Geographical distribution and
Pathogeny............. 3 51
Pathological anatomy...... 3 52
Clinical picture........ 3 53
Treatment.............. 35 5
Actions for fight against plague 35 6
Plague (pestis) — the acute infectious disease which is shown heavy intoxication, damage of skin, lymph nodes, easy and other bodies; treats quarantine (conventional) diseases.
According to the classification offered by G. P. Rudnev (1940) and accepted in the USSR distinguish the following a wedge, forms of plague: preferential local — skin, bubonic, skin and bubonic; vneshnedisseminirovanny — primary and pulmonary, secondary and pulmonary, intestinal; internally - disseminated, or generalized — primary and septic and secondary and septic. According to most of researchers, in a crust, time the intestinal form represents only manifestation of a septicaemia and therefore as the independent form Ch. is not allocated. Adams and Megreyt (A. R. D. Adams, V. of G. Maegraith, 1984) consider it expedient to allocate only bubonic and pulmonary forms.
Distinguish the natural, synanthropic (antropourgichesky) and anthropo-noznye centers of plague.
History. Plague is among ancient inf. diseases, devastating epidemics to-rykh brought to mankind huge disasters. Mentioning of this disease is available for Ruff of Efessky (Rufus Ephesius); he reported about the bubonic Ch.'s epidemics with a high lethality arising in the territory of modern Libya, Egypt and Syria since the end of 3 century B.C. In China the earliest data on Ch. belong to 224 BC. The first known pandemic of this disease in 6 century became history under the name «yustinianova plague». This pandemic began in Nizhny Novgorod Egypt, captured all Byzantine empire and carried away in 50 years apprx. 100 million human lives. The second pandemic of Ch. known under the name «black death» arose in 14 century. Reasons to believe are had that it began in Asia, on trade ways got into Europe, and then was brought through Pskov*v Russia. During the second pandemic the St. 50 million people died from Ch. During this pandemic (1348) in Venice the quarantine as a warning facility of a drift of an infection was introduced for the first time. In 15 — 18 centuries of epidemic of Ch. arose in a number of the countries of the world, including in Russia, however they did not gain character of pandemics. The third pandemic of Ch. began in Hong Kong in 1894, and then was brought in a row seaports of the South China Sea, and also to Japan, on the lake of Taiwan, to India and other countries. In 10 years (1894 — 1903) plague captured 87 seaports, from them in Asia — 31, Europe — 12, Africa — 18, North America — 4, South America — 15, Australia — 7. In Russia zabo-
levaniye plague were registered in Odessa in 1901, 1902 and 1910. Feature of the third pandemic was the fact that it seldom got into depth of continents and was shown preferential in a bubonic form; emergence of a pulmonary form Ch. was observed seldom. At the beginning of 20 century two epidemics of pulmonary Ch. in Manchuria are noted (in 1910 — 1911 and 1921 — 1922). During the first epidemic of plague in Manchuria (1910 — 1911) the active help in the organization and holding anti-epidemic actions was rendered by the Russian scientists of V. K. of high-HIV, D. K. Zabolotny, S. M. Nikanorov, A. A. Churilina,
B. I. Isaev, etc.
dibody, pathogeny, immunity and prevention of plague. G. P. Rudnev in the monograph «Clinic of Plague» described a clinical picture of a disease and gave classification of plague.
For deep studying of the natural centers of Ch., development and holding about-tivoepizootichesky, sanitary and preventive and anti-epidemic actions in the natural centers of Ch. in the Soviet Union the network of antiplague institutions is created (see). In 1918 in Saratov «Microbe» was organized by in-t, to-ry since 1920 became the antiplague center of the southeast of the country, and in a crust, time is the methodical center for Ch.'s prevention in the territory of the USSR. Besides in-that, there are zone antiplague in-you, antiplague stations and departments. Implementation of system of measures for fight against plague in the natural centers in the USSR, and also actions for the prevention of a drift of plague on its territory provides in our country full epidemiological wellbeing concerning this disease.
Geographical distribution and statistics. The natural centers of Ch. are available on the Euroasian, African and American continents in a zone between 50 ° northern and 40 ° southern latitude. The synanthropic (antro-pourgichesky) centers of Ch. where a source of a disease-producing factor are gray and black rats, are characteristic only of tropics and subtropics in the territory between 35 ° northern and 35 ° southern latitude. To
Ch.'s Distribution it was quite often connected with wars. So, the Russian-Turkish war of 1770 — 1771 was followed by spread of plague in Moldova, Hungary, in the east of Poland and in Ukraine. Heavy losses from plague were suffered by the French army during Napoleon's expedition to Egypt (1798 — 1799) and Syria (1799); in the Russian-Turkish war of 1828 — 1829 the outbreaks of plague on the Balkans, in World War I (1914 — 1918) — in the British army which was in Mesopotamia were observed.
In 1894 Mr. A. E. J. Yersin and
C. Independently from each other opened for Kitasato the causative agent of plague. A. E. J. Yersin proved participation of rats in distribution of the causative agent of this disease. A bit later Simone (R. of L. Simond, 1898) revealed existence of a plague infection at palm squirrels; Ogat (M. of Ogata) and Simone was established that fleas transfer activators Ch. to rats and from rats to the person. In 1914 A. Bacot and Martin (S. of Martin) described the mechanism of transfer of the activator Ch. fleas.
In Ch.'s studying the big role belongs to scientists of Russia. D. S. Samoylovich the first in detail described clinic of a disease and developed system of anti-epidemic actions evidence-based for those times. D. K. Zabolotny in 1899 suggested that various breeds of rodents (see) represent in the nature that Wednesday, in a cut plague bacteria remain. In 1911 this idea received full confirmation: from bodies of the groundhog delivered to JI. M. Isaev in laboratory on the station Borzya (in Transbaikalia), marked out culture of a plague bacillus. D. K. Zabolotny's opening laid the foundation for the doctrine about a natural ochagovost of plague (see. Natural ochagovost). The same year H. N. Nlod-nitspy proved value of camels in spread of an infection.
G. I. Koltsov and N. I. Tikhomirov in 1913 proved Ch.'s infectiousness of a house mouse. I. I. Mechnikov was engaged in Ch.'s studying, to-ry in 1911 directed work of groups on studying of plague in the Astrakhan steppes.
In 1912 I. A. Deminsky allocated the activator Ch. from a gopher; in operating time with the marked-out culture he caught and died. Several hours prior to death he wrote: «I caught pulmonary plague from gophers. Come, take the got cultures. Records everything is all right. Осталь^ Nov everything will be told by laboratory. Open my corpse as a case of experimental infection of the person from gophers. Farewell. Deminsky». I. G. Ioff's researches on a systematics and ecology of fleas, their epidemic value as carriers of causative agents of plague have world fame. B. K. Fenyuk,
N. I. Kalabukhov, BB. M. Rall, N. V. Ne-kipelov, N. P. Naumov, etc. developed what logo - the physiological direction at the characteristic of rodents — carriers of the causative agent of plague. V. N. Fedorov, N. A. Gaysky, I. S. Tinker, I. I. Rogozin, M.P. Kozlov, V. V. Kucheruk, etc. gave the characteristic epidemiol. Ch.'s features in different geographical conditions also created harmonious system of antiplague actions. Works of H. N. Zhukov-Verezhnikov, E. I. Korobkova, G. N. Lenskaya, M. P. Pokrovsk, V. M. Tumansky, etc. representations about the vozbu-beginnings of 20 century expanded they were revealed in a number of seaports of Asia, Africa and South America. Ch.'s epizooty arising in populations of rats in seaports of Europe and North America was not long and through a nek-swarm time faded. Features of distribution of Ch. are caused favorable for resettlement of animals — the main carriers and carriers of activators — klimatogeografichesky and landscape conditions. In the rat centers of plague the climate exerts impact not so much on the number of rats how many on the number of carriers of causative agents of plague — fleas of Hepo-psylla of cheopis (see the Flea), to-rye cannot breed in cold weather, and decrease in relative humidity lower than 40% causes death of larvae of fleas until their pupation. X. cheopis, optimum for development, is temperature apprx. 24 ° at relative humidity not lower than 70%. Ch.'s diseases people are registered preferential among the population living in the territory of the natural centers. In 20 century every decade ha -
it rakterizovatsya by decrease in number of epidemics of Ch. Odnako even in the 30th. according to medical service of the League of Nations, tens of thousands of cases of plague annually were registered. Data on incidence of plague in 1974 — 1983 in the nek-ry countries of the world, on dannkm weekly Epi-demiol. reports of WHO, are provided in the table.
Carrying out a complex and r about ti in about e p and dekhm and ches is the main reason for universal reduction of incidence of people of Ch. to and x actions, to-rykh fading of the centers of plague where sources of activators are rats (rat Ch.'s centers) was a consequence. Recession of incidence of Ch. was promoted by also interstate actions for sanitary patrolling (see); epidemiol. the supervision which is carried out directly in the natural centers of Ch.; development of effective methods of treatment of a disease that Ch.
Etiologiya leads to reduction of danger of emergence of epidemics pulmonary. The activator Ch. — Yersinia pestis [(Lehmann et Neumann, 1896) van Loghem, 1944] enters into the Enterobacteriaceae family. Y. pestis — a stick of 1 in size, polymorphic small motionless with the rounded-off ends — 2x0,3 — 0,7 microns. The dispute does not form; in an organism of an animal and at cultivation at t ° 37 ° forms the capsule, is a facultative anaerobe (see Anaerobe bacterias).
Bacteria are easily painted by aniline dyes, gram-are negative. In smears from allocations of patients (a phlegm, contents of a bubo or an ulcer), blood, and also from bodies and blood of corpses of people and animals of a stick of a bipolyarna (fig. 1) due to more intensive coloring of their ends methylene blue and across Romanovsky — to Gimza (see Romanovsky — Gimza a method), have the ovoidny form. In smears from agar cultures the bipolarity usually is absent. In broth and a semi-fluid agar of a bacterium often have an appearance of short sticks.
At crops on usual environments of the material containing single bacteria of plague, the activator does not grow. Growth is possible only after addition on Wednesday of reducers, napr, sodium sulfite; stimulates growth also addition to the environment 0,01 — 0,1% of gemolizirovanny blood. The optimum of growth is observed at pH 7,0 — 7,2 (limits of pH 5,0 — 9,5). Growth of a microbe is possible at a temperature from 2 to 45 ° (an optimum of growth at 25 — 30 °). It is usually cultivated at f 28 °. The causative agent of plague on Hottinger's agar (see the X ottinger an agar) and other environments can grow in the form of colonies of R-and S-for we (see Dissociation of bacteria). R-
of Fig. 1. Microcontact preparation of a spleen of the Guinea pig who died from experimental plague: 2 — bipolyarno
the painted bacteria of Yersinia pestis; 2 — macrophages; coloring across Romanoveky — to Gimza; x 900.
the form (fig. 2) is the main for virulent strains; The S-form of an avirulentn and in natural material usually does not meet. In 8 — 10 hours on a surface of agar mediums at crops of 10 000 and more
Fig. 2. Colony of three-day culture of Yersinia pestis (R-form) which is grown up on dense synthetic medium (it is increased approximately by 10 times).
bacteria it is possible obnaruzhityyud a microscope the initial growth of colonies in the form of «broken glass», to-rye in 18 — 20 hours take a form of the light deckle-edged plates reminding lacy kerchiefs. At further cultivation the center of colonies darkens, becomes hilly and granular, brownish-brown coloring with transparent «lacy» kaykhmy around. Such registered colonies usually are formed in the 48th hour. In the colonies which grew on an agar with blood or hemin, the peripheral zone is expressed poorly or is absent; in 48 hours and later in the reflected and transmitted light the isolated colonies of 2 in size — 3 mm of rounded shape of grayish-white color with more dark convex center, translucent with a flat scalloped border are visible. On a slant the causative agent of plague grows in a type of a grayish-white plaque. At cultivation of the causative agent of plague on broth the last grows turbid in the beginning, then flakes at the bottom and a film on a surface, at first the gentle, and then quite dense, sticking to a wall test tubes in a look e by l about in and t about about rings are formed.
In 1928 A. A. Bessonova suggested to allocate two kinds
of the activator Ch. on ability to ferment glycerin. Strains glycerin onegativny differently vidnos ti
are found in animals in seaports and on islands of a tropical belt therefore this version is called oceanic. Glitserinopozitivny strains come to light preferential in the central regions of Eurasia, South America, Africa — a continental version.
The activator Ch. is highly sensitive to usual desinfectants (phenol, chloroamine), is unstable in the environment, especially to action of high temperature and UF-radiation. Transfers low temperatures well, in the frozen corpses it is found in several months. Has thermolabile capsular and thermostable somatic antigens. One of components of capsular antigen (fraction I) is highly specific and therefore it is widely applied at serological diagnosis of a disease.
Epidemiology. Owners of the activator Ch. are rodents (see) more than 200 types and subspecies. Activators Ch. are found also in hares, predators (jackals, foxes, polecats, etc.), insectivorous (hedgehogs, shrews). From domestic animals of Ch. camels and cats are ill (see. Domestic animals). Vysokovospriimchiva to plague people.
Rodents of different types have unequal value in maintenance of a natural ochagovost of a disease. It is accepted to divide rodents into the main and minor carriers of the causative agent of plague. The main carriers provide the continuous course of an epizooty of plague in the centers (see the Epizooty) and, thus, are tanks of the causative agent of plague in the nature whereas rodents — minor carriers — are only involved in an epizooty during their mass reproduction and do not play an independent role in preservation of an infection in the nature. The main carriers of the activator Ch. are rodents of those types, places of resettlement to-rykh are located rather densely on big spaces and connected among themselves where on climatic conditions existence of a large number of fleas both on rodents, and in their holes is possible. In the territory of the USSR Transbaicalian marmots, gray and red groundhogs, big and midday sandworts, a small gopher, etc. concern to them. Minor carriers are house mice, an ordinary vole, etc.
Within territories, enzootichny on plague, on the globe it is accepted to allocate separate zones of a natural ochagovost of this disease
| 'see P ra a native ochagovost), in to-rykh comes to light from one to several rather autonomous natural centers with the carriers and carriers of the causative agent of plague.
The Mongolian and Transbaikal area of a natural ochagovost of Ch. covers the southern districts of the Chita Region, Tuva the ASSR, the Gorno-Altaysk autonomous region within the USSR, the most part of the territory of the Mongolian People's Republic and plateau Barga in the territory of China. In a zone there are several natural centers of Ch. where the main carriers of a disease-producing factor are a Transbaicalian marmot, the Mongolian creeper, Brandt's vole, the Mongolian sandwort, daursky and long-tailed gophers. Also rodents of many rather small local types are involved in an epizooty.
The Manchurian zone of a natural ochagovost of Ch. is located in the territory of the Inner Mongolia, and also province Girin and Sypin-gay. The main carrier of the activator Ch. in this zone is the daursky gopher. In this territory the rodents of St. 20 different types who are periodically involved in an epizooty live. Feature of an epizooty is that they as the rule, extend to rats - early, living in settlements where there are secondary centers of Ch. during the aestivo-autumnal period that is promoted by abundance of rat fleas.
The southern Chinese zone of a natural ochagovost of Ch. is located in the south of China, in the Provinces of Yunnan, Guangdong, Jiangxi. It is supposed that the main carriers of the activator Ch. are zheltogrudy, field and an andersonova of a rat, living in the nature. Mouse-like rodents, hl are involved in an epizooty. obr. gray and black rats that leads to emergence of the secondary centers of plague in settlements.
The Tibetan zone of a natural ochagovost of Ch. passes in sowing. parts of the Plateau of Tibet where the main carrier of activators Ch. is the Himalaya groundhog.
The Indochina zone of a natural ochagovost of Ch. covers the territory of Vietnam, Kampuchea, Laos, Burma, Thailand and Indonesia (island of Java). Within this zone there are several (autonomous) centers of Ch. which are rather not connected among themselves where the main carriers are the rats living in the nature — Rattus concolor and R. argen-tiventer. Mouse-like rodents and other small species of the wild and living in settlements (synanthropic) rats are involved in an epizooty, among to-rykh there are secondary centers with is long the proceeding epizooty.
The Indian zone of a natural ochagovost of Ch. is located within the peninsula of Hindustan. The main carrier of the activator Ch. is the Indian sandwort here. The plastinchatozuby rats of different types living in nature, and synanthropic rats are involved in an epizooty that leads to developing of an epizooty of Ch. and among other rodents in settlements.
The Central Asian mountain area of a natural ochagovost of Ch. covers a number of districts of the Central Tien Shan and Alay, spurs of Pamir in the territory of the USSR, and also East Tien Shan and spurs of the Himalayas within India, China and Nepal where there are several rather autonomous centers. The main carriers of the activator Ch. in this zone are the gray and red groundhog, an archevy vole.
Central Asian flat the probe of a natural ochagovost of Ch. it is located within deserts and semi-deserts of Central Asia, Kazakhstan and Northeast Prikaspiya between Volga and Ural; there are several rather autonomous natural centers. The main carriers of the activator Ch. are the big and midday sandwort, a small gopher. The St. 20 species of the wild rodents living in this territory are periodically involved in an epizooty.
The zone of a natural ochagovost of Asia Minor of Ch. is located in the territory of Iran, Iraq, Turkey, Central Caucasus Mountains and Transcaucasia; in its limits there are several rather autonomous centers of different type; carriers of the activator Ch. are the redtailed (Libyan) sandwort, the Persian sandwort, an ordinary vole, a mountain gopher.
The Arabian zone of a natural ochagovost of Ch. is located within the Arabian peninsula. It is supposed that the main carrier Ch. — the Libyan sandwort. Other types of sandworts living here are involved in an epizooty.
The Caspian zone of a natural ochagovost of Ch. includes Black lands and the Nogai steppe. The main carrier Ch. — a small gopher and, perhaps, a midday sandwort. The mouse-like rodents and jerboas living in this territory are involved in an epizooty.
The zone of a natural ochagovost of Ch. in Northeast Africa covers Egypt, Sudan and Libya; here numerous types of sandworts live. The main carriers of the activator Ch. with reliability are not installed.
The zone of a natural ochagovost of Ch. in Northwest Africa covers the deserts of Tunisia, Algeria,
Morocco and Mauritania occupied by sandworts of the sort Meriones and Gerbillus to-rye, apparently, and are carriers Ch. In the cities located on the coasts synanthropic rats are involved in Ch.'s epizooty that promotes emergence of the secondary centers.
The zone of a natural ochagovost of Ch. in the Western Africa includes the territory of Senegal, Equatorial Guinea, Ivory Coast, Ghana, Nigeria, Mali and Cameroon. The main carrier of the activator Ch. in this zone with reliability is not installed. Apparently, carriers of the activator Ch. are much and mamillar, Nile, Guinean and Senegalese shrubby rats.
The zone of a natural ochagovost of Ch. in the Equatorial Africa is in borders of Zaire, Uganda, Kenya and Tanzania. In this zone there are probably several rather autonomous natural centers of different type. The main carriers Ch. in them are a multimamillar rat, sandworts of the sort Tatera and rodents of the sort Otomus.
The zone of a natural ochagovost of Ch. in South Africa covers huge spaces of Angola, Zambia, Malawi, Namibia, Botswana, Zimbabwe, Lesotho, Mozambique and the Republic of South Africa. Within this zone there are several rather autonomous natural centers where sandworts of different types can be the main carriers.
The zone of a natural ochagovost of Ch. on Madagascar is defined by an area of the main carrier of the activator Ch. — a black rat of two independent populations, from to-rykh another lives alone in the nature, and — in settlements. Populations of synanthropic rats also are involved in Ch.'s epizooty among wild rats that constantly creates threat of epidemic trouble in settlements.
The North American zone of a natural ochagovost of Ch. is located within the U.S. Western States and the provinces of Canada adjacent to them in the north, and in the territory of Mexico adjoining on these states of the USA. There are several rather autonomous natural centers of Ch. where the main carriers of the causative agent of plague are gophers of different types, meadow doggies, the Californian vole and hamsters of the sort Neotoma.
The Argentina zone of a natural ochagovost of Ch. covers the territory of Argentina and Bolivia. In this zone there are several natural centers where the main carriers of causative agents of plague are the dwarfish mumps, hamsters of the sort Graomus.
Synanthropic rats are involved in an epizooty among wild rodents, and also the cultivated Guinea pigs, meat to-rykh local population eats.
The Brazilian zone of a natural ochagovost of Ch. is located in the territory of Brazil along the coast of the Atlantic Ocean and in the territory of Venezuela. Here existence of several rather autonomous natural centers of H is supposed. The main carriers of the activator are the hamsters of the sort Zygodontomys, Orysomys, Sig-modon and Guinea pigs of two types living in the nature.
The Peruvian zone of a natural ochagovost of Ch. covers the territory of Peru and Ecuador. In it there are several rather autonomous natural centers. Assume that the main carriers Ch. are hamsters of the sort Acodon and Orysomys, a cape ground squirrel and a shrubby rabbit. Synanthropic rats are involved in an epizooty among wild rodents.
Not only the main carriers (Transbaicalian marmots, gray and red groundhogs, big and midday sandworts, a small gopher, etc.), but also minor, especially during their mass reproduction (e.g., house mice, ordinary voles) can be sources of a contagium in the natural centers as it was noted above, Ch.'s infection from hares is possible. From a rodent to a rodent the activator Ch. is transferred in the transmissible way; carriers are fleas. It is suggested also about a possibility of transfer of activators through ticks.
Mechanism of transfer of the activator Ch. fleas following: excite
a body, the fleas who got to an organism, at a krovososaniye it animal, sick Ch., breed in a pre-stomach of a flea; activators stick together in lumps and form continuous slush — «the plague block», to-ry fills all cavity of a pre-stomach and a stomach. «The plague block» completely corks a digestive tract of a flea and does not pass blood at the subsequent krovososaniye. Such fleas are hungry and often try to suck blood of an animal. The hungry flea transfers activators in attempt of a krovososaniye when nasasyvayemy blood, without finding pass through a prestomach, is returned (is ruminated) to a wound, entraining the sticks of plague which came off the block. In the absence of the block of a flea practically do not transfer activators though the possibility of allocation of activators with excrements of the infected fleas and their transfer through raschesa on leather of animals is not excluded. Formation of «the plague block» and, therefore, transfer of the activator Ch. are not identical at fleas of different types and childbirth. The most active carriers of the activator Ch. in the natural centers are the fleas of nek-ry types of the sort Xenopsylla and Neopsylla parasitizing on rodents.
In the natural centers infection of the person occurs in the transmissible, contact and alimentary way. The transmissible way of transfer is observed usually in the presence of sharply proceeding Ch.'s epizooty, in time the cut occurs a considerable case of rodents and accumulation of the fleas infected with plague attacking other animals and the person.
In those natural centers of Ch. where hunting for wildings (hares, groundhogs, gophers is conducted, etc.), infection can occur in also contact way at removal of skins from the killed rodents sick with Ch., cutting of their carcasses and an alimentary way at consumption of insufficiently thermally processed meat of animals (hares, groundhogs). In these cases the activator gets into a human body through a limfoglotochny ring therefore develops septic or bubonic forms of plague.
In development of epidemics of Ch. in the territory of the natural centers, except biol. factors (Ch.'s epizooty among rodents, virulence of the activator, abundance of fleas and rodents), the socio-economic factors promoting infection of the person Ch are of great importance. First of all it is the nature of its contact with the nature: proximity of housing to the enzootichny territory, nature of production activity (e.g., trade of rodents, zaytseobrazny, fur-bearing animals); economic familiarity of the enzootichny territory; sanitary and hygienic, cultural and material standard of living of the population; life, national traditions and habits of the population; types of settlements, character of dwellings, population density; development of communications; nature of transport bonds and migratory processes of the population; condition of health care and veterinary service; state and mobility of anti-epidemic service.
Diseases of people of Ch. in the territory of the natural centers have the expressed seasonal nature. E.g., in the natural centers where carriers of the activator Ch. are the rodents falling into hibernation in the winter (groundhogs, gophers), diseases of people are registered in the spring and in the summer as an epizooty among these rodents proceeds only in the period of their activity.
In the synanthropic centers the main source of an infection are rats, especially gray and black, house mice, and from domestic animals — camels and, perhaps, cats are more rare. Transfer of the activator from an animal to an animal happens in the transmissible way; the main carrier of the activator — a rat flea (Xenopsylla cheopis). Transfer of the activator Ch. through a flea of the person (Pulex irritans), fleas of cats, dogs (sort Ctenoce-phalides), etc. is possible. The mechanism of transfer of activators fleas is similar described above. A way of infection of people from rodents and cats — transmissible (through fleas), from camels — contact (during slaughter, removal of a skin, cutting of carcass of a camel, sick Ch.) and alimentary (the use of insufficiently thermally processed meat of a sick camel). It is established that diseases of people of Ch. develop usually after an epizooty among rats with a gap in 10 — 14 days. In the natural and synanthropic centers of plague people get sick with a bubonic form, at a heavy current a cut secondary and pulmonary and secondary and septic forms of plague can develop.
The person sick with a bubonic form Ch. is almost safe for people around (at absence in the dwelling of fleas). Confirmation of it is the fact that the persons who are looking after patients with a bubonic form Ch. never caught. Allocation of a disease-producing factor to the environment is observed only after opening of a bubo. However and during this period danger of infection is small since the pus emitted from a bubo does not contain activators Ch. or supports them very little. The beginning of epidemic of bubonic Ch. is connected with development of an epizooty among rodents. At the beginning of an epizooty usually there is a small amount of the fleas capable to infect the person; increase of diseases of people goes parallel to increase of death of rodents and increase in number of the fleas infected H. Fading of epidemics is explained by the fact that the possibility of infection of the rats who survived and living rather absent-mindedly and wild rodents considerably decreases or even completely disappears, also the fleas who lost the owners perish.
The Antroponozny centers of plague arise where the person, sick primary or secondary pulmonary form Ch becomes a source of a contagium. At the person the primary and pulmonary form Ch., as a rule, results from infection from the patient with the WC bubonic form at to-rogo the secondary plague pneumonia (secondary le - an exact form Ch.) which is followed by cough with plentiful allocation of a foamy phlegm with impurity of the blood containing a large number of activators developed. It leads to Ch.'s distribution in the airborne way. The primary and pulmonary form of plague begins with pneumonia. There is an assumption that emergence of epidemics of a pulmonary form Ch. is caused by special virulence of the activator and an airborne way of its transfer. Pulmonary forms Ch. differ in high contageousness: for a short time plague can extend far beyond the natural center, affecting a large number of people. Epidemics of a primary and pulmonary form Ch. arose in the past due to the lack of rational anti-epidemic measures, to-rykh the rupture of an airborne way of transfer of contagiums is the cornerstone. Besides, for development of epidemics of a primary and pulmonary form Ch. the season of year matters. Optimum conditions for distribution of activators are created in the airborne way in cold and rainy weather when people are forced to be in the enclosed space.
The whole families usually perish from a pulmonary form Ch. Having appeared in one house, the disease is transferred by the persons visiting the patient to other houses of the settlement, and they become the new centers of an infection. It can be transferred to other settlements on long distances by the people who are in an incubation interval or patients with already appeared symptoms of a disease h. Degree and speed of such spread of an infection depend on population density and on a way of movement of people. During epidemic of plague in Manchuria (1910 — 1911) it was noted that at airborne infection also the septic form Ch can develop. Patients with a septic form Ch. at intensive bacteremia and existence in the room of fleas of X. cheopis and R. of irritans can sometimes become a source of an infection for people around. There is a danger of infection of Ch. at contact with corpses of the dead (washing of corpses, farewell and other funeral rituals) as with the ichor following from a mouth and a nose of a corpse the causative agent of plague is allocated.
Pathogeny. Development inf. process at Ch. substantially is defined by entrance gate of the activator. Skin and mucous membranes possess weak barrier function concerning a plague bacillus. Only occasionally on site penetrations of the activator the reaction which is characterized by formation of primary affect is observed (see below Pathological anatomy). Healing of ulcers happens slowly. At a skin form Ch. usually there is a regional bubo. In most cases the plague bacillus from entrance gate reaches in the lymphogenous way regional limf, nodes where intensively breeds, causing a gemorragiche-ski-necrotic inflammation in the limf, a node and adjacent fabrics, characteristic of a bubonic form of a disease.
Distinguish primary and secondary buboes. Primary buboes arise limfogenno and are always connected with entrance gate of activators. Usually there is one primary bubo, but sometimes two and more that is probably caused by simultaneous implementation of the activator in different places. Inguinal buboes meet more often, is more rare — axillary and are even more rare — cervical. Frequency of defeat of these or those limf, nodes is directly proportional to the area of skin, about a cut in them the lymph gathers. The dobrokachestvenny current
of Ch., the big sizes reach buboes.
Distribution of activators Ch. leads in the hematogenous way to formation of secondary buboes in limf, the nodes remote from entrance gate infictions. They more often are multiple, appear in later terms of a disease, inflammatory process in them is expressed more weakly, seldom is followed by defeat of surrounding fabrics, activators Ch. in them are found in a small amount. Secondary buboes, as a rule, do not suppurate and at recovery of patients resolve. Patol. changes in the location of entrance gate and regional limf, nodes are followed by bacteremia (see) and a toxaemia (see Intoxication) that causes defeat cardiovascular, nervous and other systems of an organism.
Upon termination of a stage of formation of a bubo there comes the phase of permission, edges can proceed in three forms: rassasyvaniye, suppuration and sclerosis. Quite often in primary buboes the aggravation of process which is followed by their increase is observed. Such changes can be observed several times, sometimes irrespective of the general condition of the patient. Buboes with signs of a sclerosis and in the absence of the activator in punctate can remain long time, sometimes for life.
At a bubonic form Ch. so-called out-patient forms (pestis minor) proceeding with moderate intoxication are observed, at to-rykh there is a little expressed and quickly resolving bubo. Similar forms, as a rule, come to light at the beginning and at the end of epidemic that apparently, is explained by smaller virulence of the activator.
In cases of insufficient barrier function regional limf, nodes (at the same time incomplete phagocytosis of plague bacilli usually comes to light) and the strengthened reproduction of the activator in various bodies and fabrics septic forms of a disease develop: pervichno-septiche-
Skye, at a cut generalization of process occurs right after infection and inflammatory changes in the field of implementation of the activator are absent, and the secondary and septic, developing against the background of a bubonic or primary and pulmonary form plagues. Dissimination of the activator is followed by sharply expressed intoxication. The septicopyemic centers (see Sepsis) are often formed in lungs (a secondary and pulmonary form Ch.).
At an airborne way of transfer of the activator the primary and pulmonary form Ch. which is characterized by changes in a mucous membrane of a trachea, bronchial tubes in paratracheal and bronchopulmonary limf, nodes, in an alveolar epithelium, a pleura develops. Serous and hemorrhagic exudate contains a huge number of activators Ch. In lungs process has creeping character with involvement everything new sites of pulmonary fabric and a pleura. Toxic defeat of an endothelium of vessels and a prelum their interalveolar exudate promote bystry development of a necrosis of pulmonary fabric. Bystry generalization of process, heavy intoxication is inherent to pulmonary forms Ch.
Irrespective of a form plague is always followed by changes of ge-morragicheski-necrotic character in various bodies and systems of an organism: in skin, a mucous membrane went. - kish. a path, walls of large and average vessels, in heart, kidneys, a liver, a spleen, marrow, endocrine glands, etc.
By data And. V. Domaraesky (1966), the leading role during and an outcome of the disease belongs to defeat of the vascular device. Long was considered that «plague kills through heart». At patients the expressed changes of a myocardium really come to light. However they are not the reason, and the investigation of a circulatory disturbance. Defeat of capillaries and large blood vessels, first of all veins, the most expressed near primary center is characteristic. Disturbances of coagulant system of blood with dominance of a fibrinolysis are observed (see) that promotes development of hemorrhages, bleeding. Haemo concentration, sharp reduction of speed of a blood-groove (see), the expressed disturbances of microcirculation are noted (see).
One of features of a pathogeny of Ch. is tendency to a recurrence, especially at generalized forms. The activator at the same time often remains in bronchopulmonary (root) limf, nodes (secondary pulmonary buboes) where the used antibacterial drugs hardly get. More often a recurrence develops at derogation from the scheme of treatment, its premature termination.
Feature of development of Ch. in a crust, time is frequent emergence of complications both specific, and nonspecific, connected with accession of consecutive infection and side effect of pharmaceuticals. Earlier similar complications usually did not manage to develop since patients quickly perished.
Pathological anatomy. At
a skin form of plague in the place of entrance gate of activators on skin of hands, legs, necks it is formed consistently the spot, a papule, a vesicle or group of vesicles, and then a pustule with is purulent - the hemorrhagic exudate containing a large number of activators. Sometimes pustules quickly merge in the general conglomerate (anthrax), to-ry is exposed to a necrosis with formation of the crateriform ulcer. Such ulcer is called primary affect (see Affect primary). In cases of a favorable course of an infection the ulcer cicatrizes.
At the most frequent bubonic form Ch. inflammatory changes on site implementations of the activator are absent, and limf, nodes on the way of distribution of activators originally are surprised.
Regional (in relation to the place of implementation of contagiums) limf, nodes (is more often inguinal, axillary or cervical) are considerably increased and konturiruyut-sya under skin in the form of conglomerates (buboes) reaching 8 — 10 cm in the diameter. Skin over buboes is strained, cyanotic-red, shining. Under it in the edematous, impregnated with serous and hemorrhagic liquid cellulose nodes with the centers of a necrosis and sites of purulent fusion are found increased rykhlo soldered among themselves dark red limf. At microscopic examination in struck limf, nodes the picture of acute serous and hemorrhagic lymphadenitis comes to light (see). Blood vessels in them are expanded, crowded with blood, staza, blood clots, diapedetic hemorrhages are visible. Sine limf, nodes are filled with proliferating reticular macrophages and mononuclear phagocytes, cytoplasm to-rykh contains contagiums (incomplete phagocytosis). In exudate the abundance of contagiums is noted. Necrotic changes and purulent fusion extend from fabric limf, a node to surrounding cellulose and skin. As a result of it ulcers are formed. Often at a skin form of plague contagiums on limf, to vessels extend in regional limf, nodes, in to-rykh there are acute inflammatory changes — buboes and the skin and bubonic form of plague develops.
For primary and secondary and pulmonary forms Ch. at rather poorly expressed changes of a mucous membrane of respiratory tracts (the hyperemia, dot hemorrhages, is more rare a catarral and purulent inflammation) typically initial damage of lungs in the form of bronchial pneumonia (see Pneumonia). In zadnebazalny departments of lungs the gray or gray-red centers of consolidation of pulmonary fabric towering over a cut surface and corresponding by the sizes to segments or segments of lungs are found. These centers can merge, creating a picture of lobar or total pneumonia. During the pressing on tissue of lungs in a zone of consolidation from a cut surface bloody or putreform viscous liquid flows down. The pleura over the corresponding segments or shares of lungs is hyperemic, covered with fibrinous or fibrinopurulent exudate, to-ry can accumulate also in pleural cavities. At removal of fibrinous films on a pleura sites of dot hemorrhages are found. Bronchopulmonary and bifurcation (tracheobronchial, T.) limf, nodes are increased, on a section plethoric, juicy, fabric them is as if loosened. Microscopically in lungs staza, thrombosis of small arteries and capillaries are noted a plethora of vessels, diapedetic hemorrhages are visible. In respiratory tracts serous and hemorrhagic exudate originally comes to light, focal necroses of pulmonary fabric are characteristic further. In the exudate filling alveoluses at pulmonary forms of plague the content of fibrin is minimum or it is not found at all. At the same time in intrathoracic limf, nodes the serous and hemorrhagic lymphadenitis which is not followed by distribution of inflammatory process on surrounding cellulose comes to light.
TI and t about l about about and N and that m and h the EU to both e and z exchanges e N and I at septic forms Ch. same as at sepsis (see), have also no specific features.
Opening of the dead from Ch. or at suspicion on it is carried out in strict compliance with special instructions of M3 of the USSR. At survey of a corpse exhaustion and poorly expressed cadaveric spasm is often noted, a cut it is allowed in short terms. On skin rash in the form of petechias and pustules, on mucous and serous membranes — dot and macrofocal hemorrhages often is defined. Plague buboes are located more often in inguinal or axillary areas. Skeletal muscles dryish, dim. In parenchymatous bodies sharply expressed dystrophic changes and the expressed hemorrhagic phenomena are noted. In a myocardium, a liver, a pancreas granular and fatty dystrophy, poorly expressed infiltration of a stroma monocytes, lymphoid cells and segmentoyaderny leukocytes comes to light. In a mucous membrane of a stomach and intestines there are focal hemorrhages. Palatine tonsils can be increased, in them focal necroses and hemorrhages are possible. Kidneys are a little increased, full-blooded, in an epithelium of renal tubules there are dystrophic changes and killing of an epithelium. The cortical necrosis of kidneys, and also change-types of not purulent intersticial nephrite is possible. The spleen is usually increased, flabby with plentiful scraping of a pulp on a section. Microscopically in a spleen proliferation of mononuclear phagocytes, hemolysis of erythrocytes, focal necroses of a pulp are found, the abundance of contagiums comes to light. In hemadens disturbances of microcirculation, dystrophy of cells of a parenchyma, focal necroses are noted. Massive hemorrhages in cortical and marrow of adrenal glands are characteristic. Marrow is full-blooded, with focal hemorrhages and necroses, in monocytic cells incomplete phagocytosis of contagiums is observed. In of N of page in acute cases of an infection the plethora of vessels is noted, there are dot hemorrhages in covers and tissue of a brain. Purulent meningitis, productive encephalitis and abscesses of a brain, defeat of ganglionic cells of the central and peripheral departments of century of N of page can come to light.
Described morfol. changes are typical for uncured
Ch., in the conditions of use of antibacterial drugs patol.
processes can not be shown in characteristic forms. Bakteriol. confirmation of the diagnosis in such cases is especially important.
For gistol. researches and laboratory diagnosis during the opening take pieces of skin (elements of rash and edge of an ulcer at damages of skin), increased limf, nodes, a spleen, lungs, to a liver.
Immunity at plague is limited on duration and tension. Many researchers described cases of recurrent diseases. Despite numerous researches in the field of Ch.'s immunology, still there are no sufficient data allowing to judge the mechanisms defining immunity to this infection. Immunity to plague is created artificially by immunization by a live or chemical plague vaccine (see below).
Clinical picture. The incubation interval fluctuates of several hours to 6 days, 2 — 3 days are more often. It the shortest at primary and septic and primary and pulmonary forms of plague — to 1 — 2 days.
At the vaccinated persons the incubation interval sometimes drags on to 8 — 10 days.
Irrespective of a wedge, forms the disease usually begins suddenly, without prodromal stage. The indisposition, weakness, a loss of appetite, irritability are only in rare instances observed, sometimes insignificant disorder of function went. - kish. path. As a rule, among full health there is a strong fever which is often combined with the accruing headache, muscular pains, weakness, sometimes with nausea and vomiting. The fever can proceed before half an hour and more and to repeat several times within a day. Temperature increases to 39 — 40 °, the concern, fussiness is noted, patients rush about «as if in search of the best place». The person is hyperemic, conjunctivitis is expressed, eyes feverishly shine. Language is covered with a dense white plaque (cretaceous), is edematous therefore the speech is muffled. In hard cases of features are pointed, the person tsianotich-but, expresses intolerable suffering and horror (facies pestica). Sleeplessness, nonsense (see), hallucinations develops (see). Delirious patients are especially uneasy, come off a bed, aiming to run somewhere; having been left without supervision, can leave quite far. The gait which is unsteady that together with other features of outward of patients gives them looking alike drunk. The painful headache is characteristic («knocks on whisky as the hammer», «breaks off the head»); from here one of national names Ch. — «a head disease».
Early defeat of cardiovascular system is defined: the expressed tachycardia (see), pulse of weak filling, arrhythmia, dullness of cardiac sounds, sharp falling of arterial pressure (see), especially systolic, cyanosis and short wind (see). At patients locks, a meteorism are noted increase in a liver and, especially, a spleen. On skin hemorrhagic rashes are often observed. They are localized by hl. obr. on a trunk. Hemorrhages have usually dark red or dark-brown color, sometimes even black. Black rash develops at patients most often shortly before a lethal outcome (the name «black death» from here).
Except the general symptoms of a disease described above also others join, characteristic for defined a wedge. forms.
At a skin form in the place of penetration of the activator there is a spot (see) which is consistently turning into a papule (see), a vesicle (see) and a pustule (see). The pustule is surrounded with a zone of the redness with a crimson shade closer to the center acting over the level of healthy skin filled with bloody and purulent contents, is very painful. Usually the pustule is soon opened, and on its place the ulcer with a yellowish infiltrirovanny bottom which is becoming covered then is formed by a black scab. Plague ulcers are characterized by duration of a current, heal slowly with formation of a hem. In nek-ry cases of an ulceration does not occur, the pustule dries up, shrivels, the redness falls down. At the same time there is an improvement of a condition of the patient. Sometimes on skin there is sharply painful plague anthrax which is exposed to an ulceration. Existence only of primary affect without involvement in process limf, nodes also formed the basis for allocation of a skin form Ch., edge is observed very seldom.
At a bubonic form in the first
1 — 2 day of a disease on site of the developing regional bubo severe pain is felt that forces the patient to adopt the forced provision (e.g., it lies with the bent leg or with the taken-away hand). In the beginning the bubo represents small sharply painful education, skin over it is not changed. Further limf, the node increases, in process of the Second World War lek and the South I close located limf, nodes and surrounding fabric, the uniform conglomerate is formed (tsvetn. tab., Art. 48, rice 14). Lack of a limfapgiit (see) and accurate contours of a bubo is characteristic. Skin over such bubo is strained, red color, sometimes with a cyanotic shade. The bubo has a cartilaginoid consistence, then to 6 — to the 8th day of a disease in the center it sites of fluctuation begin to be defined. The outcome of a bubo can be various. Usually on 8 — the 12th day of a disease it is opened in one or several places, at the same time is allocated serous gnokhshaya liquid with impurity of blood (tsvetn. the tab., Art. 48, fig. 15), is formed badly healing fistula. Purulent ulcers on site of a bubo heal slowly with growth of granulyatsionny fabric and formation of a hem (tsvetn. tab., Art. 48, fig. 16; color tables according to WHO data). At accession of consecutive infection extensive adenoflegmona can be formed.
At a high-quality current
of Ch., especially at early prescription of antibiotics, with 6 — the 8th day of a disease inflammatory changes in a bubo begin to decrease, and during
2 — 3 weeks, sometimes and more, there is its full rassasyvaniye. In some cases in a bubo sclerous changes develop, and it can be probed in the form of large consolidation quite long time, sometimes during all life. Cases when after the first days of formation a bubo are describedand its bystry rassasyvaniye begins. Often the bubo begins to increase again. Such changes at the patient can be observed several times, and sometimes irrespective of the general state. In nek-ry cases the bubo can not develop, and the initial stage of a disease passes into a stage of fading at once; at the same time, except a headache, small weakness and moderate morbidity on site of the forming bubo, any drugggkh manifestations can not be. At development of cervical buboes disease usually heavy, but the greatest danger is constituted by axillary buboes, at to-rykh a thicket secondary and pulmonary plague develops (see below).
At a bubonic form Ch. the temperature curve can be various. High temperature usually keeps 3 — 4, 6 — 8 days, sometimes with sharp fluctuations are more rare, then fall of temperature is noted, a cut can happen either critically, or gradually to quite big daily fluctuations. Changes of body temperature at Ch. only occasionally are followed by a fever and the subsequent sweating. Perhaps long current of a bubonic form Ch. when fever lasts several weeks, remaining even after disappearance of buboes. At such patients the severe exhaustion passing into a cachexia (see) that conducts usually by death can be observed.
Skin and bubonic forms Ch. are often combined (a skin and bubonic form). In these cases along with primary affect the regional bubo appears, to-ry passes the same stages of development, as at a bubonic form of a disease.
A primary and pulmonary form Ch. — the heaviest on a wedge, to a current a form of a disease. Distinguish three main periods of a disease: period of initial feverish excitement, period of a heat of a disease and terminal (soporous) period. The first hours or the first days of a disease are similar to the beginning of other
forms Ch., but sharply expressed intoxication is noted. Soon there are cutting stethalgias, tachycardia and short wind are expressed. Cough is noted, to-ry is followed by expectoration, the quantity considerably varies it (from insignificant up to the huge weight — the whole Tazy). The phlegm in the beginning foamy, vitreous, then becomes bloody, usually has a liquid consistence. These percussions and auscultations are very poor and do not correspond to a serious general condition. Depression of the patient in process of increase of intoxication is replaced by the general excitement, the nonsense appears. Other hemorrhagic phenomena — a hematemesis, an enanthesis join. The period of a heat of a disease lasts from several hours to 2 — 3 days. In the terminal period the soporous state develops (see Devocalization), then a coma (see), the phenomena of a pulmonary heart accrue (see. Pulmonary heart). Death usually comes on 3 — the 5th day of a disease.
The secondary and pulmonary form Ch. develops hl. obr. at patients with a heavy current of a bubonic form. Its development is adverse from the point of view of as epidemiology (the patient becomes a source of contagiums), and an outcome of the disease. Razky rise in temperature is characteristic, the accruing cough with a phlegm is noted, in a cut streaks of blood soon appear. At auscultation the weakened breath, a small amount of wet rattles come to light. Involution of the phenomena of pneumonia occurs very slowly.
The primary and septic form Ch. meets extremely seldom and is characterized by intoxication with disturbance of consciousness, excitement, nonsense that reminds the heavy typhus status (see the Typhoid), and the expressed hemorrhagic phenomena. Changes of skin in the place of penetration of the activator and in regional limf, nodes, as a rule, are absent. Only occasionally at height of a disease secondary buboes appear. According to Adams and Megreyt (A. R. D. Adams,
V. of G. Maegraith, 1984), it is caused by defeat deeply located limf, nodes, to-rye to reveal extremely difficult. As a rule, massive skin hemorrhages (see Skin, pathology), hemorrhages (see) in internals and different bleedings are noted (pulmonary, gastrointestinal, renal, uterine etc.). On weight and on outcomes this form of a disease most closer costs to primary and pulmonary Ch. Obychno in 2 — 3 days at the phenomena of the increasing weakness of cordial activity and oppression of c. the N of page a disease comes to an end letalno. Sometimes death comes in several hours — a fulminant current.
The secondary and septic form Ch. is characterized by the sharp and progressing aggravation of symptoms and same a wedge, signs, as at a primary and septic form.
Seldom or never from the first hours of a disease or, more often, in its heat at patients with septic forms Ch. vomiting, abdominal pains, diarrhea are observed (see Ponosa). At the same time the chair can be frequent, excrements plentiful, watery, sometimes with considerable impurity of slime and blood.
Complications. Purulent meningitis belongs to seldom found specific complications of Ch. (see). Sharp strengthening of headaches, stiff neck are characteristic, quickly there comes unconsciousness. As a rule, accession of specific meningitis conducts by a lethal outcome. From other complications in a crust, time note different accession of an endogenous purulent infection (see Autoinfection) that is observed more often already against the background of improvement of a condition of the patient.
The diagnosis is established on the basis of data epidemiol. anamnesis, wedge, pictures and results of laboratory researches. The greatest value has identification of sporadic cases of Ch., to-rye can precede flash. In epidemiol. the anamnesis establishment of the fact of stay of the diseased before a disease in a zone of a natural ochagovost of Ch. is important in recent days, it is necessary to consider professional and household factors: stay
in field conditions, contact with rodents, hunting on Transbaicalian marmots, gophers, etc., a mass case of rodents in the area where there was a patient, presence of fleas, mites, consumption of camel or hare meat etc. It is necessary to find out existence among people around or in the area where there was a patient, cases of a similar disease or sudden death.
Laboratory diagnosis is based on allocation of the activator Ch. or definition of antigen in the studied material and detection of specific antibodies in blood serum. All researches make in special laboratories.
Serve as material for a research: contents of a bubo, vesicles, pustules, an anthrax, a discharge of ulcers, a phlegm and slime from a nasopharynx (at a pulmonary form), blood at all forms of a disease, kcal in the presence of diarrhea.
In blood the neutrophylic leukocytosis comes to light (see), during recovery there can be a leukopenia, a lymphocytosis, decrease in amount of hemoglobin and erythrocytes. In urine — traces of protein, there can be erythrocytes and cylinders.
For a bakterioskopichesky research (see. Bacteriological techniques) from allocations of the patient prepare smears, to-rye later fixing paint more often across Gram (see a frame a method) or to Romanovsky — Gimz'E (see Romanovsky — Gimza a method). Existence of clinical and epidemiological data, detection of the gram-negative the painted sticks ovoid-ny bipolyarno allow to suspect plague. The final diagnosis is made on the basis of allocation and identification of culture.
For bacterial. researches along with production of smears make crops on agar mediums and in broth. At a research of the contaminated material add inhibitor of foreign microflora to an agar — a methylrosanilinum chloride (see) in concentration from 1:100 Ltd companies to 1:200 Ltd companies depending on quality of dye. Crops incubate at t ° 28 °, looking through them during
3 — 5 days at increase in a microscope by 30 — 50 times. Suspicious colonies oversow on nutrient agar for release of pure growth, to-ruyu identify on characteristic growth on an agar and in broth, sensitivity to plague, and sometimes and pseudotuberculous to bacteriophages (see), to lack of fermentation of urea and existence of one of components of capsular antigen — of fraction I (see below — the Serodiagnosis).
Cultures usually differentiate with pathogenic intestinal microflora, activators of a hemorrhagic septicaemia (see Pasteurellosis) and tularemias (see) on morphological, to at l t at r and l N about - and about x and m and h e with to both m and serological signs. It is more difficult to differentiate microbes of plague and a pseudotuberculosis (see). Main differences of the causative agent of pseudo-
tuberculosis: virulence in S-
to a form, nonsensitivity to a plague bacteriophage, mobility at t ° 20 ° thanks to existence of flagellums, fermentation of urea, glycerin, rhamnose, sensitivity to a pestitsin of I, lack of antigen of fraction I, fibrinolysin and a plaz-mokoagulaza.
For the purpose of Ch.'s diagnosis and epizootological inspection on plague 20 century began to apply a serological method widely from 60th. Put reactions of passive hemagglutination, neutralization of antibodies and antigen, braking of passive hemagglutination (see. Serological researches). At the same time use formalinizirovanny erythrocytes, sensibilized fraction I of the causative agent of plague or antibodies to it. By means of this method it is possible to find traces of the activator in those substrates, from to-rykh it is not possible to allocate it with other listed methods (the mummified and decayed corpses of rodents, bone residues, etc.). The serological method allows to inspect the territory in shorter terms, on a cut diseases of plague of rodents are found and to define borders of an epizooty.
Biol. the research (see the Bioassey) is conducted on Guinea pigs and white mice. Usually studied material is entered an animal subcutaneously. If material is contaminated by foreign microflora, it is rubbed in the scarified skin. The infected animals perish usually within 3 — 9 days after infection; the diagnosis of plague at them is confirmed by allocation of the activator.
A number of methods of the accelerated diagnosis of H is offered. Among them the greatest recognition was gained by the luminescent serological method (see. And a mmunoflyuorestsention) definitions of antigen in the studied material based on use of specific antibodies, marked by fluorescent substances.
Differential diagnosis. Pulmonary forms Ch. should be differentiated with the flu (see) which is especially complicated by pneumonia, a lung fever (see), damage of lungs at a tularemia (see) and a malignant anthrax (see). Unlike Ch. the catarral phenomena with dominance of symptoms of tracheitis, a leukopenia are characteristic of flu. Duration of a disease can be important. At primary pulmonary form Ch. in case of lack of treatment to 3 — to the 5th day the end-stage of a disease usually is already observed. At flu often in these terms pneumonia only joins.
A lung fever big expressiveness of physical changes in lungs, more later (to 4 — to the 5th day of a disease) distinguishes emergence of the expressed signs of defeat of a cardiovascular and nervous system, as well as at flu, duration of a disease is important.
The pulmonary form of a tularemia usually proceeds with less expressed intoxication, the bloody phlegm is seldom observed.
At a malignant anthrax the catarral phenomena from upper respiratory tracts are observed, the expressed changes in lungs at auscultation and percussion.
Septic forms Ch. can remind sepsis (see), a fulminant form of a meningokoktsemiya (see. Meningococcal infection), an epidemic sapropyra (see the Sapropyra epidemic). In tropical districts they should be differentiated with the heavy course of malaria (see). During the carrying out the differential diagnosis of a septic form Ch. with sepsis, first of all, duration of a disease matters. Pallor at high temperature is usually characteristic of sepsis, plentiful sweats, there is no cretaceous fur, arthritis, thrombophlebitis often join.
A fulminant form of a meningokoktsemiya emergence from the first hours of a disease of polymorphic hemorrhagic rashes with necroses distinguishes, a frequent combination to meningitis.
Existence of petechias helps to differentiate plague with a sapropyra clinically at it on skin, to-rye appear with 4 — the 5th day of a disease; the big duration of a disease is characteristic of a sapropyra considerably.
The heavy course of malaria distinguishes recurrence of a disease with natural attacks, the expressed increase in a spleen, identification of malarial plasmodiums in blood.
Skin and skin and bubonic forms Ch. should be differentiated with a skin form of a malignant anthrax, at a cut skin manifestations take place similar stages of development. However at a malignant anthrax intoxication is less expressed, there is no local morbidity around a scab, puffiness of hypodermic cellulose is more intensive, it is noted limfangiit, lymphadenitis more moderate. Besides, at differential diagnosis of a skin and skin and bubonic form Ch. it must be kept in mind also a furuncle (see), an anthrax (see). At a furuncle and an anthrax instead of characteristic of Ch. continuous blackness of a scab in their center is available the whitish-yellow site of devitalized fabric, it is often noted limfangiit, there are, as a rule, no sharply expressed phenomena of intoxication.
The bubonic form Ch. should be distinguished with a bubonic form of a tularemia (see), acute nonspecific lymphadenites (see). The greatest practical value has carrying out differential diagnosis with a tularemia. The expressed contours of a bubo, a rarity of emergence of a periadenitis, smaller morbidity of a bubo, moderately expressed intoxication are characteristic of a bubonic form of a tularemia. Skin ulcers at a tularemia (if those are available) are less painful, than at Ch., often comes to light limfangiit.
At acute nonspecific lymphadenites the increased nodes remain mobile and usually are not soldered to surrounding fabrics. The place of implementation of the activator are grazes, wounds, cuts. General disease доброкачест^ wine.
Treatment. Sick Ch. strictly isolate in the conditions of a hospital (see Isolation of infectious patients). Joint keeping of patients with a primary and pulmonary form Ch. with patients with a secondary and pulmonary form Ch., and also with patients with bubonic and skin forms of a disease is not allowed.
Therapy shall be directed to suppression of life activity of the activator, fight against intoxication and a hemorrhagic syndrome. From etiotropic drugs most widely at all forms of plague since 1948 apply streptomycin (see). At skin, bubonic and skin - but-bubonic forms etiotropic treatment begin 1 — 1,5 g of streptomycin with intramuscular injections, then administer the drug on 0,5 — 1 g every 8th hour. After normalization of temperature usually in 36 — 48 hours from an initiation of treatment the drug continues to be administered within 3 — 5 days in a dose of 1,5 — 2 g a day. At septic and pulmonary forms the daily dose of streptomycin is increased to 4,5 — 5 g. After normalization of temperature the drug is administered in a dose 2 — 2,5 g a day to the current of 5 — 7 days. At treatment by streptomycin it is necessary to watch a condition of hearing of the patient and urine protein content.
At intolerance of streptomycin or development of stability of the activator to it drugs of a tetracycline row, first of all Oxytetracyclinum can be used, to-ry enter intramusculary 6 times into days on 0,2 g, levomycetinum succinate (to 6 — 8 g a day, after normalization of temperature the dose is reduced), Pasomycinum, Monomycinum, rifampicin, etc. At generalized forms Ch. the combination of streptomycin (a daily dose to 1 — 2 g) and chlortetracyclin is effective (a daily dose to 2 g). Increase in efficiency of an antibioticotherapia requires definition of sensitivity of the allocated activators to antibiotics.
In case of a slow rassasyvaniye of plague buboes antibiotics enter in a bubo (streptomycin on 0,5 g or ampicillin on 0,5 g daily). Locally apply salve dressings with antibiotics. At the suppurated buboes the operative measure which is carried out with strict observance of rules of work at quarantine infections (see below) is shown.
At development of a consecutive purulent infection it is recommended to add antibiotics of a broad spectrum of activity, without reducing a dose of streptomycin.
For the purpose of desintoxication appoint reopoliglyukin, Haemodesum, isotonic solutions of glucose, Ringer's solution, etc. At sharply expressed intoxication and considerable frustration of a hemodynamics (see) introduction of glucocorticosteroids (Prednisolonum to 100 — 150 mg a day), cordial and respiratory analeptics (Cordiaminum, Sulfocamphocainum, Cytitonum, lobeline, etc.), cardiac glycosides is shown. Patients dalezhna to receive high doses ascorbic to - you (to 1,5 — 2 g a day), vitamins of Vkh, Wb, B12, K
The extract from a hospital of the persons who transferred local forms Ch. is made not earlier than in 4 weeks after normalization of body temperature and which transferred disseminated (pulmonary and septic) of a form Ch. — not earlier than in 6 weeks in the presence of negative takes of a research of punctate from a bubo, a hmok-company, the slime from a nasopharynx (depending on a form of a disease) taken for
the 2, 4 and 6 day after the termination of causal treatment. For convalescents dispensary observation within 3 months is conducted. Convalescents with the remained sclerotized buboes can be written out from a hospital after double bacterial. researches of punctate of a bubo.
Forecast. Before use of antibiotics the disseminated forms Ch. in 100% of cases came to an end letalno; at local forms Ch. lethal outcomes made up to 60 — 70%. At modern methods of treatment the lethality manages to be lowered, according to Adams and Megreyt (A. R. D. Adams, V. of G. Maegraith), even at the disseminated forms Ch. to 5 — 10%.
Actions for fight against plague. Distinguish preventive and about-tivozpidemiches Kia Merop acceptance on fight against plague.
P r about f and l and to t and the p e with it and e m of ER about p r and I am t and I are carried out in two main directions overseeing by a condition of the natural centers of Ch. and the prevention of a possible drift of Ch. from other countries.
Epidemiol. observation in the natural centers of Ch. includes systematic epizootological inspection of the territory, enzootichny on plague, for the purpose of detection of an epizooty among rodents and destruction of rodents (see Deratization); early detection of diseases of Ch. of camels. Besides, medical overseeing by the population for the purpose of identification of possible first cases of diseases of plague, constant readiness for timely expansion in necessary cases of anti-epidemic actions is necessary.
Special significance in
Ch.'s prevention is attached to early identification of the first human cases, the immediate message on it in higher bodies of health care (see. Emergency notice) and to bystry expansion of anti-epidemic actions. To this work, along with personnel of antiplague institutions (see), employees of all medical network are attracted, to-rye previously in a planned order have training on epidemiology, clinic, diagnosis of plague and fight against it.
For the purpose of early identification and suppression of an epizooty of Ch. in the territory of the natural center overseeing by dynamics of number of rodents and destruction of rodents with simultaneous processing of holes dezinsi-tsiruyushchy means (see) for extermination of fleas is conducted (see). Apply chemical, biological and mechanical ways of destruction of rodents. In fight against rodents (especially mice and rats) various economic actions counted on deprivation of these animal favorable conditions for life have importance (construction of storages, impenetrable for rodents, collecting garbage in rodent-proof tanks, etc.). Destruction of gophers and sandworts perhaps only during the holding the broad actions demanding considerable expenses (an afforestation, irrigation and plowing of steppes).
Specific prevention of diseases of Ch. of people is carried out according to epidemic indications (see Immunization). It consists in vaccination of the population living constantly or temporarily in the enzootichny territory or in case of appearance of the person sick with plague.
V. Kolle and R. Otto in 1903
showed that live vaccines (see) the t prepared from an avirulent, but immunogene strain of the activator protect Guinea pigs from a disease. Then Girard and Robik (G. Girard, J. Robie) in 1936 established that the vaccinal strain of a plague bacillus (a strain of EV) allocated with them creates immunity at Guinea pigs. In 1936 Mr. L. Otten on the lake of Java, and Girard and Robik on the lake of Madagascar for the first time applied the live vaccines prepared from a strain of EV to vaccination of people. In the Soviet Union M. M. Faybich and R. V. Korneev in 1941 received a dry live vaccine from a strain of EV, to-ruyu it is possible to keep a long time at a temperature of 2 — 4 °. This vaccine is applied nakozhno and subcutaneously. H. N. Zhukov-Verezhni-kovym (1940), M. P. Pokrovsk (1947), E. I. Korobkova (1944), M. M. Faybich (1946), N. I. Nikolaev (1949), etc. in experiments showed high immuno-gene properties of live vaccines and weak — the killed. In recent years the chemical vaccine having high antigenic properties for mice, white rats and monkeys is received. However the chemical vaccine before live has no advantages.
Despite obvious advantages of live vaccines before the killed, in the USA and some other countries still because of high reactogenicity of a live vaccine apply an inactivated vaccine. In our country for inoculations use an antiplague live dry vaccine, with the help a cut create relative immunity lasting up to 6 months. In especially unfavorable epidemic conditions in 6 months carry out a revaccination.
The important part in Ch.'s prevention is assigned a dignity. - a gleam, work among the population which is constantly living or working as a part of expeditions in a zone of a natural ochagovost of H.
Actions for the prevention of a drift of Ch. from other countries are defined by a condition of incidence of Ch. in the countries of the world, especially in seaports, including the airports, and are regulated by Rules on sanitary patrolling of the USSR (see. Sanitary patrolling). In them requirements of the International medical and sanitary rules are considered (see). For the purpose of the prevention of a drift of plague from other countries constantly study an epidemic environment on plague in the world and timely inform all interested sanitary and epidemiologic and other institutions. According to the international rules conduct survey and medical examination of the passengers who arrived from the countries, neb lago-poluchny but H. and in the presence of indications they are directed to 6-dnev-yauyu observation (see), and also will organize a dignity. survey of transport. Carry out isolation of persons, at to-rykh plague (see Isolation of infectious patients), and an observation having with them contact is suspected. For the period of their isolation or an observation issue of sick-lists is provided. Regularly control presence of rodents and ectoparasites and their quantity on automobiles and if necessary carry out deratization (see) and disinsection (see). Besides, planned preventive deratization and disinsection of vessels and other objects is provided; instructing of the medical staff working at transport concerning clinic, diagnosis and prevention of plague. The listed events are held by sanitary and quarantine departments and points in seaports and border crossing points the passengers following from other countries on iron and to highways and also the air transport.
P r about t and in about e p and d e and h e with to and e events are held by m at identification of sick H. They are carried out according to in advance made operating plan of anti-epidemic actions providing the amount of works and functions of specialists of medical institutions of this area.
At detection of the first case of Ch. information on phone (telegraph) urgently goes to M3 of the USSR, management of troops of the boundary district, the Head medical and sanitary department of Ministry of Railways of the USSR, Medical and sanitary management of the Ministry of civil aviation of the USSR (see. Medical and sanitary service of departments). Actions for localization of flash and its elimination are at the same time carried out. The Extraordinary Anti-epidemic Commission (EAEC) created according to the decision of territorial Executive committee of Council of People's Deputies directs actions for elimination of outbreak of plague. From the very beginning of work on localization and elimination of flash as the solution of ChPK the chief of the center is appointed, the anti-epidemic headquarters are created and at it special groups: hospital, with An it and rno-the EDS and miologichesky, laboratory, advisory, disinfection, zoologo-parazitolo-gicheskaya, quarantine and administrative.
Localization and elimination of flash of Ch. includes a number of necessary actions. Reveal and hospitalize patients. Reveal and isolate the persons adjoining to the patients infected with things, corpses, and also the persons participating in cutting of carcass of the camel who died from plague. To these persons carry out the emergency prevention (preventive treatment). Take measures for detection and burial of corpses of people,” died from plague, with observance of necessary rules; carry out disinfection of the infected objects. Will organize overseeing by the state of health of the population and provisional hospitalization of all sharply in a fever patients. Enter the restrictive (quarantine) actions (see the Quarantine, a karantinization) directed to the prevention of spread of an infection out of limits of the center. The question of imposing of a quarantine for the city, the settlement, the area is solved territorial ChPK. Carry out treatment of patients; the current and final disinfection in the center; deratization and disinsection both in field conditions, and in settlements; vaccination (see) the population against plague; zoologo-parazito-logical inspection in the settlement and out of it for establishment of a source of an infection and the prevention of spread of an epizooty.
The emergency prevention is carried out by streptomycin, dihydrostreptomycin, Pasomycinum, Monomycinum. All these antibiotics enter intramusculary 2 times a day in a dose 0,5 g. If at mikrobiol. a research or necropsy, died of Ch., there was a spraying of infectious material, to medical staff, in addition to intramuscular introduction, antibiotics dig in in a nose or enter in the form of an aerosol.
The emergency prevention can be carried out also by antibiotics of a tetracycline row without addition of other antibiotics or to combinations with them. Chlortetracyclin and Oxytetracyclinum appoint inside 0,5 g 3 times a day, and Oxytetracyclinum as well intramusculary on 0,2 g 4 times a day. At the combined introduction of antibiotics preference should be given to a combination of antibiotics of a streptomitsi-new row to chlortetracyclin or Monomycinum with chlortetracyclin. The single dose of each of the specified antibiotics makes 0,5 g; appoint them 2 times a day. Duration of a course of preventive treatment — 5 days.
At emergence of the first symptoms of a disease in the persons isolated for performing the emergency prevention, preventive doses of drugs urgently replace with medical.
The center is considered liquidated after an extract from hospital of the last patient and under a condition if in the center of a disease all events for disinfection and deratization are held.
An indispensable condition during the work in the center of diseases and the natural center of Ch. is strict observance of a duty at quarantine infections (see. Quarantine diseases). The personnel shall be prepared concerning a duty, are vaccinated and supplied with special protective clothes — antiplague suits.
The Protivochumny suit intends for protection from Ch.'s infection and nek-ry other infections. It consists of a pajamas or overalls, an antiplague dressing gown, a hood (or a big kerchief), a wadded and gauze mask (or about-tivopylevogo the respirator filtering or the oxygen isolating gas mask), safety spectacles, rubber (or kersey) a boot or deep galoshes, socks (or a stocking), slippers, a hat, rubber gloves (surgical or anatomic), towels. The suit can be added with the rubberized (polyethylene) apron and the same oversleeves, the second pair of rubber gloves.
The overalls are sewed from dense fabric (coarse calico or a cloth) with a deaf fastener on buttons in front, with ties on ankles and wrists, a pajamas — from monophonic light fabric. In winter time during the work out of the room overalls, hoods and antiplague dressing gowns put on over warm clothes (wadded trousers, a jacket and a cap) therefore they shall be the big sizes. The Protivochumny dressing gown is sewed from coarse calico or a cloth as surgical, but is much longer (to the lower third of a shin); floors it shall come deeply one on another, and the belt, two-piece (everyone is sewn to separate the field), shall be wider and longer usual that it could be tied in front a loop. Ties of a high collar do on the same type, as a belt. For setting of sleeves sew a long tape. The hood closing completely a forehead, cheeks, a neck and a chin is sewed also from coarse calico or a cloth, an antiplague kerchief of 90x90x125 cm in size — from the same fabric. The wadded and gauze mask is produced from a piece of a gauze 125 cm long and 50 cm wide. In a middle part of a piece of a gauze in lengthwise direction stack a layer of cotton wool 25 cm long, 17 cm wide (the weight of cotton wool of 20 g, thickness of a layer of 1,5 — 2 cm). Edges of a gauze turn, the ends cut it lengthways, without reaching a wadded layer (length of a section of 50 cm) a little, after that fold a mask, paper and will sterilize. As safety spectacles ispolzu-
Fig. 3. Full protivochumny suit.
yut points of type flight with wide, skintight edge, isomr. at t ymiy flew down l and mi or any other design providing tightness.
Depending on the nature of the performed work apply four main types protective kostyu-mo century Pe rvy type — a full protivochumny suit — consists of a pajamas and overalls, a hood or a big kerchief, an antiplague dressing gown, a wadded and gauze mask, points, rubber gloves, socks, boots and a towel (fig. 3). The second type — the facilitated protivochumny suit; the same objects, except for points enter it. The third type of an antiplague suit consists of a pajamas, an antiplague dressing gown, a big kerchief, rubber gloves, socks, galoshes and a towel. The fourth type of a suit includes a pajamas, a protivochumny (surgical) dressing gown, a medical hat (a small kerchief), socks and slippers. Use of this or that type of an antiplague suit is regulated by the special instruction about an anti-epidemic duty with the material infected or suspicious on infectiousness causative agents of quarantine infections.
The Protivochumny suit is put on to an entrance to the room where work with infectious material, or on the territory of the center. That in a suit it was convenient and safe to work, it needs to be put on in front of the mirror in strictly established sequence: at first pajamas (or overalls), then socks, boots, hood (or big kerchief), protivochumny dressing gown, wadded and gauze mask, points, gloves. If it is necessary to use a phonendoscope, it is put on earlier, than a hood. Tapes on a collar of a dressing gown, and also a belt tie in front on the left side, obligatory a loop, after that tie tapes on sleeves. The mask (or a respirator) is put on the person so that the mouth and a nose therefore the upper edge of a mask shall be at the level of the bottom of an eye-socket were closed, and lower — under a chin. Upper tapes of a mask are tied a loop on a nape, lower — on a darkness (as a mitella). Having put on a mask (or a respirator), on each side wings of a nose put cotton plugs that air did not pass under a mask. Points shall be well driven and checked for durability and tightness. Glasses of points rub with a special pencil or a piece of dry soap for the prevention of their fogging. Gloves put on after check them integrity. The towel is put for a belt of a dressing gown on the right side. During the opening of corpses in addition put on oil-cloth (or polyethylene) an apron, the same oversleeves and the second pair of rubber gloves. The towel is put for a belt of an apron. Duration of continuous operation in an antiplague suit of the first type shall not exceed 3 hours (in hot season — 2 hours); after that 1 hour is necessary a break.
After completion of work the suit is taken off slowly, in strictly established order, immersing hands in gloves in disinfecting solution after removal of each part of a suit. Boots (or galoshes) wipe from top to down with the separate tampons which are plentifully moistened with disinfecting solution. Take out and immerse a towel in disinfecting solution. Wipe with the cotton plug moistened with disinfecting solution an apron and remove it, turning the outer side inside. Remove oversleeves and upper pair of gloves, then points, the smooth movement delaying them two hands forward, up and back, for the head, also immerse in bank from 70% alcohol. Without concerning open parts of skin, are exempted from a phonendoscope and immerse it in bank from 70% alcohol. The wadded and gauze mask is untied and, without touching the person its outer side, remove, curtailed inside the outer side, since the end of ties and without letting go them. Untie ties of a collar and a belt of a dressing gown, then, having lowered the upper edges of gloves — tapes of sleeves, take off a dressing gown and wrap it the outer side inside. Take off a kerchief, carefully collecting the ends it on a nape in a hand, then gloves, an integrity to-rykh check, having filled them with disinfecting solution. Boots (or galoshes) remove after repeated washing them in a tank with disinfecting solution. After removal of a protective suit of a hand process 70% alcohol and carefully wash with soap. After work in a protective suit it is recommended to take a shower.
The Protivochumny suit is disinfected after each use by boiling, by autoclavings or soakings in disinfecting solution (see Disinfection, the table).
The table NUMBER of CASES of PLAGUE IN SOME COUNTRIES of ASIA, AFRICA AND AMERICA from 1974 to 1983
(according to World Health Organization)
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G. P. Rudnev, F. A. Tumanov;
A. V. Dmitriyev (protivochumny suit),
A.S. Zinovyev (stalemate. An.), I. D. Ladny (epidemiology, actions for fight
BB. G. Suchkov (etiology, laboratory diagnosis).