an out-patient stage. This study considers the issues of a primary medical facility. Analysis of screening studies was done for cervical cancer, breast cancer,
colorectal cancer, diabetes, circulatory system diseases, and glaucoma. Organization of hospital
replacing technologies, patient hospitalization is considered.
13
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
The goal of the study was to develop recommendations for improving primary medical care
by assessing the organization of out- and inpatient facility.
Materials of the study are statistical data of the departments of statistics and quality control
of medical services, of the center of family health and out-patient department of the Municipal
state public enterprise «Polyclinic №1» of the Pavlodar city.
Methods of study used: information and analytical, statistical, transverse analysis.
Many indicators of this organization have improved. There is an improvement of demographic situation, increase of the birth rate, decrease and stabilization of mortality indicator, increase
of the natural population growth coefficient up to 9,8±0,6 (2011 - 7,7±0,5) per 1000 of population. Birth rate indicator per 1000 people in 2011 is equal to 17,9±0,8, in 2012 - 19,1±0,8.
Birth rate for the last two years is below average, the indicator has increased by 7 %. The mortality indicator per 1000 of people in 2011 is equal to 10,2±0,6, in 2012 - 9,3±0,6. Mortality indicator per 1000 people has decreased by 8%, mortality level is average. Infant mortality decreased by 2, infant mortality in 2011 was 9,1±4, in 2012 4,6±3 (low) per 1000 live-born children. There is a trend of minor increase of incidents from 2,4±0,4 to 2,9±0,4.
During the year of 2012, 3033 patients have been treated in the day hospital. Among them
2895 - in the day patient facility and 138 - in the house-based facility.
Average cost of treated patients in 2012 was 14 765 KZT, patient-day- 17506 KZT, average
length of stay – 6 days, bed turnover – 54 times a year.
Inappropriate organization of medical care leads to the increase of patient movement. Service
to the patients, who are not registered in this hospital leads to the increase of the indicators and
decrease of the incentive component. In order to improve the organization of primary medical
care the following is necessary. In order to decrease errors in all cases it is necessary to do internal analysis, heads of the departments should have personal responsibility for the incidents
prevention; it is necessary to establish a medical expertise system for improving the quality of
medical services.
ties, early identification of malignant neoIntroduction
plasms by means of screening programs, and
According to the health care and medical
promotion of healthy lifestyle. According to
science development concept in the Repubthe task of the President of the Republic of
lic of Kazakhstan, there is a stage by stage
Kazakhstan N.A. Nazarbayev «Program of
reform of the medical care organization sysoncologic care development in the Republic
tem. The priorities change – the focus is
of Kazakhstan for 2012-2016» was develshifted from treatment to prevention, from
oped and adopted. One of the priority direcin-patient to out-patient facilities [1]. Gentions of the program is development of early
eral level of accessibility and quality of
diagnostics of oncologic diseases, expansion
medical care is largely defined on an outof screening studies.
patient stage [2].
Center for family health provides qualiCurrently there is a creation of different
fied pre-hospital service to the population in
organizational models of out-patient clinical
the out-patient conditions, at home at a day
help on the basis of stage by stage implepatient facility or home-based care, includmentation of role of general practice physiing implementation of prevention and
cian [3]. General practice physicians in the
screening programs [5]. National screening
structure of out-patient facilities play the
system allows to identify and prevent dismain role in the PHC system, with the goal
eases at early stages [6]. Screening examinaof providing most of the prevention work,
tions of adult population are aimed at preensuring certain social effect [4]. State
vention, early identification and prophylaxis
health care development program «Salaof the following 1) main diseases of circulamatty Kazakhstan» for 2011-2015 emphatory system – arterial hypertension, ischemic
sized the strengthening of prevention activiheart disease and their development risk fac14
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
tors among men and women; 2) diabetes
among men and women; 3) pre-tumor, malignant neoplasm of cervix among women;
4) pre-tumor, malignant neoplasm of breast
among women; 5) glaucoma among men
and women; 6) pre-tumor, malignant neoplasm of large intestine and rectum among
men and women [7].
Thanks to a common national health care
system, the Ministry of Health of the Republic of Kazakhstan allocates funds for improvement of medical workers motivation in
local services (incentivizing component to
the per capita norm) for the provision of accessible and high quality primary medical
care. Work of the local service is evaluated
by the following indicators: maternal mortality, pregnancy with extra genital pathology, abortion to the number of live births ratio, infant mortality from acute intestinal or
respiratory infections, neglected cases of
lung TB, neglected cases of malignant neoplasms, hospitalization level with complications of the cardiovascular system, level of
out-patient care use.
The goal of our study is to set recommendations for improving the activity of
primary medical care services by assessing
the organization of medical services in an
out-patient facility.
In order to achieve this goal the following
objectives were set:
1. To calculate main demographic indicators;
2. To assess the organization of screening activities based on statistical information;
3. To conduct monitoring of scheduled
hospitalization on the republican and
regional levels under the framework of
guaranteed amount of free medical help;
4. Assessment of organization of inpatient-replacing care.
This study was done on the basis of Municipal state public enterprise «Polyclinic
№1» of the Pavlodar city, Kazakhstan.
Number of people registered in this hospital
was 91080 in 2012, and 91340 in 2011.
Materials and methods
Materials of the study are statistical data
of the departments of statistics and quality
control of medical services, of the center of
family health and out-patient department of
the Municipal state public enterprise «Polyclinic №1».
Methods of study used: informational and
analytical, statistical, cross-section analyses.
Study design - descriptive. This type of
design allowed to identify programs for further health care development and improvement of primary medical care provision to
the population. With the help of «REST»
program we have received statistical data for
the screening-based studies. Statistical data
of the portal of hospitalization bureau allowed identifying cases related to incorrect
hospitalization of patients. The quality and
level of medical care provided can be evaluated based on demographic indicators.
Results
During the research, the demographic indicators have been calculated, organization
of screening-based studies and MSPE Polyclinic №1 of Pavlodar city hospitalization
bureau were assessed, results of mathematic
calculations and statistical data are shown in
Tables №1,2,3.
Many indicators of the MSPE Polyclinic
№1 of Pavlodar city have improved. There
is an improvement of demographic situation,
increase of the birth rate, decrease and stabilization of the mortality coefficient, increase
of the natural population growth coefficient
up to 9,8±0,6 (2011 - 7,7±0,5) per 1000
population. Whereas the general birth rate
coefficient (in %) is varying from 15 to 19,9,
the assessment of the birth rate is below average. Whereas the general mortality coefficient (in %) was varying from 10 to 14,9,
the mortality indicator is considered as low.
In this case the birth rate indicator per 1000
people in 2011 is equal to 17,9±0,8, in 2012
- 19,1±0,8. Birth rate level for 2 years was
lower than average, the indicator increasing
by 7%. Mortality indicator per 1000 population has decreased by 8%, mortality remained at average level. Infant mortality has
15
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
decreased by half, the level of infant mortality in 2011 was 9,1±4, in 2012 4,6±3
(low) per 1000 of live-born children (Table
1). Population registered in the polyclinic
undergoes screening according to the plan
and schedule. Despite positive changes in
the demographic situation according to the
data of screening studies, there is still low
level of health among women and children.
In course of screening in 2012 there were 7
cases of breast cancer, 5 cases of colorectal
cancer, 1 case of cervical cancer identified
(Table 2). There is a trend of minor increase
of incidents from 2,4±0,4 to 2,9±0,4 (Table
3).
Table 1 – Demographic indicators of the MSPE «Clinics №1» of the Pavlodar city
Demographic indicators
2011
2012
N
%
N
Birth rate per 1000 people
1635
17,9±0,8
1740
Mortality rate per 1000 people
929
10,2±0,6
849
Infant mortality per 1000 live-born children 15
9,1±4
8
Natural growth
706
7,7±0,5
891
Table 2 – Preventive screening in 2012
Population group
Plan of
Patients identified
prof. Exam cov- N
%
erage
Children and
18001–
6193 34,4±0,7
adolescents
100%
Women (30-60) years
2492 –
1
0,04±0,08
old for cervix cancer
100%
Women (50-60) for
23817
0,3±0,2
breast cancer
100%
Men and women (408122 –
8
01,±0,07
70) for glaucoma
100%
Men and women (1810085 – 394
64) for circulatory dis3,9±0,4
100%
eases, diabetes
Men and women (505300 –
70) for colorectal can5
0,09±0,08
100%
cer
Healed
N
%
6193 34,4±0,7
%
19,1±0,8
9,3±0,6
4,6±3
9,8±0,6
Included into
register
N
%
966
5,4±0,3
1
0,04±0,08
1
0,04±0,08
7
0,3±0,2
7
0,3±0,2
8
01,±0,07
8
01,±0,07
394
3,9±0,4
394
3,9±0,4
5
0,09±0,08
5
0,09±0,08
Table 3 – Scheduled hospitalization and round the clock in-patient departments
2011
2012
Scheduled hospitalization
N
%
N
%
Hospitalized
7014
7,7±0,2
7216
7,9±0,2
Incidents
167
2,4±0,4
209
2,9±0,4
As for the in-patient replacing care there
is a day patient care facility at the polyclinic
for 53 beds. State order in 2012 was 3015
patients with a total of 42 518 000 KZT
(with additional 2 000 000 KZT in December 2012). Day patient care works 2 shifts.
For 12 months of 2012 there were 3033 patients treated in day patient care, out of them
2895 in the day patient care facility and 138
at home-based care.
Average cost of a treated patient in 2012
was 14 765 KZT, bed-days –17 506, average
16
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
length of treatment was 6 days, bed turnover
– 54 times a year (4,5 times per month).
Discussion
Each year the issue of oncologic conditions becomes more serious, which is supported by the organizational statistics. Local
services, which ideally should include general practice physicians, local nurses, social
workers, conducts preventive work with
population, however new cases of neoplasms are registered more often. This is related to the fact that these specialists serve
not only the population registered to this
hospital, but others too. According to the
Prikaz of the Republic of Kazakhstan «On
health of the population and health care system», the citizens have a guaranteed right to
the free choice of medical organizations and
a physician, as well as high quality and
timely medical care, however, each clinics
of family outpatient facility should strive to
serve only the population registered with
them, because incentivizing coefficient to
each local area facility depends on that
number. New cancer cases can decrease
their quarterly payments because it is one of
the indicators for assessing the work of medical staff. In order to exclude cancer diagnostics cases it is necessary to crosscheck
whether the patient is found in the portal of
population registry, this will allow to lower
the values of this indicator and increase the
incentivizing component. The trend of insignificant increase of incidents is related to
the fact that when registering the patients
through the portal of bureau for hospitalizations, physicians may enter the wrong the
IDC-10 code. Furthermore, certain conditions can be treated in a day patient facility.
Conclusion
In order to improve the organization of
primary medical care it is necessary to pay
attention to the following aspects.
1. To decrease mistakes, the internal investigations of all cases is essential; all department heads also need to take personal
responsibility for not allowing such incidents to happen;
2. It is necessary to create medical expertise system to improve medical services
quality;
3. Physicians need to know the list of diseases that should be treated in day patient
facility, because the lack of awareness on
this issue leads to increased patient movement and incidents;
4. It is necessary to decrease the level of
in-patient care, providing out-patient replacing care;
5. By decreasing the level of in-patient
care provision, we safe state budget funds
and increase funds for motivation of medical
workers;
6. Patients service, who are not registered
with this particular polyclinic, leads to the
increase of indicators and decrease of incentivizing component.
References
1. State program of health care development in the Republic of Kazakhstan
«Salamatty Kazakhstan» for 2011 – 2015,
approved by the decree of the President of
29 November 2010, № 1113;
2. Ricbard J. Baron, MD, Maryland,
USA. “New pathways for primary care: an
update on primary care programs from the
innovation center at CMS”// Journal Article.
Annals of Family Medicine 2012 Mar-Apr;
Vol. 10 (2), pp. 152-5.
3. Chizhikova T.V. Improvement of
primary medical care to the population of
rural municipal area // author’s summary,
Moscow, 2010;
4. Sinyavskiy V.M., Zhuravlev V. A.
Organization of systemic management, records and control in out-patient clinics service // Glavvrach. – 2006., №6. – P.41-50;
5. Order of the acting Minister of
healthcare of the Republic of Kazakhstan of
5 January 2011, № 7 On approval of the Policy on work of medical organizations,
providing out-patient services. Registered in
the Ministry of justice of the Republic of
Kazakhstan on 14 February 2011, № 6774;
6. Address of the President of the Republic of Kazakhstan– Leader of the nation
17
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
10 November 2009, № 685 «On approval of
the Rules of preventive medical examinations of the target population groups» with
amendments and changes of 16 March 2011,
№ 145.
Nursultan Nazarbayev to the people of Kazakhstan «Strategy «Kazakhstan-2050» new political course of an accomplished
state» of 14.12. 2012;
7. Order of the acting Minister of
healthcare of the Republic of Kazakhstan of
UDC:616.36-002
1
1
2
3
M.K.Saparbekov , A.A.Bekbulatova , I.H.Shuratov , E.S.Utegenova , A.S.Mutaliyeva
1
3
Kazakhstan school of public health of the Ministry of Health of the Republic of Kazakshstan
2
Research center of hygiene and epidemiology named after Kh. Zhumatov
3
Scientific-research center of sanitary-epidemiological expertise and monitoring of the MoH RK
APPROACHES TO IMPROVEMENT OF EPIDEMIOLOGIC SURVEILLANCE
OVER VIRAL HEPATITIS C ON REGIONAL LEVEL
Key words: hepatitis С virus, epidemic process, epidemiological surveillance, laboratory
diagnostics, prevention, Almaty, Kazakhstan.
Summary. Hepatitis C virus (HCV), forming a chronic process in the liver, is a relevant topic
for public health. According to WHO assessment in different countries of the world there are 180
million people infected with HCV. Progressing growth of the HCV morbidity, difficult process
with relapses, often complications, high mortality require organization and conduct by health
care organizations of an efficient and high quality epidemiological surveillance over Hepatitis
C.
The aim of the work is to form approaches to improvement of epidemiological surveillance
over HCV on the basis of epidemiological characteristics study of the HCV in Almaty city.
There were epidemiologic, serologic, sociologic and statistical methods used. Analysis of epidemiological situation with HCV in Almaty was done on the basis of official reporting study of
Department of state sanitary epidemiological surveillance of Almaty for the period of 19982012, as well as results of serological study of etiological structure of viral hepatitis in 171
adults with subclinical manifestations of hepatitis C – all Almaty residents- with the help of enzyme immunoassay (EIA). In order to establish possible factors and infection ways an anonymous survey was done.
Peculiarities of HCV distribution in Almaty were specified. It was noted that according to the
official statistics data for the studied period among Almaty population there was a low level of
acute HCV morbidity registered (3 per 100 thousand people). Serological study of 171 people,
who came to the laboratory with chronic hepatitis has identified that the share of acute hepatitis
is 52,0%. High frequency of antibodies to HCV was identified in the age group of 20-24 years –
30,3%. During the analysis of anonymous questionnaires it was found out that the leading infection risk factor is sexual transmission (64,0%). In the process of study with consideration of the
reference data there were approaches identified to improvement of epidemiological surveillance
over HCV in Almaty, the essence of which lies in enhancing the quality of etiological diagnostics, systematic tracking of different determinants of epidemic process (monitoring of epidemiological situation, laboratory-epidemiologic control, social monitoring).
The studies allowed to identify peculiarities of epidemic process of acute hepatitis C virus in
Almaty, show high frequency of chronic hepatitis C identification (52,0%) among people with
18
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
subclinical hepatitis forms on the regional level with consideration of identified peculiarities of
epidemic process.
Background
Hepatitis C is a globally spread viral
infection and is the main reason for chronic
liver diseases, including liver cirrhosis,
hepatocellular carcinoma [1-5]. According
to the WHO assessment there are 180 million people in the world infected with hepatitis C virus [6]. The data on hepatitis C
prevalence in Kazakhstan are incomplete
and contradictory, because official registration of HCV in the republic has started in
1998 [7]. Currently there is a range of research studies in Kazakhstan aimed at studying the infection and morbidity of HCV in
certain regions of the country among different population groups [7-10]. At the same
time there are not enough studies related to
the improvement of epidemiological surveillance system over hepatitis C virus on the
regional level with consideration of infection prevalence in a particular administrative
district.
The aim of our study was to form approaches to improvement of epidemiological
surveillance over HCV on the basis of epidemiological and etiological characteristics
study of the HCV in Almaty city.
Materials and methods
In order to achieve the aim and objectives
there were epidemiologic, serologic, sociologic and statistical methods used. Almaty
was chosen as the territory for study conduction, where hepatitis C identification and
registration on the basis of clinicalbiochemistry and laboratory tests is better
compared to other regions of the country.
Materials for the study were data of official
reporting of Department of state sanitary
epidemiological surveillance of Almaty for
the period of 1998-2012.
During retrospective epidemiological
analysis of HCV morbidity longstanding
dynamics and morbidity development trends
were studied. In order to assess morbidity
intensive indicators per 100 thousand people
were used. Intensity of changes in a dynamic
time series was defined by means of increase (decrease) rate calculation Тincr (±).
Increase (decrease) rate is a ratio of absolute
increase (decrease) of the present period and
absolute level of the previous period, represented in percent [11].
In order to identify the prevalence of
HCV among 171 inhabitants of Almaty,
who turned to the laboratory of Research
center of hygiene and epidemiology named
after Kh. Zhumatov an identification of antibodies to HCV with EIA method was done,
using testing systems «Best– anti-HCV Ig G
and Ig M» of the CJSC «Vector- Best» (Novosibirsk, Russian Federation). The results
of optical density measurements were registered at the wave length 450 nm with a reader «Bio – Rad Instruments Inc».
At the same time in order to assess demographic indicators and study of the possible infection factors and ways an anonymous survey was done of the people tested
for HCV. There were a total of 171 people
surveyed, including 107 men (59,1%) and
70 women (40,9%). Mean age was 32,5 ±
3,4 years. Surveyed individuals were people
diagnosed with «chronic hepatitis», who
were referred for study of viral hepatitis
markers, as well as people, who turned with
the request to get tested for viral hepatitis.
Statistical analysis was done using a PC
and «Excel» application. Mean error was
calculated– m, reliability of mean differences was defined using Student’s test – t,
with р ≥95%.
Results
Study of the acute hepatitis C virus morbidity among Almaty population in the given period has shown that during the first
year of hepatitis C cases registration there
was high morbidity within the limits of 1,7
to 2,8 per 100 thousand people. Later on
there was a gradual decrease of morbidity
indicators down to 0,07 – in 2012. Calculated decrease rate Т inc(-) in Almaty was
95,9%. Analysis of the serological study re19
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
sults has shown that antibodies to HCV were
identified in 89 people (52,0 ± 3,8%), to
HBV in 65 people (38,0 ± 3,7%). Mixed
cases of chronic hepatitis C and B were (3,9
± 1,4%), B and D– 4 (2,3 ± 1,1%). In 7 (4,1
± 1,5%) cases there were no specific antibodies of chronic hepatitis В, С and D identified. Among antibodies carriers there were
41 (46,1%) men, 48 (53,9%) women. The
age distribution among the carriers was as
follows: 27 people were ages 20-24 (30,3%),
23 people –in the age group of 25-29 years
(25,8%), 22 people – in the age group of 3039 years (24,7%), 17 people were 40 and
older (19,1%). An important question was
related to the information on possible factors
and ways of infection. Out of 89 carriers of
HCV antibodies 64,0% pointed out the sexual contact as a possible way of transmission, 11,2% pointed out IV use of drugs,
16,8% surgical interventions, 7,9% of the
respondents did not provide an answer.
In course of the study based on the reference data and collected data, there was an
epidemiological surveillance algorithm created for HCV (picture 1).
When developing main points of the algorithm we were aware that epidemiological
surveillance system is rather comprehensively developed by both domestic and foreign
authors [6,12-14]. However, despite relative
consensus over «epidemiological surveillance» definition in the literature there are
seen different approaches to its contents
from functional standpoint. A range of authors [15] points out surveillance as a generalized form of epidemic work, i.e. surveillance is matched with the system of epidemiologic services to population in general.
Lately CDC experts have taken an active
part in the development of epidemiological
surveillance concept, who define epidemiological surveillance as a «systematic collection, analysis, interpretation and distribution
of data on health» [6,13,14]. This definition
considers modern epidemiology as a diagnostic instrument for public health care, allowing to identify and solve problems to
improve health of the nation. We suggest the
following definition of epidemiologic sur-
veillance for hepatitis C virus. Epidemiologic surveillance for HCV means continued
collection, systemic analysis of epidemiological and diagnostic information on HCV,
having the goal of assessing possible territorial spread of infection in order to implement targeted epidemic and prevention activities, analysis and assessment of their efficiency, forecasting, justification and development of efficient managerial decisions.
As it is seen from picture 1, recommended algorithm for epidemiologic surveillance
system suggests in its structure 2 blocks, ensuring its function:
1. Block of information-diagnostic support;
2. Block of epidemiologic analysis.
Guided by the WHO recommendations
on «10 elements of epidemiologic surveillance» [4,13], we have identified the following information flows in the epidemiologic
surveillance system:
1. Information, characterizing the situation with HCV in the world, Kazakhstan,
and in certain regions of the country.
2. Information, characterizing the condition of laboratory-epidemiological control
of hepatitis C virus. By laboratoryepidemiological control we mean a system
of activities, including organization of HCV
laboratory diagnostics, tracking the epidemic process dynamics by transmission ways
and factors, ensuring laboratory testing quality control on pre-analytical, analytical and
post-analytical stages.
3. Information, characterizing social
environment factors, which determine epidemic process (social monitoring).
It should be noted that such distribution
of information flows for HCV is not accidental, and it is related to the fact that epidemiological surveillance in Kazakhstan on
a regional level of implementation is mostly
a prerogative of practical facility, capabilities of which in regards of access to certain
part of information are limited. Furthermore,
the issue of correct information flows organization is also important for the republic
from the standpoint of tracking (monitoring)
20
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
organization with the help of computer technologies.
The baseline in the recommended HCV
epidemiological surveillance system is block
of epidemiologic situation analysis, including descriptive-analytical methods, forecast
and development of a relevant prevention
program.
Block of informational diagnostic support
Information
on HCV in
the world,
CIS, Kazakhstan and specific region
Laboratory-epidemiological control
State of HCV epidemic process by
transmission ways
and factors
Information on
social factors,
influencing
spread of HCV
(social monitoring)
Serologic diagnostics of
viral hepatitis, registration of acute, chronic and
subclinical forms
Ensuring of laboratory testing quality control
Epidemiologic analysis block
Retrospective analysis
Operational analysis
Prospective analysis
HCV epidemiological situation assessment in the region
Forecast
HCV prevention program
Picture 1 – HCV epidemiological surveillance algorithm
From organizational standpoint implementation of epidemiologic surveillance system implies participation both of treatment
and prevention, as well as specialized medical facilities. Epidemiologic surveillance is
done by comprehensive interaction of all
healthcare bodies and facilities of a given
region. Central role among organizations is
played by the Department of sanitaryepidemiological surveillance, laboratory of
the Sanitary-epidemiological expertise center with organizational-methodological support of the Research center of sanitaryepidemiologic expertise and monitoring of
the
committee
of
state
sanitaryepidemiological surveillance of the MH of
RK.
Discussion
Conducted study has shown that in initial
years of HCV registration (1998-2001) in
Almaty there were the highest morbidity indicators seen in the range of 1,7 to 2,8 per
100 thousand people. Such wide interval of
morbidity indicators is probably explained
by a range of reasons, such as: imperfect
diagnostics testing-systems of EIA on an
initial stage, their insufficiency and diagno21
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
sis «acute hepatitis C » on the basis of only
clinical-biochemistry data, as well as unsatisfactory qualification level of the lab technicians at that period. Assessing epidemiologic situation in Almaty with acute hepatitis
C it is necessary to state that by morbidity
level it is insignificant, its intensive indicator being no more than 3,0 per 100 thousand
people and it is not possible to assess the
infection development trend in the region
with it. A similar low morbidity with acute
forms of viral hepatitis is seen in many
countries of the world. So, according to the
data of the US Centers for disease control
and prevention (СDС), in the USA the level
of acute hepatitis C prevalence has decreased from 80-s till 1996 by more than
80% and was 1,8% [16]. Nechayev et al.
(2011), studying chronic hepatitis epidemic
process evolution in Saint-Petersburg have
noted that despite significant decrease of
acute hepatitis C morbidity in general the
situation with hepatitis C in the region is adverse [1]. The authors recommend to conduct HCV prevalence assessment for three
registered clinical entities: acute hepatitis,
chronic hepatitis (CHC) and anti-HCV carriage.
Considering the US experience, where
acute hepatitis C is currently not registered
[16], for assessment of epidemiologic situation with HCV in Kazakhstan we recommend to exclude «acute hepatitis C» from
reporting, and include «chronic HCV» a
general registry of all cases of HCV – infection among patients with acute and chronic
hepatitis, including laboratory confirmed
subclinical forms.
Analysis of possible transmission factors
and ways has shown that among hepatitis C
patients the predominant transmission way
is sexual (64,0%), although by the data of
E.S. Utegenova (2009) this way is almost 3
times lower and is 23,2% [8].
As follows from the survey conducted
the rate of HCV infection by using IV drugs
is 11,2%. Apparently, IV drug use, although
is a high risk factor according to the references [3,4,7,16,17], in our studies of the
given population did not have a significant
impact.
The study of etiological structure of 171
examples of serum of the patients with suppressed form of hepatitis have shown that
except for the cases of independent nosological forms of chronic hepatitis В and С there
are mixed forms of these diseases (3,9%),
including cases of chronic hepatitis D
(2,3%), as well as not-typed chronic hepatitis (4,1%). Let us emphasize that identification of mixed forms of chronic viral hepatitis is important for both clinicians and epidemiologists for improvement of epidemiological surveillance quality over viral hepatitis. Furthermore, identification of the nottyped forms of chronic liver damage suggests existence of other types of hepatitis
and stimulates search for them. With regard
to this data we thing it is reasonable to study
each hepatitis case for all specific antibodies
of acute and chronic hepatitis with the goal
of maximizing identification and registration
of all possible cases. Such methodological
approach, in our opinion, will allow quality
implementation of epidemiological surveillance over acute and chronic forms of hepatitis in the country, significantly raising the
quality, information and efficiency of prevention activities for this infection in practice.
Conclusions
1. Dynamics of acute hepatitis C morbidity of Almaty population does not reflect
objective reality, does not allow to judge
trends of infection development or epidemiological potential of HCV – infection.
2. Proposed approaches to improvement of epidemiological surveillance system
over hepatitis C virus that are epidemiological-diagnostic in nature and that consider
different surveillance levels (information
flows), ensure control over epidemiological
situation, fast implementation of epidemiological activities and targeted prevention.
22
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
logical factors that influence health of urban
territories population // XIV International
scientific conference «Family health - XXI
century»- Rimini (Italy), 28 April-5 May,
2010.-P.337-338.
11. ReznikV.L., Arystanova G.T., Nurbayev A.S. et al. Bases of statistical analysis
and its application in medicine and public
health care (educational-methodological
guideline). Алматы, 2003, - 60 p.
12. Dalmatov V.V. Current state of epidemiological surveillance issue as a specific
form of epidemiological diagnostics in the
system of epidemiological services to population // In the book: «Epidemiological surveillance.
Theory,
methods
and
organization». Saint Petersburg, 1997. – P.
127-13.
13. Davidyanz V.A., Gyirdzhan K.T.
Modern epidemiological survewillance
(study guide).- Yerevan, 2007.-153 p.
14. Saparbekov M.K. Lectures on general epidemiology. Selected lectures.- Almaty, 2012.- 78 p.
15. Belyakov V.D. Epidemiological surveillance as the basis of modern epidemiological work organization // Microbiology
journal. – 1985. - №5. – P. 53-58.
16. Margolis H. Viral Hepatitis // Public
Health Preventive Medicine/ Ed by R.B.
Walace. – Stamford, 1998. – 1291 p.
17. Nechayev V.V., Mukomolov S.L.,
Nazarov V.Yu et al. Evolution of epidemiological process of chronic hepatitis in Saint
Petersburg // Gastroenterology of Saint Petersburg – 2011. - №1. – P. 21-24.
References
1. Report on health care condition on
Europe. 2009 // WHO, 2011. -205 p. (translated form English).
2. Lobzin Yu.V. Infectious diseases.
Saint Petersburg, 2001.-543 p.
3. Anderson R., May R. Human infectious diseases. Dynamics and control. М,
2004.-784 p (translated form English).
4. Johan Gisecke. Modern encyclopedia
of infectious diseases. Stockholm, 2004.-276
p (translated form English).
5. Kudyrova B.M. Quality of life of
Hepatitis C virus patients in different treatment types //Epidemiological and infectious
diseases.- 2007.- №3.- p.36-38.
6. Viral hepatitis: etiology, epidemiology, clinical diagnostics, treatment and management of patients // CDC- USAID Edition.- 2001. – 253 p.
7. Shuratov I.H., Saparbekov M.K.
Problems of viral hepatitis and HIVinfection on the verge of the XXI century
and their solution ways //Journal. Medicine
of Kazakhstan. -2001.-№3.-P.23-30.
8. Utegenova E.S. Hepatitis C morbidity of Almaty city.- Medicine, 2009. -№1. P.47-48.
9. Shuratov I.H., Khan O.E., Omarova
M.N.et al.. Improvement of hepatitis C epidemiological surveillance technology // XIV
International scientific conference «Family
health - XXI century»- Rimini (Italy), 28
April-5 May, 2010.-P.498-499.
10. Omarova M.N., Orakbay L.Zh.,
Shuratov I.H., Saparbekov M.K. Biotechno-
UDC: 616.36-002
1
1
2
2
3
I.Kh.Shuratov , A.B.Dzhumagaliyev , A.M.Kuatbayeva , Sh.U.Zhandossov , Z.K.Kushtekova ,
4
E.V.Karpushnikova , S.T.Suleymenova
5
1
Research Center for Hygiene and Epidemiology named after Khamza Zhumatov of the Ministry of Health of the
Republic of Kazakhstan;
2
Republican state budget-supported enterprise «Scientific-Practical Center of the Sanitary Expertise and Monitoring» of the committee of the state sanitary-epidemiologic surveillance of the Ministry of Health of the RK;
3
State sanitary-epidemiological surveillance of the Zhambyl area of Almaty region, Republic of Kazakhstan;
23
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
4
Sanitary-epidemiological surveillance of Atbasar area of Akmola region, Republic of Kazakhstan
5
Sanitary-epidemiological surveillance department of the sanitary-epidemiological surveillance administration of
the Alamly area of Almaty, Republic of Kazakhstan.
EPIDEMIOLOGIC PARAMETERS OF HEPATITIS A IN CENTRAL AND SOUTHEASTERN REGIONS OF KAZAKHSTAN
Key words: hepatitis А, epidemiologic parameters, vaccination, immunizing power.
Summary. Up until 2000 viral Hepatitis А was characterized by high prevalence among Kazakhstan population. Despite notable decrease of Hepatitis A morbidity, up to present time the
share of children under 14 among all people with the disease ranges between 65-80% in different years. There is a difference in the distribution of Hepatitis A cases across the regions of Kazakhstan. Under this conditions, the characteristics of epidemiologic parameters of Hepatitis A
and vaccination efficiency are important to control the infection.
The work was done with the application of the generally accepted epidemiologic analysis
methods of morbidity and enzyme immunoassay of the serums from children for the presence of
anti-HepA IgG.
In Almaty and Akmola regions the main parameters of epidemiological process of Hepatitis A
are preserved. The differences are related to the lower share of children under 14 (50%) and
morbidity shift to older groups (11-14 years) in the age structure of people with the disease, as
well as high prevalence of students (41%) in the structure of social-professional groups of patients in Akmola region. Additionally, high immunizing power of the Hepatitis A vaccine is
shown for the children in rural areas.
It is necessary to further strengthen epidemiological surveillance and etiological control over
Hepatitis А with identification of the HepA genotypes, as well as nation-wide vaccination of
children.
Introduction
Recently a notable decrease in Hepatitis
A (HepA) morbidity is seen in a range of
countries, including Kazakhstan [1-4]. The
reason is tied both with the natural cycle of
HA epidemiological process dynamics and
decrease of birth-rate, reduction of number
of pre-school organizations and number of
children attending them, and selective immunization for HA by epidemiologic indications [5 - 7].
However, the issue of Hepatitis A remains topical for healthcare in many, including Kazakhstan. This is primarily related to
the identification of the mutant and recombinant virus strains of the HepA, their dissemination across the population and complexity of epidemic situation [8 - 12].
Under these conditions, the most radical
way to manage epidemic process of HepA is
vaccination of children against this infection, which is shown on the example of
Mangistau region, where the HepA morbidity among children has decreased more than
60 times during the period of 2001-2010 as
the result of widespread immunization. [13].
Unfortunately, high cost of the HepA
vaccine has limited wide-scale application
of the vaccine in a number of regions in Kazakhstan up to 2012. In this regard, ensuring
adequate surveillance over HepA is very
important on the basis of identifying the differences of epidemiologic parameters of the
disease in various regions.
Materials and methods
We used the official HepA morbidity data
of the departments of the state sanitaryepidemiological surveillance, published in
the bulletin of the Republic sanitaryepidemiological service during 2005-2011.
Epidemiologic analysis of the HepA morbidity was performed according to the methods described elsewhere [14].
24
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Serums of 156 children ages 3 to 13-14,
vaccinated against HepA with one and two
doses of vaccine, received in 3-5 months
after the last shot, as well as 97 nonvaccinated children were studied for the
presence of anti- HepA IgG using the Enzyme-linked immunosorbent assay (ELISA).
To perform ELISA we used testing systems
of the CJSC «Vector Best» (Novosibirsk) on
the equipment of “Anthos” (Austria).
The work was done in Almaty (South
Region) and Akmola (Central Region) Oblasts, which are different in the nature of
productive activity and climatic conditions.
HepA morbidity analysis for the last 7 years
has been performed. 156 vaccinated and 97
non-vaccinated (control group) kids, who
live in rural area, were tested for the presence of anti-HepA IgG.
Results and discussion
Dynamics of annual HepA morbidity indicators among the general population in
2005-2011 across the country and in Almaty
and Akmola regions specifically is shown in
table 1.
Table 1 - Dynamics of HepA morbidity among the general population across the country and
in Almaty and Akmola regions
Regions
Republic of Kazakhstan
Almaty region
Akmola region
Morbidity indicator (0/0000) by years
2005 2006 2007 2008 2009
53,5 52,2 69,6 40,4 31,6
32,5 25,6 44,4 43,7 35,1
16,3 13,8 25,8 9,5
7,7
As seen from the table, HepA morbidity
in Kazakhstan was fluctuating from 53,5 to
13,7 per 100 thousand people with slight
increase up to 69,7 in 2007. The rate of decrease in 2005-2011 was 3,9.
In Almaty region the incidence indicators
were fluctuating from 32,5 down to 11,8. In
2007 there was a slight increase up to 44,4
per 100 thousand people. In general, the
morbidity has decreased 2,75 times. In Akmola region the indicators were lower compared to Almaty region and the country
overall; the variations were within the limits
of 16,3 to 6,3. The decrease rate was 2,6.
There was a slight increase in 2007 (25,8).
In general, it should be noted that the HepA
Decrease rate
2010
27,4
26,7
11,0
2011
13,7
11,8
6,3
3,9 times
2,75 times
2,6 times
morbidity indicators among the population
of Almaty region are similar to those of the
country. The annual HepA morbidity indicators in Akmola region were 2-4 times lower
than in Almaty region and the country, but
the decrease rate is the slowest at 2,6. Perhaps, these differences depend on the age
structure of the registered patients.
The HepA morbidity dynamics among
children, the data for which is presented in
Table 2, in the studied regions follows the
HepA dynamics among the general population. In Akmola region morbidity among
children was also lower than in other regions. The decrease rate was the lowest as
well (3,2).
Table 2 – Dynamics of HepA morbidity among children population of the RK and studied
regions
Regions
Republic of Kazakhstan
Almaty region
Akmola region
Morbidity indicator (0/0000)
2005
2006
2007
175,0
180,2
239,9
83,3
68,2
68,1
47,7
34,7
56,9
The share of children among the HepA
patients was predominating. So, in the RK
the share of children under 14 (table 3) is
fluctuating from 65,9% to 86,2% (80,8% on
average), in Almaty region - 76,8% (fluctua-
2008
133,5
141,2
19,3
2009
102,2
37,5
14,4
2010
84,0
80,9
22,8
2011
36,9
22,0
14,9
Decrease
rate
4,7 times
3,8 times
3,2 times
tions from 63,3% to 88,5%). In Akmola region the share of children with HepA in
2005 was 70,3%, during the next years
2006-2011 it was fluctuating from 40,3% to
55,3%. The average annual value was
25
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
50,6%. In other words the other half of patients (50%) in Akmola region was com-
prised of adults, whereas in Almaty region
their share was 23,2%.
Table 3 – Share of children under 14 with HepA
Regions
Republic of Kazakhstan
Almaty region
Akmola region
Share of children with HepA (in%).
2005 2006 2007 2008 2009
86,2 85,1 82,2 87,1 85,1
88,5 87,5 74,1 78,4 73,8
70,3 55,3 48,2 43,6 40,3
Obviously? The abovementioned low
morbidity level and low rate of decrease in
HepA morbidity in Akmola region is related
to the higher prevalence of adult population
among patients who were unlikely to be
2010
74,5
72,4
44,4
2011
65,9
63,3
52,2
Average annual
value
80,8
76,8
50,6
vaccinated because of the epidemiologic indications.
Average HepA incidents indicators for
2005-2011 by age risk groups are shown in
Table 4.
Table 4 – HepA incidence by age group (average values for 2005-2011)
Age groups
Average HepA incidence by regions for 2005-2011
Kazakhstan
Almaty region Akmola region
3-6 years
150,0
95,6
24,7
7-10 years
122,8
102,3
38,7
11-14 years
72,8
86,3
36,3
15-29 years
27,2
32,ё
16,4
By
the
social-professional
status, school
As seen in the country, HepA prevalence
children dominate among the HepA patients
was the highest in the age group of 3-6 years
in Almaty region (64,2 per 100 thousand),
(150,0). In Almaty region in the group of
followed by organized (29,5) and nonchildren of 7-10 years old the morbidity inorganized children (22,6). In Akmola region
dicator was 102,3; in the group of 3-6 years
significant morbidity is seen among the stuit was slightly lower (95,6). In Akmola redents (41,1), school children (17,0) and nongion with rather low indicator in the group
organized children (8,0).
of children of 3-6 years (24,7), as well as in
As it can be seen the studied regions difother older groups of 7-10 and 11-14, the
fer
in social-professional structure of the
indicators were almost the same (38,7 and
HepA patients. For instance, in Akmola re36,3 respectively).
gion the HepA is more common in adult
Therefore, there is a notable shift in morpopulation.
bidity seen to the elder groups of children
Analysis of HepA transmission factors
and adolescents. Average annual HepA
has
shown that in Almaty region the share of
morbidity indicators of the population of the
identified factors is on average 61,5, includstudied area are shown in the picture.
ing swimming– 1,1%, water factor – 5,5%,
As seen in picture 1, compared the counfood factor - 0,0 and household contact –
try with a long-standing average HepA mor54,9% ; in 38,5% of the cases the transmisbidity indicator of 136,4, in Almaty region it
sion factor has not been identified. In Akmowas 71,6 (almost 50%), in Akmola region it
la region the share of identified factors was
was even lower (30,1). In the areas of Al73,9%, including water factor – 28,3%,
maty region, namely in Karatak area, this
household contact– 45,6%; in 26,1% of the
indicator was 26,5; on the territory of
cases the factor has not been identified.
Zhambyl area is was 29,5. In the areas of
The similarities of both regions lie in the
Akmola region these indicators were lower.
dominant
role of contact-household transThus, in Atbasar area - 8,9; in Burabai area mission route, as well as participation of the
8,6.
26
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
water factor in this process. Earlier we
HepA have shown that water factor acts like
a trigger, spreading HepA further by means
of close contact in households, among colleagues and in teams (at home, at preschool, school and others) [15].
Results of the analysis of the share of
children susceptible to HepA and the influence of children vaccination are presented in
table 5.
As seen from the data in table 5, among
97 non-vaccinated children 42 (43,3%) were
not susceptible to HepA. They had antibodies to HepA in blood, apparently as a result
of earlier HepA infection. Other 55 (56,7%)
children were susceptible to HepA, and
among them the HepA morbidity was
spread, which is seen in the regions. After
vaccination with 2 doses of vaccine 97,4%
of the vaccinated people became unsusceptible to HepA, creating specific IgG – antibodies against HepA.
Table 5 – Decrease of HepA susceptibility by means of children vaccination
Serums studied
Groups of children
HepA resistant
HepA susceptible
(presence of anti(absence of antiHepA IgG)
HepA IgG)
abs (M±m %)
abs (M±m %)
Serums from nonvaccinated (n=97)
Serums from vaccinated
(n=156)
Children age 3-11
(n=97)
Children age 3-11
(n=156)
The refore, vaccination immediately increases the resistance of children to HepA,
due to its high immunizing power.
However, vaccination of children in the
regions is funded from local budget with
tactically different selective methods: either
42
43,3±5,03
152 97,4±1,24
55
56,7±5,03
4
2,6±1,24
only children of 2-3 years, or children from
3 to 6 years of age, as the most vulnerable,
or as pre-seasonal vaccination of the risk
groups or children, who were in contact with
HepA patients in their teams. Such HepA
fight tactics, conducted in the regions since
27
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
2003, did not lead to drastic changes of its
epidemiologic parameters and HepA epidemic process dynamics.
The preserved epidemiologic parameters
of HepA in the regions are a sign of active
HepA spread.
In the midst of the growth of birth rate i
seen in Kazakhstan, Russian Federation and
other neighboring countries, the children are
being the main group, among who HepA
spreads in the first place. A strong correlation coefficient was identified (r=0,7) between HepA morbidity and number of children in a range of regions in the Russian
Federation [16]. Relatively high HepA morbidity is seen in Kyzylorda, SouthKazakhstan, Zhambyl and Almaty regions,
where relatively high birth rate is recorded.
The abovementioned conditions are a favorable setting for unfettered spread of
HepA strains, including mutant and recombinant strains, which are increasingly circulating among the population of different regions and countries [17 - 22].
Understanding the serious nature of the
problem, one of the leading hepatologists, P.
Van Damme, [1] has mentioned, that in the
last years we have witnessed «a new fight
with an old disease », and the fight against
HepA, mostly affecting children, requires all
efforts.
In such conditions the situation can only
be saved by large scale vaccination of the
child population against HepA, because the
antigenic structure of all virus strains is constant.
References
1. Andre F., Van Damme P., Safary A.
et al. Inactivated hepatitis A vaccine: immunogenicity, safety and review of official recommendations for use. //Expert Rev. Vaccines.-2002.-V.1.-P.9-23.
2. Shlyakhtenko L.I. Epidemiologic peculiarities and vital measures of hepatitis A
prevention
in
the
modern
period
//Newsletter. World of viral hepatitis.-М.2002. № 11.-P. 4-6.
3. Shuratov I. Kh. Saparbekov M.K.
Modern issues of viral hepatitis and AIDS
on the verge of XXI century, their solutions.
//Medicine of Kazakhstan.- 2003.- №3.P.25-28.
4. A. B. Dzhumagaliyeva, Ospanova
E.N. Dependency of the hepatitis A morbidity on the level of collective immunity
//Hygiene, epidem. And immunobiol.,
2005.-№3.-P.78-82.
5. Onishenko G.G. About the infectious
hepatitis prevention measures in the Russian
Federation. //Epidemic and infectious diseases. 2002.-№3.-P.4 - 8.
6. Viral hepatitis in the Russian Federation. Epidemiologic peculiarities of the hepatitis A and its sanitary-epidemiological surveillance system in the RF in 2002-2003.
//Analytical review.-St. Petersburg.-2005.issue 5.- P.19-39.
7. Modern epidemiological characteristics of hepatitis А. Enteral viral hepatitis (M.
I. Mikhalkov etc.) –М.-2007.-P.77-126.
8. Costa-Mattioli M., Ferree V., Casane
D. et al. Evidence of recombination in natural populations of hepatitis A virus.
//Virology.-2003.-V. 311. –P. 51-59.
9. Costa-Mattioli M., Di Napoli A.,
Ferree V. et al. Genetic variability of hepatitis A virus. //J. Gen.Virol.-2003.-V. 84. –P.
3191-3201.
10. Stene-Johanson K., Jonassen T.O.,
Skaug K. Characterization and genetic variability of hepatitis A virus genotype IIIA.
//J. Gen.Virol.-2005.-V. 86. –P. 2739-2745.
11. De paula V.S., Saback F.L., Gaspar
A.M., Niel C. Mixed infection of a child
care provider with hepatitis A virus isolated
from subgenotypes 1A and 1B revald by
heteroduplex mobility assay. //J viral. . //J.
Gen.Virol.-2003.-V. 84. –P. 3191-3201.
12. .Tjon G., Xiridou M., Coutindo R.,
Bruisten S. Different transmission patterns
of hepatitis A virus for main risk groups as
evidenced by molecular cluster analysis. //J.
Med.Virol.-2007.-V.79.-P.488-494.
13. I.Kh. Shuratov, M.N. Omarova,
A.M. Kuatbayeva, E.U. Beybossynov, A.B.
Dzumagaliyeva, Akkoshkarova A.O., Salimbayeva A., Sultanbayeva S.N. Analysiss
28
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
of epidemiologic situation with hepatitis A
in Kazakhstan for 2005 –2009 and improvement measures. // Hygiene, epidemiology and immune biology.. 2010 № 4, C 5356.
14. Omarova M.N., Umbetpayev A.T.,
Laikov R.T., Shuratov I. Kh. et al. Retrospective epidemiological analysis of infectious morbidity (methodological guidelines).
–Astana.-.2004..-.53 p.
15. Shuratov I.Kh., Surdina T.Yu., Victor J.C., Favorov M.O. Study of the vulnerability to viral hepatitis A of the contact persons. //Hygiene, epidemiology and immune
biology. 2002 № 3-4, P. 85-92.
16. Mindlina L.Ya. Ways to optimize epidemiologic surveillance for anthroponosis
fecal-oral
transmission
mechanism.//Epidemiologic and infections newsletters.-2012. -№4.-P.16-20
17. Tallo T., Norder H., Teyanova V. et
al. Sequential changes in hepatitis A virus
genotype distribution in Estonia during 1994
to 2001. //J. Med. Virol.-2003.-V.70.-P.
187-193.
18. Stene-Johanson K., Jenum P.A.,
Hoel T. et al. An outbreak of hepatitis A
among homosexuals linked to a family outbreak. //Epidemiol Infect.-2002.-V.120.P.113-117.
19. Mukomolov S.L., Iriya Davidkin,
Zheleznova N.V. et al. Molecular epidemiology of hepatitis A in Saint-Petersburg in
1997-2006. //World of viral hepatitis. –М.2007.-№4.-P.10.
20. Nainan O.V., Armstrong G,L., Hanx
H. et al. Hepatitis A molecular epidemiology
in the United States, 1996-1997: sources of
infection and implications of vaccination
policy. //J. Infect. dis. -2005.-V.191.-P.957963.
21. Cuvalon V.P., Podkolzin A.T.,
Nedachin A.E. et al. Molecular epidemiology of hepatitis A virus in Russian Federation
Infection. //Genetics and Evolution.-2003.V.2.-P.211.
22. Ternovoy B.A., Chaussov S.B.,
Bondarenko T. Yu. Et al. Genetic diversity
of hepatitis А in Siberia. //Issues of virology.-2003.-№1.-P. 23-27.
UDC: 616-002.26-06:616.155.194.8
A.Balibayevа
Karmakshy TB dispensary, Kyzylorda region, RK
ANALYSIS OF LONGSTANDING DYNAMICS OF TUBERCULOSIS MORBIDITY IN
KARMAKSHY AREA OF THE KYZYLORDA REGION OF KAZAKHSTAN
Key words: morbidity, tuberculosis, Kazakhstan, Kyzylorda region.
Summary. As a result of implementing a complex of TB prevention activities in the country
since 2000 there was seen a stable trend in the decrease of morbidity, which by the end of 2012
was lower than target numbers, identified by the state health care development program «Salamatty Kazakhstan» for 2010-2015. However despite certain successes in the country, the
morbidity rate is still high, especially among the adolescents. In 2012 in the area there was a
growth in incidence rate among the adolescents from 117,5 to 238,7 per 100 thousand (49,2 %).
Materials for the analysis were data, that was gathered by the automated information system
of the national register of the TB patients in the Karmakshy area of the Kyzylorda region of Kazakhstan. Material analysis was done by calculating intensive, extensive factors, statistical series indicators, and confidence intervals. For the assessment of the longstanding trend of
morbidity, the method of the least squares, the growth (decrease) rate was also calculated.
29
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
During the period of 2000-2012, the total TB morbidity indicator of the Karmakshy area
decreased by 5,3 times and was equal to 70,3 per 100 thousand of population. For the
investigated period of time, the share of children and adolescents among the TB patients was
high - 9,5% and 8,6 % accordingly. In order to study epidemic process presentation in different
population groups and risk factors, the ranking of the average morbidity level and ratio of patients was established. Analysis done for the average longstanding data has shown that the most
significant risk for morbidity was seen in the adolescents group (251,6%+-24,4).
By assessing the ranking of the prognostic intensive and extensive indicators of the TB
morbidity among the population of the Karmakshy area it was established that without the
change in trend the most epidemiologically significant groups will be adolescents of 15-17 years.
Among the adult population despite high ration (1 rank) of the prognostic value, in the
longstanding dynamics there is a clear decrease trend.
Introduction
One of the priority key directions of
Kazakhstan’s social policy is battle with
tuberculosis. This is underlined in the
Statement of the President of the Republic
of Kazakhstan to the nation of Kazakhstan.
As a result of successful implementation of
TB prevention activities, since 2000 there
was seen a stable trend of decrease in tuberculosis morbidity in the country, which at
the end of 2012 was lower than target indicators of the state healthcare development
program «Salamatty Kazakhstan». However,
despite certain successes in the country, the
morbidity rate is still high, especially among
the adolescents. TB morbidity indicator in
Kyzylorda region is 97,9 per 100 thousand
of population (2011) [1]. There is a growth
of TB morbidity among adolescents. The
number of adolescents in the area is 7 times
smaller than the total number children
population; at the same time the morbidity
of this population group exceeds the children morbidity by 5 times. So in 2012 there
was a growth of TB morbidity among adolescents from 117,5 to 238,7 per 100 thousand (49,2 %) [2].
Due to the current situation, the goal was
set to study the longstanding dynamics of
morbidity to identify the most vulnerable
group of population.
national TB patients register of the
Karmakshy area of Kyzylorda region from
2000 to 2012. We have studied annual reports data № 8,33 on new incidents of TB,
registered in the area. We have performed
calculations of intensive, extensive indicators, mean values, statistical series
indicators, and confidence intervals. In order
to assess the longstanding dynamics trends
we used the least squares method. The
growth (decrease) rate was calculated using
the formula:
T growth= B ⋅ K / Icp⋅100%
In order to exclude the «pop-up» values
of the morbidity indicator we calculated significantly different indicators using Chauvenet criteria. In the analyzed range no significantly different, «pop-up», values were
identified.
Results
In dynamics, the indicator of initial TB
morbidity of the population of the area decreased from 376 ± 28,5 cases per 100
thousand people in 2000 to 70,3 ± 11,6 in
2012, the difference was statistically significant (р<0,05). When adjusted the total TB
morbidity indicators with the least squares
method, there was a moderate trend towards
the decrease and annul decrease rate was = 11,9 ( Picture 1).
Materials and methods
Data was collected on the basis of
automated information system of the
30
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Picture 1 – TB morbidity trend of the Karmakshy area of Kyzylorda region from 2000 to 2012
Regarding the trend in dynamics of total
TB morbidity during the period of 2000 to
2012 there were high (2001, 2003-2005,
2008) and low morbidity levels (2000, 2002,
2006-2007, 2009-2012). When leveling the
dynamic curve with weighted moving line
there were periods of 4 years with increases
in TB morbidity long and periods of 3 years
with low morbidity.
By applying the method of prognostic
extrapolation we have calculated theoretical
morbidity. During the calculation we found
that theoretical morbidity exceeded the
registered values and was within the limits
of 191-148 per 100 thousand people since
2006. Actual TB morbidity level for 2012
was 1,1 times lower than theoretical; in 2011
– it was 1,3 times lower. Therefore, decrease
in morbidity in 2013 was a continuation of
the total decrease in morbidity.
Average children morbidity level for the
mentioned period of time was 56,5 ± 10,7
per 100 thousand population and in dynamics a decrease was seen from 110,2 to 20,0
per 100 thousand children. Adjusting the
statistical series with the method of the least
squares allowed to identify a moderate trend
of morbidity decrease, with the average
decrease rate of 12,1% (Picture 2). Difference between the indicators was statistically
significant (р<0,05).
Picture 2 – TB morbidity trend in children of Karmakshy area of Kyzylorda region in
Kazakhstan for the period 2000 - 2012
Regarding the trend line in the
longstanding dynamics of TB morbidity
among children under 14 high level was registered in 2000-2001, 2005, 2009, 201131
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
2012; low morbidity level was registered in
2002-2004, 2006-2008, 2010. There was no
cycle identified.
In the dynamics the indicator of initial
TB morbidity among adolescents had a
decreasing trend from 279,6 ± 93,1 in 2001
to 238,7 ±90,1 in 2012. Long-time average
annual indicator of initial TB morbidity was
254,2 +-24,5 per 100 thousand people
(р<0,05).
When adjusting the indicators of absolute
TB morbidity in adolescents, a trend to a
moderate decrease was seen, with the
average decrease rate of 4,8% (Picture 3).
Regarding the trend line in the
longstanding dynamics of intensive TB
morbidity among adolescents, an alternation
of the high morbidity years in
2001,2005,2007,2010 and 2012 and low
morbidity years in 2000, 2002- 2003, 2006,
2008-2009, 2011 was observed.
In order to study the manifestation of epidemic process in different population groups
as well as possible risk factors, a ranking of
the average morbidity level and share of diseased people was conducted. Analysis of the
table material (table 1), conducted with the
long-time average annual data shows that
the highest morbidity risk was seen in the
adolescents group (251,6%+-24,4).
Table 1 – Long-time average annual intensive indicator and share of TB morbidity in
different population groups in 2000-2012
Group
Children
Adolescents
Adults
Long-time average annual TB morbidity indicators
I ‰rank
Average intensive indicator
Р%
I -+м
Р%+-м
59,7+-5,5
3
9,5+-0,8
251,6+-24,4
1
8,6-+0,8
257,8-+8,1
2
81,9+-1,1
rank
2
3
1
Picture 3 – TB morbidity trends among adolescents
Considering the morbidity share volumes,
the most epidemiologically significant
groups were children under 14, as well as
adolescents of 15-17 years.
32
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
The long-time morbidity dynamics in
different population groups is characterized
with explicit and versatile trends. Analysis
of level and structure for prognostic values
is done.
Table 2 – Prognostic intensive indicator and share of people with TB by population groups in
2013
Group
Children ages 0-14
Adolescents ages 15-17
Adults
TB morbidity forecast for 2013.
I‰
rank
30,6+-3,9
3
186,9+-21,0
1
162,2+-6,4
2
Having assessed the ranked prognostic
intensive and extensive TB morbidity
indicators for the population of Karmakshy
area, it was established that if the trend does
not change, then the most epidemiologically
significant group will be adolescents ages
15-17 лет. For the adult population, despite
high share of the prognostic value (1 rank),
an explicit decrease trend was seen in the
long-time dynamics.
Conclusion
Thus, for the period of 2000-2012, the total TB morbidity indicator for the population
of Karmakshy area has decreased 5,3 times
and was equal to 70,3 per 100 thousands of
population. During the time of this study,
the share of children and adolescents in the
Р%
8,3+-1,3
10+-3,9
81,7+-5,1
rank
3
2
1
total number of TB patients was high, 9,5
and 8,6 % accordingly. In dynamics, this
indicator of TB morbidity among adolescents will remain on a high level: the longtime average annual indicator for this period
being from 229,7 to 278,7 per 100 thousand
people. Adolescents will be of the most
significance for TB epidemiologic process
in Karmakshy area in 2013.
References
1. TB statistical review for Kazakhstan /
Almaty -2009-P.5-6
2.
Bekembayeva
G.S.
Modern
epidemiologic situation in TB among
children and adolescents in Kazakhstan //
Medicine-2012- №8- P .43-44
UDC: 616-002.5
F.A.Iskakova
School of Public Health of the Ministry of Health of the Republic of Kazakhstan, Almaty
FIBROUS-CAVERNOUS TUBERCULOSIS AS AN INDICATOR OF THE
ANTITUBERCULOSIS PROGRAM EFFICIENCY ASSESSMENT IN KAZAKHSTAN
Key words: Fibrous-cavernous tuberculosis, indicator, DOTS strategy, correlation, mortality,
morbidity, prevalence.
Summary. Global TB burden still exists despite the decrease in mortality (41% (2011-1990),
morbidity and prevalence due to implementation of new anti-TB programs (DOTS strategy, Stop
TB, treatment of multi-drug-resistant tuberculosis (MDR-TB)), justifying the control of TB by the
World Health Organization. Kazakhstan is a country that has implemented new programs and
reached a decrease in main epidemiological TB indicators. The aim of the work was to assess TB
programs with application of well-known and new indicators.
Materials were statistical data on absolute numbers and TB patients’ indicators, patients with
fibrous-cavernous tuberculosis on the country level during 1973-2012. Descriptive and analytical methods were used.
33
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Analysis of epidemiological indicators for the period of 1973-2012 on TB in Kazakhstan defined the trends in the decrease of prevalence by 4,3 (r=0,45), mortality by 3,1 (r=0,01) and
morbidity by 1,4 (r=0,15). Analysis of the dynamics with consideration of biological and social
factors identified changes in five time periods respectively: soviet (1973-1985), anti-alcohol
campaign (1986-1991), social and economic crisis (1992-1998), DOTS strategy implementation
(1999-2004) and stabilization period (2005-2012). Patient levels with fibrous-cavernous TB
(FCTB) were identified among new cases and patients of TB treatment facilities, which served as
indicators for assessment of anti-TB programs. The level of newly identified FCTB reflects not
timely patient identification and FCTB as health outcome reflects treatment inefficiency.
Decrease in the main epidemiological TB indicators and stable decrease of initially identified
FCTB (lower than 1%) and decrease of FCTB share among the target groups by 2,7 during
1973-2012 reflects success and efficiency of new anti-TB programs in the condition of the TB
epidemics.
In the last years there is a significant proIntroduction
gress in the fight against TB in the world:
Global burden of TB is still significant
TB mortality has decreased (by 41% during
due to high morbidity and mortality in the
2011-1990) as well as morbidity (8.7 mln.)
world despite the fact that the disease has
(16). There are some achievements on the
been well researched in the last 300 years.
part of the domestic TB fighting service:
TB morbidity and mortality growth in Eurodecrease of TB morbidity, prevalence and
pean countries in XYIII – XIX centuries
mortality.
were the reasons for developing anti-TB
At the same time activity of the anti-TB
programs and improvement of the global TB
service in conditions of the new programs
situation by the mid-XX century, which lead
has raised discussions in the medical comto the creation of a concept of TB as a dismunity and mass media (10,11). More inappearing disease (1,5). Increase in the
depth research is necessary to assess the efnumber of patients and deaths from TB by
ficiency of the existing programs on the bathe end of XXth century lead to WHO prosis of evidence methods and distribution of
nouncing TB a world threat and recommenthe results to ensure their utilization and
dation of «DOTS strategy», new program of
benefits for the medical community. EpideTB control in 1993 and program «Stop TB»
miological situation with TB and efficiency
since 2004 (2,3,4). Significance of the disof anti-TB programs is characterized by inease grew even more due to the pandemic of
dicators, which mainly are intensive indicaHIV-infection, because co-morbidity of TB
tors of morbidity, prevalence and mortality,
and HIV is fatal for ¼ of HIV-infected peoas well as treatment efficiency. At the same
ple. In Kazakhstan there were same trends
time, the informational capacity of the epiidentified in epidemiological situation with
demiologic indicators is influenced by many
TB, delayed by two centuries, which were
factors, which are not always taken into acaccompanied by implementation of anti-TB
count by the traditional analysis methods.
programs according to the current TB
That is why the aim of our study was to
fighting concepts (7). The time period since
evaluate anti-TB program efficiency in Ka1998 is characterized by the implementation
zakhstan with application of new indicators
of the DOTS strategy, efficient program in
on the basis of modern statistical methods.
the conditions of TB epidemics and insuffiThere were objectives of the study identicient funding. Since 2002 anti-TB program
fied: analysis of the epidemiological situawas adopted to country conditions, in 2003 a
tion with TB by level of morbidity indicaprogram was implemented for treating pators, mortality indicators, disease prevatients with MDR-TB, and since 2007 it was
lence; correlation analysis of extensive indistrengthened by the elements of «Stop TB»
cators – share of patients with fibrousprogram (7,8,9).
cavernous TB among initially identified
34
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
lung TB cases and among patients of TB
clinics and its ratio indicator from 1973 to
2012. The observation period was divided
into different sub-periods based on the presence of bio-social network risk factors.
Materials included statistical data on absolute numbers and indicators of TB patients, FCTB patients on the country level
during 1973-2012. Descriptive and analytical methods were used.
The first observation period (1973 -
1985), also known as «soviet period», is related to the period of Kazakhstan being a
part of USSR; it is characterized by stable
economic structure, efficient healthcare and
anti-TB system, which was regulated by
Prikaz №747 from 7 September 1972 «On
measures to enhance the fight against TB of
the Ministry of Health of USSR», Prikaz №
361 from 23 April 1974 «On approval of
new TB classification», pictures 1 and 2.
Picture 1- Morbidity, prevalence and mortality indicators in the RK, 1973 -2012.
In this period there was a stable decrease
of morbidity for the whole period by 39.8%
(range of 71,1-118 per 100 thousand of
population), mortality by 2 (range of 2.9 12,8 per 100 thousand of population) and
prevalence by 1,9 (range of 321,7 – 618 per
100 thousand of population). Analysis of
ratio of patients with FCTB identified its
decrease by 2,9 among initially identified
patients with lung TB (range 4-1,4%) and
among the target groups by 20,2% (range
23.8-18,5%); its ratio has been 9,0 (picture
2).
35
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Picture 2 – Proportion of patients with fibroid-cavernous TB among initially identified TB forms
and target groups in Kazakhstan, 1973-2012
Table 1- Correlation analysis by Pearson’s test on the level of patients with FCTB among initially identified patients and target groups in the RK, 1973-2012
№
1
2
3
4
5
Years
1973-1985
1986-1991
1992-1998
1999-2004
2005-2012
Periods
RK, r
Soviet
Anti-alcohol campaign
Social and economic crisis
Implementation of DOTS strategy
Stabilization
The second observation period (19861991) was characterized by the implementation of anti-alcohol campaign. On 7 and 16
May 1985 there were legislative acts published of the Central committee of the communist party of the Soviet union and Cabinet
of the USSR on enhancing efforts against
alcoholism and home-brewing, which was
caused by the increase in mortality from alcohol and shorter life expectancy compared
to other countries (10). During the period of
alcohol ban there was the most favorable
situation according to the indicators: morbidity was on average 70,4 (- 9,4%, range
64,4 – 73,9 per 100 thousand people), prevalence (-9,0%, range 308,2- 292,6 per 100
thousand people) and mortality (-17,2%,
range 12.8 – 9,9 per 100 thousand people).
There was a stable level of FCTB recorded
0.91
0.20
-0.78
0.76
0.66
among patients with initially identified lung
TB (1,3-1,5%) and slight decrease of FCTB
among target groups from 17,7% to 16,7%;
their ratio was 13.3.
Correlation analysis by Pearson pointed out weak relations
between extensive indicators in Kazakhstan
(r=0.20).
The third observation period (1992 1998 гг.) is related to the transition policy,
which should have improved economic state
and liberalize political life of the country.
This lead to the collapse of the USSR into
independent republics. Within independent
countries there were social and economic
changes happening, which were accompanied by decrease of healthcare system funding, including anti-TB service. This period
in the RK was signified by the increase of
mortality by 3,3 times (indicator range 11,7
36
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
– 38,4 per 100 thousand people); increase of
morbidity by 1,8 times (range 59.7 – 118,8
per 100 thousand people) and prevalence by
34.4%, (range 268 - 379.6 per 100 thousand
people). There was an increase recorded in
the share of FCTB among new cases by 1,7
(range 1,5-2,5%), decrease of its share
among target groups by 21,6% (range 13,1%
-16,3%), at the same time the value of the
indicator has decreased to 7,4 (4,7 - 11),
which was an adverse prognostic sign, reflecting the worsening of situation on TB.
Increase of epidemiological indicators was
seen along with destabilization of anti-TB
service: weak funding, lack of TB drugs,
decrease of disease identification cases and
uncontrolled growth of TB mortality.
There was a negative correlation identified between extensive indicators of FCTB
share in the morbidity structure and target
groups in Kazakhstan (r= -0.78).
Growth of lethal outcomes of TB in the
country is related to the growth of individuals with initially identified forms and individuals with active TB forms. Sharp worsening of situation with TB in the RK is a consequence of DOTS strategy implementation
recommended by the WHO to the countries
with difficult TB situation in October 1998.
The fourth observation period (1999 –
2004) is related to the activities of anti-TB
service on implementation of DOTS strategy. The period is characterized by sharp decrease of mortality indicators by 1,9 times
(range 20,6 - 38,8 per 100 thousand people)
and prevalence by 18,4% (range 323 - 449.5
per 100 thousand people) with further increase of the morbidity indicators by 29,9%
(range 141 - 165,1 per 100 thousand people)
in Kazakhstan. Morbidity increase is related
to significant increase of new TB cases identification by the mucus swab microscopy
and by other methods (mostly x-ray method), which is proven by the share of new
cases with positive swab in 1/3 and with 2/3
with negative mucus swab. In 2002 – 2003
there were the highest morbidity levels recorded (165,1 – 160,4 per 100 thousand people). There was a decrease seen in the share
of FCTB among new cases by 4,6 times
(2,3% - 0,5%) and among target groups by
34,8% (15.8%-10,3%), at the same time the
indicator for their share was 14,9 (range 5,227,8).
There was a strong positive correlation
seen between the shares of FCTB among
new cases and target groups in Kazakhstan
(r= 0.76).
The fifth observation period (2005-2009)
is characterized by further decrease of epidemiological indicators of TB in Kazakhstan: prevalence by 2,5 (range 180 - 449.5
per 100 thousand people), mortality by 1,6
(range 12,9 – 20,8 per 100 thousand people),
morbidity by 1,5 (range 105,3 – 154,3 by
100 thousand people). The present observation period is compatible in the intensity of
epidemic process with the Soviet period. By
the morbidity level the country has come
close to epidemic threshold (105,3 per 100
thousand people in 2009).
There was a negative correlation identified between the share of FCTB among new
cases and target groups in Kazakhstan (r= 0,33). The data of correlation analysis show
dissociation between extensive indicators,
this is possibly related to changes of the registration and management conditions among
target groups; and, which is no less important with the accuracy of data collection.
Analysis of TB situation with traditional
assessment of the intensive and extensive
indicators level, indicator of ratio of patients’ shares with FCTB in the morbidity
and prevalence structure, and presence of
interrelation during correlation analysis by
Pearson depending on the biosocial environment factors has identified certain trends
of epidemic processes, anti-TB programs
and activities of the healthcare system efficiency.
In the Soviet period there was a decrease recorded in intensive indicators, share
of FCTB in the morbidity structure and
prevalence, and presence of positive correlation between the indicators in the country
and regions reflects high efficiency of antiTB program, the aims of which were prevention, identification and treatment of TB
patients in conditions of stable social and
37
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
economic environment and healthcare system.
The anti-alcohol campaign period is
characterized by insignificant decrease in
intensive indicators and relatively stable
share of FCTB in the morbidity and prevalence structure. At the same time there was
no interrelation identified between FCTB
shares among new cases and patient target
groups in the country, which shows effects
of other factors on the TB epidemiology,
namely increase of general health level, related to sharp decrease of alcohol consumption on the the country level.
In the period of social and economic crisis and transition with decline of social and
economic conditions and health care system
collapse, including anti-TB service, there
was a development of TB epidemics seen in
the country with dramatic increase of intensive indicators. During this time there was
an increase recorded of the share of patients
with FCTB among new cases, which reflects
decrease of TB patients’ diagnostics; and
decrease of its share among target groups
shows low efficiency of its treatment associated with lethal outcomes.
DOTS strategy implementation period
is characterized by significant decrease of
mortality in the RK by 1,9, insignificant decrease of prevalence (14,8%) with increase
of morbidity in Kazakhstan (29,9%). Such
situation was justified with the DOTS program objectives – identification of new TB
cases aimed at identification of TB mycobacteria (70%) and its treatment (85%). At
the same time decrease of mortality of TB
associated with efficient treatment does not
correlate with the growth of new TB cases,
justified by increase of recorded morbidity.
In this period there was no correlation identified between the shares of FCTB in the
morbidity and prevalence structure in Kazakhstan.
The period from 2005 to 2012 is characterized by the most favorable situation with
TB, the country passed an epidemic threshold by morbidity level (81,7 per 100 thousand people). There was a decrease recorded
in all indicators of TB, especially prevalence
and morbidity in Kazakhstan by 2,8 and 3,1.
In this period there was a positive correlation identified between the shares of FCTB
among new cases and TB clinics target
groups during correlation analysis, which
demonstrates efficiency of anti-TB programs
for the issues of timely identification and TB
cases treatment efficiency in general. The
efficiency of treatment of new cases with
positive swabs increased in Kazakhstan in
the last 15 years of DOTS strategy, STOP
TB program implementation, and reached
83,1% in the country in 2012. On the territory of 62,5% of the country (Almaty city,
Almaty, Zhambyl, North Kazakhstan, West
Kazakhstan, Pavlodar, Almaty, Atyrau,
Mangystau, Kyzylorda regions) there has
already been a target indicator achieved for
the treatment of new TB cases in 2012. Correlation analysis of the share of patients with
FCTB among the target groups and indicators treatment efficiency of the new cases
with positive swab has identified a strong
correlation between them (r=0,79).
A significant contribution to the efficiency of anti-TB program, which is identified
by TB cases treatment efficiency indicators,
intensive and extensive morbidity, mortality
and prevalence indicators, by the level of
patients with FCTB among target groups, is
made by the treatment program of patients
with MDR-TB. Treatment efficiency of patients with MDR-TB has reached 75,8%.
Discussion
The epidemiologic situation with TB depends on many biosocial environment factors, which have negative or positive influence on TB epidemiology. The last observational period is assessed by us as a stabilization period according to the level of intensive indicators and share of FCTB in the
morbidity and prevalence structure. Correlation analysis of FCTB shares among new
cases and target groups of TB clinics on the
national level demonstrates efficiency of
anti-TB program by its main tasks: timely
identification and treatment efficiency. Indicator of FCTB shares can serve as a criteria
for not only the control of program efficien38
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
cy, but also the reliability of extensive indicators – frequency of FCTB.
The value of ratio of patients with FCTB
in the structure of initially identified TB
lower than 3% in the Russian Federation is
evaluated as positive prognostic sign for efficiency of TB activities for identification of
new disease cases.
In Kazakhstan with morbidity indicator
value of around 100 per 100 thousand people until present time, the share of patients
with FCTB is lower than 1% (0,4%) for the
last 10 years, in the conditions of new TB
program implementation, which is a consequence of new cases identification due to
large scale of preventive medical examinations of population, integration of TB clinics
with PMC and raising awareness about TB
among population. Great work is done to
improve identification of new TB cases
among population, results of patients treatment, education of the PMC staff, preventive medical work among population and in
target groups, work is conducted with governmental and non-governmental organizations. Established increase in share of patients with FCTB among target groups of
TB clinics in the last period during 20062008 indirectly reflects the low performance
of TB patients’ treatment, related to growth
in cases with multiple resistance. Implementation of treatment programs for patients
with MDR-TB in the country in general contributed to decrease of its share by 1,5 in the
last years (2007-2012). Along with identifying the share of FCTB among new cases and
target groups, the correlation method reflects
severity of the disease, success level of tasks
of identification and treatment of TB patients. The data on the lowest ratio (6,3; 5,1;
4,7; 4,9; 5,2; 6,9 and 6,7, 1994-2000) reflects the worst situation with TB in Kazakhstan. And vice versa, increase of the
ratio reflects improvement of the situation,
as the data show – 11,1 in 2001, 20,6 in
2004, 29,8 in 2008 and 86 in 2012.
Conclusion
In general the situation with TB in Kazakhstan should be assessed as stabilizing by
significant decrease of intensive indicators
of morbidity, prevalence and mortality. At
the same time, the morbidity level exceeds
the epidemic threshold by 1,6 times (50 cases per 100 000 people), which points out the
presence of TB activator spread, unidentified infection sources and incomplete
amount of epidemic and preventive activities. Despite successes reached in the decrease of TB spread on the territory of Kazakhstan there are problems and outstanding
issues in TB epidemiology and fight against
it.
In order to achieve the UN Millennium
Development Goals for decrease of prevalence and mortality of TB by 50% compared
to 1990 data and liquidate TB as a public
healthcare issue (WHO) and achieve country
goal, it is necessary to conduct the assessment of epidemiologic situation with TB and
assessment of TB programs efficiency to
identify priority tasks and plan further activities. New approaches are needed for the
assessment of the situation with TB and operative reaction and correction of changes
with the use of analytical epidemiological
methods.
References
1. Palomino JC, Leao SC, Ritacco V.
Tuberculosis 2007. From basic science to
patient
care//www.tuberculosis
textbook.com.
2. Tuberculosis. Handbook, WHO,
1998, 222 P.
3. The global plan to stop TB 20062015: progress report 2006-2008, November
2009
4. Global Tuberculosis Control Report.
This is the 13th WHO annual report on
global TB control, March 2009.
5. Khomenko A.G. Modern trends of
tuberculosis spread in Russia .- 1998. № 17,
5.
6. Zhangiryeev A.A. Tuberculosis epidemiology in Kazakhstan. International conference on tuberculosis control and 5th congress of phthisiologists of Kazakhstan. Almaty,1998, 3-4.
39
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
7. Zubritskiy A.N. TB according to the
autopsy data, p.14.
8. Ismailov S.S. Significance of general
practice physician in the PMC system in
control
over
TB
//http://www.kzfamilydoctor.org/news/kafp_
news/files/FMFP/18.06.2009/Ismailov_Doct
orRole_OLS.ppt.
9. Mishkinis K., Muminov T.A., Iskakova F.A.. DOTS strategy. Main provisions and start of implementation in the Republic of Kazakhstan //Almaty, 1999, p.24
10. Aliyev M.A. On the modern issues in
fighting TB ///Materials collection of the I
congress of phthisiologists of Kazakhstan,
Almaty, 1998, p. 200.
11. Statistical review of TB in the Republic of Kazakhstan, Almaty, 2010, 70 p.
12. TB in the Russian Federation. Analytical review of the main statistical TB indicators used in the Russian Federation
//edited by M.I. Perelman, Yu.V. Mikhaylova.– М., 2009. – 172 p.
13. Statistical review of TB in the Republic of Kazakhstan, Almaty, 2011, 71 p.
14. Statistical review of TB in the Republic of Kazakhstan, Almaty, 2012, 76 p.
15. Global tuberculosis report, WHO,
2012, p.
UDC: 613.1
R.O.Kasymova
Kyrgyz- Russian Slavic University named after B.N. Yeltsin , Bishkek , Kyrgyz Republic
WEATHER AND CLIMATE: EFFECT OF CHANGE ON HUMANS
Global climate change presents a relatively new challenge for the international community
and determines new policies and efforts of the governments to protect human health. Development of climate change adaptation strategies in the countries of the WHO European Region, including Kyrgyz Republic, has been studied taking into account a number of different characteristics such as population growth , poverty , medical care , nutrition , access to health care services
and medications , the level of environmental distress caused by anthropogenic pollution of the
living environment, i.e .complex factors influencing the vulnerability of the population and its
adaptive capacity . This lead to the development of response activities to the climate change by
the health sector, taking into account specific morbidity and mortality indicators. Our study presents expected indicators in relation to climate change in the Kyrgyz Republic.
UDC: 616. 61-036. 11:618 3/7
K.N.Mambetov, S.T.Nurpolatova, A.U.Seitnazarova, Z.O.Kunazarova, G.A.Karimova, R.M.Begaliyeva,
E.Zh.Yesenbekova
Nukuss branch of Tashkent pediatric medical institute
ACUTE RENAL FAILURE, CAUSED BY BLOOD LOSS DURING DELIVERY
Key words: acute renal failure, pregnancy, delivery, blood loss.
40
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Summary. Acute renal failure (ARF), condition that can develop during pregnancy and delivery is still one of the leading causes of maternal death in the Republic of Uzbekistan, especially
in the Aral area [1,2] .
The data provided in the article is a part of the study of specifics of development, clinical process and causes of ARF, developed during pregnancy and delivery in the conditions of ecological
disaster of Aral area, forecasting and prevention of purulent-septic complications and improvement of the general treatment outcome.
During the study general biochemistry tests were used: complete blood count and simple
urine test, BUN, creatinine, blood electrolytes, total protein, protein fractions, acid-base balance, central hemodynamics value, volemic value; x-ray and ultrasound.
34 women ages 23,14,0 years have been examined in nephrology unit with hemodialysis and
in intensive therapy of the Republican clinical hospital №1 of Nukuss city, in which ARF was a
result of massive bleeding during delivery which occurred in a normal pregnancy.
It was identified that there were following reasons for bleeding: Premature separation of
normally positioned placenta (in 29 patients - 79,2%), hypo- and atonic hemorrhage (in 3 patients - 12,5%), central placental presentation (in 2 patients - 8,3%), long time between membrane rupture and delivery, prolonged labor. In all cases there were diuretics administered secondary to non-compensated blood loss. 21 patients (61%) had long inefficient conservative haemostatic treatment and surgical intervention for restoring haemostasis was delayed.
Introduction
Acute renal failure (ARF), can develop as
a result of pregnancy and during delivery
and is still one of the leading causes in of
maternal death in the Republic of Uzbekistan, especially in the Aral area [1,2] .
ARF is a condition caused by a decreased
kidney function and is characterized by hyperazotemia, water-electrolyte and acid-base
imbalance, normotonia and erythropoeisis
defect. The data provided in the article are a
part of the results of studying peculiarities of
development, clinical process and results of
ARF, caused as a results of pregnancy and
delivery in the conditions of ecological disaster of Aral area, forecasting and prevention of purulent-septic complications and
improvement of the general treatment outcome.
Materials and methods
In the study general biochemistry blood
tests were used: complete blood count and
simple urine test, BUN, creatinine, blood
electrolytes, total protein, protein fractions,
acid-base balance, central hemodynamics
value, volemic value; x-ray and ultrasound
studies.
34 women ages 23,14,0 years have been
examined in nephrology unit with hemodi-
alysis and in intensive therapy of the Republican clinical hospital №1 of Nukuss city, in
which ARF was a result of massive bleeding
during delivery which occurred in a normal
pregnancy. In order to exclude the role of
extragenital diseases (EGD) this group of
patients with ARF of obstetrical etiology
included birthing mothers who had normal
pregnancy with no extragential pathology.
The only case of extragenital disease was
recorded as moderate anemia with initial
values of Нb (according to labor and delivery record), within the limits 11 – 12 g/l.
Results
It was identified that there were following reasons for bleeding: premature separation of normally positioned placenta (in 29
patients - 79,2%), hypo- and atonic hemorrhage (in 3 patients - 12,5%), central placental presentation (in 2 patients - 8,3%), long
time between membrane rupture and delivery, prolonged labor. Records of labor and
delivery evidenced that pregnancy was with
no obstetric or extragenital pathology. Red
blood cell count showed light anemia (Hb –
11,10,2 g/l). In all cases blood loss was
more than 30 ml/kg of body mass, there was
obvious hypotension lasting on average
1,90,7 hours. On average, volume of blood
41
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
loss was 2,10,2 l (31 ml/kg). Hemorrhagic
shock treatment conducted in obstetric organizations, as a rule, was different both in
qualitative and quantitative way. A common
feature was delayed transfusion in all cases
(from 1,5 to 8 and more). The volume of
transfused blood was no more than 36% of
the blood loss, which in majority of the cases
was underestimated by more than 40%.
In all cases there were diuretics administered secondary to non-compensated blood
loss. 21 patients (61%) had long inefficient
conservative haemostatic treatment and surgical intervention for restoring haemostasis
was delayed.
All patients during admission had moderate increase of blood pressure. On average
blood pressure was 160,45,1 by 90,92,7
mm Hg, which is higher than initial values.
The majority of the patients had elevated
blood urea and creatinine (35,73,0 mmole /l
and 490,1167,0 mcmole/l). Daily increase
of urea in the period of anuria was on average 7,90,6 mmole /l, and creatinine –
106,99,7 mmole/l. There were changes noted in electrolyte balance. 24 patients had hyperkalemia, being on average 7,70,4
mmole/l. Potassium level in plasma was
normal in 2 patients, being 5,01,0 mmole/l.
They had moderate hyponatremia and hypocalcemia. Sodium concentration in plasma
was 120,01,2 mmole/l. Therefore there was
a decrease of sodium in red blood cells
16,20,6 mmole/l. Apparently, hyponatremia
was a result of extrarenal losses of this electrolyte (diarrhea, vomiting) and massive infusions. Hypocalcemia was more expressed
1,350,15 mmole/l. Level of magnesium in
blood was slightly elevated (2,10,21
mmole/l).
In all patients the abovementioned electrolyte imbalance was accompanied by hypoproteinemia, registered during admission.
Total count of protein in blood was decreased to 44,02,0 g/l by means of both
fractions, with slightly higher decrease of
albumins. A/G index was 0,610,02. All
studied women had metabolic acidosis. Acid-base
balance
was
as
follows:
рН=7,200,007, рСО2=4,1300,350 kPa,
SВ=15,11,6
mmole/l,
ВВ=28,01,6
mmole/l, ВЕ=-13,11,6 mmole/l, which is a
sign of decompensated metabolic acidosis
with a slight compensation of breathing and
depletion of reserves of bicarbonate and hemoglobin buffer systems. In 10 (29,4%)
studied patients there were circulating auto
antibodies to kidney tissue and its structural
elements identified. In 11 patients (32,3%)
antibodies were found for tissue and subcellular liver elements, which was also clinically manifested with more expressed changes
of liver tests (serum transaminase, bilirubin)
and clinical manifestations of moderate cholestasis. All of the above gave us the right to
consider this as a combination of acute liver
and renal failure. During discharge the following criteria were considered: general
condition, haemogynamics indicators normalization, water-electrolyte balance, acidbase balance, diuresis, decreasing azotemia
to normal or subnormal level, decrease of
pathological urine changes.
At the time of discharge 10 women still
had leukocyturia (up to 70-90 in per HPF), 5
had cylindruria, 8 patients had microhematuria. All patients were recommended to get
monitoring by physician (nephrologist) at
place of residence and second consult in a
month.
Special attention was paid to the analysis
of death causes for further development of
treatment and prevention activities. We have
studied all complications in detail, which had
adverse influence on ARF that directly or
indirectly have caused death. In this group
12 patients have died, which is 35,2%, 6 patients died secondary to reversible renal processes, moderate necrotic nephrosis. Three
women (8,8%) have died within first few
hours after admission (in 6 – 12 hours) as a
result of progressing cardiac weakness with
expressed overhydratation, hypotension,
pulmonary edema and posthemorrhagic
anemia. In four patients (11,8%) there was
an acute symmetric cortical necrosis recorded.
Among the studied patients acute cortical
necrosis was developed in 11,8% of cases,
42
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
which has significantly surpassed the data
that consider renal cortex necrosis a rare
cause of ARF. Therefore, only for 5 patients
in this group applied treatment methods were
inefficient. They have died within 10 – 25
days. In these cases causes of death were
complications (hemorrhage, infections, circulation dysfunction). In 50% of the patients
in the process of ARF treatment besides
anemia developed other complications. Majority of them have developed in the oligoanuria period (20 patients). The most difficult were: septic metroendometritis in 2
patients, genital hemorrhage in 2 patients,
acute cardiovascular failure and pulmonary
edema in 7 patients, pneumonia in 4 patients,
peritonitis in 2 patients, with suture lack on
uterus in 2 patients, major thrombophlebitis
of lower limb with venous insufficiency cases in 1 patient.
Discussion
In our opinion blood loss during delivery
that worsened initial anemia is a condition
for septic infection development. For prevention purposes right after the blood loss we
consider antibiotics prescription to be essential. In majority of the described cases this
has not been done. 4 of the patients, who
died, had operations too late (after 5 – 7
hours after the onset of bleeding) after blood
loss and hemorrhagic shock manifestation.
One of the patient had second hemorrhage in
the period of dieresis restoration with high
level of azotemia (from uterus stump), it was
necessary to do second laporatomy for the
purpose of hemostasis.
Several patients with acute cortical necrosis have died as a result of progressing cardiovascular and cardio-pulmonary failure secondary to uremia. Causes of deaths of the
studied patients were: bilateral cortical renal
necrosis, acute cardiovascular and cardiopulmonary failure, purulent-septic complications. Patients treatment and hospitalization
depended on the severity of disease progress
and complications, and it lasted 21 – 42
days, on average 34,14,1 days.
Therefore in this group of women ARF
occurred secondary to normal pregnancy,
complicated by massive > (30 ml/kg body
mass) inadequately compensated blood loss.
During labor and delivery all patients
have suffered hemorrhagic shock for 4,51,2
hours. To almost all of them vasoconstrictors, cardiotonics and hormones were administered secondary to uncompensated blood
loss to increase blood pressure. It was noted
that the main reason for ARF in this group of
patients was massive blood loss with development of hemorrhagic shock, i.e. all patients had shock kidney. Abundant data have
shown that if blood pressure decreases lower
than 70 – 60 mm Hg there are glomerular
filtration and canaliculi defects with changes
of intrarenal blood flow from surface cortical
layer to deeper ones. The reason for intrarenal circulatory failure during blood loss and
shock is increased activity of reninangiotensin system, catecholamines.
Hypovolaemia that occurs in hemorrhage
and shock is a kind of mechanism launching
neuro-endocrine reactions (vasoconstriction,
anti-diuresis), aimed at normalization of circulatory volume by means of decreasing the
volume of blood-stream, fluid replacement.
Therefore decreased renal blood flow and
oliguria are peculiar phenomena in
hypovolaemia.
Among the scientists there is a widely accepted opinion that ARF is developed according to the following scheme: shock-renal
ischemia –renal hypoxia – canaliculus necrosis and other changes of ARF [3,4].
Because blood loss of absolute number of
patients in the group was practically related
to premature separation of normally and abnormally positioned placenta, we have paid
much attention to impairment of initial immune status of these women.
Conclusions
Therefore, it can be stated that kidneys are
the weakest link in the chain of defects that
can be caused by hemorrhage and shock in
pregnant women, as a result of which ARF is
developed.
References
1. Avakov V.E., MAmbetov K.N. // Peculiarities of clinical progress and outcomes
43
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
of acute renal failure, caused by pregnancy
and delivery pathology in women with difficult forms of gestational toxicosis and extragenital diseases in conditions of Aral area
/Medical journal of Uzbekistan, №1, 2008 17-20 p.
2. Atabiyazova O.A. //Anemia in pregnant women in Karakalpakstan republic. In
the book «Materials of international seminar
«Environmental factors and maternal and
child health in Aral crisis region ». - Tashkent, 2001,. 18-19 p.
3. Avakov V.E., et al. //Acute renal failure of obstetric etiology. Modern state of the
problem / Journal of theoretical and clinical
medicine– 2000 - № 6 - 6-8 p.
4. Avakov V.E., Makhmudov O.A.,
Mambetov K.N. Н. // Acute renal failure of
obstetric etiology. Modern state of the problem / Journal of theoretical and clinical medicine– 2000 - 6-8 p.
UDC: 616.314-74:053(053.54)
Zh.A. Kalmatayeva, Z.N. Yelzhanova
Kazakhstan School of Public Health, MоH RK
PROBLEMS OF DENTAL CARE PROVISION TO CHILDREN WITH INFANTILE
CEREBRAL PALSY ON THE EXAMPLE OF THE REHABILITATION CENTER FOR
CHILDREN WITH DISABILITIES «ARDI»
Key words: infantile cerebral palsy, dental care, children with disabilities.
Summary. The study was conducted on the basis of the rehabilitation center for children with
disabilities «ARDI». The study subjects were disabled children diagnosed with infantile cerebral
palsy (ICP) (n = 60) and their parents (n = 60). All children were separated into the three age
groups: children under 5 of age (30,5%), ages 5 to 10 years (49,2%) and ages 10-14 years
(20,3%). In order to analyze the specifics of dental care provided to children with ICP, a structured interviewing of children was conducted at the first phase of the study. At the second phase,
dental status of the patients was studied. As a result of the survey it was found that the main
source of information about the prevention of dental disease was inner circle and mass media.
Dental health education by the dentists in this category of patients was absent. Therefore, dental
hygiene knowledge level among children with ICP was low. A high percent of cases with complicated caries was identified, the prevalence of dento-facial anomalies was 96%, with an overall
complicated clinical situation with anomalies. Almost all interviewed children (98,3%) had impairments of physiological functions: respiratory issues, difficulties swallowing, chewing and
sucking. Changes in oral vestibule were seen in 73,3% of the cases. Delayed eruption of deciduous (temporary) and permanent teeth was observed. 75% of all children had cavities; with almost of them having more than one cavity.
The reasons that prevented seeing the dentist included fear of treatment (72% of children)
and high cost of treatment (18%).
The lack of specialized dental care for children with ICP leads to the deterioration of dental
health. This in turn has an adverse effect on the underlying condition. Therefore additional state
funds are needed for treatment and care for this category of patients. This justifies the creation
of specialized care for children with ICP.
Introduction
Based on the official data provided by the
Ministry of Labor and Social Protection the
Republic of Kazakhstan, more than 388 000
people or 3,5% of population in the country
live with disabilities, including 211 000
women. There are 49 000 children under 16
44
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
(13% of all people with disabilities), 58 800
people have been disabled since childhood
[1].
According to the data of CJSC «Medinfo» RK, ICP morbidity per 100 thousand
people in 2011 in the republic was 71. For
the period from 1990 to 2011 ICP morbidity
in the RK increased by, in the city of: Almaty from 26,5 to 124,1 people per 100
thousand [2]. As of 2013, there are 8301
children under 14 years registered with ICP
in the RK [3].
When looking at statistical data on ICP
prevalence and morbidity among children
with ICP, issues were raised on the prevalence of dental diseases among disabled
children with ICP diagnosis. Currently there
are no statistical data on dental issues among
children with ICP in our country. There are
only few publications from within the CIS
and abroad on the diseases of oral cavity
among disabled children (R.S. Starodubtseva, 1974, B. Bayzhanov 1980, Solonko
G.M., 1991,PodeJ.ECurron 1991, Kilyin
E.T., 2002, Atezhanov D.O. 2005). Those
studies show that prevalence and intensity of
caries among children with disabilities is
higher than in healthy children. Unlike
healthy children, those with disabilities tend
to have more pernicious habits and need
more orthodontic treatment. On average, the
prevalence of malocclusion in children with
disabilities is 73,5 %, while in healthy children the prevalence is shown to be 62% [4].
Severity of ICP, significant impairments of
dentofacial system (DFS), peculiarities of
care, treatment specifics and difficulties with
performing corrective manipulations and
other procedures in oral cavities of these
children call for the organization of specific
evidence-based dental care help to this category of children [5].
Presence of dental pathologies not only
worsens the condition of DFS, but also affects general wellbeing of a child, which
leads to higher spending of public funds on
providing in-patient care for these children
[6].
All of the abovementioned has defined
the goal of our study, which is to evaluate
the state of dental care provision to children
with ICP on the basis of a rehabilitation center for children with disabilities.
Materials and methods
The study subjects were disabled children
diagnosed with infantile cerebral palsy (ICP)
(n = 60) and their parents (n = 60). All children were separated into the three age
groups: children under 5 of age (30,5%),
ages 5 to 10 years (49,2%) and ages 10-14
years (20,3%). 57,6% were male and 42,4%
female.
In order to analyze the specifics of dental
care provided to children with ICP, a structured interviewing of children was conducted at the first phase of the study. When children were not able to answer the questions
due to their pathology, their parents were
interviewed instead. The questionnaire contained 18 questions and included questions
on demographics, awareness about dental
disease prevention and child’s health, and on
the organization of dental care for children
with ICP.
During the second stage of the study dental status of a patient was examined. To do
this an examination scheme was created:
collection of demographic data, patient history, objective examination, physiological
processes, condition of the oral vestibule,
paradontium tissue and dental arch.
Descriptive characteristics of the data
were done with calculation of standard deviation. Data analysis was done with the help
of Microsoft Excel and IBMSPSS Statistics
19.
Results
The interview questions on the behavioral
factors revealed that only 28% of children
under 5, 41% of children ages 5 to 10, 33%
of children from 10 -14 years brush their
teeth twice a day. At the same time, only
66%, 41% and 75% of children in each of
the respective groups did that for more than
2 minutes. With age the number of children
that do not change the toothbrush in half of a
year increases (16%, 27%, 33% in respective groups). At the same time, only 37% of
45
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
children and their parents think about brand
of toothpaste and its benefits. Almost half of
the respondents (51,6%) never rinse they
mouth after food intake, this relates both to
boys and girls.
When studying the issue of visits to dentist the survey has shown that 20% of children visit the dentist once a year during the
regular checkup examination, 66% go to the
specialists if they have a toothache. It was
found out that the patients do not turn to
dentist on their own, and it is known that
these children need to visit dentists no less
than 3 times a year.
The reasons for not seeing the dentist included fear of treatment (72%) and high cost
of treatment (18%). Based on patient history
it was established that if these children went
to dental clinics there were difficulties in
conducting treatment and prevention procedures, which sometimes resulted in using
general anesthesia or referring the patients to
other specialized medical facilities. Almost
all of the respondents (96,6%±2,36) saistated that dentists never visited this rehabilitation center. Likewise, only 8,5%±3,63 of the
respondents have received information on
oral hygiene from the dentist, 40,7%±6,4
from mass media, 50,8%±6,51 from a
friend, peer or a relative.
Based on the primary documentation of
children it was revealed that 86,7% had an
serious health condition, 83,3%±4,2 had a
co-morbidity.
Data received during oral examination is
presented in Table 1.
Table 1 – Results of oral examination of children with ICP
Characteristics
External assessment of
dentofacial
area
Physiological
processes
Acute distress
seen
No acute distress
Impaired
Not impaired
vestibulum
orus
Pathology
No pathology
buccal
mucous
membrane
With changes
Paradontal
tissue condition
Pathology
Dental arch
Physiological
No changes
No pathology
Pathological
Age
Under 5
1
11,1± 10,47
8
88,9± 10,47
9
100
0
0
8
88,9±10,47
1
11,1±10,47
8
88,9±10,47
1
11,1±10,47
5
55,6±16,56
4
44,4±16,56
3
33,3±15,71
6
66,7±15,71
During oral examination it was found that
almost all children have buccal mucous
membrane pathology (88,3%). There were
tongue changes: increased size, swelling,
flattening or hyperplasia of filiform papilla,
Total
From 5 to 10
4
16,0 ±7,33
21
84,0± 7,33
24
96,0±3,92
1
4,0±3,92
19
76,0±8,54
6
24,0±8,54
22
88,0±6,5
3
12,0±6,50
9
36,0±9,60
16
64,0±9,60
1
4,0±3,92
24
96,0±3,92
From 10 to 14
3
11,5± 6,26
23
88,5± 6,26
26
100
0
0
17
65,4±9,33
9
34,6±9,33
23
88,5±6,26
3
11,5±6,26
14
53,8 ±9,78
12
46,2±9,78
4
15,4±7,08
22
84,6±7,08
8
13,3± 4,38
52
86,7± 4,38
59
98,3±1,67
1
1,7±1,67
44
73,3±5,71
16
26,7±5,71
53
88,3±4,15
7
11,7±4,15
28
46,7±6,44
32
53,3±6,44
8
13,3±4,38
52
86,7±4,38
tongue and articulation hyperkinesias, desquamative and geographical tongue. On the
part of buccal mucous membrane there was
catarrhal stomatitis, ulcerative stomatitis.
Paradontium tissues condition identification
46
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
has shown that almost all children have
chronic generalized paradontitis. During oral
examination major dental deposits were
seen, which evidences insufficient care for
oral cavity. Almost all examined children
(98,3%) had impairments of physiological
processes: respiratory, swallowing, sucking,
and chewing acts. In vestibulum orus there
are changes in 73,3% of the cases. Delayed
eruption of both deciduous and permanent
teeth was seen. 75% of children had cavities,
among them almost half had multiple teeth
with caries.
Discussion
In Kazakhstan dental care is provided
free of charge to the following groups of
population:
1. Emergency dental care for socially
unprotected groups of population,
2. Scheduled dental care (except orthodontic and orthopedic) to children under 18
and to pregnant women, including teeth extraction, preparation and tooth filling form
composite materials chemical cure.
3. Orthodontic care to children with
congenital pathology of dentofacial area
with use of dentofacial anomalies correction
apparatus (biteplate) [7]. In the RK provision of dental care to children with falls under the framework of state guaranteed
amount of free medical care.
However, children with ICP, especially
with its hyperkinetic form, have significant
difficulties in conducting treatment and prevention activities. The quality of general
dental service to this category of people is
not perfect and for the patients with severe
form of ICP it is usually impossible to get
such care. Provision of additional services or
their provision in a more comfortable way
requires additional costs, both for the patient
and the family in general. There is insufficient information on the services provided
for free, and low incentives for healthcare
workers. Under the framework of state guaranteed amount of free medical care there is
no scheduled orthopedic and orthodontic
care, therapeutic care is only provided in the
form of chemical tooth filling. There is no
preventive medical examination of children.
The lack of specialized dental care for children with ICP leads to the deterioration of
dental health. This in turn has an adverse
effect on the underlying condition. Therefore additional state funds are needed for
treatment and care for this category of patients. This justifies the creation of specialized care for children with ICP.
Conclusions
The study allows to draw the following
conclusions:
1. Currently in the RK there is no specialized program of dental care provision to
children with ICP;
2. There are no official statistical data
on dental status of children with ICP.
3. Under the framework of guaranteed
amount of state medical care scheduled orthopedic and orthodontic care, therapeutic
care to children with ICP is only done in the
form of chemical tooth filling.
4. Study of records of MSPE «Pediatric
dental clinic» (form № 043/у, 039) identified that there are not records of children
with ICP diagnosis;
5. As a result of the survey it was found
that the main source of information about
the prevention of dental disease was inner
circle and mass media. Dental health education by the dentists in this category of patients was absent. Therefore, dental hygiene
knowledge level among children with ICP
was low.
6. High prevalence of caries complications, prevalence of dental anomalies is
96%, difficult clinical picture of anomalies
is frequent. Children are in need of orthodontic treatment. Severe impairments of
mucous membrane and oral cavity paradontium are seen. Children with ICP diagnosis
have impairment of physiological processes:
respiratory function, swallowing, sucking,
and chewing acts. 96,2% of children with
indications for orthopedic treatment do not
receive it.
47
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
References
1. Leyla Muzarapova.//Situation of the
disabled: problems and ways of social rehabilitation.- Kazakh institute of strategic research -2006.
2. CJSC «Medinfo»
http://www.medifo.kz
3. Web site of the Ministry of labor and
social
protection
of
the
RK
http://www.enbek.gov/kz
4. Starobudtseva R.S. // Teeth caries in
cerebral paralysis cases/ Dental issues.- Almaty 1978- 38-40 p.
5. Atezhanov D.O.// Dental issues
№4(30)- 85-88 p.
6. Elizarova V.M., Bashirova N.V.//
Dental care for children with limited abilities, children with ICP / Topical issues of
child dental care and dental diseases prevention: collection of research works edited by
prof. Kisselnikova L.P., ass.prof. Drobotko
L.N.– М., SPb, 2012.
7. Act of the Government of the Republic of Kazakhstan of 15 December 2009, №
2136.
UDC: 616.697
G.N. Nazarova
Kazakhstan School of Public Health, MoH RK
MEDICAL AND SOCIAL ASPECTS OF MALE INFERTILITY
Key words: male infertility, medical-social factor, reproductive health.
Summary. Infertility in marriage is a complex problem, solution of which is important not only from the medical, but from the social and demographic standpoints as well. Currently there is
an increase in the number of male infertility cases registered in the world [1].
We attempted to study the prevalence of male infertility as well as specific factors affecting
male fertility based on the utilization of medical services by the population of Almaty from 2010
to 2012.
Materials included patients medical charts and annual reports. A total of 122 charts have
been studies. The study was conducted on the basis of the City Center for Reproduction in Almaty, Kazakhstan. In order to assess the relationship of medical and social factors to infertility,
Pearson's chi-squared test was used. Linear regression was used to predict the prevalence of
male infertility.
Based on the study findings, the prevalence of male infertility increased in 2012 compared to
2011 by 37%. Some social and demographic factors influencing male infertility included: social
status, place of residence, age period. The prevalence was highest in the age group of 30 to 39
years. It was revealed that urban population is at higher risk for being diagnosed with infertility
than rural population. Infertility rates are higher among labor workers. More than half of all
patients (66%) represented the native ethnicity.
The main underlying cause of infertility was candida infection. Chronic prostatitis was the
most common co-morbidity. Disturbed spermatogenesis in male infertility most of the time was
represented by asthenozoospermia.
Results of our study highlight the need to implement measures for prevention of male infertility among the population, as well as more comprehensive study of social and medical aspects of
the condition.
48
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Introduction
Materials and methods
Protection of male and female reproductive health is one of the priorities of medical
and social directions.
The need to improve the demographic
situation in the country determines the need
for close examination of lifestyle factors and
reproductive behavior and their impact on
reproductive health [1]. According to the
data of screening study of the National Center of Urology named after B.U. Dzharbussynova, signs of fertility abnormalities were
found in 30,4% of men in the Republic of
Kazakshstan, signs of erectile dysfunction
were found in 56,3% of men [2].
A range of studies is devoted to problem
of male health, but they are mainly devoted
to study of etiological and pathogenic factors of male infertility and its treatment [2,
3]. At the same time there is a lack of research in the area of reproductive health of
young men with consideration of medical
and social factors influencing it. Furthermore, there is a need to improve medical
and social approaches to the prevention of
men reproductive health abnormalities
[4,5,6].
According to some researchers, the situation with infertility and diseases leading to
this pathology is a consequence of insufficient research on this issue, as well as differences in methodological approaches [6].
The aim our research was to study the
prevalence of male infertility among the
population of Almaty and identification of
social and demographic factors that influence the development of male infertility.
The study was conducted on the basis of
the medical faciity «City center for reproduction» (CCR) of the Department of
Healthcare of the city of Almaty.
According to the research design, during
the first stage we conducted content-analysis
conducted of CCR annual reports for the
period of 2010 – 2012. Prevalence of primary and secondary male infertility was studied
for the given period, as well as data on male
infertility co-morbidities.
During the second stage of the study,
medical and social information derived from
122 medical charts (primary morbidity) of
patients with infertility was done. The following information was considered: medical
record number, date of birth, place of residence, ethnicity, profession and diagnosis. Data analysis was done using Microsoft Excel
and IBMSPSS Statistical Application. In
order to analyze the relationship of medical
and social factors with infertility, Pearson's
chi-squared test was performed. Linear regression method was used to predict the
prevalence of male infertility.
Results
Based on the annual reports of CCHR
(2010-2012), 452 men were treated for male
infertility. Table 1 presents data on male infertility for the period of 2010-2012 which
shows that the prevalence of this condition
is increasing. From 2011 to 2012 the prevalence increased by 37%.
Table 1 – absolute and relative indicator of male infertility for the period of 2010-2012 and
prediction up to 2030
Types of infertility
I primary infertility
II secondary infertility
Total
Absolute and relative indicator of male infertility for the period of 20102012 and predictions up to 2030.
2010
102
(67,6±3.8)
49
(32,4±3,8)
151 (100)
2011
59
(46,5±4,4)
68
(53,5±4,4)
127 (100)
2012
2020
129
(74,1±3,3)
45
(25,9±3,3)
218
(86±2,2)
36
(14±2,2)
174 (100)
254 (100)
2030
353
(96±1,0)
16
(4±1,0)
369 (100)
49
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
During the analysis of medical charts it
was identified that 66% of patients with infertility were of Kazakh, 24% of Russian
and 8% of Uyghur origin (Picture 1).
It is necessary to note that both primary
and secondary infertility is more spread
among the native ethnicity (Picture 1).
Statistical confidence of connection of
ethnicity with infertility type is defined with
chi-squared criteria (χ2 = 7.48, p = 0.05).
Picture 1– Distribution of infertility types with consideration of ethnicity
Most often infertility is registered in the
age group of 30 to 39 years (51%), followed
by the age group from 20 to 29 (31%). In the
first age group the prevalence of primary
infertility is 53±6,1% and secondary is
59,1±6,1%. Picture 2 there shows data on
the prevalence of primary and secondary
infertility in each of those age groups.
59,1%
60,0%
53,0%
50,0%
40,0%
33,0%
30,0%
20,0%
10,0%
22,7%
13,6%
12,0%
2,0%
4,5%
0,0%
Picture
2 – Distribution
of infertility types in each age
group.
I infertility
II infertility
Main share of primary (80,2±4,0%) and
and secondary infertility is more spread
from 20 to 29 years from 30 to 39 years from 40 to 49 years From 50 to 59 years
secondary (81,8±3,9%) infertility is seen
among labor workers (37,7±4,4%) of inferwithin the urban population. Both primary
tility (Picture 3).
50
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
38,0%
40,0%
36,4%
35,0%
30,0%
25,0%
21,0%
18,2%
20,0%
15,0%
18,2%
15,0%
15,0%
13,6%
11,0%
10,0%
5,0%
Picture 3 – Distribution of infertility morbidity with consideration of patients social status
0,0%
The data peculiarities on pathogenic
I infertilitymicroflora in infertility cases were also studoffice
employee
ied. Picture 4 presents infection
structure
in
male infertility. Leading place
is taken by
II infertility
candida infection, which is seen in
worker
Individual
labor
unemployed
Other
23,2±1,5%
of infertility
cases.
23,2%
12,7%
14,9%
12,4%
12,3%
12,0%
5,9%
6,7%
Picture 4 – Infection structure in male infertility
Most common co-morbidity is chronic
prostatitis (77±1,9%) (picture 5).
51
13,6%
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
8%
2%
chronic prostati
6%
varicocele
77%
7%
hypogenitalism
epididymitis
epididymis cyst
Picture 5 – Co-pathology in male infertility
It was identified that spermatogenesis abnormality in male infertility (picture 6) is
mostly presented by asthenozoospermia
(61,6±2,4%) and oligospermia (21,7±2,0%).
22%
Asthenozoospermia
8%
62%
8%
oligospermia
Aspermia
Hypooligoasthenozoospermia
Picture 6 – Co-pathology of male infertility
Discussion
In the gender equality strategy of the Republic of Kazakhstan for 2006-2016 is stated
that it is necessary to increase men responsibility for preserving their health, provide
free information on different male health
issues, and ensure the provision of consultation on family issues. Currently in Kazakhstan there is no targeted policy for protection
of male reproductive health; there is no special infrastructure for men in the healthcare
system on the level of primary medical care;
there is low awareness of men in the issues
of health protection [8]. In recording primary documentation it is necessary to pay attention to medical and social factors, such as
knowledge on the issues of preserving and
strengthening men health, work and living
conditions, contraception methods, nutrition,
behavioral risk factors.
In the joint report of WHO/World Bank
on disabilities from 9 June 2011 it is stated
that infertility is an eighth by prevalence and
serious global abnormality, which is no less
urgent than maternal sepsis and unsafe abortion. Among the population groups under 60
years infertility takes 5th place by prevalence
as a serious global abnormality after depression, refractive visual impairments, unintentional trauma and alcoholism [9].
Study results evidence that it is necessary
to take measures to prevent the progression
of male infertility, as well as study social
and medical aspects of this pathology more
thoroughly.
52
Центрально-Азиатский научно-практический журнал по общественному здравоохранению
Conclusions
There is a growth of male infertility cases
and according to the forecast, in the next 10
years the male infertility indicators will increase thrice.
The study has identified effect of social
factor on the development of infertility,
namely: а) dependency of infertility on ethnicity, b) disease localization in the age
group from 30 to 39 years, c) disease concentration among state population, d) specifics of disease development among labor
workers.
There were medical aspects of male infertility identified: а) specifics of special microflora in infertility, with dominance of
candida infection, b) co-morbidity with
chronic prostatitis, c) spermatogenesis abnormality in infertility with domination of
asthenozoospermia.
References
1. WHO, World Bank / World Report
on Disability // Geneva, World Health Organization, 2011.
2. M.K. Alchinbayev.// State of male
health according to the data of NUC named
after B.U. Dzharbussynov,/ Urology and
nephrology of Kazakhstan, 4(5) - 2012. - 616 p.
3. T.E. Khussainov //Main causes of
male infertility and new treatment directions
/ Urology and nephrology of Kazakhstan.
4(5), 2012. - 108-122 p.
4. Kulavskiy V.A., Dautova L.A.//.
Medical and social aspects of reproductive
health protection / Mother and child: Materials of the IV Russian forum. M.,2002. –
50-52 p.
5. Medik V.A., Yuriyev V.K., Petrenko
A.A., Pribysh I.A.// Female infertility/ Spb.:
«Chimera», 2001. - 160 p.
6. Vassilyeva T.P., Bostrikov E.B.
//Medical and social problems of fatherhood/ Young family at the turn of the ХХХХ1 centuries: regional experience and
problems: materials of regional scientificpractical conference – Ivanovo, 2000. – 3233 p.
7. Ivanov A.G. // Comprehensive medical and social assessment of reproductive
potential of modern youth // author’s summary of dissertation of doct.med.sci / Ryazan, 2005. – 35 p.
8. Act of the President of the Republic
of Kazakhstan of 29 November 2005, N
1677 On approval of Gender equality strategy in the Republic of Kazakhstan for 20062016.
9. Current practices and controversies
in assisted reproduction: report of a WHO
meeting on "Medical, Ethical and Social
Aspects of Assisted Reproduction, 2001.
Geneva, World Health Organization, 2001.
53