WHO Expert Research Articles

CLINICAL CASE OF SILENT UTERINE PERFORATION AFTER INNECTORAL CONTRACEPTIVES PLACEMENT IN ANAMNESIS

The most dangerous complication when using intrauterine contraceptives is the perforation of the uterus. According to the WHO expert group, uterine perforation in contraceptive carriers is associated with significant frequency fluctuations (one case per 1509,000 placements). The frequency of perforations depends on the type of contraceptive, the material from which it is made, as well as on the anatomical features of the uterus (retroflexion of the uterus, scar narrowing and deformation of the cervical canal, deformation of the external cervical os after diathermocoagulation of the cervix, etc.).Uterine perforation usually occurs in three places: at the bottom of the uterus, in the corner between the cervix and its body and at the wall of the cervix (WHO data, 2005).A clinical case of "silent uterine perforation" has been published to avoid or reduce the incidence of complications with the placement and use of intrauterine contraceptives. The article presents a clinical case of detected uterine perforation with uterine contraceptive, which has been asymptomatic for 10 years and has been diagnosed as an accidental finding during surgery for large size uterine fibroids. The anamnesis data, description of the clinical picture and features of the course of surgery are given; ways of prevention of this complication are discussed. Analyzing the clinical case, the authors concluded that in order to prevent the above complications, it is necessary to verify the localization of the intrauterine contraceptivewith the ultrasound after its placement. In case of difficulty in removing the intrauterine contraceptive, this procedure may be performed under the control of a hysteroscope.

Expansion of the 1st WHO international standard for antiserum to respiratory syncytial virus to include neutralisation titres against RSV subtype B: An international collaborative study

An International Standard to harmonise results from RSV subtype A neutralisation assays was generated and established by the World Health Organization in 2018. Here we report on a study to expand the use of that standard to include neutralisation assays using human sera against RSV subtype B and to test its ability to harmonise neutralisation titres from neutralisation assays including complement.The study included 11 laboratories from 6 countries. All participants used their own in-house virus neutralisation assay and their own virus stocks. The study samples comprised the current International Standard (16/284) and its potential replacement (16/322), individual sera from naturally infected humans, a monoclonal antibody to RSV (palivizumab) and samples from the BEI Resources panel of human antiserum and immune globulin to RSV. Of the 11 laboratories that took part in the study, 5 returned data from neutralisation assays with and without the inclusion of serum complement.The study showed that inter-laboratory variability in neutralisation titres was significantly reduced when values were expressed relative to 16/284 or 16/322. Complement did not affect the ability of the International Standard to decrease inter-laboratory variability as the standard was able to reduce the differences between titres from assays with and without complement. Based on these results, we will recommend to the WHO Expert Committee on Biological Standardisation (ECBS) that 16/284 and 16/322 be expanded in their use to include neutralisation assays against RSV/B.

Workshop: EUPHA and Europe-wide action on digital public health

Abstract The World Health Assembly Resolution on Digital Health unanimously approved by WHO Member States in May 2018 demonstrated a collective recognition of the value of digital technologies to contribute to advancing universal health coverage (UHC) and other health aims of the Sustainable Development Goals (SDGs). The World Health Organization has just released first ever guideline on digital interventions for health system strengthening. Et the European level, in June 2018 the WHO Regional Office for Europe launched the WHO/Europe initiative for Digitalization of Health Systems and in February 2019 organized the first Symposium on the Future of Digital Health Systems in the European Region. The European Commission in April 2018 published a Communication on Digital transformation of health and care in the digital single market and requested the Expert Panel on effective ways of investing in health (EXPH) to release an evidence-based opinion on how to assess the impact of digital transformation of health services. In such context, the European Public Health Association (EUPHA) has at an early stage acknowledged and understood the crucial importance of applying the potential offered by digitalization to public health. Not only its most prominent members work and research as WHO and EC experts on how to plan, implement and evaluate effective digital public health interventions, but EUPHA itself - as umbrella organization representing public health associations and institutes across Europe had: i) actively participated to the WHO Euro Symposium successfully co-organizing a session on the ‘beautiful marriage’ between digitalization and public health, ii) supported the publication of a EJPH supplement on digital health and iii) has planned to create a EUPHA Section on Digital Health. With the overall goal of positioning the proposed EUPHA Section on Digital Health in the enriching and constructive context of the European Public Health Conference the workshop specifically aims to: present a comprehensive conceptual framework for the application of digital technologies to public health in Europe;present and report on EUPHA collaborative action on digital health, aligned with European institutions;present the structure and content of the EJPH supplement on digital health;present the general aim, specific objectives, scope, mission and preliminary outputs of the proposed EUPHA Section on Digital Health, as well as its synergy with other EUPHA’s Section workPresent the results of two/three specific projects on digital public health to serve as concrete examples of the application of digital solutions to public healthEngage with the audience to promote the active participation of the broader EUPHA community to the activities of the Section, collect interests and best practices, and share ideas and projects worth scaling up at the Section-level. Key messages The ‘beautiful marriage’ between digitalization and public health has to be concretely planned, implemented and evaluated. EUPHA action on digital public health can be further strengthened through the collaborative action and work of its dedicated Section.

The Relevance of the Methodology Hospital Safety Index to Ensure Work Health Care Facilities in Emergencies

The objective: to analyze the existing methods for ensuring the safety of hospitals in the event of natural and man-made disasters, as well as the current regulatory framework for the safety and functioning of the healthcare facility during emergencies in Ukraine.Materials and methods. The study is based on the analysis of data from scientific and specialized sources of information regarding the state of hospital safety, including The Center for the Study of Natural Disaster Epidemiology at the Catholic University of Leuven (Belgium), the International Disaster Database (EMDAT), and official WHO expert reports. Research methods were: bibliographic, synthetic, formal logic. A logical analysis of the data was conducted, summarizing the results, identifying the main causative factors of the deficiencies and the risk creating factors using complex data analys is and computer technologies.Results. WHO-recommended Worldwide Hospital Safety Index methodology, developed to implement a new approach to preventing and reducing the health effects of natural disasters, helps local authorities determine which agencies need to take appropriate action first to reduce vulnerability. Priority should be given to an institution where the safety of patients and staff is at highest risk during a disaster, or to an institution, where there is a risk of equipment damage or where measures are needed to maintain performance. It is established that the activities of any healthcare facilities ofUkraine are evaluated by three standards – management of the institution (including services and personnel), finances and material resources, as well as medical activity. According to the current legislation ofUkraine, the regulations governing the activities of the POPs do not provide for the assessment of the safety of carrying out the medical-diagnostic process in these institutions when providing medical assistance to patients and victims in the event of emergency situations. It is revealed that in our country the criteria and methods of assessment of hospitals’ safety are not fully adapted to the actual health care system, while at the same time there is no description and characterization of risks and factors that adversely affect the state of organization of medical-diagnostic process in the process of providing medical care to the victims in emergency situations that significantly reduce the capacity of healthcare facilities to function properly.Conclusions. Ensuring that hospitals operate in emergencies require the development and implementation of adequate response measures, taking into account the existing risks of technical and functional factors. The worldwide methodology for determining the Hospital Safety Index is an effective tool for assessing the safety and vulnerability of hospitals, adopting low-cost, high-efficiency measures to improve safety and emergency preparedness. It is appropriate to apply this methodology in Ukraine, taking into account the world experience in its use, but it requires adaptation to the realities of the national health care system and improvement of the existing legal acts.

Application of the concept of the hospital safety index taking into account clinical risks in assessing the level of hospital safety in Ukraine

The aim of the study. Provision the increasing hospitals safety in Ukraine by identifying and assessing the risk creating factors, organizational, structural, functional readiness of institutions ability to function effectively in providing medical assistance to victims in emergency situations (ЕS).Materials and methods of research. The research is based on the analysis of official WHO expert reports, information from special and scientific sources, namely: International Disaster Database (EM-DAT), Center for Natural Disaster Epidemiology Studies at the Catholic University of Leuven (Belgium), safety assessment reports Kiev City Clinical Hospital Emergency Medical Services (KCCHEMS) in 2012 and 2017.The research methods were: formal logic methods, bibliographic, experts review and evaluation, risk management and full-scale modelling. For the first time the adapted classification of HSI has been applied, taking into account the values of clinical risk, which is based on a methodology for identifying risks as an element of crisis management.Research results. The overall safety of KCCHEMS , assessed by the existing classification of HSI in both 2012 and 2017, is at a high level (A), meaning that further activities - work on the plan, the hospital will function during the ES. When applying our proposed clinical risk classification, we have significantly different results: in 2012, a C (critical risk) score, meaning that the hospital needs immediate action to increase its capacity to respond to emergencies, there is a high likelihood of termination functioning of the hospital under such conditions; in 2017 - at level B (significant risk): correction of the proposed measures is required, there is a likelihood of termination of hospital operation in the event of ES. Thus, the incomplete result of improving the safety of the KCCHEMS from the implementation of the recommended measures in 2012, which was established during the re-evaluation of this hospital in 2017, may be due not only to the incomplete implementation of these measures, but also to their speed of implementation and depth, which also proves the need for a correction of the 2017 Hospital Action Plan to improve hospital safety.Conclusions. Methodology of determining the Hospitality Safety Index, recommended by WHO, is appropriate to apply in Ukraine, increasing its effectiveness is possible with the application of the adapted classification the HSI levels, taking into account clinical risks

The World Health Organization's Essential Diagnostics List: Diagnostics for neurologic disorders.

On the recommendation of the WHO Expert Committee on the Selection and Use of Essential Medicines in 2017, the inaugural WHO Essential Diagnostics List (EDL) was published by the WHO's Strategic Advisory Group of Experts on In-Vitro Diagnostics in May 2018.1 The EDL seeks to improve global treatment by providing “a catalogue of tests needed to diagnose both the most common conditions worldwide and diseases of global importance in both primary care and advanced settings.”1,2 This first iteration of the EDL includes diagnostic tests enabling the use of medications on the WHO Essential Medicines List (EML), which has guided international policies and funding decisions for the last 4 decades.3 Yet there is little representation of neurologic treatments on the EML, including a lack of medications for dementia, multiple sclerosis, neuropathic pain, and movement disorders, as well as commonly used medications for migraine such as triptans (table).4

Fine-Needle Aspiration Biopsy of Neuroendocrine Neoplasms in the Liver: A 9-Year Retrospective, Single Institutional Study

Abstract Objectives Neuroendocrine neoplasms (NENs) are divided into two major categories according to the 2018 WHO expert consensus proposal: well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinoma (NECs). Primary liver NENs are very rare and majority of NENs in the liver are metastatic. In this study, we retrospectively reviewed NENs in the liver diagnosed by fine-needle aspiration biopsy (FNAB). Methods We retrospectively reviewed malignant neoplasms diagnosed by imaging-guided liver FNAB performed between 2010 and 2018 in our institution. Patients’ electronic medical records and selective slides were reviewed. Results A total of 624 liver FNAB cases with a diagnosis of positive for malignancy were identified. Among those cases, 56 cases (9%) were NENs. Poorly differentiated NECs constituted 71% (40/56) of cases, and well-differentiated NETs constituted 29% (16/56) of cases. The most common primary sites of poorly differentiated NECs were lung (35%, 13/40), followed by pancreas (20%, 8/40), GI tract (17.5%, 7/40), GU (7.5%, 3/40), breast (5%, 2/40), head and neck (2.5%, 1/40), GYN tract (2.5%, 1/40), and CNS (dedifferentiated glioblastoma, 2.5%, 1/40). The remaining three cases (7.5%, 3/40) were diagnosed as primary liver NECs based on the clinical presentation. All three patients presented with a single large liver mass with no other mass lesions identified in other organ systems. For well-differentiated NETs, majority were from the GI tract (81.3%, 13/16), followed by pancreas (6.25%, 1/16) and lung (6.25%, 1/16). One patient was diagnosed with metastatic NET of unknown primary. Conclusion NENs in liver are predominantly metastatic, and majority of them are high-grade NECs. Most of well-differentiated NETs are metastases from the GI tract, while more than one-third of poorly differentiated NECs are metastases from the lung. Primary liver NENs also occur and all three cases in this study are poorly differentiated NECs.

Normal Body Mass Index and Heart Rate Variability

The autonomic nervous system (ANS) works in synergy with the Endocrine system that affects the body-mass and height and in turn the body mass index (BMI). The ANS activities are often assessed with one index that is heart rate variability (HRV). Reduced HRV has been reported in underweight (low BMI) and overweight (high BMI) individuals, but there is scarce information available on the relationship between normal BMI and HRV. Further, as per WHO expert consultation report, the Asian population has higher percentage of body fat than their European counterparts, therefore Asian people may have greater risk factors for type 2 diabetes and cardiovascular disease even below the existing upper edge of normal BMI. Thus it was recommended by WHO to consider the intermediate cutoff points within the normal BMI range as 18.5 Kg/m2, 20 Kg/m2, 23 Kg/m2, and 25 Kg/m2 for the Asian population. Therefore, the present study was aimed to investigate ANS activity among intermediate cutoff points of normal BMI using HRV. Seventy young individuals participated in the non-invasive and benign study. Subjects were divided into three groups based on their BMI as per the recommendation of the WHO report; NB1 (18.5<BMI≤20), NB2 (20<BMI<23) and NB3 (23<BMI<25). For all the subjects, 10 min of electrocardiogram was recorded and short term HRV analysis was carried out. Student t test was carried out to find the significance of study parameters in BMI groups. The BMI was correlated with HRV measures using Spearman’s correlation method. Statistically significant negative correlation was found between BMI and various HRV parameters. The sympathovagal balance was comparable in NB1 and NB2 group whereas it shifted towards sympathetic dominance in NB3 group. Higher sympathetic activity for BMI greater than 23 in Indian youth may lead to predictability of risks associated with overweight and obesity

Quality health care in extreme adversity-an action framework.

There are record-setting numbers of people living in settings of extreme adversity and they continue to increase each year. There is a paucity of validated data on quality and safety across settings of extreme adversity. This paper argues for an action framework to address the unique challenges of providing quality in extreme adversity. We describe a preliminary Quality in Extreme Adversity framework which has been informed by-and will continue to be validated through-literature, data collection, WHO expert consultations and through working in settings of extreme adversity with national authorities and NGOs. Poor quality care costs lives, livelihoods and trust in health services. The recommended framework, based on evidence and experiential lessons, intends to address the WHO goal for 2019-2023 of 'one billion people better protected from health emergencies' (9).

Continued provision of WHO International Standards for total and free PSA: Content and commutability of replacement preparations

ObjectivesReplacements are required for the WHO International Standards (IS) for free PSA, coded 96/668 and total PSA (90:10), coded 96/670, which were established in 1999 to support efforts to harmonise PSA assays and address non-equimolarity. An important consideration is that the introduction of the replacements should have minimal impact on PSA measurements. Design and methodsWe report the development of a replacement strategy, informed by field assessment of preparations through an external quality assessment scheme and the subsequent evaluation of the candidate ISs in worldwide collaborative studies. ResultsBy immunoassay, data from participants confirmed the value assigned to the current standards. Robust geometric mean estimates of the free PSA content of the candidate replacement for 96/668 coded 17/102 was 0.533 μg/ampoule (n = 21). The ratio of the content estimates of 17/102:96/668 was 0.516 (GCV 12.5%, n = 21). Robust geometric mean estimates of the total PSA content of the candidate replacement for 96/670, coded 17/100, was 0.505 μg/ampoule (n = 22). The ratio of the content estimates of 17/100:96/670 was 0.490 (GCV 5.3%, n = 22). Through concomitant measurement of a panel of 15 representative patient samples, the candidate ISs were shown to exhibit commutability with patient samples that was comparable with that of the current ISs. ConclusionOn the basis of these results, the preparations coded 17/102 and 17/100 were established by the WHO Expert Committee on Biological Standardization as the 2nd ISs for free and total PSA (PSA-ACT+free PSA) respectively, with assigned contents of 0.53 μg/ampoule and 0.50 μg/ampoule.

Is waist-to-height ratio better than body mass index as a predictive indicator of coronary atherosclerosis disease? A cohort study

Being overweight and obese are strongly associated with cardiovascular disease. 1 Snijder M.B. van Dam R.M. Visser M. Seidell J.C. What aspects of body fat are particularly hazardous and how do we measure them?. Int J Epidemiol. 2006; 35: 83-92 Crossref PubMed Scopus (398) Google Scholar Several different anthropometrical measurements are used in the clinical setting to predict disease risk in relation to overweight and obesity. Body mass index (BMI) is well known and frequently used, both in clinical practice and in the health and fitness industry. 2 WHO Expert Consultation Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004; 363: 157-163 Abstract Full Text Full Text PDF PubMed Scopus (7948) Google Scholar However, BMI is a measure of general adiposity which does not distinguish between central and general obesity. Prospective epidemiological studies have revealed that central obesity was more relevant to CAD risk compared to general obesity. 3 Pischon T. Boeing H. Hoffmann K. et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008; 359: 2105-2120 Crossref PubMed Scopus (1526) Google Scholar Waist-to-height ratio (WHR) was suggested in the mid-1990s as an anthropometric measurement that may improve on BMI because it was used commonly to evaluate central obesity. 4 Browning L.M. Hsieh S.D. Ashwell M. A systematic review of waist-to-height ratio as a screening tool for the prediction of cardiovascular disease and diabetes: 0.5 could be a suitable global boundary value. Nutr Res Rev. 2010; 23: 247-269 Crossref PubMed Scopus (842) Google Scholar However, there was little data available about whether WHR was better than BMI as a predictive indicator of coronary artery disease (CAD) in large cohort.

Editorial introductions

Editorial introductions

Development of an Approach to the Assessment of Changes to Approved Biological Products

The need to strengthen the post-approval regulation of biological products stems from their increasing role in the treatment of serious human diseases. Until recently, there were open questions on the classification of changes and supporting data necessary to confirm the comparability of a biological medicinal product before and after any changes, as well as on the procedures and deadlines for the submission and approval of variations. In October 2017 the WHO Expert Committee on Biological Standardisation developed and published the «Guidelines on procedures and data requirements for changes to approved biotherapeutic products». The WHO recommendations are primarily aimed at resolving the complexities and current problems in the global life cycle management of biotherapeutic products. Guidelines suggest approaches that ensure continued quality, efficacy, and safety of this group of products, as well as continuity in supply and access. The purpose of this paper was to analyse the WHO recommendations on post-approval changes to biotherapeutic products in order to develop harmonised approaches to the assessment of post-approval changes to biological medicinal products in the Russian Federation. The categories of quality changes, supporting data, conditions to be fulfilled, procedures and deadlines set forth in this paper can serve as a basis for further improvement of the national regulatory and methodological framework.

The development and establishment of the 1st WHO BKV International Standard for nucleic acid based techniques

Immunocompromised patients are at significant risk from BKV reactivation, causing allograft dysfunction or loss. Patient management relies on viral DNA monitoring, using a viral load cut-off to reduce immunosuppression. However, consistency between viral load detection assays cannot be achieved without an effective means of standardisation.We have worked with the WHO's Expert Committee on Biological Standardisation to develop suitable reference materials and undertake an international collaborative study to establish the 1st WHO International Standard for BKV detection assays.We report on the evaluation of two lyophilised candidate cell culture derived, whole virus preparations, undertaken by 33 expert laboratories. By employing the principles of biological standardisation, we show improved agreement across laboratories, demonstrating the suitability of either candidate for use as a primary order calibrant. Candidate 14/212 was established by the WHO ECBS with an assigned potency of 7.2 log10 International Units/mL intended for the calibration of BKV secondary reference materials.

Соціальні програми в контексті державної підтримки паліативної медицини в країнах Європейського Союзу (на прикладі Великобританії).

The paper devoted to the issue of establishment and development of palliative care institute in Ukraine and abroad, as well as the role of the World Health Organization in solving the problems. The urgency of this problem is justified by the fact that the current Ukrainian society requires significant changes in this direction. Indeed, various domestic and international experts assessed the problem as unsatisfactory due to the low level of social care for the elderly and those who are incapable of self-care or are on the verge of life and death, namely the category of people in need of palliative care and hospice care. Social policy should be based on the development of effective mechanisms of public administration of palliative and hospice care, with the borrowing of the best practices of foreign experience. The systematic development of this issue, highly relevant for Ukrainian society, may be based on: WHO recommendations, international standards and the experience of the most developed countries in this area (especially the European Union countries). Palliative care is a relatively new component of modern medicine but has recently been recognized as one of the essential components of the health care system. The need for this type of care is constantly growing. According to WHO experts, 40 million people in the world annually need the care recent years. Almost 80% of those people live in low- and middle-income countries. The paper presents contemporary foreign experience of applying the organizational mechanism of state management of palliative and hospice care. The results of the study give reason to argue that different organizational mechanisms of public administration of palliative and hospice care, forms and approaches to providing such assistance are used in the world. It was noted that the best state of palliative and hospice care was observed in the United Kingdom.

Prevalence of main dental diseases in children who live in conditions of biogeochemical fluorine and iodine deficiency

Dental status is one of the main indicators of overall health. We examined it in children aged 6-15 years who live in conditions of biogeochemical fluorine and iodine deficiency (Transcarpathian region, Ukraine), to improve the quality of dental care. In this cross sectional study To assess the state of teeth, we used indicators recommended by the WHO Expert Committee. The prevalence and intensity of dental caries, periodontal status, oral hygiene status and dentoalveolar anomalies were determined using a questionnaire and descriptive analyses was done (P < 0.05). The total prevalence of caries in deciduous teeth in children was 57.86% ± 1.56%, with intensity of 2.61 ± 0.6. The total prevalence of caries in permanent teeth was 71.45% ± 1.31%, with intensity of 2.36 ± 0.52. Analysis of the results showed a high prevalence of periodontal disease, which increases with age. The level of oral hygiene was evaluated as unsatisfactory. Studying the prevalence of dentoalveolar anomalies showed the lowest prevalence (40.05% ± 2.56%) at the age of 6 years and the maximum value at 12 years (77.20% ± 2.75%). In addition, we found poor hygienic knowledge of the parents, lack of medical activity of parents to preserve dental health of the child, lack of dentists' work on hygiene education, and public health education for prevention of dental diseases. On the other hand, a high level of confidence was revealed in the information received from dentists. The high prevalence of leading dental diseases requires modernization of the existing prevention programs for children.

The Advanced Development Pathway of the RTS,S/AS01 Vaccine.

Following successful phase 1 and 2 trials, RTS,S/AS01 was evaluated in a large phase 3 trial in 7 African countries in which 8922 young children and 6537 infants were enrolled and followed for a median of 48 and 38months, respectively. The vaccine efficacy against uncomplicated malaria in children was 28% without booster and 36% with booster. The vaccine received the approval of the European Medical Agency in 2015, but two WHO expert committees requested more data before the programmatic use of RTS,S/AS01 in African children can be recommended. To provide such data, a very large, cluster randomized trial is currently in progress in three African countries. The integration of RTS,S/AS01 in national childhood vaccination programs will benefit the individual vaccinated child but is unlikely to make an impact on malaria transmission. Mass vaccination campaigns that include all age groups over short periods are more likely to harness the short but high protection afforded by RTS,S/AS01.

Pattern of referral before and after referral intervention among primary health centers in North-Western Nigeria

Introduction: The revised Nigerian National Health Policy and the WHO Expert Committee on the Role of Hospitals as the First Referral Level both recognize primary health care (PHC) as the entry point in the referral system. This study was carried out to assess the effect of training of PHC workers on referral and instituting referral focal person among PHCs on key referral indicators in Zaria and Giwa local government areas, North-Western Nigeria. Methodology: The study was a quasi-experimental study with pre- and postinterventional components carried out among seventy participants in the intervention and 62 participants in the control groups who were selected through a multistaged sampling technique. Data were collected using a structured self-administered questionnaire containing close-ended questions. Data were analyzed with SPSS software version 20.0. Results: Preintervention, majority of the respondents (74.3%) in the intervention and (67.7%) control groups had not received training on referral process. Postintervention, increase was noted in mean referral rate from 0.18 ± 0.28 to 0.52 ± 0.34, which was statistically significant, and mean counter referral rate from 0 ± 0 to 40.34 ± 45.53 in the study group, but there was no statistically significant change in the control group. Conclusion: Postintervention, significant increases were noticed in two of the practice indicators; referral rate and counter-referral rate in the study group only. The other practice indicators did not record a significant increase.

Новая концепция рационального применения антибиотиков в амбулаторной практике

In recent years, there has been a significant increase in the frequency of antibiotic-resistant pathogens of community-acquired respiratory infections, especially pneumococcus, in most regions of the world, including Russia. This requires a review of recommendations on the use of antibiotics in the treatment of infections in outpatient practice. In 2017, two fundamental documents on the rational use of antibiotics in outpatient practice were issued: Eurasian Clinical Guidelines (document available at www.antimi-crob.net) and the 20 th WHO Essential Medicines List with recommendations on the choice of antibiotics for community-acquired infections. The opinions of the experts in these two documents almost completely coincided with the main provisions of rational antibiotic therapy. 5 key provisions of these documents are as follows. 1. In the recommendations for antibiotic therapy, antibiotics are divided into three lines or groups by administration priority. 2. Amoxicillin is an antibiotic of the 1st line of therapy in the treatment of all acute infections of the upper and lower respiratory tract. 3. Macrolides should be considered as antibiotics of the 2nd line of therapy (or the second group) for respiratory infections; their use is justified only when it is impossible to use penicillins; Azithromycin is not recommended for the treatment of respiratory infections due to environmental hazards and the risk of car-diotoxicity. 4. Fluoroquinolones are reserve antibiotics and are not recommended for the treatment of acute uncomplicated infections in outpatient practice. 5. The antibiotic must be of adequate quality and in optimal dosage form; WHO and UNICEF experts recommend the use of antibiotics in the most optimal form - in the form of dispersible tablets, which increases the safety of treatment and patient adherence to medical recommendations.

Mоnitoring the features of the episothology of the talk in scada district of Kherson region

Mоnitoring the features of the episothology of the talk in scada district of Kherson region