Toman s Tuberculosis

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2 Toman s Tuberculosis Case detection, treatment, and monitoring - questions and answers SECOND EDITION Edited by T. Frieden WORLD HEALTH ORGANIZATION GENEVA 2004

3 nasromis qartulad Targmnis da gamocemis saavtoro ufleba jandacvis msoflio organizaciam mianiwa tuberkulozisa da filtvis daavadebata erovnul centrs. qartuli gamocema dafinansebulia samedicino momsaxureobis saertasoriso korporaciis (MSCI) mier, romelic amerikis saertasoriso ganvitarebis saagentos (USAID) mxardawerit saqartvelosi anxorcielebs tuberkulozis mkurnalobis da kontrolis programas. MSCI uvcfslvmp{jtb!eb!gjmuwjt! ebbwbefcbub!fspwovmj!dfousj Targmanis redaqtireba _ l. vasakize, r. marsanisvili, r. aspinzelasvili, m. janelize, l. goginasvil, q. zedasize, l. kupreisvili, S. gamcemlize. l. kawarava Targmani _ q. kandelaki da n. goglize

4 tomanis tuberkulozi SemTxvevaTa gamovlena, mkurnaloba da moitoringi kitxvebi da pasuxebi meore gamocema redaqtirebulia t. fridenis mier jandacvis msoflio organizacia Jeneva 2004

5 jandacvis msoflio organizaciis biblioteka tomanis tuberkulozi _SemTxvevaTa gamovlena, mkurnaloba da monitoringi: kitxvebi da pasuxebi/ redaqtirebulia t. fridenis mier - II gamocema. 1. filtvismieri tuberkulozi _ diagnostika 2. filtvismieri tuberkulozi- medikamenturi Terapia 3. rezistentuli tuberkulozi 4. antituberkulozuri sasualebebi - farmakologia I. kurt tomani II. tomas frideni III. tuberkulozis SemTxvevaTa gamovlena, mkurnaloba da monitoringi ISBN (NLM classification: WF 360) WHO/HTM/TB/ jandacvis msoflio organizaciis biblioteka yvela ufleba daculia momusave personali, iseve rogorc am gamocemasi warmodgenili masala ar gulisxmobs sakutari azris gamoxatvas jandacvis msoflio organizaciis mier, rac romelime qveynis, teritoriis, qalaqis, adgilis an avtoritetuli figuris legalur statuss exeba an exeba misi sazrvrebis, an sasazrvro fortebis delimitacias. rukebze arsebuli wertilovani xazebi miutitebs miaxloebul sasazrvro xazebs, ris Sesaxebac konkretuli Tanxmoba ar aris mirweuli. garkveuli kompaniebis an manufaqtorebis produqciis xsenebisas ar igulisxmeba, rom es rekomendebulia an dadgenilia msoflios jandacvis organizaciis mier, romelic upiratesobas aniwebs mas sxva amgvari saxis produqciastan SedarebiT. Sesworebuli Secdomebi, dapatentebuli produqciis saxelebi ganmoyofilia da iwyeba didi asoebit. jandacvis msoflio organizacia ar izleva garantias imis Sesaxeb, rom informacia, romelsac es wigni Seiavs sruli da sworia da ar iqneba pasuxismgebeli im zianze, romelsac am literaturis gamoyeneba gamoiwvevs. am wignsi asaxul Sexedulebebze pasuxismgebloba mxolod avtorsa da redaqtors ekisrebat. damatebiti informaciisatvis mimartet : gadamdeb daavadebata (Department of Communicable Diseases) resursebis sainformacio centrs, jandacvis msoflio organizacia 1211 Jeneva 27, Sveicaria, faqsi: (+41) , el. fosta: cdsdocs@who.int dizaini minimaluri grafikis gamoyenebit akrefilia Contour Ltd. TbilisSi dabewdilia Contour Ltd. TbilisSi

6 sargevi pirveli gamocemis winasityvaoba meore gamocemis winasityvaoba Sesavali madlobis werili pirveli gamocemisatvis madlobis werili meore gamocemisatvis madlobis werili qartuli gamocemisatvis monawileta sia SemTxvevaTa gamovlena 1. ra rols asrulebs SemTxvevaTa gamovlena tuberkulozis kontrolis saqmesi f. luelmo ras warmoadgens tuberkulozis SemTxveva f. luelmo ra rols asrulebs naxvelis mikroskopia im pacientebis gamokvlevasi, romlebic mimartaven samedicino dawesebulebebs f. uelmo ramdeni baqteria unda iyos napovni nacxsi, rata igi mivicniot dadebitad k. tomani ramdenad sarwmunoa nacxis mikroskopia k. tomani ra aris cru-dadebiti da cru-uaryofiti pasuxebis ZiriTadi mizezebi k. tomani rogoria cru-pozitiuri da cru-negatiuri nacxis ZiriTadi Sedegebi T. freideni ra dadebiti da uaryofiti mxareebi aqvs fluoroscentul mikroskopul kvlevas k. tomani rogoria mikobaqteriuli kulturebis gamokvlevis roli tuberkulozis diagnostikasa da SemTxvevaTa dadgenasi van deuni rogoria kultura_uaryofiti Sedegis mirebis albatoba nacxit dadebiti tuberkulozis dros k. tomani ra damatebiti Sedegebi moaqvs naxvelis gamnmeorebit gamokvlevas nacxis mikroskopiuli da kulturaluri kvlevis sasualebit a. harisi...57 v

7 12. ramdenad sandoa gulmkerdis rentgenografiuli kvleva r. kopaka da n. boki ra SedarebiTi upiratesobebi aqvs gulmkerdis rentgenografiasa da nacxis gamokvlevas (nacxis mikroskopiuli kvleva da kultura) tuberkulozis axali SemTxvevebis gamovlenasi im pacientebs Soris, romlebsac arenisnebat gaxangrzlivebuli simptomebi gulmkerdis aresi a. harisi rogor vitardeba filtvis tuberkulozi da rogor gamovavlinot is adreul etapze k. tomani ra rols asrulebs tuberkulozis kontrolis saqmesi SemTxvevaTa gamovlena perioduli masiuri rentgenografiuli gamokvlevis mesveobit h. raideri rit gansxvavdeba tuberkulozis diagnostika aiv-inficirebul pacientebsa da arainficirebul pirebsi a. harisi ra rols asrulebs tuberkulinis kanis testi tuberkulozis diagnostikasi d. menziesi rogoria sxva diagnostikuri testebis arsebuli da potenciuri roli d. menziesi rogor unda itanamsromlon kerzo da saxelmwifo seqtorebma tuberkulozis gamovlenis, mkurnalobisa da monitoringis dros t. frideni mkurnaloba 20. tuberkulozis mkurnalobis ganvitarebis ZiriTadi etapebi k. tomani rogor moqmedebs tuberkulozis mkurnaloba k. tomani ra rols asrulebs makroorganizmis faqtorebi tuberkulozis patogenezsi, prevenciasa da mkurnalobasi m.lademarko da m. ricleri ra Terapiuli efeqti da toqsiuroba axasiatebs tubsawinaarmdego medikamentebs T. frideni da m. sarnali ra mizans emsaxureba orfaziani mkurnalobis sawyisi intensiuri mkurnaloba k. tomani rogoria Tanamedrove rekomendaciebi standartuli rejimis mimart a. harisi ra diagnostikuri kategoriebi arsebobs da ra principebi udevs mat safuzvlad a. harisi vi

8 27. ras warmoadgens intervalebit intermitiuli mkurnaloba da ra mecnieruli safuzvlebi aqvs mas t. frideni ra dozebit gamoiyeneba tubsawinaarmdego medikamentebi yoveldriur da intermitiul rejimsi h. reideri ra mecnierul mtkicebulebebs efuzneba tubsawinaarmdego medikamentebis dozirebastan dakavsirebuli rekomendaciebi h. raideri rogoria mkurnalobis optimaluri xangrzlivoba T. santa ra ZiriTadi gverditi reaqciebi axasiatebs pirveli rigis tubsawinaarmdego medikamentebs da rogoria mati ganmeorebit danisvnis procedura a. harisi ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazids plus TioacetazoniT mkurnaloba h. raideri rit gansxvavdeba eqstrapulmonaruli tuberkulozis martva filtvis tuberkulozis martvisagan r. balasubramaniani, r. rajesvari, T. santa rit gansxvavdeba tuberkulozis mkurnaloba fexmzime qalebsi, RviZlis an Tirkmlis daavadebis mqone pacientebsi a. harisi rit gansxvavdeba tuberkulozit daavadebuli aivinficirebuli pacientebis mkurnaloba a. arisi ra ZiriTadi Sedegebi iqna mirebuli madrassi Catarebuli kvlevebit, romelta mizanic iyo binaze da sanatoriumsi mkurnalobis formebis Sedareba k. tomani ramdenad xsirad Sewyveten vadamde adre pacientebi mkurnalobas j. sbarbaro ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves j. sbarbaro ratom aris mkurnaloba warumatebeli da ra unda gaketdes mkurnalobis arasasurveli Sedegebis armosafxvrelad f. luelmo ra upiratesobebi da nakli aqvs tubsawinaarmdego medikamentebit fiqsirebuli dozebit mkurnalobas k. lasersoni da m. lademako rogor vitardeba medikamentebisadmi rezistentoba k. tomani ratom unda davicvat gansakutrebuli sifrtxile rifampicinis gamoyenebisas a. vernoni vii

9 43. medikamentebisadmi rezistentobis ra tipebi arsebobs m. espinali ras warmoadgens ~vardnisa da matebis fenomeni da rogoria ~Tanmimdevruli rejimis meqanizmi m. espinali ramdeni medikamentisadmi rezistentuli bacila SeiZleba iqnes armocenili tuberkulozit daavadebuli, aranamkurnalebi pacientebis naxvelsi a. pablos-menozi ra mizezebi ganapirobebs medikamentebisadmi rezistentuli tuberkulozis ganvitarebas m. espinali da t. frideni rogor avicilot Tavidan medikamentebisadmi rezistentoba t. frideni ramdenad sandoa medikamentebisadmi mgrznobelobis testebi m. espinali rogoria medikamentebisadmi mgrznobelobis arazusti testirebis SesaZlo Sedegebi m. espinali ra sarezervo rejimebi arsebobs da ra adgili uwiravt mat tuberkulozis kontrolis programebsi m. espinali ra rols asrulebs latenturi tuberkulozis mkurnaloba, tuberkulozis kontrolis programasi m. e. vilarino ra epidemiologiuri zegavlena aqvs latenturi tuberkulozuri infeqciis mkurnalobas z. teilori monitoringi 53. rogoria tuberkulozis avadobit gamowveuli janmrtelobis, socialuri da ekonomikuri mdgomareobis gauareseba i. smiti rogoria tuberkulozis kontrolis globaluri miznebi da ras efuzneba is i. smiti ra aris DOTS-i i. smiti aris Tu ara DOTS-i xarjtefeqturi i. smiti rogor ganvaxorcielot mkurnalobis Sedegebis warmatebis monitoringi t. santa ramdenad efeqturia tuberkulozis mkurnaloba da risi gaketebaa sawiro momavalsi t. santa warmoadgens Tu ara pirveladi rezistentoba sasisroebas tuberkulozis kontrolisatvis m. espinali da t. frideni viii

10 60. gankurebis ra ZiriTadi sasualebani arsebobs k. tomani ra mnisvneloba eniweba mkurnalobis Sewyvetas tuberkulozis mkurnalobis dros n. boki ramdenad mnisvnelovania mkurnalobis gavrcelebis faza da rogoria recidivis sixsire mkurnalobis dasrulebis Semdeg t. santa ristvis aris sawiro registrirebisa da angarisgebis sistema da romeli sistemis gamoyenebaa am TvalsazrisiT rekomendirebuli d. maheri, m. ravilione rodis unda moxdes tuberkulozit daavadebuli pacientebis hospitalizacia da ramdenad baqteriagamomyofni arian isini mkurnalobis dros e. a. talboti, s. d. velsi rogor xdeba tuberkulozis nozokomialuri transmisia da rogoria misi prevencia f. m. simone Cveulebriv sad vrceldeba tuberkulozi da rogor SevamciroT misi gavrceleba h. reideri ra principebi da motxovnebi arsebobs kontrolirebadi klinikuri kvlevebis mimart f. rehmani ra aris molekuluri epidemiologia da ra rols asrulebs igi tuberkulozis kontrolis saqmesi k. derimeri da f.m. smoli SesaZlebelia Tu ara tuberkulozis kontroli t. frideni SesaZlebelia Tu ara SemTxvevaTa gamovlenis da mkurnalobis mesveobit medikamentebisadmi rezistentobis prevencia da ukuqceva sazogadoebasi m. ravilione ra macvenebeli aqvs tuberkulozis kontrolis efeqtur programas f. luelgo da t. frideni tuberkulozis kontrolis efeqturi programis magalitebim. ravilione da t. frideni ra SedarebiTi prioritetebi aqvs tuberkulozis kontrolis programas da ra saqmianoba ar unda ganxorcieldes f. leilmo da t. frideni ra zegavlenas axdens aiv-infeqcia tuberkulozis epidemiologiaze mosaxleobasi a. harisi rogor SevuwyoT xeli tuberkulozis kontrolis samsaxurebs da rogor SevinarCunoT mati qmeditoba t. frideni ix

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12 pirveli gamocemis winasityvaoba jandacvis msoflio organizaciis (WHO) ert-erti mtavari funqcia mecnieruli codnis praqtikuli faseulobis janmrtelobastan dakavseirebul problemebtan misadagebaa. tuberkulozis kontrolsi moqceulia codnisa da gamocdilebis udidesi maragi. jandacvis msoflio organizaciis mxardawerit ganxorcielebuli proeqtebit SesaZlebeli gaxda msoflios ganvitarebadi qveynebis yvelaze ufro miusadegar da Sor teritoriebze tuberkulozis gamartivebuli da standartizirebuli kontrolis metodebis samedicino praqtikasi gamoyeneba. tuberkulozis nacionaluri kontrolis programis koncefcia formulirebul iqna jandacvis msoflio organizaciis mier, rata axali teqnologia ufro efeqturad yofiliyo gamoyenebuli. organizaciis strategia, romelic tuberkulozis kontrols exeba, WHO-s eqspertta komitetis mokle werilobiti moxsenebis saxit arsebobda, romelmac TavisTavad mravali kitxva da damatebiti informaciis motxovnis safuzveli warmosva. didi xania arsebobs azri imis Sesaxeb, rom detaluri komentari mecnieruli codnis praqtikuli gamocdilebisa, romelic WHO-s tuberkulozis kontrolis strategias ukavsirdeba, metad Zvirfasi elementi iqneboda msoflio jandacvis organizaciis wevr qveyanata teqnikuri urtiertobisatvis. es wigni, romelic kitxva-pasuxis saxit aris warmodgenili, am mimartulebit gadadgmuli pirveli nabijia. imedi maqvs es yvela tuberkulozis daavadebastan momusave musaks Seexeba, visac sakmaod gadamwyveti da mnisvnelovani Tanamdeboba ukavia: organizatorebsa da administratorebs, romlebic erovnul programebsi tuberkulozis kontrolze arian pasuxismgebelni. es, agretve, exebat im dargis musakebs, romlebic dainteresebulni arian sazogadebasi tuberkulozis kontroltan dakavsirebuli yoveldriuri problemebit. wigni aseve gankutvnilia mattvis, vinc tuberkulozis kontrolis SeswavliTaa dakavebuli samedicino skolebsi, sazogadoebrivi jandacvis saswavleblebsi, saeqtno skolebsa da sxva msgavs dawesebulebebsi. h. maleri generaluri direqtori Jeneva, 1979 weli xi

13 meore gamocemis winasityvaoba ukve oc welze metia, rac kurt tomanis wigni, _ tuberkulozis SemTxvevaTa gamovlena da qimoterapia kitxva-pasuxis saxit _ yvelaze ufro avtoritetuli rekomendaciaa racionalurad dasabutebuli tuberkulozis diagnostikasa da mkurnalobisatvis. Zalzed cota wigni gazlebda ase didxans, mitumetes codnis aseti didi siswrafit ganvitarebis epoqasi. wigni mravaljer iqna dabewdili inlisur, espanur da arabul enebze msoflio jandacvis organizaciis mier da gadatargmnili frangul da portugaliur enebze saertasoriso gaertianebis mier tuberkulozisa da filtvis daavadebata winaarmdeg. saubedurod, miuxedavad imisa, rom 30 welze metia mkurnaloba sakmaod xelmisawvdomia, SesaZlebelia zusti diagnostika da TiTqmis 100%-iT gankurnebadi mkurnaloba, tuberkulozi kvlavac ert-ert mtavar infeqciur daavadebad rceba, romelic globalurad iwvevs sikvdilianobas da weliwadsi daaxloebit or milion adamians uswrafebs sicocxles. tuberkulozi ganvitarebadi qveynebis zrdasrulta Soris otxidan erti sikvdilis mizezad itvleba, romelic SeiZleba acilebuli iqnes. Sidsis epidemia situacias kidev ufro auaresebs. afrikis mraval qveyanasi Sidsis epidemiis arsebobis gamo tuberkulozis SemTxvevaTa raodenoba or-otxjer gaizarda. bolo ati wlis ganmavlobasi, msoflio jandacvis oprganizaciis partniorebisa da wevr qveyanata konsultaciebis safuzvelze, WHOm gaaumjobesa da mxari dauwira tuberkulozis kontrolis strategias, romelic DOTS-is saxelit aris cnobili. DOTS-i uzrunvelyofs rogorc swor diagnostikas, sando mkurnalobasa da sistematur monitorings, aseve politikur da administraciul mxardaweras, rac tuberkulozis efeqturi mkurnalobisatvisaa sawiro. magram unda arinisnos isic, rom DOTS-is mkurnalobis safzvlebi zogjer kitxvis nisnis qvesac dgeba. DOTS-i dogmas ar warmoadgens. es is saqmianobis sferoa, romelic ZiriTad klinikur da epidemiologiur kvlevebs eyrdnoba. es procesi ki ganvitardeba yoveli axali infomaciis armocenastan ertad. am kutxit tomanis tuberkulozis meore gamocema gansakutrebit drouli da misadagebulia. msoflios ufro da ufro meti qveyana zrdis DOTSxii

14 is danergvis procesebs. programis menejerebs, eqimebs, samedicino skolebis profesorebsa da sxva dainteresebul adamianebs xsirad ebadebat kitxvebi DOTS-is safuzvlebis strategiebisa da praqtikebis Sesaxeb. unda variarot, rom udidesi mnisvneloba mecnieruli wignisa, romelic 24 wlis win daiwera, eqimi tomanis winaswarmetyvelebis dasturi ki ar aris, aramed tuberkulozis kontrolis sferos bolo oci wlis ganmavlobasi metad neli ganvitarebis samwuxaro ariarebaa. ukanasknel wlebsi arinisneba tuberkulozisadmi ganaxlebuli interesi. Cveneburi xedva am daavadebisa, SesaZleblobebi misi diagnostikisa da mkurnalobisa, agretve efeqturi kontrolis strategiebis danergva, sagrznoblad unda gaumjobesdes ise, rom gacilebit male gaxdes sawiro Semdegi gamocemis Seqmna. vimedovneb, rom es fasdaudebeli wigni didi mxardawera iqneba mattvis, vinc wina xazebze ibrzvis tuberkulozis winaarmdeg: programis menejerebis, strategiis Semqmnelebis, eqimebis, eqtnebis, samedicino skolis profesorebisa da sazogadoebis wevrebis CaTvliT, vinc MdauRalavad Sromobs, rata SeaCeros tuberkulozi. li iong-vuki generaluri direqtori Jeneva, 2004 weli xiii

15 Sesavali tomanis wignis pirveli gamocemis ert-erti qvetavi tuberkulozis SemTxvevaTa armocena da qimoterapia kitxva-pasuxis saxit, agretve qvetavi ra aris umtavresi tuberkulozis mkurnalobis ganvitarebis processi, tomanis wignis ZiriTad dedaazrad SeiZleba CaiTvalos. pirveli gamocemis dabewdvidan Zalian male, 1979 wels, k.stiblom da saertasoriso gaertianebam tuberkulozisa da filtvis daavadebata winaarmdeg (IUATLD) ganavitara modeli, romelic tuberkulozis kontrolis yvela umtavres elements Seicavda. es modeli SemdgomSi afrikisa da amerikis ramodenime qveyanasi iqna gamoyenebuli da dresdreobit DOTS-is saxelit aris cnobili. DOTS strategia, saertasorisod rekomendebuli tuberkulozis efeqturi kontroli, SemdgomSi ufro srulyo jandacvis msoflio organizaciam (WHO). igi eyrdnoba faqtebs, romlebic mravalgzis Seswavlili da gamocdilia. faqtebi, romlebic safuzvlad udevs tuberkulozis diagnostikas, mkurnalobasa da monitorings, warmodgenilia yovlismomcveli da gasagebi formit. informacia gatvaliswinebulia yvelasatvis, vinc ki Cabmulia tuberkulozis diagnozirebis, mkurnalobis, am daavadebisagan Tavis dacvasa da kontrolis saqmesi. isini rogorc am dargis specialistebi, aseve pirveladi jandacvis musakebic SeiZleba iyvnen. tuberkulozis armocenasa da mkurnalobisas, tomanis koncefcia itvaliswinebs WHO/IUATLD-s mecnieruli sawyisebis gabatonebas. udidesi nawili imisa, rac tomanma 24 wlis win dawera, dresac mnisvnelovani da mtavaria; amitomac ar swirdeba wignis bevr Tavs ganaxleba. bevr ganvitarebad qveyanasi tomanis mier gamoyenebuli nateli da zusti informacia, gasagebi axsna-ganmartebebi da gaazrebuli midgoma safuzvelia imisa, rom misi wigni tuberkulozis eqpertebis sayrdeni dedabozia rogorc mati profesiuli STamomavlebisaTvis, aseve mravali mkurnali eqimisatvis. Mdaavadebis kontrolis arwera, Tu raoden efeqturia tuberkulozis pacientebis pativiscemit mopyroba da gulitadi mkurnaloba, isetive misadagebuli da sworia dres, rogorc masin, rodesac es wigni pirvelad daiwera. gaazrebuli da gulitadi dacva gamocdili xiv

16 klinikuri cdebisa, ertguleba marali mecnieruli da etikuri principebisa dresac isetive aqtualuria, rogorc masin. tomanis sistematuri diskusia medikamentebisadmi rezistentobis ganvitarebis Sesaxeb da sirtuleebi, romlebic sarezervo medikamentebit mkurnalobas sdevs Tan, Zalian waagavs drevandel aqtualur diskusias, romelic rezistentuli tuberkulozis mkurnalobas ukavsirdeba. ra Tqma unda, mtliani Tavi, romelic SemTxvevaTa armocenas etmoba klasikuri da SesaniSnavi axsna-ganmartebaa imisa, Tu raoden didia mjavagamzle nacxis roli, agretve mkerdis radiograma, kulturaluli testebis Semcirebis uaryofit efeqti da tuberkulozit daavadebuli pacientebis armocenis mnisvneloba pirveladi jandacvis sitemis mesveobit. tomanis tuberkulozis meore gamocemasi SeiniSneba mcdeloba, SenarCunebul iqnes is ubraloeba da gasagebi ena, romelic pirvel gamocemasia mocemuli, agretve is sistematuri mecnieruli foni, rac mocemul pasuxebs udevs safuzvlad. is nawili, romelic tuberkulozis armocenas exeba ganaxlebulia, xolo nawilebi, romlebic adamianis imunodeficitis viruss-tuberkulinis tests da axal diagnostikis models exeba, Camatebulia. es gamocema, agretve Seicavs tuberkulozis Sesabamisi armocenis strategiebsac. Mis nawili, sadac tuberkulozis mkurnaloba ganixileba, sawiroebis mixedvit ganaxlda. am nawilsi mokle kursis mkurnalobis Sesaxeb iqna Setanili informacia. Emkurnalobis es forma originaluri teqstis daweris dros jer kidev ar iyo danergili. agretve, damatebul iqna ganaxlebuli informacia virusisagan dacvis, medikamentis mimart rezistentobis ganvitarebis, medikamentebis dozebis gansazrvris, arafiltvismieri tuberkulozis mkurnalobisadmi nebisyofis gamomusavebisa da pirdapiri dakvirvebit mkurnalobis Sesaxeb. am gamocemasi ATavmoyrilia rogorc informacia tuberkulozis mkurnalobis safuzvlebis, misi rolisa da limitebis Sesaxeb, aseve is sakitxebi, romlebic tuberkulozis monitoringis programis efeqturobas exeba. es sakitxebi sxvadasxva qveynebsi DOTS-is danergvis gamocdilebazea damyarebuli. stiblos mier danergili arwerisa da Sedegebis moxsenebis sistema ubralo, Zlieri da metad efeqturia. es uyris safuzvels mkurnalobis programis monitorings da pasuxismgeblobas irebs mkurnalobis efeqturobaze. xv

17 madlobis werili pirveli gamocemisatvis me valsi var yvelas winase, vinc pirdapir an arapirdapir damexmara, rom es wigni damewera. Ddavalebuli var eqim h. maleris winase, vinc ati wlis win warmoisva idea Seqmniliyo teqnikuri saxelmzrvanelo tuberkulozis kontrolis Sesaxeb, romelic ZiriTadad ganvitarebadi qveynebis am dargis araspecialisti medpersonalisatvis iqneboda gankutvnili. didi madloba minda gadavuxado saertasoriso gaertianebas tuberkulozis winaarmdeg (IUAT) mis yofil direqtors eqim j. holmsa da mis Semdgom mosul movaleobis armsrulebels, eqim d.r. tomfsons, romlebmac pirveli nabijebi gadadges am wignis gamocemisatvis da didi Tanadgoma gamomicxades misi teqnikuri redaqtirebis sakitxebsi. axlandeli IUAT-is direqtorma, profesori v. fargamac metad saintereso rcevebi mogvawoda. eqimma anik ruilonma, pasuxismgeblobis farto arealsi, mravali gulitadi Tanadgoma gagviwia. agretve, mravali gulwrfeli, nayofieri da mastimulirebeli diskusiebi mqonda ukve aw gardacvlil profesor g. kanettan, romelic IUAT-is tuberkulozis mecnieruli komitetis Tavmjdomare iyo. madloba minda gadavuxado, agretve im pirs, vinc SemdgomSi misi Tanamdeboba ewira-eqim j.r. bingals da axlandel komitetis Tavmjdomaresa da direqtors (tuberkulozis metvalyureobiti kvlevebis ganyofileba) eqim k. stiblos. eqim k. maieris didi interesis wyalobit da eqim h.a. van goinsis iniciativit, niderlandebis sonevankis federaciam, Tanxis nawili dafara. eqimma k.l. hitcem, tuberkulozisa da sasuntqi gzebis daavadebata ganyofilebis ufrosmac (msoflio jandacvis organizacia) gamomicxada mxardawera, mravali rceva momca da gamamxneva. eqim valis foqss tuberkulozisa da mkerdis daavadebataa kvlevis ganyofilebis direqtors (samedicino kvlevis sakonsulo) da professor d.a. mitcisons (londonis hamersmitis samedicino aspirantura), romlebmac Zireuli cvlilebebi Seitanes tuberkulozis mkurnalobasi, madloba minda gadavuxado am sferosi dainteresebasa da kritikisatvis da imisatvis, rom ufleba momces mat pionerul codnas davyrdnobodi. xvi

18 madloba minda gadavuxado, agretve, Cems TanamSromlebs da studentebs ganvitarebad qveynebsi: eqimebs, medpersonals, damxmareebs, maswavleblebsa da sazogadoebrivi dajgufebebis liderebs, romlebic TavdadebiT ibrzodnen, rata matiatanamozmeni usafuzvlo tanjvisagan exsnat. mat maizules gametvitcnobierebina, rom tuberkulozi da sxva janmrtelobastan AdakavSirebuli problema SeiZleba moixsnas, roca kulturuli, socialuri da ekonomikuri urtiertdamokidebuleba gaanalizebuli da gatvitcnobierebulia. me madlobeli var Cemi meurlisa. misi daxmarebisa da nebisyofis garese es wigni ar daiwereboda. k. tomani xvii

19 madlobis werili meore gamocemisatvis es RirsSesaniSnavi wigni swored, rom tomanis tuberkulozia. kurt tomanma safuzveli Cauyara da Seqmna wigni, romelic SeiZleba micneul iqnes Sedevrad wlebis bolos dawerili es wigni diagnozis, mkurnalobisa da tuberkulozis kontrolis yvela mnisvnelovan kitxvas exeba. aq mokledaa Tavmoyrili tuberkulozis mecnieruli codna. wigni gamoirceva saocrad gasagebi enita da lakonurobit, swored amitom vart udides valsi im adamianis winase, visac es wigni ekutvnis da es kurt tomania. unda arinisnos isic, rom erteuli avtorebis era dasasruls miuaxlovda da tomanis tuberkulozis am gamocemas mravali pirovnebis daxmareba da mati wvlilis Setana daswirda. es SesaniSnavi sacuqaria im mirwevebisa da suliskvetebisa, ritac es teqsti tuberkulozis eqspertebis mier msoflios sxvadasxva nawilsi daiwera. eqimma fabio luelmom udidesi wvlili Seitana Sesworebul gamocemasi, Zalisxmeva gairo, rata misi Sinaarsi ufro gasagebi gamxdariyo. aseve wvlili Seitana, mravali Tavis ganaxlebasi da frtxilad gadaamowma mtliani manuskripti. sxva kolegebma Jenevis msoflios jandacvis organizaciidan, eqimebis, mario ravigliones, ian smitisa da markos espinalis CaTvliT, wvlili Seitanes rogorc mtliani wignis, aseve calkeuli qvetavebis srulyofasi. eqimebma antoni harisma da hans raiderma, didsulovnad gamoyves TavianTi dro da angarisgasawevi eqspertizis unari, rata daewerat an gadaemowmebinat qvetavebis sakmaod didi raodenoba da mat, iseve rogorc eqimma martien borgdorfma, mteli manuskriptis gadamowmebac itaves. aseve didi wvlili Seitanes mravalma ass-s daavadebata kontrolisa da misgan Tavdacvis centrebma (CDC) axali da ukve gadamowmebuli seqciebis srulyofasi. Cven martlac gagvimartla, rom sasualeba mogveca Cinaisa da indoetis tuberculozis kvlevis centrebis eqspertta daxmareba da gamocdileba gamogveyenebina. sxva avtorebis/semmowmebelta saxelebi CamoTvlilia sarcevsa da am saqmesi monawileta calke siasi; mati mondomeba dafasebulia. yvela didi motminebit musaobda, rac metad mwidro rejimsi mimdinareobda wlamde arsebuli sarekomendacio masala mopovebul iqna CDC-s (atlanta, jorjiis Stati, ass), Culalongkornis universitetis samedicino bibliotekis (bankoki, xviii

20 tailandi), Cennais tuberkulozis kvlevis centris, bangloris tuberkulozis erovnuli institutisa da indoetis tuberkulozis asociaciis (axali deli, indoeti) daxmarebit. beivordis redaqtoruli konsultaciebma uzrunvelyo proeqtis mtliani kordinireba da redaqtireaba wels, rodesac es wigni pirvelad daibewda, eqimma Kkarel stiblom da misma kolegebma (tuberkulozisa da filtvis daavadebata internacionaluri gaertianeba da samefo niderlandebis tuberkulozis asociacia) strategiis ganxorcieleba daiwyes, romelic SemdgomSi DOTS- is saxelit gaxda cnobili. am strategiis arsanisnavi aspeqtebia gansakutrebit Zlieri monitoringis sistema da DOTS-is menejmentis mtliani paketi, romelic am wignsia Tavmoyrili, fartod faravs efeqturi diagnostikis, mkurnalobisa da monitoringis strategiebs. redaqtors martlac Zalian gamoadga indoetsa da samxret armosavlet aziasi tuberkulozis sakitxebze momusave pirebtan diskusiebi, romelic mravali saati grzeldeboda. Mmisi didi interesi da kritikuli midgoma masve Zalian daexmara, rata pasuxi gaeca mnisvnelovan kitxvebze, romelsac SemdgomSi mravaljer daubrunda. mravalma adamianma Seitana wvlili am wignis dawerasi; pasuxismgebloba Secdomebze ki redaqtors ekisreba. tomas r. frideni axali deli indoeti 2003 xix

21 madlobis werili qartuli gamocemisatvis k. tomanis tuberkulozi ert-erti im nasromtagania, romelmac drois gamocdas gauzlo da romelsac samecniero literaturis Sedevrad moixsenieben. wignis pirvel da meore gamocemebs Soris or ateul welze metia gasuli, avtorta nawili, romelebma meore gamocemis SevsebaSi da damatebebsi miiro monawileoba, tuberkulozis eqspertebad Camoyalibebis processi samagido wignad swored pirveli gamocemas iyenebdnen. ukve ati welia, rac saqartvelosi xorcieldeba tuberkuloztan brzolis saxelmwifo programa, romelic dafuznebulia jandacvis msoflio organizaciis (WHO) da tuberkulozsa da filtvis daavadebebtan brzolis saertasoriso kavsiris (IUATLD) mier SemuSavebul DOTS strategiaze. programas koordinacias uwevs tuberkulozis da filtvis daavadebata erovnuli centris armasrulebeli direqtori b-ni arcil salayaia. winamdebare wignis qartuli gamocemis ideac swored mas ekutvnis. man sxvaze uket uwyis, rom miuxedavad mravali Catarebuli treningisa da sagangebod Seqmnili metoduri rekomendaciebisa, praqtikos eqimebs da jandacvis menejerebs yoveldriuri musaobis processi ucndebat kitxvebi, romlebzec pasuxis gacemasi mat es wigni udides samsaxurs gauwevs. imisatvis, rom wignsi gamoyenebuli samedicino terminologia qartul enaze inglisur dedantan srul SesabamisobaSi yofiliyo didi wvlili miuzrvit ftiziatriasi momusave specialistta jgufs: q-nebs r. marsanisvils, r. aspinzelasvils, m. janelizes, l. goginasvils, q. zedasizes, l. kupreisvils, b-n S. gamcemlizes. miuxedavad mati datvirtuli samusao grafikisa, TiToeuli matganis entuziazmma da maralma pasuxismgeblobis grznobam ganapiroba is faqti, rom mat mokle drosi individualurad daamusaves wignis gankutvnili nawilebi da Semeg miires monawileoba teqstis jgufur ganxilvasi. gansakutrebuli arnisvnis Rirsia profesori q-n l. vasakizis xx

22 wvlili, romelmac Seajama jgufis musaoba da nasromis xelaxla gadamusavebis Semdeg saboloo saxe misca mas. am wignis TargmnasTan, redaqtirebastan da gamocemastan dakavsirebuli yvela teqnikuri da finansuri sakitxi uzrunvelyofili iqna samedicino momsaxurebis saertasoriso korporaciis (MSCI) mier, romelic ass-s ganvitarebis saertasoriso saagentos (USAID) dafinansebit da tuberkulozis erovnul programastan mwidrod TanamSromlobiT axorcielebs saqartvelosi tuberkulozis mkurnalobisa da kontrolis programas. qartveli mkitxvelis madlobas imsaxureben korporaciis prezidenti b-n j. kontisi da vice-prezidenti b-n l. iansensi, romeltac saqartvelosi ramodenime wlis saqmianobis Sedegad gansakutrebuli urtiertoba CamouyalibdaT Cvens TanamemamuleebTan. rom ara mati kerzo iniciativa da daintereseba wignis qartuli gamocemit, qartvel eqimebs SesaZlebelia kidev didxans ar hqonodat sasualeba gacnobodnen am metad Rirebul nasroms. arsanisnavia, agretve korporaciis Tbilisis ofisis TanamSromlebis, programis diretoris q-n T. axalazis da programis direqtoris moadgilis b-n n. nasizis damsaxureba, romlebic, erti mxriv, koordinacias uwevdnen specialistebis, Tarjimnebis da redaqtoris musaobas da meore mxriv, Tanmimdevrulad agvarebdnen yvela organizaciul sakitxs. gaweuli mravaldriani skurpulozuri momqancveli SromisaTvis gansakutrebul madlobas imsaxurebs korporaciis TanamSromeli q-n q. gocaze. sagangebo madloba ekutvnis jandacvis msoflio organizacias, romlis TanxmobiTac qartulad itargmna da gamoica es wigni. xxi

23 monawileta sia rani balasubramaniani eqimi diplomi ginekologiasa da obstetriasi, direqtoris moadgile, tuberkulozis kvlevis centris direqtoris moadgile, Cenai, indoeti naomi boki eqimi, magistris wodeba mecnierebis dargsi, kvlevisa da Sefasebis ganxris samedicino musaki, tuberkulozis ganadgurebis ganyofileba, Sidsis, sasqeso gzit gadamdebi daavadebebisa da tuberkulozisagan Tavdacvis erovnuli centri, daavadebis kontrolisa da Tavdacvis centrebi, atlanta, jorjiis Stati, ass. qesi deraimleri mecnierebata doqtori geografiuli medicinisa da infeqciur daavadebata ganyofileba, stanfordis universitetis samedicino centri, stanfordi, kaliforniis Stati, ass. markos espinali eqimi, mecnierebata doqtori samedicino ganxrit, msoflio jandacvis organizacia, Jeneva, Sveicaria tomas r. frideni eqimi, medicinis mecnierebata doqtori, medmusaki, tuberkuloztan brzolis ganyofileba, msoflios jandacvis organizacia - samxret-armosavlet azia, msoflios jandacvis organizacia - axali deli, indoeti (trieden@health.nyc.gov) antoni harisi biologiis swavlebis ofisis eqimi, fizikosta samefo kolejis wevri, malaviis erovnuli tuberkulozis kontrolis programa-teqnikuri mrceveli, lilongue, malavia (adharriesmalawi.net) maikl f. iademarko eqimi, magistris wodeba sazogadoebrivi jandacvis sferosi, tuberkulozis armofxvris ganxris mecnieruli ganyofilebis direqtoris moadgile, Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da Tavdacvis centrebi, atlanta, jorjiis Stati, ass. (miademarco@cdc.gov) ram kopaka mecnierebata doqtori samedicino ganxrit, medmusaki, tuberkulozis armofxvris ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli xxii

24 centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass. qeila f. lasersoni doqtoris xarisxi mecnierebata dargsi, epidemiologi, tuberkulozis armofxvris saertasoriso saqmianobis ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass. fabio luelmo eqimi, mecnierebata doqtori samedicino ganxrit, tuberkulozis kontrolis programebis konsultanti, Jeneva, Sveicaria dermo maeri bakalavris xarisxi medicinasi, bakalavris xarisxi qirurgiasi, fizikosta samefo kolejis wevri, medicinis musaki, tuberkuloztan brzolis departamenti, msoflios jandacvis organizacia, Jeneva, Sveicaria dik menziesi, eqimi medicines dakvirvebisa da Tvalyuris devnebis centri, tuberkulozis klinikis eqimi, monrealis mkerdis instituti, makgilis universiteti, montreali, PQ, kanada ariel pablos mendesi eqimi, mecnierebata doqtori samedicino ganxrit, direqtoris moadgile, janmrteloba da uflebebi (samartliani janmrteloba), rokfeleris fundamenti, niu iurki, niu iorkis Stati, ass. rajesvari ramaxandran eqimi, DM mecnierebata doqtori, direqtoris moadgile, tuberkulozis kvlevis centri, Cenai, indoeti mario raviglione eqimi, kordinatori, tuberkulozis strategia da operaciebi, tuberkulozis SeCerebis ganyofileba, gadamdebi daavadebebi, msoflios jandacvis organizacia, Jeneva, Sveicaria fatima remani BSc, mtavari kvleviti musaki, tuverkulozis kvlevis centri, Cenai, indoeti m. raixleri eqimi, tuberkulozis armofxvris ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass. hans l. raideri eqimi, mecnierebata doqtori samedicino ganxrit, tuberkulozis ganyofileba, saertasoriso gaertianeba xxiii

25 tuberkulozisa da filtvis daavadebata winaarmdeg, parizi, safrangeti t. santa eqimis xarisxi (brit.), diplomi tuberkulozisa da mkerdis daavadebebis sferosi, direqtoris moadgile (marali safexuri), tuberkulozis kvlevis centri, Cenai, indoeti jon a. sbarbaro bakalavris wodeba samedicino dargsi, magistris xarisxi sazogadoebrivi jandacvis sferosi, FCCP, medicinisa da TavdacviTi medicines profesori; samedicino skola, kolorados jandacvis samecniero centris universiteti, denveri, kolorados Stati, ass. patricia m. simone eqimi, jandacvis mxardaweris ofisis ufrosi, direqtoris ofisi, piter smoli eqimi, adiunkt profesori, infeqciuri daavadebebisa da geografiuli medicines ganyofileba, stanfordis samedicino universiteti, stanfordi, kaliforniis Stati, 94305, ass. ian smiti eqimi, tuberkulozis SeCerebis ganyofileba, jandacvis msoflio organizacia, Jeneva, Sveicaria elizabet a. talboti eqimi, tuberkulozisa da Sidsis kvlevis direqtori, BOTUSA proeqti, internacionaluri saqmianoba tuberkulzis armofxvris ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass. zaqari teilori eqimi, MS, daavadebis kontrolisa da Tavdacvis centrebi, atlanta, jorgiis Stati, ass arman van doini eqimi, mikobaqteriis ganyofileba, tropikuli medicines instituti, antverpi, belgia endriu a. vernoni eqimi, MHS, sametvalyureo samedicino epidemiologis ganyofileba, kvlevisa da Sefasebis ganxra, tuberkulozis armofxvris ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass margarita elsa vilarino sazogadoebrivi jandacva-magistris wodeba, diagnostikuri da Terapevtuli ganyofilebis ufrosi, kvlevisa da Sefasebis ganxra, tuberkulosis armofxvris xxiv

26 ganyofileba. tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass Carlz d. uelsi eqimi, internacionaluri saqmianobis sferos direqtoris moadgile, tuberkulosis armofxvris ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass jandacvis msoflio organizaciis tuberkulozis departamenti ariarebs redaqtoris, eqim t. fridenis Tavdauzogav Sromas, agretve im ZviradRirebul komentars, romelic eqimebma: m. borgdorfma da enarsonma, p. hopevelma, a. seitam da a. van doanma wignis saboloo variants daurtes. ra Tqma unda, arsanisnavia is daxmarebac, romelic eqimma f. luelmom gagviwia. tomanis tuberkulozi xxv

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28 SemTxvevaTa gamovlena 1

29 2

30 1. ra rols asrulebs SemTxvevaTa gamovlena tuberkulozis kontrolis saqmesi 1 f.luelmo 2 tuberkulozis yvelaze infeqciuri variantis, kerzod, naxvelis nacxis gamokvlevit, mgb pozitiuri (nacxit dadebiti) filtvis formis gamovlena tuberkulozis kontrolis sakvanzo elementia. misi mizania bacilagamomyofi anu im pirovnebis gamovlena, romelic sazogadoebasi avrcelebs tuberkulozis gamomwvevi baqteriis did raodenobas. mkurnaloba xels uwyobs aseti infeqciuri pacientebis swrafad gadayvanas abacilur mdgomareobasi, ritac gawyvets daavadebis gadacemis jawvs. SemTxvevaTa drouli gamovlenis kidev erti upiratesoba aris mkurnalobis dawyebis dagvianebis minimumamde dayvana, rac zrdis gankurnebis albatobas 1. Tu gamovlenil pacients ar Cautarda efeqturi mkurnaloba - wamlebis uqonlobis, mkurnalobis cudi organizaciis an samkurnalo dawesebulebebisadmi xelmiuwvdomlobis gamo SemTxvevaTa gamovlenis RonisZiebebs ekargeba Tavdapirveli Rirebuleba. SemTxvevaTa gamovlena mkurnalobis garese iwvevs samedicino sistemisadmi ndobis Sesustebas da zrdis iseti infeqciuri pacientebis raodenobas, romlebic rezistentuli Stamebis wyaros warmoadgendnen. iq, sadac axali SemTxvevebis efeqturi mkurnaloba da gankurneba ver xorcieldeba, umjobesia resursebi da Zalisxmeva mimartuli iyos mkurnalobis Sedegebis amarlebaze da ara axali SemTxvevebis gamovlenis macveneblis gazrdaze 2. garda im pacientebisa, romlebic simptomebis gamo sakonsultaciod mimartaven samedicino dawesebulebebs, gamosakvlev jgufs unda warmoadgendnen is pacientebic, romlebmac mimartes samedicino dawesebulebebs mdgradi anu gaxangrzlivebuli (2-3 kviraze xangrzlivi) xvelis gamo. warsulsi SemTxvevaTa gamovlena warmoebda masiuri miniaturuli radoigrafiit (MMR)-fluorografiiT e.w. aqtiuri gamovlena, 1 k. tomanis pirvel gamocemasi arsebul Tavze dayrdnobit 2 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria 3

31 magram filtvis rentgenogramaze Crdili ar aris tuberkulozis diagnozis specifikuri macvenebeli im pacientebs Sorisac ki, romlebsac arenisnebat filtvis aqtiuri tuberkulozi. rentgenologiuri kvleva ar aris sakmarisi imistvisac ki, rom moxdes diferenciacia infeqciis gamomyof da im pacientebs Soris, romlebic ar warmoadgenen sasisroebas sazogadoebisatvis. masobrivi skriningi ar amartlebs xarjebs, radganac es metodi nakleb specifikuria infeqciis wyaros gamovlenistvis. bevr SemTxvevaSi daavadeba iwyeba SemowmebaTa Soris drois intervalsi da arnisnul SemTxvevebSi pacientebs ara aqvt mkurnalobis dasrulebis motivacia, amitom isini xsirad ikargebian 3,4, (ix. Tavi: ra rols asrulebs perioduli masiuri rentgenologiuri gamokvlevvebis metodi tuberkulozis kontrolis saqmesi ). mdgradi xvelis mqone mozrdili pacientebis gamovlena (im pirtagan, vinc mimartavs samedicino dawesebulebebs) naxvelis nacxis gamokvlevis mesveobit gacilebit ufro xarjefeqturi metodia, vidre rentgenografia. es metodi ufro zustad gamoavlens infeqciis gavrcelebis TvalsazrisiT sasis pacientebs. im regionebsi, sadac pacientebi uzrunvelyofili arian satanado mkurnalobit, unda Catardes mosaxleobis saganmanatleblo RonisZiebebi, romelta mizanic iqneba miawodos mcxovreblebs informacia, Tu ramdenad sasisia xangrzlivi xvela, sad mdebareobs Sesabamisi samedicino dawesebuleba da unda davarwmunot adamianebi, mimarton samedicino personals naxvelis nacxis gamokvlevis Casatareblad. Nnaxvelis mgb dadebiti nacxis mqone pacientebtan kontaqtsi myofi adamianebi arian inficirebisa da tuberkulozit daavadebis marali riskis qves, rac kidev ertxel adasturebs SemTxvevaTa aqtiurad gamovlenis aucileblobas am individebsi. kontaqtebis, kerzod, ki naxvelis dadebiti nacxis mqone tuberkulozit daavadebul pacientebtan kontaqtsi myofi pirebis samedicino Semowmeba rekomendirebulia tuberkulozis SemTxvevebis gamovlenisa da mkurnalobisatvis, aseve prevenciuli mkurnalobis Catarebis miznit iseti marali riskis jgufebsi, rogoricaa bavsvebi da aiv-inficirebuli individebi. amastanave, infeqciis wyaroebis gamovlenisa da mkurnalobis miznit, mnisvnelovania im pirta gamokvleva da perioduli Sefaseba, romlebic imyofebian tuberkulozis gavrcelebis marali riskis dawesebulebebsi: cixeebsi, usaxlkarota TavSesafrebSi da saavadmyofoebsi. 4

32 2. ras warmoadgens tuberkulozis SemTxveva 3 f. luelmo 4 tuberkulozis kontroli miznad isaxavs arnisnuli daavadebis gavrcelebis Semcirebas. misi gavrcelebis Semcirebis yvelaze efeqturi metodia infeqciis potenciuri wyaros, kerzod, tuberkulozis baqteriagamomyofi filtvis formit daavadebuli pacientis identificireba 5 (SemTxvevaTa gamovlenis, diagnostikis gzit) da mkurnaloba. amis garda, sikvdilianobisa da avadobis macveneblebis Sesamcireblad, tuberkulozis kontroli miznad isaxavs daavadebis yvela formis gankurnebas. tuberkulozis kontrolis programebis miznebisatvis, termini SemTxveva~ gamoiyeneba iseti pacientis arsanisnad, romelsac tuberkulozi daudginda baqteriologiurad an eqimis mier 6. programis sawiroebis gamo SemTxvevaTa klasificireba warmoebs dazianebis lokalizaciis mixedvit: filtvis (rodesac dazianeba lokalizebulia filtvis parenqimasi) da FfiltvgareSe (rodesac dazianeba lokalizebulia, nebismier adgilas filtvis parenqimis garda) formebad. filtvis forma, naxvelis nacxis analizis mixedvit, iyofa pozitiurad an negatiurad (rac moicavs naxvelis nacxis daudgenel SemTxvevebsac). naxvelis nacxis pozitiuroba damokidebulia tuberkulozis bacilebis raodenobaze (ix. ramdeni baqteria unda inaxos naxvelis nacxsi, rom is CaiTvalos pozitiurad nacxis mikroskopiuli analizis mixedvit gv. 12) da korelaciasi imyofeba sxva individebis inficirebisa da tuberkulozit gardacvalebis risktan. im individebs, romlebic kontaqtsi iyvnen nacxit dadebit avadmyoftan, tuberkulozis mikobaqteriit inficirebisa da tuberkulozit daavadebis ufro marali riski aqvt, vidre mxolod kulturit pozitiur pacientebtan kontaqtsi 3 k. tomanis pirvel gamocemasi arsebul Tavze dayrdnobit 4 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria 5

33 myoft 7. im qveynebsi, sadac naxvelis nimusebis kulturebis kvleva problemas ar warmoadgens, nacxit uaryofiti SemTxvevebi SeiZleba daiyos tuberkulozis dadgenil SemTxvevebad (dadebiti kulturit tuberkulozis mikobaqteriis kompleqsistvis), an sxvadasxvad (kultura-negatiuri an/da daudgeneli). diagnozis dasadgenad pacientebis klasificireba xorcieldeba imisda mixedvit, hqonda Tu ara pacients Catarebuli tuberkulozis mkurnaloba. mkurnalobis mixedvit, pacientebi iyofian Semdegnairad: axali SemTxveva: pacients mkurnaloba utardeboda ert Tveze naklebi periodis ganmavlobasi an saertod ar umkurnalia; recidivi: nacxit an kulturit dadebiti pacienti, romelsac Cautarda mkurnaloba da Catarebuli mkurnalobis Sedegad micneul iqna gankurnebulad, an sruli kursit namkurnalebad; usedegod namkurnalevi: pacienti, romlis naxvelis nacxic pozitiuri iyo mkurnalobis dasrulebidan 5 an ufro xangrzlivi periodis Semdeg (2 Tvis, an ufro xangrzlivi periodis Semdeg mkurnalobis dawyebidan, Tu Tavdapirvelad pacienti iyo nacxit uaryofiti); Sewyvetili mkurnalobis ganaxleba: mkurnalobis ganaxleba misi Sewyvetidan ori Tvis an meti drois Semdeg; gadmoyvanili pacienti: sxva tubsamkurnalo dawesebulebidan mkurnalobis gagrezelebis miznit gadmoyvanili pacienti; sxva: yvela is SemTxveva, romelic ar ganekutvneba zemot CamoTvlil gansazrvrebebs (amasi Sedis qronikuli SemTxvevebi, anu is SemTxvevebi, roca pacientebi ganmeorebiti mkurnalobis Semdeg arian nacxit dadebiti). Tumca, nacxit negatiuri filtvis da filtvgarese tuberkulozis SemTxvevebSic SesaZloa gvqondes relafsi, usedegod namkurnalebi 6

34 avadmyofebi an qronikuli SemTxvevebi. arnisnuli gvxvdeba isviatad da unda efuznebodes patomorfologiuri an baqteriologiuri kvlevis Sedegebs 6. arricxvianobis warmoebis miznebit, mkurnalobis Sedegebis mixedvit SeirCa pacientta eqvsi kategoria: gankurnebuli: pacienti romelic aris nacxit uaryofiti mkurnalobis bolo TveSi da rogorc minimum ertxel mainc mkurnalobis periodis ganmavlobasi; sruli kursit namkurnalebi: pacienti, romelmac daasrula mkurnaloba, magram ar Seesabameba arc gankurnebulta da arc usedegod namkurnaleb pacientta kategoriebs; usedegod namkurnalebi: pacienti, romelsac arenisneba pozitiuri nacxi mexute Tveze an mkurnalobis nebismier ufro gvian etapze; gardacvlili: pacienti, romelic gardaicvala mkurnalobis dros raime mizezit; mkurnalobasewyvetili: pacienti, romelsac Seuwyda mkurnaloba 2 TviT an ufro xangrzlivi periodit mkurnalobis dawyebis Semdeg; gadayvanili: pacienti, romelic gadayvanil iqna sxva ganyofilebasi da, romlis mkurnalobis Sedegebic aris ucnobi. mkurnalobis warmateba ganisazrvreba, gankurnebuli da sruli kursit namkunalebi pacientebis jamuri ricxvit. im qveynebsi, sadac kvlevasi kulturis gamoyeneba xelmisawvdomia, SesaZloa pacientebis klasificireba kulturebis kvlevis Sedegebis mixedvit: gankurnebuli an usedegod namkurnalebi. 7

35 3. ra rols asrulebs naxvelis mikroskopia im pacientebis gamokvlevasi, romlebic mimartaven samedicino dawesebulebebs f. luelmo 5 naxvelis mikroskopiuli gamokvleva tuberkulozuri infeqciis wyaros gansazrvris yvelaze efeqturi sasualebaa. (es metodi gamoiyeneba tuberkulozis diagnostikistvis pacientebsi, romlebtanac savaraudoa filtvis daavadeba da infeqciis wyaros dasadgenad im pirebs Soris, romeltac arenisnebat xvela da nebismieri mizezit mimartes samedicino dawesebulebas.) naxvelis mikroskopia aseve gamoiyeneba infeqciuri pacientebis mkurnalobis progresis monitoringisa da gankurnebis faqtis dasadastureblad. diagnozi naxvelis nacxis gamokvlevis diagnostikuri efeqtianobis sakitxebi ganxilulia TavSi: ramdenad sarwmunoa naxvelis mikroskopiuli gamokvleva nacxis mikroskopiis gamoyenebas aqvs ramodenime funqciuri upiratesoba kulturis gamokvlevastan SedarebiT. Sedegebi vlindeba ufro swrafad da gvicvenebs, Tu ramdenad sasisia infeqciurobis TvalsazrisiT; xdeba im pacientebis identificireba, romlebsac aqvt darupvis marali riski, Tu ar imkurnaleben; gamoavlens pacientebs, romlebsac didi baqteriuli datvirtvis gamo mkurnalobis sawyis rejimtan ertad esawiroebat damatebiti medikamentebi. pacientebis gansazrvruli nawili eqims mimartavs tuberkulozze saewvo simptomebis gamo. Aam SemTxvevaSi eqimis valia ewvi miitanos tuberkulozze da Cautaros pacients Sesabamisi diagnostikuri 5 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria 8

36 testebi. mdgradi xvelis SemTxvevaSi filtvis infeqciuri tuberkulozis diagnostikis yvelaze mnisvnelovani diagnostikuri testi naxvelis gamokvlevaa. gulmkerdis rentgenologiuri kvleva gamoiyeneba filtvis daavadebebis diferenciuli diagnozistvis nacxit uaryofit pacientebsi. diagnostikuri procedurebis danisvnis periodi damokidebulia qveyanasi tuberkulozis prevalentobis macvenebelze. im adgilebsi, sadac tuberkulozis SemTxvevebi xsiria, anu maralia prevalentoba, pirvel rigsi, unda iqnes gamoyenebuli naxvelis nacxis gamokvleva. im adgilebsi, sadac arinisneba daavadebis dabali prevalentoba, SesaZlebelia nacxis gamokvlevis da gulmkerdis rentgenologiuri kvlevis ertdroulad Catareba. aseve SesaZlebelia tuberkulozisatvis araspecifikuri antibiotikebis mokle kursis danisvna. gulmkerdis rentgenologiuri kvleva unda Catardes rogorc damxmare procedura naxvelis nacxisa da kulturis gamokvlevis Catarebamde. nebismier SemTxvevaSi, rentgenologiurad patologiuri cvlilebebis gamovlenisas filtvis tuberkulozis diagnozis sabolood dadgenamde, pacientma unda Caabaros naxvelis ramodenime sinji nacxis analizisatvis. SemTxvevis gamovlena xsirad filtvis tuberkulozis diagnozis dadgena ver xerxdeba daavadebis gvian stadiamde im SemTxvevaSic ki, rodesac pacienti mimartavs samedicino dawesebulebas daavadebis sawyis periodsi. arnisnulis ZiriTadi mizezi aris is, rom eqims ar miaqvs ewvi tuberkulozze, an ar moitxovs, rom pacientma xvelis sindromit Caitaros naxvelis nacxis analizi, gansakutrebit masin, rodesac daavadebis mimdinareobisas ar vlindeba sxva respiratoruli nisnebi. gamoangarisebulia, rom ganvitarebadi ekonomikis qveynebsi im mozrdil pacientta 5-10%-s, romlebic mimartaven ambulatoriul dawesebulebas, arenisnebat mdgradi xvela 2-3 kviris ganmavlobasi 8, 9. filtvis tuberkulozis nacxit dadebiti formebis Tanafardoba nacxit uaryofit formebtan damokidebulia sazogadoebasi am daavadebis prevalentobaze. samedicino dawesebulebebis ambulatoriul pacientebisagan mdgradi xvelis mqone avadmyofebis identificireba izleva tuberkulozuri infeqciis wyaros didi nawilis gamovlenis 9

37 SesaZleblobas 10. arnisnuli amcirebs daavadebis mkurnalobis dawyebis dagvianebis safrtxes, aseve amcirebs sxva pacientebis da personalis inficirebis risks. aseti pacientebis warmatebuli mkurnaloba swraf zegavlenas axdens tuberkulozis prevalentobaze, sikvdilianobasa 11 da infeqciis gavrcelebaze 8. didi datvirtvit momusave samedicino dawesebulebebi, parasamedicino da administraciuli personali, pasuxs unda agebdes qronikuli xvelis mqone pacientebis gagzavnaze naxvelis nacxis gamosakvlevad. arnisnuli skrining-metodit daavadebulta gamovlena warmoadgens sazogadoebrivi jandacvis RonisZiebas, romelic miznad isaxavs mxolod infeqciis wyaros gamovlenasa da mkurnalobas. amastan is aris damatebiti diagnostikuri RonisZieba iset pirta diagnostikisatvis, romlebic spontanurad mimartaven ambulatorias. vinaidan pirveladi mizani sazogadoebistvis sargeblis motanaa, es procedura unda iyos martivi, mosaxerxebeli gamosakvlevi piristvis, ufaso da ar unda scildebodes pacientis im Tavdapirvel mizezs, ris gamoc man miakitxa ambulatorias. Zalian mnisvnelovania pacientis saxelis, gvarisa da misamartis dafiqsireba. laboratoriis mier nacxis pozitiurobis gamovlenisas, pacienti unda saswrafod moinaxos da dawyebul iqnes mkurnaloba. kulturis analizit gamokvleva ar warmoadgens SemTxvevaTa sistematuri gamovlenis prioritetul tests. mxolod kulturit pozitiuri individebi ufro naklebad kontagiozurebi arian, vidre isini, romelta mikroskopuli testic dadebitia. amis garda, kulturis kvleva ufro Zviria da ufro rtulad Sesasrulebeli, pasuxis mireba ki, did dros moitxovs. xvelis zrvruli xangrzlivoba, romlis drosac rekomendirebulia naxvelis nacxis testis Catareba, ganisazrvreba TiToeuli qveynis mier da efuzneba: nacxit dadebiti tuberkulozis SemTxvevebis saxsires qveyanasi, mosaxleobis mier jandacvis obieqtebsi mimartvis sixsires da arsebul laboratoriul sasualebebs. Tu tuberkulozis prevalentoba Zalian dabalia, masin azri ara aqvs nacxis testebis sistemurad gamoyenebas gaxangrzlivebuli xvelis mqone individebs Soris (dabali xarjefeqturoba da cru-dadebiti Sedegebis mirebis marali riski). samkurnalo dawesebulebebsi mimartva sxvadasxva qveyanasi gansxvavebulia. ganvitarebuli ekonomikis qveynebsi xalxi samedicino dawesebulebebs konsultaciebisatvis ufro adreul 10