Toman s Tuberculosis

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

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

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

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 92 4 154903 4 (NLM classification: WF 360) WHO/HTM/TB/2004.334 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) 22 791 4285, el. fosta: cdsdocs@who.int dizaini minimaluri grafikis gamoyenebit akrefilia Contour Ltd. TbilisSi dabewdilia Contour Ltd. TbilisSi

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...3 2. ras warmoadgens tuberkulozis SemTxveva f. luelmo...5 3. ra rols asrulebs naxvelis mikroskopia im pacientebis gamokvlevasi, romlebic mimartaven samedicino dawesebulebebs f. uelmo...8 4. ramdeni baqteria unda iyos napovni nacxsi, rata igi mivicniot dadebitad k. tomani...13 5. ramdenad sarwmunoa nacxis mikroskopia k. tomani...16 6. ra aris cru-dadebiti da cru-uaryofiti pasuxebis ZiriTadi mizezebi k. tomani...27 7. rogoria cru-pozitiuri da cru-negatiuri nacxis ZiriTadi Sedegebi T. freideni...33 8. ra dadebiti da uaryofiti mxareebi aqvs fluoroscentul mikroskopul kvlevas k. tomani...37 9. rogoria mikobaqteriuli kulturebis gamokvlevis roli tuberkulozis diagnostikasa da SemTxvevaTa dadgenasi van deuni...42 10. rogoria kultura_uaryofiti Sedegis mirebis albatoba nacxit dadebiti tuberkulozis dros k. tomani...54 11. ra damatebiti Sedegebi moaqvs naxvelis gamnmeorebit gamokvlevas nacxis mikroskopiuli da kulturaluri kvlevis sasualebit a. harisi...57 v

12. ramdenad sandoa gulmkerdis rentgenografiuli kvleva r. kopaka da n. boki...63 13. 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...75 14. rogor vitardeba filtvis tuberkulozi da rogor gamovavlinot is adreul etapze k. tomani...82 15. ra rols asrulebs tuberkulozis kontrolis saqmesi SemTxvevaTa gamovlena perioduli masiuri rentgenografiuli gamokvlevis mesveobit h. raideri...89 16. rit gansxvavdeba tuberkulozis diagnostika aiv-inficirebul pacientebsa da arainficirebul pirebsi a. harisi...98 17. ra rols asrulebs tuberkulinis kanis testi tuberkulozis diagnostikasi d. menziesi...103 18. rogoria sxva diagnostikuri testebis arsebuli da potenciuri roli d. menziesi...106 19. rogor unda itanamsromlon kerzo da saxelmwifo seqtorebma tuberkulozis gamovlenis, mkurnalobisa da monitoringis dros t. frideni...111 mkurnaloba 20. tuberkulozis mkurnalobis ganvitarebis ZiriTadi etapebi k. tomani...119 21. rogor moqmedebs tuberkulozis mkurnaloba k. tomani...122 22. ra rols asrulebs makroorganizmis faqtorebi tuberkulozis patogenezsi, prevenciasa da mkurnalobasi m.lademarko da m. ricleri...127 23. ra Terapiuli efeqti da toqsiuroba axasiatebs tubsawinaarmdego medikamentebs T. frideni da m. sarnali...131 24. ra mizans emsaxureba orfaziani mkurnalobis sawyisi intensiuri mkurnaloba k. tomani...148 25. rogoria Tanamedrove rekomendaciebi standartuli rejimis mimart a. harisi...151 26. ra diagnostikuri kategoriebi arsebobs da ra principebi udevs mat safuzvlad a. harisi...157 vi

27. ras warmoadgens intervalebit intermitiuli mkurnaloba da ra mecnieruli safuzvlebi aqvs mas t. frideni...160 28. ra dozebit gamoiyeneba tubsawinaarmdego medikamentebi yoveldriur da intermitiul rejimsi h. reideri...170 29. ra mecnierul mtkicebulebebs efuzneba tubsawinaarmdego medikamentebis dozirebastan dakavsirebuli rekomendaciebi h. raideri...172 30. rogoria mkurnalobis optimaluri xangrzlivoba T. santa...175 31. ra ZiriTadi gverditi reaqciebi axasiatebs pirveli rigis tubsawinaarmdego medikamentebs da rogoria mati ganmeorebit danisvnis procedura a. harisi...182 32. ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazids plus TioacetazoniT mkurnaloba h. raideri...191 33. rit gansxvavdeba eqstrapulmonaruli tuberkulozis martva filtvis tuberkulozis martvisagan r. balasubramaniani, r. rajesvari, T. santa...195 34. rit gansxvavdeba tuberkulozis mkurnaloba fexmzime qalebsi, RviZlis an Tirkmlis daavadebis mqone pacientebsi a. harisi...199 35. rit gansxvavdeba tuberkulozit daavadebuli aivinficirebuli pacientebis mkurnaloba a. arisi...203 36. ra ZiriTadi Sedegebi iqna mirebuli madrassi Catarebuli kvlevebit, romelta mizanic iyo binaze da sanatoriumsi mkurnalobis formebis Sedareba k. tomani...207 37. ramdenad xsirad Sewyveten vadamde adre pacientebi mkurnalobas j. sbarbaro...217 38. ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves j. sbarbaro...219 39. ratom aris mkurnaloba warumatebeli da ra unda gaketdes mkurnalobis arasasurveli Sedegebis armosafxvrelad f. luelmo...221 40. ra upiratesobebi da nakli aqvs tubsawinaarmdego medikamentebit fiqsirebuli dozebit mkurnalobas k. lasersoni da m. lademako...227 41. rogor vitardeba medikamentebisadmi rezistentoba k. tomani...232 42. ratom unda davicvat gansakutrebuli sifrtxile rifampicinis gamoyenebisas a. vernoni...235 vii

43. medikamentebisadmi rezistentobis ra tipebi arsebobs m. espinali...238 44. ras warmoadgens ~vardnisa da matebis fenomeni da rogoria ~Tanmimdevruli rejimis meqanizmi m. espinali...240 45. ramdeni medikamentisadmi rezistentuli bacila SeiZleba iqnes armocenili tuberkulozit daavadebuli, aranamkurnalebi pacientebis naxvelsi a. pablos-menozi...243 46. ra mizezebi ganapirobebs medikamentebisadmi rezistentuli tuberkulozis ganvitarebas m. espinali da t. frideni...248 47. rogor avicilot Tavidan medikamentebisadmi rezistentoba t. frideni...250 48. ramdenad sandoa medikamentebisadmi mgrznobelobis testebi m. espinali...253 49. rogoria medikamentebisadmi mgrznobelobis arazusti testirebis SesaZlo Sedegebi m. espinali...255 50. ra sarezervo rejimebi arsebobs da ra adgili uwiravt mat tuberkulozis kontrolis programebsi m. espinali...257 51. ra rols asrulebs latenturi tuberkulozis mkurnaloba, tuberkulozis kontrolis programasi m. e. vilarino...263 52. ra epidemiologiuri zegavlena aqvs latenturi tuberkulozuri infeqciis mkurnalobas z. teilori...271 monitoringi 53. rogoria tuberkulozis avadobit gamowveuli janmrtelobis, socialuri da ekonomikuri mdgomareobis gauareseba i. smiti...277 54. rogoria tuberkulozis kontrolis globaluri miznebi da ras efuzneba is i. smiti...282 55. ra aris DOTS-i i. smiti...286 56. aris Tu ara DOTS-i xarjtefeqturi i. smiti...292 57. rogor ganvaxorcielot mkurnalobis Sedegebis warmatebis monitoringi t. santa...297 58. ramdenad efeqturia tuberkulozis mkurnaloba da risi gaketebaa sawiro momavalsi t. santa...301 59. warmoadgens Tu ara pirveladi rezistentoba sasisroebas tuberkulozis kontrolisatvis m. espinali da t. frideni...301 viii

60. gankurebis ra ZiriTadi sasualebani arsebobs k. tomani..309 61. ra mnisvneloba eniweba mkurnalobis Sewyvetas tuberkulozis mkurnalobis dros n. boki...313 62. ramdenad mnisvnelovania mkurnalobis gavrcelebis faza da rogoria recidivis sixsire mkurnalobis dasrulebis Semdeg t. santa...317 63. ristvis aris sawiro registrirebisa da angarisgebis sistema da romeli sistemis gamoyenebaa am TvalsazrisiT rekomendirebuli d. maheri, m. ravilione...320 64. rodis unda moxdes tuberkulozit daavadebuli pacientebis hospitalizacia da ramdenad baqteriagamomyofni arian isini mkurnalobis dros e. a. talboti, s. d. velsi... 65. rogor xdeba tuberkulozis nozokomialuri transmisia da rogoria misi prevencia f. m. simone...329 66. Cveulebriv sad vrceldeba tuberkulozi da rogor SevamciroT misi gavrceleba h. reideri...334 67. ra principebi da motxovnebi arsebobs kontrolirebadi klinikuri kvlevebis mimart f. rehmani...337 68. ra aris molekuluri epidemiologia da ra rols asrulebs igi tuberkulozis kontrolis saqmesi k. derimeri da f.m. smoli...353 69. SesaZlebelia Tu ara tuberkulozis kontroli t. frideni...358 70. SesaZlebelia Tu ara SemTxvevaTa gamovlenis da mkurnalobis mesveobit medikamentebisadmi rezistentobis prevencia da ukuqceva sazogadoebasi m. ravilione...369 71. ra macvenebeli aqvs tuberkulozis kontrolis efeqtur programas f. luelgo da t. frideni...376 72. tuberkulozis kontrolis efeqturi programis magalitebim. ravilione da t. frideni...381 73. ra SedarebiTi prioritetebi aqvs tuberkulozis kontrolis programas da ra saqmianoba ar unda ganxorcieldes f. leilmo da t. frideni...385 74. ra zegavlenas axdens aiv-infeqcia tuberkulozis epidemiologiaze mosaxleobasi a. harisi...391 75. rogor SevuwyoT xeli tuberkulozis kontrolis samsaxurebs da rogor SevinarCunoT mati qmeditoba t. frideni...396 ix

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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

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

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

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

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

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

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

madlobis werili meore gamocemisatvis es RirsSesaniSnavi wigni swored, rom tomanis tuberkulozia. kurt tomanma safuzveli Cauyara da Seqmna wigni, romelic SeiZleba micneul iqnes Sedevrad. 1970 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. 1965-wlamde arsebuli sarekomendacio masala mopovebul iqna CDC-s (atlanta, jorjiis Stati, ass), Culalongkornis universitetis samedicino bibliotekis (bankoki, xviii

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. 1979 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

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

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

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. (nbock@cdc.gov) qesi deraimleri mecnierebata doqtori geografiuli medicinisa da infeqciur daavadebata ganyofileba, stanfordis universitetis samedicino centri, stanfordi, kaliforniis Stati, ass. (kathy@molepi.stanford.edu) markos espinali eqimi, mecnierebata doqtori samedicino ganxrit, msoflio jandacvis organizacia, Jeneva, Sveicaria (espinalm@who.int) 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

centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass. (vcr4@cdc.gov) 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. (klaserson@cdc.gov) fabio luelmo eqimi, mecnierebata doqtori samedicino ganxrit, tuberkulozis kontrolis programebis konsultanti, Jeneva, Sveicaria (luelmof@xs4all.nl) dermo maeri bakalavris xarisxi medicinasi, bakalavris xarisxi qirurgiasi, fizikosta samefo kolejis wevri, medicinis musaki, tuberkuloztan brzolis departamenti, msoflios jandacvis organizacia, Jeneva, Sveicaria (maherd@who.int) dik menziesi, eqimi medicines dakvirvebisa da Tvalyuris devnebis centri, tuberkulozis klinikis eqimi, monrealis mkerdis instituti, makgilis universiteti, montreali, PQ, kanada (dick.menzies@mcgill.ca) ariel pablos mendesi eqimi, mecnierebata doqtori samedicino ganxrit, direqtoris moadgile, janmrteloba da uflebebi (samartliani janmrteloba), rokfeleris fundamenti, niu iurki, niu iorkis Stati, ass. (APablos-Mendez@rockfound.org) 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 (raviglionem@who.int) 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. (mrr3@cdc.gov) hans l. raideri eqimi, mecnierebata doqtori samedicino ganxrit, tuberkulozis ganyofileba, saertasoriso gaertianeba xxiii

tuberkulozisa da filtvis daavadebata winaarmdeg, parizi, safrangeti (TBRieder@tbrieder.org) 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. (John.Sbarbaro@UPIColo.org) patricia m. simone eqimi, jandacvis mxardaweris ofisis ufrosi, direqtoris ofisi, (psimone@cdc.gov) piter smoli eqimi, adiunkt profesori, infeqciuri daavadebebisa da geografiuli medicines ganyofileba, stanfordis samedicino universiteti, stanfordi, kaliforniis Stati, 94305, ass. (peter@molepi.stanford.edu) ian smiti eqimi, tuberkulozis SeCerebis ganyofileba, jandacvis msoflio organizacia, Jeneva, Sveicaria (smithi@who.int) 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. (edt7@cdc.gov) zaqari teilori eqimi, MS, daavadebis kontrolisa da Tavdacvis centrebi, atlanta, jorgiis Stati, ass (Zxt0@cdc.gov) arman van doini eqimi, mikobaqteriis ganyofileba, tropikuli medicines instituti, antverpi, belgia (armand.vandeun@ping.be) 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 (avernon@cdc.gov) margarita elsa vilarino sazogadoebrivi jandacva-magistris wodeba, diagnostikuri da Terapevtuli ganyofilebis ufrosi, kvlevisa da Sefasebis ganxra, tuberkulosis armofxvris xxiv

ganyofileba. tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri, daavadebata kontrolisa da matgan Tavdacvis centrebi, atlanta, jojiis Stati, ass (mev1@cdc.gov) 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 (mev1@cdc.gov) 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

SemTxvevaTa gamovlena 1

2

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

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

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

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

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

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

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

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

etapze da ufro xsirad mimartavs, amitom skriningis miznebisatvis xvelis xangrzlivoba unda ufro xanmokle iyos. es, erti mxriv, zrdis araspecifikuri xvelis mqone pacientebis ricxvs da laboratoriis datvirtvas, xolo meore mxriv, amcirebs xarjefeqturobas. xvelis prevalentobis (SemTxvevaTa sixsiris) Seswavla im mozrdil pacientebs Soris, romlebic mimartaven ambulatoriul dawesebulebebs, gvexmareba davadginot xvelebis is optimaluri xangrzlivoba, romlis drosac rekomendirebulia naxvelis nacxis rutinuli wesit gamokvleva 9,12,13. ambulatoriul pacientebsi naxvelis mikroskopuli kvlevis mesveobit SemTxvevaTa gamovlenam SesaZloa mnisvnelovnad gazardos infeqciis diagnostirebul wyarota ricxvi. gamokvleuli ambulatoriuli pacientebis raodenoba, sadiagnostiko nacxebis raodenoba da infeqciis identificirebul wyarota raodenoba, warmoadgenen SemTxvevaTa gamovlenaze orientirebuli saqmianobis macveneblebs. magalitad, 1990 wels Catarda 210 905 nacxis gamokvleva, romlis mesveobitac gamovlinda filtvis tuberkulozis nacxit dadebiti formis 24 023 SemTxveva, 1993 wels ki, gamokvleuli iyo 332 000 daavadebulidan arebuli 602 000 nacxi, aqedan identificirebul iqna daavadebis 35 646 SemTxveva. 1999 wels daavadebis SemTxvevaTa ricxvi Semcirda 24 511-mde, miuxedavad imisa, rom nacxis gamokvlevebis ricxvi gaizarda. 1 085 748 adamians Cautarda 1 938 201 - mde gamokvleva 8,11. pozitiuri nacxebis proporcia negatiurtan warmoadgens sazogadoebasi tuberkulozis SemTxvevaTa Semcirebaze programis gavlenis arapirdapir macvenebels. perusi respiratoruli simptomebis mqone pacientebsi nacxis pozitiurobis macvenebeli iyo 1990 wels 18,7%-i, 1991w. _ 14,9%, 1995w. _ 8,5%, 1997 wels 2,7%. amis msgavsad 20 wlis ganmavlobasi CileSi mgb+ ricxvi Semcirda 10%-dan 2%-mde. 1999 wlistvis perusi, tuberkulozis gamovlenis miznit, yovelwliurad tardeboda mozrdili mosaxleobis 5%-is gamokvleva nacxis mikroskopiuli analizis mesveobit. naxvelis nacxis mikroskopuli kvleva mkurnalobis dros da mkurnalobis Semdeg naxvelis nacxis mikroskopiul kvlevas fundamenturi mnisvneloba eniweba filtvis tuberkulozis infeqciuri SemTxvevebis mkurnalobis efeqturobis monitoringis TvalsazrisiT. nacxis 11

gamokvleva unda Catardes mkurnalobis intensiuri fazis bolos. Tu nacxi pozitiuri armocndeba, masin intensiuri faza unda gagrzeldes kidev erti Tve. gankurnebis dadasturebis miznit nacxi unda gamokvleul iqnes rogorc gagrzelebis fazis ganmavlobasi, aseve misi dasrulebisas. konversiis macvenebeli mkurnalobis me-2-me-3 TvisTvis (es ukanaskneli ganisazrvreba, rogorc Tavdapirvelad nacxit dadebiti da mkurnalobis Sedegad nacxit uaryofiti pacientebis wili, im avadmyofebis saerto raodenobidan, vinc daiwyo mkurnaloba) warmoadgens karg samanipulacio indikators. is gamoxatavs programis SesaZleblobas bolomde miiyvanos pacientebis mkurnaloba, moipovis nacxis nimusebi, da aseve, moaxdinos infeqciis wyaros armofxvra. es mkurnalobis Sedegebis indikatoris adreuli surogatia. 14 marali efeqturobis mqone mokle kursis mkurnalobis rejimis dros nacxi SeiZleba darces pozitiuri 2-3 Tve darupuli bacilebis arsebobis gamo kultura-uaryofit pacientebsi. amrigad, 5 Tvemde nacxis pozitiurobis SenarCunebis SemTxvevaSi mkurnaloba ar ganixileba rogorc usedego. (ix. rogor unda Catardes progresis monitoringi? ). imisatvis, rata pacienti mivicniot tuberkulozisgan gankurnebulad, aucilebelia nacxis negatiuri Sedegebi mkurnalobis periodsi da mkurnalobis dasrulebisas. 12

4. ramdeni baqteria unda iyos napovni nacxsi, rata igi mivigniot dadebitad k. tomani 6 Tu nacxi sworad aris momzadebuli, masin mjavagamzle baqteriebis raodenoba am nacxsi koleraciasia mgb-s raodenobastan. Nnaxvelis nimussi, es Tanafardoba, romelic mravali avtoris 15,16,17,18 (1-4) mier aris gamokvleuli, SeiZleba Semdegnairad iqnes warmodgenili. sasagne minaze nacxis preparati Seicavs 0.01 ml naxvels. es odenoba Tavsdeba 200 (10X20)mm² fartobze, radgan imersiuli are, romelic Cans mikroskopsi Seadgens 0,02mm 2. mtlianad nacxis Sesaswavlad sawiroa 10 000 aseti aris gamokvleva 1 000X gadidebisas, e.i. 100X gadideba xdeba imersiuli obieqtivis linzit da 10X okularis linzit. (gasasinji sivrcis zoma fluoroscentuli mikroskopit datvalierebisas Seadgens 15X, didi linzistvis 25X da okularis linzistvis 10X.) nacxis erti sigrzis (20mm) datvalierebisas, rac Seadgens nacxis mteli fartobis daaxloebit 1%-s, xdeba 100-120 mikroskopuli velis skriningi. zemot moyvanili gaangarisebani exeba 10X20mm 2 fartobze gantavsebul nacxs. sazogadod, yoveldriur praqtikasi gamoiyeneba 20X30mm 2 zomis nacxebi. amrigad, Tu naxvelis sinji Seicavs daaxloebit 5000 mikobaqterias yovel ml-si, mteli nacxi (Tu is momzadebulia zemot arwerili metodit) unda Seicavdes daaxloebit 50-s. im SemTxvevaSi, Tu es mikobaqteriebi Tanabrad arian ganawilebulni nacxis 10 000 areze, masin 200 areze unda modiodes erti mgb. Tu Seswavlili iqna 100 are, masin baqteriis monaxvis Sansi 50%-ia. imisatvis, rom vipovot sami e.w. mjavagamzle baqteria (mgb) unda Catardes daaxloebit 600 aris skriningi (datvaliereba). Tu 6 gardacvlilia 13

gamokvleul iqna 300 are masin mjavagamzle baqteriata povnis Sansi kvlav 50%-ia 19,20,21. amastanave, rom vipovot erti mjavagamzle baqteria (mgb) yovel 10 mxedvelobis aresi an 10 yovel 100 aresi, masin nacxsi unda arsebobdes 1 000 aseti baqteria (10 000 are), an 100 000 (10 5 ) unda modiodes naxvelis TiTi ml-ze.(ix. cxrili #1). imisatvis, rom TiToeul aresi inaxos erti mgb, sawiroa, rom naxvelis ert mm-ze sasualod 10 6 baqteria modiodes (ix. cxrili #1). amgvarad, nacxi, romelic mgb-ta raodenobis mixedvit mudmivad dadebitia, unda Seicavdes sul mcire 100 000 mgb-s yovel ml-ze. cxrili #1. mjavagamzle baqteriata savaraudo raodenoba naxvelis nimusebsa da nacxebsi (savaraudo minimaluri raodenoba) imersiuli areebis raodenoba ert baqteriaze gaangarisebit 100 10 1 mgb-s raodenoba TiToeul nacxsi 100 1000 10000 Mmgb-s raodenoba naxvelis nimusze 1ml-Si 10000 100000 1000000 es gaangarisebebi efuzneba im azrs, rom mgb nacxsi Tanabradaa gafantuli. e.i. TiToeuli masalis ulufa Seicavs mgb-s ertsa da imave ricxvs, Tanabrad ganawilebuls mtel nacxze. Tumca SeiZleba, rom baqteriebi ar iyos Tanabrad ganawilebuli nacxsi, xsirad isini gvxvdeba koltebad Sejgufuli. amrigad, rodesac naxvelis sinjidan virebt ramodenime nimuss sxvadasxva nimusi Seicavs baqteriata sxvadasxva ricxvs. Tumca, rodesac naxvelis sxvadasxva nimusebidan arebuli didi raodenobis sinjebsi baqteriebis ricxvis Sedarebisas gamoiyenes kulturebtan musaobis specialuri metodebi mnisvnelovani Sedegebi iqna mirebuli. kerzod, erti da igive nimusidan arebuli sinjebidan kultivirebuli koloniebis ricxvi meryeobs ara randomizirebulad, aramed mxolod gansazrvrul farglebsi (ix. ~ramdenad sandoa naxvelis nacxis mikroskopuli gamokvleva ). msgavsad amisa, sxvadasxva nimusidan arebul sinjebsi 14

koloniebis sxvadasxva raodenoba ar warmoiqmneba randomizirebulad, aramed ganpirobebulia masalasi mgb -s gansxvavebuli koncentraciit. amrigad, miuxedavad mnisvnelovani variaciebisa, baqteriata ricxvi nacxsi TiTqmis Seesabameba baqteriata koncentracias naxvelsi 18. naxvelis nimussi baqteriata koncentraciis garkveuli donis qvemot albatoba imisa, rom mgb SesaZloa nimusidan nacxsi gadavides da gamocndes mikroskopsi udris nuls. miuxedavad amisa, gamotvlilia, rom optimalur laboratoriul pirobebsi dadebiti nacxis pasuxis mireba SesaZlebelia im SemTxvevaSi, rodesac mikroorganizmebis ricxvi ml-ze Seadgens 100-1000 22. ufro praqtikuli gaangarisebaa 10 000 mikroorganizmi. Tuki, TiToeuli naxvelis nacxis nimusis mgrznobeloba mxolod 22-43%-ia, masin mravali nimusis gamokvlevisas gamovlenis sixsire mnisvnelovnad matulobs; magalitad, rodesac xdeba 2-3 nacxis gamokvleva 2 dreze meti drois ganmavlobasi, filtvis aqtiuri tuberkulozis mqone pacientebis 50-70%-s, nacxis dadebiti pasuxi aqvs 23. 15

5. ramdenad sarwmunoa nacxis mikroskopia k. tomani 7 naxvelis mikroskopiuli kvlevis sandoobis raodenobrivad Sefasebis miznit pasuxi unda gaeces Semdeg kitxvebs: 1. rogoria mjavagamzle baqteriebis (mgb) armocenis albatoba nacxsi, romelic damzadebulia mcire, sasualo da didi raodenobit mgb-s Semcveli naxvelisagan? 2. rogoria (cru) dadebiti pasuxis mirebis albatoba naxvelis im nimusebis nacxebsi, romlebic ar Seicaven tuberkulozis mokobaqteriebs? 3. ra sixsirit xdeba pasuxebis Tanxvedra sxvadasxva laborantebs, an laboratoriebs Soris erti da igive nimusidan mirebuli nacxebis gamokvlevisas? cxrili #1, romelic mocemulia qvetavsi: ramdeni mikobaqteria unda iyos nacxsi rom igi CaiTvalos dadebitad, garkveulwilad pasuxobs pirvel kitxvas. am cxrilsi mocemuli cifrebi mirebulia eqsperimentuli kvlevebis safuzvelze da ewinaarmdegeba varauds, rom mikobaqteriebi Tanabrad arian ganawilebulni nacxsi. radganac mgb-s Semcveloba nimusebsi gansxvavebulia, amitom sawiroa aseti gazomvebis Catareba didi raodenobit nimusebze, xolo kulturis analizis Sedegi standartul macvenebelad unda iqnes micneuli 24. ramodenime kvlevasi 25, 26 nacxsi mgb-s raodenoba Sedarebulia imave nimusidan mirebul kulturaze armocenebuli koloniebis raodenobastan. 1 gardacvlilia 16

rva laboratoriis mier Catarebuli ertoblivi kvlevit dadasturda, rom erti da igive nimusidan mirebul kulturebsi koloniebis raodenoba icvleboda, Tumca es gansxvaveba iyo minimaluri. gaketda daskvna, rom arsebobs pozitiuri korelacia nimusebsi kultivirebuli mikobaqteriebis koncentracias, Sesabamiss nacxsi mjavagamzle baqteriata raodenobasa da mati pirdapiri mikroskopit identificirebis albatobas Soris. mocemuli Sedegebi (cxrili #2) gvicvenebs, rom nacxsi mgb-s povnis Sansi matulobs nimussi baqteriata koncentraciis zrdastan ertad. am monacemebis sqematurad ganlagebis Sedegad mivirebt mruds, romelic gvicvenebs, rom nimussi mgb-s identificirebis 50%-iani albatoba arsebobs im SemTxvevaSi, rodesac nacxi Seicavs 6 000 baqterias ert ml-ze. asetive monacemebi iqna mirebuli adre Catarebuli kvlevebis Sedegadac 25, 26. cxrili #2 mjavagamzle baqteriata raodenoba nacxebsi, baqteriata kultivirebadi koncentracia naxvelis nimussi da pozitiuri Sedegebis albatoba baqteriata raodenoba 0-100 an meti aredan 1-2 300 aresi 1-9 100 aresi 1-9 10 aresi 1-9 1 areze 10 an meti areze baqteriata raodenobis koncentraciis nimusi 1 - ml-si <1000 5000-10 000 daaxloebit 30 000 daaxloebit 50 000 daaxloebit 100 000 daaxloebit 500 000 dadebiti Sedegis albatoba <10%-ze 50% 80% 90% 96,2% 99,95% *cxrili #2 moyvanilia literaturuli wyarodan N 1. *daaxloebit 0,01ml homogenizirebuli naxveli motavsebuli da ganawilebul iqna daaxloebit 200mm 2 fartobis mqone sasagne minaze. mikroskopis imersuli mxedvelobis are da 1000 X-iT gadidebit Seadgens 0,02mm 2, aqedan gamomdinare naxveli unda Seicavdes 10 000 aset vels (ix. gv.11). imisatvis, rom Seemowmebina es Sedegebi David-ma sxva avtorebtan ertad cada daedgina, nacxsi mgb gamovlenis SesaZlebloba baqteriata sxvadasxva koncentraciis dros. mat Seafases 432 17

nimusi sam sxvadasxva eqsperimentsi. baqteriata koncentraciebi meryeobda 15 000-dan 300 000-mde ml-si. TiToeul laborants pirdapiri mikroskopit unda Seeswavla SerCeuli pacientebisgan mirebuli masalis yvela nimusebidan arebuli nacxebi. nacxis momzadebis da gamokvlevis teqnikuri procedurebis unificirebuli sistemis uzrunvelsayofad am kvlevasi monawile laboratoriasi SemuSavebul iqna standartuli protokoli. kvleva ise mimdinareobda, rom arc ertma laborantma ar icoda meore laborantis mier Catarebuli mikroskopuli gamokvlevit mirebuli Sedegebis, an masalis wyaros Sesaxeb. Llaborantebs xeli ar miuwvdebodat iset informaciaze, romlis gamoyenebis Sedegadac gveqneboda cdomileba im nacxebis procentuli Sefardeba, romlebic CaiTvala uaryofitad mocemulia cxrilsi #3. cxrili #3 gvicvenebs, rom nacxsi mgb-s armoucenlobis albatoba mcirdeba naxvelis nimusebsi baqteriata koncentraciis matebastan ertad. rodesac koncentracia awarbebs 100 000 baqteria 1 ml-ze, negatiuri pasuxis mirebis albatoba utoldeba nuls. es adasturebs adre mirebul debulebas, rom nacxebi, romlebic nebismieri kvlevis dros mudmivad pozitiuria, momzadebulia, rogorc wesi, im nimusebisgan, romlebic Seicavs 10 5 10 6 mgb-s an mets 1 ml-si. cxrili #3 uaryofiti pasuxebis sixsire im nimusebis nacxebsi, romelic Seicavs mjavagamzle baqteriata cvalebad koncentracias, gansazrvruls kulturata mixedvit (koloniebis raodenobit) baqteriata SefasebiTi koncentracia nimusis 1 ml-si eqsperimenti N 1 2 3 negatiuri pasuxebis % sasualo % 1 500-85 92 88.5 3 000 84 83 77 81.3 15 000 25 28 6 19.6 30 000 16 30 6 17.3 150 000 0 0 5 1.6 300 000 0 0 0 0.0 Seswavlil nacxta 42 100 289 - raodenoba 18

warmodgenilia mciredi cvlilebebit hl.devidis da Tanaavtorebis Sromidan mjavagamzle baqteriata mikroaris sizuste da specifikuroba. naxvelsi baqteriata Semcvelobis gansazrvris miznit kulturata koloniebis datvlis metods aqvs garkveuli SezRudvebi. garda amisa, am metodit zusti Sedegebis mireba teqnikur sirtuleebs ukavsirdeba. uamravi nimusia gamosakvlevi da rodesac nacxi Seicavs didi raodenobit baqteriebis agregatebs, teqnikuri wunis Sesamcireblad sawiro xdeba specialuri teqnikis gamoyeneba (SeuZlebelia rom gansazrvro kulturis niadagze kolonia gaizarda erti baqteriisagan, Tu mati didi jgufidan). meore mxriv, pirdapiri mikroskopiit gamovlenili mgb SesaZloa ar gaizardos kulturasi imis gamo, rom aseti baqteria darupulia an sicocxlis unars moklebuli (ix. ra aris naxvelis nacxis cru-dadebiti da crunegatiuri pasuxebis mtavari mizezi, gv. 27) amitom es mkvlevarebi xmaroben metods, romelic ar emyareba kulturis pasuxebs. mecnierta mizans Seadgenda naxvelis nacxis mikroskopiis metodit mirebuli pasuxebis sarwmunoobis dazusteba. amisatvis Sedarebul iqna ramodenime gamocdili laborantis mier erti da igive nacxis gamokvlevis Sedegebi. miuxedavad imisa pasuxi swori iyo Tu ara, ganisazrvra mat Soris Tanxvedrisa da aratanxvedris sixsire. nacxis kvleva xdeboda absoluturad damoukideblad, rogorc amas protokoli moitxovda. eqsperimenti Catarda Semdegnairad: otxma laborantma gamoikvlia 54 nimusi. TiToeuli nimusidan damzadda 4 nacxi da gamokvleul iqna damoukideblad. TiToeuli nacxis analizit mirebuli 4 pasuxi fasdeboda qulebis sistemis gamoyenebit: negatiuri _ baqteriebis SefasebisTvis arasakmarisi raodenoba (1-9 baqteria 100 mxedvelobis aresi) an pozitiuri ( 1+, 2+, da 3+). TiToeuli nimusis gamokvlevis Sedegi Seadares ertmanetisgan damoukideblad. erti laborantis mier mirebul Sedegebs adarebdnen danarceni sami laborantis pasuxebs, yvela SesaZlo kombinaciis gatvaliswinebit. ase rom TiToeuli nimusidan mirebul iqna 12 pasuxi. amitom SesaZlebeli gaxda korelaciuri cxrilis SemuSaveba (cxrili #4), romelic gvicvenebs 4 laborantis Sedegebis Tanxvedrisa da gansxvavebebis sixsires. Sedarebebis saerto ricxvi iyo 648, saidanac 4-Tan dakavsirebit Canawerebi ar gaketebula. 19

cxrili #4. otxi laborant-baqteriologis Sedegebis Tanxvedris an aratanxvedris sixsire a erti laborantbaqteriologis Sedegi negatiuri arasruli monacemebi g yvela danarceni laborantis mier mirebuli negatiuri 233 24 arasruli monacemebi 25 5 Sedegebi b +1 +2 +3 8 1 2 7 0 4 Catarebuli dakvirvebebis saerto raodenoba 268 41 309 +1 8 2 11 18 4 43 +2 2 8 16 39 50 115 335 +3 0 4 4 49 120 177 sul: 267 44 40 115 178 644 311 333 a wyaro: hl.devidi da Tanaavtorebi. mjavagamzle baqterioskopiuli kvlevis sizuste da specifikuroba. atlanta ass. b martkutxedsi cifrebi warmoadgens nebismieri laborantis mier pozitiurad interpretirebuls e.i. 1+, 2+ an 3+. g ganisazrvra, rogorc 1-9 baqteria 100 mxedvelobis aresi. cxrili #4 gvicvenebs, rom Tanxvedris umarlesi sixsire arinisneboda eqstremalur qulebze, anu negatiurze da 3+ze. (yvela identuri Sedegi SeiZleba inaxos diagonalze). amis garda, cxrili #4-dan Cans, rom erti laborantis mier dafiqsirebuli 309 uaryofiti an gaurkveveli Sedegidan mxolod 22-Si (7%) gvaqvs sxva laborantis mier mirebuli gansxvavebuli dadebiti Sedegi (1+, 2+, an 3+). sxva sityvebit rom vtqvat, 309-dan 287 SemTxvevaSi (93%) laborantebis daskvnebi Tanxvedrilia. rodesac erti specialisti izleva nacxis dadebit pasuxs, danarcenebis SedegebTan Tanxvedris albatoba Seadgens 335 dan 311-s (93%). Tanxvedris yvelaze dabali sixsire arinisneba iseti pasuxebis dros, rogoricaa ~gaurkveveli (ix. cxrili #4). erti laborantis mier mirebuli aseti Sedegis SemTxvevaSi arsebobda 88% albatoba imisa, rom (41 SemTxvevidan 36) sxva laborantebis Sedegebi gansxvavebuli iqneboda. 24 SemTxvevaSi 41 variantidan (59%) sxva 20

laborantebis pasuxebi iyo negatiuri. es Seesabameba sxva kvlevebit mirebul Sedegebs, rodesac gulmkerdis aresi saewvo simptomebis mqone pacientebis naxvelis analizi kulturaze 4-idan 3 SemTxvevaSi uaryofiti iyo, xolo nacxsi mxolod 1-2 mgb iqna armocenili (hg tendami, 1976, gamouqveynebeli gamokvlevebi). gansazrvreba gaurkveveli, gamoiyeneba im SemTxvevebSi, rodesac nacxsi nanaxia 1-2 mgb baqteria da analizi unda ganmeordes. rac Seexeba pozitiur Sedegebis daxarisxebas, monacemebi gvicvenebs, rom Tanxvedra mnisvnelovnad mcirdeba +3-is qvemot. cxrili #5 mixedvit +1 da +2 qulebs Soris Tanxvedra iyo sakmaod dabali 25% da 34% Sesabamisad. (ix. monacemebi diagonalze). amrigad, +1 da +2-s Soris diferenciacia sakmarisad iluzorulia. zemoarnisnulma eqsperimentma gamoavlina Sedegebis marali sarwmunooba. erti da igive nimusidan mirebuli nacxebis urtiertdamoukideblad gamokvlevam acvena, rom Tanxvedris sixsire identuri momzadebis mqone laborantebs Soris arwevda 93%. Tumca, unda arinisnos, es Sedegebi mirebul iqna eqsperimentis pirobebsi da gamocdili laborantebis mier. ibadeba kitxva: rogor warmoebs nacxis gamokvleva savele pirobebsi, kerzod, ki ganvitarebadi qveynebis periferul centrebsi? am kitxvas pasuxi gaecema momdevno TavSi. cxrili #5. otxi laborant-mikroskopistis Tanxvedrisa da Seusabamobebis sixsire pozitiuri Sedegebis mixedvit (meotxe cxrilis monacemebi procentebsi) yvela sxva laboranti negatiuri gaurkveveli 1+ 2+ 3+ sul erti 1+ 19 5 25 42 9 100 mikroskopistis 2+ 2 7 14 34 43 100 pasuxebi 3+ 0 2 2 28 68 100 21

mikroskopuli gamokvleva ganvitarebadi qveynebis periferul centrebsi, savele pirobebsi periferiul jandacvis centrebsi naxvelis Segroveba, nacxis damzadeba, SeRebva da mikroskopit gamokvleva warmoebs araoptimalur pirobebsi _ xsirad arasatanado kvalifikaciisa da gamocdilebis mqone laborantebis mier. es exeba sasoflo regionebis periferuli jandacvis centrebis umetesobas, gansakutrebit imat, romlebsac mimartavs gulmkerdis aresi saewvo simptomebis mqone pacientebis umetesoba. rogorc wesi, aset pacientebs stavazoben naxvelis gamokvlevas. aqedan gamomdinare, ganvitarebad qveynebsi SemTxvevaTa gamovlena, garda laboratoriis funqcionirebis faqtorebisa, didad aris damokidebuli nacxis mikroskopuli gamokvlevis teqnikuri Sesrulebis xarisxze. bangalorsi, indoetsi, tuberkulozis nacionalur centris mier 27,28 soflis regionebis jandacvis dawesebulebebsi naxvelis gamokvlevis teqnikuri Sesrulebis xarisxobrivi Sefasebis miznit Catarebuli iqna ramodenime kvleva samxret indoetis teritoriaze, sadac xorcieldeboda tuberkulozis kvlevis raionuli programa. kvlevis Catarebamde 6 TviT adre Seiswavles jandacvis randomizirebulad SerCeuli 9 obieqtis musaoba. am centrebis laborantebs ar hqondat specialuri momzadeba. mat gaiares mxolod 2-4 kviriani kursi naxvelis Segrovebisa da gamokvlevis metodikasi im saxelmzrvanelos mixedvit, romelic mat daurigda. amastan, gamocdili laborantis xelmzrvanelobit, romelic amave dros iyo tuberkulozis kontrolis gundis wevri, mat gaiares treningi 29,30. es gundi pasuxs agebda tubprogramis danergvasa da zedamxedvelobaze mtlianad am raionsi, romlis mosaxleobac Seadgenda 1,5 mln. Sefasebis metodi SerCeuli cxra centridan TiToeulSi yvela im pacientidan vinc ucioda mdgrad xvelas, arebul iqna erti naxvelis nacxi. nacxi momzadda da Semowmda dauyovnebliv ~wvetis metodi. amis Semdeg slaidebi naxvelis nimusit gaigzavna tuberkulozis nacionalur centrsi, sadac moxda mati gadamowmeba. naxvelis nimusi gamoyenebul iqna axali (dublikati) nacxisa da aseve kulturis mosamzadeblad. periferiuli laboratoriis Sedegebi Seadares referalur laboratoriasi mirebul Sedegebs anu Caatares: 22

_ periferiul centrsi gamokvleuli nacxis xelaxla gamokvleva; _ dublikati, axali (meore) nacxis gamokvleva; _ kulturis gamokvleva. es Sedegebi gaanalizebul iqna hiper da hipo interpretaciis TvalsazrisiT da Setanil iqna cxrilsi TviToeuli centristvis cal-calke. kulturebis pasuxi mirebulia standartad, anu saindeqsacio macveneblad. 1681 masalidan 228 micneuli iyo kultura-pozitiurad (13,6%) da 1453 kultura-negatiurad (86,4%) kultura-negatiuri nimusebis hiperinterpretacia jandacvis periferiul dawesebulebebsi hiperinterpretaciis SemTxvevebis sixsiris gansasazrvravad, kultura-negatiuri nimusebi mirebul iqna standartad da Sedarebul iqna rogorc periferiul, aseve referalur laboratoriasi Catarebuli imave nacxebis gamokvlevebis SedegebTan. ix. cxrili #6. cxrili #6. nacxebis hiperinterpretacia (momzadebuli kultura negatiuri sinjebidan) Sesrulebuli periferiul samedicino centrsi da referalur laboratoriebsi centri sul kulturanegatiuri sinjebis raodenoba interpretirebulia, rogorc nacxit pozitiuri periferiul samedicino centrsi referalur laboratoriasi A 306 5 4 B 233 8 1 C 159 7 7 D 156 2 2 E 108 12 2 F 111 3 1 G 100 1 1 H I 84 196 0 0 1 0 sul 1453 (100%) 38 (2.6%) 19 (1.3%) 23

kulturis mixedvit negatiuri 1453 nimusidan 2,6% jandacvis periferiul centrebsi micneuli iyo kultura_pozitiurad. igive nacxebi xelaxla Semowmda laboratoriasi, sadac mxolod 1,3% armocnda pozitiuri. ase rom, hiperinterpretaciis macvenebeli ufro marali iyo periferul laboratoriasi, vidre centralursi. rogorc ufro detalurma analizma gvicvena, hiperinterpretacia axasiatebda upiratesad ert centralur laboratorias (E). am centris monacemebis saerto Sedegidan gamoricxvis Semdeg, analizebis hiperinterpretaciis macvenebeli Semcirda 1,9%-mde. hiperinterpretaciis proporcia dublikati nacxis kvlevis mixedvit Seadgenda 1,2%, SedarebiT 1,3%-Tan xelaxali Semowmebisas 28. kultura-pozitiuri nacxebis hipointerpretacia periferiul centrebsi hipointerpretaciis SemTxvevebis sixsiris gansazrvris miznit, standartulad arebul iqna kulturapozitiuri nimusebi da Sedarda, rogorc periferiuli centrebsi, aseve referalur laboratoriebsi Catarebul amave nacxebis gamokvlevis SedegebTan (ix. cxrili 7). cxrili #7. nacxebis hipointerpretacia (momzadebuli kultura-pozitiuri sinjebidan) Sesrulebuli periferiul samedicino centrsi da referalur laboratoriebsi centri A B C D E F G H I sul sul kulturanegatiuri sinjebis raodenoba 101 21 23 22 15 16 15 10 5 228 (100%) interpretirebulia, rogorc nacxit pozitiuri periferiul samedicino centrsi 27 7 7 19 6 5 7 8 1 38 (2.6%) referalur laboratoriasi 26 8 5 9 6 4 5 3 1 19 (1.3%) 24

228 nimusi kulturis kvlevis Sedegebis mixedvit iyo pozitiuri, matgan 87 (38,2%) da 67 (29,4%) periferiuli da centraluri laboratoriebis daskvnit nacxit pozitiuri iyo. amrigad, yvelaze cudi mdgomareoba hipointerpretaciis TvalsazrisiT iyo periferiul laboratoriebsi (38% da 29,4% Sesabamisad). es gansxvaveba ZiriTadad gamowveuli iyo ori centris _ (D) da (H) arasatanado musaobit. rodesac es ori klinika gamoiricxa kvlevis Sedegebis analizidan miviret hipointerpretaciis praqtikulad igive xarisxi rogorc periferiul centrebsi, aseve referalur laboratoriasi (23% da 26%). kvlevis avtorebma gamoitanes daskvna, rom hiperinterpretacia warmoadgenda 9 centridan mxolod erti periferiuli centris problemas. damatebiti swavleba, zedamxedveloba da sxva makoregirebeli qmedebebi Seavsebs arsebul deficits. es aseve exeboda zemot xsenebul or centrs, sadac aucilebelia damatebiti 31, 32 swavlebis Catareba da satanado zedamxedveloba. indoetis sxva tub laboratoriebsi mopovebuli Sedegebis Sedarebam gamoavlina hipo da hiperinterpretaciis igive diapazoni, rodesac safuzvlad irebdnen kulturis gamokvlevis Sedegebs. garda amisa, avtorebma daaskvnes, rom samedicino dawesebulebata araspecializebul personals Seswevda nacxis mikroskopiis damakmayofileblad Catarebis unari. Tu gavitvaliswinebt imas, rom laborantebi Cveulebriv gadian momzadebis xanmokle kurss sistematuri ganmeorebiti swavlebit SeiZleba vivaraudot, rom am laborantebis musaoba SeiZleba SenarCunebul iqnes damakmayofilebel doneze. (ix. ~ra aris cru-dadebiti da cruuaryofiti pasuxebis ZiriTadi mizezi ). aljirsi Catarebuli msgavsi kvlevisas 33, ganxorcielda periferiuli samedicino centris araspecializirebuli personalis mier momzadebuli da interpretirebuli nacxebis Sedegebis xelaxali gamokvleva. amgvarad, 104 nacxis xelaxalma wakitxvam Sedegad mogvca identuri pasuxebis 95%. centralur laboratoriasi uaryofitad klasificirebuli 86 nacxidan 2 periferul laboratoriasi interpretirebul iqna, rogorc dadebiti da centralur laboratoriasi pozitiurad micneuli 18 nacxidan periferiul laboratoriasi 3 interpretirebuli iyo rogorc negatiuri. kvlevis avtorebi izlevian rekomendacias, rom periferul 25

laboratoriasi unda tardebodes pirdapiri mikroskopia centraluri laboratoriis zedamxedvelobis qves. ufro metic, avtorebi arnisnaven, rom radgan samedicino samsaxurebi yvela diagnostirebuli SemTxveveisaTvis, satanado mkurnalobas jerac ver uzrunvelyofen, rac, Tavis mxriv warmoadgens tuberkulozis SemTxvevaTa gamovlenis mtavar mizans, azrs moklebuli iqneboda laboratoriebisgan mogvetxova ufro srulyofili metodebit gamokvleva da meti sizuste. orive kvleva gvicvenebs, rom araspecializirebuli personalis mier periferiul laboratoriebsi Catarebuli mikroskopuli kvleva SesaZloa sarwmuno iyos. sizustis damakmayofilebeli donis misarwevad gansakutrebit mnisvnelovania im laborantebis uzrunvelyofa swavlebit, romelta mier Catarebuli gamokvlevebi ar akmayofilebs standarts. swavleba SeiZleba Catardes samusaodan mouwyvetliv. kvalificirebuli laborantis mier naxvelis erti da imave nimusidan momzadebuli nacxebis gadamowmeba da xelmeore dublikati nacxebis gamokvleva Rirebuli xerxia periferiul samedicino centrebsi naxvelis mikroskopuli kvlevebis superviziisa da teqnikuri daxmarebis gansaxorcieleblad. mogvianebit, rodesac Seiqmneba kulturebis gamokvlevisatvis sawiro laboratoriebi, kulturis kvleva gamoyenebuli iqneba nacxis usualo mikroskopiis Sedegebis sizustis Sesafaseblad da momavalsi, Tu es SesaZlebeli iqneba, klinikuri diagnostikisa da mkurnalobis SefasebisaTvis. 26

6. ra aris cru-dadebiti da cru-uaryofiti pasuxebis ZiriTadi mizezebi k.tomani 8 cru-uaryofiti pasuxebi mjavagamzle baqteriata nawilakebi romlebic ar warmoadgenen tuberkulozis baqteriebis zogjer naxveli SeiZleba Seicavdes iseti nawilakebs, romlebic ar warmoadgenen tuberkuliozis mikobaqterias. isini mjavagamzleni arian, anu inarcuneben Tavis witel sarebavs (karbolis fuqsins) cil-nilsenis metodit damusavebisas da uzleben acidalkoholit dekolorizacias. es witeli nawilakebi zogjer mogvagoneben tuberkulozis baqteriebs. isini Seicaven garkveuli saxis sakvebis nawilakebs, (mag: safuars, cximebs), precipitatebs, sxva mikroorganizmebs, araorganul nivtierebebs artefaqtebs da sxva 34, 35, 36, 37, 38, 39 (1-6). sakvebis nawilakebi. piris RruSi darcenili sakvebis nawilakebis naxvelsi moxvedris Tavidan asacileblad, naxvelis amorebamde pacientma unda gamoivlos piris Rru sufta wylit, ise rom ar gamoiyenos kbilis pasta, an sadezinfeqcio sasualeba. uketesia Tu masala arebuli iqneba uzmoze sauzmemde. precipitatebi. miuxedavad imisa, rom precipitatebis diferencireba mjavagamzle baqteriebisagan Zneli ar aris, mainc SesaZlebelia daabnios gamoucdeli laboranti. SeRebili nacxidan mati mocileba SesaZlebelia xsnarebis gafiltvrit. Tumca, ufro saimedoa kargad garecxil botlebsi motavsebuli axladmomzadebuli xsnarebis gamoyeneba, vidre Zvelis. garemodan nacxsi moxvedrili (mjavagamzle) baqteriebi. es baqteriebi bunebrivad gvxvdeba wyalsi, miwasi da nacxis damusavebis 8 gardacvlilia 27

dros SesaZlebelia aseti baqteriebit masalis SemTxveviT dabinzureba. es SesaZloa Tavidan avicilot Tu gamoviyenebt gansakutrebulad suftad garecxili konteineridan arebul distilirebul wyals. aratuberkulozuri mikobaqteria an nokardias (nokardia)-s saxeobebi. isini SesaZloa SemTxveveiT armocndnen nacxsi. Tuki isini iwveven filtvis daavadebebs, masin isini didi raodenobit arian nacxsi. bacila subtilis sporebi. isini Zalian isviatad gvxvdeba umetesad kvercxiseburi moyvanilobisaa da tubbacilaze ufro didia. sokoebi irebeba Zalze Ria witel ferad. Termuli fiqsaciis Semdeg isini SeiZleba daisalon jgufebad an did granulebad. bowkoebi da mcenaris mtveri. bowkovani qsovilebi, rogoricaa bamba, Sali, filtris qaraldi da sxva gvxvdeba erteulovani saxit, Tanac mxolod ert mikroskopul aresi. garkveuli saxis fiwvis xis mtveri nacxsi isviatad gvxvdeba mokle (cocoid rod) kokoiduri Cxiris formit. nakawrebi sasagne minaze. am nakawrebma SesaZloa SeinarCunos witeli sarebavi da daabnios gamoucdeli laboranti. Cveulebriv es nakawrebi paraleluria, inarcuneben witel fers da ufro grzelia, vidre mjavagamzle baqteriebi. es nakawrebi ar eqvemdebarebian ganzavebas. mati amocnoba advilia, radgan isini ufro qveda SreSia ganlagebuli da qreba, rodesac laboranti fokusirebas axdens nacxis ujredebze (leikocitebze.). nacxis dabinzureba, gamowveuli baqteriebis gadatanit erti nacxidan meoreze SesaZloa mjavagamzle baqteriebis SemTxveviTi gadatana pozitiuri sasagne minidan negatiurze. es xdeba masin, rodesac mimdinareobs ramdenime nacxis sasagne minis ertdroulad dekolorizacia, an SeRebva ert saerto rezervuarsi. amis Tavidan acileba SesaZlebelia, Tu moxdeba sasagne minebis cal-calke damusaveba e.w. Taroebze. dabinzureba SeiZleba moxdes maryujit, romelsac iyeneben nacxis mosamzadeblad, romelic kargad ar aris 28

damusavebuli cecxlze. am saxis dabinzurebas Tavidan avicilebt, Tu am miznit gamoviyenebt ertjeradi xis Cxirebs. baqteria SesaZloa gadavides erti nacxidan meoreze, Tuki minis wkiri an sawveturi, romelic gamoiyeneba imersiuli zetis dasawveteblad, exeba pozitiuri slaidis zedapirs. am dros mjavagamzle baqteria SeiZleba ahyves wkirs an sawveturs da moxvdes Semdeg sasagne minaze. es SesaZloa moxdes aseve masinac, rodesac mikroskopis imersiuli linza exeba slaidis zedapirs an sasrobi qaraldit xdeba ramodenime slaidis gasroba ertmanetis miyolebit. amitom: sawveturi, romelic gamoyenebulia imersiuli dasawveteblad ar unda exebodes sasagne minas, es zeti Tavisuflad unda ecemodes da imersiuli obieqtivic ar unda Seexos slaidis zedapirs. vidre SevudgebodeT momdevno nacxis Seswavlas, linza unda gaiwmindos specialuri sawmendi qaraldit an sufta bambit. sasrobi qaraldi saertod ar unda iqnes gamoyenebuli, an mxolod erti slaidisatvis. mjavagamzle baqteriata gamovlenistvis slaidi unda gamoiyenon mxolod ertxel. cru-negatiuri pasuxebi cru-negatiuri pasuxebi SeiZleba mirebul iqnes nacxis arasworad momzadebis, SeRebvis an Semowmebis gamo 39. nacxis sworad momzadebisatvis nimusebis sworad arebasa da Semdgom naxvelis nawilakebis SerCevas gansakutrebuli mnisvneloba eniweba da moitxovs gansakutrebul yuradrebas. uxarisxo naxveli crunegatiuri Sedegebis ert-erti yvelaze gavrcelebuli mizezia pozitiuri naxvelis mqone pacientebsi. qvemot moyvanilia nacxis arasworad momzadebis mtavari mizezebi. naxvelis araswori Segroveba zogjer pacients natlad ar ganumartaven Tu, ras nisnavs naxvelis masalis sworad Segroveba da rogor unda moxdes misi gamoyofa. mattvis gasagebi unda iyos, rom nerwyvi da nazofaringealuri gamonadeni Seusabamoa gamosakvlevad. mat unda miecet dro, rata gamoyon bronqialuri naxveli, gulmkerdis sirrmidan amoaxvelon. mat ramdenjerme Rrmad unda CaisunTqon da Semdeg, rac SeuZliaT 29

Zlierad da sirrmidan amoaxvelon. Tu es mcdeloba ramdenjerme marcxit damtavrda, masin sawiroa CxiriT xorxsarqvelis an traqeis garizianeba, ramac SeiZleba gamoiwvios Zlieri xvela naxvelis gamoyofit. zog SemTxvevaSi SeiZleba gamoyenebul iqnes sxva xerxebi, iseti rogoricaa aerozolit induqcia, beta-agonistebi, bronqoskopia da kuwis SigTavsis aspiracia. Tbili (3%) hipertonuli xsnaris inhalacia nebulaizeris gamoyenebit izleva satanado masalas analizistvis 40. dilis saatebsi mirebuli masala savaraudot ufro mgb pozitiuria, vidre dris ganmavlobasi arebuli naxveli. Tu sawiroa dilis naxvelis areba, masin pacients azleven konteiners da stxoven massi Seagrovos pirveli naxveli, romelic ki mas gamoeyofa uzmoze, sauzmemde. naxvelis nimusebis da SeRebili nacxebis araswori Senaxva SeRebilma nacxebma SesaZloa dakargon Seferiloba mzis sxivebis pirdapiri moqmedebit, radiaciis (ultraiisferi sxivebit), sitbos zemoqmedebit, an didi drois ganmavlobasi SenaxviT marali temperaturisa da tenianobis pirobebsi (kviraze met periodis ganmavlobasi) 41 (8). miuxedavad amisa, tropikul pirobebsi erti Tvis ganmavlobasi Senaxuli nimusebic ki inarcuneben TavianTi pozitiurobis imave macvenebels. amitom sawiroa yvela nimusis gasinjva. fluoroqromit SeRebili nacxebi Senaxvisas kargaven Tavis fluoroscencias. nacxis momzadebisas naxvelis satanado nawilakebis SerGevis dros dasvebuli Secdomebi tuberkulozis mikobaqteriebi yvelaze xsirad gvxvdeba mrgvali formis (lentilebi) momwvano-moruxo an moyvitalo sqeli konsistenciis mqone masasi. (aseti masebi Cveulebriv Sedgeba filtvis kavernidan gamoyofili mkvdari kazeozuri qsovilisgan). Tu ver xerxdeba am masis satanadod damusaveba, romelic moicavs centrifugasi mis damusavebas, masin igi frtxilad unda gamovyot naxvelis danarceni nawilidan da gadavitanot sasagne minaze. es masa kargad Cans Sav fonze. 30

nacxis araswori momzadeba an slaidis (sasagne minis) araswori SeRebva cru-negatiuri Sedegebi SeiZleba mivirot, rodesac: sasagne minaze (slaidze) metismetad cota masalaa gantavsebuli da nacxis fena Zalzed Txelia; nacxi metismetad sqelia da Suqi ver arwevs mis sirrmesi; sasagne mina (slaidi) metismetad iyo gacxelebuli masze nacxis fiqsirebis dros.; nacxi ar iyo kargad fiqsirebuli da masalis nawili Camoirecxa; karbolis fuqsinit SeRebvis procesi an metismetad xanmokle iyo, an piriqit zedmetad gadadurebuli; sapirispiro SeRebva metismetad intensiurad mimdinareobda, ramac ganapiroba baqteriebis gaurkvevel ferad SeRebva. nacxis arasworad gamokvleva mikroskopuli gamokvlevis daudevrad, upasuxismgeblod an zedmetad swrafad Catarebisas mxolod metismetad mcire raodenobis mxedvelobis areta gamokvlevaa SesaZlebeli. Ppasuxi, agretve SesaZloa iyos cru-negatiuri, Tu laboranti ver ganasxvavebs witlad SeRebul mgb-s ferebis arqmastan dakavsirebuli an mxedvelobis sxva problemebis gamo. mcdari pasuxebis sxva mizezebi administraciuli Secdomebi mcdari pasuxebi SesaZloa mirebuli iyos administraciuli Secdomebis gamoc. aset administraciul Secdomebs ganekutvneba: _ pacientis saidentifikacio monacemebis arasworad registrireba, gvaris arasworad Cawera, gvarebis an kodebis areva nacxze da nimusze; _ konteinerebze warweris arasworad gaketeba (mag., saidentifikacio warweris konteineris saxuravze gaketeba, 31

_ nacvlad imisa, rom aseti warwera gaketdes konteiners gverdze); pasuxebis da Canawerebis falsificireba. Sedegebis araswori interpretacia laborantis mier dasvebuli Secdoma gvxvdeba praqtikulad yvela diagnostikur_klinikuri da laboratoriuli dawesebulebebis musaobasi. am fenomenis buneba, romelsac xsirad uwodeben ~adamianis faqtors, metwilad ucnobia. miuxedavad amisa, garkveul pirobebsi is gazomvadia. im Secdomebis xarisxi da sixsire rogoricaa, magalitad, monacemta hiperinterpretacia da hipointerpretacia, icvleba adamianta mixedvit da agretve, erti da igive adamiani sxvadasxva dros SeiZleba sxvadasxva odenobit Secdomas usvebdes. naxvelis baqterioskopuli gamokvlevisas interindividualuri variaciebi warmoadgenda sistematuri kvlevis sagans da armocnda, rom misi sixsire SedarebiT naklebia gulmkerdis rentgenografiis wakitxvisas dasvebul SecdomebTan SedarebiT (ixilet: ~ramdenad sarwmunoa nacxis mikroskopuli gamokvleva da ~ramdenad sarwmunoa gulmkerdis rentgenografia ). sxvadasxva laborantis mier erti da imave masalidan damzadebuli nacxebis ertmanetisgan damoukideblad Catarebuli kvlevis pasuxebis Sedarebis miznit Catarda ramodenime gamokvleva. rodesac mat ekitxebodnen, iyo Tu ara nacxi mgb dadebiti, Tanxvedris sixsire Seadgenda 93%. Tanxvedris aseti marali macvenebeli arasodes ar arinisneboda gulmkerdis rentgenografiis ganxilvis dros, Tundac iset martiv kitxvaze pasuxisas, rogoricaa aris Tu ara es rentgenograma normis farglebsi da ~aris Tu ara aq kaverna (ix. ~ramdenad sarwmunoa gulmkerdis rentgenografia ). laboratoriuli personalis satanado momzadeba da aseve mkacri motxovna, rom mat Caiweron mxolod is, rasac sinamdvilesi xedaven da ara is, ris danaxvasac elian, SesaZlebels gaxdis Tavidan avicilot Sedegebis araswori interpretacia. subieqturi damokidebulebis safuzvelze individis avadmyofad Seracxva an namkurnalebi pacientebis gankurnebulad gamocxadeba sakmaod cnobili diagnostikuri Secdomaa. Tumca nacxis mikroskopiuli gamokvlevis mcdari pasuxebi ufro metad ganpirobebulia naxvelis arasworad mirebisa da nacxis arasworad momzadebit, vidre laborantis mier Sedegebis interpretaciit. 32

7. rogoria cru-pozitiuri da cru-negatiuri nacxis ZiriTadi Sedegebi t.freideni 9 cru-dadebiti nacxi: cru-pozitiuri pasuxis ZiriTadi Sedegebia 42,43,44 : tuberkulozis cru (hiper) diagnostika ris Sedegadac: pacientebi da mattan kontaqtsi myofi pirebi iwyeben tuberkulozis mkurnalobas, romelic mat ar esawiroebat da rasac SeiZleba mohyves gartulebebi. sxva wamlebsac Tu ireben, mat SeiZleba ganuvitardet wamlebze interreaqciebi; zusti diagnostikis dagvianeba. tuberkulozis diagnozis dasmis Semdeg pacients enisneba antituberkulozuri medikamentebit mkurnaloba da, rogorc wesi, sxva diagnozis dasadgenad gamokvlevebi arar tardeba. radgan antituberkulozuri mkurnalobis Sedegebis mirebas didi dro esawiroeba, alternatuli diagnozis ganxilvamde 1-2 Tve an zogjer meti droc gadis. zusti diagnozis aseti dagvianebit dadgenam SeiZleba gamoiwvios realuri daavadebit gamowveuli avadobis da sikvdilianobis zrda; emociuri stresi. mraval pacientsi tuberkulozis diagnozma SeiZleba gamoiwvios seriozuli emociuri stresi, radgan 9 SeaCere tuberkulozis medmusaki, samxret armosavlet aziis regionaluri ofisi, msoflios jandacvis organizacia. axali deli, indoeti 33

jer kidev bevria iseti qveyana, sadac tuberkulozis diagnozi mnisvnelovani stigmis matarebelia; medikamentebis gaumartlebeli xarjva. cru-pozitiuri nacxis pasuxi iwvevs antituberkulozuri medikamentebis gaumartlebel danisvnasa da gamoyenebas; finansuri danakargebi. ufaso mkurnaloba yvelgan da yvela pacientisatvis ertnairad misawvdomi ar aris. amitom tuberkulozis diagnozi SeiZleba asocirebuli iyos pacientisatvis usargeblo finansur danaxarjtan; pacientma da sazogadoebam SeiZleba dakargos tubprogramebisadmi ndoba. jandacvis musakebma unda ganumarton pacientebs, rom mat unda miiron medikamentebi 6 Tvis ganmavlobasi da rom winaarmdeg SemTxvevaSi isini SeiZleba mzimed gaxdnen avad, an gardaicvalon. Mmagram, Tu nacxis pasuxi cru-dadebiti iyo da pacienti sinamdvilesi ar aris tuberkulozit avad, man SeiZleba Sewyvitos mkurnaloba mxolod ramdenime kviris Semdeg. aman SeiZleba Seamciros imis albatoba, rom tuberkulozit daavadebuli adamiani dauyovnebliv mimartavs saswrafo daxmarebas da danisnulebisamebr miirebs medikamentebs. sazogadoebis ndoba aucilebeli pirobaa programis aqtiuri danergvistvis; bavsvebis arasawiro gamokvleva da mkurnaloba. rodesac warmoebs inficirebul pacientebtan kontaqtsi myofi bavsvis samedicino Semowmeba. araswori informacia mkurnalobis progresis an gamosavlis Sesaxeb ris Sedegadac: Tu Semdgomi monitoringis miznit gaketebuli nacxis kvlevebis Sedegi kvlav cru_dadebiti iqneba mkurnaloba SeiZleba gagrzeldes ufro didxans, vidre sawiroa; SeiZleba pacientis mkurnaloba arasworad, usedegod iyos micneuli da realuri sawiroebis garese daenisnos ganmeorebiti mkurnaloba. 34

cru-negatiuri nacxi cru-negatiuri pasuxis ZiriTadi Sedegebia: tuberkulozit daavadebul pacientebs SesaZloa ar CautardeT mkurnaloba, rac gamoiwvevs daavadebis damzimebas, tuberkulozis infeqciis gavrcelebasa da sikvdils. tuberkulozis arasatanado diagnostikam da mkurnalobis garese pacientis datovebam SeiZleba gamoiwvios daavadebis damzimeba da filtvis parenqimis dasla SemdgomSi intensiuri fibrozit. mkurnalobis droulad dawyebis SemTxvevaSi filtvis funqciis aseti darrveva ar xdeba. garda amisa, hipodiagnostika sasisia mosaxleobasi daavadebis gavrcelebis gamoc; pacientebma, eqimebma da sazogadoebam SesaZloa dakargos rwmena tuberkulozis programebisadmi; infeqciuri pacientebis mkurnaloba SesaZloa iyos araadekvaturi (kategoria III kategoria I-is nacvlad. ix. ras nisnavs diagnostikuri kategoriebi da rogor xdeba am kategoriebis dadgena~) da arasatanado xangrzlivobis (im SemTxvevaSi, rodesac nacxi arebulia intensiuri fazis bolos). arnisnulma SesaZloa gazardos medikamentebisadmi rezistentobis an recidivis ganvitareis sixsire, aseve tuberkulozis gavrcelebis riski. rodesac klinikuri gamovlinebebis mixedvit maralia albatoba imisa, rom saqme gvaqvs tuberkuloztan, SeiZleba daviwyot daavadebis empiruli mkurnaloba, magram medikamentebis ufro naklebi raodenebit, vidre sawiroa, radgan pacienti micneulia nacxit negatiurad. aman SeiZleba ganapirobos mkurnalobis usedegoba da rezistentobis ganvitareba medikamentebis mimart; arasawiro gamokvlevebi. cru-negatiuri analizis pasuxma SesaZloa ganapirobos usedego gamokvlevebis Catareba sxva daavadebis gamovlinebis miznit xangrzlivi periodis ganmavlobasi; finansuri danakargebi. tuberkulozis diagnozis dagvianebis gamo SesaZloa pacients Cautardes damatebiti, Zvirad- Rirebuli testebi sxva SesaZlo problemebis gamo. 35

mjavagamzle baqteriebis zustad gamovlenis uzrunvelsayofad sawiroa laboratoriis personalis satanadod momzadeba, mxardawera da zedamxedveloba. nacxebis xarisxis kontrols gadamwyveti mnisvneloba eniweba 45. pasuxebis sizuste gansakutrebit mnisvnelovania iq, sadac filtvis tuberkulozis diagnostika ZiriTadad xdeba naxvelis nacxis analizis safuzvelze. 36

8. ra dadebiti da uaryofiti mxareebi aqvs fluoroscentul mikroskopul kvlevas k.tomani 10 fluoroscentuli mokroskopiis mesveobit mjavagamzle baqteriebis gamovlenis metodi dainerga 1930-ian wlebsi. Tavdapirvelad mikroskopebs bevri teqnikuri nakli hqondat. mati moxmareba sirtuleebtan iyo dakavsirebuli da mxolod Cabnelebul otaxsi iyo SesaZlebeli. am sizneleebis gamo fluoroscentuli mokroskopiis metodi fartod ar gamoiyeneboda. mas Semdeg mikroskopebi sagrznoblad gaumjobesda da naxvelis nacxis analizis Catareba fluoroscentuli mikrokopit ukve fartod aris gavrcelebuli, gansakutrebit didmasstabian laboratoriebsi. fluoroscentuli mikroskopiis ZiriTadi upiratesoba aris is, rom igi iyenebs dabali simzlavris (25X) obieqtivs. amis gamo xedvis are bevrad didia vidre Cveulebrivi sinatlis mikroskopis, imersiuli obieqtivis SemTxvevaSi. fluoroscentul mikroskopsi xedvis are daaxloebit 0.34mm² Seadgens, masin, rodesac imersiuli obieqtivit xedvis are mxolod 0.02mm²-ia. fluoroscentuli mikroskopi izleva nacxis bevrad ufro swrafad gamokvlevis SesaZleblobas, vidre Cveulebrivi mikroskopi amastan, fluoroscentruli mikroskopiit laborants dris ganmavlobasi SeuZlia gamoikvlios 100-mde naxvelis nacxi, masin rodesac cilnilsenis metodit SeRebili mxolod 30-40 nacxis gamokvleva aris SesaZlebeli dris manzilze 46,47,48. vinaidan drois ertsa da imave periodsi fluoroscentuli mikroskopit SesaZlebelia 15-jer meti aris gamokvleva, vidre Cveulebrivi mikroskopit, iqmneba mjavagamzle baqteriebis armocenis ufro didi albatoba, gansakutrebit masin, Tu nacxi cota baqterias 10 gardacvlilia 37

Seicavs. es dadasturda fartomasstabiani SedarebiTi kvlevit, romelmac gvicvena, rom fluoroscentuli mikroskopit 1 wutis ganmavlobasi Catarebuli gamokvlevisas mirebul iqna ufro meti WeSmaritad-dadebiTi da (arc erti cru-dadebiti) pasuxi, vidre Cveulebrivi mikroskopit 4 wutis ganmavlobasi 46. arnisnuli ori teqnikis Sedareba mravali kvlevisas Catarda. ert-erti gamokvlevis dros paralelurad Semowmebuli iqna 175 nacxi (Devid et. al, 1975 gamouqveynebeli informacia). TiToeuli nimusidan momzadda ori nacxi. TiToeuli nacxi damoukideblad iqna gamokvleuli konvenciuli mikroskopit da fluoroscentuli mikroskopit. mirebuli Sedegebi arricxul iqna cal-calke da amis mixedvit aigo SefardebiTi cxrili (cxrili #8). ertnairi Sedegebi gantavsebulia diagonalze. Tu dadebiti Sedegebis Sefasebisas gansxvavebebs ugulebelvyoft, masin 157 pasuxi 175 wyvilidan identuri armocnda, anu Tanxvedris macvenebelia 90%. cxrili #8. korelacia fluoroscentul da sinatlis (cil-nilsenis metodi) mikroskopebs Soris cil-nelsenis mikroskopia 0 an daudgeneli dadebiti sul fluoroscentuli mikroskopuli kvleva 0 an daudgeneli dadebiti 10 12 6 53 110 65 sul 116 59 175 meore kvleva itvaliswinebda orive teqnikis Sedarebas kulturis analizis metodtan 48. am miznit Segrovda 1383 nimusi, da TiToeulidan momzadda ori nacxi da erti kultura. nacxebi gamokvleul iqna urtiertdamoukideblad, fluoroscentuli mikroskopit da cil-nelsenis mikroskopiis gamoyenebit (cxrili #9). gamokvelvis MmTavari mizani iyo am ori metodis efeqturobis Semowmeba kulturalul analiztan SedarebiT. meore mizani iyo imis dadgena, izleoda Tu ara fluoroscentuli mikroskopia cru- 38

dadebit Sedegebs da Tu izleoda, ramdenad mnisvnelovani iyo es informacia. arsebobda mosazreba rom nacxi TavisTavad Seicavda bunebriv fluoroscentul nawilakebs, romlebic SeiZleboda SecdomiT micneuli yofiliyo mjavagamzle baqteriad 49. Sedarebis gaadvilebis miznit cxrilsi #9 mocemuli informacia cxrilsi 10 gaslilia ori formis saxit. fluoroscentuli analizisa da cil-nelsenis metodis gamoyenebit mirebuli dadebiti Sedegebis raodenobis Sedarebam kulturis kvlevit mirebul pasuxebtan mogvca Zalzed umnisnvelo upiratesoba fluoroscentuli mikroskopis sasargeblod: 655 kulturit dadebiti nimusidan 441 (67,7%) dadebiti iyo fluoroscentuli metodit, xolo Cveulebrivi mikroskopit-433 (66.1%). cru-dadebiti Sedegebis mixedvit, arnisnul or metods Soris gansxvaveba praqtikulad ar iyo gamovlenili. fluoroscentuli mikroskopit dadgenil 456 dadebit SemTxvevadan 15 (3.3%) ar iyo dadasturebeli kulturit. Cveulebrivi mikroskopit Catarebuli kvlevit mirebuli 447 dadebiti Sedegidan kulturis kvlevis metodit ar dadasturda mxolod 14(31%). sxva sityvebit rom vtqvat, nacxebis orive metodit gamokvlevisas mirebuli dadebiti pasuxebis 97%. ertmnisvnelovnad dasturdeba kulturis analizis Catarebisas, anu, SeSfoTeba fluoroscentuli mikroskopis dabali specifikurobis gamo usafuzvlo armocnda 50. gamokvlevebsi monawileobda laboratoriis rigiti personali, romlebsac hqondat fluoroscentuli mikroskopit musaobis gamocdileba. anu Sedegebi SeiZleba mivicniot standartulad, radgan kvlevebi Catarda met-naklebad kompetenturi laborantebis mier. ufro Tanamedrove gamokvlevebi adasturebs am ori metodis gamoyenebit mirebul Sedegebs. miuxedavad amisa, sawiroa yuradrebis mobilizeba, rata araorganuli mjavagamzle obieqtebis mcire raodenoba ar mivicniot mgb baqteriad. 39

cxrili #9. 1383 nacxis fluoriscentuli (FI) da cil-nilsenis (ZN) mokroskopiita da kulturit Gatarebuli analizis Sedegebi kategoria nacxis Sedegebi nimusebi fl. c-n. # % 1 nacxi + kultura + + + + - 405 36 33.9 2 nacxi + kultura _ - + + + + - 28 11 4 1.2 3 nacxi _ - + 3 kultura + - - 186 13.4 4 nacxi _ kultura _ - - 681 51.5 dabinzurebuli - - 29 kulturebi sul 1383 100.0 cxrili #10. fluoroscentuli da cil-nilsenis metodit mikroskopuli gamokvlevis Sedegebis Sedareba kulturis kvlevit mirebul SedegebTan fluoroscentuli cil-nilsenis mikroskopia + - sul mikroskopia + - sul + 441 214 655 + 433 222 655 kultura kultura _ 15 713 728 _ 14 714 728 sul 456 927 1383 sul 447 936 1383 fluoroscentuli mikroskopis gamoyenebisas SesaZlo mcired dadebiti nacxis gamovlenisas yoveltvis unda gvaxsovdes, lozungi ~yvelaferi rac brwyinavs mgb araa. fluoroscentuli mikroskopis uaryofiti mxarea misi marali fasi da eqspluataciis marali xarjebi. miuxedavad amisa, centralur 40

da sxva did laboratoriebsi, sadac samusao datvirtva aremateba sami laborantis sam Cveulebriv mikroskoptan musaobas (100-150 slaidze meti dresi), SesaZloa finansurad ufro rentabeluri iyos erti fluoroscentuli mikroskopis gamoyeneba. es gaangariseba orientirebulia iset laboratoriebze, sadac laborantebs SedarebiT dabali xelfasebi aqvt, magalitad ganvitarebad qveynebsi 18. xolo, ganvitarebul qveynebsi, sadac xelfasebi maralia, fluoroscentuli mikroskopis gamoyeneba xarjtefeqturia ufro mcire moculobis samusaos SemTxvevaSic ki, radganac is moitxovs naklebi raodenobit Zvir musaxels 52, 53. fluoroscentuli mikroskopis kidev ert nakls warmoadgens is, rom optikuri arwurvilobis movla da eqsploatacia moitxovs maralkvalificiur teqnikur personals. fluoroscentuli mikroskopi ufro naklebad mdgradia, vidre Cveulebrivi mikroskopi. dro da dro sawiroa nawilebis Secvla. es nawilebi Zviria da zogjer deficiturobis gamo mati SeZenac sirtulestan aris dakavsirebuli. amastan, igi periodulad moitxovs SekeTebas. aseve, eleqtroenergiis mowodeba unda iyos uwyveti, voltajis minimaluri cvalebadobit. am pirobebis Seqmna Zalzed Znelia ganvitarebad qveynebsi. sasurvelia, rom im laboratoriebma, romlebic SeiZenen fluoroscentul mikroskops, ganagrzon sinatlis mikroskopis gamoyeneba xarisxis kontrolisa da laborantis momzadebisatvis. 41

9. rogoria mikobaqteriuli kulturebis gamokvlevis roli tuberkulozis diagnostikasa da SemTxvevaTa dadgenasi 11 a. van deuni 12 mikobaqteriuli kulturis gamokvlevis roli tuberkulozis diagnostikasi baqteriata gamovlenis albatoba nacxis mikroskopuli kvlevis mesveobit didadaa damokidebuli naxvelsi mat koncentraciaze. (ix. Tavebi: ~ra koncentraciit unda iyos baqteriebi naxvelis nimussi, rom nacxis mikroskopuli kvlevis Sedegis safuzvelze igi micneul iqnes dadebitad? an ~ramdenad sarwmunoa nacxis mikroskopia ). Tu bacilata koncentracia naxvelis 1 ml-si 1000- ze naklebia, masin nacxis mikroskopiuli kvlevit mati armocenis SesaZlebloba 10%-ze naklebia. SedarebisaTvis, kulturis gamokvlevit baqteriata gamovlenis Sansi bevrad maralia: gamovlena SesaZlebelia masinac ki, Tu mati koncentracia 1ml-Si aris 100- ze naklebia. ufro metic, kultura izleva mikobaqteriebis saxeobebis identificirebis SesaZleblobas mati bioqimiuri da sxva Taviseburebebis safuzvelze. nacxis mikroskopiit arasarwmunoa sxvadasxva patogenuri da arapatogenuri mikrobebis diferencireba, radgan yvela isini mjavagamzle da morfologiurad msgavsni arian. aqedan gamomdinare, SeiZleba itqvas, rom kulturis kvlevis metodi, misi mgrznobelobisa da specifikurobis gatvaliswinebit, gacilebit ufro misarebia tuberkulozis diagnostikisatvis, vidre naxvelis nacxis mikroskopuli gamokvleva. realobasi, nebismieri metodis diagnostikur efeqturobaze gavlenas axdens misi mgrznobeloba teqnikuri arasrul- 11 k. tomanis pirvel gamocemasi arsebul Tavze dayrdnobit 12 tropikuli medicines institutis, mikobaqteriologiis ganyofileba. Aantverpi,belgia 42

yofilebisadmi da agretve, is pirobebi, ra pirobebsic xdeba misi gamoyeneba. nacxis mikroskopuli kvlevis dros teqnikuri xarvezebi did gavlenas ar axdens testis maral specifikurobaze misi marali mgrznobelobis gamo (ix. Tavi: ~ramdenad sarwmunoa nacxis mikroskopiuli kvleva ). kulturis gamokvlevis Sedegebze ki mnisvnelovan gavlenas axdens teqnikuri xarvezebi da amcirebs mis specifikurobas, rac SeiZleba dabinzurebit iyos gamowveuli: SesaZloa moxdes am baqteriis gadatana erti nacxidan meoreze, anu kultura-pozitiuridan kultura-negatiurze. am problemis masstabebis Sesaswavlad britanetis samedicino kvlevebis sabwos samxret afrikis kolaboraciul laboratoriebsi Catarda kvleva: pozitiuri nacxis rifampicin_monorezistentuli sarebavit markirebuli Stamebi Sereul iqna negatiur StamebTan. mogvianebit arsebobda SesaZlebloba am gamonaklis Stamebze metvalyuerobisa 54. masinac ki, rodesac WeSmaritad pozitiurobis sixsire am seriasi iyo 25%, kulturaluri izolatebis 1,6 4,7% iyo cru-pozitiuri. ufro mogvianebit dnm-is peptiduri qromatogramis Seswavlis metodis (fingerprinting) gamoyenebit mirebuli iqna jvaredini kontaminaciis asetive macvenebeli, rac araertxel iqna gamovlenili iseti qveynebis laboratoriebsic, sadac tuberkulozis prevalentoba dabalia 55, 56. im qveynebsi, sadac tuberkulozis gavrcelebis macvenebeli maralia nacxis mikroskopiuli kvlevis specikfiuroba SesaZloa arematebodes kulturis kvlevis specifkiurobas. es SesaZloa WeSmariti iyos tuberkulozis diagnostikitvisac 57, radgan naxvelis nacxsi mjavagamzle baqteriebis arseboba uewvelad miutitebs tuberkuliozis mikobaqteriaze, im qveynebsic ki, sadac maralia aiv-is gavrceleba 58 da piriqit im qveynebsi, sadac tuberkulozis gavrcelebis macvenebeli dabalia, kulturis kvleva (an identifikaciis sxva alternatiuli metodis gamoyeneba) tuberkulozisa da sxva mikobaqteriuli patologiis diferenciebis Seucvleli sasualebaa. amastanave, ganvitarebad qveynebsi samkurnalo dawesebulebebi xsirad xelmiuwvdomelia finansuri, kulturuli, geografiuli da sxva faqtorebis gamo. amitomac pacientebi eqims mimartaven ukve Sors wasuli formebis, anu kavernis stadiaze. naxvelsi miobaqteriebis koncentracia ZirTadad ganisazrvreba mati raodenobit im dazianebuli qsovilis aresi, saidanac isini 43

warmoisva. amrigad, 2 sm diametris kaverna (romelic gaxsnilia bronqsi), SeiZleba Seicavdes 100 mln mikobaqterias, masin rodesac imave zomis arakavernozuli, kerovani ubani Seicavs mxolod 100_1000 bacilas 59. tuberkulozur kaverniani filtvisgan mirebuli naxveli Seicavs didi raodenobit qsovilis nekrozul nawilakebs uamravi raodenobis baqteriebit. aseti nacxis mikroskopuli kvlevis Sedegi TiTqmis yoveltvis dadebitia. amis sapirispirod, kerovan nodozuri, inkafsulirebuli dazianebis SemTxvevaSi naxveli Seicavs bacilebis Zalzed mcire raodenobas da nacxis mikroskopuli kvlevac TiTqmis yoveltvis uaryofit pasuxs izleva. naxvelis nacxis analizis mgrznobelobis damokidebulebis aspeqtebi patologiuri procesis xasiatis Taviseburebebze natlad aris warmodgenili Kim-isa da Tanaavtorebis nasromsi 60, romelsic Sedarebulia SemTxvevis kultura-pozitiuri, rentgenologiurad gamovlenili daavadebis simzime da xarisxi koncentrirebuli naxvelis mikroskopiul kvlevis SedegebTan (surati #1). surati #1 nacxit daedebiti SemTxvevebis procentuli magvenebeli filtvis tuberkulozis mqone, yvela kultura-dadebit pacientsi daavadebis rentgenografiuli kvlevis safuzvelze dadgenili simzimis mixedvit minimaluri simzime (81) sasualo simzime arakavernozuli (157) Sorswasuli arakavernozuli (88) sasualo simzime kavernozuli (131) Sors wasuli kavernozuli (520) sul SemTxvevaTa raodenoba (n=977) 44

moyvanili monacemebidan gamomdinare, ioli gasagebia, rom kulturis gamokvlevasa da nacxis mikroskopiul gamokvlevas Soris gansxvaveba mgrznobelobis TvalsazrisiT ufro metad gamovlindeba SemTxvevebis aqtiuri gamovlenisas, an gamokitxvebis Catarebisas. am dros gamovlenili SemTxvevebis udidesi nawili warmodgelili iqneba naklebad mzime an subklinikuri formebit, masin roca kavernozuli stadiebi, baqteriebis didi odenobis gamoyofit, SedarebiT isviatad Segvxvdeba. am faqtis sailustraciod gamodgeba indoetsi benagaloris tuberkulozis nacionaluri institutis mier Catarebuli kvlevebi, romelic miznad isaxavda mikroskopuli kvlevisa da kulturata analizis Sedegebis Sedarebas. armocnda, rom gamokitxvit gamovlenili SemTxvevebidan kultura-dadebiti Sedegebis mxolod 40-50% gamovlinda mikroskopuli kvlevit, macvenebeli izrdeboda 85%-mde im adamianebs Soris, vinc Tavad mimartavda eqims CivilebiT gulmkerdis aresi. 61 (8) metodikis zusti gamoyenebit, naxvelis pirdapiri mikroskopiis marali diagnostikuri macvenebeli gvaqvs aiv-is SemTxvevaTa konteqstsic 62, 63, (ix. aseve Tavi rogor gansxvavdeba tuberkulozis diagnostika aiv-inficirebul da arainficirebul pacientebsi? gv.80). kulturata da mikroskopiuli gamokvlevebis SedarebiTi mgrznobeloba ilustrirebulia cxril #11-Si, urbancikis publikaciidan 64. am Sromis gamoqveynebis Semdeg warmodgenili iyo ufro marali macvenebeli (80 %-ze meti) marali prevalentobis regionebidan, mat Soris iseti qveynebidanac, sadac aiv-is gavrcelebis macvenebeli Zalzed maralia. rogorc Cans, mikroskopiis pasuxebi, kulturis gamokvlevis SedegebTan SedarebiT, praqtikulad marali variabelobit xasiatdeba. nawili am variantebisa SeiZleba aixsnas mosaxleobasi arsebuli gansxvavebit (maral an dabali prevalentobis qveynebi, SemTxvevis adreuli an dagvianebuli gamovlena). gamoyenebuli metodebit (fluoroscentuli mikroskopia, koncentraciis metodi). nawilobriv es Sedegebi damokidebulia testebis Sesrulebis xarisxzec. miuxedavad kulturis testis marali mgrznobelobisa, misi gamoyeneba SeiZleba naklebefeqturi iyos gansakutrebit im pacientebis kvlevisas, romlebic SemTxveviT armocndnen gamokvlevaze gulmkerdis simptomatikit CivilebiT. tuberkulozis marali prevalentobisa da aiv-infeqciis gavrcelebis qveynebsi. orive am metodis sworad gamoyenebis pirobebsi kulturis kvlevis efeqturoba 45

Seadgens 25%-s mikroskopul kvlevastan Sedarebi 65. dabali prevalentobis qveynebsi es macvenebeli ufro maralia da SesaZloa gaormagebulic. amis garda, kulturis gamokvleva izleva mikobaqteriis saxeobebis dadgenis SesaZleblobas, risi gaketebac mikroskopuli kvlevebit SeuZlebelia. cxrili #11. qveyana/regioni ass ass ass afrika/evropa azia/ass ass didi britaneti germania ass ass germania weli 1976 1975 1976 1980 1980 1975 1992 monacemebi ar aris 1977 1980 monacemebi ar aris kulturit da nacxit dadebiti SemTxvevebis % 62 22 43 53 ceil-nelseni 63 fluoroscentuli 24 53 54 50 25 37 masasadame, baqteriologiuri TvalsazrisiT, ganirceva ori ZiriTadi kategoriis pacienti; erti Zalzed infeqciuri, romelic gamoyofs didi raodenobit Cxirebs da amitom advilad gamovlindeba nacxis mikroskopiuli kvlevis mesveobit, da meore naklebad infeqciuri, romlic nakleb mikobaqterias gamoyofs da ramdenadac naxvelis mikroskopuli kvleva aset SemTxvevebSi naklebad efeqturia, misi diagnostika xdeba kulturis kvlevis safuzvelze. rogorc ukve arinisna, zemot xsenebuli pacientebi gamoyofen baqteriebs intervalebit. natelia, rom es ori kategoria mnisvnelovnad gansxvavdeba ertmanetisgan klinikuri da epidemiologiuri TvalsazrisiTac. naxvelis Sefaseba (statusi) da klinikuri prognozi prognozis TvalsazrisiT, filtvis tuberkulozit davadebul im pacientebs, romlebic baqteriebis nakleb raodenobas gamoyofen garemosi, da romelta gamovlenac mxolod kulturis gamokvlevitaa SesaZlebeli, filtvi naklebad aqvt dazianebuli, da zogadad 46

ufro ketilsaimedo prognozi aqvt, vidre nacxit pozitiur pacientebs. samxret indoetsi sadac epidemiologiuri kvleva tardeboda garkveul intervalebsi scades ganesazrvrat axladgamovlenili pacientebis momavali 66, 67. im pacientebis naxevarze meti, romlebsac nacxit negatiuri pasuxi hqondat (ori nacxi) da mxolod kulturis gamokvlevit daesvat diagnozi, ukve 18 Tvis Semdeg klasificirebuli iyo rogorc gankurnebuli (negatiuri nacxit da kulturit) xolo ori mesamedi- 3 wlis Semdeg. sikvdilianobis macvenebeli Seadgenda nacxit pozitiuri SemTxvevebis ert mesameds. amrigad, soflis mosaxleobis mzime sacxovrebel pirobebsic ki, mkurnalobis garesec, nacxit negatiuri da kultura-pozitiuri formebis dros prognozi SedarebiT ketilsaimedoa. cnobilia, rom nacxit negatiur formebs axasiatebt sikvdilianobis ufro dabali macvenebeli. itvleboda, rom aset pacientebs hqondat daavadebis adreuli stadia, xolo mosalodneli iyo mati mdgomareobis gauareseba da nacxit pozitiur mdgomareobasi gadasvla. amis Tavidan asacileblad cdilobdnen pacientebis gamovlenas daavadebis ~adreul stadiaze, anu masin, rodesac filtvis dazianeba aris minimaluri da es ubani Seicavs mcire raodenobit mikobaqteriebs, romelta gamovlena xdeba mxolod kulturis kvlevit. aseve gaketda daskvna, rom am pacientebs isviatad aqvt klinikuri Civilebi da amitom mati gamovlena unda moxdes masobrivi rentgenologiuri kvlevit. gaocebas iwvevs is faqti, rom am debulebam drois gamocdas ver gauzlo. xangrzlivvadian kvlevasi, romelic didi sizustit Catarda da ganxorcielda (ix. ~rogor vitardeba filtvis tuberkulozi da rogor unda moxdes misi gamovlena adreul stadiaze ) CexoslovakiaSi, mosaxleobas 2-3 wlis ganmavlobasi utardeboda rentgenologiuri da baqteriologiuri gamokvleva 68. am kvlevam moicva mosaxleobis Sesabamisi raodenoba (95%), anu TiTqmis mteli mosaxleoba. yoveli raundis dros kvleva utardeboda mnisvnelovan raodenobas im pacientebisa, romeltac arenisnebodat mcire rentgenologiuri dazianebani da iyvnen kulturit pozitiuri, magram negatiuri nacxis mikroskopiit. (nimusebi grovdeboda zedized sam dris ganmavlobasi). yvela am pacientis mkurnaloba dauyovnebliv daiwyo da warmatebit dasrulda. hipotezis mixedvit, am pacientebs CautardaT profilaqtikuri mkurnaloba mdgomareobis gauaresebisa 47

da tuberkulozis mzime, nacxit pozitiuri formebis ganvitarebis Tavidan acilebis miznit. amastan mosalodneli iyo, rom mzime, nacxit pozitiuri SemTxvevebis ricxvi am RonisZiebis Sedegad swrafad daiwyebda klebas, magram, daavadebis adreul gamovlenas da mkurnalobis adreul dawyebas mohyva gasaocrad mcire efeqti: miuxedavad Catarebuli RonisZiebebisa, TiToeuli raundis dros vlindeboda sakmao raodenobit axal-axali, nacxit dadebiti SemTxvevebi tuberkulozis Sorswasuli formebit. zemot arwerilma da sxva kvlevebma gvicvena, rom ar aris aucilebeli tuberkulozis axali, nacxit dadebiti formebi ganvitardes nacxit-negatiuri stadiidan (ix. rogor vitardeba filtvis tuberkulozi da rogor unda moxdes misi gamovlena adreul stadiaze ). aseve gairkva, rom im pacientebis prognozi, romlebsac arenisnebodat nacxit dadebiti tuberkulozi, mosalodnelze uketesi armocnda, radgan is dazianebebi, romlebic mat arenisnebodat an ganikurna an ucvleli darca. pacientta mxolod mcire raodenobis mdgomareoba gauaresda, da aqedan gamomdinare, mxolod mcire raodenobis nacxit dadebiti SemTxvevebis prevencia aris SesaZlebeli ufro mgrznobiare diagnostikuri testebis gamoyenebit. naxvelis mdgomareoba (statusi) da mkurnalobis araefeqturoba epidemiologiuri TvalsazrisiT, SemTxvevaTa am or tips Soris gansxvaveba gasaocaria. nacxit uaryofiti pacientebi mnisvnelovnad naklebad infeqciurni arian, vidre nacxit dadebiti. es gasagebia, radgan baqteriata gamoyofis TvalsazrisiT mat Soris uzarmazari gansxvavebaa. nacxit dadebiti pacientebisgan inficirebis riski gacilebit ufro maralia, radgan es pacientebi axveleben ufro xsirad da Zlier 69. ojaxis wevrebis dasnebovanebis TvalsazrisiT, nacxit uaryofiti pacientebi procentulad naklebad infeqciurni arian, vidre nacxit dadebiti avadmyofebi. inficirebis ZiriTad risks emateba araojaxur garemosi dasnebovnebis damatebiti riski.dainficirebis ZiriTadi riski Cveulebriv ufro maralia mwidrod dasaxlebul, xalxmraval garemosi, vidre sasualo riski mteli populaciistvis, romelic xsirad mcdarad gamoiyeneba SedarebisaTvis. amis garda cnobilia, rom ojaxuri kontaqtebit 48

inficirebis riski kultura-pozitiuri, magram nacxit uaryofiti pacientebisgan Seadgens mxolod 10-20%-s, nacxit dadebiti pacientebisgan inficirebis risktan SedarebiT 70, 71 (ix. Tavi: ~ra rols asrulebs tuberkulozis SemTxvevebis gamovlenasi mosaxleobis perioduli masiuri rentgenologiuri kvleva ) es mosazrebebi dadasturda cdebit, romelic Catarda san-franciskosi, ass-si da mimdinareobda 1991-1996 wlebsi. tuberkulozis mikobaqteria izolatebis Stamebis urtiertkavsiris gamovlena dnm peptiduri gamokvlevit xorcieldeboda. Catarebuli kvlevis Sedegad dadginda, rom daavadebis gavrceleba nacxit uaryofiti, kulturapozitiuri pacientebidan 72 mxolod 17%-Si xdeba. tuberkulozis kontrolis programis TvalsazrisiT, im pacientebis gamovlenas, romlebic gamoyofen baqteriebis mcire raodenobas SedarebiT naklebi prioriteti eniweba. Tuki aseti pacientebis gamovlena mainc xorcieldeba tuberkulozis kontrolis programis farglebsi, es ar unda gadaiqces mis ZiriTad prioritetad SemTxvevaTa gamovlenasi infeqciis wyaros identifikaciis TvalsazrisiT. zemot moyvanili yvela monacemis gatvaliswinebit, SeiZleba darwmunebit itqvas, rom infeqciis wyaros 90%-is deteqcia marali prevalensis qveynebsi SesaZlebelia ganxorcieldes nacxis mikroskopiit. arsebobs kidev sxva mizezic, ris gamoc tuberkulozis mikobaqteriis kulturis kvleva naklebad gamoiyeneba tuberkulozis SemTxvevaTa gamovlenis miznit. marali prevalentobis qveynebsi kulturata kvlevis SesaZlebloba Zalzed mwiria da mati Seqmna TiTqmis SeuZlebelia finansuri da teqnikuri siduxwiris gamo. mikobaqteriuli kultura sxavadasxva standartuli niadagis mixedvit (levenstein iensenis standartis mixedvit kvercxis niadagze an agaris niadagze, midel-brukis standarti) 5-10-jer ufro ZviradRirebulia ert nimusze Rirebulebis gaangarisebit, vidre nacxis mikroskopia. amastan sawiro aparatura da Sesabamisi praqtikis mqone personali ufro Znelad mosaziebelia. im samedicino dawesebulebebsic ki, sadac yvelaferi es xelmisawvdomia, metodi gamoiyeneba ZiriTadad tuberkulozis diagnozis dasadastureblad im SemTxvevebSi, rodesac tuberkulozis mkurnaloba ukve Catarebulia. es ganpirobebulia imit, rom kulturebis umetesoba inokulaciis momentidan 3 kviris Semdeg xdeba pozitiuri, ase rom, kulturebis kvlevis pasuxebi SesaZloa mirebul iqnes 49

dagvianebit, sul mcire, erti Tvis Semdeg. klinicistebis umetesoba ar icdis amden xans da diagnozs adgens rentgenografiis sasualebit. amrigad, rentgenografiul diagnostikas, rogorc sistemuri diagnostikuri algoritmis Semadgenel nawils, avtomaturad eniweba upiratesoba kulturis kvlevastan SedarebiT (ix. Tavi: ~ra SedarebiTi upiratesobebi aqvs gulmkerdis radiografias da naxvelis gamokvlevas - nacxisa da kulturis kvleva - gulmkerdis aresi gaxangrzlivebuli Civilebis mqone ambulatoriul pacientebs Soris SemTxvevaTa gamovlenis dros ). kulturis kvlevis Tanamedrove metodebis gamoyenebit, kerzod Txevadi niadagebisa da zrdis gamosavlenad ufro mgrznobiare sistemebis gamoyenebit pozitiuri kulturis gamovlena SesaZlebeli xdeba ufro SemWidrovebul vadebsi 1 an 2 kvirasi. Tumca aseti komerciuli sistemebi ZviradRirebulia, mati operireba moitxovs did xarjebs da marali donis teqnikur codnas. ufro metic, diagnostika standartuli algoritmis gamoyenebit naklebi finansuri danaxarjebit mkurnalobis ufro swrafad dawyebis SesaZleblobas izleva, vidre kulturalur kvlevaze dafuzvnebuli diagnostika. yvela arnisnuli mizezis gamo tuberkulozis diagnostikasi mikobaqteriis kulturis gamokvlevis roli ufro aqtualuri gaxdeba, Tu am daavadebis prevalentoba daiklebs. tuberkulozis gavrcelebis Semcirebis SemTxvevaSi klinicistebs naklebad eqnebat safuzveli, rom ivaraudon tuberkulozis diagnozi da mogvianebit mirebuli kulturaluri kvlevis Sedegebic mnisvnelovani iqneba. daavadebis gamovlenis SemTxvevaSi warmodgenili iqneba naklebad mzime formebi da Sesabamisad Semcirdeba nacxit dadebiti tuberkulozis SemTxvevebis raodenobac. naklebad patogenuri mikobaqteria ufro metad gavrceldeba (ufro xsirad gamoiwves daavadebas), ris gamoc ufro aqtualuri gaxdeba mjavegamzle baqteriebis saxeobata identificireba. da bolos, tuberkulozis SemTxvevebis Semcireba sazogadod, gamoiwvevs qveyanasi ekonomikur zrdas, rac SesaZlebels gaxdis ZviradRirebuli aparaturit laboratoriebis arwurvas da kulturebis optimalur gamoyenebas. vidre tuberkulozi fartod aris gavrcelebuli sazogadoebasi, mikobaqteriis kulturebis kvlevis metodi meorad sasualebad rceba nacxis kargad Catarebul mikroskopiasa da radiografiul/ klinikur diagnostikastan SedarebiT. Tu SesaZlebelia, kulturebis kvleva unda gamoyenebul iqnes eqstrapulmonaluri 50

tuberkulozis, e.w. jirkvlovani tuberkulozis dasadgenad. AaivdadebiT pacientebsi es mnisvnelovnad Seamcirebs diagnostikur da teqnikur Secdomebs. kulturis gamokvleva aqtualuri rceba medikamentebisadmi rezistentulobis zedamxedvelobis ganxorcielebis TvalsazrisiT. mikobaqteriul kulturata gamokvlevis roli tuberkulozis SemTxvevaTa klasifikaciasi mikobaqteriis kulturis kvleva Zalzed mnisvnelovan rols asrulebs tuberkulozis diagnozis dadasturebasi, magram programis pirobebsi misi mnisvneloba SesaZloa mtlianad Seicvalos nacxis mikroskopiastan mimartebasi. gaxanrzliavebuli kvlevam, romelic ganxorcielda samxret indoetsi 68, nateli mohfina difernciul gadarcevas, Sedegebi am mimartulebitac iyo gaanalizebuli. kulturisa da nacxis analizi Cautarda yvela im pirs, romlebsac radiografiuli gamokvlevis safuzvelze savaraudod hqonda aqtiuri tuberkulozi. Semdgom, aranamkurnaleb amave pacientebs CautardaT ganmeorebiti kvleva daavadebis progresis dasadgenad im pirobit, rom pozitiurobis zrvrul macveneblad mirebuli iqneboda 3 mg bacila. armocnda, rom tuberkulozis mikobaqteria izrdeboda nacxit-pozotiuri SemTxvevebis mxolod 10%-Si. amis sapirispirod, 3-dan 2 SemTxvevaSi rentgenologiuri kvlevit ewvmitanili tuberkulozi ar dadasturda da aseve ar iqna armocenili mdgomareobis progresirebis raime mtkicebuleba. mogvianebit Catarebulma kvlevebma 73 daadastura nacxis mikroskopiis sandooba, romelic tuberkulozis SemTxvevaTa klasifikaciisatvis SeiZleba iyos gamoyenebuli kulturis kvlevis nacvlad, radgan nacxit dadebit SemTxvevebis mxolod 3-6%-Si iyo kultura uaryofiti. bevr SemTxvevaSi am natlad cru-pozitiuri pasuxis mizezi SeiZleba iyos mkurnaloba, Tumca sinjebis xelaxali gadamowmeba adasturebs (arapozitiuri, arasicocxlisunariani) bacilebis arsebobas. definiciebi ~nacxit dadebiti da nacxit negatiuri filtvis tuberkulozis SemTxveva itvaliswinebs mikroskopuli analizisatvis damaxasiatebel SezRudvebs. amave dros, isini xazs usvamen filtvis nacxit dadebiti tuberkulozis SemTxvevebis prioritetul mnisvnelobas. 51

kulturis kvleva SesaZloa ufro relevaturi iyos daavadebis warmatebuli Tu warumatebeli mkurnalobis, an recidivis definiciisatvis. mravali kvlevis avtorebi mag., al-moamari 74 da sxvebi dokumenturad asabuteben nacxis dagvianebul konversias dadebitidan uaryofitisaken da adareben kulturis monacemebs (grafiki 2). mikroskuli kvlevisas zogierti pacientis naxvelsi aracxovelmoqmedi baqteriebi rceba mkurnalobis dawyebidan 5 da meti Tvis Semdegac. reideris da misi Tanaavtorebis 75 mier Catarebuli kvlevit, 8 SemTxvevidan romelsac armocnda nacxit dadebiti forma me-5 Tvis ganmavlobasi mxolod 2 pacients daswirda ganmeorebiti mkurnaloba. kultura izleva ufro zusti klasifikaciis sasualebas, magram xsir SemTxvevaSi ar aris problemis praqtikuli gadawyveta. programis miznebis Sesabamisad, mkurnaloba itvleba usedegod, rodesac mkurnalobidan 5 an meti Tvis Semdeg Cxirebi kvlav rceba. nacxit dadebiti Sedegis sxva mizezi laboratoriuli Secdomaa. meore mxriv, kulturis gamokvlevis garese, rig pacientebtan, mkurnalobis warumateblobis mizezebi amoucnobi rceba, gansakutrebit masin, rodesac mikroskopuli kvleva arasatanadod tardeba. es pacientebi SeiZleba warmoadgendnen e.w. naadrev recidivs. rogorc mkurnalobis warumateblobis, aseve recidivis mxolod mikroskopul kvlevaze dafuznebuli klasifikacia naklebad sarwmunoa. Tumca, aparaturis deficitis da metodis ganxorcielebis teqnikuri sirtulis, aseve kulturis Sedegebis dagvianebit mirebis gamo, gankurnebis, recidivis an mkurnalobis warumateblobis gansazrvra usualod efuzneba nacxis mikroskopias, xolo kulturis kvleva ganixileba SesaZlo variantad iq, sadac misi Catareba xelmisawvdomia. 52

grafiki #2. Tavdapirvelad nacxit dadebiti pulmonaluri tuberkulozis nimusebis konversia nacxsa da kulturasi negatiuris %, (kumulaciuri) kvireebis raodenoba konversiamde 53

10. rogoria kultura - uaryofiti Sedegis mirebis albatoba nacxit dadebiti tuberkulozis dros k. tomani 13 singapuris tuberkulozis kontrolis programis farglebsi Catarda kvleva baqteriologiur metodebis efeqturobis Sesaxeb 76. Seswavlil iqna 1162 axali pacienti, romelta klinikuri da rentgenologiuri monacemebi izleoda tuberkulozze ewvis mitanis safuzvels. mat CautardaT gamokvleva Semdegi metodikit: TiToeuli pacientisgan arebul iqna naxvelis ori nimusi gamocdili specialistis TandaswrebiT, zedized ori dris manzilze. TiToeuli nacxi gasinjul iqna pirdapiri mikroskopiit ert laboratoriasi, xolo kulturaze_meore laboratoriasi (erti nacxi da erti kultura TiToeul laboratoriasi). 1162 axali pacientisgan 500-s hqonda dadebiti nacxi erti an orive nimusidan. qvemot cxrilsi moyvanilia mirebuli Sedegebi: mjavagamzle baqteriebze nacx-pozitiuri axali pacientebis ricxvi nacxis pirveli nimusidan 428 damatebiti monacemebi nacxis meore nimusidan 72 sul 500 cxrili #12 gvicvenebs am nacxit-pozitiuri pacientebis naxvelis ori kulturis kvlevis Sedegebs. 500 pacientidan 17-Si, rac 4%-ze naklebia, nacxis pozitiuri pasuxebi ar dadasturda kulturebis gamokvlevit. dausves ra is faqti, rom yvela dabinzurebuli kultura micneuli unda yofiliyo negatiurad, daudasturebeli 13 gardacvlilia 54

pasuxebis wilma Seadgenda ara umetes 6%-isa. mati Semdgomi analizit gamovlinda, rom am ori nacxidan mxolod ertis gamokvlevis safuzvelze pozitiurad micneuli 115 pacientidan, 101 (TiTqmis 90%) kulturis kvlevis SedegebiT baqteriata gamomyofi iyo. mirebuli Sedegebidan avtorebma daaskvnes, rom tuberkulozis baqteriebi identificirebuli iyo nacxis gamokvlevit, xolo ori nimusis kulturuli kvleva adasturebda nacxis mikroskopuli analizis Sedegebs mcire gamonaklisebit; aqedan gamomdinare, ori nacxis mikroskopuli kvlevit mirebuli pozitiuri Sedegis kulturaluri analizit dadastureba ar warmoadgens aucileblobas. es gansakutrebit exeba im qveynebs, sadac tuberkulozi fartod aris gavrcelebuli da sadac pacientebi eqims mimartaven mxolod masin, rodesac uvitardebat hemoftizi an gaxangrzlivebuli xvela. cxrili #12. mgb dadebiti 500 axali pacientis ori dris ganmavlobasi Tanmimdevrulad arebuli naxvelis nimusis kulturebze kvlevis Sedegebi sul gamokvleulia diagnozi dadasturebuli pirveli kulturit diagnozi dadasturebuli meore kulturit (damatebiti) dabinzurebuli (orive kultura) diagnozi ar dadasturda arc erti kulturit pacientebis ricxvi 500 399 73 11 17 % 100 80 14 2 4 tuberkulozis baqteriebis Semcveli naxvelidan uaruofiti pasuxis mirebas SesaZloa hqondes mravali mizezi. pacientis mkurnalobis periodsi baqteria kargavs kulturasi zrdis unars da praqtikulad kvdeba. rifampicinis Semcveli rejimit mkurnalobisas pacienti kultura - uaryofiti xdeba ZiriTadad mkurnalobis dawyebidan 3 kvirasi, Tumca SesaZloa isini nacxit 55

pozitiurebi darcnen, anu mgb an darupulia, an sicocxlis uunaro. im SemTxvevebSi, Tu pacients ar utardeba mkurnaloba, nacxi SeiZleba moxvdes mzis pirdapiri sxivebis qves, dazveldes, gamosres, an dabinzurdes, rac ganapirobebs uaryofit Sedegs. inokulaciamde dekontaminaciis proceduris arasatanadod Catareba, zedmetad gacxeleba centrifugirebis dros, kulturistvis araadekvaturi niadagis gamoyeneba an inkubaciis arasakmarisi dro aseve izleva uaryofit Sedegebs. isviat SemTxvevaSi dadebiti pasuxi SeiZleba ganpirobebuli iyos aratuberkulozuri, aramed sxva mikobaqteriis arsebobit nacxsi. orive nacxis kvlevis mixedvit negatiur pacientebsi pozitiuri kulturis gamovlenis albatoba sruliad gansxvavebuli problemaa da es problema ganxilulia am wignis ert-ert TavSi sataurit: rogoria mikobateriul kulturata gamokvlevis roli tuberkulozis diagnostikasa da SemTxvevis gansazrvrasi. 56

11. ra damatebiti Sedegebi moaqvs naxvelis gamnmeorebit gamokvlevas nacxis mikroskopiuli da kulturaluri kvlevis sasualebit a. harisi 14 indoetis tuberkulozis nacionalur institutsi Catarda kvlevebi 77, 78, rata ganesazrvrat, Tu ra damatebiti Sedegebis mireba SeiZleboda gaxangrzlivebuli respiratoruli Civilebis mqone, savaraudodd tuberkulozit daavadebuli ambulatoruli pacientebis SemTxvevaTa gamovlenis gaumjobesebis TvalsazrisiT, TiToeuli individidan arebuli naxvelis rva sinjis rogorc mikroskopuli, aseve kulturis kvlevit (ix. Tavi: ra upiratesobebi aqvs gulmkerdis rentgenografiasa da nacxis gamokvlevas (nacxis mikroskopuli da kulturis kvleva). TiToeuls im 119 individidan, romeltac filtvis rentgenologiuri kvlevisas arenisnebodat anomaluri Crdilebi, xolo gulmkerdis mxriv gaxangrzlivebuli Civilebi, Tanamimdevrulad aures naxvelis 8 nimusi (4 samedicino dawesebulebasi da 4 dilas binaze momsaxure personalis mier) da ertdroulad gamoikvlies rogorc nacxis mikroskopiit cilnilsenis metodit, aseve kulturaluri analizit. am xerxit gamokvleuli nimusebis saerto raodenoba Seadgenda 1552-s. yvela es nimusi Seiswavles cal-calke. laboratoriis personalma ar icoda sxva anlizebis Sedegebi da arc is, Tu visgan iyo es nimusi arebuli. (ormxrivi brma metodit kvleva) tubrkulozis baqteria armoacnda 75 pacients (cxrili #13). cxrili #14 qronologiurad gvicvenebs axali SemTxvevebis gamovlenis Sedegebs, mirebuls pirveli da Semdgomi nimusebis kvlevidan Tanamimdevruli kvlevebit, rogorc nacxis mikroskopuli 14 malaviis tuberkulozis kontrolis erovnuli programis teqnikuri mrceveli. lilongue,malavia 57

gamokvlevit, aseve kulturis testit _ axali pozituri Sedegebis umetesoba ertmnisvnelovnad mirebuli iqna pirveli da meore nimusebidan. natlad gamocnda, rom axali dadebiti Sedegebis umetesoba orive tipis kvlevebis dros mirebulia ZiriTadad pirveli da meore nimusidan. cxrilis zeda nawilsi mocemulia, rom 45 pacienttan (85%) yvela nacxit dadebiti SemTxvevis dadebitoba vlindeboda ukve pirveli ori nimusis gamokvlevis dros. rac Seexeba kulturis gamokvlevit dasabutebul nacxit dadebit SemTxvevebs, 41 pacientis (89%) pozitiuroba gamovlinda pirveli ori gamokvlevit. ase rom, meore kulturam gazarda kulturata mgrznobeloba 63%-dan 84%-mde, Sesabamisad, optimaluri kulturebis raodenoba aris ori, an ara umetes samisa. cxrili #13. naxvelis 8 nacxis mikroskopiisa da kulturaluri analizis mesveobit naxvelis gamokvlevis Sedegebi 194-idan TiToeuli pacientisgan naxvelis 4 sinji arebuli gamokvleluli sinji gamokvleuli pacienti negatiuri pacientebi (yvela nacxi da kultura) pozitiuri pacientebi: sul mcire 1 nacxi da 1 kultura sul mcire 1 kultura (yvela nacxi negatiuria) sul mcire 1 nacxi (yvela kultura negatiuria) 46 22 7 a 1551 194 119 75 a amatgan or pacients nacxsi armoacnda sami an ufro naklebi mjavagamzle baqteria. am kvlevis meore mnisvnalovani Sedegi (cxrili 14) iyo is, rom pirveli ori nacxis kvlevit gamovlinda axali dadebiti SemTxvevebis (45) igive raodenoba, rac pirveli kulturis gamokvlevit (43). SesaZloa davaskvnat, rom axal aranamkurnaleb pacientebsi, romlebsac aqvt gaxangrzlivebuli Civilebi gulmkerdis aresi da anomaluri Crdilebi filtvsi, naxvelis ori Tanamimdevrulad arebuli nimusis (erti samedicino dawesebulebasi arebuli da meore momdevno dilas binaze) gamokvleva praqtikulad kulturis gamokvlevis ekvivalenturia. 58

cxrili #14. filtvis rentgenogramaze anomaluri Grdilebisa da gulmkerdis aresi tuberkulozze saewvo gaxangrzlivebuli simptomebis mqone 194 individidan TiToeulidan Tanamimdevrulad arebuli naxvelis 8 sinjis nacxis (S) da kulturis (C) ertdrouli kvlevis mesveobit gamovlenili axali SemTxvevebi baqteriologiuri kategoria SemTxvevebis raodenoba SemTxvevaTa raodenoba, pirveli pozitiuri sinjis seriuli nomris mixedvit I II III IV V VI VII VIII nacxit dadebiti kultura dadebiti S+ C+ S+ C- sul S+ C+ S+ C- sul 46 7 53 46 22 68 34 7 41(89%) 2 2 36 9 45(85%) 34 34 9 9 43 43 1-1 1 1 2 1-1 1 1 2 - - - - 1 1-1 1-1 1 1 1 2 1 2 3 2 1 3 2-2 es daskvna emtxveva sxva kvlevebis Sedegs, romlebic Catarda indoetsi, tuberkulozis kvlevis centris axal pacientebs Soris (madrassi yofili tuberkulozis qimioterapiis centri) 79, aseve singapursi Catarebul kvlevas 80, romlis Seswavlis sagansac warmoadgenda baqteriologiuri kvlevis mesveobit SemTxvevaTa gamovlena im pacientebsi, romlebic mimartaven samedicino dawesebulebas. es kvleva moicavda 1162 axal pacients, romlebsac arenisnebodat tuberkulozze saewvo rentgenologiuri simptomebi da Civilebi gulmkerdis aresi. naxvelis pirveli sinjis kulturalurma analizma gamoavlina 535 SemTxveva, xolo ori Tanmimdevruli nacxis analizma gamoavlina 500 SemTxveva (~rogoria naxvelis nacxis mikroskopiit dadgenili dadebiti sinjidan uaryofiti kulturis mirebis albatoba ). yovelive zemot Tqmuli amtkicebs mitcisonis azrs 81, rom ~ganvitarebul qveynebsi nacxis gamokvleva, kerzod, ki yoveli pacientidan ramodenimejer arebuli nacxis kvleva isetive efeqturia, rogorc kulturis gamokvleva. es metodi SeiZleba 59

gamoviyenot tuberkulozis marali prevalentobis qveynebsi pacientebis im jgufebsi, romlebmac mimartes samedicino dawesebulebebs iseti simptomebis gamo, rogoricaa gaxangrzlivebuli xvela, Cirqiani naxveli, hemoftozi da sxva 82. kidev erti mnisvnelovani dakvirveba iyo, rom 46 pacienti, romelic dadebiti iyo rogorc nacxis, aseve kulturis analizis mixedvit, tuberkulozis baqteriebs gamoyofda praqtikulad yoveldre (46 pacientisgan arebuli 368 nimusidan 347(94%) iyo kultura dadebiti) xolo 172 nacxit uaryofiti da mxolod kultura- dadebiti pacientisgan mxolod 62(35,2%). danarceni baqteriebs gamoyofda mxolod yovel measame dres da mxolod naxvelis yovel mesame ulufasi arinisna dadebiti pasuxi (ix. cxrili #11. TavSi: ~ra rols asrulebs mikobaqteriuli kultura tuberkulozis diagnostikasa da SemTxvevaTa gamovlenasi ), rac adasturebs, rom pacientebi, romlebic nacxit-negatiuri da mxolod kultura dadebiti arian epidemiologiuri TvalsazrisiT nakleb sasisroebas qmnian, vidre isini, vinc dadebitia rogorc nacxis mikroskopiit, aseve kulturit. msgavsi epidemiologiuri kvleva Catarda imave institutis mier samxret indoetis 78 ert-ert raionsi. kvlevasi monawileobda rentgenologiurad filtvebsi anomaluri Crdilebisa da gulmkerdis aresi gaxangrzlivebuli Civilebis mqone 1652 pacienti, romeltagan TiToeuls Tanamimdevrulad aures naxvelis 8 sinji da gamoikvlies ise, rogorc es zemot iyo arwerili. Sedegebi Seadares ertmanettan. nacxit da kultura pozitiuri pacientebis 86,7%-Si pirveli nacxi iyo pozitiuri, meore nacxis analizma damatebit kidev 10% pozitiuri Sedegi mogvca. mat Soris, vinc pozitiuri iyo mxolod kulturis pasuxis mixedvit, pirvelma sinjma dadebiti pasuxebi mogvca mxolod 32%-Si da meoredan 18%- Si. unda arinisnos, rom pacientebs, romlebic gamoyofdnen didi raodenobit baqteriebs, TiTqmis yoveli nacxi dadebiti hqondat, masin rodesac piriqit, kultura-dadebiti da nacx-negatiuri pacientebi, rogorc wesi, avrcelebdnen naklebi raodenobit baqteriebis da xsirad gamoyofdnen naxvels, romelic bacilebs saertod ar Seicavda (ix. cxrili #11. TavSi: ~rogoria mikobaqteriuli kulturata roli tuberkulozis diagnostikasa da SemTxvevaTa dadgenasi ). 60

samxret saharis teritoriaze, afrikasi, sadac Zalzed maralia aiv-infeqciis gavrceleba, mecnieruli mtkicebulebebit dgindeba, rom ori nacxis gamokvleva SeiZleba gamoviyenot, rogorc qronikuli xvelis Sefasebis safuzveli. tanzaniis 83 gaertianebul respublikasi gaanalizebuli iqna tuberkulozze ewvmitanili 61580 pacientis mg baqteriebis arsebobaze Catarebuli naxvelis nacxis usualo mikroskopiis rutinuli Sedegebi. nacxit-pozitiuri armocnda 18,9%. im pacientebs Soris, romlebsac sami naxvelis nacxis testis sruli kompleqsuri kvleva CautardaT, pirveli sinjit nacxit pozitiuri SemTxvevebi dadasturda 83,4%-Si, 12,2% - meore sinjis kvlevit da 4,4% - mesame sinjit. malavisi Catarebuli kvlevis Sedegad 84 280 pacientidan, romlebsac arenisnebodat qronikuli xvela, wonis kleba da usedego antibiotikoterapia, 71-Tan gamovlinda dadebiti Nnacxi. nacxit dadebiti tuberkulozis mqone pacientebs Soris, pirveli sinjit diagnozi dasmuli iyo SemTxvevaTa 83%-Si, meore sinjit 13%-Si da mesame sinjit ki 4%- Si. malavis ert ubansi, ori da sami nacxis gamokvlevis strategiis Sedareba warmoebda 6 Tvis manzilze 85. orive SemTxvevaSi tuberkulozze saewvo pacientebis 16% armocnda nacxit dadebiti. tuberkulozis klinikuri modeli, gansakutrebit nacxit dadebiti filtvis tuberkulozis SemTxvevaSi, miuxedavad gamoyenebuli strategiebis nairgvarobisa igive rceboda. ori da sami naxvelis gamokvlevis strategia Sedarebuli iyo ertmanettan afrikis sasoflo raionebsi 86, aiv-infeqciis farto gavrcelebit. kvlevisas gamoyenebuli iyo fluoroscentuli mikroskopiis metodi, xolo dasadastureblad ki cil-nilsenis SeRebvis metodi. sami nacxis strategiis gamoyenebisas 97%-Si swori pasuxebi mirebul iqna ukve pirveli ori nacxis Seswavlisas. upiratesoba eniweba sami nacxis kvlevas. WeSmaritad nacxit dadebiti pacientebis umetesobas aqvs ori an sami dadebiti nacxi. Tu mxolod erti nacxia dadebiti, es SesaZloa iyos teqnikuri SecdomiT gamowveuli cru-pozitiuroba (ix. Tavi: ~ram SeiZleba gamoiwvios nacxis cru-pozitiuri an cru-negatiuri Sedegebi ). masinac ki, Tu mikrobiologiuri laboratoria musaobs kargad, pozitiuri pasuxebis 1-4% SesaZloa iyos cru-pozitiuri 87,88. Catarebuli kvlevebis Sedegebi metyvelebs janmos mier rekomendirebuli algoritmis sasargeblod, romlis mixedvitac 61

nacxis Semdgomi Semowmeba sawiroa im SemTxvevaSi, rodesac pacients aqvs erti pozitiuri nacxi. damatebit unda itqvas, rom sami sinjis areba pacients ar uqmnis imaze met diskomforts, vidre oris, Tuki mati areba xdeba Tanamimdevrulad ori dris manzilze (erti samedicino dawesebulebasi da meore binaze adre dilas). Tumca, im adgilebsi, sadac sakadro da finansuri resursebi mnisvnelovnad SezRudulia, naxvelis ori sxvadasxva nimusis nacxis Semowmebis strategia savsebit gamartlebulia. 62

12. ramdenad sandoa gulmkerdis rentgenografiuli kvleva 15 r. kopaka 16 da n. boki 17 rentgenologiis, rogorc diagnostikuri metodis gamoyeneba, udidesi gardatexa iyo tuberkulozis Sesaxeb codnis gafartoebisa da misi diagnostikis TvalsazrisiT. amdenad gasakviri ar aris, rom is entuziazmi, ritac es metodi dainerga da gamoiyeneboda xsirad iwvevs mis gadawarbebit Sefasebas. jerjerobit fartod aris mirebuli, rom filtvis tuberkulozis diagnostika SesaZlebelia mxolod filtvis rentgenografiis mesveobit. magram praqtikuli gamocdileba da mravali mecnieruli kvleva gvicvenebs, rom rentgenologiuri gamokvleva ar warmoadgens tuberkulozis diagnostikis ertadert utyuar SesaZleblobas. filtvis mravali daavadeba izleva tuberkulozis msgavs rentgenologiur surats. AamasTanave, filtvis qsovilis dazianebebma tuberkulozis dros SesaZloa miiros nebismieri sxva daavadebis rentgenologiuri saxe 89. gulmkerdis rentgenografia SeiZleba dagvexmaros dazianebis lokalizaciis dadgenasi, magram diagnozis Semdgomi dadastureba SesaZlebelia mxolod baqteriologiuri kvlevis safuzvelze. 15 tomanis wignis wina gamocemasi arsebul Tavze dayrdnobit 16 tuberkulozis armofxvris ganyofilebis med-musaki. tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati, ass. 17 kvlevisa da Sefasebis ganyofilebis medmusaki tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati, ass. 63

rentgenologis Secdomebi bevri fartod gamoyenebuli klinikuri testi da laboratoriuli procedura, romelic ariarebulia rogorc zusti da obieqturi, sinamdvilesi Semsruleblis mier dasvebul Secdomebzea damokidebuli. aset klinikur testebs ganekutvneba: sisxlis wnevis gazomva, eleqtrokardiografia, endoskopia, sisxlis ujredebis manualuri datvla, vizualuri kolorimetruli testebi da gulmkerdis rentgenografia. gulmkerdis rentgenografiis sargeblianoba didad aris damokidebuli rentgenologis unarze gamoavlinos anomaluri Crdilebi da moaxdinos mati swori interpretireba. rentgenologs ar unda gamorces da ar unda moaxdinos, erti mxriv, rentgenografiuli Crdilebis arasatanado interpretacia, xolo, meore mxriv, ar unda ariqvas normaluri Crdilebi anomaliebad. rentgenologis mier gulmkerdis rentgenologiuri kvlevisas dasvebuli Secdomebi Seswavlili iqna ramodenime atwleuli wlis win, rodesac bevr ganvitarebul qveyanasi daiwyo tubsawinaarmdego kampaniebis Catareba. adre Catarebuli kvlevebis udidesi nawilis avtori iyo ieresalmi, specialobit biostatistikosi. igi miznad isaxavda ganesazrvra sxvadasxva rentgenologiuri da fotofluorografiuli metodebis da arwurvilobis efeqturoba. hiper da hipointerpretacia ert-erti kvlevit, romelic miznad isaxavda ganesazrvra, Tu ra zegavlenas axdenda firis sidide gulmkerdis rentgenografiis Sedegze, gamovlinda rom es cvladi gacilebit ufro nakleb mnisvnelovania, vidre is Secdomebi, romlebsac usvebs rentgenologi 90. kvlevasi monawileobda xuti eqsperti. TiToeuls im xuti eqspertidan, romlebic monawileobdnen kvlevasi, mxedvelobidan gamorca pozitiuri firebis daaxloebit 25% (hipointerpretacia) (ix. cxrili #15.), rodesac sami Tvis Semdeg firebi kidev ertxel Seamowmes, eqspertebma Secvales Tavis daskvna im SemTxvevebis TiTqmis 1/5-is mimart, romlebic mat pirveli Semowmebisas miicnies ~pozitiurad. (specialisttasorisi Seusabamoba -20%). 64

damatebitma kvlevebma daadastura, rom firebis 26-43% SeiZleba iyos hipointerpretirebuli 91, 92, 93. daniel mkvlevarta jgufma 94, 95, romelic Sedgeboda sami gamocdili rentgenologisgan ertmanetisgan damoukideblad, Seiswavla 5000 firi yovelgvari SerCevis garese (cxrili #15). sasualod, hipointerpretacia moxda 32%-Si, xolo hiperinterpretacia 2%-Si. es mogvianebit dadasturda kvlevebit did britanetsic 96. cxrili #15 rentgenologis Secdoma: gulmkerdis rentgenogragfiuli suratis hipo da hiperinterpretacia kvleva (mititebulia bibliografiasi) hipointerpretacia hiperinterpretacia 1. xuti eqspertis interpretacia (2) 2. sxvadasxva gamocdilebis specialistebi (3) 3. masobrivi radiografia 4. tuberkulozis indeqsi daniasi masobrivi radiografiuli kvleva 5. suratis interpretatorta jgufi sul 50 firis sauketeso suratis interpretatori jgufi A jgufi BB 25 27 32 32 39 21 25 1,7 1,7 1,6 1,2 0,5 0,3 ass-si Catarebul fartomasstabian kvlevasi 97, 98, romelic miznad isaxavda gulmkerdis perioduli rentgenografiis sargeblianobis gansazrvras, fotofluorografia gauketda universitetis 15000 pirvelkursels (cxrili #15). mirebuli firebi gaanalizebuli iqna 50 specialistisagan Semdgari jgufis mier, romelsic Tanabari proporciit iyvnen warmodgenili radiologebi da gulmkerdis daavadebata specialistebi. randomizirebuli sqemis mixedvit, TiToeulma matganma Seiswavla 3000 firi, rac izleoda SesaZleblobas erti da igive firi gamokvleuli (wakitxuli) yofiliyo 10-jer. studentebs, romelta rentgenofiri erti an meti specalistis mier micneuli iyo pozitiurad, CautardaT baqteriologiuri analizi, tuberkulozis testi da tomografia. 65

matze dakvirvebebs awarmoebdnen universitetsi swavlis mteli periodis ganmavlobasi. sabolood damoukidebeli eqspertebis jgufis mier, romlebsac xeli miuwvdebodat yvela monacemze, 249 firi klasificirebuli iyo rogorc ~uewvelad pozitiuri. hipointerpretaciis done Seadgenda 39%-s, xolo hiperinterpretaciisa ki 1,2% (156). rodesac ganixiles 10 sauketeso~ interpretatoris (5 rentgenologi da 5 gulmkerdis daavadebata specialisti) Sedegebi armocnda, rom rogorc hiper aseve hipointerpretaciis macvenebeli SedarebiT dabali iyo, Tumca mainc aradamakmayofileblad marali. gamocdilebis faqtoris zegavlena gulmkerdis rentgenografiis Sedegebis interpretaciaze tokios tuberkulozis samecniero kvleviti institutis mier Catarda tuberkulozis SemTxvevaTa gamovlenis iaponiis erovnul programsi monawile 192 eqimis mier hiper da hipointerpretaciis sixsiris kvleva 99. gansakutrebuli yuradreba eqceoda gamocdilebis faqtoris zegavlenas TiToeuli specialistis mier rentgenografiis Sedegebis interpretirebis xarisxze (cxrili #16). cxrili #16 rentgenolog-interpretatoris Secdoma: gulmkerdis rentgenografiis hipo da hiperdiagnostika a gamoyenebul iqna 70 sm sarkis refleqsuri kamera. gamocdileba firis hipointerpretacia interpretatorta raodenoba hiperinterpretacia 1-4 weli ** 5-9 weli >10 weli an 1-500 firi yovelwliurad 5.000-20.000 firi yovelwliurad > 20.000 firi yovelwliurad 37 37 88 43 48 41 28,0 19,2 17,6 22,4 24,0 15,0 18,0 19,0 17,0 17,5 18,0 15,5 monawileta sasualo raodenoba 21,8 19,5 66

b. wyaro g im eqimebis daskvnebi, romelta gamocdileba ert welze naklebi iyo an romlebic weliwadsi 1000-ze nakleb firs aanalizebdnen gamoiricxa daskvnebidan. damoukidebeli kvlevisatvis SerCeuli iqna 50 individis rentgenograma, romelta janmrtelobis mdgomareobac kargad iyo cnobili institutis TanamSromlebisaTvis. matgan 25-s hqonda dadasturebuli tuberkulozi an gulmkerdis sxva daavadeba, 5-s gankurnebuli tuberkulozis narceni dazianebebi da 20-s ar arenisneboda aranairi anomalia. SerCeuli interpretatorebis gamocdileba meryeobda erti wlidan 10 wlamde diapazonsi da isini kitxulobdnen 1000-dan 20000-mde an met firs weliwadsi (cxrili #16). mat stxoves mxolod gadaewyvitat sawiro iyo Tu ara Semdgomi kvlevebis Catareba. Tuki rentgenologiurad anomaliis mqone adamians specialisti ar daunisnavda Semdgom gamokvlevas, es CaiTvleboda hipointerpretaciad, xolo, Tu piriqit, normaluri rentgenogramis SemTxvevaSi danisnavda Semdgom kvlevas, es micneul iqneboda hiperinterpretaciad. hipointerpretaciis sasualo macvenebeli Seadgenda 21,8%, xolo hiperinterpretaciisa ki 19,5%. hipointerpretaciis SemTxvevebi im specialistta Soris, romlebsac 10 welze meti xnis gamocdileba hqondat, an romlebic weliwadsi 20000-ze met firs kitxulobdnen 6-8%-iT dabali iyo sxvebtan SedarebiT, Tumca ar iyo arc erti iseti specialisti, romelsac ar hqonda dasvebuli ori Secdoma mainc. mkvlevrebma daadastures, rom iaponiasi masobrivi rentgenologiuri kvlevis Catarebisas ikargeba aqtiuri tuberkulozis SemTxvevebis daaxloebit erti mexutedi. Seusabamo monitoringis miznit Gatarebuli rentgenologiuri kvlevebis Sedegebis interpretaciebsi Seusabamoba rentgenologebis pasuxebs Soris warmoiqmneba ara mxolod masin, rodesac rentgenogramebis interpretacia warmoebs SemTxvevaTa gamovlenis an diagnostikis miznit, aramed ukve diagnostirebul SemTxvevebSi monitoringis miznit gaketebuli firebis seriata Sedarebis drosac. ert-ert samecniero kvlevasi 98 Seswavlili iqna TiToeuli pacientis (zomebit 35,6X43,0sm) 67

sxvadasxva periodsi 5-jer gadarebuli or-ori firi (sul 9000 wyvili). specialistebs stxoves ganesazrvrat, Tu ra mdgomareobas asaxavda meore firi mdgomareobis gauaresebas, gaumjobesebas Tu ucvlel surats. Sedegebi (cxrili 17) didad ar gansxvavdeboda, miuxedavad imisa, firebis wakitxva xdeboda sami radiologisa da sami pulmonologisgan Sedgenili ori jgufis, Tu mxolod ori eqspert interpretatoris mier. Seusabamobis xarisxi mat Soris Seadgenda 27-30%-s, xolo SemTxvevaTa 19-24%-Si calkeuli specialisti ewinaarmdegeboda adre mis mierve gaketebul daskvnebs. cxrili #17. 900-gamokvleuli pacientis gulmkerdis rentgenogramebis kvlevisas rentgenologebs Soris arsebul azrta sxvadasxvaoba firis interpretatori eqspertta ori jgufi interindividualuri gansxvaveba intraindividualuri gansxvaveba (3 rentgenologi da 3 pulmonologi) jgufi A jgufi B ori eqsperti (igive firebis Sefaseba) 28 27 30 19 24 21 gulmkerdis rentgenologiuri kvlevis Sedegebis klasifikaciis saertasoriso kvleva IUAT tuberkuloztan brzolis saertasoriso kavsiris (IUAT) mier Catarebuli iqna gulmkerdis rentgenologiuri kvlevebis Sedegebis interpretaciastan dakavsirebuli problemebis ert-erti umnisvnelovanesi SedarebiTi kvleva. kvlevis ZiriTadi mizani iyo rentgenologiuri kvlevebis Sedegebis interpretaciisa da universaluri nomenklaturis ertiani sistemis SemuSaveba, rac SeiZleba safuzvlad dadeboda gulmkerdis rentgenografiis saertasoriso klasifikacias 100,101. nimusad SerCeuli iqna 1100 firi im rentgenogramebidan, romlebic gadaures ramodenime aseul atas adamians norvegiis mosaxleobis 68

masobrivi rentgenorafiuli kvlevis dros. nimusad arebuli firebidan 200 ekutvnoda infeqciuri tuberkulozis mqone adamianebs, 400 mat, visac adre hqonda aqtiuri tuberkulozi, 100 ki im pacientebs, romlebsac minimaluri klinikuri nisnebi hqondat da ar esawiroebodat arc referaluri mimartva da arc Semdgomi monitoringi. 300 firi ekutvnoda im individebs, romlebsac ar arenisnebodat cvlilebebi, xolo 100 pacientebs filtvis verificirebuli aratuberkulozuri daavadebebit. firebi gaaertianes Svid kasetad da gaaketes TiToeulis 10 asli. firebi Seiswavla 90 gamocdilma eqimma (radiologebma da pulmonologebma), matgan 80 im cxra qveynidan iyo mowveuli, sadac mravali wlis ganmavlobasi tardeboda masobrivi gamokvlevebi. esenia: Cexoslovakia, dania, fineti, safrangeti, norvegia, SvedeTi, didi britaneti, ass da iugoslavia. danarceni 10 specialisti SerCeuli iyo janmos proeqtis personalidan. kvleva igegmeboda, upirveles yovlisa, specialistebs Soris Sedegebis Tanxvedrisa da Seusabamobebis xarisxis gansasazrvrad da ara interpretatoris iseti Secdomebis gamosavlineblad, romlebsac movyavart hipo an hiperinterpretaciamde 102. TiToeul mkvlevars damoukideblad unda gaeca pasuxi winaswar momzadebul kitxvebze. kitxvebis umetesoba moitxovda pasuxebs ~diax an ~ara, magalitad, ~raime anomalia xom ar SeiniSneba filtvsi?, xom ar Cans kaverna?, ~xom ar esawiroeba pacients stacionaruli movla?. mirebuli masalis Sefaseba warmoebda specialuri statistikuri procedurit 103, romlis mixedvitac TiToeuli kitxvidan irebdnen mtel rig cvladebs. am cvladebis mesveobit Sedgenil iqna mrudi, romelic gvicvenebda mkvlevarebis Sedegebs Soris Tanxvedris dones mocemul kitxvastan dakavsirebit (grafiki #3). Seusabamobis xarisxi gamoixateboda rogorc indeqsi, romlis diapazonic meryeobda 0-dan 100-mde. 0 arnisnavda, rom Seusabamoba ar iyo, xolo 100-srul Seusabamobas. rac ufro uaxlovdeba mrudi ori RerZis gadakvetis wertils, mit ufro naklebia Seusabamoba. rac ufro brtyelia mrudi da rac ufro metad scildeba RerZebs, mit ufro maralia Seusabamoba. am metodma gamoavlina, rom pirvel kitxvaze pasuxebsi Seusabamoba ufro dabali iyo, vidre me-3 kitxvaze. 69

grafiki #3. Seusabamobebi interpretatorebis pasuxebs Soris IUAT is mier Gatarebuli rentgenologiuri kvlevebis Sedegebis klasifikaciis mixedvit Seusabamobis indeqsi efuzneboda Semdeg kitxvebs: 1. arinisneboda Tu ara raime darrveva sasuntq organoebsi? 2. arinisneboda Tu ara raime darrveva limfur kvanzebsi? 3. arinisneboda Tu ara kalcifikacia limfur kvanzebsi? indeqsi warmaodgens urtiertsapirispiro pasuxebis procentuli wilebis jams mrudis im wertilsi, sadac isini tolia, anu iq, sadac mrudi ikveteba diagonalit, romelic sataves irebs nulovan kutxesi ara pasuxebis % pozitiuri filmis dros Seusabamobis indeqsi kitxva (1) kitxva (2) kitxva (3) diax pasuxebis % pozitiuri firis dros 70

gulmkerdis rentgenografiuli kvlevis da nacxis gamokvlevis Sedegebs Soris Seusabamobis Sedareba naxvelsi mjavagamzle baqteriebis arsebobaze nacxis interpretaciisas laborantebis pasuxebs Soris Seusabamobebis xarisxis gansazrvris miznit asetive kvleva Catarda IUAT I gamocdili laborantebis mier. 10 laboratoriasi gamokvleul iqna naxvelis 250 nacxis seriebi. grafiki 4 gvicvenebs Seusabamobis mruds pozitiurobis sami kriteriumis mimart. Seusabamobis xarisxi yvelaze dabali iyo (indeqsi 10) masin, rodesac pozitiurobis macveneblis kriteriumi iyo sul mcire 8 mjavagamzle bacila. Seusabamobis xarisxi odnav ufro marali iyo (indeqsi 12), rodesac sami mjavagamzle baqteria iyo micneuli pozitiurobis damadasturebel minimalur motxovnad. yvelaze marali (indeqsi 18) Seusabamoba interpretatorebs Soris masin arinisneboda, rodesac pozitiurobis damadasturebel kriteriumad mirebuli iyo mxolod erti mjavagamzle baqteria. Tumca mikroskopuli kvlevisas laborantebis Sedegebs Soris Seusabamobis yvelaze marali macvenebelic ki ufro dabali iyo, vidre gulmkerdis rentgenologebis Sedegebs Soris Seusabamobis yvelaze dabali macvenebeli. meotxe grafikze warmodgenili mrudi 1 gvicvenebs rentgenologebis interpretaciebs Soris Seusabamobis yvelaze dabal dones (indeqsi 28) anu Seusabamoba kitxvaze: aris Tu ara nacxi pozitiuri mjavagamzle bacilebze _SedarebiT dabali iyo dadgenili limitis gatvaliswinebit (Tundac erti mg baqteria), vidre Seusabamoba pasuxebsi kitxvaze: Cans Tu ara suratze kaverna. kvlevis organizatorebma daaskvnes, rom naxvelis nacxis Sedegebis interpretaciisas, miuxedavad imisa Tu pozitiurobis kriteriumad ra iyo arebuli, Tanxvedra ufro marali iyo, vidre radiologebis mier rentgenologiuri kvlevis Sedegebis interpretaciis dros (ix. agretve, `ramdenad saimedoa nacxis mikroskopuli kvleva~). SeusabamobaTa doneebi gulmkerdis rentgenologiuri kvlevis Sedegebis interpretaciis dros da daskvnebi ramodenime sxva kitxvis pasuxebs Soris Seusabamobebis doneebi mocemulia cxrilsi #18. kitxvebi SerCeul iqna im TvalsazrisiT, rom SemdgomSi isini gamoeyenebinat rentgenologiuri kvlevebis 71

Sedegebis klasifikaciisatvis. SeirCa kitxvebi, romelta pasuxebi izleoda Seusabamobebis, rogorc umcires, aseve umarles dones. grafiki #4. rentgenologiuri da naxvelis nacxis kvlevis Sedegebis interpretirebisas Seusabamobebis mrudi proporcial (%) ara pasuxebis disonansi. rentgenologiuri kvleva 1. aris Tu ara kaverna? naxvelis nacxis kvleva 2. erti an meti baqteria slaidze? 3. sami an meti baqteria slaidze? 4. rva an meti baqteria slaidze proporcia (%) diax pasuxebis disonansi. cxrili #18. IUAT-is mier Gatarebuli kvleva rentgenologiuri kvlevis Sedegebis klasifikaciis sakitxebze, Seusabamobis indeqsi sxvadasxva kitxvebze mirebul pasuxebsi kitxva darrveva limfur kvanzebsi? darrveva filtvsi, savaraudod tuberkulozurikalcifikacia filtvsi? dazianeba kalcifikaciis garese, savaraudod tuberkulozuri? rentgenis surati anomaliuria? sawiroa samedicino Careva? Cans kaverna? Seusabamobis indeqsi 60 45 42 37 34 31 28 72

Seusabamobis is done, romelic gamovlinda iset kitxvaze, rogoricaa: xedavt Tu ara raime darrvevas filtvebsi? sakmaod moulodneli iyo, iseve rogorc Zalzed dabali Tanxvedra kalcifikaciastan dakavsirebul kitxvaze. limfur kvanzebsi darrvevebtan dakavsirebuli azrta sxvadasxvaoba, mat Soris, kalcifikaciis (ert-erti yvelaze fartod gavrcelebuli Sedegi) Sesaxebac gansakutrebit gasaocari iyo. Tanxvedris yvelaze marali done an, ufro sworad, Seusabamobis yvelaze dabali done arinisneboda kavernebtan dakavsirebul kitxvebsi. es informacia ganxiluli unda iyos samedicino saqmianobis konteqstsi. amitom nacxit dadebiti tuberkulozis mqone pacientebis 5%-is rentgenograma micneuli iyo normalurad, 17%-is mcire (savaraudod aratuberkulozuri) darrvevebit, xolo 24%-Si gaketda daskvna, rom isini ar sawiroebdnen klinikur RonisZiebebs tuberkulozuri dazianebebis gamo. mkurnaloba rom Semofargluliyo iseti pacientebit, romelta rentgenologiuri kvlevis Sedegebis interpretirebisas rentgenologebis 50% da meti Tvlida, rom mat hqondat kaverna, mkurnaloba Cautardeboda pozitiuri nacxis mqone pacientebis mxolod ert mesameds. meores mxriv, mat Soris, visac interpretatorta 50%-s an, metis azrit, savaraudod hqondat tuberkulozi, daaxloebit 4-5-jer ufro met baqteriologiurad negatiur adamians Cautardeboda mkurnaloba, vidre nacxit dadebit pacientebs (disproporcia isetivea, rogorc im klinikebsi, sadac diagnozi dgindeba mxolod rentgenologiuri kvlevis safuzvelze 104. Aaiv-infeqciisa da tuberkulozis Tanaavadoba kidev ufro amcirebs gulmkerdis rentgenologiuri kvlevis sandoobas filtvis tuberkulozis diagnostikasi. rogorc zemot iyo arnisnuli, aivasocirebuli tuberkulozis problemis warmosobamde ramodenime atwleulit adre kargad momzadebul da gamocdil radiologebsa da pulmonologebs Soris dafiqsirda sakmaod marali interkolegialuri da intrapirovnuli Seusabamobebi gulmkerdis rentgenogramebis interpretaciisas. aiv/sidsis problemis warmosobis Semdeg klinikur kvlevebsi sistematurad xdeboda atipuri rentgenologiuri suratis dafiqsireba aiv asocirebuli tuberkulozit daavadebul pacientebsi. hilaruli, an mediastinaluri adenopatia, filtvis Sua da qveda wilebis infiltratebi, pulmonaruli infiltratebisa da kavernebis ararseboba, iseve damaxasiatebelia am pacientebisatvis 105, rogorc 73

gulmkerdis normaluri da minimaluri darrvevebis amsaxveli rentgenogramebi 106. malavisi, sadac aiv-infeqcia warmodgenilia tuberkulozit daavadebuli pacientebis 75%-Si, pulmonaruli tuberkulozis simptomebis mqone 402 mozrdili asakis pacientsi Sedarebul iqna ori hipotezuri diagnostikuri strategia 107. ert-erti diagnostikuri strategiis pirveli etapi moicavda rentgenografias. Semdgom im pacientebsi, visi rentgenogramac tuberkulozur dazianebebs asaxavda unda Catarebuliyo naxvelis nacxis gamokvleva. 172 pacientidan, romlebsac gulmkerdis rentgenogramebis interpretaciit tuberkulozuri dazianebebi ar arenisnebodat, 13 (8%) armoacnda mgb pozitiuri nacxi, xolo 53 (31%) mgb nacxit an pozitiuri kultura. skriningis strategiis gamoyenebis SemTxvevaSi yvela es pacienti dakarguli iqneboda da piriqit, im 230 pacientidan, romlebsac rentgenologiuri kvlevis safuzvelze daudgindat tubekulozi da, romlebsac mkurnaloba utardebodat nacxit uaryofit tuberkulozze 27% iyo rogorc nacxit, aseve kulturit negatiuri. meore strategia itvaliswinebda pirvel etapze pacientebis Sefasebas naxvelis nacxis mixedvit, xolo Semdgom mattvis, visac nacxit uaryofiti Sedegi armoacndeboda, gulmkerdis rentgenografiis Catarebas. 291 nacxit uaryofit pacientidan 159 (55%) rentgenograma ar asaxavda tuberkulozis simptomebs da ar iqneboda diagnostirebuli, miuxedavad imisa, rom 40 pacienti (25%) faqtiurad kultura-pozitiuri iyo. am strategiis mesveobit gamovlinda pacientebis ufro naklebi raodenoba da nacxit pizitiuri tuberkulozis arc erti SemTxveva ar iyo gamorcenili. gulmkerdis rentgenografia, rogorc diagnostikis meore etapi nacxit negatiur pacientebsi ar iyo sensitiuri. piriqit, nacxit negatiuri da rentgenologiurad tuberkulozis nisnebis mqone 132 pacientidan, romlebsac am strategiis safuzvelze CautardebodaT tubsawinaarmdego mkurnaloba, 47% rogorc nacxit aseve kulturit uaryofiti iyo. Tu yovelive zemot arnisnulis SevajamebT, SeiZleba itqvas, rom mravalwliani gamocdileba da monacemta analizi gvicvenebs, rom gulmkerdis rentgenografia, rogorc filtvis tuberkulozis, aiv-koinfeqciit an mis garese, diagnostikisa da monitoringis sasualeba sarwmuno ar aris 107, 108. 74

13. 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 18 a. harisi 19 es kitxva ert-ertia im ramodenime kitxvidan, romlebzec pasuxis misarebad bengaloris tuberkulozis erovnuli institutis (indoeti) 109, 110 mier Catarda mravlismomcveli socialurepidemiologiuri kvleva 2229 randomizebulad SerCeuli pacientis monawileobit. gulmkerdis aresi Civilebis mqone (xvela 2 an meti kviris ganmavlobasi, tkivili gulmkerdis aresi da sicxe 4 kviris, an meti drois manzilze, an hemmaptoe) ambulatoriuli pacientebi gamokvleul iqnen rogorc rentgenologiurad, aseve baqteriologiurad. naxvelis sinjebi arebuli iyo TiToeuli pacientidan adgilze samedicino dawesebulebasi da gaketda, rogorc nacxis pirdapiri mikroskopuli kvleva, aseve kulturaluri gamokvleva. nacxis kvleva tardeboda cil-nilsenis metodit, vidre pacienti icdida. kulturis analizi Catarda levenstein-iensenis niadagze. SemdgomSi yvela pozitiuri kultura identificirebuli iyo da testirebuli in vitro medikamentebisadmi mgrznobelobis dadgenis miznit. baqteriologiur kvlevas axorcielebdnen tuberkulozis erovnuli institutis kvleviti laboratoriis gamocdili specialisti-laborantebi. cxrili #19 gvicvenebs, rom 2229 pacientidan 227-s rentgenologiuri gamokvlevit daudginda tuberkulozi (da aqedan gamomdinare, mkurnalobis sawiroeba), Tumca matgan 81 pacients baqteriologiuri kvlevit tuberkulozi ar daudasturda. 18 k.tomanis wina gamocemis Tavze dayrdnobit 19 malaviis tuberkulozis kontrolis erovnuli programa, teqnikuri mrceveli. ilongue, malavia 75

darcenili 2002 pacientidan, romlebic micneul iqnen janmrtelad, an romlebsac hqondat aratuberkulozuri daavadeba 31 naxvelis kulturis da/an naxvelis nacxis mikroskopuli kvlevit armoacnda tuberkulozis bacila. vinaidan naxvelis nacxis mikroskopuli kvleva itvleba yvelaze sarwmuno diagnostikur metodad, dadginda korelacia rentgenologiur da kulturis kvlevit mirebul Sedegebs Soris. me-20 cxrilsi mocemuli monacemebi cxril #19-Si warmodgenili informaciis identuria, garda erti gansxvavebisa, romelic rentgenologiurad normaluri, an aratuberkulozuri pacientebis ori jgufis gaertianebit gamoixateba. Tu kulturis kvlevis Sedegebs mivirebt swori diagnozis kriteriumad, 20 (12%) pacienti 162 kultura-pozitiuri pacientidan dakarguli iqneboda, radgan isini rentgenologiuri kvlevis safuzvelze arasworad miakutvnes aratuberkulozuri daavadebis mqone pacientebis jgufebs. meores mxriv, im 227 pacientidan, romlebsac rentgenologiurad daudginda tuberkulozi 85 (37%) es diagnozi daudasturda kulturis mixedvitac. aseve ganisazrvra Sefardeba naxvelis mikroskopiisa da kulturis kvlevis Sedegebs Soris. rogorc gvicvenebs cxrili #21, 32 (20%) pacienti 162 kultura-pozitiuri pacientidan dakarguli iqneboda adgilze arebuli naxvelis erti nacxis usualo mikroskopuli analizit, xolo 145 nacxit pozitiuri pacientidan 15 (10%) kulturis kvlevit armocnda negatiuri. cxrili #19 rentgenologiuri kvlevis Sedegebis Sedareba naxvelis nacxis mikroskopiuli kvlevisa (S) da kulturis kvlevis SedegebTan (C) tuberkulozze saewvo klinikuri simptomebis mqone ambulatoriul pacientebsi klasifikacia pacientebis naxvelis nacxis kvlevis Sedegebi rentgenografiis mixedvit tuberkulozi raodenoba 227 S+ C+ 122 S- C- 20 S+ C- 4 S- C- 81 sxva anomaliuri Crdilebi (aratuberkulozuri) normaluri sul 304 1698 2229 8-130 4 8 32 1 10 15 291 1680 2052 76

cxrili #20 korelacia radiologiuri da naxvelis kulturis kvlevebit mirebul pasuxebs Soris tuberkulozze saewvo klinikuri nisnebis mqone pacientebsi radiografia kultivireba pozitiuri negatiuri sul pozitiuri 142 85 227 negatiuri 20 1982 2002 sul 162 2067 2229 cxrili #21 korelacia tuberkulozze saewvo klinikuri simptomebis mqone pacientebisgan samedicino dawesebulebasi arebuli naxvelis erti nacxis usualo mikroskopiisa da kulturis kvlevis Sedegebs Soris nacxi kultivireba pozitiuri negatiuri sul pozitiuri 130 15 146 negatiuri 32 2052 2082 sul 162 2057 2229 Tu swori diagnozis kriteriumad mivirebt naxvelis kulturis kvlevis Sedegebs, Catarebuli socialur-epidemiologiuri gamokvlevis Sedegebi SeiZleba SevajamoT Semdegnairad: 162 tuberkulozit daavadebuli pacientidan, romelta diagnozis verifikacia moxda kulturis kvlevis safuzvelze, 32(20%) daikargeboda naxvelis mikroskopiis safuzvelze da 20 (12%) rentgenologiuri kvlevit. nacxis mixedvit pozitiuri 145 pacientidan, 130 (90%) dadasturda kulturis mesveobit. darcenil 10%-Si mirebuli iyo askarad crupozitiuri Sedegi, rac ganpirobebuli iyo interpretaciis uzustobit, an artefaqtis arsebobis gamo. SesaZloa im baqteriebs, romlebic mikroskopsi Canda, dakarguli hqondat kulturis zrdis unari. arsebobs aseti mdgomareobis gamomwvevi uamravi mizezi. pacientebsi, romlebsac utardebat mkurnaloba, efeqturi Terapiis 77

Sedegad mikrorganizmebi irupeba, an mnisvnelovnad ziandeba. aranamkurnaleb pacientebsi tuberkulozis baqteriis unari _ mogvces kultura _ SeiZleba daziandes, magalitad, Tu arebuli sinji zedmetad gacxeldeba, an moxvdeba mzis pirdapir sxivebsi, aseve misi xangrzlivi drois ganmavlobasi Senaxvisas, dekontaminaciis arasatanado proceduris, xangrzlivi inkubaciis, an centrifugasi misi xangrzlivad damusavebis gamo. Tumca im pacientebs, romelta pirveli nacxis mikroskopuli analizis Sedegi udavod pozitiuria, magram negatiuria kultura, aqvt imis didi albatoba, rom naxvelis momdevno sinjebis kvlevisas rogorc nacxis, aseve kulturis analizit miireben pozitiur Sedegebs (ix.tavi: ~ra damatebiti Sedegebi moaqvs naxvelis ganmeorebit kvlevas nacxis mikroskopuli da kulturaluri analizit ). Amitom, tuberkulozis nisnebisa da simptomebis mqone pacients utardeba mkurnaloba mxolod zustad Sesrulebuli da askarad pozitiuri nacxis mikroskopiis Sedegebis safuzvelze, Tundac igi ar iyos kulturit dadasturebuli. Zalzed mcirea gadawarbebuli mkurnalobis Catarebis albatoba. meore mxriv, 227 pacientidan, romelsac rentgenologiuri kvlevis safuzvelze daesva tuberkulozis diagnozi, da daudginda mkurnalobis sawiroeba, sakmaod did nawils_37% ar daudasturda tuberkulozi kulturis mixedvit. am kvlevis dros pacientebs CautardaT yvela procedura imis gamo, rom mat hqondat saewvo simptomebi. es proporciuli wili ufro gaizrdeba mosaxleobis masobrivi rentgenografiuli gamokvlevebis SemTxvevaSi, anu rodesac skriningi tardeba miuxedavad imisa, aqvs Tu ara individs tuberkulozis simptomebi. martlac ramodenime kvlevit dadasturda, rom im pirebs, visac rentgenologiurad arenisnebodat ucnobi warmosobis Crdilebi da adre ar hqondat tuberkulozis istoria, nacxis mikroskopiit an kulturis kvlevit naxvelsi tuberkulozis baqteria ar armoacndat, gansakutrebit ganmeorebiti kvlevisas 111, 112, 113, 114. sinamdvilesi isini ar iyvnen daavadebulni tuberkulozit. Tumca sakontrolo kvlevebma gamoavlina, rom arsebobs aseti adamianebis kultura-pozitiur mdgomareobasi gadasvlis ufro didi albatoba normaluri rentgenogramis mqone pirebtan SedarebiT. mxolod mat mcire nawilsi (0,4-4,8%) wlebtan ertad riskic mcirdeba. 78

iseti individebis mkurnaloba, romlebsac gulmkerdis rentgenogramaze aqvt ucnobi warmosobis Crdilebi, nisnavs, rom mat did nawils da SesaZloa umetesobasac ki CavutaroT arasawiro da rig SemTxvevebSi araswori mkurnalobac ki. Aaiv-infeqciis marali prevalentobis regionebsic ar aris mosaxerxebeli gulmkerdis rentgenografiis Catareba yvela im pacientisatvis, romelsac arenisneba tuberkulozis simptomebi. malavisi Catarebul kvlevasi, romelsic monawileobda 402 tuberkulozze saewvo individi 115, 230-is rentgenografiuli surati tuberkulozisatvis tipuri iyo. naxvelis nacxi pozitiuri iyo pacientta 43%-Si, xolo naxvelis kultura 71%-Si. meores mxriv, im 172 pacientidan, romelsac normaluri rentgenologiuri surati hqonda an suratze arenisneboda tuberkulozistvis aradamaxasiatebeli cvlilebebi 13 (8%) nacxit pozitiuri iyo, xolo 49 (28%) ki kultura-pozitiuri. gulmkerdis rentgenologiuri kvlevit mosaxleobis skriningi da Semdgom tuberkulozistvis tipuri rentgenografiis mqone pacientebsi naxvelis nacxis gamokvlevis Catareba ufro ZviradRirebuli da naklebad sensitiuria, vidre naxvelis nacxis mikroskopia da Semdgom gulmkerdis rentgenologiuri gamokvleva im pirebsi, vinc naxvelis nacxis mikroskopis SedegebiT negatiuri iyo. gulmkerdis rentgenografiis, naxvelis kulturis kvlevisa da nacxis mikroskopiis Gatarebis teqnikuri da operaciuli aspeqtebi rentgenologiuri gamokvlevit skriningis Catareba afrikis samxret-saharis regionebsic ki, sadac aiv infeqcia fartod aris gavrcelebuli, ganapirobebs hiperdiagnostikis maral macveneblebs. ufro metic, ganvitarebad qveynebsi Zalzed xsiria rentgenografiuli aparaturis gamoyenebastan dakavsirebuli problemebi da Secdomebi. rentgenologiuri centrebi ZviraRirebulia da mati funqcionireba moitxovs maralkvalificiur, specialurad momzadebul teqnikur personals. xsirad aparatura xangrzlivi droit gamodis mwyobridan, rac gamowveulia satadarigo nawilebis uqonlobita da SemkeTebeli saxelosnoebis ararsebobit, firebis simwirit an/da arasatanado eleqtromomaragebit. kidev erti operaciuli nakli isaa, rom rentgenografiis Sedegebs virebt 79

mxolod 2-3 dris Semdeg an ufro dagvianebit. pacientebis sakmaod didi nawili arar brundeba samedicino dawesebulebasi pasuxis wasarebad da medpersonalis yovelgvari mcdeloba moizidon pacientebi warumateblad mtavrdeba. cnobilia, rom rogorc diagnostikuri metodi, naxvelis kultura gacilebit ufro sensitiuria, vidre naxvelis nacxis mikroskopia. am metodit SesaZlebelia tuberkulozis bacilis diferencireba sxva mikroorganizmebisagan da amis safuzvelze bacilis ufro zusti identifikacia. kulturis teqnikuri upiratesoba naxvelis nacxis mikroskopiastan SedarebiT ganpirobebulia rigi raodenobrivi faqtorebit. masin, rodesac naxvelis nacxis odenoba Seadgens 0,01 ml (ix. Tavi: ~ramdeni baqteriaa nacxis mikroskopis mixedvit mgb pozitiuri adamianis naxvelsi ), inokulumis sidide Cveulebrv 0,1ml-ia, e.i. 10-jer meti. ufro metic, mikroskopit SeiZleba SeviswvaloT mxolod nacxis 1% (100 imersiuli veli), xolo kulturis sinjarasi praqtikulad Tvalis erti SevlebiTac ki Cans koloniebis didi raodenoba. Miuxedavad imisa, rom dekontaminaciis procedura anadgurebs organizmebis mnisvnelovan nawils, raodenobrivi sxvaobebi imdenad didia, rom kulturis testis mesveobit mikroorganizmis gamovlenis albatoba bevrad ufro maralia, vidre naxvelis usualo mikroskopiit. es askara upiratesobaa iseti SemTxvevebisaTvis, rodesac naxvelis sinji Seicavs mjavagamzle baqterebis mxolod umnisvnelo raodenobas (ix. Tavi: ~ramdenad sandoa naxvelis mikroskopuli kvleva ). samwuxarod, kulturis gamoyenebas aqvs rigi, ZiriTad operaciuli xasiatis, naklovanebebic. metodi moitxovs specialurad momzadebul da maralkvalificirebul personals. umetes ganvitarebad qveynebsi aseti personali Zalzed deficituria. garda amisa, kulturis gamokvlevis Casatareblad sawiroa specializirebuli dawesebulebebi da arwurviloba, mudmivi deni, wyali, sando Termoregulacia ~cxel otaxsi. cxel da nestian klimatsi haeris kondicirebasa da gamwmendi specialuri filtrebis arsebobas gansakutrebuli mnisvneloba eniweba haersi arsebuli mikroorganizmebita da nawilakebit kulturis dabinzurebis Tavidan asacileblad. aseve sawiroa inokulaciis kabinetebis satanado ventilaciit uzrunvelyofa da usafrtxoebis zomebis mireba. yvela mizezis gatvaliswinebit, kulturis kvlevis metodis praqtikuli 80

ganxorcieleba SesaZlebelia ganvitarebadi qveynebis mxolod ramodenime laboratoriasi. kulturis metodis ert-erti yvelaze didi nakli aris is, rom misi Sedegebis mireba SesaZlebelia mxolod Zalian xangrzlivi intervalis Semdeg: 4-6 kvira an meti im SemTxvevaSi, Tu myari niadagia gamoyenebuli. ganvitarebad qveynebsi aseti dagvianeba ganapirobebs mravali pacientis ~dakargvas. isini SeiZleba ararasodes dabrundnen samedicino centrsi da xsirad mati Tvalyuris midevneba praqtikulad SeuZlebeli xdeba. aqedan gamomdinare, kulturis kvlevis metodis upiratesobebs xsirad gadawonis xolme naklovanebebi, romlebic ukavsirdeba Sedegebis misarebad drois xangrzlivi intervalis sawiroebas; maral sensitiurobas ki upirispirdeba am metodis Sesrulebis teqnikuri sirtuleebi. naxvelis nacxis usualo mikroskopul kvlevasac, ra Tqma unda, aqvs teqnikuri naklovanebebi, magram misi operaciuli upiratesoba askaraa. igi SedarebiT advilad gansaxorcielebelia, gacilebit iafia, vidre rentgenografia an kulturis metodi da ar moitxovs marali specializaciis personals. is faqti, rom pirebs, romlebic gamoyofen didi raodenobit baqteriebs, gamokvlevis Catarebis dresve SeiZleba daudgindet diagnozi da daenisnot mkurnaloba, ewvgareses xdis naxvelis mikroskopiis udides upiratesobas. operaciuli TvalsazrisiT, es metodi minimumamde amcirebs ~dakarguli pacientebis raodenobas, rac xsirad xdeba, rodesac pacients gamokvlevis pasuxis misarebad swirdebat didi xnis lodini. amave dros, es aris faqtiurad ertaderti diagnostikuri metodi, romlis ganxorcieleba praqtikulad TiTqmis yvelagan aris SesaZlebeli. CamoTvlili mizezebis gamo SemTxvevaTa gamokvleva da diagnostika iset qveynebsi, sadac arinisneba tuberkulozis marali prevalentoba unda efuznebodes ZiriTadad am metods. 81

14. rogor vitardeba filtvis tuberkulozi da rogor gamovavlinot is adreul etapze k.tomani 20 rogorc klinikuri, aseve epidemiologiuri TvalsazrisiT aqcenti yoveltvis sworad ketdeboda tuberkulozis adreul stadiasi diagnostikaze. Tumca arnisnulma ganapiroba ertgvari gaurkvevloba. adreuli, anu dawyebiti tuberkulozi xsirad ariqmeboda, rogorc minimaluri tuberkulozuri daavadeba. msgavsad amisa, tuberkulozis Soris wasul formas Cveulebriv miicnevdnen qronikul tuberkulozad, Tumca iseti terminebi rogoricaa adreuli~, ~dawyebiti, qronikuli da Zveli mxolod da mxolod usualod drois armnisvneli sityvebia, masin rodesac minimaluri, sasualo da ~Sors wasuli arnisnavs daavadebis xarisxs, anu filtvis qsovilis im nawilis sidides, romelic moculia daavadebit. terminebs adreuli da minimaluri ar gaacniat raime myari urtiertdamokidebuleba, aseve ar aris aucilebeli, rom isini urtiertdakavsirebulni iyvnen. faqtiurad ori Tvis ganmavlobasi ganvitarebuli dazianeba SeiZleba iyos minimaluric da sakmaod Sors wasulic. dazianebis xarisxi naklebad miutitebs misi ganvitarebis xangrzlivobaze. axali dazianebis xangrzlivoba SeiZleba ganisazrvros mxolod im SemTxvevaSi, Tu arsebobs janmrteli filtvis adre gadarebuli rentgenografiuli surati. ramodenime grzelvadian rentgenologiur kvlevasi Seswavlilia adreuli tuberkulozis ganvitarebis istoria. ert-erti kvlevis dros, romelic Catarda Cexoslovakiis qalaq kolinsi (mosaxleoba Sedagenda 100.000), ramodenimejer Catarda ToTxmeti wlis da ufrosi asakis mosaxleobis gamokvleva. Epidemiologiuri kvleva 116, 117 grzeldeboda 20 gardacvlilia 82

Tormeti wlis ganmavlobasi. am periodsi rentgenologiuri kvleva mocemuli asakobrivi jgufis TiToeul warmomadgenels Cautarda xutjer, ori an sami wlis intervalit. rentgenografiul raundebs Soris adgilobrivi samedicino samsaxurebi agrzelebdnen SemTxvevaTa gamovlenas im pacientebs Soris, romlebic mat mimartavdnen tuberkulozze saewvo simptomebit an janmrtelobis regularuli Semowmebis miznit. yovel rentgenografiul surats stanadod inaxavdnen, rata SesaZlebeli yofiliyo mati Sedareba SemdgomSi gadarebul suratebtan, amitom moxerxda axali dazianebis warmosobis periodis gansazrvra. suratebis wakitxva xorcieldeboda damoukideblad ori rentgenologis da erti eqspertis mier (ixilet cxrili #22). 165 pacientsi, romelsac hqonda axladgamovlenili tuberkulozi da visi adre gadarebuli rentgenologramebic normaluri iyo, ganisazrvra drois monakveti gulmkerdis ukanasknel normalur rentgenogramasa da pirvel anomalur rentgenogramas Soris. pacientebi daajgufes sam kategoriad: isini, romlebic iyvnen nacxit pozitiurebi da aseve kultura - pozitiurebi, isini vinc iyo nacxit negatiuri, magram kultura - pozitiuri da isini visi diagnozic pirvelad daisva autofsiis dros da verificirebuli iyo baqteriologiuri gamokvlevit 116,117. cxrili #22 gvicvenebs, rom Tormeti Tvis ganmavlobasi warmoisva ocdarva baqteriologiurad pozitiuri SemTxveva. gasaocari iyo is, rom mat mnisvnelovan nawils ukve hqonda ganvitarebuli Sors wasuli tuberkulozi naxvelis pozitiuri nacxitkkidev, ufro gasaocari iyo is, rom eqvsi SemTxveva ganvitarda imdenad swrafad, rom isini armoacines mxolod autofsiis dros Tormet Tveze nakleb periodsi gulmkerdis bolo normaluri rentgenografiidan (zogiert aset SemTxvevaSi tuberkulozi identificirebul iqna patologoanatomiis mier, rogorc sikvdilis usualo mizezi). kolinis kvlevis meore etapze (1965-1972) gamovlenili iqna tuberkulozis iqamde ucnobi 10 SemTxveva, romelta diagnostika pirvelad moxda autofsiis dros zogiert SemTxvevaSi tuberkulzi ganvitarda Zalian mokle periodsi bolo normaluri rentgenogramidan. im periodsi es 10 SemTxveva Seadgenda tuberkulozit sikvdilis yvela SemTxvevis ert meotxeds da yovelive es moxda miuxedavad mteli mosaxleobis sistematuri da intensiuri masobrivi gamokvlevisa. realuri cifri SesaZloa ufro 83

marali iyos, radgan kvlevis zonasi gardacvlil adamianta mxolod ert meotxeds Cautarda nekrofsia (ZiriTadad mat vinc gardaicvala saavadmyofosi) 117. cxrilsi #22 mocemuli monacemebi SeiZleba Seicavdes cdomilebas, radgan rentgenografiul kvlevebs Soris intervali arasdros ar iyo or weliwadze naklebi da Cveulebriv sam weliwads moicavda. am TvalsazrisiT Zalian zusti monacemebi aris mirebuli iaponiasi, sadac mosaxleobis masobrivi rentgenografiuli gamokvlevebi tardeboda ertwliani intervalebit 118. msgavsi monacemebi mopovebulia aseve iaponiasi niigatas 119 prefeqturasi Catarebuli epidemiologiuri kvlevit (mosaxleoba 2350000). cxrili #22. intervalebi bolo normaluri rentgenografiisa da filtvis tuberkulozis diagnozs Soris intervali nacxis + (TveebSi) kultura + raodenoba kumulaciuri % nacxkultura+ raodenoba kumulaciuri % autofsiis dros diagnostirebulta raodenoba < 12 < 24 < 36 > _ 37 sul 8 18 16 8 50 16 52 84 100 14 39 31 14 98 14 53 86 100 6 7 1 3 17 rogorc dadginda (ixilet Tavi: ~ra rols asrulebs perioduli masobrivi rentgenografiuli gamokvlevis mesveobit SemTxvevaTa gamovlena tuberkulozis kontrolis saqmesi ), naxvelis nacxis usualo mikroskopiit pozitiuri SemTxvevebis naxevarze metsi tuberkulozi ganvitarda bolo normaluri rentgenogramis gadarebidan 12 Tvis ganmavlobasi, masin, rodesac masobrivi rentgenografiuli kvlevebit gamovlenil iqna axali SemTxvevebis mxolod 1/5. mati umetesoba (72%) gamoavlines samedicino dawesebulebebsi, romlebsac pacientebi ZiriTadad mimartavdnen gulmkerdis aresi Civilebis gamo. igive exeba mxolod kulturapozitiur axladgamovlenil pacientebs 119. 84

arnisnuli kvlevebit mirebuli Sedegebis safuzvelze SeiZleba gaketdes Semdegi daskvnebi: axali SemTxvevebis didi nawili ganvitarda jansar filtvsi ramodenime Tvis ganmavlobasi; aset Sors warsul SemTxvevebSi, romelta drosac gamoiyofoda didi raodenobit bacilebi, rac Tavis mxriv dadgenili iyo mikroskopuli analizit, SesaZloa kavernebic ganvitarda Zalian swrafad; aucilebeli ar aris, rom Sors wasuli, nacxit pozitiuri tuberkulozis SemTxveva pirveli gamovlenis momentisatvis. iyos Zveli an qronikuli. igi SeiZleba iyos axladwarmoqmnili, mxolod kultura-pozitiuri minimaluri dazianeba; daavadebis es orive tipi Sors wasuli, mzime, nacxit pozitiuri tuberkulozi da mxolod kultura-pozitiuri, minimaluri tuberkulozi vitardeba erti da igive drois ganmavlobasi. aqedan gamomdinare, savaraudoa, rom nacxit pozitiuri SemTxvevebi imdenad swrafad vitardeba, rom isini ar gaivlian minimalur fazas. daavadebis swrafi ganvitareba ar unda agverios egret wodebul elvisebur WleqSi. tuberkulozis es forma, romelic ukiduresad swrafad mimdinareobs, arwerili iyo Zvel literaturasi da gvxvdeboda gansakutrebit mzime stresul mdgomareobasi myof da fizikurad dauzlurebul individebsi. yovelma gamocdilma klinicistma icis, rom aratipuri Civilebi (da Tavdapirvelad normaluri rentgenografuli surati) zogjer SeiZleba uecrad, ramodenime dresi gartuldes tuberkulozuri plevritit da RruSi TiTqmis 1 litramde sitxe dagrovdes, an Sorswasuli infiltraciuli dazianeba ramodenime dresi SeiZleba ganvitardes Tavdapirvelad jansar filtvsi, xolo kaverna gacndes ert kvirasi 120. ass-si Catarebuli kvlevis safuzvelze, romelsic monawileben tuberkulozis adreuli stadiis mqone 1000 pacienti 121, 122 avtorebma daaskvnes, rom: filtvis tuberkulozis uecari simptomatikis Camoyalibeba ar aris isviati; 85

dazianebis xarisxi ar ukavsirdeba daavadebis xangrzlivobas (yvela im pacientidan, visac arenisneboda Sorswasuli forma, es mdgomareoba Camouyalibda pirveli 6 Tvis ganmavlobasi); kaverna mxolod bolo etapebze ar vitardeba, misi warmoqmna SesaZlebelia nebismier etapze. meore kvlevit ganisazrvra is intervalebi, romelta dacvitac unda moxdes risk-jgufis individebis (kontaqtebis) perioduli gasinjva, rata SesaZlebeli gaxdes yvela SemTxvevis SeZlebisdagvarad adreul etapze gamovlena 120. aset pacientebs Semowmebas utardebdnen erti wlis intervalit ert seriasi aseti sakontrolo gasinjvebi tardeboda yovel 6 TveSi da kidev ert seriasi es intervali ufro mokle iyo. miuxedavad amisa, arc ert am seriasi ar moxda yvela SemTxvevis diagnostika minimaluri dazianebebit. masinac ki, rodesac gasinjvebs Soris intervali 4 Tve iyo, pacientta 21%-s armoacnda zomierad ganvitarebuli forma, xolo SedarebiT mcire nawils daavadebis Zalian Sorswasuli formac ki. daskvna Semdegia: eqvstviani intervali metismetad xangrzlivia imisatvis, rom Tavidan avicilot daavadebis Sorswasuli, mwvave formebis ganvitareba. yvelaze mdidar qveynebsic ki, mozrdili mosaxleobis skriningi sayoveltao rentgenografiit 12 Tveze ufro mokle periodsi ar iyo micneuli praqtikulad. ufro metic, rogorc iaponiasi Catarebuli kvlevit dadginda, SesaZlebelic, rom iyos samedicino Semowmebis ufro xsirad Catareba, gamovlenili SemTxvevebis didi nawili mainc ukve Sorswasul, nacxit pozitiur etapze iqneboda. gamovlenili askaraa, rom masobrivi rentgenografia ver uzrunvelyofs SemTxvevaTa umetesi nawilis gamovlenas daavadebis CamoyalibebisTanave. dawyebiti tuberkulozi da misi simptomebi zogjer moitxoven, rom mosaxleobis skrinings masobrivi rentgenografiit gansakutrebuli mnisvneloba mieniwos, vinaidan axali pacientebis naxevraze mets aravitari simptomebi ar arensineba 117. am sakitxtan dakavsirebit mravali literaturuli wyaro arsebobs. kargad aris cnobili, rom monacemebis safuzvlad SemTxvevebis istoriebis areba arasarwmuno da sakamatoa is faqti, rom erti SexedviT janmrteli adamianebis skriningit SesaZlebelia 86

bevri axali SemTxvevis gamovlena, sulac ar nisnavs imas, rom am adamianebs ar arenisnebat aravitari simptomebi. zustad aseve, rodesac axladgamovlenil pacients ekitxebian aqvs Tu ara raime simptomi da is uaryofit pasuxs gvazlevs, es ar unda mivicniot simptomebis ar arsebobis obieqtur WeSmaritebad. warmodgenili ramodenime praqtikuli kvleva ise iyo dagegmili, rom Tavidan yofiliyo acilebuli cdomileba, yovel SemTxvevaSi didi cdomileba mainc. zogierti matgani SemuSavebuli iyo sociologebis mier da mis ganxorcielebasi monawileobda specialurad momzadebuli personali, romelic kargad flobda 123, 124, gasaubrebis protokolit gansazrvrul standartul metodikas 125, 126, 127, 128. ert-ert seriasi adamianebis gamokitxva da Semowmeba paralelurad xdeboda, ise rom mat ar icodnen Catarebuli gamokvlevis Sedegebi. indoetsi, soflis Raribi mosaxleobis ert socialur epidemiologiur kvlevasi, romelic gasuli saukunis 60- ian wlebsi ganxorcielda, armocnda, rom gamokitxulta 95%, romlebic nacxis usualo mikroskopit mgb dadebitebi iyvnen, icnobdnen tuberkulozis mxolod ert an met simptoms. daaxloebit 70%-s arenisneboda xvela 123,129. TiTqmis or mesameds es simptomebi awuxebda 1-3 Tvis manzilze 124,125. es gasaocari iyo im mosaxleobasi romelsac arsebuli SexedulebiT ar unda hqonoda raime informacia tuberkulozis simptomebis Sesaxeb. meore perspeqtiul kvlevasi, romelic ganxorcielda SemTxvevaTa gamovlenis miznit daaxloebit 6 milionian mosaxleobasi, simptomebtan dakavsirebit gamokitxva Cautarda 1600 nacxit pozitiur pacients 126. es kvleva kolinis (Cexoslovakia) kvlevis paralelurad mimdinareobda (ix. cxrili #22) da warmoadgenda tuberkulozis sazedamxedvelo kvleviti organizaciis ert-ert proeqts. orive kvlevis samizne mosaxleoba msgavsi Semadgenlobis iyo. Sedegebic gamaogneblad msgavsi iyo: pacientebis 73% ucioda xvelas da mnisvnelobis mixedvit am simptoms aniwebda pirvel an meore adgils, 20% ucioda sicxianobas an gripozul mdgomareobas da mxolod 7%- ma arnisna, rom ar hqonda subieqturi simptomebi. Civilebis xangrzlivobac msgavsi iyo: 62%-s es Civilebi awuxebda 3 Tveze naklebi drois manzilze, xolo 83%-s ki 6 Tvis ganmavlobasi. aqedan gamomdinare, Cans rom aseti simptomebi arenisnebodat nacxit pozitiuri pacientebis 90%-s da rom isini vlindeba daavadebis adreul stadiaze. 87

SeiZleba daibados kitxva, nisnavs Tu ara naklebad mzime daavadebis ganvitareba _ nacxitnegatiuri da mxolod kultura - pozitiuri asiptomaturobas? indoetsi Catarebulma socialur epidemiologiurma kvlevam gvicvena 123, rom nacxit negatiuri da kultura-pozitiur pacientebs arenisnebodat tuberkulozze saewvo erti an ori simptomi. xangrzliv vadian kvlevasi, romelic kolinsi Catarda 1961-64 wlebsi 180 mxolod kultura-pozitiuri axali pacientebidan 91 (51%) arenisneboda tuberkulozis simptomebi. niigatasi 119 Catarebuli kvlevisas 109 mxolod kultura-pozitiuri pacientidan 63-s (57%) hqonda tuberkulozis simptomebi, romlebic SemTxvevaTa otx mexutedsi grzeldeboda 3 Tveze naklebi drois ganmavlobasi. ramdenadac infeqciuri pacientebis 90%-ze mets aseti simptomebi uvitardeboda tuberkulozuri procesebis dawyebidan ramodenime kvirasi, SeiZleba itqvas, rom tuberkulozis gamovlena adreul stadiebze SesaZlebelia ara mxolod tradiciuli masobrivi rentgenografiit, aramed tuberkulozze saewvo simptomebis mqone individebis naxvelis nacxis gamokvlevit. masobrivi rentgenografia gamoavlens aset SemTxvevebs mxolod 1-3 wlis Semdeg daavadebis Camoyalibebidan 129. am droisatvis mosaxleobas ukve miyenebuli aqvs is ZiriTadi ziani, romelsac iwvevs tuberkulozi (ixilet: ~ra rols asrulebs SemTxvevaTa gamovlena perioduli masiuri rentgenografiuli kvlevebis mesveobit tuberkulozis kontrolis saqmesi? ). tuberkulozis sakitxebis janmos eqspertta komitetis merve da mecxre Sexvedraze xazi gaesva SemTxvevaTa gamovlenis aucileblobas tuberkulozis simptomebis mqone pacientebsi. komitetis sxdomaze aqcenti gaketda sazogadoebasa da jandacvis musakebs Soris tuberkulozze saewvo simptomebis Sesaxeb codnis donis amarlebis sawiroebaze. SemTxvevaTa gamovlenis upirvelesi prioritetia naxvelis nacxis mikroskopuli gamokvleva im pacientebsi, romlebsac ramodenime kviris ganmavlobasi awuxebt xvela. Tu nacxi pozitiuri armocnda, masin upirvelesi prioriteti am pacientebis mkurnalobaa. mxolod kulturit pozitiuri pacientebis gamovlenas meoradi epidemiologiuri mnisvneloba aqvs 128,130. pacientebi, romlebsac simptomebi ar aqvt gamovlenili, ar warmoadgenen sazogadoebrivi jandacvis urgentul problemas. mat uketesi prognozi aqvt da infeqciis gavrcelebis TvalsazrisiTac naklebad sasisni arian. martlac damtkicebul iqna, rom Tu pacienti ar axvelebs infeqciis gavrceleba misgan praqtikulad SeuZlebelia 131. 88

15. ra rols asrulebs tuberkulozis kontrolis saqmesi SemTxvevaTa gamovlena perioduli masiuri rentgenografiuli gamokvlevis mesveobit 21 h.raideri 22 SemTxvevaTa gamovlena nisnavs im pirebis gamovlenas adreul stadiaze, romlebic gamoyofen da avrceleben tuberkulozis bacilebs. Tavisavad SemTxvevaTa gamovlena ar warmoadgens tuberkuloztan brzolis saboloo etaps aseti pacientebis identificireba xorcieldeba im miznit, rom vumkurnalot infeqciis am wyaros, SevamsubuqoT misi mdgomareoba da gadaviyvanot arainfeqciur mdgomareobasi. tuberkulozis baqteriebis gamomyofta mier sxva adamianebis dasnebovnebis macvenebeli sxvadasxvagvaria. baqteriologiuri da epidemiologiuri kvlevebit gamovlinda fundamenturi gansxvavebebi pulmonaruli tuberkulozit daavadebuli pacientebis sxvadasxva kategoriebis inficirebis xarisxsi. Catarda aranamkurnaleb pacientta dazianebuli filtvis qsovilis mravalmxrivi kvleva massi baqteriata raodenobrivi Semcvelobis dadgenis miznit 132. mkvlevrebma armoacines, rom tuberkulozis bacilebis raodenoba mnisvnelovnad gansxvavdeboda ertmanetisgan dazianebebis xasiatis mixedvit. inkapsulirebul, mkvriv, 2sm diametris mqone kvanzsi, romelsac ar hqonda kavsiri bronqtan, bacilebis raodenoba meryeobda ara umetes asidan (10 2 ) ramodenime atasamde (10 4 ). amis sapirispirod, imave zomebis mqone kavernozuli dazianebebi SeiZleba Seicavdes 10 milionidan miliard bacilamde (10 7-10 9 ) e.i. 100 000-jer mets, vidre arakavernozuli dazianebebi. naxveltan ertad gamoyofili tuberkulozis baqteriebis aseti uzarmazari raodenoba advilad SeiZleba gamovlindes nacxis martivi 21 k. tomanis wignis wina gamocemis Tavze dayrdnobit 22 internacionaluri gaertianeba tuberkulozisa da filtvis daavadebata winaarmdeg, tuberculosis ganyofilebis med-musaki. parizi, safrangeti. 89

mikroskopiit. masin, rodesac arakavernozuli dazianebebis dros gamoyofili SedarebiT mcire raodenobis bacilebis demonstrireba SeiZleba mxolod kulturis testit an amplifikaciis (gazrdis) metodis gamoyenebit. amit SeiZleba aixsnas, Tu ratom aqvt tuberkulozis arakavernozuli formit daavadebul nacxit uaryofit da kulturapozitiur pacientebs SedarebiT uketesi klinikuri prognozi. aset pacientebsi arsebobs spontanuri gankurnebis ufro marali albatoba, vidre kavernozuli dazianebebis mqone pacientebsi, romlebic gamoyofen didi raodenobit tuberkulozis baqteriebs, rac Cans naxvelis usualo mikroskopuli analizit. amave mizezit, gansxvavebuli baqteriologiuri statusis mqone pacientebs, romlebic gamoyofen tuberkulozis bacilis mcire an did raodenobas ar aqvt ertnairi epidemiologiuri mnisvneloba. ramodenime eqsperimentuli 133 da epidemiologiuri kvlevit Seswavlili iqna 134, 135, 136 urtiertkavsiri infeqciis sixsires da infeqciis wyaros baqteriologiur statuss Soris. grafiki #5 kontaqtebis inficirebis riski tuberkulozis wyaros baqteriologiuri statusis mixedvit (S+/ C+ arnosnavs nacx da kultura - pozitiur SemTxvevebs, S-/C+ nacx da kultura - pozitiur SemTxvevebs, S-/C- nacxit-negatiur da kultura - negatiur SemTxvevebs) 90

grafiki #5 asaxavs sami epidemiologiuri kvlevis ZiriTad Sedegebs. TiToeul kvlevasi tuberkulozit daavadebul pacientebtan kontaqtsi myofi 15 wlamde asakis bavsvebi testirebulni iyvnen tuberkulinit da dajgufdnen infeqciis im wyaros mixedvit, romeltanac iyvnen kontaqtsi. kvlevebs Soris absoluturi gansxvavebebi ar aris mnisvnelovani (isini ganxorcielda sxvadsxva dros, sxvadasxva adgilebsi da savaraudod matsi gamoiyeneboda kontaqtis gansxvavebuli definiciebi). mtavaria, rom TiToeuli es kvleva natlad gvicvenebs, rom infeqciis ZiriTad wyaros warmoadgens nacxit pozitiuri pacienti: tuberkulozis infeqciis yvelaze marali prevalentoba gamovlinda im bavsvebsi, romlebsac kontaqti hqondat nacxit pozitiuri tuberkulozit daavadebul pacientebtan. britanetis kolumbiasa da saktacevansi 136 Catarebuli kvlevebidan nacxitpozitiur tuberkuloztan dakavsirebuli infeqciis proporciuli Sefardeba SeiZleba daangarisebuli iqnes ise, rogorc es mocemulia grafikze #6. aq yvela infeqciuri SemTxvevis 90% ukavsirdeboda nacxit pozitiur wyaroebs. amis msgavsad ass-si san-franciskosi bolo periodsi, molekuluri epidemiologiuri metodebis gamoyenebit Catarebulma kvlevam gvicvena, rom daavadebis gavrcelebis yvela SemTxvevis 80%-ze meti dakavsirebuli iyo nacxit pozitiur wyaroebtan 137. dadginda, ra rom nacxit pozitiuri pacientebis kategoria epidemiologiuri TavlsazrisiT yvelaze mnisvnelovania, warmoisva Semdegi kitxvebi: ~Cveulebriv rogor xdeba infeqciuri pacientebis gamovlena da ra rols asrulebs masobrivi rentgenografiuli gamokvleva aset maral prioritetuli jgufebis gamovlenasi? nacxit pozitiuri tuberkulozis SemTxvevebis gamovlena: masobrivi rentgenografiis Sedegebi cxrilsi #23 Sejamebulia janmos mxardawerita da tuberkulozze zedamxedvelobis samecniero-kvlevit ganyofilebastan TanamSromlobiT Catarebuli kvlevis Sedegebi 138. am kvlevasi monawile yvela qveyanasi tuberkulozis SemTxvevis gamovlena masobrivi rentgenografiis CatarebiT warmoadgenda rutinul proceduras daaxloebit oci wlis ganmavlobasi. rogorc es 23-e cxrilidan Cans, masobrivi rentgenografiis mesveobit gamovlenili 91

iqna nacxit pozitiuri SemTxvevebis gasaocrad mcire raodenoba. SemTxvevaTa umetesoba gamovlenili iyo sxva sasualebebit, ZiriTadad im adamianebs Soris, romlebic Civilebis gamo sakutari iniciativit mimartavdnen samedicino dawesebulebebs. grafiki 6 nacxit pozitiuri da mxolod kultura-pozitiuri pulmonaruli tuberkulozis transmisiis proporciuli Sefardeba inficirebuli SemTxvebis wiladi nacxit uaryofiti kulturit pozit. nacxit dadebiti kulturit pozit. filtvis tuberkulozis SemTxvevebi inficirebuli kontaqtsi myofni < 15 weli nacxit negatiuri SemTxvevebis wiladi nacxit dadebit SemTxvevebis wiladi cxrili #23 nacxit pozitiuri tuberkulozis SemTxvevebis gamovlenis rejimi proeqti kvlevis xangrzlioba saskacevani 1960-1969 ontario 1967-1968 kolini 1965-1972 niderlandebi 1951-1967 nacxit dad.-semtxvevebis raodenoba 265 632 132 9301 gamovlenis rejimi masobrivi simptomebi rentgenografia 12 66 15 66 23 54 25 39 sxva 22 19 23 36 92

cxrili #24. GexoslovakiaSi, kolinis olqsi gamovlenili nacxit pozitiuri SemTxvevebi gamovlenis 1965 1966 1967 1968 1969 1970 1971 1972 sul metodi simptomebi 16 6 7 9 8 7 8 10 71 masobrivi - 14 - - 11 1-4 30 rentgenografia sxva 6 4 2 5 3 3 4 4 31 sul 22 24 9 14 22 11 12 18 132 kidev erti mnisvnelovani daskvna, romelic SeiZleba gamovitanot am kvleviti proeqtebidan, kerzod, niderlandebsi da kolinsi Catarebuli kvlevebidan (kvleva ganxorcielda regionebsi, romelta mosaxleoba daaxloebit 100 000-s Seadgenda) isaa, rom nacxit-pozitiuri SemTxvevebis wili axlad gamovlenil pacientebsi didad ar Secvlila, miuxedavad imisa, rom 2-3-wliani intervalebit tardeboda intensiuri masobrivi rentgenografia. aqedan gamomdinare, niderlandebsi, miuxedavad imisa, rom tuberkulozis SemTxvevaTa sixsiris wliuri macvenebeli ganuxrelad mcirdeboda dakvirvebis periodsi (1951-1967) nacxit pozitiuri tuberkulozis SemTxvevebis proporciuli Sefardeba ar icvleboda. yoveli 100 bacila gamomyofi axali pacientidan 46 nacxit pozitiuri iyo, miuxedavad imisa, rom aq 17 wlis ganmavlobasi 3-wliani intervalebit tardeboda masobrivi rentgenografiuli kvlevebi 138. asetive gamaognebeli daskvnebi SeiZleba gavaketot kolinsi Catarebul kvlevastan dakavsirebitac. axali, nacxit pozitiuri SemTxvevebis macvenebeli 14 wlis da ufro meti asakis mosaxleobis 95%-Si (ganmeorebiti gamokitxvebis safuzvelze SeiZleba itqvas, rom ar Secvlila. am axali SemTxvevebis ¾sami meotxedi modioda im adamianebze, romlebsac wina gamokvlevis dros hqondat gulmkerdis normaluri rentgenografiuli surati. imis SesaZlebloba, rom Sorswasuli SemTxvevebi ganvitarda adre arsebuli, magram mxedvelobidan gamorcenili dazianebebidan SeiZleba gamoiricxos, vinaidan firis Sefaseba xdeboda ori damoukidebeli rentgenologis da erti eqspertis mier. garda amisa, janmos eqspertebic axorcielebdnen am firebis randomizebul Sefasebas. yoveli axali 93

SemTxveveis gamovlenisas xdeboda adre gadarebuli firebis detaluri Seswavla, rata ganesazrvrat xom ar iyo firze iseti Crdili, romelic adrec arsebobda, magram mxedvelobidan iqna gamorcenili, an arasworad iyo interpretirebuli. nebismieri kvlevis dros gulmkerdis rentgenografiis mesveobit gamovlenili yvela individi da tuberkulozis yvela SemTxveva eqvemdebareboda an mkurnalobas, an mkacr monitorings. aqedan gamomdinare, mosalodneli iyo, rom am Tanmimdevrul kvlevebsi axali SemTxvevebi unda gamovleniliyo ZiriTadad im pirebsi, romlebsac adre normaluri rentgenografia hqondat. amitom mati armocena unda momxdariyo adreul etapze, an yvelaze ukidures SemTxvevaSi im fazasi mainc, rodesac pacienti mxolod kultura dadebitia. Miuxedavad amisa, wlidan wlamde axladgamovlenili SemTxvevebis didi nawili mainc modioda ukve Sors wasul, nacxit pozitiuri tuberkulozis mqone pacientebze, masin rodesac SemTxvevaTa umetes nawilsi (daaxloebit 75%) wina rentgenografiuli gamokvlevit ar fiqsirdeboda filtvis xiluli dazianeba. ertaderti SesaZlo daskvna, romelic SeiZleba am mimartebit gaketdes isaa, rom nacxit dadebiti tuberkulozis axali SemTxvevebi vitardeboda Zalian swrafad. es daskvna iyo testirebulic da dasabutebulic 139, 140, 141, ix. grafiki #7. grafiki #7. drois intervali bolo normalur rentgenogramasa da tuberkulozis ganvitarebas Soris sxvadasxva baqteriologiuri statusis mqone pacientebsi (niigata, iaponia) pacientis baqteriologiuri statusi misi gamovlenis momentsi nacxit pozitiuri nacxit negatiuri kulturit pozotiuri nacxit negatiuri kulturit negatiuri procenti 94

TiToeuli sveti warmoadgens pacientis baqteriologiur statuss gamovlenis momentsi grafiki # 7 gvicvenebs, rom axlad gamovlenili nacxit dadebiti SemTxvevebis 50% warmoisva 1 welze nakleb periodsi. kulturapozitiuri SemTxvevebi (Cveulebriv filtvis minimaluri dazianebebit) ganvitarda drois imave monakvetsi. situacia gamoiyureba ise, TiTqos tuberkulozuri dazianebebi procesis sawyisi momentidan vitardeba an nela, an Zalian swrafad.. jer kidev ucnobi mizezebis gamo, tuberkulozis baqteria gansazrvruli dazianebebis SemTxvevaSi vitardeba Zalian nela da amitom warmodgenilia mcire raodenobit, magram sxva dazianebebsi mravldeba Zalzed swrafad da sul ramodenime kviris ganmavlobasi izleva TaobaTa uzarmazar raodenobas. aqedan gamomdinare, araswori iqneboda gvefiqra, rom kavernozuli dazianebis mqone nacxit pozitiuri yvela SemTxveva dagvianebuli diagnostikis gamo Zveli an qronikuli formaa da yvelaferi eqimis daudevrobas unda davabralot, rogorc es warmodgenilia grafikze #7. filtvis nacxit pozitiuri tuberkulozi SeiZleba isetive Zveli an axladwarmoqmnili iyos, rogorc mxolod kultura-pozitiuri mcire dazianebebi, radganac erti wlis ganmavlobasi aseti SemTxvevebi ganvitarda praqtikulad janmrtel adamianebsi normaluri rentgenografiuli suratit. kolinsi Catarebuli kvlevebit mirebuli monacemebi gvicvenebs, rom im axladgamovlenil pacientta 4/5-s romlebsac bolo masobrivi rentgenologiuri gamokvlevis dros gulmkerdis normaluri rentgenograma hqondat, daavadeba ganuvitardat 3 weliwadsi. Ees imaze metyvelebs, rom masiuri gamokvlevebis dros, romlebic tardeba 3 wlis intervalebit, faqtiurad ver xorcieldeba daavadebis adreul etapze gamovlena. 6-Tviani intervalebic ki SeiZleba iyos Zalian xangrzlivi 142, rogorc amas SvedeTSi Catarebuli kvleva gvicvenebs. pacientta did nawilsi daavadeba simptomebis gamovlenidan nacxit pozitiur stadiamde Zalzed swrafad progresirebda. (grafiki #8). 95

grafiki #8 naxvelis nacxis pozitiurobis kumulaciuri procentuli magvenebeli simptomebis Gamoyalibebis Semdeg, nacxit pozitiur pacientebsi. SvedeTi 1910-1911 da 1934 w simptomebis gamovlenasa da pirvel pozitiur nacxs Soris drois intervali (TveebSi). daskvnebi dadasturda, rom tuberkulozuri infeqciis yvelaze sasis wyaros, kerzod, nacxit pozitiuri filtvis formis, adreul etapze gamovlena perioduli masobrivi rentgenografiit_arapraqtikulia, masinac ki, rodesac aseti rentgenografia meordeba mokle intervalebit. nacxit dadebiti SemTxvevebis didi umravlesoba, masiuri rentgenografiuli kvlevis raunds Soris yvelaze mcire intervalze ufro mokle periodsi vitardeba 143. ufro metic, swrafad progresirebadi filtvis tuberkulozis mqone pacientebis 90%-s arenisneboda iseti obieqturi simptomebi, rogoricaa: xvela, sicxe, wonasi dakleba, naxveli da hemaptoe. es simptomebi gacilebit swrafad vitardeboda daavadebis dawyebistanave da aizulebda pacientebs miemartat eqimisatvis 144. aqedan gamomdinare, nacxit pozitiuri tuberkulozis SemTxvevebis umetesoba vlindeba ara aseti perioduli kampaniebis dros, aramed samedicino dawesebulebebsi, romlebsac pacientebi mimartaven Civilebis SemTxvevaSi. 96

am mizezebis gamo, masiuri rentgenografia ar aris SemTxvevaTa gamovlenis optimaluri metodi. damatebit winaarmdegobebs, ris gamoc masiuri rentgenografiuli kampaniebis Catareba rekomendirebuli ar aris, ganekutvneba kargi savali gzebis nakleboba, manqanebisa da rentgenologiuri aparaturis gaumartaoba, ZviradRirebuli da Znelad mosapovebeli satadarigo nawilebi da SemkeTebeli saxelosnoebis simcire. janmos tuberkulozis sakitxebis eqspertta me-9 angarissi arnisnulia 145, rom masiuri rentgenografiuli gamokvleva warmoadgens tuberkulozze mosaxleobis skriningis Zalzed ZviradRirebul proceduras, im SemTxvevaSic ki, Tu tuberkulozis prevalentoba Zalian maralia. Masiuri rentgenografiis sxva naklovanebebia: 1. misi daxmarebit xerxdeba SemTxvevaTa mxolod mcire nawilis gamovlena; 2. is ver axdens mnisvnelovan zegavlenas nacxit pozitiuri SemTxvevebis warmosobaze, radgan daavadeba imdenad swrafad vitardeba, rom warmoiqmneba gamokvlevata Soris periodsi (amitom dawesebulebebi, sadac xorcieldeba SemTxvevaTa gamovlena da mkurnaloba nebismier periodsi xelmisawvdomi unda iyos mosaxleobisatvis); 3. is moitxovs maralkvalificiuri teqnikuri da samedicino personalis momsaxurebas, romlebic SeiZleba uket gamoviyenot samedicino dawesebulebebis sxva saqmianobasi; 4. misi transportirebisatvis sawiro aparatura an satransporto sasualebebi xangrzlivi gamoyenebis gamo xsirad mwyobridan gamodis, gansakutrebit iq, sadac arsebobs mati satadarigo nawilebis deficiti. 97

16. rit gansxvavdeba tuberkulozis diagnostika aiv inficirebul pacientebsa da arainficirebul pirebsi a. harisi 23 filtvis tuberkulozi warmoadgens tuberkulozuri daavadebis yvelaze fartod gavrcelebul gamovlinebas aiv-inficirebul pacientebsi. tuberkulozi vitardeba aiv-infeqciis sxvadasxva etapze, iseti klinikuri modelit, romelic Seesabameba pacientis imunur statuss. Aiv-infeqciis adreul etapebze, rodesac imunuri sistema mxolod nawilobriv datrgunulia, nisnebi ufro metad hgavs tipiur tuberkulozs. igi ZiriTadad gamoxatulia kavernit filtvis zeda wilsi da isetivea, rogorc im periodsi, rodesac aiv-infeqcia jer ar arsebobda. imunuri deficitis gazlierebastan ertad aivinficirebul pacientebs uvitardebat atipuri pulmonaruli daavadeba, romelic mogvagonebs pirvelad tuberkulozs an eqstrapulmonarul da diseminirebul daavadebas, ZiriTadad fesvis limfadenitit da qveda wilis dazianebit. 146 filtvis tuberkulozis diagnozi klinikuri maxasiateblebi: filtvis tuberkulozis klinikuri maxasiateblebi zogadad msgavsia, rogorc aivinficirebul aseve aiv-negatiur pacientebsi, Tumca aivincifirebuli adamianebistvis xvela naklebad damaxasiatebelia, vinaidan aq naklebad arenisneba kavernozuli dazianebebi da endobronqialuri garizianeba, rac ganpirobebulia ujreduli imunitetis datrgunvit 147. msgavsad amisa, hemaptoe, romelic 23 malaviis tuberkulozis erovnuli programis teqnikuri mrceveli. lilongue, malavia 98

warmoadgens bronqialuri arteriis kazeozuri nekrozis Sedegs, naklebad gvxvdeba aiv-infificirebul pacientebsi. tuberkulozis kanis testi naklebadmnisvnelovania mozrdili pacientebis diagnostikisatvis, Tumca es metodi gamoiyeneba sazogadoebasi tuberkulozis inefqciis gavrcelebis gansasazrvravad. tuberkulozis aqtiuri formis dros kanis testi SeiZleba negatiuric iyos, magalitad, zairsi filtvis tuberkulozis mqone aiv-pozitiuri pacientebis kvlevisas, kanis anergia armoacnda im pacientebis 8%-s, sadac CD4 limfocitebis raodenoba iyo >500 /m 1, xolo 54% mat Soris visi CD4 limfocitebis raodenoba iyo <200 /m 1 148. naxvelis nacxis mikroskopia kvlavac rceba tuberkulozis diagnostikis qvakutxedad iset regionebsic ki, sadac aivprevalentoba Zalzed maralia. afrikis samxret-saharis regionis qveynebsi Catarebulma sistematurma kvlevebma gvicvena, rom tuberkulozit daavadebuli aiv-inficifirebuli pacientebis naxvelis nacxi pozitiuri iyo, Tumca filtvis tuberkulozze saewvo nacxit negatiuri pacientebis raodenoba aiv-inficirebulebs Soris gacilebit metia, vidre aiv-negatiur pacientebsi. nacxit pozitiuri, aiv-inficirebuli paceintebi aseve SedarebiT mcire raodenobis mikroorganizmebs gamoyofen naxvelsi, vidre aivnegatiuri pacientebi, ramac arasatanadod Zlieri velebis mikroskopuli kvlevisas SeiZleba gamoiwvios mjavagamzle baqteriebis dakargva 146 149. grafiki #9 rentgenologiuri kvlevis Sedegebi tuberkulozit daavadebul aivinficirebul pacientebs Soris aiv-inficirebis adreuli stadia aiv-inficirebis gviani stadia (mwvave imunokompromisi) 99

gulmkerdis rentgenografia gamoyeneba tuberkulozze saewvo nacxit uaryofit iset pacientebsi romlebic ar reagireben antibiotikebit mkurnalobaze. aiv-inficirebul pirebsi xsiria streptococcus pneamoniae, Haemophilus influenzae da sxva patogenebit gamowveuli bronqiti da pnevmonia. rentgenologiuri cvlilebebi ar warmoadgenen tuberkulozis diagnozis kriteriums, Tumca tipiuri cvlilebebia kavitacia, apikaluri dazianeba, fibrozi, SeWmuxvna da kalcifikacia. aiv-inficirebuli pacientebi, romlebsac SedarebiT uket aqvt SenarCunebuli imunuri funqciebi, xsirad avlenen aset tipur nisan-tvisebebs. imunosupresiis zrdastan ertad gulmkerdis rentgenografiul suratze ufro metad Cans atipiuri maxasiateblebi, rogoricaa pulmonaruli filtvis infiltracia qveda wilebsi da intratorakaluri limfadenopatia. zogjer gulmkerdis rentgenografia normaluria 146,149 : ass-si Catarebul ert-ert kvlevasi nacxit da kultura-pozitiuri tuberkulozuri pacientebis 21%-s, romelta CD4 lifocitebis ricxvi < 200/m 1 iyo gulmkerdis rentgenografiul kvlevas normaluri Sedegebi hqonda 150. rentgenografiis dros sxva aratuberkulozurma daavadebebma SeiZleba klasikuri da atipuri maxasiateblebi gamoavlinos 146,149. Tu naxvelis nacxi negatiuria, diagnozis diferencirebis dros gatvaliswinebuli unda iyos sxva monacemebic 151. aiv-infeqciisatvis damaxasiatebelia filtvis is seriozuli daavadebebi, romlebic SeiZleba SecdomiT mivicniot filtvis tuberkulozad, magalitad, pnevmocista carini it gamowveuli pnevmonia, kaposis sarkoma, baqteriuli pnevmonia, sokovani infeqciebi da nokardiozi. filtvgarese tuberkulozi eqstrapulmonaluri tuberkulozis ZiriTad manifestacias aivinficirebul pacientebsi warmoadgens limfadenopatia, eqsudatiuri plevriti, eqsudaturi perikarditi da miliaruli tuberkulozi. samedicino diagnostikuri samsaxurebis simciris gamo xsirad rtulia eqstrapulmonaluri tuberkulozis diferenciuli diagnostika. magalitad, tanzaniis gaertianebul respublikasi eqstrapulmonaluri tuberkulozis mqone pacientebis mxolod 18%-s Cautarda diagnozis damadasturebeli laboratoriuli kvleva. 100

sazogadod filtvgarese tuberkulozi aiv-inficirebul da aivnegatur pacientebsi didad ar gansxvavdeba ertmanetisagan, Tumca aiv-dakavsirebul tuberkulozuri limfadenopatia SeiZleba mwvaved mimdinareobdes da mogvagonebdes mwvave baqteriul infeqcias; diagnozi dgindeba iseti martivi metodit, rogoricaa aspiracia nemsit, limfuri kvanzebis bioptatis datvaliereba da Wrilobidan arebuli nacxis gamokvleva; tuberkulozuri meningitis dros aivpozitiur pacientebs cerebrospinaluri sitxe SeiZleba sruliad normaluri hqondes. gansakutrebit rtulia disiminirebuli tuberkulozis diagnostika. magalitad, spilos Zvlis sanapiroze aseti mdgomareoba gamovlinda aiv-sindromis mqone pacientebis 44%-s autofsiis dros 152. samwuxarod diagnozis dasma pacientebis gardacvalebamde ver moxerxda, tuberkulozis mikobaqteriit gamowveuli baqteriemia SesaZloa iyos ucveulo da SeiZleba axldes xvela da SemTxvevaTa naxevarze naklebsi arinisnebodes gulmkerdis anomaliuri rentgenografia 153,154, 155. isviati ar aris tuberkuliozuri perikarditi, romlis diagnostikac xdeba rentgenologiurad am patologiisatvis damaxasiatebeli bustisebri formis Crdilis arsebobit gulis saproeqcio areze. tuberkulozis diagnostika bavsvebsi mozrdilebis msgavsad pulmonaluri tuberkulozi tuberkulozuri daavadebis yvelaze fartod gavrcelebuli formaa aiv-pozitur bavsvebsi. filtvis tuberkulozis diagnostika otx wlamde asakis bavsvebsi yoveltvis Znelia, xolo aiv-infeqcia kidev ufro artulebs diagnostikas. tuberkulozit daavadebul aiv-inficirebul bavsvebsi maralia kanis anergiuli reaqciebi da umetes SemTxvevaSi diagnostika xdeba araspecifikuri da rentgenologiuri kriteriumebit. vinaidan aiv-infeqciastan asocirebuli pulmonuri tuberkulozis diferencireba Cveulebrivi pulmonuri tuberkulozisagan xsirad rtulia, bevr SemTxvevebSi vxvdebit hiperdiagnistikas. 101

diagnostikuri sirtuleebi aiv-infeqciis warmoqmnam gaartula tuberkulozis diagnostika. cru diagnozebis albatoba aiv-asocirebul sxva daavadebebis mqone pacientebs Soris Zalian maralia. ram Tu gaketda am mnisvnelovani problemis gadasawrelad an armosafxvrelad, cru pozitiuri diagnozi Cveulebriv tuberkulozis yvela formis mxolod mcire nawils Seadgens da aqedan gamomdinare, ver amcirebs tuberkulozis gavrcelebis zrdas aiv-endemur regionebsi. naxvelis nacxis mikroskopia diagnostikis qvakutxedad rceba, radgan misi mesveobit SesaZlebelia tuberkulozis gavrcelebis SeCereba. 102

17. ra rols asrulebs tuberkulinis kanis testi tuberkulozis diagnostikasi d. menziesi 24 kanis testi erti SexedviT Zalzed mimzidvelia, radgan igi ar moitxovs rtul teqnologias, iafia, advilad Casatarebelia da misi interpretacia ar warmoadgens did sirtules. Tumca interpretacia kvlavac urtiertdapirispirebuli Sexedulebebis da gaugebrobis sagania, rac ganpirobebulia sxvadasxva kvlevebit mirrebuli urtiertgamomricxavi SedegebiT. variaciebis aseti speqtri ar asaxavs gansxvavebebs testis sizustesa da mgrznobelobasi. es gansxvavebebi ufro asaxavs WeSmaritad pozitur an WeSmaritad negatur Sedegebis prevalentobis da cru-pozituri da cru-negaturi Sedegebis variaciebs sxvadasxva mosaxleobasi. tuberkulozuri infeqciis diagnostikis TvalsazrisiT, tuberkulinis testi praqtikulad ertaderti xelmisawvdomi testia. misi sargeblianoba damokidebulia klinikur situaciaze, populaciaze, tuberkulinis reaqciebis martvisatvis sawiro resursebis xelmisawvdomobaze. tuberkulinis testi gamoiyeneba daavadebis riskis winase myofi iseti pacientebis gamosavlenad, rogoricaa aiv-inficirebuli pacientebi an kontaqtebi, romlebsac unda Cautardes mkurnaloba latentur tuberkulozur infeqciaze (ixilet: ra rols asrulebs latenturi tuberkulozuri infeqciis mkurnaloba tuberkulozis kontrolsi? ). Tumca testi sarwmuno ar aris tuberkulozis diagnostikisatvis da xsirad izleva araswor, cru-dadebit an cru-uaryofit pasuxebs. diagnostikis dros tuberkulinis testi izleva cru-negatiur pasuxs aqtiuri tuberkulozis mqone pacientebis 10% - 47% 156, 157, 158, 159. cruuaryofiti reaqciebis albatoba izrdeba daavadebis simzimisa da 24 tuberkulozis klinikis direqtori. montrealis mkerdis institute, makgilis universiteti. montreali, kanada. 103

individis asakis matebastan ertad. sainteresoa, rom tuberkulinze anergia droebitia; pacientebis 95%-ze mettan mkurnalobis dawyebidan 1 an meti Tvis Semdeg testi pozitur Sedegebs izleva. aiv-koinfeqciis SemTxvevaSi testi cru-negatiur Sedegs izleva aqtiuri tuberkulozis mqone pacientebis ufro met raodenobasi. es dakavsirebulia imunosupresiis xarisxtan: cru-negatiur Sedegebs mivirebt pacientta 30%-Si, sadac CD4 T-limfocitebis raodenobaa >500/µl da TiTqmis 100%, sadac CD4 T-limfocitebis raodenobaa <200/µl 160,161. tuberkulinis kanis testi warmoadgens mikobaqteriebze mgrznobelobis gansazrvris araspecifikur metods. is SeiZleba pozituri iyos im pacientebsi, romlebsac Catarebuli aqvt BCG vaqcinacia, Tumca Tu BCG vaqcinacia Catarebulia axalsobilobisas, masin 5 wlis asakis zevit 10 mm-ze didi zomis reaqcia isviatia 162. individebs, romlebsac vaqcinacia ufro mozrdil asaksi CautardaT, (magalitad, dawyebit skolasi), SesaZlebelia 15-25%-s SenarCunebuli hqondes pozitiuroba 20-25 wlis asakamde 162, 163, 164. testis crupozitiuri pasuxebi aseve ganpirobebulia jvaredin-reaqtiuli mgrznobelobit baqteriul antigenebze(11), romlebic damaxasiatebelia tropikuli da subtropikuli klimatisatvis 165, 166, 167. am metodis yvelaze didi nakli aris is, rom igi ar izleva latenturi, anu infeqciis aqtiuri tuberkulozisagan diferenciaciis SesaZleblobas. Tu testi gamoiyeneba umnisvnelo respiratoruli simptomebis mqone pacientis gamosakvlevad, dadebiti Sedegi mxolod zrdis tuberkulozis arsebobis albatobas. es imis gamo xdeba, rom im pacientebs Sorisac ki, visi testis dadebiti pasuxic WeSmariti tuberkulozit aris ganpirobebuli, kvlevis momentisatvis umravlesobas SeiZleba arar hqondes aqtiuri stadia. skriningis dros, axali SemTxvevebis gamovlenis TvalsazrisiT, tuberkulinis testi, kidev ufro nakleb Rirebuleba aqvs. tuberkulozis marali prevalentobis qveynebsi, anu ganvitarebadi qveynebi, negatiurma pasuxma SeiZleba SecdomaSi Segviyvanos. gvexmareba Tu ara reaqciis zomebi infeqciis daavadebisagan gansxvavebasi tuberkulinze didi zomis reaqciebi yoveltvis gacilebit ufro STambeWdavia rogorc mosaxleobis, aseve medikosebisatvis. Cveulebriv arasworad miacniat, rom rac ufro didi zomisaa tuberkulinis testze kanis reaqcia, mit ufro metia aqtiuri 104

daavadebis arsebobis albatoba. rogorc amas grafiki #10 gvicvenebs, es Sexeduleba mcdaria. martalia, daavadebis arsebobis albatoba SeiZleba icvlebodes imis mixedvit tuberkulinis testis reaqcia sididit 5 mm-ze metia Tu naklebi, magram 5 mm-is zemot reaqciis sidide ar izleva gansxvavebas aqtiur tuberkulozs, araaqtiur tuberkulozs (rentgenografiuli cvlilebebi), axlad inficirebas (kontaqtebi), an didi xnis win inficirebas Soris. aqedan gamomdinare, garkveuli zrvaris zemot zoma kargavs azrs tuberkulinis kanis testis interpretirebasi 156. grafiki #10. tuberkulinis testze reaqciis nimusebi, tuberkulozis aqtiuri da araaqtiuri formit daavadebul pacientebsi, aqtiuri formit daavadebulebtan kontaqtsi myof pirebsa da janmrtel adamianebsi procentuli macvenebeli kontaqtebi aqtiuri tb araaqtiuri tb janmrteli reaqciebi tuberkulozis testze (mm-si) 105

18. rogoria sxva diagnostikuri testebis arsebuli da potenciuri roli d.menzieri 25 naxvelis nacxis kvleva mjavagamzle baqteriebis arsebobaze warmoadgens tuberkulozis infeqciis gavrcelebis wyaros identificirebis arazviradrirebul, maral specifikur sasualebas, Tumca misi nakli aris is, rom igi gansakutrebul pirobebs moitxovs. Tu laborantebs ar aqvt satanado momzadeba, motivacia, dro da kontroli, masin testis Sesrulebis xarisxi programis pirobebsi, potenciurtan SedarebiT Zalzed dabali iqneba. afrikasi tuberkulozis SemTxvevebis raodenoba Zalian maralia. zogiert qveyanasi SemTxvevebis raodenoba 2-4-jer gaizarda 168. yoveli otxi nacxit negatiuri diagnozis mqone pacientidan erti faqtiurad nacxit pozitiuri iyo. ufro metic, nacxis mikroskopia sawiroebs pacientis orjer misvlas samedicino dawesebulebasi. testis kargad Sesrulebis drosac ki SeiZleba ver moxdes im pacientebis identificireba, romlebic naxvelsi mcire raodenobit baqteriebs gamoyofen da mxolod kultura - pozitiurebi arian. (ix. Tavi: ra rols asrulebs mikobaqteriuli kultura diagnostikasa da SemTxvevaTa gamovlenasi~). miuxedavad imisa, rom aseti pacientebi naklebmnisvnelovan problemas warmoadgenen daavadebis transmisiisa da sikvdilianobis macveneblebis zrdis TvalsazrisiT, matma diagnostikam da martvam SeiZleba mnisvnelovani Zalisxmeva moitxovos tuberkulozis kontrolze pasuxismgebeli klinikuri da sazogadoebrivi jandacvis personalis mxriv. aqedan gamomdinare, sawiroa swrafi, iafi da martivad Sesasrulebeli testi, romelic SeZlebda nacxit negatiuri da eqstrapulmonaruli tuberkulozis identificirebas. aq ar igulisxmeba is qimiuri testebi, romlebic 25 tuberkulozis klinikis direqtori, montrealis gul-mkerdis instituti. makgilis universteti, montreali, kanada. 106

gamoiyeneba eqstrapulmonaruli tuberkulozis diagnostikasi (magalitad, adenozin diaminaza, tuberkulostearuli mjava). imunologiuri testebi tuberkulinis kanis testi tuberkulinis kanis testi klinikur praqtikasi ukve 90 welia gamoiyeneba (ix: ra rols asrulebs tuberkulozis kanis testis tuberkulozis diagnostikasi ) Tumca mas ar Seswevs unari gamijnos ertmanetisgan tuberkuliozit inficireba da daavadeba, da amastan rig tuberkulozur pacientebsi Tvadapirvelad kanis tetsi uaryofit pasuxs izleva. aqedan gamomdinare, tuberkulozis diagnostikis TvalsazrisiT, es testi mozrdilebsi arainformatiulia. serologia termini serologia arnisnavs humoraluri pasuxis gazomvas tuberkulozis mikobaqteriaze (antisxeuli umetes SemTxvevaSi IgG) sisxlis testis mesveobit. robert koxma 1898 wels Caatara pirveli serologiuri testi, Tumca erti saukunis Semdegac ki ver moxerxda iseti serologiuri testis Seqmna, romelsac eqneboda satanado mgrznobeloba da specifikuroba. arnisnulis yvelaze savaraudo mizezi aris is 169, rom tuberkulozis mikobaqteriaze pirveladi imunuri pasuxi aris ara humoruli, aramed ujreduli. bolo periodsi mopovebuli mtkicebulebebis safuzvelze SeiZleba itqvas, rom humoraluri pasuxi tuberkulozis mikobaqteriaze heterogenuria 170,171. ert-ert kvlevasi, romelsic monawileobda aqtiuri tuberkulozit daavadebuli 59 pacienti, 52-s (88%) hqonda antisxeulebis reaqcia sul mcire 10 mikobaqteriul antigenze, magram 50% naklebi reagirebda nebismier ert antigenze 171. adrindel serologiur testebsi gamoiyeneboda daumusavebeli eqstraqtebi, iseti rogoricaa tuberkulinis kanis testis masala, amitom hqonda dabali mgrznobeloba da dabali specifikuroba 169. yvelaze uaxlesi testebi, romlebsic gamoiyeneba Zalzed gasuftavebuli antigeni, ufro srulyofilia 169. am testebis yvelaze mnisvnelovani upiratesoba aris is, rom Sedegis mireba SeiZleba erti saatis ganmavlobasi da amastan mati Catarebis metodika martivia, moitxovs minimalur arwurvilobas da mcire momzadebas. 107

bolo periodsi bevrma mwarmoebelma gamousva serologiuri testebi 172. isini xelmisawvdomi da SedarebiT iafia (1 ass dolari 1 testi), rac mat Zalzed mimzidvels xdis Raribi qveynebisatvis, sadac iqmneba mati agresiuli marketingis SesaZlebloba. Tumca am tests didi naklic aqvs, rac mis dabal mgrznobelobasa da specifikurobasi mdgomareobs mgrznobeloba 172, 173 yvelaze maralia nacxit dadebit pacientebsi 170, 174, 175, magram Zalzed dabalia bavsvebsi 176 da eqstrapulmonuri (filtvqvese) tuberkulozit daavadebul adamianebsi 175,176,177. e.i. iset pacientebsi, romlebsac mjavagamzle baqteriis arasensitiurobis gamo esawiroebat sxva swrafi testi 178. specifikuroba yvelaze kargad vlindeba janmrtel moxaliseebsi, araendemiur qveynebsi(3,7). igi gacilebit dabalia testisatvis Sesabamis mosaxleobasi, rogoricaa aqtiuri formit daavadebulebtan axlo kontaqtsi myofi adamianebi, pacientebsi, romlebsac savaraudod aqvt aqtiuri tuberkulozi. Endemiuri 173 kerebis mosaxleobasi serologiuri testebi ar izleva aqtiuri tuberkulozis da tuberkulozis mikobaqteriit inficirebis SesaZleblobas. amjamad (2003) yovelive zemotqmulidan gamomdinare, serologiuri testebi aravitar rols ar asruleben tuberkulozis diagnostikasi. ujreduli imunuri pasuxi bolo ati wlis mirwevebma molekulur biologiasi stimuli misca iseti testebis SemuSavebas, romlebic SeZlebdnen tuberkulozis mikoaqteriaze ujreduli imunuri pasuxis gansazrvras. cirkulirebadi dimfocitebi gamoiyofa venozuri sisxlidan da matze zemoqmedebas axdenen tuberkulozis mikobaqteriis antigenit, 6-24 st-is Semdeg, izomeba citokinebis warmoqmna (antebis mediatorebi, ufro xsirad gama interferoni) 179. am metodis yvelaze didi upiratesoba is aris, rom misi mesveobot SesaZlebelia ganisazrvros adamianis pirveladi imunuri pasuxi tuberkulozze. meores mxriv, mzime pacientta 20%_47% diagnostikis momentisatvis SesaZloa anergia qondet 180, 181, 182, 183. SesaZloa es movlena droebit xasiats atarebdes da erti an meti Tvis mkurnalobis 184 Semdeg Seicvalos, man mainc SeiZleba Seamciros testis mgrznobeloba, kerzod, marali prevalentobis regionebsi. kidev erti nakli isaa, rom aseti rtuli testi amjamad tardeba 108

mxolod ganvitarebuli qveynebis ramodenime teqnikurad srulyofil kvlevit laboratoriasi. vidre aseti testi xelmisawvdomi gaxdebodes farte klinikuri gamoyenebisatvis, mis gamartivebasa da avtomatizirebaze orientirebul samecniero musaobas unda mohyves misi mgrznobelobis, specifikurobis da prognozirebis unarianobis macveneblebis gansazrvra. gafartoebis amplifikaciis testebi gafartoebis amplifikaciis testebi, romlebic SemuSavebuli iqna bevri sxvadasxva mikroorganizmisatvis, mat Soris tuberkulozis mikobaqteriisatvisac warmoadgens molekuluri biologiuri metodebis klinikur praqtikasi gamoyenebis kidev ert magalits. nukleinis mjavis Zalzed specifikuri sinjebi amoicnoben da emagrebian dnm-is samizne segmentebs. mikroorganizmis dnm- da praimeri ganicdian replikacias mravali ciklis ganmavlobasi ise, rom moxdes dnm-is mravaljeradi kopireba anu gafartoeba. mas Semdeg rac gafartoeba dasruldeba, umateben DNA-s sinjs, romelic emagreba mxolod mikroorganizmebis gafartoebul DNA-s da awarmoebs kolorimetrul reaqcias, romlis gazomvac SesaZlebelia 185. am metodis ZiriTadi upiratesoba is aris, rom Sedegebis mireba SesaZlebelia ramodenime saatsi (Tumca gafartoebis zogierti testis Catarebas ramodenime dre 186 esawiroeba). misi specifikuroba 98-100%-s Seadgens, xolo mgrznobeloba ki 95%-ze maralia mgb dadebit naxvelsi 187, Tumca nacxit uaryofit, kultura pozitiur pacientebsi mxolod 50-60% inarcunebs 188,189,190. bolo periodsi SemuSavebuli gafartoebis testebs gaacniat ufro marali sensitiuroba mgb uaryofiti SemTxvevebis dros da inarcuneben specifiurobis maral dones 186,187,191. mocemul metods aqvs naklic: is ZviraRirebulia.da 192, 193 ganxorcielebastan SedarebiT dabali specifikuroba axasiatebs (cru-pozitiurobis marali macveneblebi). testebis binaze Catareba SeiZleba ufro iafi iyos, magram Sedegebis misarebad didi droa sawiro, ufro rtulad gansaxorcielebelia 186 da moitxovs kargad momzadebul personals. arsebobs avtomatozirebuli sistemebi, magram mati sawyisi TviTRirebuleba da TiToeuli testis axlandeli Rirebuleba Zalzed maralia, yoveli testis fasi 15 dolarze metia. 109

marali Rirebuleba da sirtule Seusabamos xdis am testebs marali prevalentobis mqone Rarib qveynebsi gamoyenebisatvis. Tumca testi, romlis Rirebulebac Seadgens 6 ass dolars SeiZleba xarjtefeqturi iyos aset regionebsi, vinaidan izleva aqtiuri tuberkulozis mqone pacientebis adreul stadiaze gamovlenis SesaZleblobas. amave dros mkurnalobas Tavidan aacilebs im pacientebs, romlebsac klinikuri TvalsazrisiT tuberkuloze saewvo nisnebi aqvt, Tumca realobasi ar arian tuberkulozit daavadebulni. gafartoebis testis efeqturoba xsirad izrudeba programis farglebsi mirebuli cru-dadebiti pasuxebis didi odenobis gamo. dabali mgrznobeloba nacxit negatiur pacientebsi, mikobaqteriis raodenobis gansazrvrisa da cocxali da aracxovelmyofeli baqteriebis diferencirebis SeuZlebloba mnisvnelovnad amcirebs am metodis Rirebulebas. daskvna naxvelis nacxis analizi maralspecifikuria, magram Zalzed Sromatevadi da ver gamoavlens nacxit negatiur pacientebs. axali imunodiagnostikuri testebi warmoadgenen aqtiuri mecnieruli kvlevis interess, radgan izlevian zusti pasuxebis swrafad mirebis SesaZleblobas da sawiroeben iset arwurvilobas, personalsa da masalebs, romelic ar aremateba SezRuduli resursebis mqone qveynebis SesaZleblobebs. amjamad ar arsebobs arc erti iseti serologiuri testi, romelic ertmnisvnelovnad rekomendirebuli iqneboda yoveldriuri klinikuri gamoyenebisatvis, tuberkulozis mikobaqteriis antigenze ujreduli imunuri reaqciis gamoyeneba ki SeiZleba mxolod kvlevit dawesebulebebsi. gafartoebis testebi momgebiania, vinaidan mat marali mgrznobeloba da specifiurobis kargi potenciali aqvt da mati usualo gamoyeneba SesaZlebelia naxvelze, Tumca, mocemuli momentisatvis, arwurvilobisa da masalebis marali Rirebulebisa da savele pirobebsi misi dabali specifikurobis gamo miurebelia Raribi qveynebisatvis. arc erti axali testi ar izleva naxvelsi tuberkulozis mikobaqteriis raodenobis gansazrvris SesaZleblobas. amgvarad, miuxedavad imisa, Tu romeli axali, iafi da martivi metodi gaxdeba xelmisawvdomi, naxvelis nacxis mikroskopia mainc sawiro iqneba seriozulad daavadebuli da infeqciuri pacientebis identificirebisa da monitoringistvis. 110

19. rogor unda itanamsromlon kerzo da saxelmwifo seqtorebma tuberkulozis gamovlenis, mkurnalobisa da monitoringis dros t.frideni 26 angarisvaldebuleba aris tuberkulozis kontrolis fundamenturi principi. yovel georgafiul erteulsi unda iyos erti pirovneba (regionsi an municipalitetsi tuberkulozis kontrolze pasuxismgebeli oficialuri piri), romelic pasuxs agebs tuberkulozis SemTxvevebis droul gamovlenaze, efeqtur mkurnalobasa da sistematur monitoringze. samedicino daxmarebis nebismier seqtorsi mkurnalobis arasatanadod ganxorcielebam SeiZleba gamoiwvios medikamentebisadmi rezistentoba, tuberkulozis gavrcelebis da sikvdilianobis zrda. aqedan gamomdinare, tuberkulozis kontrolze pasuxismgeebli piri satanado RonisZiebebs unda atarebdes misdami rwmunebul geografiul teritoriaze tuberkulozit daavadebuli TiToeuli pacientis mimart da ara mxolod sazogadoebrivi jandacvis sistemis pacientebis mimart. bevr qveyanasi sazogadoebrivi jandacvis dawesebulebebis mier gaweuli momsaxureba mcirdeba 194. jandacvis sxva samsaxurebs ganekutvneba saqvelmoqmedo organizaciebi da samedicino daxmarebis samsaxurebi saxelmwifo seqtorsi dasaqmebulebistvis, agretve dazrveuli musaxelis, patimrebis, samxedro mosamsaxureebis, da mati ojaxebisatvis gankutvnili samsaxurebi bevr qveyanasi tuberkulozit daavadebuli adamianebis didi nawili Tavdapirvelad mimartavs kerzo samedicino samsaxurebs 195. mat ganekutvneba licenzirebuli da aralicenzirebuli eqimebi da bevr qveyanasi 26 tuberkulozis klinikis direqtori, montrealis gul-mkerdis instituti, makgilis universteti. montreali, kanada 111

diplomirebuli an aradiplomirebuli farmacevtebi, romlebic receptis (danisnulebis) garese yidian tubsawinaarmdego medikamentebs. pacientebis mier samedicino daxmarebisatvis aseti personalis gamoyeneba asaxavs mat ukmayofilebas sazogadoebrivi jandacvis seqtoris samsaxurebit. samwuxarod, kerzo seqtoris mier SemoTavazebul momsaxurebas ZiriTad Sedegad mohyveba dagvianebuli diagnostika, nawilobrivi da arastandartuli mkurnaloba, medikamentebisadmi rezistentoba, infeqciis gavrceleba da pacientisatvis usargeblo xarjebi. ar arsebobs arcerti srulyofili meqanizmi, romelic yvela qveyanasi uzrunvelyofda koordinacias kerzo da saxelmwifo seqtors Soris. efeqturi programa moicavs qvemot CamoTvlilidan yvela an ramodenime midgomas, magram rogori midgomac ar unda avirciot efeqturi saxelmwifo samsaxurebi yoveltvis rceba warmatebis winapirobad. konkurencia garkveuli xarisxit konkurencia warmodgenilia tubsawinaarmdego kontrolis TiTqmis yvela programasi: kargadorganizebuli ambulatoriuli qimioterapia, gansakutrebit im SemTxvevaSi Tu igi ufasoa, miizidavs simptomatur SemTxvevebs yvela mxridan 196. es midgoma efeqturia im SemTxvevaSi, Tu saxelmwifo samsaxurebi ufaso, mosaxerxebeli, pacientebisadmi ketilganwyobili da mkurnalobis TvalsazrisiT sando da fartod ariarebulia. gamoricxva meore midgoma gulisxmobs kerzo seqtoris gamoricxvas. yvela ganvitarebuli da zogierti ganvitarebadi qveyana krzalavs tubsawinaarmdego medikamentebis daxlidan Tavisufal gayidvas. zog qveyanasi es medikamentebi xelmisawvdomia mxolod saxelmwifo seqtorsi. tuberkulozis kontrolis programebi unda Seecadon Tavidan aicilon tubsawinaarmdego medikamentebis aseti gayidvebi. magram gamoricxvis ufro seriozuli formebi politikurad, kulturulad da socialurad misarebi unda iyo da unda gaacndes 112

tubkontrolis satanado, sando samsaxurebi sazogadoebrivi jandacvis seqtorsi. aseti pirobebi SedarebiT isviatia. xelsekrulebebi tubsawinaarmdego kontrolis uzrunvelyofisatvis saxelmwifo seqtors SeuZlia xelsekrulebebi dados kerzo seqtortan. ar aris aucilebeli, saxelmwifom uzrunvelyos yvela saxis momsaxureba, SesaZlebelia klinikuri momsaxurebis delegireba samedicino daxmarebis sxva samsaxurze. Tumca saxelmwifos pasuxismgeblobasi rceba pacientebisatvis efeqturi klinikuri samsaxurebis xelmisawvdomobis uzrunvelyofa. mkafiod Camoyalibebuli perspeqtivebi da natlad gansazrvruli funqciebi gansakutrebit mnisvnelovania warmatebuli TanamSromlobisaTvis. monawileoba kerzo seqtori aqtiurad monawileobs tuberkulozis kontrolis rig programebsi. bevr qveyanasi, sazogadoebrivi jandacvis programebi da iseti profesiuli jgufebi, rogoricaa pulmonologta erovnuli sazogadoebebi ertoblivad moqmedeben. isini TanamSromloben, mkurnalobis standartebis SemuSavebis sferosi, romlebic gamoyenebuli unda iqnes rogorc kerzo, aseve saxelmwifo samedicino dawesebulebasi. aseve ertoblivad musaoben samedicino skolebis saswavlo programebze, rata matsi aisaxos SemuSavebuli standartebi. niu-iorksi tuberkulozis kontrolis programa warmoadgens aseti midgomis gamoxatulebas. niu-iorkis yvela eqimi, mat Soris isinic, vinc jer kidev swavlobs, irebs tuberkulozis diagostikisa da mkukrnalobis kompleqsur sacnobaro instruqciebs, romelic aseve Seicavs informacias imis Sesaxeb, Tu sad da rogor unda gaigzavnon tuberkulozit daavadebuli pacientebi. garda amisa, konferenciebze, leqciebze da did Sexvedrebze cirkularebis mesveobit xdeba tuberkulozis mkurnalobisa da diagnostikis standartebis fartod gavrceleba. maralteqnologiuri laboratoriebi ufasod emsaxureba kerzo seqtoris pacientebs, kerzo laboratoriebi da saavadmyofoebi sakvle nimusebs testirebisatvis agzavnian samedicino laboratoriebis departamentsi. jandacvis departamenti mouwodebs pacientebs, rom 113

mimarton mat pulmonologiur klinikebs da moitxovs eqimebisagan ar daiwyon mkurnaloba manamde, vidre ar eqnebat misi dasrulebis garantiebi. deparatmenti, sazogadoebrivi jandacvis TanamSromlobebis mesveobit, aseve axorcielebs mkurnalobis zedamxedvelobas, kerzo praqtikis pacientebze, ramdenadac kerzo praqtikis eqimebi axorcieleben standatuli mkurnalobis rejimebis danisvnas. ufro metic, departamenti kerzo praqtikis eqimebis pacientebs uzrunvelyofs ufaso medikamentebit, imis garantiit, rom usualo metvalyureobis pirobebsi daculi iqneba medikamentebis mirebis standartuli rejimi. cxeli xazi eqimebs uzrunvelyofs klinikuri konsultaciebit da pacientze orientirebuli specifikuri informaciit. samwuxarod, xsirad vxvdebit samedicino skolebis damfuzneblebsa da sazogadoebrivi jandacvis sistemis warmomadgenelta Soris urtiertupativcemulobis Zvel tradicias. aset antagonizmis dazleva SeiZleba mxolod Tanamimdevruli, urtiertsewyobili da teqnikurad gamartuli ZalisxmeviT. angarisgeba bevr qveyanasi angarisgeba an Setyobinebis sistema Zalzed mnisvnelovan rols asrulebs tuberkulozis efeqturi kontrolis saqmesi 197. sazogadoebrivi jandacvis saagentoebs, romlebic awarmoeben laboratoriebis aqtiur zedamxedvelobas da aqvt laboratoriisatvis licenziis CamorTmevis ufleba (saqmianobis satanadod Seusruleblobis, an gamovlenil SemTxvevaTa Sesaxeb angarisgebis ganuxorcieloblobis, gamo) SeuZliaT mnisvnelovnad gaazlieron nacxit pozitiuri da kultura-pozitiuri tuberkulozis SemTxvevebis angarisgebis sistema. baqteriologiurad dadasturebuli tuberkulozis mqone pacientebis gvarebi Setanili unda iyos reestrssi, xolo mat mkurnalobaze unda dawesdes monitoringi. amis mesveobit SesaZlebeli gaxdeba baqteriologiurad dadasturebuli tuberkulozis mqone TiToeuli pacientis klinikuri gamosavlis Sefaseba. mirebul midgomas unda hqondes kolegialuri xasiati da xels ar unda uslides laboratoriebis saqmianobas. laboratoriebs regularulad unda miewodebodes uaxlesi cnobebi tuberkulozisa da im mirwevebis Sesaxeb, romlebic SeiniSneba am sferosi. laboratoriebis xelmzrvanelobam monawileoba unda miiros 114

iseti sakitxebis ganxilvasi rogoricaa, magalitad, koordinaciis gaumjobeseba, risi ganxorcielebac SesaZlebelia koordinatorta jgufis mesveobit, romlebsic warmodgenili iqneba yvela mtavari laboratoriis xelmzrvaneli. aseti midgoma mnisvnelovnad gazrdis gamovlenis macveneblebs, gansakutrebit Tu igi kombinirebuli iqneba diagnostikasi mgb nacxebis mnisvnelobis Sesaxeb eqimta ganatlebisa da laboratoriuli testebis Sesrulebis satanado xarisxtan. amastan, angarisgeba ganapirobebs sazogadoebrivi jandacvis yuradrebis fokusirebas baqteriologiurad pozitiur SemTxvevebze, romlebic warmoadgens daavadebis gavrcelebis wyarosa da sikvdilianobis zrdis mizezs. sistema didad uwyobs xels zedamxedvelobis ganxorcielebas, vinaidan laboratoriebis raodenoba gacilebit ufro naklebia, praqtikosi eqimebis raodenobastan SedarebiT. rogorc minimumi, sazogadoebrivi jandacvis programebs unda gaacndet samedicino daxmarebis yvela msxvili mimwodeblis sia da unda cdilobdnen mat Cabmas tuberkulozis standartizebul diagnostikasi, mkurnalobasa da monitoringsi. didi warmatebit funqcionireben saxelmwifo seqtorze damokidebuli tubkontrolis programebi 198, 199, 200, 201, 202. saxelmwifoebrivi RonisZiebebis efeqtianobis zrdastan ertad, gaumjobesdeba kerzo dawesebulebebis saqmianobis monitoringic, amastan uzrunvelyofili iqneba standartuli samedicino momsaxureba da angarisgeba. saxelmwifo organizaciebi xels Seuwyobs kerzo seqtors, Tu isini moqmedeben samedicino daxmarebasa da angarisgebis politikis Sesabamisad. Aamrigad, saxelmwifo seqtoris roli mdgomareobs ara mxolod samedicino daxmarebis uzrunvelyofasi, aramed moicavs marali xarisxis samedicino momsaxurebis garantirebas yvela seqtorsi, rac nisnavs angarisvaldebulebas regionsi mcxovrebi yvela an, TiTqmis yvela, pacientze. 115

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20. tuberkulozis mkurnalobis ganvitarebis ZiriTadi etapebi k.tomani 1 1. 1940 weli, armocenili iqna sulfonamidis baqteriostatuli efeqti tuberkulozis bacilebit inficirebul zrvis gowebsi. pirvelad moxda demonstrireba, rom qimioterapiul agents dafsonis derivats, romelic prominis saxelwodebit iyo cnobili (glucosulfone sodium) Seswevda unari SeeCerebina sxva SemTxvevaSi letaluri gamosavalis mqone tuberkulozis progresireba zrvis gowebsi 1. miuxedavad imisa, rom dafsonisa da sulfonis sxva derivatebis moqmedebam adamianebis tuberkulozze imedis gacrueba gamoiwvia, armocnda, rom isini karg efeqts izleodnen ketris mkurnalobisas da dafsoni dremde rceba sabaziso antileprozul medikamentad 2. 2. 1944 wels vaqsmanis mier niadagis organizmidan Streptomyces griseus-is axladgamoyofilma antibiotikma streptomicinma moaxdina gasaocari Terapiuli efeqti eqsperimentul tuberkulozze zrvis gowebsi. Zalian male am movlenis Semdeg igi pirvelad gamoyenebuli iqna tuberkulozit daavadebul adamianebsi 3, 4 (ix. Tavi: ra Terapiuli efeqti aqvt da ramdenad toqsiuria tubsawinaarmdego medikamentebi? ) 3. 1949 weli, gaketda armocena, rom P aminosalicilis mjavas (PAS) gaacnda medikamentebisadmi rezistentobis ganvitarebis prevenciis unari, Tuki gamoiyeneboda kombinaciasi streptomicintan ertad. amis Semdgom ori medikamentis kombinaciis gamoyeneba ariarebuli iqna aucilebel midgomad tuberkulozis adekvaturi mkurnalobisatvis. 1 gardacvlilia 119

4. 1952 weli, gamovlenili iqna izoniazidis ormoci wlit adre sintezirebuli qimiuri preparatis antituberkulozuri moqmedeba. misi SemoRebis Semdeg izoniazidi yvela pirveladi medikamentozuri rejimis komponentia, radgan gamoirceva marali efeqturobit, SedarebiT mcire toqsikurobita da dabali fasit. 5. 1956 wels, madrassi (amjamad Cenai) dawyebuli kvlevis winaswarma Sedegebma gvicvena, rom ambulatoriuli mkurnaloba maralefeqturia da ar zrdis ojaxis wevrebis inficirebis risks (ix. Tavi ra ZiriTadi Sedegebi iqna mirebuli madrasis kvlevidan, romelsic Sedarebuli iyo binaze da sanatoriumsi mkurnaloba ). kvlevit mirebulma Sedegebma ganapiroba sanatoriumsi mkurnalobis tradiciuli metodebis Secvla da axali perspeqtivebi Seuqmna mkurnalobis nacionalur programebs ganvitarebad qveynebsi. 6. mnisvnelovan armocenad iqca is, rom pacientebis didi nawili miuxedavad mati farto ganatlebisa am sferosi, ar irebs medikamentebs danisnulebis Sesabamisad 5,6. am armocenam medikamentebisadmi rezistentuli tuberkulozis ganvitarebisa da gavrcelebis safrtxestan ertad ganapiroba tuberkulozis usualo metvalyureobit mkurnalobis standartad ariareba 7,8,9. 7. 1964 weli, dadginda, rom intermitirebuli mkurnaloba isetive efeqturia, rogorc yoveldriuri rejimi. amastanave xelsayrelia pirdapir kontrolirebadi mkurnalobis rejimis metvalyureobisatvis (ix. Tavebi: ras warmoadgens intervalebis dacvit intermitiuli mkurnaloba da rogoria misi mecnieruli dasabuteba da ra upiratesobebi aqvs usualo metvalyureobas ). 8. 1960-ian wlebsi armocenil iqna rifampicini, tuberkulozis mkurnalobasi ert-erti yvelaze efeqturi medikamenti 10. igi warmoadgens farto speqtris antibiotiks, romelic upiratesad tuberkulozis mkurnalobasi gamoiyeneba. rifampicinis gamoyenebam ganapiroba mkurnalobis Tanamedrove, efeqturi, moklevadiani rejimebis warmoqmna. 9. britanetis samedicino kvlevis sabwosa da misi partniorebis monumenturi Sromis Sedegad SesaZlebeli gaxda qimioterapiis standartuli moklevadiani rejimis SemuSaveba 11,12. kvlevebis Sedegad Camoyalibda ramodenime sakvanzo debuleba, romelic qmnis Tanamedrove mkurnalobis ganvitarebis CarCoebs. aset debulebebs ganekutvneba: 120

6 da 8 Tvis xangrzlivobis rejimi Zalzed efeqturia, izleva gankurnebis maral macveneblebs recidivis mcire albatobit 13 ; rifampicinis Semcveli rejimi izleva mkurnalobis efeqtur mokle kurss, iset nacxit dadebit pacientebsic ki, romlebsac aqvt kavernozuli daavadeba; rogorc 6-Tviani, aseve 8-Tviani kursis rejimisatvis aucilebelia rifampicinisa da pirazinamidis gamoyeneba, magram pirazinamidi sawiroa mxolod mkurnalobis sawyis etapze; mkurnalobis moklevadiani kursis Semdeg recidivi Cveulebriv vitardeba pirveli erti wlis ganmavlobasi; recidivi, romelic vitardeba poliqimioterapiis Semdeg, Cveulebriv ganpirobebulia iseti organizmebit, romlebsac SenarCunebuli aqvt Tavdapirveli mgrznobeloba; ramodenime medikamentis ertdrouli gamoyeneba SeiZleba minimaluri toqsiurobit. 10. gasuli saukunis 80-ian wlebsi Catarebulma kvlevebma, romelta amocanas Seadgenda 6 Tveze naklebi xangrzlivobis mkurnalobis rejimebis efeqturebis Sefaseba, daadgina, rom isini xasiatdebodnen relafsis marali macveneblebit (11-40%) filtvis tuberkulozit daavadebul nacxit pozitiur pacientebsi 14. 11. standartizebuli da gamartivebuli 6-Tviani rejimebi periodulobis dacvita da usualo metvalyureobit 15, 16 Zalzed efeqturi armocnda. 121

21. rogor moqmedebs tuberkulozis mkurnaloba k.tomani 2 tubsawinaarmdego medikamentebis armocenamde tuberkulozis mkurnaloba ZiriTadad moicavda daavadebis mimart pacientis rezistentobis gazlierebas. es gulisxmobda iset tradiciul RonisZiebebs, rogorcaa fizikuri da gonebrivi gadarlis Tavidan acileba, woliti rejimi, kaloriuli kveba, xelovnuri pnevmotoraqsi da Torakoplastika. amjamad makroorganizmis faqtors (ix. Tavi ra rols asrulebs makroorganizmis faqtorebi tuberkulozis patogenezsi, prevenciasa da mkurnalobasi ) gankurnebis TvalsazrisiT naklebi mnisvneloba eniweba da aqcenti ketdeba tuberkulozis baqteriaze medikamentebis moqmedebaze. sxva sityvebit rom vtqvat, mkurnaloba mkacrad antimikrobuli xasiatisaa. tuberkulozis mkurnalobis mizania gankurnebis mirweva recidivis garese da imavdroulad medikamentebisadmi rezistentobis prevencia. amgvarad, mkurnalobis efeqtze unda vimsjelot ara filtvis dazianebis anatomiuri gankurnebit, aramed misi sterilizebit an, ukidures SemTxvevaSi, baqteriebis gaqrobit naxvelidan. tuberkulozis mikobaqteria warmoadgens nelamzard aerobul organizms, romelic xangrzlivi periodis ganmavlobasi SeiZleba rcebodes araaqtiur mdgomareobasi. aqedan gamomdinare, imisatvis, rom uzrunvelvyot sruli gankurneba recidivebis warmoqmnis SesaZleblobebis garese da Tavidan avicilot rezistentoba, sawiroa xangrzlivi drois ganmavlobasi poliqimioterapia. mkurnalobis efeqti ZiriTadad ganisazrvreba 2 gardacvlilia 122

baqteriologiuri garemos (anatomiuri da bioqimiuri) da farmakologiuri faqtorebit. baqteriologiuri faqtorebi raodenobrivi faqtori dazianebis tipis mixedvit icvleba tuberkulozis baqteriis raodenobac. im monacemebis mixedvit, romlebic eyrdnoba aranamkurnalebi pacientis filtvis rezeqciit mirebuli nimusis Seswavlas 17, baqteriata raodenoba bronqtan dakavsirebuli sasualo zomis kavernasi Seadgens daaxloebit 10 8 (as milions), masin, rodesac igive zomis inkafsulirebul kerovan dazianebasi, romelsac bronqebtan ara aqvs kavsiri baqteriebis raodenoba Zalzed mcirea da aris 10 2 (asi). es ricxvebi SedarebiT mcirea eqstrapulmonaruli dazianebis dros, rogoricaa kanis, limfuri kvanzebis, Zvlebis tuberkulozi da tuberkulozuri meningiti. rac ufro didia baqteriis populacia, mit ufro maralia imis albatoba, rom mat Soris mkurnalobis dawyebamdec ki arsebobs rezistentuli Stamebi (ix. Tavi rogor vitardeba medikamentebisadmi rezistentoba? da medikamentebisadmi rezistentuli ramdeni baqteria SeiZleba iqnes armocenili im pacientis naxvelsi, romelsac arasdros ar umkurnalia tuberkulozze ) rodesac mkurnalobis rejims vircevt, es faqti yoveltvis unda gvaxsovdes. metaboluri faqtori medikamentebi anadgureben iset organizmebs, romlebic aqtiurad metabolozirdebian da ganuwyvetliv mravldebian, magram TiToeul baqteriul populaciasi yoveltvis arsebobs iseti baqteriebi, romlebsac aqvt dabali metaboluri macvenebeli. zogi matganis damuxruweba xdeba dabali ph-is gamo. sxvebi drois umetes nawilsi imyofebian araaqtiur mdgomareobasi da izrdebian mxolod Zalze mokle periodebsi. medikamentebis didi nawili aset organizmebze ZiriTadad ar moqmedebs, mxolod rifampicins an pirazinamids SeuZlia mati efeqturad ganadgureba gansazrvruli pirobebis dros. aset baqteriebs Seswevs gadarcenis unari iseti Zlieri medikamentebis moqmedebis drosac, rogoricaa izoniazidi da streptomicini, miuxedavad imisa, rom mat gaacniat mgrznobeloba 123

arnisnuli medikamentebis mimart. aset organizmebs xsirad uwodeben mdgradebs. es movlena garkveulwilad xsnis imas, Tu ratom ar irupeba yvela baqteria mkurnalobis dros da ratom xdeba mgrznobelobis mqone baqteriebis gamovlena mkurnalobis Semdeg garkveuli drois ganmavlobasi. medikamentebisadmi mgrznobelobis mqone baqteriebit gamowveuli recidivi an baqteriis endogenuri reaqtivacia SeiZleba ganpirobebuli iyos narcen dazianebasi xangrzlivi drois ganmavlobasi araaqtiur mdgomareobasi myofi mdgradi baqteriebis gaaqtiurebit. garemos faqtorebi anatomiuri faqtorebi medikamentebis moqmedebaze gavlenas axdens qsovilis tipi, romelsic bacilebia dabudebuli. yvela medikaments ar Seswevs unari SeaRwios yvela saxis qsovilsi da ujredsi, an gadalaxos biologiuri membranebi, mat Soris, hemato-encefaluri barieri. izoniazidi, rifampicini da pirazinamidi Tavisuflad arweven biologiur membranebsi masin, rodesac streptomicini ujredebsi naklebi SeRwevadobiT gamoirceva da aqedan gamomdinare, naklebad efeqturia ujredsida baqteriebtan brzolasi, vidre ujredgare baqteriebis mimart 18,19. adamianebsi kavernozul dazianebebsi arsebuli baqteriebi, ZiriTadad ujredis garet imyofebian 20. bioqimiuri faqtorebi medikamentebis antimikrobul moqmedebas mnisvnelovnad gansazrvravs ph da Jangbadis parcialuri wneva (po 2 ). normaluri ph-is SemTxvevaSi, yvela baqteriociduli tubsawinaarmdego medikamenti marali efeqturobit gamoirceva, Tumca streptomicini gansakutrebulad aqtiuria odnav tutovan (ujredisgare) garemosi, masin rodesac pirazinamidi fartod moqmedebs acidur garemosi, ujredis SigniT. cota ram aris cnobili im faqtorebis Sesaxeb, romlebic ganapirobeben baqteriis araaqtiur, mtvlemare mdgomareobas, magram savaraudoa, rom aseti organizmebi sicocxles inarcuneben ujredis SigniT, an Zveli inkafsulirebuli dazianebebis nekrotul adgilebsi, romlebic bronqebtan 124

dakavsirebuli ar aris. aset garemosi ph ufro aciduria, xolo po 2 ki SedarebiT dabali. is faqti, rom po 2 mnisvnelovani faqtoria, dasturdeba daxurul eqstrapulmonarul dazianebebsi baqteriebis mcire raodenobit. farmakologiuri faqtorebi doza medikamentis doza baqteriebis gavrcelebis adgilebsi unda uzrunvelyofdes inhibitorul koncentracias, magram ar aris aucilebeli am koncentraciis mudmivad, ert doneze SenarCuneba. faqtiurad, izoniazidis dozisa da sisxlis SratSi misi koncentraciis SeswavliT dadginda, rom baqteria reagirebda mxolod medikamentis pikur doneze 20. amitom, 400 mg izoniazidis mireba dresi ertxel Terapiuli TvalsazrisiT ufro mnisvnelovania, vidre igive dozis orad gayofa da 12 st-iani intervalit mireba 20. medikamentebis kombinireba rejimi unda moicavdes sami an meti medikamentis kombinacias, gansakutrebit mkurnalobis sawyis etapze (ix. Tavi ra mizans emsaxureba oretapiani mkurnalobis sawyisi intensiuri faza ). im pacientebsi, romelta tuberkulozuri dazianebebi didi raodenobit bacterias Seicavs, gamoyenebuli unda iyos sul mcire ori iseti medikamenti, romlis mimartac baqterias aqvs mgrznobeloba. winaarmdeg SemTxvevaSi mivirebt medikamentebisadmi rezistentobit ganpirobebul warumatebel mkurnalobas (ix. Tavi: ~rogor vitardeba medikamentebisadmi rezistentoba da ratom aris mkurnaloba warumatebeli da ra unda gaketdes mkurnalobis arasasurveli gamosavalis Tavidan asacileblad ). qimioterapiuli mkurnalobis adreul etapze pacientebs ezleodat erti medikamenti. Tu es wamali pacients ar argebda, masin mas cvlidnen sxva preparatit, an amatebdnen kidev ert wamals, arnisnulma ganapiroba aseti pacientebis qronikul mdgomareobasi gadayvana da yvela im medikamentisadmi rezistentobis ganvitareba, romlebsac isini irebdnen. amrigad, tuberkulozis mkurnaloba arasdros ar unda xorcieldebodes mxolod erti medikamentit, amastan Tu mkurnaloba 125

usedegod mimdinareobs, ar SeZleba mxolod erti medikamentis damateba. ~ dayovnebis periodis~ faqtori eqsperimentma in vitro acvena, rom rodesac tuberkulozis mikobaqteriebi ganicdian medikamentis zemoqmedebas xanmokle drois ganmavlobasi (6-24sT), xolo wamlis moqmedebis Sewyvetis Semdeg gadatanili arian medikamentebisagan Tavisufal niadagze, gadarcenili mikrobebi isev iwyeben zrdas ramodenime dris intervalit. aset intervals ewodeba dayovnebis periodi. igi icvleba ertis mxriv, medikamentis tipisa da koncentraciis, xolo meores mxriv, zemoqmedebis xangrzlivobis mixedvit (ix. Tavi: ras warmoadgens intervalebit mkurnaloba da ra mecnieruli safuzvlebi aqvs mas ). yvela tubsawinaarmdego medikamentma gaiara testireba dayovnebis periodis warmoqmnis unarianobaze, rac miznad isaxavda intervalebit mkurnalobis rejimebisatvis mati Sesabamisobis dadgenas. rig medikamentebs aseti movlenis gamowvevis unari ar aqvt da baqteria iwyebs zrdas medikamentis moqmedebis SewyvetisTanave. rogorc Cans, am kategoriis wamlebs mxolod baqteriostatikuri moqmedeba aqvs da ar gamodgeba intervalebit mkurnalobisatvis. 126

22. ra rols asrulebs makroorganizmis faqtorebi tuberkulozis patogenezsi, prevenciasa da mkurnalobasi m.lademarko 3 da m.rigleri 4 adamianis mteli sicocxlis manzilze garemo, janmrtelobis mdgomareoba da genetika mudmiv urtiertqmedebasi imyofeba. tuberkuloztan mimartebasi makroorganizmis (maspinzelis) mxriv mnisvnelovan faqtorebs ganekutvneba: asaki, kvebis mdgomareoba, emociuri da fizikuri stresi, Tanmxlebi daavadeba, socialuri mdgomareoba, samedicino samsaxurebisadmi xelmisawvdomoba da SesaZloa genotipi (mat Soris sqesi). qimioterapiis SemoRebamde tuberkulozis mkurnaloba mimartuli iyo recipientis 21,22 rezistentobis gazlierebaze. miacndat, rom specialuri dietita da dasvenebit, mkacri woliti rejimisa da iseti kolafsuri metodebis gamoyenebit, rogoricaa xelovnuri pnevmotoraqsi, pnevmoperitoniumi, Torakoplastia da plombaji, gaumjobesdeboda pacientis imunuri reaqciebi. klinicistebi cdilobdnen SeeCerebinaT daavadebis progresireba da xeli SeewyoT gajansarebisatvis. qimioterapiis SemoRebasTan ertad es metodebi istoriis kutvnileba gaxda da daviwyebas mieca. garda amisa, bevrma mecnierulma mirwevam sasualeba mogvca gagvefartovebina Cveni codna im biologiuri principebis Sesaxeb, romlebic martaven adamianis imunur reaqcias tuberkulozze. SesaZloa adamianis janmrtelobis mdgomareoba warmoadgens tuberkulozis progresirebis determinants, cxrili #25 gvicvenebs 3 direqtoris moadgile mecnierebis dargsi, tuberkulozis armofxvris ganyofileba, Sidsis, tuberkulozisa da sqesobrivi gzit gadamdeb daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati 4 tuberkulozis armofxvris ganyofilebis medmusaki. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdeb daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati. 127

tuberkulozit daavadebis sixsires tuberkulinze dadebiti testis mqone pacientebsi. cxrili #26 gvicvenebs daavadebis ganvitarebis SedarebiT risks SerCeuli klinikuri mdgomareobis mixedvit 23. mozrdli mamakacebi tuberkulozit daavadebis ufro marali riskis winase dganan, rac SeiZleba asaxavdes biologiuri da socialuri mizezebis ertobliobas. stresi da kveba aseve SeiZleba mnisvnelovan gavlenas axdendnen daavadebis mimdinareobaze 24,25. respiratoruli sistemis zeda da qveda sasuntqi gzebis fizikuri da qimiuri Tvisebebi qmnian pirveli rigis dacvas SesunTquli mikobaqteriis winaarmdeg. Tu es barieri dairrva da mikobaqteriam miarwia alveolebs, brzolasi CaerTveba makrofagebi. isini qmnian meore rigis dacvas. Tu makrofagebi ver gaanadgureben mikobaqterias, baqteria iwyebs ujredebsi gamravlebas. SeWrilma infeqciam SeiZleba ganapirobos cocxali organizmebis gavrceleba sisxlis nakadis mesveobit, rac ganapirobebs limfocitebis brzolasi CarTvas, antigenis ganmeorebit prezentacias, limfokinebis gamoyofas da Sedegad tuberkulozis formirebas. miuxedavad imisa, rom tuberkulozis dros Cans antisxeulebis reaqcia, savaraudot T-limfocitebiT ganpirobebuli reaqcia warmoadgens pacientis tuberkuluri infeqciis daavadebad gardaqmnis unaris umtavres imunologiur determinants. cxrili #25 tuberkulozit daavadebis sixsire tuberkulinis dadebiti testis mqone individebsi, SerGeuli risk-faqtorebis mixedvit risk-faqtorebi tuberkulozis SemTxvevaTa raodenoba/1000 individweliwadi tuberkulozit uaxloes warsulsi inficireba infeqcia < 1 weli 12.9 infeqcia 1-7 wlebsi 1.6 tuberkulozit inficireba > 2 wlis win 0.7 aiv-infeqcia 35.0-162 intravenuri narkomanebi aiv-seropozitiuri 76.0 aiv-seronegatiuri an ucnobi 10.0 silikozi 68 rentgenologiuri monacemebi Seesabameba tuberkulozis 2.0 13.6 Zvel formas wonis gadaxra standartulidan 15% an metit naklebi wona 2.6 10-14%-iT naklebi wona 2.0 5-9%-iT naklebi wona 2.2 standartis 5%-is farglebsi 1.1 5% an metit Warbi wona 0.7 128

cxrili #26 tuberkulozis aqtiuri formis ganvitarebis SedarebiTi riski SerGeuli klinikuri mdgomareobis mixedvit samedicino mdgomareoba SedarebiTi riski organos transplantacia: Tirkmeli silikozi organos gadanergva guli kisris an Tavis karcinoma Tirkmlis qronikuli ukmarisoba gastroeqtomia Saqriani diabeti 37 30 27-63 20-54 16 10.0-25.3 2-5 2.0-4.1 tuberkulozis infeqciis 26 SesaCereblad moqmedebs ori SeZenili imunuri procesi 27. pirveli procesis dros limfokinebit gaaqtiurebuli makrofagebi anadgureben ujredsi SeWril organizmebs, meore procesis dros citolizuri T-ujredebi Slian tuberkulozis mikobaqteriit inficirebul makrofagebs. es meqanizmi warmoadgens dagvianebuli tipis hipermgrznobelobis reaqcias da aseve pasuxs agebs maspinzeli makroorganizmis reaqciaze tuberkulinit intradermaluri sinjis dros inficirebul pirebsi. balansi mikroorganizmis zrdasa da recipientis reaqcias Soris garkveuli periodis Semdeg gvicvenebs moxda Tu ara infeqciis progresireba da daavadebad Camoyalibeba 28. aiv-infeqciam TvalnaTliv dagvanaxa Tu ramdenad mnisvnelovan rols asrulebs recipientis imuniteti tuberkulozis infeqciis daavadebad Camoyalibebis prevenciasi. aiv-inficirebuli pacientebis mgrznobeloba tuberkulozis mimart da SemdgomSi daavadebis klinikuri gamovlineba TvalnaTliv gvanaxebs imunur statusis mnisvnelobas. Aaiv-infeqciis adreul stadiaze pacientebs uvitardebat kaverna da aqvt pozitiuri nacxi, rac dakavsirebulia mati imunuri sistemis mcdelobastan SeaCeros infeqcia, romelic iwvevs filtvis parenqimis destruqcias da baqteriebis didi raodenobis dagrovebas kavernebsi. aiv infeqciis progresirebastan ertad CD4 ujredebi ifiteba da recipientis imunuri reaqcia nakleb qmediti xdeba, amitom am SemTxvevaSi kavernebis formireba 129

da naxvelis dadebiti nacxi naklebad gavrcelebulia. am dros ZiriTadad gvxvdeba tuberkulozis diseminirebuli formebi. Aaivinfeqcia zrdis tuberkulozis infeqciis daavadebad Camoyalibebis rogorc risks, aseve temps. SidsiT daavadebul hospitalizirebul pacientebsi inficirebidan nacxit dadebit mdgomareobamde da tuberkulozis daavadebad Camoyalibebamde sainkubacio periodi sasualod 12 kviras Seadgens 29. epidemiologiuri mtkicebulebebi gvicvenebs, rom SesaZloa aq moqmedebdes tuberkulozze recipientis imunuri reaqciis genetikuri komponenti. 1978 wels monozigotur da dizigotur tyupebs Soris Catarebulma kvlevam mogvca pirveli myari mecnieruli mtkicebulebebi imisa, rom tuberkulozisadmi mgrznobeloba SeiZleba memkvidreobiti iyos 30. bolo periodsi identificirebuli iqna mgrznobelobis araerti geni. mat Soris aris bunebriv rezistentobastan asocirebuli protein-1, interferongama receptori 30, 31, 32, 33, vitamin D-s receptori, adamianis leikocitis antigeni (HLA) da sxva. genotipi dakavsirebulia daavadebis progresirebis risktan da tubsawinaarmdego mkurnalobis araefeqturobastan 33. recipientis imunuri reaqciis SeswavlasTan dakavsirebuli dakvirvebebi safuzvels udebs tuberkulozis diagnostikis axali metodebis Ziebas, mkurnalobisa da SesaZlebelia vaqcinaciis axali midgomebis SemuSavebas. 130

23. ra Terapiuli efeqti da toqsiuroba axasiatebs tubsawinaarmdego medikamentebs 5 T. frideni 6 da m. esarnali 7 Zalzed rtulia gansazrvro da gazomo calkeuli tubsawinaarmdego medikamentis toqsiuroba an efeqturoba, radgan isini TiTqmis yoveltvis ramodenime medikamenttan ertad kombinaciasi gamoiyeneba. amastan, ori an meti medikamentis ertdrouli gamoyenebisas medikamentebsa da organizms Soris warmoiqmneba sinergistuli da antagonisturi urtiertqmedeba, rac SeuZlebels xdis imis gagebas, Tu ra ris gamo xdeba. miuxedavad imisa, rom Catarebuli eqsperimentebit dagrovda codnis mnisvnelovani moculoba jer ar arsebobs in vitro an cxovelebis modelebze mirebuli informacia, romelsac uyoymanod gamoviyenebt adamianebsic. izoniazidi izoniazidi warmoadgens izonikotinis mjavis hidrazids es qimiuri nivtiereba pirvelad sintezirebuli iyo prarasi 1912 wels. miuxedavad amisa, misi efeqturoba tuberkulozis mkurnalobasi gamovlenili iqna mxolod 1952 wels. mas Semdeg igi itvleba ertert uzlieres tuberkulozis sawinaarmdego preparatad. izoniazidi efeqturia mxolod tuberkulozis baqteriis mimart, magram ara sxva baqteriebisadmi. igi swrafad iwreba yvela qsovilsa da dazianebasi. masze zemoqmedebas ver axdens garemos ph. misi 5 tomanis wignis wina gamocemasi arsebul Tavze dayrdnobit 6 tuberkulozis SeCerebis ganyofilebis medmusaki. jandacvis msoflio organizaciis regionaluri ofisi. samxret armosavlet azia. axali deli, indoeti 7 medmusaki, SeaCereT tuberkulozis gadamdeb daavadebata ganyofileba. jandacvis msoflio organizacia, Jeneva, Sveicaria. 131

sizlieris, dabali toqsiurobis, mcire moculobisa da dabali fasis gamo izoniazidi fartod gamoiyeneba tuberkulozis mkurnalobasi. igi aseve gamoiyeneba prevenciis kurssi (ix. Tavi: ra rols asrulebs latenturi tuberkulozuri infeqciis mkurnaloba tuberkulozis kontrolis programasi ). izoniazidis mireba xdeba peroralurad, yoveldriuri rejimisatvis doza Seadgens 5 mg/kg (4-dan 6-mde diapazonit). e.i. Cveulebriv 300 mg. iseti rejimisatvis, rodesac izoniazidis mireba xdeba samjer kvirasi, doza 10 mg/kg-ia (8-dan 12-mde diapazonsi), rac Seadgens daaxloebit 450 600 mg-s ert dozasi, romelic miecema 40 60 kg wonis pacients. xolo kvirasi orjer medikamentis mirebisas pacients ezleva 15 mg/kg (13-dan 17-mde). medikamentis micema gayofili dozebit ar SeiZleba. gamokvlevebma gvicvena, rom SratSi medikamentis pikuri Semcveloba ufro efeqturia, vidre mudmivi inhibitoruli done 34. dro, romlis ganmavlobasic SenarCunebulia izoniazidis satanado done qsovilebsa da organizmis sitxeebsi damokidebulia aseve medikamentis inaqtivaciaze. misi metabolireba ZiriTadad xdeba acetilirebit, romlis xarisxic gansxvavebulia individebis mixedvit, Tumca mudmivia erti individisatvis. inaqtivaciis xarisxi ganisazrvreba ZiriTadad genetikuri faqtorebit da pacientebi SeZleba zogadad daiyos or nawilad: izoniazidis nel da swraf inaqtivatorebad (acetilatorebad). ukureaqciebi izoniazidis toqsikurobis yvelaze fartod gavrcelebul gamovlineba periferiuli neiropatiaa. neiropatiis ganvitarebis gansakutrebit marali riski aqvt aiv-inficirebul pacientebs. yvelaze adreuli simptomia parstezia, romelsac mohyveba mcxvletavi tkivili da wvis SegrZneba jer fexis terfebsi, xolo Semdeg xelebsi. Tu am simptomebis mosaxsnelad mkurnalobas droulad ar CavatarebT, mdgomareoba gauaresdeba da gamoiwvevs pacientis dauzlurebas. neiropatiis sixsire izrdeba dozis matebastan ertad. aseti mdgomareoba ufro damaxasiatebelia neli inaqtivatorebisatvis, diabetit, uremiit an alkoholizmit daavadebuli adamianebisatvis, mattvis, vinc cudad ikvebeba. 132

izoniazidis neirotoqsiurobis prevencia SesaZlebelia piridoqsinit (vitamini B 6 ) SedarebiT dabal dozebsi (10 mg/dresi). piridoqsins aseve aqvs Terapiuli moqmedeba izoniazidit gamowveul neirotoqsikurobaze, magram misma didi dozebit gamoyenebam SeiZleba Seamciros izoniazidis baqteriociduli aqtivoba 35. zogierti pacienti ucivis letargias, Tavbrusxvevas da motentilobas, gansakutrebit masin,rodesac medikamentis mirebas Soris didi intervalebia. drota ganmavlobasi aseti efeqti qreba. izoniazidma SeiZleba aseve ganapirobos hepatotoqsiurobac, ufro xsirad 35 welze ufrosi asakis individebsi, gansakutrebit masin, rodesac izoniazidtan ertad gamoiyeneba potenciurad hepatotoqsikuri medikamentebi. izoniazidit gamowveuli hepatotoqsikuroba swrafad qreba Tuki medikamentis gamoyeneba Sewydeba adreul etapze, Tumca mas SeiZleba fataluri Sedegebic mohyves 36, 37. isviatad, rogorc wesi swraf inaqtivatorebsi, SeiZleba ganvitardes toqsikuri fsiqozi da generalizebuli epilefsiuri konvulsiebi. izoniazidi zrdis fenitonisa da karbamazepinis koncentracias SratSi. mis Sewovas asustebs antacidebis Semcveli aluminis hidroqsidi. rifampicini rifampicini warmoadgens naxevrad sintezur antibiotiks, romelic Seiqmna 1965 wels da gamoirceva Zalin marali aqtiurobit tuberkulozis bacilis mimart. in vitro da in vivo kvlevebma gamoavlina rifampicinis gansakutrebuli moqmedeba baqteriebze da misi Sesabamisoba intermitirebuli rejimisatvis 38,39,40. ramdenadac aratoqsikuri peroraluri dozebi 100-jer ufro maral koncentracias qmnian SratSi, vidre es sawiroa tuberkulozis mikobaqteriis zrdis SesaCereblad, rifampicinma SeqmnisTanave warmosva mkurnalobis xangrzlivobis Semcirebis imedi 41. baqteriis velur Stamebs Soris rifampicin-rezistentuli mutantebis proporciuli Sesabamisoba (1 : 10 8 ) mnisvnelovnad ufro dabalia, vidre izoniazidrezistentuli mutantebisa (1 : 10 6 ). amjamad rifampicini tuberkulozis mkurnalobis ZiriTadi komponentia da warmoadgens mkurnalobis mokle kursis ert-ert umnisvnelovanes medikaments. misi mireba xdeba peroralurad, 133

xolo Cveulebrivi doza Seadgens 10 mg/kg (diapazonsi 8-dan 12-mde) (maqsimum 600 mg), orjer an samjer kvirasi. rifampicins ireben 30 wutit adre Wamamde, radgan sakvebtan ertad misi mirebis SemTxvevaSi misi Sewova mcirdeba. gverditi reaqciebi dreisatvis rekomendirebuli dozebit pacientebis umravlesoba rifampicins kargad itans. gansxvavebit sxva medikamentebisagan, rifampicins aqvs rigi iseti gverditi reaqciebisa, romlebic ufro ukavsirdeba misi mirebis intermitul rejims, vidre yoveldriurs. ufro metic, gverditi movlenebis riski matulobs dozebs Soris intervalis gazrdastan ertad. aqedan gamomdinare, toqsikuroba gacilebit ufro maralia iseti rejimis dros, rodesac medikamentis mireba xdeba kvirasi ertxel. amjamad rekomendirebuli rejimebit arnisnuli reaqciebi ar aris xsiri da Cveulebriv umnisvneloa. isviatad SeiZleba adgili hqondes seriozul hepatotoqsikurobas, Cveulebrivi qolestatikuri modelit. rifampicini ganapirobebs sxeulidan gamoyofili sitxeebis, magalitad, Sardis, ganavlis, cremlis, oflis, narinjisfer-witel Seferilobas da SeiZleba gamoiwvios rbili kontaqturi linzebis gauferuleba. intervaliani intermituli rejimis dros rifampicinis yvelaze fartod gavrcelebuli reaqciebia: kanis sindromilgawitleba da/an qavili gamonayarit, an mis garese, rac ZiriTadad vlindeba saxeze da Tavis qalis kanze, xsirad axlavs Tvalebis siwitle da cremlianoba; abdominaluri sindromi moicavs muclis tkivils da gulisrevis SegrZnebas, rasac zogjer axlavs pirrebineba an ufro isviatad fararati; gripis sindromi moicavs cxelebas, Semcivnebas, Tavis tkivils, sisustes da Zvlebis tkivils ( mtvrevis SegrZnebas); respiratoruli sindromi SedarebiT isviati gverditi reaqciaa. xasiatdeba qosinit, isviatad kolafsita da SokiT; purpura da sxva isviati reaqciebi, rogoricaa mwvave anemia, Soki da Tirkmlebis dazianeba, Tirkmlis ukmarisobit an mis garese; 134

transaminazis donis momateba SratSi (sakmaod xsiria, magram xanmoklea mkurnalobis gagrzelebis SemTxvevaSic ki) da hepatotoqsikuroba; zemot CamoTvlili gartulebebidan pirveli otxi vitardeba 2-3 saatsi rifampicinis pirveli dilis dozis mirebis Semdeg. bevr pacients gamoxatuli aqvs ertze meti sindromi ertdroulad. kanis forma Cveulebriv vitardeba pirvelive Tves, xolo gastrointestinaluri simptomebi ki grzeldeba pirveli eqvsi Tvis ganmavlobasi. gripozuli sindromi arinisneba mxolod intervalebiani intermitiuli rejimis dros da Cveulebriv iwyeba mkurnalobis dawyebidan mesamemexute Tves 38. rifampicinis gverditi reaqciebis martva 42, 43, 44 im pacientebis TiTqmis naxevari, romlebsac arenisneba gverditi reaqciebi, ar sawiroebs raime mnisvnelovani cvlilebebis Setanas mkurnalobis rejimsi. kanis sindromi xsirad TavisiT qreba da sawiroebs mxolod simptomatur mkurnalobas. rejimis Secvla isviatad aris sawiro, garda iseti SemTxvevisa, roca ertdroulad ganvitarebulia generalizirebuli hipersensitiurobis reaqciebi. abdominaluri sindromi, Tu mxolod es gartuleba vitardeba, sawiroebs mxolod simptomatur mkurnalobas: Tu pacienti wamals irebs uzmoze rogorc es rekomendirebulia reaqcia Cveulebriv wydeba medikamentis sakvebis mcire ulufastan ertad mirebis Semdeg. gripozuli sindromi Cveulebriv ar aris mwvave da ar sawiroebs raime cvlilebas rejimsi. savaraudot igi imunologiuri xasiatisaa da Tu didi xnis ganmavlobasi gagrzelda, sawiro gaxdeba yoveldriur rejimze gadasvla. sifrtxilea sawiro im pacientebtan mimartebasi, romlebsac respiratoruli sindromi ganuvitardat, radgan am SemTxvevaSi SesaZloa Sokis ganvitareba, sistoluri wnevis uecari dacemita da anuriit. aset SemTxvevaSi sawiroa saswrafo hospitalizacia. Tu Soki ganvitarda Tirkmlis ukmarisobis gamo (rac Zalian isviatia), rifampicini unda moixsnas da arar iqnes gamoyenebuli mkurnalobasi. igive unda gaketdes hemolitikuri anemiis ganvitarebisas. 135

daskvnis saxit unda itqvas, rom rifampicinis kontroli Cveulebriv SeiZleba ganxorcieldes an dozirebis, an mirebis intervalebis koregirebit, magalitad, kvirasi samjer mirebis rejimis nacvlad yoveldriurad mirebaze gadasvla. Cveulebriv, aseti RonisZiebebis Sedegad movlenebi qreba an imdenad umnisvnelo an isviati xdeba, rom ar warmoadgens problemas (ix. Tavi: romelia pirveli rigis tubsawinaarmdego medikamentebis fartod gavrcelebuli gverditi reaqciebi da ra procedurebis dacvaa sawiro am medikamentebis xelaxla danisvnisatvis? ). Tu ganvitarda purpura, rifampicinis mireba unda Sewydes da arar iqnes xelmeored gamoyenebuli mcire satesto dozebic ki. amis Sedegad Trombocitebis raodenoba ramodenime dresi normalur dones miarwevs. rifampicinis mirebisas SratSi transaminazis donis momateba simptomebis garese xsiria da Cveulebriv mdgomareoba spontanurad swordeba. isviatad pacients SeiZleba ganuvitardes askara hepatiti. Tu pacients ganuvitarda medikamentozuri hepatotoqsikuroba, unda Sewydes yvela potenciurad hepatotoqsikuri medikamentis mireba, vidre klinikuri an bioqimiuri hepatiti ar Cacxreba. mat nacvlad SeiZleba arahepatotoqsikuri medikamentebis - streptomicinis, etambutolis da ftorqinolonebis gamoyeneba, (garda ciprofloqsacinisa, romelic RviZlis mier gamoiyofa). hepatitis problemebis mogvarebis Semdeg SesaZlebelia tubsawinaarmdego medikamentebis etapobrivi gamoyenebis ganaxleba. rifampicini acqarebs RviZlis citoqromis p450-is moqmedebas da amcirebs bevri medikamentis dones SratSi, mat Soris sokos sawinaarmdego medikamentebis, kortikosteroidebis, varfarinis da oraluri hipoglikemiuri wamlebis. rifampicini aseve amcirebs proteazas inhibitorebisa da transkriptazas inhibitorebis aranukleozidur ukuqcevas, rac gamoiyeneba aiv-pacientebis samkurnalod 45. asetma urtiertqnedebam SeiZleba ganapirobos proteazas inhibitorebis rezistentuli aiv-stamebis swrafi ganvitareba 46. rifampicini amcirebs oraluri kontraceptivebis efeqtianobas da sawiroa gavafrtxilot mati momxmareblebi, rom rifampicinit mkurnalobis periodsi da mkurnalobis Sewyvetidan erti Tvis ganmavlobasi gamoiyenon kontracefciis arahormonaluri sasualebebi. 136

SemuSavda rifampicinis axali derivatebi. rifabutins aqvs msgavsi moqmedeba tuberkulozis mikobaqteriis mimart, magram mas axasiatebs ufro xangrzlivi naxevardaslis periodi, vidre rifampicins da nakleb zemoqmedebas axdens zogierti antiretrovirusuli medikamentis farmakokinetikaze 47. rifapentini warmoadgens rifampicinis derivativs naxevardasilis xangrzlivi periodit da igive moqmedebit mokobaqteria tuberkulozze. amjamad mimdinareobs misi efeqturobis Sefaseba 48. mikobaqteriis is Stamebi, romlebic rezistentulni arian rifampicinis mimart, Cveulebriv, magram ara yoveltvis, rezistentulni arian rifabutinis da rifapentinis mimartac. pirazinamidi pirazinamids aqvs masterilizebeli moqmedeba im makrofagebs SigniT, sadac organizmebi garemos ph gamo neli tempit izrdeba. amitom, pirazinamids Seswevs unari gaanadguros tuberkulozis is baqteriebi, romlebic miuwvdomelia amjamad arsebuli sxva medikamentebis mier. vinaidan pirazinamidi amcirebs mkurnalobis xangrzlivobas, igi warmoadgens moklevadiani kursis Semadgenel komponents. mireba xdeba oralurad da Cveulebriv driuri doza Seadgens daaxloebit 25 (20 30 diapazonsi) mg/kg-ze. intermitiuli mkurnalobisas Tu medikamenti danisnulia 3-jer kvirasi, misi doza Seadgens 35 mg/ kg-ze (30 40-is diapazonsi), xolo kvirasi orjer mirebisas ki 50 mg/kg-ze (40 60). gverditi reaqciebi rekomendirebuli dozebit piraziamidi isviatad iwvevs seriozul toqsikozs, Tumca marali dozebis gamoyenebisas hepatotoqsiuroba SeiZleba ganvitardes. saxsrebis tkivili fartod gavrcelebuli gverditi movlenaa, romelic ZiriTadad axasiatebs am medikamentis yoveldriurad mirebas. artralgiis warmatebit martva SeiZleba acetilsalicilis mjavit an sxva analgetikebit, antebis sawinaarmdego medikamentebit da ar sawiroebs pirazinamidis amorebas mkurnalobis kursidan. isviatad vxvdebit klasikur podagras. Tu igi mainc ganvitarda, masin problemis samkurnalod 137

SeiZleba gamoviyenot kolxicini. xsirad im pacientebs, romlebic ireben pirazinamids, momatebuli aqvt Sardovana SratSi. Sardis mjavas asimptomaturi momateba ar sawiroebs raime mkurnalobas. mwvave hepatotoqsikuroba arinisneba masin, rodesac gamoiyeneba rifampicinisa da pirazinamidis Semcveli rejimebi 49. SeiZleba drodadro gamovlindes hipersensituloba, mat Soris, cxeleba, gamonayari da sxva kanismieri gamovlinebebi. etambutoli etambutoli warmoadgebs sintezur naerts, romelic ar aris dakavsirebuli sxva tubsawinaarmdego medikamentebtan. igi efeqturad moqmedebs tuberkulozis mikobaqteriaze da kidev ramodenime sxva mikobaqteriaze, magalitad mikobaqteria kanzasi da sxva, magram araefeqturia sxva baqteriebis an sokos mimart. etambutoli ZiriTadad baqteriostatikuria. etambutolis mireba xdeba oralurad. Cveulebriv, misi driuri dozaa 15 (15 20) mg/kg-ze, kvirasi samjer mirebisas doza Seadgens 30 mg/kg-ze (25 35) da 45 mg/kg-ze (40 50) kvirasi orjer mirebis SemTxvevaSi. gverditi reaqciebi etambutolma SeiZleba ganapirobos retrobulbaluri nevriti, romelsac axasiatebs mxedvelobis gauareseba, mxedvelobis simaxvilis Semcireba, witeli da mwvane ferebis arqmis unaris dakargva, centraluri skomatozi da periferiuli velis dazianeba. okularuli toqsikuroba, rogorc scans, dozazea damokidebuli da Zalian isviatad warmoiqmneba, Tu driuri doza ar aremateba 15 mg/kg-ze 50,51 pacientebi, romlebic ireben etambutols, gafrtxilebulni unda iyvnen, rom aseti simptomebis gamovlenistanave konsultaciisatvis unda mimarton okulists. medikamentis gamoyenebis Sewyvetidan ramodenime kvirasi mxedveloba ubrundeba nirmalur mdgomareobas, magram Tu pacienti ganagrzobs etambutolis gamoyenebas, misi mxedvelobis nervi permanentuli zemoqmedebis qves iqneba. etambutoli ar enisneba mcirewlovan bavsvebs, romlebsac ar SeswevT unari satanadod gadmoscen Civilebi an romelta mxedvelobis simaxvilis testirebac SeuZlebelia. 138

radgan tropikul klimatsi etambutolo swrafad isleba, misi warmoeba da Senaxva unda moxdes nestisgan dacul adgilas. streptomicini 1943 wels vaksmanis mier niadagis organizmidan gamoyofili streptomicini amjamad gamoiyeneba streptomicinis sulfatis formit da iyideba msrali fxvnilis saxit flakonebsi. igi inisneba kuntsida inieqciis saxit. Cveulebrivi doza 0,75 1 gr (12 18 mg/ kg-ze) driuri, an kvirasi orjer an samjer gamoiyenebisas. ketdeba erti inieqcia. xandazmul pacientebsi da im pacientebsi, romlebic 35 kg-ze naklebs iwonian 0,5 gr iseve efeqturi da naklebtoqsiuria. streptomicini maqsimalur koncentracias SratSi arwevs Seyvanidan daaxloebit 1 st-si da inihibitorul doneze rceba ramodenime saatis ganmavlobasi. streptomicini ver arwevs ujredis kedlebsi an normalur biologiur membranebsi, rogoricaa meningialuri garsi an plevra, Tu ar eqneba adgili antebit gamowveul cvlilebebs (ix. Tavi rogor moqmedebs tuberkulozis mkurnaloba ). medikamenti TiTqmis mtlianad gamoiyofa Tirkmlebidan. pacientebsi, romlebsac dazianebuli aqvt Tirkmlis funqcia, aman SeiZleba gamoiwvios medikamentis kumulireba organizmsi da, aqedan gamomdinare, toqsikuroba. gverditi reaqciebi garda hipersensitiurobis reaqciisa, rogoricaa cxeleba da gamonayari (ix. Aseve, Tavi: ra ZiriTadi gverditi reaqciebi aqvs pirveli rigis tubsawinaarmdego medikamentebs da ra procedura unda davicvat mati ganmeorebiti danisvnisas ) streptomicinis ZiriTadi toqsikuri efeqti gamoixateba sisxlzarrvebis dazianebita da ototoqsikurobit. riski izrdeba dozisa da asakis matebastan ertad (40 wels zevit). toqsiurobis gamovlena aris Tavbrusxveva da ataqsia, tinitusi da smenis dakargva. ataqsiis gamovlenis yvelaze martivi gzaa pacients stxovt daxuwuli TvalebiT gaiaros swor xazze. Tu pacienti aramyarad miabijebs, Tvalaxilul mdgomareobastan SedarebiT, masin saxezea ataqsia. Tu pacienti ucivis Tavbrusxvevas, medikamentis mirebis SewyvetiT an dozis 139

SemcirebiT es problema SeiZleba moixsnas. mkurnalobis gagrzelebis SemTxvevaSi sisxlzarrvebis dazianebam da smenis problemebis gauaresebam SesaZloa permanentuli xasiati miiros. riski gansakutrebit maralia im pacientebsi, romlebsac Tirkmlis funqcia moslili aqvt, Tumca igi srulad ardgeba, Tu streptomicinis gamoyenebas dauyovnebliv SevwyvetT. iseti gardamavali da mcire gverditi movlenebi, rogoricaa dabujeba (gaseseba) da wkrialis xma yurebsi, SeiZleba inieqciis gaketebidan maleve gacndes. streptomicini ar unda iqnes gamoyenebuli fexmzime qalebsi, rata Tavidan iqnas acilebuli nayofis merve kranialuri nervis dazianeba. streptomicini aseve azlierebs neiromuskulatorul blokatorul agentebs, romlebic gamoyeneba anesteziis dros da ar unda iqnes gamoyenebuli im pacientebsi, visac aqvs miastenia (miastenia gravis). iseve, rogorc nebismieri inieqciis gaketebisas, streptomicinis SemTxvevaSic gamoyenebuli unda iyos steriluri ertjeradi nemsi. Tioacetazoni Tioacetazonis efeqturobasa da toqsiurobaze bevrs msjeloben (ix. Tavi: ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazid + Tioacetazonis rejimi? ). Tioacetazoni gamoiyeneba mxolod oralurad; Cveulebriv misi doza Seadgens 2,5 mg/kg-ze. igi araefeqturia intervalebit intermituli gamoyenebisas. erti dozis saxit mirebul 150 mg Tioacetazoni isetive toqsikuria, rogorc PAS. misi gverditi movlenebia gamonayari, siyvitle, Zvlis tvinis Seqcevadi supresia. kanze gamonayari am SemTxvevaSi gacilebit ufro seriozuli xasiatisaa, vidre sxva mdikamentebis SemTxvevaSi da, Tu medikamentis mirebas ar SevwyvetT, SeiZleba ganvitardes eqsfoliaciuri dermatiti an stivens-jonsis sindromi, yvelaze seriozuli gartulebebi arinisneboda medikamentis mirebidan pirveli 4 6 kviris ganmavlobasi. Tioacetazonis toqsikuroba Seswavlili iqna fartomasstabian, kontrolirebad, ormagad brma kvlevit (ix. Tavi ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazid + Tioacetazonis rejimi? ). armocnda, 140

rom mis mimart dabali amtanobit gamoirceoda singapuris Cineli mosaxleoba da CineTis hong-kongis administraciuli regionis mcxovreblebi, samagierod kargad gamoiyeneboda armosavlet afrikis qveynebsi. aiv-pacientebsi kanis Zalzed seriozuli, rig SemTxvevebSi potenciurad fataluri gartulebebis riski miureblad maralia 52. aqedan gamomdinare, Tioacetazoni arasdros ar unda iqnes gamoyenebuli aiv- pozitiur pacientebsi an iset regionebsi, sadac aiv infeqciis prevalentoba Zalzed maralia. sarezervo medikamentebi 53 sarezervo medikamentebs ganekutvneba aminoglikozidebi (kanamicini, amikacini), polipeptidebi (kapreomicini), Tioamidebi (etionamidi da protionamidi), ftorqinolonebi (mag., ofloqsacini da ciprofloqsani), cikloserini da PAS 53. mati klasificireba SeiZleba moxdes Semdegi principit 54, 55 : baqteriociduli aqtivobis mqone medikamentebi: aminoglikozidebi, kapreomicini da Tioamidebi; dabali baqteriociduli moqmedebis mqone medikamentebi ftorqinolonebi; baqteriostatikuri efeqtis mqone medikamentebi - cikloserini da PAS. kanamicini da amikacini kanamicini da amikacini warmoadgenen aminoglikozidebis klasis medikamentebs.; mati efeqturoba da gartulebebi isetivea, rogorc streptomicinis SemTxvevaSi, Cveulebrivi dozaa 0,75 1 gr (12 18 mg/kg-ze) ertjeradi inieqciis saxit. gartulebebi am medikamentebis kuntsida inieqciebi gacilebit ufro mtkivneulia, vidre streptomicinis an kapreomicinis. adgilobrivad nanemsaris masaji, Tbili satburi garkveulwilad Svebis momgvrelia. Kkanamicinsa da amikacins Soris vitardeba jvaredini rezistentoba. SeiZleba ganvitardes Tavbrusxveva, ototoqsikuroba da sruli 141

siyrue. SeiZleba ganvitardes nefrotoqsikurobac, magram igi Seqcevadia. Tirkmlis funqciis moslisas unda Semcirdes driuri doza an gaizardos inieqciebs Soris intervali, rata Tavidan avicilot am medikamentis organizmsi akumulireba. garda amisa, aset pacientebsi medikamentis gamoyenebis mteli periodis ganmavlobasi sawiroa Tirkmlis funqciis regularuli monitoringi. amikacinisa da kanamicinis gamoyeneba fexmzime qalebsi ar SeiZleba, garda im SemTxvevebisa, rodesac es medikamentebi ukanaskneli imedia. kapreomicini kapreomicini polipeptidebis klasis baqteriaciduli medikamentia. mirebulia Streptomyces capreolus-idan. misi baqteriociduli moqmedeba Zalzed mnisvnelovania streptomicins, kanamicinsa da amikacinisadmi rezistentul pacientebsi. aq ar arinisneba aranairi jvaredini rezistentuloba aminoglikozidebtan. normasi doza Seadgens 0,75 1 mg (12 18 mk/ kg-ze), ertjeradi inieqciis saxit. gartulebebi (gverditi reaqciebi) am medikaments isetive gartulebebis gamowveva SeuZlia, rogorc streptomicins. umetes SemTxvevaSi es aris tinitusi da Tavbrusxveva, Tumca siyruis ganvitarebis naklebi riskit. SeiZleba ganvitardes Tirkmlis dazianeba. kvlevebit gamovlinda iseti gartulebebic, rogoricaa hipokaliemia, hipokalciemia da hipomagneziemia. aseve arc Tu isviatia eozinofilia da gamonayari kanze. rac Seexeba kanze generalizirebul reaqciebsa da hepatits, iseni isviatad vitardeba. inieqcia ar unda gaketdes Rrmad kuntsi, aman SeiZleba gamoiwvios nanemsari adgilis tkivili da SeSupeba. kapriomicini ar unda gamoviyenot smenisa da Tirkmlis problemebis mqone pacientebsi. mkurnalobis processi sawiroa SratSi Sardovanasa da eleqtrolitebis monitoringi. medikamentis gamoyeneba fexmzime qalebsi ar SeiZleba, garda im SemTxvevebisa, rodesac es medikamenti ukanaskneli imeda. 142

etionamidi (an protionamidi) etionamidi da protionamidi Tioamidis klasis baqteriociduli medikamentebia. miuxedavad imisa, rom etionamidi qimiurad dakavsirebulia izoniazidsa da pirazinamidtan (yvela isini izonikotinis mjavis derivatebi arian) mat Soris arinisneba Zalzed mcire jvaredini rezistentoba. misi qimiuri struqtura gvagonebs Tioacetazinis struqturas, romeltanac mas aqvs xsiri nawilobriv jvaredini rezistentoba (Tioacetazonze rezistentul bacilebs xsirad mgrznobeloba aqvt Tioamidis mimart, magram piriqit ara. rifampicinis armocenamde EeTionamidi (anu protionamidi) warmoadgenda tuberkulozis mkurnalobis sabaziso komponents izoniazidisa da streptomicinis mimart rezistentul pacientebsi. etionamidis maqsimalurad optimaluri driuri doza Seadgens 15-20 mg/kg-ze, e.i. 0,5 1 gr dresi pacientis sxeulis wonisa da amtanobis mixedvit. im pacientebisatvis, romlebsac utardebat mkurnaloba usualo metvalyureobis qves da ar SeuZliaT ertjeradi dozis atana, driuri doza 750 mg SeiZleba gaiyos or mirebad, 500 mg-is mireba unda moxdes usualo metvalyureobit, xolo darcenili 259 mg damoukideblad, mogvianebit dris ganmavlobasi. gverditi reaqciebi etionamidi yvelaze arasasiamovno tubsawinaarmdego medikamentia pacientisatvis. mas ZiriTadad gastro-intestinaluri gartulebebi axasiatebs anoreqsia, salivacia, gulisrevis SegrZneba, rkinis gemos SegrZneba, tkivili muclis aresi da fararati. medikamentma SeiZleba gamoiwvios hipotiroidizmi gansakutrebit masin, rodesac gamoiyeneba PAS-Tan kombinaciasi. aseve hipoglikemia diabetit daavadebul pacientebsi, Tumca isviatad, magram SeiZleba miiros sasisi forma. zogierti gartuleba ganpirobebulia medikamentis moqmedebit centralur nervul sistemaze da misi kontroli am SemTxvevaSi rtulia. aseve arinisneba hepatitis ganvitarebac. diabetit, RviZlis daavadebebit, alkoholizmit daavadebuli da fsiqikuri problemebis mqone pacientebsi am medikamentis gamoyenebisas sawiroa seriozuli monitoringis Catareba. mnisvnelovani faqtori, romelmac SeiZleba zemoqmedeba iqonios pacientis mxriv etionamidis amtanobaze aris misi ganwyoba ar Sewyvitos mkurnaloba. es moitxovs mtkice Tanadgomas da klinikuri da saeqtno personalis sistematur musaobas pacienttan. amastan 143

Zalzed mnisvnelovania mkurnalobis efeqturad organizeba, rac uzrunvelyofs pacients xelsayreli Terapiuli da socialuri momsaxurebit, vinaidan pacientebis umetesobas SeiZleba hqondes seriozuli socialuri problemebi. etionamids SeiZleba teratogenuri efeqti hqondes da ar unda iqnes gamoyenebuli fexmzime qalebsi. sxva isviati gartulebebia ginekomastia, menstrualuri ciklis darrveva, impotencia, akne, Tavis tkivili da periferiuli neiropatia. ftorqinologebi rogorc ofloqsacini, aseve ciprofloqsacini in vitro baqteriociduli efeqtis mqone medikamentebia. ufro axali Taobis ftorqinolonebi SeiZleba ufro aqtiuri iyos. miuxedavad imisa, rom es medikamentebi ar aris Seswavlili, fartod kontrolirebadi klinikuri kvlevebit mirebuli mtkicebulebebi cxadyofs, rom ofloqsacins da ciprofloqsacins TiTqmis ertnairi Terapiuli moqmedeba aqvt. mat ar arenisnebat jvaredini rezistentoba sxva antituberkulozur medikamentebtan, magram mat Soris sruli jvaredini rezistentobaa (da aseve sxva ftorqinologebisadmi, rogoricaa magalitad, levofloqsacini, romelic warmoadgens ofloqsacinis L-izomers). ofloqsacinis driuri dozaa 7,5 15 mg/ kg-ze (maqsimumi 800 mg); cifrofloqsacinis driuri dozaa 1000 1500 mg. leofloqsacini gacilebit ufro aqtiuria da naklebad toqsikuri, magram ufro Zvirad Rirebuli. multirezistentuli tuberkulozis mkurnalobisas ftorqinolonebi sxva tubsawinaarmdego medikamentebtan gamoyenebisas avlenen zomier efeqturobas 56, 57. isini aseve gamoiyeneba im SemTxvevaSi, rodesac pacientebs problemebi aqvt sxva tubsawinaarmdego medikamentebis amtanobis TvalsazrisiT. magalitad, RviZlis mwvave daavadebis dros. gverditi reaqciebi am medikamentebis gartulebebi xsiri ar aris da ZiriTadad warmodgenilia gastrointestinaluri darrvevebit (anoreqsia, gulisrevis SegrZneba, pirrebuneba) an centraluri nervuli sistemis problemebit (rogoricaa Tavbrusxveva, Tavis tkivili, ganwyobis 144

cvlileba da isviatad kruncxvebi). Aaseve, arctu isviatia kofeinis msgavsi efeqti, ufro isviatad SeiZleba moxdes aqilevsis myesis spontanuri gaxlecva. es medikamentebi ar unda iqnes gamoyenebuli fexmzime qalebsi da bavsvebsi, radgan mat SeZleba gamoiwvion zrdis Seferxeba da mzardi xrtilebis dazianeba. rac Seexeba medikamentebs Soris urtiertqmedebas pacientebi, romlebic mkurnaloben ftorqinolonebit unda moeridon antacidebis, rknis, TuTiis preparatebis, sakralfatisa da didanozinis gamoyenebas (DDI). cikloserini (an terizidoni) cikloserini warmoadgens aminomjava D-alaninis struqturul analogs, mas aqvs SedarebiT susti antituberkulozuri efeqti. terizidoni mirebuli iyo cikloserinis ori molekulis kombinirebit. cikloserini gamoiyeneba mxolod sarezervo rejimebsi. misi mireba xdeba oralurad. driuri dozaa 0,5 1 gr. igi Cveulebriv iyofa or an sam driur dozad, Tumca yoveldriurad erti gramis mireba isviatia pacientis amtanobis TvalsazrisiT. jerjerobit ar gamovlenila jvaredini rezistentoba sxva tubsawinaarmdego medikamentebis mimart. Tumca medikamentebisadmi mgrznobelobis testireba SeiZleba ar iyos sando. cikloserini kargad gamoiyeneboda etionamidisadmi rezistentobis prevenciisatvis ganmeorebiti mkurnalobis iset rejimebsi (etionamidi, cikloserini, pirazinamidi an kanamicini), romlebic ixmareboda rifampicinis Seqmnamde. amjamad igi ZiriTadad gamoiyeneba sxva sarezervo medikamentebisadmi rezistentobis prevenciis miznit. gverditi reaqciebi ZiriTadad azianebs centralur nervul sistemas. cikloserinma SeiZleba gamoiwvios Tavis tkivili, gonebagafantuloba, depresia, kruncxvebi, qcevis Secvla da SeiZleba suicidis provocirebac moaxdinos. Zalian isviatad SeiZleba warmoisvas generalizirebuli hipersensitiurobis reaqcias an ganvitardes hepatiti. aqedan gamomdinare, cikloserinis gamoyenebisas umnisvnelovanes amocanas warmoadgens centraluri nervuli sistemis reaqciebis monitoringi. 145

umnisvnelo gverditi reaqciebis prevenciis miznit, rogoricaa magalitad, uziloba, zogjer rekomendirebulia trankvilizatoris mcire dozebit danisvna. piridoqsinma SeiZleba Seamciros centraluri nervuli sistemis dazianeba. samedicino dawesebulebebis TanamSromlebi, romlebic pasuxs ageben stacionaruli avadmyofebis mkurnalobaze da aseve ambulatoriuli pacientebis ojaxebi valdebulni arian dauyovnebliv Seatyobinon eqims depresiis an fsiqikis cvlilebebis Sesaxeb. cikloserini (da terizidini) ar unda mieces epilefsiit da alkoholizmit daavadebulebs da fsiqiur avadmyofebs. mat didi sifrtxilit unda gamoiyenon es medikamenti. es medikamenti frtxilad unda iyos gamoyenebuli pacientebsi, romlebsac awuxebt Tirkmlis funqciis mosla. cikloserinsa da terizidons Senaxvis gansakutrebuli pirobebi esawiroeba. P-aminosalicilis mjava P-aminosalicilis mjava (PAS) Seiqmna lehmanis mier da pirvelad gamoyenebuli iyo 1944 wels. mozrdilta normaluri doza Seadgens 10 12 gr. mireba xdeba oralurad da yoveldriurad. doza iyofa 2 3 dozad 58. ufro mcire dozebi, magalitad, 6-8 grami SeiZleba aseve, efeqturi iyos. ramdenadac PAS Zalze swrafad gamoiyofa organizmidan misi mireba unda moxdes marali dozebit dresi ramdenjerme, rata SenarCunebuli iyos sawiro marali done sisxlsi. es baqteriostatikuri medikamentia da izoniazidtan kombinaciasi gamoyenebisas xels uslis izoniazidze rezistentobis ganvitarebas. amjamad igi gamoiyeneba sarezervo rejimsi multirezistentuli tuberkulozis mkurnalobis dros. PAS-i warmodgenilia tabletebis, fxvnilis an granulebis formit, preparati kargad ar inaxeba tropikul klimatsi. kidev erti nakli tabletebis didi zomaa. Aucilebelia didi raodenobit mireba da aqvs usiamovno gemo. uketesi amtanobit gamoirceva misi kaliumis marilis forma da specialuri safarit dafaruli preparatebi, Tumca isini ufro ZviradRirebulia. 146

gverditi reaqciebi garda hipersensitiurobis reaqciebisa, rogoricaa cxeleba, gamonayari da qavili, PAS ZiriTadi gartulebaa gastrointestinaluri darrvevebi: anoreqsia, gulisrevis SegrZneba, pirrebineba, diskomforti mucnis aresi gacilebit ufro xsiria, vidre fararati. aseti gverditi movlenebis mnisvnelovnad Semcireba SeiZleba, Tu wamals mivirebt Wamis Semdeg an rzestan ertad. gverditi reaqciebis sixsire icvleba qveynebisa da damkvirveblebis mixedvit. Tumca pacientebs yoveltvis urceven, rom Seeguon am gverdit movlenebs da mxolod SemTxvevebis 1-2%- Sia sawiro medikamentis gamoyenebis Sewyveta. gastrointestinaluri darrvevebis Semcireba SesaZlebelia PASis Wamis dros an usualod Wamis dasrulebis Semdeg mirebit. hepatiti da siyvitle gacilebit ufro isviati gartulebaa, romelta ganvitarebis SemTxvevaSi medikamentis mireba unda Sewydes. SesaZlebelia, aseve ganvitardes hipokaliemia. medikamentis xangrzlivi drois ganmavlobasi gamoyenebisas arsebobs hipotireodizmis ganvitarebis safrtxe, Tumca mdgomareoba umjobesdeba wamlis SewyvetisTanave. PAS-is natriumis marilis formam SeiZleba ganapirobos natriumit gadatvirtva da medikamentis es forma didi sifrtxilit unda iqnes gamoyenebuli pacientebsi, romlebsac SezRuduli aqvt natriumis marilebis moxmareba. Zveli tabletirebuli formit amcirebda rifampicinis Sewovas. axali preparati warmodgenilia granulebis formit da xels ar uslis rifampicinis Sewovas. pacientebi mis mimart odnav uketesi amtanobit gamoircevian da SeuZliaT misi mireba dresi orjer (nacvlad 3 4-jer mirebisa) misi efeqturobis ucvlelad SenarCunebiT. 147

24. ra mizans emsaxureba orfaziani mkurnalobis sawyisi intensiuri mkurnaloba k.tomani 8 arsebobs didi moculoba eqsperimentuli da klinikuri mtkicebulebebisa, romlebic gvicvenebs, rom sawyis etapze ertze meti medikamentis, kerzod, sami an otxi medikamentis gamoyeneba mnisvnelovnad zrdis mkurnalobis efeqturobas. mitcisonis 59, kanetisa 60 da sxva avtorebis adreul nasromebsi (1960) natqvamia, rom aqtiuri tuberkulozis samkurnalod sawiroa sul mcire ori medikamentis ertdrouliad gamoyeneba. savele kvlevebma acvena, rom monoterapia ganapirobebs mkurnalobis warumateblobas da relafsebis maral macvenebels. arnisnulma xeli Seuwyo tuberkulozis aqtiuri formit daavadebuli pacientis multimedikamentruri mkurnalobis aucileblobis koncefcias. intensiuri medikamentozuri mkurnalobisa da SemdgomSi mcire raodenobis medikamentebit mkurnalobis gagrzelebis ideam Tavisi adgili daimkvidra, Tumca, nebismieri ori an meti medikamentis kombinacia ar izleva aset efeqts. sawyisi, intensiuri mkurnalobis etapze aucilebelia sul mcire ori medikamentis gamoyeneba mainc, magalitad, izoniazidi da streptomicini, an izoniazidi da rifampicini. pirazinamidi sawyisi, intensiuri mkurnalobis etapze izleva mkurnalobis 9-dan 6 Tvemde Semcirebis SesaZleblobas. etambutoli efeqturia Tu gvaqvs medikamentebisadmi sawyisi rezistentoba an baqteriuli tvirti Zalzed maralia (ixilet Tavi ramdenad efeqturia tuberkulozis mkurnaloba da rogoria samomavlo perspeqtivebi? ) mgrznobelobis mqone organizmebis gamravleba wydeba efeqturi mkurnalobis 59,60 pirvelsave dres da baqteriata saerto raodenoba 8 gardacvlilia 148

naxvelsi, gansakutrebit pirveli 2 kviris ganmavlobasi 61, swrafad mcirdeba. qvemot Sejamebulia laboratoriuli da kontrolirebadi kvlevebis Sedegebi: baqteriebis gamravlebis swrafi SeCereba da mgrznobelobis mqone organizmebis SeZlebisdagvarad swrafad ganadgureba mkurnalobis SedegebisaTvis Zalzed mnisvnelovania, gansakutrebit im pacientebsi, romlebsac marali baqteriologiuri datvirtva arenisnebat, rata: - mkurnalobis pirvel kvirebsi Tavidan avicilot janmrtelobis mdgomareobis Semdgomi gauareseba an sikvdili; - Tu baqteriata populacia swrafad Semcirda, davusvat 10 8 - dan (es aris baqteriata is raodenoba, rasac xsirad vxvdebit filtvis kavernebsi) 10 3 -mde, masin mcire albatoba arsebobs imisa, rom gacndeba mutanti baqteriebi inhibiciis pirobebsi mirebul Svid TaobaSic ki. aqedan gamomdinare, mkurnalobis sawyisi, intensiuri faza izleva axali rezistentuli mutanti baqteriebis warmosobis minimumamde dayvanis an SeCerebis SesaZleblobas; - arsebobs sakmaod myari in vitro mtkicebulebebi, rom rac ufro swrafad mivarwevt antibaqteriul efeqts 62, mit ufro naklebia gamzle baqteriebis wamosobis albatoba, rac amcirebs relafsis ganvitarebis risks. satanado multimedikamentozuri kombinacia yoveltvis Secavs or iset medikaments, romelsac unari Seswevs dazlios velur StamebSi ukve arsebuli erti medikamentisadmi rezistentuli mutantebi. aqedan gamomdinare, sami an otxi medikamentis kombinacia xels SeuSlis aset organizmebs gamravlebasi. mikroorganizmebis gamravleba gansakutrebit sasisia mkurnalobis adreul stadiasi, radgan am etapze SeiZleba arsebobdes medikamentebisadmi rezistentuli mutantebis sakmaod mnisvnelovani raodenoba_tuberkulozis baqteriata ert milionsi (veluri StamisaTvis) daaxloebit 10 50 izoniazid rezistentuli da 1 5 streptomicin rezistentuli baqteria. aqedan gamomdinare, 10 8 populaciasi (aseti raodenobit baqteria Cveulebriv gvxvdeba filtvis kavernebsi) 5000-mde izoniazidrezistentuli da ramodenime 149

aseuli streptomicinrezistentuli mutanti baqteria SeiZleba arsebobdes (ixilet Tavi: ramdeni rezistentuli bacila SeiZleba iqnes armocenili tuberkulozze aranamkurnalebi pacientis naxvelsi? ). Tu davusvebt baqteriebis gamravlebas, rezistentoba ori medikamentis mimart swrafad gaizrdeba 63. mkurnalobis sawyis etapze sami an otxi medikamentis gamoyeneba erti medikamentisadmi (ara rifampicinisadmi) sawyisi rezistentobis mqone pacientebsac azlevs gankurnebis SesaZleblobas (ixilet Tavi: rogoria medikamentebisadmi mgrznobelobis arazusti testirebis Sedegebi ). mkurnalobis intensiuri sawyisi faza gansakutrebit sargeblobis momtania baqteriata marali tvirtis mqone individebistvis, anu, vinc nacxit dadebitia pirdapiri mikroskopiit. 150

25. rogoria Tanamedrove rekomendaciebi standartuli rejimis mimart a.harisi 9 mkurnalobis rejimebi gamoiyeneba Semdegi miznebis gansaxorcieblad: pacientebis gankurneba, aqtiuri tuberkulozit gamowveuli Sedegis an sikvdilianobis prevencia, medikamentisadmi rezistentuli organizmebis warmosobisa da gavrcelebis prevencia, recidivebis minimumamde dayvana da sazogadoebis dacva tuberkulozis infeqciis gavrcelebisgan. mkurnalobis yvela rejimi moicavs or fazas sawyis, intensiur mkurnalobis fazas da SenarCunebis, gagrzelebis fazas 64,65. sawyisi, intensiuri mkurnalobis faza sawyisi, intensiuri mkurnalobis faza miznad isaxavs aqtiurad mzardi da naxevradmtvlemare baqteriebis ganadgurebas. es ki nisnavs infeqciurad sasisi periodis Semcirebas. mas axasiatebs naxvelis nacxis swrafi konversia (80 90%) mkurnalobis pirvel 2-3 TveSi. rejimis mkacrad dacvis miznit, rifampicinis Semcveli mkurnalobis sawyisi faza yoveltvis unda mimdinareobdes usualo zedamxedvelobit. am etapze, rogorc wesi, gamoiyeneba sami an xuti medikamenti. Tu sawyisi rezistentobis macveneblebi maralia, sami medikamentis gamoyeneba qmnis rezistentuli mutantebis SerCeviTi gadarcenis sasisroebas, gansakutrebit baqteriebis didi raodenobis mqone pacientebsi anu pulmonaruli tuberkulozis, nacxit dadebit SemTxvevebSi. otxi medikamentis gamoyeneba amcirebs rogorc medikamentebisadmi rezistentobis, aseve warumetebeli mkurnalobisa da recidivis risks. Tu pacienti Sewyvets 9 malaviis tuberkulozis kontrolis erovnuli programis teqnikuri mrceveli. Llilongue, malavia 151

mkurnalobas sawyisi intensiuri fazis Semdeg, recidivi naklebad savaraudoa. gagrzelebis faza gagrzelebis faza uzrunvelyofs darcenili baqteriebis umetesi nawilis ganadgurebas da amcirebs warumeteblobisa da recidivis albatobas. gagrzelebis fazis dawyebisas, baqteriebis raodenoba SedarebiT mcirea da medikamentebisadmi rezistentuli mutanti bacilebis seleqciis SesaZleblobac naklebia. aqedan gamomdinare naklebi medikamentia sawiro. tuberkulozis standartuli mkurnalobis rejimebi janmos mier rekomendirebuli 64 mkurnalobis rejimebi mocemulia cxrilsi #27. tuberkulozis mkurnalobis rejimebisatvis gamoiyeneba standartuli kodebi: TiToeuli tubsawinaarmdego medikamenti wamodgenilia standartuli abreviaturit da TiToeuli rejimi moicavs mkurnalobis or fazas. fazis win mocemuli nomeri arnisnavs xangrzlivobas TveebSi. abreviaturis Semdeg miwerili, frcxilebsi mocemuli cifri gvicvenebs am medikamentis an medikamantebis dozas erti kviris ganmavlobasi. Tu aseti cifri abreviaturas axlavs, es nisnavs, rom medikamentis mireba xdeba yoveldriurad. frcxilebi miutitebs imaze, rom medikamenti mocemulia fiqsirebuli dozebis kombinaciasi. aseti formulirebis gamoyeneba rekomendirebulia yvelgan, sadac ki es SesaZlebelia. alternatiuli medikamentebic aseve abreviaturit arinisneba da mocemulia kvadratul frcxilsi. magalitebi 2 (HRZE)/6(HE) sawyis fazasi gamoiyeneba rejimi 2(HRZE). misi xangrzlivoba 2 Tvea. medikamentebis mireba yoveldriurad xdeba (mocemuli ar aris rejimis armnisvnelo cifri). rejimsi gamoiyeneba izoniazidi (H), rifampcini (R), pirazinamidi (Z) da etambutoli (E) fiqsirebuli dozebis kombinaciit. gagrzelebis fazis rejimia 6 HE. fazis xangrzlivobaa 6 Tve. 152

rejimi yoveldriuria da Seicavs izoniazidsa da etambutols fiqsirebuli dozebs kombinaciasi. 2 (HRZ) 3 E 3 /4(HR) 3 sawyis fazasi medikamentebis mireba xdeba kvirasi 3-jer (amas gvicvenebs abreviaturis qvemot miwerili patara cifri). rejimsi gamoiyeneba izoniazidi (H), rifampcini (R) da pirazinamidi (Z) fiqsirebuli dozebis kombinaciasi, plus etambutoli. fazis xangrzlivobaa 2 Tve. mkurnalobis gagrzelebis fazasi medikamentebis mireba warmoebs kvirasi samjer (amaze miutitebs abreviaturis qves miwerili cifri). rejimi moicavs izoniazidis (H) da rifampcins (R) fiqsirebuli dozebit kombinaciasi, fazis xangrzlivoba 4 Tvea. cxrili #27 sxvadasxva diagnostikuri kategoriebisatvis rekomendirebuli mkurnalobis rejimebi a diagnostikuri kategoria tuberkulozit daavadebuli pacienti tuberkulozis mkurnaloba b sawyisi faza (yoveldre an kvirasi 3-jer) g gagrzelebis faza (yoveldre an kvirasi 3-jer) g I axladgamovlenili nacxit dadebiti SemTxvevebi; axlad gamovlenili nacxit 2 HRZE d 4 HR an 6 HE yoveldriurad uaryofiti filtvis tuberkulozi parenqimis farto dazianebit; mwvave aiv-koinfeqcia an eqstrapulmonaruli tuberkulozis mwvave formebi II namkurnalebi nacxit-pozitiuri pulmonaruli tuberkulozirecidivi-mkurnalobis ganaxleba Sewyvetis Semdeg-mkurnalobis warumatebloba e 2 HRZES / 1 HRZE 5 HRE III nacxit uaryofiti filtvis 2 HRZE z 4 HR an 6 HE tuberkulozis axali SemTxveva (ar ganekutvneba I kategorias) da yoveldriurad eqstrapulmonaruli tuberkulozis naklebad mwvave formebi v IV qronikuli da MDR-TB-is SemTxvevebi(nacxiT-pozitiuri metvalyureobit mkurnalobis Semdeg) 153

a) wyaro b) H=izoniazidi, R=rifampicini, Z=pirazinamidi, S=streptomicini. asoebis win motavsebuli cifrebi miutitebs mkurnalobis xangrzlivobas TveebSi. g) sawyis fazasi sawiroebs mirebas usualo metvalyureobit nacxit dadebit SemTxvevebSi da yoveltvis rifampicinis Semcveli mkurnalobis rejimsi. d) streptomicini SeiZleba gamoyenebuli iqnes etambutolis nacvlad meningitis dros, etambutoli yoveltvis Canacvlebuli unda iyos streptomicinit e) warumatebeli mkurnalobis SemTxvevaSi II kategoriis mkurnalobis danisvnamde rekomendirebulia medikamentebze mgrznobelobis testis Catareba. dadasturebuli MDR-TB-iT daavadebul pacientebsi gamoiyeneba IV kategoriis mkurnaloba v) kulturit dadasturebul MDR-TB-iT daavadebul pacientebtan kontaqtsi myof individebs unda CautardeT kulturisa da mgrznobelobis testebi z) arakavernozuli, nacxit uaryofiti filtvis tuberkulozit daavadebuli aiv-negatiuri, medikamentebisadmi sensitiuri pacientebisa da pirveladi tuberkulozit daavadebul bavsvebis mkurnalobis sawyis fazasi SeiZleba etambutolis amoreba rejimidan. tuberkulozis axali SemTxvevebi mkurnalobis rejimebi moicavs sawyis (intensiur) fazas, romlis xangrzlivoba 2 Tvea da gagrzelebis fazas, romelic Cveulebriv 4 Tvis ganmavlobasi mimdinaeobs. sawyis fazasi, Cveulebriv gamoiyeneba otxi medikamenti, romelta mesveobit xdeba tuberkulozis baqteriis swrafi ganadgureba da infeqciuri pacienti ramodenime kvirasi gadadis arainfeqciur mdgomareobasi. pacientis janmrtelobis mdgomareoba umjobesdeba, simptomebi qreba da bevri matgani 4-8 kviris ganmavlobasi mkurnalobis Sedegad asimptomuri xdeba. nacxit pozitiuri pulmonaruli tuberkulozit daavadebuli pacientebis umetesoba 2 Tvis ganmavlobasi abacilaruli xdeba. mkurnalobis sawyisi fazis dros gamoiyeneba pirazinamidi da am periodis ganmavlobasi igi arwevs sterilizaciis maqsimalur efeqts. pirazinamidis ufro xangrzlivad gamoyeneba usargebloa. igive SeiZleba itqvas medikamentebisadmi mgrznobelobis mqone pacientebzec da amitom es medikamenti ar gamoiyeneba gagrzelebis fazasi. gagrzelebis fazis rejimi Cveulebriv moicavs or medikaments. 154

nacxit negatiuri an eqstrapulmonaruli tuberkulozit daavadebul pacientebs baqteriebis ufro naklebi raodenoba arenisnebat. aqedan gamomdinare, medikamentebisadmi rezistentuli mutanti baqteriebis seleqciis naklebi albatobaa, amdenad rekomendirebulia moklevadiani mkurnalobis kursis Catareba sawyis fazasi sami medikamentit da ori medikamentis gamoyeneba gagrzelebis fazasi. zogiert qveyanasi jer kidev gamoiyeneba mkurnalobis 12-Tviani rejimi nacxit uaryofiti pulmonaruli, an eqstrapulmonaruli tuberkulozit 65 daavadebul pacientebsi. rejimi moicavs izoniazidisa da Tioacetazonis gamoyenebas, streptomicinisa da etambutolis damatebit sawyis fazasi 2 Tvis ganmavlobasi. mkurnalobis 12-Tviani xangrzlivoba ganpirobebulia imit, rom aset rejimsi ar gamoiyeneba arc erti medikamenti (arc rifampicini da arc pirazinamidi), romelsac Seswevs tuberkulozuri dazianebis sterilizaciis unari; amitom rejimi ZiriTadad efuzneba mkurnalobis periodsi naxevradmtvlemare baqteriebis metabolur gaaqtiurebasa da mat sensitiurobas izoniazidze. TiTqmis yvela qveyanasi, sadac es rejimi gamoiyeneba, gankurnebis macveneblebi Zalze dabalia da amitom janmo ar uwevs mas rekomendacias. amastan, Tioacetazons axasiatebs seriozuli toqsiuroba aiv-inficirebul pacientebsi da Canacvlebuli unda iyos etambutolit. Tumca, SeiZleba sawiro gaxdes am rejimis gamoyeneba manamde, vidre DOTS strategia srulad ar moicavs mtel qveyanas. ganmeorebiti mkurnalobis SemTxvevebi namkurnaleb pacientebs rezistentuli baqteriebis gamoyofis (izoniazidisadmi mainc) ufro meti albatoba aqvt, vidre axlad gamovlenil individebs. ganmeorebiti mkurnalobis rejimi moicavs xut medikaments sawyis stadiasi da sul mcire sam medikaments gagrzelebis fazasi. sawyis fazasi pacients unda daenisnos sul mcire ori iseti medikamenti, romlebsac jer kidev SeuZliaT Seamciron rezistentuli baqteriebis seleqciis riski. 155

janmos mier rekomendirebuli mkurnalobis rejimebi janmos mier rekomendirebuli rejimebi mocemulia cxrilsi #27. arsebobs ramodenime SesaZlo rejimi, romelta gan\xorcielebac damokidebulia qveynis biujetze, pirveladi jandacvis ganvitarebaze, usualo metvalyureobis danergvis SesaZleblobebze, periferiul donis samedicino dawesebulebebis medpersonalis kvalifkaciaze. TiToeuli pacientis mimart rekomendirebuli rejimi ganisazrvreba mkurnalobis kategoriit (ixilet Tavi: ra diagnostikuri kategoriebi arsebobs da ra principebi udevs mat safuzvlad ). 156

26. ra diagnostikuri kategoriebi arsebobs da ra principebi udevs mat safuzvlad a.harisi 10 arsebobs mkurnalobis otxi sxvadasxva diagnostikuri kategoria (ixilet Tavi: rogoria Tanamedrove rekomendaciebi standartuli rejimebis mimart ). pacientebi iyofa kategoriebad im prioritetebis mixedvit, ristvisac mat utardebat mkurnaloba. aseti prioritetebia: pacientis gankurneba, sikvdilis prevencia, medikamentebisadmi rezistentobis prevencia da sazogadoebasi tuberkulozis infeqciis transmisiis Semcireba. yvelaze marali prioriteti eniweba axlad gamovlenili nacxit dadebit pulmonaruli tuberkulozita da am daavadebis sxva seriozuli formebit daavadebul pacientebs. SesaZlebeli rom iyos nacxit dadebit tuberkulozis axali SemTxvevebis 100%-iT gamovlena da gankurneba, tuberkulozis prevalentoba swrafad Semcirdeboda (ixilet Tavi SesaZlebelia Tu ara tuberkulozis kontroli? ). I kategoria es kategoria moicavs: axladgamovlenil, nacxit dadebit pulmonaruli tuberkulozit daavadebul pacientebs mati marali infeqciurobis da mkurnalobis garese darcenis SemTxvevaSi darupvis marali riskis gamo. mkurnalobis warumatebloba nisnavs medikamentebisadmi rezistentuli organizmebis gavrcelebas mosaxleobasi. axali nacxit dadebiti SemTxvevebis didi nawilis gankurneba mnisvnelovan zegavlenas moaxdenda tuberkulozis kontrolze; 10 malaviis tuberkulozis kontrolis erovnuli programis teqnikuri mrceveli. Llilongue, malavia 157

eqstrapulmonaruli tuberkulozis iseti mwvave formebit daavadebul, axladgamovlenil pacientebs, rogoricaa miliaruli tuberkulozi, perikarditi, meningiti, xerxemlis daavadebebi zurgis tvinis dazianebit. miuxedavad imisa, rom es pacientebi arainfeqciurni arian, medikamentebis efeqturi kombinaciebit mkurnalobis garese isini darupvis didi safrtxis winase dganan; nacxit uaryofit mwvave da Sorswasuli pulmonaruli tuberkulozit daavadebul axladgamovlenil pacientebs, aiv-koinfeqciit daavadebul pacientebs, romlebic darupvis gansakutrebit didi riskis winase dganan. II kategoria moicavs tuberkulozze namkurnaleb pacientebs, romlebsac ganuvitardat nacxit dadebiti pulmonaruli tuberkulozi, recidivis warumateblobeli mkurnalobis da adre mkurnalobis Sewyvetis SemTxvevebs. am pacientebs enisnebat multimedikamentozuri rejimi, radgan isini, Zalze infeqciurni arian da, Tu mkurnaloba ar CautardebaT savaraudot medikamentebisadmi rezistentuli organizmebis gavrcelebis wyarod iqcevian. aset pacientebs mkurnalobis mteli kursi unda CavutaroT pasuxismgebeli medmusakis usualo metvalyureobis qves; adre namkurnaleb pacientebs mkurnalobis Sewyvetis ufro marali riski aqvt. bevri pacientisatvis aseti mkurnaloba mati gadarcenis ukanaskneli realuri SesaZleblobaa. III kategoria es kategoria aertianebs nacxit uaryofiti pulmonaruli tuberkulozit daavadebul da eqstrapulmonaruli tuberkulozis iseti naklebad seriozuli formebis mqone pacientebs, rogoricaa limfadenopatia da eqsudaciuri plevriti. aseti pacientebi nacxit dadebiti tuberkulozit daavadebul individebtan SedarebiT naklebad infeqciurni arian. aqvt medikamentebisadmi rezistentobisa da darupvis naklebi riski, Tumca nacxit uaryofiti pulmonaruli tuberkulozit aiv-inficirebul pacientebs darupvis ufro marali riski aqvt vidre nacxit dadebiti pulmonaruli tuberkulozit 158

daavadebul aseve aiv-inficirebulebs, radgan isini gacilebit ufro marali imunokompromisit gamoircevian. aiv-inficirebul pacientebs meti midrekileba aqvt medikamentebisadmi SeZenili rezistentobis mimart. ufro metic, necxit uaryofiti pacientebi SeiZleba iqcnen tuberkulozis gavrcelebis wyarod sazogadiebasi. yvela am mizezisa da kidev imis gamo, rom tuberkulozis SemTxvevaTa umetes nawilsi pecientebis aiv-statusi ucnobia, janmos rekomendaciit aset pacientebs unda CautardeT kategoria I-iT gansazrvruli mkurnalobis rejimi, otxi medikamentit sawyis fazasi. IV kategoria kategoria IV aertianebs necxit dadebiti pulmonaruli tuberkulozis SemTxvevebs, romlebmac daamtavres ganmeorebiti mkurnalobis sruli kursi zedamxedvelobis qves da multirezistentuli tuberkulozit daavadebul adamianebs (marali kategoriis laboratoriasi dadasturebuli rezistentobit izoniazidisa da rifampicinis mimart). aseti pacientebis mkurnaloba xangrzlivia da ZviradRirebulia, amave dros Zneladasatania rogorc pacientebis, aseve personalistvisac da xsirad warumatebelia. marali prioritetuloba unda mieniwos aseti SemTxvevebis prevencias efeqturi, usualo metvalyureobit ganxorcielebuli mkurnalobis pirveladi rejimebis gamoyenebit iq, sadac amis SesaZleblobas izleva resursebi da codna. zogjer aseti individualuri SemTxvevebis mkurnaloba xorcieldeba humanitarul safuzvlebze (ix. Tavi: ra sarezervo rejimebi arsebobs da ra adgili uwiravs mat tuberkulozis kontrolis programebsi ). iset regionebsi, sadac multirezistentuli tuberkulozi fartodaa gavrcelebuli da bevri pacienti imunokomprometirebulia, multirezistentuli tuberkulozze kontrolis swrafad ganxorcielebis miznit SeiZleba sawiro gaxdes IV kategoriis rejimit mkurnalobis gamoyeneba. 159

27. ras warmoadgens intervalebit intermitiuli mkurnaloba da ra mecnieruli safuzvlebi aqvs mas 11 T.frideni 12 intervalebit intermitiuli mkurnalobis rejimis dros xdeba calkeuli medikamentis mireba ertze meti dris intervalit, magalitad, kvirasi samjer. Tavdapirvelad arsebobda Sexeduleba, rom tubsawinaarmdego medikamentebi mati koncentraciis in vitro permanentuli SenarCunebisa- Tvis pacientebs yoveldriurad unda mierot. Tumca invitro gamokvlevebma da cxovelebze Catarebulma eqsperimentebma gvicvena, rom garkveuli medikamentebi masinac inarcunebdnen efeqturobas, rodesac mati koncentracia droebit qveitdeboda am donestan SedarebiT da masinac ki, rodesac medikamenti sruliad qreboda dazianebuli 66 adgilidan an niadagidan 67. eqsperimentebma in vitro cxadyo, rom tuberkulozis kulturaze garkveuli drois ganmavlobasi gansazrvruli medikamentebis zemoqmedebis Semdeg axali zrdis dasawyebad ramodenimedriani Sualedi iyo sawiro( dayovnebis periodi ). cxrili #28 gvicvenebs tuberkulozis mikobaqteriis zrdis dayovnebis periods sxvadasxva medikementebit zemoqmedebis Semdeg. dayovnebis periodi ar arinisneboda Tioacetazonis SemTxvevaSi 24 da 96 saatis ganmavlobasic ki. kulturis niadagidan Tioacetazonis amorebistanave zrda kvlav iwyeboda, rac sasualebas gvazlevs davaskvnat, rom es medikamenti ar gamodgeba intervalebit intermitiuli mkurnalobis rejimisatvis. es daskvna dadasturebul iqna cxovelebsi Catarebuli eqsperimentebit. 11 k. tomanis wina gamocemis Tavze dayrdnobit. 12 tuberkulozis SeCerebis ganyofilebis medmusaki, jandacvis msoflio organizaciis regionaluri ofisi, samxret armosavlet azia, axali deli, indoeti 160

TiToeuli baqteriociduli medikamentisatvis ganisazrvra dayovnebis maqsimaluri periodi (ukanaskneli sveti cxrilsi), romelic gvicvenebs or dozas Soris intervalis im praqtikul limits, romelsac ar unda gadavawarbot. cxovelebsi Catarebulma kvlevebma gamoavlina, rom rac ufro xangrzlivia 68 dozebis mirebas Soris SerCeuli intervali, medikamentis mit ufro marali dozaa sawiro. gamonakliss warmoadgens rifampicini. aqedan gamomdinare, izoniazidis marali dozebisatvis optimaluria sami dris intervali. am intervalis gazrdam rva dremde SeiZleba ganapirobos Zalzed arasasiamovno Sedegebi. eqsperimentebis seriebma 69 cxovelebsi gvicvena, rom intervalebit dozirebam faqtiurad gazarda izoniazidit, rifampicinit da pirazinamidit mkurnalobis efeqturoba. cxrili #28 tuberkulozis mikobaqteriis zrdis dayovnebis xangrzlivoba medikamentis droebiti zemoqmedebis Semdeg a medikamenti izoniazidi rifampicini pirazinamidi etambutoli streptomicini etionamidi cikloserini Tioacetazoni koncentracia(mg/l) 1 0.2 50 10 5 5 100 10 dayovnebis xangrzlivoba medikamentis zemoqmedebis Semdeg (dreebsi) 6 saati 24 saati 0 6-9 2-3 2-3 5-40 b 40 b 0 4-5 8-10 8-10 0 10 0 4-8 0 0 a wyaro b niadagis ph-is mixedvit 161

grafiki #11. daavadebis sasualo fesvuri indeqsebi dozebis administrirebas Soris intervalebtan dakavsirebit zrvis gowebsi, romlebsac mkurnaloba utardebodat izoniazidit, etambutolit an rifampicinit etambutoli izoniazidi rifampicini a) wyaro intervali dozebis administrirebas Soris (dreebsi) intervalebit intermitiuli mkurnalobis standartuli rejimebi miuxedavad imisa, rom eqsperimentebit mirebuli Sedegebis meqanikurad gadatana adamianebze SeuZlebelia, es daskvnebi sakmaod imedis momcemi iyo imisatvis, rom klinikuri kvlevebit SeeswavlaT. pirveli aseti randomizirebuli, kontrolirebuli klinikuri kvleva Catarda indoetsi Cenais tuberkulozis kvlevis centrsi 70. cxrili #29 streptomicini/izoniazidis (SH) kvirasi 2-jer mirebis rejimis Sedareba p-aminosalicilis mjavisa da izoniazidis (PH) a yoveldriuri mirebis rejimtan (12 Tvis Semdeg mirebuli Sedegebi) daavadebis statusi baqteriologiurad pasiuri baqteriologiurad aqtiuri (tuberkulozit gamowveuli sikvdili) sul pacientebi SH orjer kvirasi b pacientebis % raodenoba 68 94 2 2 2 3 72 100 PH yoveldriurad g pacientebis % raodenoba 56 85 9 14 1 2 66 100 162

a wyaro b SH streptomicinis 1 g, kuntsida inieqcia + izoniazidi 14 mg/kg-ze g PH, natriumis PAS 10g + izoniazidi 200 mg, yoveldriurad gayofili or Tanatol dozad izoniazidisa da PAS-is standartuli per oraluri rejimi, dresi orjer mirebit, Sedarebuli iyo erti grami streptomicinis kuntsi inieqcias + 14 mg/kg izoniazidi oralurad ertjeradi dozit kvirasi orjer administrirebis rejimtan. oraluri medikamentebi pacientebs ezleodat xelze, rata Tavad mierot isini. intervalebit mkurnalobit rejimis Casatareblad pacientebi unda mosuliyvnen klinikasi kvirasi orjer 3-4 dris intervalit. mkurnaloba sruli zedamxedvelobit mimdinareobda, e.i. pacienti jer irebda izoniazidis abs metvalyureobaze pasuxismgebeli piris TandaswrebiT (romelic amowmebda namdvilad gadaylapa Tu ara pacientma abi) da Semdeg uketdeboda streptomicinis inieqcia. 12-Tviani mkurnalobis kursis Sedegebi mocemulia cxrilsi #29. intervalebit intermitiuli mkurnalobis rejimi iyo Zalzed warmatebuli da SesaZloa odnav ufro efeqturi, vidre yoveldriuri rejimi. interval;ebit mkurnalobis potenciuri SesaZleblobebi mit ufro sakvirveli iyo, rom kvlevasi monawile pacientebis umetes nawils arenisneboda Sorswasuli, ormxrivi kavernozuli procesi masiuri baqteriagamoyofit. es maxasiatebeli saerto iyo CenaiSi (yofili madrasi) Catarebuli yvela kvlevisatvis, romelsic monawileobdnen ZiriTadad mzimed daavadebuli pacientebi. recidivebis macvenebeli ori wlis ganmavlobasi Seadgenda 8% im SemTxvevaSi, rodesac medikamentebis mireba xdeboda kvirasi orjer da 12% mati yoveldriurad mirebis dros. otxi wlis Semdeg es macveneblebi iyo 12% da 15%. xutidan otx pacients, sadac recidivi ganvitarda intermitiuli mkurnalobis Semdeg, SenarCunebuli hqonda mgrznobeloba izoniazidis da streptomicinis mimart. amas mivyavart daskvnamde, rom mkurnalobis dasawyissi intensiuri fazis gamoyenebis SemTxvevaSi mgrznobelobis mqone baqteriebi savaraudod, ganadgurebuli iqneboda. kidev ert kvlevasi, romelic aseve CenaiSi Catarda ambulatoriul pacientebs Soris, Seswavlili iqna dozebis mirebas Soris intervalis ert kviramde gazrdis SesaZlebloba. am miznit Seiswavles ertdroulad mimdinare otxi intervalebiani rejimi. simartivisatvis aq mxolod ori matgania arwerili. 163

cxrili #30 12 Tvis ganmavlobasi streptomicini (S) + izoniazidi (H) kvirasi orjer da kvirasi ertxel mirebis rejimebis Sedareba a daavadebis statusi S 2 H 2 orjer kvirasi b b S 1 H 1 kvirasi ertxel b pacientebis % pacientebis % raodenoba raodenoba baqteriologiurad pasiuri 107 91 82 71 baqteriologiurad aqtiuri 9 8 30 26 (tuberkulozit gamowveuli 1 1 3 3 sikvdili) sul pacientebi 117 100 115 100 a wyaro b asoebis qves miwerili cifri miutitebs dozebis raodenobaze kvirasi g SH: streptomicini 0,75 1 g kuntsida inieqcia + izoniazidi 15 mg/kg-ze cxrili #31 streptomicini + izoniazidis (S 2 H 2 ) kvirasi orjer mirebis rejimis Sedareba kvirasi ertxel (S 1 H 1 ) mirebis rejimtan izoniazidis inaqtivaciis macveneblisa da streptomicinis dozebis mixedvit rejimi pacientebi daavadebis pasiuri formit (%) izoniazidis inaqtivaciis macvenebeli streptomicinis doza neli swrafi 1 g 0,75 g S 2 H 2 (orjer kvirasi) S 1 H 1 (kvirasi ertxel) 91 82 91 60 91 76 92 62 Seadares ori rejimi, pirveli streptomicins plus izoniazidi kvirasi orjer, meore - streptomicins plus izoniazidi kvirasi ertxel. doza orive SemTxvevaSi Tanabari iyo: 1,0 g an 0,75 g streptomicini plus 15 mg/kg izoniazidi. Seswavlili iqna streptomicinis ufro dabali dozis efeqti (0,75g), radganac arsebobda varaudi, rom igi ufro advilad asatani iyo xandazmuli pacientebisatvis, vidre Cveulebrivi doza (1,0 g). 12-Tviani mkurnalobis Sedegebi Sejamebuli saxit mocemulia cxrilsi #30. rejimma, romlis drosac medikamentebi gamoiyeneboda kvirasi orjer, kidev ertxel daamtkica, rom igi Zalzed efeqturi iyo, xolo rejimi, romelic 164

gulisxmobda medikamentebis kvirasi ertxel mirebas SedarebiT naklebad efeqturi. sakmaod STambeWdavi iyo is faqti, rom miuxedavad daavadebis simwvavisa, medikamentebis kvirasi ertxel mirebis rejimis drosac, pacientta 71% miarwia baqteriologiur gaumjobesebas 71. mizezebi, ris gamoc Seswavlili iyo kvirasi ertxel medikamentebis gamoyenebis rejimi sainteresoc iyo da mnisvnelovanic. am analizis dros pacientebi dajgufebulni iyvnen izoniazidis inaqtivaciis macveneblebisa da streptomicinis dozebis mixedvit. cxrili #31 gvicvenebs, rom medikamentebis kvirasi orjer gamoyenebis rejimze zemoqmedebas ver axdenda verc izoniazidis inaqtivaciis macvenebeli da verc streptomicinis dozis 25%-iT Semcireba da piriqit, medikamentebis kvirasi ertxel mirebis rejimze askara zemoqmedebas axdenda izoniazidis inaqtivaciis xarisxi da aseve streptomicinis dozis Semcireba, Tumca ufro naklebad. gamovlinda, rom rejimi medikamentebis kvirasi orjer mirebit sawyisi fazis garesec ki Zliermoqmedi da efeqturi iyo. izoniazidis inaqtivaciis macvenebeli aseve zegavlenas axdenda kvirasi ertxel medikamentebis mirebis rejimit ganpirobebul reaqciaze. amjamad arsebuli medikamentebit intermitiuli mkurnaloba arwevs Tavisi efeqturobis praqtikul limits, rodesac dozebis mirebas Soris intervali ert kviramde xangrzlivdeba. rifampicinis garese intermitiuli mkurnalobis gamocdilebidan SeiZleba gaketdes Semdegi daskvnebi: izoniazidis marali dozebis (14-15 mg/kg) mireba kvirasi orjer plus streptomicini (0,75 1 g) Zalzed efeqturia, miuxedavad imisa am rejimit mati mireba xdeba mkurnalobis dawyebistanave, Tu sawyisi intensiuri fazis Semdeg. aseti rejimi SeiZleba maralefeqturi iyos Sorswasuli formis dros da iset mosaxleobasi, romelsac axasiatebs inaqtivaciis marali macveneblebi; izoniazidis kvirasi ertxel mireba (15 mg/kg-ze) streptomicintan ertad (1g), medikamentebis yoveldriuri mirebis otxkviriani sawyisi Terapiis Semdeg, arwevda kvirasi orjer mirebis rejimis efeqtianobas. Tumca am rejimisgan gansxvavebit, swrafi inaqtivaciis mnisvnelovnad dabali macveneblit gamoirceoda da amitomac ar SeiZleba iyos rekomendirebuli. 165

intermitiuli mkurnalobis mokle kursi rifampicinisa da pirazinamidis Seqmnam ganapiroba intermitiuli mkurnalobis mokle kursis SesaZleblobis Seswavlis idea. Tavdapirvelad mkvlevrebma Seiswavles intensiuri fazis yoveldriuri rejimebi da mati momdevno gagrzelebis faza intermitiuli rejimit. mkurnalobis efeqturobis macvenebeli iyo recidivis riski. mravali rejimis mesveobit iqna mirweuli daaxloebit 100%-iani gankurneba da relafsis macvenebeli 5%-ze naklebi. mtelma rigma kvlevebma gvicvena, rom intermitiuli mkurnalobis rejimi, romelic mosdevs intensiur fazas cxrili #32 mkurnalobis nawilobriv intermitirebuli kursis gamoyenebit Gatarebuli kvlevebi qveyana an kvlevis regioni Catarebis weli madrasi b 1974 indoeti 1974 hong-kongi d madrasi 1977 singapuri 1978 poloneti 1982 singapuri e 1983 poloneti 1984 zairi 1989 1993 rejimi a 2HRZS/3H 2 Z 2 S 2 2HRZS/5H 2 Z 2 S 2 2HRZS/4H 2 Z 2 S 2 2HRZS/6H 2 Z 2 S 2 3HRZS/2H 2 Z 2 S 2 2HRZS/4H 3 R 3 1HRZS/5H 3 R 3 2HRZ/4H 3 R 3 2HRZS/4H 2 R 2 2(HRZS)/4H 3 R 3 2HRZS/4H 3 R 3 1(HRZS)/5H 3 R 3 1HRZS/5H 3 R 3 2(HRZ)/4H 3 R 3 2HRZ/4H 3 R 3 2HRZ/4H 2 R 2 2HRZS/4H 2 R 2 2HRZE/4H 2 R 2 2HRZE/9H 2 R 2 2HRZE/4H 2 R 2 0.5HRZE/ 1.5H 3 R 3 Z 3 E 3 /4H 2 R 2 0.5HRZE/ 1.5H 3 R 3 Z 3 E 3 /7H 2 R 2 relafsze Semowmebuli pacientebis raodenoba 129 132 87 relafsi 2wlis monitoringis ganmavlobasi 5 g 0 g 7 bibliografuli wyaros nomeri 72 73 3 87 4 187 1 73,74 97 94 109 85 46 47 42 46 40 1 1 0 7 0 5 2 8 2 75 76 77 4 78 44 2 116 9 79 56 119(aiv-inficirebuli) 121(aiv-inficirebuli) 180(aiv-inficirebuli) 293(aiv-inficirebuli) 50 (aiv-inficirebuli) 2 5 0 1 80 166

a H=izoniazidi, R=rifampicini, Z=pirazinamidi, E=eTambutoli, S=streptomicini. asoebis win mocemuli cifri miutitebs mkurnalobis xangrzlivobaze TveebSi, asoebis Semdeg, qvemot miwerili cifri miutitebs dozebis raodenobaze kvirasi. b amjamad ewodeba Cenai g mkurnalobis Semdgomi monitoringi 18 Tvis ganmavlobasi d amjamad hong-kongis gansakutrebuli administraciuli regioni CineTSi e frcxilebsi mocemuli medikamentebis armnisvneli asoebi miutitebs fiqsirebuli dozebis kombinaciaze, frcxilebis garese ki ert medikaments v pacientebis naxevari intensiur fazasi aseve irebda levofloqsacins. medikamentebis yoveldriuri mirebit da SeiZleba sul ori kviris xangrzlivobis iyos, aseve Zalzed efeqturia, Tuki igi mimdinareobs metvalyureobis qves (ix. cxrili #32). mtlianad intermitirebuli mkurnalobis rejimi aseve maral efeqturi armocnda (ix. cxrili # 33). 2-Tviani rejimi izoniazidis, rifampicinis, pirazinamidisa da etambutolis oraluri gamoyenebit, romelsac mosdevda 4 - Tviani rejimi izoniazidisa da rifampicinis gamoyenebit Seswavlili iqna, rogorc yoveldriuri mirebis, aseve nawilobriv da mtlianad intermitirebuli rejimis SemTxvevebSi. mtlianad intermitirebuli mkurnalobis rejimi ufro mosaxerxebelia metvalyureobis gansaxorcieleblad rogorc jandacvis musakebisatvis, aseve pacientebisatvisac, igi maralefeqturia, izleva mkurnalobis warmatebis maral da recidivis dabal macveneblebs. aseti rejimebi amjamad fartod gamoiyeneba da karg Sedegebsac izleva 81. 6 Tvis ganmavlobasi kvirasi orjer rifampicinis Semcveli rejimis Catarebam, romelic agrzelebda 2 kviris ganmavlobasi medikamentis yoveldriuri mirebis rejims, aseve marali 82 efeqturoba acvena. Tumca erti dozis gamotovebisas rejimi ukve icvleba da gadadis kvirasi ertxel medikamentebis mirebis rejimze, romelic naklebefeqturia da meti toqsikurobac gaacnia, rac ganpirobebulia imunologiurad induciurebuli gverditi reaqciebit. rifampicinze gverditi reaqciebi ufro xsiria kvirasi ertxel misi mirebisas. 167

cxrili #33 mkurnalobis mtlianad intermitirebuli mokle kursis gamoyenebit Gatarebuli kvlevebi qveyana an kvlevis rejimi a recidivze recidivi2wlis bibliogra- regioni Catarebis Semowmebuli monitoringis fuli wyaros weli pacientebis ganmavlobasi nomeri raodenoba hong-kongi b 1974 4H 3 R 3 Z 3 S 3 /2H 2 Z 2 S 2 71 6 73 4H 3 R 3 Z 3 S 3 /4H 2 Z 2 S 2 83 1 samxret afrika 1975 6H 2 R 2 Z 2 S 2 279 6 83 hong-kongi b 1977 6H 3 R 3 Z 3 E 3 S 3 152 1 84 6H 3 R 3 Z 3 S 3 151 1 6H 3 R 3 E 3 S 3 166 8 6H 3 R 3 Z 3 E 3 160 2 hong-kongi b 1979 2H 3 R 3 Z 3 S 3 /4H 3 R 3 S 3 220 3 85 2H 3 R 3 Z 3 S 3 /2H 3 R 3 S 3 205 5 2H 3 R 3 Z 3 S 3 /4H 3 R 3 Z 3 S 3 208 3 2H 3 R 3 Z 3 /4H 3 R 3 Z 3 199 6 madrasi, 1980 2H 3 R 3 Z 3 S 3 /4H 2 R 2 S 2 111 2 86 indoeti g 2H 3 R 3 Z 3 S 3 /4H 1 R 1 S 1 111 5 2H 3 R 3 Z 3 S 3 /4 R 2 H 2 101 3 2H 3 R 3 Z 3 S 3 /4 R 1 H 1 116 2 2H 3 R 3 Z 3 S 3 /4H 2 S 2 151 3 2H 2 R 2 Z 2 S 2 /4H 2 R 2 S 2 108 3 2H 2 R 2 Z 2 S 2 /4H 1 R 1 S 1 117 4 2H 2 R 2 Z 2 S 2 /4 R 2 H 2 102 6 2H 2 R 2 Z 2 S 2 /4 R 1 H 1 109 7 2H 2 R 2 Z 2 S 2 /4H 2 S 2 155 10 kanaris kunzulebi d 1990 2H 2 R 2 Z 2 (E 2 ) /4H 2 R 2 80 3 87 madrasi, indoeti g 1990 2H 3 R 3 Z 3 E 3 /4H 2 R 2 273 6 88 haiti 1990 2H 3 R 3 Z 3 E 3 /4H 3 R 3 129(aiv-inficirebuli) 5 81 2H 3 R 3 Z 3 E 3 /4H 3 R 3 211(aiv-inficirebuli) 2 CineTi 1991 2H 3 R 3 Z 3 S 3 /4H 3 R 3 300 3 89 a b H=izoniazidi, R=rifampicini, Z=pirazinamidi, E=eTambutoli, S=streptomicini. asoebis win mocemuli cifri miutitebs mkurnalobis xangrzlivobaze TveebSi, asoebis Semdeg, qvemot miwerili cifri miutitebs dozebis raodenobaze kvirasi. amjamad CineTSi hong-kongis gansakutrebuli administraciuli regioni g amjamad ewodeba Cenai d etambutoli, romelic ezleoda mxolod mkurnalobis Sewyvetis istoriis mqone pacientebs 168

janmos tuberkulozis qimioterapiis praris kolaboraciuli centris mier warmodgenili iyo kvlevis Sedegebi (99 100% efeqtianoba), romlis umnisvnelovanesi maxasiatebeli iyo mkurnalobis moqnili organizacia 90,91. TiToeul pacients SesaZlebloba hqonda Tavad aercia medikamentebis misarebad mistvis yvelaze mosaxerxebeli adgili, gulmkerdis daavadebebis klinika iqneboda es, eqimis kabineti, fabrikis dispanseri, jandacvis centri Tu saavadmyofo, romelic misi samusao adgilidan saxlisken mimaval gzaze mdebareobda. sawiroebis SemTxvevaSi mas binaze moemsaxureboda jandacvis musaki. 169

28. ra dozebit gamoiyeneba tubsawinaarmdego medikamentebi yoveldriur da intermitiul rejimsi h.raideri 13 cxrilsi #34 mocemulia janmos mier tubsawinarmdego medikamentebis amjamad rekomendirebuli dozebi sxeulis wonaze (mg/kg-ze) gadaangarisebit 92. Tumca, janmo 93 da IUATLD 94 ar uwevs rekomendacias kvirasi orjer medikamentebis mirebas, vinaidan erti dozis dakargvam SeiZleba ganapirobos mkurnalobis uefeqtoba da toqsiurobis marali riski. cxrili #34. tubsawinaarmdego medikamentebis dozebi mg/kg sxeulis wonaze gadangarisebit medikamenti izoniazidi rifampicini pirazinamidi streptomicini etambutoli Tiopcetazoni driuri doza mg/kg-ze yoveldriuri Mkurnaloba mkurnaloba 3-2jer dresi 5 10 (4-6) (8-12) 10 10 (8-12) (8-12) 25 35 (20-30) (30-40) 15 15 (12-18) (12-18) 15 30 (13-17) (25-35) 2.5 NA (2-3) mkurnaloba 2-jer dresi 15 (13-17) 10 (8-12) 50 (40-60) 15 (12-18) 45 (40-50) NA 13 tuberkulozis ganyofilebis medmusaki, saertasoriso gaertianeba tuberkulozisa da filtvis daavadebata winaarmdeg. parizi, safrangeti 170

praqtikulad ufro xelsayreli armocnda sxeulis wonaze gadaangarisebit dozebis gansazrvra, radgan es amartivebs medikamentebis danisvnisas tabletis sawiro raodenobis gamotvlas. rogorc gvicvenebs grafiki #12. tuberkulozit daavadebuli pacientebis wona sxvadasxva qveyanasi gansxvavebulia. wonis cvlilebebis diapazoni, romelic grafikze arnisnulia vertikaluri wyvetili xazit - IUATLD-is 77 rekomendaciit sawiroebs adaptacias qveynebis mier, rac uzrunvelyofs pacientebis maqsimalurad didi nawilisatvis koreqtuli dozebis danisvnas. grafiki #12. sxeulis wonis maxasiateblebi sqesis mixedvit keniasi, nepalsa da senegalsi qalebi mamakacebi kenia nepali senegali sxeulis wona (kg-si) sxeulis wona (kg-si) arsebobs alternativa, rom gamoyenebuli iqnes pacientebis umravlesobistvis Sesabamisi erti doza, rogorc es gaketda tuberkulozis ganaxlebuli programit indoetsi 95. bavsvebi da Zalzed dabalwoniani individebi ireben mati wonis SesabamisobaSi moyvanil dozebs, xolo Warbwonianebs ezlevat eqstra-abebi. es izleva medikamentebis winaswar dafasoebuli kolofebis momzadebis SesaZleblobas, rac mnisvnelovnad uwyobs xels menejments. 171

29. ra mecnierul mtkicebulebebs efuzneba tubsawinaarmdego medikamentebis dozirebastan dakavsirebuli rekomendaciebi h.raideri 14 TiToeuli medikamenti gamoyenebuli unda iqnes im minimaluri koncentraciit, romelic izleva tuberkulozis mikobaqteriis zrdis SeCerebis SesaZleblobas. medikamentis aset koncentracias minimaluri inhibitoruli koncentracia ewodeba (MIC) da ganisazrvreba in vitro mravalricxovani veluri Stamebis testirebit im koncentraciis dasadgenad, romelzec mati umetesobis zrda SeCerdeba. vinaidan es in vitro sistema-metodi mnisvnelovan zegavlenas axdens Sedegebze, amitom MIC sidide gansxvavdeba imisdamixedvit niadagi momzadebulia kvercxze, bulionsa Tu agar-garze. im umarlesi dozis dadgena, romelic ar iwvevs xsir toqsikur reaqciebs, xdeba in vivo. Tu medikamentis maqsimaluri koncentracia, romelic SratSi SeiZleba iyos mirweuli toqsikuri reaqciis garese naklebia MIC-ze, masin medikamenti ar unda iqnes gamoyenebuli. Tuki medikamentis maqsimalurad mirwevadi doza SratSi bevrad aremateba MIC misi Terapiuli veli fartoa, xolo Tu igi mxolod odnav aremateba MIC-s moqmedebas - veli SedarebiT viwroa. mesame mnisvnelovani elementi, garda MIC-isa da SratSi preparatis maqsimaluri koncentraciisa - drois is xangrzlivobaa, romlis ganmavlobasic medikamentis done SratSi MIC-ze maralia. es ganisazrvreba naxevardaslis periodis xangrzliobit. TiToeuli wamlis koncentraciis done SratSi gansazrvruli minimaluri periodis ganmavlobasi MIC-ze marali unda iyos, rata SesaZlebeli gaxdes tuberkulozis mikobaqteriaze satanado zemoqmedebis moxdena. aseti minimaluri dro yvela medikamentisatvis gansxvavebulia. 14 tuberkulozis ganyofilebis medmusaki, saertasoriso gaertianeba tuberkulozisa da filtvis daavadebata cinaarmdeg. parizi, safrangeti 172

MIC-ze ufro mnisvnelovania minimaluri baqteriociduli koncentracia MBC koncentracia, romlis Sedegadac baqteria irupeba medikamentis moqmedebit. MBC yoveltvis ufro maralia MIC-ze da MBC /MIC Sefardeba gansxvavdeba medikamentebis mixedvit. medikamentis maqsimalurad asatani doza da, aqedan gamomdinare, SratSi misi maqsimaluri koncentracia ganisazrvreba klinikuri praqtikit, xolo realuri Terapiuli efeqti ki kontrolirebuli klinikuri kvlevebit. ZiriTadi amocanaa ganisazrvros iseti umciresi doza (rata toqsikuroba Tavidan iqnes acilebuli), romelic uzrunvelyofs SratSi MIC-ze maral koncentracias (an MBC-ze uketess). magalitad, kvleva romelic Catarda armosavlet afrikasi, miznad isaxavda gansazrvras gaaumjobesebda Tu ara TioacetazonTan kombinaciasi izoniazidis dozis gazrda 300 mgdan 450mg-mde mkurnalobis rejimis efeqtianobas 96. mirebuli Sedegi uaryofiti iyo, Tumca izoniazidis Tanmxlebi toqsiuroba am ori dozisatvis mocemul kvlevasi didad ar gansxvavdeboda. sxva wyaroebit mirebuli informacia gvicvenebs, rom izoniazidis toqsikuroba izrdeba misi dozebis momatebastan ertad. dadginda, rom izoniazidis optimaluri driuri doza 300mg-ia. aseve ganisazrvra streptomicinis optimaluri dozac 97. xangrzlivvadiani mkurnalobis periodsi streptomicinis doza 0,75g isetive eefqturi armocnda, rogorc 1,0gr. ufro dabali dozebis gamoyeneba izleoda izoniazidisadmi rezistentobis warmoqmnis prevenciis SesaZleblobas da uzrunvelyofda naxvelis konversias, amastan SedarebiT naklebi iyo vestibularuli darrvevebis sixsire. Sefasebis aseti midgoma, romelic gulisxmobs toqsikurobasa da maqsimaluri Terapiuli moqmedebis gawonasworebas, gamoyenebuli iyo yvela tubsawinaarmdego medikametis mimart. es qmnis racionalur safuzvels dozebis gansazrvrastan dakavsirebuli rekomendaciebisatvis. 173

grafiki #13 izoniazidis (H), rifampicinis (R), pirazinamidis, (Z) etambutolis (E), streptomicinis (S) da Tioacetazonis (T) minimaluri inhibitoruli koncentraciebi (MICs) da maqsimaluri koncentraciebi SratSi wreebi arnisnavs maqsimalur koncentracias in vivo SratSi, xazebi ki sxvadasxva kvlevebsi in vivo gansazrvrul MICs s diapazons. koncentracia (mg/l) samusao Skala MIC-isa da SratSi maqsimalur koncentracias Soris urtiertdamokidebulebis Sejamebuli monacemebi eqvsi ZiriTadi medikamentisatvis gvicvenebs, rom izoniazidsa da rifampicins aqvs Terapiuli moqmedebis farto speqtri, danarcen medikamentebs ki, SedarebiT naklebi (ixilet grafiki #13) 98, 99, 100, 101, 102, 103. 174

30. rogoria mkurnalobis optimaluri xangrzlivoba 15 T.sanTa 16 mkurnalobis mokle kursi pacientebis umetes nawilsi, 2-3 TveSi izleva nacxisa da kulturis konversiis SesaZleblobas. mkurnalobis bevri rejimi uzrunvelyofs sasurvel Sedegebs, rac dasturdeba kulturis negatiurobit mkurnalobis dasrulebis etapze, 97-100%, Tumca amocanas Seadgenda mkurnalobis iseti praqtikuli rejimis SemuSaveba, romelsac eqneboda recidivis dabali macvenebeli (<5%). nacxit dadebiti pulmonaruli tuberkulozi rigma kvlevebma gamoavlina, rom rifampicinis Semcveli 6-Tviani rejimi da pirazinamidi intensiur fazasi Zalzed maral efeqts izleva tuberkulozit daavadebul nacxit dadebit pacientebsi (cxrili #35). cxrili #35. nacxit-pozitiuri pulmonaruli tuberkulozis mkurnalobis xangrzlivoba gagrzelebis fazasi rifampicinis gamoyenebit qveyana an regioni afrika hong-kongi singapuri kvlevis Catarebis weli 1972 1978 1974 1973 1978 rejimi 2HRZS/4H 2 Z 2 S 2 2HRZS/4HR 2HRZS/4H 2 Z 2 S 2 2HRZS/4 HRZ 2HRZS/4HR 2HRZS/4H 3 R 3 2HRZ/4H 3 R 3 mkurnalobis xang-oba (TveebSi) 6 6 6 6 6 6 6 Sefasebuli pacientebis raodenoba 159 166 87 78 80 97 109 recidivis macvenebeli 2 wlis manzilze(%) 15 k. tomanis wina gamocemis Tavze dayrdnobit 16 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeti. 4 3 7 0 2 1 1 bibliografiuli wyaro 104,105 106,107 108,109 110,111,112 113,114 175

es rejimebi medikamentebisadmi mgrznobelobis mqone pacientebsi mkurnalobis dasrulebis TiTqmis 100% efeqturobas izleva. recidivis macvenebeli ki 0,6%-s Seadgenda. cxrili #36. nacxit dadebiti pulmonaruli tuberkulozis mkurnalobis xangrzlioba gagrzelebis fazasi rifampicinis garese qveyana an regioni afrika madrasi, indoeti kvlevis Catarebis weli 1972 1974 1977 rejimi 2HRZS/4HT 2HRZS/4HT 2HRZS/6HT 1HRZS/5HT 1HRZS/7HT 2HRZS/6HE mkurnalobis xang-oba (TveebSi) 6 6 8 6 8 8 Sefasebuli pacientebis raodenoba 179 75 81 79 58 305 recidivis macvenebeli 2 wlis manzilze(%) 7 13 0 18 7 5 bibliografiuli wyaro 104,105 115,116 117 armosavlet afrikasi Catarebulma kvlevebma gamoavlina, rom rifampicini inisneboda mxolod intensiur fazasi, rejimi mimdinareobda 8 Tve (cxrili #36). 6-Tviani gagrzelebis faza, romelic ar Seicavda rifampicins gamoirceoda recidivis marali macvenebelit - 7-18%, masin, rodesac 8-Tviani rejimis dros recidivis macvenebeli Seadgenda 0-7%-s. recidivis asetive macveneblebi (5%) iyo mirebuli izoniazidisa da etambutolis yoveldriuri mirebisas gagrzelebis fazis 6 Tviani rejimis dros 117. pirvel kvlevasi medikamentebis mireba xdeboda yoveldriurad mteli mkurnalobis manzilze an sawyis intensiur fazasi mainc. indoetsi, madrassi (amjamad ewodeba Cenai) tuberkulozis kvlevis centris mier Catarebulma kvlevebma da hong-kongis kvlevebma cxadyo 106, rom intermitiul rejims isetive efeqturoba aqvs da mkurnalobis bolos izleva TiTqmis 100%-ian warmatebas, xolo recidivis macvenebeli 2-7%-s Seadgens, amastan gverditi reaqciebic mnisvnelovnad mcirdeba (cxrili #37). 176

cxrili #37. intermitiuli qimioterapiis mokle kursi qveyana an regioni kvlevis Catarebis weli rejimi mkurnalobis xang-oba (TveebSi) Sefasebuli pacientebis raodenoba recidivis macvenebeli 2 wlis manzilze(%) bibliografiuli wyaro hong-kongi 1974 4H 3 R 3 Z 3 S 3 /2H 2 Z 2 S 2 6 71 3 108,109 madasi, 1980 2H 3 R 3 Z 3 S 3 /4H 3 R 3 S 3 6 220 3 118,119 indoeti 2H 3 R 3 Z 3 S 3 /4H 2 R 2 S 2 6 111 7 2H 3 R 3 Z 3 S 3 /4R 2 H 2 6 101 0 2H 2 R 2 Z 2 S 2 /4H 2 R 2 S 2 6 108 2 1995 2H 2 R 2 Z 2 S 2 /4R 2 H 2 6 102 1 2H 3 R 3 Z 3 E 3 /4H 2 R 2 6 519 1 rogorc aq warmodgenili kvlevebis Sedegebi gvicvenebs, axlad gamovlenil nacxit dadebit pacientebs unda CautardeT mkurnalobis yoveldriuri, an intermitiuli rejimi 6-8 Tvis ganmavlobasi. 8 Tvis xangrzlivobis mkurnaloba sawiroa im SemTxvevaSi, Tu rejimi gagrzelebis fazasi ar Seicavs rifampicins 108. intensiuri fazis xangrzlivoba unda Seadgendes sul mcire 2 Tves. nacxit negatiuri pulmonaruli tuberkulozi nacxit uaryofiti pulmonaruli tuberkulozis mkurnalobis optimalur xangrzlivobas Seiswavlidnen hong-kongsi Catarebuli kvlevis dros. pacientebs, romlebsac mjavagamzle baqteriaze 5 negatiuri nacxi hqondat, xolo rentgenologiuri gamokvlevebit ewvi iqna mitanili, CautardaT 2 an 4 - Tviani mkurnaloba HRZS (cxrili #38). recidivis macvenebeli 2-3 - Tviani mkurnalobis rejimis Semdeg ufro marali iyo da gaketda daskvna, rom nacxit uaryofit pacientebs unda Cautardes sul mcire 4 - Tviani mkurnaloba. Tumca Sesabamisobisa da usafrtxoebis miznit, janmo rekomendacias uwevs nacxit uaryofiti pulmonaruli tuberkulozit daavadebul pacientebsi 6-Tviani rejimis gamoyenebas. 177

cxrili #38. Tavdapirveladve nacxit uaryofiti pulmonaruli tuberkulozis mkurnalonis xangrzlivoba hong-kongsi kvlevis Catarebis kulturis sawyisi rejimi mkurnalobis xang-oba Sefasebuli pacientebis recidivis macvenebeli 2 bibliografiuli wyaro weli statusi (TveebSi) raodenoba wlis manzilze(%) 1976 negatiuri - 176 40 120,121,122 2HRZS 2 165 4 3HRZS 3 162 2 pozitiuri 3PHS/ H 2 S 2 12 160 0 2HRZS 2 72 15 3HRZS 3 69 9 1978 negatiuri 2PHS/H 2 S 2 12 68 0 3HRZS 3 364 1 3H 3 R 3 Z 3 S 3 3 345 1 123 pozitiuri 4H 3 R 3 Z 3 S 3 4 325 1 4HRZS 4 157 3 4H 3 R 3 Z 3 S 3 4 136 3 6H 3 R 3 Z 3 S 3 46 166 4 mkurnalobis rejimis xangrzlivobis kidev ufro metad Semcirebis Sedegebi mkvlevarta orma jgufma safrangetsa da indoetsi, pulmonaruli tuberkulozis mkurnalobis ufro xanmokle rejimebis Ziebis processi, gamoscades 3 Tvis xangrzlivobis yoveldriuri rejimi (HRZS is 90 doza) (cxrili #39). HRZS is yoveldriuri mirebis 3- Tviani rejimit, romelic gamoiyenes indoetsi 3 Tvis Semdeg mirweuli iyo kulturis 100%-iani konversia, magram pacientebis 20%-s arenisnebodat baqteriologiurad dadasturebuli recidivi. rodesac pacientebs azlevdnen ufro dabal dozebs, magram ufro xangrzlivi drois ganmavlobasi_kvirasi samjer 2 Tvis ganmavlobasi (27 doza) da Semdeg kvirasi 2-jer 4 Tvis ganmavlobasi, rac sul Seadgenda 63 dozas 6 TveSi recidivi areisna 4-6%-s(15,16). masasadame, mnisvnelovania periodis xangrzlivoba, rodesac pacientebs ezlevat medikamentebi da ara dozebis raodenoba. 178

cxrili #39. nacxit dadebiti pulmonaruli tuberkulozis SedarebiT xanmokle kursis xangrzlivoba qveyana an regioni kvlevis Catarebis rejimi mkurnalobis xang-oba Sefasebuli pacientebis recidivis macvenebeli 2 bibliografiuli wyaro weli (TveebSi) raodenoba wlis manzilze(%) singapuri 1973 2HRZS/2HRZ 4 79 11 110,111,112 afrika 1976 2HRZS/2HR 4 77 8 madrasi, 1977 2HRZS/2HRZ 4 104 16 124,125 indoeti 1974 2HRZS/2HR 4 104 11 1977 3HRZS 3 200 20 126,127 2HRZS/3H 2 Z 2 S 2 5 129 128,129 3HRZS/2H 2 Z 2 S 2 5 187 4 126 msgavsad amisa, singapursi Catarebuli kvlevebis dros gamoyenebul 4-Tvian rejimsac axasiatebda recidivis marali macveneblebi (8-16%) 110,111,112. madrassi gamoyenubuli orive 5-Tviani rejimi (2HRZS/ 3HRZ da 3HRZS/2H 2 Z 2 S 2 ) efeqturi iyo da arinisneboda recidivis dabali macvenebeli (4-5%). Tumca es ertaderti kvlevaa, romelmac Seiswavla 5 - Tviani rejimebi, xolo misarebi Sedegebi mirweul iqna mxolod streptomicinis gamoyenebit mkurnalobis aqedan gamomdinare, jerjerobit ar arsebobs mkurnalobis 6 Tveze naklebi xangrzliobis iseti rejimi, romelic misareb Sedegebs mogvcemda nacxit dadebiti tuberkulozit daavadebul pacientebsi. rogoria rifampicinis garese mkurnalobis standartuli rejimis optimaluri xangrzlivoba arsebobs situaciebi, romlis drosac rifampicini an fizikurad ar aris xelmisawvdomi, an rifampicinisa da pirazinamidis micema pacientisatvis ar SeiZleba. pirazinamidisa da rifampicinis xmarebasi Semosvlamde pacientebis mkurnaloba xangrzliv periods moicavda. sawyis etapzeve nacxit dadebiti tuberkulozit daavadebul pacientebsi baqteriologiurad pasiuri mdgomareobis mirweva SesaZlebelia praqtikulad yvela efeqturi rejimis gamoyenebit 6 Tvis ganmavlobasi mkurnalobis dawyebidan, Tumca relafsi uvitardeba im pacientebis TiTqmis ert meotxeds, romlebsac mkurnaloba utardebat streptomicinit, izoniazidita 179

da Tioacetazonis yoveldriuri mirebit 6 Tvis manzilze (cxrili #40). cxrili #40. rifampicinis garese mkurnalobis xangrzlivoba qveyana an regioni kvlevis Catarebis rejimi mkurnalobis xang-oba Sefasebuli pacientebis recidivis macvenebeli 2 bibliografiuli wyaro weli (TveebSi) raodenoba wlis manzilze(%) armosavlet 1970 6HTS 6 104 22 130,131 afrika 6HS 6 112 29 madrasi, 1962 2HTS/16HT 18 133 3 132 indoeti 12HT 12 72 19 12HP 12 454 17 133 12EHE 12 107 16 12H 2 S 12 199 9 meores mxriv, arsebobs seriozuli mtkicebulebebi imisa, rom 18 Tveze meti xangrzlivobis kargi mkurnaloba izleva mcire damatebit upiratesobebs mkurnalobis warmatebisa da recidivis prevenciis TvalsazrisiT 109. armosavlet afrikasi Catarebulma, kvlevebma gvicvena, rom streptomicinis pirveli rigis danamatis saxit gamoyenebam Teopiocetazon plus izoniazidis ZiriTadi rejimisatvis, romelic moicavda Teoacetazionisa da izoniazidis yoveldriur mirebas 8 kviris ganmavlobasi warmatebuli mkrunalobis macvenebeli 96%- mde gazarda iset pacientebsi, romelta mkurnaloba usedego iyo, rezistentobis warmoqmna isviatad xdeboda. orkviriani sawyisi intensiuri fazis Semdeg mkurnalobis warumateblobis macvenebeli 10%-s Seadgenda da yvelani izoniazidisadmi rezistentulni iyvnen. baqteriologiuri reaqcia im pacientebsi, romlebic 4 kviris ganmavlobasi irebdnen streptomicins, rogorc danamats sul umnisvnelod CamorCeboda sasurvel Sedegs (2%), im pacientebtan SedarebiT, romlebic danamats 8 kviris ganmavlobasi irebdnen (cxrili #41). 180

cxrili #41. reaqcia 2,4 an 8 kviris ganmavlobasi streptomicini_izoniazidita da TioacetazoniT (STH) mkurnalobis yoveldriur rejimze gagrzelebis fazasi izoniazid+tioacetazonis gamoyenebit, Sefaseba gaketebulia 1 wlis Semdeg qveyana an regioni sawyisi fazis xang-oba Sefasebuli pacientebis raodenoba sasiketo baqteriologiuri reaqcia izoniazidisadmi rezistentoba bibliografiuli wyaro armosavlet 8 kvira 162 3 3 134 afrika 4 kvira 159 5 5 2 kvira 161 10 10 arcerti 147 10 10 mkvlevrebma daaskvnes, rom mkurnalobis pirveli 8 kviris ganmavlobasi sasurveli iyo Tioacetazon-izoniazidis rejimisatvis streptomicinis damateba, Tuki es SeuZlebeli iyo, masin pirveli 4 kviris ganmavlobasi mainc. madrsassa da singapursi Catarebulma kvlevebma acvena, rom 2_ kviriani sawyisi intensiuri fazis damateba ar izleoda raime gansakutrebul sargeblobas da didad ar aumjobesebda mkurnalobis saboloo Sedegebs 135,136. CexoslovakiaSi Catarebulma kvlevam 137 Seiswavla am sami medikamentis roli sawyisi fazisatvis sruli intermitiuli rejimis dros da gamoavlina, rom intensiuri fazis xangrzliobis 13 kviramde gazrda, aranair dametebit sargeblobas ar izleoda (ZiriTadad, 98% da 99%). amgvarad, tradiciuli grzelvadiani mkurnalobisas sawyisi intensiuri fazis optimaluri xangrzlivoba 8 kviraa. 181

31. ra ZiriTadi gverditi reaqciebi axasiatebs pirveli rigis tubsawinaarmdego medikamentebs da rogoria mati ganmeorebit danisvnis procedura a.harisi 17 138, 139, 140 izoniazidi gverditi reaqciebi: gamonayari kanze; Zilianoba da letargia; periferiuli neiropatia (parastezia, dabujeba da tkivili kidurebsi); hepatiti. isviati gverditi reaqciebi: konvulsia, pelagra, artralgia, anemia, lupozuri (mgluriseburi) reaqciebi. martva: kanis reaqciebze ixilet qvemot; letargiis SemTxvevaSi pacientis damsvideba; periferiuli neiropatiisas misi prevencia SesaZlebelia vitamini B 6 is gamoyenebit (piridoqsini), 10mg dresi an B jgufis vitaminebis kompleqsit. Camoyalibebuli periferiuli neiropatiis SemTxvevaSi parodoqsinis micema unda moxdes ufro marali dozebit 50-75mg/dReSi; hepatiti ix. qvevit. rifampicini gverditi reaqciebi: 17 malaviis tuberkulozis kontrolis erovnuli programis, teqnikuri mrceveli. Llilongue, malavia. 182

gastrointestinaluri reaqciebi (muclis tkivili, gulisrevis SegrZneba, pirrebineba); hepatiti; kanis generalizebuli reaqciebi; Trombocitopeniuri purpura; intervalebiani rejimis dros gripozuli sindromi. isviati gverditi reaqciebi: osteomalacia, fsevdomembranuli koliti, fsevdoadrenaluri krizisi, Tirkmlis mwvave ukmarisoba, Soki, hemolituri anemia. rifampicinma SeiZleba gamoiwvios iseti gastrointestinaluri simptomebi, rogoricaa anoreqsia, gulisrevis SegrZneba, muclis tkivili da pirrebineba. es simptomebi maleve warmoisoba medikamentis mirebis Semdeg da SeiZleba gagrzeldes ramodenime saati. gripozuli sindromis dros arinisneba sicxe, surdo, motentiloba, Tavis tkivili da Zvlebis tkivili. rifampicini warmoadgens Zlier fermentebis mainducirebel sasualebas da SesaZloa ganapirobos SratSi sxva medikamentebis koncentraciis Semcireba. es gansakutrebit yuradsarebia qalebsi, romlebic sargebloben oraluri kontraceptivebit. pacientebi winaswar unda gaafrtxilon, rom rifampicini witel an narinjisfer Seferilobas azlevs organizmis sekreciis produqtebs (Sards, cremls, ofls da ganavals). martva: gastrointestinaluri reaqciebis SemTxvevebi. Tu gastrointestinaluri movlenebi imdenad mwvavea, rom qmnis mkurnalobis Sewyvetis safrtxes, pacientebi unda davamsvidot. gamoiyenet iseti medikamentebi, romlebic simptomatur Svebas moutans aset pacientebs (magalitad, metoklopramidi pirrebinebis SesaCereblad) an ukidures SemTxvevaSi miecit rifampicini sakvebis mcire ulufastan ertad, rac TiTqmis yvela SemTxvevaSi izleva medikamentis mirebis gagrzlebis SesaZleblobas 138. miuxedavad imisa, rom sakvebtan ertad rifampicinis Sewova odnav mcirdeba, es gacilebit uketesia, vidre misi mirebis Sewyveta; 183

rac Seexeba hepatitsa da kanis reaqciebs ixilet qvemot; Trombocitopenuri purpuris, Sokis, Tirkmlis mwvave ukmarisobis an hemolituri anemiis dros rifampicini dauyovnebliv unda iqnes amorebuli mkurnalobis rejimidan da ararasodes ar iyos xelaxla gamoyenebuli; gripozuli sindromis dros intermitiuli rejimis yoveldriuri rejimit Secvla. pirazinamidi gverditi reaqciebi: artralgia; hepatiti. isviati gverditi reaqciebi: gastrointestinaluri reaqciebi, reaqciebi kanze, sideroblasturi anemia. pirazinamidma SeiZleba gamoiwvios artralgia ganpirobebuli Sardis mjavas tubularuli gamoyofis inhibiciit, xolo Sardis mjavis maralma koncentraciam ki, SeiZleba gamoiwvios podagris ganvitareba. latenturi tuberkulozis mkurnalobasi rifampicinisa da pirazinamidis Semcveli rejimebis gamoyenebisas SeiZleba ganvitardes mwvave hepatotoqsikuroba. martva: saxsrebtan dakavsirebuli problemebis dros Cveulebriv, analgetikebit Catarebuli martivi mkurnaloba minimumamde amcirebs simptomebs, indometacini SeiZleba gamoiyenot ufro mwvave SemTxvevebSi. askarad gamoxatuli podagrisas sawiroa mkurnalobasi kolxicinis gamoyeneba. artralgia gacilebit naklebad vitardeba medikamentebis kvirasi samjer mirebis dros. mosalodnelia SratSi Sardis mjavis donis asimptomuri momateba, Tumca es ar sawiroebs raime cvlilebebis Setanas medikamentebsi an mati mirebis rejimsi; rac Seexeba hepatits ixilet qvevit. 184

etambutoli gverditi reaqciebi: iritadi reaqciis retrobulbaluri nevriti isviati verditi reaqciebi: kanis generalizebuli reaqciebi, artralgia, periferiuli neiropatia da Zalian isviatad hepatiti. SeniSvna: etambutolma SeiZleba gamoiwvios mxedvelobis dazianeba witeli da mwvane ferebis arqmis dakargva, fokussa da simaxvilis daqveiteba. Tumca toqsikurobis xarisxi damokidebulia dozis sidideze da Zalin isviatad vitardeba 15mg/kg-ze gaangarisebit yoveldriuri mirebisas an 25mg/kg-ze odenobit kvirasi samjer mirebis dros. martva: kargi iqneboda etambutolit mkurnalobis dawyebamde mxedvelobis sabaziso gamokvlevis Catareba. yvela pacienti gafrtxilebuli unda iyos, rom mxedveloba unda Semowmdes mxedvelobis problemis gacenistanave. mdgomareoba Cveulebriv swordeba medikamentis mirebis Sewyvetidan ramodenime kvirasi. zogierti programa itvaliswinebs witeli da mwvane ferebis arqmis testebis Catarebas yoveltviurad (magalitad, isiharas testi), Tumca mati gansakutrebuli sargeblianoba mititebuli ar aris. streptomicini umnisvnelo gverditi reaqciebi: nanemsaris tkivili, gamonayari, siwitle, gamagreba; piris Rrus aresi gabujebis SegrZneba da wkrialis xma yurebsi, romelic inieqciis Semdeg maleve warmoiqmneba. seriozuli gartulebebi: kanis hipersensitiuroba; vestibularuli aparatisa da smenis nervis dazianeba. fexmzime pacientebsi nayofsi analogiuri problemebis ganvitareba; Tirkmlis ukmarisoba. 185

martva: mcire gverditi reaqciebis dros sakmarisia pacienti davamsvidot; kanis hipersensitiurobis Sesaxeb ixilet qvemot; vestibularuli, auditoruli da renaluri dazianebebis SemTxvevaSi riski imatebs dozisa da asakis matebastan ertad. doza ar unda arematebodes 15-20 mg/kg-ze da unda Semcirdes 45 welze meti asakis pacientebsi, vestibularuli da auditoruli sistemis dazianeba vitardeba mkurnalobis pirveli 2 Tvis ganmavlobasi da vlindeba yurebsi zaris rekvis xmis SegrZnebis, TavbrusxveviT, ataqsiita da/an siyruit. procesi ukuqcevadia medikamentis dozis Semcirebis an medikamentis moxsnis SemTxvevaSi. intervalebit mkurnaloba (mag: kvirasi 3-jer) naklebad iwvevs seriozul toqsikurobas. Tioacetazoni gavrcelebuli gartulebebi: martva: kanze gamonayari, zogjer TandarTuli sokovani daavadebit isviati gartulebebi; RviZlis mwvave ukmarisoba, agranulocitozi, eqsfolaciuri, dermatiti, SesaZlo fataluri gamosavlit, ufro xsiria aiv-inficirebul individebsi; gamonayaris an hipersensitiulobis sxva nisnebis warmoqmnis SemTxvevaSi medikamenti unda moixsnas mteli mkurnalobis dros da misi ganmeorebiti gamoyeneba arar SeiZleba. igi Canacvlebuli unda iqnes etambutolit mas Semdeg, rac simptomebi gaqreba. aiv-pacientebsi toqsikurobis Zalzed marali sixsiris gamo, Toacetazoni ar unda iqnes gamoyenebuli savaraudod aiv-inficirebulni pacientebsi, an aiv-infeqciis marali prevalentobis regionebsi (ixilet: ra Rirebulebebi aqvs Tioacetazons, rogorc izoniazidis Tanxmleb medikaments da rogoria izoniazid plus Tioacetazonis rejimis efeqturoba ). kanis hipersensitiulobis martvis Sesaxeb ixilet qvemot. 186

kanisa da generalizirebuli hipersensitiulobis reaqciebi tubsawinaarmdego medikamentebis mimart kanis reaqciebi qavili gamonayris garese an umnisvnelo gamonayarit Tu pacienti (romelic ar irebs Tioacetazons) ucivis qavils umnisvnelo gamonayarit an gamonayaris garese, SeiZleba gamoviyenot simtomaturi mkurnaloba antihistaminebit, xolo tuberkulozis mkurnaloba gagrzeldes. pacientis monitoringi unda moxdes antituberkulozuri medikamentis yoveli momdevno dozis mirebisas. qavili zomieri/zlieri gamonayarit Tu ganvitardeba zomieri an Zlieri gamonayari mteli mkurnaloba unda Sewydes. Zlieri gamonayaris martva Tu gamonayari Zlieria, arinisneba sokovani gamonayaris simptomebi, hipotenzia an sxva mwvave daavadeba - gamoyenebul unda iqnes kortikosteroiduli mkurnaloba. prednizoloni inisneba oralurad, 40-60 mg dozit yoveldriurad sasurveli Sedegebis mirebamde, Semdeg doza TandaTanobiT mcirdeba, imis Sesabamisad, Tu rogor reagirebs amaze pacienti. tuberkulozis mkurnaloba unda Sewydes manamde, vidre gverditi reaqcia ar Cacxreba. rekomendaciebi tubsawinaarmdego medikamentebtan dakavsirebit mas Semdeg rac reaqcia Cacxreba, tubsawinaarmdego medikamentebis xelaxali danisvna unda moxdes Semdegi grafikit: dre medikamenti/doza 1. izoniazidi 50mg 2 izoniazidi 300mg 3. rifampicini-izoniazidi (RH) (naxevari tableti) 4. rifampicini-izoniazidi (1 tableti) 187

5. rifampicini-izoniazidi (sruli doza) 6. me-5 dris rejimi+pirazinamidi (naxevari tableti) 7. me-5 dris rejimi+pirazinamidi (erti tableti) 8. me-5 dris rejimi+pirazinamidi (sruli doza) 9. me-8 dris rejimi+etambutoli (naxevari tableti) 10. me-8 dris rejimi+etambutoli (erti tableti) 11. me-8 dris rejimi+etambutoli (sruli doza) 12. rifampicini izoniazidi+ pirazinamidi+ etambutoli (sruli doza) savarudod, izoniazidi da rifampicini naklebad iwveven gverdit reaqcias, amitom isini pirvel rigsi unda gamoviyenot. cxrilis bolos mocemuli medikamentebi, savaraudod, ufro metad iwveven reaqcias, amdenad, Tu kanismieri reaqcia mwvave iyo, ufro mcire dozebi unda iqnes gamoyenebuli. tubsawinaarmdego medikamentebis xelaxla mirebisas ar aris rekomendirebuli im medikamentis gamoyeneba, romelmac gamoiwvia gverditi reaqciebi. medikamentebit gamowveuli hepatiti nisnebi, romlebic miutiteben medikamentis gamoyenebis Sewyvetis aucileblobas: mkurnalobis pirvel kvireebsi SratSi vitardeba RviZlis transaminazis gardamavali, asimptomuri momateba. Tu anoreqsia, motentiloba, pirrebineba da gamoxatuli siyvitle ar arenisneba, mkurnalobis Sewyveta an Secvla ar aris sawiro. sagangaso klinikur nisnebs ganekutvneba pirrebineba, fsiqikuri cvlilebebi, sisxldenis nisnebi, rac miutitebs RviZlis mwvave ukmarisobaze da tubsawinaarmdego medikamentebit mkurnalobis Sewyvetis aucileblobaze. siyvitlisa da sxva mwvave maxasiateblebis martva siyvitlisa da sxva iseti klinikuri nisnis gamovlenisas, romelic miutitebs RviZlis ukmarisobaze yvela medikametis gamoyeneba unda Sewydes manamde, vidre siyvitle da hepatitis sxva nisnebi ar gaivlis da RviZlis fermentebi ar daubrundeba 188

sawyis dones. Tu RviZlis fermentebis gansazrvra SeuZlebelia, tuberkulozis mkurnalobis ganaxleba xdeba siyvitlis gaqrobidan 2 kviris Semdeg, aseve gamokvleuli unda iyos hepatitis sxva mizezebi. tubsawinaarmdego medikamentebit mkrunalobis ganaxleba hepatitis problemis mogvarebis Semdeg tubsawinarmdego medikamentebit mkurnaloba unda ganaxldes etapobrivad, an ertdroulad. Tumca, Tu hepatiti sicocxlisatvis sasis mdgomareobas qmnida da ar iyo virusuli warmosobis, nakleb saxifato iqneba streptomicinit, izoniazidit da etambutolit mkurnalobis rejimis gamoyeneba. simptomebze dafuznebuli midgoma medikamentebis gverditi reaqciebis martvasi umnisvnelo gverditi movlenebi, romlebic ar sawiroebs mkurnalobis Sewyvetas simptomebi muclis tkivili, gulisrevis SegrZneba fexis terfebis wva Zilianoba gastrointestinaluri problemebi saxsrebis tkivili witeli Sardi rifampicinis gamoyeneba qalebsi medikamenti rifampicintan dakavsirebit izoniazidtan dakavsirebuli periferiuli neiropatia izoniazidtan dakavsirebit ara izoniazidit gamowveuli nebismieri oraluri medikamentis gamo pirazinamidis gamo rifampicinis gamo rifampicinma SeiZleba Semaciros oraluri kontraceptivebis efeqturoba martva pacientis damsvideba izoniazidis gagrzeleba, piridoqsini 50-75mg yoveldriurad. piridoqsinis maralma dozebma SeiZleba xeli SeuSalos izoniazidis moqmedebas. pacientis damsvideba pacientis damsvideba medikamentis mireba naklebi wylit. medikamentebis micema ufro xangrzlivi periodis ganmavlobasi (mag., 20 wutis), medikamentebis mireba sawmlis mcire ulufastan ertad, Tu es RonisZiebebi arasakmarisi armocnda, gamoiyenet pirrebine-bis sawinaarmdego medikamentebi ganagrzet pirazinamidis micema, gamoiyenet aspirini an sxva arasteroiduli medikamenti, gamoiyenet intermitiuli mkurnaloba pacientis damsvideba kontracepciisalternatiuli metodebis gamoyeneba 189

ZiriTadi gverditi movlenebi, romlebic sawiroebs mkurnalobis Sewyvetas simptomebi medikamenti martva smenis dakargva Tavbrusxveva generalizebuli reaqciebi, mat Soris Soki an purpura siyvitle zomieri-zlieri gamonayari kanze mxedvelobis dazianeba pirrebineba streptomicinis gamo auroskopiis Catareba gogirdis sacobebis amosarebad. Tu Tavbrusxveva da nistagi streptomicinis gamoyenebis Sewyveta, streptomicintanaa Tu ar arsebobs sxva axsna da mis dakavsirebuli magivrad etambutolis gamoyeneba streptomicinis Sewyveta, Tu mxolod Tavbrusxvea da nistagmia. cadet dozis Semcireba, Tu gaumjobeseba ar moxdeba SecvaleT etambutolit SesaZloa gamowveuli iyos SewyviteT yvela medikamentis micema, rifampicinit, pirazinamidit gamoiyenet medikamentebis sxva da/an streptomicinit kombinaciebi SesaZlebelia gamowveuli SewyviteT yvela tubsawinaarmdego iyos medikamentebit medikamenti siyvitlis gaqrobamde ganpirobebuli hepatitit da vidre RviZlis fermentebi ar daubrundeba normaluri dones (ix. teqstsi). tubsawinaarmdego SewyviteT yvela tubsawinaarmdego medikamentebis gamo medikamenti. etambutolis gamo mxedvelobis Semowmeba, SewyviteT etambutoli savarudot medikamentebit RviZlis fermentebis testis ganpirobebuli hepatiti saswrafod Catareba, Tu testi SeuZlebelia, SewyviteT medikamentebis gamoyeneba da daakvirdit. 190

32. ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazidis plus TioacetazoniT mkurnaloba 18 h. raideri 19 Tiocetazini warmoadgens ert-ert yvelaze Zvel tubsawinarmdego medikaments sxva cnobil wamlebs Soris. gasuli saukunis 40-ian wlebsi, rodesac misi gamoyeneba daiwyes, arsebobda preparatis maralefeqturobis damadasturebeli mtkicebulebebi, magram SedarebiT marali dozebit misi gamoyeneba ukavsirdeboda gverditi movlenebisa da toqsikurobis xsir ganvitarebas. ase rom, mkurnalobasi izoniazidis gamoyenebidan ramodenime wlis Semdeg Tiocetazoni swrafad iqna daviwyebuli. gasuli saukunis 60-iani wlebis dasawyissi Tioacetazoni xelaxla Seiswavles, rogorc izoniazidis Tanxmlebi medikamenti. es kvleva miznad isaxavda P aminosalicilis mjavas (PAS) alternatiuli medikamentis gansazrvras, romelic xels SeuSlida izoniazidis mimart rezistentobis Camoyalibebas da iqneboda naklebad ZviradRirebuli. orive medikamentis optimaluri dozis dasadgenad Catarda mravali piloturi kvleva, ris Sedegadac mirebuli iqna mkurnalobis yoveldriuri rejimi: 150mg Tioacetazoni da 300mg izoniazidi ertjeradi dozit, romelic isetive efeqturi armocnda, rogorc PAS izoniazidis kombinacia. Tioacetazoni plus izoniazidis rejimi pirveladi danamatis saxit streptomicinis gamoyenebit ramodenime qveyanasi Seswavlili iqna sawyis fazasi Tioacetazonizoniazidis rejimze mesame medikamentis damatebis efeqturoba. 18 tomanis wina gamocemis Tavze dayrdnobit 19 tuberkulozis ganyofilebis medmusaki, saertasoriso gaertianeba tuberkulozisa da filtvis daavadebata cinaarmdeg. parizi, safrangeti 191

streptomicinis gamoyeneba sawyisi danamatis saxit aumjobesebda Sedegebs da 4-8 kviris ganmavlobasi izleoda TiTqmis igive rezultats. bevr dabalsemosavlian qveyanasi Tioacetazinis Semcveli rejimebi fartod gamoiyeneba Semdegi upiratesobebis gamo: isini mosaxerxebelia pacientebisatvis, radgan sawiroa dresi mxolod erti abis mireba; efeqturi mkurnalobis yvelaze naklebad ZviradRirebuli rejimia; abebs xangrzlivi Senaxvis vada aqvt. Tioacetazoni sakmaod mdgardia tropikul klimatsi. Tioacetazoni izoniazidis efeqturoba yoveldriur praqtikasi keniasi Catarebuli kvlevebis Sedegebi Sedarebuli iqna pacientebis im jgufis mkurnalobis SedegebTan, romlebsac utarebdat tuberkulozis rutinuli mkurnaloba 141. orive jgufs utardeboda mkurnalobis erti da igive rejimi, e.i. sami medikamentit (300mg. izonizidi, 150mg Tioacetazoni da 1g streptomicini) yoveldriurad 2 Tvis ganmavlobasi da Semdgom etapze ori medikamentit (150mg Tioacetazoni + 300mg. izonizidi ert tabletsi) yoveldre 10 Tvis ganmavlobasi. keniasi Catarebuli kvlevis dros baqteriologiuri gaumjobeseba mirweuli iqna pacientebis 96%-Si. rutinul jgufsi ki mkurnalobis 12 Tvis ganmavlobasi mxolod 76% 141. Canawerebis analizma TvalnaTliv gvicvena, rom Sedegebi damokidebuli iyo mkurnalobis regularobasa da mkurnalobis xangrzlivobaze sawyisi intensiuri fazis Semdeg. im pacientebis mdgomareoba, romlebic araregularulad, wyvetilad itarebdnen mkurnalobas da ar asrulebdnen mkurnalobis kurss, Zalzed cudi iyo. xolo, isini, vinc medikamentebs regularulad irebda da Caitara mkurnalobis sruli ertwliani kursi, mkurnalobis dasrulebis Semdeg Tavs gacilebit uket grznobdnen. kvlevasi monawileebtan SedarebiT Aararegularuli mkurnaloba gaclebit ufro xsiri iyo rutinul jgufsi. araregularulma mkurnalobam gagrzelebis fazasi SeiZleba sruliad gaabatilos intensiuri fazis dros mirebuli Sedegebi. ramdenadac SeuZlebelia 192

regularobis garantireba, umarlesi rangis rejimmac ki araadekvaturi Sedegebi SeiZleba mogvces. Tioacetazoni plus izoniazidit mkurnaloba gagrzelebis fazasi, rifampicinis Semcveli intensiuri fazis rejimis Semdeg armosavlet afrikasi 142 Catarebuli kvleva mizanad isaxavda izoniazidis, rifampicinis, pirazinamidis da streptomicinis 2- Tviani rejimisa da Semdgomi Tiacetazins+izoniazidis 6-Tviani rejimis Seswavlas (2HRZS/6HT). Sejamebuli saxit Sedegebi warmodgenilia cxrilsi #42. cxrili #42. mkurnalobis klinikuri gamosavali 2HRZS/6HT rejimit namkurnaleb pacientebsi Sedegi Stami mkurnalobis dawyebamde mgrznobeloba izoniazidze mgrznobelobis mqone rezistentuli mkurnalobis warumateblobarecidivi 0/81 0/81 1/8 1/7 arnisnuli rejimi tuberkulozit daavadebuli nacxit dadebiti aranamkurnalebi pacientebis mkurnalobis ZiriTad rejimad iqca SezRuduli resursebis mqone bevri nacionaluri programisatvis. misi upiratesobebia: mocemuli rejimi mkurnalobis yvelaze naklebad Rirebuli mokle kursia da Zalzed eefqturia sruli mgrznobelobis mqone pacientebsi; SesaZlebelia usualo metvalyureobis ganxorcieleba sawyis etapze, gagrzelebis fazasi ki pacienti Tavad miirebs medikamentebs. Ddabalia rifampicin-rezistentuli mutantebis seleqciis albatoba, izoniazidisadmi sawyisi rezistentobis arsebobis SemTxvevaSic ki; usedegod namkurnaleb pacientebs unargundebat SesaZlebloba ganikurnon mxolod pirveli rigis medikamentebit, radgan 193

rceba sul mcire ori iseti medikamenti, (rifampicini da etambutoli), romelta mimartac organisms aqvs mgrznobeloba. Tioacetazoni da aiv-infeqcia Tioacetazonis yvelaze fartod gavrcelebuli gartulebaa kanis reaqcia. Tavdapirvelad SeiZleba is gamoixatebodes qavilit, Semdeg qavilis SegrZnebas SeiZleba mohyves gamonayari, romelic SesaZloa Zalzed swrafad gadavides toqsikur epidermul nekrolizsi, romelic 20-30%-Si mtavrdeba sikvdilianobis SemTxvevebiT. saintereso kvleva Catarda keniasi, romelmac gamoavlina mizezobrivi urtiertkavsiri kanis reaqciebs, Tioacetazonsa da aiv-infeqcias Soris 143. es kavsiri imdenad mtkicea da Sedegebi imdenad seriozuli, rom arsebobs universaluri SeTanxmeba, romlis safuzvelzec, aivinficirebul pacientebs arasdros ar unda daenisnot Tioacetazoni. ufro metic, im pacientebs, romlebic mkurnaloben TioacetazoniT da kanze ganuvitardat nebismieri formis reaqcia, dauyovnebliv unda moexsnas es medikamenti da igi ararasodes arar unda iqnes gamoyenebuli samkurnalod. vinaidan tuberkulozit daavadebul pacientebs, romlebic cxovroben aiv-infeqciisa da tuberkulozis farto gavrcelebis regionebssi aiv-testi rutinulad ar utardebat da mati aivstatusi ucnobia, Tioacetazonis gamoyeneba samkurnalod ar aris mizansewonili. yvelaze axlomdgomi alternatiuli rejimi gagrzelebis fazasi aris etambutolisa da izoniazidis igive xangrzlivobit gamoyeneba. am medikamentebs pacientebi kargad itanen da marali efeqturobitac gamoircevian 144 Tumca am rejims naklic aqvs: igi ZviradRirebulia da amastan etambutols Senaxvis SedarebiT xanmokle vada aqvs, garda amisa, pacientebisatvis, romelta mkurnalobac usedegod anu warumateblad dasrulda, janmos mier rekomendirebuli ganmeorebiti mkurnalobis rejimi SeiZleba naklebadefeqturi armocndes etambutolisadmi rezistentobis warmosobis gamo. aman SeiZleba gazardos rifampicinisadmi rezistentobac, kerzod, aivinficirebul pacientebsi 145. 194

33. rit gansxvavdeba eqstrapulmonaruli tuberkulozis martva filtvis tuberkulozis martvisagan r.balasubramaniani 20 r.rajesvari 20 T.sanTa 20 diagnostikis problemebi eqstrapulmonaruli tuberkulozis martva ramodenime aspeqtit gansxvavdeba pulmonaruli tuberkulozis menejmentisagan. es ZiriTadad ganpirobebulia diagnostikis sirtuleebit, rasac xsirad mivyavart empiriul mkurnalobamde patologiuri da baqteriologiuri dadasturebis garese. mxolod klinikur gamovlinebebze dafuznebuli diagnozi ki ganapirobebs hiperdiagnostikas da arasawiro mkurnalobis Catarebas pacientebis udides nawilsi 146. diagniostikuri resursebis simwiris gamo problema ufro rtuldeba ganvitarebad qveynebsi. aset situaciasi diferencirebuli diagnostikis dros tuberkulozi SeiZleba sulac ar iyos gatvaliswinebuli 147. amas ki, Sedegad mohyveba mkurnalobis dagvianebit dawyeba an misi ugulvebelyofa. eqstrapulmonaruli tuberkulozi SeiZleba ganvitardes yvela asakobriv jgufsi. es ufro artulebs diagnostikasa da mkurnalobas. eqstrapulmonaruli tuberkulozis mkurnaloba da martva eqstrapulmonaruli tuberkulozi Cveulebriv naklebad baqteriasemcvelia da filtvis tuebrkulozis mkurnalobis nebismieri rejimi aseve efeqturi SeiZleba iyos eqstrapulmonaruli tuberkulozis drosac. mkurnalobis miznebisatvis eqstrapulmonaruli tuberkulozi SeiZleba daiyos mwvave da aramwvave formebad. 20 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeti 195

mwvave formebs ganekutvneba tuberkulozuri meningiti, spinaluri tuberkulozi, neiro-tuberkulozi, abdominaruli tuberkulozi, bilateraluri eqsudaciuri plevriti, eqsudaciuri perikarditi da Zvlebis da saxsrebis tuberkulozi, romelic adamianis sxeulis ertze met adgils moicavs. sxeulis sxva nawilebis eqstrapulmonaruli tuberkulozi ganekutvneba aramwvave formas. arsebobs ramodenime statia, romlebsic ganxilulia qimioterapiis mokle kursis gamoyeneba eqstrapulmonaruli tuberkulozis mkurnalobasi 148. radgan im momentis gansazrvra, rodesac eqstrapulmonaruli tuberkulozis mkurnaloba maqsimalurad efeqturia sirtuleebtanaa dakavsirebuli, mkurnalobis xangrzlivobac gansxvavdeba. am sakitxis SeswavlasTan dakavsirebit Catarda ramodenime kontrolirebadi klinikuri kvleva 149. eqstrapulmonaruli tuberkulozis mkurnalobisa da diagnostikis principebi arebuli iyo pulmonaruli tuberkulozis randomizirebuli klinikuri kvlevebit mirebuli gamocdilebidan. eqstrapulmonaruli tuberkulozis Semswavleli kvleva (xerxemlis tuberkulozi, tuberkulozuri limfadeniti, abdominaluri tuberkulozi da Tavis tvinis tuebrkulozi) natlad gvicvenebs moklevadiani kursis efeqturobas (6-9 Tviani), rogorc bavsvebsi 150, aseve mozrdilebsi da meryeobs 87%-dan 99%-mde (cxrili #43). intervalebiani rejimi isetive efeqturi iyo, rogorc yoveldriuri rejimi. rac Seexeba mwvave formebs, sawyis intensiur fazasi rekomendirebulia otxi medikamentis gamoyeneba. sawiroebis SemTxvevaSi SesaZlebelia mkurnalobis gagrzeleba 9 Tvemde, gansakutrebit tuberkulozuri meningitis da neirotuberkulozis dros. tuberkulozuri meningitis dros, romelsac axlavs nevrologiuri dazianebebi, aseve masiuri eqsudaciuri plevritis an tuberkulozuri perikarditis SemTxvevaSi gamoyenebuli unda iqnes steroidebi. tuberkulozis mkurnalobis processi SeiZleba ganvitardes limfuri kvanzebis SeSupeba, gamagreba da baqteriebit superincifireba, zogadad mkurnalobis modifikacia an gaxangrzliveba ar aris nacvenebi. miuxedavad imisa, rom eqstrapulmonaruli formebis mkurnaloba umetes SemTxvevaSi karg Sedegebs izleva, arsebobs iseti gamonaklisebic, rogoricaa meningiti, xerxemlis tuberkulozi (potis daavadeba), am dros klinikuri gamosavali damokidebulia adreul diagnostikaze. tuberkulozuri meningitis SemTxvevaSi mkurnalobis mokle kursis Catarebisas Sedegebi dakavsirebulia imastan, Tu 196

cxrili #43. mkurnalobis rejimebis efeqturoba eqstrapulmonaruli tuberkulozis sxvadasxva formebis dros kvlevebi mkurnalobis rejimi xangr-oba (Tveebi) pacientebis raodenoba monitoringis xangroba (TveebSi) sul sasurveli Sedegebi (%) xerxemlis tuberkulozi potis daavadeba tuberkulozuri limfadeniti abdominaluri tuberkulozi Tavis tvinis tuberkulozi 6HR + hong-kongsi modificirebuli qirurgia 6HR 9HR radikaluri qirurgia+ 2HERS7H 2 R 2 2HERS/7H 2 R 2 2H 3 R 3 Z 3 S 3 /4H 2 S 2 2HRZ/4HR EHS/HE 3HRZ/3H 2 R 2 3H 3 R 3 Z 3 /6H 2 R 2 6 6 9 9 9 6 6 12 9 9 78 78 79 20 11 168 85 93 47 44 120 120 120 60 60 36 60 60 24 24 90 94 99 90 73 97 94 87 89 91 bibliografiuli wyaro 151 152 153 154 155 197

daavadebis ra etapze iqna dawyebuli mkurnaloba 156. daavadebis mwvave formis dros pacientebis mcire nawili arwevs srul gamojanmrtelebas. arasasurveli Sedegebis wina pirobaa axalgazrda asaki da Sors wasuli forma. nevrologiuri Sedegebi usualodaa dakavsirebuli daavadebis stadiastan da hospitalizaciamde simptomebis xangrzlivobastan. amis msgavsad xerxemlis tuberkulozis SemTxvevaSi nevrologiuri gamojanmrtelebisatvis sawiro dro ar aris damokidebuli mkurnalobis rejimis tipze. is ganicdis iseti faqtorebis zemoqmedebas, rogoricaa sawyisi motoruli statusi, nawolebis arseboba an ararseboba da kifozis xangrzlivoba 156. sxvadasxva kvlevebsi Seswavlili iqna mkurnalobis moklevadiani rejimis Soreuli Sedegebi eqstrapulmonaruli tuberkulozis sxvadasxva formebis dros 150. mkurnalobis Semdgomi monitoringi pacientebs utardebodat sistematiurad 5-10 wlis ganmavlobasi. yvela kvlevis monacemit recidivis macvenebeli xangrzlivi monitoringis ganmavlobasi 4%-ze naklebi iyo. rac adasturebs mkurnalobis moklevadiani rejimebis adeqvaturobas eqstrapulmonaruli tuberkulozis dros. qirurgiis roli eqstrapulmonaruli tuberkulozis mkurnalobasi moklevadiani Terapiis gamoyenebam qirurgiuli intervenciebi naklebad mnisvnelovani gaxada. am saxis Carevebi sawiro iyo iseti gartulebebis diagnostikisa(biofsia) da martvisatvis, rogoricaa tuberkulozuri empiemia da qronikuli funqciadakarguli Tirkmeli, an filtvis rekurentuli infeqciebi. britanetis samedicino kvlevis sabwos 157 mier Catarebul kvlevasi Seswavlili iyo qirurgiuli operaciebisa da medikamentozuri mkurnalobis roli xerxemlis tuberkulozit daavadebuli pacientebis martvasi. kvlevis safuzvelze daaskvnes, rom zogadad qirurgiuli operaciebi ar iyo sawiro, vinaidan ambulatoriuli mkurnalobis mokle kursebi Zalzed efeqturi armocnda. qirurgiuli Careva nacvenebi iyo 15 welze umcros pacientebsi im SemTxvevaSi, Tu kifozis kutxe 30 0 -s aremateboda 158. qirurgiuli Cvenebis SemTxvevaSi rekomendirebulia wina da ukana artrodezi. kifozis Semcirebisa da xerxemlis funqciis gaumjobesebis miznit 159. 198

34. riti gansxvavdeba tuberkulozis mkurnaloba fexmzime qalebsi, RviZlis an Tirkmlis daavadebis mqone pacientebsi a.harisi 21 160, 161 mkurnaloba fexmzime qalebsi otxi sabaziso tubsawinaarmdego medikamenti izoniazidi, rifampicini, pirazinamidi da etambutoli ar xasiatdeba teratogenurobit da amitom mati gamoyeneba fexmzime qalebsi ar aris sasisi. streptomicini da sxva aminoglikozidebi potenciurad ototoqsiuria nayofisatvis da, aqedan gamomdinare, ar unda moxdes mati gamoyeneba fexmzimobis dros, mat SeiZleba Caenacvlos etambutoli. PAS aseve SeiZleba iqnes gamoyenebuli yovelgvari gartulebebis garese. etionamidi da protionamidi teratogenuria da mat SeiZleba gamoiwvion naadrevi msobiaroba. aqedan gamomdinare, mati gamoyeneba fexmzime qalebsi ar SeiZleba. ftorqinolonebic teratogenobas avlenen laboratoriul cxovelebsi. aqtiuri tuberkulozi fexmzimobis dros sawiroebs mkurnalobas, radgan daavadebam SeiZleba ufro meti ziani moutanos pacients, vidre medikamentebma. Zalzed mnisvnelovania, rom fexmzime qalebs esmodet tuberkulozis warmatebulad mkurnalobis aucilebloba ert-erti standartuli rkeomendirebuli rejimit, da rom mkurnalobis warmateba qalis fexmzimobis normaluri dasrulebis garantiaa. mezuzuri qalebisa da Gvil bavsvta mkurnaloba tuberkulozit daavadebulma mezuzurma qalma unda Caitaros mkurnalobis sruli kursi. yvela tubsawinaarmdego medikamenti 21 malaviis tuberkulozis kontrolis erovnuli programis, teqnikuri mrceveli. Lilongue, malavia 199

SeiZleba gamoyenebuli iyos ZuZuTi kvebis dros da qals, romelic mat irebs SeuZlia yovelgvari SiSis garese bavsvis kveba ZuZuTi. deda da bavsvi ertad unda iyvnen da bavsvs unda ezleodes dedis rze Cveulebrivad. Tumca, medikamentebis koncentracia dedis rzesi arasakmarisia bavsvis prevenciis an mkurnalobisatvis. tuberkulozi gansakutrebit sasisia eqvs wlamde asakis bavsvebsi, kerzod, sami wlis an ufro umcros bavsvebsi. bavsvi, romelic axlo kontaqtsi imyofeba tuberkulozit daavadebul individtan aucileblad unda Semowmdes samedicino dawesebulebasi daavadebis simptomebze. bavsvebs, romlebsac ara aqvt simptomebi prevenciuli mkurnaloba latenturi tuberkulozuri infeqciis winaarmdeg unda CautardeT miuxedavad imisa, CautardaT mat BCG vaqcinacia Tu ara. prevenciuli mkurnaloba moicavs izoniazidis (5mg/kg sxeulis wonaze) yoveldriur mirebas 6-9 Tvis ganmavlobasi. Tu arsebobs tuberkulozis kanis testis Catarebis SesaZlebloba, igi unda Catardes 3 Tvis Semdeg. Tu tuberkulozze kanis testis induracia 6mm diametrze nakleb ares moicavs prevenciuli mkurnaloba unda Sewydes da bavsvs gauketdes BCG vaqcina (Tu es adre ar iyo gaketebuli); Tu induraciis are 6mm-ze meti diametrisaa, prevenciuli mkurnaloba izoniazidit kidev 3-6 Tves unda gagrzeldes. mkurnaloba RviZlis dazianebis mqone pacientebsi 160,162 pacientebs, romeltac aqvt qvemot CamoTvlili problemebi, SeuZliaT Caitaron mkurnalobis Cveulebrivi mokle kursi. RviZlis dadgenili qronikuli daavadeba izoniazids plus rifampicini da plus erti an ori arahepatotoqsikuri medikamenti, iseti rogoricaa magalitad, sterptocini da etambutoli, SeiZleba gamoyenebuli iyos mkurnalobis mteli rva Tviani kursis ganmavlobasi. Tu arsebobs RviZlis dazianebis xarisxtan dakavsirebuli problema, magalitad, asciti da portaluri hipetenzia, sawyis etapze SeiZleba gamoyenebul iqnes alternatiuli rejimi_streptomicini plus izoniazidi plus etambutoli, romlis Semdegac unda Catardes 200

gagrzelebis faza izoniazidisa da etambutolis gamoyenebit. sruli mkurnalobis xangrzlivoba 12 Tvea. RviZlis qronikuli daavadebis mqone pacientebma ar unda miiron pirazinamidi, aqedan gamomdinare, rekomendirebuli rejimebi Semdegia: 2HRES/6HE 2HRE/6HE an 2HSE/ 10HE. mwvave hepatiti Zalzed isviatia, rodesac pacients ertdroulad aqvs tuberkulozic da mwvave virusuli hepatitic. Tumca arc Tu isviatia, rom tuberkulozis mkurnalobis dros pacients ganuvitardes mwvave virusuli hepatiti. bevr situaciasi igi mkurnalobis dros siyvitlis ZiriTadi mizezia 163. zog SemTxvevaSi SesaZlebelia tuberkulozis mkurnalobis SeCereba hepatitis problemebis gaqrobamde sxva dros SeiZleba sawiro gaxdes tuberkulozis mkurnalobis gagrzeleba am ukanasknel SemTxvevaSi streptomicinisa da etambutolis kombinirebul gamoyeneba maqsimum 3 Tvis ganmavlobasi yvelaze usafrtxo variantia hepatittan dakavsirebuli problemebis mosagvareblad. amis Semdeg pacients SeiZleba Cautardes gagrzelebis faza izoniazidita da rifampicinit 6 Tvis ganmavlobasi (6HR). Sorswasuli tuberkulozis SemTxvevaSi SeiZleba gamoyenebuli iqnes ftorqinolonebi, rogoricaa ofloqsacini streptomicintan da etambutoltan ertad, rogorc Semcvleli arahepatotoqsikuri rejimi, romelsac pacientebi zogadad kargad itanen. Tirkmlis ukmarisobis mqone pacientebis mkurnaloba 164,162 Tirkmlis ukmarisobit daavadebul pacientebs SeiZleba mivcet izoniazidi, rifampicini da pirazinamidi normaluri dozebit, radgan isini TiTqmis mtlianad isleba narvlis zemoqmedebit an metabolizirdeba aratoqsikur naertebad. Tirkmlis mwvave ukamarisobis dros pacientebs, romlebic ireben izoniazids unda daenisnos piridoqsini, rata Tavidan avicilot periferiuli neiropatia. pirazinamids SeuZlia gaartulos hiperemia, romelic warmoiqmneba Tirkmlis ukmarisobis dros. etionamidisa da protionamidis gamoyofa TiTqmis mtlianad xdeba Tirkmlis garese 201

gzebit, amitom mati micema Tirkmlis ukmarisobis dros normaluri dozebit savsebit dasasvebia. streptomicini da etambutoli gamoiyofa SardiT. Tirkmlis ukmarisobis SemTxvevaSi orive medikamentis doza unda Semcirdes. Tu arsebobs Tirkmlis funqciis monitoringis sasualeba, dozebi pacienetis mdgomareobastan SesabamisobaSi SeiZleba iqnes moyvanili. Tioacetazoni nawilobriv gamoiyofa SardTan ertad, magram diapazoni Terapiul da toqsikur dozas Soris imdenad mcirea, rom Tirkmlis ukmarisobit daavadebul pacientebs es medikamenti ar unda mieces. Tirkmlis ukmarisobisas gamoiyeneba Semdegi yvelaze usafrtxo rejimi 2HRZ/4HR. 202

35. rit gansxvavdeba tuberkulozit daavadebuli aiv-inficirebuli pacientebis mkurnaloba a.harisi 22 mkurnalobis kategoriebi da mkurnalobis rejimi zogadad tuberkulozis mkurnaloba msgavsia rogorc aivpozitiur, aseve aiv-negatiur pacientebsi, magram gamonakliss warmoadgenen is pacientebi, romlebic ireben Tioacetazons. Tioacetazonis gamoyenebas aiv-inficirebulo pacientebsi Tan axlavs mwvave 165, fataluri kanismieri reaqciebis ganvitarebis riski amitom Tioacetazonis nacvlad aiv-inficirebul pacientebsi gamoyenebuli unda iyos etambutoli (ixilet: ra Rirsebebi aqvs Tioacetazins, rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia izoniazidi plus Tioacetazonis rejimi ). zogiert qveyanas SeiZleba ar hqondes Tioacetazonis etambutolit Canacvlebis resursebi. iq, sadac Tioacetazonis gamoyeneba gardauvalia, Zalzed mnisvnelovania pacientebis gafrtxileba kanis mwvave reaqciebis Sesaxeb. pacientebs unda mieces rceva, rom aset SemTxvevaSi mat dauyovnebliv Sewyviton Tioacetazonis gamoyeneba da Seatyobinon amis Sesaxeb uaxloes samedicino dawesebulebebs. streptomicini kvlavac rceba sawiro medikamentad, Tumca imavdroulad garantirebuli unda iyos Spricebisa da nemsebis satanado sterilizacia da moxmarebis Semdeg mati ganadgureba. aiv-infeqciis marali prevalentobis mtel rig qveynebs ara aqvt Spricebisa da nemsebis satanado sterilizaciis uzrunvelyofis SesaZleblobebi da amitom aset qveynebsi streptomicini ar unda iqnes gamoyenebuli. 22 malaviis tuberkulozis kontrolis erovnuli programa, teqnikuri mrceveli. Lilongue, malavia 203

tuberkulozit daavadebuli aiv-inficirebuli pacientebis reaqcia tuberkulozis mkurnalobaze im pacientebis reaqcia, romlebmac Gaitares mkurnalobis sruli kursi tuberkulozis mkurnalobis sruli kursis dasrulebisas yvela pacienti avlens msgavs klinikur, mikrobiologiur, rentgenografiul Sedegebs, miuxedavad imisa, aiv-pozitiuria igi Tu aiv-negatiuri 166,167. SemTxvevaTa fataluri Sedegebi aiv-inficirebul pacientebsi sikvdilianobis macvenebeli, mkurnalobis dros da Semdeg, 166,167 aiv-negatiur pacientebtan SedarebiT ufro maralia. samxret-saharis regionsi nacxit dadebiti tuberkulozit daavadebuli aiv-pozitiuri pacientebis daaxloebit 30% irupeba mkurnalobis dawyebidan 12 Tvis ganmavlobasi, 25% matgan, vinc sruli kursi Caitara, irupeba momdevno 12 Tvis ganmavlobasi. adamianis imunodeficitis virusis warmosobamde, nacxit uaryofiti tuberkulozi itvleboda kargi klinikuri gamosavlis mqone daavadebad. amjamad nel-nela xdeba mtkicebulebebis akumulireba imis Sesaxeb, rom aiv-infeqciis marali prevalentobis regionebsi nacxit uaryofiti tuberkulozit daavadebul aivinficirebul pacientebs SeiZleba hqondes ufro cudi prognozi, vidre nacxit dadebiti tuberkulozis mqone aiv-inficirebulebs. tuberkulozit daavadebul aiv-inficirebul pacientebsi mkurnalobis dros an misi dasrulebis Semdeg sikvdilianobis SemTxvevebi nawilobriv gamowveulia tuberkulozit, umetesoba ki ganpirobebulia aiv-tan dakavsirebuli sxva problemebit. SemTxvevaTa fataluri gamosavali SedarebiT dabalia iset aivinficirebul tuberkulozit daavadebul pacientebsi, romlebsac CautardaT mkurnalobis mokle kursi nacvlad standartuli 12- Tviani mkurnalobisa rifampicinis garese 168,169. arnisnuli nawilobriv aixsneba mokle kursis meti efeqturobit, magram aseve SeiZleba dakavsirebuli iyos rifampicinis maral, farto antibaqteriul aqtivobastan. aqedan gamomdinare, rifampicinma SeiZleba Seamciros adamianis imunodeficitis virustan dakavsirebuli baqteriuli infeqciebit gamowveuli sikvdilianoba. 204

antituberkulozuri medikamentebit damxmare mkurnalobam SeiZleba Seamciros fataluri SemTxvevebis macvenebeli. arsebobs mtkicebulebebi imisa, rom mkurnaloba usualo metvalyureobit gacilebit ufro mnisvnelovania tuberkulozit daavadebul aiv-inficirebul pacientebsi. mravalvariaciul analizsi, alferma da Tanaavtorebma 170 gamoavlines, rom aiv_inficirebul pacientebsi, romlebic TviTon irebdnen medikamentebs, sikvdilianobis macvenebeli ufro marali iyo, vidre iq sadac xorcildeboda kontrolirebuli mkurnaloba. alvudma da Tanaavtorebma 171 aseve armoacines, rom fataluri SemTxvevebis macvenebeli aiv-inficirebul tuberkulozit daavadebul im pacientebsi, visac mkurnaloba usualo metvalyureobit utardeboda Seadgenda 15%-s da pacientebsi, romlebic TviTon irebdnen medikamentebs 43%. recidivi tuberkulozis recidivs macvenebeli tuberkulozit daavadebul aiv-pozitiur pacientebsi, romlebmac daasrules rifampicinis Semcveli mokle kursi Zalzed dabalia. mkurnalobis rejimis gazrda 6-dan 12 Tvemde kidev ufro amcirebs recidivis macvenebels 172. Tumca es gansxvaveba marginaluria da misi Rirebulebis, toqsikurobis da im sirtuleebis gatvaliswinebit, romlebic axlavs xangrzliv mkurnalobas tuberkulozis programebis umetesi nawili aiv-inficirebul pacientebsi 6 an maqsimum 9-Tvian kurss atarebs. recidivis macvenebeli maralia aiv-inficirebul pacientebsi, SedarebiT aiv-negatiur tuberkulozit daavadebul individebtan, romelta mkurnalobac xorcieldeba standartuli rejimit, an mokle kursit etambutolisa da izoniazidis gamoyenebit gagrzelebis fazasi 173,174,175. tuberkulozis mkurnaloba da antiretrovirusuli Terapia antiretrovirusuli (ARV) medikamentebi fartodaa xelmisawvdomi aiv SidsiT daavadebul pacientebsi, romeltagan bevri tuberkulozis latenturi an aqtiuri formitaa daavadebuli. efeqturi gamoyenebisas, ARV medikamentebi TandaTanobiT azlierebs 205

pacientebis imunitets (maspinzeli organizmis), ramac principsi unda Seamciros latenturi tuberkulozis progresireba da misi gadasvla tuberkulozis aqtiur formasi. paradoqsia, magram aivpozitiur pacientebsi ARV medikamentebma zogjer SeiZleba ganapirobon latenturi tuberkulozis gadasvla aqtiur formasi. amis gamomwvevi mizezi aris imunuri rekonstruqciis sindromi. amjamad licenzirebuli ARV medikamentebidan, proteazas inhibitorebisa da aranukleoziduri reversuli transkriptazis inhibitorebi urtiertqmedeben rifampicintan da, aqedan gamomdinare, ar unda iqnan gamoyenebuli rifampicinis Semcvlel rejimtan ertad. Tumca, yovelgvari riskis garese SeiZleba mati micema rifabutintan ertad 176,177,178,179 jer kidev gansasazrvria ARV mkurnalobis optimaluri rejimebi, romlebic SeiZleba gamoyenebuli iqnes tuberkulozis mkurnalobastan ertad da mkurnalobis dawyebis sauketeso vadebi. raoden paradoqsulic ar unda iyos im pacientebs Soris, romlebsac utardebat tubsawinaarmdego mkurnaloba da romlebmac daiwyes antiretrovisuli medikamentebis mireba, daavadebis simptomebi uaresdeba, rac ZiriTadad dakavsirebulia antebit procesebze organizmis reaqtiulobis gaumjobesebastan 180,181. savarudod, antiretrovirusul Terapias SeuZlia Seamciros aivsikvdilianoba da avadoba tuberkulozis mkurnalobis dros da misi dasrulebis Semdeg, aseve SesaZlebelia Seamciros tuberkulozis recidivi aiv-pozitiur pacientebsi, romlebmac warmatebit daasrules tubsawinaarmdego mkurnaloba. 206

36. ra ZiriTadi Sedegebi iqna mirebuli madrassi Gatarebuli kvlevebit, romelta mizanic iyo binaze da sanatoriumsi mkurnalobis formebis Sedareba k.tomani 23 kvlevis amocanebi kvleva SemuSavda binaze da sanatoriumsi mkurnalobis formebis upiratesobata Sedarebis Sesafaseblad. kvlevis mizani iyo SeeswavlaT, Tu ra zemoqmedebas axdens fizikuri aqtivoba, kveba da kargi sacxovrebeli garemo mkurnalobis gamosavalze da rogor aisaxeba es rentgenografiul da baqteriologiur Sedegebze. gansakutrebul interess Seadgenda infeqciurobis problema im pacientebisa, romlebsac mkurnaloba utardebodat binaze anu daavadebis ganvitarebis sixsire pacientis uaxloes ojaxis wevrebs Soris. kvlevis arweriloba kvlevasi monawileobisatvis dasasvebad micneuli iyo madrasis (amjamad Cenais) macxovrebeli, 12 welze ufrosi asakis nacxit da/ an kultura pozitiuri aranamkurnalebi (an namkurnalebi ara umetes 2 kviris ganmavlobasi) nebismieri individi, romlis sacxovrebeli adgilic 8km-iT iyo dasorebuli tuberkulozis qimioterapiis centridan (amjamad ewodeba tuberkulozis kvlevis centri). pacientebis umravlesobas arenisneboda Sorswasuli kavernozuli daavadeba. izoniazidze an P-aminozalicilis mjavaze (PAS) rezistentuli, an iseti seriozuli Tanmxlebi daavadebis mqone pacientebi, rogoricaa mglura da diabeti, aseve fexmzime pacientebi da isini, visac esawiroeboda gadaudebeli samedicino daxmareba gamoricxes kvlevidan. TiTqmis yvela pacienti cxovrobda madrasis uraribes regionsi. 23 gardacvlilia 207

medikamentebis mirebis rejimi yvela pacienti irebda izonizidsa da PAS (natriumis marilit) anu gasuli saukunis 50-iani wlebis standartul mkurnalobas kvlevis momentisatvis. binaze mkurnalobis rejimi pacientebs, romlebsac daenisnat binaze mkurnaloba stxoves medikamentebi waerot saxlsi da yovel kviras mosuliyvnen samedicino centrsi momdevno kviris wamlebis wasarebad. garda amisa, TiToeul pacienttan binaze midioda jandacvis musaki da adgilze itvlida medikamentebs. amastan pacientebs utardeboidat Sardis analizi imis dasadgenad irebda Tu ara pacienti medikaments danisnulebisamebr. pacientis ojaxi yoveltviurad ufasod irebda rzes da fqvils. mkurnaloba sanatoriumsi sanatoriumsi mkurnalobisatvis SerCeuli pacientebi moatavses madrasis mtavar sanatoriumsi, romelic arwurvili iyo sruli diagnostikuri aparaturit da dakompleqtebuli iyo maralkvalificiuri personalit. yovel kviras pacientebs naxulobdnen centris medikosebi, jandacvis musakebi an socialuri musakebi. fizikuri aqtivoba pacientebi, romelta mkurnalobac mimdinareobda sanatoriumsi3-4 Tvis ganmavlobasi imyofebodnen srul wolit rejimze. am periodis Semdeg mat ezleodat ufleba amdgariyvnen jer ori, xolo Semdeg 4sT-iT dresi. 6 Tvis Semdeg mat, visi mdgomareobac SedarebiT gaumjobesebuli iyo eqimebi azlevdnen nebas TveSi ertxel wasuliyvnen saxlsi da imave saramos dabrunebuliyvnen ukan, sanatoriumsi. pacientebs, romlebic mkurnalobdnen binaze, unisnavdnen nawilobriv wolit rejims, xolo rodesac janmrtelobis mdgomareoba SesaZleblobas miscemda, uflebas azlevdnen dabrunebodnen fizikur aqtivobas da samusaos. umetesi matgani 208

ambulatoriuli pacienti iyo. mdedrobiti sqesis pacientebi.agrzelebdnen Tavis Cveul saojaxo saqminanobas, xolo bevri mamakaci daubrunda samusaos uforo adre, vidre samedicino Cveneba iqneboda. zog mamakacs saertsod ar Seuwyveia musaoba. visac regularuli samusao ar gaacnda, Cveulebriv enisnebodat xangrzlivi gaseirnebebi. im pacientebs, romlebsac binaze utardebodat mkurnaloba, kvirasi ertxel mainc uwevdat samedicino centrsi misvla, anu daaxloebit 8km manzilis gavla Cveulebriv fexit, vinaidan kvlevasi monawile pacientebi ZiriTadad Raribebi iyvnen. pacientebis umravlesobas Seadgendnen xelosnebi, dabalkvalificiuri musebi, saxlsi mosamsaxureebi an qucasi momusave adamianebi, romlebsac mteli dris ganmavlobasi uwevdat mzime tropikul klimatsi musaoba. kveba sanatoriumsi myofi pacientebi uzrunvelyofili iyvnen maralkaloriuli kvebit, didi raodenobit cximis, cilebis (mat Soris cxoveluri warmosobis cilebis) mineralebisa da vitaminebis Semcvleli produqtebit 182. mati kveba, visac binaze utardebodat mkurnaloba, gacilebit uaresi iyo. magalitad, mxolod 8% irebda yoveldriurad 30gr cxovelur cilas, masin rodesac sanatoriumsi myofi yvela pacienti irebda cxovelur cilebs. kvebasi gansxvaveba Zlierdeba imit, rom binaze myof pacientebs dasvenebis gacilebit naklebi SesaZlebloba hqondat da male ubrundebodnen Cveul saqmianobas. ketilmowyoba masin, rodesac sanatoriumsi myof pacientebs mkurnaloba utardeboda sufta, kargad ganiavebul otaxebsi, pacientta umravlesoba, romelic binaze mkurnalobda, cxovrobda mravalsulian, mwidroddasaxlebul saxlebsi, sadac ert adamianze 4,5m 2 naklebi modioda. mkurnalobis gadanawileba gadanawileba moxda randomizirebulad, anu kvlevasi monawile TiToeuli pacientisatvis ixsneboda dabewdili konverti, romelsic 209

motavsebuli iyo danomrili qaraldis furceli randomizirebuli cifrit, romlis gasifvrasac awarmoebda centris statistikis ganyofileba (ixilet Tavi rogoria kontrolirebuli klinikuri kvlevebis principebi da motxovnebi ). centris personalidan winaswar aravin (arc samedicino da arc arasamedicino) ar icoda, Tu romel jgufsi moxvdeboda pacienti. miuxedavad randomizirebuli SerCevisa, SemTxvevam ganapiroba, rom pacientebs, romlebsac binaze utardebodat mkurnaloba, upiratesad qalebs, gacilebit cudi mdgomareoba hqondat. TiTqmis yvelas arenisneboda kavernozuli procesi filtvis mzime dazianebit da baqteriagamoyofa. Sedegebi da daskvnebi klinikuri Sedegebi kvlevis processi sami pacienti dairupa ori sanatoriumsi myoftagan da erti, visac binaze utardeboda mkurnaloba (darupvis kidev erti SemTxveva iyo binaze myof pacientebsi. gamowveuli eleqtrotravmit). sanatoriumsi myofma pacientebma ufro metad moimates wonasi, vidre mat, vinc binaze mkurnalobda. rentgenologiuri Sedegebi orive jgufsi msgavsi rentgenologiuri Sedegebi iqna mirebuli kavernozuli dazianebebis zomebis Semcirebis an kavernebis daxurvis. mxriv. Tavdapirveli dazianebebis gaumjobeseba kidev ufro askara gaxda Sedegebis Sedarebisas baqteriologiuri Sedegebi orive jgufsi gamovlinda swrafi baqteriologiuri gaumjobeseba (ixilet cxrili #44, grafiki #14). pozitiuri nacxebis raodenoba 4 Tvis mkurnalobis Semdeg TiTqmis ertnairad Semcirda. pacientebis 90%-Si mirweuli iyo naxvelis konversia, e.i. naxvelis yoveltviuri gamokvleva kultura-negatiuri iyo, Tumca rigi individualuri cvlilebebi mogvianebit gacnda. naxvelis konversiis marali macveneblebi SenarCunebuli iyo mkurnalobis 12-Tviani periodis bolomde. 210

cxrili #44. naxvelis konversia (yvela kultura - negatiuria) 2-Tviani intervalebit binaze da sanatoriumsi myof pacientebsi Tveebi binaze myofi pacientebis procentuli wili sanatoriumsi myofi pacientebis procentuli wili 2 4 6 8 10 12 45 89 91 89 92 90 49 93 96 95 95 92 grafiki #14. naxvelis konversia binaze an sanatoriumsi myof pacientebsi (mravaljeradi kultura-negatiuri sinjebi) sanatoriumsi ojaxsi kultura negatiuri mkurnalobis xangrzlivoba (TveebSi) daavadebis pasiuri mdgomareoba da recidivi daavadebis pasiuri mdgomareobis Sefaseba warmoebda mkacri kriteriumebit, rac gulisxmobda, rom bolo 3 Tvis ganmavlobasi 7-9 kulturis yvela testi negatiuri unda yofiliyo. sanatoriumsi 211

mkurnalobaze myofi 81 pacientidan 75-s (92%) da binaze namkurnalebi 82 pacientidan 71-s (86%) daudginda daavadebis pasiuri forma (cxrili #45) 183. cxrili #45. daavadebis pasiuri faza mkurnalobis erti wlis Semdeg, rogorc binaze, aseve sanatoriumsi namkurnaleb pacientebsi mkurnalobis adgili binaze sanatoriumsi pacientebis raodenoba 82 81 pasiuri faza erti wlis mkurnalobis Semdeg # % 71 86 75 92 baqteriolologiuri recidivis sixsire Seswavlili iyo im 126 pacientsi, romelsac ertwliani mkurnalobis dasrulebis Semdeg 184 daavadebis pasiuri forma arenisneboda. 59 sanatoriumsi mkurnalobaze myofi pacienti da 57 binaze namkurnalebi ayvanili iyo Semdgom kontrolze 5 wlis ganmavlobasi. dakvirvebis am periodsi sanatoriumis jgufsi recidivis mxolod 7 SemTxveva iyo (10%), xolo binaze myoftagan mxolod 4 (7%), sul 11 SemTxveva. gansxvavebebi, romlebic arinisneboda mkurnalobis erti wlis bolos TandaTanobiT swordeboda. recidivis 11 SemTxvevidan 8 ganvitarda monitoringis pirvelive wlis ganmavlobasi. cxrili #46. recidivis SemTxvevebi tuberkulozis pasiuri stadiis mqone pacientebsi 1 wlis mkurnalobis Semdeg rogorc sanatoriumsi, aseve binaze namkurnaleb pacientebsi otxwliani monitoringis periodsi statusi binaze sanatoriumsi sul recidivi pasiuri formis dros me-2 wels me-3-5 wels sul recidivebi relafsis mqone pacientebis % 57 2 2 4 7 69 6 1 7 10 126 8 3 11 9 212

riski pacientis ojaxis wevrebisatvis 5 wlis ganmavlobasi xorcieldeboda kvlevasi monawile pacientebis ojaxis uaxloesi wevrebis (saojaxo kontaqtebis) sistematiuri monitoringi. inficirebis macvenebeli 185, 186. ZiriTadad Seswavlili iyo im ojaxebsi, sadac infeqciis matarebeli iyo ojaxis mxolod erti wevri da warmoadgenda saindeqso SemTxvevas. am mimartebit Sedareba gaketda sanatoriumsi myofi pacientebis saojaxo kontaqtebsa (im ojaxis, visi infeqciuri indeqsic izolirebuli iyo ojaxidan 1 wlis ganmavlobasi) da binaze myofi pacientebis kontaqtebs Soris (romlebic ganagrzobdnen ra cxovrebas mteli mkurnalobis ganmavlobasi inefqciurad sasis ojaxis wevrtan ertad, kvlavac imyofebodnen inficirebis safrtxis winase), amastan orive jgufis kontaqtebs garemodan inficirebis Tanabari riski hqondat. yvela is kontaqti, romelsac rentgenografiulad arenisneboda tuberkulozze saewvo dazianebebi gamoricxuli iqna kvlevidan, danarcenebi daiyo or kategoriad: individebad, romlebsac hqondat reaqcia tuberkulinis testze da, romlebsac aseti reaqcia ar hqondat (0-4mm da 5mm-ze naklebi induracia, ZiriTadad tuberkulinis 5TU-ze kansida inieqciit.) cxrili #47. tuberkulozit daavadebis sixsire binaze da sanatorimsi mkurnalobaze myofi pacientebis ojaxis wevrebs Soris tuberkulinis sawyisi statusi kontaqtebis jgufi riskis mqone pacientebis raodenoba dakvirvebis periodsi warmosobili SemTxvevebi sul SemTxvevebi 5 wlis ganmavlobasi reaqciis garesereaqciis mqone binazes anatoriumsi binazes anatoriumsi 86 87 159 177 1 7 7 5 13 2 0 1 4 4 3 1 2 4 7 4 1 0 1 2 5 0 0 1 2 # 9 10 15 28 % 10,5 11,5 9,4 15,8 213

rogorc amas gvicvenebs cxrili #47, daavadebis sissire arareaqtiul~ jgufi TiTqmis Tanabari iyo, rogoric binaze, aseve sanatoriul mkurnalobaze myofi pacientebis kontaqtebsi (testze reaqtiuli pacientebis jgufsi, romlebic naklebad homogenuri iyo, vidre ara-reaqtiuli jgufi daavadebis sixsire gacilebit ufro marali iyo sanatoriul mkurnalobaze myofi pacientebis kontaqtebs Soris). Catarebuli kvlevis kidev erti mnisvnelovani armocena aris is, rom monitoringis pirveli wlis ganmavlobasi daavadebuli konataqtebis umetesobas daavadeba ZiriTadad ganuvitarda pirveli sami Tvis ganmavlobasi, miuxedavad imisa, mati ojaxis wevri binaze itarebda mkurnalobas, Tu sanatoriumsi. es sakmaod seriozuli minisnebaa imisa, rom kontaqtebi savaraudod pirveli Semowmebis dros ukve inficirebulni iyvnen tuberkulozis miobaqteriit anu savsebit dasasvebia, rom isini saindeqso SemTxvevis gamovlenamdec ki yofiliyvnen inficirebulni. pacientta TanamSromloba miuxedavad pacientebisa da mati ojaxebis wevrebis aqtiuri xelsewyobisa, sanatoriul mkurnalobaze myofma Tormetma pacientma miatova mkurnalobis kursi, Tumca otxi matgani isev daubrunda mkurnalobas. im pacienttagan, romlebsac kursi utardebodat binaze, mxolod ertma Sewyvita mkurnaloba da gamoetisa kvlevas. rac Seexeba medikamentebis regularulad mirebas, sanatoriumsi myof pacientebsac zogjer aviwydebodat da gansazrvruli periodis ganmavlobasi ar irebdnen danisnul medikamentebs. SesaZloa, es ganpirobebuli iyo im faqtit, rom sanatoriumsi avadmyofta metvalyureoba yoveltvis ar iyo satanado doneze da ar mowmdeboda irebda Tu ara TiToeuli pacienti yvela dozas. socialuri problemebi kvlevasi monawile TiToeuli pacientis ojaxis socialuri mdgomareobis Sesaxeb sistematurad xdeboda Canawerebis gaketeba. ZiriTadi problemebi warmoisva binaze myofi pacientebis 8 da sanatoriul mkurnalobaze myofi pacientebis 20 ojaxsi. sirtuleebi 214

am ukanasknelsi gacilebit ufro seriozuli xasiatisa iyo da xsirad ojaxebi ingreoda kidec. reziume mocemuli kontrolirebadi kvleva miznad isaxavda mkurnalobis efeqturobis Sedarebas pacientebis or jgufsi _ erti jgufis mkurnaloba mimdinareobda sanatoriumis karg pirobebsi, xolo meore jgufs kursi utardeboda saxlis Zalzed cud pirobebsi. sanatoriumis pirobebsi Catarebuli mkurnalobis Sedegebi, miuxedavad ketilmowyobili garemosi, kargi saeqtno momsaxurebis, kaloriebit mdidari kvebisa da xangrzlivi woliti rejimisa, didad ar aremateboda saxlis pirobebsi Catarebuli mkurnalobis Sedegebs, sadac pacientebi cxovrobdnen da mkurnalobdnen mravalsulian ojaxebsi, cudi kvebit, cudi sabinao pirobebit, arasakmarisi dasvenebit da xsirad xangrzlivi samusao saatebitac ki. orive jgufsi kavernis zomis Semcirebisa da/an daxurvis mixedvit, TiTqmis ertnairi rentgenologiuri gamosavali iyo mirebuli. aseve ertnairi iyo naxvelis nacxis uaryofitad konversiis fardobiti wilic da sicqarec. mkurnalobis dawyebidan daaxloebit 4 Tvis Semdeg rogorc binaze, aseve sanatoriumsi namkurnalebi pacientebis 90% mravaljeradad Seswavlili naxveli yvela SemTxvevaSi kultura-negatiuri iyo da aseti done SenarCunda mteli mkurnalobis ganmavlobasi. rac Seexeba daavadebis pasiur formasi gadasvlas mkurnalobis erti wlis Semdeg da recidivs mkurnalobis Semdgomi otxwliani monitoringis manzilze, aqac Zalzed umnisvnelo gansxvavebebi armocnda ori jgufis Sedegebis Sedarebisas. masasadame, sanatoriumis pirobebsi mkurnalobam ver gazarda gankurnebis albatoba da verc recidivis SesaZlebloba Seamcira. am kvlevasi gamoyenebuli iyo zogadad mirebuli mkurnalobis tipi; moklevadiani mkurnaloba gansakutrebit mosaxerxebels xdis tuberkulozit daavadebuli pacientebis ambulatoriul menejments. 5 wlis ganmavlobasi mimdinareobda pacientis ojaxis wevrebis inficirebis riskis Seswavla. daavadebis sixsiris TvalsazrisiT aranairi gansxvaveba ar iqna gamovlenili binaze da sanatoriumsi namkurnalebi pacientebis ojaxis wevrebs Soris, xolo infeqciuri 215

pacientis efeqturi mkurnaloba mnisvnelovnad amcirebda misi ojaxis wevrebis inficirebis risks. aqedan gamomdinare, binaze mkurnaloba ar qmnida raime gansakutrebul safrtxes, risi prevenciac moitxovda infeqciuri pacientebis uewvelad sanatoriumsi mkurnalobas. kvlevam gvicvena, rom pacienti mastan kontaqtsi myofi pirebisatvis gansakutrebit sasisia diagnostikamde da mkurnalobis dawyebamde. am momentisatvis mteli ziani, risi motanac tuberkulozis daavadebul infeqciur pacients SeuZlia mastan kontaqtsi myofi ojaxis wevrebisatvis, mas ukve miyenebuli aqvs. ase rom, aseti pacientebis sanatoriumsi izolireba naklebad sasargeblo armocnda. sanatoriumsi mkurnalobis nakli isaa, rom igi Tavganwirvas moitxovs pacientisgan. Znelia pacienti xangrzlivi droit mowyvito ojaxs da SeunarCuno sanatoriumsi disciplina. kidev erti socialuri naklia is, rom igi damangrevlad moqmedebs ojaxur urtiertobebze. martlac, am kvlevis monawile 12 pacientma miatova sanatoriumsi mkurnaloba (Tumca 4 kvlav iqna mirebuli), masin rodesac jgufsi, sadac pacientebs binaze utardebodat kvleva, aseti SemTxveva mxolod erti iyo. sanatoriumis pirobebsi mkurnaloba TavisTavad sulac ar izleva medikamentebis regularulad mirebis garantias, Tuki wamlebis mireba ar xdeba medikosis metvalyureobit da misi TandaswrebiT. am kvlevam didi bizgi misca mkurnalobis institucionaluri orientaciidan ambulatoriul mkurnalobis zogadi politikis principebze gadasvlas (ix. Tavi: ra ZiriTadi etapebi gamoikveta tuberkulozis mkurnalobis istoriasi da rodis aris sawiro tuberkulozit daavadebuli pacientis hospitalizacia da ramdenad infeqciurad sasisni arian tuberkulozit daavadebuli pacientebi mkurnalobis dros ). 216

37. ramdenad xsirad Sewyveten vadamde adre pacientebi mkurnalobas j.sbarbaro 24 medikamentebis mirebis darrveva universaluri da sawirboroto movlenaa, romelic yoveltvis unda gavitvaliswinot pacientebis mkurnalobisa da daavadebis kontrolis dros. Rrmad fesvgadgmuli kulturuli tradiciebisa da adamianta Sexedulebebis Zlieri da negatiuri zegavlena sazogadoebrivi jandacvis programebze askara gamoxatulebas povebs pacientebis mier ketris, filarioizis da revmatiuli cxelebis 187 profilaqtikuri mkurnalobis SewyvetaSi. mravali kvlevit gamovlinda, rom sami pacientidan erti vadamde adre wyvets medikamentebis mirebas 188. msgavsi macveneblebi dafiqsirebulia im pacientebsic, romlebsac utardebodat tubsawinaarmdego mkurnaloba 187,189,190,191. samwuxarod aseti qceva damaxasiatebelia ara mxolod ambulatoriuli pacientebisatvis, aramed mattvisac, visac mkurnaloba binaze utardeba. sisxlis SratSi medikamentis Semcvelobisa da SardSi metabolitebis gansazrvrit natlad Cans, rom is pacientebic ki, romeltatvisac saavadmyofosi sawoltan moaqvt medikamentebi, xsirad malaven an yrian mat, rata ar miiron es abebi 189. medikamentebis mirebis Sewyvetis marali macvenebeli - 65% dafiqsirebulia daavadebulta farto speqtrsi, hipertenzia iqneba es, diabeti Tu artriti da gulis ukmarisoba. es daavadebebi adasturebs, rom seriozuli simptomebis arsebobac ki ver uzrunvelyofs pacientebis mier rejimis dacvas. simptomebis gaqroba kidev ufro zrdis mkurnalobis Sewyvetis macveneblebs. avadmyofobis simwvave, misi xangrzlivoba, funqcionaluri dazianebebi da 24 medicinisa da TavdacviTi medicinis doqtori. kolorados janmrtelobis mecnierebata centris universiteti. denveri, kolorados Stati. ass. 217

Tanmxlebi daavadebebi, zegavlenas ver axdenen samedicino rekomendaciebis Sesrulebaze. mcdelobebi, ganesazrvrat raime maxasiateblebi an nisnebi, romelta daxmarebitac SesaZlebeli gaxdeboda Sesabamisi da arasesabamisi pacientebis gamijvna, warumateblad dasrulda. kvlevebma gvicvena, rom asaki, sqesi, etnikuri da rasobrivi warmomavloba, socialuri-ekonomikuri statusi, ganatlebis done, ojaxuri mdgomareoba da religiuri Sexedulebebi ver dagvexmareba imis dadgenasi, Tu vin daicavs an ar daicavs mkurnalobis rejims. binaze gaufrtxilebeli vizitebi da abebis datvla cxadyofen, rom klinikasi regularuli misvla ar izleva garantias, rom pacientebi medikamentebs danisnulebisamebr miireben. intensiuri saganmanatleblo musaoba da ojaxis uaxloes wevrebze, Tundac dedebze imedebis damyarebac ki, rom isini uzrunvelyofen medikamentebis regularul mirebas, aseve araefeqturi armocnda. miuxedavad amisa, jandacvis bevr musaks mainc miacnia, rom mat SeuZliaT ganasxvavon sandoa pacienti Tu ara, gansakutrebit Tu isini am pacients didi xania icnoben. kidev, kvlevebma daadastura, rom aset profesionalebsac ki ar SeuZliaT winaswar zustad gansazrvron ramdenad regularulad imkurnaleben mati pacientebi 189. moulodneli arc is aris, rom isinic ki, vinc zustad icavs rejims kvireebisa da Tveebis manzilze, asusteben regularobas. mkurnalobis Rirebuleba, masze daxarjuli droisa da finansebis gatvaliswinebit, mkurnalobis araregularobis kidev erti mizezia. rtuli rejimebi asocirdeba mkurnalobis mitovebis ufro maral macveneblebtan. mkurnalobis Sewyvetis 192 sixsiris Semcireba SesaZlebelia tuberkulozis kargad funqcionirebadi programit, romelic amcirebs mkurnalobis regularobis xelissemslel faqtorebs (ixilet Tavi: ratom mtavrdeba mkurnaloba warumateblad da ra unda gaketdes mkurnalobis arasasurveli Sedegebis Tavidan asacileblad ). araregularobis prevencia is umtavresi mizania, ristvisac unda dainergos usualo metvalyureobit mkurnaloba, romelic strategiis warmatebis sakvanzo elements warmoadgens. 218

38. ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves 25 j.sbarbaro 26 masinac ki, rodesac tuberkulozis kontrolis samsaxurebis novatoruli midgomebi ganapirobebs pacientebis kmayofilebas da survils itanamsromlos medikosebtan, mkurnalobis rekomendaciebis araregularuli dacva an mati ugulvebelyofa kvlavac seriozul problemad rceba. tuberkulozis efeqturi mkurnaloba sawiroebs xangrzlivi drois ganmavlobasi ramodenime medikamentis mirebas, ris Sedegadac daavadebis damaxasiatebeli simptomebi swrafad qreba da kargad yofnis SegrZnebas badebs _ es ki is faqtorebia, romlebic ganapirobeben rejimis darrvevas. amitom tuberkulozis kontrolis programebi, romlebic miznad isaxaven pacientebis gankurnebas, mteli mkurnalobis ganmavlobasi unda musaobdnen im mimartulebit, rom Tavi daarwion am problemas. usualo metvalyureobis qves mkurnalobis upiratesoba osaa, rom mkurnalobis mteli kursi mimdinareobs programis zedamxedvelobit. mxolod aset SemTxvevaSi arsebobs sruli garantia, rom pacientma miiros wamali metvalyuris TandaswrebiT. am SemTxvevaSi mkurnaloba ar iqneba araregularuli, rac Zalzed xsiria masin, rodesac pacientebi Tavad ireben medikamentebs. mkurnalobis metvalyure uzrunvelyofs, rom medikamenti mirebul iqnes satanado intervalebita da satanado dozebit _ mxolod aset SemTxvevaSia uewveli sargeblobis momtani mkurnaloba rogorc pacientis, aseve sazogadoebisatvis. amis yvelaze nateli 25 k. tomanis wignis wina gamocemis Tavze dayrdnobit 26 medicinisa da TavdacviTi medicinis doqtori. kolorados janmrtelobis mecnierebata centris universiteti. denveri, kolorados Stati. ass. 219

gamoxatuleba mkurnalobis dasrulebisas gankurnebis marali macvenebelia. asetive mnisvneloba aqvs medikamentebisadmi rezistentobis mkvetr Semcirebas, vinaidan usualo metvalyureoba ar azlevs sasualebas pacients ganzrax, an daudevrobis gamo Sewyvitos erti an ramodenime medikamentis mireba, rac iwvevs medikamentebisadmi rezistentuli Stamebis warmoqmnas (ixilet Tavi: rogor vitardeba medikamentebisadmi rezistentoba ). ufro metic, vinaidan am SemTxvevaSi jandacvis musaktan myardeba mwidro da sistematuri kavsiri, iqmneba mkurnalobis yvela gverditi movlenisa da gartulebis droulad da swrafad alagmvis SesaZlebloba. es gansakutrebit mnisvnelovania mkurnalobis kritikul, sawyis fazasi. garda amisa, metvalyuresa da pacients Soris xsiri kontaqti amcirebs dros mkurnalobis Sewyvetasa da ganaxlebas Soris, romlis xangrzlivobac pacientebis mier medikamentebis damoukideblad mirebis SemTxvevaSi SeiZleba iyos erti Tve an meti. usualo metvalyureobisas igi ert dremde mcirdeba. mkurnalobis rejimis dacvis uzrunvelyofa kidev ufro amcirebs sazogadoebasi infeqciis gavrcelebis SesaZleblobas da, aqedan gamomdinare, avadobis tvirts da tuberkulozit daavadebis axali SemTxvevebis warmoqmnis albatobas. mravalma analizma acvena, rom usualo metvalyureobit mkurnalobis programasa da massi monawile personalize garebuli xarjebi ufro met danazogs izleva im uzarmazar xarjebtan SedarebiT, romlebic warmoiqmnevba ganmeorebit mkurnalobisas, rezistentuli formebis da axali ( xsirad ukve rezistentuli) SmemTxvevebis arakontrolirerbadi mkurnalobis Sedegad 193,194,195. daumorcilebeli pacientebi dauyonebliv gamovlindeba da sazogadoebas ezleva SesaZlebloba SeimuSaos mati mkurnalobis alternatiuli gzebi. es Zalzed mnisvnelovania imisatvis, rom uzrunvelyofili iyos TiToeuli pacientis mier medikamentebis mireba. amisatvis metvalyurem pacients unda miawodos wyali an Cai, rac daexmareba avadmyofs abis gadaylapvasi. aseve kargi iqneba, Tu metvalyure medikosi, medikamentis mirebis Semdeg kidev ramdenime wuts dayofs pacienttan da gaesaubreba mas. es ganamtkicebs kavsirs pacientsa da metvalyures Soris da izleva sasualebas davrwmundet, rom medikamenti pacientma namdvilad Caylapa. usualo metvalyureoba nisnavs, rom pacienti TiToeul dozas irebs metvalyuris TandaswrebiT. 220

39. ratom aris mkurnaloba warumatebeli da ra unda gaketdes mkurnalobis arasasurveli Sedegebis armosafxvrelad 27 f.luelmo 28 tuberkulozit daavadebulebs gankurnebis unikaluri Sansi ezlevat gansakutrebit im SemTxvevaSi, Tu mat ar CatarebiaT tubsawinaarmdego mkurnaloba warsulsi da ar arian aivinficirebulni. umkurnaleb pacientebsi mkurnalobis mokle kursis rejimit SesaZlebelia gankurnebis 95%-ze marali macveneblebis mireba. realobasi aseti warmatebis mirweva Zalzed isviatad xdeba. warumatebeli mkurnalobis ZiriTadi mizezebia mkurnalobis naadrevad Sewyveta (defolti) da medikamentebis araregularuli mireba, arasatanado rejimebis danisvna, medikamentebisadmi rezistentoba, mkurnalobis dawyebis dagvianeba, gardacvaleba Sidsis mizezit da medikamentebis toqsikuroba. mkurnalobis naadrevad Sewyveta da medikamentebis araregularulad mireba mkurnalobis cudi Sedegebis ZiriTadi mizezebia mkurnalobis naadrevi Sewyveta da medikamentebis araregularulad mireba. Aamas Semdegi faqtorebi ganapirobeben : _ samedicino obieqtebisadmi xelmiuwvdomoba (geografiuli, finansuri, SezRuduli an mouxerxebeli saatebi, jandacvis araketilganwyobili personali) da amis Sedegad pacientebis mier Semosavlebis dakargva; 27 k. tomanis wignis wina gamocemis Tavze dayrdnobit 28 tuberculosis kontrolis programa, konsultanti. Jeneva, Sveicaria 221

_ medikamentebit araregularuli momarageba, romelic ganapirobebs monoterapiaze gadasvlas da samedicino samsaxurebisadmi ndobis dakargvas; pacientze nakleb orientirebuloba mkurnalobis xangrzlivobis gansazrvrisas; pacientebisatvis damaxasiatebeli gulmaviwyoba wamlebis mirebastan dakavsirebit da mkurnalobis Sewveta, rodesac odnav uket igrznoben Tavs (ixilet Tavi: ramdenad xsirad Sewyveten vadamde adre pacientebi mkurnalobas ). sxvadasxva pacientebs axasiatebt alkoholizmtan da narkotikebtan dakavsirebuli problemebi, rac xels uslis mkurnalobis regularobas da sawiroebs specialuri strategiis SemuSavebas TiToeuli pacientis mimart 196. araadekvaturi rejimebi araadekvaturi rejimebi, romlebic ZiriTadad inisneba kerzo klinikasi 197. zrdis mkurnalobis warumateblobas da recidivis risks. Aamitom gamoyenebuli unda iyos mkurnalobis mxolod is rejimebi, romlebic damtkicebulia warmatebuli kontrolirebadi kvlevebit da Seesabameba motxovnebs rogorc medikamentebis swori kombinaciis, aseve mati dozirebis, mirebis periodulobis da xangrzlivobis TvalsazrisiT 198. medikamentebisadmi rezistentoba bevr dasaxlebul regionsi medikamentebisadmi rezistentoba ar warmoadgens mkurnalobis warumateblobis ZiriTad mizezs. magalitad, cudad organizebuli programebis SemTxvevaSic ki, pirveladi rezistentobis 10%-iani macveneblit, gankurnebis dabali macveneblebi ZiriTadad ganpirobebulia ararezistentuli pacientebis mkurnalobis SewyvetiT 199. iset regionebsi, sadac tuberkulozis menejmenti gaumjobesda, medikamentebisadmi rezistentoba warumateblobis mtavari mizezia gansakutrebit im SemTxvevaSi, rodesac Stamebi rezistentulia ori iseti baqtericiduli medikamentis mimart, rogoricaa izoniazidi da 222

rifampicini (multirezistentuli Stamebi). medikamentebisadmi rezistentoba vitardeba araadekvaturi da araregularuli mkurnalobisa da cudad organizebuli programebis Sedegad (ixilet Tavi: ra mizezebi ganapirobebs medikamentebisadmi rezistentobas ). multirezistentuli Stamebi SeiZleba gavrceldes mosaxleobasi an daxurul garemosi, Caenacvlon mgrznobiare Stamebs da uefeqto gaxadon pirveli rigis medikamentebit mkurnaloba. dagvianebuli diagnostika diagnostikisa da mkurnalobis dawyebis dagvianeba zrdis daavadebis gamwvavebisa da gardacvalebis risks. dagvianebebi ZiriTadad ganpirobebulia samedicino dawesebulebebisadmi xelmiuwvdomlobit da mkurnalobis iseti xelsemsleli pirobebit, rogoricaa Semosavlis dakargva, sakonsultacio xarjebi, diagnostikuri testebisa da mkurnalobis gadasaxadebi da eqimtan ramodenimejer misvlis sawiroeba, informaciis nakleboba daavadebis simptomebis da samedicino dawesebulebebis Sesaxeb, aseve jandacvis sistemis dagvianebuli reagireba diagnostirebul SemTxvvebze dagvianebuli (laboratoriuli kvlevebis Sedegebi, samedicino gadawyvetileba da sxva). Sidsi adamianis imunodeficitis virusit inficireba zrdis pacientebis darupvis albatobas mkurnalobis processi. xsirad es iseti mizezebit aris ganpirbebuli, romlebic ar ukavsirdeba tuberkulozs (ix. Tavi: rit gansxvavdeba aiv-inficirebul pacientebsi tuberkulozis mkurnaloba ). prognozi damokidebulia imunosupresiis xarisxze. SidsiT daavadebuli da aseve antiretrovirusul mkurnalobaze myofi pacientebis Tanmxlebma daavadebebma SeiZleba gaartulos tuberkulozis mkurnaloba, xolo aiv-infeqciastan dakavsirebulma cudma prognozma ki Seamciros pacientis motivacia tuberkulozis mkurnalobis gagrzelebaze, rasac mkurnalobis xsir Sewyvetamde mivyavart. tuberkulozisa da aiv/sidsis samedicino daxmarebis uzrunvelmyofelta Soris kargi koordinacia izleva tuberkulozis, rogorc adamianis 223

imunodeficitis virustan dakavsirebuli daavadebis, mkurnalobis problemebis gadawris SesaZleblobas. medikamentebis toqsikuroba medikamentebis toqsikurobam SeiZleba ganapirobos mkurnalobis warumatebloba da zogjer sikvdilic, Tu ar moxdeba satanado samedicino daxmarebis drouli uzrunvelyofa. medikamentebis toqsikurobit gamowveulma cvlilebebma SeiZleba gazardos mkurnalobis xangrzlivoba, gansakutrebit xandazmul pacientebsi. hepatitis an hipersensitiurobis movlenebma aseve SeiZleba gaartulos mkurnalobis menejmenti. mkurnalobis arasasurveli Sedegebis prevencia warumatebeli mkurnalobis macveneblebis Semcireba SesaZlebelia Semdegi RonisZiebebiT : mkurnalobis decentralizacia jandacvis adgilobrivi da sazogadoebrivi dawesebulebebis donemde samedicino dawesebulebis personalis an Temis specialurad momzadebuli moxaliseebis daxmarebit, romlebic maqsimalurad axlos iqnebian pacientebis sacxovrebel an samusao adgilebtan. pacients unda mieces SesaZlebloba aircios visi zedamxedvelobis qves da sad surs mkurnaloba. jandacvis sistema valdebulia gaumartivos pacientebs mkurnalobis mireba, informacia miawodos mkurnalobis xangrzlivobis Sesaxeb, auxsnas Tu rogor unda moiqcnen misamartis Secvlis SemTxvevaSi; aseve jandacvis sistemam uzrunvelyos pacientebis swrafad mozebna da samedicino dawesebulebasi dabruneba, Tu isini acdenen danisnul vizitebs. uzrunvelyofili unda iyos pacientebis gadayvana diagnostikuri samedicino dawesebulebebidan samkurnalo dawesebulebebsi, saavadmyofoebidan poliklinikebsi da erti geografiuli regionidan meoresi mati adgilze miyvanisa da mkurnalobis monitoringi; maralxarisxiani ufaso medikamentebit pacientebis regularuli momarageba, mati satanado sarezervo maragebis 224

arseboba. TiToeuli pacientisatvis mkurnalobis mteli kursis medikamentebis Semcveli paketebi Tavidan agvacilebs sxva pacientis medikamentebis gamoyenebas maragis gamolevis SemTxvevaSi, rac ganapirobebs mkurnalobis Sewyvetas; medikamentebis mireba usualo zedamxedvelobis qves _ es uzrunvelyofs pacientis mier yvela medikamentis mirebas, gaazlierebs kontaqts pacientebsa da jandacvis sistemas Soris da Seamcirebs dros mkurnalobis Sewyvetasa da ganaxlebas Soris (ix. Tavi: ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves ); mkurnalobis adekvaturi standartuli rejimebis gamoyeneba yvela doneze, mat Soris kerzo seqtorsic. mkurnalobis rejimi axlad gamovlenili pacientebisatvis unda Seicavdes otx medikaments (an sam medikaments nacxit uaryofiti pulmonaruli da zomieri eqstrapulmonaruli tuberkulozis dros) da sul mcire 5 medikaments adre namkurnaleb pacientebsi. mtavrobam unda SeimuSaos nacionaluri standartizebuli mkurnalobis rejimebi medikamentebis efeqturobis Sesaxeb monacemebis safuzvelze da gamocdilebis gatvaliswinebit uzrunvelyos mati gamoyeneba, rogorc saxelmwifo, aseve kerzo samedicino dawesebulebebsi; unda SemuSavdes mati monitoringis meqanizmebi (ixilet Tavi: rogor avicilot Tavidan medikamentebisadmi rezistentobis prevencia ); fiqsirebuli dozebis kombinacia, romelic uzrunvelyofs pacientebis mier yvela an arc erti medikamentis mirebas, gaamartivebs danisnulebas da gaaumjobesebs pacientebis mier rejimis dacvis aucileblobis arqmas; dagvianebuli diagnostikis vadis Semcireba sazogadoebisatvis informaciis miwodebit iset sakitxebze, rogoricaa tuberkulozis simptomebi. samedicino daxmarebis xelmisawvdomoba, nacxis analizis Sedegebis angarisgebis efeqturi procedurebi da SemTxvevebis gaumjobesebuli gamokvleva respiratoruli simptomebis mqone pacientebsi, romlebic nebismieri mizezit mimartaven samedicino dawesebulebebs; 225

aiv-infeqciis prevencia, adreuli diagnostika da tuberkulozit daavadebuli aiv-inficirebuli pacientebis adekvaturi menejmenti. aqedan gamomdinare, mkurnalobis warmatebis ZiriTadi faqtoria mkurnalobis organizeba da satanado administracia 200. yvelaze sauketeso rejimmac ki SeiZleba dabali Sedegebi mogvces, Tuki mkurnaloba ar iqneba fokusirebuli pacientisatvis samedicino momsaxurebis xelmisawvdomobis gazrdaze da ar uzrunvelyofs medikamentebis regularul mirebas 201. 226

40. ra upiratesobebi da nakli aqvs tubsawinaarmdego medikamentebit fiqsirebuli dozebit mkurnalobas k.lasersoni 29 da m.lademako 30 tuberkulozis efeqturi kontrolis ZiriTadi elementia maralxarisxiani tubsawinaarmdego medikamentebit satanado momarageba; medikamentebi pacientebisatvis unda iyos ufaso. fiqsirebuli dozis kombinaciebi (FDCs), rac gulisxmobs ori an meti tubsawinaarmdego medikamentis ert tabletsi fiqsirebuli proporciebit gaertianebas, gamoiyeneba gasuli saukunis 80-iani wlebidan da registrirebulia 40-ze met qveyanasi 202. Cveulebriv gamoiyeneba izoniazidis da Tioacetazonisa da izoniazidetambutolis kombinacia. rac Seexeba mkurnalobis mokle kurss, yvelaze gavrcelebulia ori FDC preparati, esenia izoniazidi, rifampicini da pirazinamidi, romlebic gamoiyeneba intensiur fazasi, izoniazidi da rifampicini xsirad gamoiyeneba gagrzelebis fazasi. otxi medikamentis _ izoniazidis, rifampicinis, pirazinamidis da etambutolis _ Semcveli FDC sul ufro fartod gamoiyeneba; janmos esencialuri medikamentebis samodelo CamonaTvali moicavs FDC-s specifikuri formulirebebit. FDC-is potencikuri upiratesobebia 203,204,205 radgan ramdenime medikamenti gaertianebulia ert FDC- Si 206,207,208 medikamentebisadmi rezistentulobis ganvitarebis albatoba naklebia. FDC-is gamoyeneba Tavidan agvacilebs 29 tuberculosis armofxvirs ganyofilebis epidemiologi. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati 30 tuberculosis armofxvris ganyofileba, mecnierebata ganyofilebis direqtoris moadgile. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati 227

tuberkulozis erti medikamentit mkurnalobis sasisroebas (monoterapia). ufro metic, Tu mkurnaloba Sewydeba (mkurnalobis Sewyvetisa da/an medikamentebit arasatanadod momaragebis gamo) avtomaturad Sewydeba yvela medikamentis gamoyeneba, rac aseve Seamcirebs rezistentuli organizmebis SerCeviTi gadarcenis risks; FDC-ebis gamoyenebis Sedegad gaumjobesdeba da ufro zusti gaxdeba klinicistebis danisnulebata warmoeba. es gansakutrebit daexmareba im klinicistebs, romlebic arasatanadod icnoben tuberkulozis mkurnalobis nacionalur gaidlainebs da radgan FDC-Si ucvlelia TiToeuli wamlis Semadgenloba, es Tavidan agvacilebs medikamentebis dozis gansazrvrastan dakavsirebul Secdomebs; FDC-is gamoyenebit martivdeba medikamentebis SeZenis, martvisa da ganawilebis procesebi. sawiroa ufro naklebi raodenobit tabletebis SekveTa da menejmenti. xolo mati ganawileba da Senaxva adgilobriv doneze ufro martivia. aqedan gamomdinare, FDC-is gamoyenebis Sedegad SesaZlebelia efeqtianobis gazrda; FDC-is gamoyenebit mkurnalobis rejimi martivdeba pacientebisatvisac (naklebi raodenobit abebi), rac ganapirobebs rejimis ufro advilad dacvas 209,210 ; rifampicini xsirad gamoiyeneba sxva infeqciebis samkurnalod da bevr qveyanasi ureceptod iyideba. rifampicinis gamoiyeneba FDC-Si Seamcirebs mis arasatanado gamoyenebas sxva infeqciebis dros da aqedan gamomdinare, SeunarCunebs mas efeqturobas tuberkulozis mkurnalobasi. da mainc, FDC-is gamoyeneba ar izleva garantias, rom pacienti miirebs abebis satanado raodenobas da daasrulebs mkurnalobas. SemTxvevebis efeqturi martva Zalzed mnisvnelovania da igi moicavs usualo metvalyureobit mkurnalobis DOTS strategias 203,204. FDC -is potenciuri naklovanebebebia 203,204,205 : rifampicinis biologiuri SeTvisebadoba (mirebuli medikamentis sisxlsi Sewovili raodenoba) SeiZleba 228

Semcirdes, rodesac igi gamoiyeneba FDC-Si sxva medikamentebtan ertad 211,212,213,214. FDC-is gamoyeneba, kerzod, sam an otx medikamenttan ertad kombinaciasi rac ganapirobebs plazmasi rifampicinis Semcvelobis SedarebiT dabal dones da mkurnalobis warumateblobas, recidivis da/an rifampicinisadmi rezistentuli Stamebis ganvitarebas 215. Tu FDC-is warmoeba kargi sawarmoo standartebis dacvit ganxorcielda, is gaxdeba erti preparatis mirebis ekvivalenturi mxolod im FDC-is gamoyenebit, romelta biologiuri SeTvisebadobac Seswavlilia adamianebsi 216,217,218. qveyanasi FDC-s registraciisatvis sawiroa misi biologiuri SeTvisebadobis demonstrireba, Tumca SesaZlebelia, rom medikamentis damtkicebis periodsi an tenderis dros Semowmdes FDC-is biologiuri SeTvisebadoba 208,219. ar arsebobs yvela momdevno partiis kontrolis meqanizmebi 218,220. sawiroa Seiqmnas maregulirebeli struqtura, romelic uzrunvelyofs kargi sawarmoo praqtikis satanado monitoringsa da FDC biologiuri SeTvisebadobis standartebis SemuSavebas (miuxedavad imisa, es preparatebi importirebulia Tu adgilobrivi warmosobis), Tumca aseti struqturebi msoflios mraval qveyanasi araadekvaturia 221. garda amisa, msofliosi arsebobs sul ramodenime iseti laboratoria, romelsac aqvs biosetvisebadobis testirebis oficialuri sertifikati 222 ; FDC-is gamoyenebis optimaluri operatiuli efeqtianoba SeiZleba ver iqnes mirweuli, vinaidan mkurnalobisatvis sawiro dozebi yvela pacientisatvis ertnairi ar aris. xsirad sawiro xdeba wonastan dozis morgeba. janmos rekomendaciit warmodgenili unda iyos FDC-is sxvadasxva dozebi, romlebic SesabamisobaSi moyvanis SesaZleblobebs izleva. amastan, gartulebis SemTxvevaSic sawiroa dozebsi cvlilebebis Setana. tuberkulozis kontrolis programebsi, romlebic iyeneben FDC, aseve unda Seiqmnas arakombinirebuli medikamentebis maragi, radgan tuberkulozis eqimspecialistebs SeeZloT mati gamoyeneba gansakutrebul situaciebsi; 229

arsebobs FDC-is sxvadasxva saxe medikamentebis gansxvavebuli kombinaciebit da gansxvavebuli dozebit. Mmagram, Tu qveyana iyenebs fiqsirebuli dozebis kombinaciis ertze met formas, SeiZleba dabneva da dozebis arasworad gamoyeneba. qveynebsi gamoyenebuli unda iyos mxolod da mxolod janmosa da IUATLD-is mier rekomendirebuli formebi. tuberkulozis erovnulma programam unda moaxdinos im formulirebebis registrirebac, romlebic amorebulia medikamentebis maregulirebeli erovnuli organizaciis mier; arsebobs Teoriuli riski, rom sami an otxi medikamentis Semcveli FDC-is xelmisawvdomobam mraval qveyanasi SeiZleba ganapirobos tubsawinaarmdego medikamentebis arasatanado gamoyenebis farto masstabebi. zogiert regionsi FDC-is propagandas uwevdnen, rogorc tuberkulozis efeqturi kontrolis alternativas, rac potenciur safrtxes uqmnida programas. FDC-s abebis rekomendirebulze naklebi raodenobit mirebam SeiZleba ganapirobos am mravalkomponentiani medikamentis subinhibitoruli koncentracia. kvlevasi pacientebis mkurnalobis Sedegebi, romlebic Tavad irebdnen FDC-s Sedarebuli iyo im pacientebis SedegebTan, visac tuberkulozis mkurnaloba utardebodat calkeuli medikamentebit usualo metvalyureobis qves, armocnda, rom pacientebis pirvel jgufsi recidivis done ufro marali iyo 223 ; rodesac intensiuri fazis dros gamoiyeneba sami an otxi medikamentis Semcveli FDC, masin gagrzelebis fazasi unda gamoviyenot ori sxva medikamentisagan Semdgari FDC, ramac SeiZleba dabneva da Secdomebi gamoiwvios; mcire adgilobriv sawarmoebs ar SeswevT unari awarmoon FDC, kerzod, otxi medikamentis kombinacia, rac amcirebs konkurencias da zrdis fasebs, Tu ar moxdeba medikamentebis saertasoriso doneze SeZena. qveyanas, romelic iyenebs FDCis, dawirdeba damatebiti momzadebis uzrunvelyofa medikamentebis SeZenis, samkurnalo rekomendaciebis, pacientebisa da med. personalis ganatlebis donis amarlebis sakitxebsi 204. 230

miuxedavad imisa, rom FDC-is gamoyenebas potenciuri upiratesobebi aqvs, arsebuli operatiuli, programuli da sxva SezRudvebis gamo am upiratesobebis gamoyeneba SeiZleba sirtuleebtan iyos dakavsirebuli. savaraudoa, rom FDCs-is gamoyeneba gaizrdeba im qveynebsi, sadac xdeba medikamentebis importireba, rac miuititebs, rom mati zegavlenis gazomvas gansazrvruli mnisvneloba eniweba. TiToeulma qveyanam didi yuradrebit unda awon-dawonos FDC-s upiratesobebi da naklovanebebi da gansazrvros mati roli programasi. 231

41. rogor vitardeba medikamentebisadmi rezistentoba k.tomani 31 klinikuri da laboratoriuli dakvirvebebita da amomwuravi eqsperimentuli kvlevebit bevri ram gaxda cnobili imis Sesaxeb, Tu rogor vitardeba medikamentebisadmi rezistentoba, rogoria misi klinikuri da epidemiologiuri mnisvneloba da rogor unda moxdes misi prevencia an kontroli. rezistentoba gamovlenil iqna mkurnalobis rejimsi streptomicinis Setanis Semdeg. rodesac pacients mxolod am medikaments azlevdnen mkurnalobis dasawyissi arinisneboda gasaocari efeqti simptomebis gaqrobit da naxvelsi baqteriebis raodenobis mkvetri SemcirebiT. momdevno periodsi ki baqteriebis raodenoba kvlav Zalian swrafad izrdeboda da pacientis mdgomareoba uaresdeboda. aseti pacientebis naxvelidan izolirebuli baqteriebi armocndnen rezistentulni, anu medikamentis marali koncentraciis arsebobisas nacvlad imisa, rom darupuliyvnen, ganagrzobdnen zrdas. martivma eqsperimentma axsna es movlena. pacientebis naxveli, romlebsac arasdros 224 ar hqondat mirebuli streptomicini, inokulirebuli iyo niadagze, romelic Seicavda medikamentebis sxvadasxva koncentracias. bevr kulturasi gamovlinda ramodenime kolonia romelic ganagrzobda zrdas niadagsi streptomicinis inhibitoruli koncentraciis fonzec (5-10 g/ml). nateli iyo, rom baqteriul populaciasi arsebuli sxvadasxva baqteriebi rezistentuli unda yofiliyvnen streptomicinis mimart, Tumca, arasdros hqoniat kontaqti am wamaltan. aseve gamovlinda, rom rac ufro didi iyo baqteriuli populacia, mit ufro marali iyo albatoba, rom rezistentuli ujredi (mutanti) warmodgeniliyo. 31 gardacvlilia 232

garda amisa, SemCneul iqna, rom mxolod streptomicinit pacientis mkurnalobis dros rezistentuli baqteriebis Sefardeba swrafad izrdeboda. 12 kviris mkurnalobis Semdeg koloniebis raodenobam niadagze, romelic Seicavda streptomicinis 100 an 1000 µg/ml miarwia isetive raodenobas, rogoric iyo sakontrolo niadagze streptomicinis garese. am gamocdilebam gvicvena, rom baqteriuli populaciebis didi nawili medikamentis mirebamde Seicavs mgrznobiare organizmebis garkveul raodenobas, romelic irupeba medikamentebis zemoqmedebit. mcire raodenobit arsebuli rezistentuli baqteriebi ki inarcuneben cxovelmyofelobas, mravldebian da medikamentebisadmi mgrznobelobadakarguli mati memkvidreebi Taobidan Taobamde TandaTanobiT Caenacvlebian mgrznobiare organizmebs. aqedan gamomdinare, klinikurad relevanturi rezistentoba warmoadgens SerCevis procesis Sedegs. pacientsi, romelsac aqvs izoniazidisadmi sawyisi rezistentoba, intensiur fazasi mxolod izoniazidita da rifampicinit Catarebulma mkurnalobam SeiZleba gamoiwvios iseti mikroorganizmebis seleqcia, romlebsac rezistentoba ganuvitardebat rifampicinis mimartac. masasadame, mxolod erti efeqturi medikamentit mkurnalobam SeiZleba gamoiwvios Stamebis rezistentulad gardaqmna. grafiki #15 efeqturi monoterapia im SemTxvevaSi, rodesac organozmidan gamoyofili baqteria sawyisad rezistentulia izoniazidis(h) da mgrznobiare rifampicinis (R) mimart. klinikuri gaumjobeseba klinikuri gauareseba erti damatebuli wamali rezistentuli izoniazidis mimart mgrznobiare rifampicinis mimart 233

arasatanado mkurnaloba mxolod ori wamlit H-iT da R-iT iwvevs rezistentobis ganvitarebas rifampicinis mimart, rasac mohyveba klinikuri mdgomareobis gauareseba. erti medikamentis araswori damateba ganapirobebs pirazinamidisadmi rezistentulobis ganvitarebas.. 234

42. ratom unda davicvat gansakutrebuli sifrtxile rifampicinis gamoyenebisas a.vernoni 32 rifampicins gansakutrebuli sifrtxilit unda movepyrat, radgan igi tuberkulozis mkurnalobis 225 moklevadiani kursis ZiriTadi masterilizebeli medikamentia. mgrznobelobis mqone baqteriebis SemTxvevaSi rifampicinis gamoyenebit mkurnaloba SeiZleba dasruldes 6-9 TveSi imisda mixedvit, Tu ra medikamenttan ertad viyenebt mas. warumatebeli mkurnalobisa da recidivis sixsire SesaZloa 5%-mde Semcirdes. rifampicinis garese mkurnaloba moitxovs 12 Tves. rifampicinisadmi rezistentoba ganapirobebs warumateblobisa da recidivis macveneblebis zrdas 226. britanetis samedicino kvlevis centris mier Catarebuli kvlevebit gamovlinda, rom rifampicinisadmi rezistentoba ganapirobebs warumateblobis 45%-s mkurnalobis processi; ufro metic, darcenil pacientta TiTqmis naxevarsi arinisneba recidivi, rac saerto jamsi iwvevs arasasurveli Sedegebis gazrdas 72%-mde 227. es gasaocari sxvaobaa im pacientebtan SedarebiT, romlebsac hqondat sawyisi rezistentoba izoniazidisa da/an streptomicinis mimart (ix.cxrilsi #48). rifampicinisadmi rezistentobis SemTxvevaSi tuberkulozis mkurnalobis minimaluri xangrzlivoba 12-15 Tves Seadgens, xolo Tu rezistentoba gamovlinda sxva medikamentebisadmic (multirezistentoba), mkurnaloba unda gagrzeldes minimum 18-24 Tves. rezistentobis ganvitareba mosalodnelia nebismieri medikamentis mimart (mat Soris rifampicinisadmi), Tu igi sxva medikamentebis 32 tuberculosis armofxvris ganyofilebis epidemiologi. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati 235

garese gamoiyeneba. es movlena pirvelad arwerili iqna streptomicinis mimart 1947 wels rogorc vardnisa da matebis fenomeni (ixilet Tavi: ra aris vardnisa da matebis fenomeni da ras nisnavs ( Tanmimdevruli rejimi ). aseti rezistentoba SeiZleba erti medikamentit mkurnalobis SedarebiT mokle periodsi ganvitardes, gansakutrebit didi raodenobit aqtiuri baqteriebis mqone pacientebsi (magalitad, tuberkulozis aqtiuri formit daavadebul an SidsiT gamowveuli imunosupresiis mqone pacientebsi). asetive rezistentobaa mosalodneli, Tu mkurnalobis rejimsi gamoiyeneba mxolod erti efeqturi medikamenti (rejimis sxva medikamentebisadmi inicialuri rezistentobis gamo). aseve kargad iyo arwerili rezistentobis ganvitarebis meqanizmi araefeqturi rejimisatvis mxolod erti medikamentis damatebis SemTxvvaSi 228. cxrili #48 rifampicinze an izoniazidze inicialuri rezistentobis mqone pacientebi an ararezistentuli pacientebis mkurnaloba inicialuri rezistentoba rifampicini izoniazidi da / an sxvastreptomicini ara rezistentuli mkurnalobis usedegoba Sefasebuli usedego 11 5 (55 %) 246 5 (2 %) 1361 0 (0 %) recidivi mkurnalobis Semdeg Sefasebuli usedego 6 3 (50 %) 360 24 (7 %) 2322 94 (4 %) rifampicinisadmi rezistentobis ganvitarebas ZiriTadad ganapirobebs tuberkulozis mikobaqteriis rpo-b genis kritikuli zonebis mutaciebi 229. rezistentoba rifampicinis jgufis yvela medikamentis mimart ganpirobebulia am saerto meqanizmit da dres SeiZleba itqvas, rom rifampicinis mimart rezistentoba nisnavs am klasis yvela medikamentebisadmi rezistentobas. erti medikamentis izolirebulad gamoyeneba Zalzed gavrcelebuli praqtikaa, rodesac wamali Tavisufal gayidvasia da adviladxelmisawvdomia pacientebisatvis. igi SeiZleba danisnul iqnes gamoucdeli eqimis mier an gamoyenebuli iyos TviTmkurnalobis miznit. rifampicinisadmi rezistentoba aseve gvxvdeba SidsiT daavadebul pacientebsi, mycobacterium avium intracellulare-s 230 236

profilaqtikis miznit rifampicinis gamoyenebisas. aseti problemebis prevencia SesaZlebelia Semdegi RonisZiebebiT: _ rifampicinisa da misi jgufis sxva medikamentebis gayidvis (rogoricaa rifabutini, rifapentini) SezRudva da mati gamoyeneba mxolod tuberkulozis kontrolis programebsi (rogorc es ganxorcielda zogiert ganvitarebad qveyanasi, sadac funqcionirebs tuberkulozis kontrolis efeqturi programa) an mati danisvnis uflebis micema mxolod licenzirebuli da gamocdilebis mqone eqimebisatvis (rogorc es ketdeba bevr ganvitarebul da zogiert ganvitarebad qveyanasi); da/an _ rifampicinis mirebis uzrunvelyofa mxolod fiqsirebuli dozebis kombinaciasi izoniazidis Semcvel produqtebsi, ise, rom SeuZlebeli gaxdes marto am medikamentis mireba 231 (ixilet Tavi: ra upiratesobebi da nakli aqvs fiqsirebuli dozebis kombinaciit mkurnalobas ). rifampicinis gamoyenebis SezRudvis Sedegebi minimaluria, radgan rifampicinsa da misi analogebis gamoyenebis Cvenebebi sxva patologiis dros mcirea. rifampicini ZiriTadad gamoiyeneba mzime stafilokokuri infeqciebis mkurnalobisa da meningokokuri daavadebebis prevenciisas. rifabutini warmoadgens meore rigis mnisvnelovan medikaments SidsTan asocirebuli diseminirebuli Mycobacterium avium intracellulere-s infeqciebis prevenciasa da mkurnalobasi. rifampicinis jgufis medikamentebi aseve gamoiyeneba sxva CvenebebisaTvisac. 237

43. medikamentebisadmi rezistentobis ra tipebi arsebobs 33 m.espinali 34 pirveladi rezistentoba gamowveulia rezistentuli StamiT inficirebit im pacientisgan, romelmac SeiZina rezistentoba arasatanado mkurnalobis gamo. aqedan gamomdinare, miuxedavad imisa, rom medikamentebisadmi pirveladi rezistentobis mqone pirs es medikamenti arasdros ar miuria, misi inficirebis wyaros aseti mkurnaloba unda hqondes Catarebuli. SeZenili rezistentoba vitardeba masin, rodesac pacients utardeba monoterapia. Tu programa ver uzrunvelyofs mkurnalobis rejimis dacvas da xdeba medikamentebis SerCeviT mireba, mizezia wamlebit araregularuli momarageba, medikamentebis cudi xarisxi, mati arasatanadod danisvna da isviatad medikamentebis SeTvisebasTan dakavsirebuli problemebi. medikamentebisadmi mgrznobelobis mqone baqteriebi irupebian. xolo rezistentuli mikroorganizmebi ganagrzoben gamravlebas. kvlevebsi da klinikur cdebsi, romlebic miznad isaxaven pirveladi rezistentobis sixsiris gansazrvas, Znelia garkveva namdvilad pirveladia es rezistentoba Tu ara, radgan pacientebma SeiZleba arc icodnen an uaryofdnen tuebrkulozis mkurnalobis faqts. aqedan gamomdinare, Tu gamoviyenebt aset gamotqmas - medikamentebisadmi rezistentoba tuberkulozit axlad gamovlenil SemTxvevebs Soris, es ganisarvreba rogorc tuberkulozis mikobaqteriis rezistentuli Stamebis arseboba im pacientebsi, romlebsac arasdros miuriat tubsawinaarmdego medikamentebi an irebdnen am medikamentebs ert Tveze naklebi drois ganmavlobasi. 33 k. tomanis wignis wina gamocemis Tavze dayrdnobit 34 gadamdeb daavadebata ganyofilebis medmusaki. jandacvis msoflio organizacia. Jeneva, Sveicaria 238

termini SeZenili rezistentoba medikamentebis mimart nisnavs, rom pacients Tavdapirvelad hqonda medikamentebisadmi mgrznobeloba, magram mkurnalobis processi mikroorganizmebi rezistentebad gardaiqmnen. realurad tuberkulozis marali prevalentobis regionebsi praqtikulad ar arsebobs mkurnalobis dawyebamde medikamentebisadmi mgrznobelobis testebis sando Sedegebi. garda amisa, epidemiologiuri mtkicebulebebi gvicvenebs, rom adre namkurnalebi rezistentuli pacientebis did nawils mkurnalobis dawyebamde ukve hqonda medikamentebisadmi pirveladi rezistentoba 232. amitom mkurnalobis dawyebamde, sanam rezistentobis testis Sedegebi gaxdeba cnobili, namkurnaleb pacientebsi medikamentebisadmi rezistentobis arsanisnavad SeiZleba gamoviyenot aseti fraza medikamentebisadmi rezistentoba namkurnaleb pacientebsi. bunebrivad rezistentuli Stami veluri Stamia da calkeuli medikamentis mimart rezistentulia miuxedavad imisa, rom arasdros hqonia kontaqti am medikamenttan: anu arc bunebrivad rezistentuli Stamis mqone pacients da arc misi inficirebis wyaros arasdros miuria es medikamenti warsulsi. medikamentis mimart aseti tipis rezistentobas praqtikuli mnisvneloba ar aqvs. velur Stamebs isviatad aqvt satanado bunebrivi rezistentoba imisatvis, rom zemoqmedeba iqonion standartul mkurnalobaze 233. gamonaklisi Tioacetazonia, romlis mimartac bunebrivi rezistentoba SeiZleba fartod iyos gavrcelebuli zogiert regionsi. pirazinamidis mimart bunebrivi rezistentoba damaxasiatebelia aseve mikobaqteria bovisisatvis 234. 239

44. ras warmoadgens ~vardnisa da matebis~ fenomeni da rogoria ~Tanmimdevruli rejimis~ meqanizmi 35 m.espinali 36 grafiki #16 gvicvenebs vardnisa da matebis fenomens izoniazidistvis, romelsac xsirad vxvdebit araadekvaturad namkurnaleb pacientebsi 235,236 (grafiki #16). grafiki #16 ~-Semcireba-momatebis~ fenomeni nacxi+ kult+ nacxikult- izoniazidisadmi mgrznobiare organizmebi izoniazid rezistentuli organizmebi nacxikult+ mkurnalobis dasawyisi, izoniazidi mxolod mkurnalobis kvirebi 35 k. tomanis wignis wina gamocemis Tavze dayrdnobit 36 gadamdeb daavadebata ganyofilebis medmusaki. jandacvis msoflio organizacia. Jeneva, Sveicaria 240

svetebis pirveli wyvili gvicvenebs baqteriul populacias mkurnalobis dawyebamde. pacientis naxveli pozitiuria nacxis usualo mikroskopiit, xolo baqteriebis saerto raodenoba Seadgens as milions (10 8 ) an mets, rac Cveulebriv damaxasiatebelia sasualo zomis kavernozuli dazianebistvis. baqteriebis mcire nawili (SesaZloa ramodenime aseuli baqteria) warmoadgens rezistentul mutants izoniazidis im koncentraciis mimart, romelsac Cveulebriv vxvdebit kavernebsi (ixilet Tavi: rogor vitardeba medikamentebisadmi rezistentoba da Tavi: ramdeni rezistentuli baqteria SeiZleba iqnes armocenili im pacientebis naxvelsi, romlebsac arasdros CatarebiaT tubsawinaarmdego mkurnaloba ). mkurnalobis dawyebis Semdeg baqteriebi saerto raodenoba swrafad mcirdeba (svetebis meore wyvili). irupeba medikamentebisadmi mgrznobelobis mqone baqteriebis nawili (TeTri svetebi), xolo populaciis rezistentuli individebi (Savi svetebi) praqtikulad xeluxlebeli rceba. mkurnalobis meore Tvis ganmavlobasi (svetebis mesame wyvili) baqteriebis saerto raodenoba kidev ufro mcirdeba mgrznobelobis mqone organizmebis darupvis xarjze. momdevno periodsi (svetebis meotxe wyvili) baqteriebis saerto raodenoba TiTqmis igive rceba, Tumca populaciis struqtura ukve mnisvnelovnad aris Secvlili, radgan axla igi ZiriTadad rezistentuli mutantebitaa warmodgenili. momdevno periodsi rezistentuli baqteriebi, amjamad ukve biologiuri upiratesobis gamo mgrznobelobis mqone baqteriebtan SedarebiT gacilebit ufro swrafad mravldebian (svetebis mexute wyvili). daaxloebit otxi Tvis Semdeg (svetebis meeqvse wyvili) mutanti organizmebi mtlianad Caenacvlebian mgrznobiare organizmebs: Stami sruliad rezistentuli xdeba, xolo baqteriebis saerto raodenoba arwevs Tavdapirvel ricxvs (svetebis mesvide wyvili). aqedan gamomdinare, naxveli romelic Seicavda baqteriebis did raodenobas, dasawyissi nacxit dadebiti iyo. mkurnalobis dawyebis Semdeg baqteriebis raodenoba mnisvnelovnad Semcirda mikroskopiit gamovlinebadobis zrvramde_grafikze igi arnisnulia horizontaluri xazit 10 4-10 5 Soris (imisatvis, rom daaxloebit 100 imersiul aresi armovacinot 10 mjavagamzle bacila, mati raodenoba naxvelis ert mililitrsi unda Seadgendes daaxloebit 241

5000 e.i. 10 4 -dan 10 5 -mde. ixilet cxrili #2. Tavi: ramdenad sandoa naxvelis mokroskopuli analizi ). Semdeg baqteriebis Semcveloba kidev ufro Semcirda; anu naxveli negatiuri gaxda nacxis mikroskopiit da mxolod kulturit iyo pozitiuri_ vardna. gansazrvruli periodis Semdeg baqteriebis raodenoba kvlav gaizarda, nacxi isev pozitiuri gaxda - mateba. sinamdvilesi arinisna Semdegi movlena: vardna~ ganpiroebuli iyo mgrznobelobis mqone baqteriebis darupvit, xolo mateba moxda Stamis rezistentuli mutantebis populaciis gazrdis xarjze. vardnisa da matebis fenomenis prevencia SesaZlebelia tuberkulozis mkurnalobasi satanado multimedikamentozuri rejimebis gamoyenebit. mkurnalobis rejimebi, romlebic xorcieldeba sawyis fazasi otxi medikamentit da gagrzelebis fazasi ori medikamentit, mnisvnelovnad amcirebs rezistentuli baqteriebis seleqciis safrtxes. multimedikamentozuri rejimebis ZiriTadi principi isaa, rom medikament A-s (magalitad, rifampicinis) mimart rezistentuli mutanti Stamebi unda ganadgurdes medikamenti B-s mier (izoniazidis), xolo B-s mimart rezistentuli mutantebi unda ganadgurdes medikamenti A-s (rifampicinis) 237 daxmarebit. arasatanado mkurnalobis ramodenime Tanmimdevruli etapis Sedegad warmoqmnil multirezistentobas uwodeben Tanamimdevruli rejimis meqanizms 238. cnobilia, rom rezistentoba SeiZleba ganvitardes araregularuli mkurnalobit, anu monoterapiis garese. rezistentuli mutantebis seleqcia SeiZleba gamowveuli iyos mkurnalobis sxvadasxva rejimebis gamoyenebit, radgan aseti rejimebi moicavs mikroorganizmebis ganadgurebisa da rezistentuli Stamebis ganaxlebuli zrdis araert cikls. rezistentoba Tavdapirvelad vitardeba kombinaciasi warmodgenili ert-erti medikamentis mimart, rasac mohyveba rezistentoba sxva medikamentebis mimartac da amgvarad, warmoisoba multirezistentuli Stamebi. 242

45. ramdeni medikamentisadmi rezistentuli bacila SeiZleba iqnes armogenili tuberkulozit daavadebuli, aranamkurnalebi pacientebis naxvelsi 37 a.pablos-menozi 38 genetikuri mutaciebi, romlebic medikamentebisadmi rezistentobas ganapirobeben spontanurad warmoiqmneba. izolirebuli rezistentuli baqteria warmodgenilia velur StamebSi, anu baqteriebis im normalur populaciasi, romlebzec tubsawinaarmdego medikamentebs arasdros ar mouxdeniat zemoqmedeba 239. es movlena Zalian male gamovlinda streptomicinis armocenidan da SemdgomSi sxva medikamentebis mimartac iqna dafiqsirebuli 240,241,242,243 (ixilet Tavi: rogor vitardeba medikamentebisadmi rezistentoba? ). ukve arsebuli rezistentuli mutantebis gamovlena advilia. tuberkulozis mikobaqteriis veluri Stami inokulirdeba romelime medikamentis, magalitad, izoniazidis Semcvel niadagze koncentraciit 0-5mg/ml. daaxloebit metotxmete dres zrda iwyeba niadagze, romelic an ar Seicavs izonizids, an misi Semcveloba 0,05mg/ml-ia. Tavdapirvelad medikamentis ufro marali Semcvelobis sinjarebi gamwirvale rceba, magram sami kviris Semdeg aqac SeimCneva koloniebis zrda. momdevno ramodenime kviris ganmavlobasi koloniebis raodenoba izrdeba da medikamentis koncentraciis mixedvit SeiZleba miarwios ramodenime aseuls. TiToeuli kolonia, rogorc wesi, warmoisoba erti rezistentuli baqteriisagan, romelic ukve arsebobda Tavdapirvel, velur StamSi. medikamentebisadmi rezistentuli mutantebis sixsire velur StamebSi damokidebulia Stamis warmosobaze, medikamentis tipsa da koncentraciaze da aseve baqteriebis saerto raodenobaze. rogorc gvicvenebs cxrili #49 baqteriebis populaciis SemcirebasTan ertad 37 k. tomanis wignis wina gamocemis Tavze dayrdnobit 38 rokfeleris fundamenti, direqtoris moadgile. niu iorki, niu iorkis Stati. ass 243

mutantebis arsebobis albatobac mcirdeba. ase magalitad, tuberkulozis baqteriebis ert milionian populaciasi 0,05mg/ml izoniazidisadmi rezistentuli mutantebis raodenoba meryeobs 20000- dan 40000-mde, xolo asi (10 2 ) baqteriis populaciasi rezistentuli organizmebis raodenoba proporciulad naklebia (mxolod 0-4 rezistentuli mutanti, medikamentis igive koncentraciis mimart). aseti raodenobrivi damokidebuleba praqtikuli mnisvnelobis mqone faqtoris gansakutrebul SemTxvevas warmoadgens. cxrili #49. sxvadasxva medikamentebisadmi rezistentuli mutantebis sasualo raodenoba gansxvavebuli zomis velur baqteriul populaciebsi - 28 dris Semdeg koloniebis raodenobisa da adamianis tuberkulozis baqteriis 50 veluri Stamis Seswavlis safuzvelze medikamentebis sxvadasxva koncentraciis Semcvel levenstein-iensenis niadagze 242,243,244,245 medikamentebis koncentracia (mg/ml) im baqteriebis raodenoba baqteriul populaciasi, romlebmac ganicades medikamentis zemoqmedeba 10 8 10 6 10 4 10 2 izoniazidi 0,05 0,1 0,2 1,0 5,0 rifampicini 5 10 20 40 80 etambutoli 1,0 1,5 2,0 3,0 pirazinamidi 10,0 50,0 streptomicini 1,0 4,0 10,0 100,0-4000 500 330 - -20 000-750 0-1 0 0 - - - - - - - - - - 20.000-40.000 0-200 0-40 0-10 0-10 - - - - - 0-15.000 0-120 0-2 0 0-1.000.000 0-30.000 1000-200.000 0-100 0-10 0-1 0-400 0-2 0 0 0 - - - - - -- - - - 0-10.000 0-300 10-2000 0-1 0 0 0-4 0 0 0 0-2 0 0 0 0 - - - - 0-100 0-3 0-20 0 0 0 244

medikamentebisadmi rezistentuli mutantebi pacientebsi SeiZleba warmodgenili iyos jer kidev mkurnalobis dawyebamde, gansakutrebit iseti dazianebebis SemTxvevaSi, romlebic didi raodenobit tuberkulozis baqteriebs Seicavs. magalitad, aranamkurnelebi pacientebis filtvis kavernebsi. kavernasi armocenili baqteriebis Cveuli raodenoba (daaxloebit 2,5sm diametris mqone kaverna) Seadgens daaxloebit as milions (10 8 ). rogorc wesi, izoniazidis mimart rezistentuli mutantebis sixsire aris daaxloebit 1-10 6 -Si da daaxloebit 1-10 8 -Si rifampicinis mimart. sakmaod isviatia ormagad rezistentuli mutantebi_daaxloebit baqteriebis 10 14 raodenobasi. romelime medikamentisadmi rezistentuli baqteriebis raodenoba gacilebit ufro dabalia latentur periodsi, aseve im pacientebsi, romlebsac ar aqvt kavernozuli dazianebebi da mkurnalobis intensiuri fazis Semdeg. cxrili #50 gvicvenebs or baqteriul populaciasi rezistentuli mutantebis prognozulad gaangarisebul raodenobas: erti populacia Seicavs as milion (10 8 ) baqterias, xolo meore 100000 (10 5 ) bacilas, romlebic izrdeba medikamentis im koncentraciaze, rogoric miirweva kavernebsi. cxrilsi mocemuli cifrebi gansakutrebulad did praqtikul mnisvnelobas izenen, rodesac mati gamoyeneba xdeba realuri situaciebis mimart. magalitad, davusvat, rom kavernozuli tuberkulozis mqone nacxis mikroskopiit mnisvnelovnad pozitiuri pacientis mkurnaloba warmoebs mxolod izoniazidit. cxrili #50 gvicvenebs, rom mkurnalobis dasrulebisas izoniazidisadmi rezistentuli baqteriebis raodenoba sakmaod didi iqneba. im SemTxvevaSi, Tu kavernis SigniT izoniazidis koncentracia iqneba 1 g/ml, rezistentuli organizmebis raodenoba iq iqneba 300; 0,2 µg/ ml koncentraciis SemTxvevaSi rezistentuli mutantebis raodenoba gaizrdeba 500-mde, xolo iseti dabali koncentraciis dros, rogoricaa 0,1 µg/ml, mati raodenoba SesaZlebelia iyos 4000. masasadame, intrakavernul did populaciebsi moipoveba medikamentebisadmi rezistentuli baqteriebis sakmaod didi raodenoba, romlebsac SeswevT gamravlebis unari da romlebzec ar moqmedebs monoterapia, magalitad, mxolod izoniazidi. es armocena ganmartavs mkurnalobis warumateblobis im xsir SemTxvevebs, romlebsac vxvdebit im pacientebis monoterapiuli mkurnalobis dros, visac arenisneboda naxvelsi baqteriebis Zalzed 245

didi raodenoba (ixilet Tavi: ras warmoadgens vardnisa da matebis fenomeni da Tanamimdevruli rejimis meqanizmi da aseve, ixilet Tavi: ra ganapirobebs mkurnalobis warumateblobas da ra unda gaketdes mkurnalobis arasasurveli Sedegebis Tavidan acilebis miznit ). cxrili #50 rezistentuli mutaciebis gaangarisebuli raodenoba baqteriebis 10 8 da 10 6 populaciasi rejimi mxolod izoniazidi mxolod streptomicini izoniazidi+streptomicini izoniazidi 1.0 0,2 0,1 - - - 1,0 1,0 1,0 0,2 0,2 0,2 1,0 1,0 1,0 medikamentis koncentracia streptomicini - - - 20 4 2 20 4 2 20 4 2 20 rezistentuli baqteriebis raodenoba populaciasi 10 8 330 500 4 000 40 4 000 >500000 0 0 >1,6 0 0 >2,5 0 0 >20 10 5 0 0 4 0 4 >500 0 0 0 0 0 0 0 0 0 Tuki pacientis mkurnaloba warmoebs ori aqtiuri medikamentit, magalitad, izoniazidita da streptomicinit, situacia sruliad gansxvavebulia (ixilet cxrili #50-is qveda nawili). rogorc wesi, erti medikamentisadmi rezistentul mutantebs meore medikamentis mimart aqvt mgrznobeloba da piriqit. problemas warmoadgens ertdroulad orive medikamentis mimart rezistentuli mikroorganizmebi. rogorc amas cxril #5 da #6 gvicvenebs, aseti ormagad rezistentuli mutantebi arsebobs mxolod medikamentebis 246

gansakutrebit dabali koncentraciis SemTxvevaSi. sabednierod aseti situaciebi isviatobaa. kidev erti mnisvnelovani armocena is aris, rom baqteriuli populaciis Semcirebisas, davusvat 10 8 -dan 10 5 -mde, rac Cveulebriv xdeba efeqturi mkurnalobis dawyebis Semdeg (ixilet cxril #50- is bolo sveti), mcirea albatoba imisa, rom Semcirebul raodenobasi iqneba erti medikamentis mimart rezistentuli mutantebi, xolo ormagad rezistentulis arsebobis albatoba kidev ufro mcirea. es Sedegebi gvicvenebs, rom erti an ori efeqturi medikamentis gamoyenebit nebismieri arsebuli rezistentuli mutantis daslis SesaZlebloba iqmneba. satanado medikamentozuri mkurnaloba sawyisi intensiuri fazit imdenad amcirebs baqteriebis populacias, rom axali rezistentuli mutantebis warmoqmnis riski minimumamde daiyvaneba da sawyisi intensiuri fazis Semdeg SesaZlebelia mkurnalobis naklebad gagrzeleba agresiuli formit, magalitad, otxi medikamentidan orze gadasvla. am hipotezas adasturebs tuberkulozze Catarebuli eqsperimentebit mirebuli mtkicebulebebi, romlebmac Seqmnes amjamad mirebuli mkurnalobis orfaziani rejimis safuzveli. 247

46. ra mizezebi ganapirobebs medikamentebisadmi rezistentuli tuberkulozis ganvitarebas m.espinali 39 da t.frideni 40 medikamentebisadmi rezistentuli tuberkulozi adamianebis mier Seqmnili problemaa. swored adamianta mier dasvebuli Secdomebi aris is ZiriTadi faqtori, romelsac ukavsirdeba tuberkulozis mikobaqteriis medikamentebisadmi rezistentuli Stamebis generireba 246,247. tubsawinaarmdego medikamentebisadmi rezistentoba vitardeba spontanuri, damoukidebeli, qromosomuli mutaciebis Sedegad, amdenad mkurnalobis multimedikamentozuri rejimebi xels uslis medikamentebisadmi rezistentobis ganvitarebas 248. medikamentebisadmi rezistentulobis ganvitareba TiTqmis yoveltvis sdevs Tan araadeqvatur medikamentozur Terapias, romlis mizezic Tavis mxriv SeiZleba iyos eqimis Secdoma (jandacvis musaktan dakavsirebuli faqtorebi), medikamentebis ukmarisoba (menejmenttan dakavsirebuli faqtori) an tuberkulozis kontrolis programis araefeqturoba, pacientis mier rejimis dacvis uzrunvelyofis TvalsazrisiT 249,250,251,252. rezistentuli tuberkulozis ganvitarebis yvelaze fartod gavrcelebuli mizezia iseti satanadod organizebuli sistemis uqonloba, romelic uzrunvelyofs efeqtur mkurnalobas (e.i. tuberkulozis nacionaluri programa), kerzod, arasrulyofilad ganxorcielebuli kontrolirebadi mkurnaloba. garda amisa, rezistentuli baqteriebis gadarcevis ert-erti mizezi aris araadekvaturi mkurnaloba 253,254 da rejimis warumateblobis SemTxvevaSi mxolod erti damatebiti medikamentis danisvna, romelsac mivyavart monoterapiamde. martvis Secdomebi moicavs standartuli Terapiuli rejimisadmi xelmiuwvdomlobas; sirtuleebs, ris gamoc Raribi 39 gadamdeb daavadebata medmusaki. jandacvis msoflio organizacia. Jeneva, Sveicaria 40 tuberkulozis SeCerebis ganyofileba, jandacvis msoflio organizaciis regionaluri ofisi, samxret-armosavlet azia. axali deli, indoeti 248

pacientebi ver izenen sawiro medikamentebs; tubsawinaarmdego medikamentebis Senaxvis rejimis darrveva da gaurkveveli biosetavsebadobis mqone medikamentebis (an kombinaciebis) mireba. tuberkulozis kontrolis sabaziso principi aris is, rom swored jandacvis sistema (da ara pacienti) aris pasuxismgebeli da angarisvaldebuli, rom yvela pacientma, vinc ki iwyebs mkurnalobas, bolomde miiyvanos Terapiis kursi. arsebobs am poziciis etikuri da pragmatuli argumenti, romelic gulisxmobs, rom zogadad tuberkulozis da kerzod multirezistentuli formis prevencia warmoadgens sazogadoebriv Rirebulebas. am RirebulebiT sargebloben ara mxolod calkeuli individebi (daavadebisgan gankurnebit), aramed sazogadoebis farto masebic, radgan xels uslis tuberkulozis axali SemTxvevebisa da multirezistentobis warmoqmnas. tuberkulozis programebma unda gaitavison, rom pacientebis mier metvalyureobis garese medikamentebis mireba araprognozirebad Sedegebs izleva, xolo pacientisatvis misarebi da mosaxerxebeli rejimit usualo metvalyureobis qves Catarebuli mkurnalobis SemuSaveba da jandacvis sistemis winase angarisvaldebuleba maqsimalurad uzrunvelyofs gankurnebas (ixilet Tavi ra upiratesobebi aqvs mkurnalobas usualo metvalyureobit ). martivad rom itqvas, Tu pacients rezistentoba ganuvitardeba, amis mizezi medikamentebis arasworad mireba iqneba, rac samartlebriv da etikur danasauls warmoadgens da jandacvis sistema pasuxs agebs mkurnalobis arasatanado organizaciaze, mat Soris usualo metvalyureobis araadekvaturad ganxorcielebaze. amitom medikamentebisadmi rezistentobis marali sixsire savsebit sworad ganixileba rogorc tuberkulozis kontrolis programis araefeqturad ganxorcielebis macvenebeli. erti medikamentisadmi SeZenili rezistentoba zrdis danarceni medikamentebisadmi rezistentobis ganvitarebis albatobas, anu tuberkulozis baqteriebi Tanamimdevrulad rezistentuli xdebian sxva medikamentebis mimartac da iqmneba multirezistentobis ganvitarebis SesaZlebloba (anu rezistentoba sul mcire izoniazidisa da rifampicinisadmi mainc). medikamentebisadmi rezistentobis prevenciis sauketeso gza aris tuberkulozis yvela axlad gamovlenili SemTxvevis uzrunvelyofa pirveli rigis medikamentebit da mkurnalobis mokle kursis Catareba usualo metvalyureobis qves. es unda ganxorcieldes tuberkulozis kontrolis kargad Camoyalibebuli programis farglebsi. 249

47. rogor avicilot Tavidan medikamentebisadmi rezistentoba t.frideni 41 medikamentebisadmi rezistentobis prevencia SesaZlebelia mkurnalobis satanado rejimebis gamoyenebit da mkurnalobis sworad organizebit. satanado rejimi yoveltvis Seicavs sul mcire or medikaments, romlis mimartac tuberkulozis baqterias mgrznobeloba aqvs. am dros gatvaliswinebuli unda iyos ramodenime mosazreba. rezistentobis prevenciis TvalsazrisiT pirazinamidi SedarebiT naklebad efeqturia, aqedan gamomdinare 255, mkurnalobis rejimsi izoniazidisa da pirazinamidis gamoyenebam SeiZleba ver Seaferxos izoniazidisadmi rezistentuli organizmebis warmoqmna (da Sedegad pirazinamidisadmi rezistentuli Stamebisac) im SemTxvevaSic ki, Tu izolats hqonda mgrznobeloba izoniazidisa da pirazinamidis mimart. mkurnalobis sawyis etapze, rodesac baqteriuli datvirtva Zalzed maralia da organizmebi swrafad mravldeba, gansakutrebit mnisvnelovania ramodenime iseti medikamentis gamoyeneba, romelta mimartac organizmebi mgrznobelobas avlenen. mkurnalobis gagrzelebis fazasi rezistentobis armocenebis albatoba gacilebit ufro naklebia. ramdenadac individualuri SemTxvevebis mkurnalobasa da sazogadoebasi daavadebis kontrolisatvis rifampicins wamyvani roli ekisreba (ixilet Tavi: ra gansakutrebuli sifrtxile unda gamovicinot rifampicinisagan dasacavad ), yoveltvis unda gamoviyenot mkurnalobis iseti rejimi, romelic minimumamde Seamcirebs rifampicinisadmi rezistentobis ganvitarebis risks. 41 tuberkulozis SeCerebis ganyofilebis medmusaki. jandacvis msoflio organizaciis regionaluri ofisi. samxret-armosavlet azia. axali deli, indoeti 250

satanado rejimis SerCeva unda moxdes qveynis avtoritetuli organoebis mier. arcevani unda efuznebodes saertasoriso rekomendaciebs, kontrolirebadi klinikuri kvlevebidan mirebul mecnierul mtkicebulebebsa da monacemebs rezistentobis sixsiris Sesaxeb im sazogadoebasi, romelsic mkurnalobis rejimi unda iqnes organizebuli. optimaluri rejimi zrdis gankurnebis Sanss da amcirebs gartulebebis, toqsikurobisa da medikamentebisadmi rezistentobis ganvitarebis damatebit risks da xarjebs. Tumca, optimalur rejimsac ki ekargeba fasi Tu igi sworad ar iqneba gamoyenebuli. idealuri~ rejimi usargebloa da SesaZloa sapirispiro Sedegic ki mogvces, Tu ar moxdeba misi gataviseba. adekvaturi standartuli rejimebis sayoveltao gamoyeneba mnisvnelovnad asustebs medikamentebisadmi rezistentobis ganvitarebis safrtxes. optimaluri da yvela pacientisatvis misarebi rejimebis Sesaxeb konsensusis misarwevad bevri qveyana daxmarebisatvis mimartavs profesiul organizaciebsa (mag. Torakalur sazogadoebebs) da sazogadoebrivi jandacvis centralur organoebs. rejimis sworad gamoyeneba nisnavs, rom medikamentebis mireba xdeba satanado dozebit, zusti intervalebit da sawiro xangrzlivobit. marali dozebi zrdis toqsikurobas, magram ar zrdis efeqturobas; dabali dozebi amcirebs efeqtianobas da qmnis rezistentobis warmoqmnis SesaZleblobas. pirveli rigis medikamentebi mirebuli unda iyos ertjeradi dozis saxit. pirveli rigis medikamentebis ramodenime dozad dayofa erti dris ganmavlobasi amcirebs medikamentebis pikur koncentracias, Sesabamisad amcirebs efeqturobas da zrdis rezistentobis ganvitarebis risks 256,257. tubsawinaarmdego medikamentebis fiqsirebuli dozebis kombinaciam SeiZleba xeli SeuSalos medikamentebisadmi rezistentobis ganvitarebas, ramdenadac is ar izleva mati izolirebulad mirebis SesaZleblobas (ixilet Tavi: ra upiratesobebi da naklovanebebi aqvs tubsawinaarmdego medikamentebis fiqsirebul dozebis kombinacias ). Tumca, fiqsirebuli dozis kombinaciis saxit rekomendirebulze naklebi abebis mirebam SeiZleba ganapirobos mravalkomponentiani medikamentis subinhibitoruli koncentraciis zemoqmedeba adamianis organizmze. garda amisa, arsebobs fiqsirebuli dozis kombinaciebis biologiuri SeTvisebadobis potenciuri problemac. fiqsirebuli 251

dozebis kombinaciebis mireba ar izleva medikamentebisadmi rezistentobis riskis Semcirebis garantias. medikamentebisadmi rezistentobis prevenciis ertaderti gzaa mkurnalobis satanado rejimis gamoyeneba usualo zedamxedvelobis qves. satanadod ganxorcielebis SemTxvevaSi usualo metvalyureoba uzrunvelyofs medikamentebis zusti dozit, zusti intervalebita da sawiro xangrzlivobit mirebas (ixilet Tavi: ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves ). im regionebsi, sadac danergili iqna standartuli mkurnalobis rejimis usualo metvalyureobis sistema, SesaZlebeli gaxda medikamentebisadmi rezistentulobis prevencia TviT aiv infeqciis macveneblebtan konteqstsic ki 258,259,260. 252

48. ramdenad sandoa medikamentebisadmi mgrznobelobis testebi 42 m.espinali 43 mgrznobelobaze testebis zustad Sesruleba sakmaod rtulia, im SemTxvevaSic ki, roca laboratoriis personali maralkvalificiuria da laboratoriebi marali standartis. sizustis dacva kidev ufro rtulia im qveynebsi sadac Sesabamisi kadrebi da laboratoriebi isviatobaa 261,262. ukanasknel atwleulsi bevri monacemi iqna mirebuli. medikamentebisadmi mgrznobelobis testis sandoobis Sesaxeb. makoordinirebelma laboratoriam tuberkulozis mikobaqteriis referaluri Stamebi yvela monawile supranacionalur laboratoriasi gagzavna. laboratoriebs mati Cveuli metodikis gamoyenebit unda CaetarebinaT referaluri Stamebis testireba mgrznobelobaze da moexdinat kulturebis diferencireba rezistentul da mgrznobelobis mqoned. Sedegebi Sedarebuli iyo oqros standartebtan. anu Seswavlili Stamebis Sesaxeb arsebuli iuridiuli dokumentaciis monacemebs. zogierti supranacionaluri laboratoriis mier Stamebi ganawilebuli iyo nacionalur referalur laboratoriebsi (qve qseli) mteli msoflios masstabit. rezistentobis testis jamuri sensitivoba Seadgens 95%, specifikuroba _95% da reproduqciuroba 96% 263. 1998 wels izoniazidisa da rifampicinis mimart rezistentobis testis jamurma sensitivobam Seadgina 100%, specifikurobam 99%-100%. Tumca samma supranacionalurma laboratoriam da ramodenime nacionalurma referalurma laboratoriam miiro standartze dabali macveneblebi (dabali specifikuroba), rac gvafiqrebinebs, rom mgrznobiare Stamebis arasworad klasificireba rezistentul Stamebad kvlavac 42 k.tomanis cignis wina gamocemis tavze dayrdnobit 43 adamdeb daavadebata ganyofilebis medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria 253

seriozul problemad rceba iset maral kvalificiur laboratoriebsic ki sadac marali sizustis sakontrolo testebi arsebobs (sakontrolo testebi rutinul praqtikastan SedarebiT realurad afaseben laboratoriis sizustes, radganac laboratoriebi Cveulebriv gansakutrebuli yuradrebit ekidebian im nimusebis panelebs, romelta gaanalizebac xdeba sworad sakontrolo testirebisatvis). mas Semdeg rac mgrznobelobis testireba mnisvnelovnad gaumjobesda, janmos da IUATLD-s iniciativa ZiriTadad mimartulia metvalyureobaze da ara klinikur praqtikaze. kvlevebi tardeba yovel 3-5 weliwadsi. SezRuduli resursebis qveynebsi klinikisatvis sawiro informacia mgrznobelobis testebis Sesaxeb jer kidev mwiria. damatebit sizneles qmnis sarezervo medikamentebisadmi mgrznobelobis dadgenis sirtule da arasandooba. ufro metic, SezRuduli resursebis mqone qveyanasi, Cveulebriv arsebobs mxolod erti nacionaluri referaluri laboratoria. askaraa, rom mxolod Zalian isviat SemTxvevebSi SeZleben es laboratoriebi mgrznobelobis testebis Sesrulebas klinikuri miznebistvis. da bolos, isic unda gvaxsovdes, rom testis arasando Sedegebze dafuznebuli klinikuri RonisZiebebi ufro saziano iqneba pacientistvis (ixilet Tavi: ra SesaZlo Sedegebi moaqvs medikamentebisadmi arazustad Sesrulebul mgrznobelobis testebs ). amitom ufro gonivrulia, Tu mgrznobelobis testebs CavatarebT im pacientebsi, romelta standartuli mkurnalobis mokle kursi usualo metvalyureobis qves warumatebeli iyo, ramdenadac rezistentobis arsebobis riski am pacientebsi ufro maralia. kulturis testirebis axali metodebi Txevadi niadagis gamoyenebit ufro swraf Sedegebs izleva, magram SeiZleba gazardos laboratoriasi kulturebis jvaredini dabinzurebis riski da amastan ZviradRirebulia. momavalsi SesaZlebelia molekularuli an swraf zrdaze dafuznebuli teqnikis gamoyeneba rifampicinze rezistentuli pacientebis saidentifikaciod, vinaidan mattvis standatizebuli rejimi araefeqturia. amjamad aseti metodebit rifampicinrezistentuli izolatebis 80%-ze naklebis identificireba aris mxolod SesaZlebeli. amastan isini ZviradRirebuli da daudasturebelia. 254

49. rogoria medikamentebisadmi mgrznobelobis arazusti testirebis SesaZlo Sedegebi 44 m.espinali 45 medikantebisadmi mgrznobelobis arazusti testebis SesaZlo Sedegebia: _ Stamebis arazusti klasificireba; arasawiro cvlilebebis Setana mkurnalobasi; sarezervo medikamentebis gamoyeneba, rac ganapirobebs: toqsikurobis gazlierebas; gankurnebis SesaZleblobebis Semcirebas; menejmentis gartulebas; hospitalizaciis sawiroebas; laboratoriuli momsaxurebis gazrdas; meti personalis aucileblobas; gazrdil xarjebs. SeiZleba moxdes rezistentuli Stamebis arasworad klasificireba mgrznobiare mqone Stamebad. Tu mgrznobelobis mqone Stamebs miicneven rezistentulad sawiro gaxdeba mkurnalobasi cvlilebebis Setana da sarezervo medikamentebis gamoyeneba, Tuki isini xelmisawvdomia. aseti medikamentebi ki, Cveulebriv ufro toqsikuri, naklebadefeqturi da gacilebit ZviradRirebulia, vidre pirveli rigis medikamentebi 264. im ToTxmeti kvlevis Sedegebis 44 k.tomanis wignis wina gamocemis Tavze dayrdnobit 45 gadamdeb daavadebata ganyofilebis medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria 255

mimoxilvisas, romelic moicavda asze meti pacientis naxvelis kulturebs, cametsi (93%) identificirebuli iyo cru pozitiuri kulturebi 265. cru pozitiuri kulturebis warmosoba SeiZleba ganpirobebuli iyos klinikuri mowyobilobebis dabinzurebit, registratorebis SecdomebiT da laboratoriasi jvaredini dabinzurebit. 236 cru pozitiuri kulturis mqone pacientidan 158-s (67%) Cautarda mkurnaloba, amastan zogierti matgans ganuvitarda mzime toqsikuroba. amdenad moxda usargeblo hospitalizacia, testireba da kontaqtsi myofi pirovnebebis gamokvleva. laboratoriuli Secdomebi isviatoba ar aris, Tumca laboratoriis musakebi da klinikis personali mat Zalian isviatad ariareben. sirtuleebtanaa dakavsirebuli im ambulatoriuli pacientebis menejmenti, romlebic ireben sarezervo medikamentebs. xsirad sawiro xdeba aseti pacientebis xangrzlivi droit saavadmyofosi motavseba, rac bevrad ufro Zviria, vidre binaze mkurnaloba da qmnis tuberkulozis gavrcelebis safrtxes saavadmyofosi. sawiro xdeba personalis raodenobis gazrda damatebiti laboratoriuli samusaoebis Sesasruleblad (Tirkmlisa da RviZlis funqciis ganmeorebiti testebi, sisxlis analizebi da mwidro baqteriologiuri monitoringi). yvelaferi es emateba hospitaluri mkurnalobis xarjebs. aqedan gamomdinare, SeiZleba moxdes Terapiul samsaxurebze gamoyofili resursebis dakargva da yvelaferi mxolod da mxolod medikamentebisadmi mgrznobelobis arazusti testebis Sedegad. ar aris sawiro imis gameoreba, rom raoden marali teqnologiuri donec ar unda hqondes laboratoriul samsaxurebs, arc ertma matganma ar unda itvirtos mgrznobelobis testebis Catareba sarezervo medikamentebze da ganmeorebit mkurnalobis uzrunvelyofa, masin, rodesac qveyanasi udidesi deficiti arsebobs SemTxvevaTa gamovlenisa da pirveladi mkurnalobis uzrunvelyofis TvalsazrisiT. aset SemTxvevebSi resursebi gamoyenebuli unda iqnes standartuli rejimit mkurnalobis gasaumjobeseblad. es warmoadgens medikamentebisadmi rezistentobis prevenciis ertert yvelaze efeqtur gzas. 256

50. ra sarezervo rejimebi arsebobs da ra adgili uwiravt mat tuberkulozis kontrolis programebsi 46 m.espinali 47 sarezervo rejimebi gamoiyeneba multirezistentuli tuberkulozit daavadebul pacientebsi (ix.tavi: rogor vitardeba medikamentebisadmi rezistentoba ) ramdenadac aseti rezistentoba warmoadgens araadekvaturi mkurnalobis Sedegs, arsebobs sarezervo rejimebit ganmeorebiti mkurnalobis Tavidan acilebis SesaZlebloba. vidre ganvixilavdet sxvadasxva rejimebs, ramodenime sityvit SevexebiT ganmeorebiti mkurnalobis menejments. DOTS-is strategiasi SemoTavazebuli organizaciuli CarCoebisa (ixilet Tavi: ras warmoadgens DOTS? ) da sarezervo rejimebit mkurnalobis operatiuli sawiroebebis codnis garese Zalzed mcirea warmatebis albatoba. es dadasturda maralsemosavlian qveynebsic, sadac araefeqturi organizacia ganapirobebda rogorc tuberkulozis, aseve medikamentebisadmi rezistentobis swraf zrdas 266. sarezervo rejimebit mkurnaloba SeiZleba resursebis arasatanado xarjvis mizezi gaxdes, kerzod, limitirebuli finansuri sasualebebis mqone qveyebsi, sadac SezRudulia rogorc samedicino obieqtebis, aseve personalis SesaZleblobebi da saxelmwifo danaxarjebi janmrtelobaze ert ass dolars ar aremateba ert sul mosaxleze. nebismieri qveynisatvis araracionaluri iqneboda misi resursebis xarjva sarezervo rejimebit ganmeorebit mkurnalobaze, masin rodesac mkurnalobis garese rceba axali infeqciuri SemTxvevebi an mati mkurnaloba arasatanadoa da moklevadiani kursi pirveli rigis medikamentebit ver arwevs srul Terapiul potencials 267. sarezervo medikamentebze didi 46 k.tomanis wignis wina gamocemis Tavze dayrdnobit 47 gadamdeb daavadebata ganyofilebis medmusaki. msoflios jandacvis organizacia, Jeneva, Sveicaria 257

motxovnileba asaxavs moklevadiani kursit mkurnalobis arasatanado menejments. grafiki #17 gvicvenebs im mankier wres, romelic SeiZleba Zalian swrafad Camoyalibdes. grafiki #17 ganmeorebiti mkurnalobis martva pirveladi mkurnalobis araadekvaturoba mwiri resursebi usedego mkurnaloba ganmeorebiti mkurnaloba sarezervo sqemit im pacientebis mkurnaloba, romlebic rezistentulni arian standartuli medikamentebis mimart an aqvt mati cudi amtanoba, bevr sirtuleebtan aris dakavsirebuli. am sirtuleebs Tavad medikamentebi qmnian da sakmaod didi xarisxit ganpirobebulia samedicino personalit. sarezervo medikamentebi ramodenime gamonaklisis garda ar gamoirceva marali efeqturobit. mat xsirad axlavs toqsikuri reaqciebi, rac ara mxolod arasasiamovno, aramed zogjer sasisic aris. aman SeiZleba Seqmnas dozis Semcirebis aucilebloba, rac ganapirobebs efeqtianobis Semcirebas. ufro metic, sarezervo medikamentebis fasi maralia da zogierti matganis Senaxva tropikul klimatsi ar SeiZleba, radgan isini kargaven stabilurobas, aseve SeuZlebelia intermituli mkurnalobis ganxorcieleba da sawiro xdeba ramodenime sarezervo medikamentis dresi ramdenjerme mireba, rac kidev ufro artulebs am rejimis administrirebas. rezistentuli pacientebis umravlesoba ganekutvneba adamianebs, romlebtanac TanamSromloba Znelad misarwevia. eseni 258

arian alkoholizmit daavadebulni, narkomanebi, patimrebi da usaxlkaroebi. gansakutrebuli Zalisxmevaa sawiro, rom daarwmunot isini mkurnalobis xangrzlivi rejimis dasrulebis aucileblobasi. aqedan gamomdinare, bevri avtori sarezervo medikamentebit mkurnalobis dawyebas gvircevs saavadmyofosi, rac xels Seuwyobs toqsikuri gartulebebis metvalyureobas da medikamentebis mirebaze zedamxedvelobis ganxorcielebas. mxolod mas Semdeg, rac dasabutdeba medikamentebisadmi tolerantoba da pacienttan damyardeba TanamSromloba, SeiZleba misi gadayvana ambulatoriul mkurnalobaze. xsirad pacientebs ar mowont saavadmyofosi moqmedi disciplina da nebartvis garese toveben mas. mnisvnelovani Zalisxmevaa sawiro imisatvis, rom davarwmunot pacienti ar miatovos mkurnaloba, romelic, miuxedavad diskomfortisa, pacientis sikvdilidan xsnis ertadert gzas warmoadgens. Tu samedicino personals amis rwmena aqvs, SeZlebs daitanxmos pacienti TanamSromlobaze, magram es nisnavs, rom TiToeuli abis mireba unda moxdes mxolod da mxolod metvalyuris TandaswrebiT. radgan sawiro xdeba marali specifikurobis bioqimiuri da mikrobiologiuri monitoringis Catareba, natelia, rom sarezervo medikamentebit ganmeorebiti mkurnaloba gulisxmobs gansakutrebul RonisZiebebs. E Tavis mxriv, es moitxovs maralkvalificiuri personalis dros 268,269 sawolebis raodenobis gazrdas da finansur resursebs. monacemebi imis Sesaxeb, Tu ra xarjebtan aris dakavsirebuli multirezistentuli tuberkulozis mkurnaloba Rarib qveynebsi Zalzed mwiria, magram aseti pacientis mkurnalobis saerto Rirebuleba ass-si Seadgens 100 000 ass dolars. am bolo periodsi Cndeba imedis momgvreli mtkicebulebebi detalurad SerCeuli sarezervo rejimebis gamoyenebis Sesaxeb hospitalizaciis pirobebsi. resursebit Rarib qveyanasi SesaZlebelia hospitalizaciis mkvetrad Semcireba. amas aqvs bevri upiratesoba rogorc pacientebis, aseve jandacvis sistemisatvis. janmo da misi ramodenime partniori amjamad awarmoebs multirezistentuli tuberkulozis SemTxvevebis menejmentis axali strategiis gamocdas dabal da sasualo Semosavlian qveynebsi, romelic gulisxmobs sarezervo medikamentebis gamoyenebas strategiis farglebsi da ambulatoriuli mkurnalobis wilis maqsimalurad gazrdas. 259

Kkvlevis mizani aris tuberkulozis erovnuli programis zedamxedvelobis qves arnisnuli preparatebis gamoyeneba SesaZleblobisa da xarjtefeqturobis Sefaseba 270. es iniciativa ar Seexeba regionebs, sadac ar funqcionirebs tuberkulozis efeqturi kontrolis sistema DOTS-i. ganmeorebiti mkurnaloba standartuli medikamentebisadmi rezistentul pacientebsi mkurnalobis sarezervo rejimis SemuSavebisas unda davicvat gansazrvruli principebi. sarezervi medikamentebi adre unda iyos gamooeynebuli, vinaidan mati danisvna araefeqturia. sawyisi mkurnaloba unda Seicavdes sul mcire sam medikaments, romelta mimartac baqteriebs savaraudod sruli mgrznobeloba aqvt. ar unda SemovinaxoT medikamentebi rezervsi_unda dainisnos savaraudod yvelaze efeqturi rejimi 271. Tu medikamentebisadmi mgrznobelobis testis Catareba SeuZlebelia da resursebi SezRuduli, SeiZleba gamoviyenot ganmeorebiti mkurnalobis standartuli rejimebi sarezervo medikamentebis gamoyenebit. mnisvnelovania imis gatvaliswinebac Catarebuli mkurnaloba usualo metvalyureobis qves mimdinareobda Tu ara da ra xangrzlivobis iyo. yvela Rone unda iyos naxmari rata Catardes mgrznobelobis zusti testi gansakutrebit im SemTxvevaSi, rodesac pacientis mkurnaloba pirveli rigis medikamentebit warumatebeli iyo da mkurnaloba tardeboda usualo metvalyureobis qves. Tu mgrznobelobis Sedegebi ar aris xelmisawvdomi, am rejimsi sul mcire sami iseti medikamenti unda iyos gamoyenebuli, romelic pacients adre arasdros miuria. magalitad, aminoglikozidi, etionamidi da ofloqsacilini, aseve saineiqcio antibiotikebi, rogoricaa kapreocini, amikacini an kanamicini. yvela sarezervo rejimi unda iyos yoveldriuri da xorcieldebodes usualo metvalyureobis qves. sawiroa baqteriologiuri Sedegebis (nacxi da SeZlebisamebs kulturis analizi) monitoringi. SesaZlebelia pirazinamidisa da etambutolis damateba meotxe da mexute arceviti medikamntebis saxit (masinac ki, Tu isini adre iyo gamoyenebuli, radgan naklebad iwveven rezistentobas). kidev erti variantia 260

etambutolis cikloserinit Secvla (an PAC-iT)._3-6-Tvian intensiur fazas unda mohyves mkurnalobis gagrzelebis 15-18- Tviani faza ori an sami yvelaze aqtiuri da kargi amtanobis mqone medikamentebit. Tu SesaZlebelia mgrznobelobis testis Catareba, masin rejimis SemuSaveba damokidebuli iqneba mtel rig iset faqtorebze rogoricaa medikamentebi, romelta mimartac tuberkulozis mikobaqteria rezistentulia. janmo rekomendacias uwevs 3-4 per oraluri da 1 sainieqcio medikamentis gamoyenebas, romlis mimartac izolati mgrznobiarea) 3-6 Tvis ganmavlobasi da Semdeg sul mcire 3 efeqturi oraluri medikamentis gamoyeneba 15-18 Tvis ganmavlobasi. cxrili #51 warmogvidgens potenciurad efeqturi samkurnalo rejimebis magalitebs. yvela es rejimi yoveldriuria 271. arsebobs mtkicebulebebi, rom rac ufro xangrzlivad viyenebt mkurnalobasi aminoglikozidis, mit ufro maralia warmatebis macvenebeli 272. sarezervo medikamentebis dozireba da gverditi reaqciebi ganxilulia am wignis TavSi: rogoria tubsawinaarmdego medikamentebis Terapiuli efeqti da mati toqsikuroba multirezistentuli formebis mqone pacientebis reaqcia meore rigis medikamentebze gansxvavebulia. qronikuli formebis gankurnbis macvenebeli qirurgiuli mkurnalobis damatebis Semeg 56% dan 85 % mde gaizarda 273. rogorc vlindeba multirezistentuli tuberkulozit daavadebuli aranamkurnalebi pacientebi ufro kargad reagireben mkurnalobaze, vidre namkurnalebi pacientebi. martlac, gankurnebis macveneblebi aranamkurnaleb pacientebsi Seadgenda 75-96%-s 274,275,276. Tumca aseti SemTxvevebs ZiriTadad vxvdebit an marali Semosavlis mqone qveynebsi an isini mirweulia mnisvnelovani klinikuri, laboratoriuli da programuli mxardawerit da zustad SerCeuli mkurnalobis rejimis gamoyenebit 227. bevri SezRuduli resursebis mqone saxelmwifosatvis qveynis masstabit zusti sarezervo rejimebis ganxorcieleba problemas warmoadgens. 261

cxrili #51 sarezervo sqemis Sejameba inicialuri faza wamlebi 48 danisvnis ritmi da periodi mgrznobelobis Sedegebi yoveldre 3-6 1 Tve miuwvdomelia KAN 49 +ETH 50 +OFL+Z+E mgrznobelobis testebi misawvdomia rezistentuli H da S is yoveldre 3-6 Tve mimart wamlebi ritmi ETH+OFL+E ( 12 Tvemde) R+E(ETH) d (6 Tvemde) gagrzelebis faza danisvnis ritmi da periodi yoveldre yoveldre R+KAN+Z+E rezistentuli sul mcire H da S is mimart yoveldre 3-6 Tve yvela garda sainieqciosi yoveldre 3-4 pre os da 1 per injection (15-18 Tve) 48 H- izoniazidi, R- rifampicini, E-etambutoli, P-pirazinamidi, S- streptomicini, ETH-eTionamidi, KAN- kanamicini, OFL- oflaqsini, (dozebistvis ix. ra aris Terapevtuli efeqti da ra toqsikuroba aqvs antituberkulozis wamlebs? gv 110) 49 amikacini an kapreomicini SeiZleba aseve gamoyenebul iqnes 50 gamoiyenet ETH, E-s magivrad, Tu aris rezistentoba H, E, S- s mimart 51 gamoyenebuli unda iqnes wamlebi, romlebzec aris mgrznobeloba. yvelaze mcire sawyisi faza unda iyos sami Tve, magram unda gagrzeldes, sanam ar iqneba nacxis an kulturis konversia 262

51. ra rols asrulebs latenturi tuberkulozis mkurnaloba, tuberkulozis kontrolis programasi m.e.vilarino 52 janmos rekomendaciit tuberkulozis programebi unda uzrunvelyofdes 278,279 latenturi tuberkulozuri infeqciis (LTBI) mkurnalobas, rasac aseve prevenciuli mkurnaloba ewodeba da xorcieldeba pacientebis Semdegi kategoriebisatvis: tuberkulozit daavadebul nacxit dadebit pacientebtan kontaqtsi myofi 5 wlamde asakis bavsvebi; tuberkulozis mikobaqteriis latenturi infeqciis mqone Cvili an mcirewlovani bavsvebi imyofebian tuberkulozis swrafad ganvitarebis safrtxis winase. sicocxlisatvis sasisi tuberkulozuri meningitisa da miliaruli tuberkulozis ganvitarebis gansakutrebit didi safrtxe emuqrebat 2 wlis da umcrosi asakis bavsvebs 280 ; adamianis imunodeficitis virusita da tuberkulozis mikobaqteriit dainficirebuli adamianebi; aiv-inficirebul, tuberkulinze pozitiur pacientebsi tuberkulozis daavadebad Camoyalibebis wliuri riski ufro maralia (gaangarisebit 6-16%), vidre tuberkulinze pozitiur, magram aiv-negatiur pacientebsi. sicocxlis manzilze tuberkulozis daavadebis ganvitarebis riski am jgufsi daaxloebit 10%-s Seadgens. aiv-inficirebuli pacientis 52 diagnostikisa da Terapiis Seswavlis ganyofilebis gamge, kvlevisa da Sefasebis ganxra, tuberkulozis armofxvris ganyofileba. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da Tavdacvis centrebi. Atlanta, jorjiis Stati 263

tuberkulozit daavadeba iwvevs imunosupresiis gazlierebas, xolo mkurnalobis gamosavali damokidebulia pirovnebis imunosupresiis xarisxsa da usualo metvalyureobis qves Catarebuli tubsawinaarmdego mkurnalobis adeqvaturobaze 281. zemot CamoTvlili marali riskis kategoriebis pacientebsi LTBI mkurnaloba potenciurad amcirebs tuberkulozis aqtiuri formis ganvitarebis risks, zrdis sicocxlis mosalodnel xangrzlivobas da amcirebs samedicino xarjebs. Tumca, arnisnulma intervenciulma strategiam SesaZloa mnisvnelovnad ver Seamciros tuberkulozit gamowveuli avadoba im sazogadoebasi, sadac aseti individebi cxovroben (ixilet Tavi: rogoria latenturi tuberkulozis infeqciis mkurnalobis epidemiologiuri efeqti ). LTBI mkurnalobis programebi ZviradRirebulia, mati fartomasstabiani gamoyeneba sirtuleebtan aris dakavsirebuli da amastan Tan axlavs medikamentebit gamowveuli toqsikurobis riski. garda amisa, Tuki ar moxdeba aqtiuri tuberkulozis satanadod martva, arsebobs sasisroeba, rom gamouvleneli aqtiuri formit daavadebul pacientebs CautardebaT LTBI mkurnaloba, rac ganapirobebs medikamentebisadmi rezistentobis ganvitarebas da mattvis zianismomtani iqneba. LTBI mkurnalobis tuberkulozis kontrolis programasi Setanis gadawyvetilebis mirebamde gatvaliswinebuli unda iqnes Semdegi faqtorebi: - hepatotoqsikuroba izrdeba (Zlierdeba asaktan ertad da sxva medikamentebis, gansakutrebit alkoholis mirebit; Zalzed isviatad gvxvdeba mcirewlovan bavsvebsi); - rejimis araregularuli ganxorcieleba (efeqturobis Semcirebis ZiriTadi faqtori); - medikamentebisadmi rezistentoba (LTBI rejimebi SeiZleba araefeqturi iyos medikamentebisadmi rezistentuli infeqciebistvis); - operatiuli problemebi misi ganxorcielebis dros (tuberkulozis kanis testis, nebayoflobiti aiv konsultaciebis da testirebis Catarebis aucilebloba); - tuberkulozis gamoricxvis sirtule da marali Rirebuleba, aseve medikamentebisadmi rezistentobis ganvitarebis riski im SemTxvevaSi, Tu gamoricxva araefeqturad warmoebs; 264

- TavisTavad marali xarjebi. bevr maralganvitarebul qveyanasi, sadac tuberkulozis sixsire sarekordod dabal donemde Semcirda, fiqroben, rom tuberkulozit daavadebis axali SemTxvevebis udidesi nawili gvxvdeba warsulsi inficirebul individebsi, romlebsac TandaTanobiT ganuvitardat tuberkulozi. miuxedavad imisa, rom tuberkulozis aqtiuri formit daavadebuli adamianebis efeqturi gamovlena da mkurnaloba kvlavac warmoadgens tuberkulozis kontrolis programis umarles prioritets, mxolod es RonisZiebebi ver uzrunvelyofs im axali SemTxvevebis prevencias, romlebic vitardeba didi xnis win inficirebul individebsi. aqtiuri tuberkulozis ganvitarebis riskis winase mdgari adamianebis LTBI mkurnaloba warmoadgens tuberkulozis kontrolis mnisvnelovan komponents dabali prevalentobis qveynebsi 282. 30 wlis ganmavlobasi LTBI-Tvis ZiriTadad iyeneben izoniazidit mkurnalobis 6-12-Tvian rejims. Tumca izoniazidis efeqturoba LTBI-is mkurnalobasi izrudeboda pacientebis mier rejimis araregularulad dacvit, rac ganpirobebuli iyo mkurnalobis SedarebiT didi xangrzlivobit da medikamentis toqsikurobit 282. amis Semdeg warmoiqmna moklevadiani rejimebis SemuSavebis interesi, romlebic izoniazidit mkurnalobis alternativas Seqmnidnen. bolo wlebsi, am miznit Catarda ramodenime kvleva aiv-inficirebul pacientebsi. mkurnalobis programis winapiroba LTBI-is mqone pirebis identificirebaa da, aqedan gamomdinare, sawiro xdeba tuberkulinit kanis testis administrirebisa da interpretirebis instruqciebis SemuSaveba. tuberkulinis testi nacvenebia mxolod tuberkulozis ganvitarebis marali riskis mqone adamianebsi, xolo dabali riskis individebsi igi usargebloa. aset pacientebs ganekutvneba adamianebi, romlebic bolo periodsi inficirebulni iyvnen tuberkulozis mikobaqteriit da isini, visac LTBI-is aqtiur tuberkulozad Camoyalibebis marali riski aqvs. garda im SemTxvevebisa, rodesac tuberkulinis testi zogadad gamoiyeneba sazogadoebasi tuberkulozis riskis Seswavlis miznit, testi unda Cautardes im pirebs, romlebsac pozitiurobis SemTxvevaSi CautardebaT LTBI mkurnaloba. aqedan gamomdinare, Tu ar CavTvliT sazogadoebasi Catarebul kvlevebs, tuberkulinis testis Catarebis gadawyvetileba praqtikulad LTBI-is mkurnalobis Catarebis gadawyvetilebaa, Tu 265

es ukanaskneli dadasturdeba. testirebuli pacientis asakis miuxedavad, LTBI-s mkurnaloba tardeba. bevr klinikur instruqciasi gamoyenebulia reitinguli sistema, romelic rekomendaciebis safuzvlianobisa da im mecnieruli mtkicebulebis xarisxobrivad (A, B da C) dayofis SesaZleblobas izleva, romelta gatvalisiwnebitac SemuSavda es rekomendaciebi (I, II an III) rogorc es mocemulia cxrilsi #52, LTBI daavadebuli mozrdilebis mkurnalobisatvis rekomendirebulia mkurnalobis otxi rejimi, xolo bavsvebisatvis ertadert rekomendirebul samkurnalo rejimad rceba 6-12-Tviani rejimi, mxolod izoniazidis gamoyenebit. cxrili #52. mkurnalobis rekomendaciebis argumentaciis sareitingo sistema wamlebi izoniazidi izoniazidi rifampicini+pirazinamidi rofampicini xangr-oba 9Tve 6 Tve 2 Tve 2-3 Tve 4 Tve intervali yoveldre 2-jer kv-si yoveldre 2-jer kv-si yoveldre 2-jer kv-si yoveldre reitigni aiv+ A (II) B (II) aiv- A(II) B(II) B (I) C(I) B (II) C(I) B (II) A(I) C (II) C(I) B (II) B(III) aiv-negatiur individebsi Catarebulma grzelvadianma perspeqtiulma kvlevebma gvicvena, rom prevenciuli mkurnalobis 12-Tvian kursi izoniazidit ufro efeqturi iyo vidre 6-Tviani. bevr qveyanasi rekomendirebulia izoniazidis yoveldriuri 9 Tviani rejimi rigi monacemebis analizit gamovlinda, rom izoniazidis maqsimaluri efeqti mirweuli iyo 9-Tviani mkurnalobit, 12 Tvemde mkurnalobis gaxangrzliveba 283 ki molod minimalur damatebit sargeblobas izleoda. placebostan Sedarebisas rogorc 6-Tviani, aseve 12-Tviani rejimebi sakmaod efeqturi iyo aiv-pozitiur pacientebsi, Tumca es rejimebi ertmanettn ar iyo Sedarebuli randomizirebul kvlevebsi. miuxedavad imisa, rom LTBI-is mkurnalobisas upiratesobas aniweben izoniazidis 9-Tvian rejims, 6- Tviani rejimic sakmaod karg dacvas uzrunvelyofs da gacilebit 266

uketesia placebos rejimze, rogorc aiv-negatiur, aseve aiv-pozitiur pacientebsi. xarjefeqturobis TvalsazrisiT zogiert situaciasi 6-Tviani rejimi ufro sasurvel Sedegebs izleoda, vidre 9-Tviani rejimi. adgilobrivi pirobebis gatvaliswinebit tuberkulozis programebi an jandacvis personali gacilebit met interess icenen 6-Tviani kursisadmi, 9-TvianTan SedarebiT. izoniazidis rogorc 9, aseve 6- Tviani kursi SeiZleba dainisnos intervalebit (mireba kvirasi 2-jer). LTBI-iT daavadebuli aiv-inficirebuli pacientebis randomizirebuli grzelvadiani kvlevebis Sedegebis safuzvelze, rekomendirebulia rifampicinita da pirazinamidit mkurnalobis yoveldriuri 2-Tviani rejimi 284. kvlevam acvena, rom 2-Tviani rejimi iseve usafrtxo da efeturi iyo, rogorc izoniazidit 12-Tviani rejimi. Tumca, mkurnalobasi rifampicinisa da pirazinamidis gamoyenebisas, arinisneboda mwvave hepatotoqsikuroba 285. Tu ar arsebobs alternatiuli rejimebis Catarebis SesaZlebloba, rekomendirebulia rifampicinisa da pirazinamidis 2-3 Tvis ganmavlobasi kvirasi 2-jer micema. intermitiuli rejimi unda xorcieldebodes usualo metvalyureobis qves. zogierti eqsperti Tvlis, rom rifampicinisa da pirazinamidis 2-Tviani yoveldriuri rejimic unda xorcieldebodes usualo metvalyureobit da moicavdes medikamentebis 5 dozis mirebas metvalyureobis qves da ori dozis pacientis mier damoukidebald mirebas. rodesac rifampicinis gamoyeneba SeuZlebelia 286 (magalitad, aiv-inficirebul pacientebsi, romlebic ireben proteazas inhibitorebs), igi unda CavanacvloT rifabutinit. rifabutini inisneba yoveldriurad 4 kviris ganmavlobasi. es rekomendacia efuzneba tuberkulin-pozitiur pacientebsi Catarebuli grzelvadiani randomizirebuli kvlevisa da izoniazid_rezistentuli tuberkulozis mqone pacientebis ararandomizirebuli kvlevit mirebul Sedegebs 287,288. mkurnalobis es varianti gansakutrebit xelsayrelia im pacientebisatvis, romeltac aqvt izoniazidis an pirazinamidis cudi amtanoba. LTBI-is mkurnalobis dawyebamde unda moxdes aqtiuri tuberkulozis gamoricxva fizikaluri gasinjvis, gulmkerdis rentgenografiis, klinikuri istoriis Seswavlisa da sawiroebis SemTxvevaSi baqteriologiuri kvlevebis mesveobit. cxrili #53 ajamebs janmos protokols, rekomendirebuls aqtiuri 267

tuberkulozit daavadebul pacientebtan kontaqtsi myofi bavsvebis Sefasebisa da mkurnalobistvis 289. cxrili #53 bavsvebis mkurnaloba eqspoziciis Semdeg nacxit dadebiti mozrdilebis tuberkuloztan Tu: da masin bavsvs arenisneba tuberkulozis simptomatika eqimi gansazrvravs rom bavsvs aqvs tuberkulozi mkurnalobis sruli kursi unda dainisnos bavsvs ar arenisneba tuberkulozis simptomatika tuberkulozis testi ar aris xelmisawvdomi tubtestis Catareba xelmisawvdomi bavsvma unda miiros LTBI-is mkurnalobis kursi bavsvma unda miiros LTBI -is mkurnalobis 3-Tviani kursi Tu: masin: bavsvis tubtesti pozitiuria bavsvis tubtesti negatiuria LTBI sr kursi (izoniazidi 5 mg/kg 6-12 Tv) wyvet mk-s sawiroabcg vaqcinacia (Tu ar aqvs manamde mirebuli) marali prevalentobis qveynebsi, sadac xorcieldeba LTBI mkurnalobis politika kintaqtsi myofi pirebisatvis. mkurnalobis dawyebamde aqtiuri procesis gamoxatvis miznit unda gaketdes rentgenografia, aiv inficirebulebsi mainc. yvela aiv-inficirebuli pacienti, romelsac arenisneba xvela, cxeleba, an raime sxva tuberkulozze saewvo simptomebi, TIME-is mkurnalobis dawyebamde unda gaxdes detaluri gamokvlevis obieqti, mat Soris baqteriologiuri gamokvlevisac. bavsvs, romelsac arenisneba tuberkulozze saewvo simptomebi (magalitad, cxeleba, xveleba da sxva), mkurnalobis dawyebamde aseve unda Cautardes rentgenografia. idealur SemTxvevaSi es midgoma gamoyenebuli unda iqnes yvela bavsvis mimart, magram Tu rentgeni ar aris xelmisawvdomi LTBI-is mkurnaloba unda gagrzeldes manamde, sanam bavsvs simptomebi ar gauqreba. rac Seexeba fexmzime aiv-negatiur qalebs, LTBI-is 268

samkurnalod rekomendirebulia izoniazidis yoveldriuri an intervalebiani intermitiuli rejimi (kvirasi orjer) 9-6 Tvis ganmavlobasi. sawiroebis SemTxvevaSi aqtiuri tuberkulozis gamoricxvis miznit fexmzime qalebsi SesaZlebelia rentgenografiis Catareba pirvel trimestrsic ki. qalebsi, romlebsac emuqrebat LTBI-is progresirebis safrtxe, gansakutrebit aiv-inficirebulebsi, romlebic warsulsi inficirebuli iyvnen tuberkulozis mikobaqteriit, mkurnalobis dawyeba ar unda dagviandes mxolod fexmzimobis gamo, is unda Catardes pirvel trimestrsic ki. aqtiuri tuberkulozis dabali riskis SemTxvevaSi, zogierti eqsperti gvircevs davelodot msobiarobas da Semdeg daviwyot LTBI-is mkurnaloba. LTBI-s mkurnalobis dasawyebad ar aris aucilebeli yvela pacients Cautardes sabaziso laboratoriuli kvlevebi. pacientebs, romlebsac sawyisi SefasebiT savaraudod arenisnebat RviZlis darrvevebi, unda Cautardes RviZlis funqciebis gamokvleva Sratis aspartat-aminotransferaza AST-ze (SGOT) an alanin_ aminotransferaza ALT-ze (GPT) da bilirubinze. asetive ZiriTadi testebi nacvenebia aiv-inficirebuli pacientebisatvis, fexmzime da axladnamsobiarebi qalebisatvis (3 Tvis ganmavlobasi msobiarobis Semdeg), RviZlis qronikuli daavadebis risk-faqtoris mqone individebsi da im pirebsi, vinc regularulad irebs alkohols. es testi ar aris savaldebulo xandazmuli adamianebisatvis. aqtiuri hepatiti da RviZlis mwvave daavadeba warmoadgens mkurnalobis ukucvenebas. LTBI-is mkurnalobis dros unda rutinuli laboratoriuli monitoringi ganxorcieldes RviZlis fermentebis darrvevebis da RviZlis daavadebis mqone pacientebsi. pacientebi informirebulebi unda iyvnen LTBI-is mkurnalobastan dakavsirebuli gverditi movlenebis Sesaxeb. mat unda icodnen, rom aseti movlenebis ganvitarebisas unda Sewyviton mkurnaloba da dauyovnebliv mimarton eqims. sawiroa pacientebis gamokitxva gverditi movlenebis Sesaxeb mati codnis Sefasebis miznit. sadavo sakitxia, Tu ramdenad mnisvnelovania LTBI-is mkurnaloba im qveynebsi, sadac tuberkulozit daavadebis sixsire kvlavac izrdeba da tuberkulozis mikobaqteriis transmisiis macveneblebi isev da isev Zalian maralia. uewvelia, rom aset situaciasi LTBIis mkurnalobis programa ar unda warmoadgendes tuberkulozis 269

kontrolis saerto strategiis prioritets. tuberkulozis kontrolis upirvelesi strategiuli amocana aris aqtiuri infeqciuri tuberkulozit daavadebuli pacientebis adreuli identificirebisa da sruli kursit mkurnalobis mesveobit tuberkulozis transmisiis riskis minimumamde dayvana. SesaZloa, LTBI-is mkurnalobis seleqciuri programebi zogierti sasualo Semosavlis mqone qveynebistvisac finansurad xelmisawvdomi da realizebadi iyos, magram mat yoveltvis ufro dabali prioriteti eqnebat, vidre tuberkulozis SemTxvevebis warmatebuli martvis programebs. dabalsemosavlian qveynebsi tuberkulozis marali prevalentobit LTBI-is mkurnalobis programebs upiratesad meoradi mnisvneloba aqvs tuberkulozis kontrolsi. tuberkulozis prevenciis strategiis saxit LTBI-is mkurnalobis gamoyeneba unda Semoifarglos im adamianebit an jgufebit, romlebsac aqtiuri tuberkulozis ganvitarebis Zalzed marali riski aqvt. im qveynebsi, sadac aiv-epidemia mzvinvarebs LTBI-is mkurnaloba sakmaod sasargeblo iqneba individebisatvis. miuxedavad imisa, rom aset strategias Teoriulad SeuZlia Seamciros tuberkulozit daavadebis sixsire da Seasustos aiv infeqciis zegavlena tuberkulozis epidemiologiaze, praqtikasi misi ganxorcieleba sirtuleebtan iqneba dakavsirebuli. gansakutrebit iset regionebsi, sadac nacxit dadebiti tuberkulozis gamovlena da mkurnaloba umarlesi prioritetia. 270

52. ra epidemiologiuri zegavlena aqvs latenturi tuberkulozuri infeqciis mkurnalobas z.teilori 53 latenturi tuberkulozuri infeqciis (LTBI) mkurnaloba warmoadgens ass-s tuberkulozis kontrolis programis mnisvnelovan komponents. CrdiloeT amerikis farglebs garet igi gamoiyeneba aqtiuri infeqciuri tuberkulozi daavadebul pirebtan kontaqtsi myofi individebis mkurnalobisatvis. arctu didi xnis win mkurnalobis ertaderti fartod rekomendirebuli rejimi iyo izoniazidis yoveldriuri an intermitiuli kursi - kvirasi 2-jer - 6 an 12 Tvis ganmavlobasi 290. latenturi infeqciis mqone pacientebis prevenciul mkurnalobasi izoniazidis efeqtianoba dadginda 291,292. randomizirebul, placebos gamoyenebit Catarebul sakontrolo kvlevebsi. aqtiuri tuberkulozis ganvitarebis Semcirebis saerto macvenebeli arnisnul kvlevebsi Seadgenda 60%-s 291, xolo im individebsi, romlebic 12-Tvis manzilze irebdnen danisnuli medikamentebis 80%-ze mets, izoniazidis efeqtianobam miarwia 90%-s. izoniazidis 6-Tviani rejimi efeqturi iyo, magram 12 Tviani kursi gacilebit ufro marali efeqturobit gamoirceoda 292. mkurnalobis ufro axali rekomendaciebi itvaliswinebs rifampicinisa da pirazinamidis yoveldriur mirebas 2 Tvis ganmavlobasi da Semdeg rifampicinis 4-Tvian rejims, romlebic warmoadgens izoniazidis 6-9-Tviani yoveldriuri an kvirasi 2-jer mirebis rejimsis alternativas. rekomendaciebi efuzneboda kontrolirebad klinikur kvlevebs, romlebmac daadastures am rejimebis ekvivalenturi prevenciuli efeqtianoba 293. LTBI-is mkurnalobastan dakavsirebit Catarebuli klinikuri kvlevebis umetesoba moicavda marali riskis mqone mosaxleobas, 53 daavadebata kontrolisa da matgan Tavdacvis centrebi. atlanta, jorjiis Stati, ass. 271

rogoricaa axlo warsulsi inficirebuli kontaqtebi, mwidrod dasaxlebuli sacxovrebeli adgilebis macxovreblebi, aivinficirebuli adamianebi an aranamkurnalebi, inaqtiuri tuberkulozis mqone pirebi 291,292,294,295. am kvlevebis epidemiologiuri mnisvneloba damokidebulia ara mxolod mkurnalobis efeqturobaze, aramed imaze, Tu ra zegavlenas moaxdens namkurnalebi adamianebis jgufebi tuberkulozit daavadebis sixsireze sazogadoebasi. grenlandiasi, aliaskaze da tunissi Caterebuli kvlevebi miznad isaxavda LTBI-is mkurnalobis zemoqmedebis gazomvas mosaxleobasi tuberkulozit daavadebis sixsireze. grenlandiasi kvleva Catarda 1956 wels da massi monawileobda 76 sofeli da 8081 adamiani 296. TiToeul sofelsi monawileebs ezleodat izoniazidi an placebo. mocemul sofelsi yvelas azlevdnen ertsa da imave medikaments. medikamentis mireba xdeboda kvirasi 2-jer, 13 kviris ganmavlobasi, or periods Soris 13- kviriani SesvenebiT. kvleva aliaskaze daiwyo 1957 wels da moicavda 30 Tems. massi monawileobda 6064 adamiani 297. am kvlevis dros moxda ojaxis wevrebis randomizirebuli SerCeva izoniazidis an placebos misarebad. da bolos, tunissi kvleva daiwyo 1958 wels. tunisis Raribi ojaxebit dasaxlebuli gareubnis sacxovrebeli korpusebi SeirCa randomizirebulad, nawils ezleoda izoniazidi, xolo nawils placebo. sul kvlevasi monawileobda 15910 pacienti. am sami kvlevis Sedegebi Sejamebuli saxit warmodgenilia cxrilsi #54. cxrili #54 izoniazidit profilaqtikuri mkurnalobis kvlevebis Sedegebi 1956-1958w kvleva /kvlevis jgufi # monawileta ricxvi SemTxvevaTa raodenoba 1000 suli/wlebi Semcirebis % grinlendis soflebi placebo izoniazidi aliaskis/soflebi placebo izoniazidi tunisis sazogadoeba placebo izoniazidi 3907 4147 3017 3047 8141 7769 13.8 9.8 7.7 3.2 3.1 2.3 31 b 59 b 26 c 272

warmodgenili Sedegebi askarad gansxvavebulia. zemoqmedebis yvelaze marali macvenebeli arinisneba aliaskaze, gacilebit naklebi grenlandiasi da sul umnisvnelo tunissi. aliaskasa da grenlandiasi kvlevebi mimdinareobda patara, izolirebul soflebsi, romlis mosaxleobac mxars uwerda kvlevebs. garda amisa, orive SemTxvevaSi teritoriebze funqcionirebda tuberkulozis kontrolis efeqturi programebi. grenlandiasi kvlevasi monawileebs azlevdnen 400-600 gr izoniazids 2-jer kvirasi, 13 kviris ganmavlobasi. amas mosdevda aseve 13-kviriani periodi, romlis ganmavlobasi pacientebi ar irebdnen medikamentebs da Semdeg isev 13-kviriani periodi, romlis drosac pacientebi kvlav irebdnen izoniazids. es aris standartuli rejimi da savaraudod suboptimaluria, ritac aixsneba misi dabali efeqturoba. rac Seexeba tunisis kvlevas, massi monawile mosaxleoba regularulad ar irebda medikamentebs. aliaskis kvlevis dasrulebis Semdeg massi monawile im adamianebs, romlebic kvlevis processi irebdnen placebos, SesTavazes da Cautares izoniazidis sruli, 12-Tviani kursi. Tumca es ar iyo kontrolirebadi kvleva. aqtiuri tuberkulozis dabali macvenebeli mkvlevrebma gamoavlines mat Soris, vinc irebda danisnuli izoniazidis 40%-ze mets 298, mattan SedarebiT, vinc irebda izoniazidis danisnuli dozis 40%-ze naklebs. avadobis macvenebeli ufro marali iyo aranamkurnaleb, inaqtiuri tuberkulozit daavadebul pacientebsi. avtorebis TvalsazrisiT, mosaxleobis mxolod am nawilis mkurnalobit SesaZlebelia sazogadoebasi tuberkulozis 40%-is prevancia. da bolos, daskvnis saxit unda itqvas, rom LTBI-is mkurnalobis epidemiologiuri zemoqmedeba sazogadoebaze SeiZleba gamoixatos aqtiuri tuberkulozis 31-59%-iT SemcirebiT mxolod im SemTxvevaSi, Tu tuberkulozis kontrolis programa efeqturad funqcionirebs, da aqtiuri tuberkulozis SemTxvevaTa umetesi nawili ganvitarebulia latenturi tuberkulozidan. Teoriulad, Semcirebam SeiZleba 80-90%- Seadgenos Tu aqtiuri tuberkulozis yvela SemTxvevas latenturi infeqciis reaqtivaciis Sedegad mivicnevt, Tu identificirebuli iqneba latenturi infeqciis yvela SemTxveva da Tu latenturi infeqciis mqone yvela pirovneba Caitarebs srul mkurnalobas. realur vitarebasi aseti Tanxvedra Zalzed isviatia. iset mdidar qveyanasic ki, rogoricaa ass, sadac 273

tuberkulozit daavadebis sixsire Zalzed dabalia, aqtiuri tuberkulozis SemTxvevebis didi nawili ganpirobebulia infeqciis transmisiit 299,300, xolo LTBI-is mkurnalobis kursis dasrulebis macvenebeli 50%-ze naklebia 301,302. aqedan gamomdinare LTBI-is mkurnalobis epidemiologiuri efeqti savaraudod ufro zomieria, vidre aliaskasa da grenlandiasi Catarebuli kvlevebit Cans. ufro metic, LTBI-is masiurad gamovlenisa da mkurnalobisatvis sawiro sakadro da fuladi resursebis odenoba bevrad aremateba tuberkulozis kontrolis programebis umetesi nawilis SesaZleblobebs. kargad dafinansebuli tuberkulozis kontrolis efeqturi programebisatvis LTBI-is kontaqtebis, patimrebis, aiv da LTBI pacientebis mkurnaloba warmoadgens SesaZlo variants. epidemiologiuri efeqturoba damokidebuli iqneba imaze, Tu ra zemoqmedebas axdens es risk-jgufi tuberkulozit daavadebis sixsireze mosaxleobasi. 274

monitoringi 275

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53. rogoria tuberkulozis avadobit gamowveuli janmrtelobis, socialuri da ekonomikuri mdgomareobis gauareseba i. smiti 1 tuberkulozis Sedegebi Zalze mzime zemoqmedbas axdens mosaxleobaze. samidan erti adamiani tuberkulozitaa inficirebuli, Ees ki msoflio mosaxleobis 2 miliards Seadgens. 1997 wlis gaangarisebit tuberkulozis aqtiuri formit yovelwliurad 8 milioni adamiani avaddeba, xolo daaxloebit ori milioni urupeba 1. tuberkulozze modis daavadebata globaluri simzimis 2,5% da igi qalta sikvdilianobis yvelaze gavrcelebuli mizezia 2. misgan ufro meti qali irupeba, vidre qalta sikvdilianobis yvela ertad arebuli mizezit, rogorc amas grafiki #18 gvicvenebs. sikvdilis mizezebis globalur CamonaTvalSi tuberkulozs amjamad me-7 adgili uwiravs da Tu tuberkulozis winaarmdeg brzolasi ar iqneba Cadebuli udidesi Zalisxmeva, miuxedavad infeqciuri daavadebebit gamowveuli avadobis macveneblis mnisvnelovnad Semcirebis prognozisa, savaraudoa rom igi SeinarCunebs pozicias 2020 wlamde 3. Aaiv-nfeqcia zrdis tuberkulozit daavadebis risks 4. qveynebsi, sadac aiv-is prevalentoba maralia, gansakutrebit sub-saharul afrikasi, mkvetrad gaizarda tuberkulozit daavadebulta ricxvi da 90-ian wlebsi SemTxvevaTa raodenobam 2_4-jer imata 5. bevr qveyanasi rezistentoba mzard problemaa, rac ganpirobebulia mkurnalobis cudi organizebit. cudad Camoyalibebuli kontrolis programebi, medikamentebis araregularulad miwodeba da kerzo seqtorsi mati ukontrolo gamoyeneba iwvevs medikamentebze rezistentobis ganvitarebas, romlis 1 tuberkulozis SeCerebis departamentis medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria. 277

Tavidan acilebac SesaZlebebia DOTS-is efeqturi danergvit. 1994_1997 wlebsi jandacvis msoflio organizaciis (WHO) da IUATLD is mier 35 qveyanasi Catarda rezistentobis globaluri gamokvleva 6,7. axali SemTxvevebis dros rezistentoba sul mcire erti wamlis mimart arinisneboda SemTxvevebis 9,9%-Si, xolo multirezistentoba (rezistentoba sul mcire izoniazidisa da rifampicinis mimart) SemTxvevaTa 1,4%-Si. globaluri zedamxedvelobis meore etapis angarissi, romelic gamoqveynda 2000 wels, nacvenebia, rom surati ucvlelia (rezistentoba romelime wamlis mimart axlad gamovlenil SemTxvevaTa 10,7% -Si da multirezistentoba SemTxvevaTa 1%-Si). es moxsenebebi adasturebs, rom rezistentobis ganvitarebis udidesi riskis faqtoria tuberkulozze adre Catarebuli mkurnaloba. aset SemTxvevaTa 23,3%-i erti wamlis mimart mainc iyo rezistentuli, xolo 9,3%-s hqonda multirezistentuli tuberkulozi 8. rezistentoba asustebs WHO-s mier rekomendirebuli standartuli kursit mkurnalobis efeqturobas da mkurnalobis warumateboba 15-jer ufro maralia multirezistentul pacientta Soris, vidre ararezistentul individebsi 9. tuberkulozi aferxebs socialur ekonomikur ganvitarebas. daavadebulta 75% 15_54 wlamde asakobrivi jgufis ekonomikurad produqtiuli, Sromisunariani adamianebi arian 10. SemTxvevaTa 95 % da sikvdilianobis 99% modis ganvitarebad qveynebze, es macveneblebi yvelaze marali afrikis sub-saharis regionsi da samxret-armosavlet aziasia. ertad, msoflios 23 qveyanaze modis tuberkulozis yvela SemTxvevis 80%, tuberkulozis mkurnalobisas xarjebi ojaxebisatvis Zalzed maralia (cxrili #55). Tumca diagnostikisa da mkurnalobis pirdapiri xarjebi Raribi ojaxebistvis Zalian maralia, ufro didi ekonomikuri zarali ganpirobebulia iseti arapirdapiri xarjebit, rogoricaa dakarguli samusao, samedicino dawesebulebebsi misasvleli da dasabrunebeli xarjebi. qonebis gayidva mkurnalobis xarjebis dasafaravad, dakrzalvis xarjebi, da, gansakutrebit, Sromisunarianobis dakargva avadobisa da naadrevi sikvdilis gamo. ugandasi Catarebulma kvlevam cxadyo, rom avadmyofi fermerebis 95%-i ucioda Sromisunarianobis daqveitebas, xolo gamomusavebaze myof adamianta 80%-ma Sewyvita musaoba 14. 278

grafiki #18. msofliosi sikvdilianobis gamomwvevi 15 ZiriTadi mizezis GamonaTvali da mati adgilmonacvleoba 1999-2020 wlebis periodsi 1999 daavadeba an dazianeba qvemo sasuntqi gzebis infeqciebi fararatit mimdinare daavadebebi perinataluri periodis mdgomareobebi Zlieri unipolaruli depresia gulis isemiuri daavadeba cerebrovaskularuli daavadeba tuberkulozi witela sagzao-satransporto ubeduri SemTxvevebi 2020 scenari, daavadeba an dazianeba gulis isemuri daavadeba Zlieri unipolaruli depresia sagzao-satransporto ubeduri SemTxvevebi cerebrovaskularuli daavadebani filtvis qronikuli obstruqciuli daavadebani tuberkulozi omi fararatit mimdinare daavadebebi aiv-infeqcia perinataluri periodis mdgomareobebi Zaladoba Tandayolli daavadeba TviTmiyenebuli ziani traqeis, brobqebis da filtvis kibo 279

cxrili #55. tuberkulozis xarjebi ert ojaxze gaangarisebit pacientis xarji bangladesi 11 indoeti 12 samxret 13 afrika uganda 14 pirdapiri xarjebi US$ samusaos dakargva dakarguli dro dakarguli Semosavali US$ arapirdapiri xarji ojaxis wliuri Semosavlis procentuli wilis saxit mtliani xarji ojaxis wliuri Semosavlisa procentuli wilis saxit 130 57% 14 Tve 115 15 31 41 ucnobia 3 Tve 89 14 20 99 ucnobia 4 Tve 272 ucnobia ucnobia 68 91% 10 Tve 161 ucnobia ucnobia im gamokvlevebis analizit, romlebic Seiswavlidnen tuberkulozis ekonomikur aspeqtebs, dadginda, rom tuberkulozit daavadebuli mozrdili adamiani weliwadsi 3-4 samusao Tves kargavs,grac ojaxis Semosavlis 20-30%-iT Semcirebas nisnavs da Tu pacienti irupeba am daavadebisgan_ikargeba daaxloebit 15 produqtiuli weli 15. tuberkulozisa da siraribis urtiertkavsiri kompleqsuri xasiatisaa, radganac es daavadeba pirvel rigsi araribebs mat, vinc tuberkulozitaa daavadebuli, xolo epidemias Sedegad mohyveba socialur-ekonomikuri mdgomareobis gauareseba. siraribe aizulebs adamianebs icxovron ert saxlsi da zrdis transmisiis risks. cudi kveba ki zrdis inficirebis risks. sabwota kavsiris daslam 1990-ian wlebis dasawyissi da ekonomikis, jandacvis da socialuri daxmarebis sistemis rrvevam gamoiwvia tuberkulozis SemTxvevebis swrafi zrda, weliwadsi daaxloebit 7%-iT rusetsi, ukrainasa da sxva yofil socialistur qveynebsi 16. kubasi 3 wlis ganmavlobasi ekonomikurma da kvebitma SezRudvam gamoiwvia tuberkulozis SemTxvevaTa Setyobinebis macveneblis uecari zrda (24% weliwadsi). gaumjobesebulma programam SesaZlebeli gaxada transmisiis donisa da SemTxvevaTa ricxvis Semcireba. negatiuri socialuri Sedegebi, iseti rogoricaa stigma, zog sazogadoebasi gansakutrebuli problemaa qalebisatvis. igi xels uslis qorwinebas, samusaos dawyebas da xandaxan ganqorwinebis 280

mizezic ki xdeba. indoetsi Catarebulma kvlevam cxadyo, rom tuberkulozit daavadebuli qalebis 15% (100 000 qali weliwadsi mteli qveynis masstabit), uaryofilni iyvnen ojaxebis mier 12. negatiuri Sedegi gadaecema Semdgom Taoebebsac. RonisZiebebi, romlebsac mimartaven Rarib ojaxebsi, rata gaumklavdnen arsebul situacias, cudad aisaxeba bavsvebze. igive kvleva, romelic Catarda indoetsi, gvicvenebs, rom soflis regionebis bavsvebis 8% da qalaqsi macxovrebi bavsvebis 13% (300 000 qveynis masstabit) gamoyvanili iyvnen skolebidan ert-erti msoblis (Cveulebriv mamis) tuberkulozit daavadebis gamo. kidev erti Soreuli Sedegi aris valis areba. indoetsi Catarebulma kvlevam gvicvena, rom ojaxebis 2/3 ze meti izulebuli iyo aero vali, rata gadaexada tuberkulozis mkurnalobis xarjebi. valis sasualo odenoba iyo 59 ass dolari, rac ojaxis wliuri Semosavlis 12% Seadgens. tuberkulozis infeqciis Semdgomi gavrceleba zrdis am daavadebit momdevno Taobebis dasnebovnebisa da darupvis risks, risi Tavidan acilebac SesaZlebeli iyo. 281

54. rogoria tuberkulozis kontrolis globaluri miznebi da ras efuzneba is i.smiti 2 tuberkulozis globaluri kontrolis miznebia nacxit dadebiti SemTxvevebis 85%-is gankurneba da nacxit dadebiti SemTxvevebis prognizirebuli macveneblis 70%-is gamovlena 17. es miznebi Tavdapirvelad jandacvis msoflio organizaciis mier daisaxa 1991 wels. SemdgomSi nateli gaxda, rom am miznebis mirweva 2000 wlisatvis SeuZlebeli iyo. 2000 wlis maissi Catarebuli jandacvis msoflio asambleis dadgenilebit miznebis ganxorcielebam gadaiwia 2005 wlisatvis. axali SemTxveebis gamovlenis macveneblis gansazrvrisatvis mricxvels warmoadgens pacientta ertwlian kohortasi nacxit dadebti tuberkulozis axali SemTxvevebis raodenoba, xolo mnisvnels_ nacxit dadebiti tuberkulozis axali SemTxvevebis prognozirebuli radenoba, romelic SeiZleba warmosobili yofiliyo igive populaciasi da drois imave monakvetsi. radgan SemTxvevaTa gamovlenis macvenebeli efuzneba tuberkulozit daavadebis SemTxvevebis raodenobis prognozirebas, umetesi raionebisatvis misi zusti gansazrvra rtulia, gansakutrebit aiv-infeqciastan mimartebasi. Ggankurnebis macveneblis gansazrvrisas mricxveli aris pacientta ertwlian kohortasi Semavali nacxit dadebiti Semxvevis is raodenoba, rmelic Seesabameba definicia gankurnebuls WHO/ IUATLD mixedvit, xolo mnisvneli pacientta mtliani radenoba, romelic Tavidan registrirebuli iyo kohortasi mkurnalobis miznit. tuberkulozis efeqturi kontrolis ganxorcieleba DOTSis strategiaze dafuznebit, Zalzed neli tempit mimdinareobda. 2 tuberkulozis SeCerebis departamentis medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria. 282

1999 wlisatvis janmos axali prognizirebadi infeqciuri SemTxvevebis mxolod 40% warudgines (DOTS programebsi 23% da 17%_ara DOTS programebsi) 18. 1998 wels DOTS-is programasi registrirebuli pacientebis gankurnebis macvenebeli_73%_bevrad ufro marali iyo, vidre sxva programasi monawile pacientebis igive macvenebeli_16%. xolo pacientebis im raodenobis damatebam, romlebmac mkurnaloba daasrules nacxis Sedegis garese, DOTS-is programebis farglebsi warmatebuli mkurnalobis 84%-iani macvenebeli mogvca, rac axlos iyo globalur mizantan. am miznebis dasaxvisas gamoyenebuli iyo ori principi: zemoqmedeba da ganxorcielebadoba. Ppirveli-zemoqmedeba. epidemoilogiurma modelirebam gvicvena, rom am miznis mirweva gamoiwvevs tuberkulozis epidemiis mnisvnelovan Semcirebas 19, rac tuberkulozit daavadebis SemTxvevaTa sixsires (Tu gamovricxavt aiv-infeqcias) 50%-iT Seamcirebs 8-12 weliwadsi. stiblosa da bumgarneris 1991 wlis moxsenebasi natqvamia Tu ra zegavlenas axdens SemTxvevaTa gamovlenisa da gankurnebis saxvadasxva macveneblebi tuberkulozis prevalentobaze da gaketebulia prognozi, rom 75%-ze marali gankurnebis macvenebeli drota ganmavlobasi gamoiwvevda prevalentobis mnisvnelovan Semcirebas masin, roca SemTxvevaTa gamovlenis gazrda gankurnebis gaumjobesebis garese gaamwvavebda epidemias. am nasromma mnisvnelovani zemoqmedeba moaxdina miznebis gansazrvris procesze. nasromsi mocemuli debulebebis siswore dasabutebuli iqna momdevno gamokvlevebitac, romlebsic gamotqmulia azri, rom qveynebsi, romlebic miarweven janmos globalur miznebs, daavadebis SemTxvevaTa sixsire yovel wels 8-12%-iT Semcirdeba (SemTxvevaTa Semcireba 50%-iT iset mokle periodsi, rogoricaa 6-9 weli) da kidev ufro swrafad Semcirdeba sikvdilianobis macvenebeli_ igi 9-13%-iT daiwevs yovel wels (anu 50% Semcireba 5 weliwadsi an nakleb drosi) 20. es Teoriuli cifrebi korelirebs warsulisa da awmyos gamocdilebastan. gasuli saukunis ganmavlobasi tuberkulozit daavadebulta ricxvi evropasi mkvetrad Semcirda, magram SemTxvevaTa sixsiris kleba weliwadsi 4-5%-dan 12-13%-mde gaizarda mxolod efeqturi mkurnalobis danergvis Semdeg 21. es informacia daasabuta perudan bolo periodsi mirebulma monacemebma, romlebic gvicvenebs, rom daavadebis SemTxvevebis Semcirebis sixsiris klebam miarwia 283

8%-s weliwadsi, rac orjer ufro metia DOTS-is danergvamde arsebul macvenebelze 18,22. Mmeore_ganxorcielebis realoba. tuberkulozis adreuli sociologiuri da epidemiologiuri gamokvlevebi indoetsi cxadyofs rom tuberkulozit daavadebuli, nacxit dadebiti pacientebis 70%-ma daavadebis simptomebit mimartes samedicino dawesebulebebs. es adasturebs SemTxvevaTa gamovlenis SesaZleblobas samedicino dawesebulebasi, rac aris kidec ZiriTadi mizani 23. IUATLD-is mxardawerit 80-iani wlebis bolos beninsi, malavisi, tanzaniis gaertianebul respublikasi da vietnamsi ganxorcielda tuberkulozis erovnuli programebi. mirebulmay gamocdilebam gvicvena, rom gankurnebis 80%-iani macveneblis mirweva da SenarCuneba SesaZlebelia, rac Tavis mxriv adasturebs dasaxuli miznebis realobas 24. tanzaniis gaertianebul respublikasi Catarebulma kvlevam cxadyo, rom programis pirobebsi SesaZlebelia axali infeqciuri SemTxvevebis 70%-is gamovlenis mirweva. 2000 wlisatvis globalur mizans Svidma qveyanam miarwia da 43-ma gankurnebis 70%-ze marali macvenebeli ucvena, SemTxvevaTa gamovlena 50%-ze marali iyo 18. Ddasaxuli miznebis mirwevis gzaze msoflio mnisvnelovani sirtuleebis winase dgas. sub-saharul afrikasi tuberkulozis epidemia yovel weliwads 10%-iT izrdeba, rac upiratesad aivpandemiit aris gamowveuli 18. sikvdilianobis marali macvenebeli aiv-koinfeqciis mqone tuberkulozit daavadebul individebs Soris mraval qveyanas xels uslis miarwios gankurnebis globalur samizne macvenebels. amastan, arc SemTxvevaTa gamovlenis da arc gankurnebis macveneblis gaumjobesebis miznebsi ar aris gatvaliswinebuli aiv infeqcia. tuberkulozis kontrolis efeqtur samsaxurebs aiv epidemiis pirobebsi ar SeuZliaT xeli SeuSalon tuberkulozis zrdas (ix. SesaZlebelia Tu ara tuberkulozis kontroli ). globaluri miznis mirwevis meore winaarmdegoba SemTxvevaTa gamovlenis da Setyobinebis araadekvaturobaa. miuxedavad imisa, rom 1999 wels msoflios mosaxleobis 43% cxovrobda DOTS-is programebis moqmedebis regionebsi, infeqciuri tuberkulozit daavadebuli pacientebis mxolod 23%-s Cautarda DOTS-is metodit mkurnaloba. amis mizezi bevr qveyanasi pirveladi jandacvis limitirebuli infrastruqturaa, rig qveynebsi ki kerzo seqtorsi 284

diagnostikisa da mkurnalobis farto SesaZlebloba, gansakutrebit, samxret aziis qveynebsi, sadac tuberkulozis msoflio SemTxvevaTa erti mesamedia Tavmoyrili. ganvitarebad qveynebsi kerzo seqtori ar awvdis informacias samedicino dawesebulebebs dadgenili diagnozis Sesaxeb. globaluri samizne macveneblis mirweva damokidebulia qveynis SesaZleblobaze, daacqaros DOTS-is programit regionebis mocvis procesi da SeinarCunos gankurnebis marali macvenebeli, aseve aivinfeqciastan asocirebuli tuberkulozis mkurnalobis strategiis efeqturobaze da tuberkulozis programebis unarze gazardos SemTxvevaTa gamovlena socialuri mobilizaciis kerzo seqtortan TanamSromlobis da momsaxurebis gaumjobesebis gzit. 285

55. ra aris DOTS-i i.smiti 3 DOTS-i aris saertasoriso rekomendirebuli strategia, romelmac unda uzrunvelyos tuberkulozisgan gankurneba 25. igi damyarebulia xut ZiriTad principze (ix. cxrili #56), romelic saertoa daavadebis kontrolis strategiisatvis da tuberkulozis gavrcelebis SewyvetisaTvis efuzneba adreul diagnostikas da infeqciuri SemTxvevebis mkurnalobas. infeqciuri SemTxvevebis mkurnaloba, rogorc daavadebis gavrcelebis prevenciisa da tuberkulozis kontrolis strategia pirvelad ganxilul iqna kroftonis mier 60-iani wlebis dasawyissi 26. pirveli efeqturi wamlis armocenidan 20-welze naklebis Semdeg da randomizirebuli kontrolis cdebis Catarebidan 10 wlis Semdeg damtkicda, rom kombinirebul mkurnalobis kurss SeuZlia pacientis gankurneba da rezistentobis gavrcelebis prevencia 27. RonisZiebaTa paketi, rasac sabolood DOTS-i ewoda, SemuSavebul iqna IUATLD-is mxardawerit ganxorcielebul erovnul programebsi, karel stiblos xelmzrvanelobit, Tavdapirvelad tanzaniis gaertianebul respublikasi da Semdgom afrikisa da latinuri amerikis sxva qveynebsi. stiblom SeimuSava tuberkulozis efeqturi kontrolis teqnikuri da menejeruli principebi, romlebic efuzneboda regionsi arsebul martvis samsaxurs. regionsi iyo kadrebi da resursebi, rac izleoda diagnostikur da samkurnalo samsaxurebis organizebis, inventaris satanado eqsploataciisa da programis ganxorcielebaze monitoringis uzrunvelyofis SesaZleblobas ubanze 100.000_150.000 mosaxleobit. stiblom gvicvena, rom mkurnalobis mokle kurss gadamwyveti mnisvneloba eniweboda 3 tuberkulozis SeCerebis departamentis medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria 286

gankurnebis adekvaturi macveneblis misarwevad. man daasabuta usualo metvalyureobis aucilebloba da SeimuSava arricxvis, angarisgebisa da medikamentta menejmentis principebi, romlebic Tavis mxriv DOTS-is ganuyofel elementebs warmoadgenen. jandacvis msoflio organizaciam am strategiis xelsewyoba daiwyo 1991 28 wels da 1994 wels Seqmna tuberkulozis efeqturi kentrolis struqtura 29, rac natlad arwerda im mtavar komponentebs, romlebic mogvianebit Camoyalibda DOTS strategiad. es struqtura Sesworda da gafartovda 2002 wels 30. mkurnaloba usualo metvalyureobit _es termini gamoiyeneboda ramodenime wlis ganmavlobasi, vidre 1995 wels ar iqna cxrili #56 DOTS-is principebi da komponentebi mtavari principi DOTS-is komponenti organizirebuli da Tanamimdevruli intervenicia saxelmwifos mzadyofna uzrunvelyos tuberkulozis kontrolis yovlis-momcveli da Tanamimdevruli RonisZiebebis ganxorcieleba. infeqciuri SemTxvevebis zusti da adreuli identifikacia naxvelis nacxis mikroskopiit SemTxvevaTa gamovlena simptomebis mqone im pacientebs Soris, romlebmac TviTon mimartes dawesebulebas. efeqturi da pacientisadmi ketilganwyobili mkurnaloba mkurnalobis standartuli mokle kursi 6-8-Tviani rejimebis gamoyenebit; yvela dadasturebuli nacxit dadebiti SemTxvevebisTvis mainc. SemTxvevaTa efeqturi menejmenti moicavs yvela nacx-dadebit pacientis usualo metvalyureobit mkurnalobas intensiuri fazis dros, gagrzelebis fazas rifampicinis Semcveli kursit da mtlianad gnmeorebiti mkurnalobis rejimis Catarebas. medikamentta efeqturi menejmenti yvela aucilebeli tubsawinaarmdego medikamentis regularuli/uwyveti miwodeba. Sedegze damyarebuli monitoringi arricxvisa da angarisgebis standartuli sistema, romelic sasualebas izleva Sefasdes SemTxvevaTa gamovlena, TiToeuli pacientis mkurnalobis Sedegebi da mtlianad programis Sesrulebis xarisxi. 287

modificirebuli WHO-s mier usualo metvalyureobit mkurnalobis mokle kursad~ 31 da gamoiyeneboda tuberkulozis kontrolis mravlismomcveli strategiis arsanisnad. miuxedavad imisa, rom DOTS - strategiasi xazgasmulia usualo metvalyureobis komponenti misi yvela aspeqti mnisvnelovania. DOTS-i arar aris ubralod akronimi, igi tuberkulozis kontrolis strategiasi iqca WHOs safirmo nisnad. DOTS-is ganxorcielebasi gadamwyveti komponentia mtavrobis roli. jandacvis msoflio organizacia xazs usvams propagandisa da socialuri mobilizaciis mnisvnelobas, rogorc mtavrobis mxardaweris mopovebis aucilebel pirobas. programis amoqmedebisatvis sawiroa Sesabamisi dafinanseba aucilebeli inventaris SesaZenad (wamlebi, mikroskopebi, reaqtivebi, bewdviti masalebi da a.s.), administraciuli daxmareba TanamSromelTa asayvanad da kontraqtebis dasamyareblad. wignis pirvel nawilsi detalurad aris ganxiluli diagnozis, upiratesad mikroskopiis Sedegebze dayrdnobit dasmis aucileblobis mizezebi. mkurnalobis usualo metvalyureoba nisnavs specialurad momzadebuli personalis metvalyureobit pacientis mier wamlis mirebas, rac DOTS-is strategiis dacvis fundamenturi principia 25. janmos adreul dokumentebsi xazgasmulia samedicino personalis usualo metvalyureobis mnisvneloba 32. mogvianebit DOTS-is progamebis ganxorcielebis gamocdilebam acvena, rom specialurad momzadebuli araspecialistebi iseve efeqturad musaobdnen metvalyureobis dros, rogorc samedicino personali. mat ganekutvnebian moxaliseebi bangladessi 33, maraziis gamyidvlebi samxret afrikasi 34, religiuri liderebi, aramedikosi jandacvis musakebi da sazogadoebis moxaliseebi. zogierti uaxles kvlevasi daisva usualo metvalyureobis aucileblobis sakitxi 35, kerzod, metvalyureobis sixsiris Semcireba da misi kvirasi ertxel ganxorcielebis sakmarisad miicneva 36. savaraudod is sargebeli, rasac es Semcirebuli metvalyureoba moutans jandacvis musakebs da pacientebs, SeiZleba gabatildes rezistentobis zrdis riskit mkurnalobis kursis farulad darrvevis gamo. mkurnalobis efeqturobis uzrunvelsayofad metvalyure advilad misawvdomi da misarebi unda iyos pacientisatvis, igi unda iyos kargad momzadebuli da angarisvaldebuli samedicino dawesebulebis mimart. 288

tubsawinaarmdego medikamentebis uwyveti momaragebis sawiroeba natelia. amastan, medikamentebis xarisxi garantirebuli unda iyos gansakutrebit masin, Tu isini dadgenili dozebis kombinaciebisgan Sedgeba, romelta damzadebac xsirad problemebs uqmnis mwarmoebels (ix. Tavi: ra dadebiti da uaryofiti mxareebi aqvs tubsawinaarmdego medikamentebis fiqsirebuli dozis kombinaciebs ). DOTS-Si angarisgebis sistema, romelic izleva pacientis mkurnalobis progresisa da programis ganxorcielebis martivi da mzlavri monitoringis sasualebas, arwerilia TavSi: ra sawiroa arricxvisa da angarisgebis sistema da rogori sistemis gamoyenebaa rekomendirebuli. DOTS-is calkeul formasi mocemuli informaciis urtiertsesabamisobisa da sxvadasxva dokumentebsi Setanil mititebas Soris Sesabamisobis Semowmeba ar unda iyos rtuli procedura. mati verificireba SeiZleba moxdes naxvelis slaidebis gadamowmebis gzit, pacientebtan da samedicino musakebtan gasaubrebit da wamlebisa da masalebis moxmarebis monitoringit. sistematuri analizisa da programis gaumjobesebis miznit SemuSavebuli operatiuli kvleva sistemuri monitoringisa da Sefasebis kidev erti aspeqtia. DOTS-is strategiis modifikacia SesTavazes iseti specifikuri problemebis gadasawrelad, rogoricaa aiv Tan asocirebuli tuberkulozi da multirezistentuli tuberkulozi. sabaziso strategiis aseti modifikaciebi cnobilia DOTS_plusis saxelwodebit 37. damatebiti elementebi, romlebic SeTavazes daavadebianobis dabali macveneblebis qveynebis (cxrili #57), moicavs aqtiuri tuberkulozis SemTxvevebis gamovlenas marali riskis jgufebsi, rutinul testebs mgrznobelobaze da tuberkulozis mkurnalobis gamoyenebas latenturi infeqciebis SemTxvevebSic. DOTS-is gafartoebis statusi angarisebs DOTS-is danergvis Sesaxeb tuberkulozis erovnuli programebidan WHO 1997 wlidan irebs da mat safuzvelze aqveynebs globalur moxsenebebs tuberkulozis kontrolis Sesaxeb. 2003 wlis moxseneba Seicavs informacias SemTxvevaTa gamovlenaze 2001 wlis ganmavlobasi da 2000 wels registrirebul pacientta mkurnalobis Sedegebze. Svidi gamoqveynebuli dokumenti gvicvenebs, 289

cxrili #57 DOTS-i daavadebianobis dabali sixsiris mqone qveynebsi DOTS-is politikis paketis aucilebeli komponentebi mtavrobis mxardawera tuberkulozis Tanamimdevruli kontrolisatvis tuberkulozis kontrolis damatebiti elementebi dabali da avadobis sixsiris mqone qveynebisatvis mtavrobis mxardawera tuberkulozis kontrolisatvis, rata SemuSavdes: samartlebrivi CarCoebi, kanonebi savaldebulo Setyobinebis, mkurnalobis Sedegebis, kohortuli analizis da medikamentebis politikis Sesaxeb; tuberkulozis kontrolis politika, romelic efuzvneba konsensuss wamyvan organizaciebsa da erovnul mmartvelobit organoebs Soris; tuberkulozis kontrolis programis efeqturi qselis SenarCuneba erovul doneze teqnikuri liderobit, xolo ufro dabal doneebze adamianuri resursebit. naxvelis nacxis mikroskopuli analizi infeqciuri SemTxvevebis gamosavlenad filtvis tuberkulozis simptomebis mqone im adamianebs Soris, romlebmac mimartes samedicino dawesebulebebs zogadad mosaxleobasi SemTxvevaTa gamovlena simptomebis mqone pacientebsi, risk-jgufebis menejmenti (anu aqtiuri gamovlena marali riskis mqone jgufebsi)kulturiseanalizit dadasturebuli diagnozi,medikamentebze mgrznobelobis testi, gansakutrebit marali rezistentobis riskis mqone jgufebsi.epidemiis menejmenti (anu wyarosa da kontaqtebis dadgena). infeqciur pacientebtan standartuli qimioterapiis mokle kursi tuberkulozis yvela SemTxvevebisaTvis usualo metvalyureobis gamoyenebit sul mcire pirveli 2 Tvis ganmavlobasi. tubsawinaarmdego medikamentebis regularuli uwyveti miwodeba (umjobesia xarisxis Semowmeba dozirebul kombinirebul wamlebsi) usualo metvalyureobit mkurnalo-ba 2 Tveze meti xnis ganmavlobasi mkurnalobis dawyebidan; dasawyissi maral riskian jgufebsi da iq, sadac gankurnebis macvenebeli dabalia.specializirebuli mkurnaloba multirezistentuli tuberkulozis dros.axladinficirebul individebsa da zogi marali riskis mqone pacientebis prevenciuli mkurnaloba (anu aiv-virusit inficirebulni). wamlebis gamoyenebis regulacia. sarezervo medikamentebit uzrunvelyofa rezistentuli tuberkulozisatvis mxolod maralkvalificirebul dawesebulebesi. Sefaseba da supervizia: nacxis mikroskopiis gamoyeneba pacientis mdgomareobis Sesafaseblad. mkurnalobis progresis dadgena supervizia - damyarebuli unificirebuli angarisgebis sistemazekulturisa da nacxis analizebi mkurnalobis Sedegis dasadgenad rezistentobis Sefaseba. tuberkulozis kontrolis xarisxis Sesaxeb monacemebis uzrunvelyofa (auditis sistema). 290

rom qveynebis ricxvi, romlebic iyeneben DOTS-s, 1995 wlidan 2003 wlamde 70-dan 155-mde gaizarda da rom 1995 wlidan 2000 wlamde DOTS-is programit 7.1 milioni pacienti iqna namkurnalebi. 2002 wlis bolostvis DOTS-ze xeli miuwvdeboda msoflio mosaxleobis 61%-s, magram DOTS-is programasi registrirebuli iyo nacxit dadebiti tuberkulozis prognozirebuli axali SemTxvevebis mxolod 32% 38. DOTS-is swrafi gavrcelebis xelissemsleli faqtoriebia finansuri problemebi, sakadro resursebis nakleboba, araadekvaturi samedicino infrastruqtura, xarisxiani tubsawinaarmdego medikamentebit sistematurad momaragebis garantiebis uqonloba da tuberkulozis sasisroebis Sesaxeb sazogadoebis arasatanadod informirebuloba 39. am sakitxebis sapasuxod WHO da tuberkulozit avadobis marali macveneblebis mqone qveynebma ertoblivad SeimuSaves DOTS-is globaluri gavrcelebis gegma, romelic arwers DOTS-is swrafad gavrcelebisatvis sawiro saqmianobebs da resursebs tuberkulozis globaluri kontrolis mirwevis miznit 40. am gegmis warmatebuli ganxorcieleba gulisxmobs tuberkulozis globaluri da adgilobrivi donis kontrolisatvis gazrdil sakadro da finansur investiciebs, aseve, axal strategiebs da damatebit resursebs, gansakutrebit aiv tuberkulozis SemTxvevebSi. 291

56. aris Tu ara DOTS-i xarjefeqturi i.smiti 4 sxvadasxva intervenciebis SefardebiTi Rirebulebis Sefaseba SesaZlebelia, Tu ertmanets SevadarebT xarjebs da mirebul efeqturobas, rac Seexeba samedicino investiciebs, amis mirweva xdeba intervenciis Rirebulebisa da Sedegebis elementebis kombinirebis mesveobit. xarj-efeqturobis Sefasebis principis gamoyeneba xelsayrelia sxvadasxva daavadeba-specifikur intervenciebs Soris prioritetebis gansazrvrisas, erti da imave situaciistvis ramodenime intervenciis SedarebiTi upiratesobis Sefasebis da intervenciebis ganxorcielebis xelsesawyobad resursebis mobilizaciisatvis. xarjebis Sedareba xdeba pirdapir, radganac zogadad mati gansazrvra ertnairia, Mmagram intervenciis Sedegis usualod Sedareba yoveltvis ar aris SesaZlebeli. magalitad, poliomielitis imunizaciit invalidobis Tavidan acileba ar SeiZleba SevadaroT DOTS-is Sedegad Tavidan acilebul sikvdilianobas.aase, rom intervenciis Sedegebis Sesadareblad sawiroa rarac standartizebuli forma. jandacvis sferosi saqmianobebis efeqturobis Sefasebis yvelaze fartod gavrcelebuli analizi xarjtefeqturobis analizia, romlis drosac intervenciis Sedegi gardaiqmneba janmrtelobaze iset zemoqmedebad efeqtad rogoricaa sicocxlis potenciuri xangrzlivobis SenarCuneba. es indikatori SeiZleba naklebad Rirebuls xdides intervencias iseti daavadebebis dros, romlebic 4 tuberkulozis SeCerebis ganyofilebis departamentis medmusaki. jandacvis msoflio organizacia. Jeneva, Sveicaria. 292

ar emuqreba sicocxles, magram iwvevs Sromisuunarobas, magalitad, ketri. Sesabamisad SemuSavebul iqna Sromisuunarobis Sefasebis macveneeli wlebis mixedvit (DALY), rogorc indikatori, romelic aertianebs sikvdilianobis da Sromisuunarobis sazomebs 41. intervenciis efeqturoba SeiZleba gaizomos xarjit, romelic adamians aacilebs Sromisuunarobas erti wlis ganmavlobasi. tuberkulozis kontrolis samsaxurebis xarjebi SeiZleba ganawildes otx kategoriad (grafiki #19): _ zogadi profilis samedicino dawesebulebis fiqsirebuli xarjebi; _ tuberkulozis kontrolis samsaxurebis fiqsirebuli xarjebi _ zogadi profilis samedicino daxmarebis dawesebulebasi tuberkulozis programis damatebis xarjebi, rac ar icvleba pacientebis raodenobis zrdastan ertad, magalitad, TanamSromelTa xelfasebi; _ tuberkulozis kontrolis samsaxurebis marginaluri xarjebi_ TiToeuli damatebiti axali pacientis diagnostikasa da mkurnalobaze garebuli xarji. magalitad, wamlebis xarjebi; _ gaertianebuli xarjebi es aertianebs tuberkulozis kontrolis samsaxuris fiqsirebul da cvalebad xarjebs. grafiki #19 Teoriuli struqtura-tuberkulozis kontrolis xarjebi xarjebi tuberkulozis samsaxuris marginaluri xarjebi tuberkulozis kontrolis mtliani xarjebi tuberkulozis samsaxuris fiqsirebuli xarjebi zogadi profilis samedicino dawesebulebis fiqsirebuli xarjebi pacientebis ricxvi 293

DOTS -is ufro marali xarjefeqturobis mtkicebulebebi janmrtelobis dacvis sxva itervenciebtan SedarebiT 1993 wels msoflio bankma gamoaqveyna statia investiciebi jandacvasi, sadac Sedarebuli iyo pirveladi samedicino daxmarebis sxvadasxva intervenciebis xarjt_efeqturoba. statiasi daangarisebuli iyo, rom tuberkulozis efeqturi kontroli 20-57 ass dolari Rirda TiToeul gadarcenil sicocxleze, xolo erti DALY 1-3 dolari anu, tuberkulozis qimioterapia iyo erterti yvelaze xarj-efeqturi metodi yvela samedicino intervencias Soris msgavsad iseti intervenciebisa, rogoricaa witelas vaqcinacia da vitamin A-s damateba 41. am publikaciis Semdeg tubsawinaarmdego medikamentebis fasebi sagrznoblad daeca. bazisuri kursi amjamad 10 dolari Rirs, rodesac 90-iani wlebis dasawyissi is 40-60 dolari Rirda 42, rac kidev ufro zrdis DOTS-is programis xarjefeqturobas. Tumca DOTS-is programa ar iqna Sefasebuli aivvirusis gatvaliswinebit. aiv-virusis pirobebsi tuberkulozit daavadebuli pacientebis mkurnalobis Semdgom sicocxlis xangrzlivobis SemcirebiT DOTS-is xarjefeqturoba ramdenadme mcirdeba. tuberkulozis kontrolis sxva strategiebtan SedarebiT DOTS-is marali xarjefeqturobis mtkicebulebebi tuberkulozis kontrolis sxva strategiebia: be-ce-je vaqcinacia, prevenciuri mkurnaloba da sazogadoebasi SemTxvevebis aqtiuri gamovlena. miuxedavad imisa, rom es strategiebi Teoriulad mimzidvelia, praqtikuli TvalsazrisisT, DOTS-Tan SedarebiT naklebefeqturebi arian. be-ce-je vaqcinaciis Catareba Cvil bavsvebsi rekomendirebulia marali prevalentobis mqone qveynebsi, rata Tavidan avicilot tuberkulozis iseti mzime formebi rogoricaa meningiti da miliaruli tuberkulozi. msoflio bankis gaangarisebit be-ce-je vaqcina 7 dolari Rirs TiTo DALY_dazogvisaTvis. intervencia xarjefeqturia mxolod masin, Tu tuberkulozit inficirebis riski weliwadsi maralia (anu 1%-ze meti weliwadsi) 43. be-ce-je vaqcinacia, radganac igi arainfeqciuri formebis pirvelad 294

prevencias uzrunvelyofs, tuberkulozis gavrcelebis prevenciis TvalsazrisiT mcired an saertod araefeqturia. msoflio bankis kvlevasi ar aris gansazrvruli prevenciuli mkurnalobis xarji TiToeul DALY-ze. gaketda daskvna, rom seleqciuri skriningi da mkurnaloba marali riskis mqone mosaxleobasi (anu ojaxsi kontaqti infeqciur pacientebtan da aiv virusit daavadebulebtan) albat mizansewonili iyo da afrtxilebda rom masobrivi profilaqtika ZviradRirebulia da limitirebuli efeqturoba aqvs. aqtiuri gamovlena Teoriulad SesaZlebelia efeqturi iyos. magram, rogorc ganxiluli iyo (TavSi: ra rols asrulebs perioduli masobrivi rentgenografiuli gamokvlevebi tuberkulozis kontrolisas ), praqtikuli ganxorcielebis TvalsazrisiT aseti strategia mkacrad limitirebulia. pirvel rigsi, misi mesveobit xdeba, prevalenturi SemTxvevebis gamovlena, romelic DOTS-iT isedac gakontroldeba (ix. SesaZlebelia tuberkulozis kontroli ). ufro metic, aseti gamokvlevebit gamovlenili pacientebi xsirad Tavs arideben mkurnalobas da ar asruleben danisnul kurss. tuberkulozis mkurnalobis sxva strategiebtan SedarebiT DOTS-is ufro marali xarjefeqturobis mtkicebulebebi adre Catarebuli ori kvleva, romelsic Sedarebuli iyo tuberkulozis mkurnalobis sxvadasxva strategiebis xarjtefeqturoba efuzneboda afrikis qveynebsi dagrovil gamocdilebas. erti kvleva moicavda botsvanas 44, xolo meore, iset qveynebs rogoricaa malavi, mozambiki da tanzaniis 45 gaertianebuli respublika. TiToeul kvlevasi Sedarebuli iyo mkurnalobis moklevadiani da grzelvadiani kursi streptomicinis, izoniazidisa da tioacetazonis gamoyenebit, aseve, Sedarebuli iyo sruli ambulatoriuli rejimi Sedarebuli iyo stacionarul kursebtan intensiuri fazis dros. miuxedavad imisa, rom wamlebis Rirebuleba mokle kursis dros 3-jer ufro marali iyo, vidre standartuli mkurnalobis dros, gamojanmrtelebis macveneblis gaumjobesebis mixedvit mokle kursi ufro xarjefeqturi strategiaa, gansakutrebit, Tu tardeba mkurnalobis ambulatoriuli kursi. sxva kvlevebma ganamtkices es Sedegebi da xarjefeqturobaze 295

orientirebulma rva kvlevam 1982 wlidan 1992 wlamde periodsi daadgina, rom ambulatoriuli mkurnalobisas mokle kursis Rirebuleba xangrzlivi kursis Rirebulebis 19-41%-s Seadgenda ortviani hospitalizaciis CaTvliT 46. qveynebsi DOTS- is danergva tubmkurnalobis xarjebis mnisvnelovnad dazogvis SesaZleblobas izleva. WHO s mier 1996 wels indoetsi Catarebulma DOTS-is ekonomikurma analizma gvacvena, rom 200 milioni dolaris damatebiti investicia yovel weliwads 750 milioni dolaris ukugebas moitanda, rac moxdeboda SemTxvevebis Semcirebis, sikvdilianobis Tavidan acilebis da hospitaluri sawolebis gatavisuflebis xarjze 47. DOTS-is ekonomikuri sargeblianoba sazogadoebisatvis ufro maralia, vidre mtavrobisatvis. bevr ganvitarebad qveyanasi saxelmwifos pirdapiri xarjebi diagnostikisa da mkurnalobistvis bevrad dabalia, vidre pirdapiri da arapirdapiri xarjebi ojaxebisatvis. ugandasi Catarebulma kvlevam ert-ertma pirvelma gamoavlina es da cxadyo, rom mtliani 324 dolaris danaxarjidan, pacienti 229 dolars ixdida pirdapiri da arapirdapiri xarjebit 48. am xarjebidan dakarguli Semosavali 3-4 Tvis musaobis ekvivalenturia da xarjebis yvelaze did wils Seadgens (ix. Tavi: rogoria tuberkulozit ganpirobebuli janmrtelobis, socialuri da ekonomikuri simzime ) 49. DOTS-is potenciuri ekonomikuri sargeblianoba sazogadoebisatvis dasturdeba tailandsi Catarebuli kvlevitac, romelic gvicvenebs, rom mtavrobis mier tuberkulozis kontrolisatvis investirebul yovel dolarze sazogadoeba 50 dolars igebs 20 wlis manzilze 50. dabalsemosavlian qveynebsi DOTS-is danegrvis sruli xarji ert sul mosaxleze mxolod 0.05 ass dolars Seadgens da Zalian isviatad aremateba 0.20 dorlars marali prevalentobis dabalsemosavlian qveynebsi 51. Sejamebis saxit SeiZleba itqvas, rom DOTS-i Zalzed xarjefeqturi strategiaa, romelsac moaqvs mnisnvnelovani danazogi saxelmwifostvis da sazogadoebisatvis. DOTS-i kargi SenaZenia jandacvis dagegmvisa da politikis SemuSavebisTvis. mwiri resursebis pirobebsi samedicino dawesebulebebisatvis DOTS-i prioritetuli unda iyos, radgan mas mnisvnelovani upiratesobebi aqvs tuberkulozis kontrolisa da mkurnalobis sxva metodebtan SedarebiT. 296

57. rogor ganvaxorcielot mkurnalobis Sedegebis warmatebis monitoringi 5 t. santa 6 arsebobs mkurnalobis warmatebuli mimdinareobis monitoringis sami midgoma: baqteriologiuri, klinikuri da radiografuli. baqterologiuri gamokvleva baqterologiuri gamokvlevis Catareba SeiZleba nacxit da kulturit. miuxedavad imisa, rom kultura ufro specifikuria, misi ganxorcieleba met dros moitxovs, ZviradRirebulia da pasuxis miireba dagvianebit xdeba. ufro metic, am testis Casatareblad sawiro Senobebi da pirobebic ar aris sayoveltaod xelmisawvdomi. ase rom, pacientebis menejmenti ZiriTadad damokidebulia nacxis mikroskopul analizze. nacxebis pasuxebis mixedvit rifampicinis garese Catarebuli 12-Tviani kursis Sedegebis prognozireba SesaZlebelia 90-92%-iani sandoobit 52. mokle kursit mkurnalobis Sedegad tuberkulozis mikobaqteria swrafad irupeba, magram darupuli bacilebi garkveuli drois ganmavlobasi SeiZleba kidev gamoiyofodes, rac Sedegad izleva dadebit pasuxs masinac ki, rodesac mkurnaloba warmatebulad mimdinareobs 53. naxvelis yoveltviuri gamokvlevisas cxrilsi #58 mocemuli otxi modelidan virebt ert-erts. cxadia rom, Tu kulturis analizis Catareba SeuZlebelia, nacxis seriuli testireba natlad gvicvenebs yvela kursis gansxvavebas. mkurnalobis monitorinigisas kultura aris mxolod dadasturebis sasualeba. isviatia, rom pacientebi, romlebsac utardebat mkurnaloba, mudmivad nacxit 5 k. tomanis wignis wina gamocemis Tavze dayrdnobit 6 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeti. 297

uaryofiti da kultura dadebiti iyvnen. Tu pacienti Tavdapirvelad nacxit dadebiti iyo is an arwevs kultura negatiurobas, an ubrundeba nacxit dadebit statuss. ar aris aucilebeli, rom baqterioskopia Catardes yoveltviurad. WHO da IUATLD nacxit dadebiti pacientebis mkurnalobis progresis monitoringisatvis nacxis samjerad analizs uwevs rekomnedacias: mkurnalobis dawyebidan ori Tvis Semdeg, 5 Tvis Semdeg da mkurnalobis dasrulebisas 54,55. es izleva mkurnalobis menejmenttan dakavsirebuli gadawyvetilebebis mirebis SesaZleblobas minimaluri testebis gamoyenebit. laboratoriis angarisebi, romlebsic dafiqsirebulia aseti daskvnebi: naxveli ver miireba an pacienti ar gamoyofs naxvels sulac ar nisnavs negatiur nacxs. aseti angarisi aradamakmayofileblad unda iyos micneuli. Tuki pacientebi ver gamoyofen naxvels dawvrilebiti instruqtajis Sedegadac, sawiroa yelis garizianeba laringologiuri wkiris mesveobit an marilxsnarit, ramac SesaZlebelia gamoiwvios xvela da testisatvis sawiro naxvelis gamoyofis provocireba. dadebiti nacxi gansakutrebit masin, roca misi pozitiurobis xarisxi klebulobs ar qmnis gangasis mizezs. cxrili #58 naxvelis nacxis gamokvlevit mirebuli interpretacia mikroskopiit da kulturis analizit Tve nacxi kultura nacxi kultura nacxi kultura nacxi kultura 0 1 2 3 4 5 6 +++ + 0 0 0 0 0 +++ + 0 0 0 0 0 +++ + 0 0 0 0 0 +++ + 0 0 0 0 0 ++ ++ ++ 0 0 ++ ++ +++ +++ ++ + + + ++ ++ ++ ++ ++ ++ +++ +++ +++ +++ ++ ++ +++ +++ +++ pasuxi xelsayrelia an dadebiti xelsayrelia an dadebiti Semcireba mateba warumatebloba 298

klinikuri Sefaseba daavadebis warmatebuli mkurnalobisas klinikuri Sefaseba subieqturia. simptomebis gaqroba, zogadi mdgomareobis gaumjobeseba, normaluri saqmianobis ganaxlebis unari da wonasi momateba klinikuri progresis macveneblebia. simptomebis SenarCuneba an mati xelaxali warmosoba, wonasi dakleba da klinikuri mdgomareobis obieqturad gauareseba nisnavs, rom sawiroa nacxis mikroskopuli gamokvleva. eritrocitebis sedimentaciis macvenebeli da sxva testebi ar aris sando da mati gamoyeneba ar aris sawiro monitoringsi. xsirad, filtvgarese tuberkulozis da nacxit uaryofiti filtvis tuberkulozis dros klinikuri Sefaseba pacientis mdgomareobis gaumjobesebis Sefasebis ertaderti sasualebaa. wonasi mateba am dros sawiro macvenebelia. Sefaseba rentgenografiit seriuli rentgenografiuli Semowmeba eqimebs Soris kvlavac popularulia, magram bevrma kvlevam cxadyo, rom SeiZleba am gamokvlevebma SecdomaSi Seiyvanos eqimi, ramac Tavis mxriv, SeiZleba ganapirobos dinamikisa da mkurnalobis gamosavalis araswori Sefaseba. pacientebs SeiZleba rentgenze arenisnebodet mdgomareobis gaumjobeseba magram mainc gamoyofdnen tuberkulozis baqterias. baqteriologiurad mtvlemare daavadebis mkurnaloba SeiZleba CaiTvalos warumateblad, Tu specifikuri dazianeba da kavernebi kvlavac Cans rentgenze. mudmivad negatiuri naxvelis mqone pacientebs SeiZleba iseti radiografuli macveneblebi hqondet, rom eqspertebma mocemuli surati miicnion mdgomareobis gauaresebad. 112 baqteriologiurad mtvlemare daavadebis mqone pacients 4 wlis ganmavlobasi utarebdnen baqteriologiur da radiologiur gamokvlevebs. radiografuli gansxvavebebi gamovlinda 35 pacientsi (31%). 12 pacientsi (11%) kavernebis momateba an gacena iyo dadgenili. askaraa, rom mxolod rentgenografuli Sefaseba SeiZleba mcdari iyos 56. 299

Sejameba nacxis mikroskopuli gamokvleva sando da iafi metodia Tavdapirvelad nacxit dadebit pacientebsi mkurnalobis Sedegebis Sesafaseblad. radiografuli da klinikuri Sefasebebi ar aris sakmarisi mkurnalobis progresis gansazrvrisatvis. nacxis mikroskopia mkurnalobis progresis da Sedegis mnisvnelovani macvenebelia. nacxit dadebiti pacientebis gamokvlevebi me-2 Tvis bolos, me-5 Tvis bolos da mkurnalobis bolos SesaZleblobas izleva ganisazrvros, Tu ramdenad warmatebuli iyo mkurnaloba fartomasstabian programebsi. nacxis Semdgomi gamokvlevebi izleva sando informacias pacientis mkurnalobis Sedegebisa da programis musaobis Sesaxeb. Tumca, calkeuli pacientebisatvis baqteriologiuri kvleva sargeblobis momtania mxolod masin, Tu warumatebeli mkurnalobis SemTxvevaSi SesaZlebelia sxva ufro efeqturi rejimis danisvna. 300

58. ramdenad efeqturia tuberkulozis mkurnaloba da risi gaketebaa sawiro momavalsi 7 t. santa 8 efeqturi tubsawinaarmdego medikamentebis Seqmnam revoluciuri gavlena iqonia tuberkulozis mkurnalobaze. tuberkulozis mkurnaloba sanatoriumis pirobebsi, stacionarulad, sufta haerit da kargi sakvebit - qimioterapiis eris dawyebamde iyo mkurnalobis sauketeso metodi, risi SeTavazebac ki SeeZloT tuberkulozit daavadebultatvis. axla SesaZlebelia pacientis efeqturad mkurnaloba missave binaze, misi cxovrebisa da musaobis normaluri ritmis daurrvevlad. (ix. Tavi: ra iyo madrasis kvlevis mtavari Sedegebi, romelsic Sedarebuli iyo binaze da stacionarsi mkurnaloba ). amjamad rekomendirebuli mkurnalobis rejimi 90-95%- Si izleva gankurnebas recidivis garese, ara marto kontrolirebad klinikur cdebsi, aramed programis farglebsic. aranamkurnaleb pacientebs Soris, romlebic regularulad da srulad itareben mkurnalobas, SeiZleba Semdegi Sedegebis mirweva: standartuli 18-Tviani kursit mkurnalobisas, romlis drosac sawyis etapze 2 Tvis ganmavlobasi gamoiyeneba sami sawyisi medikamenti, magram rifampicinis garese, potenciuri gankurnebis macvenebeli 96%-ia, xolo relafsis macvenebeli 3%-ze naklebi. Tumca am rejimis masobrivi danerga SeuZlebeli gaxda; qimioterapiis 8 _Tviani mokle kursi, rifampicinis gamoyenebit intensiuri fazis dros mainc izleva gankurnebis macvenebels 97-99%, xolo relafsis macvenebeli 6%-ze naklebia (ix. Tavi: rogoria mkurnalobis optimaluri xangrzlivoba ); 7 k. tomanis wignis wina gamocemis Tavze dayrdnobit 8 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeti 301

pacientebs daavadebis recidivit 80-90%-Si SeuZliaT miarwion gankurnebas, Tu Caitareben mkurnalobis 8-9-Tvian kurss 5 medikamentit, rifampicinis CarTviT intensiur fazasi da 3 medikamentit gagrzelebis fazasi, imis gatvaliswinebit, rom recidivis 80% xdeba wamlisadmi mgrznobiare organizmebit 57 ; im pacientebs Soris, romlebmac ar daasrules dawyebuli mkurnaloba Sedegi damokidebuli iqneba, rogorc im medikamentebsa da dozebze, romlebsac isini adre irebdnen, aseve mkurnalobis xangrzlivobaze, radganac es faqtorebi zegavlenas axdenen SemdgomSi medikamentebisadmi mgrznobelobaze 58. kargadfunqcionirebad programasi aseti pacientebis 70-80% inkurneba 59 ; naklebad savaraudoa, rom nacxit dadebiti pacientebi, romelta mkurnalobac DOTS-is mokle an ganmeorebiti kursit warumatebeli iyo, ganikurnon mxolod pirveli rigis medikamentebit, vinaidan am SemTxvevaSi maralia ramodenime medikamentebisadmi rezistentobis albatoba. aseti pacientebis sarezervo (meore) rigis medikamentebit mkurnalobam xangrzlivi drois ganmavlobasi (18-24 Tve) sauketeso SemTxvevaSi SeiZleba mogvces recidivis garese gankurneba SemTxvevaTa 2/3-Si. mkurnalobis Tanamedrove kursebis efeqturoba mtlianobasi maralia: pacients, romelic icavs mkurnalobis rejims 98% albatoba aqvs imisa, rom mxolod erti kursit ganikurnos. umetesoba im pacientebisa, romlebic Sewyveten mkurnalobas an aqvt recidivi, SeiZleba ganikurnon mkurnalobis ganmeorebiti kursit. aqedan gamomdinare, mcirea imis, albatoba rom axalma medikamentebma SeiZleba imoqmedon gankurnebis macveneblis gaumjobesebaze. Tumca mat SeiZleba xeli Seuwyon tuberkulozis kontrols mkurnalobis xangrzliovobis an SemTxvevaTa sixsiris Semcirebis mesveobit. mkurnalobis warumatebloba ufro xsirad ganpirobebulia mkurnalobis rejimis daucvelobit da ara mkunalobis kursis araefeqturobit da warumateblobit. cudad organizebul programebsi pacientebis 30%-ze meti anebebs Tavs mkurnalobas. mkurnalobis araregularuloba xsiria gansakutrebit masin, roca ar xdeba wamlis mirebis kontroli da medikamentebis miwodeba ar aris regularuli, ufaso da advilad xelmisawvdomi. sikvdilianoba mkurnalobis processi 302

(yvela mizezis gamo) SeiZleba iyos marali aiv-koinfeqciis an mkurnalobis dagvianebis SemTxvevaSi. bevris mirweva SeiZleba tuberkulozis kontrolis programis operatiuli aspeqtebis gaumjobesebit (ix. Tavi: ra aris DOTS-i ). Tumca SeiZleba axali wamlebis Seqmnamac mnisvnelovnad Seuwyos xeli programis ganxorcielebas. intermituli dozebis mirebas Soris intervalebis gazrdam (ix. Tavi: ratom aris mkurnaloba warumatebeli da ra unda gaketdes mkurnalobis arasatanado Sedegebis Tavidan asacileblad, ramdenad xsirad Sewyveten pacientebi mkurnalobas ) SeiZleba Seamciros pacientis vizitebis sixsire da gaamartivos medikamentebis mirebis metvalyureoba. amisatvis sawiroa msgavsi moqmedebis da naxevardaslis periodis mqone ori-sami maralefeqturi medikamentis gamoyeneba. izoniazidsa da rifampicintan ertad efeqturi medikamentebis gamoyenebam SeiZleba Seamciros mkurnalobis sawyisi faza, dazlios rezistentoba da mkurnalobis pirvel ramodenime kvirasi Seamciros sikvdilianobis riski. dresdreobit kvlavac mtavar problemad rceba, is rom arsebuli medikamentebi ver axdenen zemoqmedebas mtvlemare baqteriaze (ix. Tavi: rogor moqmedebs tuberkulozis mkurnaloba ). mkurnalobis meore fazis mizania gaanadguros is baqteroebi, romlebic mravldebian nela an drogamosvebit. es hgavs im adamianebis prevenciul mkurnalobas, romlebic inficirebulni arian mikobaqteriit, magram daavadeba ar CamouyalibdaT. medikamenti, romelic imoqmedebda mtvlemare baqtereaze, an imunomodulatori, romelic gaaumjobesebda am baqteriebis ganadgurebis SesaZleblobebs_Seamcirebda mkurnalobis xangrzlivobas. ufro xanmokle mkurnaloba ki, Seamcirebda mkurnalobis Sewyvetis sixsires da gazrdida gankurnebis macvenebels, aseve Seamcirebda pacientebis mier mkurnalobis rejimis dacvisatvis garebul Sromasa da xarjebs. es gaxlavt is ramodenime sfero, romlebic amjamad warmoadgenen kvlevis sagans. Tumca, arsebuli teqnologiit da kargad organizebuli programis mesveobit SesaZlebelia tuberkulozit daavadebulta umetesi nawilis gankurneba da infeqciis wyarota aragadamdeb mdgomareobasi gadayvana mkurnalobis dawyebidan ramodenime kvirisa an dris ganmavlobasi. infeqciis wyaroebis gamovlenisa da mkurnalobis SemTxvevaSi SesaZlebeli gaxdeba tuberkulozis gavrcelebisa da sikvdilianobis macveneblebis swrafad Semcireba. 303

59. warmoadgens Tu ara pirveladi rezistentoba sasisroebas tuberkulozis kontrolisatvis 9 m. espinali 10 da t. frideni 11 qimioterapiis adreul xanasi mkurnalobis kursebi xsirad araadekvaturi, araregularuli iyo da, aqedan gamomdinare, marali iyo warumateblobis donec. amis Sedegad filtvis qronikuli rezistentuli tuberkulozit daavadebuli bacilgamomyofi pacientebis ricxvi gaizarda. arsebobda imis SiSiroeba, rom rezistentuli tuberkulozi epidemiologiuri da klinikuri problema gaxdeboda (ix. Tavi: rezistentulobis ra gansxvavebuli saxeebi arsebobs~) msgavsad penicilinisadmi rezistentuli stafilokokuri daavadebebisa. rezistentobis SemaSfoTebeli doneebi arinisna axali SemTxvevebis 50%-Si, umetesad ganvitarebad qveynebsi, sadac pacientebis umravlesobas hqonda mkurnalobis (faruli) warumatebeli Sedegi da, aqedan gamomdinare, SeZenili da ara pirveladi rezistentoba. sxvadasxva klinikuri moxsenebebit an kvlevebit mopovebuli informaciis Sedarebis SesaZlebloba ar arsebobda, rac ganpirobebuli iyo mnisvnelovani gansxvavebebis arsebobit rogorc laboratoriuli kvlevis metodebsi, ise medikamentebisadmi rezistentobis dadgenis kriteriumebsa da gamosakvlevi pacientebis SerCevis metodebsi. tubsawinaarmdego medikamentebisadmi rezistentobis metvalyureobis WHO/IUATLD globaluri proeqtis mesveobit SesaZlebeli gaxda am metodologiuri problemebis dazleva. 9 k. tomanis wignis wina gamocemis Tavze dayrdnobit 10 gadamdeb daavadebata centris medmusaki. jandacvis msoflio organizacia, Jeneva, Sveicaria. 11 tuberkulozis SeCerebis ganyofilebis medmusaki, jandacvis msoflio organizaciis regionaluri ofisi. samxret-armosavlet azia. axali deli, indoeti. 304

epidemiologiuri kvlevebi 1994_1999 wlebsi 72 ze met qveyanasi/ regionsi Catarda mkacri metodebis gamoyenebit. igi moicavda kvlevasi monawile sacdeli jgufis mosaxleobaze orientirebul reprezentaciul SerCevas, axali da namkurnalebi SemTxvevebis zust diferenciacias, standartul laboratoriul metodebs da maralkvalificiuri testirebis saertasoriso programebs. informacia tendenciebis Sesaxeb mirebuli iyo 28 qveynidan/ regionidan 60. 65 gamokvleuli qveynidan 11-Si gamovlinda multirezistentuli tuberkulozis SedarebiTYmaRali prevalentoba (ix. grafiki #20). darcenil qveynebsi mdgomareoba aseti problemuri ar iyo, rac mianisnebs, rom multirezistentuli tuberkulozi ar aris fartod gavrcelebuli. bevr qveyanasi marali iyo streptomicinisadmi rezistentobis prevalentoba, magram es informacia nakleb mnisvnelovania, radganac axladgamovlenili pacientebis mkurnalobis dros am qveyanasi streptomicins arar iyeneben 61. aseve dafiqsirda izoniazidis mimart rezistentobis marali prevalentoba, magram ara rifampicinis an etambutolis mimart. grafiki #20 multirezistentuli tuberkulozis yvelaze marali prevalentobis qveynebi/regionebi. WHO/IUATLD-s tubsawinaarmdego medikamentebisadmi rezistentobis metvalyureobis proeqtis farglebsi estoneti henani/cineti latvia ivanovo/rus dominikis resp tomski irani spilos Zvlis sanapiro zejangi/cineti mozambiki tamil nadu/ indoeti prevalentoba 305

cxrili #59 izleva infromacias axal SemTxvevaTa Soris rezistentobis ganawilebis Sesaxeb. im 28 qveynis/regionis monacemebi, sadac ori an meti SedarebiTi kvelva Catarda ar gvazlevs axal SemTxvevaTa Soris rezistentobis zrdis mtkicebulebas (anu pirveladi rezistentoba) 1994 wlidan 1999 wlamde periodsi. rogorc gamovlenili tendenciebi gvicvenebs, regionebis umetesobasi misi done stabiluria. sistemuri kvlevebi da matematikuri modelebi metyveleben, rom tuberkulozis axali rezistentuli SemTxvevebis, gansakutrebit multirezistentuli SemTxvevebis raodenoba msoflios umetes qveynebsi 62 kvlavac dabali darceba. es prognozi gamomdinareobis im varaudidan, rom multirezistentuli mikobaqteriis Stami dabali genetikuri Sesabamisobisaa (an naklebad transmisirebadi, an transmisiis SemTxvevaSi naklebad iwvevs infeqciur tuberkulozis) mgrznobiare StamebTan SedarebiT. SedarebiTi Sesabamisoba izomeba limitirebuli fragmentuli sigrzis polimorfizmis klastersi, rezistentuli Stamis armocenis albatobis gayofit mgrznobiare Stamis armocenis albatobaze klastersi. SedarebiT dabali Sesabamisobis gamo naklebad savaraudoa, rom multirezistentuli baqteriebi SeZleben arsebobas TviTSenarCunebadi transmisiis ciklebsi. axali multirezistentuli SemTxvevebi ZiriTadad warmoiqmneba medikamentebisadmi mgrznobelobis mqone an monorezistentul pacientebs Soris gankurnebis dabali macveneblebis gamo. mkurnalobis Sewyvetis maralma macveneblebma SeiZleba rezistentobis macveneblis zrda gamoiwvios axal SemTxvevebSi. magalitad, estonetsi, latviasa da rusetis federaciis regionebsi. aset situaciasi ZiriTadi gamosavalia mgrznobiare Stamisa da monorezistentuli tuberkulozis dros gankurnebis macveneblis zrdis uzrunvelyofa. sarezervo medikamentebi sawiro gaxdeba individualuri multirezistentuli tuberkulozis SemTxvevebis mkurnalobisatvis. multirezistentuli Stamebis epidsasisi situaciis SesaCereblad mati gamoyeneba damokidebulia specifikuri Stamebis gamzleobis xarisxze, mosaxleobis maxasiateblebze (mag., mosaxleobis simwidrove) da garemo faqtorebze (magram mwidrod dasaxlebuli sacxovrebeli adgilebi), romelic zegavlenas axdens infeqciis gavrcelebis dinamikaze. 306

cxrili #59 erti an ori medikamentis mimart rezistentobis magvenebeli axladgamovlenil, aranamkurnaleb pacientebs Soris Seswavlili 1996-1999 ww 58 qveyanasi/regionsi Stami sasualo min/maqs sul gamokvleuli sul rezistentuli rezistentuli erti romelime medikamentis mimart rezistentuli izoniazidis mimart rezistentuli rifampicinis mimart rezisntentuli streptomicinis mimart rezistentuli etambutolis mimart rezistentuli ori medikamentis mimart rezistentuli sami medikamentis mimart rezistentuli otxi medikamentis mimart multirezisntentuli (sul mcire izoniazi-disa da rifampicinis mimart) 474 10.7% 7% 3% 0.2% 2.5% 0.5% 2.5% 0.6% 0.1% 1% (41, 12 063) (1.7, 36.9) (1.3, 17.9) (0, 7.9) (0, 2.0) (0, 14.5) (0, 3.0) (0, 11.9) (0, 7.3) (0, 8.5) (0, 14.1) warmodgenili iyo multirezistentuli tuberkulozis Zalzed gamzle Stamis swrafad gavrcelebis SemTxvevebi mwvave imunosupresiis mqone, SidsiT daavadebul pacientebsi 63. romlebic infeqciis araadekvaturi kontrolis gamo motavsebuli iyvnen saavadmyofosi 64. msgavsad amisa SesaZlebelia, multirezistentuli tuberkulozis zogierti Stami swrafad gavrceldes sakvebit naklebaduzrunvelyofil da mcire fartze gantavsebul patimrebs Soris. aset SemTxvevebSi multirezistentuli tuberkulozis epidemiis SesaCereblad sawiro xdeba sarezervo (meore rigis) medikamentebis gamoyeneba. ar aris damtkicebuli, rom mnisvnelovani imunokompromisis ar arsebobis dros, multirezistentuli Stamebi iwveven TviTSenarCunebad sazogadoebriv epidemias. axla arsebobs satanado mtkicebuleba, rom mxolod erti medikamentebisadmi _ orond ara rifampicinisadmi _ pirveladi rezistentobis mqone pacientebis standartuli mkurnalobis prognozi TiTqmis isetive sasiketoa, rogoric medikamentebisadmi mgrznobelobis mqone pacientebis 65. pirveli rigis rezistentobis mxolod Zalzed marali donis arsebobis SemTxvevaSi aris SesaZlebeli standartuli 307

orfaziani mkurnalobis efeqturobis macveneblis mnisvnelovani Semcireba. (mkurnalobia, romelic gulisxmobs sawyis fazasi 4 wamlis yoveldriurad gamoyenebas). aqedan gamomdinare, ar arsebobs mizezi, vifiqrot, rom rezistentoba pirveli rigis wamlebis mimart ufro sasisia sazogadoebisatvis, vidre amave medikamentebisadmi mgrznobiare organizmebit arsebuli safrtxe. 308

60. gankurebis ra ZiriTadi sasualebani arsebobs k. tomani 12 ratom xdeba, rom miuxedavad mkurnalobis amjamad arsebuli ukiduresad efeqturi sasualebebisa, bevr qveyanasi gankurnebis macvenebeli mainc Zalzed dabalia? zogi eqimi miicnevs, rom warmatebis marali donis mirweva SesaZlebelia mxolod gansazrvrul samedicino centrebsi da vidre ar Seiqmneba ufro srulyofili medikamentebi, warmatebis done dabali darceba. es Zalzed zedapiruli Sexedulebaa. 25 welze metia rac arsebobs medikamentebi, romelta kombinirebit SesaZlebelia 100%-iani efeqturobis mqone arazviradrirebuli, aratoqsikuri da misarebi mkurnalobis rejimebis Sedgena, anu gankurnebis macvenebeli ar aris damokidebuli axali da uketesi medikamentebisa da rejimebis Seqmnasa da gamoyenebaze (ix: ratom aris mkurnaloba warumatebeli da ra unda gavaketot cudi Sedegebis Tavidan acilebis miznit ). warmatebuli mkurnalobis mnisvnelovani teqnikuri motxovna aris satanado rejimis danisvna anu mxolod im Terapiis gamoyeneba, romelta efeqturobac dadasturebulia sakontrolo klinikuri kvlevebit. kursi unda Seicavdes sul cota 2 medikaments, romlis mimartac organizmi mgrznobiarea. SerCeuli medikamenti unda mieces pacients imave dozit, imave ritmit (yoveldriurad an intervalebit) da igive periodis ganmavlobasi, rogorc kvlevis Catarebisas. dadgenili rejimidan gadaxveva mecnierulad rekomendirebuli ar aris da is, risi dadasturebac SeuZlebelia, unda CaiTvalos araswor mkurnalobad. sxva teqnikuri TiTqmis aqsiomatur winapirobas warmoadgens medikamentis regularulad mirebaa. mas Semdeg, rac praqtikasi 12 gardacvlilia 309

dainerga tuberkulozis medikamentozuri mkurnaloba, bevri ram Seicvala, kerzod medikamentebis kombinaciebi da dozebi, mati mirebis ritmi, mkurnalobis vada, magram regularobis sawiroeba ucvlelia. arc ert axal kurss an wamals ar SeuZlia Seamciros xangrzlivi drois manzilze medikamentebis regularulad mirebis aucileblobis piroba, radgan mkurnalobis Sewyveta dresac zrdis warumateblobis risks. unda gavitvaliswinot, rom mkurnalobis warumateblobis mtavari mizezi aris ara rezistentoba, aramed medikamentebis areregularuli mireba. iluzorulia imis molodini, rom axali medikamentebi gadawyveten mkurnalobis am mtavar problemas, vidre ar iqneba SemuSavebuli Terapiis iset rejimi, romlis gansaxorcielebladac sul erti inieqcia an medikamentis mxolod ramodenime dris ganmavlobasi mireba iqneba sawiro. mkurnalobis warmateba ganisazrvreba, rogorc operaciuli, aseve teqnikuri faqtorebit. amjamad arsebuli mkurnalobis yvelaze efeqturi kursic ki, miuxedavad medikamentebis kombinaciebisa da mkurnalobis vadebisa, SeiZleba warumatebeli iyos, Tu ar iqna daculi medikamentebis regularulad mirebis rejimi 66. anu drevandeli problema adekvaturi mkurnalobis ucodinroba ki ar aris, aramed araadekvaturi administrirebaa. swored amasi mdgomareobs problemis arsi (ix. Tavi: ratom aris mkurnaloba warumatebeli da rogor avicilot Tavidan mkurnalobis arasasurveli Sedegebi ). es aris problema, romlis gadawyvetac SesaZlebelia ara teqnikuri an samedicino sasualebebit, aramed organizaciuli RonisZiebiT. medikamentis regularulad mirebis uzrunvelyofa menejeruli davalebaa da sworad aris arnisnuli, rom tuberkulozis kontroli menejmetis problemaa. cda, pacientis ganatlebit yofiliyo mirweuli rejimis dacva, ar armocnda sakmarisi. miuxedavad pacientebisatvis miwodebuli amomwuravi informaciisa medikamenetbis regularuli mirebis aucileblobisa da reimis darrvevit gamowveuli warumateblobis Sesaxeb, Sedegebi ar gaumjobesda, anu pacientebs ar gaucndat regularuli mkuranalobis motivacia(ix. Tavi: ra sixsirit Sewyveten pacientebi mkurnalobas ). sityvieri motivacia isviatad aris warmatebuli, Tuki mas ar axlavs satanado organizaciuli gegma, romelic unda akmayofilebdes specifikur operaciul motxovnebs. 310

operaciuli motxovnebi samkurnalo dawesebulebebis advilad xelmisawvdomoba. mzimed avadmyof pacientebs SeiZleba gaacndet survili marali reputaciis mqone eqimis sanaxavad gaemgzavron Tundac Sor manzilze. magram savaraudoa, rom isini iq xsirad ver ivlian, an ver SesZleben xangrzlivad darcenas samkunralod. amitom, samkurnalo dawesebulebebi unda iyos pacientistvis advilad misasvleli da ufaso 67,68. samkurnalo dawesebulebebi unda iyos misarebi da gamoyenebuli sazogadoebis mier. janmrtelobis dacvis musakebs unda SeeZloT pacientebtan mattvis gasageb enaze saubari da isini unda iyvnen TanagrZnobiT ganwyobilni mati Civilebisa da sawiroebebis mimart. isini unda exmarebodnen pacientebs mkurnalobis Sewyvetis mizezebis dazlevasi. samedicino samsaxuri unda Seesabamebodes socialur garemos, qveynis tradiciebs, Cvevebs da unda iyos efeqturi. mokled, personalma unda Caunergos xalxs ndoba (ix. Tavi: ra mnisvneloba eniweba mkurnalobis Sewyvetas tuberkulozis mkurnalobasi ). wamlebi unda iyos satanado raodenobit da yvelasatvis xelmisawvdomi. Tu ver moxerxdeba pacientebis medikamentebit sistematurad da satanado raodenobit uzrunvelyofa, mkurnaloba ganwirulia warumateblobisatvis. mkurnaloba unda xorcieldebodes usualo metvalyureobis qves. es nisnavs, rom pacienti TiToeul dozas unda irebdes kargad momzadebuli da angarisvaldebuli personalis usualo metvalyureobis qves. arnisnuli gansakutrebit mnisvnelovania, rodesac rejimi itvaliswinebs rifampicinis mirebas da aseve, intensiur fazasi, anu, rodesac baqteriata ricxvi gansakutrebit maralia. TiToeuli pacientisatvis aseti mkurnalobis organizeba yoveltvis ar aris SesaZlebeli. bevr SemTxvevaSi, mkurnalobis metvalyureobis uzrunvelyofis miznit sawiroa individualuri grafikis SemuSaveba. xandaxan metvalyureoba ekisreba sxva organizacias an individs, magalitad, saavadmyofos, an pacientis sacxovrebeli adgilis mixedvit, samedicino sadgurs. mokled, mkurnaloba organizebuli unda iyos maqsimaluri komfortis uzrunvelyofis principit pacientisatvis da ara samedicino dawesebulebebisatvis. 311

gankurnebis garantia mkurnalobis maqsimalurad efeqturad organizebasia. warmatebis macvenebeli sauketeso kursis SemTxvevaSic ki, dabali iqneba, Tu samedicino samsaxuri ar iqneba pacienttan TanamSromlobaze orientirebuli. meore mxriv, arc Tu kargi kursic warmatebuli iqneba, Tu mkurnaloba satanadod iqneba organizebuli. 312

61. ra mnisvneloba eniweba mkurnalobis Sewyvetas tuberkulozis mkurnalobis dros 13 n. boki 14 gamovlenil pacientebs Soris warumatebeli mkurnalobis yvelaze mnisvnelovani mizezi aris mkurnalobis Sewyveta, xolo tuberkulozis programis warumateblobis yvelaze seriozuli faqtori dasrulebuli mkurnalobis dabali macvenebelia. pacientebi, romeltac mkurnaloba Sewyvites, isev warmoadgenen sazogadoebasi infeqciis gavrcelebis wyaros, amjerad ukve SeZenili rezistentobis StamebiT. mkurnalobis warmatebis macvenebeli sul mcire 70-85% unda iyos, rom moxdes tuberkulozis sixsiris Semcireba 69. sistemuri kohortuli analizi gvicvenebs, rom mkurnalobas amtavrebs naxevarze naklebi im pacientebisa, romlebmac daiwyes mkurnaloba. mkurnalobis rejimebi, romlebsac SeuZliaTY gankurnon tuberkulozit daavadebuli TiTqmis yvela pacienti 40 welia rac arsebobs, magram mati didi nawili warumatebuli iyo. 1964 wlis angarissi, romelic exeba samxret indoetsi ganxorcielebul tuberkulozis mkurnalobis programas, arnisnulia, rom izoniazidisa da P-aminosalicilis mjavas gamoyenebit, mkurnalobis 12 Tvis Semdeg 123 pacientidan mxolod 64% gaxda nacxit uaryofiti, masin roca rejims SeeZlo ganekurna 90% 70. warmatebis aseti dabali macvenebeli ganpirobebuli iyo samedicino momsaxurebis organizebis warumateblobit, radgan igi ver uzrunvelyofda pacientebis mier 13 k. tomanis wignis wina gamocemis Tavze dayrdnobit 14 kvlevisa da Sefasebis ganxris medmusaki, tuberkulozis armofxvris ganyofileba. Sidsis, tuberkulozisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da matgan Tavdacvis centrebi. atlanta,ajorjiis Stati, ass. 313

rejimis dacvas. 12 Tvis ganmavlobasi pacientebis 27%-ma uari Tqva mkurnalobaze, 10% dairupa an Seicvala sacxovrebeli adgili da darceniltagan naxevarze naklebma mattvis sawiro medikamentebis mxolod 80% miiro. keniasi Catarebul kvlevasi Sedarebuli iqna klinikuri cdebis pirobebsa da rutinuli wesit Catarrebuli mkurnalobis Seedgebi sami medikamentis (sterptpomicini+izoniazidi+tioacetazoni) kombinaciit. kvlevit gamovlinda, rom rogorc mkurnalobis Sewyvetas, aseve samedicino momsaxurebis organizebas udidesi mnisvneloba aqvs mkurnalobis warmatebisatvis. kontrolirebad klinikur cdebsi, sami medikamentis kombinirebit Catarebuli mkurnalobis kursi, kulturis negatiurobas 1 wlis Semdeg arwevs pacientebis 96% samedicino daxmarebis 71 rutinuli ganxorcielebis pirobebsi ki 76%-Si. kargad organizebuli klinikuri cdebis pirobebsi, 91%-ma daasrula 12-Tviani gagrzelebis faza rutinuli servisis dros ki 51%-ma. mkurnalobis Sewyveta didi problemaa yvela regionsi. magalitad, niu-iorksi, mkurnalobis sruli kursi daamtavra im pacientebis mxolod 11%-ma, romlebmac daiwyes stacionaruli mkurnaloba tuberkulozis kontrolis programis gaumjobesebamde, anu 1988 wels 72. mkurnalobis dasrulebis dabali macveneblebi gaxda 80-90 ww niu- iorksi tuberkulozis mkvetri momatebisa da amerikis SeerTebul StatebSi rezistentobis gavrcelebis ZiriTadi mizezi wlebis dasawyissi 72,73,74. im faqtorebs, romlebic ganapirobebda pacientis mier mkurnalobis Sewyvetas, miekutvneboda mkurnalobis rejimis arasworad arqma 75, tuberkuloztan asocirebuli diskriminaciisa da stigmis SiSi 76, finansuri xarjebi da klinikasi misasvlelad Sor manzilze gadaadgilebis aucilebloba 77. jandacvis sistemis faqtorebi iyo wamlit arasistematiuri momarageba, medikamentebis mirebis mouxerxebeli saatebi, pacientebis arasatanado swavleba da jandacvis musakta mxriv mati araadeqvaturi daxmareba, aseve musakta dabali motivacia 78. efeqturi mkurnalobis 1 an 2 Tvis bolos pacenti Tavs uket grznobs da simptomebi exsneba. am momentidan mistvis gaugebaria, ratom unda miiros wamali, romelic usiamovnoa da iwvevs iset gverdit movlenebs, romlebic zogjer ufro Semawuxebelia, vidre Tavad daavadeba. bunebrivia mdgomareobis gaumjobesebit gamowveuli sixaruli da pacienti wyvets mkurnalobas. 314

mkurnalobis Sewyveta dafiqsirda iset SemTxvevebSic, rodesac sawiro iyo medikamentis xangrzlivi periodis ganmavlobasi mireba, magalitad, gul-sisxlzarrvta daavadebebis, revmatizmis, ketris, epilefsiis, diabetis, malariis mkurnalobis SemanarCunebel fazasi. msgavsi problema warmoiqmneba peroraluli kontraceptivebis mirebis drosac. mkurnalobis Sewyvetis sinonimuri sityva defolti~ leqsikuri ganmartebit nisnavs kanonit an movaleobit gansazrvruli davalebis Sesrulebisas warumateblobas. rodesac defolti zianis momtania sazogadoebisa an individastvis, masin unda Catardes makoregirebeli an prevenciuli RonisZiebebi. tuberkulozis SemTxvevaSi araregularuloba an mkurnalobis naadrevi Sewyveta seriozul Sedegebs ganapirobebs ara marto pacientebisatvis, aramed mtlianad sazogadoebisatvis. aset dros samedicino dawesebulebis moraluri valia, samartlebrivze rom araferi vtqvat, miiros sawiro zomebi. radganac mkurnalobis Sewyveta an Tavis arideba adamianis qcevisatvis damaxasiatebelia, misi dacviti RonisZiebebi mkurnalobis strategiis ZiriTadi faqtori an mkurnalobis organizebis Semadgeneli elementi unda gaxdes. mkurnalobis Sewyvetis prevencia da menejmenti mkurnalobis ganuyofeli komponentia da amitom eqimis an mkurnalobaze pasuxismgebeli piris usualo movaleobaa. DOTS-is strategias pacientis gankurnebaze pasuxismgebloba pacientidan samedicino sistemaze gadaaqvs. ase rom, Tu mkurnalobis warumatebloba ganpirobebulia mkurnalobis SewyvetiT, swori ar iqneba mtavari pasuxismgebloba daekisros pacients. vidre mkurnalobis organizatorebi Tavis Tavze ar aireben pasuxismgeblobas, mkurnalobis yvelaze efeqturi kursic ar mogvcems gankurnebisa da epidemiolgiuri warmatebis iset maral macveneblebs, risi potencialic mat aqvt. ufro advilia mkurnalobis Sewyvetis mizezebis identifikacia, vidre Sedegebis gamosworeba. medicinis bevr musaks sjera, rom avadmyofebisa da sazogadoebis samedicino ganatleba sakmarisia eqimis mititebebis Sesrulebis uzrulvelsayofad. Samwuxarod, gamocdileba gvicvenebs, rom aseti cdebi an detaluri instruqciebi sakmarisi ar aris pacientebis motivirebisatvis regularulad miiron danisnuli medikamenti. 315

motivacia gacilebit ufro bevrs nisnavs, vidre instruqtaji: igi adamianta urtiertobis nawilia da sawiroebs pacientis arasamedicino problemebis arqmas, misi cxovrebis, samusaos, rwmenis, survilebis, SiSebis da tradiciul an Tanamedrove medicinaze Sexedulebebis gagebas. motivaciis Sesaqmnelad medicinis musaki pacients mistvis gasageb enaze unda esaubrebodes, man unda Seavsos inteleqtualuri da socialuri gansxvavebebi, dazlios kulturuli winaarmdegobebi, Secvalos adamianta Sexedulebebi da Cvevebi. pozitiuri motivaciaa: efeqturi profesionaluri musaoba, maralzneobrioba, TanagrZnoba da TanamSromelTa Sesabamisoba im sazogadoebastan, romelsac isini emsaxurebian. jamsi, motivacia aris adamianta urtiertobis problema da ganxvavdeba pacientebisa da sazogadoebebis mixedvit. amitomac ar arsebobs raime universaluri recepti. arakomkunikabeluroba, patronajuli midgoma an upativismcemloba gaaucxoebs pacients da Seuqmnis undoblobas, rac, Tavis mxriv, gamoiwvevs mkurnalobis uaryofas. mkurnalobis danisnulebisamebr Catarebis uzrunvelyofa SesaZlebelia mxolod usualo metvalyureobit (ixilet Tavi: ra upiratesobebi aqvs mkurnalobas usualo metvalyureobis qves ). pirdapiri metvalyureobis efeqturi programis pirobebsi gatvaliswinebuli unda iyos, TiToeuli pacientis sawiroebani da sazrunavi. amastan, aucilebelia adamianuri urtiertobebis damyareba pacientsa da damkvirvebels Soris, rac minimumamde Seamcirebs mkurnalobis uaryofit risks. 1998 wels kohortuli kvlevis safuzvelze janmosatvis miwodebuli monacemebit, DOTS-is programis farglebsi Catarebuli moklevadiani mkurnalobis Sedegad nacxit dadebiti 725275 SemTxvevidan mkurnalobis Sewyvetis macvenebeli Seadgenda 6%-s 79. DOTS-is strategiit namkurnaleb pacientebs Soris defoltis macvenebeli, erti meotxedit naklebi iyo mattan SedarebiT, vinc ar mkurnalobda DOTS-is metodit (11% vs 58%). anu DOTS-is strategia, misi warmatebit gamoyenebisas, samedicino sistemasi arsebuli im organizaciuli problemebis gadawris SesaZleblobas izleva, romlebic mkurnalobis Sewyvetis mizezi xdeba. 316

62. ramdenad mnisvnelovania mkurnalobis gavrcelebis faza da rogoria recidivis sixsire mkurnalobis dasrulebis Semdeg 15 t. santa 16 recidivis ganmarteba asetia: tuberkulozit daavadebuli adre namkurnalebi pacienti, romelic CaiTvala gankurebulad an daasrula mkurnaloba da amjamad isev aqvs baqteriologiurad dadasturebuli (nacxit an kulturit-dadebiti) tuberkulozis diagnozi 80. medikamentozuri mkurnalobis SemuSavebamde filtvis nacxit dadebiti tuberkulozis sruli gankureba Zalzed isviatad xdeboda. klinicistebi darwmunebuli iyvnen, rom daavadeba arasdros morceboda am sityvis sruli mnisvnelobit, magram SeiZleboda misi izolireba, stabilizireba an araaqtiur mdgomareobasi gadayvana. radganac baqteriebi TiTqmis yoveltvis rceboda tuberkulozit dazianebul narcen adgilebsi, relafsi xsiri iyo. amis gamo dadgenili iyo, rom mkurnalobis Semdgomi monitoringi sicocxlis bolomde unda ganxorcielebuliyo. pacientebi registrirebulni iyvnen da mati gamokvleva regularulad xdeboda ramdenime TveSi an weliwadsi ertxel. es rutinuli procedurebi mnisvnelovnad zrdida samedicino dawesebulebebis datvitvas, aseve drosa da finansebis xarjvas. mkurnalobis mnisvnelovanma warmatebam ewvs qves daayena mudmivi monitoringis sawiroeba da politikis gadamowmeba moitxova. am miznit, sawiroa pasuxi gaeces iset or kitxvas, rogoricaa: - rogoria recidivebis sixsire? - rogor gamovavlinot recidivi? grzelvadiani da analitikuri gamokvlevebit dadginda, rom recidivi Seadgens yovelwliuri axali SemTxvevebis 15-20% 81,82,83 15 tomanis wignis wina gamocemis Tavze dayrdnobit 16 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeti. 317

kontrolirebadma klinikurma kvlevebma, sadac pacientebis monitoringi mkurnalobis Semdeg 2 da meti wlis ganmavlobasi regularulad mimdinareobda gvicvena, rom recidivis sixsire standartuli qimioterapiis Semdeg Seadgens 3-7%. msgavsi Sedegebi mirebul iqna 6-Tviani kursis Semdegac, rodesac rifampicini gamoiyeneboda mteli kursis ganmavlobasi da mkurnalobis 8-Tviani kursis Semdegac rifampicini gamoyenebit mxolod sawyis etapze. relafsebis daaxloebit 80% vitardeba mkurnalobis Sewyvetis pirveli 6 Tvis ganmavlobasi 84. relafsebis 80%-ze meti modis Catarebuli mkurnalobis dros gamoyenebuli medikamentebis mimart mgrznobelobis mqone organizmebze da amitom ganmeorebiti mkurnaloba ar aris problema 85. aseve dadginda, rom recidivis individualuri riski im pacientebsi, romlebsac baqteriologiurad dadasturebuli tuberkulozi hqondat, mnisvnelovnad gansxvavdeba da ganpirobebulia 3 faqtorit: i Cautarda Tu ara pacients mkurnaloba (Tu ara, SeiZleba CaiTvalos, rom pacients eqneboda recidiuli tuberkulozi da ara relafsi); i iyo Tu ara Catarebuli mkurnalobis rejimi adekvaturi da regularulad irebda Tu ara pacienti medikamentebs; i ra dro daswirda nacxis kulturis negatiurad gardaqmnas. recidivis yvelaze marali macvenebeli arinisneba aranamkurnaleb pacientebsi-5% weliwadsi da pacientebsi, romelebsac araadekvaturi mkurnaloba CautardaT-2% 86. 3-5 wlis Semdeg recidivebis ganvitarebis riski mnisvnelovnad am or jgufsi 1%- mde mcirdeba 86. yvelaze mnisvnelovani iyo is gamoagnebeli efeqti, rasac adekvaturi mkurnaloba axdenda relafsze. relafsis raodeoba yovel milion daavadebulze weliwadsi ramodenime SemTxvevamde Semcirda 87,88. miuxedavad imisa, rom namkurnaleb pacientebsi daavadebis riski ufro maralia SedarebiT im adamianebtan, visac adre ar hqondat tuberkulozi, es ar nisnavs, rom sawiroa sicocxlis bolomde monitoringi. ufro metic, aqtiuri kontrolis pirobebsic ki, recidivi umetesad vlindeba simptomebis gacenis Semdeg da ara rutinuli Semowmebisas. ert-ert grzelvadian kvlevasi, romelic 12 weliwads mimdinareobda, tuberkulozit daavadebis istoriis mqone TiToeul adamians baqteriologiuri kvleva 318

utardeboda yovel 6 TveSi da rentgenografia weliwadsi ertxel. gamokvlevit recidivebis SemTxvevaTa naxevarze naklebi gamovlinda, miuxedavad imisa, rom es gamokvlevebi mkacri disciplinit tardeboda. pacientebs Soris, romlebsac adekvaturi mkurnaloba Cautarda, relafsis riski imdenad dabalia, rom ver asabutebs xangrzlivi monitoringis aucileblobas 89. aqedan gamomdinare, xangrzlivi monitoringis metodi ar amartlebs da ar aris aucilebeli. aseti daskvna gamotanil iqna ass-s 90 sazogadoebrivi jandacvis daavadebebis kontrolis centrebisa da im mkvlevrebis mier, romlebic monitorings uwevdnen namkurnaleb pacientebs SotlandiaSi 91. isini amtkiceben 90, rom tuberkulozit daavadebuli pacientebi, romlebsac CautardaT adekvaturi qimioterapiuliy mkurnaloba, micneuli unda iyvnen gankurnebulad da mattvis ar aris sawiro sicocxlis bolomde rentgenografiuli monitoringis Catareba. aseti midgoma moitxovs bevr drosa da resurss, rac xels uslis samedicino personals Seasrulos Tavisi ZiriTadi movaleoba da uzrunvelyos satanado momsaxurebit isini, vinc amas namdvilad sawiroebs. eqspacientebs unda miecet gafrtxileba mimarton eqims, rogorc ki ganuvitardebat tuberkulozze saewvo simptomebi 89. zogadi praqtikis eqimebi da specialistebi, romlebsac uxdebat tuberkulozis istoriis mqone pacientebtan urtiertoba, informirebulni unda iyvnen recidivis riskis Sesaxeb da MMdayovnebliv unda Seafason xelaxla warmoqmnili respiratoruli simptomebi (rogoricaa, xangrzlivi xvela). Tumca, aseve unda gvesmodes, rom simptomur eqspacientebsi xvela ufro aris filtvis Seuqcevadi dazianebis Sedegi, vidre aqtiuri tuberkulozis ganmeorebit ganvitarebis macvenebeli 92. 319

63. ristvis aris sawiro registrirebisa da angarisgebis sistema da romeli sistemis gamoyenebaa am TvalsazrisiT rekomendirebuli d.maheri 17, m.ravilione 18 pacientebis registrirebisa da angarisgebis sistemebi gamoiyeneba pacientebis mdgomareobis gaumjobesebis, mkurnalobis Sedegebisa da programis ganxorcielebis procesis Sesafaseblad, aseve gadasawreli problemebis gansazrvrisatvis 93,94. tuberkulozis efeqturi kontrolis fundamenturi principi aris is, rom programa pasuxs agebs TiToeuli im pacientis monitoringsa da Sedegebze, romelmac yovelgvari gamonaklisebis garese daiwyo mkurnaloba. specializirebuli dawesebulebebisa da calkeuli eqimebis umetesobas gulwrfelad swams, rom rac ufro met pacients dauwyeben mkurnalobas, mit meti ganikurneba, magram sistematuri Sefaseba gvicvenebs, rom pacientebis mxolod mcire, xsirad umciresi nawili, asrulebs mkurnalobis kurss 95. rogoria registrirebis rekomendirebuli sistema pacientta registrirebis rekomendirebuli sistema unda moicavdes: - tuberkulozis laboratoriis saregistracio furcels, romelsic dafiqsirebuli unda iyos yvela im pacientis monacemebi, visac ki Cautarda naxvelis nacxis gamokvleva; - pacientis samedicino Canawerebs, romelsiac detalurad iqneba dafiqsirebuli medikamentebis regularuli mireba da naxvelis nacxis sakontroli gamokvlevis monacemebi; 17 tuberkulozis SeCerebis ganyofilebis medmusaki. jandacvis msoflio organizacia. Jeneva, Sveicaria. 18 tuberkulozis strategiisa da operaciebis kordinatori, tuberkulozis SeCerebis departamenti. jandacvis msoflio organizacia. Jeneva, Sveicaria 320

- tuberkulozis saregistracio furcels, romelsic Setanili iqneba tuberkulozit daavadebuli TiToeuli pacientis monacemebi da da mkurnalobis monitorngis Sedegebi rogorc calkeuli pirebis, aseve adamianta didi jgufebis 93,96 (zogiert qveyanasi awarmoeben tuberkulozit daavadebuli mxolod im pacientebis registracias, romlebmac daiwyes mkurnaloba). tuberkulozis laboratoriis registracia laboratoriis registraciasi laboranti afiqsirebs pacientis Sesaxeb monacemebs, pacientis seriuli saidentifikacio nomrit. naxvelis nacxis gamokvlevis Sedegebi fiqsirdeba im samedicino dawesebulebasi, sadac pacienti mimagrebulia mkurnalobistvis. laboratoriuli registraciis da rutinuli klinikuri Canawerebis mesveobit advilia im pacientebis monitoringi, romlebmac nebismieri mizezit mimartes samedicino dawesebulebas da im nawilis, romlebsac gamokvleva CautardaT diagnozis dasasmelad da armocndnen nacxit dadebitni. pacientis samedicino barati tuberkulozis diagnozis mqone yovel pacients (nacxit dadebiti iqneba, nacxit uaryofiti, Tu eqstrapulmonaruli) aqvs samedicino barati. baratsi Setanili unda iyos ZiriTadi epidemiologiuri monacemebi (asaki, sqesi da a.s.) klinikuri informacia (pacientis tipi, mkurnalobis kategoria, naxvelis nacxis Sedegebi, wona) da medikamentebis mirebastan dakavsirebuli informacia. TiToeuli barati aseve izleva informacias pacientis misamartisa da samkurnalo centris Sesaxeb. es sawiroa im SemTxvevisaTvis, Tu pacienti grafikis mixedvit ar gamocxaddeba wamlis misarebad. janmrtelobis musaki pacientis samkurnalo barats iyenebs, rata daafiqsiros informacia pacientis mkurnalobis rejimisa da naxvelis nacxs sakontroli kvlevebis Sedegebis Sesaxeb. gagrzelebis fazasi da mkurnalobis bolos pacientebi abareben naxvels nacxis mikroskopuli analizisatvis, anu imis dasadastureblad, rom nacxma ganicada konversia da gaxda negatiuri da es negatiuroba SenarCunebulia. aqedan gamomdinare, es adamianebi itvlebian tuberkulozisgan 321

gankurnebulebad. es Sedegebi pacientis wonis kontroltan ertad, aseve iwereba samedicino baratsi. tuberkulozis registracia jandacvis musaki, romelic pasuxs agebs administraciuli regionis an dawesebulebis superviziaze, tuberkulozit daavadebuli individebis mkurnalobis Sedegebis monitorigis miznit iyenebs tuberkulozis saregistracio formas. es uzrunvelyofs jandacvis regionaluri an adgilobrivi ganyofilebis xelmzrvanelobis swraf da sistematur ukukavsirs regionsi tuberkulozis programastan. amave formasi iwereba TiToeuli pacientis misamarti da samkurnalo centri, rac izleva im pacientebis metvalyureobis SesaZleblobas, romlebmac Sewyvites mkurnaloba. ra aris kohortuli analizi kohortuli analizi moicavs mkurnalobis standartuli Sedegebis sistematur Sefasebas da angarisgebas. tuberkulozit daavadebuli pacientebis kohorta Sedgeba im pacientebisagan, romlebic registrirebul iqnen drois gansazrvrul periodsi, Cveulebriv erti kvartlis ganmavlobasi (e.i. 1 ianvridan 31 martis CaTvliT, 1 aprilidan 30 ivnisis CaTvliT, 1 ivlisidan 30 seqtembris CaTvliT da 1 oqtombridan 31 dekembris CaTvliT). nacxit dadebiti pulmonaruli tuberkulozis mqone pacientebi (infeqciuri SemTxvevebi), nacxit uaryofiti da eqstrapulmonaruli tuberkulozis mqone pacientebi qmnian gancalkavebul kohortas. nacxit dadebiti pulmonaruli tuberkulozis mqone pacientebisatvis mkurnalobis standartul gamosavals warmoadgens gankurneba, mkurnalobis dasruleba, mkurnalobis warumatebloba, sikvdili, mkurnalobis Sewyveta da sxva samkurnalo dawesebulebasi gadayvana. nacxit uaryofiti pulmonaruli tuberkulozis da eqstrapulmonaruli tuebrkulozis mqone pacientebsi gankurnebis sistemuri Sefaseba SeuZlebelia, vinaidan klinikuri gamosavlis macveneblebi damokidebulia naxvelis nacxis gamokvlevaze. aqedan gamomdinare, am pacientebisatvis fiqsirdeba mkurnalobis dasruleba, sikvdili, mkurnalobis Sewyveta, mkurnalobis warumatebloba da sxva 322

saavadmyofosi gadayvana. axali da namkurnalebi pacientebi qmnian damoukidebel kohortebs. kohortuli analizi tuberkulozis kontrolis RonsiZiebebis efeqturobis Sefasebis ZiriTadi samenejmento metodia. igi izleva problemebis identificirebis SesaZleblobas ise, rom programam SeZlos satanado RonisZiebebis Catareba misi gaumjobesebis miznit. Tu SemTxvevaTa gamovlenis kvartaluri angarisit dadginda diagnostikis dabali xarisxi, masin arsebobs diagnostikis praqtikis swrafad gaumjobesebis SesaZlebloba. naxvelis konversiis Sesaxeb kvartaluri angarisi da mkurnalobis warmatebis kvartaluri da wliuri angarisebi (gankurnebuli pacientebis nawili plus isini, vinc daasrula mkurnaloba) sasualo da marali donis nebismier menejers uzrunvelyofen mirwevebis an gadasawreli problemebis Sesaxeb drouli informaciit da konkretuli macveneblebit. problemebis magalitebs ganekutvneba gankurnebis dabali macvenebeli, mkurnalobis Sewyvetis marali macvenebeli, nacxit uaryofiti pulmonaruli tuberkulozis an eqstrapulmonaruli tuberkulozis mosalodnelze ufro marali macvenebeli da SemTxvevaTa gamovlenis mosalodnelze ufro dabali macvenebeli. registrirebisa da angarisgebis sistema izleva im pacientebis miznobrivi da individualuri kontrolis ganxorcielebis sasualebas, romlebsac ar arenisnebat progresi, aseve TiToeuli institutis, dawesebulebis, raionis, regionis an dawesebulebis doneze programis saerto Sesrulebis menejeruli Sefasebis swrafad Catarebis SesaZleblobas. sistema uzrunvelyofs mudmiv angarisgebas. Sida da gare Semowmebebi ar izleva yalbi angarisgebis SesaZleblobas da advilad gamoavlens mas. magalitad, laboratoriis nomeri formdeba tuberkulozis laboratoriis saregistracio formasi, pacientis mkurnalobis baratsa da tuberkulozis saregistraico formasi. es sami dokumenti xsirad inaxeba jandacvis sxvadasxva erteulsi, ramac teqnikurad xeli unda SeuSalos yalb angarisebs, radgan tuberkulozis saregistracio formebi SeiZleba Seicavdes asobit an atasobit Canawerebs. rogoria angarisgebis da monitoringis rekomendirebuli sistema mkurnalobis Sedegebis monitoringi kohortuli analizis metodit xorcieldeba daaxloebit sami Tvis Semdeg, anu roca 323

kohortasi Semavali yvela pacienti daasrulebs mkurnalobis kurss. tuberkulozis sakitxebze pasuxismgebeli piri valdebulia warmoadginos mkurnalobis Sedegebis kohortuli analizi yoveli kvartlis da wlis bolos. mkurnalobis Sedegebis kvartaluri angarisebi igzavneba Sualedur doneze (magalitad, regioni). tuberkulozze pasuxismgebeli musaki Sualedur doneze axorcielebs verificirebas adgilobrivi angarisebis koreqtulobis da Sesabamisobis Sesaxeb. regionsi mcxovrebi yvela pacientis kohortuli analizis Sedegebze dayrdnobit igi SeimuSavebs angariss da waradgens tuberkulozis kontrolis nacionaluri programis centraluri ofissi. nacionaluri programa SeimuSavebs kohortuli analizis angarisebs yvela registrirebuli pacientis mimart. janmo krebs da aqveynebs informacias, ajamebs monacemebs yovelwliurad, zogjer kvartalurad 97, 98. 324

64. rodis unda moxdes tuberkulozit daavadebuli pacientebis hospitalizacia da ramdenad baqteriagamomyofni arian isini mkurnalobis dros 19 e.a. talboti 20 ; s.d. velsi 21 tuberkulozit daavadebul pacientta umravlesobas, daavadebis gavrcelebis riskis garese, mkurnaloba SeiZleba Cautardes ambulatoriul dawesebulebasi. iset situaciebsi, rodesac mkurnalobis aseti formit ganxorcieleba ar aris SesaZlebeli, aucilebelia hospitalizaciis rutinuli politikis gamoyeneba. arsebobs mtkicebulebebis didi raodenoba, romlebic adastureben, rom tubpacientebis ambolatoriuli mkurnaloba iseve efeqturia, rogorc stacionaruli im SemTxvevaSic ki, rodesac daavadebis Sorswasuli formaa da isini cud pirobebsi cxovroben. madrasis klasikur kvlevasi (ix. Tavi: rogori iyo madrasis kvlevis ZiriTadi Sedegebi, binaze da sanatoriumsi mkurnalobis SedarebiTi eefqturobis Sesaxeb ) pulmonaruli tuberkulozit daavadebuli 163 pacienti randomizirebulad iqna SerCeuli binaze an sanatoriumsi mkurnalobisatvis. sanatoriumsi mkurnalobis pirobebi moicavda wolit rejims, kvebas, saeqtno momsaxurebas, sufta haersa da karg sacxovrebel pirobebs, rac ganixileboda, rogorc tuberkulozisgan gankurnebis wamyvani pirobebi. erti wlis izoniazidita da Pp aminosalilis mjavit mkurnalobis Semdeg klinikuri, radiografiuli da baqteriologiuri sakontrolo 19 k. tomanis wignis wina gamocemis Tavze dayrdnobit 20 tuberkulozis/sidsis kvlevis direqtori, BOTUSHA-s proeqti. tuberkulozis armofxvris ganyofileba. tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da matgan Tavdacvis centrebi. atlanta, jorjiis Stati, ass 21 direqtoris moadgile saertasoriso saqmianobis dargsi, tuberkulozis armofxvris ganyofileba. tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da matgan Tavdacvis centrebi. atlanta, jorjiis Stati, ass 325

kvlevebis Sedegebi orive jgufsi ekvivalenturi iyo. 126 pacients 5 wlis ganmavlobasi sistematurad akontrolebdnen da aranairi gansxvaveba recidivebis macveneblebsi binaze da sanatoriumebsi namkurnaleb pacientebs Soris ar iyo 99. am da sxva sakontrolo kvlevebis safuzvelze rogorc ganvitarebad 100,101,102, ise ganvitarebul qveynebsi aqcenti gadatanil iqna tuberkulozis arastacionarul menejmentze 103. miuxedavad amisa, tuberkulozit daavadebul pacientta hospitalizacia kvlavac gavrcelebuli praqtikaa mtel rig qveynebsi 104,105 da SeiZleba misi macvenebeli izrdebodes kidec 106,107. mizezi, romelic xsirad moyavt sawyisi hospitalizaciis sasargeblod aixsneba imit, rom pacienti infeqciuria, da aqedan gamomdinare, izolirebuli unda iyos ojaxisa da sazogadoebisagan. amjamad SeuZlebelia zustad ganvsazrvrot, Tu rodis xdeba pacienti arainfeqciuri, Tumca daavadebulta umetesoba medikamentebisadmi mgrznobiarea da mkurnalobis dawyebidan daaxloebit ert kvirasi xdeba arainfeqciuri, anu kontaqtsi myofi pirebis inficirebis riski mnisvnelovnad mcirdeba 108. madrasis kvlevis 5 wliani monitoringis periodsi tuberkulozit daavadebul pacienttan uaxloes kontaqtsi myof pirebze dakvirveba mimdinareobda kanis testis mesveobit. binaze mkurnalobis rejimze myofi pacientebis kontaqtebs tuberkulozis 109 testze negatiuri reaqciis pozitiurad konventirebis imaze ufro meti albatoba ar hqondat, vidre sanatoriumsi namkurnaleb pacientebtan kontaqtsi myofebs. binaze namkurnalebi pacientebis kontaqtebsi daavadeba ganvitarda 10.5%, sanatoriumsi namkurnalebi SemTxvevebis kontaqtebsi ki 11.5% 109. kontaqtebs tuberkulozi ganuvitardat pirveli Tvis ganmavlobasi pacientis mkurnalobis dawyebidan, rac miutitebs daificirebaze mkurnalobis dawyebamde 110,111. arsebobs, rogorc nacionaluri aseve saertasoriso rekomendaciebi, romlebsic mocemulia tuberkulozit daavadebuli im pacientebis hospitalizaciis Cvenebebi, romelta martvac SeuZlebelia arastacionarul pirobebsi 108,112,113. tuberkulozis dadgena xsirad xdeba saavadmyofosi, nebismieri sxva mizezit hospitalizirebisas. sxva sityvebit rom vtqvat, pacientis saavadmyofosi yofnisas mas SemTxveviT SeiZleba daudgindes tuberkulozi. tuberkulozis gamo hospitalizaciis da saavadmyofosi dayovnebis xangrzlivobis Cveneba igivea, rac nebismieri sxva daavadebis SemTxvevaSi. isini moicavs 326

sicocxlisatvis potenciurad sasis iset mdgomareobebs rogoricaa miliaruli meningialuri forma, suntqvis ukmarisobis sindromi, intravaskularuli koagulacia, mwvave hemoftoe da medikamentebze mwvave reaqcia 114. TavisTavad infeqciis sasisroeba, mcire gamonaklisebis garda, ar warmoadgens pacientis saavadmyofosi motavsebis Cvenebas. miuxedavad imisa, rom misarebia pacientis dabruneba ojaxsi mkurnalobisatvis, arsebobs gansakutrebuli garemoebebi,mag: xalxit gadatvirtul samxedro yazarmebi, sasjelarsrulebiti dawesebulebebi rodesac pacientis izolireba rekomendirebulia im dromde, vidre igi ar gaxdeba asimptomuri da ar eqneba negatiuri an baqteriebis naklebi raodenobis Semcveli naxveli 115. zogierti programa migvititebs, rom Tu pacientebi gaweril unda iqnen iset sacxovrebel adgilebsi, sadac didi raodenobit macxovrebeli iyris Tavs (magalitad, TavSesafari, sakani, cixe an sxva), isini samkurnalod unda darcnen saavadmyofosi nacxit uaryofit mdgomareobasi gadasvlamde 116. isviatia situaciebi, rodesac pacientis hospitalizacias eniweba upiratesoba. magalitad, arsebobs SezRuduli monacemebi imis Taobaze, Tu izoniazidze an rifampicinze rezistentuli (multirezistentuli) pacientebi mkurnalobis dawyebidan ra periodis ganmavlobasi xdebian arainfeqciurebi. mteli rigi multirezistentuli pacientebisatvis, romlebic mkurnaloben nacionalur ebraul hospitalsi, intervali mkurnalobis dawyebidan pirveli negatiuri kulturis seriebamde meryeobda 1-dan 8 Tvemde (sasualod 2 Tve) 117. multirezistentuli tuberkulozit daavadebul pacientebtan axlo kontaqtsi myofi adamianebi, romlebic dasnebovdnen multirezistentuli StamebiT da aqvt daavadebis aqtiuri forma, sawiroeben xangrzliv da ZviradRirebul mkurnalobas. mat gankurnebis naklebi albatoba aqvt da darupvis realuri safrtxis winase dganan 118,119,120. imis gatvaliswinebit, rom multirezistentuli tuberkulozit daavadebuli pacientebi ufro xangrzlivi drois ganmavlobasi arian infeqciurebi, hospitalizaciam SeiZleba dadebiti roli Seasrulos. gansakutrebit im SemTxvevaSi, rodesac mat kontaqti aqvt bavsvebtan da imunokomprometirebul adamianebtan. dawesebulebebsi, sadac mimdinareobs aset pacientebis mkurnaloba unda moqmedebdes inefqciis kontrolis mtkice politika da praqtika (ixilet Tavi: rogor xdeba tuberkulozis nozokomialuri 327

gavrceleba da rogor movaxdinot misi prevencia ) iset SemTxvevebSi, roca infeqciebis satanado kontroli ar xorcieldeba, multirezistentuli tuberkulozis 120,121,122,123. epidemia saavadmyofosi damaxasiatebelia rogorc ganvitarebuli, aseve ganvitarebadi qveynebisatvis. aseti epidemiebi ZiriTadad gvxvdeba adamianis imunodeficitis virusit inficirebul pacientebs Soris, rac mnisvnelovnad zrdis sikvdilianobas. amerikis Torkalurma sazogadoebam ganacxada 124 : qimioterapiis erasi, tuberkulozis mkurnaloba unda ganxorcieldes iq, sadac yvelaze uket xdeba pacientebisa da mosaxleobis sawiroebata dakmayofileba. zogierti pacientis mkurnaloba SeiZleba ganxorcieldes mtlianad binaze. sxvebi sawiroeben moklevadian hospitalizacias zogadi profilis saavadmyofosi, Semdgomi ambulatoriuli mkurnalobit. pacientebis nawils SeiZleba daswirdes ufro grzelvadiani mkurnaloba samedicino dawesebulebasi sxva samedicino da socialuri problemebis gamo. tuberkulozi, rogorc faqti, ar unda gaxdes adgilobrivi samedicino daxmarebis pirveladi determinanti. aseve ar unda iyos SemzRudveli faqtori yvela SemTxvevaSi, rodesac garantirebulia mkurnalobis uwyvetoba da qimioterapiis kursis dasruleba. es gamojanmrtelebis safuzvelic aris. 328

65. rogor xdeba tuberkulozis nozokomialuri transmisia da rogoria misi prevencia f.m. simone 22 tuberkulozis nozokomialuri transmisia nisnavs tuberkulozis aqtiuri formit daavadebuli pacientidan sxva pacientis an samedicio personalis inficirebas mikobaqteriit samedicino dawesebulebasi. hospitalsi multirezistentuli tuberkulozis farte gavrcelebis gamo 80-90 ww. ass-si Catarebulma kvlevebma acvena 125,126,127,128,129. rom transmisiis ZiriTadi mmizezi iyo dagvianebuli diagnostika da mkurnaloba, aseve cudi kontroli. garda amisa, pacientebis didi nawili incifirebuli iyo adamianis imunodeficitis virusit da mat Soris Zalzed marali iyo sikvdilianobis macvenebeli. aiv-inficirebul pacientebsi, romlebic dasnebovnebulni arian tuberkulozis mikobaqteriit, swrafad vitardeba tuberkulozis aqtiuri forma. aseti meoradi SemTxvevebis diagnostikis da mkurnalobis dagvianeba xels uwyobda transmisias da cud Sedegebs. ramodenime kvlevam cxadyo tuberkulozis mikobaqteriis nozokomialuri transmisiis gazrdili safrtxe afrikis, samxret amerikisa da aziis 130,131,132,133,134,135,136 tubsawinaarmdego dawesebulebebis medicinis musakebisatvis. mat ganekutvneba eqimebi, saeqtno da samedicino saswavleblebis studentebi da laboratoriis TanamSromlebi. riski ufro maralia mat Soris, visac xangrzlivi da mwidro kontaqti hqonda tuberkulozit daavadebul adamianebtan. kvlevebit dadginda, rom nozokomialuri tranmisiis TvalsazrisiT 22 prevenciis mxardaweris servisis ufrosi. direqtoris ofisi, tuberkulozis, Sidsisa da sqesobrivi gzit gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebata kontrolisa da matgan Tavdacvis centrebi. atlanta, jorjiis Stati, ass. 329

yvelaze sasisi arian pacientebi, romelta diagnozic ar aris dadgenili da romlebsac ar utardebat mkurnaloba. tuberkulozis mikobaqteriis transmisiis prevencia da Semcireba SesaZlebelia infeqciis kontrolis satanado RonisZiebebis gatarebit 137. arsebobs sami donis kontroli: - administraciuli kontroli pacientebisa da medmusakebis tuberkulozit dasnebovnebis Semcirebis miznit; - dawesebulebis Sida garemos kontroli, haersi mikroorganizmebis koncentraciis Semcirebis miznit da - sasuntqi gzebis dacvis sasualebebis gamoyeneba TanamSromlebis dacvis miznit gansazrvrul dawesebulebebsi, sadac mikroorganizmebis koncentraciis Semcireba haersi ver xorcieldeba administraciuli an garemos kontrolis RonisZiebebiT. administraciuli kontroli am TvalsazrisiT yvelaze mnisvnelovania. dawesebulebis Sida garemos kontroli da sasuntqi gzebis individualuri damcavi sasualebebi araefeqturi iqneba kargi administraciuli kontrolis garese. administraciulma kontrolma prioritetuli adgili unda moipovos tuberkulozis kontrolis nebismier programasi. administraciuli kontrolis sabaziso RonisZiebebi unda dainergos jandacvis yvela dawesebulebasi, xolo damatebiti kontrolis RonisZiebebis gatareba rekomendirebulia ufro farto referaluri donis dawesebulebebsi. administraciuli kontrolis yvelaze mnisvnelovani aspeqtia satanado politikisa da procedurebis SemuSaveba SemTxvevaTa adreuli diagnostikis da mkurnalobis xelsewyobis miznit. tuberkulozi SeiZleba vivaraudot yvela im pacientsi, visac aqvs tuberkulozis simptomebi, an risk-faqtorebi. rodesac ibadeba ewvi tuberkulozis arsebobaze saswrafod unda ganxorcieldes diagnostikuri Sefaseba da Sedegebi dauyovnebliv iqnes mirebuli, rata droulad daiwyos mkurnaloba. daavadebis recidivisa da pacientis xelaxali hospitalizaciis Tavidan acilebis miznit mnisvnelovania pacientis mier yvela medikamentis usualo metvalyureobit mireba da saavadmyofodan gaweris Semdeg mkurnalobis gagrzelebisa da dasrulebis uzrunvelyofa. administraciuli kontrolis damatebiti RonisZiebebi rekomendirebulia yvela tipis dawesebulebistvis da moicavs: 330

- dawesebulebis sxvadasxva nawilsi transmisiis riskis Sefasebas; - infeqciata kontrolis gegmis SemuSavebas; - jandacvis TanamSromlebis momzadebas tuberkulozisa da misi gavrcelebis sakitxebsi da mati rolis gansazrvras infeqciata kontrolis RonisZiebebis gatarebasi - pacientebisatvis mititebebis micemas xvelebis dros piris dafarvis aucileblobis Sesaxeb; - naxvelis arebas kargad ventilirebul otaxebsi; - arastacionarul dawesebulebebsi tuberkulozze saewvo pacientebisatvis prioritetis miniwebas, sxva momlodine pacientebis inficirebis riskis Semcirebis miznit: - dasnebovnebis riskis Semcirebas laboratoriebsi. unda moxdes aseti intervenciebis perioduli Sefaseba. referaluri donis dawesebulebebisatvis rekomendirebulia damatebiti RonisZiebebis gatareba. transmisiis safrtxis Semcirebis ert-erti efeqturi gza tuberkulozit daavadebuli pacientebis menejmentis xelsewyobaa arastacionarul dawesebulebebsi. arsebobs amis ganxorcielebis ori sasualeba: pacientebis adre gawera da yvela pacientis saavadmyofosi ertad Tavmoyris Tavidan acileba. hospitalizaciis Tavidan acileba SesaZlebelia pacientis drouli mimartvit tubsawinaarmdego ambulatoriul dawesebulebasi. Tu hospitalizaciis Tavidan acileba SeuZlebelia, pacientebi saavadmyofosi unda motavsdnen calke palatasi mattvis gamoyofil ganyofilebasi an idealur SemTxvevaSi calke SenobaSi. es Seamcirebs imave samedicino dawesebulebasi gantavsebul pacientebsi tuberkulozis gavrcelebas. rodesac es xerxebi gamoiyeneba administraciuli kontrolis RonisZiebebTan ertad, romlebic Tavis mxriv orientirebulia tuberkulozis adreul diagnostikasa da mkurnalobaze efeqti kargia. ufro didi samedicino dawesebulebebistvis optimaluri iqneba cal-calke SenobebSi ori ganyofilebis gamoyofa, erti tuberkulozze saewvo pacientebisatvis, xolo meore tuberkulozit daavadebuli pacientebisatvis, romlebsac utardebat mkurnaloba. absoluturi izolacia Cveulebriv SeuZlebelia, vinaidan es sawiroebs ZviradRirebul sainjinro-teqnologiur kontrols. unda SemuSavdes da Sefasdes izolaciis sawiroebis dadgenisa da Sewyvetis politika. yuradreba unda mieqces aseve im monacemebis Segrovebas, romlebic 331

exeba tuberkulozis diagnozis mqone TanamSromelTa raodenobas da risk-faqtorebs. dawesebulebis Sida garemos kontrolis RonisZiebebi gansakutrebit misarebia referaluri donis samedicino dawesebulebebisatvis. sawiroa tuberkulozis mikobaqteriit dabinzurebuli haeris gasuftaveba im ganyofilebebsi, sadac motavsebuli arian tuberkulozit daavadebuli pacientebi. dawesebulebis Sida garemos kontrolis yvelaze martivi da iafi RonisZiebaa aseti ganyofilebis bunebrivi ventilacia Ria fanjrebit. askaraa, rom am RonisZiebis gamoyeneba ver xerxdeba gansazrvruli klimatis mqone qveynebsi. sawiroa haeris nakadis mimartulebis kontroli, rom ar moxdes dabinzurebuli haeris tuberkulozit daavadebuli pacientebis palatebidan Senobis sxva nawilsi moxvedra, magram es moitxovs iset ufro ZviradRirebul sasualebebs, rogoricaa fanjris ventilatorebi an ventilaciis rtuli sistemebi. ultraiisferi germiciduli dasxivebit SesaZlebelia haersi gamoyofili mikobaqteriis ganadgureba da am gzit haeris gawmenda. aseti naturebi Tavsdeba WerTan axlos, rac haeris zeda fenebis gasuftavebis SesaZleblobas izleva otaxsi myofi pacientebisa da samedicino musakebis dasxivebis garese. am metodis maqsimaluri efeqtisatvis sawiroa otaxsi haeris satanado Semadgenloba. maralma nestianobam SeiZleba Seasustos naturebis efeqturoba, garda amisa sawiroa sifrtxile mati damontajebis dros 137. respiratorebi specialuri nirbebia romlebic damzadebulia iseti masalisgan, romelic izleva mcire nawilakebis gafiltvris SesaZleblobas (0,3 mmk diametris mqone nawilakebis SemTxvevaSi filtris efeqturoba 95%-ia). individualuri respiratorebis gamoyeneba ufro nakleb prioritetia dawesebulebis Sida garemosa da administraciul kontroltan SedarebiT. referaluri donis dawesebulebebsi respiratorebi SeiZleba gamoyenebuli iqnes administraciuli da dawesebulebis Sida garemos kontrolis RonisZiebebTan ertad iseti marali riskis adgilebsi, rogoricaa saizolacio otaxebi, aseve otaxebi, sadac xdeba bronqoskopiis Catareba, naxvelis mireba da xorcieldeba spirometria an autofsiebi. sifrtxilis zomebis dacva gansakutrebit mnisvnelovania aivinfeqciis gavrcelebis regionebsi. mat garese tuberkulozi 332

swrafad gavrceldeba im ganyofilebebsi, sadac SidsiT daavadebuli pacientebi tuberkulozit daavadebis safrtxis winase dganan, aseve jandacvis aiv-inficirebuli musakebic. idealur SemTxvevaSi isini ar unda musaobdnen tuberkulozit daavadebulebtan. tuberkulozuri infeqciis kontrolis iseti programebis danergva, sadac aqcenti gaketebuli iqneba administraciul kontrolze xels Seuwyobs tuberkulozis mikobaqteriis transmisiis Semcirebas jandacvis dawesebulebebsi da daicavs ara mxolod sxva pacientebs, aramed jandacvis musakebsac, romlebic warmoadgenen tuberkulozis winaarmdeg mebrzol Zalas. 333

66. Gveulebriv sad vrceldeba tuberkulozi da rogor SevamciroT misi gavrceleba h.reideri 23 tuebrkulozis mikobaqteriis dasnebovnebis riski ZiriTadad damokidebulia sam faqtorze: - tuebrkulozis mikobaqteriis transmisiis unaris mqone SemTxvevebis raodenoba mosaxleobasi (ZiriTadad, nacxit dadebiti pacientebi); - aseti SemTxvevebis infeqciurobis xangrzlivoba da - infeqciis wyarosa da individs Soris Sexvedrebis raodenoba da xangrzlivoba. tuberkulozis mikobaqteriit inficirebis riskic aseve damokidebulia sam faqtorze: - infeqciis wyaros mier gamofrqveuli infeqciis Semcveli wvetebis raodenoba; - haeris moculoba, romelsic moxda infeqciis Semcveli wvetebis gamofrqveva; - drois is periodi, romlis ganmavlobasic janmrteli individi SeisunTqavs inficirebuli wvetebis Semcvel haers. aqedan gamomdinare, tuberkulozis mikobaqteriis gavrceleba ufro xsiria mosaxleobis im jgufebsi, sadac tuberkulozis prevalentoba maralia, sadac pacientebi didi xnis ganmavlobasi rcebian infeqciasasis mdgomareobasi da sadac aset adamianebtan kontaqti xsiria. transmisiis albatoba mit ufro maralia iset garemosi, sadac maralia baqteriebis koncentracia haersi da didia mati iq dayovnebis xangrzlivoba. inficirebis riski Senobis SigniT gansxvavdeba inficirebis riskisagan Senobis garet. Senobis garet infeqciuri wvetebi swrafad vrceldeba haeris ganusazrvrel moculobasi (da aseve swrafad 23 tuberkulozis ganyofilebis medmusaki. saertasoriso gaertianeba tuberkulozisa da filtvis daavadebata winaarmdeg. parizi, safrangeti 334

irupeba mzis sxivebit), Senobis SigniT ki isini haersive rceba, gansakutrebit masin, Tu otaxebi kargad ar niavdeba. amitom infeqciuri pacientebis ojaxuri kontaqtebi gacilebit ufro maral risktan aris dakavsirebuli, vidre kontaqtebi sazogadoebasi. ojaxsi kontaqtebs Soris yvelaze marali riskis matarebeli intimuri kontaqtebia 138. arnisnulidan gamomdinare, tuberkulozis mikobaqteria yvelaze metad vrceldeba iset garemosi, romelic akmayofilebs CamoTvlil pirobebs, anu cixeebsi, skolebsi, ofisebsi, TviTfrinavebSi da a.s. Tumca epidemiologiuri kitxva aris is, Tu sazogadoebrivi jandacvis TvalsazrisiT romel matgans eniweba umtavresi mnisvneloba. ojaxuri kontaqtebi yvelaze xsiri movlenaa da TiTqmis yoveltvis, axali SemTxvevis gamovlenisas, aseti ojaxis wevrebi imyofebian infeqciis zemoqmedebis qves 139. meore mxriv, TviTmfrinavSi inficireba isviati movlenaa, radgan SemTxveviTi inficirebis albatoba Zalzed dabalia, kontaqtis xangrzlivoba mcirea, xolo ventilacia kargi 140. mosaxleobis gansakutrebuli jgufebi, magalitad, jandacvis musakebi, ufro xsirad imyofebian zemoqmedebis qves, vidre danarceni sazogadoeba da axlo da xangrzlivi kontaqti aqvt adamianebtan, visi diagnozic jer garkveuli ar aris da amitom jer ar imyofebian mkurnalobaze. amdenad jandacvis musakebs tuberkulozis daavadebis marli riski aqvt 141 amis msgavsad, cixesi tuberkulozit sixsire maralia qveynebsi, sadac maralia patimarta raodenoba, xolo kontaqtebi xangrzlivia garemo daxuruli, infeqciuri SemTxvevebis diagnostika dagvianebuli. amdenad, transmisiis riski Zalze maralia 142. tuberkulozis gavrcelebis Semcirebis sasualebebi SeiZleba ganisazrvros zemot arnisnuli principebidan gamomdinare. arsebuli metodebit cota ramis gaketeba Tu SeiZleba masebsi infeqciuri SemTxvevebs usualo prevenciisatvis. infeqciasasisi situaciis xangrzlivobis Semcireba SesaZlebelia infeqciuri SemTxvevebis drouli identifikaciisa da mattvis sruli mkurnalobis Catarebis mesveobit. es aris tuberkulozis mikobaqteriis gavrcelebis Semcirebaze mimartuli ZiriTadi intervencia. iset specialur organizaciebsi, romlebic cnobilia tuberkulozis gavrcelebis marali riskit, magalitad, cixeebi da samedicino dawesebulebebi, ventilaciis gaumjobesebis miznit 335

(da haersi baqteriata koncentraciis Sesamcireblad) SesaZlebelia administraciuli da sainjinro RonisZiebebis gatareba xelmisawvdomi xarjebit. infeqciis gavrcelebis Semcirebaze mimartuli RonisZiebebi standartulia, miuxedavad TavSeyris obieqtis xasiatisaa. tuberkulozis SemTxvevebi unda gamovlindes SeZlebisdagvarad swrafad. rodesac individi samedicino dawesebulebas mimartvas respiratoruli simptomebit, mas unda Cautardes efeqturi mkurnaloba, amastan uzrunvelyofili unda iyos mkurnalobis satanado rejimi da xangrzlivoba. es strategia gansakutrebit efeqturad amcirebs infeqciis zemoqmedebis risks sazogadoebaze da sabolood mivyavart axali infeqciuri SemTxvevebis warmosobis Semcirebamde. 336

67. ra principebi da motxovnebi arsebobs kontrolirebadi klinikuri kvlevebis mimart 24 f.rehmani 25 gonieri eqimebi pacientebs mkurnaloben mxolod im metodebit, romlebsac isini floben da romlebisac sjerat. sxvadasxva eqimebi xsirad ertsa da imave daavadebebs sxvadasxvagvarad mkurnaloben. Tu pacienti ganikurna, eqimebi warmatebas mat mier SerCeul metods miaweren. ramdenad subieqturni da cvalebadni arian isini Tavis msjelobasi, kargad Cans mkurnalobis im uamravi gamocenili metodidan, romlebsac xotbas asxamdnen misi damcvelebi da Semdgom daiviwyes. magalitad, TiTqmis 20 wlis ganmavlobasi tuberkulozis samkurnalod iyenebdnen oqros marilebs, romlebic fartod iyo rekomendirebuli daaxloebit 200 samecniero statiasi, vidre ar armocnda, rom mat aranairi sargebloba ar mohqondat, rom araraferi vtqvat zianze 143, 144. me-20 saukunis pirvel naxevarsi tuberkulozis samkurnalod gamoiyeneboda uamravi Terapiuli metodi, dieta Tu rtuli naertituberkulini, sxva biologiuri agentebi, magalitad rogoricaa baqteriuli eqstraqtebi, aseve, dasustebuli mikobaqteria, antisrati, antitoqsini, oqros marilebi, virtevzas RviZlis cximi, vitamini C, kalciumis inieqciebi, kreozoti, umarilo dietebi, sxivuri Terapia da sxvadasxva klimati (cxeli da msrali, maralmtiani, zrvis) yvela am metods hyavda Tavdadebuli damcvelebi 145. garda amisa, gamoiyeneboda uamravi Terapiuli intervencia pnevmotoraqsi, diafragmis nervis alkoholizacia(dambla), pnevmolizi, oleotoraqsi, plombireba, kavernis drenaji, Torakoplastika da bolos rezeqciuli qirurgia. miuxedavad imisa, rom es arasruli CamonaTvalia, igi gvaxsenebs warsulis Ziebebs. 24 k. tomanis wignis wina gamocemis Tavze dayrdnobit 25 tuberkulozis kvlevis centris mtavari kvleviti musaki. Cenai, indoeti 337

ukanaskneli 50 wlis ganmavlobasi Zalisxmeva mimartuli iyo tuberkulozis mkurnalobis metodebis mecnieruli Sefasebisken. am mimartulebit mnisvnelovad wingadadgmuli nabiji Sefasebis metodis SemuSavebaa, romelic cnobilia kontrolirebuli kvlevebis saxelwodebit. bevri kontrolirebadi kvleva Catarda da SesaZlebloba mogvca gagvesazrvra amjamad rekomendirebuli samkurnalo metodebis efeqturoba, toqsikuroba da gamoyenebadoba. zogierti eqimi satanadod ver afasebs am metodis Rirebulebas da masstabebs. Aaseve arseboben avtorebi, romlebic sakutar gamokvlevebs moixsenieben, rogorc kontrolirebad kvlevebs, Tumca ar itvaliswineben mis ZiriTad motxovnebs. amitom SesaZloa am metodis ZiriTadi maxasiateblebis gaxseneba ar iyos urigo. metodi kontrolirebad kvlevebsi ayalibeben or an met ekvivalentur jgufs, ert jgufs sakontrolos ar utareben mkurnalobas, an mkurnaloba utardeba cnobili rejimit, masin rodesac meore jgufs eqsperimentuls, utardeba mkurnalobis is kursi, romelic Seswavlis sagania (araetikuria mkurnalobis garese dagrces jgufi, Tuki arsebobs efeqturi mkurnaloba). amjamad sakontrolo jgufs Cveulebriv mkurnaloba utardeba standartuli rejimit, romelsac gaacnia TiTqmis 100%-iani efeqturoba da recidivis minimaluri macvenebeli. Tu sakontrolo rejimi ar aris Setanili kvlevis protokolsi mititebuli unda iyos, romeli rejimi (cnobili efeqturobit) SeiZleba iyos gamoyenebuli kontrolis jgufisatvis. kvlevis gansazrvruli sqemebis gamoyenebit, romelic cnobilia rogorc faqtorialuri dizaini, SesaZlebeli xdeba ara mxolod mkurnalobis rejimebis efeqturobis gansazrvra, aramed medikamentis moqmedebis identificireba, im pirobit, rom es medikamentebi ar unda urtiertqmedebdnen ertmanettan 146. aseti dizainis gamoyenebit SesaZlebelia 10 sxvadasxva Sedarebis gaketeba. arsebobs TiToeuli eqsperimentuli rejimis sakontrolo rejimtan Sedarebis SesaZlebloba. eqsperimentuli rejimebis ertmanettan Sedareba gvazlevs calkeuli medikamentis an faqtoris moqmedebis da aseve, mat Soris urtiertqmedebis Seswavlis sasualebas baqteriologiuri da rentgenografiuli reaqciis, 338

gverditi movlenebis, medikamentebisadmi rezistentobis da recidivis ganvitarebis macveneblebis TvalsazrisiT. Sedarebas aseve SeuZlia gamoavlinos im medikamentebis an faqtorebis sinergisturi an antagonisturi urtiertqmedeba, romlebic warmoadgenen kvlevis sagans. grafiki #21 mkurnalobis rejimis Sedareba kontrolirebad jgufebsi, magaliti X, Y da Z-iT mkurnalobis eqsperimentuli rejimebis Semadgeneli medikamentebis, sakontroli rejimis simboloa ABC, otxi rejimi agebulia X, Y, Z medikamentebis sxvadasxva kombinaciebze eqsperimentuli kursebi kontrolis kursi aseti dizainis gamoyenebit SeiZleba ati sxvadasxva Sedarebis gaketeba. SeiZleba TiToeuli eqsperimentuli rejimis Sedareba sakontrolo rejimtan. eqsperimentuli rejimebis ertmanettan Sedareba izleva TiToeuli medikamentis an faqtoris individualuri moqmedebis da mat Soris urtiertqmedebis Seswavlis SesaZleblobas baqteriologiuri da rentgenografiuli Sedegis, gverditi reaqciebis, medikamentebisadmi rezistentobis warmoqmnisa da recidivis macveneblis gatvaliswinebit. Sedarebam aseve SeiZleba gamoavlinos sakvlev medikamentebs Soris sinergetika an antagonizmi. etikuri mosazrebebi arsebobs kritikuli gamonatqvamebi, romlebic uaryofs kontrolirebad kvlevebs Semdegi saxis ganzogadoebebit: kontrolirebadi kvlevebi nisnavs eqsperimentebis warmoebas adamianebze da amitom araetikuria. aseti gamonatqvamebi ar itvaliswinebs rom nebismieri mkurnalobis danisvna, romelic dafuznebuli ar aris am mkurnalobis sargeblianobis da riskis 339

raodenobriv mtkicebulebebze, faqtiurad adamianebze eqsperimentirebas nisnavs. ufro metic, sworedac rom eqsperimentirebaa, rodesac iyeneb iset mkurnalobas, romlis Sedegebic nateli ar aris. Tu cnobili ar aris, rom mkuraloba fataluri SeiZleba iyos - cdomileba advilad gadaiqceva Secdomad. dres yvelasatvis cnobilia, rom eqimisatvis araetikuri, xolo pacientisatvis saxifatoa mkurnalobis iseti axali kursis danisvna, romelic ar aris testirebuli klinikuri cdebit. yoveltvis unda arsebobdes kvlevis Catarebis seriozuli mizani, magalitad mkurnalobis ufro marali efeqturoba an xelmisawvdomoba, mkurnalobis kursis xangrzliobis, toqsikurobis donis, relfasis macveneblebis, an xarjebis Semcireba. ufro metic, unda arsebobdes Zalian seriozuli dasabuteba imisatvis, rom gawion riski. eqsperimentuli mkurnalobis riski unda Sedardes pacientisa da sazogadoebis risktan, romelic SeiZleba warmoisvas, Tu mat ar vumkurnalebt an vumkurnalebt Cveul rejimsi. kvlevasi monawile eqimebs unda mieces garantiebi protokolebsi dafiqsirebit, rom mat aqvt ufleba gamoricxon pacienti eqsperimentidan, rodesac ki CaTvlian, rom mkurnalobis gagrzelebam SeiZleba seriozulad avnos mas. es garantia unda arsebobdes im SemTxvevaSic, Tu es ganapirobebs kvlevis gabatilebas. amitom axali mkurnalobis SemoReba kontrolirebadi kvlevebis principebis mkacrad dacvit icavs samedicino etikas da uzrunvelyofs samecniero kvlevis marali standartebit ganxorcielebas. sakontrolo kvlevis protokoli kontrolirebadi kvlevis Catarebis ert-erti umtavresi motxovnaa misi dagegmva da ukiduresad detaluri gegmisa da samusao programis, protokolis mixedvit warmartva. kontrolirebadi kvlevis Catarebis Taobaze gadawyvetilebis mirebis Semdeg eqspertebis jgufi, romelsic unda Sediodnen ara mxolod eqimebi, aramed im disciplinebis warmomadgenlebic, romlebsac moicavs es kvleva, magalitad, baqteriologebi, statistikosebi, eqtnebi, sociologebi, bioqimikosebi, imunologebi da administraciuli musakebi, SeimuSaveben protokols. protokolsi Camoyalibebuli unda iyos Sesasrulebeli amocanebi, samusao procedurebi, samusao grafiki da aseve kvlevasi monawile mxareebis valdebulebebi. 340

kvlevis TiToeuli monawile mkacrad unda icavdes protokolis motxovnebs, irebdes konsultacias da instruqciebs kvlevis mimdinareobis manzilze. protokolidan umciresi gadaxrac ki, unda SeTanxmebuli iyos sakoordinacio centrtan, winaarmdeg SemTxvevaSi, mteli kvleva seriozuli problemebis winase armocnda. amitom, protokoli unda SemuSavdes didi gulisyurit, codnita da pasuxismgeblobit. daugegmavi kvleva e.i. kvleva protokolis garese, ukve arar aris kontrolirebadi kvleva, misi Sedegebi dausabutebulia da usargeblo. winaswari testireba protokolze musaobis dasrulebamde SesaZlebelia winaswari e.w. piloturi kvlevebis ganxorcieleba, rac iseti informaciis swrafad mopovebis SesaZleblobas izleva, rogoricaa gansazrvruli procedurebis ganxorcielebis SesaZlebloba an mati operatiuli efeqturoba, ucnobi efeqti an ramdenad misarebia esa Tu is politika. Zogjer, naklis gamovlenis miznit, sasargebloa protokolis mokle testireba. kvlevasi monawileobis mirebamde yvela mkvlevars ufleba aqvs moitxovos cvlilebebis Setana. mat unda hqondet imis SegrZneba, rom protokoli mattvis sruliad misarebia da isini mzad arian gaiziaron masze pasuxismgebloba. protokolis bolo versia kvlevis dawyebamde SeTanxmebuli unda iqnes yvela uflebamosil monawilestan. protokolsi insruqciebi da ganmartebebi Cveulebriv Semdegi dasataurebit unda iyos moyvanili: 1. kvlevis mizani; 2. kvlevis sagani (mkurnaloba, romelic unda iqnes Seswavlili, misi argumentacia, etikuri sakitxebi da mastan dakavsirebuli sxva kvlevebi); 3. sakvlevi jgufebi da mati SerCevis motxovnebi; 4. kvlevasi monawile jgufebis gantavseba; 5. mkurnalobis menejmenti; 6. progresis monitoringi; 7. arricxva-angarisgeba; 8. monacemta analizi, Sefaseba da Sedegebis interpretireba. 341

kvlevis mizani problema natlad unda iqnes gansazrvruli da kvlevis amocanebi mkafiod Camoyalibebuli (anu risi damtkiceba gvaqvs gamiznuli), anu zustad unda gaviazrot problemis gadawris ra sasualebebs gvtavazobs es kvleva. magaliti: problema: mkurnalobis 6-Tviani kursi metismetad xangrzlivia imisatvis, rom pacientebma igi daasrulon. amocana: mkurnalobis xangrzlivobis Semcireba 4 Tvemde. kvlevam unda daamtikos, rom es SesaZlebelia (an ar aris SesaZlebeli) da amisatvis sawiro damatebiti resursebis xarjva gamartlebuli iqneba mirebuli SedegebiT. kvleva ise unda warimartos, rom gvicvenos erti rejimis upiratesoba meorestan SedarebiT klinikuri, epidemiologiuri da ekonomikuri TvalsazrisiT. Tumca Teoriulad SesaZlebelia bevri problemebis ert kvlevasi gaertianeba gonivruli iqneba, Tu mxolod ramodenimes SeviswavliT. tuberkuloztan dakavsirebuli kontrolirebadi kvlevebis umravlesoba miznad isaxavs mkurnalobis iseti aspeqtebis Seswavlas, rogoricaa mati xangrzlivoba, efeqtianoba, medikamentebis sxvadasxva dozebis toksiuroba da qmeditoba, gverditi movlenebi, recidivis SesaZlebloba, medikamentebis sxvadasxva kombinaciebis gamoyenebis SemTxvevaSi da sxva (ixilet Tavi: ras warmoadgens intervalebit intermitiuli mkurnaloba da ra mecnieruli safuzvlebi aqvs mas ). tuberkulozis mkurnalobis Sesaxeb arsebuli Tanamedrove codna TiTqmis mtlianad efuzneba kontrolirebad kvlevebs. kontrolirebadi kvleva ara mxolod medikamentebis efeqturobis gansazrvris sasualebaa, aramed igi warmatebit gamoiyeneba tuberkulozit daavadebuli pacientebis mkurnalobisa da zogadi menejmentis politikis gansasazrvravadac. amis yvelaze cnobili magalitia madrassi Catarebuli kvleva, romelic miznad isaxavda binaze da sanatoriumis pirobebsi Catarebuli mkurnalobis efeqturobis Sedarebas (ixilet Tavi: rogori iyo madrassi Catarebuli 147 kvlevis ZiriTadi Sedegebi mirebuli binaze da sanatoriumis pirobebsi mkurnalobis Sedarebisas ). 342

aqedan gamomdinare, kontrolirebad kvlevebs SeiZleba Ghqondes amocanebis mteli speqtri. Seswavlis sagani - mkurnaloba kvlevisas gamoyenebuli yvela medikamenti, mati dozebi da administrirebis metodebi zustad unda iqnes arwerili, ise rom SesaZlebeli gaxdes, ertis mxriv, mati zustad ganmeoreba nebismier adgilze, xolo, meores mxriv mati Sedegebis verificireba. aqedan gamomdinare, protokolsic da angarissic natlad unda iyos mocemuli: gamoyenebuli kombinacia (magalitad, streptomicinistreptomicinis sulfatis 1g/0,75g fxvnili sulfatze unda gaixsnas sterilizebuli gamoxdili wylit), preparatis forma (magalitad fxvnili, kafsulebi, abebi, specialuri apkit dafaruli granulebi), TiToeuli dozis zusti odenoba da mati mirebis detalebi (magalitad, mtliani doza, dayofili doza, dresi ramdenjer, dozebis mirebas Soris intervalebi, Wamamde Tu Wamis Semdeg, usualo metvalyureobit, Tu metvalyureobis garese). sakontrolo rejimi, miuxedavad imisa, standartulia igi Tu ara Zalzed detalurad unda iyos arwerili, arc erti mnisvnelovani sakitxis mimart ar unda warmoisvas raime ewvi an gaugebroba, ramac SeiZleba ganapirobos zianis momtani Secdomebi. ZiriTadi kvlevisa da winaswari testirebis mnisvneloba, aseve etikuri sakitxebi unda iqnes gaanalizebuli da ganxiluli. mosaxleobis sakvlevi jgufebi kvlevasi monawileta SerCevis kriteriumebi natlad da gasagebad unda iyos Camoyalibebuli da gansazrvruli ara mxolod im adamianebis mimart, romlebic monawileobas unda irebdnen kvlevasi, aramed mat mimartac, vinc kvlevidan unda gamoiricxos. magaliti: kvlevasi monawileobisatvis misarebia: orive sqesis pacientebi, 15 wlis da ufrosi asakisa, mcxovrebi kvlevis centridan 5 km-is radiusis farglebsi, naxvelis nacxisa da kulturis analizis safuzvelze baqteriagamomyofi, romlebsac aqvt mgrznobeloba izoniazidsa da rifampicinze. 343

kvlevasi monawileobisatvis ar daisveba: pacientebi, romlebsac warsulsi Catarebuli hqondat tuberkulozis gamo mkurnaloba, 40 kg-ze naklebi wonis, diabetit daavadebuli an hepatitiani, fexmzime qalebi, an emigrantebi, romlebmac SeiZleba Seicvalon adgilsamyofeli uaxloesi ori wlis ganmavlobasi. Sefasebis miznebidan gamomdinare kargi iqneba, Tu sxvadasxva samkurnalo jgufebis pacientebs ertnairi maxasiateblebi (asaki, sqesi, daavadebis simzimis stadia da sxva) eqnebat. samizne jgufis sawiro sididis gaangarisebi safuzvelze kvlevasi monawile pacientebis raodenobis gansazrvra, aseve Zalzed mnisvnelovani sakitxia. igi damokidebulia kvlevis xasiatsa da amocanebze, samkurnalo jgufebis raodenobaze, SedegebSi mosalodneli gansxvavebebis winaswar gaangarisebul magnitudaze da sizusteze, romlitac unda Catardes Sedegebis Sedareba. aq sawiroa kompetenturi statistikosis konsultacia. ar aris aucilebeli, rom kontrolirebad kvlevasi monawileobdes pacientebis didi raodenoba. faqtiurad, Tu SesaZlebeli gaxdeba zustad Sedarebadi jgufebis Sedgena, statistikosma SesaZloa sakmarisad miicnios 100 an naklebi pacientis monawileoba. TavisTavad, Tu jgufebis Sedareba ver xorcieldeba monawileta didi raodenoba xsirad ufro cudia, vidre usargeblo, aman SeiZleba potenciurad araswori Sedegebisadmi cru rwmuneba ganapirobos. im SemTxvevaSi, roca sawiroa kvlevasi didi raodenobit pacientebis mozidva xangrzlivi drois periodsi, an mati raodenoba aremateba erti samkuralo centris simzlavris SesaZleblobebs, aucilebelia kvlevis decentralizacia. kontrolirebadi kvlevis ert-erti upiratesobaa is, rom igi SeiZleba mimdinareobdes ertdroulad ramodenime centrsi, ramodenime qveyanasi, an kontinetzec ki. am SemTxvevaSi kvlevis periodi mnisvnelovand Semcirdeba da, miuxedavad imisa, rom pacientebis mkurnaloba sxvadasxva adgilebze warimarteba, dadgenili protokolis mixedvit SesaZlebeli gaxdeba mkurnalobis unificirebulad Catareba. samkurnalo jgufebis ganawileba kontrolirebadi kvlevis sworad warmartvisatvis Zalze mnisvnelovania pacientebis sworad ganawileba sxvadasxva 344

samkurnalo jgufebsi. Ees miznad isaxavs jgufebs Soris statistikuri Sedarebis warmoebis SesaZleblobis uzrunvelyofas. aqedan gamomdinare, jgufebi ertgvarovani unda iyos yvela aspeqtsi, garda mkurnalobisa. mxolod am pirobis dacvit gaxdeba SesaZlebeli mkurnalobis sxvadasxva kursisatvis damaxasiatebeli Sedegebis Soris gansxvavebebis gazomva. ganawileba unda moxdes mkacrad randomizirebulad. winaarmdeg SemTxvevaSi, Tu kvlevasi ertdroulad ramdenime pacienti monawileobs da konverti nomris miniwebamde gaixsneba, mkurnaloba SesaZloa mkvlevaris Sexedulebisamebr ganawildes. Tu randomizacia arasrulyofilad Catarda, mteli kvleva nulovani Sedegebis momtani da usargeblo iqneba. DdReisaTvis gamoyenebuli randomizaciis zogi procedura namdvilad Sors aris srulyofilebisgan. magalitad, randomizaciis Catareba morigeobit (periodulobit)-yoveli meore an mesame pacientis raime gansazrvruli rejimis jgufsi mimagreba, an ganawileba dabadebis wlis (kenti an luwi cifrebis) mixedvit,_aradamakmayofilebelia. am SemTxvevaSi advilia gansazrvruli mkrnalobis identificireba da mkvlevarma an Semfasebelma SeiZleba Segnebulad Tu Seugneblad dausvas cdomileba. ufro metic, SesaZlebelia garkveuli manipulirebac. magalitad, Tu kvlevasi monawileobs ertdroulad ramodenime pacienti, mati mirebis Tanamimdevroba SeiZleba ise moewyos, rom zogi miakutvnon jgufs, romelsac uketesi mkurnaloba utardeba. bevr kvlevasi iyeneben e.w. konvertis sistemas. mklevars azleven ramodenime, seriuli nomris mqone daluqul koverts. TiToeulSi mocemulia kvlevasi monawile pacientebisatvis gansazrvruli mkurnalobis mititebebi: seriuli nomeri pacients ezleva kvlevasi mirebis dros satanado konvertis gaxsnamde. konvertebis sistema damakmayofileblad musaobs. kodi saidumlod rceba da misi gamjravneba SesaZlebelia mxolod gadaudebel situaciebsi an saboloo Sefasebis dros. ert-erti randomizirebeli metodi itvaliswinebs seriuli nomrebis saidumlo siis gamoyenebas, romelic xelmisawvdomia mxolod neitraluri mxarisatvis (Cveulebriv statistikosebisatvis) an im pirebisatvis, romlebsac ara aqvt raime interesi warmoebuli kvlevis mimart. siasi Setanili TiToeuli seriuli nomeri Seesabameba gansazrvrul mkurnalobas da mkurnalobata Tanamimdevrul wyobas, romelic 345

struqturizebulia randomizirebulad SerCeuli nomrebis mimart. rodesac mkvlevrebi kvlevasi monawileobisatvis pacientebs irceven, isini mesame mxares atyobineben pacientebis detalur monacemebs da Semdeg ireben informacias mkurnalobis Sesaxeb (an kodirebul informacias ormagad brma kvlevebis dros). aseti procedura sasualebas gvazlevs Tavidan avicilot yovelgvari darrveva. da bolos, randomizacia Zalzed mnisvnelovania, radgan SerCevis dros Tavidan avicilot cdomilebebi, uzrunvelvyot ekvivalenturi jgufebis formireba iseti maxasiateblebis mixedvit, rogoricaa nacxit dadebitoba, daavadebis simzime, asaki, sqesi da sxva. swori randomizirebuli ganawileba kvlevasi monawile TiToeuli pacients azlevs Tanabar SesaZleblobas, mimagrebuli iyos ertert sakvlev jguftan; aqedan gamomdinare, iqmneba msgavsta Sedarebis SesaZlebloba. idealur SemTxvevaSi kvlevebi unda iyos ormagad brma, rac imas nisnavs, rom arc pacientma da arc mkvlevarma ar icis, Tu ra mkurnaloba utardeba pacients. es arapraqtikulia, magalitad, iseti kvlevebis SemTxvevaSi, romlebic axdenen yoveldriuri da perioduli mkurnalobis Sedarebas. Tumca, am metodis gamoyeneba SeiZleba vitaminebis (mag., piridoqsini) damatebis Semswavlel kvlevasi, rodesac pacientebs standartul mkurnalobaze damatebit azleven vitamins. am SemTxvevaSi SeiZleba gamoviyenot placebo, romelic fizikurad ar gansxvavdeba namdvili medikamentebisagan, amastan arc pacientebisa da arc mkvlevrisatvis ar aris cnobili, Tu vin irebs namdvil medikamentebs da, vin placebos. mkurnalobis martva protokolit gansazrvruli aucilebeli gamokvlevebis Catarebisa da sawiro formebis Sevsebis Semdeg iwyeba mkurnaloba da xorcieldeba zustad ise, rogorc amas moitxovs protokoli. pacientis Secvla, pacientisatvis mkurnalobis Sewyveta an SeCereba SeZlebisdagvarad unda ganxorcieldes sakoordinacio centris TanxmobiT. sruli protokoli aseti situaciisatvis satanado kriteriumebsa da procedurebs unda Seicavdes. centri aseve irebs gadawyvetilebas imis Taobaze, pacienti unda gamovricxot kvlevidan Tu davtovot Semdgomi monitoringisa da SefasebisaTvis. pacientis kvlevidan gamoricxvis nebismieri SemTxveva, ra mizezetac ar 346

unda iyos igi ganpirobebuli, iqneba es pacientis Tvalsawieridan dakargva, Tu mkurnalobis an mnisvnelovani gamokvlevis uaryofa, guldasmit unda iqnes ganxiluli, vinaidan mati gamoricxvit Catarebuli Sefasebisas SeiZleba SedegebSi mnisvnelovani cdomilebebi mivirot. procesis monitoringi protokolsi specialuri ganyofileba unda miezrvnas monitoringis sxvadasxva RonisZiebebis arweras da mat ganawilebas drosi. yvela rutinuli testi da specialuri danisnulebis gamokvleva, romelic tardeba mxolod gansakutrebul SemTxvevebSi (magalitad, gverditi movlenebis ganvitarebis SemTxvevaSi) detalurad unda iqnes arwerili. uzrunvelyofili unda iqnes monitoringis procedurebis ertgvarovneba. umjobesi iqneba, Tu gamokvlevebi, romlebic moitxovs gansakutrebul unar-cvevebsa da sizustes, Sesruldeba centralur (referalur) laboratoriebsi. arricxva da angarisgeba xsirad arasatanadod afaseben saarricxvo formebisa da informaciis mozraobis efeqturi sistemis dizainis mnisvnelobas. forma (saarricxvo iqneba is Tu saangariso) maqsimalurad gasagebi unda iyos. misi gamoyenebisatvis ar unda gaxdes sawiro grzeli instruqciebis SemuSaveba, massi Setanili unda iyos mxolod iseti kitxvebi, romlebic moitxovs mkafio pasuxs diax/ara. formis SemuSavebis dasrulebamde sawiroa misi testireba, Tu ramdenad advilad gasagebi da srulyofilia igi im personalis azrit, romelmac am formebit unda imusaos. zogjer gonivruli iqneba e.w. damabneveli kitxvebis gamoyeneba, rac mogvcems Cawerili monacemebis koreqtulobis jvaredini Semowmebis SesaZleblobas. Tumca, saarricxvo Canaweri unda gamoiyenebodes mxolod saqmianobisadmi relevanturi informaciis Sesakrebad da Catarebuli kvlevis Sesafaseblad. natelia, rom tuberkulozis problemebtan dakavsirebuli grzelvadiani samecniero kvlevebi sawiroebs monacemta uzarmazari masivebis Sekrebasa da damusavebas, rac kargad organizebuli 347

administraciuli da saofise procedurebis SemuSavebis aucileblobas qmnis. sistematiurad unda warmoebdes monacemebisa da saangariso informaciis sisrulisa da sizustis Semowmeba da sawiroebis SemTxvevaSi Setyobinebis dauyovnebliv gagzavna saangariso centrsi. ramodenime centris monawileobit didmasstabiani kvlevebis Catarebisas sawiroa monacemta kompiuterizebuli martva. moncemebis Seyvana unda xdebodes dublirebis principit, ori sxvadasxva adamianis mier. monacemta es ori masivi avtomatur rejimsi unda Sedardes ertmanettan da gamovlenili Seusabamoebebi Seswavlil iqnes da gaswordes. monacemta analizi da Sefaseba monacemta analizis Catarebamde, miuxedavad imisa analizi Sualeduria Tu saboloo, monacemebi unda Semowmdes sisrulesa da sisworeze. ert-erti mnisvnelovani Sualeduri analizi SeiZleba moicavdes magalitad, baqteriologiuri gamokvlevebis Sedegebisa da preparatebis gverditi movlenebis cxrilebis Sedgenas mkurnalobis rejimebis, mati xangrzlivobisa da imisda mixedvit, Tu ramdenad regularuli iyo medikamentebis mireba. es izleva mkurnalobis saeqsperimento rejimebis Rirsebebis Sesaxeb informaciis ganaxlebis da arsebuli riskis adreul etapze gamovlenis SesaZleblobas. Tu aseti Sualeduri analizi tardeba, masin saboloo analizis SemuSaveba did dros ar moitxovs da bolo monacemebis Seyvanidan, maleve iqneba mzad, rac Tavis mxriv daacqarebs saboloo angarisis dasrulebasac. analizi, cxrilebis Sedgena da monacemta interpretacia yoveltvis unda mimdinareobdes statistikosebtan mwidro TanamSromlobiT. ar arsebobs azrta sxvadasxvaoba im faqtorebtan dakavsirebit, romelta analizic medikamentis an mkurnalobis rejimis efeqtianobis dadgenis miznit unda ganxorcieldes. Tuki protokolsi natlad da ertmnisvnelovnad Camoyalibebuli kriteriumebi ar iqneba mocemuli, romlebic mkacrad da ertmnisvnelovnad unda iqnes gamoyenebuli, masin mkurnalobis baqteriologiuri, rentgenologiuri da klinikuri TvalsazrisiT mirebuli Sedegebis klasifikacia da Sefaseba sxvadasxva centrebsi SeiZleba gansxvavebuili iyos. aqedan gamomdinare iseti terminebis 348

ganmartebebi, rogoricaa stabiluroba, xelsayreli/ dadebiti (sasurveli) reaqcia, kavernis daxurva, gaumjobeseba, warumatebloba, saewvo, mkurnalobis Sewyveta da recidivi martivi da yvelasatvis advilad gasagebi da zustad gansazrvruli unda iyos. rentgenologiuri Sefasebis SemTxvevaSi (miuxedavad imisa, rom amas didi mnisvneloba ara aqvs) filtvis dazianebebis xarisxis Sedarebisas, monacemta interpretatori (rentgenologi) unda sargeblobdes saerto nomenklaturit. vinaidan rentgenografiuli firebis kitxvisas ver avicilebt subieqtur interpretacias, rentgenogramebis Sefaseba unda warmoebdes damoukidebeli rentgenologebis jgufis mier, Tu es SesaZlebelia, Tumca aseti Sefasebis Catareba fartomasstabiani kvlevebis dros Zalzed rtulia. aqedan gamomdinare, yvela firs kitxulobs erti rentgenologi, romelic sxvagvarad ar monawileobs kvlevasi. aseti gadawyvetileba Cveulebriv damakmayofileblad itvleba, radgan mtavari mizani pirveli da momdevno rentgenogramebis Sedarebaa. nebismier SemTxvevaSi rentgenografiuli Sefaseba unda Catardes ise, rom ar unda iyos cnobili arc pacientebis monacemebi da arc is, Tu ra mkurnaloba utardeba mas. SeZlebisdagvarad aseve brmad unda Catardes baqteriologiuri da sxva kvlevebis Sedegebis Sefasebac. usedego mkurnalobis, recidivebisa da gardacvalebis mizezebis analizi iseve mnisvnelovania, rogorc efeqtianobis an warmatebis Sefaseba. miuxedavad mirebuli Sedegebisa, detalurad unda iqnes Seswavlili yvela is pacienti, romlis mkurnalobis rejimi Seicvala gverditi movlenebis gamo, an visac xangrzlivi droit Seuwyda mkurnaloba, masinac ki, Tu es erti SexedviT aravitar kavsirsi ar aris mkurnalobastan. mkurnalobis naadrevi Sewyveta toqsikurobis gamo SesaZloa Terapiis nakli iyos. mkurnalobis Sewyveta da medikamentebis araregularuli mireba xsirad SeiZleba miutitebdes calkeuli rejimebis autanlobas da amitom specialur Seswavlas sawiroebs. gamokvlevis Sesaxeb angarisis prezentacia Zalze mnisvnelovania rom kvlevis Sedegebis prezentacia Seicavdes kvlevis gegmisa da misi ganxorcielebis mimoxilvas. 349

anu, angarisi unda moicavdes protokolis ZiriTad sakitxebs, kerzod, kvlevasi pacientta CarTvis kriteriumebs, Sesaswavl rejimebs, randomizaciis metodebs, pacientebis martvastan dakavsirebul sakitxebsa da mkurnalobaze reaqciis Sefasebis Sedegebs. aseve ganxiluli unda iyos kvlevasi CarTuli pacientebis saerto raodenoba, mati ganawileba jgufebsi da pacientebis analizidan gamoricxvis ZiriTadi mizezebi. angarissi arwerili unda iyos cdomilebis armosafxvrelad Catarebuli yvela RonisZieba, imgvarad, rom mkitxvelma SeZlos individualuri gadawyvetilebebis sisworis gansja. sxvadasxva jgufebis Sedarebisas angarissi mocemuli unda iyos cxrilis saxit warmodgenili monacemebi kvlevasi monawile pacientis mdgomareobis Sesaxeb (rogoricaa asaki, sqesi, wona, baqteriologiuri statusi, medikamentebisadmi mgrznobeloba, daavadebis simzime rentgenografiulad da kavernebi). mkurnalobis Sedegebis Sefasebisas satanado yuradreba unda mieqces iseti cvladebis analizsac, romlebic usualod ar aris mkurnalobastan dakavsirebuli, magram garkveul zemoqmedebas axdenen mkurnalobis Sedegebze da relafsis macveneblebze. avtorebma unda moiyvanon sakmaod seriozuli mizezi, radgan daamtkicon, Tu ratom miaweren mkurnalobis gamoyenebul rejimebs ama Tu im efeqts. angarisi iseti saxit unda iyos warmodgenili, rom mkitxveli advilad gaerkves, Tu ra gaketda da rogor. aqedan gamomdinare, satanadod Seafasos Catarebuli kvlevis Rirsebebi. mkitxvelebma sakutari daskvnebis gamotana unda SeZlon mecnierulad dasabutebuli faqtebisa da armocenebis safuzvelze. amitom aris, rom kargad ganxorcielebuli kontrolirebadi kvlevebis Sedegebi aseti damajerebelia da amitom ariareben mat ase fartod da iolad. daskvnebi kontrolirebad kvlevis metods Tavidanve sayoveltao ariareba ar moupovebia. xsirad kamatoben, rom Sedegebis ganzogadebis dros igi ver izleva satanado sizustes, rac ganpirobebulia mteli rigi mizezebit, rogoricaa: sakvlevi jgufebis metismeti sidide da ertmanetisagan Zalze gansxvavebuli adamianebi. individualuri 350

gansxvavebebi SeiZleba imdenad didi iyos, rom ganapirobos araswori ganzogadeba, vinaidan TiToeuli individi gansxvavebulad reagirebs medikamentebze da aqedan gamomdinare, es reaqciebi araprogronizebadia. WeSmaritebaa is, rom asaki, sqesi, metabolizmi, genetikuri da imunologiuri faqtorebi, sacxovrebeli pirobebi, fizikuri da fsiqikuri stresi da sxva garese faqtorebi, romlebic gansazrvraven daavadebis mimdinareobasa da Sedegebs individualuria. amis safuzvelze kontrolirebadi kvlevebis oponentebi askvnian, rom ertnairi SemTxvevebis Sedareba ar unda moxdes da, rom aseti Sedareba arasworia. Tumca aseti daskvna ar itvaliswinebs am metodis umtavres principebs. biostatistikidan kargad aris cnobili 148, rom cvalebadoba cocxali arsebis mtavari maxasiatebelia da aqedan gamomdinare, absoluturad bunebrivi da normaluria. variabeluroba meryeobs gansazrvrul diapazonsi, romlis gansazrvrac statistikuri metodebit SesaZlebelia. magalitad, rodesac mteli rigi dakvirvebebi ert gansazrvrul cvladze warmoebs, randomizirebul jgufsi SeiZleba armocndes, rom mirebuli mnisvneloba mzardi sixsirit jgufdeba erti gansazrvruli mnisvnelobis irgvliv. ganawilebis maxasiateblebi SeiZleba gamoxatuli iyos gazomvadi formit, rac sasualebas mogvcems movaxdinot dakvirvebis erti seriis Sedareba meorestan. aseti saxit mopovebuli informacia sworia yvela sacdeli jgufis mimart. kontrolirebad kvlevebsi ZiriTadad miireba e.w. jgufuri Sedegebi, anu Sedegebi, romlebic sworia mteli jgufisatvis. am Sedegebidan gamomdinare SeuZlebelia winaswar zustad ganvsazrvrot, Tu ra reagirebas moaxdens calkeuli individi im mkurnalobaze, romelic adre testirebuli iyo gansazrvrul jgufsi, magram sakvlevi jgufis msgavsi jgufis reaqcia maqsimaluri sizustit SeiZleba ganisazrvros. mxolod kontrolirebadi kvlevis metodit xdeba SesaZlebeli individualuri gansxvavebebis Sedegebis neitralizacia. aqedan gamomdinare, gansxvavebebi am metodis arasandoobaze ki ar miutitebs, aramed piriqit, mis sasargeblod metyvelebs. meores mxriv cnobilia, rom subieqtur Sexedulebebze dafuznebuli gadawyvetilebebi SeiZleba xsirad araswori iyos. pirad Sexedulebebze dafuznebuli klinikuri codna ra Tqma unda Zvirfasia, magram Sefaseba, magalitad, Terapiuli rejimis, romelic 351

efuzneba mxolod da mxolod intuicias, ar SeiZleba mirebuli iyos skepticizmis garese. bevri eqimi Tavis yoveldriur saqmianobasi xelmzrvanelobs an sakutari klinikuri SexedulebebiT, an naswavli doqtrinebit, romlebic efuzneba sxvebis Sexedulebebs. aseti doqtrinebi, gansakutrebit masin, rodesac isini saxelmzrvaneloebsia mocemuli da sistematiurad imeoreben cnobili maswavleblebi advilad fiqsirdeba adamianis gonebasi formulebis saxit, TiTqos isini damtkicebul faqtebs warmoadgenen. swavlebisa da Seswavlis tradiciuli metodebi gulisxmobs, rom avtoritarul daskvnebs da debulebebs pativi unda vcet da kritikis garese mivirot. studentebi xsirad ireben mat ise, TiTqos isini mecnierulad iyvnen dasabutebuli. avadmyofebis mkurnaloba unda efuznebodes mecnierulad yvelaze dasabutebul codnas. ukanskneli 50 wlis gamcodilebam gvicvena, rom dreisatvis kontrolirebadi kvleva axali mkurnalobis efeqturobaisa da risktan dakavsirebuli sando informaciis mirebis yvelaze swrafi gzaa. is didi progresi, romelsac medicinam miarwia tuberkulozis mkurnalobasi ZiriTadad ganpirobebulia imit, rom mkurnalobis amjamad gamoyenebuli metodebis testireba ganxorcielda kontrolirebadi klinikuri kvelvebis dros. am kvelvebma safuzveli Cauyara standartizaciis procesebs tuberkulozis mkurnalobasi da ganapiroba standartuli rejimebis msoflio masstabit gamoyeneba. 352

68. ra aris molekuluri epidemiologia da ra rols asrulebs igi tuberkulozis kontrolis saqmesi k.derimeri 26 da f.m.smoli 27 ra aris molekuluri epidemiologia molekuluri epidemiologia aertianebs baqteriis calkeuli Stamebis laboratoriuli indentificirebis molekulur metodebs, konversiul epidemiologiur metodebs da miznad isaxavs daavadebis determinantebisa da mati ganawilebis Seswavlas 149. tuberkulozis mikobaqteriis dnm-is peptiduri rukis gansazrvra iseti teqnikis gamoyenebit, rogoricaa SezRuduli sigrzis fragmentis polimorfizmis analizi (RFLP) sasualebas azlevs mkvlevrebs daadginon klinikuri izolatebis genetikuri natesaoba. identuri StamebiT inficirebuli pacientebi SeiZleba ertmanetisgan iyvnen dasnebovnebulni an dasnebovnebis saerto wyaro gaacndet. epidemiologiuri monacemebis konteqstsi SesaZlebelia aqtiuri tuberkulozis transmisiis mtkicebulebata mopoveba. arnisnul teqnologias aqvs SezRudvebi, kerzod jer kidev SeuZlebelia Tvalyuri vadevnot daavadebis gavrcelebas adamianebs Soris, Tuki ar gveqneba TiToeuli individidan arebuli tuberkulozis mikobaqteriis kultura. dnm-is peptiduri rukis analizis ganxorcieleba sawiroebs marali xarisxis kontrols, Sesabamisobas da marali sizustis laboratoriul metodebs. hipotezebis testirebaze ufro mnisvnelovani aris is, rom kvlevis dizani sauketeso saxit Seesabamebodes am hipotezis Semowmebas. 26 infeqciuri daavadebebisa da geografiuli medicinis ganyofilebis wevri. stanfordis universitetis samedicino centri. stanfordi, kaliforniis Stati, ass. 27 profesoris TanaSemwe, infeqciuri daavadebebisa da geografiuli medicines ganyofileba. stanfordis universitetis samedicino centri. stanfordi, kaliforniis Stati, ass. 353

amastan sawiroa sakvlevi nimusebis SerCevis sqemebis mkafiod Camoyalibeba da swori ganxorcieleba. magalitad, Tu ar gveqneba damatebiti epidemiologiuri monacemebi, nimusebis dnm-is peptiduri analizit mxolod SezRudul informacias mivirebt. ra rols asrulebs molekuluri epidemiologia tuberkulozis kontrolis saqmesi tuberkulozis epidemiis kvlevisas molekuluri epidemiologiis metodebi pirvelad gamoyenebuli iqna saewvo epidemiologiuri kavsirebis dadasturebisa da kontrolis RonsiZiebebis eefqturobis demonstrirebis miznit. tuberkulozis kvlevisas im samedicino dawesebulebebsi, sadac motavsebulni iyvnen aiv-inficirebuli pirebi sxvadasxva pacientebidan arebuli Stamebis dnm-is peptidurma analizma Seavso mati gamokitxvit mirebuli informacia da epidemiis mrudma gansazrvra infeqciis wyaro da transmiiis HjaWvi. ufro mnisvnelovania is, rom molekuluri analizi xels uwyobs sazogadoebrivi jandacvis specifikuri miznobrivi intervenciebis efeqtianobastan dakavsirebul rekomendaciebis SemuSavebas da aseve mati obieqturi monitoringis SesaZleblobas izleva. magalitad, skriningi da SemTxvevaTa adreuli gamovlena, mati izolireba mgrznobelobis mqone kontaqtebisgan da prevenciuli mkurnalobis gamoyeneba pacientebtan axlo kontaqtsi myofi adamianebis mimart. dawesebulebebsi, sadac tuberkulozis epidemiam ifetqa, uwyvetmazedamxedvelobam da sakontrolo RonisZiebebma transmisiis jawvi gawyvita 150. ukanasknel wlebsi tuberkulozis epidemiebis kvlevisas dnm-is peptiduri analizi gamoiyeneba, rac tuberkulozis gavrcelebis axali adgilebisa da transmisiis mimartulebis demonstrirebis sasualebas izleva. molekuluri epidemiologiis metodebma gamoavlina tuberkulozis iseti fartod gavrcelebis adgilebi da mimartulebebi, rogoricaa legaluri da aralegaluri gasartobi adgilebi 151,152 mitovebuli saxlebi 153, cixeebi da TavSesafarebi 154,155,156,157 romlebic fartod gamoiyeneba qalaqis usaxlkaro mosaxleobis mier 158,159. dnm-is peptiduri analizit SeiZleba swrafad gamoiricxos epidemiis SesaZlebloba da, aqedan gamomdinare, Tavidan avicilot, rgorc ZviradRirebuli xangrzlivi epidemiologiuri kvlevebi, aseve arasatanado intervenciebi. Zalzed mnisvnelovania 354

tuberkulozis TiToeuli infeqciuri SemTxvevis mkurnaloba da pacienttan efeqturi kontaqtis damyareba Tundac es iyos rtuli, rejimis damrrvevi, araregularuli pacienti. es gamovlinda mciremasstabiani epidemiis dros, romelic ZiriTadad gamowveuli iyo mravali wlis win dasnebovnebul adamianebsi SemTxvevebis indeqsirebit 160. aseti metodebi jandacvis dawesebulebebsi gamoyenebul iqna tuberkulozis transmisiis demonstrirebis miznit. magalitad, pacientis mier pacientis inficireba, pacientidan medicinis musakze transmisia 161,162 aseve medicinis musakis mier pacientebis dainficireba. dafiqsirebul iqna tuberkulozis transmisia arasatanadod sterilizebuli samedicino danisnulebis sagnebisa da aparatebis mesveobit, mag. rogorica bronqoskopi 163,164. am informaciis Rirebuleba is aris, rom igi miutitebs specifikuri institucionaluri da sazogadoebrivi jandacvis intervenciebis aucileblobaze, romelta ganxorcielebac Seamcirebs an SeaCerebs tuberkulozis transmisias. efqturi intervenciebit SesaZlebelia rogorc transmisiis, aseve SemTxvevaTa sixsiris macveneblebis Semcireba. mosaxleobaze orientirebuli molekulur-epidemiologiuri kvlevebi rtulad gansaxorcielebelia, moitxovs dazabul musaobas, didi raodenobit musaxels da ZviradRirebulia. meores mxriv, mati mesveobit SesaZlebeli xdeba problemis arssi Cawvdoma da sazogadoebasi tuberkulozis transmisiis dinamikis Sesaxeb axali codnis mopoveba. magalitad, mosaxleobaze orientirebulma kvlevam, romelic ganxorcielda san-franciskosi (ass) cxadyo, rom tuberkulozis transmisiis macveneblebis Semcireba nawilobriv SesaZlebeli gaxda sazogadoebrivi jandacvis specifikuri intervenciebis gatarebit, rac ass-si dabadebul mosaxleobasi aisaxa baqteriebis klasterebad dayofisa da saerto Stamebis macveneblebis SemcirebaSi 165. san-franciskosi tuberkulozis registrirebuli SemTxvevebis 65% modis ucxoetsi dabadebul adamianebze, kvlevam gvicvena, rom ucxoetsi dabadebulebidan ass- Si dabadebul adamianebze tuberkulozis transmisiis macvenebeli sakmaod SezRudulia da qalaqebsi transmisiis yvelaze didi wili modis iseti risk-faqtorebis mqone individebze, rogoricaa aivinficirebulni, narkotikebis da sxva nivtierebebis momxmareblebi da usaxkaroebi 166. mosaxleobaze orientirebulma molekulurepidemiologiurma 5- wlianma kvlevam, romelic samxret meqsikasi 355

Catarda gvicvena, rom marali prevalentobis qveynebsi DOTS-is danergvis Sedegad bolo periodsi Semcirda SemTxvevebi, transmisiis xarisxi da rezistentoba pirveli rigis preparates mimart, (gamouqveynebeli kvleva, m. garsia-s saxelobis nacionaluri instituti. meqsika). molekulur-epidemiologiuri metodebi Zalzed xelsayrelia laboratoriasi jvaredini dabinzurebis gamosavlenad 167, romelic marali standartis laboratoriebsic ki pozitiuri kulturebis 1-4%-s Seadgens. garda amisa, am metodit gamovlinda egzogenuri reinfeqciebi 168,169 da ertdrouli inficireba tuberkulozis mikobaqteriis ertze meti StamiT 170, anu movlena, romlis arsebobasac varaudobdnen, da romlis dadasturebac mxolod mas Semdeg moxda, rac xelmisawvdomi gaxda tuebrkulozis mikobaqteriis izolatebis dnm-is peptiduri analizis Catareba. amjamad araerti samecniero kvleviti dawesebuleba cdilobs daadginos reinficirebis roli da odenoba tuberkulozis marali prevalentobis mqone qveynebsi. sazogadoebrivi jandacvis intervenciebis potenciuri zemoqmedeba SeiZleba ganisazrvros axladinficirebuli da reinficirebuli pacientebis SefardebiT, xolo amis dadastureba SeiZleba molekuluri epidemiologiis mesveobit. molekuluri-epidemiologiis metodebis sasualebit aseve dadginda, rom arsebobs nacxit uaryofiti pulmonaruli tuberkulozis transmisiis SemTxvevebi da dabali prevalentobis sazogadoebebsi is transmisiis 1/5-s Seadgens 171. molekuluri epidemiologia, sxva tradiciul metodebtan magalitad, tuberkulozis kanis testtan ertad, superinfeqciuri da patogenuri Stamebis gamovlenis SesaZleblobas izleva 172. rogori gamoyeneba eqneba molekulur-epidemiologiur kvlevas momavalsi savaraudoa, rom molekuluri genotipirebis metodi, magalitad, SezRuduli (limitirebuli) fragmentis sigrzis polimorfizmis (RFLP) analizi kvlavac povebs gamoyenebas laboratoriasi jvaredini dabinzurebis mizezebis kvlevisas, aseve recidivisa da egzogenuri reinfeqciis diferencirebisas 173. Tu winaswari molekulurepidemiologiuri analizebi daadastureben, rom tuberkulozis SemTxvevaSi arsebobs Stamebis mixedvit gansxvavebebi, SesaZlebelia 356

moxdes am gansxvavebebis gamokvleva tuberkulozis prevenciisa da kontrolis gaumjobesebis miznit, rac gazrdis molekuluri epidemiologiis rols tuberkulozis kontrolis saqmesi. magalitad, molekuluri epidemiologiuri metodebi SeiZleba gamoyenebuli iqnes tuberkulozis mikobaqteriis infeqciurobisa da patogenurobis xarisxis, specifikuri gansxvavebebis identificirebisatvis. tuebrkulozis mikobaqteriis SedarebiTi genomuri analizit SeiZleba ganisazrvros baqteriuli virulentobis, aerozolizaciis, infeqciurobis, patogenurobis, wamlebisadmi rezistentobis da sxva maxasiateblebis genetikuri determinantebi. molekulurma epidemiologiam da funqcurma genomebma SeiZleba Tavisi wvlili Seitanon axali diagnostikuri teqnikis, metodebis, medikamentebis da SesaZloa, vaqcinebis SeqmnaSic. 357

69. SesaZlebelia Tu ara tuberkulozis kontroli 28 t.frideni 29 zogiert qveyanasi mtkicd swamt, rom tuberkulozi amindis msgavsad SeiZleba ariweros, magram misi kontroli SeuZlebelia. tuberkulozis macveneblebi social-ekonomikuri pirobebis gaumjobesebastan ertad mcirdeba 174,175. am faqtma zogierti mkvlevari miiyvana im araswor daskvnamde, rom tuberkulozis kontrolis ganxorcieleba SesaZlebelia mxolod saarsebo pirobebis gaumjobesebis SemTxvevaSi. Tumca arsebobda Teoriuli dasabuteba 176 da axla praqtikuladac damtkicda, rom tuberkulozis kontroli SesaZlebelia nebismier socialur-ekonomikur vitarebasi 177,178,179 am TavSi ganxilulia daavadebis kontrolis xuti aspeqti avadobis simzime, sikvdilianoba, daavadebis prevalentoba, inficirebis riskis macvenebeli da daavadebis sixsire kontrolis TvalsazrisiT darmavali TanamimdevrobiT. avadobis simzime tuberkulozis avadobis simzime avadmyofobis, Sromisuunarobis da avadmyofobastan dakavsirebuli pirdapiri Tu arapirdapiri xarjebis CaTvliT SeiZleba swrafad Semcirdes, Cqari diagnostikisa da efeqturi mkurnalobis mesveobit. efeqturi mkurnalobis Sedegad SesaZlebelia ara mxolod sikvdilianobis, (rac ufro detalurad qvemot iqneba ganxiluli), aramed avadmyofobis xangrzliobis mnisvnelovnad Semcireba. aranamkurnalebi pacientebi 28 adaptirebuli da dabewdili epidemiologiis internacionaluri Jurnalis nebartvit. 2002w. 31:894-899 29 tuberkulozis SeCerebis ganyofilebis medmusaki, jandacvis msoflio organizaciis regionaluri ofisi. samxret-armosavlet azia, axali deli, indoeti 358

tuberkulozit sasualod ori weli avadmyofoben. efeqturi programit SesaZlebelia tuberkulozze saewvo simptomebis Camoyalibebidan ert TveSi, tuberkulozis SemTxvevebis gamovlena. usualo zedamxedvelobis mokle kursit mkurnaloba ki, srulad aradgens funqcias 1 an 2 TveSi. aqedan gamomdinare, avadmyofobis xangrzlivobis Semcireba SesaZlebelia sasualod 24 Tvidan daaxloebit 2,5 Tvemde anu 90%-iT. SemTxvevaTa gamovlenis globaluri miznis ganxorcielebam SeiZleba Sedegad gamoiros avadobis macveneblebis daaxloebit 2/3-iT Semcireba, masinac ki, Tu mxedvelobasi ar mivirebt daavadebata SemTxvevebis sixsiris Semcirebas (ixilet Tavi: rogoria tuberkulozis kontrolis globaluri miznebi da ras efuzneba isini ), sikvdilianoba tuberkulozis medikamentozuri mkurnaloba usualo zedamxedvelobis qves swrafad amcirebs sikvdilianobas. erti medikamentit mkurnaloba Sedegad izleva sikvdilianobis mnisvnelovan, Tumca xanmokle Semcirebas (naxazi #22) amjamad gamoyenebuli mkurnalobis rejimebi, satanado menejmentis pirobebsi, medikamentebisadmi mgrznobelobis pirobebsi TiTqmis 100%-iani gamojanmrtelebis SesaZleblobas izleva da sikvdilianoba mnisvnelovnad mcirdeba. aranamkurnalebi, nacxit dadebiti pacientebis 50-80% irupeba 180. cudad Catarebul tuberkulozis programasi nacxit dadebiti pacientebis 30% irupeba 181, xolo DOTS-is programis farglebsi sikvdilianobis macvenebeli mteli msoflios masstabit 5%-ze naklebia: 725275 axladgamovlenili nacxit dadebiti pacientidan, romlebsac 1998 wels mkurnaloba CautardaT DOTS-is programit, gardaicvala mxolod 3,8% 182. im qveynebsi, sadac arsebobs sabaziso monacemebi, winaswar aris SesaZlebeli sikvdilianobis Semcirebis gaangariseba, romelic mirwevadia DOTS-is danergvit. perusi ganxorcielda DOTS-is yvelaze maralefeqturi programa(5), romlis Sedegad sam weliwadsi mirweuli iqna sikvdilianobis Semcirebis gamaognebeli macvenebeli 80%. es SesaZlebeli gaxda swrafi diagnostikisa da efeqturi mkurnalobis mesveobit da aseve mkurnalobasi pacientebis Zalian didi raodenobis CarTviT. indoetsi, nacxit dadebit pacientebs Soris sikvdilianobis macvenebeli adre Catarebuli programis 359

farglebsi 20-30%-s Seadgenda, romelic DOTS-is programastan SedarebiT 181, sadac igive macvenebeli 4%-ia TiTqmis Svidjer naklebi iyo. Tu ganvixilavt rogorc nacxit dadebit, aseve nacxit uaryofit SemTxvevebs, DOTS-is programit sikvdilianobis macvenebeli daaxloebit 18%-iT mcirdeba. (gamovlenis gazrdili macveneblisa da meoradi SemTxvevebis sikvdilianobis gamoklebit) 2002 wlis dasawyisisatvis DOTS-is programit, indoetsi mkurnaloba Cautarda 2 milionze met adamians da 350000-ze meti gadarca. CineTSi DOTS-is nacionaluri programit yovelwliurad 50 000-ze met adamians unarcundeba sicocxle 183. grafiki #22 tuberkulozit gamowveuli sikvdilobis Semcireba perusi 1990-1999 sikvdilianobis raodenoba sxvadasxva Sewyvetili mkurnaloba aranamkurnalebi daavadebis prevalentoba SesaZlebelia tuberkulozis prevalentobis swrafad Semcireba. tuberkulozis kontrolis cudad funqcionirebad programasi tuberkulozit daavadebis SemTxvevaTa sixsiris da prevalentobis Sefardeba SeiZleba Seadgendes 1:3,5 184. tuberkulozis globaluri miznebis ganxorcielebis Sedegad prevalentoba mnisvnelovnad Semcirdeba, masinac ki, Tu yvela SemTxvevis mxolod mcired nawils Cautardeba mkurnaloba yovel wels. es modeli mocemulia Zalzedmartivi modelis saxit (nax. #23). naxazze warmodgenilia 360

insidentobisa da prevalentobis dinamika wlebis mixedvit. am modelsi gaketebulia dasveba, rom, rogorc gamovlenis (70% axali nacxit dadebit SemTxvevebis), aseve mkurnalobis warmatebis TvalsazrisiT (85%), dasaxuli miznebi Sesrulda, rom nacxit dadebiti prevalenturi da insidenturi SemTxvevebis naxevars yovelwliurad utardeba mkurnaloba. Tu warmatebuli mkurnalobis macvenebeli 85%-ia, es nisnavs rom usedego mkurnalobis procentuli Sefardeba daaxloebit isetivea, rogoric DOTS-is globalur programasi 182 da, daavadebis SemTxvevaTa sixsiris macvenebeli yovelwliurad 5%-iT iklebs. rogorc xedavt prevalentoba Zalian swrafad mcirdeba da daaxloebit sam weliwadsi miarwevs Zveli macveneblebis naxevars. programis ganxorcielebis pirobebsi am Teoriuli modelis sizuste dadasturda rogorc ganvitarebul, ise ganvitarebad qveynebsi. yofili Cexoslovakiis qalaq kolinsi zedamxedvelobisa da kontrolis intensiurma programam 100 000 mosaxlesi qronikuli tuberkulozis 185 prevalentoba 33%-ze metit Seamcira yovel ert weliwadsi 3 wlis manzilze, rac Seadgens Zveli macveneblebis 1/ 4-ze cota naklebs. pozitiuri pacientebis raodenoba niu-iorksi 3 weliwadsi 2/3- it Semcirda, rac yovelwliurad 30%-s Seadgens 186,187. amis dokumenturad dadastureba SesaZlebeli iyo, radgan monitoringis sistema afiqsirebda TiTqmis yvela pacients, romelsac baqteriologiuri testit armoacnda tuberkulozi. pekinsi, rogorc amas TemSi Catarebuli kvlevebi gvicvenebs 177, nacxit dadebiti SemTxvevebis prevalentobam 1979-1990 wlebis periodsi 87%-iT iklo anu 127 SemTxveva yovel 100 000 mosaxleze davida 16 SemTxvevamde yovel 100 000 mosaxleze. e.i. arinisna 17%-iani Tanamimdevruli myari kleba yovelwliurad 11 wlis ganmavlobasi 188. infeqciurobis magvenebeli tuberkulozis mikobaqteriit inficirebuli pacientebis raodenoba tuberkulozis mikobaqteriit inficirebis xarisxi gansazrvravs sazogadoebasi epidemiis mimdinareobas, amitom tuberkulozis 361

xangrzlivi kontrolis TvalsazrisiT infeqciis macveneblis kleba Zalzed mnisvnelovania. tuberkulozis baqteriit inficirebis riski ganvitarebuli ekonomikis mqone qveynebsi jer kidev qimioterapiis SemoRebamde daaxloebit 5%-iT Semcirda. efeqturi mkurnalobis danergvis Semdeg inficirebis macvenebelma wliurad 15%-iT 189 da metitac iklo. ganvitarebad qveynebsi ki, piriqit, tuberkulozit inficirebis riski Zalzed mcired, an TiTqmis ar iklebs. mdgomareoba ar Seicvleba, vidre am qveynebsi satanado doneze ar ganxorcieldeba tuberkulozis efeqturi mkurnaloba. tuberkulozis efeqturi mkurnaloba swrafad amcirebs inficirebis risks. Teoriulad ganvitarebad qveynebsic ki, SesaZlebelia inficirebis riskis Semcireba weliwadsi 10% da metit 176. logikuria, rom aseti kvlevebis Catareba sirtuleebtan aris dakavsirebuli da drota ganmavlobasi ufro gartuldeba tuberkulinis testis interpretaciastan dakavsirebuli problemebis gamo. koreasi Catarebulma ert-ertma kvlevam gamoavlina tuberkulozit inficirebis riskis Semcireba 8-14%, miuxedavad imisa, rom warmatebuli mkurnalobis macvenebeli ar iyo 85% 190. BCG vaqcinaciis mudmivi macveneblis SemTxvevaSi, Cvil bavsvebsi tuberkulozuri meningitit daavadebis sixsire asaxavs inficirebis riskis wliur macvenebels. 1986-1996 wlebsi pekinsi tuberkulozuri meningitis macvenebeli 2,1-dan 0,1-mde Semcirda yovel 100 000 mosaxleze, macveneblis Semcireba Seadgens 26%-s weliwadsi 188. garkveulwilad es Semcireba vaqcinaciis praqtikis gaumjobesebis Sedegs warmoadgens. tuberkulozit daavadebis SemTxvevaTa sixsire tuberkulozit daavadebis sixsire Sedgeba: - tuberkulozis recidivebi pacientebsi, romlebsac warsulsi hqondat avadmyofobis epizodebi; - tuberkulozis daavadebis swrafi progresi inficirebul an SedarebiT mokle periodsi (2 weliwadsi) reinficirebul individebs Soris - mravali wlis win SeCerebuli tuberkulozis infeqciis gaaqtiureba. 362

molekuluri epidemiologiis bolodroindelma mirwevebma tradiciul epidemiologiur kvlevebtan ertad xeli Seuwyo TiToeuli zemot moyvanili jgufidan armocenebuli SemTxvevebis Tanafardobis gansazrvras, romelic drota ganmavlobasi SeiZleba gansxvavdebodes. magalitad, tuberkulozis epidemiologiis Semswavlel mravalaspeqtian kvlevasi, romelic 1972 wels samxret indoetsi ganxorcielda, gamovlinda, rom yvela nacxit dadebiti SemTxvevis mxolod 37% gamovlinda mkurnalobis dawyebamde normaluri rentgenogramis mqone individebsi. 12 wlis manzilze mati fraqcia 2/3 gaizarda da Tanafardoba pacientebtan, visac mkurnalobis dawyebamde kultura-negatiuri tuberkulozis Sesabamisi surati hqonda 33%dan 8% Semcirda. es Seesabameba tuberkulozis ganvitarebis wliuri riskis Semcirebas 7%-dan 3,2%-mde seriozuli darrvevebis amsaxveli rentgenogramis mqone pirebsi 184, rac metyvelebs, rom mat CautardaT rarac saxis, Tundac nawilobrivi mkurnaloba. bolo periodsi norvegiasi Catarebulma kvlevam gvicvena, rom 5-dan ertze nakleb pacients uvitardeboda tuberkulozi axali inficirebis Sedegad. SemTxvevaTa udidesi raodenoba ganpirobebuli iyo Zveli infeqciit an tuberkulozis recidivit 191. tuberkulozis SemTxvevaTa sixsiris kontroli aiv-koinfeqciit an mis garese didad aris damokidebuli adgilobriv epidemiologiaze, ertis mxriv, gvaqvs situacia, rodesac tuberkulozis SemTxvevebis udidesi umravlesoba ganpirobebulia Zveli inficirebit da mati prevencia arsebuli teqnologiebit SeuZlebelia. isini ver gaxdebian prevenciul mkurnalobis kandidatebi da im SemTxvevaSic ki, Tu aseti prevenciuli mkurnaloba Catardeba misi warmateba garantirebuli ar aris (ix. Tavi: ra danisnuleba aqvs latenturi tuberkulozis infeqciis mkurnalobas tuberkulozis kontrolis programasi ). meore mxriv, warmodgenilia mosaxleoba, romelta Soris tuberkulozis SemTxvevebis naxevari ganpirobebulia axali infeqciit an reinfeqciit wina ori wlis ganmavlobasi. am konteqstsi tuberkulozis kontrolis efeqturma RonisZiebebma SeiZleba ganapirobos tuberkulozis SemTxvevebis swrafi Semcireba. magalitad, niu-iorksi tuberkulozit daavadebis SemTxvevaTa sixsire ass-si dabadebul pirta Soris 5 wlis ganmavlobasi (1992-1996w.w) 25%-iT Semcirda weliwadsi. multirezistentuli 363

tuberkulozis SemTxvevaTa sixsire, romelic ZiriTadad dakavsirebuli iyo samedicino dawesebulebasi transmisiastan, wliurad drois igive periodsi 34%-iT Semcirda 192. amis msgavsad san-franciskosi Catarebuli kvlevit dafiqsirda, rom SemTxvevaTa 1/3-ze meti ganvitarda axlo warsulsi transmisiis Sedegad. kontrolis gaumjobesebuli RonisZiebebiT SemTxvevebis saerto macveneblma 7%-iT iklo weliwadsi. klasterirebul SemTxvevaTa macvenebeli 15%-iT Semcirda weliwadsi, masin rodesac araklasterirebuli SemTxvevebis macvenebeli Semcirda mxolod 5%-iT weliwadsi 193. 1991-1997 w.w. molekuluri epidemiologiuri kvlevit niu-iorksi tuberkulozis SemTxvevaTa prognozirebuli raodenobis 26% Semcireba dafiqsirda. ganvitarebad qveynebsi Catarebuli reprezentaciuri kvlevebis SezRuduli raodenoba gvicvenebs, rom uaxloes warsulsi inficirebit gamowveuli axali SemTxvevebi 29%-48% SeiZleba meryeobdes da efeqturi mkurnalobis gamoyenebit swrafad SeiZleba Semcirdes 194,195,196,197. drois garkveul periodsi SeiZleba Zveli procesis reaqtivaciit gamowveuli SemTxvevebis mnisvnelovani Semcirebac. masasadame, Teoriuli TvalsazrisiT, ganvitarebad qveynebsi SesaZlebeli unda iyos SemTxvevaTa sixsiris kontroli. es prognozi gamocdilebis safuzvelze gaketda. ganvitarebad qveynebsi, sadac mkurnalobis efeqturi praqtika jer ar aris danergili 184, tuberkulozis SemTxvevaTa sixsire statikur mdgomareobasi rceba da piriqit, tuberkulozis kontrolis efqturi RonisZiebebis gamoyenebisas tuberkulozis SemTxvevaTa sixsire swrafad mcirdeba. 1986-1996w.w. pekinsi 188, rodesac Setyobinebis macvenebeli Zalze marali da mudmivi iyo, axali nacxit dadebiti SemTxvevebis 90%-iani yovelwliuri Semcireba dafiqsirda. kubasi, mkurnalobis efeqturi organizaciit, axali nacxit dadebiti SemTxvevebis macvenebeli 26 wlis ganmavlobasi 179 yovelwliurad 10%-iT Semcirda. perusi tuberkulozis SemTxvevebi daaxloebit 8%-iT Semcirda wliurad(5). 8-10%-ianma wliurma Semcirebam SemTxvevaTa raodenoba 7 weliwadsi SeiZleba naxevramde daiyvanos. amgvarad aiv-infeqciis epidemiis ararsebobis SemTxvevaSi, tuberkulozit daavadebianobis sixsire mnisvnelovnad SeiZleba Semcirdes ganvitarebad qveynebsic ki. 364

tuberkulozis kontroli aiv-infeqciastan konteqstsi aiv-epidemia Zirs utxris tuberkulozis kontrols da mainc, aiv-inefqciastan mimartebasi tuberkulozis kontrolis efeqturi programis SemuSavebiT SesaZlebelia tuberkulozit gamowveuli avadobis tvirtis, sikvdilianobis, prevalentobisa da savaraudod inficirebis macveneblis kontrols daqvemdebareba. Tumca es SeiZleba gaketdes mxolod udidesi Zalisxmevisa da Secdomebis minimumamde dayvanis mesveobit. imis gamo, rom tuberkulozit inficirebul pacientebsi baqteriis reaqtivaciis mzardi safrtxe arsebobs da aseve tuberkulozis swrafi da fartomasstabiani gavrcelebis safrtxe arsebobs aivinficirebul mosaxleobasi, msoflios umetes regionebsi tuberkulozis insidentoba gaizrdeba, Tu aiv-inficirebulta raodenoba mosaxleobasi 5% metia. tuberkulozis kontrolis efeqtur programas unari Seswevs Searbilos aseti zrdis efeqti da Tavidan agvacilos multirezistentuli tuberkulozis gavrceleba. problema mxolod is ki ar aris, rom mravali wlis win SeZenili infeqciis gamo daavadebianobis sixsire izrdeba, aramed isic, rom tuberkulozit daavadebuli TiToeuli pacienti individualurad xels uwyobs meoradi SemTxvevebis gazrdas, vinaidan axlo kontaqtsi imyofeba imunosupresiis mqone adamianebtan. tuberkulozis afetqebis mkvetri zrda arinisneba msoflios im regionebsi, sadac aiv-endemuri infeqciaa. aseti zrda mnisvnelovnad dabalia iq, sadac funqcionirebs tuberkulozis kontrolis efeqturi samsaxurebi 198. am TvalsazrisiT garkveulwilad mnisvnelovania tanzaniis gaertianebuli respublikis gamocdileba. miuxedavad imisa, rom qveyana aiv-epidemiis centrsi imyofeba, ukanaskneli 15 wlis ganmavlobasi inficirebis wliuri riskis sistematiuri kvlevebit gamovlinda inficirebis stabiluri macveneblebi da mati umnisvnelo klebac ki (2%-iT weliwadsi) 199. es gvafiqrebinebs, rom tuberkulozis kontrolis efeqtur programas Cqari diagnostikis da efeqturi mkurnalobis mesveobit SeuZlia SezRudos meoradi infeqciebisa da SemTxvevebis raodenobis zrda. Teoriulad dasasvebia, rom tuberkulozis infeqciis mqone aivinficirebuli pacientebis prevenciuli mkurnalobit SesaZlebelia Semcirdes aiv-infeqciis zegavlena tuberkulozis epidemiologiaze. 365

ramdenadac ganvitarebad qveynebsi aiv-inficirebul individta umetesma nawilma araferi icis sakutari infeqciuri statusis Sesaxeb da arsebobs materialur-teqnikuri sirtuleebi didi raodenobit iseti pacientebis mkurnalobit uzrunvelyofsi, romlebsac simptomebi ara aqvt Camoyalibebuli (ixilet Tavi: ra rols asrulebs latenturi tuberkulozis mkurnaloba tuberkulozis kontrolis programasi ), praqtikulad latenturi tuberkulozuri infeqciis mkurnaloba SeiZleba Semoifarglos mxolod individebit da ver miiros sazogadoebrivi jandacvis intervenciis saxe. niu-iorkis magaliti gvicvenebs, rom aiv-infeqciastan konteqstsi tuberkulozis epidemiis kontroli SesaZlebelia im regionebsic ki, sadac multirezistentoba fartodaa gavrcelebuli 175. es mirweul iqna swrafi diagnostikit, maralkvalificiuri laboratoriuli saqmianobit, mkurnalobis standartizebuli rejimebit, usualo metvalyureobis mkurnalobis standartis saxit gamoyenebit da mkacri kohortuli angarisgebit, romelic moicavda angariss TiToeuli diagnostirebuli SemTxvevebis Sesaxeb. garda amisa, saavadmyofoebsic Semcirda tuberkulozis gavrceleba (ixilet Tavi: ras nisnavs tuberkulozis nozokomialuri gavrceleba da rogor avicilot is ). Tumca, niu-iorksi aiv-infeqciis prevalentoba mozrdil mosaxleobasi albat, ar aremateboda 3%, afrikis im qveynebtan SedarebiT, sadac igive macvenebeli 30%-ze metia. daskvnebi kontrolis uzrunvelyofa tuberkuloztan brzolis ufro zomieri mizania, vidre daavadebis absolutur minimumamde dayvana an armofxvra. termini absolutur minimumamde dayvana nisnavs mosaxleobis ert milionze tuberkulozis mxolod ert axal SemTxvevas weliwadsi anu tuberkulozit inficirebis 1%-ze nakleb prevalentobas mtels mosaxleobasi 200. amis mirweva damatebiti mowinave teqnologiuri sasualebebis SemuSavebis garesec SesaZlebelia, zogiert ganvitarebul qveyanasi uaxloes 20-50 weliwadsi. Tumca, vidre tuberkulozis kontroli yvela qveyanasi ertiani ZalisxmeviT ar ganxorcieldeba migraciam da tuberkulozis maralma macvenebelma sxva qveynebsi SeiZleba xeli SeuSalos amas. armofxvra ganisazrvreba, rogorc iseti mdgomareobis mirweva, 366

grafiki #23 nacx-poziciuri tuberkulozis dinamika globaluri miznebis ganxorcielebis SemTxvevaSi SS+ =naxvelis nacxit dadebiti (1 mln mosaxleoba; tuberkulozit daavadebis SemTxvevaTa sixsire = 100/100.000) 367

rodesac tuberkulozis SemTxvevebi arsad ar iqneba da misi kontrolis RonisZiebebi sawiro arar iqneba. amjamad situacia namdvilad ar izleva armofxvris RonisZiebebis gatarebis SesaZleblobas. aqedan gamomdinare, pasuxi kitxvaze, SesaZlebelia Tu ara tuberkulozis kontroli aris diax - Tu daculi iqneba mecnieruli principebi, ganxorcieldeba klinikuri da sazogadoebrivi jandacvis Sida da saertasoriso seqtorebis efeqturi menejmenti mimartuli tuberkulozis kontrolis koordinaciaze. es brzolaa, romlis mogebac SesaZlebelia. 368

70. SesaZlebelia Tu ara SemTxvevaTa gamovlenis da mkurnalobis mesveobit medikamentebisadmi rezistentobis prevencia da ukuqceva sazogadoebasi m.ravilione 30 1994-1997 wlebsi janmos mier ganxorcielda multirezistentuli tuberkulozis (MDR-TB) prevalentobis kvleva 35 qveyanasi. armocnda, rom multirezistentuli tuberkulozis prevalentoba dakavsirebulia tuberkulozis programis kontrolis xarisxtan 201. qveynebi klasificirdebodnen or jgufad: tuberkulozis kontrolis efeqturi da naklebad efeqturi programis mqone qveynebad. efeqturi kontroli itvaliswinebda DOTS-is programit mosaxleobis srul mocvas, ukidures SemTxvevaSi qveynis mteli teritoriis erti mesamedis mocvas, an tuberkulozis 10-ze nakleb registrirebul SemTxvevas yovel 100 000 mosaxleze. nebismieri qveyana, sadac DOTS ar xorcieldeba, an moicavs misi teritoriis ert mesamedze naklebs_ ganekutvneba naklebad efeqturi tubkontrolis programis mqone qveynebis rigs. analizma gamoavlina, rom qveynebsi, sadac tuberkulozis kontrolis efeqturi programa funqcionirebda, arinisneboda MDR-TB-is ufro dabali prevalentoba, vidre iq sadac tuberkulozis kontrolis programa naklebad efeqturi iyo. (1,6%-3,9%-Tan SedarebiT, P<0,05). aseve, MDR-TB-is prevalentoba SedarebiT dabali iyo namkurnaleb pacientebsi im qveynebsi, sadac xorcieldeboda tuberkulozis kontrolis efeqturi programa (7,7%-17%-Tan SedarebiT), Tumca MDR-TB-is prevalentoba axladgamovlenil SemTxvevebSi ertnairi iyo qveynebis orive kategoriasi. 30 tuberkulozis strategiisa da operaciebis kordinatori. tuberkulozis SeCerebis departamenti, jandacvis msoflio organizacia. Jeneva, Sveicaria 369

meore kvlevasi Seswavlis sagani iyo programis Sesrulebasa da medikamentebisadmi rezistentobis prevalentobas Soris urtiertkavsiri 202. es kvleva Catarda qveynebsi, romelsac hqondat sando monacemebi, rogorc medikametebisadmi rezistentobis, aseve mkurnalobis Sedegebis Sesaxeb. mkurnalobis warmatebis macvenebeli, rogorc tuberkulozis kontrolis programis funqcionirebis sauketeso gamoxatuleba, proporciul damokidebulebasi, MDR-TB-is prevalentobastan. martlac, im qveynebsi sadac mkurnalobis warmatebis macvenebeli maralia, MDR-TB-is prevalentobis macvenebeli SedarebiT dabalia da es urtiertkavsiri statistikurad mnisvnelovania (r 2 =0,5, p=0,03). zogiert qveyanasi, sadac mkurnalobis warmatebis macvenebeli kvlevis Catarebis periodsi marali iyo, magalitad, perusi da vietnamsi, MDR-TB-is prevalentoba zomierad marali rceboda (2-3%). es SesaZloa ganpirobebuli iyo imit, rom DOTS-is programis danergvis Semdeg jer kidev arsebobda Zveli, susti programebis Sedegad warmosobili MDR-TB-is SemTxvevebi. es dakvirvebebi gvafiqrebinebs, rom tuberkulozis satanadod ganxorcielebuli kontrolis mesveobit, iseve rogorc es mirweuli iqna DOTS-is programit, SesaZlebelia MDR-TB-is warmosobis minimalur doneze Sekaveba, iq, sadac igi jer ar arsebobs. afrikis isetma qveynebma, rogoricaa benini, bocvana da kenia, romlebmac rifampicinis gamoyeneba mkurnalobis standartul mokle kurssi tuberkulozis kontrolis ganxorcielebastan ertad daiwyes (upiratesad 1983, 1986 da 1996) miarwies kidec gankurnebis maral macveneblebs. minimumamde iqna dayvanili MDR-TB-is warmosobisa da gavrcelebis macveneblebi. msgavsad imisa, latinuri amerikis qveynebsi_ Cile, kuba da urugvai_sadac tradiciulad funqcionirebs tuberkulozis kontrolis marali efeqturobis programebi da mkurnaloba pacientebis udides nawils utardeba, dresdreobit MDR-TB-is Zalzed dabali donea. meore mxriv, iset qveynebsi, rogoricaa spilos Zvlis sanapiro, dominikis respublika, estoneti, latvia, rusetis federacia da tailandi, sadac, rifampicini fartod gamoiyeneboda tuberkulozis kontrolis programebis gazlierebamde, MDR-TB-is prevalentoba ufro maralia. aqedan gamomdinare, tuberkulozis efeqturi kontroli xels uslis MDR-TB-is 370

gavrcelebas. situacia SeiZleba gansxvavebuli iyos iset dasaxlebebsi, sadac MDR-TB-is ukve fartodaa gavrcelebuli. rig SemTxvevebSi miacniat, rom janmosa da IUATLD-is mier rekomendirebuli mkurnalobis standartuli rejimebis mteli qveynis masstabit danergva ganapirobebs MDR-TB-is prevalentobis TandaTanobiT Semcirebas. faqtiurad bevri pacientis gankurnebaa SesaZliebeli, im SemTxvevaSic ki, Tu isini inficirebulni arian multirezistentuli tuberkulozis StamebiT: mati nawili (25-30%) spontanurad ganikurneba, zogierti matgani swrafad dairupeba da Sewyvets sxvebis inficirebas 203. ass-si arsebuli monacemebi gvicvenebs, rom specializebuli da individualizebuli mkurnalobit SesaZlebelia pirveladi multirezistentuli tuberkulozit daavadebuli pacientebis SedarebiT didi nawilis gankurneba da amrigad mati gamoricxva infeqciis matarebelta ertobliobidan. Tumca drois monakveti infeqciasasisi mdgomareobidan naxvelis konversiamde an infeqciis wyaros gardacvalebmde sakmaod xangrzlivia. masasadame, imis dasveba, rom MDR-TB-is daavadebuli pacientebis didi nawili inkurneba an maleve irupeba (da aqedan gamomdinare, Sewyveten infeqciis gavrcelebas) ar aris swori. ass-i, sadac aseti varaudi iqna gamotqmuli, mkurnalobis ZviradRirebuli individualuri rejimebic da qirurgiuli Carevac ufri xelmisawvdomia, vidre bevr sxva qveyenasi. ganvitarebad qveynebsi, mkurnalobis standartuli mokle kursis gamoyeneba DOTS-is programis Semadgeneli nawilis saxit, pacientebis ufro did raodenobas moicavs. armocnda, rom mxolod izoniazidisadmi an streptomicinisadmi rezistentuli tuberkulozis umetesi SemTxvevebis gankurneba SesaZlebelia standartuli pirveli rigis rejimis gamoyenebit. izoniazidisadmi rezistentuli tuberkulozis 6-Tviani mkurnalobis Semdeg warumateblobis macvenebeli mxolod 1%-s Seadgenda, xolo recidivis macvenebeli 11% 204. warumateblobis asetive dabali macvenebeli (0-2%) iqna mirebuli klinikur kvlevebsi, rodesac izoniazidisadmi an streptomicinisadmi rezistentuli Stamebis mqone pacientebis mkurnalobisas sul mcire 6-Tvian kurss iyenebdnen 205. tuberkulozis kontrolis nacionaluri programebis mier ukanasknel periodsi janmosatvis warmodgenili monacemebidan Cans, rom erti medikamentisadmi (garda rifampicinisa) rezistentuli 371

Stamis mqone pacientebsi mkurnalobis moklevadiani kursis gamoyenebisas gankurnebis macveneblebi didad ar CamorCeba im pacientebis macveneblebs, romlebsac sruli mgrznobeloba aqvt. perusi mgrznobelobis mqone pacientebis 90% (1029/1145) da erti medikamentebisadmi rezistentobis mqone pacientebis 87% (105/121) gankurnebuli iqna pirveli rigis medikamentebit (P=0,27). koreis respublikasi macveneblebi iyo 85% (1668/1968) da 80% (104/129; P=0,11). am monacemebis safuzvelze SeiZleba itqvas, rom mkurnalobis moklevadiani kursis gamoyenebit SesaZlebelia monorezistentulobis SemTxvevaTa umetesi nawilis mkurnaloba. Tumca, mkurnalobis warmatebis macvenebeli rifampicinrezistentul da MDR-TB-is SemTxvevebiT gacilebit dabalia. perusa da koreasi warmatebis macvenebeli MDR-TB-is SemTxvevaSi 58% da 50% Seadgenda, rac mnisvnelovnad dabalia mgrznobelobismqone SemTxvevebTan SedarebiT (P<0,001 orive qveyanasi). kvlevasi, romelsic ramodenime centri monawileobda da moicavda eqvs regions (dominikianelta respublika, hong-kongis specialuri administraciuli regioni CineTSi, italia, peru, koreis respublika da rusetis federaciis ivanovos olqi) mkurnalobis warmatebis sasualo macvenebeli axal MDR-TB-is SemTxvevebisaTvis Seadgenda 52%, warumateblobis sasualo macvenebeli 21%, sikvdilianobis macvenebeli zogadad 10%-ze naklebi iyo 206. aqedan gamomdinare, namdvilad SesaZlebelia arsebobdes gansazrvruli reaqcia pirveli rigis wamlebit mkurnalobaze, Tumca warumateblobis macvenebeli Zalzed maralia. kvlav ismis kitxva, sakmarisia ki axlad- gamovlenil MDR-TB pacientebs Soris mkurnalobis warmatebis 50%-iani macveneblis mirweva da fatalur SemTxvevaTa SedarebiT dabali macveneblebis SenarCuneba mkurnalobis warumateblobis marali donis CarCoebSi, imistvis rom MDR-TB armoifxvras. qveynis masstabit MDR-TB-is prevalentobis tendenciebi DOTSis kargad organizebuli programis pirobebsi usualod pasuxobs kitxvas. am TvalsazrisiT, ganvitarebadi qveynebidan Zalzed mcire monacemebia mirebuli, Tumca koreis respublikis 207,208,209 monacemebi tendenciebis Sesaxeb sakmaod TvalsaCinoa. rezistentuli tuberkulozis SemTxvevebis yvela gaangarisebuli raodenoba nelnela iklebda 1965-1980 wlebsi. xolo 1980-1985 wlebsi mkvetri progresireba ganicada. MDR-TB-is SemTxvevaTa raodenoba gaizarda 372

1975-1985 wlebsi, magram 1990-1995 wlebis macvenebeltan SedarebiT dabali iyo. yvela rezistentuli SemTxvevis da mat Soris MDR- TB-is SemTxvevebis raodenobis kleba emtxveva koreis respublikasi gankurnebis macveneblebis swraf zrdas, gansakutrebit 1980-1985 wlebsi. ra Tqma unda, es ar aris sakmarisi imis dasamtkiceblad, rom kargad organizebuli programis pirobebsi pirveli rigis medikamentebis gamoyeneba ukuaqcevs MDR-TB, magram es monacemebi imis safuzvlebs izleva, rom vifiqrot efeqturi mkurnaloba axali MDR-TB-is SemTxevevbis warmoqmnis prevenciit zemoqmedebas axdens zogadad MDR-TB-is problemis Semcirebaze. medikamentebisadmi rezistentobis tendenciebi Seswavlil iqna aljirsic. aljiris 210 regionsi 1965-1990 wlebsi axal SemTxevvebSi medikamentebisadmi rezistentoba 15%-dan 5,2%-mde Semcirda, xolo ganmeorebiti mkurnalobis SemTxvevebSi 81,9%-dan 21%-mde. aseti kleba daemtxva ori mnisvnelovani politikuri cvlilebis gatarebas: 60-iani wlebis bolos mkurnalobis standartuli rejimebis danergvas da 1980 wels rifampicinis Semcveli mkurnalobis SemoRebas. Tumca daiklebda Tu ara MDR-TB, es cvlilebebi rom ar ganxorcielebuliyo cnobili ar aris, vinaidan ar gagvacnia informacia adre arsebuli tendenciebis Sesaxeb. ganmeorebiti mkurnalobis rejimis SemTxvevaSi MDR-TB-is 1985 da 1986-1990 wlebsi tendenciebsi cvlilebebi ar arinisneboda arc SemTxvevaTa raodenobis, arc procentuli macveneblebis TvalsazrisiT (11% da 11,5%). rogorc aljiris, aseve koreis respublikis gamocdileba gvicvenebs, rom pirveli rigis medikamentebis gamoyenebit SesaZlebelia MDR-TB-is SemTxvevebis Semcireba, magram ara armofxvra. bolo periodsi bobo-diolasosa da burkina fasosi 1992-1994 wlebsi Catarebulma kvlevam cxadyo, rom 1989 wels mkurnalobis mokle kursis danergvam da gaumjobesebuli superviziis da metvalyureobis qves mkurnalobis politikis ganxorcielebam ganapiroba medikamentebisadmi, mat Soris rifampicinisadmi, rezistentobis gavrcelebis Semcireba SedarebiTi 1978-1986 wlebsi Catarebuli kvlevis monacemebtan. samwuxarod, ar moipoveba monacemebi MDR-TB-is tendenciebis Sesaxeb 211. niu-iorkis gamocdileba gvicvenebs, rom MDR-TB-is kontroli SesaZlebelia 212. 1991-1992 da 1994 wlebsi, mas Semdeg rac ganxorcielda kontrolis efeqturi RonisZiebebi, MDR-TB-is 373

SemTxvevebis raodenoba TiTqmis ganaxevrda (44%-iani kleba), 1992-1997 wlebsi MDR-TB-is SemTxvevebis raodenoba 85%-ze metit Semcirda. kontrolis RonisZiebebi moicavda usualo metvalyureobit mkurnalobas, ramac uzrunvelyo mkurnalobis dasrulebis marali macveneblebi, aseve infeqciis kontrolis intervenciebs iseti mwidro TavSeyris adgilebsi, rogoricaa saavadmyofo, sakani da usaxlkarota TavSesafari da mkurnalobis adekvaturi rejimebis gamoyenebas, rogorc mgrznobelobis mqone, aseve MDR-TB-is SemTxvevaSi (am ukanasknelis SemTxvevaSi, warmatebis marali macveneblebis misarwevad gamoiyeneboda sarezervo medikamentebi). niu-iorkis gamocdilebidan SesaZlebelia Semdegi daskvnebis gaketeba: kargad organizebulma mkurnalobam pirveli rigis medikamentebit gazrda gankurnebis macveneblebi mgrznobelobis mqone, ara MDR-TB-is SemTxvevebSi, daketa onkani da Sewyvita SeZenili MDR-TB-is generireba. aman Seamcira MDR-TB-is Stamebis gavrceleba, ramac xeli Seuwyo pirveladi MDR-TB-is klebas. amastan ganxorcielda MDR-TB-is arsebuli SemTxvevebis mkurnaloba sarezervo medikamentebit ( avzis dacla xdeba ). yovelive aman, saavadmyofos Sida infeqciebis kontrolis efeqtur RonisZiebebTan ertad mnisvnelovnad Seamcira MDR-TB-is gavrceleba. natelia, rom sarezervo medikamentebis garese SeuZlebeli iqneboda, MDR-TB-is SemTxvevaTa Soris gankurnebis 50%-ze marali macveneblebis mirweva. gankurnebis marali macveneblebis garese ki MDR-TB-is gavrcelebis swrafad Sewyveta an misi armofxvra uaxloes ramodenime weliwadsi SeuZlebeli gaxdeba. da bolos, dres arsebuli informacia tuberkulozis mkurnalobis moklevadiani kursis efeqturobis Sesaxeb gvicvenebs, rom medikamentebisadmib rezistentobis ganvitareba SeiZleba minimumamde iqnes dayvanili iseti programebis mesveobit, romlebic uzrunvelyofen pacientebis mier medikamentebis sworad mirebas da arweven gankurnebas. Tumca DOTS-is programit rekomendirebuli mkurnalobis rejimebi MDR-TB-is gavrcelebas swrafad ver amcirebs, Tu igi ukve Camoyalibda rogorc seriozuli problema. MDR-TB-is absolutur minimumamde dayvanis mnisvnelovani faqtoria mkurnalobis warmateba: rac ufro maralia rogorc mgrnobelobis mqone, aseve MDR-TB-is SemTxvevebis gankurnebis macvenebeli, mit naklebia MDR tuberkulozis armocenebis SesaZlebloba. MDR-TB- 374

is gankurnebis marali macvenebeli garantias izleva, rom MDR-TB arar ganvitardeba, amis Sedegad Semcirdeba aseve pirveladi MDR-TB-is SemTxvevebic. imavdroulad, arsebuli MDR-TB-is gankurnebis macveneblebis zrda, sazogadoebasi infeqciis transmisiis wyaros armofxvris. 375

71. ra magvenebeli aqvs tuberkulozis kontrolis efeqtur programas f.luelmo 31 da t.frideni 32 macveneblebit izomeba procesi, klinikuri gamosavali da zemoqmedeba. mati mesveobit izomeba is elementebi, romlebic aucilebelia saqmianobis gansaxorcieleblad, am saqmianobis masstaburoba, xarisxi da Sedegebi. isini unda warmoadgendnen programis gansakutrebulad mnisvnelovani elementebis markerebs. radgan epidemiologiuri (zemoqmedebis) indikatorebi Zalze nela icvleba da mati gazomva rtulia, efeqtianobis Sefasebis miznit xsirad gamoiyeneba procesisa da Sedegebis operatiuli macveneblebi. procesis magveneblebi tuberkulozis programis upirvelesi mizania tuberkulozis infeqciuri SemTxvevebis gamovlena transmisiis, sikvdilianobisa da avadobis Sesamcireblad. amis misarwevad programa sawiroebs zogadi profilis samedicino dawesebulebebisa da mosaxleobistvis xelmisawvdomi laboratoriebis dakompleqtebas satanado momzadebis mqone personalit, aseve medikamentebita da samedicino danisnebulebis iseti sagnebit uzrunvelyofas, rogoricaa tubsawinaarmdego wamlebi da mikroskopebi. Sesabamisi procesis administrirebis macveneblebi gulisxmobs: programuli RonisZiebebiT mocvas (rogoricaa mosaxleobis is nawili, romelsac gaacnia diagnostikisa da mkurnalobis rekomendirebuli 31 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria. 32 tuberkulozis SeCerebis ganyofilebis medmusaki. jandacvis msoflio organizaciis regionaluri ofisi, samxret-armosavlet azia. axali deli, indoeti 376

politikisadmi xelmisawvdomoba da im samedicino dawesebulebis nawili, romlebic atareben am politikas), satanado maragebs (medikamentebis maragebis deficitis sixsire), satanadod momzadebuli personalis arsebobas, superviziis sixsires, angarisgebis srulyofilebas da intervenciebis xarisxs (magalitad, naxvelis nacxis kvlevis xarisxi, naxvelis pozitiuri nacxit dadasturebuli pulmonaruli SemTxvevebis wili diagnostirebul pulmonarul SemTxvevebs Soris, mititeba mikroskopiis, rogorc diagnostikuri xerxis gamoyenebaze). kidev erti mnisvnelovani macvenebelia im pacientebis wili, romlebic laboratoriis registraciasi gatarebulni arian, rogorc nacxit dadebitebi da romlebsac tuberkulozis registraciasi dafiqsirebuli informaciis Sesabamisi mkurnaloba utardebat. klinikuri gamosavlis magveneblebi efeqturi programis klinikuri gamosavlis ZiriTadi indikatoria gankurnebis macvenebeli gankurnebuli pacientebis wili diagnostirebuli pacientebis saerto raodenobidan. ramdenadac gankurnebis dadastureba xdeba mxolod baqteriologiurad bevr qveyanasi naxvelis mikroskopuli analizit_,xolo prioriteti infeqciis nacxit dadebiti wyaroebia, gankurnebis macvenebeli ZiriTadad ganisazrvreba pulmonaruli tuberkulozis axal, nacxit dadebit SemTxvevebSi. zogierti pacienti mkurnalobas asrulebs klinikuri gaumjobesebit, magram gankurnebis baqteriologiuri dadasturebis garese (mkurnalobis dasrulebis macvenebeli), es pacientebis mxolod mcire nawils Seadgens. kargad organizebulma programam unda uzrunvelyos gankurnebis mkurnalobis dasrulebis (aseve uwodeben warmatebuli mkurnalobis macvenebels) 85%-ze maral macveneblebs, garda aiv-endemuri kerebisa. aset regionebsi umetes SemTxvevaSi pacientebis sul mcire 10% irupeba mkurnalobis dasrulebamde (Cveulebriv sxva mziezebit da ara tuberkulozit) da amitom 85% macveneblis mirweva praqtikulad SeuZlebelia. gankurnebis/mkurnalobis dasrulebis macvenebeli da SemTxvevaTa gamovlenis macvenebeli monitoringis programis efeqtianobis klinikuri gamosavalis ZiriTadi indikatorebia. DdamatebiTi indikatorebia warumatebeli mkurnalobis macvenebeli (1-2% Cveulebriv araadekvaturi rejimis an 377

medikamentebisadmi rezistentulobis Sedegi), pacientebis wili, romlebmac miatoves mkurnaloba (kargad organizebuli programis pirobebsi es macvenebeli 5%-ze naklebi unda iyos), sxva samedicino dawesebulebebsi gadayvanil pacientta wili, romelta klinikuri gamosavlis Sesaxeb informacia ucnobia (xsirad gamowveulia migraciit) da nebismieri mizezit gamowveuli sikvdilis wili (xsirad ganpirobebuli dagvianebuli diagnostikit, aiv/sidsit an raime sxva mizezit ara tuberkulozit). igive analizi SeiZleba gaketdes ganmeorebiti mkurnalobis SemTxvevebis mimartac, mtlianobasi da calkeuli kategoriebis mixedvit, rogoricaa recidivi, pacientebi romlebmac miatoves mkurnaloba da axla ganmeorebit utardebat Terapia, pacientebi, romlebmac ar Caitares sawyisi mkurnaloba da sxva. mkurnalobis gamosvlis indikatorebi unda moicavdes yvela gansazrvrul periodsi registrirebul SemTxvevebis kohortas, Cveulebriv 3 Tvis ganmavlobasi, xolo analizi unda ganxorcieldes mas Semdeg rac kohortasi Semavali yvela pacienti daasrulebs mkurnalobas, Cveulebriv 1 wlis Semdeg. mkurnalobis dasrulebis ert-erti adreuli macvenebelia nacxit dadebiti SemTxvevebis raodenoba, romlebsac mkurnalobis dawyebidan 2-3 Tvis Semdeg gauxdat uaryofiti nacxi (naxvelis nacxis konversiis macvenebeli). es macvenebeli gamoxatavs programis SesaZleblobas uzrunvelyos pacientebis mier mkurnalobis dasruleba, awarmoos sakontrolo gamokvlevebi (naxvelis nacxis) da mkurnalobit Seamciros infeqciuri pacientebis raodenoba. programis meore funqciuri prioritetia infeqciuri SemTxvevebis gamovlena ZiriTadad naxvelis nacxis mikroskopiit, romelic zogadi profilis samedicino dawesebulebebsi utardeba arastandartul avadmyofebs. am SemTxvevaSi ZiriTadi indikatorebia gamovlenili axali infeqciuri SemTxvevebis raodenoba, daavadebianobis mosalodneli sixsiris procentuli nawili (SemTxvevaTa gamovlenis macvenebeli), tuberkulozze saewvo im ambulatoriuli pacientebis procentuli raodenoba, romlebsac Cautarda naxvelis nacxis analizi da nacxit dadebiti pacientebis procentuli raodenoba. tuberkulozis SemTxvevebis sixsire SeiZleba daangarisebuli iyos mxolod miaxloebit qveynis doneze (tuberkulozis infeqciis prevalentobis, sikvdilianobis da Setyobinebis Seswavlis safuzvelze) da ara regionalur an 378

adgilobriv doneze. mikroskopuli analizit gamokvleuli ambulatoriuli pacientebis procentuli wilisa da Setyobinebuli axali nacxit dadebiti SemTxvevebis tendenciebis macveneblebi ufro sawiro da gamosadegia regionalur an janmrtelobis centris doneze. damatebit indikatorebs, romlebic asaxaven SemTxvevaTa gamovlenaze fokusirebul saqmianobas ganekutvneba diagnostikis miznit gasinjuli pacientebis raodenoba da tuberkulozit daavadebulebtan mwidro kontaqtsi myofi gamokvleuli, diagnostirebuli da mkurnalobit uzrunvelyofili adamianebis wili. zemoqmedebis indikatorebi efeqturi programis epidemiologiuri zemoqmedeba izomeba sikvdilianobis, avadobisa da transmisiis SemcirebiT 213. tuberkulozit gamowveuli sikvdilianobis monitoringi SesaZlebelia ramodenime wlis ganmavlobasi gacemuli gardacvalebis cnobebis SeswavliT, Tumca aseti monacemebi yoveltvis ar aris xelmisawvdomi an xsirad arazustia da cvlilebebi mxolod ramodenime wlis Semdeg vlindeba. sikvdilianobis macvenebelze yvelaze did zemoqmedebas axdens gardacvalebis SemTxvevaTa Semcireba mkurnalobaze myof pacientebs Soris (samedicino dawesebulebebis monacemebi). tuberkulozis SemTxvevaTa prevalentobis Semcireba SeiZleba Sefasdes pirdapiri gzit_ mosaxleobis perioduli gamokitxvebit, romlebic ZviradRirebuli da rtulia da arapirdapiri gzit_nacxit dadebiti pacientebis prevalentobis SemcirebiT, axali SemTxvevebis Sesaxeb Setyobinebebis klebit im SemTxvevaSi, Tu SemTxvevaTa gamovlenis done ucvlelia. Semcirebuli prevalentoba Tavis mxriv amcirebs transmisiebs, risi gazomvac SesaZlebelia bavsvebsi inefqciis prevalentobis kvlevit, romelic yovel 5 weliwadsi ertxel meordeba. infeqciis prevalentobis kvlevebi SesaZleblobas izleva winaswar ganvsazrvrot tuberkulozis infeqciis wliuri riski da misi tendenciebi. daavadebis sixsiris Semcirebis gazomva rtulia, radgan operatiuli faqtorebi moqmedeben SemTxvevaTa gamovlenasa da notifikaciaze. rodesac SemTxvevaTa gamovlenis done ucvlelia insidentobis tendencia daavadebis sixsiris tendenciis macvenebelia. kargad organizebuli programit 379

tuberkulozit daavadebis SemTxvevaTa sixsirisa da infeqciis gavrcelebis Semcirebis maqsimaluri mosalodneli wliuri macvenebelia 12-15% (magalitad, germaniasi, niderlandebsi, niuiorksi), xolo ganvitarebadi qveynebisatvis weliwadsi 7-10% kargi macvenebelia (brazilia/riogrande do suli, Cile, kuba, peru) 214,215,216,217,218. transmisiis Semcirebis Sedegia daavadebis sixsiris ufro swrafi kleba bavsvebsi da axalgazrdebsi, rac cvlis SemTxvevaTa asakobriv da sqesis mixedvit ganawilebas. tuberkulozis Setyobinebis sixsire da 5 wlamde asakis bavsvebsi tuberkulozuri meningitebis SemTxvevaTa raodenoba asaxavs rogorc transmisiis Semcirebas, aseve BCG vaqcinaciit damcav efeqts. vaqcinaciit mocvis ucvleli donis SemTxvevaSi es programis qmeditobis kargi macvenebelia. medikamentebisadmi rezistentobis prevalentoba kerzod multirezistentoba, miutitebs ra mkurnalobis arasatanado xarisxis programebis negatiur efeqtze warmoadgens damatebit macvenebels. mkurnalobis warumateblobisa (medikamentebisadmi rezistentoba) da fataluri SemTxvevebis macveneblebis zrdis gamo, rom araferi vtqvat sikvdilianobis, prevalentobis da transmisiis zrdaze, pirveladi MDR-TB-i xels uslis gankurnebis macveneblebis gaumjobesebas. 380

72. tuberkulozis kontrolis efeqturi programis magalitebi m.ravilione 33 da t. frideni 34 tuberkulozis kontrolis efeqturma programam unda gamoavlinos axali nacxit dadebiti SemTxvevebis sul umciresi 70% da warmatebuli mkurnaloba Cautaros gamovlenil SemTxvevaTagan 85%- s. SemTxvevaTa dauyovnebeli gamovlenisa da mkurnalobis satanado rejimis gamoyenebis uzrunvelyofit efeqturi programa, xels unda uslides tuberkulozis medikamentebisadmi rezistentuli formebis Camoyalibebasa da gavrcelebas. tuberkulozis kontrolis programis ufro mkacri motxovnaa tuberkulozis transmisiis Sewyveta, rasac unda moyves daavadebianobis sixsiris swrafi Semcireba, sanam tuberkulozi, rogorc sazogadoebrivi jandacvis problema, sabolood ar armoifxvreba. amis ganxorcieleba SeuZlebeli iqneba gamovlenili SemTxvevebis 85%-is gankurnebit Tu gamovavlena iqneba dabali. aseti Sedegebis misarebad, efeqturma programam unda uzrunvelyos instruqciebis SemuSaveba, swavleba da resursebis mozidva, rac Tavis mxriv Seqmnis tuberkulozis SemTxvevaTa satanadod martvis SesaZleblobas. amastan, programa prioritets unda aniwebdes infeqciis wyaroebis gamovlenasa da mkurnalobas. aset programas unari Seswevs ganaxorcielos rogorc procesis, aseve efeqtis monitoringi. misi efeqturoba izomeba arapirdapiri gzit. zemoqmedebis im xarisxis mixedvit, romelsac igi axdens sikvdilianobis, avadobisa da transmisiis macveneblebze. programis 33 tuberkulozis strategiisa da operaciebis kordinatori, tuberkulozis SeCerebis departamenti, jandacvis msoflio organizacia. Jeneva, Sveicaria. 34 tuberkulozis SeCerebis ganyofilebis medmusaki. jandacvis msoflio organizaciis regionaluri ofisi, samxret-armosavlet azia. axali deli, indoeti. 381

xarisxis gansazrvra pirdapiri xerxitac SeiZleba da es moicavs fataluri SemTxvevebis, gankurnebisa da dafarvis macveneblebs. janmos rekomendaciebis safuzvelze tuberkulozis kontrolis strategia 2002 wlisatvis msoflios 155 qveyanam miiro. Tumca matgan mxolod 102-ma miarwia mosaxleobis srul mocvas da qveyanasi mcxovrebi yvela adamianisatvis tubkontrolis samsaxurebisadmi xelmisawvdomobis uzrunvelyofas. 2002 wlisatvis mxolod TxuTmetma qveyanam ganaxorciela globaluri miznebi. garda amisa, 54 qveyanasiu SemTxvevaTa gamovlenis macvenebeli sul mcire 50%-ia, xolo warmatebuli mkurnalobis macvenebeli 70%-s Seadgens 219. SesaZloa tuberkulozis kontrolis efeqturi programis ganxorcielebis ert-ert sauketeso magalitad mivicniot peru. mas Semdeg, rac janmos rekomendaciebis safuzvelze qveyanasi daiwyo tuberkulozis kontrolis axali strategiis ganxorcieleba, perum SeZlo janmos miznebis ganxorcieleba jer kidev 1995 wels da mas Semdeg inarcunebs am dones. 1999 wels SemTxvevaTa gamovlenis gaangarisebuli macvenebeli 90%-s aremateboda. yvela SemTxvevis analizis safuzvelze gamovlinda, rom 1998 wels warmatebuli mkurnalobis macvenebeli Seadgenda 90%-s. ufro mnisvnelovania is faqti, rom amjamad SeimCneva kleba pulmonaruli tuberkulozis axali SemTxvevebis kleba, romelic mohyva SemTxvevaTa matebis 2-wlian periods, da ganpirobebuli iyo 1991 wels ganaxlebuli programis danergvit. miuxedavad imisa, rom diagnostikaze ixarjeba 10-jer meti Zalisxmeva, kleba sasualod 7,5% Seadgens weliwadsi. adre arsebul tendenciebtan SedarebiT, 1991-1999 wlebis periodsi Tavidan acilebuli iqna mosalodneli axali SemTxevevbis warmosobis 16%, xolo sikvdilis mosalodneli SemTxvevebis 70% 220. amis mirweva SesaZlebeli gaxda diagnostikuri SesaZleblobebis decentralizaciisa da mteli qveynis masstabit kargad arwurvili samedicino centrebis SeqmniT, aseve SemTxvevaTa efeqturi menejmentit, romelic efuzneba usualo zedamxedvelobit mkurnalobis princips. yovelive amis Sedegad mkurnalobis mitovebis SemTxvevebi minimumamde iqna dayvanili da SesaZlebeli gaxda SemTxvevaTa 90%-ze metis gankurneba. perusi ganxorcielda jandacvis samsaxurebis arwurva sawiro diagnostikuri aparaturit, zogadi profilis personalis intensiuri swavleba da gadamzadeba tuberkulozis martvis sakitxebsi, Seiqmna momaragebis efeqturi sistema, romelic uzrunvelyofda medikamentebis 382

regularul miwodebas. satanado sainformacio sistemis Seqmnam SesaZlebeli gaxada programis Sesrulebis monitoringi da makoreqtirebeli RonisZiebebis ganxorcieleba da bolos fartomasstabianma sainformacio kampaniam uzrunvelyo satanado codnis miwodeba da gatvicnobierebebis (codnis an informirebulobis) amarleba sazogadoebrivi struqturis yvela doneze. saxelmwifos mxriv programas hqonda sruli mxardawera. adgilobriv doneebze xdeboda rogorc standartuli, asev adgilobrivi mnisvnelobis indikatorebis monitoringi (mag., diagnozirebis dagvianeba, mkurnalobis Sewyvetis mizezebi, simptomebis mqone Semowmebuli pacientebis procentuli wili), rogorc nacionaluri, aseve regionalur doneze dainerga da wlebis manzilze funqciurad SenarCunebul iqna martvis qmediti sistema. ai asetia tuberkulozis kontrolis efeqturad ganxorcielebis recepti ganvitarebadi qveynebisatvis. msgavsi warmatebis mqone programebi ganxorcielda latinuri amerikis iset qveynebsic rogoricaa Cile, kuba da urugvai. es programebi dainerga marokosa da vietnamsi. sxva programebs, romlebmac mnisvnelovan Sedegebs miarwies gankurnebis marali macveneblebis TvalsazrisiT, ganekutvneba beninsi, kambojasi, CineTSi, malivisi, nikaraguasa da tanzaniis gaertianebul respublikasi ganxorcielebuli programebi 221,222,223,224,225,226,227,228. Tumca am qveynebsi jer ar arsebobs mtkicebulebebi imisa, rom saerto nacionaluri masstabit tuberkulozis kontrolis RonisZiebebis meoxebit daavadebianobis sixsirem iklo. ert-erti dokumentalurad yvelaze kargad Camoyalibebuli programaa CineTSi, kerzod, pekinsi ganxorcielebuli programa 229. am programit usualo metvalyureobit mkurnaloba gamoiyeneboda 1979 wlidan. aman ganapiroba tuberkulozis SemTxvevebis mnisvnelovani da progresirebadi kleba (prevalentobis 87%-iani Semcireba 1979-1990w.w.) sikvdilis SemTxvevebis Semcireba (80%) da aseve qronikuli SemTxvevebis Semcireba. medikamentebisadmi rezistentoba minimalur doneze iqna SenarCunebuli. programis ert-ert mnisvnelovani aspeqtia sistemuri, damoukidebeli dazusteba imisa, rom mkurnalobaze tuberkulozis kontrolis efeqturoba aisaxeba SemTxvevaTa Sesaxeb notifikaciis Zalian dabali macveneblebit. evropis mraval qveyanasi da ass-si 219. SetyobinebaTa sistemis gazlierebam, mkurnalobis mkafio standartebis SemuSavebam, specialuri RonisZiebebis ganxorcielebam 383

aiv-inficirebul individebsa da uaxloes periodsi Camosul emigrantebs Soris, inefqciuri kontrolis RonisZiebebis gatarebam gansakutrebit mwidrod dasaxlebul adgilebsi mnisvnelovani wvlili Seitana tuebrkulozis SemTxvevebis zrdis tendenciis ukuqcevasi 80-iani wlebis Sua periodidan 1992 wlamde 230. ass-si tuberkulozis kontrolis efeqturi programis sauketeso magaliti niu-iorksi ganxorcielebuli programa. aq arinisneboda tuberkulozis SemTxvevebis mnisvnelovani zrdis tendencia 1980-1992 wlebsi.( SemTxvevebis kleba daiwyo mas Semdeg, rac dainerga tuberkulozis kontrolis ganaxlebuli programa. niu-iorkis gamocdilebam gvicvena, rom multirezistentuli tuberkulozis swrafad Semcireba SesaZlebelia aiv-infeqciis epidemiis drosac. eqvsi wlis ganmavlobasi programis ganxorcielebis mesveobit multirezistentuli SemTxvevebi 80%-iT, xolo tuberkulozis SemTxvevebi ass-si dabadebulta Soris 60%-iT Semcirda. kontrolis RonisZiebebi moicavda satanado mokle kurss day mkurnalobaze usualo metvalyureobis Catarebas, rac Tavis mxriv izleoda mkurnalobis dasrulebis marali macveneblebis mirwevis SesaZleblobas, aseve infeqciata kontrolis intervenciebis ganxorcielebas adamianta TavSeyris adgilebsi, rogoricaa saavadmyofoebi, usaxlkarota TavSesafarebi da penitancialuri sistemis dawesebulebebi, satanado rejimebis gamoyeneba tuberkulozze saewvo SemTxvevebisa da multirezistentuli Stamebis mkurnalobasi 231. idealuri programa ara mxolod akmayofilebs SemTxvevaTa gamovlenisa da gankurnebis motxovnebs, aramed uzrunvelyofs pacientebs ketilganwyobili garemos SeqmniT, rac mat SesaZleblobas azlevs Tavi Rirseulad da dafasebulad igrznon. es savaraudod kidev ufro gaaumjobesebs SemTxvevaTa gamovlenisa da gankurnebis macveneblebs. ufo metic, idealuri programa sawiroebs mkacr angarisgebas jandacvis musakebis mxriv da mat monawileobas programis srulyofis saqmesi. aseti programa yoveltvis axorcielebs monacemta zustsa da regularul analizs, rac misi Sesrulebis obieqturi Sefasebisa da koregirebis SesaZleblobas izleva. da bolos optimaluri programa gvazlevs resursebis efeqturad gamoyenebis sasualebas, zogavs xarjebs da dokumentalurad afiqsirebs mas, satanadod martvis sakadro da finansur resursebs, uzrunvelyofs ra amit programis xangrzlivvadian qmeditobas. 384

73. ra SedarebiTi prioritetebi aqvs tuberkulozis kontrolis programas da ra saqmianoba ar unda ganxorcieldes f.leilmo 35 da t.frideni 36 tuberkulozis kontrolis prioritetebis gansazrvra efuzneba programis amocanebs, intervenciebis efeqturobas da arsebul resursebs. pirveladi prioritetia im pacientebis identificireba, gankurneba da gankurnebis dokumentalurad dafiqsireba, romlebic mimartaven samedicino dawesebulebebs. misarebi mizania axladgamovlenili nacxit dadebiti pacientebis gankurnebis 85%. am miznis ganxorcielebis Semdeg programas SeuZlia gaafartovos da gamoavlinos axali SemTxvevebis meti raodenoba da SemTxvevaTa gamovlena moaxdinos ufro adreul etapze. es prioritetebi usualod orientirebulia transmisiis jawvis gawyvetasa da sikvdilianobis Semcirebaze. miznis ganxorcieleba SesaZlebelia zusti da dauyovnebeli diagnostikis, medikamentebis ufasod miwodebis, medikamentebis regularulad mirebisa da nacxit dadebiti pulmonaruli tuberkulozit daavadebuli pacientebis kohortis mkurnalobis warmatebis sistematuri monitoringis mesveobit. amisatvis programam unda uzrunvelyos: tuberkulozit daavadebuli (yvela formebis, axalic da ganmeorebiti mkurnalobaze myofi) pacientebis ambulatoriuli mkurnalobis organizacia, rac moicavs instruqciebis SemuSavebas, swavlebas, medikamentebita da samedicino danisnulebis sagnebit momaragebas, registrirebas, naxvelis nacxis gamokvlevas, monitoringsa 35 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria. 36 tuberkulozis SeCerebis ganyofilebis medmusaki. Msoflio jandacvis organizaciis regionaluri ofisi, samxret armosavlet azia. axali deli, indoeti. 385

da supervizias. es aseve moicavs usualo metvalyureobit mkurnalobis decentralizacias jandacvis periferiul musakebsa da sazogadoebrivi moxaliseebis donemde; diagnostikisatvis sawiro pirobebi, rogoricaa laboratoriuli qseli, saxelmzrvanelo instruqciebis gamocema, swavleba, xarisxis kontroli, monitoringi da supervizia; SemTxvevaTa gamovlena arastacionarul samedicino dawesebulebebsi, rac moicavs swavlebasa da monitorings, aseve sazogadeobis informirebas tuberkulozis ufaso diagnostikisa da mkurnalobis Sesaxeb, gaxangrzlivebuli xvelebis SemTxvevaSi pacientebis dauyovnebeli diagnostikis aucileblobis Sesaxeb. meorad prioritetebs, romelta ganxorcielebac unda moxdes mas Semdeg, rac sabazo paketi daiwyebs warmatebit funqcionirebas, ganekutvneba: medikamentebis xarisxis kontrolis gazliereba; SemTxvevaTa gamovlenisa da mkurnalobis uzrunvelyofasi arasamtavrobo organizaciebisa da kerzo seqtoris CarTva; laboratoriuli qselis saqmianobis gafartoeba, kulturisa da mgrznobelobis testebis nacionalur laboratoriasi Catarebis SesaZleblobebis Seqmna. kulturis testebis gamoyeneba tuberkulozze saewvo nacxit uaryofiti pacientebis diagnostikisatvis; diagnostikisa da mkurnalobis instruqciebis SemuSaveba da ganxorcieleba bavsvta da eqstrapulmonaruli tuberkulozis, aiv/sidstan asocirebuli tuberkulozis, patimrebis, emigratebisa da sxva gansakutrebuli jgufebisatvis; SemTxvevaTa Setyobinebis, medikamentebisadmi rezistentobis, tuberkulozuri/aiv infeqciis, bavsvebsi tuberkulozuri meningitis, infeqciis prevalentobis da sikvdilianobis (Tu sikvdilis SemTxvevaTa registracia warmoebs) zedamxedveloba; operatiuli kvleva arwerilobit epidemiologiaze aqcentit, diagnozis dagvianebis risk-faqtorebi, mkurnalobis mitoveba, mkurnalobis warumatebloba da sikvdili. intervenciebis xarjefeqturobis monitoringi da 386

samedicino daxmarebis racionalizacia (hospitalizacia, qirurgia, referaluri sistema, specializirebuli daxmareba, kontrolis sxva RonisZiebebTan integracia zogadi profilis samedicino daxmarebis farglebsi); resursebisadmi xelmisawvdomobisa da epidemiologiuri konteqstidan gamomdinare SesaZlebelia Semdegi RonisZiebebis ganxorcielebac: pacientebtan axlo kontaqtsi myofi pirebisa da marali riskis mqone jgufebis ufro fartod mocva gamokvleevbit diagnostikisa da prevenciuli mkurnalobis Catarebis miznit (magalitad, mwidrod dasaxlebuli binebis macxovreblebi, marali prevalentobis jgufebi, aiv-inficirebuli pacientebi, individebi, romlebmac ar daasrules tuberkulozis mkurnaloba); tuberkulozis paketis ganvrcoba medikamenetbisadmi rezistentul SemTxvevebze. es saqmianoba gansakutrebit prioritetulia im regionebsi, sadac maralia sawyisi multirezistentuli tuberkulozis macveneblebi da sadac maralia imunodeficitis mqone adamianebis raodenoba, kerzod, mwidrod dasaxlebul adgilebsi (SidsiT daavadebulta palatebi, cixeebi, mararoebi). tuberkulozis programis da samedicino momsaxurebis sistemis personalis da resursebis gamoyeneba dabali efeqturobisa da sazogadoebisatvis mcire sargeblobis momtan saqmianobasi ar aris dasvebuli. usargeblo, araadekvaturi da zianis momtani intervenciebis ramodenime magaliti SemTxvevaTa gamovlena aqtiuri SemTxvevebis gamovlena zogadad mosaxleobis masiuri miniaturuli radiografiis mesveobit (ixilet Tavi; ra rols asrulebs perioduli masobrivi radiografiuli kvlevebis mesveobit SemTxvevaTa gamovlena tuebrkulozis kontrolsi ). skriningis Catareba tuberkulinis testis, rentgenografiis an baqteriologiuri analizebit dabali riskis 387

mosaxleobasi, rogoricaa studentebi, maswavleblebi, kvebis sistemis musakebi da sxva. im samsaxurebis aqtiuri xelsewyoba, romlebic xelmisawvdomi ar aris sazogadoebisatvis, xelsewyoba medikamentebis deficitis dros an cudad organizebuli momsaxurebis SemTxvevaSi. specializirebuli mobiluri brigadebis gamoyeneba. mati gamoyofa jandacvis organizaciebisa da personalisgan, romeltac unari Seswevs uzrunvelyon regularuli mkurnaloba gankurnebamde. zogadi profilis samedicino dawesebulebebidan izolirebuli tuberkulozis diagnostikuri centrebis Camoyalibeba. tuberkulozze saewvo simptomebis mqone pacientebi mimartaven zogadi profilis samedicino dawesebulebebs, ise rom arc ician aqvt tuberkulozi Tu ara. diagnostika mxolod klinikuri an mxolod rentgenologiuri gamokvlevis safuzvelze. dabali specifikurobis gamo, aset SemTxvevaSi bevr pacients, romelsac sinamdvilesi ara aqvs tuberkulozi, an ukve gankurnebuli dazianebebis mqone adamianebs SesaZloa Cautardes arasawiro mkurnaloba, rac Seicavs dazianebis risksa da resursebis arasawiro xarjvas. nacxebis areba, rac moitxovs pacientta ramodenime vizits (sami nacxi SeiZleba Seikribos). centralizebuli diagnostika an diagnozis dadastureba specializirebul dawesebulebebsi (magalitad, tubdispansersi). respiratoruli simptomebis mqone pacientebi pirvelad mimartaven zogadi profilis samedicino dawesebulebebs, ambulatoriul ganyofilebebs, pirveladi jandacvis centrebs da kerzo eqimebs kompleqsuri arasatanado teqnologiebis gamoyeneba. agalitad, kontrolis programebsi polimerazis jawvis reaqcia. mkurnaloba centralizebuli mkurnaloba mxolod specializirebul dawesebulebebsi, Tumca tuberkuloztan da klinikur 388

gartulebebtan dakavsirebuli codna Cveulebriv aseti saxis dawesebulebebsi ufro srulia da mat aqvt ufro meti diagnostikuri resursebi. centraluri klinikebi kargaven mati pacientebis did nawils imis gamo, rom Cveulebriv didi manzilit arian dasorebuli pacientebis saxlebidan, garda qalaqis tipis dasaxlebebisa, aseti tipis samedicino dawesebulebebi gamoyenebuli unda iqnes referaluri miznebisatvis, rtuli SemTxvevebis diagnostikisa da gartulebebis martvisatvis pacientebi unda gaigzavnon an gadayvanil iqnen advilad - misawvdom samedicino dawesebulebebsi SeZlebisdagvarad swrafad. medikamentebit araregularulad momaragebis gamo pacientebi izulebulni arian SeiZinon naklebi raodenobit medikamentebi. mkurnalobis gaxangrzliveba. Zalian cotaa iseti pacientebi, romlebistvisac sasargebloa xangrzlivi mkurnaloba, amastanave ar arsebobs aranairi dasabuteba. rom yvela pacients gaugrzeldes mkurnaloba. aseve ar arsebobs mecnieruli mtkicebuleba imisa, rom magalitad, meningitis an tuberkulozis raime formis mkurnalobis gaxangrzliveba damatebiti sargeblobis momtania. ZviradRirebuli vitaminebis, sakvebis danamatebis, mineralebis an sxva medikamentebis damateba, Tuki ar arsebobs raime specifikuri deficiti. pacientis mada umjobesdeba baqteriuli datvirtvis SemcirebasTan ertad. kveba mnisvnelovani risk-faqtoria imisa, rom tuberkulozis infeqcia Camoyalibdes daavadebad, magram mas aranairi zegavlenis unari ara aqvs gankurnebis procesebze, masin rodesac gamoiyeneba mkurnalobis moklevadiani maral efeqturi rejimebi, Tumca, sakvebi (pacientisa da ojaxisatvis) SeiZleba gaxdes maralefeqturi motivacia mkurnalobis rejimis dacvis gaumjobesebisatvis. yoveltviuri monitoringi rentgenografis mesveobit. qirurgiuli nirbebis gamoyeneba dawesebulebis personalis mier. aseti nirbebi ar gamodgeba bacilebis SesunTqvis prevenciisatvis. es iwvevs personalis gamijvnas pacientebisgan da uqmnis mcdar Sexedulebas usafrtxoebaze. 389

monitoringi (kvlevis GaTvliT) procesis iseti indikatorebis monitoringi, rogoricaa mkurnalobaze myofi pacientebis raodenoba drois nebismieri momentisatvis. standartuli indikatorebi (diagnostikis xarisxi, konversiis macvenebeli, gankurnebis macvenebeli, gamovlenili SemTxvevebis saprognozo wliuri raodenobis macvenebeli) ar unda iyos gadatvirtuli naklebadmnisvenlovani informaciit. yoveltviuri didi moculobis angarisebi. Cveulebriv dauyovnebeli an meyseuli monitoringisatvis savsebit misarebia kvartaluri angarisebi. tuberkulozze Sekrebili monacemta Serwyma (kvartaluri angarisgeba) jandacvis sainformacio sistemastan. meore mxriv, kvartaluri angarisebi unda gavrceldes SeZlebisdagvarad farto auditoriaze jandacvis sainformacio sistemis an sxva sasualebebis gamoyenebit Warbi resursebis gamoyeneba pilotur proeqtebsa an operatiul kvlevebsi, rac testirebul intervenciebs gamousadegarsa da SeuTavsebels xdis qveynis masstabit gamoyenebisatvis. 390

74. ra zegavlenas axdens aiv-infeqcia tuberkulozis epidemiologiaze mosaxleobasi a.harisi 37 aiv-infeqcia amcirebs ujreduli imunitets da warmoadgens Zlier risk-faqtors tuberkulozis ganvitarebisatvis 232, 233. aiv-infeqciis tuberkulozis epidemiologiaze zegavlenis xarisxi damokidebulia imaze, Tu ra Sefardebaa aiv-inficirebul adamianebsa da tuberkulozis mikobaqteriit inficirebul an inficirebis riskis mqone adamianebs Soris. amjamad aiv-tuberkulozis koinceqciis mqone adamainebis 70% cxovrobs afrikis subsaharasi 234. aqtiuri tuberkulozis ganvitarebis wliuri riski koinficirebul adamianebsi meryeobs 5%-dan 15%-mde da damokidebulia imunokompromisis 232 xarisxze. arsebobs aseve myari mtkicebuleba imisa, rom aiv-infeqcia xels uwyobs aqtiuri tuberkulozis swrafad ganvitarebas tuberkulozis mikobaqteriit inficirebidan mis aqtiur formebamde. mwvave imunokompromisis mqone pacientebsi, romlebic hospitalizebulni iqnen Sidsis gartulebebis gamo da kontaqtsi imyofebodnen tubinfeqciur pacientebtan dainficirebasa da daavadebis ganvitarebas Soris sasualo dro 12 kviras Seadgenda 235. aiv-is zegavlena aiv-infeqcia udides zegavlenas axdens tubsituaciaze afrikis sub-saharis regionsi, Tumca indoetis zogiert nawilsi miamarsa da tailandsi am or infeqcias Soris kavsiri sul ufro askara xdeba. qvemot arwerilia aiv-infeqciis zegavlenis bevri aspeqti. 37 malaviis tuberkulozis kontrolis erovnuli programis teqnikuri mrceveli. Llilongue, malavia. 391

tuberkulozis SemTxvevebis raodenoba bolo 10-15 wlis ganmavlobasi tuberkulozis SemTxvevaTa raodenoba 300-400%-iT gaizarda afrikis im qveynebsi, sadac maralia aiv-is prevalentoba 236. ZiriTadad es xdeba imis gamo, rom aivinfeqcia zrdis daavadebis reaqtivaciis risks. latenturi tuberkulozis mikobaqteriis mqone adamianebsi SemTxvevaTa raodenobis zrdastan ertad arinisneboda nacxit uaryofiti pulmonaruli tuberkulozis da eqstrapulmonaruli tuberkulozis SemTxvevebSi disproporciuli zrda 232. SemTxvevaTa mzardi raodneoba mzime tvirtad awveba tuberkulozis kontrolis programas, radgan igi moitxovs met personals, kerzod, ki tuberkulozis programis oficrebs da laboratoriis personals. arsebobs mzardi sawiroeba laboratoriuli resursebis, wamlebis, naxvelis konteinerebis da sakancelario saqonlis. iq, sadac pacientebi hospitalizebulni arian mkurnalobis sawyisi fazis Casatareblad, palatebi itvirteba xalxit, rac SeuZlebels xdis saeqtno-samedicino daxmarebis uzrunvelyofasa da aseve zrdis nozokomialuri infeqciebis risks. tuberkulozis transmisiis ~cxeli wertilebi~ tuberkulozis gavrcelebis cxeli wertilebi, sadac mdgomareoba SeiZleba ufro gamwvavdes aiv-infeqciit, SeiZleba warmoisvas yvelgan, sadac ki didi raodenobit adamianebi iyrian Tavs: magalitad, cixeebi, ltolvilta banakebi, mararoebi, samedicino dawesebulebebi da skola-internatebi. aset adgilebsi tuberkulozis transmisiis Sewyvetis miznit SeiZleba zogjer sawiro gaxdes aqtiuri SemTxvevebis gamovlena. fataluri SemTxvevebis zrda aiv-pozitiur, tuberkulozit daavadebul pacientebs Soris tuberkulozis mkurnalobis periodsi arinisneba aiv-infeqciastan dakavsirebuli sikvdilianoba. aset pacientebsi ufro xsiria gverditi reaqciebi tubsawinaarmdego medikamentebze, kerzod, TioacetazoniT gamowveuli kanis reaqciebi, rac iwvevs mkurnalobis Sewyvetas da ganapirobebs sasikvdilo SemTxvevebs. ar aris 392

gasaocari, rom aiv-inficirebul pacientta Soris tuberkulozis mkurnalobis periodsi an misi dasrulebis Semdeg, sikvdilianoba gacilebit ufro marali iyos, vidre aiv-negatir pacientebsi 237. afrikis samxret saharis regionsi aiv-inficirebuli nacxit dadebiti tuberkulozit daavadebuli pacientebis 30% ganwirulia sasikvdilod mkurnalobis dawyebidan 12 Tvis ganmavlobasi, xolo daaxloebit 25% dairupeba mkurnalobis dasrulebis Semdgomi 12 Tvis periodsi 232. sikvdilianobis marali macveneblebi aiv-inficirebul, nacxit dadebiti tuberkulozit daavadebul pacientebsi miutitebs, rom mati mkurnaloba sicocxlis SenarCunebuli wlebis raodenobis TvalsazrisiT naklebad xarjtefeqturia, vidre aiv-negatiuri pacientebis SemTxvevaSi. aiv-infeqciis warmosobamde nacxit uaryofiti pulmonaruli tuberkulozis mkurnalobas kargi gamosavali hqonda. mtkicebulebebi, romlebic TandaTan akumulirdeba afrikis samxret-saharis regionsi, gvicvenebs, rom aiv-inficirebuli nacxit uaryofiti pulmonaruli tuberkulozis mqone pacientebsi mkurnalobis gamosavali SeiZleba ufro cudi iyos, vidre nacxit dadebiti pulmonaruli tuberkulozit daavadebulebsi 238. tuberkulozis recidivi mkurnalobis dasrulebis Semdeg recidivebis macveneblebi (rac nisnavs aqtiuri tuberkulozis klinikuri suratis gameorebas, nacxit dadebitobis da tuberkulozis mikobaqteriit pozitiur kulturebs) ufro maralia aiv-inficirebul pacientebsi, mkurnalobis iseti rejimebis gamoyeneba, romlebic ar Seicavs rifampicins da mkurnalobis xsiri Sewyveta medikamentebze reaqciebis gamo, tuberkulozis recidivebis maral risktan asocirdeba 232. recidivi moicavs rogorc WeSmarit recidivis, aseve recidivuli daavadebis Tanmxleb xelaxal inficirebas. daavadebis reaqtivaciit gamowveuli recidivisa da reinfeqcias Soris Sefardeba ucnobia. medikamentebisadmi rezistentoba aiv-inficirebul pacientebsi medikamentebisadmi rezistentuli tuberkulozis epidemiebi aris rogorc ganvitarebul, aseve 393

ganvitarebad qveynebsi. TavisTavad adamianis imunodeficitis virusi ar iwvevs medikamentebisadmi rezistentul tuberkulozs, magram igi xels uwyobs inficirebidan daavadebis ganvitarebamde procesebis progresirebis dacqarebas. tuberkulozis kontrolis globaluri miznebi tuberkulozis kontrolis zogadi mizania daavadebit gamowveuli avadobis, sikvdilianobisa da daavadebis transmisiis Semcireba. amjamad am miznis ganxorcielebis sauketeso gza nacxit dadebiti tuberkulozis SemTxvevebze fokusireba (gamovlenili nacxit dadebiti SemTxvevebis sul mcire 85%-is gankurneba) da infeqciuri SemTxvevebis 70%-is gamovlenaa. aiv-i artulebs gankurnebisa da gamovlenis arnisnul macveneblebis mirwevas. aiv-infeqciit ganpirobebuli marali macveneblebis mimart praqtikulad SeuZlebelia nacxit-pozitiuri tuberkulozis 85%-iani gankurnebis mirweva. SemTxvevaTa gamovlenis 70%-iani macveneblebic ganuxorcielebelia, vinaidan jer ar SeumuSavebiaT iseti metodi, romlis mesveobitac SesaZlebeli gaxdeba aseti SemTxvevebis sarwmuno saerto raodenobis gansazrvra, gansakutrebit ki, aivinefqciis marali prevalentobis pirobebsi. Sedegebi aiv-infeqcia daundoblad aaskaravebs tuberkulozis programis nebismier sust mxares. gamovlenis dabali macveneblebi ganapirobebs aranamkurnalebi pacientebisgan infeqciis swraf gavrcelebas. gankurnebis dabali macvenebeli, Tu mas axlavs mkurnalobis Sewyvetis marali macveneblebi, Sedegad izleva medikamentebisadmi rezistentuli Stamebis swrafad warmoqmnasa da gavrcelebas. xolo infeqciata araefeqturi kontroli ganapirobebs tuberkulozis swraf da potenciurad farto institucionalur gavrcelebas. tuberkulozis macveneblebi saertod gaizrdeba, imdenad, ramdenadac izrdeba aiv-infeqciis prevalentoba. Tu aivprevalentoba ganvitarebadi qveynis mozrdil mosaxleobasi miarwevs 5%, masin arsebuli teqnologiebi verar Seakavebs SemTxvevaTa zrdas. DOTS-i garkveulwilad axangrzlivebs calkeuli pacientis sicocxles, xels uslis medikamentebisadmi rezistentobas 394

da SedarebiT asustebs SemTxvevaTa raodenobis zrdis process. tuberkulozis SemTxvevebisa da recidivis macveneblebis zrda aiv-inficirebul pacientebsi tuberkulozis ganvitaebis marali riskis Sedegia e.w. cxel wertilebsi. aiv-infeqciis prevalentobam SeiZleba Sewyvitos intensiuri zrda da Tanabar sworxazovan ganvitarebasi gadavides. am SemTxvevaSi savaraudoa, tuberkulozis SemTxvevaTa notifikaciis mrudis mkvetrad armavali mdgomareobidan sworxazovansi gadasvla, Tumca ramodenimejer ufro marali macveneblebit, vidre es iyo aiv-infeqciis warmosobamde. marali aiv-prevalentobis regionebsi tuberkulozis kontroli mnisvnelovnadaa damokidebulia aiv-infeqciis kontrolze. 395

75. rogor SevuwyoT xeli tuberkulozis kontrolis samsaxurebs da rogor SevinarGunoT mati qmeditoba t.frideni problemebi da upiratesobebi tuberkulozis efeqturi kontroli sawiroebs mtkice politikur nebas da administraciul mzadyofnas rogorc saerto nacionalur, aseve adgilobriv doneebze. aqedan gamomdinare, tuberkulozis kontrolis efeqturma programam stimuli unda misces, Camoayalibos da SeinarCunos aseti SemarTeba da mzadyofna es misi amocanaa. tuberkulozit daavadebuli pacientebis udidesi nawili ekonomkiurad arasaxarbielo mdgomareobasia da aqedan gamomdinare, naklebi politikuri gavlenac aqvt. ufro metic, am daavadebas tuberkulozit daavadebuli adamianebis sazogadoebisagan izolaciis tendenciebi axlavs. tuberkulozit daavadebuli pacientebi Cveulebriv ar qmnian asociaciebs an mxardaweris jgufebs mati interesebis dacvis, momsaxurebis ufro farto speqtris an meti resursebis motxovnis miznit da bolos, tuberkulozis kontroli TavisTavad xangrzlivi brzolaa da moitxovs sistematur mxardaweras. msofliosi amjamad tuberkulozit inficirebuli 2 miliardi adamiania, matgan sul mcire 100 milions, savaraudod, cxovrebis romelime etapze ganuvitardeba tuberkulozis aqtiuri forma. amgvarad, kidec rom moxerxdes tuberkulozis gavrcelebis sruli Sewyveta da daavadebis prevenciis miznit, efeqturi vaqcinis Seqmna 38 tuberkulozis SeCerebis ganyofilebis medmisaki. jandacvis msoflio organizaciis regionaluri ofisi, samxret-armosavlet azia. axali deli, indoeti. 396

da gamoyeneba arainficirebul pacientebsi, tuberkulozis kontrolis samsaxurebi uaxloesi 40-50 wlis ganmavlobasi manc sawiro iqneba. amastan, aiv-epidemiam gansakutrebit gazarda tuberkulozis SemTxvevaTa simzime ZiriTadad SezRuduli resursebis mqone qveyanasi. mraval ganvitarebad qveyanasi mimdinareobs jandacvis seqtoris reforma, rac axal winaarmdegobebs uqmnis tuberkulozis kontrolis programas. miuxedavad imisa, rom jandacvis seqtoris reformas unari Seswevs gazardos programis efeqturoba da sazogadoebis monawileoba, praqtikulad igi xsirad gamoixateba mxolod gadasaxadebsi, momsaxurebis Semcirebasa da daavadeba-specifikuri kontrolis programebis, magalitad, tuberkulozis programis funqciuri SesaZleblobebis SezRudvaSi 239. miuxedavad aseti seriozuli problemebisa, tuberkulozis kontrolis programas aqvs ramdenime upiratesoba. pirveli, tuberkulozi gankurnebadi daavadebaa, xolo brzola tuberkulozis winaarmdeg gamarjvebis momtani gansxvavebit janmrtelobisa da socialuri sferos bevri sxva problemebisgan. meore, tuberkulozis programa kargi angarisgebit gamoirceva. tuberkulozis kontrolis programis SesaZleblobebSi Sedis gamokvleuli, diagnostirebuli, namkurnalebi da gankurnebuli pacientebis zusti raodenobis dadgena, aseve, sikvdilis SemTxvevebis prognozuli raodenobis daangariseba, romlis Tavidan acilebac SesaZlebeli gaxda programuli RonisZiebebiT da bolos, mtliani informaciis miwodeba programis damfinansebeli da mxardaweri organizaciebisatvis. mesame, tuberkulozis programa Zalze xarjtefqturia (ixilet Tavi: aris Tu ara eqimis usualo metvalyureobit mkurnalobis strategia xarj-eefqturi ). meotxe, adamianebs, romlebic cxovroben tuberkulozis marali prevalentobis regionebsi kargad esmit, rom tuberkulozi warmoadgens avadobisa da sikvdilis seriozul mizezs da amitom sworad ariqvamen tuberkulozis kontrolis programis efeqtur satanado samsaxurebs, rogorc martvis mnisvnelovan indikators. mexute, DOTS strategiis warmatebit ganxorcieleba SeiZleba TiTqmis yvela konteqstsi, radgan igi ZiriTadad efuzneba SedarebiT martiv intervenciebs da bolos yvelaze mnisvnelvani, DOTS i efuzneba sando mecnierul mtkicebulebebs mat Sorisaa diagnostikuri strategiebis mxardamweri monacemebi, rogorc es 397

Sejamebuli saxit mocemulia wignis nawilsi, romelic ezrvneba SemTxvevaTa gamovlenis randomizirebul kontrolirebad klinikur kvlevebs da cxadyofen wignis mkurnalobis nawilsi ganxiluli mkurnalobis mokle, praqtikuli kursebis efeqturobas. aseve registrirebisa da angarisgebis sistemas, romelic izleva problemis swrafad identificirebis SesaZleblobas individualuri da agregirebeli SefasebiT (ixilet Tavi: ristvis aris sawiro registrirebisa da angarisgebis sistema, da ra sistemaa rekomendirebuli ). tuberkulozis kontrolis samsaxurebis xelsewyoba zogadad, tuberkulozis kontrolis qmediti samsaxurebis xelsewyobis sauketeso sasualebaa tuberkulozis nacionaluri programebi, romelic satanadodaa dakompleqtebuli kadrebit da Sesabamisi mxardawerit sargeblobs. programis saerto strategia miznad unda isaxavdes mnisvnelovani teqnikuri politikis Camoyalibebas, maqsimaluri Zalisxmevis gamoyenebas rata gadawyvetilebebis mimrebi pirebi daarwmunon aseti politikis ganxorcielebis aucileblobasi, tuberkulozis efeqturi kontrolis da xelsewyobis miznit calkeuli individebis, jgufebisa da sazogadoebrivi jgufebis mozidvas. programebis umetes nawils esawiroeba xelmzrvaneli, romelic daiqiravebs personals, ganaxorcielebs saqonlisa da aparaturis Sesyidvebs da gaaformebs kontraqtebs momsaxurebaze. am funqciebis efeqturad ganxorcieleba mxolod qveyanasi politikuri nebis arsebobisa da administraciuli mzadyofnis SemTxvevaSia SesaZlebeli. tuberkulozis kontrolis samsaxurebis funqcionirebis SenarGuneba tuberkulozis kontroli xangrzlivi brzolaa. ramodenime qveyanasi tuberkulozis kontrolis Tavdapirvelma warmatebam ganapiroba SemTxvevaTa zrda da medikamentebisadmi rezistentoba 240,241 (termini - sazrunavis U formis mrudi gamoiyeneboda iseti fenomenis arsawerad, rogoricaa tuberkulozis kontrolisadmi interesis, SemarTebisa da mxardaweris Semcireba, rasac mohyveba 398

daavadebis simzimis zrda, rogorc Sedegi programis arasatanadod ganxorcielebisa 242. tuberkulozis kontrolis samsaxurebis SenarCunebis ert-erti umnisvnelovanesi strategiaa dokumentebsi momsaxurebis efeqturobis sistematurad asaxva da am informaciis damfinansebeli organizaciebisatvis regularulad miwodebis uzrunvelyofa. efeqturi ganxorcieleba sawiroebs monacemta mimdinare analizs da misi obieqturi Sefasebis gaumjobesebas. qveynis SigniT ZiriTadi strategiaa momxmarebelta identificireba da mati mxardaweris SenarCuneba. saxelmwifo seqtoris saqmianoba ufro SezRudvebzea orientirebuli, vidre Sesasrulebel amocanebze. am zegavlenis Semcirebis miznit tuberkulozis kontrolis programam unda moipovos calkeuli pirebis, dawesebulebebis da arasamtavrobo organizaciebis mxardawera. tuberkulozis kontrolis SemTxvevaSi mat ganekutvneba is individebi, Tu jgufebi, romlebic dainteresebulni arian, rom tuberkulozis kontrolis samsaxurebi kvlavac xelmisawvdomi iyos. aqedan gamomdinare, arasamtavrobo jgufebs da arasaxelisuflo pirovnebebs SeuZliaT mnisvnelovani roli Seasrulon tuberkulozis kontrolis efeqturi samsaxurebis xelsewyobasa da SenarCunebaSi. da bolos, tuberkulozis kontrolis maralxarisxovani samsaxurebis Seqmna 243. 1. 399

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7. uunaroba- Sromisunarianobis SezRudva 8. intervalebis dacvit mkurnaloba- intermitiuli mkurnalona 9. nacx-dadebiti- nacxit dadebiti nacx-uaryofiti- nacxit uaryofiti 10. Cakafsulebuli- inkafsulacia 11. reaqtivacia= ortografiuli leqsikoni 12. peroraluri- per oraluri 13. hipersensitivoba- anoreqsia 14. tabletirebuli forma- abebi 15. mikobaqteria tuberkulozi- tuberkulozis mikobaqteria 16. fataluri- letaluri 17. Temi- mosaxleoba- sazogadoeba 18. bacilagamomyofi- infeqciis matarebeli, infeqciis gamavrcelebeli 19. hemaftozi- hemaftoe 20. AFB- mgb 21. inokulaciis kabineti- baqterioskopiis kabineti 22. kulturaluri analizi- kulturis analizi 23. zemowilovani- apikaluri 24. pulmonaluri infiltracia- filtvis infiltracia qveda wilebsi 25. tuberkulozis perikarditi 26. baqteriologiuri-baqterioskopiuli 27. nacxit negatiuri- baqteriagamomyofi 28. nacxit Sefaseba/ baqterioskopulad gamokvleva 29. relafsi- recidivi 30. reestri- dokumentebis saregistracio Jurnali 31. pulmonaluri tuberkulozi- filtvis tuberkulozi 32. eqstrapulmonaluri tuberkulozi- filtvgarese tuberkulozi 33. WHO- janmo 450