The Expert Group for Liver Diseases of the...

The following measures are recommended in order to prevent viral hepatitis:

1. It is obligatory to report and to test all new cases with chronic viral hepatitis and posthepatitic cirrhoses.

2. Observation and recording about all accidental cases (injuries and eventual infection of the public-health service personnel, first of all).

3. Making a decision about doctrinaire attitudes connected with indications for blood transfusion and giving blood derivatives.

4. Educating the population. First of all, the students of high schools should be educated at the obligatory lessons about sexual transmission of diseases (as, for example, HBV, HCV, AIDS,...).

5. The adoption of the Protocol of desinfection of thermolabile instruments (equipment).

6. Routine and periodic testing of all the groups with risk factors of HBC and HCV infection.

7. Routine testing of pregnant women for HBV infection before delivery (the third period of the pregnancy).

8. Universal immunization by hepatitis B vaccine of all newborn infants, adolescents and groups at risk.

PREVENTION OF VIRAL HEPATITIS INFECTION ON DRUG ADDICTS

Easy access to single-used syringes and needles (to distribute them free of costs, changing the supply of intravenous equipment is very important for correct extermination of the contaminated material)

- to promote the usage of condoms

- surveillance of persons with risky behaviour

- to educate (give explanation to...) infected drug addicts how to behave

- vaccination against hepatitis B, including drug addicts’ children

- routine testing of drug addicts for viruses, including hepatitis B and C and AID free of costs

- to spread the net of counseling service for AIDS, HBV and HCV

- to cooperate with WHO in order to put all the measures into effect

- the Government is obligated to provide the necessary financial and skilled help to all suggested measures

RATIONAL ACCESSIBLE DISINFECTION / STERILIZATION AT HOSPITAL

It is not necessary for all hospital equipment and surfaces to be either sterilized or disinfected. The decision about the necessity of sterilization or disinfection is made primarily according to the purpose which the equipment have in the diagnosis, nursing and treatment , as well as acording to the current possibility of equipment and surface contamination which causes occurring and spreading of hospital infections. Today by Spaulding the equipment and surfaces, in accordance with their risk, are divided into three categories: critical, half-critical and uncritical.

Critical equipment (laparascopes and artroscopes) must be sterile, though in everyday routine high level of disinfection is carried out. This measure is accepted as a satisfactory one, regarding the fact that only 0,04% of all invections appeared as a result of using laparascopy or artroscopy.

Half-critical equipment (endoscopy) must be exposed to high level disinfection. According to the data from the books there were hospital infections and epidemics as a result of performing the endoscope inaccurate decontamination. Taking into consideration the fact that endoscopes were made of thermolabile material and it was not possible to sterilize them using any physical cleanser, the solutions for improving mechanical cleaning by special machines for endoscope reprocessing were looked for. Such procedure does not satisfy the needs properly, so further efforts are directed to the improvement of endoscopes, so they could be sterilized.

Uncritial equipment (blood pressure monitors, stetoscopes, bed linen, medical equipment, furniture, surfaces) According to the last recommendation all above-mentioned equipment should be washed, and only in the case of contamination they should be disinfected.

The list of means for disinfection with the recommendation of applying and indications should be made on the national level and it should be sent to public-health protection institutions. One of the main criterion in choosing the way of disinfection and sterilization is thermostable equipment. For the critical equipment sterilization is performed by using high temperatures. In the case of thermolabile equipment sterilization is performed by ethyl oxide. Having been used for prolonged sterilization for years, formaldehyde was thrown out of the usage in most European countries and in the USA because of its irritative, carcinogenic and toxic characteristics. The thermolabile critical equipment can be sterilized by dipping into chemicals with high level of disinfection for 6 – 10 hours prolonging the performing time or as it is suggested by the producer.

From the professional point of view for this purpose the folowing chemicals can be used: 2% glutaraldehyde, 7,5% hydrogen peroxide, 0,2% acetic acid, 0,55% orthoftalaldehyde, 0,08% acetic acid/1%hydrogen peroxide (glutaraldehyde is not in the list in 2004)

The chemicals used for half-critical equipment are the same as for the critical equipment (2% glutaraldehyde, 0,55% ortoftalaldehyde, 7,5% hydrogen peroxide, 0,2% acetic acid and 0,8% acetic acid / 1% hydrogen peroxide), but the suggested time in order to reach high level of disinfection is for 5 to 20 minutes. While choosing the chemicals for the endoscope disinfection, especially gastroscope, the permission connected with compatibility of that chemical and gastroscope should be asked from the endoscope producer (Olympus, Storz, Fujinon, Pentax).

Glutaraldehid, a chemical which was used for most of the time in 2004, is thrown out of the list of chemicals for disinfection.

Ethyl and propyl-alcohols can be used for uncritical equipment disinfection, sodium hypochloride can be used for equipment which is not sensitive to corrosive action of chlorine and also can be used ammonia compounds.

Predlozi za prevenciju virusnih hepatitisa

EKSPERTSKA RADNA GRUPA:

Delić Dragan, Carević Biljana, Janković Tomislav, Jemuović LJiljana

U cilju prevencije virusnih hepatitisa predlažu se sledeće mere:

1. Obavezno prijavljivanje svih novootkrivenih bolesnika sa hroničnim virusnim hepatitisom i posthepatitisnom cirozom jetre, kao i kontrola ovoga

2. Izrada Protokola za praćenje svih akcidentalnih slučajeva (povredjivanje i moguća infekcija,pre svega,zdravstvenih radnika),

3. Donošenje doktrinarnih stavova o indikacijama za transfuzije krvi i davanje derivata krvi,

4. Edukacija stanovništva, pre svega srednjoškolske omladine kroz obavezne časove o seksualno prenosivim bolestima (npr.HBV, HCV, HIV,....).

5. Usvajanje Protokola o procedurama za dezinfekciju termolabilnih instrumenata (opreme),

6. Rutinsko i periodično testiranje svih rizičnih grupa na HBV i HCV infekciju,

7. Rutinsko testiranje trudnica na HBV infekciju pre porodjaja (treći trimestar trudnoće),

8. Univerzalna imunizacija sa hepatitis B vakcinom sve novorodjene dece, adolescenata i rizičnih grupa.

PREVENCIJA INFEKCIJE VIRUSIMA HEPATITISA KOD NARKOMANA

-laka dostupnost špriceva i igala za jednokratnu upotrebu (deliti besplatno, zamena starog pribora za intrvensku primenu je važna zbog pravilnog uništavanja zaraženog materijala)

-propagirati upotrebu kondoma

-organizovati nadgledanje osoba rizičnog ponašanja

-zaraženim narkomanima objasniti kako da se ponašaju – edukacija

-vakcinacija protiv hepatitisa B, uključujući i decu narkomana

-redovno testiranje narkomana na viruse, uklj. hepatitis B i C i HIV besplatno

-Proširiti mrežu savetovališta za AIDS, HBV i HCV

-saradjivati sa WHO u sprovodjenju svih mera

-država je u obavezi da obezbedi finanasijsku i stručnu pomoć svim predloženim merama

RACIONALNI PRISTUP DEZINFEKCIJI/ STERILIZACIJI U BOLNICI

Nije neophodno da sva oprema i površine u bolničkoj sredini budu sterilne niti dezinfikovane. Odluka gde su sterilizacija i dezinfekcija neophodni, prvenstveno se donosni na osnovu namene koju oprema ima u postupku dijagnostike, nege i lečenja, kao i na osnovu postojanja mogućnosti kontaminacije opreme i površina, pa samim tim i rizika za nastanak i širenje bolničkih infekcija. Danas se, u odnosu na rizik koji predstavljaju prema Spaulding-u, oprema i površine dele, u tri kategorije: kritična, polukritična i nekritična

Kritična oprema (laparoskopi i artroskopi) mora biti sterilna, mada se u svakodnevnoj praksi uglavnom sprovodi visok nivo dezinfekcije. Ovo je prihvaćeno kao zadovoljavajuće, obzirom da infekcije nastale kao posledica izvođenja laparoskopije ili artroskopije čine samo 0.04% od ukupnog broja registrovanih bolničkih infekcija.

Polukritična oprema (endoskopi) moraju biti podvrgnuti visokom nivou dezinfekcije Prema podacima iz literature, opisane su bolničke infekcije i epidemije, nastale kao posledica neispravne dekontaminacije endoskopa. Obzirom da su endoskopi napravljeni od termolabilnog materijala i nije ih moguće sterilisati fizičkim sredstvima, tražena su rešenja u poboljšanju mehaničkog čišćenja, korišćenjem posebnih mašina za reprocesovanje endoskopa Ovakav postupak, takođe, ne zadovoljava u potpunosti pa su dalji napori usmereni ka usavršavanju endoskopa uz mogućnost sterilizacije.

Nekritičnu opremu (aparati za merenje krvnog pritiska, stetoskopi, posteljina, nemedicinska oprema, nameštaj i površine), prema najnovijim preporukama, treba samo prati, a u slučaju kontaminacije dezinfikovati.

Listu preparata za dezinfekciju sa preporukama o načinu primene i indikacijama treba sačiniti na nacionalnom nivou i dostaviti zdravstvenim ustanovama. Jedan od osnovnih kriterijuma za izbor sredstava, odnosno načina dezinfekcije i sterilizacije je termostabilnost opreme. Za kritičnu opremu sredstvo izbora je sterilizacija visokim temperaturama ili ukoliko je oprema termolabilna sterilizacija u etilen-oksidu. U većini zemalja Evrope i SAD-a zbog svoje toksičnosti, iritativnost i kancerogenosti formaldehid, koji se godinama koristio za produženu sterlizaciju, je izbačen iz upotrebe. Termolabilna kritična oprema se u izuzetnim situacijama može sterilisati potapanjem u hemijska sredstva sa visokim nivoom dezinfekcije, s tim što se vreme delovanja produžava na 6-10 časova ili prema preporuci proizvođača. Stručni stav je, da se u ove svrhe mogu koristiti: 2% glutaraldehid, 7.5% hidrogen peroksid, 0.2% persirćetna kiselina, 0.55% ortoftalaldehid i 0.08% persirćetna kiselina/ 1% hidrogen peroksid. ( sa liste se u 2004god. briše glutaraldehid).

Od hemijskih dezinficijenasa za polukritičnu opremu u upotrebi su ista sredstva kao za kritičnu opremu (2% glutaraldehid, 0.55% ortoftalaldehid, 7.5% hidrogen peroksid, 0.2% persirćetna kiselina i 0.08% persirćetna kiselina/ 1% hidrogen peroksid), s tim što je preporučeno vreme za postizanje visokog nivoa dezinfekcije od 5-20 minuta. Kod odabira sredstva za dezinfekciju endoskopa, pogotovu gastroskopa, treba od proizvođača endoskopa (Olympus, Storz, Fujinon, Pentax) zatražiti saglasnost o kompatibilnosti datog dezinficijensa sa gastroskopom.

Glutaraldehid, najduže korišćeno sredstvo za dezinfekciju, u toku 2004god. briše se sa liste preparata za dezinfekciju.

Za dezinfekciju nekritične opreme mogu se koristiti etil i propil-alkoholi, natrijum hipohlorit za opremu koja nije osetljiva na krozivno delovanje hlora i kvaternerna amonijum jedinjenja.