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frinvelis gripi A(H5N1)

klinikuri marTvis nacionaluri rekomendacia (gaidlaini)

(forma N1)

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1. daavadebis definicia, sinonimebi, klasifikacia, terminologia

daavadebis definicia

frinvelis gripi warmoadgens zoonozur infeqcias, romelsac iwvevs gripis A virusi. frinvelis gripi gareul gadamfren frinvelebSi (gansakuTrebiT ixvebSi) sakmaod gavrcelebuli daavadebaa. gareuli frinvelebidan es daavadeba SeiZleba Sinaur frinvelsac gadaedos. frinvelis gripma A(H5N1) gadalaxa saxeobrivi barieri da SeiZina sxva saxeobis frinvelebisa da cxovelebis dainficirebis unari.

daavadebis sinonimebi

frinvelis gripi A(H5N1) sinonims warmoadgens frinvelis maRalpaTogenuri gripi A(H5N1).

mosaxleobaSi gavrcelebuli terminia: qaTmis gripi. inglisurad daavadebas ewodeba Avian influenza A(H5N1), Avian flu A(H5N1),

daavadebis klasifikacia

janmrTelobis msoflio organizaciis daavadebaTa klasifikaciisa da kodirebis sistemis mixedviT (Disease classification and coding systems DIMDI- ICD-10 WHO - 2006) frinvelis gripi A(H5N1) ganekuTvneba respiratoruli sistemis daavadebaTa jgufs. kodi -J09 – gripi, ganpirobebuli frinvelis gripis identificirebuli virusiT.

terminologia

mwvave respiratoruli distres sindromi _ mrds (Zveli ganmartebiT mozrdilTa respiratoruli distres sindromi) aris filtvis SeSupebiT ganpirobebuli mwvave respiratoruli ukmarisoba, rasac safuZvlad udevs alveolebis kapilarebis kedlebis ganvladobis mateba. reasortireba (reassortment) – gripis A virusis antigenuri cvlilebis - Siftis erTerTi saxe, rasac safuZvlad udevs genetikuri informaciis gacvla adamianisa da cxovelis gripis gamomwvev virusebs Soris. aseTi virusis mimarT mosaxleobas saerTod ar gaaCnia imuniteti (bunebrivi an postvaqcinaluri). amitom Tuki virusi SeiZens adamianidan adamianze iolad transmisiis unars, Seiqmneba mocemuli qvetipis virusiT gamowveuli pandemiis saSiSroeba.adapturi mutaciebi – gripis A virusis antigenuri cvlilebis - Siftis erTerTi saxea, rac gulisxmobs adamianis gripis A axali qvetipis warmoqmnas wertilovani mutaciebis wyebiT virusSi, ramac mas SeiZleba mniSvnelovnad ucvalis saxe. frinvelis dabalpaTogenuri gripis virusi – gripis virusi, romelic mudmivad cirkulirebs msoflioSi da msubuq simptomebs iwvevs Sinaur frinvelebSi (bumbulis cvena, kvercxis debis Semcireba, wonaSi kleba, msubuqi respiratoruli simptomatika). es virusebi maRalpaTogenuri gripis virusebis progenotorebs warmoadgenen

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frinvelis maRalpaTogenuri gripis virusi - gripis virusi, romelic iSviaTad Cndeba da maRali virulentobiTa da letalobiT gamoirCevian inficirebul Sinaur frinvelebSi, gansakuTrebiT qaTmebsa da indaurebSi, sadac letaloba mokle drois ganmavlobaSi TiTqmis 50 -100%-s aRwevs. maRalpaTogenuri frinvelis gripis qvetipebi, rogorc wesi, H5 da H7 hialuronidazas Seicaven. maRalpaTogenuri frinvelis gripi diagnostirebisaTvis garkveul molekulur da paTogenur kriteriumebs saWiroebs.

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2. epidemiologia

frinvelis maRalpaTogenuri gripis bolo epidafeTqeba mTeli msoflios masStabiT eqspertTa meTvalyureobis sagans warmoadgens, vinaidan frinvelis gripis dReisaTvis cnobili Teqvsmeti qvetipidan erT-erTma virusma - H5N1 SeiZina saxeobaTaSorisi barieris gadalaxvis unari da adamianebSi gamoiwvia umZimesi daavadeba maRali letalobiT. Seiqmna globaluri epidemiis –pandemiis gavrcelebis Teoriuli saSiSroeba, rac daazianebs msoflios mosaxleobis farTo nawils.

cxrili 1. me-20 saukunis adamianis gripis pandemiebi

weli saxelwodeba qvetipi warmoSobis adgili

virusis genetikis warmoSobis wyaro

letalobamsoflioSi

1918-1919 espanuri gripi

A(H1N1) CineTi? evropa? Crdilo amerika?

ucnobia. savaraudod adapturi mutacia

40-50 mln

1957 aziis gripi A(H2N2) CineTi reasortireba frinvelis virusTan

daaxloebiT, 2 mln

1968 hongkongis gripi

A(H3N2) CineTi reasortireba frinvelis virusTan

daaxloebiT, 1 mln

Tanamedrove A(H5N1) virusi 1997 wlamde savaraudod frinvelis dabalpaTogenuri gripis virusis saxiT cirkulirebda aziis qveynebSi da msubuq simptomebs iwvevda Sinaur frinvelebSi (bumbulis cvena, kvercxis debis Semcireba, wonaSi kleba, msubuqi respiratoruli simptomatika). Semdeg man frinvelis maRalpaTogenuri gripis virusis saxe miiRo da gamoiwvia Sinauri frinvelebis ganadgureba am qveynebSi.

adamianTa inficirebis pirveli SemTxvevebi A(H5N1) virusiT 1997 wels dafiqsirda CineTSi, sadac 18 SemTxvevidan gardaicvala 6 adamiani. garkveuli mSvidi periodis Semdeg 2003 wlidan gripis virusma A(H5N1) intensiurad ifeTqa jer aziis Sinaur frinvelebs Soris, Semdeg ki evropisa da afrikis qveynebSic. virusis gavrceleba savaraudod daukavSirda gareuli wylis frinvelebis gadafrenis marSrutebs. virusis Semdgomi gavrcelebis Tavidan asacileblad ganadgurda 150 milionze meti Sinauri frinveli, rac gavrcelebis SezRudvis efeqtur RonisZiebad iqna miCneuli.

frinvelebis inficirebis SemTxvevebi A(H5N1) infeqciiT dReisaTvis ukve msoflios 60-ze met qveyanaSia aRwerili, rac adamianTa Soris infeqciis farTo gavrcelebis winapirobas warmoadgens.

maRalpaTogenuri frinvelis gripis virusi A(H5N1) saqarTveloSi 2006 wlis 21 Tebervals gamovlinda, rodesac aWaris teritoriaze tbis napirze aRmoCenil iqna ori mkvdari gedi. frinvelebis RT-PCR kvlevam daadastura maTi inficireba H5N1 infeqciiT. mTavrobam gadamWreli zomebi miiRo daavadebis lokalizaciisaTvis, gamoacxada sagangebo

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situacia regionSi, SemTxvevis adgilidan 3 kilometris radiusSi akrZala Sesvla da gasvla, agreTve moniSnul zonaSi moaxdina Sinauri frinvelebis ganadgureba.

kavkasiis regioni ganlagebulia frinvelebis gadafrenis ori ZiriTadi marSrutis gzajvaredinze. kerZod ki aRmosavleT afrika-dasavleT aziisa da centraluri aziis frinvelebis gadafrenis marSrutebze. orive marSruti kveTs Crdilo-aRmosavleT evropis regionebs, sadac gamovlenilia Sinauri da gareuli frinvelebis inficireba frinvelis gripis virusiT. geografiuli TvalsazrisiT, kavkasiis da centraluri aziis regionebi warmoadgenen im regionebs, romlebSic frinvelis gripis gavrcelebis SesaZlebloba Zalian maRalia.

adamianTa Soris A(H5N1) inficirebis SemTxvevebi jer iSviaTobas warmoadgens, ar aris mdgradi da sporadul xasiaTs atarebs, Tumca daavadeba Zalian mZimed mimdinareobs da maRalia letaluri gamosavlis procenti.. Sinaur frinvelebSi daavadebis afeTqebas ukve aT qveyanaSi Tan axlda adamianTa inficirebis SemTxvevebi. sul 2003 wlis 26 dekembridan 2006 wlis 19 seqtembramde janmos mier aRweril iqna laboratoriulad dadasturebuli 247 SemTxveva adamianebSi, romelTa Soris 144 fatalurad damTavrda.

cxrili 2.frinvelis gripis A(H5N1) laboratoriulad dadasturebuli SemTxvevebi adamianebSi 2006 wlis 31 oqtombrisaTvis. aRniSnvebi: 1-avadoba, 2-letaloba (miTiTebulia mxolod laboratoriulad dadasturebuli SemTxvevebi, avadobis ricxvi moicavs sikvdilis SemTxvevebs).

qveyana 2003 2004 2005 2006 sul

1 2 1 2 1 2 1 2 1 2

azerbaijani 0 0 0 0 0 0 8 5 8 5

kamboja 0 0 0 0 4 4 2 2 6 6

CineTi 1 1 0 0 8 5 12 8 21 14

jibuti 0 0 0 0 0 0 1 0 1 0

egvipte 0 0 0 0 0 0 15 7 15 7

indonezia 0 0 0 0 19 12 53 43 72 55

erayi 0 0 0 0 0 0 3 2 3 2

tailandi 0 0 17 12 5 2 3 3 25 17

TurqeTi 0 0 0 0 0 0 12 4 12 4

vietnami 3 3 29 20 61 19 0 0 93 42

sul 4 4 46 32 97 42 109 74 256 152

daavadebis gavrcelebis sixSire adamianebSi zustad dadgenili ar aris, vinaidan amisaTvis saWiroa Seswavlil iqnas A(H5N1) seroprevalentoba im qveynebSi an regionebSi, sadac adgili hqonda frinvelis gripis afeTqebas.

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miuxedavad imisa, rom adamianidan adamianze infeqciis gadacema dRes iSviaTobas warmoadgens, H5N1 daavadebis savaraudod ojaxuri klasteris arseboba indoneziaSi xazs usvams, romHam viruss aqvs potenciali SeiZinos adamianebs Soris advilad gavrcelebis unari. winaswar SeuZlebelia ganisazRvros rekombinaciebi an mutaciebi, romelic viruss pandemiuri virusis Tvisebebs SesZens, aseve ucnobia drois periodi, rac saWiroa am cvlilebis CamoyalibebisaTvis.

dReisaTvis H5N1-virusiT SesaZloa dainficirdes frinvelebi (gareuli da Sinauri, maT Soris, qaTmebi, indaurebi, xoxbebi, mwyerebi, ixvebi, batebi da sxva), Rorebi, cxenebi, katisebrTa ojaxis warmomadgenlebi (katebi, vefxvebi, leopardebi), veSapebi, selapebi da adamiani. gamokvlevebi miuTiTebs, rom virusis maspinZelTa wre TandaTan farTovdeba, rac xels Seuwyobs virusis pandemiuri Stamis warmoSobas reasortirebis gziT. mecnierTa nawili fiqrobs, rom reasortireba SesaZloa moxdes TviTon adamianis organizmSi Sualeduri maspinZlis monawileobis gareSe. Tuki es mosazreba gamarTlda, maSin rac meti adamiani dainficirdeba H5N1 virusiT, meti iqneba virusis Stamis reasortirebis SesaZleblobac. aseve SesaZlebelia, rom H5N1 virusma ganicados e.w. adaptiuri mutaciebis wyeba adamianebSi, rogorc es savaraudod ganxorcielda 1918 wlis H1N1 virusis SemTxvevaSi da SeiZinos adamianidan adamianze mdgradi gadacemis unari.

2003 wlis dekembridan moyolebuli 2006 wlis aprilamde laboratoriuliad dadasturebuli da janmosaTvis oficialurad Setyobinebuli yvela SemTxvevis epidemiologiuri monacemebis gaanalizebis Sedegad gamotanili iqna ramodenime winaswari daskvna H5N1 epidemiologiasTan dakavSirebiT.

• A(H5N1) SemTxvevebi aRiniSneba mTeli wlis ganmavlobaSi, magram adamianTa inficirebis SemTxvevaTa pikuri maCveneblebi zemoT moyvanili samwliani periodis ganmavlobaSi fiqsirdeba CrdiloeT naxevarsferos zamTrisa da gazafxulis periodebSi.

• laboratoriul dadasturebuli SemTxvevebis saSualo asaki Seadgens 20 wels. asaki meryeobs 3 Tvidan 75 wlamde. SemTxvevaTa naxevars warmoadgens 20 welze naklebi asakis, xolo 90% -s 40 wlamde asakis adamianebi.

• gardacvlilTa raodenoba daavadebulebis saSualod 56%-s Seadgens. igi maRalia yvela asakobriv jgufSi, magram umaRlesi maCveneblebi fiqsirdeba 10-19 wlis asakSi (73%). es maCvenebeli yvelaze dabalia 50 wels gadacilebul adamianebSi (18%).

• letalobis maCveneblis profili asakobriv WrilSi gansxvavdeba sezonuri gripisTvis damaxasiaTebeli profilisagan, romlis SemTxvevaSic sikvdilianoba yvelaze metad maRal asakobriv jgufebSi aRiniSneba.

• gardacvlilTa wili daavadebulebs Soris yvelaze maRalia 2004 wels da Seadgens 73%-s, 2005 wels - 43%, xolo 2006 wels 63%-s.

• inkubaciuri periodi saSualod Seadgens 3-4 dRes, simptomebis dawyebidan hospitalizaciamde periodis saSualo xangrZlivoba

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yovel Seswavlil wels - 4-5 dRes, xolo simptomebis dawyebidan gardacvalebamde - 9 dRes

• sikvdilobis maCveneblis, aseve simptomebis dawyebidan hospitalizaciamde da gardacvalebamde gasuli drois Sefaseba miuTiTebs, rom daavadebis xasiaTi mniSvnelovnad ar Secvlila gasuli sami wlis ganmavlobaSi.

janmo-s mier SemuSavebulia gripisaTvis mzadyofnis globaluri gegma, (ix.cxrili 3) romlis mixedviT, msoflio dReisaTvis imyofeba mosalodneli pandemiis safrTxis periodSi – me-3 fazaSi. cxrilSi mocemulia sazogadoebrivi jandacvis mizani pandemiis safrTxis zrdis mixedviT.

cxrili 3:gripisaTvis mzadyofnis globaluri gegmafaza sazogadoebrivi jandacvis mizani

stadiebis mixedviTinterpandemuri periodi

faza 1. gripis virusis axali qvetipebi jer aRmoCenili ar aris adamianebSi. gripis virusis qvetipi, romelmac gamoiwvia adamianis daavadeba SeiZleba iyos cxovelebSi. Tu es asea, adamianis inficirebis an misi daavadebis safrTxe umniSvneloa.

faza 2. gripis virusis axali qvetipebi jer aRmoCenili ar aris adamianebSi. miuxedavad amisa, cxovelebSi gavrcelebuli gripis virusis qvetipi qmnis adamianTa daavadebis seriozul safrTxes.

gripis pandemiisaTvis mzadyofnis ganmtkiceba globalur, regionul, erovnul da qve-erovnul doneebze.

minimumamde iqnes dayvanili adamianebze gadadebis riski; gadadebis faqtis SemTxvevaSi dauyonebliv moxdes am faqtis aRmoCena da dafiqsireba.

pandemiuri gangaSis periodi

faza 3. adamianis infeqci/ebis axali qvetipi dafiqsirda, magram adgili ar aqvs adamianidan adamianze gavrcelebis SemTxvevebs, an Zalian iSviaTad aris aseTi SemTxveva uSualo kontaqtis dros.

faza 4. adamianidan adamianze gavrcelebis mcire klasteruli SemTxvevebi, magram gavrcelebis SesaZlebloba maqsimalurad lokalizebulia, rac imis maCvenebelia, rom virusi ver aris adamianTan Seguebuli.

faza 5. adamianidan adamianze gavrcelebis SemTxvevebi marTalia msxvil klasterebSi dafiqsirda, magram jer kidev lokalizebulia, rac imis maCvenebelia, rom virusi adamianis garemosTan Seguebas iwyebs, magram jer kidev ar aris srulad gadamdebi (pandemiis seriozuli riskis arseboba).

virusis axali qvetipis gadaudebeli kategorizacia da adreuli gamovlena, axali SemTxvevebis Setyobineba da maTze reagireba

axali virusis keris lokalizeba an gavrcelebis Seneleba drois mogebis mizniT, raTa moxdes mzadyofnis RonisZiebebis gatareba da vaqcinis SemuSaveba.

gamoyenebuli iqnes maqsimaluri Zalisxmeva virusis lokalizebis an misi gavrcelebis SenelebisaTvis, raTa Tavidan iqnes acilebuli pandemia da mogebul iqnes dro pandemiis sawinaaRmdego zomebis gatarebisaTvis.

pandemiis periodi

faza 6. pandemia: zogadad mosaxleobaSi gadadebis SemTxvevebi matulobs da mdgradi xdeba.

pandemiis uaryofiTi Sedegis minimumamde dayvana.

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a faza 1-sa da faza 2-s Soris sxvaoba efuZneba cxovelebSi gavrcelebuli Stamebisagan adamianTa inficirebis an daavadebis Camoyaliebebis riskis dones. gansxvaveba damokidebulia sxvadasxva faqtorze da maT fardobiT mniSvnelobaze arsebuli samecniero codnis TvalsazrisiT. am faqtorebs SeiZleba ganekuTvnebodes paTogenuroba cxovelebsa da adamianebSi, SemTxvevebi moSinaurebul cxovelebsa da cocxal saqonelsa da frinvelSi Tu mxolod gareul frinvelsa da cxovelebSi, virusi enzotikuria Tu epizotikuri, geografiulad lokalizebulia Tu gavrcelebuli, da /an sxva mecnieruli parametrebiT.

b faza 3-s, faza 4-sa da faza 5-s Soris sxvaoba efuZneba pandemiis safrTxis donis Sefasebas. aseve gasaTvaliswinebelia sxva faqtorebi da maTi fardobiTi mniSvneloba arsebuli mecnieruli codnis TvalsazrisiT. faqtorebSi SeiZleba Sevides gadadebis siswrafe, geo-grafiuli mdebareoba da gavrceleba, daavadebis simZime, adamianis StamSi (Tu igi nawarmoebia cxovelis Stamidan) genebis arseboba da/an sxva samecniero parametrebi.

adamianebs Soris ioli gadacemis unaris mqone virusis gamoCenis SemTxvevaSi pandemia gardauvali aRmoCndeba. sazRvrebis CaketviTa da mogzurobis akrZalviT SesaZloa Seyovndes virusis gavrceleba, magram misi aRkveTa ver moxerxdeba. Tuki wina saukunis pandemiebi msoflioSi gavrcelda 6-9 Tvis ganmavlobaSi, rodesac qveynebs Soris gadaadgileba ZiriTadad gemiT xorcieldeboda, dRevandeli satransporto saSualebebisa da mogzaurobis moculobis gaTvaliswinebiT virusi yvela kontinents savaraudod 3 TveSi miaRwevs.

gripis pandemiis gavrcelebisaTvis saWiro sami winapirobidan dReisaTvis saxezea ori piroba:

• (+) gamoCndes A gripis virusis axali manamde ucnobi qvetipi;

• (+) viruss gaaCndes adamianebSi replikaciis unari;

• (-) virusi aqtiurad gadaeces adamanidan adamians.

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2. etiopaTogenezi

A(H5N1) maRalpaTogenuri frinvelis gripis virusi miekuTvneba orTomiqsovirusebis ojaxs, frinvelis gripis A tips. virusi Seicavs 8 segmentis mqone erTZafian rnm-s, romlebic virusis garsSia moTavsebuli nukleoproteinTan (NP) da virusuli polimerazas sam suberTeulTan (PA, PB1, PB2) erTad. iqmneba ribonukleoproteinis (RNP) kompleqsi, romelic uzrunvelyofs rnm replikaciasa da transkripcias. garda amisa, virionSi aris M2 da virusis nuklearuli eqsportis cila, romlebic monawileoben virusis awyobasa da ujredidan gamoTavisuflebaSi, aseve ribonukleoproteinis SeRwevaSi birTvis SigniT.

gripi A(H5N1) virusis garsis zedapirze aris glikoproteinebi: hemaglutininis (HA) me-5 tipi da neiraminidazas (NA) 1-li tipi. hemaglutinini emagreba maspinZlis ujredis zedapirze arsebul sialis mJavas receptorebs, rac ganapirobebs virusis SeWras ujredSi. hemaglutinini mTavari antigenuri determinantia maneitralizebeli antisxeulebis warmoqmnisaTvis, amitomac sezonuri vaqcinebis umniSvnelovanesi komponents warmoadgens. neiraminidaza antisxeulebis warmoqmnis meore determinantia. is xleCs glikozidur kavSirebs maspinZlis ujredis sialis mJavasa da virionis zedapirs Soris, riTic aadvilebs virusis gamoTavisuflebas ujredidan. am mniSvnelovani funqciis inhibireba antivirusuli mkurnalobis erT-erT yvelaze efeqtur strategias warmoadgens. mesame membranuli proteini e. w. M2 proteini mcire raodenobiTaa warmodgenili A virusebSi. is ionuri arxebis msgavsad funqcionirebs da aregulirebs virusis Sinagan pH-s, rac mniSvnelovania virusis replikaciis adreul stadiebze, rodesac virusi axorcielebs nukleinis mJavas e. w. “gaSiSvlebas”. am funqciis blokireba xorcieldeba amantadinisa da remantadinis saSualebiT.

frinvelis gripis virusi sakmaod gamZlea garemoSi. is inaqtivdeba 56OC-ze 3 saaTis ganmavlobaSi, xolo 600C-ze 30 wuTis ganmavlobaSi.

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frinvelis eqskrementebSi 400C-ze 35 dRe, xolo 370C-ze - 6 dRe inarCunebs inficirebis unars.

gripis virusi mgrZnobiarea temperaturis (560C-ze 3 saaTis, 600C-ze 30wT ganmavlobaSi, xolo 650C-ze iRupeba 5-10wT-Si), gamoSrobis, mzisa da ultraiisferi sxivebis zemoqmedebis mimarT; oTaxis temperaturaze iRupeba ramodenime saaTSi. masze advilad moqmedebs sadezinfeqcio xsnarebi, mgrZnobiarea tute da mJave garemos mimarTac inaqtivdeba

mJangveli agentebis, lipidebis gamxsnelebis, β-propionlaqtonis, aseve formalinisa da iodis komponentebis zemoqmedebiT.

iTvleba, rom frinvelis gripis virusis transmisia ar xdeba Termulad srulyofilad damuSavebuli xorciT, xorcproduqtebiT, kvercxiT.

A adamianis gripis virusi inficirebuli msxvili respiratoruli

nawilakebis (wveTebi zomiT > 5 µm) inhalaciiT, pirdapiri da SesaZloa arapirdapiri kontaqtebiT gadaecema. virusis gadacema xorcieldeba 1 metr manZilze. H5N1 infeqcia savaraudod aseve msxvili respiratoruli

nawilakebis (diametri > 5µm) meSveobiT gadaecema, Tumca eqsperimentuli monacemebisa da klinikuri dakvirvebebis safuZvelze ar gamoiricxeba

infeqciis gadacema wvrili aerozoluri nawilakebis (<5 µm) meSveobiT 1 metrze met manZilzec, gansakuTrebiT garkveuli samedicino manipulaciebis Sesrulebis dros, rogoricaa traqeis intubacia, sekretis amoqaCva, nebulaizeris gamoyeneba da sxva. virusi TviTinokulirdeba zemo respiratoruli traqtisa da koniuqtivas lorwovan garsSi. efeqturi transmisiis sxva gzebi ar aris dadgenili.

frinvelidan adamianze A(H5N1) transmisias adgili aqvs axlo kontaqtis Sedegad frinvelis daxarisxebisa da ganadgurebis, dakvlis, gaputvis, damuSavebis procesSi, aseve maTTan TamaSis dros. ar aris aRwerili adamianTa inficireba aseT situaciebSi, roca isini adeqvaturad iyvnen aRWurvili individualuri dacvis saSualebebiT.

intensiuri kvlevebi mimdinareobs imis dasadgenad, Tu ratom aris

gaZnelebuli H5N1 virusis transmisia adamianebSi.haerwveTovani gziT gavrcelebadi virusis transmisiisaTvis

aucilebelia virusi ukavSirdebodes respiratoruli traqtis zemo nawilis receptorebs, raTa misi gadacema iolad ganxorcieldes xvelisa da ceminebis dros. frinvelis gripis virusi A(H5N1) saWiroebs

receptors e.w. SAα-2,3-Gal kavSiriT respiratoruli traqtis ujredTan dasakavSireblad. aseT receptorSi galaqtoza sialis mJavasTan bmulia alfa-2,3 kavSiriT. adamianis gripis virusis Stamebi ukavSirdeba alfa-2,6 sialis mJava/galaqtozas kompleqss. cxviris lorwovanis, paranazaluri sinusebis, xaxis, traqeis, bronqebis lorwovanSi, iseve rogorc terminalur da respiratoruli bronqiolebSi ZiriTadad receptorebis e w “alfa-2,6” formaa warmodgenili. xolo “alfa-2,3” bmis mqone ujredebi ZiriTadad warmodgenilia araciliarul kuboidalur bronqiolur ujredebSi, romlebic lokalizebulia respiratoruli bronqiolebis alveolebSi gadasvlis adgilas, agreTve alveoluri kedlis amomfen ujredebSi (kerZod, me-2 tipis alveolocitebSi). me-2 tipis alveolocitebi surfaqtantis ZiriTadi producentebi arian da maTi dazianeba alveolebis kolafss iwvevs, rac erTerTi faqtoria frinvelis gripis dros mZime respiratoruli ukmarisobisa.

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mecnierebTa azriT, virusis hemaglutinogenis mravlobiTi mutaciebis gziT viruss SesaZloa mieces unari, raTa gamoicnos adamianis zemo sasunTqi gzebis receptorebi, gamravldes zemo respiratorul traqtSi da gadaeces ceminebisa da xvelis dros sxva adamianebs. Tumca sxva virusul proteinSic (magaliTad, PB2) momxdarma cvlilebebmac SesaZloa SesZinos viruss adamianis organizmSi efeqturad gamravlebis unari.

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4. klinikuri simptomatika

H5N1 infeqciis inkubaciuri periodi saSualod 2-4 dRes Seadgens. janmos miTiTebiT inkubaciur periodis maqsimalur vadad unda CaiTvalos 7 dRe.

pacientTa umravlesobas daavadeba ewyeba maRali cxelebiTa (Cveulebriv, 380C-ze meti) da respiratoruli infeqciis niSnebiT/simptomebiT. adamianis gripis dros ufro zemo respiratoruli traqti ziandeba. frinvelis gripis H5N1 dros ki upiratesad qvemo respiratoruli traqtia dazianebuli. A(H7) frinvelis gripisagan gansxvavebiT A(H5N1) gripis dros iSviaTad viTardeba koniuqtiviti.

zogierT pacientSi daavadebis sawyis etapebze adgili aqvs diareas, gulisrevasa da Rebinebas, muclis tkivils, plevralur tkivils, sisxldenas cxviridan da RrZilebidan. wyliani diarea sisxlisa da anTebiTi cvlilebebis gareSe gacilebiT ufro xSirad vlindeba A(H5N1) virusiT inficirebisas, vidre adamianis gripis SemTxvevaSi da zogjer erTi kviriT win uswrebs respiratorul gamovlinebebs.

gamovlinebani qvemo respiratoruli traqtis mxriv xSirad viTardeba daavadebis sawyis etapebze. dispnea viTardeba daavadebis dawyebidan saSualod me-5 dRes (1-16 dRe), xSiria respiratoruli distresi, taqipnea, zogjer xvela sisxliani naxveliT. TiTqmis yvela pacients aReniSneba klinikurad gamoxatuli pnevmonia. Cveulebrivi adamianuri gripiT dainficirebul pacientebs uviTarebaT meoradi baqteriuli pnevmonia. am SemTxvevaSi ki pnevmonias iwvevs TviTon gripis virusi, pacienti ar eqvemdebareba antibiotikoTerapias da kvdeba.

H5N1 inficirebul pacientebSi daavadeba swrafad progresirebs. tailandSi drom daavadebis dawyebidan mwvave respiratoruli distresis sindromis Camoyalibebamde saSualod Seadgina 6 dRe (4-13 dRe). TurqeTSi klinicistebma SeniSnes, rom respiratoruli ukmarisoba viTardeboda simptomebis gamoCenidan 3-5 dReSi. sxva damaxasiaTebeli niSnebidan SeiniSneboda poliorganuli ukmarisoba.

gulmkerdis rentgenogramaze cvlilebebi ar aris specifiuri da vlindeba konsolidaciis, xSirad bilateraluri da multifokaluri, laqovani, wilovani da intersticiuli infiltratebis saxiT, romlebic viTardeba simptomebis gamoCenidan saSualod 7 dReSi (3-17 dRe).

laboratoriuli maCveneblebidan gamoxatulia leikopenia (ZiriTadad limfopenia, CD4/CD8 Tanafardobis inversiiT), Trombocitopenia, aminotransferazebis mateba da diseminirebuli intravaskularuli koagulaciis Sesabamisi cvlilebebi koagulogramaSi. SeiniSneba hiperglikemia (rac SesaZloa kortikosteroidebis xmarebasTan yofiliyo dakavSirebuli) da kreatininis mateba. tailandSi letalobis risk-faqtorebs laboratoriuli maCveneblebis mixedviT warmoadgenda leikopenia, limfopenia da Trombocitopenia.

daavadebis garTulebebidan xSirad aRiniSneba mwvave respiratoruli distres sindromi da poliorganuli dazianeba Tirkmlis, gulis ukmarisobiT, rasac axlavs kardiodilatacia da supraventrikuluri taqiariTmia. sxva garTulebebidan aRiniSneba filtvebis xelovnur ventilaciasTan dakavSirebuli filtvis dazianeba, hemoragiebi filtvSi, pnevmoToraqsi, aseve pancitopenia, reis sindromi da sefsisi dokumentirebuli baqteriemiis gareSe.

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pacientTa nawilSi pnevmoniisa da sasunTqi sistemis dazianebani saerTod ar vlindeba an viTardeba sikvdilis wina saaTebSi. aRwerilia A(H5N1) atipuri mimdinareba or vietnamel bavSvSi, romelTac daavadeba daewyoT cxelebiT, diareiTa da RebinebiT, respiratoruli gamovlinebebis gareSe, rasac Semdgom daerTo krunCxva. mogvianebiT maT ganuviTardaT sunTqvis ukmarisoba da daiRupnen. erTerTi gardacvlilis cerebrospinaluri siTxidan, xaxidan, Sratidan da ganavlidan izolirebul iqna A(H5N1) virusi.

yovelive zemoaRniSnulis gaTvaliswinebiT dReisaTvis arsebobs imis saSiSroeba, rom atipuri klinikuri gamovlinebebis mqone pacientebs SesaZloa ar CautardeT A(H5N1) testireba. cnobilia, rom 1918 wlis gripis pandemiisas pacientTa nawilSi xdeboda qoleris, denges cxelebisa da tifis diagnozis araswori dasma.

qvemoT moyvanil cxrilSi N 4 warmodgenilia frinvelis gripis A(H5N1) calkeuli klinikuri da laboratoriuli simptomebis gamovlineba H5N1–is 59 dadasturebul SemTxvevaSi, romlebic hong-kongSi, tailandSi, vietnamsa da kambojaSi aRiniSna 1997-2005 ww-Si.

klinikuri niSnebi saSualo gavrceleba (%)

cxeleba (>380C) * 98

xvela* 88

qoSini * 62

cxviridan gamonadeni 55

yelis tkivili* 52

faRaraTi 39

Tavis tkivili 28

kunTebis tkivili 29

muclis tkivili 23

Rebineba 31

infiltratebi filtvSi 88

limfopenia 64

aminotransferazebis donis mateba 67

Trombocitopenia 54

cxrili 4 SeniSnva: varskvlaviT (*) moniSnulia is simptomebi, romlebic H5N1 savaraudo SemTxvevis gansazRvrebisaTvis gamoiyeneba

letaluri gamosavlis maRali sixSire miuTiTebs, rom

SesaZlebelia H5N1 gripis paTogenezi msgavsi iyos 1918 wlis H1N1 gripis paTogenezisa. mkvlevarebi fiqroben, rom 1918 wlis pandemiuri Stamis mier gamowveuli daavadebis paTogenezSi mniSvnelovan rols asrulebda e.w. “citokinuri Stormi” (citokinebis Warbi produqcia).

A(H5N1) virusiT dazianebul alveolur da bronqul epiTelur ujredebSi citokinebisa da qemokinebis donis SeswavliT aRmoCnda, rom adgili hqonda IP-10-is (interferon-gama-inducirebuli-protein-10),

interferon−β, Τ -ujredebis (e.w. RANTES tipis) da interleikin-6-is Warbi raodenobiT produqcias, rac daaxloebiT 10-jer aRemateboda adamianis gripis virusis mier imave nivTierebebis produqcias, rac SesaZloa erT-erTi mizezi iyos daavadebis mZime mimdinareobisa adamianebSi.

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5. daavadebis diagnozi

jandacvis msoflio organizaciis rekomendaciebis (29 agvisto, 2006 w) mixedviT H5N1 saeWvo SemTxvevad iTvleba pacienti , romelsac aReniSneba qvemoT CamoTvlili klinikuri niSnebi da sul mcire erTi epidemiologiuri kriteriumi

klinikuri niSnebi:respiratoruli traqtis mwvave, auxsneli daavadebiT, romelic mimdinareobs cxelebiT (>380C) da xveliT, qoSiniT an gaZnelebuli sunTqviT

erTi an meti eqspoziciiT qvemoT CamoTvlilTagan simptomebis dawyebamde 7 dRis ganmavlobaSi

a) axlo (1 metramde) kontaqti adamianTan (mag. movla, saubari an Sexeba), romelic aris H5N1-is saeWvo, savaraudo an dadasturebuli SemTxveva;

b) eqspozicia (mag. movla, dakvla, gaputva, danawileba, moxmarebisaTvis momzadeba) Sinaur an garul frinvelTan an maT narCenebTan (gvamebTan) an maTi eqskrementebiT dabinZurebul garemosTan im teritoriaze, sadac bolo 1 Tvis manZilze, adamianTa an cxovelTa Soris iyo H5N1-is savaraudo an dadasturebuli SemTxveva;

g) Sinauri frinvelis, umad an Termulad arasaTanadod momzadebuli, produqtebis moxmareba im teritoriaze sadac bolo 1 Tvis manZilze adamianTa an cxovelTa Soris iyo H5N1-is savaraudo an dadasturebuli SemTxveva;

d) Sinauri an gareuli frinvelis garda sxva cxovelTan (mag. kata an Rori) axlo kontaqti, romelSic dadasturebuli iyo H5N1-is infeqcia;

e) urTierToba sinjebTan (cxovelur an adamianur) romelic saeWvoa H5N1-is Semcvelobaze laboratoriaSi an sxva garemoSi.

H5N1-is savaraudo SemTxveva (Setyobineba igzavneba janmo-Si)

savaraudo gansazRvreba 1:

adamiani romelic Seesabameba saeWvo SemTxvevis gansazRvrebas

da

erTi Semdegi kriteriumidan:

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a) infiltraciuli an radiologirad dasabuTebuli pnevmonia plus dadasturebuli respiratoruli ukmarisoba (hipoqsemia, mZime qoSini)

an

b) A gripis infeqciis dadebiTi laboratoriuli dadastureba, magram arasakmarisi laboratoriuli dasabuTeba H5N1 infeqciaze.

savaraudo gansazRvreba 2:

adamiani, romelic gardaicvala auxsneli mwvave respiratoruli daavadebiT romelsac dadasbuTebuli epidemiologiuri kavSiri qonda drois, adgilis da eqspoziciis mixedviT H5N1-is savaraudo an dadasturebul SemTxvevasTn;

A(H5N1) saeWvo SemTxvevis mimarT xorcieldeba daavadebis kontrolis Sesabamisi RonisZiebani da iwyeba daavadebis klinikuri marTva. amasTan erTad grZeldeba pacientis Semdgomi kvleva A(H5N1) infeqciaze.

A gripis sadiagnostikod gamoiyeneba Semdgomi kvlevebi:1) antigenis swrafi deteqcia. 2) virusuli kultura. 3) polimeraza jaWvuri reaqcia.

A/H5 gripis saidentifikacio procedurebis Catareba warmoebs daavadebaTa kontrolis erovnul centrSi, sadac Catardeba RT PCR (myisieri polimeraza jaWvuri reaqcia) kvleva A/H5 gripis virusze. RT PCR mZlavri sadiagnostiko meTodia gripis virusis genomis identifikaciisaTvis. gripi A/H5-s yvela dadebiTi Sedegi unda dadasturdes janmos mier rekomendirebuli referaluri laboratoriebis mier. sadac masala unda gadamowmdes sxva meTodebiTac, rogoricaa imunofluorescentuli kvleva, virusis kultivireba, serologia. masala, maT Soris, adamianis organizmidan aRebuli nimuSi virusis satransporto niadagiT, am nimuSidan eqstragirebuli rnm an TviTon virusi ujreduli kulturis saxiT an kvercxis alantoisis siTxeSi winaswari SeTanxmebis safuZvelze igzavneba referalur laboratoriaSi.

inficirebis dadasturebis SemTxvevaSi informacia pirvel rigSi unda ecnobos im laboratorias, saidanac gaigzavna es masala da maTi nebarTviT ecnobos janmos regionalur ofisebs an janmos saTavo ofiss JenevaSi. Sedegebi konfidencialuri unda darCes Sesabamisi qveynis mTavrobis mier maT gamoqveynebamde.

gripi A/H5 specifiuri antisxeulebis sakvlevad rekomendirebulia mikroneitralizaciis testi, magram. vinaidan testi sadReisod cocxali virusis gamoyenebas saWiroebs, is mxolod biousafrTxoebis me-3 donis laboratoriebSi gamoiyeneba.

15

biologiuri masala frinvelis gripis infeqciaze laboratoriuli kvlevisaTvis

respiratoruli virusebis diagnostika damokidebulia maRalxarisxovani masalis Segrovebaze, mis swraf transportirebasa da testirebamde Sesabamis pirobebSi Senaxvaze. virusi kargad deteqtirdeba inficirebuli ujredebis an sekretis Semcvel masalaSi. masala virusis antigenis an nukleinis mJavas deteqciisaTvis da virusis izolirebisaTvis ujreduli kulturebidan ukeTesia aRebul iqnas klinikuri simptomebis gamoCenidan pirvel 3 dReSi.masalis saxeebizemo sasunTqi gzebis virusuli infeqciebis kvlevisaTvis gamoiyeneba Semdegi masala:

• cxviris nacxi

• nazofaringealuri nacxi

• nazofaringealuri aspirati

• cxviris gamonarecxi

• xaxis nacxizemo respiratoruli traqtidan nacxis aRebis garda SesaZloa

Catardes invaziuri procedurebi virusuli infeqciis diagnostikisaTvis qvemo respiratoruli gzebidan:

• transtraqealuri aspirati

• bronqoalveolaruli lavaJi

• filtvis biofsia

• gvamis filtvis an traqeis qsovilivirusuli antigenis pirdapiri deteqciisaTvis inficirebuli

ujredebis imunofluorescentuli SeRebvisas masala unda gaiyinos da damuSavdes aRebidan 1-2 saaTSi. pacientis sawolTan gamosayenebeli komerciuli testebisaTvis masala Senaxul unda iqnas miTiTebuli instruqciebis Tanaxmad. masala virusis izolaciisaTvis unda gaiyinos SegrovebisTanave da inokulirdes Sesabamis ujredul kulturaSi rac SeiZleba male. Tuki masalis damuSaveba SeuZlebelia 48-72 saaTSi, is unda iqnas Senaxuli -700C-ze.

WHO 2006 wlis 29 agvistos rekomendaciebis mixedviT, gripis A (H5N1) diagnozi dadasturebulad iTvleba, Tuki pacients aReniSneba mwvave respiratoruli, cxelebiT mimdinare daavadeba da laboratoriuli gamokvleviT dgindeba erTi an meti qvemoCamoTvlili niSani:

adamiani romelic Seesabameba saeWvo an savaraudo SemTxvevis gansazRvrebas

da

erT-erTi qvemoT moyvanili dadebiTi Sedegi, romelic miRebulia gripis im nacionalur, regionalur an saerTaSoriso laboratoriebSi, romelTa H5N1 testis Sedegebi aRiarebulia damadastureblad janmo-s mier:a) H5N1 virusis izolacia;

16

b) PCR-iT H5-ze dadebiTi Sedegi ori sxvadasxva praimeris gamoyenebiT, mag. A gripisa da H5 HA mimarT specifiuri praimerebi;g) H5N1 mimarT antisxeulebis titris oTxjeradi an metad momateba mwvave (Srati unda aviRoT simptomebis gamovlenidan pirvel 7 dReSi) da konvalescenciur periodebSi aRebuli Sratis nimuSebSi. konvalescenturi antisxeulebis titri unda iyos 1:80 an meti;d) H5N1 mimarT antisxeulebis titri 1:80 an metis toli Sratis nimuSSi, romelic erTjeradadaa aRebulia simptomebis gamovlenidan 14 an meti dRis Semdeg da dadebiTi Sedegi sxva serologiuri testis gamoyenebiT, mag. cxenis eriTricitebis hemaglutinaciis inhibirebis titri 1:160 an metis toli an H5–specifiuri blotingis (western blot) dadebiTi Sedegi.

H5N1-is dadasturebuli SemTxvevaze Setyobineba igzavneba janmo-Si.

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6. gamokvlevis sqema (algoriTmi)

A(H5N1) infeqciis gamokvleva, misi klinikuri marTva da infeqciis kontrolis RonisZiebebi erTdroulad xorcieldeba, rac asaxulia qvemoT moyvanili sqemebze.

6.1 . gamokvlevis sqema pirveladi jandacvis rgolisaTvis

18

saeWvo A(H5N1) SemTxveva!

pacientTan mimarTebaSi SeasruleT A(H5N1) infeqciis Sesabamisi usafrTxoebis RonisZiebebi da daiwyeT daavadebis klinikuri marTva.

A(H5N1) infeqcia gamoricxulia


niSani ar aris saxeze

pacienti gadaagzavneT specializebul meoradi jandacvis an referalur hospitalSi Semdgomi gamokvlevisa da klinikuri marTvisaTvis.







6.2. gamokvlevis sqema regionuli hospitalisaTvis, romelic akmayofilebs frinvelis gripis marTvisaTvis saWiro kriteriumebs

19

SeagroveT masala virusis diagnostirebisTvis: (nazofaringealuri nacxi) da gadaagzavneT is diagnostikuri

testirebisaTvis A(H5N1) infeqciaze daavadebaTa kontrolis nacionalur centrSi

dadebiTi Sedegi

A (H5N1) infeqciis diagnozi gamoricxulia

diagnozi: A (H5N1) infeqcia



uaryofiTi Sedegi

saeWvo A(H5N1) SemTxveva!

pacientTan mimarTebaSi SeasruleT A(H5N1) infeqciis Sesabamisi usafrTxoebis RonisZiebebi da daiwyeT daavadebis klinikuri marTva.







6. 3. gamokvlevis sqema referaluri hospitalisaTvis

20

diagnostikuri testireba A gripze

dadebiTi Sedegi uaryofiTi Sedegi

masala gaigzavnos da Catardes konfirmatoruli testireba RT-PCR an kultivirebis gziT janmos mier rekomendirebul referalur laboratoriaSi

Catardes diagnostikuri testireba A/H5-ze daavadebaTa kontrolis erovnul centrSi

A (H5N1) infeqcia gamoricxulia

diagnozi: adamianis A gripi, A(H5N1) infeqcia gamoricxulia



uaryofiTi Sedegi

dadebiTi Sedegi

saeWvo A(H5N1) SemTxveva!pacientTan mimarTebaSi SeasruleT A(H5N1) infeqciis Sesabamisi usafrTxoebis RonisZiebebi da daiwyeT daavadebis klinikuri marTva.







21

diagnozi: A(H5N1) infeqcia dadasturebulia

amasTan erTad mimdinareobs adamianebSi an frinvelSi/cxovelSi gripis SemTxvevis kvleva da Setyobineba

Sesabamisi sqemiT

`saeWvo~

SemTxveva

klinikuri niSnebis

gansazRvra; epidkvleva;

nimuSis aReba

nimuSi

dkssec-s an vet. gripis

laboratoria

uaryofiTi Sedegi

SemTxvevis moxsna dadebiTi Sedegi:

saTanado RonisZiebebi

janmo-s an veterinariis

referaluri

laboratoria

22

Setyobinebis sqema

SeniSvna: wyvetili isrebi - adamianTa daavadebis SemTxveva;

uwyveti isrebi - frinvelTa/cxovelTa daavadebis SemTxveva

frinveli:gareulis masobrivi dacema

adamiani

adgilobrivi sjc

adgilobrivi vet. samsaxuri

vet.departamenti regionuli sjcdkssec

uwyebaTaSorisi samuSao jgufi an analogi

dainteresebuli mxareebi:mTavroba, parlamenti, masmedia da sxv.

jandacvis saministro

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7. mkurnalobis sqema

A(H5N1) gripis virusiT gamowveuli davadebis klinikuri marTva moicavs Semdeg samedicino RinisZiebebs: vaqcinacia sezonuri gripis sawinaaRmdegod; vaqcinacia pandemiuri gripis sawinaaRmdegod; profilaqtika antivirusuli preparatebiT; mkurnaloba antivirusuli preparatebiT; mkurnaloba antibaqteriuli preparatebiT; mkurnaloba antipiretikebiT; damxmare Terapia (oqsigenoTerapia); personaluri Tavdacvis saSualebebis gamoyeneba.

vaqcinacia sezonuri gripis sawinaaRmdegod;amJamad gripis vaqcina Seicavs virusis sam Stams (2 A tipis virusis

da erTi B), romlebic savaraudod cirkulireben damdeg zamTars. vaqcina inaqtivirebulia. acril bavSvTa da axalgazrda pirTa umravlesobas uviTardeba postavqcinirebuli hemaglutinaca-inhibitoruli antisxeulebis titri. es antisxeulebi icavs daavadebis ganviTarebisagan Tu emTxveva im Stams, romelic im wels cirkulirebs. xanSiSesulebsa da qronikul avadmyofebSi viTardeba SedarebiT susti imuniteti, magram vaqcina maT am adamianebs icavs gripis garTulebebisa da gripis letaluri formis ganviTarebisagan.

vaqcinis efeqturoba damokidebulia recipientis asakze da imunokompetenturobaze, aseve vaqcinaSi arsebuli da cirkulirebadi Stamebis Tanxvedraze. Tu Tanxvedras aqvs adgili maSin vaqcina efeqturia 70-80%-Si 65 wlamde asakis pirebSi, xanSiSesulebSi ki 30-70%.

sezonuri gripis sawinaaRmdego vaqcinis deficitis pirobebSi prioritetuli jgufebs vaqcinaciis Casatareblad saqarTveloSi warmoadgens:

• medmuSaki;

• vetrinari;

• sunTqvis organoebis daavadebiT daavadebulni;

• Tirkmlis qronikuli ukmarisobiT daavadebulni;

• Saqriani diabetiT daavadebulni;

• imunodeficituri daavadebebiT daavadebulni;

• 65 wlis zeviT asakis adamianebi;

• bavSvebi da mozardebi (6 Tvidan 18 wlamde) reis sindromis ganviTarebis riskiT;

• orsulebi meore an mesame trimestrSi;

• mefrinveleobasa da mecxoveleobaSi dasaqmebulebi;

• dazaralebuli teritoriis macxovreblebi (sofeli an daba);

• sxva organizebul dawesebulebaSi momuSave.

24

pnevmokokis sawinaaRmdego vaqcinacia naCvenebia baqteriuli pnevmoniis, rogorc gripis garTulebis ganviTarebis gansakuTrebiT maRali riskis mqone adamianebisaTvis, rogoricaa 65 welze meti asakis pirebi, pirebi, visac aReniSnebaT gulis ukmarisoba, emfizema, Saqriani diabeti, alkoholizmi, RviZlis qronikuli ukmarisoba, imunokomprometirebuli pirebi.

vaqcinacia pandemiuri gripis sawinaaRmdegod;efeqturobisaTvis gripis sawinaaRmdego vaqcinas unda axasiaTebdes

subtipuri da Stamuri specifiuroba. gripis axali Stamis sawinaaRmdego vaqcinis SemuSavebasa da Semdgom masiur warmoebas sul mcire ramodenime Tve dasWirdeba pandemiis dawyebis momentidan. gripis vaqcinis warmoeba mTlianad koncentrirebulia evropasa da Crdilo amerikaSi. produqciis dRevandeli moculoba mniSvnelovnad CamorCeba pandemiis dros Seqmnil saWiroebas.

janmo specialuri gripis laboratoriebis qselis meSveobiT yuradRebiT adevnebs Tvals H5N1 virusis evolucias adamianebSi misi pirveli gamoCenidan hong-kongSi 1997 wels. es laboratoriebi amzadeben prototipul vaqcinebs, romelic Semdgom miewodeba vaqcinis mwarmoebel korporaciebs. sadReisod SemuSavebulia rigi kandidaturi vaqcinebi A(H5) bolodroindeli izolatebis mimarT. erT-erTi aseTi inaqtivirebuli vaqcina 2004 wlis H5N1 izolatis gamoyenebiT avlens imunogenobas hemaglutininis maRali Semcvelobis SemTxvevaSi. saWiroa adiuvantebis damatebisa da Semdgom vaqcinis efeqturobis Seswavla am TvalsazrisiT.

mimdinareobs klinikuri kvlevebi sxvadasxva kandidaturi vaqcinebis SesamuSavebladac, Tumca gaurkvevelia, H5 prototipul vaqcinebs eqnebaT Tu ara mosalodneli pandemiis gamomwvevi gripis virusiT dainficirebisagan dacvis unari.

aucilebelia garkveuli gegmis Camoyalibeba imunizaciis programis gansaxorcieleblad interpandemiur periodSi, vinaidan optimaluri dacvisaTvis savaraudod saWiro iqneba vaqcinis ori dozis miReba 21-dRiani SualediT. aucilebelia pandemiuri vaqcinis usafrTxoebis, efeqturobisa da imunogenobis SefasebisaTvis mudmivi monitoringi.

mkurnaloba antivirusuli preparatebiT;

pandemiis gamomwvevi frinvelis gripis virusis Stami Tavisi bunebiT gansxvavebuli iqneba dReisaTvis mocirkulire gripis virusebisagan. amdenad SeuZlebelia winaswar zustad ganisazRvros am virusis rezistentobis profili antivirusuli preparatebis mimarT da dadgindes mkurnalobis sqemebi.

gripis sawinaaRmdego antivirusuli preparatebi or jgufad iyofa: neiraminidazas inhibitorebi (oseltamiviri da zanamiviri) da adamantanis derivati M2 inhibitorebi (amantadini da rimantadini).

neiraminidazas inhibitorebi - oseltamiviri da zanamaviri 1999 wlidan gamoyeneba da amdenad klinikuri monacemebi maTi gverdiTi moqmedebis Sesaxeb SezRudulia. isini msgavsi qimiuri bunebis preparatebia da aqtiuria gripis A da B virusebis mimarT. es preparatebi

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N-acetil neiraminis mJavas (ujredis zedapirze arsebuli gripis virusis receptori) analogebi arian. isini gripis virusuli enzimis neiraminidazas aqtiuri ubnis blokirebas axdens, rac ganapirobebs virusis agregacias maspinZlis ujredis zedapirze da xels uSlis inficirebuli ujredidan virusis gamoTavisuflebas.

sezonuri gripis dros daavadebis dawyebidan pirveli 48 saaTis ganmavlobaSi gamoyenebis SemTxvevaSi preparatebi amcireben daavadebis xangrZlivobas daaxloebiT 1-1,5 dRiT placebosTan SedarebiT.

in vitro kvlevebSi A(H5N1) gripis virusebi mgrZnobiareni arian neiraminidazas inhibitorebis klasis orive preparatis – oseltamivirisa da zanamiviris mimarT. oseltamiviri da zanamiviri aseve aqtiuri iyo A(H5N1) gripis virusiT dainficirebul eqsperimentul cxovelebSi.

oseltamiviri (komerciuli saxelwodeba - tamiflu) gamodis kafsulebisa da oraluri suspenziis mosamzadebeli fxvnilis saxiT. preparatis dozis 75% RviZlSi gardaqmnis Semdeg oseltamiviris karboqsilatis saxiT aRwevs sistemur cirkulacias.

oseltamiviris gamoyeneba ar aris daSvebuli 1 welze naklebi asakis pacientebSi. gripis profilaqtikisTvis iniSneba 13 welze meti asakis pirebSi.

oseltamiviris dozireba Seadgens bavSvebisaTvis:

– 15 kg-mde - 30mg 2-jer dReSi– 15-23 kg – 45mg 2 jer dReSi– 23-40 kg - 60mg 2 jer dReSi– 40 kg-is zemoT - 75mg 2 jer dReSi

dozireba 13 welze meti asakis bavSvebsa da mozrdilebSi Seadgens 75 mg 2 jer dReSi 5 dRis ganmavlobaSi.

preparati Cveulebriv kargad gadaitaneba. wamlis miReba ar aris dakavSirebuli raime seriozul gverdiT movlenebTan; gverdiTi efeqtebidan, romlebic vlindeba 1%-ze ufro xSirad, aRsaniSnavia: Rebineba (15.0%; placebo -9.3%); muclis tkivili (4.7%; placebo - 3.9%); cxviridan sisxldena (3.1% placebo - 2.5%); yuris mxriv problemebi (1.7%; placebo - 1.2%). 1%-ze nakleb SemTxvevaSi vlindeba koniuqtiviti (1.0%; placebo -0.4%).

neiraminidazas inhibitorebis klinikuri gamoyeneba iSviaTadaa asocirebuli cns darRvevebTan. Tumca iaponiaSi oseltamiviris pediatriul gamoyenebas gripis samkurnalod Tan axlda rigi nevrologiuri da fsiqiatriuli gamovlinebani, am gamovlinebebis mizezi dReisaTvis ucnobia da is Semdgom Seswavlas saWiroebs.

aris gamoqveynebuli observaciuli kvleva oseltamiviris gamoyenebis Sesaxeb 1 wlamde asakis 47 bavSvSi, sadac ar gamovlenila raime mniSvnelovani gverdiTi efeqtebi (Tamura 2005). ar aris mowodebuli dozis Semcireba pacientis xandazmulobis gamo. SezRudulia monacemebi neiraminidazas inhibitorebis gamoyenebis Sesaxeb orsulebSi.

oseltamiviris aqtiuri metabolitis - oseltamiviris karboqsilatis (GS4071) koncentracia SratSi izrdeba Tirkmlis funqciis daqveiTebasTan erTad. pacientebSi kreatininis klirensiT 10-30

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ml/wT, miRebuli dozirebaa: samkurnalod 75 mg/dReSi erTxel da saprofilaqtikod 75 mg dRegamoSvebiT.

oseltamiviri ar aris Seswavlili pacientebSi RviZlis funqciis moSlis dros.

aRwerilia gulyrebi oseltamivirisa da zanamiviris miRebis Semdeg. Tumca epidemiologiurma kvlevebma ver daadgina kavSiri gulyraTa gamovlinebis risksa da preparatebis miRebas Soris.

monacemebi neiraminidazas inhibitorebis mimarT antivirusuli rezistentobis Sesaxeb SezRudulia am preparatebis klinikuri gamoyenebis xanmokle istoriis gamo. virusuli rezistentoba oseltamiviris mimarT male viTardeba N1 neiraminidazaSi erTi aminomJavas CanacvlebiT (mutacia - His274Tyr). virusis aseTi varianti gamovlenil iqna gripis A(H1N1) virusiT inficirebuli bavSvebis 16%-Si, romlebic oseltamiviriT mkurnalobdnen. es Stami naklebad infeqciuri iyo ujredul kulturebsa da eqsperimentul cxovelebSi da inarCunebda mgrZnobelobas zanamiviris mimarT. is mgrZnobelobas inarCunebda neiraminidazas axali inhibitoris - paramiviris mimarT, romelic amJamad Seswavlis fazaSia.

ar aris Catarebuli klinikuri kvlevebi oseltamiviris efeqturobis Sesaxeb H5N1 pacientebis samkurnalod. H5N1 gripis dros preparatis sargeblobisa da gverdiTi movlenebis Sesaxeb msjeloba eyrdnoba sezonuri gripis dros preparatis gamoyenebis Sedegebs. qvemoT moyvanili rekomendacia Seesabameba mtkicebulebis siZlieris dones IV (Muir Gray) da rekomendaciis xarisxs DD (Cook et al).

klinikuri rekomendacia 1 janmrTelobis msoflio organizaciis rekomendaciebis mixedviT vinaidan A(H5N1) daavadeba Zalian mZimed mimdinareobs da ar arsebobs alternatiuli preparati daavadebis samkurnalod, oseltamiviri dauyovnebliv unda iqnas gamoyenebuli H5N1 savaraudo/dadasturebul SemTxvevebis samkurnalod mozrdilebSi, bavSvebsa da orsulebSi sezonuri gripis dros gamoyenebuli dozirebis Sesabamisad (mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSnva: oseltamiviris dozirebisa da mkurnalobis xangrZlivobis Sesaxeb rekomendaciebi SesaZlebelia Seicvalos pandemiuri Stamis gamoCenisa da preparatis efeqturobis Sesaxeb meti informaciis dagrovebis Semdeg.

preparati maqsimalurad efeqturia daavadebis dawyebidan pirvel 48 saaTSi, Tumca misi gamoyeneba mizanSewonilia A(H5N1) virusis replikaciis mTels periodSi.

zanamiviri inhalirebadi fxvnilia(komerciuli saxelwodeba - relenza). inhalacia xorcieldeba maRali nakadiT. preparatis dozis 78% orofaringealur areSi xvdeba, 15% ki traqeobronqul xesa da filtvebSi. preparati gamoiyeneba A da B gripis samkurnalod 7 welze meti asakis pirebSi. zanamiviri gripis profilaqtikisaTvis ar gamoiyeneba.

zanamiviri amerikis sursaTisa da wamlis administraciis (US FDA) mier mowodebulia 7 welze meti asakis bavSvebis samkurnalod.

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rekomendirebuli dozirebaa 2 inhalacia (erTi blisteri 5 mg-iania, erTjeradi doza Seadgens 10 mg) 2 jer dReSi. ar aris mowodebuli dozis Semcireba pacientis xandazmulobis gamo. SezRudulia monacemebi neiraminidazas inhibitorebis gamoyenebis Sesaxeb orsulebSi.

monacemebi zanamiviris gamoyenebis Sesaxeb pacientebSi Tirkmlis da RviZlis funqciis moSlis dros SezRudulia. rekomendirebulia, rom inhalirebadi zanamiviris 5 dRiani kursi ar Seicvalos pacientTa am populaciaSi.

zanamiviris gverdiTi movlenebia: gulisreva, diarea, Tavis tkivili, Tavbruxveva, xvela, rac SesaZloa misi fxvniliseburi formiT iyos ganpirobebuli.

zanamiviri ar aris rekomendirebuli respiratoruli daavadebis mqone pirebisaTvis, vinaidan SesaZloa gamoiwvios bronqospazmi. mZime respiratoruli gverdiTi movlenebi aRwerilia rogorc filtvis qronikuli daavadebebis mqone, aseve jansaR adamianebSi.

inhalaciuri zanamiviri A(H5N1) gripis virusiT dainficirebul pacientebSi ar yofila gamoyenebuli. Zalian mcire raodenobiT in vitro da eqsperimentuli gamokvlevebia Catarebuli zanamiviris efeqturobis Sesaswavlad H5N1 virusis sawinaaRmdegod. zanamiviri inarCunebs aqtivobas oseltamiviris mimarT rezistentuli H5N1 virusis sawinaaRmdegod, romelic Seicavs H274Y mutacias (Le 2005).

.

klinikuri rekomendacia 2janmrTelobis msoflio organizaciis rekomendaciebis mixedviT, zanamiviri SesaZloa gamoyenebul iqnas H5N1 savaraudo/dadasturebul SemTxvevebis samkurnalod mozrdilebSi, bavSvebsa da orsulebSi sezonuri gripis dros gamoyenebuli dozirebis Sesabamisad (susti rekomendacia, Zalian dabali xarisxis mtkicebuleba ).

SeniSnva: es rekomendacia miznad isaxavs maRalpaTogenuri H5N1 gripis dros letalobis Semcirebas da iTvaliswinebs preparatis gverdiT efeqtebs (maT Soris bronqospazms), rezistentobis potenciur Camoyalibebas da mkurnalobis Rirebulebas. zanamiviris bioSeRwevadoba respiratoruli traqtis gareT dabalia oseltamivirTan SedarebiT. is SeiZleba aqtiuri iyos oseltamiviris mimarT rezistentuli zogierTi Stamis sawinaaRmdegod. zanamiviri SesaZloa gamoyenebul iqnas pacientebSi, rodesac preparatebis peroraluri miReba SeuZlebelia.

adamantanis derivatebi, M2 inhibitorebi - amantadini da rimantadini, qimiurad msgavsi bunebis peroraluri preparatebia, romlebic gamoiyeneba gripis profilaqtikisa da mkurnalobisaTvis. es preparatebi moqmedeben A gripis virusis membranis ionuri arxis M2 cilaze da ainhibireben virusis garsis Semoclas, virusis replikaciasa da gamoyofas ujredidan. amantadini da rimantadini specifiurad ainhibireben A gripis virusis replikacias.

amantadini iniSneba A gripis samkurnalod 1 welze meti asakis pacientebSi; rimantadini gamoiyeneba A gripis samkurnalod mozrdilebSi

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daavadebis dawyebidan 48 saaTis ganmavlobaSi. orive preparatis gamoyeneba amcirebs virusis gamoyofis da avadobis xangrZlivobas 1 dRiT placebosTan SedarebiT. mkurnaloba rekomendebulia 5 dRis manZilze. orive preparati efeqturia gripis profilaqtikisaTvis 1 welze meti asakis adamianebSi.

amantadini da rimantadini daaxloebiT 70-90%-Sia efeqturi A gripis virusiT inficirebis prevenciisaTvis. maTi efeqturoba meoradi garTulebebis Tavidan acilebis mizniT gaurkvevelia.

orive preparatis gamoyeneba dakavSirebulia gastrointestinur (gulisreva da Rebineba) da centraluri nervuli sistemis mxriv gamovlinebebTan (cns toqsiuroba: Tavbruxveva, koncentraciis daqveiTeba, uZiloba, suicidi da krunCxvebi, gansakuTrebiT im pacientebSi, romelTac anamnezSi aReniSnebaT nevrologiuri moSlilobani). aris monacemebi preparatebis toqsiuri zemoqmedebis Sesaxeb gulze. rimantadini naklebad asocirdeba gverdiT efeqtebTan, vidre amantadini.

amantadini teratogenul da embriotoqsiur zegavlenas axdens cxovelebze. rimantadins ar axasiaTebs mutagenuri Tvisebebi. amantadinisa da rimantadinis usafrTxoeba orsulebSi ar aris Seswavlili.

es preparatebi male iwveven rezistentobas gripis virusebSi. rezistentuli Stamebi SesaZloa gavrceldes mkurnalobis procesSi myofi pacientebis garSemomyof pirebze, maT Soris maTzec, vinc itarebs qimioprofilaqtikas.

rezistentobis meqanizmi msgavsia adamantanebisaTvis da gripis virusi, romelic rezistentulia erTi preparatis mimarT, rezistentobas avlens meores mimarTac. ar aris monacemebi adamantan-rezistentuli gripis virusebis meti virulentobis Sesaxeb.

adamantanebis mimarT rezistentoba ar ganapirobebs jvaredin rezistentobas neiraminidazas inhibitorebis mimarT.

dReisaTvis adamianis sezonuri gripis virusebis izolatebi avlenen rezistentobas amantadinisa da rimantadinis mimarT.

amantadini arsebobs 100 mg tabletebis, kafsulebisa da sirofis formiT.

sezonuri A gripis dros misi rekomendirebuli dozirebaa 100 mg 2-jer dReSi mozrdilebsa da bavSvebSi (10-65 weli) 5 dRis ganmavlobaSi. 65 welze meti asakis adamianebSi dRiuri dozireba ar unda aRematebodes 100 mg-s erTjer profilaqtikis an mkurnlobis mizniT Tirkmlis funqciis daqveiTebis gamo. ufro xandazmul pacientebSi doza SeiZleba kidev ufro Semcirdes.

1-9 wlamde bavSvebSi rekomendebulia Semdegi dozireba 5 mg/kg/dReSi (ara umetes 150 mg /dReSi or miRebaze).

mowodebulia dozis Semcireba pacientebisaTvis, sadac kretininis klirensi (ml/wT/1.73 m2) naklebia 50 ml/wT.

30-50 ml/wT. - 200mg pirvel dRes da 100 mg yoveldRiurad Semdgom15-29 ml/wT. - 200mg pirvel dRes da 100 mg alternatiul dReebSi Semdgom<15 ml/wT. - 200mg yovel 7 dReSi

hemodializze myof pacientebSi rekomendirebuli dozirebaa 200 mg 7 dReSi erTxel. dozis SerCevasTan erTad es pacientebi saWiroeben

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monitorings gverdiTi movlenebis gamovlinebis mxriv. hemodializi naklebefeqturia preparatis klirensisaTvis.

amantadini frTxilad unda iqnas gamoyenebuli pacientebSi, romlebic Rebuloben neirofsiqiatriul preparatebs da pacientebSi romlebsac anamnezSi aReniSnebaT krunCxva, sadac potenciuri riski aRemateba potenciur sargebels. es preparati ar gamoiyeneba meZuZur qalebSi. gverdiTi efeqtebi ganapirobeben preparatis autanlobas pacientebis mier.

1997 wlis A(H5N1) virusebisagan gansxvavebiT frinvelis gripis virusis A(H5N1) dRevandeli izolatebi rezistentulia adamantanis derivatebis mimarT da Sesabamisad, savaraudoa, rom es rezistentoba pandemiur A(H5N1) Stamsac aRmoaCndeba. Tumca janmos monacemebis mixedviT TurqeTSi mocirkulire H5N1 virusebis zogierTi Stami mgrZnobiare aRmoCnda antivirusuli preparatebis orive klasis mimarT.

ar aris Catarebuli kontrolirebadi klinikuri kvlevebi amantadinis gamoyenebis Sesaxeb H5N1 infeqciis sawinaaRmdegod. Tumca aris SezRuduli monacemebi amantadinis gamoyenebis Sesaxeb H5N1 infeqciis dros, magram pacientebis mcire ricxvi ar iZleva daskvnebis gakeTebis saSualebas. ar Catarebula eqsperimentuli kvlevebi am TvalsazrisiT. qvemoT moyvanili rekomendacia Seesabameba mtkicebulebis siZlieris dones IV (Muir Gray) rekomendaciis xarisxs DD (Cook et al).

klinikuri rekomendacia 3-janmrTelobis msoflio organizaciis rekomendaciis mixedviT, Tuki neiraminidazas inhibitori xelmisawvdomia pacientisaTvis, ar unda iqnas daniSnuli amantadini rogorc pirveli rigis preparati monoTerapiis saxiT H5N1 savaraudo/dadasturebuli SemTxvevis samkurnalod (mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).

SeniSnva – miuxedavad daavadebis simZimisa, es rekomendacia did mniSvnelobas aniWebs rezistentobis Camoyalibebisa da gverdiTi efeqtebis ganviTarebis maRal Sanss. rekomendacia mkacri saxisaa, vinaidan iTvaliswinebs sxva ufro efeqturi preparatis xelmisawvdomobas pacientisaTvis.

klinikuri rekomendacia 4 Tuki neiraminidazas inhibitori ar aris pacientisaTvis xelmisawvdomi da Tuki virusi savaraudod /dadasturebulad mgrZnobiarea amantadinis mimarT, amantadini SesaZloa dainiSnos rogorc pirveli rigis preparati H5N1 savaraudo/dadasturebuli SemTxvevis samkurnalod (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia iTvaliswinebs daavadebis mZime mimdinareobas da maRal l;etalobas. SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efetebsa da rezistentobis SesaZlo Camoyalibebas situaciebSi, rodesac ar arsebobs alternatiuli preparati. sanam sxva informacia iqneba xelmisawvdomi, preparati unda dainiSnos sezonuri gripis dros gamoyenebuli dozirebiT.

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amantadinis gamoyenebisas gaTvaliswinebuli unda iqnas virusis rezistentoba preparatis mimarT mocemul regionSi. aseve mxedvelobaSi unda iqnas miRebuli preparatis sargeblobisa da SesaZlo gverdiTi efeqtebis Tanafardoba gverdiTi efeqtebis maRali riskis mqone pacientebSi, magaliTad, orsulebSi.

rimantadini arsebobs tabletebisa da sirofis saxiT.sezonuri A gripis dros preparatis dozirebaa 100 mg orjer dReSi

mozrdilebsa da bavSvebSi 10 wlis zemoT. Tumca 40 kilogramamde bavSvebSi miuxedavad asakisa miRebulia 5 mg/kg dReSi dozireba. bavSvebSi rimantadini iniSneba 1 an 2 miRebaze doziT 5 mg/kg/dReSi (ara umetes 150mg-sa dReSi 1-9 w asakis bavSvebSi).

pacientebSi mZime RviZlisa da Tirkmlis disfunqciiT (kreatininis klirensi <10 ml/wT) da asakovnebSi dozis Semcirebaa rekomendebuli 100 mg-mde dReSi. dozis SerCevasTan erTad es pacientebi saWiroeben monitorings gverdiTi movlenebis gamovlinebis TvalsazrisiT. hemodializi naklebefeqturia preparatis klirensisaTvis.

ar aris monmacemebi preparatis usafrTxoebis Sesaxeb pacientebSi mZime RviZlisa da Tirkmlis disfunqciiT.

aRwerilia gulyraTa (an gulyrismagvari aqtivobis) mateba pacientebSi, romelTac anamnezSi aReniSnebodaT gulyra da ar iRebdnen antikonvulsantebs. ar aris Catarebuli kontrolirebadi klinikuri kvlevebi rimantadinis gamoyenebis Sesaxeb H5N1 infeqciis sawinaaRmdegod. aseve ar Catarebula

eqsperimentuli kvlevebi am TvalsazrisiT. eqsperimentuli da in vitro gamokvlevebi aCveneben adamianis gripis virusis jvaredin rezistentobas M2 inhibitorebis mimarT. (Abed 2005, Hay 1996, Hayden 1996).

rimantadini savaraudod ar unda iyos ufro efeqturi H5N1 virusis sawinaaRmdegod, rogorc pirveli rigis preparati, vidre neiraminidazas inhibitorebi. Tumca preparatis gamoyeneba SesaZloa mizanSewonili iyos im situaciaSi, rodesac neiraminidazas inhibitorebi ar aris xelmisawvdomi pacientisaTvis, Tuki virusi savaraudod/dadasturebulad mgrZnobiarea am preparatis mimarT. aseT SemTxvevebSi rimantadinis gamoyeneba SesaZloa ufro gamarTlebuli iyos amantadinTan SedarebiT preparatebis gverdiTi efeqtebis gaTvaliswinebiT (Dolin 1982). qvemoT moyvanili rekomendacia Seesabameba mtkicebulebis siZlieris dones IV (Muir Gray) rekomendaciis xarisxs DD (Cook et al).

klinikuri rekomendacia 5 janmrTelobis msoflio organizaciis rekomendaciis mixedviT Tuki neiraminidazas inhibitori xelmisawvdomia pacientisaTvis, ar unda iqnas daniSnuli rimantadini rogorc pirveli rigis preparati monoTerapiis saxiT H5N1 savaraudo/dadasturebul SemTxvevaSi (mkacri rekomendacia Zalian dabali xarisxis mtkicebuleba).

SeniSnva – miuxedavad daavadebis simZimisa, es rekomendacia did mniSvnelobas aniWebs rezistentobis Camoyalibebisa da gverdiTi efeqtebis ganviTarebis maRal Sanss. rekomendacia mkacri saxisaa, vinaidan iTvaliswinebs sxva ufro efeqturi preparatebis xelmisawvdomobas pacientisaTvis.

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klinikuri rekomendacia 6 Tuki neiraminidazas inhibitori ar aris pacientisaTvis xelmisawvdomi da Tuki virusi savaraudod/dadasturebulad mgrZnobiarea am preparatis mimarT, rimantadini SesaZloa dainiSnos rogorc pirveli rigis preparati H5N1 savaraudo/dadasturebuli SemTxvevis samkurnalod (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia iTvaliswinebs daavadebis mZime mimdinareobas da maRal l;etalobas. SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efetebsa da rezistentobis SesaZlo Camoyalibebas situaciebSi, rodesac ar arsebobs alternatiuli preparati. sanam sxva informacia iqneba xelmisawvdomi, preparati unda dainiSnos sezonuri gripis dros gamoyenebuli dozirebiT.

amantadinis gamoyenebisas gaTvaliswinebuli unda iqnas virusis rezistentoba preparatis mimarT mocemul regionSi. aseve mxedvelobaSi unda iqnas miRebuli preparatis sargeblobisa da SesaZlo gverdiTi efeqtebis Tanafardoba. saerTod, rimantadins gverdiTi efeqtebis ukeTesi profili gaaCnia, vidre amantadins. kombinirebuli Terapia

ar aris Catarebuli klinikuri kvlevebi M2 inhibitorebisa da neiraminidazas inhibitorebis kombinaciis gamoyenebis Sesaxeb H5N1 infeqciis dros.

Catarebulia mcire randomizirebuli klinikuri kvlevebi, sadac Sedarebuliaa nebulaizer-zanamivirisa (16mg 4-jer dReSi) da rimantadinis (100 mg erTxel an orjer dReSi) efeqturoba

hospitalizebul pacientebSi sezonuri A gripis dros rimantadisa da placebos kombinaciasTan SedarebiT aSS-Si. (Ison 2003, Madren 1995, Leneva 2000, Govorkova 2004). aseve mwiri eqsperimentuli da in vitro gamokvlevebia Catarebuli kombinirebuli Terapiis efeqturobis Sesaxeb H5N1 infeqciis dros. oseltamivirisa da rimantadinis gamoyeneba frinvelis gripis H9N2 virusiTa da adamianis H1N1 da H3N2 virusiT dainficirebul TagvebSi miuTiTebda aseTi kombinaciis efeqturobaze letalobis Semcirebis TvalsazrisiT. preparatebi avlendnen urTierT gamaZlierebel efeqts im SemTxvevaSi, Tuki virusi mgrZnobiare iyo am agentebis mimarT.

ar arsebobs monacemebi M2- da neiraminidazas inhibitorebis kombinirebuli gamoyenebis Sesaxeb H5N1 inficirebul pacientebSi. ar aris monacemebi aseTi kombinirebuli Terapiis gamoyenebis efeqturobis Sesaxeb adamianis sezonuri A gripis drosac.

klinikuri rekomendacia 7Tuki neiraminidazas inhibitorebi xelmisawvdomia pacientisaTvis da Tuki virusi savaraudod/dadasturebulad mgrZnobiarea M2 inhibitoris mimarT, SesaZloa dainiSnos M2 inhibitorisa da neiraminidazas inhibitoris kombinacia H5N1 savaraudo/dadasturebuli SemTxvevis samkurnalod (janmos ara mkacri rekomendacia, Zalian dabali xarisxis

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mtkicebuleba). rekomendacia unda daefuZnos garkveul virusologiur da klinikur monacemebs.

SeniSnva: es rekomendacia iTvaliswinebs daavadebis mZime mimdinareobas da maRal letalobas. SedarebiT nakleb mniSvnelobas aniWebs preparatebis gverdiT efeqtebsa da rezistentobis SesaZlo Camoyalibebas, aseve mkurnlobis maRal Rirebulebas. kombinirebuli mkurnalobis gamoyenebisas gaTvaliswinebuli unda iqnas mocemul teritoriaze virusis rezistentobis profili preparatebis mimarT. kombinirebuli Terapia unda Catardes mxolod detaluri klinikuri da virusologiuri monacemebis Segrovebis Semdeg mocemul regionSi. unda gadawydes romel pacients daeniSnos kombinirebuli Terapia daavadebis simZimis gaTvaliswinebiT.

profilaqtika antivirusuli preparatebiT; vinaidan gripis sawinaaRmdego vaqcinis SemuSaveba da warmoeba

droSi dayovnebuli procesia, frinvelis gripis profilaqtikisaTvis antivirusul preparatebs eniWebaT didi mniSvneloba.

antivirusuli preparatebiT profilaqtikas da profilaqtikis monitorings (gverdiTi movlenebi, zianis gamovlena) infeqciasTan kontaqtis riskis jgufebSi ganaxorcielebs pirveladi jandacvis rgolis eqimebi. gverdiTi movlenebisa da zianis gamovlenis semTxvevaSi samedicino personalis klinikur gadawyvetilebas gansazRvravs am gamovlenaTa simZime da xasiaTi.

antivirusuli profilaqtikis dawyebis Sesaxeb gadawyvetilebis miRebis dros saWiroa Sefasdes infeqciasTan kontaqtis riski. qvemoT mocemuli monacemebi Seesabameba janmrTelobis msoflio organizaciis rekomendaciebs, eyrdnoba klinikur dakvirvebas H5N1 infeqciis SemTxvevebze da maRali sarwmunoebis mqone monacemebs sezonuri gripis Sesaxeb.

A(H5N1) virusiT inficirebis TvalsazrisiT maRali riskis eqspoziciad iTvleba

• ojaxuri, axlo kontaqtebi (igulisxmeba daucveli kontaqti 1 metrze nakleb manZilze) savaraudo an dadasturebul H5N1 infeqciasTan ojaxSi/pacientis movlisas, vinaidan am dros SesaZlebelia am adamianebis eqspozicia infeqciis saerTo wyarosTan.

zomieri riskis eqspoziciad iTvleba

• xeliT kontaqti avadmyof cxovelebTan an dasvril masalasTan misi gauvnebelyofisas (maT Soris cxovelebis gadayra) Tuki individualuri dacvis saSualebebi ar iyo adeqvaturad gamoyenebuli

• daucveli da Zalian axlo kontaqti avadmyof an mkvdar cxovelebTan, romlebic dainficirebuli iyo H5N1 virusiT an garkveuli tipis frinvelebTan, romlebic gaxda adamianebis H5N1 –iT dainficirebis wyaro

• jandacvis muSakebis axlo kontaqti savaraudo an dadasturebul H5N1 infeqciasTan, magaliTad intubaciis an traqeis aspiraciis procesSi, an araadeqvaturad SefuTuli laboratoriuli

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masalis xelSi daWerisas individualuri dacvis saSualebebis araadeqvaturad xmarebisas. es jgufi aseve moicavs laboratoriis TanamSromlebs, romelTac daucveli kontaqti hqondaT virusis Semcvel masalasTan.

eqspoziciis dabali riskis jgufs miekuTvnebian

• jandacvis muSakebi ara axlo kontaqtiT (1 metrze meti) H5N1 savaraudo an dadasturebul SemTxvevasTan, da arapirdapiri kontaqtiT pacientis inficirebul masalasTan

• jandacvis muSaki, romelic adeqvaturad iyo aRWurvili individualuri dacvis saSualebebis pacientTan urTierTobisas.

• pirebi, romlebic anadgurebdnen arainficirebul an savaraudod arainficirebul frinvelebs kontrolis zomebis saxiT.

• individualuri dacvis saSualebebiT adeqvaturad aRWurvili pirebi, romlebsac hqondaT kontaqti avadmyof frinvelebTan.

amJamad, rodesac ar xdeba adamianebs Soris infeqciis efeqturi gadacema, zogadi populacia ar iTvleba riskis jgufad.

qvemoT moyvanili rekomendaciebi Seesabameba mtkicebulebis siZlieris dones IV (Muir Gray) rekomendaciis xarisxs DD (Cook et al).

rekomendacia 1maRali riskis eqspoziciis jgufebSi oseltamiviri unda dainiSnos profilaqtikis mizniT SesaZlo bolo eqspoziciidan 7-10 dRis ganmavlobaSi (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs maRali letalobiT mZimed mimdinare daavadebis profilaqtikas. is SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis fass. profilaqtika unda iqnes dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-10 dRis manZilze. arsebobs oseltamiviris 8 kviris manZilze gamoyenebis gamocdileba sezonuri gripis profilaqtikis mizniT. H5N1 infeqciis profilaqtikisaTvis gamoiyeneba oseltamiviris igive dozebi, rac sezonuri gripisaTvis. es rekomendacia exeba orsul qalebsac eqspoziciis maRali riskis jgufidan.

rekomendacia 2zomieri riskis eqspoziciis jgufebSi oseltamiviri SesaZloa dainiSnos profilaqtikis mizniT SesaZlo bolo eqspoziciidan 7-10 dRis ganmavlobaSi (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs maRali letalobiT mZimed mimdinare daavadebis profilaqtikas. is SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. qimioprofilaqtika unda iqnas dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-

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10 dRis manZilze. arsebobs oseltamiviris 8 kviris manZilze gamoyenebis gamocdileba sezonuri gripis profilaqtikis mizniT. H5N1 infeqciis profilaqtikisaTvis gamoiyeneba oseltamiviris igive dozebi, rac sezonuri gripisaTvis. es rekomendacia exeba orsul qalebsac eqspoziciis zomieri riskis jgufidan.

rekomendacia 3dabali riskis eqspoziciis jgufebSi oseltamiviri SesaZloa ar dainiSnos profilaqtikis mizniT (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 4 orsul qals eqspoziciis dabali riskis jgufidan ar unda daeniSnos oseltamiviri profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis SesaZlo gverdiT efeqtebsa da zians, rac man SeiZleba gamoiwvios orsulobis dros. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 5maRali riskis eqspoziciis jgufebSi zanamiviri unda dainiSnos profilaqtikis mizniT SesaZlo bolo eqspoziciidan 7-10 dRis ganmavlobaSi (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs maRali letalobiT mZimed mimdinare daavadebis profilaqtikas. is SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. qimioprofilaqtika unda iqnas dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-10 dRis manZilze. H5N1 infeqciis profilaqtikisaTvis gamoiyeneba zanamiviris igive dozebi, rac sezonuri gripisaTvis. zanamiviris bioSeRwevadoba respiratoruli traqtis gareT ufro naklebia, vidre oseltamivirisa. zanamiviri SesaZloa aqtiuri iyos oseltamiviris mimarT rezistentuli zogierTi Stamis mimarT. Sesabamisad is SesaZloa kargi arCevani iyos jandacvis muSakebis profilaqtikisaTvis im SemTxvevaSi, Tuki maT maRali riskis eqspozicia hqondaT oseltamiviriT namkurnaleb H5N1 pacientebTan. es rekomendacia exeba orsul qalebsac eqspoziciis maRali riskis jgufidan.

rekomendacia 6zomieri riskis eqspoziciis jgufebSi zanamiviri SesaZloa dainiSnos profilaqtikis mizniT SesaZlo bolo eqspoziciidan 7-10 dRis ganmavlobaSi (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

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SeniSva: es rekomendacia iTvaliswinebs maRali letalobiT mZimed mimdinare daavadebis profilaqtikas. is SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. qimioprofilaqtika unda iqnas dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-10 dRis manZilze. zanamiviris bioSeRwevadoba respiratoruli traqtis gareT ufro naklebia, vidre oseltamivirisa. zanamiviri SesaZloa aqtiuri iyos oseltamiviris mimarT rezistentuli zogierTi Stamis mimarT. es rekomendacia exeba orsul qalebsac eqspoziciis zomieri riskis jgufidan.

rekomendacia 7dabali riskis eqspoziciis jgufebSi zanamiviri SesaZloa ar dainiSnos profilaqtikis mizniT (janmos ara mkaci rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 8orsul qals eqspoziciis dabali riskis jgufidan ar unda daeniSnos zanamiviri profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis SesaZlo gverdiT efeqtebsa da zians, romelic man SeiZleba gamoiwvios orsulobis dros. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 9Tuki H5N1 virusi savaraudod/dadasturebulad aris rezistentuli amantadinis mimarT, amantadini ar unda dainiSnos profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis SesaZlo gverdiT efeqtebs, im SemTxvevaSi, rodesac preparatisagan ar veliT raime efeqturobas.

rekomendacia 10Tuki neiraminidazas inhibitori pacientisaTvis ar aris xelmisawvdomi da gansakuTrebiT Tuki virusi savaraudod/dadasturebulad mgrZnobiarea amantadinis mimarT, amantadini SesaZloa dainiSnos H5N1 infeqciis profilaqtikis mizniT maRali an zomieri riskis eqspoziciis jgufebSi (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia ar exeba orsul qalebs, asakovan adamianebs, adamianebs Tirkmlis funqciis moSliTa da neirofsiqiatriuli darRvevebiT an krunCxvebiT, maT, vinc iRebs neirofsiqiatriul preparatebs. rekomendacia iTvaliswinebs daavadebis mZime mimdinareobas

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da maRal l;etalobas. SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo Camoyalibebasa da preparatis fass. qimioprofilaqtika unda iqnas dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-10 dRis manZilze. amantadinis miReba SesaZloa gaxangrZlivdes 6 kviramde sezonuri A gripis SemTxvevaSi. es rekomendacia gamoiyeneba situaciebSi, rodesac neiraminidazas inhibitorebi pacientisaTvis ar aris xelmisawvdomi an Znelad xelmisawvdomia.

rekomendacia 11Tuki neiraminidazas inhibitori pacientisaTvis ar aris xelmisawvdomi im SemTxvevaSic ki, Tuki virusi savaraudod/dadasturebulad mgrZnobiarea amantadinis mimarT, amantadini SesaZloa ar dainiSnos H5N1 infeqciis profilaqtikis mizniT dabali riskis eqspoziciis jgufebSi (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 12orsulebSi, xandazmulebSi, pacientebSi Tirkmlis funqciis moSliT, neirofsiqiatriuli darRvevebiT/ krunCxvebiT an maTSi, vinc iRebs neirofsiqiatriul preparatebs amantadini ar unda dainiSnos H5N1 infeqciis profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 13Tuki H5N1 virusi savaraudod/dadasturebulad aris rezistentuli M2 inhibitorebis mimarT, rimantadini ar unda dainiSnos profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSva: es rekomendacia iTvaliswinebs preparatis SesaZlo gverdiT efeqtebs im SemTxvevaSi, rodesac preparatisagan ar veliT raime efeqturobas.

rekomendacia 14Tuki neiraminidazas inhibitori pacientisaTvis ar aris xelmisawvdomi da gansakuTrebiT Tuki virusi savaraudod/dadasturebulad mgrZnobiarea rimantadinis mimarT, rimantadini SesaZloa dainiSnos H5N1 infeqciis profilaqtikis mizniT maRali an zomieri riskis eqspoziciis

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jgufebSi (janmos ara mkacri rekomendacia , Zalian dabali xarisxis mtkicebuleba ).SeniSnva: es rekomendacia iTvaliswinebs daavadebis mZime mimdinareobas da maRal l;etalobas. SedarebiT nakleb mniSvnelobas aniWebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo Camoyalibebasa da preparatis fass. qimioprofilaqtika unda iqnas dawyebuli eqspoziciidan rac SeiZleba male da gagrZeldes uwyvetad 7-10 dRis manZilze. rimantadinis miReba SesaZloa gavaxangrZlivoT 7 kviramde sezonuri A gripis saprofilaqtikod. es rekomendacia ar exeba orsulebs.

rekomendacia 15Tuki neiraminidazas inhibitori pacientisaTvis ar aris xelmisawvdomi im SemTxvevaSic ki Tuki virusi savaraudod/dadasturebulad mgrZnobiarea rimantadinis mimarT, rimantadini SesaZloa ar dainiSnos H5N1 infeqciis profilaqtikis mizniT dabali riskis eqspoziciis jgufebSi (janmos ara mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba).SeniSnva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

rekomendacia 16orsulebSi, rimantadini ar unda dainiSnos H5N1 infeqciis profilaqtikis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba ).SeniSnva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, rezistentobis SesaZlo ganviTarebasa da preparatis Rirebulebas. is nakleb mniSvnelobas aniWebs H5N1 infeqciis dabali riskis Tavidan acilebas.

mkurnaloba antibaqteriuli saSualebebiT;gripi xSirad rTuldeba meoradi baqteriuli infeqciebiT,

gansakuTrebiT filtvebis mxriv. A(H5N1) infeqciis dros gamovlinebani qvemo respiratoruli traqtis mxriv viTardeba daavadebis sawyis etapebze. daavadebis dawyebidan saSualod me-5 dRes (1-16 dRe) TiTqmis yvela pacients aReniSneba klinikurad gamoxatuli pnevmonia. umravles SemTxvevaSi pnevmonias iwevs TviTon gripis virusi da ar eqvemdebareba antibiotikoTerapias.

saerTod gripis Semdgom ganviTarebuli baqteriuli pnevmoniis gamomwvevebia: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae (iSviaTad). arCevis antibiotiks am SemTxveaSi warmoadgens farTo

speqtris da antistafilokokuri aqtivobis antibiotikebi (β laqtamazisagan daculi penicilinebi, cefalosporinebi, ftorqinolonebi, makrolidebi, vankomicini da sxva). mkurnalobis xangrZlivoba ganisazRvreba cxelebis xangrZlivobiT - temperaturis normalizebidan kidev 5 dRis ganmavlobaSi, garda zogierTi gamonaklisi

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SemTxvevisa, magaliTad, stafilokokuri pnevmonia, roca mkurnaloba 21 dRemde SeiZleba gaxangrZlivdes..

rekomendacia 1A(H5N1) inficirebul pacientebSi mZime arahospitaluri pnevmoniis SemTxvevaSi klinicistebma unda gamoiyenon qveyanaSi moqmedi regularulad ganaxlebadi Sesabamisi gaidlainebi (janmos mkacri rekomendacia ).SeniSnva: antibiotikis SerCeva unda moxdes lokaluri paTogenebis SeswavliT, sxva Tanmxlebi daavadebebisa da rezistentobis profilis Sefasebis Semdeg.

rekomendacia 2savaraudo/dadasturebuli H5N1 infeqciis mqone pacientebSi, romlebic ar saWiroeben meqanikur ventilacias da ara aqvT antibiotikoTerapiis Catarebis sxva Cveneba, ar unda dainiSnos antibiotikebi baqteriuli garTulebebis profilaqtikis mizniT. (janmos mkacri rekomendacia).

SeniSnva: es rekomendacia mkacr xasiaTs atarebs nawilobriv imis gamo, rom dReisaTvis ar arsebobs mtkicebuleba profilaqtikis mizniT Catarebuli antibiotikoTerapiis efeqturobis Sesaxeb baqteriuli garTulebebis Tavidan acilebis TvalsazrisiT H5N1 infeqciis an sezonuri gripis dros. antibiotikebi savaraudod iwveven rezistentuli baqteriis gadarCevas superinfeqciis darTvis SemTxvevaSi.

rekomendacia 3savaraudo/dadasturebuli H5N1 infeqciis mqone pacientebSi, romlebic saWiroeben meqanikur ventilacias klinicistebma unda gamoiyenon qveyanaSi moqmedi regularulad ganaxlebadi Sesabamisi gaidlainebi ventilaciasTan asocirebuli an hospitaluri infeqciebis samkurnalod/saprofilaqtikod (janmos mkacri rekomendacia).

SeniSnva: vinaidan baqteriuli garTulebebis riski maRalia pacientebSi filtvebis xelovnuri ventilaciiT, es rekomendacia iTvaliswinebs dadasturebuli/savaraudo baqteriuli infeqciis Tamxlebi movlenebis Tavidan acilebas da nakleb mniSvnelobas aniWebs antibiotikebis gverdiT efeqtebs, rezistentobis SesaZlo Camoyalibebasa da preparatis fass. saWiroa dainiSnos Sesabamisi farTo speqtris antibiotiki klinikur an mikrobiologiuri monacemebze dayrdnobiT.

antipiretikebi;saWiroa Tavis arideba salicilatebis (rogoricaa, aspirini) xmarebisagan 18 wlamde asakis bavSvebSi reis sindromis ganviTarebis maRali riskis gamo. saWiroebisas gamoiyeneba paracetamoli an ibuprofeni.

damxmare Terapia (oqsigenoTerapia); saWiroa ganisazRvros Jangbadis saturacia. desaturaciisas ki Catardes oqsigenoTerapia. vinaidan nebulaizerebi da maRali nakadis Jangbadis

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niRbebi potenciurad respiratoruli infeqciis nozokomiuri gavrcelebis mizezia, saWiroa am mowyobilobebis gamoyeneba mxolod klinikurad aucilebel SemTxvevebSi epidkontrolis mkacri dacviT.

• imunomodulatorebiA(H5N1) gripis virusiT dainficirebul pacientebSi farTed gamoiyeneboda kortikosteroidebi, Tumca maTi efeqturoba gaurkvevelia. da isini gamoyenebul unda iqnas mxolod klinikuri kvlevis TvalsazrisiT, radgan A(H5N1) gripis virusis sawinaaRmdego imunuri pasuxi Semdgom kvlevas saWiroebs. interferon alfas gaaCnia antivirusuli da imunomodulaciuri Tvisebebi, magram Sesabamisi kvlevebis Catarebamde maTi rutinuli daniSnva ar aris rekomendirebuli.

• ribavirinis efeqturoba gripis virusebis sawinaaRmdegod ar aris dadasturebuli. ufro metic, anemiam, rac Tan axlavs am preparatis xmarebas, SesaZloa daamZimos pacientis mdgomareoba.

rekomendacia 1savaraudo/dadasturebuli H5N1 infeqciis mqone orsulebSi, ar unda dainiSnos ribavirini H5N1 infeqciis profilaqtikis an mkurnalobis mizniT (janmos mkacri rekomendacia, Zalian dabali xarisxis mtkicebuleba)

SeniSnva: es rekomendacia iTvaliswinebs preparatis gverdiT efeqtebs, da ribavirinis teratogenulobas orsulobis dros.

individualuri dacvis saSualebebis (ids) gamoyeneba.jandacis dawesebulebebSi A(H5N1) gripis infeqciis kontroli gulisxmobs:

• daavadebis profilaqtikas jandacvis muSakebSi,

• respiratoruli da xvelis higienis dacvas,

• standartuli, kontaqturi, haer-wveTovani infeqciebisaTvis usafrTxoebis wesebis dacvas

• daavadebuli mnaxvelebisa da samedicino personalis mkacr kontrols.

frinvelis A(H5N1 ) gripis dros ids-s iyenebs:

• pacientis uSualod momvleli yvela samedicino muSaki;

• damxmare personali (damlageblebi da sxva);

• laboratoriis yvela muSaki, romlebsac uxdebaT frinvelis A(H5N1) gripis mqone pacientis biologiur masalasTan muSaoba;

• sasterilizacio dawesebulebebis muSakebi, romlebsac uxdebaT frinvelis A(H5N1) gripis mqone pacientTan naxmari mowyobilobebis, instrumentebis, sagnebis damuSaveba.

• mnaxvelebi da ojaxis wevrebi

ids moicavs:

• arasteriluri xelTaTmanebi

• niRabi (maRalefeqturi niRabi – NIOSH-sertificirebuli N-95 respiratori an misi eqvivalenti)*

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• qirurgiuli xalaTi wyalgaumtari qsovilisagan grZeli saxeloebiT da daxuruli guliT.

• damcavi saTvale (an damcavi niRabi saxisaTvis)

• qudi (SesaZlebelia gamoyenebul iqnes situaciaSi, sadac maRalia respiratoruli aerozolis warmoqnis saSiSroeba)

• wyalgaumtari winsafari, iq sadac arsebobs sisxlis, qsovilovani siTxis, eqskretebisa da sekretebis gaSxefebis saSiSroeba.

* janmos mier rekomendirebulia samedicino niRbebis xmareba jandacvis muSakebisaTvis, romlebic 1 metris manZilze imyofebian A(H5N1) saeWvo an daavadebuli pacientebisagan. gamoyenebul unda iqnas qirurgiuli an proceduruli niRabi. proceduris gasamartiveblad mowodebulia aseTi niRbebis gamoyeneba im dawesebulebaSi SesvlisTanave, sadac imyofebian aseTi pacientebi.samedicino muSakis mier 95%-iani efeqturobis mqone respiratorebis gamoyeneba naCvenebia specialuri procedurebis Catarebis dros, rogoricaa endotraqeuli intubacia, siTxeebis amoqaCva, aerozoluri inhalacia, roca maRalia inficirebuli aerozoluri nawilakebis gamoyofis riski. Tuki samedicino personali erT izolirebul pacients emsaxureba, mis mier gamoyenebuli niRabi an respiratori unda ganadgurdes oTaxidan gamosvlisTanave, xolo Tuki eqimi ramodenime pacients emsaxureba erT SenobaSi, SesaZlebelia erTi niRbis/respioratoris gamoyeneba Senobidan gamosvlamde. gamosvlis Semdeg niRabi/respiratori unda ganadgurdes. pandemiis periodSi samedicino personali Zalian maRali riskis qveS iqneba inficirebis TvalsazrisiT. maT pacientTa nawilTan diagnozi laboratoriulad iqneba verificirebuli, nawilTan ki klinikuri niSnebis safuZvelze daismeba. aRniSnuli rekomendaciebi gamoyenebul unda iqnas orive SemTxvevaSi.

vinaidan adamianis gripis virusis gadacema xorcieldeba msxvili

respiratoruli nawilakebis (wveTebi zomiT > 5 µm), qirurgiuli niRbebis gamoyeneba savsebiT gamarTlebulia da rekomendirebulia yvela jandacvis muSakisaTvis, romlebic 1 metris manZilze imyofebian pacientebisagan. magram eqsperimentuli monacemebisa da klinikuri dakvirvebebis safuZvelze ar gamoiricxeba infeqciis gadacema wvrili aerozoluri nawilakebis (wveTovani birTvebi) meSveobiT 1 metrze met manZilze. amis gaTvaliswinebiT respiratorebi uzrunvelyofen samedicino personalis damatebiT dacvas aerozoluri nawilakebis warmoqmnis meti albaTobis pirobebSi. janmo ganacxadebs, rom rigi qveynebisa moiTxovs respiratorebis gamoyenebas, xolo danarCeni ki qirurgiuli niRbebis gamoyenebas pacientebTan samedicino personalis muSaobisas.

ids moxsna Semdegi TanamimdevrobiT sruldeba:

• gaixadeT xalaTi da CaagdeT sanagveSi;

• gaixadeT xelTaTmanebi (ukuRma gadmotrialebiT) da gadaagdeT;

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• gamoiyeneT alkoholis Semcveli xelebis sawmendi an daibaneT xelebi;

• moixadeT qudi da saxis niRabi an saTvale da gadaagdeT an CadeT dekontaminaciisaTvis gankuTvnil konteinerSi;

• moixseniT niRabi ise, rom SeexoT ara TviTon niRabs, aramed dasamagrebel rezins an Tasmas;

• gamoiyeneT alkoholis Semcveli xelebis sawmendi an daibaneT xelebi;

• datoveT oTaxi;

• oTaxis gareT isev gamoiyeneT alkoholis Semcveli xelebis sawmendi an daibaneT xelebi;

• xelebi daibaneT Cveulebrivi sapniT, antimikrobuli saSualebiT an uwylo antiseptikiT.

8. reabilitacia/meTvalyureoba

gamojanmrTelebuli pacienti raime specialur sareabilitacio RonisZiebebs an meTvalyureobas ar saWiroebs.

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raime garTulebebis gamovlenis SemTxvevaSi pacients Caurtardeba Sesabamisi mkurnaloba gamovlenaTa xasiaTisa da simZimis gaTvaliswinebiT pirveladi jandacvis rgolis eqimis gadawyvetilebiT.

saavadmyofodan gaweris Semdeg, im SemTxvevaSi, Tuki pacienti jer kidev infeqciis wyaros warmoadgens, ojaxis wevrebs unda Cautardes specialuri swavleba piradi higienis da infeqciis kontrolis RomisZiebebis Sesrulebis Sesaxeb (mag. xelebis dabana an qirurgiuli an proceduruli niRabis gamoyeneba pacientis mier Tu is isev axvelebs da a.S). dReisaTvis miRebulia, rom gripis dros pacienti infeqciis wyaros warmoadgens Semdegi drois ganmavlobaSi: 12 welze meti asakis pirebi cxelebis CaTavebidan kidev 7 dRis ganmavlobaSi, 12 wlamde pacientebi cxelebis CaTavebidan 21 dRis ganmavlobaSi.

9. eTikur-samarTlebrivi rekomendaciebi

dRes neiraminidazas inhibitori preparatebis mniSvnelovani problemaa maTi SezRuduli moculobiT warmoeba msoflioSi da maRali fasi. miuxedavad imisa, rom bolo periodis ganmavlobaSi preparatis warmoeba oTxjer gaizarda, dRevandeli SesaZleblobebis farglebSi aTwleulebia saWiro, raTa oseltamiviriT dakmayofildes msoflio populaciis 20%.

janmos-s mier gamoyofil iqna Tanxebi, raTa 2006 wlis dasawyisisaTvis uzrunvelyofil iqnas antivirusuli preparatebis (oseltramiviris) 3 milioni mkurnalobis kursisaTvis saWiro maragi. maTematikuri gaTvlebis mixedviT preparatebi SesaZloa gamoyenebul iqnas profilaqtikuri miznebisaTvis mxolod pandemiis dasawyis stadiebze, raTa SeizRudos virusis mier adamianidan adamianze transmisiis unaris srulad SeZena, pandemiis Semdgomi gavrceleba da mogebul iqnas dro vaqcinis warmoebisaTvis. yoveli aseTi damatebiTi dRe damatebiT 5 milioni doza vaqcinis warmoebis saSualebas iZleva.

dReisaTvis antivirusuli preparatebi avadmyofebis samkurnalod da maTTan axlo kontaqtSi myofi samedicino personalisa da ojaxis wevrebis saprofilaqtikod gamoiyeneba. virusis adamianidan adamianze gadacemis gaadvilebis pirobebSi antivirusuli preparatebis daeniSneba adamianTa ufro did jgufebs, romelTa Soris aRmoCndeba daavadebis SemTxvevebi.

am wamlebma ar SeiZleba gaswion vaqcinis movaleoba maSinac ki, Tuki qveyanas amis SesaZlebloba gaaCnia. profilaqtikuri mizniT oseltamiviris masiuri gamoyeneba janmrTel adamianebSi ar aris rekomendirebuli, vinaidan is gamoiwvevs preparatis mimarT rezistentobas.

savaraudod qveynebSi arsebuli preparatis maragi ar aRmoCndeba sakmarisi moTxovnilebis srulad dasakmayofileblad. qveynebis mier arCeul unda iqnas prioritetuli jgufebi preparatis dasaniSnad samedicino dawesebulebis TanamSromlebisaTvis da konsultantebisaTvis eqspoziciis maRali riskiT an iseTi pirebisaTvis, romlebsac aReniSnebaT qronikuli daavadebebi (kardialuri, respiratoruli, da

43

sxva), bavSvebisa da mozardebisaTvis (Tumca dReisaTvis SeuZlebelia daavadebis mimdinarebis simZimis gaTvla asakobriv jgufebze). DdReisaTvis A(H5N1) gripis yvelaze mZime mimdinareobas adgili aqvs axalgazrda adamianebSi.

prioritetuli jgufebis SerCeva aseve aucilebeli gaxdeba pandemiis dasawyisSi, rodesac Seiqmneba pandemiuri vaqcinis deficiti. prioritetuli jgufebi oseltamivirisa da vaqcinis misaRebad Semdegnairad SeiZleba ganawildes:

prioritetuli jgufi 1jandacvis muSakebi, romelTac kontaqti aqvT pacientebTan mizani: jandacvis sistemis Seuferxeblad muSaoba;

prioritetuli jgufi 2aucilebeli momsaxureobis uzrunvelmyofi samsaxurebis TanamSromlebi, rogoricaa: policia, saxanZro, dacva, komunikaciebis uzrunvelyofa, SeiaraRebuli Tavdacva, damkrZalavi biuro.mizani: qveynis sasicocxlod aucilebeli funqciebis SenarCuneba;

prioritetuli jgufi 3garTulebebis maRali riskis mqone pirebi _ qronikuli respiratoruli an kardiologiuri daavadebis, Tirkmlis ukmarisobis, Saqriani diabetis, imunosupresiis mqoneni daavadebis an mkurnalobis Sedegad, orsulebi mesame trimestrSi, moxucebulTa saxlis personali;mizani: jandacvis momsaxurebaze moTxovnilebis minimumamde dayvana;

prioritetuli jgufi 465 welze meti asakis pirebi;mizani: jandacvis momsaxurebaze moTxovnilebis minimumamde dayvana;

prioritetuli jgufi 5calkeuli sawarmoebi;mizani: aucilebeli momaragebis uzrunvelyofa, magaliTad farmaciaSi; ekonomikuri zaralis dayvana minimumamde;

prioritetuli jgufi 6calkeuli asakobrivi jgufebi, magaliTad, bavSvebi;mizani: daavadebis gavrcelebis Semcireba mosaxleobaSi; populaciis maRali riskis mqone jgufebze zegavlenis moxdena;

prioritetuli jgufi 7mTeli mosaxleoba;mizani: daavadebis gavrcelebisa da zegavlenis minimumamde dayvana saqarTveloSi;

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10. praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi

mocemuli gaidlainis praqtikaSi adaptaciisaTvis aucilebelia samedicino personals Cautardes specialuri swavleba H5N1 infeqciis savaraudo SemTxvevis diagnostirebis da Semdgom misi marTvis Taobaze. gansakuTrebuli yuradReba unda mieqces individualuri dacvis saSualebebis xmarebis wesebis Seswavlas daavadebis saavadmyofosSida kontrolisaTvis. aRniSnuli swavleba unda Catardes periodulad. periodulobis sixSire unda ganisazRvros H5N1 gripis pandemiuri fazis Sesabamisad.

protokolebis SemuSaveba unda moxdes janmrTelobis msoflio organizaciis rekomendaciebisa da qveynis lokaluri resursebis gaTvaliswinebiT. misi ganaxleba ki moxdes H5N1 gripis pandemiuri fazis cvlis Sesabamisad.

11. gaidlainebis gadasinjvis da ganaxlebis vada

msoflio dReisaTvis imyofeba mosalodneli pandemiis safrTxis periodSi – me-3 fazaSi, rodesac adamianidan adamianze virusis gadacema ar xdeba an Zalian iSviaTad registrirdeba maT Soris axlo kontaqtebis dros. sasurvelia gaidlaini gadaisinjos da Seivsos axali informaciiT mocemuli infeqciis Sesaxeb 2 weliwadSi erTxel an msoflioSi frinvelis gripis pandemiis fazis SecvlasTan dakavSirebiT janmo-s mier SemuSavebuli pandemiuri gripisaTvis mzadyofnis gegmis mixedviT.

12. gaidlainis miRebis xerxi/wyaro

gaidlaini miRebulia janmrTelobis msoflio organizaciis gaidlainebsa da saqarTvelos frinvelis gripis pandemiisaTvis mzadyofnis erovnul gegmaze dafuZnebiT. gaidlainSi gamoyenebuli literatura, romelic Seicavs informacias gripis A(H5N1) Sesaxeb, Seesabameba mtkicebulebis siZlieris done (Muir Gray) III, IV, rekomendaciis xarisxs (Cook et al) C da D.

13. alternatiuli gaidlaini amJamad ar arsebobs

14. gamoyenebuli literatura

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http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_7


http://www.who.int/entity/csr/disease/avian_influenza/guidelines/humanspecimens/en/index.html

http://www.who.int/entity/csr/disease/avian_influenza/guidelines/humanspecimens/en/index.html


http://www.who.int/entity/csr/disease/avian_influenza/guidelines/rapid_testing/en/index.html


http://www.who.int/entity/csr/disease/avian_influenza/guidelines/WERAvianinfluenza/en/index.html

http://www.who.int/entity/csr/disease/avian_influenza/guidelines/WERAvianinfluenza/en/index.html


http://www.who.int/entity/csr/disease/avian_influenza/guidelines/referencelabs/en/index.html

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23. WHO Disease classification and coding systems DIMDI- ICD-10 WHO - 2006 mtkicebulebis siZlieris done (Muir Gray) I, rekomendaciis xarisxs (Cook et al) A24. Welliver R, Monto AS, Carewicz O, et al. Effectiveness of oseltamivir in preventing influenza in household contacts: a randomized controlled trial. JAMA 2001;285:748-754 mtkicebulebis siZlieris done (Muir Gray) I, rekomendaciis xarisxs (Cook et al) A25. Harrison’s Manual of Medicine 15 th edition, Eugene Braunwald, Anthony S. fauci, Dennis L. Kasper, Stephen L. Hauser, dan L. Longo, J. Larry Jameson).

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frinvelis gripi a(h5n1) - medportal.gefrinvelis maralpatogenuri gripis virusi - gripis virusi,...

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