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Yu.V. Lobzin, L.N. Konovalova, N.V. Skripchenko
Prevalence of infections diseases in children of the Russian Federation
Pediatric Research and Clinical Center for Infectious Diseases, St. Petersburg, Russia
Keywords: children, infections, morbidity, Russia.
Children and infections are inseparable notions because a child's organism being in the process of growth and development is influenced by the environment reality factors to a greater degree than an adult's organism. It is the pediatrics where there can be found the "keys" to the prevention of chronic diseases of the adult period of life, to the formation of significant features of intelligence, many-sided abilities and potential longevity. The proportion of infectious diseases is over 90% in the structure of whole morbidity in children as a multitude of types, subspecies, and subclasses of pathogens, type-specific formation of postinfectious immunity, and easiness of infection transmission cause their total prevalence, especially in childhood. The review article deals with pressing
issues of morbidity in children's population of the Russian Federation reflecting the results of interactions of economic, ecological, social-hygienic and medical-organizational factors in the society. There is given the analysis of official statistics concerning the condition of infectious diseases in children of the Russian Federation within the period of 2015—2016. There are specified the causes of morbidity and the ways of problem solutions in the sphere of children infectology are defined. Public health officials should have the possibility to use available reserves more rationally to make the problem of saving and strengthening of reproductive, personnel and mental potential (which children are) in the conditions of modern economic instability of the country not so keen.
The processes of globalization, actively occurring in modern society, have a multi-factorial impact on human health, which is a comprehensive social and hygienic and economic indicator, reflecting the level of economic and cultural development of society, the state of medical care [4]. In the ongoing economic crisis, key financials decrease of economic development immediately affects the deterioration of the overall social background, one of the main social characteristics of which is the health of children as the country's reproductive, personnel and intellectual potential. The present situation is a positive dynamics of the child population, so the analysis of child health is of great importance for ensuring the vital activity of the state. The founder of the St. Petersburg pediatric school, S.F. Khotovitsky noted: «Recognition and treatment of childhood diseases needs much more careful observation, much greater insight and practical skill, rather than as is necessary in relation to the diseases of adults; ... the children's organism has a much greater natural disposition to a convenient and rapid transition from a healthy to a morbid state, which is also soon approaching a safe and dysfunctional outcome; The ubiquity of the
spread of the suffering that began»1. It should be noted that it is in pediatrics the «keys» to the prevention of chronic diseases of the adult period of life, the formation of high intelligence, versatile abilities and potential longevity.
Individual organizations and individuals have repeatedly declared elimination of certain infections [5]. However, the introduction of new technologies into everyday life, changes in the way of life of mankind, the influence of ecological factors, in particular anthropogenic factors, are the causes of the appearance of regular outbreaks, the emergence of «new» pathogens, the registration of unusual combinations of known infections. In modern conditions, the problem of bioterrorism is extremely acute, against which, while humanity is powerless [15]. According to the World Health Organization (WHO), in modern conditions, it takes only a few hours for an infection that breaking out in one region of the world caused an emergency situation on the other side of the planet [5]. A number of diseases of mankind are classified by official statistics in the category of somatic (in the section «pulmonology»,
1 Khotovitsky S.F. Pediatrica / Op. Hon. Prof., Acad. Stepan Khotovitsky. SPb.: E. Praca, 1847.
«nephrology», «ophthalmology»), not taking into account the fact that the registered pathology is a consequence (complication) of the disease, which is of an initially infectious nature. The list of diseases previously considered somatic, with the improvement of the evidence base will only expand. The ease of transmission of infections, many subspecies and subtypes of pathogens, the type-specific formation of postinfection immunity determine their universal prevalence, especially in childhood. In the structure of the total incidence of children, the share of infectious diseases exceeds 90%. Infectious factor is important in 35% of deaths [5]. Viral infections account for more than 97% of all cases of infectious diseases, bacterial infections — only 2%, others less than 1% [1]. This fact often leads to an unjustified prescription of antibacterial drugs, outlining the problem of increasing resistance of pathogens of a number of infectious diseases. The human microbial biocenosis is transformed, leading to a change in herd immunity in the population [2]. According to the calculations of a group of independent experts-economists, with the current rates of resistance spreading and the absence of countermeasures measures to 2050, up to 10 million people will die annually from infections caused by resistant bacteria [27]. The share of disability from the effects of infectious and somatic diseases, according to statistical data, has sharply reduced (the level was reduced nearly twice). However, according to some researchers, this is most likely due to the imperfection of the system of medical and social expertise (underestimation of children's disability) [1]. So, in case of chronic diseases of the genitourinary organs, trigger of which is all the same infection, the actual disability registration corresponds to the number of people who need it as 1: 4.4 [7]. The dynamics of indicators characterizing the state of children's health is determined mainly through the analysis of official statistics. Quality information is very important that reflects the true situation that helps the process of shaping public health policies. It must be remembered that the morbidity of the population, including children, reflects, on the one hand, the prevalence of pathology in the population, and on the other hand, the availability of medical care.
The purpose of this review is to assess the state of infectious morbidity in the Russian Federation, including children, and identify ways to solve problems.
The descriptive statistics method was used to analyse the incidence of the child population according to official statistics for 2015-2016.
According to official statistics in 20152016 increase in infectious morbidity continues in the Russian Federation. So, if in 2014 the increase in rates of infectious morbidity (for the first time since 2008) averaged 0.2%, then in 2015 - already 4.1, and in 2016 - 7.58%. The proportion of children under 17, inclusive, in the age structure of infectious patients did not change significantly and amounted to 70.1% [22; 23].
The increase in the rates of infectious morbidity is undoubtedly due to an improvement in the registration of individual nosologies within the framework of federal state statistical observation, the improvement of epidemiological surveillance, the improvement of laboratory diagnostics, and the direct increase in the incidence of infections. In connection with the massive migration to the epidemiological situation in the Russian Federation, the adverse epidemiological situation in the countries of the world, including the European region, has a significant impact [4; 12]. Nevertheless, in 2016 there was a decrease in the incidence of the following infections: Measles by 5.2 times, typhoid by 2.2 times, acute hepatitis B by 16.2%, acute hepatitis C by 13.9, meningococcosis by 24.2 (including disseminated infection by 25.6), for the first time revealed brucellosis by 15.4, hemorrhagic fever with renal syndrome (HFRS) by 34.7, tick-borne viral encephalitis (KVE) by 12, ixodes tick-borne borreliosis (ITB) by 17.2 %, human granulocytic anaplasmosis by 2.2 times, new-onset syphilis by 10.7%, gonococcal infection by 22.1, pseudotuberculosis by 34.9% [22; 23].
It should be noted that in the Russian Federation in 2016 an increase in morbidity rates was observed for infections controlled by means of specific immunoprophylaxis. Thus, the incidence of whooping cough increased by 27.4%, rubella by 2.2 times, epidemic mumps by 5.7 times (in children by 6.7 times).
The incidence of enterovirus infections, primarily due to the child population, increased 1.8 times ( including enterovirus meningitis by 45.6%), tularaemia by 1.8, Western Nile fever by 3.3 times, Crimean hemorrhagic fever by 16.4%, Q fever by 2 times, salmonella infections by 2.7%, acute intestinal infections caused by agents of unknown etiology by 5.5, leptospirosis by 29.5, community-acquired pneumonia by 23,8%, trichinosis by 4 times.
When analyzing the incidence of previous years, there was an excess of long-term average annual of whooping cough incidents by 1.4 times (5.6 in 2016 vs. 4.0 in 2006-2015), epidemic parotitis by 1.9 (0.76 vs. 0.4), enterovirus infection by 1.7 times (9.8 vs. 5.7), enterovirus meningitis by 27.2% (3.0 vs. 2.4), community-acquired pneumonia by 20% (418.3 vs. 348.5) [13; 23].
The most significant in terms of economic losses, including the costs of treatment, are still acute upper respiratory infections, tuberculosis, acute intestinal infections initiated by identified and unidentified pathogens, and the disease caused by the human immunodeficiency virus (HIV).
In the structure of infectious and parasitic diseases in the Russian Federation in 2016, acute upper respiratory infections (ARVI) and influenza (more than 89%) still prevail. This fact is a worldwide trend. According to the WHO, every third resident of the planet has ARVI per year.
Over the past year, the incidence of ARVI exceeded the level of 21 thousand per 100 thousand of the population. The maximum indicators (about 120 thousand per 100 thousand of the population of the corresponding age group) are registered in groups of children from 1 to 2 years and from 3 to 6 years. In these age groups in 70-80% of cases, from 4 to 12 episodes of acute respiratory viral infections are caused by pathogens determined severe complications [4]. Among them, respiratory syncytial virus (RSV) is of significant importance, which is the main cause of acute lower respiratory infections in children of early and preschool age. The virus owes its name to its ability to form syncytia («syncytium») - a tela structure of cells with cytoplasmic processes among themselves, as well as a special affinity
to the cells of the respiratory tract. At relatively mild flow in adults in the paediatric age group, this infection can lead to the development of severe pneumonia, obstructive bronchitis, bronchiolitis, which outcomes in 50% of cases give a high risk of developing bronchial asthma and atopy. About 2% of patients require long-term hospitalization and intensive care. The only drug for the prevention of this infection, which is also the main cause of deaths in young children, is palivizumab (Sinagis), the effectiveness of which has been proved by scientific clinical studies conducted at FSBI Pediatric Research and Clinical Center for Infectious Diseases of the FMBA of Russia. In order to develop a strategy for coordinated systematic and global surveillance of the RSV, an informal consultation with representatives of science and public health was organized in the framework of the WHO global program to combat viral infection, which was held in Geneva on March 25-27, 2015. There is the issue of creating a global surveillance system of RSV infection on the basis of a successful Global Influenza Surveillance and Response System (GISRS) [5].
In recent years, the coverage of the population with preventive vaccinations against influenza has significantly increased, which affects the nature of the epidemic process of influenza in the country. On the eve of the epidemic season of influenza and ARVI 20152016 more than 44.9 million people were vaccinated, or 31.3% total population of the country. More than 13.3 million children -47.6% of children under 17 years old were immunized. It allowed to prevent the wide spread of influenza viruses on the territory of the Russian Federation. However, the incidence rate in 2016 increased by 1.8 times (to 60.73, and among children - up to 116.55 per 100 thousand of the population of the corresponding age) compared with the level of 2015, which at one time almost four times exceeded the incidence rate of 2014 [13; 22; 23].
A high incidence of pneumonia is associated with seasonal rises in the incidence of respiratory infections, an epidemic rise in the incidence of influenza. However, despite the fact that the scientifically proven association of pneumonia with the incidence
of ARVI allows planning preventive measures with a wider range of effects on the epidemic process of community-acquired pneumonia, in 2016 by 23.8% more cases of community-acquired pneumonia were registered in comparison with 2015. The average of the incidence in the country was 418.3, and in childhood — 702.71 per 100 thousand of the population in comparison with 337.8 (600.08) in 2015 [23].
It should be noted that the increase in the incidence in childhood is associated with a violation of sanitary and hygienic standards and conditions of placement of children in educational institutions, with the untimely isolation of patients with ARI. There is no proper control by doctors assigned to kindergartens and schools. All these factors are the cause of outbreaks observed in a number of regions of the Russian Federation. The highest incidence of community-acquired pneumonia (from 595 to 793.2 per 100,000 population) was registered in the Yaroslavl, Arkhangelsk, Kirov, Orenburg, Kemerovo regions, the Republic of Karelia, Buryatia, the Republic of Udmurtiya, Primorsky, Perm Krai, Chukotka Autonomous District [23].
In modern conditions, the problem of herpesvirus infections, in particular chicken pox is of particular relevance. The disease is relevant for both children and adults. At present there is an epidemic rise in this infection. For many years in the Russian Federation there was a very slight fluctuation in the incidence of chicken pox. In 2016 this indicator was 544.59 (in 2015 - 562.08) per 100 thousand of the population. In the last decade there has been some «maturity» of the infection. However, 94.3% of cases are still children (preschool children, it is registered more than 70% of cases). Thus, the average Russian incidence rate was 3027.15 per 100 thousand population in 2016 in the age group up to 14 years, and, for example, in St. Petersburg exceeded the mark of 5000 (5041.8 per 100 thousand of the population of the corresponding age). In some regions of the Russian Federation (Moscow, Sverdlovsk Region) vaccination against varicella has been introduced into regional calendars of preventive vaccinations, which has made it possible to reduce the incidence of this infection
in the field [10; 13; 23]. However, it must be remembered that vaccination against this infection can not be less than 80%; otherwise there is a risk of an even sharper shift in morbidity and mortality in the elderly. The risk of complicated course in adults is 25 times higher than in children, and the mortality in adults is 15 times higher than the level of mortality in childhood [21].
The epidemiological and social importance of chickenpox is due to both a remaining high incidence rate, the possibility of severe specific and nonspecific complications, and heavy economic losses. Although the burden of chickenpox is less than that of other vaccine-preventable infections (measles, whooping cough, rotavirus or pneumococcus), its role in morbidity and mortality, especially in risk groups cannot be underestimated. For example, in HIV-infected children, a severe course of infection is observed in 40% of cases. Taking into account the severity of the course of chickenpox in adults and people with immunodeficiency, according to epidemic indications vaccination against chickenpox has been included in the national schedule of preventive vaccinations of the Russian Federation since 2014. Children and adults are subject to the vaccination from risk groups, previously not vaccinated and did not have chickenpox, including those subjects who are liable for military service. [18]
A particular concern of the society is the high tuberculosis burden, the emergence of forms of infection with multiple drug resistance, and a dual infection - tuberculosis and HIV threatening global healthcare security. The tuberculosis elimination strategy of the WHO is aimed at eradicating the tuberculosis epidemic by 2035. It outlines concrete steps for providing patient centered medical care, implementing changes in health policy, and intensifying active research and innovation [4]. In the 1990s, the level of registered incidence of tuberculosis in the Russian Federation increased 2.5 times. The primary incidence of active tuberculosis reached its highest value in 2000 — 90 cases per 100 thousand people [5]. In 2004, tuberculosis was recognized as a socially significant disease, after which the provision of subjects of the Russian Federation with necessary medical
equipment and anti-tuberculosis drugs began. A steady tendency toward a reduction of morbidity has been established since 2009, but the situation remains tense. In 2016, the incidence rate of bacillary (open) forms of tuberculosis decreased by less than 4% (21.66 vs. 22.47 per 100 thousand population), and active forms of tuberculosis was 49.72 per 100 thousand population (2015 - 53.24). The proportion of people of working age, from 18 to 54 years old, invariably constitutes about 80% of all registered cases of active tuberculosis. In 2016, the trend of reducing the incidence of active forms of tuberculosis in children aged 0-17 years by 9.4% (to 13.06 per 100 thousand population of the corresponding age), which began in 2013, continued, but the incidence rate of bacillary forms of tuberculosis is only by 1.8%. In addition, in St. Petersburg, the incidence of open forms of tuberculosis among children increased more than 5 times (1.41 vs. 0.27 per 10 thousand population of the corresponding age). It is proved that among the child population the highest incidence of tuberculosis is registered in adolescence. In St. Petersburg the infection rate among adolescents aged 15-17 is 59.7%. In children and adolescents from among migrants and refugees (18,6% of registered cases of tuberculosis) the clinical structure of the incidence of tuberculosis is much worse. Among them owing to the late application for medical care, that a large share of eliminators of bacilli is noted, and the frequency of generalized processes is significant [13; 14; 17; 23]. The current course of infection is often characterized by a reduction in the latent period, an increase in the incidence of acute onset of the disease under a mask of respiratory diseases and long-lasting symptoms of intoxication that imitate somatic pathology, which reduces concernment of doctors in case of the development of tuberculosis. The disease is often diagnosed after ineffective treatment with wide-spectrum antibiotics, which can lead to the development of multiple drug resistance. In 20% of new cases of tuberculosis, the causative agent shows signs of resistance to drug therapy [5].
According to the specialists of Federal Centre on Monitoring of TB Spread Counter-
action in the Russian Federation, stabilization of the epidemic situation in tuberculosis has begun in Russia with an improvement trend. In the future, the situation will be adversely affected by the developing epidemic of HIV infection. The relative risk of developing tuberculosis among HIV-positive patients is 20-30 times higher than among seronegative ones. In 2015 the global HIV epidemic took less human lives than any other year for the almost 20 years. Thanks to prevention programs, since 2000 the number of new HIV infections has declined by 35% over the year. Massive expansion of carrying out of antiretroviral therapy led to 45% reduction in the lethality from this infection [5]. However, despite considerable efforts, HIV remains one of the main public health problems in the WHO European Region, especially in its eastern part, where in 2015 a record number of new infections were registered in 50 countries in the WHO European Region, more than 153 thousand people were first diagnosed as «HIV-infection». Western European countries accounted for 18% of the detected cases, 3% for Central Europe, and 78% for Eastern Europe, including Russia, where the HIV epidemic is far from safe [6]. In 2015 the HIV infection rate among Russians is 11.5% higher than in 2014. The growth in the age group under 17 was 3.7% (from 4.27 to 4.43 per 100 thousand population of the corresponding age group). In 2016 there is a slight (by 1.1%) growth in the overall Russian rate with a decrease of 6.5% (to 4.14 per 100 thousand of the population) in the age group from 0 to 17 years. Reduction in the incidence rate (by 4.9 and 30% in the corresponding age groups) was noted in St. Petersburg, which is considered one of the most affected subjects of the Russian Federation. The main reason (in 53.6% of cases) of HIV infection is intravenous drug use. Sexual transmission of HIV infection, characteristic primarily for women, is observed in 45.5% of cases. The peculiarities of the HIV epidemic in our country are the spread of the disease in previously HIV-positive areas. The number of registered cases of morbidity in the age group of the able-bodied population of reproductive age is still growing ( up to 47.7%), and the share of older people with HIV infection is also increasing [17]. In 2000 the
total incidence of HIV infection among men was 4 times higher than the incidence of women ( 90 vs. 22 per 100 thousand people). Since 2002 there has been a feminization of the infection, and by the beginning of 2016 the differences have decreased to 1.5 times (490 vs. 318). A steady increase in the number of infected women leads to an increase in the number of children born to HIV-infected mothers. The incidence of HIV infection in children continues to be documented in breastfeeding: 2015 — 21 children (2014 - 24 children) [13].
Acute intestinal infections (All) are a polyethological group of infectious diseases, which at the present stage are still widespread and from year to year growing economic importance. The prevalence of intestinal infections is one of the most important indicators of social and sanitary well-being. This group of diseases remains predominantly a childhood infection and mainly in early childhood is characterized by a high frequency of the development of severe forms and complications and by the risk of formation of chronic gastroenterological pathology. The prevalence of viral gastroenteritis is still noted, reaching 50—70% at this time, and the number of viral agents affecting the intestine is growing steadily. There is a high share of AII, the etiology of which remains unidentified (according to 2016, 68.1%). This is because of the use in a number of subjects of the Russian Federation mainly routine laboratory methods, which in modern conditions is not enough for the etiological interpretation of AII. An unsatisfactory situation with the use of laboratory-diagnostic methods for the detection of pathogens AII was observed in the Chechen and Karachay-Cherkess Republics, where the share of etiologically refined diagnoses was 0.58 and 2.79%, respectively. In 2016 the incidence of children under 17 years of AII caused by established bacterial and viral pathogens, including food toxicoinfections, amounted 725.73 per 100 thousand population of the corresponding age. Despite the fact that in recent years there has been a tendency towards an increase in the number of registered cases of AII, in a number of regions this incidence is still masked by somatic nosology. Adequate registration of this infectious pathology will
give a dramatic increase in the incidence of children with intestinal infections. Thus, in one of the largest megacities in the country, in St. Petersburg, according to official statistics, the incidence of children under 17 years old is 1300.4 per 100 thousand population for AII of known etiology and 1967.9 per 100 thousand population for infections unknown etiology, which does not indicate an increased level of morbidity in this region [17; 23].
Among AII of the known etiology, mainly rotavirus infection (RVI) is verified. That is the highest susceptibility to RVI in children under 5 due to anatomical and physiological features of the gastrointestinal tract, immaturity of immune defense factors. The widespread preval ence of rotaviruses, a high level of clinical manifestation causes an increased incidence of the adult population of the Russian Federation. Thus, the incidence rate of RVI in 2015 was 85.45 per 100 thousand people, which is 14% higher than in the previous year. The absence of registered cases of RVI among the population, for example, the Chechen Republic, indicates a corresponding level of clinical and laboratory diagnosis. Introduction since 2014 in the national calendar of preventive vaccinations on the epidemiological indications of vaccination against this infection has not had any significant impact on the course of the epidemic process [18].
Despite the continuing decline (3.6% to 6.61 per 100 thousand population) in 2016, the incidence of bacillary dysentery, the situation remains tense, as children under 17 years remain the most involved (59% of all cases) in the epidemic process. The incidence rate in this age group was 20.18 per 100 thousand of the population. In 2016 after a three-year decline, the increase in the incidence of salmonellosis increased by 2.7% (to 26.8 per 100 thousand population), which causes great caution. Children are involved in the epidemic process equally with adults, accounting for up to 50% of the victims. The incidence rate of children under 17 in 2016 was 64.33 per 100 thousand, which is only 2.4% lower than in 2015. The leading serovar S. Enteritidis accounts for up to 81% of the total number of detected salmonellae. However, the increasing role of S. Infantis may indicate the formation of new reservoirs of the
pathogen in nature and, as a result, changes in the dynamics of the epidemic process [13; 23].
In the structure of geohelminthoses, asca-riasis remains the dominant invasion (90.2%), for the formation of foci in most of the country favorable natural and climatic and living conditions have developed. In 2015 the incidence of ascariasis was 16.51 per 100 thousand of the population and decreased by 10.4% compared to 2014 (18.42). In 2015 16068 cases of infection with ascarids of children under the age of 14 years were detected. The incidence of ascariasis (per 100 thousand of the population) exceeds the average in 33 constituent entities of the Russian Federation, with the highest rates in the Republic of Dagestan (250.5) and the Pskov region (229.89). This pathology is most often detected during clinical examination, as well as when visiting medical institutions with respiratory and allergic reactions. The high incidence rate of the population with toxocariasis is a serious problem in the Russian Federation in recent years, including due to the widespread introduction into healthcare practice of methods for its diagnosis. The incidence rate was 1.72 per 100 thousand of the population. The share of children in the age group under 14 years was 37% of cases. In some regions, when helminth eggs are detected in the soil, its disinfection with ovicide preparations is not carried out, and toxocariasis diagnosis is still not worked out. Thus, according to the data of studies, for example, the Reference Center for Monitoring Helminthiases on the basis of the Rostov Research Institute of Microbiology and Parasitology, the proportion of people positive for toxocarosis detected by immunological examination in the southern regions of the Russian Federation is 39.8%. A complex epidemiological situation remains in the foci of biohelminthosis - trichocephaliasis, strongy-loidiasis, the course of the disease in which is often accompanied by chronicization process and irreversible complications [11].
This year, a number of countries in the European and Asian regions are experiencing an epidemic rise in the incidence of enterovirus infection (EVI) with the formation of outbreak foci among the population and in organized groups. So, in Spain from mid-April 2016 there was an outbreak of EVI caused
by 71-type of enterovirus. In the epidemic process mainly children were involved in the age group 1-4 years. The disease was severe and moderately severe. In the Russian Federation after some decline in 2014-2015 the level of the incidence of EVI in 2016 also registered an increase in the incidence by 1.8 times, including enterovirus meningitis by 45.6-47.6%. In the structure of morbidity, the proportion of children under 14 years is almost 90% of the total number of cases. The incidence rate of children under the age of 14 was 51.81 compared to 29.15 (2015) per 100 thousand population of the corresponding age for EVI and 14.7 vs. 10.06 (2015) for enteroviral meningitis. The highest incidence of EIV (23.9-102.7 per 100 thousand of the population) was registered in the Yaros lavl, Tomsk, Amur, Magadan, Sakhalin regions, the Republics of Buryatia, Mari El, Khakassia, Kalmykia, Tyva, Sakha (Yakutia), Krasnoyarsk, Khabarovsk Territory, the Jewish Autonomous Region [23]. In connection with the widespread prevalence of enteroviruses, this variability in the incidence rate is largely determined by the quality of the organization of epidemiological surveillance of EVI and the completeness of the registration of the disease. In addition, due to the technical complexity of the diagnostic laboratory verification of EVI is low. In St. Petersburg for 20 years the method of rapid diagnosis of EVI is successfully used, which allows to detect an antigen of enterovirus within 24 hours, with its simultaneous typing. The mRSC method was developed at FSBI Pediatric Research and Clinical Center for Infectious Diseases of the FMBA of Russia (St. Petersburg) and is protected by a patent in 2013 [16].
According to official statistics, in 2016 there was 1 case of vaccine-associated poliomyelitis in the Russian Federation. In 2015 the indicator of the timeliness of the vaccination of children against poliomyelitis was 97.4% on average in the country, and revaccination 96.898.3%. However, this indicator has not been achieved in a number of areas: vaccination in the Republic of Crimea and the Nenets Autonomous District, revaccination in the Republics of Crimea and Buryatia, Nenets Autonomous Okrug, Vladimir and Kaluga regions. Because
of the registration of 2 cases of poliomyelitis in Ukraine in 2015, a two-day supplementary immunization against poliomyelitis in preschool children in the Crimean Federal District is organized, as well as immunizing children in other regions of the Russian Federation. At present Russia maintains the status of a territory free of poliomyelitis, confirmed in May 2013 at the 27 th meeting of the European Regional Commission for the Certification of the Eradication of Poliomyelitis. To maintain this status, it is extremely important constantly to carry out quality epidemiological surveillance, taken into account the easy possibility of importing wild poliovirus into our country due to the scale of labor migration, international tourism, and armed conflicts [13; 23].
Until now, meningococcosis infection (MI) remains a socially significant health care problem. In the Russian Federation the overall incidence of MI has steadily declined in recent years. In 2016 the all-Russian indicator was 0.51 per 100 thousand people, which is significantly lower than the epidemic level. However, the infant morbidity of MI (up to 17 years inclusive) traditionally remains high and four times higher than that of adults, amounting to 1.94 per 100 thousand children of the corresponding age. More than 50% of MI cases occur in children under 5 years and about 20% in adolescents aged 14—17 years. Among children of the younger and older age groups not only the incidence of MI is higher, but also the risk of developing generalized, most severe forms of the disease (GFMI). The possibility of a lethal outcome with this infection also depends largely on the age of the child: the younger he is, the higher the probability of an unfavorable outcome. Up to 75% of deaths from GFMI are children under 2 years old, with the share of children in their first year of life reaching 40%. In 63% of cases daily mortality was registered as a result of hypertoxic «fulminant» form of the disease. In recent years in the Russian Federation severe forms of MI have also been observed in adolescents and young people aged 17-25: first-year students and recruits. The cause of the development of the disease, as a rule, is meningococcus serogroup W-135 [8; 9].
One of the determining factors in control -ling the incidence of MI is specific prevention.
And although from 2014 in the Russian Federation, according to the epidemiological indications, vaccination against the infection caused by meningococcus serogroups A and C are received, including those who are subject to military recruitment, a problem of low coverage with vaccine prevention remains. Immunization by epidemiological indications cannot influence the epidemic process. It should be noted that during the routine vaccination of children of the first year of life, it is possible to predict a decrease in the incidence of MI in this age group by 5.6—5.7 times [9; 18].
Despite the continuing decline in the incidence in all age groups of viral hepatitis (VH) A, B, C, the problem remains urgent, which is determined by the high incidence of predominantly chronic forms. In 2016 the incidence of acute forms of VHA was 4.39, and in children under 17 years — 8.9 per 100 thousand population of the corresponding age group. There is still a relevant carrying of infection in children's organized groups, which, in the conditions of non-compliance with the anti-epidemic regime, leads to the formation of epidemic foci; contamination of water supply sources; imperfection of purification systems [13; 23]. Thanks to the vaccination against hepatitis B, introduced into the national calendar of preventive vaccinations, as well as additional immunization within the National Priority Health Care Project in the Russian Federation, there is a tendency toward a reduction of this infection. In the structure of acute viral hepatitis, the share of acute hepatitis B in 2016 accounted for 21.5%, and the incidence rate was 0.94 per 100 thousand of the population against 1.13 in 2015. Among the children under 17 years, single cases of AHB are registered: In 2016 20 cases (0.07 per 100 thousand children) were registered against 23 in 2015. In 2016 the incidence rate of children under 17 years of acute hepatitis C (0.25 per 100 thousand population) decreased by 15.3% in comparison with 2015. Decrease of indicators (within 5%, and among children — within 20%) is noted among the first time indicated VH with a chronic form. However, the incidence rate is still high. So, for 2016 the average Russian indicator was 46.55 per 100 thousand of the population; in children under 17 years was
2.11. In one of the largest megacities of the country that is St. Petersburg (a city with a good level of diagnostics), the incidence rate is higher than the Russian average by more than 3 times (148.1 per 100 thousand people). Due to the introduction of the registration of cases of viral hepatitis E in 2013, the registration this infection is increasing. In total in 2016 17.5% of cases of this infection were registered with the indicator 0.08 per 100 thousand people (in 2015 - 0.07), including 6 cases among children under 17 (0, 02 per 100 thousand population) [13; 17; 23]. Taking into account the magnitude and complexity of the VH pandemic, the World Health Organization has developed recommendations for WHO member states on the implementation of national strategies for the prevention, diagnosis and treatment of viral hepatitis (Global health sector strategy on viral hepatitis, 2016-2021). In the Russian Federation a single federal register of people with VH is being developed and implemented, which should improve the quality and volume of specialized medical care provided to these patient groups [5].
In 2015 the implementation of the three-year program «Prevention of measles and rubella during the verification of the elimination of infections in the Russian Federation» was completed and a new «Program for the elimination of measles and rubella in the Russian Federation (2016-2020)» was approved, as well as a plan for its implementation. In 2016 the decrease in the incidence of measles, which began in 2015, continued (5.2 times compared with the same period in 2015). It amounted to 0.11 per 100 thousand of the population (2015 - 0.58 per 100 thousand of the population). 162 measles cases were registered in 24 subjects of the Russian Federation. The greatest number of cases (9-62) was observed in the Sverdlovsk and Irkutsk Regions, the Republic of Buryatia, Moscow, the Stavropol Territory. The level of morbidity in children is three times higher than the average Russian one. There is a high incidence of children of the first years of life, which can be associated with a low level of maternal immunity in children of the first months of life, and with untimely vaccination ( medical withdrawals, refusals, etc.) [13; 23].
One cannot but be alarmed by the increase in the incidence of certain infections controlled by means of specific immunoprophylaxis. So, despite the consistently high (more than 96%) coverage of timely vaccinations against whooping cough in children of the first years of life, in 2016 the next cyclical rise in the incidence of this infection continued. The incidence increased by 27,4% and amounted to 5,6 per 100 thousand of the population against 4,4 for the same period of 2015. High incidence rates (up to 37,6 per 100 thousand of the population) were recorded in Lipetsk, Yaroslavl, Voronezh, Astrakhan Regions, St. Petersburg, the Republic of Tatarstan, the Chukotka Autonomous District. The share of children under the age of 17 accounted for more than 96% of cases (28.25 per 100 thousand children) . Timely vaccination and revaccination of children below the regulated 95.0% was noted in the Nenets Autonomous Okrug, Chuvash and Chechen Republics, the Republic of Crimea. The normative indicator is not reached in the Vladimir, Kurgan and Novosibirsk regions.
After reaching the minimum level in 2015 in the history of observation in 2016, there was a two-fold increase in the incidence of rubella (0.03 per 100 thousand people), including children. In January-December 2016, 44 cases of rubella were registered, including 6 cases in children under 17 years old (in 2015 - 20 cases, and 4 in children under 17 years old). Mostly unvaccinated people are ill, as well as persons with an unknown vaccination history. Rubella diseases are registered in Moscow, Yaroslavl, Arkhangelsk, Orel, Kursk, Moscow, Rostov, Kirov, Tyumen regions, Krasnodar and Stavropol regions, the Chechen Republic [23].
At present, the periodicity of the long-term morbidity of epidemic parotitis (EP) has been preserved, which indicates an insignificant effect of social changes on this process. After a long period of epidemic well-being in 2016, there is a six-fold increase in the incidence rate, to 0.76 per 100 thousand people [23]. Epidemic parotitis is primarily a pediatric infection. In the structure of cases for children under 17 years accounted for 56.9% of cases (2.24 per 100 thousand children). Such a high level of involvement of children in the epidemic
process is due to their greater susceptibility to EP, especially in organized collectives. Patients play an important epidemiological role not only with typical, but also with suppressed and asymptomatic forms of the disease, which constitute 25—50% of all cases of infection. Parotitis can cause serious complications: deafness and inflammation in the tropic virus tissue. In boys the disease is often accompanied by painful swelling of the testicles, which can lead to impaired fertility: approximately 25% of all cases of male infertility are due to the infection borne in childhood. In some cases, the encephalitis caused by EP is able to lead to a lethal outcome. The situation is exacerbated by the increasing number of unjustified refusals of preventive vaccinations that have become more frequent in recent years. And although in about 15% of cases the vaccine does not protect against the disease itself, it can prevent the development of complications of the disease, in addition, the vaccinated EP proceeds on average easier than unvaccinated.
In view of the tense situation of managed infectious diseases, the WHO Regional Office for Europe carried out large-scale campaigns on immunization of the population from 24 to 30 April 2017 in 51 countries of the world uniting the European Region. The aim of the 12th European Immunization Week was to raise public awareness of the benefits of vaccine prevention of infectious diseases, to attract attention of territorial executive bodies, professional groups of population, the business community, and public organizations to the issues of improving the measures for organizing vaccination in the regions [5].
The continued expansion of the scale and intensity of development of natural areas, the organization of horticulture in endemic areas, the registration of cases among nonimmune urban population — all this requires the continuous improvement of preventive and antiepidemic measures in regard to natural focal and zooanthroponous infections, the epidemiological situation in which, despite the reduction in morbidity on some nosologies, remains unsuccessful. In 2016 an increase in the incidence of tularemia was registered 1.8 times on average, and the children's population is affected on an equal basis with an adult one.
In 2016 20 cases of tularemia were detected among children under 14 years old ( against 1 in 2015). The cause of mass morbidity was, first of all, the lack of immunization of the population which is the most reliable way to prevent this infection. The greatest number of cases of tularemia was revealed in the Republic of Karelia, Omsk region, St. Petersburg, Ryazan region, Nenets autonomous region. In 2016, the increase in the incidence of Crimean hemorrhagic fever was registered (by 16.4%), West Nile fever increased 3.3 times (to 0.11 and 0.09 per 100 thousand people, respectively) [23].
In the structure of the registered incidence of natural focal and zoonotic infections, more than 50% are occupied by infections, the pathogens of which are transferred by ticks. Expanding the range of vectors, the detection of a symbiosis of pathogens that cause mixed infection, make one pay close attention to this problem. Despite a slight decrease in the incidence rate, the number of cases of tickborne encephalitis (TBE) infection registered annually in the Russian Federation remains fairly high (1.39 per 100 thousand of the population). Annually there are lethal outcomes associated with late seeking medical help, untimely diagnosis, lack of vaccination and specific immunoprophylaxis. As before almost 70% of the cases are urban residents, more often unvaccinated, whose infection occurs in forests, in horticultural plots, in urban square and parks. TBE for today remains the only infections, transferred by ticks, against which there are means of specific prevention. In 2015 the plan for vaccination against HEM was fulfilled by 78.6% in the Russian Federation [13; 23].
Tick-borne borreliosis (Lyme disease) is the most common disease from a group of infections transmitted by ticks. Since the official registration of this infection (1992), the number of patients in the country has increased from 2,247 to 6,103 by 2016, and the incidence is high throughout the country, with the exception of regions where the pathogen is absent due to climatic conditions (Yamalo-Nenets and Chukotka Autonomous Okrugs). This infectious pathology is characterized by a high susceptibility of the child population (more
than 10% of cases), a variety of clinical forms, a high probability of transition to chronic forms and a significant frequency of long-term effects. The incidence rate of this nosoform in 2016 was 2.4 per 100 thousand in children under the age of 17 [23].
The issue related to congenital infections in the Russian Federation outlines the problem of three specialties — midwifery, neonatology and childhood infections. The manifestation of congenital infections in the elderly with their slow course from the moment of intrauterine infection has the greatest practical significance. According to the studies, in most children who died before the age of 14 years from various causes, the background disease was intrauterine infection and the associated immunodeficiency condition [1]. However, with a modern examination of pregnant women, the professional participation of infect ious disease physicians in determining the risk factors for congenital infections in the prenatal period is not foreseen [19]. This fact, as well as insufficiently developed criteria for the detection of congenital infections in young children, causes a late diagnosis of pathological conditions. The leading causes of any pathology of the fetus are primarily acute or slow-running infections: rubella, cytomegalia, enterovirus, chlamidia and many others. It is estimated that, in the Russian Federation, up to 400 cases of congenital rubella, up to 1000 cases of congenital toxoplasmosis, can be observed annually. The frequency of congenital cytomegalovirus infection in the Russian Federation is unknown (in the US it is estimated as 0.6—0.7%), congenital infection with the herpes simplex virus (HSV) — 1 case per 1000 newborns, parvovirus infection — 1 case per 400 newborns [24]. Mortality with congenital manifest toxoplasmosis is 12%, congenital infection with HSV — up to 90, enterovirus infection — 80, parvovirus infection — up to 25, subacute sclerosing panencephalitis (consequence of congenital rubella) — 100% [26; 28].
In conditions of changing ecology, decreasing immunological protection and sexual revolution, any infectious disease of the mother or father can be dangerous for the fetus, the newborn, the child. Sexually transmitted infections (STIs) occupy a special socially significant position in the overall structure of
morbidity, with pronounced age dependence. The period of the late XX - early XXI century was characterized by an unprecedented increase in the incidence of sexually transmitted infections in Russia: cases of chlamidia among children increased by 6-7 times, syphilis -by more than 10.8 times, the incidence of «new generation» infections in adolescents increased by 17 times. The structure of STI in 49% of cases is represented by trichomoniasis and chlamidia, second place is occupied by syphilis and gonorrhea - 32-33%, followed by herpetic urogenital infections, infections caused by human papillomavirus (HPV) -18.2%. The share of adolescents accounts for up to 72% of all cases of disease. Adolescence is the most vulnerable when infected with HPV, which on average in 70% of cases becomes the cause of cancer of the genital sphere [3]. After a sharp rise in the 1990's, the incidence of STIs continues to decline at a rapid pace that began in 2003. So, in comparison with 2015, in 2016 the incidence rate of newly diagnosed syphilis in children under the age of 17 declined by 26, 7%, and gonococcal infection - by 27.8%, amounting to 1.48 and 1.92 per 100 thousand people, respectively. At the same time, according to the statistics, in 2016 the incidence in the same age group, for example, syphilis and gonococcal infection in St. Petersburg, is 3-4 times lower than in the Russian Federation (even with a high level of diagnosis) [17; 23]. More than 75% of patients in the children's and adolescent contingent either do not know or underestimate the consequences of STIs, becoming an unintended source of infection. Adolescents often use methods of self-medication, which aggravate the existing and already delayed danger in the form of a violation of the reproductive function, the birth of their physically and mentally defective descendants. At present about 3 million couples of reproductive age in Russia are infertile (by region - from 8 to 15%), in 35-40% of cases - due to female infertility, 30-35% -male, in other cases - infertility of both spouses [20; 25].
As for other infections of «social ill-being», it should be noted that there is a continued significant number of registered cases of pediculosis - illness of the war years,
abandoned children and homeless people. That is for a short period of decline in 1995—1997 followed by a long period of increase. Increasing to 224 cases per 100 thousand people in 2004, the incidence of pediculosis varies with minor deviations up to 146 cases per 100 thousand people in 2016. Among children under the age of 14, the incidence is higher than that of adults in 1.5 times and is 216.61 per 100 thousand of the population of the corresponding age [23].
Thus, in the context of globalization, an increase in the population, active migration processes that significantly complicate the epidemiological situation and increase the burden on the public health system, infectious diseases remain an important component in terms of morbidity and mortality of the population, including children. The analysis of the quality of medical care for children with infectious pathology indicates the advisability of developing and implementing technologies for managing patients with postinfection syndromes, as well as improving the system of providing medical care to children with infectious diseases on the basis of an interdisciplinary approach with close interaction of infectious disease specialists and pediatricians of various specialties. «Infectious diseases» is the most integrated specialty. However, due to the low specific gravity of the section dealing with infectious diseases in children, the level of knowledge of doctors in this section is low in the structure of the educational process at the level of higher and additional professional education. This is a trigger for a high risk of the admitted diagnostic errors, underestimation of the severity of the child's condition. At the VIII Annual All-Russian Congress on Infectious Diseases in March 2016, it was said that a reduction of 5 rates of infectious disease doctors and / or 3 children's infectious beds leads to one additional fatal outcome. Ways to solve the problems of infant infectology are closely related to the improvement of the available and the development of innovative diagnostic methods, especially express diagnostics, the introduction of modern unified quantitative and semiquantitative methods of research. It is also important to develop immunization as a promising direction for improving the health and global safety of mankind, the way of changing
the economy, demography, the evolution of diseases. It is really necessary to improve the national calendar of preventive vaccinations by including scientifically based vaccinations and revaccinations against a number of infectious diseases. The development of personalized approaches to therapy and prevention based on fundamental studies of the human genome, immunomorphology technologies in the diagnosis and prognosis of infectious diseases is relevant. It is necessary to introduce innovations in the organization of medical care for children with infectious pathology at the prehospital and hospital stages, while preserving the number of infectious-type children beds, as well as using an interdisciplinary approach in diagnosing and treating children. Equally important is the introduction of a multi-level system of providing rehabilitation assistance, since children with the consequences of infectious diseases have the greatest rehabilitation potential.
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Contacts:
Konovalova Lyubov,
Senior Researcher of the Scientific and Organizational
Department Pediatric Research and Clinical Center for
Infectious Diseases,
Candidate of Medical Sciences.
Tel.: (812) 234-43-85.
E-mail: [email protected]
