General Hygiene and Medical Ecology

Ministry of Education & Science of The Russian Federation

Crimean Federal University named after V.I.Vernadsky

Medical Academy named after S. I. Georgievsky

Department of General Hygiene and Ecology

General Hygiene and Medical Ecology

TEXTBOOK for Students of Medical Faculties

Simferopol

2018

Recensents: Prorector Crimean Federal University named after V.I.Vernadsky, Head of the Department of pathological physiology Medical Academy named after S. I. Georgievsky, doctor medical sciences, professor A.V.Kubyshkin Head of the Department of medical biology Medical Academy named after S. I. Georgievsky, doctor medical sciences, professor S.A.Kutiya

Textbook is reccomended for issue by Scientific Counsil of Medical Academy named after S. I. Georgievsky 28.12.2017, protocol N 12

Shibanov S.E. General Hygiene and Medical Ecology. TEXTBOOK for Students of Medical Faculties. – Simferopol, 2018. - 247 p.

The manual has been elaborated by the Head of the department of general hygiene with ecology of the Crimean state medical university professor S.E.Shibanov according to the State Federal Educational Standart and program on general hygiene and ecology for the students of medical faculties and elucidates the basic questions of the discipline. The manual is designed for the students of the 3rd course of medical faculties and the 2nd course of stomatological faculty.

The authors: professor S.E. Shibanov.

CONTENT Introduction. Goals and Objectives of Studying General Hygiene and Medical Ecology

3 at medical faculties Theme No 1. Subject and Tasks of Hygiene and Ecology Theme No 2.Hygiene of the Environment. Hygienic Regulation of Adverse Factors in Objects of the Environment. Influence of the Environment Quality on Health of Population Municipal Hygienе Theme No 3.Hygienic Requirements to Microclimate Theme No 4.Weather and Health. Prevention of Heliometeotropic Reactions. Climate and Problems of Acclimatization Theme No 5.Chemical Composition of Atmospheric Air. Effect of its Components on the Man. Protection of Atmosphere from Pollution Theme No 6.Significance of Solar Radiation. Hygienic Requirements to Lighting Theme No 7.Hygienic Requirements to Drinking Water Quality Theme No 8.Hygiene of Water Supply. Methods of Improving Water Quality Theme No 9-10.Hygienic Significance of Soil. Hygiene of Inhabited Locality. Hygienic Requirements to Cleaning Inhabited Locality from Waste Products

Hospital Hygiene Theme No 11-12. Hygienic Requirements Hospitals. Prevention in-hospital infections

Hygiene of Nutrition Theme No 13.Principles of Sanitary Examination of Foodstuff. Sanitary Examination of Milk Theme No 14.Principles of Rational Nutrition. Prevention of Alimentary Diseases Theme No 15.Value of Various Nutrients in Nutrition. Functions of Proteins, Fats and Carbohydrates in the Body Theme No 16.The Significance of Vitamins and Minerals in Nutrition Theme No 17.Food Poisonings. Reasons, Symptomatology, Prevention Theme No 18.Medical and Prophylactic Nutrition. Prophylactic Nutrition

Hygiene of Work Theme No 19.Subject and Tasks of Hygiene of Work. Physiology of Work. The Occupational Harmful Factors and Occupational Diseases. Prevention of Occupational Pathology. The Occupational Dust Pathology and its Prevention Theme No 20.Hygiene of Work at Effect of Physical Occupational Harmful Factors (Noise, Vibration, Electro-Magnetic Fields) Theme No 21.Radiation Hygiene and Ecology Theme No 22.IndustrialToxicology.Toxicology of Agrochemicals and Hygiene of Their Application

Hygiene of Children and Teenagers Theme No 23.The Physical Development of Children and Teenagers as a Criterion of Health Theme No 24.Hygienic Requirements to Children's Preschool Institutions and Schools. Hygienic Requirements to Training, Physical Training and Hardening of Children and Teenagers. Hygiene of Children‘s Nutrition

Hygiene of Hot Climate Theme No 25.Hygienic Characteristics of Hot Climate and Its Effect on a Human Organism. Hygiene of Nutrition, Hygiene of Work, Personal Hygiene under Conditions of Hot Climate

Final Control on Hygiene and Ecology 1. Key questions 2. Samles of Tests 3. Situational tasks

LITERATURE

Attachment 1 Students’ Independent Work. Evaluation of adequacy of an individual nutrition

Attachment 2 Symptoms of poisoning by Lead and Mercury

INTRODUCTION

Goals and Objectives of Studying General Hygiene and Medical Ecology at Medical Faculties The purpose of studying hygiene and ecology at medical faculties is the formation in a future doctor of hygienic thinking, i.e. understanding the interrelation between health and quality (degree of the pollution level) of the environment that is a necessary condition of scientifically proved systems of health protection, healthy lifestyle, effective public and individual prevention of various diseases. While studying hygiene and medical ecology, the students should acquire the knowledge of:  methodology, basic laws of a hygienic science and common laws of relation of health with factors and conditions of the environment.  origin, characteristics and laws of influence of the basic natural and technogenic factors of the environment and social conditions on the ecological situation and health of the population.  methodology of studying the influence of the environmental factors and conditions on health of various groups of population; qualitative and quantitative parameters of hygienic estimation of the environment condition and its influence on health of the population.  methodology and principles of hygienic regulation of harmful factors in the environment, organization and contents of preventive and current sanitary supervision over medical-preventive establishments, inhabited and other objects of sanitary-municipal purpose, establishments of nutrition, children's and educational establishments, enterprises of industrial and agricultural manufacture.  bases of a healthy lifestyle, personal hygiene and balanced diet, to be able to prove recommendations for prevention of various diseases. In the future professional activity the hygienic knowledge and practical skills are necessary for the doctor in the following situations:  At differential diagnostics of diseases, administration of treatment, medical-preventive conditions and medical-labour examination.  In the work on professional orientation, professional training and employment of persons with a different level of health.  At estimation and maintenance of sanitary-hygienic and antiepidemic conditions of medical-preventive establishments, institutions of preschool, school and professional

training, establishments of public catering and others.  For optimization of conditions of life, education, training, work, prevention of intrahospital and other infections, substantiation of recommendations on personal hygiene, balanced diet.  At development and realization of complex programs of prevention of various diseases.  In the work on propaganda of medical knowledge and hygienic education of various groups of population.

Theme No 1.

Subject and Tasks of Hygiene and Ecology

Hygiene as a Medical Science In medicine it is possible to distinguish 2 areas: medical and preventive. They are interrelated and supplement each other, but are separate scientific disciplines. The object of studying clinical medicine is a sick person (patient); its aim is diagnosis and treatment of diseases. The preventive medicine or "hygiene" (from Greek — "bringing health") studies a healthy person (individual health) or health of the population of a region or country (population health) with the purpose of maintaining or improvement of health. Specialists in this area are referred to as doctors-hygienists or sanitary inspectors (abroad — doctors of public health). The task of studying hygiene in medical university is to inculcate hygienic thinking in a future doctor, which means:  to be able to connect the occurrence of disease in a separate person or certain population of people with the influence of factors of the environmental, industrial or household surroundings, with sanitary conditions of life  to be able to develop the appropriate measures for prevention of negative influence of adverse environment factors on human health. The Concept of Hygiene Hygiene is a medical science studying the influence of environmental factors on a human organism and on public health in order to prove hygienic measures, sanitary rules and measures for maintenance and improvement of a human health and prevention of diseases. Factors Influencing the Health of Population According to the data of the World Health Organization (WHO), the health of population of any country of the world depends on the following factors:  in 48-53% — on socio-economic conditions in the country or region and a lifestyle of a person (physical training, smoking, etc.)  in 18-20 % — on the genetic factor (spread of hereditary illnesses in population)  in 17-20 % — on quality (degree of pollution) of the environment  in 8-10 % — on level of development and quality of medical aid. Thus, the improvement of quality of the environment can theoretically produce a positive effect two times greater than that of the development of the clinical medicine. It shows the significance of preventive medicine or hygiene for improvement of health of population.

The Origin and Development of Hygiene A centuries-old history of hygiene can be conditionally divided into 2 periods: Empirical hygiene (experimental hygiene) is a gradual accumulation of hygienic knowledge by people from the time of primitive society on the basis of own experience or experience of the previous generations (the use and preservation of various food, water from different water sources, arrangement of habitation in different districts, etc.). The further development of empirical hygiene took place in the slave-owning system, to a great extent under the influence of religious instructions of Ancient East, Babylon, Greece, Rome. In the Middle Ages the centers of medical science shifted from Europe, suppressed by inquisition, to the East (the works by Avicenna or Ibn-Sina). The period of empirical hygiene had been completed by the epoch of Renaissance in Europe (15th century), by discovery of microscope and nature of infectious diseases (16-17th centuries). The period of scientific-experimental hygiene is a period of studying the harmful factors influencing the health of a person in natural and experimental conditions (on laboratory anivals) and development of scientifically grounded preventive recommendations. The first known scientific work on hygiene was "Reflections on Illnesses of Handicraftsmen" by Italian doctor B. Ramazzini in which the conditions of work of 52 trades were described (17th century). In Russia the president of Petersburg medicosurgical academy A. Frank (18th century) issued the multivolume book "A Complete System of Medical Police". The first department of hygiene in the territory of the Russian empire was opened in 1863 at Kiev University, in 1865 — in St. Petersburg. The prominent hygienists in Russia before the revolution were N. A. Dobroslavin and F. F. Erisman. In the Soviet period the outstanding scientists-hygienists were academicians A. N. Sysin, A. N. Marzeev, L. I. Medved. In USSR such eminent scientists as academician J. I. Kundiev (director of scientific research institute of occupational hygiene), academician E. I. Goncharuk (rector of Kiev medical university), academician A. M. Serdyuk (director of Ukrainian scientific hygienic centre), A.N.Sysin (director of Moscow scientific research institute of general and municipal hygiene was worked. Subject of Hygiene The subject of studying hygiene is health of a person and environment in their complex interaction. The environment in a wide sense is everything that surrounds person and influences him. In hygiene the environment is considered as 4 objects, which primarily influence the organism of a person. They are:  Atmospheric air and air of a working zone;  Water of reservoirs and drinking water;  Soil;  Foodstuffs. Table 1 Structure of Environment and Biosphere Environment Biosphere 1. Atmosphere air (Air in premises) 1. A troposphere — a low surface layer of atmosphere (10-18km) 2. Water of reservoirs and drinking water 2. Hydrosphere — up to 11km 3. Soil 3. A lithosphere — up to 12 km 4. Foodstuffs

Primary Tasks of Hygiene They include:  Studying natural and anthropogenic factors of the environment (table 2) influencing a human being — their sources, reasons of occurrence, ways of influence on a person,

basic quantitative and qualitative characteristics. In hygiene all the variety of the environment factors influencing a person are subdivided into:  Physical factors (noise, vibration, radiation);  Chemical factors (various chemical substances);  Biological factors (microbes, viruses, biological agents, etc.);  Psychogenic factors (informational — a high level of negative information can cause illness or even death of a person);  Social factors (level of life, conditions of rest, etc.)

Table 2 Classification of Environmental Factors Hygienic Ecological 1. Physical (noise, vibration, EMF, radiation, etc.) 1. Abiotic (nonliving nature) 2. Chemical (various materials, steams, gases) 2. Biotic (alive nature) 3. Biological (macro- and microorganisms, bioactive 3. Anthropogenic (man-caused) materials) 4. Psychogenic (psychophysiological)

 Studying the influence of the environment factors on the organism (in natural or laboratory experiments).  Scientific substantiation and elaboration of hygienic standards, rules and recommendations to decrease or eliminate the influence of harmful factors and strengthen the effect of positive factors.  Implementation of hygienic recommendations in practice, check of its efficiency and further perfection.  A scientifically grounded prognosis of sanitary situation in certain region or country for the nearest and remote period on the basis of multifactorial mathematical modelling. The Basic Sections of Hygiene The contents of hygiene as a science is determined by the list of its basic sections:  General hygiene (propaedeutics of hygiene)  Hygiene of nutrition  Municipal hygiene  Hygiene of environment  Occupational hygiene  Hygiene of children and teenagers  Hygiene of medical-prophylactic establishments  Hygiene of extreme conditions  Military hygiene  Hygiene of hot climate  Radiative hygiene  Other sections — transport, sports hygiene, etc. Methods of Hygienic Researches Alongside with methods used in other medical sciences — physical, biochemical, physiological, morphological, hygiene has a number of specific methods of research:  Epidemiological method — studying health of population according to basic quantity indicators as an integrated criterion of quality of the environment. The basic quantity indicators of population health are:  Demographic — death rate, birth rate, natality, average life expectancy, etc.;  Parameters of morbidity (common sickness rate, morbidity, etc.);  Physical development — (weight, height) — is especially important in children and teenagers;  Disablement (invalidity) of population (amount of invalids in population, reasons

(diseases) of invalidity, etc).  Method of sanitary inspection. The very first method in hygiene is a sanitary inspection of an object (for example, a canteen with drawing up the act of sanitary inspection).  Method of sanitary examination — examination of civil-engineering designs of objects from the point of view of hygienic requirements, examination of foodstuffs (comparison of product parameters to requirements of the state standards and making the decision on possibility of food product realization).  Method of hygienic experiment — studying the effect of a harmful factor on the organism of animals in laboratory experiment with modelling conditions of real influence on a person with revealing the affected organs and systems, the threshold and noneffective levels of effect — is the basis of hygienic regulation of harmful factors. The State Sanitary Inspection and Its Structure Hygiene is a scientific part of preventive medicine. Sanitary is a practical part of hygiene; its aim is application of hygienic requirements to practice and the control of their fulfilment. To fulfill this task, each country has a special public service supervising the observance of the sanitary legislation. In Russia and Ukraine such special public service was called a sanitary-epidemiological service (SES), which is a part of Ministry of Public Health of the country. From 2004 in Russia was formed Federal Service for Supervision of Consumer Rights Protection and Human Welfare (Rospotrebnadzor RF), which includes Territorial Administrations and Centers of Hygiene and Epideviology. Types of State Sanitary Inspection These are the following: Preventive sanitary inspection — it is carried out at designing, construction and putting enterprises in operation by means of sanitary examination of projects and sanitary inspection of enterprise under construction in conformity with hygienic requirements. To this also hygienic normalization of harmful factors in the environment refers. Current sanitary inspection — supervision of observance of hygienic requirements on functioning enterprise, control over the levels of pollution of the surrounding or industrial environment, application of economic, administrative or criminal sanctions with respect to those who infringes the sanitary legislation.

Bases of General Ecology Ecology is a biological science concerned with interrelationships among living organisms, encompassing the relations of organisms to each other, to the environment, and to energy balance within a given ecosystem. Ecology (bionomics) is subdivided into the following sections: Autoecology — a section of bionomics which studies all ecological aspects of separate species. Autoecology studies the effect of the environmental factors on each living organism. Thus, an investigated organism is considered outside the link with other living entities of the given ecological system. Synecology studies communities of various living organisms, for example, the community of microorganisms, plants, animals and their interaction with each other, as well as with inorganic environment. In ecology the hygienic concept "environment" approximates to the concept of "biosphere", but ―biosphere‖ is a wider one. The Concept of Biosphere and Its Structure The term "biosphere" was introduced in 1875 by the Austrian scientist E. Zyuss. The doctrine of biosphere as a complex multicomponent planetary system was created by V. I. Vernadsky. Biosphere — the sphere of life on Earth — includes:  Troposphere — a surface layer of atmosphere (its height is up to 25 km)  Ground — lithosphere (its depth is up to 10 km)  Hydrosphere (depth of oceans is up to 12 km).

Ecosystem is a set of organisms interacting with each other, as well as with the environment, in which they live. Any ecosystem consists of two parts: The 1st part is called biocenosis. It includes all living organisms of ecosystem. The 2nd part is called biotope. It is a part of the earth surface with particular physicochemical properties, on which biocenosis lives.

Types of Ecosystems

 Microecosystems — a small stream, glade.  Mesoecosystems — a sea, wood, pond, river.  Macroecosystems — an ocean, continent.  Global ecosystems — biosphere as a whole. Larger ecosystems include smaller ecosystems.

Fig. 3. Types of ecosystems

Fig. 2. Structure of ecosystem

Environment is a wider concept. The environment consists of biocenosis, biotope and also physical, chemical, biological, anthropogenic factors (forces) effecting a living organism (Fig. 4).

Fig. 4. Structure of the environment

Ecological Factors  аbiotic (factors of lifeless nature)  biotic (mutual relations of alive organisms, trophic chains, etc.)  anthropogenic (connected with a human activity) At effect on a living organism the ecological factors depending on their intensity can be:  irritants causing adaptive reactions;  signals testifying to the change of other factors of the environment;  modifiers causing morphological changes;  terminators stopping or suppressing the vital activity of organism.

The rule of limiting ecological factors. The more the value of a separate ecological factor keeps away from the zone of optimum for the given kind, the more it suppresses the vital activity and is called limiting.

Ecological niche is a set of ecological factors providing the normal vital activity of the given kind of organisms.

Ecosystem is a set of in common living species of living organisms and conditions of their existence.

Biogeocenosis is a set of homogeneous ecological factors and species of living organisms in a certain territory; it consists of 2 parts:  ecotope — a set of аbiotic factors,  biocenosis — a complex of living organisms. The basic parameters of ecosystem are:  Qualitative — a species variety of ecosystem, amount of species of living organisms  Quantitative — a number of species of a separate kind. Every ecosystem is in a condition of mobile-stable balance — homeostasis. A gradual change of parameters of ecosystem under the influence of any factors is a succession of ecosystem. The Laws of Existing Ecosystems The law of ecological optimum (Fig. 5): The vital activity of organisms, their quality and quantity conditions of life depend on different factors of the Environment. The zone of ecological optimum is a range of values of ecological factor, optimal for vital activity of the given species of living organisms. Above and below the value of ecological factor in the zone of optimum there are zones (points) of pessimum (suppression of vital activity). The range of zone optimum for each ecological factor for the given species of organisms is called ecological valency of species. Ecological spectrum of species is a set of ecological valencies on different ecological factors. By width of ecological spectrum all species are divided into eurybiontic (for example, eurythermal), having a wide spectrum, and stenobiontic, having a narrow ecological spectrum. The zone of ecological optimum is a zone of comfort for living organisms, when the environment factors act favourably on animals and plants. Quantity and quality of organisms in this zone is greatest. The zone of pessimum (depression) is behind (lower or higher) the zone of optimum. The environment factors act unfavourably on animals and plants. The indexes of quantity and quality of organisms are lower in this zone. The critical point of life is the value of environment factor. In this point life is impossible.

Fig. 5.

The law of trophic chain. The trophic chain is a chain of transmission of substance or energy from low-organized to high–organized organisms in ecosystems (Fig. 6). The first level of trophic chain is the level of producents (plants). The second level is the level of consuments of the1st order (herbivorous animals). The third level is the level of consuments of the 2nd order (carnivorous).

Fig. 6. A trophic chain

The law of accumulation of polluting substances in trophic chains. Polluting substances can accumulate in plants, herbivorous and carnivorous. Polluting substances are transmitted from a lower to a high level of a trophic chain (Fig. 6). The Significance of Studying Trophic Chains for Hygiene In these chains due to bioconcentration toxicants may accumulate up to the levels dangerous to a human being. Moreover, the loss of some parts of trophic chains under anthropogenic influence results in disappearance of trade species of animals or fish that can worsen the quality of nutrition of population. Interrelation and Differences of Hygiene and Ecology Common features of these sciences are the following: they study factors of environmental effect on organisms, maintain the environment (habitat) from degradation due to pollution. Changes in ecosystem sooner or later have a negative effect on conditions of life or health of a person. Differences are as follows:  Different objects of research — a person (in hygiene) or living organisms (in ecology)  Different methods of research in these sciences in connection with different objects of research  Differences in principles of normalization of harmful factors (in hygiene — maintaining

health of each person, in ecology — preservation of basic parameters of ecosystem with possible partial destruction of organisms). Recommendations for Practical Classes on the Theme

Key Questions: 1. History of development of hygiene and ecology. Common features and differences of hygiene and ecology. Tasks of medical ecology. 2. Basic tasks and sections of hygiene. Basic laws of hygiene. 3. Basic methods of hygienic researches and examples of their realization. 4. Structure of the environment and biosphere, kinds of monitoring of their pollution. 5. Classification of factors of environment in hygiene and ecology. 6. The basic concepts of ecology: ecological factors, ecosystem, biocenosis, trophic chain. 7. Parameters of health of population and factors influencing the health of population. 8. Types of state sanitary supervision, the structure of sanitary-epidemiologic service of Ukraine, the structure of sanitary-epidemiologic station (SES).

Self-control Test 1. Identify the major factors determining health of the population. А. Climatic features, geographical position, degree of urbanization of territory * В. Socio-economic, genetic, ecological, medical С. Quality of nutrition, lifestyle, conditions of habitation, occupational factors D. Lifestyle, national features, religious factors, social system Е. Age, sexual, individual, hereditary factors.

2. Among the majority of factors determining health of the population, the following group is greatest influence on parameters of population health: А. Level of development of public health services and quality of medical aid to the population В. Level of a hereditary pathology С. Educational and cultural level of the population * D. Lifestyle and socioeconomic conditions Е. Degree of the environment pollution

3. Identify the proportion of influence of the environment quality on the health of population: А. 45-53 % * В. 17-20 % С. 8-10 % D. 24-25 % Е. 15-17 %

4. What components are included into the concept "environment"? А. Air, plants, animals, water, ground В. Abiotic and biotic factors of the environment * С. Water, air, ground, foodstuffs D. Plants, buildings, ground, air Е. Water of reservoirs, air, ground

5. What components does biosphere consist of? А. Exosphere, ionosphere, mesosphere, troposphere * В. Lithosphere, hydrosphere, troposphere С. Air, water, ground, ecosystems D. Autotrophic and heterotrophic organisms Е. Space, globe

6. What parameters of population health are the most sensitive to pollution of the environment? А. Demographic * В. Sickness rate С. Sickness rate with temporary loss of work capacity D. Disability * Е. Physical development

7. What diseases refer to ecologically caused (ecopathology)? А. Diseases which worst yield to treatment in the given district * В. Most frequently encountered diseases in the given district С. Diseases, for which the role of the environmental factors is proved D. Diseases among the most sensitive groups of population (children, elderly people) Е. Diseases considerably differing in frequency in various regions

8. What parameters are studied at application of epidemiological method of research in hygiene? А. Parameters of pollution levels of the environmental objects В. Frequency and incidence of infectious diseases among the population * С. Parameters and indexes of population health D. Incidence of endemic diseases in the given district Е. Parameters of ecosystems condition on the investigated territory 9. What does the method of sanitary inspection consist in? * А. The study of object with drawing up the act of hygienic inspection В. Sanitary inspection of object with the purpose of its closing С. Selection of tests of the environmental objects and their comparison with standards D. The study of object quality as to conformity to the requirements Е. Carrying out experimental researches on animals 10. What does the method of sanitary examination consist in? А. The study of object with drawing up the act of hygienic inspection В. Sanitary inspection of object with the purpose of its closing С. Selection of tests of the environmental objects and their comparison with standards * D. The study of object quality as to conformity to the requirements Е. Carrying out experimental researches on animals 11. Identify the classification of the environment factors in hygiene. А. Biotic, abiotic, anthropogenic В. Air, water, ground, foodstuff * С. Chemical, physical, biological, informative D. Dangerous, harmful, indifferent Е. Of natural and anthropogenic origin 12. Identify the classification of the environment factors in ecology. * А. Biotic, abiotic, anthropogenic В. Air, water, ground, foodstuff С. Chemical, physical, biological, informative D. Dangerous, harmful, indifferent Е. Of natural and anthropogenic origin

Theme No 2.

Hygiene of the Environment. Hygiene of the environment is a section of hygiene studying medical aspects of the environment protection as a scientific basis of prevention of unfavorable influences of the environment factors on a person at individual and population levels. The following concepts of the environment exist:  The internal environment of the organism is the internal content, the nervous and humoral mechanisms of regulation and maintenance of homeostasis.  The external environment is everything that is outside the organism and acts on its membranes and receptors. From the point of view of physiology, the internal and external environments are very individual and dynamic for each person.  The environment is everything that surrounds and affects the life and development of an organism. It is not individual but common for the population. In hygiene the basic objects of the environment are atmospheric air, water of reservoirs, ground and foodstuffs. Depending on degree of influence of anthropogenic factors the following conditions of the environment are distinguished:  unchangeable (natural) — part of the environment not subjected to anthropogenic influence (reservations, etc.)  changed (polluted) — as a result of human‘s activity, it can render negative influence on people‘s health.  artificial — the environment specially created by human (a spaceship, submarine, etc.) The Basic Sources of the Environmental Pollution Natural and anthropogenic sources of the environmental pollution are distinguished. Natural sources include volcanoes, earthquakes, floods, forest fires, typhoons, and other natural cataclysms. The dimensions of the environmental pollution in this case may be significant, cover great territories, and levels of pollution may exceed anthropogenic pollution. Anthropogenic sources are caused by human activity: industry, atomic power stations, transport, agriculture, municipal services, etc. Major factors of the environmental pollution are:  chemical (pesticides, oil products, heavy metals, etc.)  physical (noise, ionizing radiation, electromagnetic fields)  biological (microorganisms, biological preparations, etc.) Concept of the Environmental Pollutant A pollutant is any natural or anthropogenic factor, being in the environment in amounts exceeding the limits of natural fluctuations or natural background, or exceeding the permissible standards for the given object of the environment. Not any presence of pollutant in the environment is pollution. Pollution is the presence of pollutant in the environment above the maximal permissible concentration, which may produce an unfavorable effect on a human health. Criteria of Danger of the Environment Pollution and Types of Its Monitoring To estimate the danger of the environmental pollution is possible by the following criteria:  According to the degree of excess of maximum permissible concentration of pollutants in the environment — analytical monitoring;  By integrated parameter — the health state of the population — medical-hygienic monitoring;  By changes in ecosystems — ecological monitoring (on a regional scale), bios- pheric monitoring (on a global scale).

The Basic Directions of the Environment Protection from Pollution  Administrative-legislative measures of the environment protection on the international, national or regional scale. These are priority measures, as they create a legal basis for all nature-protective activity. Now there is a special direction in jurisprudence — the nature protection law.  Hygienic actions — realization of preventive and current sanitary inspection. The preventive sanitary inspection is examination of projects of enterprises, capable to pollute the environment, regulation of pollutants in objects of the environment. The current sanitary inspection is the control of pollution levels of the environment, revealing sources of pollution and acceptance of measures to decrease pollution.  Architecture-planning measures — a proper location of pollution sources for decrease of influence on especially important objects (for example, zones of sanitary protection of water sources, functional zoning in cities, sanitary-protective zones near enterprises, etc.).  Medico-hygienic measures — studying the parameters of population health, revealing, treatment and health improvement of persons having disturbances of health due to the environmental pollution. These measures allow revealing the most dangerous sources and factors of the environmental pollution and the most sensitive to pollution parameters of population health.  Ecological monitoring — studying the condition of ecosystems and separate species of living organisms under the influence of the environmental pollution with the purpose of prevention of irreversible disorders of ecosystems.  Technological measures: transfer of enterprises into the closed cycle (without emissions into the environment), change of technology for decrease of emissions into the environment (for example, transfer of motor transport into electricity), development of sanitary engineering (cleaning constructions for purification of emissions into atmosphere, for reservoir burial, construction of areas and storages of waste products, etc.) Hygienic Regulation of Harmful Factors in the Environment Regulation of harmful factors in the objects of environment is an important element of preventive sanitary inspection as it establishes the criteria of the permissible content of pollutants in objects of the environment. In hygiene there are 2 approaches to regulation of factors of the environment affecting the man:  In respect to natural factors (parameters of microclimate, lighting, ventilation of air, requirements to nutrition), regulation is substantiation of optimal levels of factor values for maintaining and improvement of human health or providing comfortable conditions for his life and work.  In respect to harmful factors in the environment there are 2 concepts:  Concept of exception — absolute prevention of entering harmful factors in the environment, but it is unreal because it means stopping industry, transport, power stations, etc.  Concept of restriction — when it is impossible to eliminate the presence of a harmful factor in the environment, it is necessary to confine its content up to safe for the man levels — hygienic regulations. The Concept of Hygienic Regulation of Harmful Factors in the Environment It is such concentration, dose or level of the harmful factor in object of the environment which neither cause any pathological changes in the organism of man and subsequent generations (which can be found out on a modern level of development of science) during the whole time of contact with this factor (during life or work experience), nor worsen the sanitary conditions of life of population. Types of Hygienic Regulation of Harmful Factors in the Environment Each country has its own regulations of harmful factors in the environment approved by the state; there are also the international standards coordinated by the WHO and UNEP (the program of the United Nations Organization for the environment protection).

In Russia such regulations are called maximal permissible (concentrations, doses, levels):  maximal permissible concentration (MPC) — for harmful substances in water, air, ground, foodstuffs;  maximal permissible dose (MPD) — for radiation;  maximal permissible level (MPL) — for noise, vibration, electromagnetic fields;  maximal permissible level (MPL) — for pesticides in foodstuffs;  permissible residual quantities — for pesticides in ground and foodstuffs. Apart from these regulations approved by Ministry of Public Health, the temporary regulations for new substances are primarily elaborated:  a tentative safe level of influence — for air,  a tentative permissible concentration — in water. Principles of Hygienic Normalization of Harmful Factors in the Environment  Priority of medical indications at establishing a standard. At determining the value of a standard only the levels of its safe effect on organism are taken into account, instead of technical and economic reasons for observance of this specification.  Differentiation of degree of biological response of organism to action of a harmful factor. Depending on level of a harmful factor, which influences organism, and resistibility of organism to harmful influence we can distinguish the following levels of biological responses:  destruction of organism,  llness,  prepathology (disturbances of organism‘s functions without clinical signs of disease),  tension of adaptive-compensatory processes (functional disturbances of unknown aetiology),  accumulation of substance in organs and tissues without functional and clinical changes. Regulations must be established not higher than the 4th level.  Division of objects of the environment for sanitary protection. As each object of the environment (air, water, ground, foodstuffs) has the physical and chemical features and different conditions of contact with a human organism, regulations are established separately for each object of the environment.  Principle of registering all probable adverse effects of the normalized factor on a certain object of the environment. There are the most important parameters reflecting the harmful action of the investigated factors on quality of a certain object of the environment. Such parameters are called signs or criteria of a harmful action. They include: organoleptic, common sanitary, phytoaccumulative, water-migratory, air-migratory, reflectory, toxicological, etc. (see table below).

Table5 Signs of Harmful Action at Regulation of Harmful Factors in Objects of the Environment Sign of harmful effect Type of unfavorable effect Organoleptic change of odour, taste, colouring, etc. Common sanitary influence on a saprophytic microflora, processes of self-cleaning Phytoaccumulative accumulation of pollutant in vegetative products Water-migratory accumulation of pollutant in ground waters Air-migratory evaporation of pollutant in the air not higher than MPC Reflective irritating activity on mucous membranes of organism Toxicological toxical effects on organism of animal Specific allergenic, gonadotropic, embryotropic effects The remote effects oncogenic, mutagenic effects

At studying each sign of harmful effect in laboratory a threshold concentration (TC) of pollutant for each sign of harm is determined; the parameter of harmful effect with the least TC is called a limiting sign of harmful action and according to it MPC is proved.  Principle of presence of threshold (limiting) harmful effect is the central principle of normalization. For each harmful factor there is a threshold of harmful action — a level at which the harmful effect is registered (LOAEL) and a low level (NOAEL) — when such effect is absent.  Principle of dependence of harmful effect on concentration (dose) of the investigated factor and time of its effect. It is based on mathematical dependences "concentration (dose) — effect" or "time — effect". The latter dependence is observed at chronic effect in the presence of cumulation (chronoconcentration poisons).  Principle of laboratory experiment. The investigations of effect of the normalized factor on organism and sanitary living conditions are carried out in laboratory conditions at unification and standardization of techniques for comparison of results received by different researchers.  Principle of aggravation. In laboratory researches the most adverse conditions are modelled promoting the maximal manifestation of harmful effects of the investigated factor. To the same principle the transfer of toxicological data received on laboratory animals to the human organism refers.  Principle of relativity of standards. The established standards are not constant and final. At occurrence of new experimental data or results of negative effect of the normalized factor on health of population at levels lower than maximal permissible concentration, standards are reconsidered towards decreasing. The Scheme of Research of Toxicological Sign of Harmful Action at Hygienic Normaliza- tion of Chemical Substances in the Environment One of the most difficult and expensive for research signs of harmful action at normalization is toxicological. It is investigated according to the following scheme: 1 Stage. Studying physicochemical properties of normalized substance with the purpose of search of similar substances, for which standards are established, for an approximate evaluation of levels of toxicity and mechanisms of activity of a new toxicant. 2 Stage. Studying acute toxicity of substance (at one-time effect — lethal doses and concentrations, threshold of acute harmful effect, etc.). 3 Stage. Studying subacute toxicity of substance at effect on experimental animals during 30-45 days (ability to cumulation, etc.). 4 Stage. Studying chronic toxicity of substance (during some months or years — threshold of chronic harmful effect). 5 Stage. Determination of threshold concentrations or doses by a toxicological sign of harmful action. The threshold (LOAEL) and subthreshold concentrations (NOAEL) for the person are determined on the basis of the data received on laboratory animals.

Features of Hygienic Normalization of Harmful Factors in Various Objects of the Environment

Hygienic Normalization of Pollutants in Atmospheric Air Pollution of atmospheric air among other objects of the environment represents the greatest health hazard for the person for the following reasons:  The majority of emissions of harmful substances get into the air and spread to big distances — a lot of people are exposed to its effect;  On inhalation a large surface of the lungs having many capillaries is exposed to effect, thus in blood a high concentration of pollutant quickly occurs and blood from the lungs bypasses liver and spreads in the organism, causing poisonings;  Except for direct negative effect on a human organism, the atmospheric pollution renders an indirect negative effect on health and living conditions of the population. Types of Hygienic Standards in Atmospheric Air By their effect on organism the atmosphere pollutants are subdivided into 3 groups:  Substances of the reflex (irritating) action  Substances of the absorption (toxic) action  Substances of the reflex-absorption action There are 2 types of maximal permissible concentration of atmosphere pollutants:  Maximal–single permissible concentrations (MPC m.s.) are designed for a 20-30- minute effect of irritation pollutants and directed at prevention of reflex reactions and poisonings in people at high concentration of pollutants in air (emergencies). They are established by irritating action on mucous membrane of the eye and by toxic effect. For toxic substances such researches are carried out on animals with transfer of the data on a human being.  Daily average maximal permissible concentrations (MPC d.a.) are designed for absence of pathological changes in people at a twenty-four-hour effect during the whole life, and also for absence of remote effects in the subsequent generations. MPC d.a. is much lower than MPC m.s. in view of greater exposure (time) to effect. The criteria of harmful effect at normalization of pollutants in atmospheric air are as follows:  organoleptic (determining the threshold concentration of pollutant by change of smell, colour, transparence of air);  reflectory (establishing the threshold concentration by irritating olfactory effect on a human or laboratory animal);  toxicological (threshold concentration is established by common toxic, specific or remote effects at inhalation on laboratory animals). Normalization of Pollutants in the Air of a Working Zone Air of a working zone is the air of industrial and other premises, which pollution affects the workers. At normalization the term of effect is estimated for 40-50 years (the maximal work experience), therefore the maximal permissible concentration of pollutants in the air of a working zone is a bit higher than the maximal permissible concentration in the atmospheric air. At normalization of substances in the air of a working zone the possibility of the skin-absorptive effect on organism is also studied in experiments on animals. Normalization of Harmful Substances in Reservoir Water Normalization of pollutants in water depends on type of water use, i.e. drinking, household, recreational, balneological, industrial, fishing, meliorative, transport. Depending on type of water use, various criteria of harm action are applied, therefore the maximal permissible concentration for the same substance can differ considerably. Hygienic standards are established for first four types of water use. At hygienic normalization of substances in reservoir water the following 3 signs of harmful effect are studied:  organoleptic (threshold concentrations changing organoleptic properties of water)  common sanitary (threshold concentrations affecting the saprophytic microflora,

oxygen regulations of reservoir, providing the processes of autopurification of reservoir from pollution)  toxicological (determination of threshold and non-effective concentrations of substance in experiments on animals as for toxic, specific and remote effects). Hygienic Normalization of Harmful Substances in Foodstuffs As standards of pollutants in foodstuffs the MPC and MPL (maximum permissible — level — for pesticides in foodstuffs) are used. For substantiation of MPC in foodstuffs very difficult researches are required, that is why maximal permissible concentrations are established only for few substances for the time being. The characteristic feature of normalization of pollutants in foodstuffs is that MPCs are established in view of PDD value (permissible daily dose of harmful substance entering the organism), thus the entry of pollutant into organism not only with foodstuffs, but also with drinking water and air are taken into account. Signs (Criteria) of Harmful Effect at Normalization of Pollutants in Foodstuffs  Organoleptic — effect on organoleptic properties of foodstuffs;  Hygienic — maintaining the nutritional value, i.e. major nutrients — proteins, fats, vitamins, etc.;  Technological — transformations of pollutant at culinary (thermal) processing of product, the formation of more toxic metabolites;  Toxicological — studying toxic, specific and remote effects at introduction into laboratory animals. Hygienic Normalization of Exogenous Chemical Substances (ECS) in the Ground ECS are substances of anthropogenic origin, purposely (pesticides, fertilizers) or acci- dentally (heavy metals, mineral oil, etc.) brought to the ground by a person. The ground is a burial place of waste products and at normalization of ECS it is necessary to keep processes of autopurification, and also to prevent pollution of subsoil waters and atmospheric air. Maximal permissible concentration of ECS in the ground is such content of pollutant in the ground, which at direct contact with a human organism (work on the ground) or at migra- tion on ecological chains guarantees absence of negative effect on a human health, does not disturb the processes of ground autopurification and does not influence the sanitary living conditions of the population. The Basic Signs of Harmful Action at Normalization of ECS in the Ground  Organoleptic — change of organoleptic properties of air, subsoil waters, vegetable foods contacting with ground, containing various concentrations of normalized substance.  Common sanitary — effect on the ground microflora and processes of its autopurification.  Phytoaccumulative (translocative) — accumulation of normalized substance in vegetable foods (not higher than maximal permissible concentration for foodstuffs).  Air-migratory — evaporation of substance in atmospheric air above the ground (not higher than MPC for air)  Water-migratory — accumulation of substance in subsoil waters (not higher than MPC for water).  Toxicological — by toxic, specific and remote effects on laboratory animals at skin or inhalation action together with a soil dust.

Hygienic Estimation of Objects of the Environment at Combined Pollution In a real life a human organism is affected, as a rule, not by a single but by a number of harmful factors and their combined effect may considerably differ from a separate effect of each factor. The following types of combined effect are distinguished:  A combined effect is a simultaneous action on organism of some factors of identical nature, for example, only physical (noise and vibration), or only chemical (chemical substances).  An associated effect is action on organism of some factors of different nature, for example, chemical materials and radiation effect.  A complex effect — a harmful factor affects the organism in different ways simultaneously (for example, with inhaled air, nutrition, water, penetrates through skin). Types of Combined Effect of Chemical Substances on the Organism  Antagonism (less than an additive action) — mutual weakening of toxic effects of poisons at combined action on organism. It has a chemical (mutual destruction of poisons) or functional nature (different influence on functions of organs and systems).  Summation (additive action) — an arithmetic addition of separate toxic effects.  Potentiation (more than an additive action) — a mutual sharp increase of toxicity of each toxin at combined action. Rules of Sanitary Estimation of the Environment at Combined Pollution 1. In case of antagonism at combined effect the estimation of environment (water, air, etc.) is carried out by comparison of concentration of each revealed substance with its MPC separately. Estimation of the object is given by formula:

C / MPC < 1,

where C — concentration of revealed substance, MPC — its maximal permissible concentration in the given object of the environment. 2. At summarizing the combined effect the estimation of the environment is carried out according to the formula of summational toxicity (Аveryanov‘s formula):

where C — concentration of the revealed substances, MPC1 MPC2 MPC3 — their standards 3. In case of potentiation in the above-stated formula 1/К is taken instead of 1 (K — factor of potentiation, i.e. how many times is toxic effect amplified at combined effect in com-

parison with separate effect of each poison).

where К — an increasing coefficient (factor of potentiation)

Hygienic Normalization of Biological Factors in the Environment To such factors in the environment the following refers:  Pathogenic organisms of infectious or invasive nature — bacteria, viruses, hel- minthes, protozoa or their toxins  Allergens of biological nature Main Principles of Normalization of Microbe Pollution of the Environment  Absence of causative agents of infectious diseases in certain volumes or amounts of the environmental object.  Substantiation of allowable content of microorganisms in objects of the environment at which they are considered safe in the epidemiological respect.  Use at normalization of indicative (sanitary-indicative) microorganisms. The indicative principle of normalization of microbes in the environment, offered more than 100 years ago by R. Koch, up to now remains a leading principle of normalization of microbe environmental pollution. On choice of sanitary-indicative microorganisms as indicators of pathogenic microbes the following is taken into account:  Commonplace of dwelling in a human organism  Identical ways of entering the environment and a human organism (ways of transfer)  Higher survival rate in the environment in comparison with pathogenic microbes, higher resistance to disinfection  Harmlessness for a human being (inability to cause infectious diseases) Now as an indicator of virus pollution of the environment bacteriophages of colibacillus (E.coli) are used. By structure, survival rate, resistance they are similar to enteroviruses, causing intestinal infections. Various sanitary-indicative microorganisms for estimation of various objects of the environment were offered, for example, for reservoir water — bacteria of Escherichia coli group (BECG), coli-phages. The quantitative evaluation is made by coli-index — quantity of BECG in a certain volume of sample and by coli titer — volume of sample in which one BECG is found out. For example, for drinking water coli-index is up to 3, coli titer is more than 300 ml, in sewage coli-index — up to 1,000, coli-phages — up to 1,000, absence of pathogenic microbes in 1 L of water (Table 6). Table 6 Bacterial Standards in Objects of the Environment for Water Estimation Kind of water Coli-index Coli-phage Absence of pathogenic viruses in volume of water Drinking < 3 - 10 L For bathing < 1000 < 1000 in 1 L 1 L Sewage after cleaning < 1000 < 1000 in 1 L 1 L

Sanitary Estimation of Microbe Air Pollution The indicative parameter of microbe air pollution of premises is a common microbe number (CMN) — quantity of microorganisms per m3 of air, a parameter of direct epidemiological danger — quantity of haemolytic streptococci per m3 of air. The criteria of estimation of bacterial pollution of premise air is given in Table 7. Special requirements to microbe air pollution are established for operating-rooms, maternity wards for prevention of intra-hospital infections, postoperative complications (see Table 8).

Table 7 Bacterial Standards in Objects of the Environment for Estimation of Premise Air Quality Common microbe num- Amount of haemolytic streptococci of air ber per m3 per m3 Clear < 2000 < 10 Satis- 2000 — 4000 11 — 40 factory clear Low 4000 — 7000 40 — 120 polluted Polluted > 7000 > 120

Table 8 Bacterial Standards in Objects of the Environment for Estimation of Operating-Room Air Time of definition Total microbe number per Amount of golden staphylococci m3 per m3 Before operation < 500 0 During operation < 1000 < 4

For estimation of bacterial pollution of ground coli-titer, Cl. Perfringens titer, amount of helminth eggs per kg are used.

Effect of the Environment Quality on the Population Health Now it is conventional that the integrated criteria of quality of environment (degree of contamination) is the health of the population. It is used at social-hygienic monitoring environment of the country. The Concept of "Health of Population" Paradoxical though it may seem, but there is no universal definition of concept "health" up to now. In medicine and hygiene most frequently the concept of health is used as an average statistical value characterizing a health state of a certain population, being in identical socioeconomic and ecological conditions. The border between health and illness is the so-called a 95 % confidence interval — in a healthy person all the investigated parameters should range within the limits, characteristic of 95 % of people of the given population.

Factors Determining Health of Population If the whole complex of factors influencing health of the population is taken for 100 %, they are distributed in the following way:

№ Name of the factor Specific Gravity in %% 1. Lifestyle and social- 49-53 %* economic conditions 2. Genetic factors 18-22 %

3. Pollution of the environ- 17-20 % ment

4. Medical factors (quality of medical aid, devel- 8-10 % opment of network of public health services, etc.) Note: * — oscillations in different countries

According to various data, the occurrence of 70 % of all diseases, 60 % of defects of physical development and more than 50 % of death cases are caused by environmental pollution. Types of Effect of the Environmental Quality on Health of Population

Types of Effect of the Environmental Quality on Health of Population

Direct Negative Effect: Indirect Negative Effect

1. Acute effect: Specific, Nonspecific

2. Chronic effect: Specific, Nonspecific

3. The specific and remote effects

 Direct Negative Effect:

 Acute effect: . Specific effect — in people sharp specific intoxications occur due to effect of big concentrations of certain pollutants; . Nonspecific (provoking) effect (toxic fogs-murderers in London, photochemical smog of a Los-Angeles type, attacks of bronchial asthma during great air pollution);  Chronic effect: . Specific — accumulation in the environment of small amounts of stable pollutants, causing specific ecologic pathology:  "Itay-itay" disease (in translation from Japan ―it hurts — it hurts‖) — it was first described in prefecture of Tokyo. Characterized by myalgia, albuminuria, glau- coma, dystrophy, spontaneous crises; in 12 years death occurs. Its reason is accumulation of cadmium compounds in the ground, water, fish and by trophic

chains it gets into a human organism;  Minamata disease — a neurologic disorder caused by methyl mercury intoxication; first described in the inhabitants of Minamata Bay, Japan, resulting from their eating fish contaminated with mercury industrial waste. Characterized by peripheral sensory loss, tremors, dysarthria, ataxia, and both hearing and visual loss.  Usho disease (oil illness) — it was also first found in Japan. Characterized by dimness of the skin, rash, affection of eyes and internal organs; the remote effects are mutagenic, embryotrophic, cancerogenic. The reason is accumulation in the environment of polychlorinated compounds containing dioxines — the extremely toxic and stable substances.  Endemic diseases (fluorosis, etc). . Chronic nonspecific effect of biosphere pollution on health — deterioration of all parameters of health of the population, nonspecific diseases, their aggravation, etc.

 The specific and remote effects of pollution of biosphere. Allergenic, gonadotropic (specific), embryotrophic, teratogenic, mutagenic, cancerogenic, immunodepres- sion effects of environmental contamination which occur in population many years after pollutant effect or in the subsequent generations.

 Indirect Negative Effect: The indirect negative effect of pollution is marked by influence on health or living conditions of the population through ecological interrelations in nature (for example, at pollution of atmosphere the level of ultra-violet irradiation decreases causing growth of rickets in children; acid rains result in destruction of crop, transition of pollutant from one object of environment to another, etc.). Degrees of Biological Response of a Human Organism to the Effect of the Polluted Envi- ronment These include:  death — 1 level of respouse  disease — 2 level of respouse  functional signs of illness without symptomatology (prepathology) - 3 level of respouse  functional shifts of unknown etiology (tension of adaptive opportunities) - 4 level of respouse  asymptomatic accumulation of pollutant in a human organism - 5 level of respouse

Basic Parameters of Population Health and their Use for Studying Influence of the Envi- ronmental Pollution  Sanitary-demographic parameters: death rate, birth rate, life expectancy, etc. For studying the effect of the environment quality they are seldom used because changes are revealed in a long time, not less than 10 thousand of population and data for not less than 10 years are necessary for research.  Parameters of morbidity (sickness rate) are the basic parameters for research of this problem; it is important to study not the common sickness rate, but that in separate groups of diseases.  Parameters of physical development are especially important in children and teenagers. It is a rather sensitive parameter of the environment pollution that is eluci- dated in researches of our department carried out in ecologically different regions of the Crimea.  Parameters of invalidity: the total amount of invalids per 100 thousand people according to groups of physical disability and reasons of physical disability. These are seldom used for estimation of quality of the environment but more often — for general characteristics of health state of the population as they largely reflect the effect of professional harmful factors.

Methodical Approaches to Studying the Influence of the Environmental Quality on Health of the Population There are a lot of approaches to studying this problem. They include:  Traditional approach — researches proceed from pollution of the environment to health of the population. Here 2 main concepts are distinguished:  A factorial sign X — the factor(s) of the environment which action on health is being studied;  An effective sign Y — the parameter (s) of the population health. There are 4 basic methodical schemes of researches: Scheme 1: (X > Y) — studying influence of one factor of the environment on one parameter of health; Scheme 2: (X > Sum Y) — effect of one factor of the environment on a complex of parameters of health; Scheme 3: (Sum X > Y) — effect of complex of the environment factors on one parameter of health; Scheme 4: (Sum X > Sum Y) — effect of complex of factors on a complex of parameters of health.  Nontraditional (inversion) approach has been used more often recently, especially abroad. A way of researches is from a health state of the population to revealing the most substantial factors of the environment determining the level of health with the purpose of their elimination or minimization. Concept of Observation (Research) Zones A very important moment at carrying out researches is a correct choice of such zones; it is possible to decrease the level of effect of other factors (socioeconomic, demographic, medical, etc.) on health of the population. Zone of observation is a certain territory in which the effect of ecological situation on health of the population is studied. At carrying out researches it is necessarily to choose 3 zones of observation:  Experimental zone — territories in which the environmental pollution in accordance with the investigated factor (complex of factors) essentially exceeds MPC  Control zone No. 1 — territories where pollution is at a level of MPC  Control zone No. 2 — territories where pollution is much lower than MPC or absent at all. Rules of Choice of Observation Zones The chosen zones of observation should be identical as for the following parameters: 1) socioeconomic conditions and lifestyle of population, 2) sex, age, professional structure of population, 3) number of population. These zones should differ only in levels of environmental pollution. Recommendations for Practical Classes on the Theme

Key Questions: Concepts of ―environment‖ and ―biosphere‖, their basic objects.  Basic sources and factors of the environment pollution. Classification of adverse factors in hygiene and ecology.  Criterion of estimation of the environment quality and types of monitoring of its pollution (analytical, medical, ecological).  Concept of hygienic regulations of pollutants in the environment, basic principles of hygienic standardization.  Features of hygienic standardization of harmful factors in various objects of the environment. Limiting attributes of harmful effect.  Hygienic standardization of biological pollutants in the environment.  Hygienic estimation of objects of the environment at simultaneous pollution by various substances.  Basic parameters of population health and their use for monitoring the environment

quality.  Factors of effect on health of the population.  Types of direct and indirect effect of the environmental pollution on health of the population (acute and chronic effect, remote consequences).  Methodology and methodical schemes of studying the environmental effect on health of the population.  Rules of choice of observation zones for research of effect of the environment quality on health of the population. Self-control Test 1. A quantitative parameter of the environmental factor which is safe for maintaining the ability to life of the man and for population health, and for future generations is called * A. Hygienic standard B. Hygienic factor C. Sanitary standard D. Level of safe effect E. Parameter of the minimal safety

2. A parameter of harmful action, which at establishment of the hygienic standard has received the minimal concentration (doses) at its action on organism or environment in comparison with other parameters of harmful action is called: * A. A limiting parameter B. A leading parameter C. A common parameter of sanitary safety D. A sanitary parameter E. A hygienic parameter of adverse effect

3. As a level of harmful action of adverse factor on organism, which is determined as minimally acceptable at establishment of its hygienic standard, is: A. Accumulation of pollutant in organs and tissues which will not cause any physiological or biochemical changes in their functional condition (V level) B. Mortality of organism (І level) C. Specific disease (ІІ level) D. Non-specific signs of pathological changes (ІІІ level) * E. Temporary and partial physiological changes of unknown origin (ІV level)

4. The features of hygienic standardization of the environmental factors based on the so-called non-line-parabolic dependence of biological effects on dose are: A. Determination of at least two hygienic standards (level of useful and harmful effect) B. Determination of at least one hygienic standard (level of harmful effect) C. Determination of at least one hygienic standard (level of useful effect) * D. Determination of least two hygienic standards (level of safe and harmful effect) E. Determination of two and more hygienic standards (useful, minimally safe and harmful effect)

5. The excess of MPC of toxic substance in the atmospheric air makes up 100. What changes in the health state of population should be expected? * A. Severe poisonings B. Expressed physiological changes in organs and systems C. Increase of specific and non-specific morbidity D. Change in health state according to separate functional parameters E. Fatal poisonings among children

6. The pollutant of atmospheric air refers to the class of extremely dangerous substances. What is the most probable effect of this pollutant? * A. Cancerogenic effect B. Irritating effect

C. Neurotropic effect * D. Embryotropic effect E. Allergenic effect

7. The hygienic normalization of a harmful factor in the environmental object is: * А. Such level of the given factor in the environment which does not cause any pathological changes in organism during the whole period of effect В. Such level of the given factor in the environment which causes pathological changes in organism during the whole period of effect С. Such level of the given factor in the environment which causes prepathological changes in organism during the whole period of effect D. Such level of the given factor in the environment which causes functional changes in organism at the end of effect Е. Such level of the given factor in the environment which does not cause irreversible changes in organism during the whole period of effect

8. To hygienic standard of the permissible content of harmful substance in reservoir water the following refers: А. MPL (maximal permissible level) В. MPD (maximal permissible dose) * С. MPC (maximal permissible concentration) D. MAL (maximal allowable level) Е. MAD (maximal allowable dose)

9. Identify a correct concept of "health" by WHO from the point of view of the individual theoretical approach. A. Condition of a human organism, at which it is capable to carry out the biological and social functions B. Condition of a human organism, when all its functions are counterbalanced by the environment * C. Condition of complete social, biological and psychological well-being of the man (simultaneously with absence of illness or physical defects in him) D. Conditional statistical concept, which is fully characterized by a complex of demographic parameters, morbidity, physical development, physical disability Е. Interval, within the framework of which the fluctuation of biological processes keeps organism at a level of a functional optimum

10. Identify the major factors determining the condition of population health. * A. Social, economic, genetic, ecological factors B. Qualitative structure of nutrition, morbidity, mortality, birth rate C. Geographical position, climatic features, urbanization D. Ethnical factors Е. Level of lethality

11. What parameters of population health are primarily worsened under the influence of the environmental pollution? A. Demographic * B. Physical development of children * C. Morbidity D. Disability Е. Quality of emergency care to population

12. To ecopathology of population the following refers: A. Diseases which most badly yield to treatment * B. Diseases caused by ecological factors C. Diseases most frequently encountered in the given district D. Diseases with a latent course Е. Diseases affecting the majority of population

MUNICIPAL HYGIENE

Theme No 3.

Hygienic Requirements to Microclimate

Concept of Climate and Microclimate Climate is a complex of average physical parameters of a surface atmosphere in significant area (region, country, etc.), such as meteorological, synoptic, heliogeophysical. Microclimate is estimated by physical parameters of air in a small area (a quarter, street) or in premises. Major factors of microclimate are temperature, humidity, speed of air movement, atmospheric pressure (the latter does not vary greatly in premises, therefore it is usually not taken into account at estimation of microclimate). Influence of microclimate on a human organism Microclimate basically affects the thermoregulation system of a human organism. Thermoregulation system of a human organism may be of 2 types: chemical (heat production) and physical (heat emission), in a healthy person they are in a dynamic balance. System of Thermoregulation It consists of chemical thermoregulation Q1 (thermogenesis) and physical thermoregulation Q2 (heat emission). Q1 = Q2 System of Thermoregulation

Chemical Thermoregulation Physical Thermoregulation (Heat (Thermogenesis) Emission): 1. Heat conduction (30-40 %)

2. Heat evaporation (10-15 %)

3. Heat radiation (40-45 %).

Chemical Thermoregulation (Thermogenesis) This is heat formation in the body due to biochemical processes, its level being determined by the basal metabolism. In a healthy person the level of heat production basically depends on air temperature (Т)* (through thermoreceptors in the skin and centers of thermoregulation in CNS). A zone of indifference has the temperature of 15-25º С. If the temperature is below 15 ºС, the increase of heat production takes place, if above 25 º С — the decrease of heat production; at over 35 ºС there may be disturbance of thermoregulation (thermal fatigue, thermal feet edema, thermal emaciation , heat cramps, heat shock, thermal syncope). Physical Thermoregulation (Heat Emission) There are three ways of heat emission:  Heat conduction (30-40 %)  Convection — emission of heat to the air (it depends on Т, Е, V)*.  Conduction — emission of heat to objects (it depends on Т of object, its thermal conductivity and area of contact with an object).  Heat evaporation (10-15 %) — it occurs on perspiration and depends on Т, Е, V of the air.  Heat radiation (40-45 %). It depends on radiation temperature, i.e. the difference

between temperature of environmental objects and a body temperature (36.6 ºC). ______*Note: Т — temperature, Е — humidity, V — speed of air movement In normal conditions (in rest) a person loses 30 % of heat due to heat conduction, 15 % — heat evaporation and 55 % — heat radiation.

Types of Thermoregulation Disturbance in Hot Climate These include thermal emaciation, thermal hypostases of legs, thermal emaciation due to dehydration and desalination on perspiration, heat spasms, heatstroke, thermal fainting. (See Theme No 25 in the end of the textbook).

Table 25 Standards of Microclimate for Different Premises and Methods of its Estimation Factor of microclimate Kind of premise Norms Temperature of air Habitable rooms 18-22˚С Devices: thermometers, Sports halls 16-18˚С thermograph Operating-rooms 22-25˚С Air humidity Habitable rooms 40-60 % Devices: psychrometer, Operating-rooms up to 55% hygrometer Speed of air movement Habitable rooms 0.2-0.4 m/sec Devices: anemometer, Child institutions 0.07-0.1 m/sec catathermometer

Air Temperature The optimal temperature range for any premises (rooms) is 18-22ºС, for sports halls — 16-18˚С, for operating-rooms — 23-25°С (prevention of postoperative complications from cold are necessary, because in patient under narcosis the centers of thermoregulation do not work).

Fig. 9. Instruments and methods of taking air temperature

The instruments for taking air temperature are called thermometers. Thermometers may be: household, minimal and maximal. The household thermometer shows temperature at the given moment, it does not fix the temperature. The minimal thermometer fixes the lowest temperature for a certain period. The minimal thermometers have a capillary with alcohol inside. The maximal thermometer fixes the highest temperature for a certain period. The maximal thermometers have a capillary with hydrargyrum inside. The medical thermometers are maximal thermometers. Rules for Taking Air Temperature in a Room

 Taking air temperature horizontally. The temperature of air is taken at a height of 1.5 meters above floor level in five points. The first, second, third, fourth points are the four corners of a room. The fifth point is in the centre of a room. The odds between measurements of air temperature in these points should be not more than 2º С.  Taking air temperature vertically. The temperature of air is taken in the centre of a room at a height of 0.1 meter above floor level (at a level of man‘s feet) and 1.5 meters above floor level (at a level of man‘s respiratory organs). The odds between measurements of air temperature in these points should be not more than 2.5º С.  Taking air temperature within a day.  The temperature is taken in a room in the morning, afternoon, evening and night. The odds between these measurements should be not more than 5º С at local heating (fireplaces, furnace). The odds between these measurements should be not more than 3º С at central heating (radiators of central heating).

Fig. 10. Thermograph

The purpose of this device is determination and recording of fluctuations of air temperature within time. Design and principle of its work:  A perceiving part — a temperature sensor: it presents a bent bimetallic plate consisting of 2 metals having various temperature coefficients. At fluctuations of temperature the radius of plate curvature changes, that is transferred to the pointer with the help of lever system including the driving mechanism — lever, rod, regulator, axis.  A recording part: the pointer, which has a writing point on one end, registering on a tape having an hour and day scale of temperature changes.  Drum with an hour mechanism. The tape is reeled up on a rotating drum; the drum can make a complete revolution for one day (daily) or for one week (week- ly). Thermograph provides continuous registration of air temperature in a range of +45 - -55º С with accuracy of ±1º.

Humidity of Air

The following types of humidity are distinguished:  Absolute — the amount of water vapours in the air at a given moment (g/m3 or mm/Hg);  Maximal — the greatest possible saturation of air with water vapours at a given temperature,  Relative = absolute/maximal in %. The norm of air humidity is 40-60 % (30-70 %); at a lower humidity dryness of skin and mucous membranes are observed, at a higher humidity the disturbance of heat emission takes place. In operating-rooms the humidity should be not more than 55 % in order to prevent the explosion of ether-air mixture).

Devices for Measurement of Air Humidity

Fig. 12. Assman’s Psychrometer (Aspirational)

Fig. 11. August’s Psychrometer

Estimation of air humidity. It is necessary to moisten the thermometer with water, to start the fan with a key, to hang up the device on a support at a distance of 2 m above the floor. The device can also be used at negative temperatures, but not lower than –10ºС. In 4-5 minutes write down the indications of dry and damp thermometers. As from the surface of a mercury ball of the damp thermometer the evaporation of moisture and absorption of heat occur, it will show a lower temperature. Calculation of absolute humidity is done by the formula:

A — absolute humidity; f — maximal pressure of water vapours at temperature of damp thermometer; 0.5 — constant psychrometric coefficient (amendment to speed of air movement); t — temperature of the dry thermometer; t 1 — temperature of the damp thermometer; Н — barometric pressure; 755 — average barometric pressure. The maximal pressure of water vapours at t° of damp (f) and dry (F) thermometers is determined by the tables. Relative humidity (R) is calculated by the formula:

R — relative humidity; A — absolute humidity; F — maximal humidity at temperature of the dry thermometer.

Speed and Direction of Air Movement The normal air speed is 0.2-0.4 m/sec (according to sensations of a person), in a day nursery — up to 0.1 m/sec (prevention of colds). Air speed is measured by an anemometer if the speed is more than 1 m/sec, or by a catathermometer if is less than 1 m/sec according to Hill‘s formula. For investigation of direction of air movement in open places weather-vanes are used. The construction of wind rose, i.e. a graphic representation of primary direction of air movement in the given area is very important at location of various objects.

Devices for Estimation of Air Movement Speed

Fig. 13. Anemometer

A large pointer goes around a dial having 100 divisions, indicating meters; small pointers move around a dial having 10 divisions and showing hundreds, thousands, tens of thousands and more meters. Each small pointer at a complete revolution shows 10 times larger values than the previous pointer; for example, the transition of the first small pointer to one division (100 m) is equal to a complete revolution of a large pointer; the transition of the second small pointer to one division is equal to a complete revolution of the first small pointer, etc. On observation a person faces a wind and establishes the device in such a way, that the dial should face the observer. The indications of pointers are written down (a large pointer is established on zero), then the scales should rotate idle for 1-2 minutes, and after that the counter of anemometer is switched on, simultaneously with a stop-watch. In 10 minutes the counter is switched off and new indications of pointers are written down. The difference in indications between the number of meters passed by air flow for the period of observation is found out. The obtained number of meters is divided into amount of seconds of the anemometer work.

Fig. 14. Katathermometer

Very weak air flows are determined with the help of katathermometer (cylindrical or spherical), representing a special spirit thermometer with a scale of 35-38º or 33-40º. At first the cooling ability of air is determined. For this purpose a katathermometer is put into hot water (about 80ºC) and heated up until the spirit rises up to half of top expansion of a capillary. After that the device is wiped and hung up on a support or held on the outstretched arm in place of investigation, protected at that from effect of sun energy by means of a small screen (cardboard, plywood). Then, keeping an eye on the stop watch, it should be found out, how much time it takes the spirit to go down from 38 to 35º; the experiment is repeated twice and the average value is calculated. CAA (cooling ability of air) is estimated by the formula: Н = F/t (mCal per second/cm2), where F — a katathermometer factor (it is indicated on the back side of each device), t — time of cooling a katathermometer.

Knowing CAA, the speed of air movement is calculated according to the Hill‘s formula:

where Н — the cooling ability of air; Q — difference between a body temperature of the man (36.5º С) and temperature of a premise; 0.2 and 0.4 — empiric factors, Х — speed of air movement in m/sec (for small speeds up to 1 m/sec).

Atmospheric Pressure. Devices for Estimation of Atmospheric Pressure

Fig. 15. Barometer

A barometer consists of a vacuum metal box with elastic wavy walls. The fluctuations of atmospheric pressure have an effect on capacity and form of the box, which walls are flexed inside at increase of pressure, and are straightened at decrease of pressure. With the aid of a spring and system of small levers these changes are transmitted to a pointer moving around a dial, on which the divisions corresponding to a scale of a mercury barometer are marked. The figures of the scale designate hundreds and tens millimeters mercury; units are counted by in- termediate divisions of the scale. Before readout it is necessary to knock cautiously on the device glass to prevent friction of the metal transmission parts. On the dial there is also a thermometer, which indications should be written down. Metal barometers are less precise than mercury ones, but they are portable and convenient in application. Some of them have the second pointer for indicating pressure at a given moment.

Fig. 16. Barograph

For continuous observation of fluctuations of atmospheric pressure a self-recording device — barograph is used, which sensor part is composed of a number of aneroid boxes connected with each other. At change of pressure these boxes move, that is transferred by the system of small levers to the pointer with a writing point rotating with the speed of one complete revolution per week. All components of the device are placed in a case, which opens only at change of tapes.

Methods of Complex Estimation of Microclimate The main goal is a complex estimation of microclimate according to one parameter. Several methods of microclimate estimation are distinguished.

Catathermometry This method was offered by American scientist Hill in 1916. It is based on speed of cooling a heated body depending on 3 factors of microclimate. A catathermometer is a model of a human body heated up to 36.6°C. The cooling ability of air (H) is determined by the formula:

H = F / t (millicalories/cm2/sec)

(F — factor of catathermometer — a specific heat emission, t — time of cooling a catathermometer from 38°C to 35°C in seconds). The normal H is 5.5-7 mCal/cm2/sec. If this value is less, it is hot and stuffy, if it is higher, then it is cold. This method is now applied for measuring small speeds of air movement by Hill‘s formula.

Method of Effective Temperatures (ET) It was developed for USA Navy (submarines, etc.). The microclimate was estimated by a thermal state of a person at mass examination of seamen in a special chamber with the following parameters of microclimate: Е (humidity) = 100 %; V (speed of air movement) = 0 m/sec; only the parameter of air temperature was variable. A comfort zone of thermal state of people upon these conditions makes up 17.2-21.7° EТ. A line of comfort is 18.1-18.9° EТ. The effective temperatures are determined by nomograms or tables with the help of indications of dry and damp thermometers and speed of air movement. The further modification of this method is the method of equivalent-effective temperatures (EEТ). Additional chambers were created where Е (humidity) or V (speed of air movement) changed in such a way that the thermal state of a person corresponded to EТ in a comfort zone. As a result tables were developed for automatic air conditioning via computer.

Application of Methods of Complex Estimation of Microclimate Methods of complex estimation of microclimate are used in the following situations:  At conditioning premises while staying indoors for a long time — spacecrafts, planes, submarines.  In balneology — for dosing air procedures.  For improvement of hygienic working conditions in hot workshops of industrial enterprises. Apart from this, microclimate can be estimated by thermal state of people staying in a given premise with the help of:  a questionnaire technique — interrogation of people in a premise about their thermal state of health — a 7-point scale of heat sensation exists (but many people are required for examination),  method of skin (dermal) temperatures by means of electrothermometer: Table 26 Temperature Temperature of Temperature of t1 — t2 Thermal sensation the forehead skin dorsum of hand (t1) (t2) 10 31.2 24.2 > 6 cold 20 33.5 29.1 3 — 4 comfort 30 35.3 33.1 2.2 hot 35 35.8 35.6 < 1.5 very hot

 Technique of perspiration measurement — by electroresistibility of skin, by

39 means of special dyes.

Recommendations for Practical Classes on the Theme Lesson No. 1. Hygienic Requirements to Factors of Microclimate

Key Questions 1. Concept of climate and microclimate. 2. Hygienic significance of air temperature and rules of its measurement. 3. Hygienic significance of air humidity and methods of its estimation. 4. Hygienic significance of speed of air movement and methods of its estimation. 5. Characteristics of microclimate of hospital wards and operating rooms, and other premises. 6. Concept of ―wind rose‖, its hygienic estimation. Learning Objectives and Their Concrete Definition 1. To know devices for estimation of air temperature and humidity. To get acquainted with a technique of estimation of air temperature and humidity in premises. 2. To know the design and rules of work with devices for estimation of temperature in degrees by Celsius: the minimal thermometer; the maximal thermometer; the household thermometer; the electronic thermometer; thermograph (see Appendixes). 3. The estimation of air humidity is carried out with the help of Assman‘s and August‘s psychrometer with application of formulas and psychrometric tables. 4. Devices for estimation of speed of air movement. A technique for estimation of air movement speed in a lecture-room. Design and rules of work with devices for estimation of air movement speed. Anemometer. 5. Method of construction of ―wind rose‖ and its hygienic estimation. Concept of "Wind Rose" Winds blow permanently in atmosphere. The direction of wind may be: northeast, north, north–west, west, south–west, south, south–east, east. The direction of wind is indicated by a point whence the wind blows.

Fig. 17. The construction of "Wind Rose"

Example:

Graphic presentation of the primary direction of air movement in a given area is called a "wind rose". The direction of wind begins in the center of the picture. Points of the wind direc-

41 tion are connected with a line. In this picture the wind blows from the east more often. Scientists use the "wind rose" at constructing industrial enterprises, hospitals, houses. Industrial enterprises must be constructed in a town zone where winds blow least of all. Example: Where must the industrial enterprises, hospitals, apartment houses be constructed? Solution Industrial enterprises must not be constructed in the east of town. They must be constructed in other town zones (north-east, west, south). In this case the town will not be polluted with industrial wastes. Hospitals must be constructed in the east of the town (the cleanest zone of the town). Blocks of flats must be constructed in the north, north–west, south–west, south– east, east of the town. Self Test 1. Which of the following devices are used for estimation of humidity? (More than one answer may be correct) *A. Psychrometer B. Thermograph *C. Hygrometer D. Anemometer E. Wind vane 2. The optimal norm of relative humidity for premises is: *A. 40-60% B. 30-70% C. 10-30% 3. In the classroom on the 5th lesson the following parameters of microclimate have been found out: temperature — 25°С, relative humidity — 79 %, speed of air movement — 0.1m/sec. What physiological parameters testify to unfavorable effect of microclimate on a functional condition of the pupils‘ nervous system? *A. parameters of capacity for work and chronoreflexometry B. pulse, respiratory rate, vital capacity of the lungs C. parameters of capacity for work D. body temperature, chronoreflexometry 4. In which operating room is microclimate for the operating surgeons more favorable? *A. temperature — 23°C; relative humidity — 40 %; speed of air movement — 0.03 m/sec B. temperature — 25°С; relative humidity — 45 %; speed of air movement — 0.09 m/sec C. temperature — 23°С; relative humidity — 40 %; speed of air movement — 0.1 m/sec D. temperature — 24°С; relative humidity — 30 %; speed of air movement — 0.05 m/sec E. temperature — 25°С; relative humidity — 50 %; speed of air movement — 0.08 m/sec 5. The relative humidity of air in a hospital ward meets the requirements of hygienic norm. Choose the optimal value. *A. 30 — 60 % B. 30 — 70 % C. 30 — 80 % D. 20 — 40 % E. 20 — 50 %

Problem Solving 1. On inspection of conditions of patients‘ staying in the hospital the following has been established: the area of a single-bed ward is 6 m2, an average air temperature — 18° C, humidity — 60 %, speed of air movement — 0.18 m/sec. Give a hygienic estimation of microclimate in the ward. 2. In city N. the engineering plant is being constructed. According to a long-term observation the recurrence of winds makes up (in percentage): N — 14, NE — 5, E — 2, SE- 6, S- 19, SW — 26, NW — 18. Specify the optimal direction of the engineering plant location in relation to the built-up area of the city.

Standard Answers: 1. The microclimate in the ward is satisfactory; all the parameters correspond to the hygienic norms. 2. East, as the recurrence of winds from the east direction was equal to 2 %, that is the least value.

Lesson No 2. Methods of Complex Estimation of Microclimate. Types of Disturbance of Thermoregula- tion in Conditions of Hot Climate

Key Questions 1. Bases of physiology of a human heat exchange and its connection with a microclimatic condition of the environment. 2. Hygienic significance and technique of estimation of organism physiological reactions, which manifest the condition of the thermoregulation system. 3. Methods of complex estimation of microclimate:  katathermometry  effective temperatures;  equivalent-effective temperatures 4. Application of methods of complex estimation of microclimate. 5. The disorders in a health condition and diseases which occur due to effect of discom- fort microclimate on the man. Measures of their prevention.

Learning Objectives and Their Concrete Definition 1. Estimation of cooling ability of air (CAA) by method of katathermometry. For the purpose a katathermometer (see the description in the previous lesson) is placed into hot water (about 80°C) and heated up until the spirit rises up to half of top expansion of a capillary. After that the device is wiped and hung up on a support or held on the outstretched arm in place of investigation, being protected from effect of sun energy by means of a small screen (cardboard, plywood). Then, keeping an eye on the stop watch, it should be found out, how much time it takes the spirit to go down from 38 to 35°; the experiment is repeated twice and the average value is calculated. CAA (cooling ability of air) is estimated by the formula:

Н = F/t (mCal per second/cm2),

where F — a katathermometer factor (it is indicated on the back side of each device), t — time of cooling a katathermometer. The normal CAA = 5.5-7.0 mCal per second/cm2; if this parameter is lower than the norm, there will be overheating, if it is higher — overcooling. 2. A technique of estimation of effective temperatures by nomogram. A total effect of temperature, humidity and air movement are expressed now in degrees of effective temperature. The indications of dry and wet thermometers of a psychrometer, as well as data about speed of air movement are necessary for estimation of effective temperature by nomogram. Having obtained them, the procedure is as follows: points on the right and left scales of nomogram corresponding to indications of dry and wet thermometers are connected by a line. The place of intersection of this line and the curve of appropriate speed of air movement gives the value of effective temperature. Example: The temperature of the dry thermometer of psychrometer is 24С, the temperature of the wet thermometer of psychrometer is 16С. Air speed is 30 m/min. Determine the effective temperature under these cinditions. Solution: On the left-hand side of nomogram we find the temperature of the dry thermometer; on the right-hand side of nomogram — the temperature of the wet thermometer. We superimpose bar on both retrieved points. We see that the bar intersects a curve of air movement speed corresponding to 30 m/min in a point marked by figure 20. This figure will thus be considered the effective temperature. On the basis of numerous observations the following

43 norms of effective temperatures are distinguished: a) The zone of comfort is 17.2–21.7 effective temperatures. At these temperatures 50 % of people feel well and comfortable. b) The line of comfort is 18.1-18.9 effective temperatures. At these temperatures 100 % of people feel well and comfortable.

3. Definition of equivalent-effective temperatures. There is a special table, according to which we can find out the optimal microclimate for a person at different values of temperature, humidity and speed of air movement so, that heat sensation of organism is as if in a zone of comfort.

Algorithm of Practical Work of Students The first stage. Testing the initial level of knowledge and skills. The second stage. Active participation in discussion of key questions on the theme of the lesson. The third stage. Independent work on estimation of CAA, speed of air movement in a premise, determination of effective temperatures. The fourth stage. Solving situational tasks and final testing on the given theme. Self-control Test 1. Where are the centers of thermoregulation in a human organism? A. brain cortex B. hypothalamus *C. medulla oblongata D. cerebellum E. reticular formation 2. What are the devices for estimation of cooling ability of air? A. psychrometer B. thermograph C. hygrometer D. anemometer *E. katathermometer 3. Specify the zone of comfort according to effective temperatures (in ° ET): *A. 17.2-21.7 B.18.0-22.0 С. 20.1-23.5 D.18.0-20.0 E.16.0-18.0 4. What factors influence the intensity of cooling the heated body? *A. air temperature, air humidity, speed of air movement B. air temperature, air humidity C. air temperature, speed of air movement D. air temperature E. air humidity; radiation temperature 5. At harvesting grain in July the air temperature outside was 31°С; in the cabin of combine harvester — 35°С, speed of air movement — 0.2 m/sec, relative air humidity — 55 %, temperature of sides and roof of the cabin — 45 oС. Normalization of microclimate in the cabin is possible by means of A. thermal isolation of sides and roof B. decrease of air humidity C. increase of air humidity *D. cooling of the air E. increase of speed of air movement 6. In patient with pneumonia the body temperature has increased up to 39°С, the skin integuments have turned pale and become dry, gooseflesh occurred. What disturbances of thermoregulation caused these manifestations of fever? A. dilatation of vessels, increase of perspiration, prevalence of heat production *B. vasoconstriction, decrease of perspiration, prevalence of heat production

C. decrease of heat production, relaxation of tonic muscles and vessels D. disintegration of brown fat E. balance of heat production and heat emission

Problem Solving 1. The dry thermometer shows 20°C, and the wet one — 16°C. The speed of air movement is absent. Determine the effective temperature under the given conditions (according to nomogram). 2. Determine CAA and speed of air movement in the corridor of a hostel, if F-factor of katathermometer is 630, time of its cooling — 90 sec. Temperature in the premise is 21.0°С. 3. What can the thermal health state of the man in a habitable room be, if the air temperature ranges within the limits of 18-20°C, difference in horizontal and vertical directions is 2.0-2.5°С respectively?

Standard Answers 1. According to nomogram we find the point of intersection of the line showing the temperature of dry and wet thermometers with the line of speed of air movement = 0. The answer: ET = 18.5°. 2. The ratio of F:t = CAA = 630/90 = 7.0 mCal/cm 2 /sec, that corresponds to the norm. According to Hill‘s formula we determine the speed of air movements, which is equal to Н = 7.0; Q = 36.6 — 21 = 15.6°. Hence Х = 0.36 m/sec, that is a norm. 3. It is satisfactory, as all parameters are within the limits of the norm. Sources of Information S. Shibanov. Lectures on Common hygiene and Ecology. Simferopol. 2003. 130p. Park‘s Textbook of Preventive and Social Medicine. India, 2000.— 16th edition.— 660p.

Theme No 4.

Weather and Health. Prevention of Heliometeotropic Reactions. Climate and Problems of Acclimatization In spite of the fact that the influence of weather on the man is known for a long time, this problem is still insufficiently investigated and even now it is little used by doctors in their practice. It is conditioned by the following:  The concept of ―weather‖ is very complex; it has many components, which are not well investigated in meteorology.  Up to now the mechanisms of development of meteotropic reactions in the organism are not well investigated. The Concept of Weather and Climate Weather is a dynamic set of physical properties of surface air (troposphere) for a short time interval (hours, day, weeks). Climate is a long-term mode of weather naturally repeated in the given area; its parameters are: an average monthly temperature of air, an average number of rainy days, etc. Thus, weather is a changeable phenomenon, while climate is a statistically constant concept. The basic weather-forming factors are:  Heliophysical — intensity of a solar radiation and a solar activity  Geophysical — intensity of a geomagnetic field, geomagnetic storms  Electric condition of atmosphere — intensity and gradient of electric field, air ionization, etc.  Meteorological — temperature, humidity, speed and direction of air movement, atmospheric pressure  Synoptic — cloudiness, atmospheric precipitation  Chemical structure of atmosphere — content of oxygen, СО2, pollutants in atmospheric air. All these factors are interrelated and affect a person in a complex way; there is a difficul-

45 ty of their all-round evaluation. Meteorological factors are sharp fluctuations of temperature and atmospheric pressure: the greater the differences — the more biotropic the weather is. These factors are most investigated as reasons of development of meteotropic reactions (MR). A certain role is played by changes of chemical composition of atmosphere — under some weather conditions there may be the decrease of absolute content of oxygen in the air by 60 g/m3 and over. The annual tendency of oxygen content is increasing in winter and decreasing in summer; the maximal fluctuations are in autumn and spring (the factor of an interdaily variability is more than 50 %). An electric condition of atmosphere includes:  The content of positive or negative aeroions in the air  The gradient of the electric field of the Earth Synoptic factors are caused by atmospheric circulation of warm and cold air masses. There are 3 types of air masses — warm, cold, neutral (local). At their movement the atmospheric fronts are formed — warm, cold, occlusions (mixture of warm and cold masses). The frequency of changing air masses is on average once per 5-6 days, but it may be more or less often — it depends on type of atmospheric circulation:  Cyclone is an atmospheric whirlwind with low pressure in the center and movement of air masses counter-clockwise. It occurs more often in winter, on average about 40 cyclones per year occur above Europe. It is characterized by unstable weather — cloudiness, atmospheric precipitation, hurricanes, typhoons; there is great difference of atmospheric pressure, temperature, content of О2. The weather is biotropic.  Anticyclone is an atmospheric phenomenon with a high pressure in the center and movement of air clockwise. The weather is clear — very hot in summer or frosty in winter. There are no sharp differences of weather factors, the weather is more favourable.

Heliophysical factors.Up to now these factors are insufficiently taken into account at estimation of weather, though the ingenious founder of heliobiology A. L. Chizhevsky in 1920s determined the influence of solar activity on living organisms, including people. There are data on coincidence of periods of increased solar activity with revolutions, wars, epidemics, even with frequency of car accidents. The difficulty of studying this question consists in cyclic changes of solar activity having different periodicity — 11 years, 22 years, 60 years and over, which can overlap each other and are poorly studied. The most investigated are 11-12-year cycles; the beginning of the last 24th cycle known to mankind is 1997, thus the maximal activity is in the middle of the cycle (2001-2002 years). Parameters of solar activity include the following:  Wolf index (W) — amount of spots on the Sun,  index S — the total area of spots,  intensity of radioactive radiation of the Sun on the wave of 10.7 cm,  the solar wind is the corpuscular streams (protons, electrons, etc.) from the Sun which carry away with themselves the magnetic fields and form the spiral-sector structure of interplanetary magnetic field (IMF) of + and -- signs. Every 6-7 days, while moving in orbit, the Earth gets in IMF of other sign that results in changes of geophysical parameters of electromagnetic field of Earth (EMF), its deviation from a usual level named "magnetic storms", which may be planetary and local or by intensity — weak, moderate and strong. Evaluation of Degree of Weather Changeability It is determined according to the formula:

K — coefficient of weather changeability in %

N — number of days with contrast change of weather n — total number of days in the observed period Table 27 Degree of Weather Changeability (V. Rusanova, 1973) Weather Coefficient of changeability, % Very stable 25 Stable 25–30 Changeable 30–50 Very changeable more than 50

Reasons, Mechanisms and Manifestations of Heliometeotropic Reactions (HMR) People as a whole has adapted to rhythmical changes of climate and weather connected with changes of day and night, season of the year. At aperiodic sharp changes of weather factors HMR occur in people: the sharper changes of weather are, the more expressed the HMR are. HMR is neither a disease nor a diagnosis, it is a specific pathological condition having manifestations of various degree of expressiveness in different people. According to meteosensitivity all people are divided into 2 categories:  meteostable, i.e. tolerant: young healthy people  meteosensitive — according to different data these are 30-70 % of population of elderly age; up to 90 % of patients with bronchial asthma, hypertension. The reasons of HMR occurrence are sharp fluctuations of above-stated weather factors. V. F. Ovcharova (1986) distinguished the following biological effects of weather influence: tonic, spastic, hypoxic, hypotensive. Manifestations of HMR  A mild degree — asthenovegetative syndrome — a mass character and syn- chronism with changes of weather allow to suspect the presence of HMR.  A moderate degree — headaches and heartache, marked changes of pulse, blood pressure.  A severe degree — aggravation and exacerbation of chronic diseases, e.g. stroke, heart attacks, aggravation of bronchial asthma resulting in growth of patients‘ mortality. Diseases at which MRs are revealed can be subdivided into two groups:  Diseases at which the presence of HМR is authentically proved, including:  Cardiovascular diseases — statistically authentic growth of number of strokes, hypertonic crises, heart attacks and mortality at biotropic weather, including the emergency data;  Bronchial asthma — increase and exacerbation of asthma attacks, mortality;  Rheumatism — activation of the process, exacerbation of polyarthritis, arthralgias in 90 % of patients;  CNPD (chronic nonspecific pulmonary diseases) are marked in 60-72% of patients (according to the data of Yalta scientific research institute).  Diseases for which data on availability of HМR is present: diseases of gastrointestinal tract (stomach ulcer, gastrites, colites, etc.) — in 40-60 % of patients, diseases of kidneys and urinary tracts — in 40-50%, diabetes mellitus (exacerbation of the course) — in 20%, psychiatric disorders — in 50 % of patients, ophthalmologic, surgical pathology, etc. Among ill children 25-45% are meteosensitive. Medical Estimation of Weather and Prevention of HМR The basis of all medical classifications is the concept suggested by N.E.Vvedensky about the force of external irritation which may be low, moderate and high. Thus, according to G. P. Fedorov's classification there are 3 types of weather: optimal, irritating and acute; according to other classifications there are from 4 to 7 types.

The main thing in medical estimation of weather is sharpness of fluctuations of weather factors, their intraday differences. The scientists of the Yalta climatic scientific research institute named after Sechenov have suggested the common clinical index of weather pathogenicity — the sum of specific indexes of weather changes per 24 hours according to the most important weather factors. If the index is 0-19, the weather is optimal, 20-49 — irritating (it demands intensive medical control), more than 50 — acute (it demands strict medical control). There are also indexes of weather changeability (for estimation of climate). The department of hygiene of Kiev medical university suggested the scheme of medical estimation of weather according to 15 parameters.

The system of prevention of HMR has 3 basic directions:  Common hygienic methods: rational nutrition, improvement of life and working conditions, etc.  Organizational measures: medical weather forecasts, medical estimation of weather.  Medical prophylactic measures, including:  Increase of nonspecific resistance of organism.  Sparing regimen  Medicinal prevention with specific and nonspecific agents, such as sedatives, spasmolytics, neuroleptics, etc. Thus seasonal and urgent prevention is distinguished. The former means a regular intake of small doses of preparations in unfavourable for the given area months (see Table below). The urgent prevention is carried out for meteosensitive cardiological and other patients in hospital in the periods and days of biotropic weather on the basis of urgent medical weather forecasts. Table 28 Periods for Seasonal Prophylaxis of Cardiovascular Diseases in the Crimea (V. Bardov, 1985) Disease The most unfavorable months for authentic increase of exacerbation rate hypertonic crises 2, 3, 4, 5 and 12th month stenocardia attacks 1, 2, 3, 4, 5 and 11th month myocardial infarction 1, 2, 3, 4, 5, 7, 8th month disturbance of cerebral circu- 1, 3, 4, 5, 6, 12th month lation (stroke, etc.) Hygienic Significance of Climate Climate is a long-term mode of weather in a given region. The basic climate-forming factors are:  the geographical latitude influencing the size of solar radiation,  height above sea level, relief and type of terrestrial surface (ice, snow, etc.),  features of circulation of air masses,  proximity to seas and oceans. Parameters of climate are average statistical (average monthly, average annual) parameters of meteorological factors, wind rose, number of clear days, etc. An important parameter is the index of weather instability:

T = a / b,

where a — the number of days with weather changes, b — number of days of the observation period (season, year). If index T is over 0.5, the climate is unfavourable (not good for ill person). At long living under certain climate a certain dynamic stereotype develops in a person which provides normal vital activity. At sharp change of climate (moving to different climatic zone) acclimatization is observed, i.e. a complex set of functional-morphological changes in organism, directed at adaptation to new climatic conditions.

Conditionally 2 stages are distinguished in this process:  partial acclimatization or adaptation — from the first hours up to 14 days (in sick people — about 30 days and over).  full acclimatization — in 14 days during some months, to conditions of Far North — up to 1.5 years. During acclimatization the resistance of organism to unfavourable factors of the environment is reduced that results in increase of disease incidence, asthenovegetative syndrome, etc. Acclimatization should be taken into account in balneology: patients should not be sent to resorts with sharply differing climate (24 days are the basic period of acclimatization). This presents a great problem for the Army, Navy, people working in the Far North. Recommendations for Practical Classes on the Theme

Key Questions: 1.The basic weather-forming factors and their characteristics: -meteorological -Synoptical -Heliophysical -Geophysical -Electical state and content of the atmosphere 2.Reasons and mechanisms of development of heliometeotropic reactions. 3.Manifestations of heliometeotropic reactions, diseases accompanied by them. 4.Medical classifications of weather and its medical estimation. 5.System of prevention of heliometeotropic reactions. 6.Acclimatization, its types and reasons. Features of acclimatization to a hot and cold climate. Significance of acclimatization for balneology.

An Example of a Problem Task on Hygienic Estimation of Weather Conditions According to the data of the city meteorological station the weather condition in town N. was characterized by the following: From October 20 till October 24 the anticyclonic weather, partly cloudy, without atmospheric precipitation was observed. The atmospheric pressure was 760 mmHg, the air temperature — +12º, daily temperature difference — 3 º, daily pressure difference — 3 mmHg, relative air humidity — 60 %, content of O2 in the air — 325 mg/l, speed of wind — 1.5 m/sec. According to synoptic forecast such weather will last for 3-4 days, then there will be its sharp change connected with moving of a cyclone and passage of a warm front. There will be significant clouding, intensive precipitation. According to forecast the meteorological parameters will be the following: atmospheric pressure — 475 mmHg, air temperature — + 6 º, daily temperature difference — 7 º, daily pressure difference — 7 mmHg, relative air humidity — 100 %, O2 content in the air — 250 mg/l, speed of wind — 10 m/sec. The tasks: 1.To determine the type of weather by medical classifications. 2.To determine the degree of weather changeability. 3.To characterize meteorotropism of the revealed types of weather.

Appendix No. 1 Medical Classification of Weather by I. Grigoriev (1974) Type of weather Characteristics of weather 1. Extremely favourable It is stable, caused by anticyclone, precipitation is absent. Atmospheric pressure is over 760 mmHg, daily pressure difference is not more than 5 mmHg, wind speed is 0-3 m/sec, O2 content is more than 315 mg/l. 2. Favourable Insignificant weather changes of a local character, there is short-term precipitation, variable cloudiness.

Atmospheric pressure — 760-755 mmHg, daily pressure difference — 6-8 mmHg, daily temperature difference is not more than 5ºC, wind speed — 4-7 m/sec, O2 content is more than 315 mg/l. 3. Unfavourable (requires a special med- It is cloudy, unstable, there is precipitation caused by a ical control) cyclone, local storms. Atmospheric pressure is 754-745 mmHg, daily pressure difference is 9-14 mmHg, daily temperature difference is 6-9ºC, wind speed is 8-10 m/sec, O2 content is 289-260 mg/l. 4. Extremely unfavourable (requires a The weather is caused by a deep cyclone. There are strict medical control) thunder-storms, intensive precipitation. Atmospheric pressure is below 745 mmHg, daily temperature difference is 10ºC and over, O2 content is below 260 mg/l. Self-control Test 1. A female patient from Kharkov, aged 62, has the diagnosis of arterial hypertension of III stage with hypertensic crises. She is administered the necessary permanent chemo- and physiotherapy. Give recommendations as for the place of health resort treatment in cardiac sanatorium. A. Black Sea coast of Caucasus (Batumi) B. Baltic Sea coast (Yurmala) *C. Local sanatorium (near Kharkov) D. Sanatorium near Kiev E. Southern coast of Crimea (Yalta)

2. A patient from Kiev, aged 70, has the diagnosis of chronic ischemic cardiac disease with vascular insufficiency of III stage. The necessary permanent chemo- and physiotherapy is administered to him. He heard the weather forecast on TV: ―A deep cyclone with low atmospheric pressure is expected tomorrow‖. Give recommendations to the patient. A. Treatment according to the common scheme or by applying a sparing regimen *B. Application of spasmolytic and anticoagulant preparations in addition to the usual scheme of treatment C. Hospitalization in the ―Biotron‖ ward D. To include vitaminotherapy E. To follow the usual home and working regimen

3. The doctor-cardilogist received the urgent warning of the weather bureau. The next day a large magnetic storm due to flare on the Sun was expected. Give recommendations concerning changes in the scheme of treatment of the patients with chronic ischemic cardiac disease in the in-patient department. *A. To intensify spasmolytic and anticoagulant therapy B. To administer hypotensive preparations C. To administer a bed regimen D. To prolong the administered earlier treatment E. To cancel the administered earlier medical-diagnostic procedures

4. What group of weather-forming factors do temperature and humidity of air refer to? A. Synoptical *B. Meteorological C. Heliophysical D. Geophysical E. Microclimatic

Theme No 5.

Chemical Composition of Atmospheric Air. Effect of its Components on the Man. Protec- tion of Atmosphere from Pollution

Significance of Atmospheric Air The atmospheric air is a source of breathing for man, animals and vegetation; stuff for processes of burning and synthesis of chemical substances; material for cooling the industrial and transport installations; the environment for natural and anthropogenic wastes and pollutant emissions. Chemical Composition of Atmospheric Air Atmosphere is a part of biosphere which is the gaseous environment of the Earth rotating together with it. This environment has some layers. The upper and lower parts of atmosphere are distinguished. The lower part, particularly troposphere, is of special interest. The air of troposphere (the surface layer of atmosphere up to 10-25 km) represents a mechanical mixture of various gases: Table 29

Gas Content volume in % Nitrogen 78.09 Oxygen 20.95 СО2 0.03 — 0.04 Other gases: argon, neon, helium, 1.0 etc.

Besides in the air different admixtures of natural and anthropogenic origin are practically constantly present, e.g. ammonia, methane, nitric oxides, hydrogen sulfide, hydrocarbons, etc. Natural dust pollution of atmosphere is composed of space dust, terrestrial dust (soil, vegetative, fire, volcanic). Effect of Components of Atmospheric Air on a Human Organism

Oxygen. Significance of Oxygen in Biosphere In the nature the processes of oxygen consumption and excretion constantly take place. The consumption of oxygen occurs at respiration of human and animals, at burning, different oxidizing processes, etc. However, its content in the atmosphere remains practically constant due to its excretion by phytoplankton of oceans and green plants. For a person oxygen is necessary for oxidizing biochemical processes in organism. At lack of oxygen in organism hypoxia of various degree of severity occurs. It is not the percentage but absolute amount of О2 in the air, depending on its partial pressure (part of the atmospheric pressure for the given gas) is of great importance for a person. Partial pressure of oxygen decreases at cyclones and also at climbing a height. Pathogenesis, Symptomatology, Prevention of Mountain (High-Altitude) Illness This disease may be encountered in mountaineers, inhabitants of mountains and pilots. Pathogenesis: It is a decrease of partial pressure of oxygen in the air at ascending heights and decrease of partial pressure of oxygen in the alveolar air. Amount of oxygen entering organism depends on gradient G (difference between the partial pressure of oxygen in the alveolar air (Pair) and in blood (Pblood):

G = Р in air / Р in blood

On ascending heights Pair decreases. If gradient of pressure decreases, hypoxia of various degree of severity occurs.

The following zones of oxygen pressure affecting a human organism are distinguished:  Inert — up to 2 km → it is safe for health  Complete compensation — up to 4 km → increase of lung ventilation, minute volume of blood  Incomplete compensation — up to 5.5 km → headache, euphoria, sleepiness, memory impairment  Critical — up to 8 km → loss of consciousness  Threshold of mortality — higher than 8 km → death. Height of 8 km is a death threshold.

Symptomatology of Mountain Illness Acute, subacute (in climbers) and chronic (in inhabitants of high-mountainous settle- ments) forms of mountain illness of a mild, moderate and severe degree are distinguished, e.g. high-mountainous lung hypostasis. The symptoms of the disease are dyspnea, palpitation, malaise, fatigability, sleepiness, nausea, vomiting, nasal bleeding, skin cyanosis. Prophylaxis of Mountain Illness  A step-by-step (gradual) climbing mountains with making camps for the development of compensatory reactions to hypoxia (development of physiological erythrocytosis).  Usage of oxygen apparatuses by pilots of planes  Cabin pressurization of planes

Ozone is an allotropic form of oxygen having formula О3. The ozone layer in atmosphere is located at a height of 20-30 km. Ozone absorbs a space short-wave radiation, including ultraviolet (UV) radiation. The decrease of ozone layer by 20 % due to anthropogenic and natural factors results in "ozone gaps" which in their turn cause the increase of UVR leading to growth of skin melanoma in people. Ozone has high oxidizing properties reducing chemical and microbe pollution of atmosphere. Nitrogen. Significance of Nitrogen in Biosphere Nitrogen is a part of some proteins and nitrogenous compounds. It is the basis of all living beings on our planet. However, living organisms cannot receive nitrogen directly from the atmosphere, except for some bacteria and blue-green seaweeds. Then nitrogenous compounds through food chains pass into other organisms.

Effect of Nitrogen on Organism Nitrogen under normal conditions (the normal atmosphere pressure) is an inert gas (no effect on organism). At the increased pressure nitrogen produces a narcotic effect on the CNS (it is proved by laboratory tests on animals). In divers on the depth of 100 m in 5 minutes dizziness, euphoria, spotty memory defect, hallucination occur. Pathogenesis, Symptoms, Prophylaxis of Decompression (Caisson) Sickness It is often encountered in divers. Pathogenesis  On diving to the depth the pressure of gases as well as solubility of gases in blood increase.  On quick rising of a diver from the depth, or decompression of a plane cabin in the upper layers of atmosphere the pressure of gases sharply falls and solubility of gases in blood decreases.  Nitrogen slowly diffuses through a pulmonary-alveolar membrane and is excreted in blood and tissues in a form of bubbles which diameter depends on depth, i.e. the difference of pressure on depth and on surface. Thus a gas (nitrogen) vascular embolism occurs. Other gases, such as oxygen, CO2, helium quickly diffuse through membrane and do

52 not form bubbles.

Symptomatology The following degrees of severity of the disease are distinguished:  A mild degree of the disease (the diameter of bubbles is very small) results in embolism of only capillaries causing numbness and pain of fingers and toes, headaches.  A moderate degree of disease is manifested by sharp pains in extremities, headaches, pains and inflation of intestines.  A severe degree leads to embolism of large vessels in the CNS (lesion of the vital centers), coronary vessels, pulmonary artery and cardiac arrest. Prophylaxis  A gradual stepped rise to the surface  Substitution of nitrogen by other inert gas — helium  Usage of altitude chamber after rising to the surface

Carbon Dioxide СО2

The content of CO2 in atmosphere is 0.03-0.04%. It is excreted in nature at breathing of biota, processes of burning, etc. Constancy of CO2 in atmosphere is maintained due to its assimilation by plants, absorption by sea and fresh-water reservoirs. CO2 acts on the man and animals as a physiological irritator of the respiratory center. At increased concentrations of CO2 in organism acidosis, disturbances of the CNS occur. Effect of Various СО2 Concentrations on Organism Table 30 СО2 concentration, % Biological effect 0.05 — 0.1 The appreciable dilatation of peripheric vessels 0.5 Change of EEG, increase of respiratory depth 1.0 Acidosis starts 1.0 — 2.0 Decrease of work capacity, toxic effect on CNS 2.0 — 3.0 Expressed irritation of respiratory center and CNS 10.0 — 12.0 Loss of consciousness and death

Maximal Permissible Concentration of СО2 in the Air of Closed Premises In the air of any room the maximal permissible concentration of СО2 is 0.1 % (It was established by Pettencofer in the 19th century). Substantiation of MPC: CO2 is a parameter of air cleanliness and efficiency of ventilation — at growth of СО2 over 0.1 % the increase of concentration of toxic and microbe air pollutants takes place, which can have a harmful effect on a human organism. Air Ventilation, Parameters of its Efficiency The aim of ventilation is to change air in a room. Ventilation is subdivided into the following kinds:  Natural (through windows, doors, window leaves) –due to difference of temperatures or speed of air movement;  Artificial — with the help of ventilators (input ventilation, extract ventilation, combined extract and input ventilation).  Mixed — a combined natural and artificial ventilation

Parameters of ventilation efficiency are the following:  Content of СО2 in the air is up to 0.1 %;  Air changes per hour (for habitable rooms it should be 0.5-1, in kitchens — 2-3, in cinema halls — 5-6);

 Air exchange capacity for 1 person per hour — 20-30 m3. Table 31 Standards of Ventilation for Different Premises Kind of premise Air changes per hour Air change capacity per 1 person Habitable rooms 0.5 — 1 20 — 30 m3 Kitchens, 2 — 3 -―- laboratories Operating room 5 — 6 (with conditioning 8 – -―- 10) Cinema hall 5 — 6 -―-

Ecological and Hygienic Estimation of Anthropogenic Atmosphere Pollution The modern mankind lives in conditions of constant and growing anthropogenic pollution of biosphere. Thus, special danger is presented by pollution of atmosphere:  It is polluted more than other objects of the environment;  Pollutants in the air are more dangerous than those in water, foodstuffs and soil because:  The area of lungs penetrated with vessels is big (120 m2 in adult), that is why at once a big concentration of pollutant in blood is formed;  Blood from the lungs by-passing liver is carried around the whole organism, thus a neutralizing function of the liver is reduced. According to prognosis of UNEP (Program of the United Nations on the environment protection), Washington Science Academy, the pollution of biosphere, including atmosphere, by stable and toxic substances (heavy metals, pesticides, dioxines, etc.), having a tendency to increase in the nearest years, constitutes a real threat of global ecological catastrophe for mankind. Major Factors and Sources of Anthropogenic Pollution of Atmosphere  Chemical substances. The sources are industry, especially petrochemical, transport, processes of fuel burning (thermal power stations, boiler-houses), rubbish-processing factories, agriculture (pesticides, etc.).  Dust — soil erosion, cement works, etc.  Biological pollution — microbes — high density of people in cities, cattle breeding, factories, biological pesticides.  Radioisotopes — nuclear power plant, industry, medicine, nuclear tests.  Thermal pollution of atmosphere — emissions of superheated gases by industrial works and boiler-houses, emission and reflection of heat by the urbanized territories. Factors Affecting the Intensity of Atmosphere Pollution  Amount and intensity of emissions per unit of area, degree of territory urbanization  Height of emissions ( in case of high emissions pollution diffuses on the big territory)  Relief of territory — bad air ventilation in low places, e.g. the center of Simfero- pol.  Meteorological factors — a temperature inversion (a vertical air exchange is complicated), humidity, amount of atmospheric precipitation, speed and direction of winds (a wind rose), etc.  Features of architecture lay-out — sanitary-protective gaps, etc.

 Amount of green plantations. The Ways of Atmosphere Autopurification  Dilution of pollutants in air masses, hence decrease of pollutant concentration up to maximum permissible concentration and lower;  Sedimentation:  Dry — fall-out of large particles,  Damp — removal of pollutants with atmospheric precipitation, i.e. with snow or steady rains. A drawback of sedimentation from air is probable pollution of water and soil.  Chemical reactions under the influence of О3 and UVR, but sometimes photooxidizers may form (smog of a Los-Angeles type) — at its action the irritation of the upper respiratory tract, mucous membranes of eyes, skin, and cancerogenic effect occur. There may be the destruction of metal designs, buildings, etc.  Bactericidal effect of О3 and UVR;  Neutralization of acid and alkaline pollutants, but there can be more dangerous metabolites;  Assimilation and processing of pollutants by ground microflora.

The effect of atmosphere pollution on health of people and conditions of their life It is possible to distinguish two kinds of effect of atmosphere pollution on health of people and conditions of their life:  A direct negative effect is an immediate effect of pollution on organism of a person which results in various biological effects;  An indirect negative effect occurs when pollution influences health of a person indirectly by change of ecological conditions.

A Direct Negative Effect Acute Effect Nonspecific Specific Acute provoking action: toxic fogs– Specific acute poisonings murderers, smog of a Los Angeles type, attacks of bronchial asthma, etc. Chronic Effect Nonspecific Specific Deterioration of parameters of population Chronic specific illnesses: health: demographic, morbidity, physical Itai-itai, Minamata disease, Usho, fluorosis, development, physical disability etc. Remote Effect It may be oncogenic, mutagenic, embryotropic, immunodepressive. An Indirect Negative Effect Increase of rachitis or melanomas (UVR) Deterioration of living conditions of population Acid rains, pollution of foodstuffs, aesthetic harm Fig. 18. Effect of Atmosphere Pollution on Health of Population Basic Directions of Atmosphere Protection from Anthropogenic Pollution  Administrative-legislative measures: Law of Ukraine on air protection, Constitution, Law on sanitary and epidemic well-being of population of Ukraine, and other laws. The administrative measures are taken by local authorities in the given territory.  Hygienic measures include:  Preventive sanitary control (see Topic 1)  Current sanitary control  Medical-preventive measures — studying the effect of pollution on health of population, treatment and improvement of victims, revealing the main negative factors, sources, etc.

 Ecological monitoring — studying the state of ecosystems and separate kinds of biota in interrelation with atmospheric pollution.  Architectural measures — zoning of cities, sanitary-protective gaps between sources of pollution and residential buildings, etc.  Technological measures include:  Application of self-contained technologies — the air is purified and again returns in operation, thus there are no emissions in free air. It is a very expensive method.  Change of technology — transfer of motor transport into usage of electricity, gas; change of chemical technologies with decreased concentration of harmful substances in emissions.  Usage of sewage disposal plants in sources of pollution: . cyclone, multicyclone — a great rotary speed is imparted to emission and the particles drop out in the bunker; . scrubber — air passes through water and gases are purified; . electric filter — the charged particles are deleted. Checking the work of sewage disposal plants is carried out by observing the specifications of MPE (maximal permissible emissions of pollutants in free air calculated in consideration of MPC in the air). Recommendations for Practical Classes on the Topic

Key Questions: 1.Chemical structure of air and physiological significance of its basic components. 2.The reasons, manifestations and prevention of high-altitude (mountain) and caisson (decompression) sickness. 3.Significance of definition of СО2 in the air of premises. MPC of СО2 and its substantiation. 4.Basic sources and factors of atmosphere pollution, criteria and parameters (physical, chemical, bacteriological) of pollution of atmospheric air. Ways of autopurification of atmosphere. 5.Manifestations of atmosphere pollution effect on a human health and conditions of life. 6.Basic directions of atmosphere protection from pollution. 7.Hygienic significance of ventilation in different premises. Types of ventilation. Classification of ventilating devices. 8.Hygienic characteristics of ventilation efficiency and calculation of its parameters. Learning Objectives and Their Concrete Definition

1. To determine efficiency of natural ventilation by CO2 content in the air of premises. The method of СO2 estimation is based on comparison of pumped by a rubber syringe atmospheric air and air of a premise (one and the same volume of passing air is taken). In Pe- try‘s absorber 10 ml of coloured by phenolphtalein solution of Na2CO3 is poured. While passing through the solution, the air with СO2 becomes colourless; its reaction with alkaline Na2CO3 to acidic Na2НCO3 varies. By pressing a rubber syringe, we slowly squeeze out air from it into absorber through a long tube, thus we fix the number of pumpings until a complete decolouration of the solution. The same procedure is carried out in the open air, the solution being substi- tuted for a new one. The calculation is made according to the formula:

Х = A x 0.04 / B,

where: Х — the required content of СО2 in % A — amount of pumpings in the atmosphere B — amount of pumpings in a premise 0.04 %- an average concentration of carbon dioxide of the air. We estimate concentration of carbon dioxide in a premise: the optimum concentration of CO2 is 0.07-0.08 %, MPC — 0.1 %. 2. Estimation of efficiency of natural ventilation and air changes per hour. Air changes per hour as a parameter of efficiency of natural ventilation is defined by an indirect method proceeding from the received results of the СО2 content in a premise according to the formula:

where: N-number of people in a premise V- cubic capacity of premise Р- found concentration of СО2 22.6- volume of СО2 exhaled by a man per hour 3 0.4 (l\m ) — an average concentration of СО2 in the air 3. Estimation of parameters of artificial ventilation in situational tasks. Example: Length of a premise makes up 22.4 m, width — 6m, height — 3.5 m. In the premise there is one vent 40 cm in diameter; the speed of air movement makes up 5 m/sec. Identify the air changes per hour and estimate it. Air changes per hour is a ratio of quantity of entering air per cubic capacity of a premise. The quantity of entering air per hour is identified by multiplying the vent area by speed of air movement and time of airing.

V- speed of air movement; S- area of vent in m2, N- number of vents T — time of airing (1hour = 3600 sec) Vp- cubic capacity of a premise (room) in m3 Solution: the area of the vent (since it is of a round form) is determined according to the formula O = π x R2n, i.e. =3.14х (0.2) 2 = 0.13 m2.

Air changes per hour is equal to 5, that exceeds the established standards. Self-control Tests

1. In the structure of atmospheric air the maximal percentage makes up: A. oxygen *B. nitrogen C. carbon dioxide D. argon E. neon

2. MPC of СО2 for various premises makes up A. 0.07% B. 1.1% *С. 0.1% D. 0.01% E. 0.04%

3. What kinds of artificial ventilation do you know? A. natural, artificial ventilation *B. input ventilation *C. extract ventilation D. combined ventilation

4. At the expense of what factors is the natural ventilation carried out? A. difference of air in a premise and outside *B. difference of temperatures in a premise and outside and increased pressure of external air at wind C. presence of sources of radiation temperature in a premise D. difference of temperatures and humidity in a premise and outside

E. difference of speed of air movement in a premise and outside Problem Solving 1. In a room 400 m3 in size there is a ventilating fan, which is switched on during a break between lectures for 10 min. Its vent is round with a radius of 0.2 m. Identify the air changes per hour, if the speed of air movement in the vent makes up 6 m/sec. 2. In a room with a cubic capacity of 60 m3 there are 5 men. Airing occurs at the expense of a window leaf, which is opened for 10 min per hour; speed of air movement is 1m/sec, area of the window leaf is 0.15 m2. Estimate the ventilation in the room. 3. Microclimate of a premise is characterized by the following parameters: the air temperature — 40oС; relative humidity — 70 %; speed of air movement — 0.1 m/sec; radiation temperature — 80-90oС. Identify the most probable pathological state of a person, which can occur under the given microclimatic conditions.

Standard Answers: 2 1. According to the formula ACh = VxSxNxT/Vp we find out: 6 х [3.14х (0.2) ] х1х600 =1.113 / Vp 400. ACh = 1, that is not enough for the given room (N=3) 3 3 2. Per 1 sec. 1 х 0.15 = 0.15 m of air enters the room; for 10 minutes — 90 m . ACh is

equal to 90 m3: 60 m3 =1.5. The necessary air changes per hour are 22.6 х 5/1-0.4=188 m3. The necessary air changes per hour are 188 m3: 60 m3 = 3. The necessary air changes per hour are 3 times/hour. 3. General hyperthermia (heat stroke).

Fig. 19. Aspirator (device for aspiration of air for detecting pollutants in the air)

In aspirator the system of regulation is on a forward panel of the device: 1 — for connection of a cord to the electricity supply with voltage of 220 V (at 127 V a transformer is applied); 2 — toggle for switching on and switching off the device; 3 — handle of rotameter valves for regulating speed of taking air samples; 4 — rotameters; 5 — connecting pipes for connection rubber tubes with filters; 6 — safety valve serving for prevention of the electric motor lugging at taking samples with small speeds; 7 — socket of a safety-lock; 8 — a bonding point of device. Starting the work, it is necessary to ground the device, attaching plug 8 to water pipe or heating system with the help of a flexible wire, and then it is connected to electricity supply. Then the safety valve 6 is fixed in position 1 and valves of rotameters 3 are opened to the full. After that the device is switched on by toggle 2 and by rotating handles of rotameter valves the necessary speed of taking air samples is established. Then the device is switched off, the necessary absorbers for taking samples are attached to connecting pipes 5 and the device is

58 switched on again, noting the time by a stop watch; by rotameter the necessary speed of air passage is established and samples are taken. Readout of air speed is carried out from the top edge of floats of rotameters. Aspirator is designed for continuous work within 3 hours.

Theme No 6. Significance of Solar Radiation. Hygienic Requirements to Lighting

Hygienic Significance of Solar Radiation All the organic life on Earth owes its existence to the Sun energy — the only external source of heat and light. On the border of atmosphere the intensity of solar radiation is on average 2 cal/cm2/min, it is called a ―solar constant‖ (it depends on activity of the Sun and other astronomical factors). Due to absorption, dispersion and reflection of solar beams the quantitative and qualitative changes of solar radiation take place in atmosphere:  Quantitative changes — only 43 % of solar constant reach the Earth surface (it depends on geographical position, height of the Sun above the horizon, clearness of atmosphere).  Qualitative changes in spectrum of solar radiation are as follows: On the border of atmosphere the ultraviolet beams (UV) make up 5 %, visible beams — 52 %, infrared beams (IR) — 43 %, near the Earth surface UV — 1 %, visible beams — 40 %, IR — 59 %. The reason of these changes is 2 screens:  the electro-magnetic field of the Earth,  an ozone layer, due to which deviation of short-wave beams and delay of long- wave part of solar radiation take place. Reasons, Manifestations and Prevention of Solar Starvation At lack of solar irradiation a peculiar pathological condition develops in people — solar starvation, which is characterized by asthenovegetative syndrome, oppression of CNS, decrease of adaptable abilities of organism. In children rickets may develop. The main reason of development of this condition is deficiency of UVR. The reasons of development of solar starvation are the following:  Insufficient stay in the open air. There is lack of solar irradiation in rooms, because window glass reflects 35-90% of solar beams.  Climatic and geographical conditions of region, e.g. in the Far North where the polar night lasts 6 months and there is no Sun, and the weather is very cold, children cannot stay in the open air.  In Europe the lack of solar irradiation is experienced by the rural population for 2 months a year, and by urban population — 4 months/year (due to high level of air pollution).  Pollution of atmosphere which results in reduction of light exposure by 40-50 %, especially of UVR. Thus in the center of London the level of UVR is 36 times lower than in its suburbs.  Occupational hazards, e.g. in miners, submariners, etc. Prevention of solar starvation includes the following measures:  The increase of staying in the open air: a correct regimen for children is of great importance.  A correct planning of residential areas and buildings (distance from each other), the observance of norms of natural lighting in premises.  Struggle against atmosphere pollution. The most effective way of solar starvation prevention is using preventive UVR in special photaria with luminescent UV lamps in mines, in the Far North, at home for children in the periods of possible solar starvation. Before administering the course of UV radiation it is necessary to determine a biodose of UVR for each concrete person, because it is different for everybody.

Biodose of UVR and Its Definition It is the minimal time of UVR causing a small erythema on not sunburnt skin (reddening of skin) in 8-20 hours after UV irradiation. The minimal daily preventive dose of UVR is 1/8 part of biodose, the optimal dose (treatment of rickets) is 1/2-1/4 of biodose. Effect of Separate Components of Solar Radiation on Organism Table 32 SPECTRAL DISTRIBUTION AND BIOLOGICAL ACTIVITY OF SOLAR RADIATION Kind of Wave Mechanism Biological effect radiation length Infrared 20000 – Thermal Heating tissues, 760 intensifying metabolism Visual 760 – 400 Thermal, weak Sensation of light, photochemical irritation of CNS Ultraviolet: 400 – 180 Photochemical Formation of melanin; Bactericidal, ery- themic effect; Synthesis of vitamin D in the skin; Fluorescent effect Range A 400 – 315 Range B 315-280 Range C 280 – 180

Range D 285 – 265

Ultraviolet (UV) Ray The most biologically important part of solar spectrum is UV-rays. The length of a wave is 10-400 nanometers. The mechanism of action is a photochemical effect: on their entry into the skin the biologically active substances are formed (histamine, choline, acetylcholine, etc.) causing photochemical erythema of the skin (its signs are precise borders, then melanin formation). Types of biological effect of UVR are as follows:  getting sunburn (melanin formation), fluorescent at UVR effect in area A (the length of wave is 400-315 nm)  erythematous, bactericidal — area B (315-280 nm)  luminescent with increasing the previous effects — area C (280-20 nm)  antirachitic — area D (285-265 nm). In optimal doses UV produces a common strengthening effect, stimulates growth and regeneration of tissues, improves metabolism and functions of endocrine and immune systems. Overdosage of UVR (a sharp effect) causes photoerythema, dermatites, burns, increase of body temperature, photoelectric ophthalmia. A chronic effect of big UVR doses results in deterioration of health state, decrease of capacity for work, aggravation of chronic diseases; it is a risk factor of skin cancer — in southern areas skin melanomas in population are 4-5 times more frequent than in the Northern areas.

Visible Light The length of wave is 400-760 nm; it has a slight photochemical effect — a photosensi- bilization action on optic nerves in retina. There is also a slight thermal effect — inhibition of light quanta in tissues. It stimulates the CNS through excitation of the visual center, has a positive effect on emotional state of the man, function of cardiovascular system and other systems. At excessive intensity it may have a blinding effect down to destruction of photosensitive elements and development of retinitis — inflammation of retina. Infrared Rays (IR) The length of wave is more than 760 nm. Their main effect is thermal — increase of os- cillatory and rotational movements of molecules in tissues. They intensify the biological effects of UVR. Two parts in infrared rays are distinguished:  long-wave infrared rays — more than 1500 nm;  short-wave infrared rays — 760-1500 nm. Biological effects of infrared rays are the following: hyperemia of skin and internal organs, increase of gas exchange in tissues, strengthening of secretory function of kidneys, analgesic effect, elimination of inflammatory foci. They are widely applied in physiotherapy. At excessive intensity of infrared irradiation the following may occur:  heating of brain membranes causing heatstroke and fainting,  damage of crystalline lens by short-wave IR-rays leading to cataract  burns on skin of different degree of severity. Hygienic Requirements to Natural Lighting (Illumination) At estimation of natural lighting in premises the following should be taken into account:  Orientation of windows according to the compass points;  Distance to the neighbouring buildings, plants (in norm distance between buildings should make up 1.5 of their height, trees should be not closer than 10 m to buildings, schools;  Size, number, form of windows in a premise; % of window sashes should make up 25 % of window area;  Availability of extraneous objects on windows. Curtains, green plants, etc. are not recommended in schools.

Then the quantitative parameters are estimated including:  Light coefficient (LC) — the ratio of the total area of windows in a room to the area of the floor. The LC in habitable rooms should be 1/8-1/10, in hospital wards and consulting rooms of doctors — 1/5-1/6, in school classrooms — 1/4- 1/5, in operating rooms — 1/2-1/4.  CNI — coefficient of natural illumination — the ratio of illumination in workplace in Lux (by luxmeter) to light exposure in the open air in Lux, expressed in %. The normal CNI for habitable rooms makes up 0.5-0.75 %, for wards — 1 %, classrooms — 1.5 %, operating rooms — 1.6-2%.  Light angle — not less than 27 degrees.  Ventiduct angle — not less than 5 degrees.

Luxmeter (the device for estimation of illumination) (Fig. 20). A perceiving part of the device is a photocell transforming light energy into electrical one. A recording part is a sensitive galvanometer graded just in lux. The received results are compared with the established norms. If the evaluation is made in the daytime, at first it is necessary to identify the illumination created by mixed illumination (natural and artificial), and then after switching off the artificial illumination. The disparity between the received data will make up the value of illumination created by artificial illumination.

Fig. 20. Luxmeter

Hygienic Requirements to Artificial Illumination The common requirements to artificial illumination are as follows:  It should be sufficient by level of illumination,  It should approximate by spectrum to natural light,  It should be uniform in space not to create sharp contrasts in illumination, otherwise tiredness occurs faster because of light adaptation,  It should be uniform in time,  It should not blind organs of vision. The main parameter of sufficiency of artificial illumination is illuminance of surfaces in lux. It is measured by luxmeter with the help of photocell. Systems of artificial illumination are the following:  Common — in a habitable room — 40-50 lux, classroom — 150 lux, operating room — 300 lux (this is the norm for incandescent electric lamps, for luminescent lamps it is 2 times more);  Local — in a habitable room — 100 lux, classroom — absent, operating room — 3,000-10,000 lux,  Mixed — local and common illumination together. The Hygienic Characteristics of Sources of Artificial Illumination  Candles, oil-stoves, etc. are characterized by nonuniform illumination in time, air pollution in premises;  Incandescent electric lamps — their spectrum differs from natural light (there are a lot of red beams);  Luminescent lamps are characterized by non-uniformity in time, differences in spectrum (there are a lot of blue beams).

Types of Lighting Fixtures  Lamps of direct light have high contrasts in illumination resulting in blinding eyes  Lamps of reflected light requiring a more powerful light source  Lamps of diffused light (frosted glass spheres) are best of all. Recommendations for Practical Classes on the Theme

Key Questions 1.Significance of solar radiation, the spectral structure of solar light. 2.Concept of solar starvation, reasons, manifestations and prevention. 3.Physiological effect of various components of a solar spectrum: UV, visible beams, IR–rays. 4.The basic sanitary-hygienic requirements to illumination. 5.Characteristics of light units. 6.Principles of estimation of natural and artificial illumination. 7.Hygienic estimation of natural illumination of premises. 8.Hygienic characteristics of systems and types of artificial illumination. 9.Hygienic requirements to illumination of habitable premises and classrooms. 10.Hygienic requirements to illumination of hospital wards. 11.Hygienic requirements to illumination of operating rooms. Identifying the Parameters of Natural and Artificial Illumination The aim of this work is to identify the parameters of natural illumination in a classroom by students, i.e. to determine CNI (coefficient of natural illumination), light coefficient (LC), light angle and ventiduct angle. For estimation of sufficiency of natural illumination some parameters are applied. At hygienic estimation of illumination as geometrical parameters the following are used:  light angle  ventiduct angle  light coefficient  premise depth To lighting technology parameters the following refer:  Coefficient of natural illumination (CNI)  Illumination in the specified point of a workplace. The artificial illumination can be estimated in the following way. At inspection of premises for the purpose of illumination sufficiency it is necessary to follow the scheme of inspection. All students of the group participate in performing the given task. The course of independent work is drawn up by the proper protocols. In the protocol the following should be reflected: The task, sequence of its performance (scheme of object inspection). The obtained results. Conclusion with hygienic estimation of the received data and recommendations.

Estimation of Natural Illumination Definition of light angle. Light coefficient (LC) represents the ratio of glassed-in surface of windows (without frames and window sashes) to the floor area. It is expressed by fraction, which numerator is 1, and denominator — a quotient of dividing the area of premise by the area of a glass surface. Task:  To measure the area of all windows of a premise (room).  To calculate the glassed-in surface of windows, subtracting 25 % of window sash area from the found area.  To measure the area of the floor.  To divide the area of a glassed-in surface of windows by the floor area. For example, the glassed-in surface of 3 windows available in the room makes up 3.6 m2; the area of the floor is equal to 30 m2. Hence, light coefficient = 3.6 : 30 = 1: 8.

Determination of light angles. As the light coefficient does not take into account the shading effect of opposite buildings, trees and various architectural elements, the light angles should be determined. Determination of light angle. The light angle is formed by two beams, one of which (horizontal) is drawn from the place of estimation (for example, a table surface) to a window frame, and another — from the same point to the top edge of the window.

Task:  To measure distance across from the middle of the table surface up to the window frame (а) and down from the windowsill up to the top edge of the window (b).  To find tangent of the light angle, having divided value ―a‖ by value ―b‖.  According to the table of tangents (see Table below) to determine the value of the light angle (α˚). Table 33 Table of Natural Trigonometrical Values of Tangents α˚ tg α α˚ tg α α˚ tg α α˚ tg α α˚ tg α α˚ tg α 1. 0.017 16 0.287 31 0.601 46 61 76 4.01 2. 0.035 17 0.306 32 0.625 47 62 77 3. 0.052 18 0.325 33 0.629 48 63 78

4. 0.070 19 0.344 34 0.675 49 1.15 64 2.05 79 5. 0.087 20 0.364 35 0.700 50 65 80 5.67 6. 0.105 21 0.384 36 0.727 51 66 81 7. 0.123 22 0.404 37 0.754 52 67 82 8. 0.149 23 0.424 38 0.781 53 1.39 68 2.47 83 9. 0.158 24 0.455 39 0.810 54 69 84 10. 0.175 25 0.466 40 0.839 55 70 85 11. 0.194 26 0.488 41 0.869 56 71 86 12. 0.213 27 0.510 42 0.900 57 72 3.07 87 13. 0.231 28 0.532 43 0.933 58 1.60 73 88 14. 0.249 29 0.554 44 0.966 59 74 89 15. 0.268 30 0.577 45 1.000 60 75 90 For example, the height of the window is 2 m (а), the distance from the window to workplace (b) is equal to 3.5 m. Identify the value of light angle α˚. Hence we find tgα = 2: 3.5 which according to the table of tangents corresponds to angle of 30˚. Definition of ventiduct angle. This angle is formed by two lines, the upper one (the same as with the light angle) goes from the place of illumination estimation to the top edge of the window, and the lower one is directed to the highest point of shading object (for example, opposite house). Ventiduct angle is determined by two students. First the angle adjacent to ventiduct angle (b) is defined. The first student, having bent his head to the level of the table, imaginary draws a direct line from the

65 middle of the table surface to the highest point of the opposite building. The second student standing at the window by instructions of the first student fixes by a hand the point of crossing this line with the window glass and measures its distance from the windowsill (а1). Having divided the received value (а1) by distance from the window up to the middle of the table surface (b), they receive tangent of angle b. For definition of ventiduct angle value (g) it is necessary to find the difference between the light angle (a) and ventiduct angle (b). For example: a — distance between the windowsill and the point of crossing of imaginary line with a window frame equal to 1.5 m., b — distance from the window to the workplace equal to 3.5 m. Hence: 1.5: 3.5 = 0.428. According to the table of tangents we find angle β = 23˚. Angle γ = 30˚- 23˚ = 7˚. Estimation of workplace illumination. The estimation of workplace illumination is carried out by luxmeter (see above). Determination of premise depth To determine this coefficient it is necessary to know the height of window from the upper edge to the floor and distance between the external and internal walls (depth of a room). Esti- mating these parameters, we get the required coefficient, which value in a workplace should be 1: 2. Determination of coefficient of natural illumination (CNI) CNI is the ratio of illumination at a given point of premise (room) to simultaneous external illumination under the conditions of scattered light, expressed in percentage. CNI can be determined experimentally with the help of luxmeter. CNI = I in. x 100% / I ex. , where: I in.— illumination in the given point of premise (room) Iex.— illumination outside the premise (room).

Estimation of Artificial Illumination It is necessary to determine type of sources (character of lamps: incandescent, luminescent; type of lighting fixtures — lamps of direct, scattered, reflected light), amount of lamps and their capacity. The latter should be divided by the area of premise, thus specific capacity of lamps in watt per m2 is received. Protocol of Independent Student Work

on the topic “Hygienic Estimation of Natural and Artificial Illumination” I. Hygienic estimation of natural illumination 1. In classroom No___ there are______windows, colour of walls is ______, colour of the ceiling is______, cleanliness of window glasses is______, size of piers between windows is ______. 2. Determination of CNI: External horizontal illumination is ______lux; Illumination in a workplace is ______lux. CNI is ______%. 3. Determination of LC: The area of glassed-in windows is ______m2, area of floor is_____ m2. LC = ______. 4. Determination of light angle (drawing and calculations) ______. 5. Determination of ventiduct angle (drawing and calculations) ______. II. Hygienic estimation of artificial illumination. 1. In classroom № ____ there is a ______system of illumination, the lamps of a ______type are fixed. 2. Estimation of uniformity of artificial illumination: Illumination in lux in points cornerwise ______. Ratio of maximal and minimal illumination at a distance of 0.75 m ______, 5 m______. 3. Estimation of illumination by a calculation method: Number of lamps is______, the floor area is______m2. Specific capacity of lighting fixture is______W/m2.

4. Conclusion (to give a hygienic estimation and recommendations on natural and artificial illumination): Variant 1. The natural illumination of workplace is sufficient (for a classroom the LC is 1:4-1:6, light angle is not less than 27˚, ventiduct angle is not less than 5˚, illumination of workplace is not lower than 150 lux, CNI is not less than 1.5 %). The artificial illumination is sufficient (not less than 150 lux at incandescent lamps or 300 lux at luminescent illumination). Variant 2. Natural and artificial illumination of workplace is insufficient (at lower values of such parameters). Self Test 1. Identify the light coefficient which should be in operating room: A. 1:10 *B. 1:4 C. 1:8 D. 1:6 E. 1: 9

2. Which parameter reflects the value of natural illumination in a workplace? A. light angle B. premise depth C. light coefficient D. ventiduct angle *E. CNI

3. How many times is the intensity of artificial illumination higher at application of day- light (luminescent) lamps than at use of incandescent lamps? *A. 2 times B. 1 time C. 10 times D. 3 times E. 5 times 4. The light coefficient is: A. the ratio of illumination in the open air to illumination indoors B. the ratio of light angle to ventiduct angle *C. the ratio of floor area to the area of windows D. the ratio of window area to tangent of ventiduct angle

5. The total artificial illumination of a school classroom is planned to provide with lamps of a uniformly dispersing type and incandescent lamps. Identify the least value of illumination in lux, which meets the hygienic requirements of artificial illumination for the given type of premises. A. 200 B. 250 C. 300 *D. 150 E. 350

6. Identify the range of ultraviolet radiation which has a bactericidal effect (in nanometers): A. 315-265 *B. 280-10 C. 380-300 D. 400-315 E. 320-280 Problem Solving 1. The glassed-in surface of 3 windows available in the room makes up 3.6 m2; the area

67 of the floor is equal to 30 m2. Identify the light coefficient. 2. The light exposure in the open air is 40,000 lux, CNI is 2 %. What is the illumination in a workplace? 3. The depth of hospital ward is 5 m, its length is 6 m. In the ward there are 2 windows, which glassed-in area makes up 2.7 m. The height of the top edge of the window is 2.8 m above floor level. Orientation of windows is SE, the walls are of light warm colours. The light angle is equal to 35˚, ventiduct angle — 10˚. Give a complex hygienic estimation of natural illumination in the hospital ward.

Standard Answers: 1. Light factor = 3.6: 30 = 1: 8. It corresponds to norm for the given room. 2. The illumination in a workplace is equal to 40,000:2х100=800 lux. 3. LC = 30:2.7 = 1:10. All other parameters correspond to norm.

Theme No 6. Hygienic Requirements to Drinking Water Quality

Significance of Water for Man Water is of great physiological, hygienic and economic significance for man. The following types of water consumption are distinguished:  drinking — this type of water consumption is the most important for the health of population; the most rigid requirements to its quality are established. Accord- ing to the WHO data 80 % of all diseases on Earth are connected with poor- quality water or with bad sanitary conditions of life caused by deficiency of clear water.  household — for providing normal sanitary conditions of life of population and prevention of infections. The requirements to its quality are the same as to drinking water.  recreational — these are reservoirs and water areas used for rest, water sports, etc. The requirements to its quality are rigid.  balneologic water use includes baths, showers, inhalations, etc. Very high requirements are set to quality of this water.  industrial — use of water in technological processes in manufacture. There are special requirements to its quality.  meliorative — irrigation of soils in agriculture, etc. There are special requirements to quality of this water.  fish-breeding — for cultivation of fish. The requirements here are sometimes even higher than to drinking water because some kinds of fish are very sensitive. On pollution of reservoirs toxicants can accumulate in fish and cause diseases in people.  transport — water transport, ports, etc. Problems of Fresh Water on Earth Only 3 % of water-supply on our planet are fresh water (the rest is seawater) intensively used for the above-stated purposes of water consumption. Thus, resources of fresh waters are located non-uniformly and are sufficient only for 20 % of densely populated areas, in other places there is deficiency of water. In addition to deficiency, fresh-water reservoirs have the greatest anthropogenic pollution that frequently makes them useless for water consumption. UNESCO makes prognoses about real threat of water famine for mankind. A cardinal way of solving water problem is desalination of seawater, but this method is very expensive; besides seas and oceans are considerably polluted and on desalination toxic and carcinogenic substances can form.

Physiological Significance of Water A daily need for water in adult person in normal conditions makes up 2.5-3 l, in a hot climate or on physical exertion — up to 10-12 l/day. Water performs a structural role — the organism of the adult consists of water for 51- 66%, and organism of a child — for 80-90 %. Besides, water is a weak electrolyte dissociating into ions of Н+ and OH- which are catalysts of biochemical reactions and water is the medium of these reactions. Hygienic Requirements to Drinking Water

Documents Regulating Quality of Water There are two State Standards (SS) of water quality:  The State Standard "Drinking Water".  The State Standard "Water of Sources of Centralized Water Supply". The latter State Standard contains less rigid requirements to quality of water; it is intended for choice of water supply source, then the water passes purification and disinfecting and after that in a water pipe it should correspond to SS "Drinking Water". WHO developed the International Standard of Drinking Water (ISDW-73), which practically coincides with Russian State Standard . The Criteria of Quality of Drinking Water The common requirements to quality of drinking water are the following:  Water should have satisfactory organoleptic properties.  Water should be harmless according to its chemical composition, both natural and anthropogenic.  Water should be safe in epidemiological respect. These criteria are the basic group of parameters of drinking water in the State Standard.

THE STATE STANDART FOR DRINKING WATER 1. ORGANOLEPTIC INDICATORS Smell & Taste of water Up to 2 points Colouring or chromaticity of wa- Up to 20 degree ter Turbidity Up to 1,5 mg/l Transparency Up to 30 sm Temperature 7 – 12 degree

2. CHEMICAL COMPOSITION Dry rest (mineralization) Up to 1000 mg/l (1 g/l) Chlorides Up to 350 mg/l Sulphates Up to 500 mg/l General Rigidity 7 – 10 mg-eq./l Ammonia 0 Nitrites 0 Nitrates Up to 10 mg/l Oxide ability 2 – 4 mg O2/l Iron Up to 0,3 mg/l Fluorine 0,7 – 1,5 mg/l

3. BACTERIOLOGICAL INDICATORS Total Microbe Number Up to 100 in 1 ml Coli-index Up to 3 in 1 l Coli-titer More 300 ml

Organoleptic Properties of Drinking Water Smell and taste — up to 2 points. These properties are determined in the open and closed experiments on people with application of 1-5-point scale: point 0 means absence of smell and taste, point 1 — smell and taste is determined only by an odorator — a person with the increased sensitivity to smell and taste, 2 — a consumer does not pay attention to smell and taste, 3 — appreciable — causes a negative attitude to water, 4 — distinct — limits water consumption, 5 — very strong — water is unsuitable for drinking). Colouring or chromaticity of water — up to 20 degrees. It is determined by a scale of ampoules containing a chrome-cobalt solution of different color. Turbidity — up to 1.5 mg/l or transparency — 30 cm. It is determined with the help of special flasks — normally there must be the opportunity of reading a text through a 30-cm layer of water. Temperature — 10-12ºC. If temperature is below, catarrhal diseases may occur, if it is higher, then оrganoleptic properties of water change. Significance of Studying Organoleptic Properties of Water  It is used for initial examination of water quality;  Change of organoleptic properties is an indirect sign of organic pollution of water. Chemical Parameters of Water, Their Influence on a Human Organism These parameters are of great importance because their changes to increase or decrease may cause different diseases. The dry residue or mineralization of water — up to 1000 mg/l (1 g/l). At higher values of dry residue (1400 mg/l and higher) changes of оrganoleptic properties of water, e.g. taste of water, take place. According to degree of mineralization, the following classification of water is suggested:  water of low mineralization — 1-2 g/l,  water of high mineralization — 10 g/l and over (seawater contains 35 g/l). At use of high mineralization drinking water (especially at sharp change of water on moving to other area) disorders of water-salt balance, retention of water in organism, dysfunctions of digestive and excretory systems, metabolic derangements occur. The increase of disease incidence of cardiovascular, urinary systems, urolithiases is statistically proved in these areas. With such water 25-100% of total amount of mineral substances of food ration gets in organism. On the other hand, it is experimentally and clinically proved that waters with low mineralization (100 mg/l and less) are biologically deficient that results in increase of secretion and acidity of gastric juice, disturbance of water absorption in gastrointestinal tract, derangement of water-salt exchange, disorder of tubular reabsorption in kidneys, hypocalcemia, decrease of osmotic resistance of erythrocytes, etc.

The content of chlorides is up to 350 mg/l. They impart salt taste to water; in big concentrations they change water taste by more than 2 points. At increase of chlorides in water the derangement of water-electrolyte exchange and dysfunction of kidneys occur. Arterial hypertension, the so-called "salty hypertension" is encountered in the areas with salty water 4 times more often. At concentration of chlorides over 500 mg/l the inhibition of secretion and acidity of gastric juice occurs. It is an indirect parameter of organic pollution of water with household sewage as there are a lot of chlorides in urine.

The content of sulfates is up to 500 mg/l. They impart bitter taste to water by more than 2 points. At their increase the inhibition of gastric secretion, disturbance of intestinal absorption, reflex diarrhea can occur. It is also an indirect parameter of organic pollution of water as lots of sulfates are found in faecal masses.

General hardness of water is up to 10 mg–equivalent/l. It depends on content of calcium and magnesium ions. Hardness of water is classified as eliminable (eliminated at boil-

70 ing), non-eliminable (preserved in water after boiling) and common (the last is normalized by SS). Classification of water according to general hardness:  up to 3.5 mg-eq/l — soft water  3.5 — 7 mg-eq/l — water of average hardness  7 — 14 mg-eq/l — hard water  over 14 mg-eq/l — very hard water. In hard water it is difficult to do washing (expenditure of washing powder on binding salts), to cook food. Protein absorption is worsened as insoluble complexes with salts form. Problems of water supply arise as deposits on pipes form (eliminated hardness).

Nitrogenous Substances in Water (Ammonia, Nitrites, Nitrates) Ammonia and nitrites should practically not be present in water, nitrates — up to 10 mg/l (converted into nitrogen). As these are the final links of protein disintegration, they give the possibility to judge about organic pollution: if only ammonia is revealed in water, then it is the recent pollution, only nitrates — the old one, all nitrogenous substances — the persisting pollution. It is an indirect parameter of organic pollution of water. At increased content of nitrates and nitrites (caused by organic pollution of reservoir or water flushing of nitric fertilizers into it) a specific illness — water-nitrate methemoglobinemia — may develop which is especially dangerous for children of the first months of life.

Water oxidizability and biochemical consumption of oxygen (BCO). It is an important index of amount of organic substances in water as for their oxidation more О2 is required. Normally water oxidizability is 2-4 mg О2/l. The dynamics of water oxidizability for 5 or 20 days (BCO) is a criterion of oxygen regimen of reservoir which is studied for normalization of pollutants in reservoir water.

The content of iron is up to 0.3 mg/l. Its source is a natural structure or water pipes. At high content of iron colouring of water changes.

The content of fluorine is 0.7-1.5 mg/l (in hot climate it may be 0.7 mg/l as more water is used, in cool climate — 1.5 mg/l). The reason of the abnormal content of fluorine in water is biogeochemical provinces and anthropogenic sources (superphosphate plants). At small content of fluorine in water caries may develop in people, at increased content — fluorosis (spotty damage of dental enamel, derangement of Са-Р exchange, fluoric cachexy, deformation and fragility of bones). ! Bacteriological Parameters of Water ! All over the world the following parameters of microbe pollution of water are used:  total number of microorganisms in water  the content of colibacillus (E.Coli) as a constant inhabitant of sewage and a relatively steadier microbe than others to disinfection of water shows efficiency of disinfecting water. Total microbe number (TNM) — up to 100 per 1 ml — amount of microbe colonies at inoculation of 1 ml water in a Petri dish at 37ºС for 24 hours. Coli index — up to 3 per liter — quantity of colibacilli per liter of water. Coli titer — not less than 300 — quantity of water in 1 milliliter per 1 colibacillus.

Epidemiological Significance of Water It is common knowledge nowadays that water factor plays a leading role in occurrence of number of infectious diseases, such as:  enteric infections — typhoid, cholera, paratyphoid, dysentery, etc.  anthropozoonoses — brucellosis, tularaemia, Siberian plague, leptospirosis,  viral infections — hepatitis, poliomyelitis, adenoviruses,  pathogenic protozoa — lamblias, amoebas, balantidia, etc.  parasitic worms.

Signs of Epidemiological Hazard of Water  direct — deterioration of bacteriological parameters of water, availability of pathogenic microbes;  indirect — deterioration of organoleptic parameters, increase of amount of chlorides, sulfates, nitrogenous substances, water oxidizability.

Signs of water epidemic (epidemic by a water-way transmission) are the following:  Quick mass episode of the same infectious diseases.  Territorial relation of disease episode to the certain water source.  After taking antiepidemic measures in the focus of infection (prohibition of using a water source, disinfection of water) a sharp decrease of disease incidence is observed, only separate cases are registered ("epidemic tail").  Hot season presents better conditions for reproduction of causative agents, besides a person consumes a lot of liquid, hence acidity of gastric juice — barrier to microbes — is reduced. Recommendations for Practical Classes on the Theme

Key Questions: 1.Physiological and hygienic significance of water. 2.Documents regulating quality of water and requirements to sources of water supply. 3.Rules of taking water tests for chemical and bacteriological researches. 4.Organoleptic parameters of water quality, methods of its research, norms. 5.Chemical parameters of water quality and diseases connected with their deviations. 6.Bacteriological parameters of water quality. Epidemic significance of water. Signs of water epidemics. 7.Chemical parameters of organic pollution of water. 8.Direct and indirect parameters of organic pollution of water. 9.Water-nitrate methemoglobinemia, its causes and prevention. Learning Objectives and Their Concrete Definition 1. Determination of organoleptic parameters of investigated water: temperature of water: 12-14ºС in norm is determined by a thermometer; c) transparency of water: drinking water should be completely transparent, allowing through a layer of 30 cm to read a text of Snellen test type; d) turbidity is determined by amount of suspension particles per 1 litre of water, they should be not more than 1.5 mg/l; e) colour: drinking water should be colourless (not higher than 20º) by the scale of ampoules with chrome-cobalt solution; f) taste and smell of water: they are determined at a room temperature (20ºС) and at heating of water up to 60ºС, taste and smell are estimated by a six-point system (0-5). Water with smell and taste of not more than 2 points is considered acceptable for drinking. 2. Qualitative evaluation of chemical substances in investigated water. Determination of:  pH of water is evaluated by litmus paper (in norm 6.5-8.5), that corresponds to colours from yellow to green.  ammonia (NН3): to investigated water we add 3-4 drops of Nessler‘s reagent, the appearance of yellow colouring indicates the presence of ammonia. In normal water NН3 should be absent.  salts of nitric acid (nitrates): to 2-5ml of investigated water in a porcelain test add some crystals of diphenylamine, then some drops of sulfuric acid. The presence of nitrates is indicated by dark blue colouring. The norm of nitrates in water is up to 10 mg/l.  salts of sulfuric acid (sulphates): to the tested water add some drops of hydrochloric acid, 2-3 drops of 10 % solution of barium chloride. The presence of white dreg quickly forming a precipitate indicates the availability of sulphates.

Their norm in water is up to 500 mg/l.  chlorides: the chloride salts form due to the presence of a silver solution (reaction of a silver mirror). To 5 ml of investigated water in a test tube add some drops of silver nitrate, the presence of chlorides is indicated by white dreg. The norm of chlorides is up to 350 mg/l.  iron: to investigated water add 2-3 drops of nitric acid and then 2-3 drops of ammonium thiocyanate solution. The presence of salts of iron is indicated by the orange-red colouring, its intensity depending on concentration of salts of iron. Their norm in water is up to 0.3 mg/l. Algorithm of Students’ Practical Work The first stage. Testing the initial level of students‘ knowledge and skills. The second stage. Active participation in discussion of key questions of the theme. The third stage. Independent work on determination of some organoleptic and chemical parameters of water. The fourth stage. Problem solving and final testing on the theme. Self Test 1. Name the basic groups of parameters of drinking water quality. *A. organoleptic *B. chemical *C. bacteriological (microbiological) D. toxicological E. helminthologic

2. The transparency of drinking water is determined by a text of standard test type (named after the author) A. Heiner B. Giss C. Herbar D. Stocks *E. Snellen

3. The qualitative reaction to chloride content in water is: *A. reaction with silver nitrate B. reaction with nitrate solution C. reaction with sulphuric acid D. reaction with nitric acid E. reaction with natrium chloride Final Testing on the Theme 1. In an hour after feeding a baby with a milk formula, the following symptoms of disease developed in it: cyanosis of lips, mucous membranes, face, then nausea, increased salivation, pain in the stomach, vomiting, diarrhea. The called in pediatrician stated the phenomena of cardiopulmonary decompensation in the child. In the course of investigation it was established that water from a well was taken to prepare milk formula. What diagnosis was established by the doctor? A. nitrate intoxication B. food toxicoinfection C. staphylococcus toxicosis D. food poisoning with heavy metals E. sulphate intoxication 2. For water supply of the city the water is used containing: fluorine — 2.0 mg/l, nitrates — 43 mg/l, chlorides — 250 mg/l, iron — 0.2 mg/l, residual chlorine — 0.5 mg/l. Identify the disease which may develop in population at use of water with the given chemical structure: A. dental caries B. thyrotoxicosis

C. methemoglobinemia D. fluorosis E. endemic goiter 3. The chemical analysis of water from a well has indicated the presence of increased concentration of nitrates, iron and sulphates. What parameter of water quality can testify to recent pollution of water by organic substances of an animal origin? A. nitrates B. ammonia C. nitrites D. sulphates E. chlorides Problem Solving 1. In people of a city district the non-uniform colour of teeth was marked. On incisors the white spots and cross brown strips were observed. Drinking water from a deep borehole was suspected in occurrence of these symptoms. What microelement of water components could have caused the disease? 2. The mountain lake is situated outside the inhabited locality. There is wood around it, lakeside is sandy, stony. The analysis of water revealed the following: taste, smell — 1 point, ammonia and nitrites are absent, colour — colourless, nitrates — 40 mg/l, transparency — 40 cm, chlorides — 50 mg/l, coli titer — 300, microbe number — 65. Give a sanitary estimation of water. 3. Disease incidence of caries among the inhabitants of town N. makes up 89 %. It is established that water contains 0.1 mg/l of fluorine. What preventive measures should be carried out?

Standard Answers: 1. Fluorine 2. Water is suitable for drinking 3. Fluorination of water.

Theme No 8. Hygiene of Water Supply. Methods of Improving Water Quality

Hygienic Characteristics of Water Supply Sources There are 4 types of water supply sources:  Surface water (open reservoirs) — rivers, lakes, water basins;  Underground water:  subsoil water is in the ground above the impervious layer — wells, springs;  middle water — between the impervious layers — artesian wells;  Atmospheric water (meteoric water) — accumulation of atmospheric precipitation,  Desalination of seawater. Hygienic Characteristics of Open Reservoirs These are big supplies of water which are easily accessible. Their drawback is that they are easily exposed to pollution for natural and anthropogenic reasons. Their chemical and microbe structure is inconstant that requires daily supervision of water quality. Ways of Autopurification of Open Reservoirs  Dilution in big water masses  Sedimentation  Biochemical oxidation by microflora  Adsorption by hydrobionts  Bactericidal effect of UVR in top layers — up to 50 cm

 Neutralization.

Estimation of Pollution Degree in Open Reservoirs Methods of estimation of pollution degree in open reservoirs are as follows:  Comparison of water parameters with SS or maximal permissible concentration — analytical monitoring;  Medical-hygienic monitoring includes observation of changes of health parameters in people using water from the given reservoir;  Ecological monitoring is carried out with application of hydrobiological parameters:  sensitive — indicatory organisms, e.g. trout;  organisms–filtrators, e.g. mussels — by accumulation of pollutants in them;  qualitative and quantitative characteristics of hydroecosystems. Hygienic Characteristics of Underground Water Subsoil water. It is better protected from pollution than water in open reservoirs, yet subsoil water in wells is frequently polluted. Inter layer water is practically sterile, but it also has drawbacks: there are small supplies of such water, its extraction is expensive and it is frequently highly mineralized and highly thermal.

Atmospheric Water This source is rather changeable, besides atmosphere is considerably polluted, so this water is polluted as well. As this water is low mineralized it causes health disorders.

Desalination of Seawater It is a very expensive matter requiring a lot of electric power. As seawater is polluted, at its boiling toxic substances can form. Hygienic Characteristics of Water Supply Systems There are 2 systems of water supply:  Centralized system — a city water pipe. Its structure includes:  Basic constructions (water supply point, pump stations, sewage disposal plants),  Distributive network (pipeline, internal water supply system).  Decentralized system — small rural water pipes, wells. This system is worse in hygienic respect as it does not have complex sewage disposal plants. Zones of Sanitary Protection of Water Sources  Zone of strict regimen. It includes water supply point, basic constructions of water pipe.  Zone of restrictions — it is the whole or partial area of water reservoir. There is a restriction of locating objects of possible pollution of water sources.  Zone of supervision. Supervision over epidemic conditions (cases of infectious diseases) in a big territory is carried out with the purpose of improvement of purification and disinfecting water at unfavourable epidemic conditions. Methods of Improving Water Quality They are divided into 3 basic groups:  Methods of water purification — removal of mechanical impurities and improvement of organoleptic parameters of water (turbidity, colouring).  Methods of water disinfecting — destruction of microflora in water.  Special methods of improvement of water quality — desalination, dechlorination, fluorination, defluorination, deodorization, decontamination, deactivation of water. Methods of Water Purification Water purification is carried out by means of water precipitation and filtration through filters (slow and fast filters). For acceleration of purification the coagulation of water is applied, i.e. adding salts of Al or Fe, which results in formation of flakes with calcium or magnesium

75 salts in water. Nowadays flocculants are used, e.g. polyacrylamide, etc. Control of efficiency of water purification is carried out according to:  organoleptic parameters — turbidity, colouring, smell, taste;  oxidability of water. Methods of Water Disinfection and their Hygienic Estimation There are 2 groups of disinfection methods:  physical  chemical Physical methods of disinfecting include the following:  boiling has a favourable bactericidal effect, but it is a very expensive method. As a great amount of power is consumed, this method is applicable only in do- mestic conditions.  UVR has a 100 % effect, but it requires a great amount of power and purifies small volumes of water, as in clean water UV penetrates through 50 cm only, in muddy water — even less.  gamma irradiation is seldom used, as it requires complex equipment, constitutes a threat of irradiation to personnel and induces water radioactivity.  ultrasonic irradiation is a complex method affecting personnel. Chemical methods of water disinfection are as follows:  ozonization — action of atomic oxygen produces a good bactericidal effect. The method requires great power consumption. It improves organoleptic properties of water. Full destruction of toxic substances in water takes place.  oligodynamic effect of silver ions, for example, "sacred water" in churches. Ions of silver have a bactericidal effect. It is a very expensive method.  chlorination of water is the most widespread method because of it is cheap.

Chlorination of Water On entering chlorine into water the hydrolysis of chlorine takes place with formation of hydrochloric and hypochlorous (HOCl) acids dissociating into Н+ and OCl- ions producing a bactericidal effect.

The Scheme of Chlorination 90 % of chlorine are bound with various substances in water and inactivated (chlorine absorptivity), the residual or free chlorine is left. For sufficient bactericidal effect it should be in amount of 0.3-0.5 mg/l (if it is below, no bactericidal effect is produced, if higher — the change of water smell by more than 2 points occurs). Chlorine absorptivity + residual chlorine = chlorine necessity for water. It is determined at experimental chlorination during practical classes. Types of Water Chlorination  According to chlorine necessity or chlorination by normal doses of chlorine under the control of content of residual chlorine amounting to 0.3-0.5 mg/l. For improvement of bactericidal effect there are other kinds of chlorination:  Superchlorination — application of big doses of chlorine exceeding the chlorine necessity of water. It is used for extremely polluted water, unknown waters by bacterial indications (field conditions), by epidemic indications. After that water requires dechlorination through activated coal, hyposulfite.  Double chlorination — introduction of chlorine before and after water purification — is the increased time of chlorine action, but the formation of toxic chlorine-organic substances increases.  Chlorination with pre-ammonation — introduction of chlorine and ammonia into water, thus chloramines are formed having a greater bactericidal effect, there is no "chemist's" smell as at usual chlorination when in water chlorphenols can be formed. Disadvantages of Water Chlorination:  Deterioration of organoleptic properties of water (smell),

 Disinfection is not always reliable (presence of hepatitis viruses, etc.),  At water pollution during chlorination toxic chlorine-organic substances are formed, such as chloroform, tetrachlorethylene, etc, having a mutagenic and carcinogenic activity. Problems of Water Pollution The basic sources of reservoir pollution are:  Natural — floods, ice drifts, rotting of biota, "flowering of water", seasonal fluctuations of number and dying off hydrobionts, etc.  Anthropogenic — household sewage, industrial sewage, agricultural drainage, regulated stream of rivers (dams, water basins), water transport, port works, dumping waste products in reservoirs, atomic power stations and military nuclear grounds, recreational loading on reservoirs. Ecological and Hygienic Consequences of Reservoir Pollution  Hygienic negative consequences:  restriction or full liquidation of water use for population,  health disorders of population (water epidemics, acute and chronic poisonings, the remote effects),  deterioration of sanitary life conditions of population, restriction of settlement development,  accumulation of dangerous levels of toxicants and microbes in fish products,  pollution of contact environments — air, ground, underground waters.  Ecological negative consequences:  reversible and irreversible changes of hydroecosystems,  decrease of efficiency and biomass of hydroecosystems,  loss of rare and valuable species of hydrobionts,  succession of hydroecosystems. Basic Directions of Protection of Water Reservoirs from Pollution These include:  Administrative-legislative measures (laws, Sanitary Standards, etc.).  Hygienic measures:  Preventive sanitary inspection . project appraisal of industrial and other objects, sewage disposal plants as to observance of MPD (maximum permissible discharges) into reservoirs; . Normalization of harmful substances in water.  Current sanitary inspection — the control over content of harmful substances and microbes in reservoir water, control of efficiency of purification and disinfecting water, control of water supply system and observance of norms of water consumption.  Architectural-planning measures — zones of sanitary protection of water sources.  Medical monitoring includes studying state of population health depending on quality of reservoir water.  Ecological monitoring consists in researching the effect of pollution on hydroecosystems and separate hydrobionts. Bioindication, biotesting are carried out.  Technological measures include application of closed technology, decrease of industrial water consumption, change of technology for decreasing toxicants in effluent, sewage disposal plants for cleaning and disinfecting sewage, etc. Recommendations for Practical Classes on the Theme

Key Questions: 1.Hygienic characteristics of water supply sources, zone of their sanitary protection. 2.Parameters of quality and pollution of water. 3.Methods of improvement of water quality. Methods of water purification and control over their efficiency. 4.Methods of water disinfection, control over their efficiency. 5.Scheme of water chlorination, its types, disadvantages.

6.Special methods of improvement of water quality. 7.Basic sources of reservoir pollution and ways of their self-purification. 8.Standardization of harmful substances in reservoir water. 9.Basic directions of protection of reservoirs from pollution. Self Test 1. The amount of residual chlorine in water in norm makes up: A. 0.1 mg/l B. 0.2 mg/l *C. 0.3 mg/l D. 0.4 mg/l E. 0.5 mg/l

2. Identify the chemical element which salts are applied for water coagulation? *A. Aluminium B. Fluorine C. Silver D. Iron E. Copper Final Testing of Students’ Knowledge 1. At substantiation of size of the 2nd sanitary protection zone of water supply sources the duration of water purification from microbes is taken into account. What period of time is necessary to purify underground water from microbes? A. 400 days B. 200 days C. 50 days D. 5 days E. 3 days

2. The military unit after a long march has stopped for 3 seasons to have a rest near the inhabited locality. According to the data of sanitary-epidemic investigation some water sources are revealed. It is necessary to choose a source, which to a great extent meets the hygienic requirements to drinking water in field conditions. A. well water B. artesian well water C. river water D. rain water E. melted snow Problem Solving 1. What parameters should testify to reliability of carried out disinfection of water in case of applying a hyperchlorination method? 2. At a distance of 20 m from apartment house there is a mineshaft, which is 10 m from a toilet and 15 m from the neighbouring house. What distance should be according to sanitary norms between the well and a source of possible pollution of water? 3. A typhoid epidemic of water origin after the water pipe failure has been registered in inhabited locality N. What are the main signs characteristic of the water epidemic?

Standard Answers 1. Residual chlorine — 0.5 mg/l, coli titer — 100, coli index — 10 2. 30 m 3. The contingent of ill population lives in the same district and a sharp increase of disease incidence, decrease of disease incidence after liquidation of water pipe failure, epidemic tail are characteristic. Methodical Recommendations for Students’ Independent Work During the work the students should carry out laboratory researches to determine resi-

78 dual chlorine in water and estimate needs of researched water in chlorine. Determination of Residual Chlorine in Water The procedure is started with an experimental chlorination of water, and then the determination of residual chlorine by titration is carried out by the students. Experimental Chlorination The purpose of experimental chlorination is to determine the necessary dose of chlorine at chlorination by normal doses. The choice of a chlorine dose is made by a three-glassful method and is usually carried out in field conditions. Table 34 Method of Carrying out an Experimental Chlorination Water 200 ml 200 ml 200 ml 1 % chloride lime solution 2 drops 4 drops 6 drops 5 % solution of potassium iodide 5 ml 5 ml 5 ml Water solution of hydrochloric acid 1 ml 1 ml 1 ml at a ratio of 1 : 3 1 % amylum solution 1 ml 1 ml 1 ml Sodium hyposulphite solution 0.01 N by drops up to decolorization of content in a flask (20 Drops = 1 ml of Sodium hyposulphite solution 0.01 N)

Fill three conic flasks with 200 ml of investigated water each. To the 1st flask add 2 drops of 1 % solution of lime chloride, to the 2nd — 4 drops and 3rd — 6 drops of this solution. Intermix the content of the flasks by a rotary movement and leave it for 15 minutes. After that add to each flask 1 ml of a hydrochloric acid solution at a ratio of 1:3, then 5 ml of 5 % solution of potassium iodide and 1 ml of 1 % Amylum solution. Shake up the flasks actively. The presence of free chlorine in water is indicated by dark blue colour; the more chlorine, the more intensive colouring. In the flask, where all chlorine was spent, the colouring will not take place. Chlorine, as the most active colloid, displaces iodine in potassium iodide, and iodine with amylum causes a dark blue colouring. Identification of Residual Chlorine Residual chlorine is determined in painted flasks. Pour the solution of sodium hyposulphite from a pipet by drops into a flask up to decolorization of the flask content. At titration after each added drop shake up the flask with a rotary movement. Then convert the amount of drops of sodium hyposulphite, used for titration of water in each flask to millilitres (20 drops on average are contained in 1 ml). Identify the residual quantity of chlorine in each flask according to the formula:

Х = 0.355  A х 5 , where

Х — residual chlorine in milligrams (mg) per litre; 0.355 — amount of chlorine in milligrams corresponding to 1 ml of sodium hyposulphite; A — amount of 0.01 N of Sodium hyposulphite solution in ml used for titration of 200 ml of water; 5 — converting per 1 litre of water. Determination of Requirement for Lime Chloride Amount at Chlorination of Water The calculation of the necessary amount of 1 % solution of lime chloride for chlorination of 1000 litres (1 cubic meter) of water: Of three flasks of investigated water to select the one in which the content of residual chlorine is within the limits of 0.3-0.5 mg of chlorine per litre. To convert the amount of drops of 1 % lime chloride solution added to the given flask at

79 experimental chlorination to milliliters (1 ml contains 20 drops on average). The amount of dry lime chloride in grams necessary for decontamination of 1 m3 of water is determined according to the formula:

where: Х — amount of lime chloride in grams per 1 m3 of water. В — amount of 1 % solution of lime chloride (in ml) added to flask at experimental chlorination; 1000 — converting per 1 m3 of water; 100 — converting to grams of dry lime chloride. Conclusion: 1 gram of dry lime chloride per 1 m3 of water is necessary for decontamination of investigated water. For example: We titrate 200 ml of water in 3 flasks. To the 1st flask we add 2 drops of 0.01 N solution of sodium hyposulphite, to the 2nd — 4 drops and 3 flask — 8 drops of the solution. What is the necessary quantity of dry lime chloride for disinfection of water (in grams per 1 m3 of water)? Solution 1) 1 ml of 0.01 N solution of sodium hyposulphitum contains 20 drops. To the 1st flask we add 2 drops 1 ml — 20 drops Х ml — 2 drops

2) 1 ml of 0.01 N solution of sodium hyposulphite contains 20 drops. To the 2nd flask we add 4 drops 1 ml — 20 drops

Х ml — 4 drops

3) 1 ml of 0.01 N solution of sodium hyposulphite contains 20 drops. To the 3rd flask we add 8 drops 1 ml — 20 drops Х ml — 8 drops

4) Residue of chlorine in each flask is determined according to the formula: Х = 0.355  A х 5 In the 1st flask: 0.1 х 5 х 0.355 = 0.17 mg of chlorine per 1 litre; In the 2nd flask: 0.2 х 5 х 0.355 = 0.35 mg of chlorine per 1 litre; In the 3rd flask: 0.4 х 5 х 0.355 = 0.71 mg of chlorine per 1 litre. We select flask № 2, where the residual chlorine is within the norm. (N = 0.3 — 0.5 mg of chlorine per litre). To the 2nd flask we add 0.2 ml of sodium hyposulphite (4 drops). 5) The amount of dry lime chloride in grams necessary for decontamination of 1 cubic meter of water is determined according to the formula:

Conclusion The amount of dry lime chloride for decontamination of 1 cubic meter of water is equal

80 to 10 grams.

Theme No 9-10. Hygienic Significance of Soil. Hygiene of Inhabited Locality.

Hygienic Requirements to Cleaning Inhabited Locality from Waste Products Soil is one of the important objects of environment where the processes of autopurification take place; in the soil many chemical and microbe pollutants can accumulate, getting then into foodstuffs, atmospheric air, surface and underground waters. The basic hygienic parameters of soil are:  Porosity. The more the porosity is, the less the water is filtered, and much of it remains in the ground forming marshy soil which is unfavourable for the man.  Air permeability is connected with porosity of soil — the more the air permeability is, the more oxygen enters the soil and more biochemical processes of autopurification take place;  Water penetration, i.e. filtration ability — at sufficient values the ground is dry, and reserves of subsoil waters form there.  Capillarity — the more the capillarity of ground is, the higher the subsoil waters rise. Structure of the Soil The soil consists of mineral, organic, mineral-organic complexes, soil solutions, air and soil microflora. These are important parameters for hygienic estimation of soil, their changes can testify to pollution of soil. In the soil 2 processes constantly take place:  Disintegration of organic substances into inorganic — nitrification  Synthesis of new organic substances called humus — humification. Sharp disturbance of correlation of these processes testifies to pollution. The soil microflora is characteristic of each kind of soil and is the basis of autopurification processes of soil. It is estimated by total microbe number (TMN) and amount of the basic groups of microbes. Hygienic Significance of Soil  Endemic significance is the main factor of formation of natural and technogenic biogeochemical provinces with abnormal content of mineral substances that may through foodstuffs and water cause endemic (characteristic for the given district) diseases of the person. The majority of such diseases refer to microelementhoses (classification and representatives — see in the theme on mineral substances). To artificial biogeochemical provinces now the accumulation of pesticides, heavy metals, etc. in the ground refer. There are data about the interrelation of health state of population in these territories with the level of accumulation of these toxicants in the ground.  Epidemiological significance of soil The causative agents of different diseases can get into the ground and long be kept there causing the following:  Intestinal infections — typhoid, paratyphoid, dysentery, cholera, etc.  Anthropozoonoses — anthrax, etc.  Viruses — hepatitis, etc.  Helminthiases — ascaridiasis, etc. With soil dust the causative agents of tuberculosis, poliomyelitis, respiratory system diseases, etc. can spread.  Ecological significance of soil  It is the environment of accumulation and circulation in the nature of pollutants of

physical, chemical and biological origin;  It is a source of pollution of other environmental objects — foodstuffs, atmosphere, surface and underground water;  It is the environment of utilization and sterilization of solid and liquid waste products, garbage, sewage, animal and human corpses. At sufficient self-cleaning ability the soil is a primary factor of autopurification of environment. Ways of autopurification of the soil are the following:  Decomposition of pollutants by means of mineralization and humification which is due to the soil microflora, О2, enzymatic activity of the soil;  Adsorption of pollutants by soil particles;  Washout by subsoil waters;  Evaporation into air above the soil;  Oxidation of toxicants by О2 and effect of UVR in higher layers of the soil;  Neutralization of toxicants in acid or alkaline soil. Concept of Soil Pollution By definition of UNEP the ground pollution is chemical substances, biological organisms and products of their vital functions encountered in the ground not in a proper place, time and amount. The Basic Sources of Soil Pollution They can be divided into natural and anthropogenic. Natural sources include dying off plants and animals, floods, earthquakes, volcanoes, fires, etc. Anthropogenic sources are subdivided into:  Sources brought into the ground by a person purposefully:  agrochemicals — pesticides (herbicides are used for struggle against weeds) and fertilizers promote the formation of artificial biogeochemical provinces affecting the health of population.  burial places of people and animals, fields of sewage cleaning are microbe pollution of ground for many years.  Sources got into the ground casually — with industrial and household sewage, dump places, atomic power station, from atmospheric air, surface waters, etc. Soil Protection Against Pollution The main directions of soil protection against pollution are the following:  Administrative–legislative measures: laws and executive decrees of authorities on protection of soil against pollution.  Hygienic measures:  Preventive sanitary control includes building project appraisal and normalization of pollutants in the soil;  Current sanitary control is monitoring of pollution levels by direct and indirect signs and its comparison with standards.  Architectural measures — a correct location of dumps, areas for waste products, etc.  Medical monitoring — studying endemic and epidemic diseases in the region connected with soil pollution.  Ecological monitoring — the control of soil microflora and other biota.  Technological measures on prevention of soil pollution. Hygiene of Inhabited Localities Hygiene of inhabited localities is an important section of municipal hygiene setting hygienic requirements to location, layout and functional zones of inhabited localities, to layout of residential area, premises. It is of great importance for health of population, for maintenance of necessary sanitary conditions in cities, etc. Concept of “Urbanization” Urbanization is a prompt growth of number and size of cities, increase of urban popula-

82 tion at the expense of rural population decrease. On average in Western Europe countries the urban population makes up 60% of the whole population, in England, Belgium, Germany — 80-90 %. According to the United Nations data, for 200 years (1800-2000) the population of Earth has increased by 7 times, and urban population — by 125 times.

The principal causes of urbanization are the following:  The development of industry, science, transport in cities that requires many workers living near the enterprises;  In cities the level of cultural, information, public service is higher than in the rural area that explains aspiration of rural youth to move to cities. Large cities create nonoptimal conditions for life and health of person, therefore at WHO a special Committee on problems of urbanization was created. Consequences of Urbanization Along with positive sides of urbanization, i.e. high level of cultural, information, public service, there is a number of negative consequences, such as:  High density of population in small territory which results in growth of infectious diseases (flu, tuberculosis, etc.).  High pollution of city environment by chemical substances, physical and biological factors.  Decrease of solar radiation by 10-20 %, including UVR, causing growth of rickets in children.  High level of noise — on big highways noise even at night reaches 80 decibel (dB), (norm for rest — 30 dB). The occurrence of noise illnesses is possible at 50-60 dB.  Because of building up the air ventilation in cities is worsened, that leads to accumulation of pollutants (fogs-murderers, smog, etc.)  Non-optimal microclimate — in summer there is overheating of buildings, roads, etc.—  High level of transport traumatism of population.  Excessive waste of time and energy while getting to work and back.  Problem of rest out of town — there are not enough parks in cities, and going out of town for rest is not always possible in large cities.  High level of negative psychogenic factors — stresses, nervous and mental disorders.  Growth of cities limits agricultural use of suburban lands. These negative consequences of urbanization for people health are illustrated by greater disease incidence of urban population in comparison with rural one, deterioration of demographic parameters, decrease of parameters of physical development of children and teenagers in large industrial centers. Urbanization has resulted in occurrence of megapolises (New York, Tokyo, etc.) with huge amount of population and sharp deterioration of all negative consequences of urbanization. Factors Causing the Occurrence and Development of Cities As a rule, cities arise not at any place; their occurrence, development or decline are determined by a number of economic, social and political factors, which are called town- planning factors. Earlier such factors included:  The development of crafts and convenient waterways — at estuary of rivers, on seashore, e.g. Athens, in the Crimea — Chersonese, Feodosiya (Cafa), Sudak (Sugdeya).  Presence of feudal fortress with lock, solid city walls for protection of population against enemies (medieval cities — center of Moscow, Bonn, Krakow).  In the 19th century growth of industry and business activity (Manchester). Modern town-planning factors include the following:

 Presence of industrial enterprises and deposits of minerals. Many such cities are in bad climatic conditions, e.g. Norilsk in Arctic zone.  Availability of large transport junctions and crossing of large highways. Thus 200 years ago Simferopol (city-gatherer) appeared.  Presence of administrative establishments of a state level — governmental, re- publican, regional. It is Washington in the USA, Brazilia — a new capital of Bra- zil.  Availability of science, education centers and scientific and technical complexes — Novosibirsk academic town, Oxford, etc.  Presence of large Naval bases — Sevastopol, Vladivostok, etc.  For cities-resorts — the presence of recreational resources (curative mud, mineral waters, coastal seawaters), i.e. cities-resorts of the Crimea, Caucasus. The Basic Groups of Urban Population All urban population is divided into 3 groups:  town-forming group — workers of industry, transport, administration, science. It makes up about 30-35 % of city population.  serving group — workers of municipal services, education, public health services, trade, communication, etc. (20-25 % of city population).  economically unoccupied population –children, students, pensioners, unem- ployed (40-45 % of city population). Functional Zoning in Cities  Inhabited or residential zone where the basic part of population lives. It should have the best hygienic conditions.  Industrial zone. There is concentration of industrial enterprises into industrial units. Between this zone and inhabited zone there should be sanitary-protective gaps (zones) with green plantations.  Тransport-warehouse zone. In Simferopol it is clearly expressed in the area of railway station near our university.  The green zone is diffusely located on the territory, it is very important for autopurification of atmosphere and creation of recreational conditions in the city.  Residential suburb — parks, woods, recreation areas, agricultural enterprises supplying city. Hygienic Characteristics of Types of City Layout  Radial-circular layout was encountered in medieval cities; in the center there was the feudal castle and narrow circular streets and streets-radiuses leading to former city gate, e.g. center of such old cities as Moscow, Bonn, Krakow, etc. The drawback of such city planning is high density of population, bad airing, lighting, insufficient number of parks and squares.  Chess layout — streets and lanes are crossed at right angle. This type of planning was characteristic of cities of 18-19th centuries, e.g. St. Petersburg, center of Simferopol, Odessa, etc. The drawback of such city planning is complicated airing, difficulties for traffic as there are a lot of crossroads, air pollution.  Linear layout is in cities located along the rivers, highways, e.g. Volgograd, Dnepropetrovsk, Zaporozhye, etc. Hygienic conditions are better but there are great losses of time for traveling by transport (a long traveling along river).  Modern type of layout is a free planning in view of relief, hygienic conditions, functional zones. Old types of city layout at reconstruction are transformed into this type of layout. Types of Layout of Residential Quarters The initial inhabited city unit is a quarter, i.e. part of residential buildings limited by streets and lanes. They can have different size depending on type of quarter building up, namely:  A continuous building up is encountered in old quarters of city center — all area of a quarter has buildings. The drawbacks of this type of layout are bad air-

ing, lighting, high level of noise, air pollution, high density of occupation.  A closed building up — it is a continuous building up on periphery a quarter, while inside there are empty places. Disadvantages of this type are bad airing, high level of noise and pollution. It is recommended for conditions of Far North.  A perimeter building up — the buildings are located with intervals on perimeter of a quarter, inside which there are green plantations. It is used at reconstruction of old types of building. Its disadvantage is an increased noise level.  A line building up — buildings are located in linear fashion along streets. There are better conditions for airing and light, but there is a high level of transport noise.  A stitch building up — a narrow part of buildings faces the roads. There are better hygienic conditions but disadvantage is an architectural monotony of quarters.  A free building up — buildings are located in one quarter in apparent disorder, but hygienic requirements are taken into consideration. In modern layout of residential zones as the initial inhabited city unit not a quarter but a microdistrict is taken. A microdistrict is a large inhabited housing estate for 10-12 thousand inhabitants with free building up. In the center of microdistrict there are consumer service establishments — school, polyclinic, post office, etc. Highways are only on periphery of microdistrict. At such layout there are only city establishments in the center that reduces time losses at traveling by transport for microdistrict inhabitants. Protection of City Environment from Pollution  Administrative-legislative measures.  Hygienic measures — revealing and assessment of all sources of city pollution, control of projected objects, participation of SES in drawing up general plans of city development, control over realization of these plans. The current control is sanitary inspection of degree of pollution and taking measures to decrease the pollution.  Architectural measures — functional zones of cities, reconstruction of systems of building cities and inhabited quarters, location of sanitary-protective zones, planting trees and gardens in cities.  Technical and sanitary-engineering measures — the closed technology, change of technology with the purpose to decrease pollutant emissions, construction of sewage disposal plants on emission points and sewage treatment, etc. Hygienic Requirements to Premises The basic purpose of hygienic requirements to premises is to provide optimal conditions for rest, work of people. Microclimate: temperature is 18-22°С, relative humidity is 40-60%, speed of air movement is 0.2-0.4 m/sec. Ventilation: air changes per hour is 0.5-1 (in kitchens — 2-3), СО2 content — 0.1 %, volume of air exchange per 1 person is 20-30 m3/h. Illumination:  natural — light coefficient is 1/8-1/10, coefficient of natural illumination — 0.5- 0.75 %.  artificial: general — 40-50 lux, local — 100 lux, combined — 150 lux. Noise level — up to 30 dB (at night). Cleaning of Populated Areas from Waste Products Introduction of hygienically proved methods of removal and neutralization of solid and liquid waste products in populated areas remains one of the prime problems of public health care all over the world. An unsatisfactory state of affairs in this sphere constitutes a real threat of adverse epidemiological conditions in the populated areas and is an important reason for growth of infectious and non-infectious pathology. One of priority problems of environmental quality in Ukraine and Crimea is an unsatis-

85 factory situation with waste products, namely:  Accumulation of great amount of highly toxic waste products and absence of effective and ecologically safe methods of their neutralization.  Unsatisfactory sanitary conditions and overload of dumps with solid household waste products (dumps), absence of places for new dumps.  Insufficient degree of cleaning household sewage, thrown in coastal seawater areas, that results in high microbe pollution of seawater presenting epidemic danger for bathing and hence closing many sea beaches.

Wastes in populated areas are divided into 2 groups:  liquid — sewage,  solid — household wastes, factory wastes, etc. Systems of Cleaning the Populated Areas  Cleaning liquid wastes. For cleaning 2 systems are used — removal and floatable ones (sewage system). In the first case liquid wastes are taken out from populated areas with the help of special transport, in the second one — are drained outside the populated areas by pipes (sewerage system).  Cleaning solid wastes (garbage). An average norm of formation of household garbage is 320 kg per person per year, or 0.75 м3. In Ukraine and countries of CIS a regular scheduled system of cleaning garbage is used (from house dustbins). Methods of Removal and Destruction of Solid Household Wastes The basic methods of removal and destruction of household wastes are controllable garbage dumps, biothermal methods, trash burning. Controllable garbage dumps are areas of solid household wastes. Their location, operation and sanitary condition are supervised by sanitary-epidemiologic service. Biothermal methods are based on creation of conditions for development of thermo- phile microbes in garbage, thus the temperature in it increases up to 50-70ºC that promotes decomposition of organic substances, destruction of pathogenic microflora. To such methods composting (formation of compost in natural conditions in countryside) refers, as well as application of artificial biothermal chambers for acceleration of compost formation (fermentative towers, biostabilizers, biotanks). Trash burning. It is carried out in special furnaces at temperature of 650-1200ºC, however this method is uneconomical, as lots of emissions are sent out in atmosphere air, that is why it is applied less often. The sanitary-dangerous materials, infected waste products of hospitals should be subjected to burning in special destructors (separately in each hospital or in a centralized way). Methods of Removal of Solid Industrial Wastes  Non-toxic industrial wastes (debris) are collected in dumps of household wastes and are used as insulating material.  Solid toxic organic wastes are burnt in special furnaces at temperature of 1000- 1200ºС with gas-cleaning and dust collecting systems.  Low-toxic insoluble in water waste products are dug in ground in places with low filtration ability of soil (clay soil).  High-toxic waste products are stored in hermetically sealed containers on special dumps of industrial wastes, are dug in concrete containers in ground or dumped in deep-water areas of seas and oceans. But it constitutes a potential threat of environmental contamination in future. Methods of Cleaning Household Sewage They are subdivided into:  Mechanical or primary — cleaning sewage out of floating impurity and suspen- sions by means of precipitating and filtration;  Biological or secondary — cleaning out of dissolved organic substances due to

processes of biological autopurification;  Tertiary — a high degree cleaning out of pathogenic microflora or toxic substances.

According to ways of carrying out cleaning, all the methods are subdivided into:  Natural (soil methods, biological ponds);  Artificial (precipitation tanks, biofilters, disinfecting).

Soil methods of sewage cleaning include the following:  Fields of irrigation. The sewage moves to fields with agricultural plants along the grooves between plants. Water passes filtration through ground, where the processes of autopurification due to soil microflora take place, thus filtrate becomes clean enough.  Fields of filtration. These are ground areas without plants. The separate plots of such fields limited by soil banks 1 m wide are irrigated by means of sewage flooding, then they "have a rest" for a year, after that they are used again. Biological ponds. Special ponds with the development of hydrobionts, plants, sapro- phyte microbes are used, which provide the processes of biological autopurification of sewage. In the process of cleaning during 3-7 days sewage passes through cascade of such ponds, first — anaerobe ponds, then — facultative and oxidizing ponds. Artificial Methods of Sewage Cleaning  Mechanical cleaning. It is carried out with the help of lattices, and primary precipitation tanks. At big sewage disposal plants silt is neutralized in closed tanks — metatanks.  Biological cleaning. Biological decomposition of organic substances is carried out in biooxidizers, where the processes of autopurification are similar to those in biological ponds, but much faster. For this purpose biological filters (filters with a thin layer of microorganisms) are used, as well as aerotanks (bring active silt, aerate and mix water).  Disinfecting. In case of using sewage after cleaning for watering agricultural plants, on filling reservoirs for drinking and recreational purposes, the additional disinfecting is carried out (chlorination in doses of 5-50 mg/l within 1 hour).  Tertiary processing. In case of repeated use of cleaned sewage in industry, for cattle drinking, replenishing underground water supply the complex and expensive methods of complete cleaning are used — coagulation, adsorption, foam removal, ionic exchange, deep disinfecting, etc.

Cleaning Sewage of Medical Establishments Sewage of infectious, tuberculous and some other departments before dumping into the city sewerage system pass additional disinfecting by chlorination. Sewage from radiological departments is collected in special precipitation tanks until the decrease of radioactivity to permissible levels, and then get into the city sewerage system. Recommendations for Practical Classes on the Theme

Key Questions: 1.What is soil?The hygienic significance of soil. 2.Concept of soil pollution. 3.Protection of soil from pollution. 4.Limiting attributes of harmful action of substances in the soil. 5.Hygiene of populated areas. Urbanization and its main hygienic consequences. 6.The town-forming factors (in the past and nowadays). 7.Urbanization and its consequences. 8.Functional zones in cities. 9.Hygienic characteristics of types of city layout. 10.Hygienic characteristics of types of residential quarter layout. 11.Protection of the city environment from pollution. 12.Hygienic requirements to living premises. 13.Hygienically proved methods of removal and neutralization of solid and liquid wastes in the populated areas. 14.Methods of removal and destruction of solid household wastes. 15.Methods of removal of solid industrial wastes. 16.Methods of cleaning household sewage.

Learning Objectives and Their Concrete Definition 1. To know the scheme of sanitary inspection of living premises. 2. A technique of drawing up the act of sanitary inspection of living premises. To draw up the act of sanitary inspection of a flat, room, hostel room, etc.

Appendix 1 Scheme of the Act of Sanitary Inspection of Apartment 1. General information: name of building, year of construction, address. 2. Topography of locality: a hill, plain, open or closed for winds. 3. The characteristics of environmental territory: green plantations, location of plants and factories and pollution of atmospheric air by them, availability of noisy, dusty streets, etc. 4. A territory improvement round the building: the total area, percent of a built-up area, percent of green area, system and condition of its cleaning. 5. The characteristics of building: its location in a quarter (with a stitch, continuous, perimeter type of layout), microdistrict. The distance from the neighbouring buildings is ______meters. The long axis of the building is located (from the south to the north; from west to east, etc.). Number of floors, number of flats on each floor and in the whole house. Building materials (ferro-concrete, stone, wood). 6. A sanitary improvement of building: system of removal of liquid and solid wastes. A sanitary condition of yard, staircases, work of lift. 7. The floor, on which the flat is located, number of rooms ____, including those oriented to the street ______, to the yard ______. Overshadowing by the neighbouring buildings (present, absent). 8. Total area of flat ______m2, height of ceiling ______m, living space ______m2, cubic capacity ______m3. 9. Number of people living in the flat, including children under 14 years ______. 10. The living space per 1 person ______m2. 11. Walls: brick, wooden, the dampness (present or not). Sound insulation, material and condition of floors, windows, doors. 12. Heating: central, furnace. Air temperature _____ ºС. 13. Ventilation: central (functioning or not). Window leaves, through airing (possible or not). 14. Illumination: light coefficient in living premises ______. Artificial illumination with incandescent lamps, luminescent lamps, type of light fixture. 15. Area of rooms in m2, whether they are encumbered with things or not. 16. Kitchen: a condition of walls, ceiling, floor. A cooker (gas, electric). A sanitary condition of kitchen. 17. Water pipe (present or not), bathroom (present or not), where clothes are washed. 18. A lavatory is canalized (or not), its sanitary condition ______. 19. Availability of insects in the flat (present or not). 20. Noise in the flat (present or not), its origin. 21. Dampness in rooms (observed or not). Reasons of its occurrence. 22. Complaints of residents. 23. General conclusion about a sanitary state of object. 24. Measures on sanitary improvement of object state.

Date of inspection ______Signature ______Appendix 2 Scheme of Sanitary Inspection of Students’ Hostel 1. General information: name of building, whether specially constructed or adapted to the present purpose, year of construction, address, who resides (students, workers), total number of single ______, married ______, married are accommodated separately. 2. Topography of area: hills, plain, marshland, open or closed for winds.

3. The ground area: total area _____ m2, green plantations (present or not), clean or not. 4. Environmental territory: the inhabited quarter, industrial enterprises, dusty roads and air polluted by them (present or not). 5. The hostel occupies ______buildings. 6. Building: stone, ferro-concrete, ____ floors, year of construction ______, dry, damp, the walls are whitewashed (or not), floors are wooden, painted (yes, no), covered with linoleum (yes, no), concrete (yes, no), the scheduled repair was last made in ______year, complete overhaul in ______year. 7. The size of basic premises (bedrooms): width, length, height (in meters). The floor space and cubic capacity per man. 8. Heating: central, local; sufficient or not; air temperature ______ºС. 9. Ventilation: window leaves, transoms, conditioners, through airing, possible or not, applied or not, complaints of residents on temperature-humidity conditions and smells. 10. Illumination, light coefficient ______, light angle, ventiduct angle. Natural illumination during ____ hours per day. Artificial illumination, type of lamps. Es- timation of natural and artificial illumination. 11. Water supply: centralized (constant, periodically absent); from well. The hot water (present or not). 12. Lavatories: canalized (yes or no), located indoors (or in the yard). Regularly cleaned (yes, no). Quality of its disinfection. 13. Wash-stands, their location, number, sanitary condition. 14. Terms of linen change. 15. Whether washing the linen, cooking food, drying clothes are carried out in bedrooms, corridors. 16. Availability of insects in rooms. 17. The list of additional premises serving the hostel as a whole: a canteen, isolator, reading hall, dryer, etc. 18. System of room cleaning: damp, dry, frequency per week. Containers for garbage (present or not), distance from the hostel. Frequency of garbage evacuation from containers per day. 19. The additional data. 20. The general conclusion about a sanitary condition of hostel. 21. Measures on sanitary improvement of hostel. Date of inspection ______Signature ______.

The Training Instruction.

Hygienic Significance of Habitation In each inhabited area the most important element is habitation. In uncomfortable accommodation, at high density of people the particularly favourable conditions for spread of respiratory infections, primarily tuberculosis, are created. In dark rooms with insufficient solar and ultraviolet radiation small children are more often ill with rickets. At preliminary and current sanitary inspection the following requirements to habitation are determined: The ground area for construction of a house should: a) be located on a well lighted by the sun and accessible to airing area; b) have good natural or artificial relief for atmospheric water flow; c) have dry, not polluted soil; the level of subsoil waters should be not closer than 1.5 m to the ground surface; d) have the appropriate parameters of a sanitary condition of the ground, namely: i) the sanitary number should be not less than 0.85. ii) amount of helminth eggs — up to 10 per 1 kg of ground; iii) coli titer should be not less than 0.01; iv) titer of anaerobe microbes (Cl.perfringens). This titer should be not less than 0.001. 6) The hygienic requirements to a building. Illumination of dwelling depends on orientation of windows to parts of the world. The win-

dows of inhabited rooms should be southern and east in hot areas (the western orientation of a window is not optimal), the windows of additional premises should be oriented to the north. The axis of the building should approach an equatorial direction. The inhabited rooms should have insolation not less than 3 hours per day. At insufficient distance between houses a neighbouring building can throw a shadow, due to which the solar irradiation is sharply reduced. Therefore the distance between the neighbouring buildings should be not less than 2 heights of the highest building. The distance between an inhabited building to a garbage container should be not less than 30 m and not more than 50 m. 7) Types of inhabited buildings: a) one-storey apartment house (detached house); b) multi-storey apartment house (cottage); c) many-room low houses (for 2-8 apartments); d) many-room multi-storey houses (3 and more floors). Density of population in such houses is considerably higher. In houses higher than 5 floors a lift should be necessarily; e) a hotel type house — hostel. 8) A flat. The structure of a flat includes habitable and additional rooms. To habitable rooms a bedroom, a living room, and a study refer. The additional premises (rooms) are a kitchen, hall, bathroom, lavatory, storeroom, bal- cony, terrace. A bedroom should not be with a through-passage, designed for not more than two persons, located far from the kitchen and hall. Its area should be not less than 10 m2. The room for staying in the daytime (living room, dining room) may be with a through- passage. Its area should be not less than 14-16 m2. Its depth should be not more than double width. A kitchen should be not less than 7 m2 and should be isolated from habitable rooms. A hall serves for undressing, storage of the outer clothing and footwear, protecting habitable rooms from penetration of cold, noise. Its width should be not less than 1.2 m. Internal corridors — their width should be not less than 1.1 m. 9) Hotel-type houses for small families. At this type of construction the habitable rooms or flats are located on both sides of the central corridor. Each flat of this type has 1-2 habitable rooms, a small kitchen, lavatory, a small hall and a built-in closet. The houses of this type have certain disadvantages: through airing is impossible, the residents often come into contact. Hostels refer to the given type of buildings. 10) Hygienic norms for a students‘ hostel are the following: a) The area of bedrooms should be 6 m2 per one person at a height of bedrooms not less than 2.7 m. b) The distance between beds should be not less than 0.5 m, from the outer walls to beds — not less than 0.3 m. c) In one bedroom there should be not more than 4 persons. d) A common corridor is not more than 40 m in length. e) The additional rooms should be located at the end of the corridor. f) In a hostel for more than 300 men a canteen should be provided. g) The building of a hostel should occupy not more than 25 % of the ground area. h) The distance from a hostel to the container with garbage should be not less than 30 m and not more than 50 m. Self Test 1. Identify the type of state sanitary supervision over habitation. *A. current *B. preliminary C. precautionary D. every ten-day E. single at approval of a building 2. The depth of underground water at construction of buildings should make up not

more than A. 1 m *B. 1.5 m C. 2.2 m D. 2.5 m E. 3 m 3. Time of insolation of habitable rooms should make up: A. 60 min/day *B. 180 min/day C. 240 min/day D. 300 min/day Problem Solving 1. For construction of shielding building (from noise) a shop is chosen 110m in length, 5.5 m in height for protection of neighbouring house № 4. A highway passes nearby. An equivalent noise level in apartments of the house at present makes up 50.5 dB, on habitable territory — 65.5 dB. Make the conclusion on expediency of screen construction. 2. In a room of a student's hostel there are 4 persons. Frequency of ventilation is 3 times/hour, СО2concentration — 0.2 %. Light coefficient — 1:5. Temperature is 20º C, air humidity -55 %. General illumination by incandescent lamps -150 lux, local illumination — 50 lux. What diseases or deviations in a physiological condition of students can occur? 3. A two-room flat is located on the 6th floor, the lift does not work. The windows are southeast. The kitchen is next to a living room. A bathroom and lavatory are combined. The total area of the apartment is 45m2, 5 persons live in it. Noise at night is 25 dB. The walls of the bedroom are of light-green colour. The relative humidity is 66 %. The air temperature is 18º C. The walls of the sitting room are pink. The temperature is 20ºС. Frequency of ventilation in the kitchen is 1.5 times/hour. Make a hygienic estimate.

Standard Answers 1. The length of a noise-protecting screen is 120 m, its height — 5 m. The height of house № 4 is not specified. We can assume that at the expense of shielding at a height a noise level will decrease by 10 dB (ratio of 110 to 50.5 = 2, that reduces a noise level by 10 dB), that will exceed the norm. Hence the shop should be built higher. 2. There may be decrease of capacity for work, headache because of exceeding MPC of СО2. 3. Hygienic conditions are satisfactory with the exception of the kitchen which should not be combined with a habitable room. It is necessary to put a partition, to change the door layout.

HOSPITAL HYGIENE

Theme No 11. Hygienic Requirements to Hospitals The hospitals are built for implementation of medical protective regimen. The Medical-Protective Regimen and Its Main Components The medical protective regimen is a complex of medicodiagnostic, hygienic, administrative and economic measures directed at the fastest restoration of work capacity or health of a person. The medical diagnostic measures include:  Diagnostic and medical procedures. They are considered to be the main factor, but without carrying out other measures of medical protective regimen their efficiency decreases. Hygienic measures include:  An optimal choice of hospital location, the observance of requirements to hospital site and its functional zones;  Providing sanitary-antiepidemic regimen in hospitals, prevention of nosocomial infections (NI);  Creation of optimal hygienic conditions of location, lay-out, isolation and functional connection of premises in hospital;  Providing hygienic requirements to microclimate, bacterial contamination of the hospital environment, illumination, ventilation, water supply, hospital heating;  Providing rational and dietetic nutrition of patients, prevention of food poisonings;  Observance of personal hygiene by patients and staff;  Creation of optimal working conditions for medical staff and prevention of occupational diseases in personnel. Administrative measures are as follows:  The establishment of schedule and routine of work of hospital and polyclinic;  Providing staff of personnel;  Estimation of work efficiency of personnel, etc. Economic measures are:  Supply with medicines, linen and equipment, foodstuffs; transport supply of hospital. Hygienic Requirements to Hospital Location While choosing place for location of hospital of general type (central regional hospital, municipal hospital with polyclinic, etc.), two basic demands should be made:  Providing optimal hygienic conditions for hospital site - preferably out of town.  Accessibility to the served population (radius of polyclinic service in town is 3-5 km) – hospital should be in the town center, where the hygienic conditions are bad. It is rather difficult to combine both of these requirements, as they are inconsistent. Nowadays the problem is solved by construction of hospital in the suburbs, and polyclinic - in the town center. For specialized hospitals (phthisical, oncological, psychoneurological, infectious, venereologic) the first requirement is priority, the second one is not essential. The Area of Hospital Site The size of ground areas for hospitals of all types is regulated by sanitary norms and depends on capacity of hospital:  at hospital capacity up to 50 cots (beds) it is 300 m2 per 1 cot,  up to 100 cots - 200 m2,  from 200 up to 400 cots - 140-100 m2,  from 400 up to 800 cots - 100 - 80 m2,  from 800 up to 1000 cots - 80 - 60 m2.

For specialized hospitals in the suburbs the area is increased:  for infectious and oncological hospitals by 15 %,  for phthisical and psychiatric - by 25 %,  for pediatric by 40 %. The area site of maternity hospital makes up 0.7 of norms for typical hospital. Hygienic Requirements for Lay-out of Hospital Site  The hospital site should be of a rectangular form with a ratio of sides as 1:2 or 3:4 for convenience of functional zones.  The density of building at hospital site should not exceed 15 %. Green plants should occupy not less than 60 % of the site area. Along the perimeter a protective green hedge not less than 15 meters wide is planted.

The functional zones of hospital site are as follows:  Zone of medical buildings (infectious and non-infectious). The infectious department is located in depth of the site.  The gardening zone - includes green plantings along the perimeter of site, among buildings.  Zone of pathoanatomical department should be located beyond the sight from windows of medical buildings.  Zone of polyclinic. The polyclinic should be located at a distance of 30-50 m from medical buildings and have a separate entrance, or be as close as possible to the main entrance to the hospital site (prevention of visitors to polyclinic from intrahospital infections).  The economic zone is located at a distance of 30-40 meters from other zones. Here the central boiler-house, laundry with desinfection chamber, warehouse premises, garage, kitchen are placed.

Plan of hospital plot

Green zone

Pathoanatomical G Green zone zone reen Eco nomic Infection zone zone diseases depart- ( ment Econom- Ec garage) ic zone onomic ( foods- zone o tuffs stores ( bstetric Green and laundry, – preparation ) steriliza- gynecol zone tion) ogic M depart Main medical buildings ment ain Green zone medical build-

ings

Gr polyclinic Green zone een zone 95

Hospital section ( 25 beds) balco- b W A R D S ph ny buff 3 3 3 3 3 3 1 1ysician et -4 -4 -4 -4 -4 -4 -2 -2 room bed beds beds beds beds beds beds beds s

corridor Post of nurse on duty

Bath- room H T nu iso Toilet ostess choll reat- rses lation M wa Toilet nurseM ment ro rd W ate r room om Sanita rial oom ry room roo m

surgical block’s scheme sterilizating Narcosis room Operating room room 2 20 м 36м2 10 м2 Preoperative

room

15 м2

2, 8 м corridor

N Nurs Room Cloa- Cl M T urses’ es for manager kroom for oakroom aterial oilet assis- Roo of surgical patients for doc- room 1 tants m block’s 10 м2 tors 10 0 м2 R 10 10 м2 10 м2 oom м2 м2 10 м2

- exit

Box ( 22 m2) for 1 patient and half-box .

corridor

Hospital ward sluice4 sluice 5 5

3 Hospital ward

1 Sanitary room7 Sanitary room 6 5 2 tambur

1 - bed; 2 - table; 3-chair ; 4- rack for doctor’s overall; 5-wash-hand-stand; 6-bath, 7-toilet

- ventilation

window for food

exit

The Systems of Hospital Construction Historical types of hospital construction are as follows:  In the 17-18th centuries a barrack type of hospital construction was applied (one big room for all patients), then a corridor-barrack type was used when big wards are connected by corridor – the conditions for patients and personnel were very bad.  A hutment type was for the first time in the world applied by N. I. Pirogov in the Crimea in 1855-1856 during the Russia-England-France-Turkey war. After operations patients stayed in one wooden barrack for a while, then they were moved to another barrack, and the former one was burnt. It gave the possibility to decrease the number of postoperative infectious complications.  A pavilion type was applied at the end of 19th-beginning of 20th century. It consisted in construction of separate premises in a park with wards having good airing and illumination.

The modern types of hospital construction have the following features:  The decentralized system is characterized by presence of several, usually one- or two- storey buildings, each of them being used for one type of department, e.g. surgical, therapeutic, etc. In some hospital buildings the general diagnostic, economic and additional services, hospital authorities, polyclinic are located. The advantages of this system are: good conditions for prevention of intrahospital infections (isolation of each department of hospital in separate building), easy access for patients to hospital garden, where they can be in the open air in good weather and get a daily dose of UV irradiation. Disadvantages of this system are as follows: it requires a very big area for hospital site, the construction of lots of one-floor buildings is very expensive, it is difficult for personnel to transport patients to different diagnostic departments (especially in bad weather), to supply departments with medicaments, food, etc. This system is now applied at construction of sanatoria and while building hospitals in mountain districts.  The centralized system is characterized by location of all medical departments, polyclinic, administrative offices (apart from pathological anatomical and economic departments) in one multi-storey building. For example, for a 900-cot hospital a 15-storey building is necessary. The advantages and disadvantages of this system as compared to decentralized system are: in such hospitals there is a high level of intrahospital infection and it is very difficult to fight against it at such system of hospital building).  The mixed system of building is characterized by tendency to decrease the number of medical buildings up to 2-4, centralization of hospital medical-diagnostic and additional services. The infectious, children's, radiological departments and polyclinic are placed in separate buildings. Thus, on hospital site there are some low and multi-storey buildings.  The centralized-block system in modern conditions is the most appropriate to large hospitals. The basic feature of centralized-block system is division of all premises of hospital complex into two groups for the best maintenance of medical-protective regimen in hospital:  premises for long-term, stable operation, including medical buildings with ward sections of any structure.  premises which functional purpose demands regular updating of equipment, reconstruction or decoration which realization should not stop the work of hospital complex as a whole, namely the surgery block, premises for functional diagnostics, diagnostic laboratories, physiotherapeutic departments, polyclinic, etc. Hygienic Requirements to the Ward Section The basic functional unit of any hospital department is a ward section for 25–30 cots, in some specialized departments (resuscitation unit) it is less. The number of ward sections in the department is determined by number of cots in it. If a department is planned for 30 cots, it has one ward section. The basic premises of ward section are: wards, doctor‘s consulting room, room for patients‘ examination, buffet, lavatory, dining-hall, material facilities. There should be two 1- bedded wards (an isolation ward - for infectious patients and a ward for agonizing patients).

Hygienic Requirements to a Hospital Ward The capacity of ward for adults and children elder than one year in hospitals should be not more than 4 cots. This parameter is optimal both in technological and in hygienic relations. The area of ward should be 7 m2 per cot, the area in the ward of intensive therapy - 13 m2 per cot. The microclimate in a ward should correspond to the main standards for living quarters: temperature is 18-22ºC, relative humidity - 40-60%, speed of air movement – 0.2-0.4 m/sec. Ventilation: СО2 content – 0.1 %, frequency rate of ventilation - 2-3, volume of ventilation - 20-80 m3/hour/cot. Natural illumination: light coefficient (LC) 1:5 – 1:6, coefficient of natural illumination (CNI) -1%. Artificial illumination: general illumination in a ward is not less than 50 lux, local -100 lux, tell-tale light (at night at exit) - 3 lux. The distance between beds is not less than 0.8-1m, and between beds and external walls is not closer than 0.9-1 m. The maximal permissible level of noise in a ward is 25 decibel. Hygienic Requirements to a Surgery Unit At designing large modern multifield hospitals it is expedient to unite several operating rooms in a uniform complex, which should have two departments: septic and aseptic with operational, auxiliary and office rooms. The structure of a surgery unit should include an operational, preoperational, sterilization, anesthetic room, premises for storing blood and portable equipment, rooms for surgeons and scrub nurses. A surgery unit is divided into 4 zones according to degree of sterility:  sterile (operational) zone;  zone of strict regimen (sanitary inspection room for personnel, sterilization room);  zone of limited regimen (washing chamber, rooms for personnel);  zone of common hospital regimen (office of a surgery unit head, etc.). Hygienic Requirements to an Operating Room An operating room is designed for one operating table. The area of operating room should be not less than 36 m2, for difficult operations with participation of big surgery team - 45-50 m2. The total number of operating tables is taken on the basis of one table per each 30 cots of surgical department. The walls of operating room should be easily washed, preferably of greenish color.

Natural illumination. Light coefficient - 1:2-1:4, coefficient of natural illumination -2.5 %. General artificial illumination - 300-500 lux, local (on operational field) - 3-10 thousand lux.

Ventilation. Air ventilation in operating room should have a 6-time input ventilation, 5- time extract ventilation with preliminary purification of air so that microbes in the air from other premises of surgery unit could not get into the operating room. An input ventilation vent must be near the ceiling, an extract one - near the floor, as anaesthetic vapour is heavier than air.

The temperature of air in operating room is 22-25ºC, because in patient under anesthesia the thermoregulation centers don‘t function and overcooling may occur; humidity is up to 55% (prevention of explosion of narcotic vapour in view of high electric conductivity of damp air), speed of air movement – 0.1 m/sec.

Hygienic Requirements to the Admission Department of Hospital Table 35 FUNCTIONS AND STRUCTURE OF HOSPITAL ADMISSION DEPARTMENT FUNCTIONS TYPES of PREMISES Admission of patients and Entrance hall with registry reception of visitors Physical examination, Doctor‘s consulting room, room for patient‘s establishing or examination, express laboratory confirmation of diagnosis Rendering emergency care Room for patient‘s examination Cleansing patients Cloakroom, bathroom, dressing room

The admission department is intended for registration, physical examination, establishing or confirmation of diagnosis, cleansing patients and if necessary - rendering emergency medical aid. Patients with doubtful diagnosis are placed at reception wards. The structure of admission department includes the following premises: entrance hall (for waiting), registration and inquiry office, room for patients‘ examination, sanitary inspection room (a cloakroom, bathroom, room for dressing), room for medical procedures, dressing room, laboratory for urgent analyses, X-ray room, wards per 1-2 cots, consulting room of doctor on duty, toilet for personnel. Hygienic Requirements to the Infectious Department The infectious patients are admitted to the infectious departments not only for treatment but also for isolation. Therefore, the interior planning and sanitary regimen of this department are arranged with the purpose of prevention of intrahospital infections. The infectious department should have two entrances: one for patients, the second - for personnel, for delivery medicines, food, etc. Sewage from infectious department before dumping into city sewerage system is disinfected (norm of residual chlorine in it is 3 mg/l). Types of wards. Isolation of patients is realized in boxes, half-boxes and isolation wards. A box is a premise with total area of 22 m2 (per cot) or 27 m2 (per 2 cots) in which there is a ward external, entrance for admission of patients, bathroom, internal entrance which is connected with a hospital corridor. In boxes patients with doubtful diagnosis and particularly dangerous infections, such as cholera, etc. are placed. Half-boxes differ from boxes only in absence of external eutrance. Patients get into a half-box through a hospital corridor. Isolation wards are usual wards, cots in which are separated by partitions 2–2.5 m high to prevent contact of infectious patients. It is impossible to place patients with respiratory infections there, as there is common air exchange in such wards. Causes and Prevention of Intrahospital Infections According to WHO’s definition the intrahospital infection (II) is any clinically expressed disease of a microbe etiology affecting the patient during hospitalization or visiting medical establishments, as well as medical staff during its professional work, irrespective of the fact, whether the symptoms of this disease are manifested or not during presence of the given persons in medical establishment or up to 3 days after discharging from the hospital.

The spread of intrahospital infection is now registered in all countries of the world, it is a very topical problem for public health services, therefore there is a special Committee in WHO for investigation and struggle with intrahospital infection.

Structure of causative agents of intrahospital infection in the 20-21 century:  Till 1950s a dominant position in the structure of intrahospital infections belonged to

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acute infectious diseases caused by pathogenic microorganisms (scarlet fever, diphtheria, chicken pox, whooping cough, gas gangrene, tetanus, etc.).  A real "plague" of many hospitals in 50-60s of the 20 century became a staphylococcal infection.  Beginning with 1970s due to wide use of antibiotic therapy the leading place is occupied by gram-negative flora – proteus, E.coli, enterobacter, etc. which are very stable to antibiotics and it is very difficult to eliminate them with the help of antibiotics.

Danger of occurrence of intrahospital infection for the patient consists in the following:  the course of the basic disease is exacerbated;  lethality of patients at generalized form of intrahospital infection is up to 60 %;  new diseases during treatment in hospital can occur.

Danger of intrahospital infection for public health services is as follows:  disorganization of hospital work, down to temporary closing of hospital or its department for disinfection;  increase of duration of patient‘s stay in hospital (on average one case of intrahospital infection increases the term of patient‘s stay in hospital up to 13-17 days);  additional economic expenses for treatment of patients, work of personnel.

Basic sources of intrahospital infection are subdivided into:  primary, including patients, medical staff, visitors (less often)  secondary, including objects of the intrahospital environment, i.e instruments; linen, furniture; air, food.

Categories of intrahospital objects according to the danger of transmission of intrahospital infection are as follows:  critical, which are the most dangerous, requiring the most careful disinfection; they include surgical toolkit, needles, endoscopes, catheters;  half-critical, including the equipment for inhalation and anesthesia, kitchen utensils;  non-critical, i.e. linen, furniture.

The basic ways of transmission of intrahospital infection are the following:  aerosol (a respiratory and air-dust way);  contact (through tools, linen, furniture);  parenteral (at injecting medicines);  fecal-oral (through dirty hands);  alimentary (through food).

Structure of intrahospital infection according to localization includes:  infections of the urinary tract - 15-40 %;  wound (surgical) infection - 10-30 %;  infections of respiratory ways - 15-20 %;  intestinal infections - 10-20 %

Causes of intrahospital infection growth nowadays in different countries are the following:  a considerable increase of intrahospital infection among hospitalized patients of risk groups, i.e. patients with various chronic diseases (cardiovascular, oncological, blood diseases, diabetes mellitus), immunodepressive states; aged patients;  weakening of natural immunity and allergization of population due to unfavourable ecological situation;  "urbanization" of intrahospital environment, concentration of great number of patients and staff in multi-storey buildings;  complicating the operative interventions, increase of their duration and traumatism, wide application of endoscope equipment which badly yields to sterilization;

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 an excessive, sometimes insufficiently grounded application of antibiotics, the formation of intrahospital strains of causative agents of intrahospital infection, polyresistant to antibiotics used in a hospital;  insufficiently careful disinfecting of injection and other instruments;  increase of duration of patient‘s stay in hospital due to numerous functional- diagnostic researches;  insufficient attention to strict observance of hygienic and sanitary-antiepidemic regimen in hospitals.

System of prevention of intrahospital infection includes the following:  Strict observance of sanitary-antiepidemic regimen:  good ventilation, air sanitation of premises, optimal microclimate;  realization of medical control of personnel;  high-quality disinfection and sterilization of equipment, linen etc.;  regular bacteriological control of instruments, linen, air, food, hands;  revealing and isolation of infectious patients;  observance of rules of personal hygiene by personnel and patients.  Architectural measures:  rational location and zoning of hospital site;  rational interposition of departments and subdivisions in buildings and on floors in order to provide disconnection of ward sections, departments, operating rooms, offices, wards;  observance of hygienic norms of area, volume of hospital premises.  Increase of resistance of patients and personnel:  optimal regimen of work and rest;  rational nutrition;  sufficient staying in the open air;  scheduled and emergency immunization of patients. Occupational Hygiene of Medical Personnel The sickness rate of medical workers as compared to other professions is marked to be rather high, especially of surgeons, anesthesiologists, infectionists, phthisiatricians, roentgenologists, radiologists, etc. Occupational Hygiene of Surgeons and Anesthesiologists During their professional work surgeons and anesthesiologists come across a number of harmful factors, such as:  action of chemical substances (preparations for narcosis) – professional poisonings;  adverse microclimate (hot temperature) - overheating;  increase of СО2 concentration and decrease of О2 content (sterile mask on face) – hypoxia and hypercapnia;  psychoemotional and physical overloads with long overstrain of visual, acoustical, tactile analyzers – cardiac diseases;  effect of X-rays;  compelled position of body (long stay in vertical position) – radiculitis, osteochondrosis;  contact with infectious agents (including AIDS);  frequent violation of working and rest regimen. To prevent a professional pathology a number of preventive measures are carried out:  creation of good artificial microclimate (air-conditioning);  the centralized supply of О2 to operating room;  combined extract and input ventilation with prevalence of input ventilation;  observance of working and rest regimen (working hours in operation day should be not more than 5 hours, alternation of one operation and two non-operation days, gymnastic exercises and taking a shower after operation);  rational nutrition;  after operation it is not recommended to have reception hours at the out-patient department.

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 supplying surgeons and anesthesiologists with white gowns made of materials providing good ventilation;  change of white gowns every four hours, mask - 2 hours after the beginning of operation (because after this period of time the sterility is lost). Recommendations for Practical Classes on the Topic Lesson No 1. Hospital Hygiene

Key Questions 1.The medical protective regimen in hospital and its components. 2.Hygienic requirements to a hospital site and structural divisions of hospital. 3.Hygienic requirements to functional zones of a hospital site. 4.Hygienic requirements to a ward section and a hospital ward. 5.Hygienic requirements to a surgery unit and operating room. 6.Hygienic requirements to the infectious department. 7.Causes of growth, sources, ways of transmission and prevention of intrahospital infections. 8.Occupational hygiene of surgeons and anaesthesiologists and doctors of other specialities. Learning Objectives and Their Concrete Definition To do the test on checking the initial level of knowledge. To master skills of locating a hospital site, systems of hospital construction according to the suggested tables and instruction. To draw the general plan of hospital in the notebook. To draw schematically in the notebook the layout of: a typical ward section; an operating room; a box, half-box, infectious department. Substantiation of necessary measures for struggle against intrahospital infections. The decision of situational tasks with estimation of necessary measures to prevent or fight against intrahospital infections. To do the test on checking the final level of knowledge on the topic. Self Test 1. One of the methods of specific prevention of intrahospital infections is A. isolation of surgery units. B. rational location of departments on floors. *C. emergency immunization of patients. D. zoning of a hospital site. E. sanitary-antiepidemic measures.

2. On sanitary examination of the project of infectious hospital it was established that the basic premises are boxes and half-boxes. Identify the element which distinguishes half-box from box. *A. Entrance from outside B. Wards C. Lavatory D. Sluice E. Entrance from the department

3. On sanitary inspection of pulmonary department for adults it was established that wards per 4 cots had the area of 28 m2. What should be the minimal area of ward in the department? A. 40 m2 B. 24 m2 *C. 28 m2 D. 30 m2

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E. 52 m2

Problem Solving 1. The obstetric department is located in a 3-storey building. The second floor is occupied by admission department, the first one – by the physiologic pregnancy department, the third one - by the pathologic pregnancy department. All the floors incorporate by channels of extract ventilation. What does not correspond to hygienic norms in the obstetric division and needs re-planning? 2. The total area of the ward is 28 m2. What number of patients is the given ward designed for? 3. In regional hospital the room for reception and discharge of patients of children department is combined with other departments. Is the similar location of reception rooms admissible in the children department and in what case? Standard Answers: 1. The admission department should be located on the first floor, thus it is necessary to interchange the physiologic pregnancy department and admission department. 2. For 4 patients, the norm is 7 m2 per patient. 3. According to the hygienic standards the admission department in the children department should always be separate. It is allowed to combine rooms for discharging patients with other rooms of the department.

Topic of Independent Students’ Work: Sanitary-Hygienic Inspection of Hospitals The student should be able to:  carry out sanitary inspection of hospital;  make the act of sanitary inspection of hospital. Purpose of independent students‘ work:  To acquire the skills of estimating the location of a hospital site, system of building a hospital complex, lay-out and equipment: reception wards, therapeutical, surgical, obstetrics, infectious, children departments (children's hospitals), ward sections, polyclinics.  To master the technique of estimation and realization of sanitary inspection of projects and construction of hospitals and departments of different type and hygienic estimation of conditions of medical personnel work, substantiate the necessary measures for struggle against intrahospital infections. Algorithm of Practical Independent Work of students The first stage. Independent sanitary inspection of hospital, department and ward of Simferopol hospital according to the scheme (see Appendix). The second stage. Presenting the project of act of sanitary inspection to the teacher. The third stage. Preparation of act of sanitary inspection. The fourth stage. Handing in the act of sanitary inspection of Simferopol medical preventive establishment to the teacher.

Appendix Scheme of Sanitary Inspection of Hospital Name, capacity, address, type of medical establishment. Hygienic estimation of location of a hospital site. Functional zoning of a hospital site, hygienic estimation. Area of a hospital site (per 1 cot). Presence of polyclinic, radius of its service. Lay-out of hospital building up. Estimation of measures providing medical protective regimen. Structure of premises of the reception ward, equipment, sanitary condition. Description of one of the basic departments: Name, amount of ward sections;

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Structure of premises of ward section; Sanitary condition of department. Description of ward in the department: № of ward; number of cots, area per 1 cot; microclimate, ventilation, illumination, colouring of walls; sanitary condition; interrogation of patients in the ward about a sanitary condition of hospital, convenience of its location; estimation of measures providing medical protective regimen (administrative, hygienic, economic). The basic drawbacks revealed at inspection of hospital as a whole, and of department and ward in particular. Suggestions to their elimination. General conclusion on possibility to provide medical protective regimen in the hospital. Date of inspection ______Signature (group, full name)______

Note: the inspection and drawing up the act of sanitary inspection is made according to the scheme: one hospital per 1 group, 3-5 students per one department, one student per one ward.

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HYGIENE OF NUTRITION

Theme No .

Principles of Sanitary Examination of Foodstuff.

Topicality of the Theme A doctor of any speciality should know the rules of estimation of foodstuff quality with the purpose of improvement and maintaining a human health. The biological and nutrient value of foodstuff is preserved under the condition of their high quality meeting the demand of standard. During reception, storage, transportation or processing the foodstuff can spoil, become contaminated by chemical substances, microorganisms, etc. Therefore it is necessary to carry out a thorough sanitary inspection of foodstuffs at all stages of their production and realization. To determine the quality of foodstuff, a sanitary examination is carried out. The doctor of any speciality should be able to reveal changes of parameters of food quality: organoleptic properties, presence of harmful impurity and reasons of foodstuff spoiling, and also to establish the order of its realization. Methods of Analysis of Food Quality  Organoleptic — colour, taste, smell and consistence;  Physical — density, temperature, etc;  Chemical — content of proteins, fats, carbohydrates and others nutrients;  Microscopic — finding foreign substances, ova of helminths, etc. in foodstuff under microscope;  Bacteriological — finding microorganisms in the food ;  Biological — biological test of dangerous foodstuff on the laboratory animal;  Radiometric — the level of radioactivity of the foodstuff. The obtained data are compared with standards of foodstuffs. For this purpose the following documents regulating the quality of foodstuffs exist:  The State Standard of a food product. This is a document defining the necessary value of main parameters of the given foodstuff and including the unified, standard procedures of its definition.  Temporal Technical Conditions of a food product. It is designed for new products and includes main parameters of the given product. Classification of Foods by Quality  A good-quality product:  Standard — a product, which parameters correspond to the requirements of the State Standard, e. g. milk with a 3.2 % fat content)  Non-standard — a product having 1-2 unessential non-standard parameters, e.g. milk containing fat lower than 2.5 %)  Conditionally suitable product demands the preliminary processing before usage (acidic milk is subjected to processing for kefir, curd, cheese and other milk products).  A bad quality product has parameters making its usage impossible for man‘s nutrition, e.g. milk with high contamination by pesticides). The further perspective of such products is destruction or utilization as forage for cattle, etc.  Falsified products. (Falsificatio from Latin means deception). Properties of such products are changed specially for deceiving the customer (for example, milk diluted with water). Falsification of products is prosecuted. Except for above mentioned categories of foodstuff quality there is another concept — a product substitute — a substitute of a natural product officially produced by the state at lack of natural products, e.g. margarine is a substitute for cow butter). It is estimated according to the State Standard and may belong to one of the categories of foodstuff quality.

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Sanitary-Hygienic Characteristics of Foods Fish is rich in proteins of high biological value. The proteins of fish have a satisfactory amino acid balance. The fish oils are rich in unsaturated fatty acids of the omega–3 family having an antisclerotic action and A and D vitamins. Fish liver oils are the richest source of calcium, phosphorus and A, D vitamins. Fish is less rich in iron (Table 3). Sea fish contains iodine, while fresh water fish does not. But fish may be a source of some diseases — fish-borne diseases, such as:  Helminthiasis: Dibothriocephalus latus, opisthorchiasis  Bacterial infections: salmonellosis, botulism  Viral infections: Hepatitis A Virus. Eggs. Egg contains all the nutrients except for carbohydrates and vitamin C (Table 3). But in eggs cholesterol is contained in a dose of 250 mg per egg. Cholesterol promotes hypercholesterolemia and the risk of atherosclerosis. Elderly people can eat only 2 eggs a week. Egg-borne diseases include bacterial infections, e.g. salmonellosis. Meat. Meat contains 15 to 20 % of protein. Meat proteins are a good source of essential amino acids. The energy provided by meat depends upon its fat content. Iron is contained in meat in a dose of 2 to 4 mg per 100 g (Table 9). Iron from meat is more easily absorbed than iron from plants and it is another major quality of meat. Meat contains some vitamins (A, B6, B2, and PP), minerals, such as phosphorus, iron, zinc. It is poor in calcium and carbohydrates. Liver is extremely rich in many nutrients. All meat should be examined by veterinary inspector before sale. It is necessary to exert a strict sanitary control over places of sale and conditions of keeping fresh meat. Fresh meat must be wet, of pink colour, elastic and have an agreeable smell. It must be clear from pathogenic bacteria. If in a slice (40 cm2) of meat not more than 3 cysts are found out, a special cooking is necessary. Meat-borne diseases:  Helminthisms: Taenia saginata, Taenia soliumand, Trichinella spiralis  Bacterial infections: tuberculosis, anthrax, brucellosis, salmonellosis  Viral infections: spongy encephalitus Table 9

Nutritive Value of Meat, Fish, and Eggs (g100 g) Proteins (g) Fats (g) Carbohydrates (g) Iron (mg) Meat 21.4 3.6 - 2-4 Fish 19.5 2.4 - 0.7-3.0 Eggs* 10.0 10.0 - 2.5

* Two large eggs weighing about 100g

Sanitary-Hygienic Characteristics of Milk and Dairy Products Milk is the most valuable foodstuff with high nutrition value. It is an ideal food for infants and children. The milk proteins contain casein, lactatalbumin and lactoglobulin; milk fat is easily digestible. Carbohydrates are present in milk as lactose. Milk contains vitamins, but vitamin С is present only in very small quantities. Human and animal milk is compared in Table 10.

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Table 10 Nutritive Value of Milk (Food Value per 100 ml) Nutrients Buffalo Cow milk Goat milk Human milk milk Fat g 6.5 4.1 4.5 3.4 Protein g 4.3 3.2 3.3 1.1 Lactose g 5.1 4.4 4.6 7.4 Calcium mg 210 120 170 28 Iron mg 0.2 0.2 0.3 0.5 Vitamin C mg 1 2 1 3 Minerals g 0.8 0.8 0.8 0.1 Water g 81.0 87 86.8 88 Energy kcal 117 67 72 65 Milk Products Vegetable milk is produced from certain vegetable foods (soyabean, groundnut). It may be used as a substitute for animal milk. Cheese — proteins 12-16%, calcium — 8OO mg, phosphorus — 400 mg, fats — 25%. Sour cream — fats up to 36%. Curds (cottage cheese) — fats — 9-20%, proteins -12-16%. Kefir is slightly alcoholic and acidic, produced by fermentation of milk with yeasts and lactobacilli. Curd. Fresh curd must be white or creamy without sour smell. Fats — 9-18%, water — 65-80 %, acidity — 20-27 Тerner.

Milk-Borne Diseases (FAOWHO) These can be divided into:  Animal infections that can be transmitted to man including those of:  primary importance, i.e. tuberculosis, brucellosis, streptococcal infections, staphylococcal poisoning, salmonellosis, Q fever  lesser importance, i.e. cowpox, foot and mouth diseases, anthrax, leptospirosis, tick- borne encephalitis.  Infections primary to man that can be transmitted through milk, such as typhoid and paratyphoid fevers, shigellosis, cholera, enteropathogenic Escherichia coli (EPEC), non- diarrheal diseases including streptococcal infections, staphylococcal food poisoning, diphtheria, tuberculosis, enteroviruses, viral hepatitis.

Sanitary Examination of Milk

Sanitary-Hygienic Expertise of Milk

Evaluation of Organoleptic Properties of Milk  Colour of milk is evaluated in a cylinder made of colourless glass, which contains 50- 60 ml of milk. Normal colour of milk is white with a yellowish shade. Skim milk has a bluish shade. Diluted with water milk has a bluish shade. Impurity of blood in milk (cows diseases) is of pinkish shade. If an animal eats some plants, shade of its milk may be: orange, yellow — at eating carrots, pinkish — at eating beet, etc.  Consistence of milk is determined by a trace remained on walls of a flask after its churning. Normal consistence has a white trace Watery consistence of milk (milk diluted with water) has no white trace.

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Mucous or viscous consistence of milk (in case of development of bacteria in milk) leaves a dragging trace on walls.  Smell. For evaluation of smell 100 ml of milk are poured in a conic flask. Milk is sha- ken and after that smell is evaluated. Fresh milk has a milk specific smell. Sour milk has a specific acidic smell. Putrefactive microorganisms of milk add the smell of ammonia, hydrogen sulfide, etc., to it. If milk is improperly stored or transported, it can acquire different smells, e.g. of petroleum, soap, fish, perfume, etc.  Taste. For evaluation of taste an oral cavity is rinsed by a small amount of milk (5-10 ml). Good-quality milk has a slightly sweet taste. Diluted with water milk or skim milk has a watery taste. Other tastes (bitter, salty, styptic, fishy) are caused by a forage animal, its illness, extraneous impurities, incorrect taking and storage of milk.

Evaluation of Physical Properties of Milk  A dry residue is determined as quantity of organic substance and salts which are found in 1 liter of milk. A dry residue is determined by boiling down of water. A normal dry residue makes up 11–12.5%.  Density of milk is evaluated with the help of a device called a lactodensimeter (Fig. 7). A lactodensimeter is immersed in a cylinder with milk and the density of milk is determined by level of milk. For example, point 20 designates the density of 1.020, point 30 — 1.030, etc. The indications of lactodensimeter are added to the number 1.0. For example, the level of milk indicates point 30 of a lactodensimeter scale; it means that the density of milk is equal to the following: 1.0 + 0.030 = 1.030. The density also depends on temperature of milk. For this purpose there is a thermometer in lactodensimeter showing the temperature of milk. If temperature of milk is lower than 20ºС, for each degree below 20ºС it is necessary to subtract 0.0002 from the readings of lactodensimeter. If temperature of milk is higher than 20ºС, for each degree above 20ºС it is necessary to add 0.0002. The normal density of milk at 20°C is 1.028 — 1.034.

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Fig. 7. Lactodensimeter

Evaluation of Chemical Properties of Milk  Fat content is determined by a butyrometer (Fig. 8). This is a glass vessel of a cylindrical form. Into the device 10 ml of milk, sulfuric acid, amyl spirit are poured. Then butyrometer is placed in a centrifuge. The device is centrifugated for 5 minutes and after that the fat content of milk is observed. The isoamyl alcohol containing milk fats is concentrated at the neck of butyrometer with points, each major scale point corresponds to 1% of fat, each small — to 0.1 % of fat. The normal fat content is 2.5 — 3.2 %

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Fig. 8. Butyrometer

 The acidity is measured by Turner‘s degrees (T). It is the quantity of 1 ml of deci- normal caustic soda (0.1 N solution of Na2CO3), which is used for titration of lactic acid in 100 ml of milk at addition of 3-4 drops of 1% phenolphthalein (10 ml of milk + 20 ml of water + phenolphthalein + titration by 0.1 N solution of Na2CO3 up to a weak-pink stain- ing). The obtained result is multiplied by 10 times. Normal acidity is 16-22°T (16-19°T is fresh milk, 20-22°T — fresh enough, over 23°T — not fresh milk). Milk diluted with water has acidity below 16°T. Tests on Falsification of Milk  Test for definition of starch. It is necessary to pour 10 ml of milk, add 1 ml of iodine solution. The appearance of a blue colour demonstrates the presence of starch in milk.  Test for definition of soda (addition of rosolic acid). It is necessary to pour 5 ml of milk + 4-5 drops of a 0.2 % solution of rosolic acid in 96 % alcohol. If milk contains soda, its colour becomes crimson (+ Test). The milk which does not contain soda becomes yellow-pink (-Test). The Main Parameters of Milk According to the State Standard  Organoleptic properties:  Colour — white with yellowish shade  Smell and taste — specific lactic,  Consistence — it should not be watery or dense  Physical properties:  Density at 20°C — 1.028-1.034  Dry residue — 11–12.5%.  Chemical properties:  Fat content — 2.5-3.2 %  Acidity: normal acidity — 16-22° Terner (16-19°T — fresh milk, 20-22°T — fresh enough, over 23°T — not fresh). Diluted with water milk has acidity below 16°T.  Bacteriological properties:  Pasteurized milk in bottles and packages: . Common microbial number per ml — 75,000

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. Coli-index per ml — 0.3  Pasteurized milk in flasks and tanks . Common microbial number per ml — 300,000 . Coli-index per ml — 0.3  Tests on Milk Falsification  Evaluation of starch addition (–)  Determination of soda (–) Falsified milk has the following parameters: The skim milk: colour — of bluish shade, watery consistence, the dry residue is less than 11%, density of milk at 20°C is over 1.034. Milk diluted with water: colour — of bluish shade, watery consistence, the dry residue is less than 11%, milk density at 20°C is less than 1.028, acidity — below 16°T. Addition of soda. Soda is added to milk if its acidity is over 23°T (not fresh milk). Thus acidity is lowered. Rosolic acid is added to falsified milk (+ Test for determination of soda). Addition of starch. Starch is added to milk diluted with water in order to increase the density and dry residue of milk. Solution of iodine is added to falsified milk (+ Test for determination of starch). Recommendations for Practical Classes A sample of milk in a cylinder (200 ml) is given to each student for him to investigate and make the conclusion about its quality. Protocol

of Independent Work on Hygienic Examination of Milk Sample 1. Organoleptic properties: Colour ______Smell ______Taste ______Consistence ______2. Density of milk: ______The readings of lactodensimeter ______Temperature ______3. Fat content of milk — ______4. Dry residue — ______5. Acidity — ______Thus, the given sample of milk should be estimated as ______accord- ing to the classification of product quality, because: ______(to enumerate parameters which do not correspond to the State Standard and possible causes of deviations).

Example 1 1. Your conclusion about the sample of pasteurized milk in bottles Results of analysis: Colour White-yellowish Odour Standard Fat content 2.5% Temperature 24° Density of milk 1.030 Acidity 2425°T C Number of bacteria 25000 /ml Coli -index 2 Starches  SodaFor definition of soda ( — )  For definition of soda ( — )

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Problem Solving 1. Temperature of milk = 24 C (above 20ºС). 24 C — 20 C = 4 C 4 C  0.0002 = 0.0008 2. The density of milk at 20 C = 1.030 + 0.0008 = 1.0308 (Normal density) Normal density of milk at 20°C = 1.028 — 1.034 3. Acidity — 25°T (above normal acidity). Normal acidity = 16-22° T 4. The rest of indexes (colour, odour, fat content, number of bacteria, Coli-index) are normal. Conclusion Milk may refer to conditionally suitable foods. It may be used for production of curd, cheese, kefir, yoghurt. Example 2 1. Your conclusion about the sample of pasteurized milk in bottles Results of analysis: Colour Bluish shade Odour Standard Consistence Watery Fat content 1.9 % Temperature 10оС Density of milk 1.029 Acidity 19°T Number of bacteria 25000 /ml Coli-index 2 Starches SodaFor definition of soda ( — ) For definition of soda ( — ) Problem Solving 1. Temperature of milk = 10 C (less than 20ºС). 20 C — 10 C = 10 C 10 C  0.0002 = 0.002 2. Density of milk at 20 C = 1.029 — 0.002 = 1.027 (less than normal density) Normal density of milk at 20°C is 1.028-1.034 3. Fat content — 1.9 % (less than normal value of fat). Normal fat content of milk = 2.5–3.2 % 4. Colour — bluish shade. Normal colour of milk — white-yellowish. 5. Consistence — watery. Normal consistence should not be watery or dense 6. The rest of indexes (odour, number of bacteria, Coli-index, acidity) are normal. Conclusion Milk may refer to falsified products (milk diluted with water). It cannot be utilized. Self-control Test 1. As a result of veterinary inspection of animals on a milk farm 20 cows with a positive reaction to tuberculosis have been revealed. Identify the possibility of using milk of such animals for nutrition. * A. It can be used after pasteurization at 85C during 30 minutes B. It can be used without any preliminary processing and restrictions C. It can be used for calves D. It can be used for technical recycling E. It should be destructed

2. A student has the following devices: Geiger’s counter, Eber’s counter, Krotov’s device, Mishchuk’s device, Eber’s device. What device should be used for evaluation of meat quality? * A. Eber‘s counter B. Geiger‘s counter C. Mishchuk‘s device

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D. Krotov‘s device E. Eber‘s device

3. In the market the milk is sold which is delivered in flasks. Smell and taste of milk are usual, colour is white with bluish shade, density — 1.015, fat content — 2 %. Aci- dy is 15 Terner. The extraneous impurity is absent. Estimate the quality of milk. A. Milk is not fresh B. Surrogated milk * C. Falsified milk D. Milk of good quality E. Conditionally suitable milk

4. A sample of milk has been taken to laboratory for examination. The following data has been established: colour, smell — without features, taste — characteristic of milk, density — 1.038, acidity — 35 Terner, fat content — 3.2 %. Identify the degree of milk quality. A. Substandard milk B. Milk of good quality * C. Conditionally suitable milk D. Milk of reduced quality E. Falsified milk Problem Solving 1. The analysis findings of a milk sample are as follows: colour, smell, taste are usual. Density -1.033 at 30˚С, fat content — 2.6 %, acidity — 20˚ Тurner. Give a hygienic estimation of milk. 2. The analysis findings of a milk sample are: smell, taste — dairy, colour — white with a bluish shade, consistence — liquid. Density — 1.033 at 8˚С, fat content — 2.3 %, acidity — 20˚ Тurner. Give a hygienic estimation. 3. A milk sample from a tank shows: taste, smell — dairy, consistence — usual. Acidity — 17˚ Тurner. Density at 22˚С — 1.032. Fat content — 3.2 %. Reaction to starch and soda — negative. Total number of bacteria in 1 ml — 120,000. Give a hygienic estimation of milk.

Standard Answers: 1. Density at 20˚С is 1.035 (normal). Fat content is increased. As density is normal, dilution with water is excluded. The milk corresponds to standard. The conclusion: milk is of good quality. 2. Density at 20˚С is 1.029 (corresponds to standard). Fat content is decreased. As density is not increased, only depriving of fat is excluded; as density is not reduced, only dilution with water is excluded. The milk is simultaneously deprived of fat and diluted. The conclusion is: the milk is falsified. 3. Milk is of good quality, standard (bacteriological parameters of milk in flasks and tank — 300,000 per ml), density at 20˚С — 1.032.

Theme No 4.

Principles of Rational Nutrition. Prevention of Alimentary Diseases Nutrition hygiene is a section of hygiene studying the influence of factors connected with nutrition on a human organism and developing recommendations for a balanced diet. A part of nutrition hygiene is nutriology — a science about nutrients (food substances). According to WHO‘s data, about 70 % of all diseases are directly or indirectly caused by a wrong nutrition or deterioration of food quality.

The basic sections of nutrition hygiene are the following:

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 A rational nutrition is nutrition of a healthy person for maintaining and improving his health,  A medical or dietary nutrition is for treatment of patients,  A medical-prophylactic nutrition includes special diets for those working in harmful conditions, i.e. with chemical substances, radiation, etc.  A preventive nutrition is for people with risk factors of development of diseases (atherosclerosis, diabetes, etc.). Table 11 Classification of Types of Nutrition According to Purpose and Biological Effect Type of nutrition Purpose Group Biological effect rational prophylaxis of nutritional dis- healthy people non-specific eases preventive prophylaxis of diseases of a risk groups of diabetes, specific multifactor nature etc. medical- prophylaxis of occupational people working in protective prophylactic diseases harmful conditions medical (dieta- correction of metaboliс distur- patients pharmacological ry) bances Classification of Alimentary and Alimentary-Conditioned Diseases  Primary (exogenic) alimentary diseases. They are connected with insufficient or surplus nutrients or energy in diet. Their main feature is that aetiology, pathogenesis, symptomatology, prevention and treatment are connected only with nutrition.  Secondary аlimentary-conditioned diseases. They are caused by diseases of organs and systems resulting in disturbances of food assimilation, increase of disintegration and consumption of nutrients. They may be infectious, surgical, oncologic illnesses. To these also endogenic avitaminoses, cerebral, hypothalamic, endocrinic adiposity or dystrophy refer. The differential diagnostics of the 1st and 2nd group is very important for the doctor, because their therapeutic approach is completely different: in the first group only the correction of nutrition is necessary, while in the second — the treatment of a primary disease plus dietetic therapy, application of biologically active additives (BAA) are required.  Diseases of multifactorial etiology, including the alimentary factor. They develop on a background of genetic predisposition, nervous-emotional causes and other factors, such as atherosclerosis, hypertension, urolithiases and cholelithic diseases, gout, gastrointestinal tract diseases, oncopathology, diabetes mellitus. In occurrence of these diseases nutrition is a risk factor, but not the only reason. Prophylaxis is a preventive nutrition, dietetic therapy at the developed pathology.  Diseases connected with availability of harmful factors in food. These are food poisonings, intestinal infections, helminthiases. Their prevention is control of food quality.  Food intolerance is a set of clinical reactions to food: a food allergy (immunopathol- ogy), pseudo-allergy (individual reactions to separate substances), idiosyncrasy of food owing to enzymopathies. Classification of Alimentary Diseases (I group)  Diseases and syndromes of malnutrition:  Protein-calorie deficiency (PCD) of various degree, alimentary marasmus, physical development delay owing to PCD.  Protein deficiency, including kwashiorkor (infantile pellagra)  Avitaminoses.  Mineral deficiency: iron-deficiency anemia, endemic goiter (hypothyroidism), caries,

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hypozincosis, hyposelenosis, etc.  Diseases and syndromes of excess nutrition:  Surplus of caloric content — alimentary adiposity of 1-4 degrees.  Hypervitaminoses A and D.  Syndrome of excess of proteins, fat acids.  Excess of mineral substances — fluorosis, selenosis, molybdenum gout.

Principles of Rational Nutrition and Methods of Control of Their Obser- vance They were developed by academician A. A. Pokrovsky in the USSR and are now recommended by WHO for estimation of adequacy of individual nutrition and nutrition of population of different countries. It is a scientific basis of hygiene of nutrition.

1. Conformity of caloric content of nutrition to the daily energy consumption. This is the main principle of rational nutrition with which the analysis of nutrition begins. Methods of Control Caloric content of nutrition is estimated by:  a table-calculation method (taking into account a dietary intake and according to tables of food value of products) with the help of calorimetric coefficients. Calorimetric coefficients of nutrients: 1g proteins and carbohydrates = 4 Kcal, 1g fats = 9 Kcal. Proteins give 14 %, fats — 30 %, carbohydrates — 56 % of daily calories.  a laboratory method — burning of 100 g of food product in a calorimetric bomb. Daily Energy Consumption It is composed of the basic exchange + energy consumption for work + 10 % of the basic exchange for food digestion. The basic exchange is calculated by tables in accordance with sex, age, height and weight. Ways of estimation of energy consumption for work:  Table-chronometric method (by time of performing any activity),  Direct calorimetry (in the calorimetric chamber)  Indirect calorimetry (by respiratory coefficient = O2/CO2)

2. Balanced nutrition. The diet should contain all necessary nutrients: proteins, fats, carbohydrates, vitamins, mineral substances in an optimum ratio. It provides a better absorption and full-value use of food substances. Examples of balance: Ratio of proteins, fats, carbohydrates (P:F:C) = 1:1:4 (an adult person), 1:1:5 (hard physical work), 1:0.8:3 (elderly people), 1:1:3 (children). Ratio of proteins: of animal origin — 60 %, of vegetative origin — 40 %, Ratio of fats: of animal origin — 70-80 %, of vegetable origin — 20-30 % Ratio of carbohydrates: digestible — 10-15 %, indigestible — 85-90 %. Ratio Са:P = 1:1.5, etc. Methods of control: а) table-calculation, b) laboratory (proteins in foodstuffs are determined by Keildal, fats — by Sokslet method).

3. Optimal diet regimen. The food should be taken every 4-5 hours (time of evacuation function of the stomach), i.e. 4-5 times a day. Food intake less than in 2 hours is not optimal because gastric secretion is suppressed. Nutrition less than 3-4 times a day is harmful, because of great appetite a person eats plenty of food that leads to hypercholesterolemia, hyperlipemia, adiposity, etc. Taking food at one and the same time (30 minutes) is of great importance as a conditioned reflex of digestion is formed. The recommended distribution of daily caloric content by meals is as follows:

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Breakfast — 25-27 %, lunch — 10-15 %, dinner 35-45 %, supper 10-20 %. Methods of control include filling in a questionnaire about a diet and evaluation of caloric content of each meal.

4. Good organoleptic properties of food, its high digestibility, favorable conditions of taking food. This is necessary for maintenance of normal conditioned-reflectory activity of digestion (Acad. I. P. Pavlov).

5. Safety of food in chemical and epidemiological respect. It means absence in foodstuffs of chemical substances or microbes in amounts higher than allowable levels which may cause food poisonings. Now it is a very important principle in view of global pollution of biosphere by heavy metals, radionuclides, pesticides, etc. Ways of control are chemical and bacteriological analyses of foods and comparison of the results with food standards. Theories and Concepts of Nutrition In ancient times the hemopoietic antique theory of nutrition by Aristotle-Galen existed, according to which blood is food transformed in intestines. Scientific Theories of Nutrition These include the following:  Classical theory of balanced nutrition by academician A. A. Pokrovsky (60s of ХХ century).  Theory of adequate nutrition by аcademician A. M. Ugolev (1975) — in addition to the theory of rational nutrition the membraneous and endocellular digestion is taken into account.  Functional-homeostatic theory of nutrition by V. V. Vanchanen (1995) also takes into account functions and biological effects of different nutrients. Nonconventional (Unscientific) Concepts of Nutrition These contain both rational moments and antiscientific statements. They include:  Vegetarianism (veganstvo)  Nutrition of macrobiotics (Japan)  The concept of ―yan‖ and ―in‖ (China)  Nutrition in yogi system  Separate nutrition by G. Shelton  Nutrition of the ancestors (raw food, dry food)  Reduced nutrition (theory of ―alive energy‖ in vegetable food)  Concept of coefficients of alimentary value by E. Carise (―point diet‖) (Germany)  Complete long-lived or temporary starvation  Absolutization of nutrition optimality (Selective diet for each separate person — USA)

Recommendations for Practical Classes on the Theme

Key Questions  Types of nutrition (rational, preventive, clinical, clinical-preventive), their differentiation and purposes.  The basic principles of a balanced diet.  Theories of nutrition. Functions of food. Concept of dietary and food status of the man, methods of its study.  Methods of controlling the observance of balanced diet principles in a separate man and in collectives of people.  Methods of assessment of a daily energy consumption of a human organism and food value of foodstuffs.  Bases of nutrition at unfavourable ecological conditions.

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 Norms of nutrition, parameters which are taken into account at their elaboration.  Classification of alimentary and alimentary-conditioned diseases, examples, causes, manifestations, treatment and prevention.

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Self Test 1. What methods are used to determine the caloricity of man’s nutrition? A. direct and indirect calorimetry * B. a laboratory and calculation method C. a tabular-chronometric method D. a spectrophotometric method 2. The optimal number of meals for an adult man is A. 2-3 times a day * B. 4-5 times a day C. 5-6 times a day D. when the feeling of hunger occurs E. every 2-3 hours 3. A clinical nutrition is developed for: A. diseases caused by ecological conditions * B. for feeding patients in medical establishments C. diseases which badly yield to treatment D. persons contacting with occupational hazards 4. On medical examination of male drivers in 10 % of persons an increased body weight (65 % higher than normally) was revealed. What is their nutritional state? A. Normal status (adequate nutrition) B. Obesity of 1st degree C. Obesity of 2nd degree * D. Obesity of 3rd degree E. Obesity of 4th degree 5. Determine the caloricity of a student’s diet, which basic exchange makes up 900 Kcal, and energy losses in all kinds of activity during a day make up 2,100 Kcal. A. Caloricity of a daily diet is 900 Kcal. B. Caloricity of a daily diet is 2,100 Kcal * C. Caloricity of a daily diet is 3,090 Kcal D. Caloricity of a daily diet is 90 Kcal E. Caloricity of a daily diet is 1,545 Kcal Problem Solving 1. The diet of a miner includes 90 grams of proteins, 65 grams of fats and 650 grams of carbohydrates. Dietary habits are chaotic. An interval between meals is very large. What group of work intensity does the miner refer to? What is the amount of his energy losses? What is the caloricity of the submitted diet? Will it cover energy losses of the miner? Estimate this diet. 2. A 39-year-old surgeon spends 3,100 Kcal daily. The diet of the surgeon contains 93 g of proteins (including 40 g of animal origin), 116 g of fats and 300 g of carbohydrates. Caloricity of the diet is 2,651 Kcal. He usually has three meals every day: breakfast — at 7.30, dinner — at 15.00, supper — at 20.00. The distribution of caloricity by meals is as follows: breakfast — 20 %, dinner — 50 %, supper — 30 %. Determine the group of work intensity, estimate caloricity of nutrition and diet regimen. Give recommendations for balanced nutrition. 3. Patient Н. aged 63 suffers from excessive body mass, there are expressed signs of coronary atherosclerosis, hypertension. He has meals 3 times a day, avoiding fatty and spicy food. Estimate his nutritional state. What recommendations for correction of nutrition of antisclerotic orientation should be given in this case? 4. A patient aged 53 has a body weight of 82 kg at a height of 162 cm. She has 3 meals a day; the diet is usual. On examination an increased sugar level in blood (during last 5 years) has been revealed. In anamnesis: her mother was ill with diabetes mellitus. Estimate the nutritional state. Give recommendations for preventive nutrition. 5. Estimate the nutrition rationality of citizen N., aged 65, having 3 meals a day (at 8 a.m., at 4 and 8 p.m.), consuming 100 g of proteins, 100 g of fats and 500 g of carbohydrates. A daily energy allowance is 2,700 Kcal.

Standard Answers 1. The miner belongs to the 4th group of work intensity. Depending on age, the amount

119 of his daily energy losses makes up 3,900-4,300 Kcal. The caloricity of his diet is = 90 х 4.1 + 65 х 9.3 + 650 х 4.1 = 3,638 Kcal. The diet of the miner by caloricity does not correspond to his energy losses. The regularity of meals is disturbed. The time and frequency of meals should be regulated. 2. By energy losses the doctor-surgeon relates to the 3rd group of work intensity. Calo- ricity of his diet does not correspond to energy losses. A qualitative structure of the diet has deviations. The total amount of proteins (93g) in the diet corresponds to physiological norms, but the content of animal proteins is below the recommended norms — 43 % (instead of 55-60 %), total amount of fats in the diet is sufficient (116 g). The amount of carbohydrates in the diet is much lower than the norm. Instead of 426 g it makes up 300 g. The ratio of proteins, fats and carbohydrates in the diet is not rational: it is 1:1.2:3.2, while normally it is 1: 1:4-5. An interval between meals is more than 7 hours. The conclusion: the nutrition of the doctor-surgeon is not rational and imbalanced. 3. The nutritional status is excessive. Alimentary obesity, the development of ischemic cardiac disease in connection with hypercholesterolemia are probable. A fractional nutrition (6- 8 times a day) with a ratio of P:F:C = 1:0.8:3, limitation of fats and unprotected carbohydrates to limit the caloricity of food up to 2,000-2,400 Кcal a day are necessary. The inclusion in a diet of alimentary antisclerotic factors is necessary, e.g. irreplaceable aminoacid methyonin (cheese, cottage cheese), PNFA (vegetable oil, fat of sea fish), phosphatides (vegetable oil, etc.), antioxidant vitamins C, A and Е. 4. The nutritional status is excessive. Alimentary obesity is quite probable. The exclusion of unprotected carbohydrates from a diet, fractional nutrition (6-8 times a day) with a ratio of P:F:C = 1:0.8:3, limited amount of fats are necessary. Daily caloricity of food should be 2,200 Кcal. It is necessary to include sugar substitutes (sorbite, xylite, fructose, etc.) in meals, to provide optimal supply of diet with vitamins. 5. We begin solving the problem with estimation of caloric content of nutrition with the help of calorimetric factors (At burning 1g of proteins and carbohydrates gives 4.1 Kcal, and 1g of fats –9.3 Kcal of heat): 100 x 4.1 + 100 x 9.3 + 500 x 4.1 = 3,390 Kcal, This exceeds a daily energy allowance (2,700 Kcal). Besides a nonoptimal balance of proteins, fats and carbohydrates (1:1:5) is observed, which for elderly people should make up 1:0.8:3. The regimen of nutrition is also irrational: three meals a day (it should be four meals a day), there are nonoptimal intervals between taking meals (between breakfast and dinner — 8 hours, between dinner and supper — 4 hours), These time intervals should make up 4 -5 hours. The conclusion: the nutrition does not meet the demands of a balanced diet. It is necessary to decrease the consumption of fats by 20 g, carbohydrates — by 200g, to have 4 meals a day with intervals of 4-5 hours.

Theme No 5.

Value of Various Nutrients in Nutrition.

Functions of Proteins, Fats and Carbohydrates in the Body A section of hygiene of nutrition devoted to studying the functions of food substances (nutrients) in organism is called nutriology. Structure of Foods  Nutrients — proteins, fats, carbohydrates, vitamins, mineral substances.  Non-alimentary substances are substances adding organoleptic properties, i.e. color, smell, etc. to foods.  Antialimentary substances — antitrypsins (in raw egg protein), antivitamins (ascorbinase, thiaminase), antimineral substances (phytates, oxalates).  Toxic substances:  inherent in foods — toxins of poisonous mushrooms, solanine in potato, etc.  casually obtained pollutants of the environment — pesticides, heavy metals, dioxines, etc.

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Table 17 Functions of Nutrients Function Nutrients Energy carbohydrates, fats, proteins, organic acids, etc. Plastic proteins, minerals, fats, carbohydrates Bioregulatory proteins, vitamins, mineral substances Adaptive-regulatory proteins, water Immunoregulatory proteins, vitamins, etc. Treatment-and- dietary foods with the improved content of nutrients and ade- rehabilitation quate caloricity Signal-motivation gustatory and extractives (spice, seasoning)

Role of Proteins in Nutrition Proteins perform a great number of very important functions in the body: structural (construction of tissues), protective (gamma-globulins, etc.), regulatory (hormones, enzymes), transport (hemoglobin of blood), energy (14 % of daily calories). According to their value, proteins are classified into high-grade and less high-grade. Attributes of High-Grade Proteins  Presence in proteins of irreplaceable amino acids at an optimal ratio. By this criterion proteins are placed in the following order: protein of eggs, milk, meat, fish, soya, sunflower.  Good assimilability of protein in organism. There are 3 groups of proteins:  easily assimilated — milk, fish,  moderately assimilated — meat, eggs (after thermal processing),  badly assimilated — leguminous, bread, mushrooms.  High biological value. After absorption a greater part of irreplaceable amino acids should be used for the main functions of proteins, except for energy. Parameters of Protein Value 1. Aminoacidic number (AAN) in %%:

The composition of ideal protein (FАО/WHO) in g per 100 g of protein: valine — 5, leucine — 7, lysine — 5.5, isoleucine — 4, methionine — 3.5, threonine — 4, tryptophan — 1, phenylalanine — 6. AAN of key products: an egg — 100 %, cow milk — 95 %, rice — 67 %, wheat — 53 %.

2. The ratio of irreplaceable and replaceable amino acids in protein:

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3. Protein efficiency ratio (PER) > 2.5

where : W1 — the initial mass of the body W2 — mass of an animal body at the end of experiment В — amount of protein (in g), received by the animal during experiment.

4. Net protein utilization (NPU) > 0.7

A — quantity of nitrogen in meal (in g) where U — quantity of nitrogen discharged A with urine (in g) F — quantity of nitrogen discharged with feces (in g) Irreplaceable Amino Acids and Their Functions Irreplaceable amino acids are not synthesized in a human organism and should be supplied from outside with foods. Among the 20 amino acids eight are irreplaceable for an adult person. They are methionine, lysine, tryptophan, leucine, isoleucine, threonine, valine, phenylalanine. Methionine. A daily need is 2-3 g. It regulates the exchange of fats, phosphatides and cholesterol — an antisclerotic factor. It is contained in milk, cottage cheese, eggs, legumes, meat, fish. Lysine. A daily need is 3-5 g. It participates in synthesis of hemoglobin, supports a nitrogenous balance, regulates content of Са in blood. It is contained in milk, meat, fish, soya. Its content in cereals is little. Tryptophan. A daily need is 1.6 g. It stimulates growth of tissues, synthesis of blood proteins and hemoglobin, maintains a nitrogenous balance. It is contained in little portions in different food proteins. For children, in addition to above mentioned, 2 more irreplaceable amino acids are necessary — аrginine and histidine. They are conditionally irreplaceable, synthesized in the organism but in insufficient amount for a growing organism, since they stimulate growth, development, metabolism, hematosis. A Protein Norm and Protein Minimum A protein norm is a necessary daily amount of protein for a person, which allows the protein to fulfill all its functions. It is a part of the nutrition norms of the population (Table 18). It depends on age, sex, intensity of work. For adults on average it makes up 70-100 g a day. The optimal ratio of animal and vegetable proteins for adults is 50 : 50%, for children 60 : 40%.

Table 18

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A Daily Need of Protein (g/kg of body mass) Country Men aged 18-59 Women aged 18-59 FAO \ WHO 0.75 0.75 USA 0.80 0.80 Canada 0.77 0.69 England 1.15 1.0 Russia 0.93 — 1.7* 0.96 — 1.4* Ukraine 0.83 — 1.53* 0.83 — 1.4*

Note: * — depending on age and work intensity A protein minimum is the necessary amount of protein for maintenance of nitrogen balance in organism — at that all protein is spent on decomposition and formation of nitrogen. Calculation: daily in the organism 6-7g of nitrogen are lost, 1 g of nitrogen is formed at decomposition of 6.25 g of protein (upon the whole about 40 g that is less than 50 % of protein norm). At nutrition on this level the basic functions of protein are not fulfilled, that can result in acquired immunodeficiency. A Protein Problem and Ways of Its Solving On a global scale nowadays in the world 50 % of the necessary amount of protein for nutrition of all population of the planet is produced. Almost in all countries, especially in those with an insufficient level of economic development and a low living standard, part of the population experience either shortage of protein in general, or shortage of high-grade (animal) proteins, that affects the population health. The traditional ways of solving a protein problem are as follows:  Increase of agricultural production by extensive and intensive ways (at these agrochemicals should be used, that results in contamination of foods and pollution of biosphere)  Increase of a crop preservation by means of chemicals  A wide use of protein products of the ocean (but they are very expensive, may cause allergic reactions and accumulate pollutants from the sea water).  Isolation of protein concentrates from soya, sunflower and their addition to sausages up to 20-30%. Unconventional ways of solving a protein problem include the following:  Application of microbiological synthesis (growth of some microbes on sugar production wastes, on oil, but it is very difficult to refine protein from waste products, and such protein cannot be used in man‘s nutrition).  Search of profitable ways of synthesis of irreplaceable amino acids (for the present such chemical synthesis is very expensive). Role of Fats in Nutrition The structure of food fats includes: neutral fats (ethers of glycerin and fat acids), fatty substances — phosphatides, mineral substances, fat-soluble vitamins (in some fats). Functions of fats in nutrition: energy (30-32% of daily calories, 1g fat gives 9 Kcal), regulatory, plastic, protective (from mechanical and temperature effects), gustatory. Characteristics of Fat Acids According to the content of free (double) links in formula, fat acids are subdivided into saturated, unsaturated and polyunsaturated.  Saturated fat acids (SFA) are stearin, palmitic acids in animal fats, butyric and caproic acids — in vegetable oils. They are nonreactive, absorbed worse than others, perform basically an energy function. They are contained in the beef, mutton fat. At excessive use they contribute to the development of atherosclerosis due to plenty of cholesterol and absence of antisclerotic factors.  Monounsaturated fat acids (MUFA) — oleic acid — contain one free link in the formula; they are better absorbed, perform basically an energy function. They are found in vegetable fats.

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 Polyunsaturated fat acids (PUSA) — linoleic, arachidonic acids (omega-6 family), lino- lenic acid, etc. (omega-3). They have several free links in the formula. They are the most biologically active and valuable among fat acids. They fulfill:  a regulative function, controlling the cholesterol exchange (an antisclerotic factor), reducing coagulability of blood and permeability of vessels.  a protective function, increasing the resistance of organism to infections, toxicants, excess ultra-violet rays (antioxidants).  a plastic function: PUSA are included into vessel walls and myelinic membranes of the nerves. Suppliers of PUSA: PUSA of omega-6 family are contained in unrefined vegetable oils, PUSA omega-3 are contained in sea fish oils (biologically are most active). Phosphatide Value Fatty substances are those in which one fatty acid is replaced by a phosphoric acid and nitrogen base. Their representatives are: lecithin, cephalin. They participate in synthesis of nucleic acids, in cholesterol exchange (an antisclerotic factor). A plastic role is as follows: they are included into cell protoplasm, especially of the nervous system and liver. Suppliers are: liver, brain, egg yolk, butter, lard, unrefined vegetable oils. Sterols. They are divided into phytosterols and zoosterols (Cholesterol). Despite a widespread opinion about its harm, cholesterol is very important for an organism. Its plastic function is as follows: it is contained in cell protoplasm, creates elasticity of tissues as hydro- phylic colloid due to preserving water. A regulative function includes synthesis of vitamin D, bile acids, sex and steroid hormones. A protective function is inactivation of hemolytic poisons. According to modern concepts the development of atherosclerosis has a multifactorial etiology, which basis is the disturbance of a fatty exchange and increased endogenic synthesis of cholesterol; excess of alimentary cholesterol is of a comparatively small significance — it is an alimentary risk factor of atherosclerosis. Value of Carbohydrates in Nutrition Functions of carbohydrates include the following:  an energy function (56 % of caloric content of a diet per day), 1 g = 4 Kcal  a regulatory function (a cellular tissue stimulates the motility and secretion of intestines)  a plastic function (carbohydrates are included in the structure of protoplasm and cellular membranes)  a protective function (carbohydrates are bound to heavy metals, cholesterol; glucose inactivates cyanides),  a gustatory function — a sweet taste. Table 19 Classification of Carbohydrates CHEMICAL HYGIENIC 1. Monosaccharides (Glucose, 1. Unprotected (refined) from absorption fructose) 2. Disaccharides (Saccharose, lactose) 2. Protected (starch) 3. Polysaccharides (starch, pectins) 3. Overprotected (Cellulose, pectin substances)

In hygiene carbohydrates are subdivided according to degree of absorption:  The unprotected (refined) carbohydrates are mono- and disaccharides (glucose, lactose, etc.). They are quickly absorbed in the organism and supply energy. At consumption of plenty of such carbohydrates alimentary adiposity, diabetes mellitus and caries may develop.  To protected carbohydrates starch relates. It is slowly absorbed in organism and supplies most of the energy.  Overprotected carbohydrates are а cellular tissue, pectin substances.

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Recommendations for Practical Classes on the Theme

Key Questions 1.Food structure. The basic groups of nutrients. 2.Significance of proteins in nutrition: concept of a protein norm and protein minimum, signs of full value of proteins and protein products; irreplaceable amino acids for adults and children; representatives, role in organism, a daily need, foods-suppliers; 3.Significance of fats in nutrition: - classification of fat acids, representatives, role in organism; - polyunsaturated fat acids, representatives, their role, foods-suppliers; - phosphatides, representatives, their role, foods-suppliers; - cholesterol, functions in organism. Alimentary antisclerotic factors. 4.Significance of carbohydrates in nutrition: hygienic classification of carbohydrates, representatives; - hygienic characteristics of various carbohydrates. Self-control Tests 1. What percentage of total fats should fats of a vegetable origin make up in a balanced diet of an adult man? * A. not less than 30 % B. not more than 30 % C. not less than 50 % D. not more than 20 % E. not less than 70 % 2. The signs of full value of proteins include the following: * A. an optimal ratio of irreplaceable amino acids B. convenience of thermal processing without loss of food value * C. good assimilability * D. high biological value E. performance of energy function 3. Identify the alimentary antisclerotic factors. * A. methionine B. lactose * C. PUSFA D. vitamin C * E. phospholipids Problem Solving 1. Suffering from bilateral pneumonia, patient N. received intensive antibacterial therapy, which resulted in dysbacteriosis of intestines. What changes expedient to the diet of the patient will you recommend? 2. What foods are the prevailing source of phospholipids? 3. Energy losses of a miner aged 35 make up 4,100 Kcal. The analysis of a daily food allowance has shown that its caloricity is equal to 3,640 Kcal. It contained proteins — 100 g, fats — 90 g, carbohydrates — 598 g. Dietary habits provide four meals a day: breakfast — at 6.00, lunch — at 11.00, dinner — at 16.00, supper — at 20.00. Caloricity is distributed by meals: breakfast — 20 %, lunch — 15%, dinner — 40 %, supper — 25 %. Determine the group of work intensity, estimate value of nutrition, balance of the diet and dietary habits.

Standard Answers: 1. It is necessary to increase the amount of dairy products (kefir, yoghurt, acidophilin) in the diet. 2. Cereals, oil, leguminous cultures.3. The 4th group of work intensity. Daily caloricity should make up 3,900-4,300 Kcal. The diet meets to principles of balanced meals.

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Theme No 6.

The Significance of Vitamins and Minerals in Nutrition

Value of Vitamins in Nutrition Vitamins are the low-molecular organic substances, biologically active in very small amounts. Functions of vitamins:  regulatory — they form enzymes and regulate metabolism,  protective — they increase the resistance of organism to the unfavourable climatic factors, harmful physical and chemical influences, infections, etc. (vitamin C is an antioxidizer). Classification of Vitamins

Water-Soluble Vitamins Vitamin C — Ascorbic acid Vitamin В1 — Thiaminum Hepatoflavin — Riboflavinum Vitamin В3 or В5 — pantothenic acid Vitamin B6 — pyridoxine, pyridoxal, pyridoxamine Vitamin В12 — cyanocobalamin Vitamin Н — biotin Vitamin РР — Niacin, nicotinamidum Folic acid

Liposoluble Vitamins Vitamin A — Retinolum, retinolacetat, retynal Vitamin D — ergocalciferol (D2), cholecalciferol (D3) Vitamin E — admixture of tocopherols Vitamin K — admixture of naphthoquinones

Vitamin-like Substances Choline Inosite — Vitamin B 8 Lipoic acid — Vitamin U Orotic acid — Vitamin B 15 Pangamic acid — Vitamin В15 Carnitine Para-aminobenzoic acid Biologically fissile materials — Bioflavonoids

Sources of vitamins Vitamins are formed basically in plants, and also accumulate in animal organisms. A person receives water-soluble vitamins with vegetable food, fat-soluble ones — with animal and vegetable food. Some vitamins can be synthesized in a human organism:  Vitamins of group B, especially B12, are formed in intestines at microflora activity;  Calciferoles (vitamin D3 — cholecalciferol) are formed in the skin from provitamin de- hydrocholesterol at ultra-violet irradiation.  Vitamin A (retinol) is formed from beta-carotenes of vegetable food in very insignificant amounts (1/6 of need for vitamin A).

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Types of Vitamin Status of Organism By level of vitamin supply of organism the following are distinguished:  Avitaminosis — a complete absence of vitamin in nutrition for a long time;  Hypovitaminosis — insufficient supply of organism with vitamins (about 50 % of requirement);  Subhypovitaminosis — a boundary condition between hypovitaminosis and a normal vitamin state;  Normal supply of organism with vitamins;  Hypervitaminosis — an excess intake of vitamins (vitamins A and D, as a rule). Avitaminosis and hypovitaminosis can be exogenic and endogenic (the latter is caused by disturbance of vitamin absorption). Methods of diagnostics of vitamin status are as follows:  According to symptomatology of disturbances, characteristic of each avitaminosis connected with a concrete vitamin (scurvy, beriberi, etc.).  Biochemical methods (by content of vitamines in blood or urine and comparing the results with the norm).  Functional tests (skin haemorrhage at vitamin C hypovitaminosis).

Factors influencing the vitamin requirement of organism are divided into:  Exogenic:  a phsychoemotional and physical overstrain  work at high and low temperature  work in mines, in the Far North  contact with industrial poisons, at medicine intake (antibiotics)  work with radiation, noise, vibration  smoking  seasonal fluctuations — insufficient amount of vitamins in a diet in winter and spring.  Endogenic:  age  pregnancy and lactation  infectious diseases  endocrine diseases (hyperthyroidism, increase of metabolism in organism)  intestinal diseases (disturbance of vitamin absorption, resection of intestines). Significance of Separate Vitamins Vitamin C — ascorbic acid. For an adult person 75-100 mg of this vitamin per day are necessary. Its functions are the following:  participation in oxidation-reduction processes  strengthening a vascular wall — prevention of haemorrhage (scurvy)  stimulation of immunity — resistance to infections  regulation of protein and carbohydrate exchange  increase of resistance to toxic substances (an antioxidizer)  influence on Са absorption (at scurvy in children — changes in bones). It is a very unstable vitamin. An ascorbic acid is easily oxidized. Factors destroying vitamin C are temperature, access of oxygen, catalysts (salts of Ferrum and Cuprum — knifes, utensils), the alkaline environment, ascorbinase enzyme (activated at cutting vegetables and fruit; inactivators of ascorbinaze are salt, sugar, vinegar).

Vitamin D is a complex of calciferols. They distinguish ergocalciferol (vitamin D2) which is formed in plants and cholecalciferol (vitamin D3) which is formed in skin at action of ultra-violet irradiation from dehydro- cholesterol. The products of their oxidation are biologically active, formed in the liver and kidneys. Lack of vitamin D causes rickets in children, infrequently osteoporosis in adults. Regula- tion of absorbtion and exchange of Са has an antirachitic effect. It is of particular importance for children. The reasons of D-hypovitaminosis are lack of a solar irradiation (Far North, pollution of the atmosphere, insufficient staying in the fresh air, work in mines, etc.), using only vegetables

127 for food. Prevention and treatment of rickets in children are introduction of vitamin Dз — 500 In- 1 1 ternational Units (IU) per day, preventive artificial UV irradiation ( /6 — /8 of biodose, at rickets — ½ — ¼ of biodose). At overdosage of vitamin D — D-hypervitaminosis — severe derangements of calcium metabolism, calcinosis of heart, kidney and other vessels occurs. Calcinosis of coronary vessels in childhood at overdosage of vitamin D results in predisposition to myocardial infarction. Vitamin A — retinol. It is necessary for vision, growth, stimulation of immune system. Avitaminosis more often occurs in children of preschool age and results in hemeralopy (night blindness) and xerophthalmia (degeneration of eye conjunctiva and cornea). "Vitamin of pros- perity" is basically contained in expensive animal foods — cod-liver oil and liver, as well as in plants — beta-carotins. A daily norm of the vitamin is 1.5 — 2 mg. Signs of A-hypervitaminosis are: headache, baldness, disorders in the bone tissue and liver, in pregnant — spontaneous abortions and deformities of foetus. The reason is overdosage of vitamin-A preparations, less often — consumption of the liver of a polar bear which is a fatal retinol poisoning. Significance of Minerals in Nutrition Of 50 elements, present in a human organism, 26 are vitally important, among which 12 are macroelements and 14 are microelements (Table 20). Table 20 Classification of Minerals Macrobioelements Microbioelements [Content is more than 10 mg/kg (mg %)] [Content is less than 10 mg/kg (1 mg %)] 1. Cations of calcium, potassium, magnesium, sodium 1. Necessary: Iron, iodine, fluorine, zinc, copper, cobalt, manganese, nickel, selenium, chrome, etc. 2. Anions of phosphorum, sulfur, chlorine 2. Necessity is not clarified: strontium, boron, bromine, cadmium etc. 3. Organic bonds with oxygen, carbon, hydrogen 3. Toxic: lead, cadmium, arsenic, hydrargyrum

Requirements for Minerals (mg/day) Calcium — 800-1500 Phosphorum — 1200-3000 Magnesium — 400-500 Iron — 15-18 Zincum — 15 Iodine — 0.15 Copper — 1.5-3 Manganese — 2-5 Fluorine — 1.5-4 Chromium — 50-200 Characteristics of Some Macroelements Calcium. Its needs are 0.8 g per day, for pregnant at lactation — 2 g. It is especially important at children's age — 1-1.5 g/day are necessary. Functions  plastic — in structure of bones, teeth (makes them harder)  regulatory — strengthening a vascular wall, participation in blood coagulability, transfer of impulses in the nervous system, maintenance of normal nervous-muscular excitability, is a part of buffer systems,  protective — increases the resistibility to infections, produces a desensibilization effect (antibiotics). Conditions of Ca Absorption  An optimal ratio with phosphorus — Са : P = 1:1.5 — in milk and dairy products (cheese, cottage cheese).

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 Presence of vitamin D — improves Са absorption  An optimal ratio with magnesium — Са : Mg = 2 : 1 (for children 9:1). Magnesium is Ca antagonist; it is contained in great amounts in cereals.  Sufficient content of proteins in meals — a better Ca absorption  Absence of great amount of fats and oxalic acid — insoluble compounds with Ca are formed.

Phosphorus. Its requirements are 1.6 g a day, for children — 3 g, for pregnant — 3.8 g. Functions  plastic — is a part of a bone tissue (providing elasticity), nerve tissue  regulatory — the formation of phosphatides and nucleic acids, ATP and buffer systems of organism. Conditions of Absorption  Ratio of Са : P = 1 : 1.5  Sufficient amount of fats in food Products-sources: dairy products, yolk, fish, legumes, meat. Microelements These are mineral substances contained in tissues of organism in amounts less than 1 mg%, required for organism in minute quantities, but playing a very important regulation role. The diseases connected with disturbance of microelement structure of nutrition are called microelementoses (Table 21). The reason of their occurrence is biogeochemical provinces (according to V. I. Ver- nadsky) — territories with abnormal contents (increased or lowered) of microelements. These provinces may be natural caused by features of geological formation of Earth's crust and anthropogenic connected to human activities (heavy metals, fluorine, etc.). People in these areas get insufficient or superfluous amount of microelements with food and water, so endemic diseases (characteristic of certain districts) occur. Table 21 Classification of Microelementoses (based on lack or excess of microelements in ground, water and foodstuffs) Hypomicroelementoses Hypermicroelementoses Monohypomicroelementoses Monohypermicroelementoses fluorine → caries 1. Natural: iodine →endemic struma molybdenum → molybden-endemic gout iron → iron-deficiency anemia selenium →selenium toxicosis strontium → strontium rachitis fluorine →fluorosis cadmium → cadmium nephropathy iodine → Basedow‘s disease Polyhypomicroelementoses : 2. Anthropogenic: iron, copper, manganese, zinc → hydrargyrum →Minamata disease anemia cadmium → illness itai-itai PCD → Usho illness lead, arsenic, pesticides, dioxines, nitrates → different disease Polyhypermicroelementoses: strontium, manganese, fluorine → river Urova disease (Kasin-Beck disease) Significance of Some Microelements Fluorine. Daily requirement is 2.5-3 mg. It regulates Ca-P exchange. It participates in

129 formation of dentin, dental enamel and bones. Due to lack of fluorine caries occurs, at its excess (5 % of Ukraine territory) — fluorosis, i. e. damage of teeth, bones, disorders of intellectual development in children. Iodine. Daily requirement is 0.1-0.2 mg (100-200 µg). It participates in synthesis of the thyroid gland hormone — thyroxin, regulates function of this gland. Because of lack of iodine hypothyroidism (endemic goiter or myxedema) occurs, at its excess — hyperthyroidism (Base- dow‘s disease). Iron. Its requirement is 15 mg a day, for women — 30 mg a day. It takes part in synthesis of hemoglobin (60% of all iron in organism), is a part of some oxidizing enzymes — peroxidase, cytochrome. It is an indispensable part of a cell cytoplasm and nucleus. Conditions of absorption: hydrochloric acid, vitamin C. Recommendations for Practical Classes on the Theme

Key Questions: 1.Vitamins and minerals. Their classifications. 2.Biological role and conditions of absorption of vitamins and minerals. 3.Physiological, natural and social factors determining the needs and supply of organism with vitamins and minerals. 4.Concept of hypovitaminoses, subhypovitaminoses, avitaminoses and normal supply of organism with vitamins. Reasons of occurrence, clinical, physiological and biochemical manifestations. 5.Concept of minerals, their classification. Concept of macroelements, their functions. Func- tions of Ca, P, Na, conditions of their absorption. Microelements (Fe, F, J, Zn, etc.). Microele- mentoses, their classification, reasons of occurrence, clinical, physiological and biochemical manifestations. 6.The basic foods-suppliers of vitamins and minerals. Conditions of storage and culinary processing of foodstuffs ensuring the maximal preservation of vitamins and minerals. 7.Methods of determination of vitamin C in foods and in biological liquids of a human organism. 8.Method of estimation of mineral salt intake in оrganism with a daily diet. Learning Objectives and Their Concrete Definition Evaluation of adequacy of individual nutrition as for vitamins and minerals according to the tables made at home beforehand, taking into account sex, age, kind of activity, body weight, diet.

Table 22 Physiological Daily Need for Vitamins and Minerals in Adults Vitamins Minerals Men Age C A E D B1 B2 B6 B12 Ca P Mg Fe Zn I mg µg mg µg mg mg mg mg mg mg mg mg mg mg 18- 70 1000 10 2.5 1.4 1.3 2 3 800 1200 400 10 15 0.1 50 Women 18- 80 1200 400 18 15 1.5 2 2.5 800 1200 400 18 15 0.1 50

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Table 23

Estimation of Vitamin and Mineral Value of Food

Food Weight С A (carotin) E B 1 B2 Ca P Fe I (g) mg mg mg mg mg mg mg mg µg

Meat 100 0 0 0 0.08 0.14 9 178 2 - Liver 100 33 3.8 - 0.3 2.2 5 339 9 - Chicken 100 -- 0.04 - 0.07 0.15 10 210 1.5 - Fowl 100 - 0.07 - 0.07 0.15 16 228 3.0 - Sausage 100 - - - 0.25 0.18 7 146 1.7 - boiled Sausage 100 - - - 0.19 0.2 10 226 2.7 - smoked Eggs 100 - 0.35 - 0.07 0.44 55 185 2.7 - Fish 100 - - - 0.1 0.1 - 310 - 100 Milk 100 1.0 0.02 - 0.03 0.13 121 91 0.1 - Kefir 100 0.8 0.02 - 0.03 0.01 121 94 0.1 - (yoghurt) Cheese 100 2.4 0.21 - 0.03 0.38 760 424 - - Butter 100 - 0.5 - - - 22 19 0.2 - Oil 100 - - 35 - - 45 - - - Bread white 100 - - 3.2 0.2 0.1 23 131 3.2 - Bread black 100 - - 2.2 0.2 0.1 21 174 3.6 - Rice 100 - - 0.4 0.08 0.04 24 97 1.0 - Buckwheat 100 - 0.01 6.6 0.4 0.2 55 298 6.6 - Oatmeal 100 - - 3.4 0.5 0.1 64 349 3.9 - Cabbage 100 50 0.02 - 0.06 0.05 48 31 1.0 Potato 100 20 - - 0.12 0.05 10 58 0.9 Carrot 100 5 9.0 - 0.06 0.07 51 55 1.2 Onion 100 10 - 0.05 0.02 31 58 0.8 Leek 100 30 2.0 0.02 0.1 121 26 1.0 Beetroot 100 10 0.01 0.02 0.04 37 43 1.4 Tomatoes 100 20 0.03 0.1 0.1 14 26 1.4 Paprika 100 250 2.0 0.1 0.08 8 16 - Orange 100 60 0.05 0.04 0.03 34 23 0.3 Lemon 100 40 0.01 0.01 0.04 40 22 0.6 Apple 100 13 0.03 0.1 0.03 16 11 2.2

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At the end of the lesson in the protocol notebook the students make up the following table: Estimation of Adequacy of an Individual Nutrition as for Vitamin and Minerals Content Nutrient Actual intake with a Norm of daily in- Difference diet per day take Vitamins: C A В1 Mineral substances: Са Р Fe F Self Tests 1. Name the basic groups of minerals. * A. microelements B. water-soluble minerals C. liposoluble minerals * D. macroelements E. phosphatides 2. A daily need for vitamin C makes up: * A. 75 mg * B. 100 mg C. 50 mg D. 60 mg E. 10 mg 3. As a result of a thorough medical examination of cadets of a military school the disorders of colour perception, conjunctivitis, dryness of the skin, skin pigmentation and nail fragility were revealed in some of them. To control the similar clinical manifestations, it is, primarily, necessary to increase in their diet the content of: A. carrot B. meat C. groats * D. bran bread E. fish Problem Solving 1. A group of students living in a hostel addressed the doctor with the complaints of general weakness, early fatigue, gingival hemorrhage. On interrogation it was established that the students had meals irregularly, frequently took canned food, food concentrates for meals. The examination has shown the presence of gingival edema and hemorrhage. What is your preliminary diagnosis and its substantiation? What objective adequate methods of research and examination can you offer? What methods can be used to carry out a mass inspection of all students living in the hostel? Give your recommendations for prevention of such diseases. 2. What hypovitaminoses should be expected first of all in patients being fed parenterally for a long time? 3. What foodstuff is the basic source of Ca, its daily norm? What is the ratio of Са: Р: Mg?

Standard Answers:

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1. Hypovitaminosis C. For specification of the diagnosis it is necessary to inspect skin integuments for revealing petechial hemorrhage. It is necessary to determine content of vitamin C in blood and urine. The inspection of all students living in the hostel should be carried out with the use of express-methods of research, tongue test and definition of capillary resistance. It is possible to recommend the enrichment of diet with vitamin C, taking fresh vegetables and fruit, correct culinary processing of products. 2. Vitamins D, K, group В1, A, Е. 3. Milk, cabbage, spinach. A daily norm is 0.8 g. The ratio of Са:Р = 1:2 (1.5), Mg:Са = 0.5:1.

Theme No 7.

Food Poisonings. Reasons, Symptomatology, Prevention Food poisonings are non-contagious, more often acute and mass diseases, caused by the use of substandard food, containing microorganisms or toxins of various origin. Their difference from the intestinal infections (dysentery, cholera, etc.) is non- contagiousness (absence of transfer of the disease from a patient to a healthy person). Food poisoning may occur only in persons, who eat food containing harmful substances or microbes. Classification of Food Poisonings  Food poisonings of a microbe etiology:  Toxoinfections are caused by entry of living microbes into organism with nutrition (E.coli, Proteus, Cl.perfringens, Bac.cereus, etc.).  Bacterial toxicoses occur at entry of microbial toxins with nutrition into organism: . staphylococcal toxicosis (Staphylococcus aureus) . botulism (Clostridium botulinum).  Food poisonings of a non-microbe etiology:  with toxic products: . toxic mushrooms (death-cup, fly-agaric, etc.) . toxic plants (belladonna, etc.) . toxic weeds (heliotrope) . toxic parts of some fish  with foodstuffs sometimes or partially toxic: . stone-fruits (amygdalin) . haricot (phasing) . potatoes (solanine)  with chemicals: . heavy metals — lead, copper, zinc, hydrargyrum, etc. . pesticides . nitrates and nitrites . food additives.

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 Mycotoxicoses Table 24 Type of Mycotoxins Foodstuffs Pathology fungi Aspergillus Aflatoxins Nuts, coffee Cirrhosis and primary cancer of the liver Aspergillus Ochrotoxins Grain, coffee Balkan epidemic nephropathy Fusarium Trichocetenes Grain 1. Fusariotoxicosis (poisoning with ―drunk bread‖) 2. Alimentary-toxic aleukia Claviceps Alkaloids of Grain Ergotism ergot Penicillium Patulin Juices, mashed Malignant tumours potatoes

 Food poisonings of non-investigated etiology:  Alimentary paroxysmal toxic myoglobinuria (Gaffen disease)  Poisoning with quail meat  Kashin-Beck disease (now it is referred to as strontium, manganese and fluorine hyperpolymicroelementosis) Food Poisonings of a Microbe Etiology These include the following:  Toxicoinfections are caused by entry into organism of food containing living microorganisms. The specific causative agents are Salmonellas, potentially pathogenic microflora — E. Coli, Proteus, etc.  Bacterial toxicoses (former — food intoxications) occur on entry into organism of foodstuffs containing bacterial toxins formed in them. The examples are staphylococcal toxicosis, botulism.  Those of mixed etiology — when food contains both living microbes and toxins, for example, Salmonellas + staphylococcal toxin. Toxicoinfections Foods-sources: meat products, especially minced meat (pies with minced meat), eggs (frequently infected with Salmonellas), fish (stuffed, cooked and hot smoked), sour milk products (sour cream). Conditions when products become dangerous in respect of toxicoinfection include the following:  The reasons of entry of causative agents into foodstuffs:  slaughter of diseased and tired animals, improper cutting of animal carcass,  improper storage and transportation of foodstuffs, processing raw and cooked foodstuffs on the same cutting board, with one and the same knife, etc.,  non-observance by the personnel of nutrition units of rules of personal hygiene, absence of regular medical examinations of personnel, attraction of unknown or ill people to work in the kitchen.  The reasons of reproduction and preservation of causative agents in foodstuffs:  improper storage — non-observance of storage temperature and terms of realization,  insufficient thermal processing.

Signs and Symptoms of Toxicoinfections There are 5 clinical forms:  Gastroenteric form: nausea, vomiting, diarrhea, stomach pains. It may be of a  mild degree — 80% of all cases;  moderate degree — 20% of cases (increase of temperature up to 38°C);  severe degree — 2% (body temperature is 38-40°С, decrease of arterial blood pressure, severe intoxication).  Typhus-like form — severe intoxication with intermittent fever

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 Choleroid form — severe intoxication with profuse diarrhea  Dysentery form — diarrhea with blood in faecal masses  Grippe-like form — signs and symptoms of grippe, gastroenteritis is slightly expressed.

Prevention of Toxicoinfections It includes elimination of reasons of entry and reproduction of causative agents of toxoinfections in foodstuffs (see above).

Bacterial Toxicoses This is a group of food poisonings of a microbe etiology caused by the microbe toxins which have accumulated in foodstuffs.

1. Staphylococcal Toxicosis Its cause is a golden staphylococcus, capable of producing exotoxin in products. Food- sources are: dairy products, creams, pies, cakes, fish and meat products. The conditions of a staphylococcus entry into foodstuffs and producing exotoxin are the following:  Staphylococcal diseases of personnel of nutrition units, such as quinsy, pustular diseases of the hand skin,  Improper storage of foodstuffs — at room temperature, non-observance of expiration date. Clinical signs and symptoms: gastroenteritis at a normal temperature, infrequent diarrhea, in severe cases — cardiac abnormalities, dehydration of organism. Prevention: physical examinations and dismissal of personnel from work, proper storage of products, especially cakes and pies in a hot season.

2. Botulism The reason of botulism is the formation of exotoxin in food products by botulinic bacillus Clostridium botulinum. Features of the causative agent are as follows:  a spore formation — spores withstand boiling for 4-5 hours, (the bacillus itself in a vegetative form dies in 15 minutes), they survive at temperature of 16ºС for 14 months, resist the action of preservatives, e.g. salt, vinegar, sugar for a long time;  an obligate anaerobe microbe — it develops without access of oxygen (canned food);  Under certain conditions (+10-30ºС without oxygen) it forms the strongest neurotropic exotoxin, which lethal dose for a person is 35 μg. Foods-sources: in the 19th century in Germany they included cooked and blood sausages (poisoning with "sausage poison"), dried and cold smoked fish, nowadays these are most frequently tinned goods (household preserved mushrooms and vegetables — it is difficult to destroy spores in home conditions), sometimes — dried and smoked meat, canned meat.

Clinical Signs and Symptoms of Botulism The toxin affects the central nervous system: medulla oblongata, nuclei of the cranial nerves. The following is affected more often:  nuclei of oculomotor nerve — ptosis (a sinking down of the upper eyelid), anisocoria (unequal pupils of the eyes), ill-sustain accommodation;  nuclei of ophthalmic nerve — blurring of vision, visual impairment;  nuclei of glossopharyngeal and hypoglossal nerve — speech disturbance up to aphonia (the person cannot speak), difficulty in swallowing — dysphagia (the person cannot drink water);  nuclei of facial nerve — disappearance of mimic and chewing muscle tonus of one half of the face;  nuclei of vagus nerve — the increase of pulse rate at a normal or lowered temperature, defecation is normal or there is a tendency to constipation (as compared to other microbe food poisonings, it is a very important differential symptom !). Then there may be spasms, pains in muscles, affection of vasomotor, respiratory centers of the central nervous system and death. The mortality of non-treated botulism is up to 70 %, at treatment — up to 30 %.

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Treatment of Botulism It includes introduction of antibotulinic serum or anatoxin (15,000 IU, recurrent introduction of a 5,000 IU dose in 5 hours). On taking suspicious food prophylaxis is necessary, namely introduction of serum in a dose of 2,000 IU.

Prevention of Botulism There should be strict observance of temperature technology in cooking tinned goods, dried fish, meat. At household conservation small jars should be used and long boiling should be applied, the storage of canned food should be at temperature less than 10°C. Food Poisonings of a Non-Microbe Etiology

Poisonings with Poisonous Mushrooms (Toadstools)

Poisoning with Death-cup It is the most poisonous mushroom containing ammonitotoxin and ammonitohemoly- sin. They block all kinds of metabolism, primarily carbohydrate and water ones. This type of poisoning results in acute gastroenteritis — a cholera-like diarrhea, dehydration of organism, disturbance of the central nervous system and cardiovascular system (a sharp fall of the arterial blood pressure). In blood hemolysis (destruction of erythrocytes) occurs manifested in skin paleness, as well as acute hepatic insufficiency (destroyed parts of erythrocytes go with blood to liver) manifested in icteritiousness of skin. Death may result from collapse at affection of the CNS.

Poisoning with Fly-agaric This mushroom has an atypical appearance, sometimes disguising itself as an edible mushroom. It contains muscarine and mycoatropine causing changes of m-cholinergic nervous system. The symptoms include: gastroenteritis, perspiration, lacrimation and salivation, mydriasis. Affection of the central nervous system is according to the type of alcoholic intoxication. Death results from paralysis of the respiratory centre of CNS.

Prevention of Poisonings with Poisonous Mushrooms  The population should get acquainted with poisonous mushrooms in the course of sanitary-educational work, including lectures, conversations, posters, mass media (TV, radio).  Supervision of markets, places of mushroom sale — mushrooms should be sold only with the sanction of the sanitary physician's assistant. The sale of mushroom salads and mixtures is forbidden. Poisonings with Poisonous Wild Plants These poisonings are most common in a child's age. Plants containing m-cholinolytics, i.e. atropine, hyosyamine, scopolamine are belladonna, henbane, stramonium. The symptoms are gastroenteritis and mydriasis (belladonna is from Latin ―a beautiful woman‖ — in the Middle centuries women dropped the solution of belladonna into their eyes which thus became dark and beautiful), spasm of accommodation (visual impairment for close distance), dryness and reddening of skin and mucous membranes. At poisoning with stramonium, henbane there are also visual and acoustic hallucinations with central nervous system depression. Death occurs from cardiac abnormalities. In case of recovery the remote effects on CNS, e.g. amnesia (loss of memory), etc., may occur. Cicuta (cicutoxin). In Ancient Greece it was used for suicide. Children use its stems as whistles. In case of poisoning excitation is changed by CNS depression. Loss of consciousness, spasms, mydriatic pupils, cold perspiration, breathlessness, cyanosis are characteristic. Death may occur in 2-3 hours from respiratory paralysis. Spurge-flax. Myserin produces an irritating action resulting in bloody vomiting, diarrhea. Daphin causes CNS and cardiac abnormalities. 10-12 berries cause a lethal outcome. Wild grapes. They contain brionin causing severe gastroenteritis, excitation, then CNS depression. Death is due to collapse. A lethal dose for adults is 40 berries, for children — 15 berries.

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Prevention of Poisonings with Poisonous Plants  Destruction of these plants on the territory of children's preschool establishments  Supervision over children in the parks. Carrying out the sanitary-instructive work with tutors. Poisonings with Products Sometimes or Partially Poisonous Solanine in potatoes. It can be found in greensprouted potatoes. It has an irritating and haemolytic effect. The symptoms are gastroenteritis of a mild and moderate degree of severity. Prevention includes the elimination of green parts of potatoes. Phasin in haricot beans. Its toxin has an irritating and hemagglutinating effect. De- composition of the toxin takes place at a long thermal processing. The use of uncooked haricot beans or haricot flour in shops is forbidden. In case of food poisoning gastroenteritis of a mild and moderate degree of severity occurs. Amygdalin in stone fruits. Most often it is found in bitter almond, in stones of apricots, peaches, cherries, etc. In organism it is disintegrated with the formation of cyanic acid, causing blockade of tissue respiration. In severe cases loss of consciousness, abundant vomiting, diarrhea, spasms, death in 2-9 hours due to paralysis of the CNS respiratory center occur. Prophylactic measures include boiling these products for a long time, because the toxins are thermolabile (they are destroyed at a high temperature). Poisonings with Salts of Heavy Metals The causes are:  food stored in containers containing heavy metals (zinc buckets, copper utensils, glaze on pottery containing lead),  ground contaminated with heavy metals — lead, cadmium (in ground and plants along motorways). Zinc and copper (cuprum). They basically act at storage of acidic products in containers comprising these metals. At poisoning a mild form of gastroenteritis occurs: in the intestines albuminates of copper and zinc are formed which are not absorbed in organism producing an ulcerating and irritating effect on intestines. Lead. Poisoning may follow the consumption of food stored in lead-glazed pottery or due to contamination of ground. Poisonings are usually chronic. The symptoms include a lead triad: lead encephalopathy (CNS dysfunction) and polyneurites (peripheral nervous system dysfunction), lead pains in the stomach, lead border of gums. In the blood basophilic granularity of erythrocytes, reticulocytosis (an irritating effect on blood-forming organs), increase of lead content in urine (more than 0.04 mg/l) are marked. See attachment 2 – Pictures – at the end of textbook Prevention:  hygienic regulation of heavy metals in foodstuffs and control over the observance of maximal permissible concentration,  prevention of entry of metals from containers, utensils in food. Food Poisonings Caused by Agrochemicals

Food Poisonings Caused by Pesticides Pesticides are chemical agents used for protection of plants from pests, diseases and weeds. Without application of pesticides the loss of crop makes up 50 %. Sometimes their accumulation in products over the maximal permissible concentration is possible, hence the development of poisonings. The reasons of pesticide accumulation in products:  application of non-permissible preparations, which are very stable or toxic,  excess of the established norms of usage or frequency rate of processing,  non-observance of term of expectation — time between the last processing of plants and harvesting. The symptoms of poisonings depend on group of pesticides — chlorine-organic (decrease of activity of cytochrome oxidase — enzyme of tissue respiration), phosphorus-organic (decrease of activity of cholinesterase — accumulation of acetylcholine in organism), carba-

137 mates, etc.

Food Poisonings with Fertilizers Fertilizers are substances increasing the crop capacity of plants. Nitrogen fertilizers are most often applied. Thus in plants nitrates can accumulate, which in organism are restored in nitrites and bind with hemoglobin in erythrocytes causing methemoglobinemia — hemoglobin cannot transport oxygen and hypoxia occurs. These poisonings are especially dangerous for children of the first 3 months of age because:  HСl is not present in the stomach and it stops restoration of nitrites from nitrates.  children of this age have fetal hemoglobin which is very sensitive to nitrites  of low activity of enzyme methemoglobin reductase in children which releases hemoglobin from nitrites At a high level of nitrates in foodstuffs nitrososubstances (NS) can form which produce carcinogenic effects. Food Poisonings with Food Additives

Food Additives and their Classification Food additives are non-nutritional chemicals, synthetically added to foodstuffs to en- hance their organoleptic properties, to facilitate foodstuff processing and preservation. For investigating food additives and putting them on the list of permissible ones there is the Joint committee of experts of FАО/WHO on food additives. Classification of Food Additives Allowed for Application in the Countries of European Union Е 100 — Е 200 — coloring agents Е 200 — Е 300 — preservatives Е 300 — Е 400 — antioxidants, acidity regulators Е 400 — Е 600 — emulsifying agents, consistence stabilizers, agents preventing con- glomeration Е 600 — Е 900 — agents strengthening taste, flavor Е 900 — Е 1000 — agents enriching quality of grain and bread. Such food additives are recommended by EU for application, but each country approves the list of allowed agents itself. In Ukraine the List of allowed food additives is affirmed by the resolution of Ministry of Ukraine and the addition of new food additives to it is admitted only according to the resolution of Ministry of Public Health Service of Ukraine. More than 5,000 chemicals are now used as food additives — coloring agents, aromat- ics, emulsifying agents, preservatives, baking powders, etc. Poisonings occur at application of forbidden additives or at exceeding their permissible amount, e. g. using nitrates as food coloring agents for sausages (see above about their action on person). Mycotoxicoses These are food poisonings caused by toxins of microscopic mould fungi on bread and bread products (grain, flour) at their storage in moist conditions. They are characteristic of countryside — bad conditions of flour storage, using spoilt grain during disasters (famine, wars, etc.). Nowadays they are encountered in connection with baking bread by private manufactur- ers from the untested flour. Ergotism. Ergot poisoning follows eating grain contaminated by ergot fungus. Foods- tuffs can contain such toxins as ergotoxine, ergotamine, ergometrine. They cause a spasm of smooth, then transversal striated muscles. Three forms of ergotism are distinguished:  Convulsive, manifested by paresthesias, dizziness, spasms, sometimes — gastroenteritis. The duration is 3-6 weeks.  Gangrenous ("Saint Anthony fire"), characterized by necrosis of skin with rejection of necrotic sites, severe pains in these sites. In severe cases death occurs in 1-2 days accompanied by secondary infection (sepsis).  Mixed — a combination of the 1 and 2 forms.

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Ergotism is especially dangerous for pregnant women, as it causes a spasm of smooth muscles of uterus leading to abortion, or premature birth. Fusariosis. This is poisoning with "drunk bread" caused by mould fungus Fusarium graminearum. The symptoms are: gastroenteritis, and damage of CNS like alcohol intoxication. This is an endemic disease in the Far East. Alimentary-toxic aleukia. As far as 1944 this disease had been called "septic quinsy". It is caused by fungus of a Fusarium type which develops in grain wintered under snow. The disease is characterized by serious disturbance of hematosis, leuko- and thrombocytopenia. The main sign is aleukia (occurs in 1-2 weeks) — a sharp decrease of leukocytes and erythrocytes, increase of lymphocytes. A severe necrotic tonsillitis and sepsis are also marked. The mortality makes up 50-80 %. Аflatoxicosis. They are caused by fungi of Aspergillis type which are found in peanuts and peanut flour, grain, corn, rice at storage in moist conditions at increased temperature. Re- cently it has been found in Spanish red wine. The disease causes a severe liver injury and produces a cancerogenic effect on liver — a primary cancer of the liver (earlier it was encountered basically in Africa and Asia). Now it is often found in the Crimea and South Ukraine. Food Poisonings of Insufficiently Investigated Etiology River Urova disease (Kashin–Beck disease). Now it is established that it is hyperpolymicroelementosis (strontium rickets). This is an endemic disease for Eastern Siberia (the Urova river is situated there) and for some other territories on Earth. The disease causes deformation of skeleton in the period of growth, severe metabolic disturbances. Gaffen disease. Gaffen gulf is in Holland. The disease occurs at use of fish from some reservoirs in certain periods of time. The cause of the disease is not established, but it is supposed that in water toxic seaweeds are formed, toxins being accumulated in fish. The official diagnosis is alimentary paroxysmal-toxic myoglobinuria (the excretion of muscular protein myoglobin in blood and urine). The disease causes the attacks of sharp muscular pains and sharp renal insufficiency due to myoglobinaemia. In this case hemodialysis is necessary. Poisoning with quail meat. Sometimes it causes gastroenteritis of various degree of severity. The causes are not established. Tactics of the Doctor at Suspicion of Food Poisoning  The establishment of primary diagnosis on the basis of:  dietary history (what food was eaten by the patient) from the patient or relatives,  characteristic clinical signs and symptoms  Rendering urgent medical aid by life-saving indication — cardiacs, respiratory analeptics, etc.  Confirmation of the diagnosis:  gathering and sending to laboratory of Rospotrebnadzor department of nutrition hygiene of remnants of food, gastric lavage waters, vomiting materials, faeces, blood, urine.  writing out the "Accompanying direction to laboratory investigation" with indication of reason of taking food samples and method of laboratory food investigation.  Disintoxication therapy: gastric lavage, abundant drinking, antibiotics, droppers. In case of botulism — antibotulinic serum, anatoxin.  To prevent mass food poisoning the "Emergency notification about food poisoning" should be sent to Rospotrebnadzor department of nutrition (especially if poisoning took place in a public catering establishment). On receiving the emergency notification the doctors within 24 hours should carry out the investigation of food poisoning — sanitary inspection of public catering establishment, examination of the personnel, etc.  If necessary the emergency hospitalization at the infectious department of hospital should be arranged.

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Recommendations for Practical Classes on the Theme

Key Questions 1.Concept of food poisoning. Characteristic features of these poisonings. Classification. 2.Etiology, pathogenesis, symptoms and prevention of food poisonings of microbe nature: Toxicoinfections Bacterial toxicoses 3.Etiology, pathogenesis, symptoms and prevention of food poisonings of non-microbe nature: Food poisonings with poisonous plants and mushrooms; Food poisonings with foodstuffs sometimes or partially poisonous; Food poisonings with salts of heavy metals; Food poisonings with food additives (nitrates); Food poisonings with agrochemicals (pesticides and fertilizers) 4.Etiology, pathogenesis, symptoms and prevention of mycotoxicoses: Fusarioses Ergotism Aflatoxicoses 5.Food poisonings of the unknown nature, symptoms, diagnostics, causes of occurrence, prevention. Learning Objectives and Their Concrete Definition To establish the diagnosis of food poisoning on the basis of suggested clinical tasks or cards of investigation of food poisonings, to determine the product caused it, to draw up the necessary documents (see Problem Solving).

Appendix 1 Clinical Symptoms of Some Food Pisonings of a Microbe Etiology Symptoms Toxicoinfection Staphylococcus in- Botulism toxication Body temperature elevated or high normal or elevated normal or sub- normal Headache + + + General weakness + ++ +++ Loss of conscious- - - - ness Spasms - + + Decrease of heart rate + ++ ++ Cyanosis - + - Cold perspiration + + - Visual impairment + + +++ Dryness in the mouth - - +++ Nausea, vomiting +++ ++ +++ Pain in epigastrium + +++ + Constipation - - +++ Diarrhea ++ + - Blood in faecal - + - masses Mucus in faecal masses Duration of disease 1-3 days 1-3 days 5-20 days at adequate treatment +++ sharply expressed symptoms

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++ clearly expressed symptoms

+ infrequently observed symptoms

— symptoms which are not observed

Self Test 1. What is the pathogenesis of botulism? * A. affection of the medulla B. involvement of the GIT and CVS C. involvement of kidneys and liver D. affection of the brain cortex E. involvement of the respiratory system 2. What clinical forms are not characteristic of toxicoinfections? A. gastroenteritis B. typhoid-like form C. grippe-like form D. cholera-like form E. dysentery-like form * F. haemolytic form 3. A citizen has picked mushrooms in the wood and has eaten them fried. In 12 hours severe pains in the stomach, vomiting, diarrhea with blood suddenly occurred. At the end of the first day of the disease jaundice, enlargement of the liver, oliguria appeared. Spasms were observed. Death occurred on the third day. What might be the cause of the disease? A. death-cup poisoning B. supercooling * C. toadstool poisoning D. poisoning with false honey fungus E. nitrate poisoning Problem Solving 1. A case of food microbe poisoning took place on 20 July in the family of a clerk after eating fried veal cutlets (the calf had been ill for a week and that is why was slaughtered without knowledge of veterinary inspectors). The main symptoms of the disease: a 12-16-hour in- cubational period, high temperature, severe pains in the abdomen, vomiting, diarrhea, general weakness, headache. Which is the most probable causative agent of the given poisoning? 2. In the reception ward of the local hospital two children of the same family aged 4 and 6 were admitted in May with complaints of nausea, vomiting, frequent liquid stool. The disease began soon after eating boiled unpeeled potatoes. On examining the potatoes used in food by the family, many sprout and green samples were revealed. Which is the most probable causative agent of the given poisoning? 3. On examination of patient С., aged 26, in order to render him first aid, the following has been established: he works on the collective farm, takes meals at home. On July 20 pains in the abdomen, nausea occurred at 11.00. At 13.00 he had vomiting. He feels bad. A daily diet for the last 3 days consists of the following: July 18 — breakfast: rice, cottage cheese, tea, bread; dinner: meat soup, bread; supper: sausage, coffee, bread. July 19 — breakfast: pasties, milk; dinner: soup with fresh fish, meat with macaroni, tea, bread; supper: meat with macaroni (left from dinner), tea, bread. July 20 — breakfast: coffee, bread. Objectively: body temperature is 37.8°C, pulse is full, 86 per minute, the abdomen is tense and tender on palpation; there is diarrhea with mucus discharge. Make the diagnosis of food poisoning, identify the product which has caused it.

Standard Answers 1. Salmonella 2. Solanine 3. Food poisoning of a microbe etiology, toxicoinfection caused by pasties

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Methods of Investigation of Food Poisoning Cases

Key Questions Tactics of the doctor on revealing food poisoning. 1.Rules of taking samples for the laboratory analysis. 2.Rules of drawing up documentation in case of revealing food poisoning (name of documents, the order and terms of paper work). 3.Measures of prevention of food poisonings. 4.Scheme of investigation of food poisoning. Self Test 1. Put the following points of the common plan of food poisoning investigation in a correct sequence: A. Inspection of conditions and ways of manufacture, storage and processing of the suspected foodstuff B. Drawing up the act of investigation based on block of data of laboratory analyses * C. Revealing clinical symptoms characteristic of the given case D. Revealing the suspected foodstuff and its exclusion from the use E. Sending samples of patients‘ biosubstances, samples of suspected foodstuffs, lavages for laboratory research

2. What documents does the doctor send to Rospotrebnadzor department of nutrition on revealing food poisoning? A. case history * B. urgent notification on food poisoning C. a sick-leave certificate (medical certificate) D. a statistical coupon E. an accompanying appointment card for laboratory analysis

3. How long should the investigation of food poisoning be carried out? A. 7 days * B. 24 hours C. 12 hours D. 10 days E. 72 hours

Problem Solving 1. Last year on August 30 from 9.00 p.m. the inhabitants of a village with the population of 91 persons addressed the medical station with complaints of high temperature (38ºC and higher), headache, pain in the epigastrium, nausea, vomiting, diarrhea. All the patients had been on the wedding party which began at 11.00 a.m. The meal was prepared overnight. As there were only two refrigerators, meat, gammon, cutlets and sausages were kept in a kitchen cellar. It was very hot that day, the air temperature during the day was 25-29ºС. In the food remnants, vomiting and faecal masses the culture Salmonella enteritidis was found out. Identi- fy and substantiate the probable reason of food poisoning, reveal the foods, which could have caused this food poisoning. Enumerate the preventive measures necessary in this case. 2. During investigation of food poisoning, caused by a river fish (it was caught, salted within 5 days, then dried and used in meal), botulinum toxin Е was revealed. What measures should the doctor take in this case? 3. Among the pupils of a children's house the case of a mass food poisoning is revealed. The reason was eating cakes with cream stored in the nutrition unit with abnormal conditions of temperature. Name the most effective method of prevention of staphylococcus toxicosis?

Standard Answers 1. The reason: non-observance of storage conditions of meat products, in which further Salmonella enteritidis has developed and caused food poisoning. It is necessary to render

142 medical aid to the patients, to interrogate them with the purpose of revealing persons who have taken the same food, to forbid the use of meat products stored in a cellar, to observe the patients during the incubation period. 2. It is necessary to inject antibotulinic serum intravenously in a dose of 15,000 IU to all patients having symptoms of this disease. All the other persons who have eaten this fish should be injected the serum in a dose of 1,000-2,000 IU. The intake of the given product, if remained, should be forbidden. 3. Prevention of opportunity of staphylococcus multiplication in foodstuffs and producing toxin; with this purpose to supervise the conditions and terms of food storage.

Additional Material for Self-Preparation All cases of food poisonings should be obligatory taken into account and thoroughly investigated with the purpose of establishing the reasons of their occurrence and carrying out preventive measures of eliminating their consequences. For this purpose it is necessary to know the rules and order of filling in documentation on revealing cases of food poisonings.

Appendix 1 Accompanying Appointment Card for Laboratory Investigations ―___‖ ______200 № ______Simferopol (Name of Rospotrebnadzor department of nutrition, where the analysis is made) ______(Name of laboratory, its address) ______(Name of establishment, sending sample, its address, phone number)

№ Name of stuff Weight of sam- Characteristics of con- Date and time ple tainer (sterility, glass, of sending polythene, cardboard, sample to la- etc.) boratory 1 2 3

Urgency of investigation, what product is suspected as the cause of food poisoning ______(Full name, position of a person who sends a sample for investigation

At reception of samples the laboratory should give the receipt with indication of samples and time of their reception.

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Appendix 2 Objects Liable to Investigation and Order of their Sending to Laboratory Name of stuff Amount of stuff Time of taking a food sample Foodstuffs 1-st day A. Remnants of suspected food 200-300 g - //- B. Samples of liquid or half-liquid 200-300 ml after careful - //- dishes or foodstuffs stirring C. Second dishes 1-2 portions - //- D. Meat of various parts of car- 500 g - //- cass E. Brine from barrels with pickles 100-200 ml - //- F. Poultry 1-2 samples - //- G. Fish: if large — samples from - //- 2-3 places, if small — several pieces H. Tinned goods: open tins, not 5-10 open tins Examination of personnel 1-st day A. Bacterial samples from hands - //- and, if necessary, smears from the oral and nasal cavity of personnel engaged in cooking food B Referral of personnel to reveal- - //- ing intestinal infections Objects of investigation from ill per- during the first hours or sons day after the disease onset A. vomiting masses 50-100 g B. first lavage waters 100-200 ml C. faecal masses 50-100 g D. urine 200 ml E. blood culture 8-10 ml from vein F. blood for serological test 2-3 ml from a finger is 7-10 days after the dis- possible ease onset Section material A. content of the stomach 50-60 g reaction of agglutina- tion on the 28-30th day for revealing the decrease of antibody titer B. a segment of small or large intestine C. liver, spleen during the first hours after section D. heart blood

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Appendix 3 Urgent Notification about Food Poisoning 1.Diagnosis______2. Full name of patient______3. Sex ______4. Age______5. Address: city/village ______district ______street______house______apartment ______6. Place and address of work (study)______7. Dates of: disease onset______primary address to the doctor (revealing) ______establishment of the diagnosis ______last visit to school, higher school, work ______hospitalization______8. Place of hospitalization______9. Indicate the place of food poisoning, the cause of poisoning ______10. Primary antiepidemic measures and additional data ______11. Date and time of primary notification of SES about disease ______Full name of a person who notified SES______Full name, position of a person who received urgent notification ______12. Date and time of sending urgent notification ______Signature of the person having sent notification to SES 13. Date and time of reception of notification by SES______Registration No______in register No ______SES ______Signature of person who sent urgent notification ______Note: It is sent to SES not later than 12 hours from the moment of establishing the diagnosis.

Appendix 4 Plan of Preventive Measures (for the Given Case of Food Poisoning) Carrying out sanitary-educational work (to specify the forms).  The necessity of sanitary inspection of a nutrition unit.  The necessity of examination of personnel of a nutrition unit.  The necessity of withdrawal of foods or closing a nutrition unit.  Measures on prevention of similar poisonings in home conditions.  Other measures. Signature of student ______

Appendix 5 Scheme of Analysis of Disease Symptoms (Food Poisoning) 1. Full name of patient______2. Date, time of disease onset, date of hospitalization ______3. Main symptoms: nausea (+ -), vomiting, diarrhea, constipation, pains in the stomach,

145 body temperature (°С), fever, headache, general weakness, dizziness, diplopia, blepharopto- sis, mydriasis of pupils, dryness in the mouth, deglutitive problem, change of voice, spasms, cyanosis, muscle pains, joint pains, influenzal phenomena, blood in feces, pulse, arterial pressure, changes of CNS. The revealed symptoms are marked by signs "+" or "-", temperature — in degrees by Celsius, the severity of disease is indicated as mild, moderate or severe. It is necessary to specify: 4. Name and address of manufacture or establishment, where samples are taken. 5. The main findings of sanitary-epidemic inspection:  date of food poisoning  time of occurrence of disease symptoms after taking suspicious meal  description of clinical signs and symptoms in patient  number of victims  number of hospitalized persons  presence of cases with lethal outcome  primary diagnosis 6. At presence of samples of several products it is necessary to specify, which of them is suspected as the cause of food poisoning. 7. Purpose of investigation:  establishment of diagnosis  last visit to children's establishment, school; hospitalization 8. Place of hospitalization. 9. If it is poisoning, it is necessary to specify, where poisoning occurred, what caused poisoning. 10. Primary antiepidemic measures. 11. Date and time of the primary signal about disease to SES (over telephone, tele- graph). The surname of the person, who has sent the message and who has accepted the message. 12. Date and time of sending notification. Signature of the person, who has sent notification. 13. Date and time of reception of notification by SES, registration number in a register. Signature of the person, who has received notification.

Appendix 6 Scheme of Drawing up the Act of Investigation of Food Poisoning Name of doctor, date of drawing up the act of investigation. 1.Description of disease onset. 2.Clinical state of the patient. 3.Establishment of the primary diagnosis. 4.To specify the number of persons having used a suspicious product. 5.To specify the number of fallen ill persons. 6.To list the stuff sent for the laboratory analysis. 7.To specify the place of food intake. 8.To identify the time passed after intake of suspicious food. 9.To identify, what particularly product could have caused food poisoning. 10.To interview the victims in order to reveal the disturbance of оrganoleptic properties of food. 11. To specify the place, where a suspected product is delivered from, or place and date of its manufacture. 12.To make a brief description of a sanitary state of a manufacturer or public catering unit. 13.To specify the name of withdrawn or utilized product. 14.To specify the results of laboratory investigation of the product. 15.To draw a valid conclusion in case of food poisoning.

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Theme No 8. Medical and Prophylactic Nutrition.

Prophylactic Nutrition Prophylactic nutrition or therapeutic-prophylactic nutrition as a measure of prevention of occupational diseases is of great importance. The basis of prophylactic nutrition is a balanced diet composed in view of metabolic changes of organism occurred under the influence of harmful physical and chemical industrial factors, using separate components of the food rendering protective effect at influence of toxic chemical compounds and adverse physical factors of manufacture. The Purpose of Prophylactic Nutrition  Increase of general resistibility of organism;  Compensation of power and plastic stocks of organism under influence harmful chemical and physical factors on manufacture.  Increase of specific resistibility of organism to industrial poisons and harmful industrial physical factors by means of:  decreasing the entry of harmful substances into organism;  acceleration of removing toxicants from an organism;  acceleration of metabolism of toxic substances in order to form less toxic compounds;  protection of separate organism systems against harmful effect of industrial physical and chemical factors. Structure of Prophylactic Nutrition  High-grade proteins, performing plastic function, stimulating general resistibility of organism, participating in detoxication of some poisons. Thus, amino acids cystine, cysteine, methionine, containing SH groups, are capable of binding heavy metals, phenol, arsenic. Methionine, producing lipophilic effect, prevents fatty infiltration of the liver, improves its antitoxic function.  Carbohydrates restore the energy losses of organism caused by poisons, participate in neutralization of some poisons. For example, fructose and saccharose transform cyanides and phosphorus compounds into low-toxic substances, pectin substances bind and excrete lead and other heavy metals, stop absorption of strontium and ra- dium.  Mineral substances, first of all calcium, increase general resistibility of organism. Calcium has an antagonistic effect on strontium, weakens the effect of chlorine, nitrogen oxides which cause pathological increase of vascular permeability and development of lung hypostasis. Salts of copper accelerate molybdenum excretion. Phytin reduces or prevents clinical signs of poisoning with lead.  Vitamins increase the general resistibility of organism to adverse physical and chemical factors. They are of great importance in destruction and removing many toxic substances from organism. Thus, vitamin C transforms arsenic poisons into less toxic compounds and promotes their removing from organism. Vitamin B1 increases resistance of organism to lead, benzene, fluorine, styrene. The Basic Therapeutic-Prophylactic Diets Milk. All mentioned above substances in the optimal ratio are contained in milk. There- fore milk is applied to prevent many industrial poisonings. However a protective effect of milk is produced on rather small number of poisons, e.g. arsenic, heavy metals, phosphorus, phenol, aromatic compounds. In other cases, milk as high-grade foodstuff, only improves a general condition of organ-

147 ism increasing its nonspecific resistibility. Depending on mechanism of effect of physical and chemical industrial factors, some types of therapeutic-prophylactic nutrition diets are distinguished: Diet No. 1 is used in conditions of lowered atmospheric pressure when hypoxia develops and non-oxidized products accumulate in organism, the functions of the nervous, cardiovascular, digestive and other systems are disturbed. In these conditions the decrease of fat amount and increase of easily digestible carbohydrates, reduction of protein quantity are necessary. Diet No. 2 is used under conditions of noise; it is prescribed in case of disturbances of oxidation-reduction processes caused by noise, lack of vitamins C, Р, B1, B2, B6, decrease of capillary and cellular membrane resistibility. The increase of protein amount in diet is conditioned by reduction of fats and carbohydrates. Diet No. 3 is used under conditions of radiation effect. This type of diet includes three groups of substances: Amino acids: cystine, cysteine, methionine acids having ability of shielding (SH-group in molecules); Substances capable of binding and removing from organism free radicals: pectin substances, cystine, cysteine, methionine, glycine, bilious and nuclein acids, vitamins and mineral substances, primarily, calcium; Lipotropic substances improving exchange of fats and increasing antitoxic function of the liver: cystine, methionine, phosphatides, polyunsaturated fatty acids, vitamins. Diet No. 4 is desensibilization nutrition administered to workers contacting the chemical substances producing an allergenic effect. The diet is limited in carbohydrates, especially sugar. A slight increase of fats, basically of vegetative origin is recommended. The acid strengthening removal from an organism of calcium, chloride sodium, biogenic amines (histamine, sero- tonin), spicy and extractive dishes should be limited. The products containing active biological allergens, pesticides, food additives are limited as well. Diet No. 5 provides special energy supply at contact with various groups of industrial poisons. It is composed in view of mechanism of effect of poisons and properties of various components of food to produce detoxical effect on the given chemical compounds by delaying their entry into organism, acceleration of removing from an organism or transfer into less toxic compounds. Organization of Therapeutic-Prophylactic Nutrition at Enterprise Therapeutic-prophylactic nutrition is administered to those, working in conditions of constant contact with harmful physical or chemical factors not less than half of working hours. It is given out free-of-charge at the expense of enterprise in a factory dining room as 0.5 litre of milk or hot breakfast. Vitamins are given out as vitamin preparations or enriched first dishes. Thera- peutic-prophylactic nutrition is given out before the beginning of work (the optimal variant) or during a lunch break. The doctor of a health center of enterprise supervises the quality of therapeutic-prophylactic nutrition and if necessary gives recommendations as for replacing the missing products with foods having the same detoxic effect. Medical Nutrition (Dietotherapy) A science about nutrition of patients is called dietology. The basis of dietology is change of nutrition and metabolism of a sick person. The main tasks of dietetic therapy are:  to give to the patient‘s organism all necessary nutrients;  to change metabolism of a sick person in the necessary direction promoting treatment of illness. A practical part of dietology is dietetic therapy, which applies the statements of dietology to clinical and out-patient conditions with respect to the given patient, taking into account the features of his disease course and individual properties of organism. The task of dietetic therapy also includes the coordination and conformity of applied diet with other medical means (medicinal therapy, physiotherapy, etc). A practical part of dietology also includes medical cooking, i.e. practical applying of statements and requirements of dietology to culinary processing of food. Dietetic therapy is a powerful medical means of strengthening effect of medicaments

148 and other kinds of therapy. Dietetic therapy can also be the main kind of therapy. Sometimes only dietetic therapy may be sufficient to cure a disease. Nutrition of the patient is making up an optimal proportion of nutrients on the basis of physiological needs of organism for food substances and energy of a person, proceeding from features of pathogenesis, clinical course, stage of disease, level and character of metabolic disturbances. Classification of Foodstuffs in View of their Medical Effect 1 group includes foods having a sparing effect on intestinal mucous: groats for a children's and dietary nutrition, homogenized vegetable and fruit canned food, dietary fruit-and- vegetable, meat and fish canned food, rolls with a lowered acidity, enpits for IV injections. Indications for administration: gastric and intestinal illnesses, postoperative conditions, craniofacial traumas. Mechanical care is necessary because of high degree of dispersion. 2 group — foods with low content of sodium chloride (saltless): bread and saltless crackers, salt substitutes (calcium chloride or ammonium chloride, sanasol). Indications: hypertonic illness of 1-2 degree, acute and chronic forms of urolithiasis, blood circulation insufficiency of 1-2 stages, nephropathy of pregnant, long treatment with corticosteroids. 3 group — foods with low food value: albumin bread (caloric content is reduced by 15- 30%, carbohydrates — by 3 times), products with methylcellulose (for replacement of butter or sour cream by 40%), aerin (a sour-milk product from skim milk with fruit additives). These foods are administered for patients with diabetes, adiposity and chronic constipations. 4 group — foods with reduced amount of fats: The skim dairy products (sandwich butter, sour cream with 10% fat content, skim milk and kefir) products with the increased content of polyunsaturated fat acids ("Dietary" oil containing 25-30% of vegetable oil, dairy dietary margarine "Health"). Foods of this group are recommended at vascular atherosclerosis, adiposity. 5 group — foods with modified carbohydrate component: group of dietary products- substitutes of sugar (sorbite, xylite, fructose, saccharin, etc), as well as stewed fruit, confectionery and juices on their basis. These foods are applied at diabetes and adiposity. 6 group — foods without protein simulating bakery, groats. As a substitute of protein corn and amylopectin starch are used. These are applied at chronic kidney insufficiency. 7 group — foods enriched with microelements and vitamins: products enriched with iodine (sea kale, iodine salt, etc.), fluorine, vitamins (milk with vitamin C, etc). Principles of Medical Nutrition The bases of dietetic therapy are principles of a balanced diet: conformity of caloric content of food with energy losses of organism, balance between nutrients, optimal diet regimen, good digestion, maintaining the feeling of pleasure and saturation, safety of nutrition. However, in case of necessity, the essential corrections caused by character of disease, condition of the patient, his specific features can be brought to these principles. Thus, in dietetic therapy the principle of qualitative and quantitative restriction of nutrition down to partial or full starvation is widely used. Full starvation during rather short time intervals is applied at acute inflammatory processes in the body, at intoxication, uremia, etc. For a long- er period of time partial starvation or so-called fasting days are used allowing apples, cottage cheese, salad, potato, water-melon, pumpkin, cucumber and fatty days used at treatment of obesity and cardiovascular diseases. To diet regimen with quantitative restriction the nutrition with limited amount of liquid also refers which, as a rule, is combined with limitation of salt — it is recommended at obesity, atherosclerosis, hypertonic disease, urological diseases, etc. Diets with increased amount of liquid are widely used: at intoxication, infectious diseases, diathesis, etc. Diets with increased amount of vegetative raw food are applied. Besides enrichment of organism with vitamins, this diet is a source of cellulose, pectin substances, tartaric acid preventing adiposity, a complex of optimum balanced mineral substances, etc. The increasing of raw vegetative food is recommended at gout, obesity, diabetes, diseases of cardiovascular system, liver, kidneys, chronic constipations, etc. In some cases (anemia, decrease of reactivity of organism, etc.) raw animal food is administered, i.e. blood, raw liver, minced meat seasoned up to a level of pleasant look and taste. At food processing the content of pathogenic microorganisms in raw food should be excluded.

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Main Principles of Medical Nutrition  Principle of mechanical safety. It is used at restriction or exclusion of indigestible foods, rich in cellulose (brown bread, cabbage, haricot, etc.), using at cooking food methods of mincing, cutting, chopping, etc., as well as special methods of food processing aimed at reduction of cellulose content, dissolving pectin and softening foods.  Principle of chemical safety. It is based on exclusion of foods rich in extractive substances, and on restriction of dishes having a stimulating effect on secretory and motor functions of the stomach, such as thick broth, rich soups, fried dishes, smoked products, etc). A stimulating effect of dishes on intestines can be lowered at steam cooking. Principles of safety are usually used at the initial stage of treatment with the purpose of strict diet, further it is necessary to pass to a principle of "training". Thus step systems with gradual transition, or systems of "zigzags" with rather sharp, but short-term changes of diets as loading (plus "zigzags") or unloading (minus "zigzags") are used. The diet regimen of dietetic therapy provides uniform within a day intake of a small amount of food with more often intakes (5-6 times a day). A fractional nutrition (a small amount every 1.5-2 hours) in some cases is applied. Hygienic Bases of Alimentary Regulation of Metabolic Disorders and Prevention of Adi- posity

Techniques of Estimation of Normal (Ideal) Body Weight  Brocka‘s Index. Ideal body weight = height (cm) -100 (height of 155-165 cm) — 105 (height of 166-175 cm) — 110 (height of more than 175 cm)  Bongard‘s Parameter: Normal body weight (kg) = Circumference of the chest (cm) 240 (It is designed for men of 25-30 years with normosthenic constitution)  Кetle‘s Index: Body weight (kg) / (height, m) 2 The ideal body weight for men — 20-25, women — 19-23, less than 15-20 — lack of body weight, 26-30 — excessive body weight, 31-40 — moderate adiposity, more than 40 — pathological adiposity  Breitman‘s Index:

Technique of Estimation of Adiposity Degree Four degrees of adiposity are distinguished:  1 — excessive body weight by 10-29 %,  2 — excessive body weight by 30-49 %,  3 — excessive body weight by 50-99 %,  4 — excessive body weight by more than 100 %. Excess of normal body weight by 5-10% testifies to presence of excessive body weight but not adiposity as illness. Hygienic Principles of Dietetic Therapy at Adiposity  Decrease of food value of nutrition (by 30-50 % of normal).  Limitation of carbohydrates, especially non-protected  Limitation of fats of animal origin at the expense of vegetable oils (up to 50 %)  Optimal amount of protein (60 % — animal protein).  Having meals 5-6 times a day to weaken the feeling of hunger.  Limitation of water and salt.  Having special fasting diets and days.  Estimation of efficiency of dietetic therapy and its correction on the basis of studying the course of illness and biochemical status of organism.

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Hygienic Principles of Alimentary Prevention of Atherosclerosis  General prevention of adiposity (see above).  Increase of antisclerotic alimentary factors: irreplaceable amino acid methionine, polyunsaturated fatty acids of omega-3 and omega-6 families, phospholipids.  Increasing the consumption of high-grade protein (especially of vegetative origin), vegetable oils, pectins, cellulose, vitamins C, B, A, D, РР.  Increase in a diet of mineral substances, such as Са, Mg, microelements Cr, Cu.  Decrease of salt, spicy and fried dishes. Hygienic Bases of Alimentary Prevention of Presenility  Keeping balance of nutrition caloricity with energy losses so that 60-65% of daily caloric content is provided with carbohydrates, basically polysaccharides (optimal caloric content for persons not engaged in physical work should make up 2600 Kcal/day).  Antisclerotic orientation of diet.  Optimal content of substances in a diet stimulating the activity of body enzyme systems.  The most varied nutrition with normal content of basic irreplaceable factors in nutrition.  Decreased consumption of fats up to 20-25% of daily caloric content, at that vegetable oils should make up 50 % from all amount of fats.  Decrease of cholesterol content in a diet up to 300 mg/day.  Decreased consumption of sugar and confectionery, their replacement by dried fruits.  Limitation of salt (5-7 g/day).  Taking food not less than 4 times a day. Types of Diets 16 types of diet have been developed. They are subdivided into diets with a choice of dishes — realization of custom-made system (diet 1, 2, 5, 9, 10, 15,). These diets can be used for a long time, completely providing the needs of organism. The second type of diet assumes its strict following without any choice of dishes (0, 0a, 1a, 1b. 1c, 4, 5a, 5b, 8). They refer to unbalanced types of nutrition and can be administered only for a short period of time. Transition (more often gradual) from strict diets to varied is provided. An excessively long following the same diet is supposed only in unusual cases. Diet 0 (liquid) — it is administered after operations on the stomach and intestines (after fasting days; in case of unconsciousness). Its purpose is to provide organism with a minimal quantity of nutrients, maximal unloading of gastric tract. It has low caloric content (1,000 Kcal), the amount of salt (5g), proteins (15g), carbohydrates (200g) is limited. It consists of easily digestible liquid dishes. It is applied every 2.5-3 hours 6 times a day. A bit less strict variants of this diet are diet 0 a and diet 0 b. Diet 1 is administered at a gastric ulcer in a stage of exacerbation (the first 8-12 days), acute gastritis, exacerbation of chronic gastritis and enteritis, after operations and at gastroenteric hemorrhages (after diet 0). Its purpose is maximal safety to promote the repairing the stomach mucous membrane, to decrease its reflex excitability. Diet 2 is prescribed at chronic gastritis with disturbance of secretory activity without any exacerbation, chronic colitis, disturbance of masticatory apparatus function. The purpose of this diet is stimulation of secretion and normalization of disturbed function of the stomach and intestines, reduction of enzyme processes in intestines. Diet 3 is administered at alimentary chronic constipations without the expressed symptoms of intestine irritation. Its purpose is stimulation of disturbed function of intestines by inclusion in a diet of components producing mechanical, thermal and chemical irritation. Diet 4 is applied at chronic colitis and enterocolitis in a stage of exacerbation, acute ga- stroenterocolitis and operations on intestines (after fasting days), dysentery, typhoid, tuberculosis of intestines (within the first 5-7 days). The purpose of this diet is maximal mechanical, thermal and chemical safety of intestines, creation of conditions for elimination of inflammatory process, restoration of dysfunction, reduction of fermentative and putrefactive processes in intestines. Diet 5 is used at acute hepatitis (Botkin‘s disease) in a stage of recovery, chronic hepati-

151 tis, cholecystitis, cholelithiasis with dysfunction of the liver and biliary tracts without any accompanying inflammatory processes in the stomach and intestines, moderate atherosclerotic cardiosclerosis. The purpose of the diet is normalization of the liver and biliary tract function, regulation of cholesterol and fatty exchange, accumulation of glycogen in the liver, stimulation of disturbed function of intestines. Diet 5a is applied at chronic pancreatitis in a stage of aggravation. The purpose is to prevent the disturbance of the secretory function of the pancreas, to provide synthesis of protein necessary for construction of pancreatic enzymes, chemical safety of the alimentary tract, prevention of fatty infiltration and dystrophy of the pancreas and liver, decrease of reflex excitability of the gallbladder. Diet 6 is administered at a gout and lithic diathesis. Its purpose is to contribute to reduction of endogenic formation of uric acid, its removing from the organism and normalization of pyrin exchange. Diet 7 is used at acute nephrolithiasis in the initial stage and at chronic form of this disease during its aggravation. The purpose of the diet is maximal safety of kidney function, decrease of albumin exchange, increase of diuresis, elimination of hypostasis, sharp limitation of proteins (25-35g) and moderate decrease of fats (up to 60g) and carbohydrates (350g). The diet should be enriched with vitamins. Liquid (up to 400-450 ml), salt in foods (1-2 g) should be sharply limited. Diet 8 is administered at adiposity but absence of disturbance of digestive organs. The purpose of the diet is prevention and elimination of fatty cell accumulation. Diet 9 is applied at diabetes, in a mild form diet 9a is used without insulin therapy. The main principle is restriction of caloric content (2300-1700 Kcal) due to carbohydrates (300- 200g), basically, unprotected, and partial restriction of fats (70-50g), the normal content of proteins (100-120g). Taking meals is 5-8 times a day with exact distribution of carbohydrates. Products with high content of carbohydrates are excluded. Diet 9 b is administered at diabetes of severe and moderate forms with application of insulin therapy. The caloric content and chemical structure of the diet is normal, similar to diet 15. Only unprotected carbohydrates are limited (sugar — 30 g per day). Diet 10 combines a number of diets used at disease of cardiovascular system, atherosclerosis, hypertonic illnesses of different forms, insufficiency of coronary blood circulation. The general requirements are restriction of caloric content due to fats and carbohydrates, limitation of liquid and salt, exclusion of products rich in cholesterol, fat products containing a lot of saturated fatty acids. Diet 10 a is one of the variants of diet 10 used at cardiovascular diseases with sharply expressed insufficiency. Its purpose is to relieve cardiac activity, safety of digestive organs and kidney function, increase of diuresis and unloading of exchange. Sharp restriction of salt (1-2 g) and free liquid (600 ml), vegetative cellulose, the products promoting meteorism and rich in cholesterol, irritating liver and kidneys. Diet 11 is used at tuberculosis of lungs and bones during recovery after infectious diseases, traumas, operations, at anemia. The purpose of the diet is to increase general nutrition and reactivity of organism, resistibility to chronic infections. The increased caloric content (3500-3900 Kcal), increase of protein content, primarily protein of animal origin. Diet 12 is applied at diseases of the central nervous system with hypererethism; it is transitive from diet 10 to a balanced diet. Its purpose is decrease of excitability of the central nervous system. Diet 13 is administered at acute infectious diseases, after operation in the lung cavity (except for operations on the alimentary tract). The purpose of this diet is intensification of toxin removing, increase of protective forces of organism, safety of digestive organs under the conditions of confinement to bed. Diet 14 is applied at phosphaturia. Its purpose is to reduce phosphaturia and to interfere with the loss of phosphorous-calcium salts in the urinary tracts with formation of stones. The diet implies moderate decrease of salt content (10-12g), restriction of calcium (0.4g), increase of amount of free liquid (up to 200 ml). Diet 15 is recommended for recovering patients and for people with various diseases at absence of indications to administering medical diets. The purpose of this diet is providing high-grade balanced nutrition in a hospital. It is a physiologically high-quality and balanced diet which is intended for persons not carrying out physical work.

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Contrast Diets (Days of Limited Food Intake) These are administered instead of the basic diet once per 7-10 days. Because of low caloric content of these diets a patient should follow a bed regimen under doctor‘s supervision. Contrast days provide significant unloading of exchange, rendering thus beneficial effect on the course of disease. Apple day is necessary at acute or chronic colites (especially at diarrheas), kidney stones, hypertonic diseases, atherosclerosis, gout, adiposity. The diet consists in 300 g raw mature apples 5 times a day every 2.5-3 hours. Sugar is applied at diseases of the liver, biliary tracts, kidneys. It consists in 1 glass of tea with 40g of sugar 5 times a day every 2.5-3 hours. Dairy (Variant 1) is used at diseases of cardiovascular system in the stage of decompensation and subdecompensation. 100 ml of milk every 1.5-2 hours 7 times a day with addition of 20-25 g of sugar and 30 g of dry white bread. Variant 2 is used at adiposity and gout. It consists of 1 glass of milk 5-6 times a day every 2 hours. Cottage cheese is administered at adiposity, diseases of cardiovascular system in a stage of subcompensation, diseases of liver, biliary tracts, kidneys. 600 g of cottage cheese with 50 g of sugar are divided into 5 intakes every 3 hours. Kefir is necessary at diseases of cardiovascular system, adiposity, gout, diseases of the liver, chronic colitis with constipations. It includes 200 ml of kefir or curdled milk 5 times a day every 3 hours. Rice compote is compote made of 120 g of fresh or 250 g dried fruit, 100g of sugar and 1.5 l of water. One glass of compote is taken every 2.5-3 hours, including 2 times with sweet boiled rice (20 g of rice cooked in water). Indications: hypertonic illness, kidney diseases, diseases of the liver and biliary tracts. Salad is used at chronic polyarthritis, atherosclerosis, kidney diseases, diathesis, gout. 200-250 g of salad from vegetables and fruits without salt with a small amount of vegetable oil 4-5 times a day. Potato is necessary at diseases of cardiovascular system in a decompensation stage. 1 kg of baked potato, 50 g of sour cream and 20 g of butter for 5 meals. Cucumber is recommended at adiposity, alimentary constipations, lithic diathesis, gout. 1.5 kg of fresh cucumbers for 5 meals and 1 boiled egg for dinner and supper. Organization of Dietetic Therapy in a Hospital Medical diets are administered by the attending physician (and included in case history). Every day the head nurse of hospital department on the basis of case histories makes up the list where the total amount of patients and amount of patients for each diet are specified. This list is passed to the nutrition unit. Dietetic nurse of nutrition unit on the basis of lists from each department writes a summary list on which basis under supervision of doctor-dietician makes up a menu according to each diet. The menu-allocation is composed only for 1 day (the next one). On Friday the menu is made up for 3 days: Saturday, Sunday and Monday). Test of the prepared food is carried out by the certifying commission consisting of the doctor on duty of the reception ward (in small hospitals — the doctor on duty of the hospital), the doctor-dietician and chef. Sanitary inspection over hospital nutrition unit does not differ basically from sanitary inspection of other public catering establishments, but it is more careful.

HYGIENE OF WORK

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Theme No 17.

Subject and Tasks of Hygiene of Work. Physiology of Work. The Occupational Harmful Factors and Occupational Diseases. Prevention of Occupational Pathology. The Occupational Dust Pathology and its Prevention Hygiene of work is a section of hygiene studying the effect of a work process and harmful occupational factors on organism of a working person and developing preventive measures to decrease and prevent occupational diseases. The basic sections of hygiene of work are:  Physiology of work studying influence on organism of various kinds of work, estimation of its difficulty and intensity, prevention of exhaustion.  Hygiene of work with adverse physical occupational factors studying the effect on organism of noise, vibration, electromagnetic fields, laser irradiation, etc.  Radiation hygiene studying the effect of radiation on organism, development of radiation protection.  Hygiene of work with industrial poisons - industrial toxicology – studying the parameters of toxicity of industrial poisonings, causes and clinical manifestations of occupational poisonings, their prevention.  Hygiene of work in agriculture and at contact with agrochemicals - agricultural toxicology - studying the parameters of toxicity of agrochemicals, causes and clinical manifestations of occupational poisonings, their prevention.  Hygiene of work in conditions of dust pollution of air – studying the effect of different kinds of dust on person, prevention of occupational dust pathology (pneumoconiosis). There is also the division of hygiene of work according to industries (chemical, mining, metallurgical, building, etc.) and branches of agriculture. Physiology of Work Physiology of work is a boundary section of hygiene and physiology studying the effect of work process on a human organism and developing measures to increase work capacity and prevent the development of early fatigue. Classification of Types of Work Work is subdivided into mainly intellectual and physical one, however the scientific and technical progress eliminates clear borders between these types of work.

The basic types of work are the following:  Physical work which demands great physical activity and energy consumption (work of a loader, etc.)  Mechanized work requires significant muscular activity, but energy consumption is less (work of a turner, combine operator, etc.)  Automated work requires less energy consumption, but is characterized by monotony (a serviceman, weaver etc.)  Work on a production line is characterized by monotony, the imposed rhythm of work  Intellectual types of work are encountered:  in the sphere of material production - engineers, operators;  out of material production - doctors, teachers, artists, etc.

By value of energy consumption work is divided into the following groups:  work with significant muscular activity (energy consumption is 4,000-6,000 kcal);  work on the production line, mechanized work (3,000-4,000 kcal);  the automated work, intellectual types of work (2,000-2,400 kcal).

Physical work is subdivided into:  static work, when only one group of muscles is loaded, that causes early fatigue as blood supply is worsened;  dynamic work, when different muscles work, this type of work is more favorable.

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Classification of Work by Degree of Gravity and Intensity The gravity of work is connected with physical gravity of work and characterized by:  amount of work (in kilogram-meters)  capacity of work (amount of work per time unit) By physical gravity work is divided into:  mild  of medium gravity  hard  very hard The intensity of work (mental, of an operator) is characterized by:  demands for attention;  emotional exertion;  strain of audition and vision;  monotony. By intensity work is divided into:  not intensive  slightly intensive  moderately intensive  very intensive. Concepts of "Exhaustion" and “Tiredness” Tiredness is subjective feeling, as a rule, accompanied by the development of exhaustion. It depends on psychophysiologic condition of a working person, degree of interest in work. Exhaustion is a complex of objective changes in organism due to work manifested in decrease of capacity for work. If exhaustion does not disappear before the beginning of the following cycle of work, it gradually accumulates and turns to overexhaustion, i.e. decrease of capacity for work, pathology of CNS, cardiovascular system, immunosuppressive state, growth of traumatism. Concept of “Capacity for Work” Capacity for work is ability of man to long work without decrease of qualitative and quantitative characteristics (with high efficiency of work). Capacity for work depends on such reasons as health state, hygienic conditions of work, organization of work process, psychophysiologic factors. Early decrease of capacity for work is an indicator of effect of these factors, therefore studying its dynamics is of great importance for estimation of health and working conditions of working people. Dynamics of Capacity for Work during a Working Process During work three stages of capacity for work are distinguished:  In-work period - a gradual increase of capacity for work;  Working excitation – a maximal level of capacity for work;  Incipient exhaustion - a gradual decrease of capacity for work. Dynamics of Capacity for Work after Termination of Work  After-work excitation – some increase of work capacity occurs.  After-work inhibition - a sharp decrease of work capacity occurs.  Restoration of work capacity. At a long duration of this stage the level of work capacity returns to the initial one and there is no overstrain.

Methods of Studying the Capacity for Work There are a lot of methods of studying the capacity for work or exhaustion, they are represented as psychophysiologic or only physiological tests. The most important of them are

155 the following:  Methods of studying the capacity for brain work (mental work):  A correcting test – crossing out definite letters or figures in special tables per minute. Estimation of results of the test is made according to Hartridge formula, i.e. according to amount of the processed information in bit/sec.  Verbal-associative experiment - estimation of speed and degree of association between with given words.  Estimation of attention stability (for schoolboys).  Estimation of time of hearing-motor and visual-motor reactions (a latent period of reflex) with the help of chronoreflexometer (for operator‗s work).  Methods of studying the capacity for any kind of work – chronometric researches:  A selective timing of work elements;  Fixing the distraction of attention (at school);  Phototiming.  Methods of studying the capacity for physical work:  Estimation of physical tolerance with the help of a dynamometer;  Studying tremor (trembling) of hands (with the help of tremometer) Exhaustion. Theories of Mechanism of Its Development Among a great variety of theories of exhaustion development (more than 20) there is no universal one up to now. At present the most recognized is the central-nervous theory by Sechenov, Uchtomsky, Vvedensky. The basic role in exhaustion is played by decrease of capacity for work of cortex cells, thus the processes of excitation and inhibition in the CNS are disturbed. Thus in the CNS the stable foci of excitation or inhibition occur – this is the theory of disbalance. This theory has been recently supplemented with the theory of reticular formation elucidating the disorder of communications between the upper and lower parts of the CNS. Earlier the humoral-local theories of exhaustion development at physical work were acknowledged, such as:  The theory of exhaustion - exhaustion of energy supply in muscles (ATF, glycogen, etc.);  The theory of poisoning - accumulation in muscles of non-oxidized products (lactic, pyruvic acids). The inaccuracy of these theories is proved experimentally, besides they do not explain the development of exhaustion at brain work. However, these processes play some role in the development of exhaustion. The Main Reasons of Development of Premature Exhaustion at Work They may be subdivided into the following way:  Endogenous:  diseases and prepathological states;  defects of development of organs and systems;  poor or non-optimal nutrition (food);  the negative attitude to work.  Exogenous:  violation of hygienic working conditions: . non-optimal microclimate; . non-optimal illumination; . a forced position of body; . a high level of occupational harmful factors (chemical, physical, biological) exceeding MPC, MPL.  non-optimal organization of a working process: . very long working hours; . very hard and intensive work; . monotonous work; . non-observance of a work and rest regimen.  non-optimal psychoemotional working conditions: . a bad moral climate in a collective (conflicts)

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. a negative attitude to work.

The basic directions of exhaustion prevention are the following:  Scientific substantiation and keeping hygienic requirements to working conditions (requirement to microclimate, illumination, areas of workplace, avoidance of exceeding MPC of harmful occupational factors);  Scientific (rational) organization of a working process (following regimen of work and rest, restrictions on working hours, labour-intensiveness, transforming static physical work to dynamic, etc.);  Technical measures to improve the working conditions of workplace (application of ergonomics – a science concerned with human factors in the design and operation of machines and the physical environment).  Psychologic measures (psychology of work - industrial psychohygiene, psychologic help in choosing particular occupation, optimization of psychologic climate in a collective). Changes in Organism during a Working Process. Changes in the CNS The first system reacting to any work is the CNS - its stimulation is marked. At adequate work the favourable changes of the nervous processes are observed, the latent time of reactions is reduced; at extremely hard work a temporary improvement of CNS parameters is replaced by their deterioration resulting in weakening of reflexes, premature exhaustion. Changes of Respiration At work the respiration of organism tissues increases. An increased delivery of oxygen to tissues and removal of СО2 is achieved by increase of respiratory rate and depth (at rest the respiratory rate is 7-22 times per minute, at work - 50 and over, the volume of lung ventilation increases by 5-10 times). The maximal entry of О2 with respiration is 3-4 l/min – it is the oxygen limit. The entry of oxygen into organism increases gradually and at the beginning of work the oxygen deficit occurs, during which non-oxidized products of metabolism accumulate. At hard inadequate work the oxygen deficit becomes great and several days are necessary for full oxidation of metabolites formed in tissues. Lingard’s phenomenon. The German physiologist Lingard has established that at hard static physical work a number of people after finishing work require an increased amount of oxygen again due to passing the non-oxidized products of metabolism from tissues into blood that causes stimulation of gas exchange. Changes of Cardiovascular System The increased metabolism in working tissues requires the increase of blood circulation. At work the rate of heartbeat, systolic volume of heart increase; therefore the minute volume of blood increases. Thus, in trained people it increases due to increase of systolic volume, in untrained ones - due to increase of a pulse rate. The arterial pressure, especially maximal one, increases that results in growth of pulse pressure. After adequate work the arterial pressure returns to normal in 5-10 minutes. The Occupational Harmful Factors and Occupational Diseases. Prevention of Occupational Pathology The occupational harmful factors (OHF) are factors affecting the working people and capable to cause health disorders, i.e. occupational diseases. The primary tasks of occupational hygiene in relation to OHF are:  Studying sources, conditions of occurrence and parameters of OHF at work.  Studying mechanisms of OHF effect on organism and its systems in experiment with laboratory animals.  Investigation of cases of occupational diseases at work.  The development of preventive measures against occupational diseases. Classification of OHF

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In occupational hygiene the following groups of OHF are distinguished:  OHF connected with non-observance of hygienic conditions in manufacture (non- optimal microclimate, action of harmful occupational factors, etc.);  OHF connected with improper organization of work (excessively intensive, hard, prolonged work, monotony of work, etc.);  OHF connected with disadvantages of working conditions (a small area of workplace, a forced position of a body, etc.).

According to the State Standard "Dangerous and harmful occupational factors. Classification" all the OHF are subdivided into:  a dangerous occupational factor which can cause an acute disorder of health or death of a person;  a harmful occupational factor which can cause a chronic disorder of health – an occupational disease.

Classification of OHF in the State Standard is as follows:  Psychophysiologic and physical factors in the organization of work, arrangement of a workplace and equipment (psychological and physical overloads, a forced position of body, overstrain of separate organs and systems);  Physical occupational factors (nonoptimal microclimate, illumination, an increased level of noise, vibrations, radiation, electromagnetic fields);  Chemical occupational factors (industrial poisons) – chemical substances used in manufacture.  Biological professional factors (microbes, substances of protein nature, allergens);  Industrial traumatism (mechanical, thermal, electric traumas). Diagnostics and Prevention of Professional Pathology The basis of diagnostics and prevention of occupational pathology is the order of Ministry of Public Health, including:  the list of manufactures and occupations which require obligatory preliminary and periodic physical examinations of workers;  the order of carrying out such examinations, staff of medical commission for the examinations;  the list of medical contraindications for admission to various kinds of manufacture.  the list of diagnoses of occupational diseases and poisonings. Purpose, Types and Organization of Physical Examinations of Workers Preliminary physical examinations are carried out for newly admitted to work with harmful and dangerous working conditions with the purpose:  to admit to work only those whose state of health completely meets the requirements of a given profession;  not to admit to work the persons having deviations in health which can amplify under the influence of working conditions, and also those who can be a source of infections or parasitic diseases. Periodic physical examinations are regular medical examinations of people working in harmful or dangerous conditions. Their periodicity is determined by order No 45. The aims of these physical examinations are the following:  to reveal early signs of occupational diseases;  to reveal common diseases interfering with further work;  to administer individual medical-prophylactic measures. Concept and Classification of Occupational Diseases The occupational disease (poisoning) is a disease which connection with effect of occupational factors is proved. In order Ministry of Public Health the ―List of Occupational Diseases‖ is stated consisting of three sections:  Names of occupational diseases - 27 diagnoses (pneumoconioses, noise disease, vibrating disease, etc., acute and chronic poisonings).

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 Dangerous and harmful production factors, which effect can result in occurrence of occupational diseases.  The list of kinds of work and professions at which the given occupational disease is encountered predominantly or as an exception. The Rules of Diagnostics and Confirmation of Diagnosis of Occupational Diseases Acute occupational diseases:  The diagnosis of acute occupational disease must be made by any doctor, who receives a patient, because it has characteristic clinical symptoms;  The doctor in case of acute occupational disease must write Emergency Notice about acute occupational disease and send it to the department of hygiene of work of Rospotrebnadzor;  The doctors of Rospotrebnadzor after receiving such Emergency Notice within 24 hours must go to the place of patient‘s work and make sanitary inspection of working conditions (as for availability of harmful occupational factor at a level higher than hygienic norms) and write the official Act of sanitary investigation case of acute occupational disease;  Official diagnosis of acute occupational disease can be made only after proving the availability of harmful occupational factor at a level higher than hygienic norms.

Chronic occupational diseases:  The diagnosis of chronic occupational disease can be made only by a doctor- specialist in occupational pathology, working in special department or hospital of occupational pathology,  After making diagnosis of chronic occupational disease this special department or hospital of occupational pathology informs the local Rospotrebnadzor (where the patient lives or works) about the case of chronic occupational disease;  The doctors of department of hygiene of work of local Rospotrebnadzor within 7 days must go to the place of patient‘s work and make sanitary inspection of working conditions (as for availability of harmful occupational factor at a level higher than hygienic norms) and write official Act of sanitary investigation case of chronic occupational disease;  Official diagnosis of chronic occupational disease can be made only after proving the availability of harmful occupational factor at a level higher than hygienic norms. The basic directions of prevention of occupational diseases include the following:  Normative-legislative measures. The CLL (the Code of Laws on Labour), State Standards, Sanitary rules, etc.  Hygienic measures: preventive and current sanitary inspection.  Medical-preventive measures: preliminary and periodic physical examinations, medical prophylactic nutrition.  Sanitary education of workers about harmful and dangerous occupational factors and occupational diseases.  Technological measures on decrease or elimination of OHF.  Individual means of protection.

Occupational Dust Pathology and its Prevention

Dust as an Occupational Harmful Factor

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Effect of dust on workers is observed in mining and coal industry, in the building industry (cement, etc.), at metalworking, in agriculture, etc.

Classification of Industrial Dust  According to origin:  inorganic (mineral, metal),  organic (vegetative, animal, polymeric),  mixed.  According to formation:  aerosols of desintegration (at crushing solid bodies),  aerosols of condensation of vapours on metal particles  According to dispersion:  visible (the size of particles > 10 microns)  microscopic (2.5-10 microns)  ultramicroscopic (< 0.25 microns) The size of dust particles determines the depth of their penetration into lungs and area of damage.  According to effect on organism:  toxic (manganese, lead, arsenic, etc.),  irritating (limy, alkaline, etc.),  infectious (microbes, spores, etc.),  allergic (woolen, synthetic, etc.),  carcinogenic (asbestos, etc.),  fibrinogenic (pneumoconiotic), containing silicium.  According to toxicity:  nontoxic dust (soil, wood) - maximum permissible concentration is 10 mg/m3;  toxic dust - silicate containing silicon (maximum permissible concentration is 1 mg/m3), lead dust (maximum permissible concentration – 0.01 mg/m3). At hygienic characteristics of dust the chemical composition, dispersion, solubility in blood, hardness, absorption properties are taken into account.

Effect of Dust on Organism There are different ways of getting dust into organism: through inhalation, deglutition with saliva and mucus, through skin. Nonspecific effect: the action of dust may cause the diseases of respiratory organs, mucous membranes of eyes, skin. It contributes to the development of tuberculosis, allergic diseases. Specific effect is manifested in the formation of pneumoconiosis, carcinogenic action. Pneumoconiosis are the most common dust occupational diseases. There are: Silicosis (effect of silicon dioxide), silicatosis (dust of silicic acid salts), asbestosis, anthracosis (coal dust) refer to them. The can also develop at effect of metal dust. Silicosis is the most common type of pneumoconiosis. Pathogenesis: dust particles in the lung tissue are absorbed by histiocytes, thus fibroblasts are formed leading to the formation of collagenic fibres (connective tissue) which results in reduction of lung surface. Symptoms and signs: respiratory insufficiency of different degree of severity, bronchitis, pneumonia, emphysema. Classification of Pneumoconiosis  Pneumoconiosis caused by effect of highly and moderately fibrinogenic dust (the content of free silicon dioxide SiO2 > 10 %): silicosis, anthracosilicosis, silicosiderosis, silicosis complicated by tuberculosis – silicotuberculosis.  Pneumoconiosis caused by effect of low fibrinogenic dust (SiO2 < 10 %): silicatosis (asbestosis, etc.), carboconiosis (anthracosis, etc.), byssinosis (vegetative dust).  Pneumoconiosis from aerosols of a toxic-allergenic action: berylliosis, aluminosis, farmer‘s lung, chronic pneumonia with allergenic component. Diagnostics of Pneumoconiosis Morphologic forms are:

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 nodular  interstitial  mixed According to the course of disease the forms are divided into:  slowly progressing  quickly progressing X-ray Diagnostics of Pneumoconiosis 1st stage - interstitial fibrosis of the lungs, formation of small nodules 1 mm in diameter along the bronchial tubes, a moderate bilateral intensification of lung pattern. 2nd stage – exacerbation of interstitial and nodular lung fibrosis and formation of numerous nodules 2-4 mm in diameter on a background of atelectasis areas (symptom of a "snow storm"), deformation of the lung pattern. 3rd stage – a massive lung fibrosis, big masses of connective tissue, marked deformation of the bronchial tree, disturbance of bronchial permeability. In addition to that metalloconioses are characterized by the increased roentgen contrast of metal dust in the lungs. Clinical and Functional Diagnostics of Pneumoconiosis Its symptomatology includes symptoms of bronchitis, lung emphysema, respiratory insufficiency, disturbances of pulmonary blood circulation – hypertrophy of the left cardiac ventricle, changes of ECG readings –"lung heart". At asbestosis there are asbestine corpuscles in sputum, at anthracosis the sputum is of black color. Complications of pneumoconiosis: lung cancer, tuberculosis, pneumonia, bronchial asthma, rheumatoid arthritis, etc. Prevention of Dust Diseases  The labour legislation, preliminary and current physical examinations.  Preventive and current sanitary control of working conditions with dust.  Struggle against formation and spread of dust.  Biological methods - increase of body resistance - UVR, alkaline inhalations, respiratory gymnastics, clinical nutrition (containing proteins and vitamins).  Individual means of protection.

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Recommendations for Practical Classes on the Theme

Key Questions 1.Basic laws of functioning of various body systems. 2.Physiology of work. Classification of kinds of work. 3.Dynamics of capacity for work during work and after its termination. 3.Methods of studying the capacity for work. 4.Changes in organs and systems during work. 5.Concept of occupational hazards and occupational diseases. Classifications. 6.Order of registration and investigation of occupational diseases. 7.Purpose, types, organization of physical examination of working people. 8.Classification of dust, pathogenesis and types of pneumoconiosis, their diagnostics and prevention. Learning Objectives and Their Concrete Definition 1. Giving the corrector test at the beginning and at the end of the lesson using the suggested by teacher tests to define the speed of processing information in bit/sec according to Hartridge formula:

where: S - speed of processing information (bit/sec), N - number of symbols looked through in the table, n - number of overlooks and mistakes, Т - time of viewing the table (60 sec.). 2. The research of muscular capacity for work. To estimate the physical force, the examinee should twice compress a dynamometer with the maximal effort; the greatest value is taken for initial. To determine the exercise tolerance, time (in sec) is estimated, during which the examinee keeps a spring of a dynamometer at a level of 0.5 of his maximal force, up to complete impossibility to continue the effort of this intensity. 3. The research of capacity for work by method of finding numbers. Time is marked during which the examinee names and shows all the numbers printed in the table containing 49 numbers (from 1 up to 25 and from 24 to1) represented by different colours. 4. The investigation of hand tremor is carried out by a tremometer. If rate of tremor movements is 8-12 per second – it is frequent, 5-8 - moderate, 3-5 - slow. 5. Investigation of capacity for work by a chronometric method. The increase of time spent on operation testifies to exhaustion. In hygiene and physiology of work a photochronometric investigation of a working day and detailed selective chronometry are used. Use of chronometry for studying influence of working process on a body state and capacity for work reveals the following: the duration of separate operations, ratio of time spent on performance of basic and auxiliary operations, business activity of a working day, productivity of work and its change within a day. On the basis of analysis of data and their comparison with the data of physiological methods of research the recommendations for rational arrangement of a working day, change of a working rhythm are grounded. 6. The verbal (associative) experiment. This method is more often applied at estimation of mental work (lecturers, announcers, teachers). It allows to estimate a functional condition of the nervous system analyzers (speech, hearing, movement). The purpose of the research is to determine the speed of occurrence in the cortex of associative communications between images of various objects and concepts. The speed of these communications depends on a functional condition of the CNS and primarily on degree of exhaustion. The essence of the method consists in the fact that the examinee is offered from 10 up to 30 words (nouns) with an interval of 10-20 sec. The examinee should name the word matching the given one in sense. For example, table - high, cap – big, etc. The researcher fixes the time of latent period in seconds (time from the moment, when the word is given and answer of the examinee is received) and number of mistakes available in the answer (the word does not match the given). The researches are carried out several times within a working day, the results are

162 compared. 7. Definition of attention stability. Change of attention during work is also connected with a number of reasons and, primarily, with exhaustion. The examinee with the help of a special device is demonstrated consistently a number of figures painted in different colours for the certain period of time. The examinee is offered to count mentally, how many such figures there were. On calculation he should not use a pencil. The researches are carried out several times within a working day, the results are analyzed. The increase of amount of mistakes testifies to approaching exhaustion. Self Test 1. Identify the method of research of capacity for work. *A. a corrector test B. Eiber‘s test C. Duglas‘ method

2. Which of the following is most frequently connected with occupational harmful factors? *A. Production, its technology and equipment B. Interruption of work (break, dinner, visit to boss, etc.) *C. Working process, its organization *D. Intensity and duration of working process

3. In a foundry the manual casting of liquid metal into small forms was carried out. In the workers, who repeatedly took part in the casting process, the signs of intoxication by aerosols of heavy metals have occurred. What radical measures of prevention of occupational poisonings can you suggest in the given situation? A. Regular medical examinations B. Control of metal aerosols in the air of a working zone and its comparison with MPC C. Expansion of ventilation *D. Installation of the automatic line of metal casting with effective ventilation Problem Solving 1. It is necessary to determine stages of capacity for work of a schoolboy according to the parameters of a corrector test: at the beginning of lessons it is 4.2; at the 3d lesson – 5.5; at the 5th lesson – 5.3. What other methods can be used to investigate the capacity for work of the schoolboy? 2. After accident in the chemical plant there was the environmental pollution with nitrose compounds. Headache, dyspnea, dizziness appeared in people living in this district. What is the reason of hypoxia? 3. Give the hygienic estimation of work in the workshop of a furniture industrial complex, where the general dust content makes up 20 mg/m3. What occupational diseases are possible in the workers? What are the principles of their diagnostics and prevention?

Standard Answers: 1. According to the data of a corrector test, at the beginning of the lessons there was an in-working stage, and then a stage of working excitation was observed. It is also necessary to carry out the similar researches with other pupils in the class for correct arrangement of the lesson and prevention of exhaustion in pupils, and if in some pupils the premature exhaustion develops, it is necessary to investigate the condition of their health. To study the capacity for work it is possible to apply methods of estimation of attention stability, verbal-associative experiment, chronometry researches. 2. The formation of methemoglobinemia. 3. MPC of non-toxic (furniture) dust makes up 10 mg/m3, in this case general dust content exceeds the standard norms by 2 times, in this connection the development of pneumoconioses in working people is possible. Their diagnostics is carried out roentgenologically and clinically (according to degree of respiratory insufficiency). Prevention: change of technology, strengthening artificial general and local ventilation, application of dust- gathering equipment, current sanitary control of a dust content of air, application of individual means of protection of respiratory organs (respirators).

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Appendix 1 Ministry of Health City Registration form No 163 Medical establishment Notification

About Acute Occupational Poisoning or Occupational Disease Enterprise ______Workshop (where poisoning occurred) Full name______Date of poisoning ______Diagnosis.______Date of sending notification______Signature of the doctor Appendix 2 Ministry of Health City Registration form No 165 Medical establishment List of persons, in whom chronic occupational poisoning or occupational disease was first revealed in ______month of year 200 __ Enterprise ______Ministry ______Branch of industry ______

No Full name Concrete profession Diagnosis

______

Appendix 3 Ministry of Health City Registration form № 163 Medical establishment Registration Card № ___

of Acute Occupational Poisoning or Occupational Disease Acute poisoning occurred in ______(month) of 200 __ (year) Enterprise ______Address ______Branch of industry Workshop, department (where poisoning occurred) Full name ______Sex ______Age ______Profession ______Record of service in the given shop ______Record of service in the given occupation ______Record of service in the previous work ______what industry______, what occupations ______(filled in case of chronic disease) Circumstances, under which poisoning occurred ______а) What poisonous substances caused occupational poisoning or occupational disease

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Theme No 18. Hygiene of Work at Effect of Physical Occupational Harmful Factors (Noise, Vibration, Electro-Magnetic Fields)

Concept of Harmful Physical Occupational Factors During work many physical occupational harmful factors can effect a person, including adverse microclimatic factors, non-optimal illumination or excess of its components, laser radiation, noise, vibration, electromagnetic fields (EMF), high or low pressure, radioactive radiation. Noise as an Occupational Harmful Factor, Its Characteristics According to WHO‘s data, noise is a universal problem for mankind, one of the main physical factors of environmental pollution. Concept of "Noise" In physics noise is the chaotic sound fluctuations of different frequency rate and intensity, having no regularity. In hygiene noise is any sound, preventing recognition of useful sound signals, interfering with rest, rendering a negative effect on a human organism and decreasing his capacity for work. Classification of Noise According to sources it is classified into:  household  transport  industrial  building  agricultural According to duration it may be:  stable – a fluctuation level of noise is not more than 5 dB  unstable - more than 5 dB  impulsive - intermittent According to frequency, noise is classified into:  audible sounds (16 - 20000 Hertz):  low-frequency - up to 400 Hz  medium-frequency - 400-1,000 Hz  high-frequency - over 1,000 Hz  infrasound - frequency up to 20 Hz – produces marked effect on internal organs since its frequency can coincide with frequency of fluctuations of internal organs; the most dangerous frequency is 8 Hz causing the disturbance of alpha-rhythm of the brain; 1-3 Hz results in disorder of respiration, etc.;  ultrasound - more than 20,000 Hz - produces a mechanical and chemical effect resulting in cavitation (formation of cavities in interstitial tissues), destruction of molecules, their ionization; a thermal effect results in tissue heating – this phenomenon is used in physiotherapy; at high levels the local damage of peripheral nervous and blood systems, disorders of the CNS, etc. occur).

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Level of Noise. Units of Its Measurement Effect of noise on organism depends not only on frequency, but also on its level. In acoustics loudness of sound is a sound pressure in Newton/m2 (difference between atmospheric and sound pressure). Unit of measurement of sound level in hygiene is a logarithmic unit, which expresses the excess of sound pressure above a sound threshold: 0-14 Bell, or 0-140 dB:

Sound threshold = threshold of perception - 2 х 10-5 Newton/m2 = 0 dB Painful sound threshold is 14 Bell = 140 dB. SON – a comparative unit of level of sounds different by frequency Abroad the unit of sound is FON (sound with frequency of 1000 Hz at a level of 1 dB). Effect of Noise on Organism Specific and nonspecific effect of noise is distinguished. Specific effect is manifested by disturbance of function of acoustic analyzer due to a long angiospasm resulting in degenerative changes in the nerve endings and neuritis of acoustical nerve (occupational deafness). Three stages of noise disease are distinguished at audiometry, i.e. estimation of hearing level:  Acoustical adaptation – at action of noise the acoustical threshold increases by 10- 15 dB, but in 1-3 min it returns to normal (a physiologic phenomenon);  Acoustical exhaustion - decrease of hearing by 15-20 dB within hours or days after stopping the noise effect;  Progressing deafness – a gradual complete loss of hearing in connection with organic changes of the auditory center in the CNS (noise at the level of more than 80 dB quickly causes the decrease of hearing and development of deafness at length of service up to 5 years). Nonspecific effect of noise is manifested by excitation of the cortex, hypothalamus and spinal cord, quick development of CNS inhibition, then exhaustion of the nervous cells and consequently irritability, emotional instability, deterioration of attention, memory, capacity for work; via the vegetative nervous system the functional changes of different systems and organs occur. As a result of long effect of intensive noise the so-called noise illness develops - a general disease with affection of organs of hearing, CNS and other systems. The struggle against noise in industry and inhabited places includes:  Administrative-legislative measures.  Architectural-planning measures (functional zones in cities, sanitary-protective intervals, transport highways).  Hygienic measures, including:  preventive sanitary control - normalization of noise - establishment of MPL according to different criteria: Table 36 Maximum Permissible Levels of Noise for Various Premises Kind of premise MPL, dB Criteria of harmful activity Habitable rooms 30 protection of sleep at the night Wards in hospitals 25 maintaining a therapeutic-protective regimen in hospital Classrooms 50 maintenance of information perception Industrial premises 65* - 85 prophylaxis of noise illness

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Note: * - for high-frequency noise  current sanitary control - the control of noise levels and its limitation.  Medical-preventive measures - preliminary and current medical examination of workers at noisy industries.  Technological measures: sound-suppressing linings, wall coverings, automatization, etc.  Individual measures: headphones, over 100 dB - flannel helmets. Hygienic Characteristics of Vibration Vibration is oscillations of elastic bodies with frequency over 1 Hz. It is characterized by amplitude, frequency, direction. Vibration is classified into: general and local. According to frequency vibration is subdivided into:  low-frequency vibration  middle-frequency vibration  high-frequency vibration According to direction vibration can be:  horizontal  vertical Local vibration of small intensity gives a positive effect (a vibrating massage); at general vibration of high intensity there are changes of the CNS; through the vegetative nervous system the changes of internal organs occur. Local vibration causes long angiospasms and mechanical trauma of the peripheral nerve endings in fingers – disturbance of trophism in tissues, polyneurites, arthroses - vibration illnesses of various degree of severity. Stages of Vibration Illness at Effect of General Vibration  Slight pain and paresthesia of extremities;  Expressed parasthesia, decrease of skin sensitivity;  Vascular and trophic disorders of fingers, changes of CNS;  Generalized sharp vascular disorders, vasospasms of heart and CNS. Degrees of Severity of Vibration Illness at Effect of Local Vibration  Peripheric angiodystonic syndrome, sensory polyneuropathy of fingers.  Expressed angiospastic syndrome of fingers.  Expressed generalized angiospastic syndrome, dystrophic changes of bones, muscles of arms, deformation of finger joints. Hygienic Characteristics of Electromagnetic Fields (EMF) EMF is a special form of substance created by moving or motionless electric charges. The basic parameters are: length of wave, frequency of fluctuations. EMF consists of electric (EF) and magnetic fields (MF). Natural and anthropogenic fields are distinguished.

Natural EMF includes:  MF of Earth (400 А/m) depending on geographical position, season and time of the day, solar activity ("magnetic storms").  EF of Earth - 130 V/m at the surface of Earth decreasing with height.

Anthropogenic (technogenic) EMF:  Electrostatic field (ESF) is created by motionless electric charges of high intensity, e.g. in industry, near power lines of ultrahigh voltage. It effects the CNS and causes functional shifts of vegetative nervous system.  Stationary magnetic field (SMF)  EMF of industrial frequency - 50 Hz  Infrared, visual, UV, laser radiation  EMF of radio frequencies.

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Table 37 Classification of EMF of Radio Frequencies Type of waves Wavelength Sources, application Low-frequency 1-10 km broadcasting, radio communication, industry Medium-frequency 100м - 1 km - " - High-frequency 1 - 100 m - " - Ultra-high frequency 10 cm - 1 m radio, TV, medicine Microwave frequencies 1 - 10 cm radiolocation, television, industry, for cooking food (microwave oven) Hyperhigh frequencies 1 mm - 1 cm industry (HHF) Effect of EMF on Organism The degree of biological effect of EMF depends on:  frequency (the higher frequency, the stronger effect)  intensity  exposure time  character of irradiation (continuous, modulated)  regimen of irradiation (constant, intermittent, periodic)

The mechanism of biological effect of EMF is the following:  Thermal effect (at very high radiation intensity) causes the destruction of organs and tissues  Non-thermal effect (at low intensity) exerts influence on substrate of organism with the formation of bioactive substances. At chronic action a cumulative effect is observed.

Clinical pathological effect of EMF:  Asthenic syndrome  Asthenic-vegetative syndrome  Diencephalic syndrome  Damage of systems: cardiac, hemopoietic, immune, endocrine, etc. Forms of pathological effect of EMF are the following:  Acute and chronic form  Mild, moderate and severe degree

Microwave syndrome is characterized by  disturbance of CNS (asthenic and vegetative syndrome)  opacity of lens cataract  damage of hair follicles (baldness) Besides there are changes of cardiovascular system, disorders of hemopoiesis, dysfunctions of immune, endocrine systems, remote effects. Prophylaxis of EMF Harmful Effect on People Working with EMF Sources, especially with Microwave EMF There are four principles of protection from electromagnetic radiation (including ionizing one). They are:  protection by dose or amount (MPD)  protection by distance  protection by time  protection by screening.

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Basic Directions of Prophylaxis of EMF Harmful Effect  Administrative-legislative measures on work protection – reduction of operating time (protection by time);  Architectural–planning measures - sanitary-protective zones at a distance from sources of EMF, correct placement of EMF sources at certain distance from other objects (protection by distance);  Hygienic measures:  preventive sanitary control - substantiation of EMF MPL (protection by dose): . in industry - MPL for a working day - 2 W per hour/m2  for population - MPL inside the inhabited buildings – 0.5 kW/m, . on territory of inhabited building - 1 kW/m, . outside the inhabited building - 5 kW/m, . near power lines of ultrahigh voltage - 10 kW/m  current sanitary control - checking the observance of MPL, hygienic prescriptions, etc.  Medical-preventive measures - physical examination of workers and population, health- improving measures.  Technological measures - change of technology to decrease the level of EMF (protection by screening). The Hygienic Characteristics of Laser Irradiation Lasers are optical quantum generators excreting a focalized fascicle of electromagnetic radiation with wavelength from IR up to UV. According to time laser irradiation is divided into:  continuous  impulsive According to direction it may be:  direct  reflecting  diffusely reflex  dissipated Effect of Laser Irradiation on Medical Staff At reflex radiation the organic changes of tissues in the place of irradiation and nonspecific reflectory changes of organs and systems may occur. Thermal specific action - prompt heating of tissues and organs. Common nonspecific effect – changes of CNS, cardiac, endocrine system, suppression of chromogenesis. Local effect:  On organs of vision - temporary loss of sight,  On skin - hyperemia, combustions, necroses. Prevention of Harmful Effect of Lasers  Hygienic measures  Planning and technical measures  Medical-preventive measures  Individual means of protection. Recommendations for Practical Classes on the Theme

Key Questions: Methods of prevention of harmful effect of noise: -What is noise, its classification and units of measurement; -Devices for measurement of level and spectrum of noise; -Effect of noise on a human organism, MPL of noise for different premises and criteria of

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their development; Methods of prevention of harmful effect of vibration: -What is vibration, its classification and units of measurement; -Devices for vibration measurement; -Effect of vibration on a human organism, norms of vibration; -Methods of prevention of harmful effect of vibration. Methods of prevention of harmful effect of EMF, ultrasound, infrasound, laser irradiation on the man. Hygienic characteristics of EMF, ultrasound, infrasound, laser irradiation; Effect of electromagnetic field, ultrasound, infrasound, laser on organism. Devices for measurement of EMF, ultrasound, infrasound, laser irradiation. Methods of prevention of harmful effect of these factors. Self Test 1. In a workshop of a machine-building factory, where women work, a periodic (up to 2 times per hour) hand moving of processed details takes place. What limiting norm of elevation and moving cargoes by women should be recommended to the authorities in accordance with standards authorized by Ministry of Health of Ukraine? *A. 10 kg B. 20 kg C. 15 kg D. 7 kg E. 5 kg

2. What are the basic methods of research of vibration effect on a person? *A. evaluation of a skin temperature B. a corrector test C. capillaroscopy D. investigation of vibration sensitivity E. evaluation of pain sensitivity

3. Which of the following is a correct definition of noise? *A. It is a chaotic combination of sounds of different frequency and intensity. B. These are mechanical fluctuations of solid bodies. C. These are sounds irritating CNS of the man. Problem Solving 1. In the bar department of a foundry shop a high-frequency heating is applied for drying bars. In the shop 10 drying chambers work simultaneously. A range of working frequencies is 30-48 MHz. What primary pathological changes can occur at work in the given conditions? 2. In one of the premises of the chemical enterprise the constant disturbance of microclimate (temperature rate, ventilation) takes place. Identify measures which should be recommended to maintain the industrial microclimate in the given premise in accordance with hygienic requirements? 3. The noise level on a workplace makes up 121 dB. What psycophysiological effect is most probable in the workers? Standard Answers: 1. Asthenovegetative syndrome. 2. To equip the premise with a conditioner. 3. Risk of an acoustic trauma.

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Theme No 19. Radiation Hygiene and Ecology

Radiation as an Adverse Physical Occupational Factor Ionizing radiation is widely applied in the atomic power station, industry, medicine for medical and diagnostic procedures, so it can have a negative effect on many workers. Besides, in connection with great radioactive pollution of biosphere, especially after accident on the atomic power station, an increased level of radioactivity may have a negative effect on health of population. A feature of effect of this factor on organism is the presence of pathological changes even at small levels of action that demands especially strict observance of hygienic requirements, norms of radiation safety (NRS) and careful medical examination of staff. Concept of Radioactivity Radioactivity is the property of some atomic nuclei of spontaneously emitting gamma rays or subatomic particles (alpha and beta rays).

In hygiene all sources of radiation are subdivided into closed and open. At closed source only ionizing radiation gets into the environment, e.g. x-ray tube. At open source both radiation and particles can get into the environment, e.g. radioactive isotopes. Characteristics of Types of Ionizing Radiation The following are distinguished:  Corpuscular radiation, including:  Alpha-radiation is a stream of alpha particles (nuclei of helium) basically from natural isotopes. The ionization ability is the formation of 6,000 ions per 1 mm3 of air, the penetrating ability is a particle track equal to 11 mm in the air and 1/6 mm in the body, so it penetrates only into a superficial layer of the skin. Protection by clothes, aluminum foil is sufficient. The basic danger appears at internal entry into organism with water and food;  Beta-radiation is a stream of beta-particles (electrons or positrons). The ionization ability is 6 pairs per 1 mm3, penetrating ability - up to 1 m in the air, 1cm in the body. Any materials, except for lead can be used for protection (formation of braking x-ray radiation).  Neutron radiation is a stream of neutrons. Ionization is 400 ions per 1 mm3, particle track in the air - hundreds meters, in the body - up to 10 m. The protection against fast neutrons is substances with a small serial number (hydrogen), e.g. water, paraffin, polymer materials; slow neutrons are absorbed by boron, cadmium.  Electromagnetic radiation including:  X-ray and gamma-radiation. Ionization is 0.1 ions per 1 mm3, particle track in the air is hundreds meters, in the body - some meters (depends on intensity of radiation, length of waves). Gamma–radiation is more severe. Materials with high density, e.g. lead, concrete may serve as protection. Basic Units of Radioactivity  Unit of isotope radioactivity: becquerel - a SI unit of measurement of radioactivity, equal to 1 disintegration per second; 1 Bq = 0.027 x 10-9 Ci. Curie (Ci) is an old unit equal to 4 х 1010 disintegrations per sec.  Unit of exposure dose. It is used for characteristics of ionization dose in the air - for gamma and x-ray radiation. Coulomb/kg (SI) - a dose producing in 1 kg of air ions with electrical charge of 1 coulomb. An old unit - Roentgen - a dose producing in 1cm3 of air 3 х 109 pairs of ions.  Units of intensity of exposure dose. Unit of a dose correlated to a time unit –

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R/hour, mR/min, µR/sec.  Unit of absorbed dose. Grey (Gy) – an absorbed dose of 1 Joule energy per 1 kg substance. An old unit - Rad - the unit for the dose absorbed from ionizing radiation, equivalent to 100 ergs per gram of tissue; 100 rad = 1 Gy.  Unit of equivalent dose. In International System of units (SI) as a unit of equivalent dose sievert (Sv) = 1 Gy . Q is accepted – it is a dose of ionizing radiation of any kind producing the same biological effect as a dose of x-ray or gamma-radiations of 1 Gy in view of a quality coefficient (1 Sv = 100 ber). Effect of Ionizing Radiation on Organism The basic stages of development of radiation damages are:  The formation of ionized and excited atoms and molecules which interact with each other and various molecular systems, forming biologically active substances; the breaks of intermolecular links are also possible due to radiation effect (the initial or starting processes);  The effect of newly formed biologically active substances (free radicals, ions, etc.) on biological structures of a cell in organism causing the destruction of biosubstances and formation of new substances unusual for organism;  Metabolism imbalance in biological systems with changes of appropriate functions on a background of neurohumoral reactions. The Major Biological Reactions of Organism to Radiation Effect All consequences of radiation effect on organism can be conditionally divided into somatic and inherited. The somatic effects occur in the irradiated organism, the inherited ones – in posterity.

All radiation effects are subdivided into the following: Stochastic (probable) effects are nonthreshold ones, which are estimated by probable risk of occurrence of radiation damage, i.e. cancerogenic, mutagenic, hereditary effects. It is difficult to investigate them in experimental research, as it is impossible to establish precisely a threshold of harmful effect. These effects are basically manifested at action of small doses (when the occupational and natural irradiation for the whole life does not exceed 100 rem). Nonstochastic (threshold) effects - the severity of damage depends on dose and it is possible to establish a threshold of damaging effect, i.e. to determine the safe levels of radiation effect. All norms of radiation are based on prevention of these effects. To nonstochastic effects the following refer:  Acute radiation sickness. It occurs at single radiation doses of more than 100 rem (100-200 rem – a mild degree; 200-300 – a moderate degree; 300-500 – a severe degree and over 500 rem - the severest). Doses of 500-600 rem at a single irradiation are absolutely lethal.  Chronic radiation sickness. It may occur at prolonged irradiation in a dose of less than 100 rem.  Radiation burns of skin. The reaction of I degree occurs at a dose up to 500 rem; II degree - up to 800 rem; III degree - up to 1200 rem; IV degree - over 1200 rem.  Irradiation cataract occurs at a dose of radiation over 30 rem per year. The researches proved that the somatic effects do not occur at observance of established hygienic standards; however the latter cannot guarantee the absence of these effects as there is no threshold of stochastic and hereditary effects. The main principle of norms of radiation safety (NRS) is decreasing a dose of radiation as much as possible. Groups of Critical Organs of Organism. Berganie’s Law The law of French scientist Berganie runs: radiosensitivity of a cell is directly proportional to its reproductive ability and inversely proportional to degree of its differentiation. Thus, the more intensive the processes of cell division in tissues or organs are, and the less differentiated the tissue is, the more sensitive a cell to radiation is.

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According to this law all organs are subdivided into 3 groups of critical organs:  the whole body, gonads, organs of blood formation (red bone marrow);  all other organs and tissues;  skin, bones, thyroid gland. Hygienic Standards of Radiation. Maximum Permissible Dose (MPD) of Ionizing Radiation To protect the working people and population against radiation the following norms are established: according to effect on 1 group of critical organs the maximaum permissible doses (MPD) of radiation at external irradiation are established:  Category A - persons professionally contacting radiation – MPD - 2 ber/year (0.2 Sv/year) or 40 miliber/week.  Category B - people who are in premises adjacent to sources of radiation – MPD – 0.2 ber (0.02 Sv/year).  Category C - all the other population - MPD – 0.1 ber (0.01 Sv/year). Principles of Radiation Safety at Work with Closed Sources of Radiation A closed source emits into the environment only electromagnetic radiation - x-ray or gamma radiation. The basis of protective measures is laws of transmission of radiation:  The dose of external radiation is proportional to intensity and time of action;  The intensity of radiation is inversely proportional to distance;  The intensity of radiation decreases depending on thickness of screens. Hence there are 4 principles of protection from radiation:  protection by amount of dose (MPD),  protection by distance,  protection by time,  protection by screens. There are 5 kinds of screens for protection from radiation:  protective containers for storage of radioisotopes;  protective screens for equipment;  mobile protective screens;  protective screens in building constructions (walls, ceilings, doors, floors);  screens of individual means of protection - lead gloves, aprons, etc. Principles of Radiation Safety at Work with Open Sources of Radiation An open source emits into the environment not only x-ray and gamma radiation, but also flows of radioactive particles (alpha-, beta-particles and neutrons). The main principles of protection are the following:  Use of principles of protection at work with closed sources;  Hermetic sealing, automatization of equipment, isolating clothing, special boxes and drafting devices for work with isotopes;  Special nonabsorbing coverings of surfaces, frequent cleaning of surfaces from radioactive pollution;  Special ventilation equipment (exhaust ventilation is equipped with filters), water drains (in special sediment chambers), sufficient water supply;  Special lay-out of premises with the protective screens; a lay-out of site of radiological department – a remote location of radiological laboratories from residential buildings, other hospital departments depending on their class (there are 4 classes of radiological laboratories according to annual amount of used radioactive substances);  Careful radiation and medical control of personnel;  Observance of personal hygiene and requirements to overalls.

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Problems of Radiation Ecology

Concept of Natural Radiation Background (NRB) Natural radiating background is a natural level of radioactivity in the given area, basically dependent on natural factors. On average it makes up about 100 miliber/year, but it can have significant fluctuations in view of natural and anthropogenic reasons. In the Crimea it makes up 6-30 miliroentgen/hour (it may be higher in the mountainous part of the Crimea due to radioactivity of granite masses containing uranium). Structure of NRB  Space radiation (25-40 %) – (2 protection screens against it – EMF of the Earth and ozone layer) - it varies in connection with fluctuations of solar activity and interplanetary EMF; due to it a person on Earth gets 28 mber/year on average;  Natural radioactivity of ground (granite - uranium), air, water;  Foodstuffs - about 25 % of NRB. Thus, in NRB the external radiation makes up 75 %, the internal one (more dangerous) - 25 %. Additional anthropogenic sources of NRB increase for population include the following:  Regions of the atomic power stations and effects of their accidents and nuclear explosions;  Diagnostic x-ray procedures (on roentgenoscopy the patient gets 1 ber at once); it is expedient to exclude unnecessary diagnostic x-ray procedures.  Television – while watching color TV 4 hours a day a person gets 50 mrem per year. It should be taken into consideration in respect to children. Dynamics of NRB It has been investigated since the 50s of the last century. The increase of NRB took place in the 50s of the last century caused by mass tests of the nuclear weapon, than the decrease was observed in the 70s connected with convention on interdiction of nuclear tests in three environments: air, water, underground (now only underground explosions are permissible); the growth of NRB since 70s is explained by the development of atomic power stations. Recommendations for Practical Classes on the Theme

Key Questions Concept of radioactivity, hygienic characteristics of the basic types of ionizing radiation. Basic values and units of ionizing radiation. Effect of ionizing radiation on organism. The threshold and stochastic (nonthreshold) effects. Estimation of doses of external and internal radiation. Groups of critical organs. MPD of radiation. Principles of protection at work with closed and open sources of radiation. Natural radiation background: components, levels, dynamics. Sources of radioactive pollution of biosphere. Ecologic and hygienic effects of Chernobyl accident. Methods of neutralization of radioactive wastes. Hygienic requirements to x-ray and radiological departments. Learning Objectives Characteristics of types of radiation. Ionizing ability. Particle track in the air and tissues. Screens. Biological effect of radiation. The basic kinds of radiation damage. Conditions of their occurrence. Concept of closed and open sources of radiation. Principles and ways of protection. Natural radiation background: levels, sources, dynamics. Its evaluation with the help of Geiger counter. Hygienic requirements to hospitals using sources of radioactive radiation. Structure of x-ray

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and radiological departments. Self Test 1. To create the radiation safety of the medical personnel of an X-ray room the protective means like screens are used including lead glass on the screen, large and small mobile protective screens, curtain and protective mittens made of lead rubber. What other means of shielding are necessary? *A. an apron from lead material B. boots from lead rubber C. limitation of a working day duration D. remote control of x-ray device E. no other measures are necessary

2. In radiological department for intracavitary therapy a gamma-device, source of cobalt isotope, is used which is in a steel ampoule. Which of the following methods of personnel protection from radiation effect should be used primarily in view of a source type? *A. shielding of the source and workplace B. hermetic sealing of device C. measures of a lay-out character (zoning of premise) D. effective ventilation of premises E. use of means of individual protection and sanitary processing of personnel

3. At graduation examinations a student said to the examiner that the greatest penetration into a human organism has alpha-radiation. A correct answer to the question is *A. gamma-radiation B. neutron radiation C. alpha-radiation D. proton radiation E. beta-radiation Problem Solving 1. At work with radioactive isotopes a radiation dose made up 100 mrem/hour at a 30- hour working week. Give your estimation of working conditions in the laboratory. 2. A radiation dose of the doctor-radiologist made up 110 mrem/week, or 6 rem per year. What protective measures are necessary in this case? Standard Answers: 1. The working conditions do not meet the hygienic requirements, as a week dose of radiation makes up 100 mrem/hour х 30 hours = 3000 mrem, at MPD = 40 mrem/week. It is necessary to find out the reasons of MPD excess and eliminate them; if impossible - to strengthen all kinds of radiation protection at work with open sources of radiation. 2. The dose of radiation exceeds MPD at external irradiation (40 mrem per week and 2 rem per year) that can result in chronic radiation illness and occurrence of remote harmful effects (mutagenic, cancerogenic). The radiologist works with open sources of radiation (emission of radiation and flows of radioactive particles). The protection by dose, time, distance, screens and complex of measures on prevention of radionuclide entry into organism are necessary.

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Appendix Devices of Dosimetric Control Depending on type of detector and methods of radiation registration the dosimetric devices are subdivided into:  ionizational (with ionization chamber, Geiger counters)  scintillational  luminescent (thermoluminescent)  photographic  chemical  semi-conductor  calorimetric Table 38 Characteristics of Dosimetric Devices Name Type Registered Range of measurements Weight, radiation kg Dosimeter СРП-68-01 gamma 1-3000 µR/h 3.6 ДРГ-05 М gamma, 1-10000 mR/sec 2.0 roentgen ДКС-04 gamma, beta, 0,1-1000 mR/h 0.25 neutrons ДБГ-06 Т gamma 0.01-99,9 mR/h 0.25 0.01-1000 µSv/h ДРГ-01 Т gamma 0.01-99.9 mR/h 0.25 Radiometer- МКС-01Р-01 alpha, beta, 1-30000 particles/min/ сm2 18.0 dosimeter gamma, 1-100000 particles/min/сm2 neutrons 0.01-10000 µSv/h µR/sec Individual КДТ-02ДТУ- gamma 5-1,000,000 mR 41.4 dosimeter 01КИД-08 C Individual КИД-2 gamma, 0.005-1.0 R 4.0 dosimeter roentgen 0.04 Individual. ИФК-2,3ИФКУ beta, gamma, 0.01-3 rad, rem a film dosimeter neutron

Theme No 20. Industrial Toxicology.

Toxicology of Agrochemicals and Hygiene of Their Application

Concept of Toxicology and Industrial Toxicology Toxicology is a science studying mechanism of action of various toxins (poisons) on organism. Toxicology is divided into military, household and industrial. Industrial toxicology is a section of toxicology studying mechanism of action on organism of industrial poisons, i.e. chemical substances which a person come in contact with in industry and which can cause the development of occupational poisonings.

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Basic Parameters of Toxicity of Industrial Poisons For the toxic and hygienic characteristics of industrial poisonings it is necessary to know the basic parameters of their toxicity, i.e. parameters of dependence "dose - effect" (toxicodynamics) and parameters of dependence "time - effect" (toxicokinetics). All these parameters are determined in experiments on laboratory animals and then approximated to a person taking into account FSS - factor of specific sensitivity - differences in toxicological parameters for different kinds of warm-blooded animals (white mice, rats, rabbits). Key Parameters of Level of Poison Toxicity Parameters of toxicodynamics are the following (See Table 39):  Acute toxicity (at a single effect):  Lethal doses (concentrations) – LD0, LD100, LD50 (amount of animals died at effect of this dose).  Threshold of acute effect - Lim ac.— a minimum effective dose for common toxic effects, Lim ac. sp.— for specific effects (for example, irritating effect).  Zone of acute effect - Z ac. = LD50/Lim ac.— the less the dose is, the more dangerous the substance is in respect of probable acute poisonings.  Subacute toxicity is studied in experiments on animals for 30-45 days. It is determined coefficient of cumulation (C. cum.) = LD50 at a single action/LD50 totally during 30 days.  Chronic toxicity (at prolonged effect – within months or years) - is the most important parameter as it represents the real conditions of effect of industrial poisons on person: Lim ch (threshold of chronic effect by common toxic and specific and remote effects). Abroad LOAEL (low observable adverse effect level) and NOAEL (non-observable adverse effect level) correspond to the concepts of threshold and subthreshold dose. The zone of chronic action - Z ch = Lim ac/Lim ch - the larger it is, the higher the risk of occurrence of chronic poisonings. Safe Levels of Industrial Poisons for Man Maximal permissible concentration or dose for man with using coefficient of safety depending on level of poison toxicity, cumulation, etc. is calculated on the basis of Lim ch (NOAEL) for animals. Key Parameters of Toxicokynetics They are as follows: Т50 - the half-life period of poison in organism (in blood, organs, biological liquids); Т95 - the period of elimination of 95% of poison from organism. It is determined in experiments with the help of radioactive labels (isotope C14). The less these parameters are, the faster poison is eliminated from organism. Toxicokynetics is closely connected with cumulation of poisons in organism.

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Table 39 Basic Parameters of Toxicometry of Chemical Substances Primary parameter Derivative parameter Parameters of Toxicodynamics 1. Acute toxicity Lethal doses and concentrations Zone of lethal effect LD0, LD50, LD100 (LC) Z = LD84 / LD16 Factor of specific sensitivity Factor of probability of inhalation poisoning FSS = LD 50 max/LD 50min FPIP = C/LC 50 Threshold of acute integrated effect Zone of acute effect Lim ac. integr. Z ac. = LD 50/Lim ac. integr. Threshold of acute specific effect - Lim ac. Zone of acute specific effect sp. Z ac.sp. = LD 50/Lim ac. sp. 2. Subacute toxicity Factor of cumulation F cum. = LD 50 total for 30 days/LD 50 single Threshold of subacute effect Lim s/a eff.

3. Chronic toxicity Threshold of chronic integrated effect Zone of chronic effect Lim ch. Integr. Z ch. = Lim ac/Lim ch. (LOAEL) * Threshold of chronic specific effect Zone of biological effect Lim ch.sp. Z ch.sp. = Lim ac.sp./Lim ch.sp. Safe levels for man Maximal non-effective dose (NOAEL) *, MPC Parameters of Toxicokinetics The half-life period of substance in organism - Т50 The period of elimination of substance from organism - Т95 Factor of cumulation - F cum. *LOAEL - low-observable adverse effect level

*NOAEL - non-observable adverse effect level

Classification of Industrial Poisons

Classification of Chemical Substances according to Toxicity I class of danger – extremely dangerous substances (extremely toxic) II class of danger - highly dangerous substances (highly toxic) III class of danger - moderately dangerous substances (moderately toxic) IV class of danger - slightly dangerous substances (slightly toxic)

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Table 40 Parameter I class II class III class IV class MPC in air, mg/m3 < 0.1 0.1 – 1.0 1.0 - 10 > 10 DL50 orally < 15 15 - 150 150 - 5000 > 5000 DL50 on skin < 100 100 - 500 500 - 2000 > 2000 CL50 inhalation < 500 500 - 5000 5000-50000 > 50000 FOIP > 300 300 - 30 30 - 3 < 3 Zone of acute effect < 6 6 - 18 18 - 54 > 54 (Z ac.) Zone of chronic > 10 10 - 5 5 – 2.5 < 2.5 effect (Z ch.)

Classification of Poisons according to Primary Effect on Organism They are subdivided into irritating, neurotropic, cardiotropic, hepatotropic, nephrotropic, gonadotropic, cancerogenic, mutagenic, etc. Basic Mechanisms of Poison Effect on Organism Toxic effect of poisons depends on:  Exogenous factors:  Chemical structure of poison (for example, increase of toxicity in homological line of hydrocarbons);  Dose, concentration of poison (dependence "dose - effect" and "time - effect");  Volatility, level of dispersion of poison;  Way of entry into organism (inhalation or others); character and rate of metabolism, way of eliminating poison from organism;  Conditions of environment (meteorologic factors);  Selective sensitivity: age-related, sexual, specific, individual;  Selective effect on organs and systems: . Commom toxic poisons . Hepatotropic . Nephrotropic . Cardiotoxic . Neurotropic  Character of effect: . Constant or intermittent . Isolated . Combined, complex  Endogenous factors depending on state of organism:  Age  Sex  Presence of diseases  Defects of detoxication system (inherited or acquired)  Pregnancy, lactation  Physical and mental overstrain. Types of Organism Adaptation to Action of Poisons Adaptation is a real accommodation of organism to action of poison without irreversible biological changes and with preservation of homeostasis (constancy) of biological system. Compensation (or accustoming) is a temporary latent pathology due to overstrain of adaptable reserves; at effect of any adverse factors decompensation, i.e. poisoning occurs. In experiment on animals the difference between adaptation and compensation is determined by special functional tests. Stages of Development of Chemical Intoxication These include:  primary decompensation

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 physiological adaptation  latent pathology  decompensated pathology (poisoning) Types of Poison Cumulation in Organism  Material - accumulation of poison or its metabolites in organism;  Functional - accumulation of only toxic effects of poison in organism;  Mixed - accumulation of metabolites or poison and pathological effects in organism Table 41 Classification of Toxic Substances according to Degree of Cumulation Level of cumulation Coefficient of cumulation Time of response, (in Ccum days) Supercumulation < 1 < 20 Expressed cumulation 1 - 3 20 - 60 Moderate cumulation 3 - 5 60 - 100 Slight cumulation > 5 > 100

Combined Effect of Poisons As a rule, in real industrial conditions the isolated effect of poisons on organism is practically not encountered, more often the combined effect takes place (the effect of many substances at the same time), which can considerably change toxic effects in comparison with separate effect. Types of Combined Effect They are as follows:  Antagonism (less than additive action),  Summation (additive action),  Potentiation (more than additive action). Hygienic Estimation of the Industrial Environment Taking into Account Type of Combined Effect of Poisons  In case of antagonism the estimation is carried out in respect of separate maximum permissible concentration for every found poison C < MPC ;  At summation the estimation is made according to the formula of summary toxicity by Averianov:

where C – concentration of the found substance MPC1 MPC2 MPC i MPC – maximum permissible concentration  At potentiation the estimation is made according to the formula:

where C – concentration of the found substance MPC1 MPC2 MPC i MPC – maximum permissible concentration K - coefficient of potentiation The Basic Methods of Detoxication of Industrial Poisons in organism They include the following:  Change of chemical structure of poison - hydroxylation (formation of OH-groups), oxidation, restoration, methylation (binding СН3-groups), connection with glucuronic acid and amino acids resulting in formation of less toxic metabolites.  Depositing in organs and tissues (material cumulation) – a temporary decrease of concentration of poison in blood (for example, heavy metals are deposited in bones,

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liver and kidneys). It is a defective way of neutralization as under unfavorable conditions the exit of poisons from depot may take place resulting in aggravation of chronic poisonings.  Elimination from organism - through lungs, kidneys, intestines, skin. Detoxication System of Organism and Parameters of Its Functioning This complex system can be presented as a 5-component protection:  Microsome oxidation by microsome monooxygenases (MOGS). Indicators are cy- tochromes R-450, b 5, etc. The accumulation of oxide radicals, etc. is possible.  Reaction of conjugation (connection) with proteins. Indicators - restored glutathione, etc.  Bioenergy processes for detoxication - oxidizing phosphorylation, etc.  Processes of peroxidation of lipides. Indicatiors – level of malonic dialdehyde, diene conjugates.  Antiradical and antiperoxidation protection (activity of enzymes: catalase, peroxidase, superoxide dismutase, vitamin C, etc.) According to the state and interrelation of these 5 components it is possible to differen- tiate adaptation and compensation: at activation of the 1st and 4th links the others links should be activated (it is adaptation): if at activation of the 1st and 4th links the others links are not activated, it is toxicogenic dishomeostasis, i.e. latent decompensation. Ways of Entry of Industrial Poisons into Organism  Inhalation is the most frequent and dangerous way (the area of the lungs with blood capillaries is 100–120 m2; there is no barrier function of the liver). This way is characteristic of volatile poisons – the higher their solubility in blood, the more dangerous they are.  Through skin and mucous membranes - lipotropic poisons (soluble in fats) get into organism through injured skin, hair follicles, sudoriferous and sebaceous glands.  Per os - through mouth and mucous membranes of stomach and intestines – this way in professional conditions is very rare; it is encountered at non-observance of rules of personal hygiene, casually with foods.

Adsorption of Poisons in Organism After absorption poisons can accumulate in the liver, blood, bones, lymph, hair, nails.

Ways of Elimination of Industrial Poisons from Organism We can distinguish the following ways of eliminating industrial poisons from organism:  Through kidneys - it is the most frequent way for many substances.  Through intestines – it is for badly soluble poisons, such as lead, mercury.  Through lungs – it is for volatile substances, e.g. sebaceous aromatic hydrocarbons.  Through skin and endocrine glands (fat-soluble substances - through sebaceous, mammary glands, heavy metals - through sudoriferous, salivary glands). Biosubstances, in which the content of poisons or their metabolites is determined to confirm the diagnosis of poisoning are as follows: blood, urine, faeces, exhaled air, secretion of glands. Manifestations of Toxic Effect of Industrial Poisons These include:  Sharp intoxications  Chronic intoxications,  Specific action (allergenic, gonadotropic)  Remote effects (mutagenic, oncogenic) Regulation of Industrial Poisons There are 3 limiting signs of harmful action at normalization of industrial poisons in the air of a working zone:  organoleptic  irritating action on person or experimental animals;

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 specific and nonspecific toxic action in experiment with laboratory animals. Scheme of Investigation of Poison Toxicity in Experiment The scheme includes the following:  Research of physical and chemical structure of poison, its chemical properties, toxicological parameters of chemical analogs for approximate estimation of a toxicity level.  Studying acute toxicity of poison in acute experiments at oral, inhalation action, at skin effect (LD50, Lim ac.)  Studying subacute toxicity in experiments for 30-45 days – estimation of C. cum., features of toxic action.  Research of chronic toxicity in 4-6-month experiments - estimation of Lim ch.  Substantiation of threshold concentration (LOAEL), MPC for a person. Prevention of Occupational Poisonings This includes the following:  Administrative-legislative measures (the list of harmful industries - medical contraindications, privileges, age restrictions, etc.);  Hygienic measures – a preventive and current sanitary control;  Medical-preventive measures - preliminary and current medical examinations, investigation and treatment of occupational poisonings; medical-preventive nutrition in harmful industries;  Technological measures - change of chemical technologies in industry, ventilation, hermetic sealing, automation, sewage disposal plants, etc.;  Individual measures - overalls, gas masks, respirators, dietetic therapy.

Table 42 Remote and Specific Effects of Industrial Poisons and Pollutants of

the Environment Remote effects Specific effects Oncogenous (cancerogenic) Gonadotropic Mutagenic Allergenic Teratogenic Embryotropic Decrease of life expectancy Immunodepressive Acceleration of organism ageing

Oncogenous (Cancerogenic) Effect Chemical cancerogen is:  substance or its admixture which can cause in man or animal the formation of tumors that are not encountered without its action (true cancerogens - the initiators);  substance which can cause acceleration of formation or earlier occurrence of usual tumors (promoters – pre-cancerogens).

Classification of Cancerogens (By International Agency of Cancerogenic Investigation)  Cancerogenic for the man (there are 23 substances - arsenic, asbestos, chrome, beryl- lium, nickel, carbon black, petroleum, benzene, etc.— their cancerogenic effect on people is proved by the epidemiological data);  Probably cancerogenic for the man:  Probable cancerogens causing tumours in 80-100% of experimental animals during 4-6 month; they include 14 substances, such as benzpyrene, chlorine – organic combinations, etc.  Possible cancerogens causing tumors in 20-30% of experimental animals during life; there are 47 substances, e.g. cadmium, nitrosocombinations, some pesticides.

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 Not categorized by cancerogenic ability (data about cencerogenic activity are discordant) - 64 substances are included, for example, lead and its salts;  Probably not cancerogenic for man – this group includes all other substances for which no data about cancerogenic effect have been obtained up to now.

Mutagenicity of Chemical Substances Nowadays more than 600 substances are found out which have a mutagenic effect on the man or laboratory animals.

Classification of Chemical Mutagens They are subdivided into:  Natural - inorganic and organic substances encountered in the nature (mycotoxins, nitrogen oxide, nitrites, etc.);  Anthropogenic - medicines, pesticides, food additives, etc.  Investigation of mutagenic action of substances is carried out in the following way:  In experiments on cell systems - microbes, plants, hexapods, cells of the man and animal in experiments in vitro, in vivo;  Cytogenetic monitoring of the population and people working in contact with mutagenic factors  Biological indication of mutagens in biosphere (ecumene) To prove mutagenicity of chemical substances for man 4 systems are used:  Dotted mutations in microorganisms with a metabolic activation  Dominant lethal mutations for mice  Chromosome changes in bone marrow of mammalia  Chromosome disturbances in human leucocytes

Embryotropic Action Types of fetation disorders under the influence of chemical substances include the following:  Embryotoxic action - destruction of fetus, decrease of mass and dimensions of emb- ryo, disturbance of normal differentiation of tissues;  Teratogenic action - anomalies and defects of a new-born development. Now there is a new science in toxicology – chemical teratology studying teratogenicity of chemical substances for the man and animals, in biosphere. The list of chemical teratogens includes more than 600 materials, such as hydrargyrum and its compunds, dioxines, pesticides, benzol, benzine, etc. The evaluation of embryotoxicity is carried out in experiments on laboratory animals. Parameters of Embryotoxic Action  Common embryonal mortality  Pre-implantation and post-implantation mortality  Number of newborn laboratory animals  Average mass and dimensions of embryos Parameters of Teratogenic Action  External and internal anomalies of development  State of places of ossification  Subdivision of newborn laboratory animals by sex.—

Lim sp. and Z sp. = Lim integr / Lim sp.

If Z sp. > 1, the material has a selective embryotropic action and this is taken into account at establishment of MPC. Other Remote Effects of Chemical Substances  Neuropsychic disorders at effect of phosphorus-organic combinations.  Disturbance of hemopoiesis (anemia), cardiac dysfunctions (acceleration of infarc- tions, development of atherosclerosis) occur at effect of chlorine-organic combina-

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tions. Toxicologic and Hygienic Characteristics of Basic Industrial Poisons

Irritating Substances (Chemical Substances of Primary Irritating Action) To such poisons ammonia, oxides of nitrogen, sulfur, vapours of chloric, hydrochloric, nitric acid, CO2, CO, chlorine and its compounds refer. These substances are widely used in industry and can frequently affect the working people. The common features of their effect are: irritation of respiratory tract and eye mucous membranes. The effect depends on solubility in water; hence they are divided into highly soluble, e.g. chlorine, sulfurous gas, ammonia which are basically retained in the upper parts of the respiratory tract and cause chemical irritation or burns here, and less soluble, e.g. oxides of nitrogen which reach deep parts and can cause pulmonary edema. Effect of chlorine. Chlorine is a yellow gas with a specific smell, 2.5 times heavier than air. Getting on mucous membranes, chlorine dissolves with the formation of hydrochloric acid and atomic oxygen producing an irritating effect on the lung tissue causing inflammation and sometimes addition of secondary infection. Chlorine poisonings are more often of an acute form and have two stages:  initial - irritation of the upper respiratory tract and mucous membranes;  lung hypostasis – respiratory failure, increase of temperature, leucocytosis. At chronic poisoning bronchitis, emphysema, pneumosclerosis, dermatitis and eczema on the skin occur. Effect of ammonia. Its effect is similar to that of poisoning with chlorine; there are severe damages at its entry into eyes and on skin. Effect of nitrogen oxides and vapours of nitric acid. It is more often results in acute poisoning of 3 stages:  initial - irritations,  latent period – any symptoms are absent,  increasing lung hypostasis. In blood there may be the formation of methemoglobin resulting in hypoxia, disorders of CNS and vegetative NS. Effect of CO2. It affects the respiratory center, causes hypoxia. Effect of CO (carbonic oxide). CO is a gas without color and smell formed at incomplete combustion of fuel in insufficiently ventilated premises. In blood it forms carboxyhemog- lobin having scarlet color. Affinity of Hb to CO is 300 times higher than to O2. It causes scarlet spots on skin. It cannot transport oxygen in blood that leads to occurrence of hemic hypoxia. The direct effect of CO on tissue breathing in the CNS and internal organs is blockade of cytochrome oxidase. Stages of acute poisoning are:  initial - headache, disorders of the CNS;  euphoria - aggravation of CNS damage;  coma - loss of consciousness, suppression of reflexes, paralysis of the respiratory center. In the remote period after poisoning with CO loss of memory, disorder of consciousness, affection of the CNS, etc., occur. Poisonings by Heavy Metals To this group such metals as lead, tetraethyl lead, mercury, etc., belong. Poisonings by lead. More than 100 occupations have contact with lead or its compounds. Poisonings are chronic, more often through inhalation. Pathogenesis - blockade of carbothiolic enzymes (containing SH-groups) and others. Mutagenic, gonado- and hepatotropic effect is produced. (See attachement 2 – pictures an the end of textbook) The main symptoms of lead poisoning are the following:  Lead border – a grey border at the edge of tooth gum due to sulphurous lead (lead is excreted with saliva and lead sulphide is formed in the mouth).  Lead colour – a pale colouring of skin - angiospasm and increased content of por- phyrin in blood.

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Characteristic changes of lead poisoning in blood are:  Reticulocytosis – increase of reticulocytes (over 15 per 10 thousand) in blood (irritation of hemopoietic organs).  Basophilic erythrocytes in blood - irritation of hemopoietic organs. Characteristic changes of lead poisoning in urine are:  Porphyrinuria - more than 50-60 µg/l.  The increased content of lead in urine - more than 0.04 mg/l. Besides in symptomatology the following is marked:  Affection of the nervous system - at the beginning the asthenic syndrome, then lead encephalopathy and polyneuritis.  Changes in blood: at the beginning reticulocytosis and basophilic granularity of erythrocytes, then - anemia and decrease of Hb.  Involvement of the gastrointestinal tract - dyspepsia, in severe cases – lead colic accompanied by severe pains in the stomach which are not controlled by spasmolytics.  Liver injury - toxic hepatitis with disturbance of all its functions, bilirubinemia. Poisonings by Tetraethyl Lead (TEL) Organic compounds of heavy metals are more toxic than elementary metals. TEL is used as an additive to gasoline to decrease detonation. Poisonings with TEL occur through inhalation and are very severe (TEL presents the 1 class of danger). They cause disturbances of the CNS - headache, asthenyc syndrome, euphoria, disorders of sleep, memory, suppression of CNS. Suppression of the vegetative NS results in vegetative triad: hypotonia, bradycar- dia (rare cardiac contractions), hypothermia. In severe cases there may be mental disorders and organic lesions of CNS. In years after poisoning the remote effects occur, such as as- tenization, emotional imbalance, decrease of intelligence. Poisonings by Mercury More often they occur through inhalation (mercury vapours). Rather often asymptomatic course (the content in urine is 0.05 mg/l and over) and chronic poisonings by mercury are possible. Symptoms of poisonings. First of all there is effect on the CNS. In Europe in the past there was a saying ―as fool as a hat maker‖ because in the past at making hats mercury was widely used. It is marked by  mercurial ―border―on gingivas of black colour;  mercurial neuroticism;  mercurial erethism (psychological disorders in emotional sphere - whining, anxiety);  mercurial encephalopathy;  mercurial gingivitis (inflammation of the tongue), and stomatitis, gastritis, colitis;  disturbances of the cardiac system (changes of electrocardiogram), kidneys (neph- roses);  in blood - lymphocytosis, monocytosis, leukopenia, anemia;  content of hydrargyrum in urine is over 0.01-0.02 mg/l. The organic compounds of mercury are more toxic, e.g. Minamata disease (poisoning with methyl mercury).

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Poisonings by Aromatic Hydrocarbons Aromatic hydrocarbons (dissolvents) are a group including hydrocarbons with aromatic structure, such as benzene, toluene, ksylol. They affect through inhalation causing:  disorder of the CNS (narcotic effect), polyneurites;  disorder of hemopoiesis - leukopenia, thrombocytopenia, aplastic anemia;  hepatotropic effect - toxic hepatitis;  allergenic action;  gonadotropic effect;  mutagenic and cancerogenic effect. Synthetic Polymeric and Plastic Substances At their heating different substances can be formed which produce the following action:  narcotic action  irritant action  effect on blood genesis, internal organs  disturbance of pregnancy  allergenic action  teratogenic and embryotropic action  cancerogenic effect. Hygiene of Work in Agriculture.

Hygiene of Application and Toxicology of Agrochemicals

Modern Ecologic and Hygienic Problems of Agriculture Agriculture is a large sphere of human activity in which a lot of people are engaged. In many regions, including Crimea, this branch takes a leading position in the structure of national economy. The modern way of agriculture development is its intensification, i.e. increase of agriculture production in the available agricultural areas. But this way requires application of many agrochemicals, e.g. pesticides, fertilizers, growth stimulators, etc. These substances can affect the working people, pollute the biosphere and accumulate in foodstuffs. Features of Hygiene of Work in Agriculture As a whole the work in agriculture has a number of features as compared to work in other spheres of industry which can negatively affect the health of working people. They include the following:  Seasonal irregularity and urgency of work - nonuniform load during a year; in some periods there is very hard work with no fixed hours (for example, sowing, harvesting seasons,). It can cause early fatiguability, overstrain and possible disorders of health.  Work in the open air in different seasons at influence of adverse meteorological factors - overheating, overcooling, excess UVR + chemicals – melanomas on the skin are more often encountered in agricultural workers in South regions.  Hard physical work may cause early overfatigue.  Contact with traumatically dangerous mechanisms. The level of traumatism in agriculture is higher than in industry.  Remoteness of work places from residence. Absence of transport causes big energy losses, hence early fatiguability.  A wide chemization of agriculture - contact with a big amount of different toxicants at combined and complex action on organism. It is the most unfavourable feature of agricultural work and we‘ll stop on it in detail.

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Hygiene of Application and Toxicology of Agrochemicals Agrochemicals are a big group of chemical substances of natural and anthropogenic origin applied in agriculture. There are more than 5,000 chemical substances used as agrochemicals. The basic groups of agrochemicals are pesticides, fertilizers, growth stimulators, etc.

Hygiene and Toxicology of Pesticides Pesticides (in translation ―eliminating harm‖) are chemical and biological means of protecting plants from pests, weeds and illnesses. It is the most dangerous group of agrochemicals due to a high level of toxicity for person. Despite the great toxicological and ecological damage from application of pesticides, it is impossible to refuse their usage, as it leads to destruction of about 50 % of crop that in conditions of world deficiency of foodstuffs, especially proteins, is inadmissible. To decrease danger of pesticides for the man and environment their assortment is constantly changed and updated by prohibition of especially stable and toxic preparations, a constant toxicological and hygienic selection of newly synthesized preparations with high selective toxicity for vermins and low toxicity for man and biota. The leading world chemical concerns (―Bayer‖, etc.) constantly synthesize new pesticides, though only 1 of one million suggested preparations is allowed for application.

The Development of Hygiene and Toxicology of Pesticides The USSR was a leading country in studying this problem. The researches began in the 30s of the XX century. The founder of the doctrine about hygiene of work with pesticides academician L. I. Medved worked in Kiev scientific research institute of hygiene of work and occupational diseases. In 1965 he organized an All-Union research institute of hygiene and toxicology of pesticides; academician J. I. Kundiev developed the doctrine of percutaneous effect of pesticides. Academician J. S. Kagan is a leading scientist in toxicology of pesticides, academician E. I. Goncharuk created the theory of regulation of pesticides in soil. Classifications of Pesticides  Hygienic classification of pesticides (Table 42)  by general toxicity for animals Table 43 Degree of toxicity LD 50 mg/kg per os Extremely poisonous substances < 50 Highly toxic 50-200 Moderately toxic 200-1000 Low toxic > 1000

 by percutaneous toxicity for animals

Degree of toxicity LD 50 on the skin, mg/kg Sharply expressed toxicity < 300 Expressed toxicity 300-1000 Poorly expressed toxicity > 1000

 by ability to cumulation Ability to cumulation Factor of cumulation Supercumulation < 1 Expressed cumulation 1-3 Moderate cumulation 3-5 Slight cumulation > 5

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 by degree of volatility Danger of inhalation poisoning Parameters Very dangerous substances The saturating concentration at 20ºС is higher or equal to toxic one Dangerous substances The saturating concentration is higher than the threshold concentration Low-dangerous substances The saturating concentration is lower than the threshold concentration

 by stability in the environment

Degree of stability Time of decomposition up to non-toxic components Very stable > 2 years Stable 0.5-2 years Moderately stable 1-6 month Not stable < 1 month

Classification by application:  Insecticides - for struggle against insects  Acaricides - for destruction of ticks  Algicides – for destruction of seaweeds  Arboricides - for destruction of trees and bushes  Bactericides – for struggle against bacterial illnesses of plants  Larvicides - for destruction of larvae and caterpillars of insects  Ovicides - for destruction of insect eggs  Zoocides - for struggle against rodents  Limacides - for destruction of molluscs  Fungicides – for destruction of fungi  Herbicides - for struggle against weeds:  Defoliants - for removal of plant foliage.  Classification by way of entry into organism of insects:  Contact - at contact with any part of an insect body;  Intestinal – getting into insect organism per os;  Fumigants - through the respiratory organs of insect;  Systemic – getting to all parts of plants.  Classification of pesticides according to chemical structure:  Chlorine-organic pesticides (CHOP) - DDT, aldrin, dildrin, hexachloran, etc.  Organophosphorus pesticides (OPHP) – carbophos, chlorophos, phosphamide, etc.  Carbamates - derivatives of aminoformic acids – sevin, zineb, maneb, ziram, etc.  Mercury and arsenic-containing pesticides – mercuran, granozan, arsenit calcium, etc.  Copper preparations – compounds of copper - copper sulfate, Bordo liquid.  Derivatives of symmetric triazines – atrazin, propazin, simazin.  Synthetic pyretroids – ambush, zimbush, decis, etc. Toxicological Characteristics of the Main Groups of Pesticides  CHOP (Chlorine organic pesticides). The mechanism of insecticide and toxic action consists in blockade of respiratory enzymes in tissues, especially cytochrome oxidase (an indicator enzyme for diagnostics of poisoning). The symptoms of poisoning are: affection of the CNS, liver, kidneys, endocrine system, a mutagenic, gonadotropic, cancerogenic action.  The ecological danger consists in the fact that they are very stable in biosphere, therefore practically all of them are forbidden for application. According to data of

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Washington Academy of Sciences the half-life period of DDT in biosphere is some centuries.  PHOP (Phosphorus organic pesticides). The mechanism of their action consists in blockade of enzyme cholinesterase in blood. Cholinesterase is necessary for destruction of acetylcholine, when it is inactivated, the accumulation of acetylcholine in synapses takes place. Two stages of poisoning are distinguished - excitation, then suppression and destruction of vital centers of CNS. The symptoms are overexcita- tion of choline-reactive systems. Poisonings due to small stability of PHOP in the environment (1-3 months) are more often acute. Last years the remote neurotoxicity is found out for PHOP, i.e. damage of the peripheral nervous system and CNS in years after poisoning (functional cumulation). Prospects for further application are insignificant because of high toxicity and adaptation of pests (the oldest group of pesticides).  Carbamates (salts of carbaminic acids). Now this group is frequently suggested by chemical firms. The mechanism of their action is similar to that of OPHP, but blockade of cholinesterase is reversible and in some time its activity is restored, therefore poisonings are less severe than at action of OPHP. They are rather stable in biosphere (about a year and more); for some preparations the remote effects are established (in experiment).  Mercury and arsenic-containing pesticides. The mechanism of their action is blockade of carbothiolic enzymes (containing SH-group). They are extremely toxic and are applied as fungicides for grain.  Preparations of copper. It is an old group of preparations applied on vineyards, including in Crimea. They are low-toxic - in intestines copper albuminates are formed – there is no absorption in blood, they have an irritating action in intestines. Poisonings are usually of mild or moderate degree. The treatment is gastric lavage, application of antidotes against heavy metals - pectins, unitiol.  Symmetric triazines. They are widely applied as herbicides in rice fields in the Cri- mea and with waste waters they pollute the coastal sea water areas. Basically they are low-toxic. They have high stability in biosphere. They produce a cytotoxic action, i.e. affect the structure of nucleic acids.  Synthetic pyretroids – a rather new group with high selectivity for insects. They are synthesized on the basis of natural pyrethrins (flowers of Dalmatia camomile at the beginning of 20th century were applied as insecticides). They are low-toxic for man and are also unstable in the environment, the mechanism of their action is poorly investigated; there is certain evidence about the remote effects. This is a promising group of preparations but they are rather expensive. Hygiene of Work with Pesticides As it is a very toxic group of agrochemicals, the demands to conditions of work and contact with these substances are very strict.

Hygiene of Work at Pesticide Storage The territory of pesticide warehouse should be protected from access of other people, it must be removed from dwelling houses and other objects at a distance of 200-1000 m depending on toxicity of stored preparations; if there is an extremely toxic group of pesticides the distance should be 1 km. On the territory, apart from warehouse building, there should be plat- forms for washing off motor transport and mechanisms from remnants of pesticides, facilities for prevention of sewage into the surroundings. The internal covering of warehouse should be made of non-adsorbing materials, preparations should be stored in a hermetic container, there should be good ventilation, premises for staying the personnel, storage of clothes, and shower. There should be constant current sanitary control over levels of pesticide pollution of air, hands, overalls of personnel, containment of preparation packing, rules of work with toxic substances.

Hygiene of Work at Pesticide Transportation The common rules of transportation of chemically dangerous cargoes include the following: special transport, routes specially chosen by sanitary service – far off towns, hospitals, sanatoria, etc. In the car there should be means of individual defence and disintoxication of pesti-

189 cides in case of accident.

Hygiene of Work at Pesticide Application As many pesticides are highly toxic substances, strict security measures are required at work with them, including:  Restriction of working time - 4 hours (pesticides of 2-3 class of danger) or 2 hours (1 class of danger);  Observance of terms of work resumption (after processing plants), in greenhouses it is very small - 1-3 days;  Observance of expectation term - the period between processing and harvesting (it depends on toxicity, stability of preparation, culture of plants), for example, for OPHP on apple trees - 20 days;  Preliminary and current physical examinations, early revealing and treatment of pesticide poisonings (in special clinics);  Preventive and current sanitary control at application of pesticides;  Use of individual means of protection of respiratory organs and skin;  Observance of rules of personal hygiene – taking shower after work, meals in special places.

Ecologic and Hygienic Estimation of Ways of Pesticide Application Pesticides in agriculture are applied by 3 ways: aircraft sprayers, tractor sprayers and individual sprayers. Each way has its advantages and disadvantages concerning health of working people and protection of biosphere. The Hygienic Characteristics of Biological Pesticides The biological means of plant protection has been intensively introduced recently in connection with toxicity of chemical pesticides. They are based on prevention of destruction and illnesses of plants due to biological means. The basic groups of biological means are:  Bacterial, fungoid, virus preparations causing illnesses of pests;  Biological preparations for struggle against illnesses of plants (antibiotics);  Ferromones (sexual hormones) of insects - for attraction in chemical traps or scaring away. Disadvantages of biological way of plant protection are as follows:  Low efficiency in comparison with chemical pesticides (30 %);  High cost;  Allergenic action on workers. Toxicology and Hygiene of Work at Application of Fertilizers Apart from pesticides many other chemicals are used in agriculture, among them fertilizers are of primary importance by frequency of application. Fertilizers are substances used to increase productivity of plants.

Classification of Fertilizers They are subdivided into:  Organic (peat, manure);  Mineral fertilizers - macrofertilizers (nitrogen, phosphorus, potassium – simple and complex fertilizers by form) and microfertilizers (microelements for plants). By application nitric fertilizers make up 90 % of all fertilizers - they promote fast growth of plant mass, but thus in ground and plants nitrates and nitrites accumulate – in big amounts they can cause methemoglobinemia in man. The control over content of nitrates in products is necessary. Phosphoric fertilizers frequently contain fluorine as impurity, and fluorosis may occur among population near such working manufactures and at application of these firtilizers, as well as the formation of anthropogenic biogeochemical provinces by fluorine.

Hygiene of Work with Fertilizers As fertilizers refer to low-toxic substances, they do not require such strict measures as

190 at work with pesticides – here the protection of respiratory organs against dust of fertilizers and protection of skin (individual means of protection) are necessary. Recommendations for Practical Classes on the Theme

Key Questions Subject and tasks of industrial and agricultural toxicology. Parameters of toxicity of substances at acute, subacute and chronic action. Basic laws of action of toxic substances on organism. Classification of industrial poisons and pesticides. Way of entry and elimination of poisons from organism. Ways of neutralization of poisons in organism. Detoxication system and its parameters. Manifestation of toxic action of these substances on organism of working people. Toxicologic characteristics of the basic groups of industrial poisons. Prevention of occupational poisonings. Classification and purpose of basic groups of agrochemicals. Toxicologic and hygienic characteristics of the basic groups of pesticides. Hygiene of work at storage, transportation and application of pesticides and fertilizers. Self Test 1. If the factor of cumulation is less than 1 it means *A. overcumulation. B. slight cumulation.

2. Into the atmospheric air of the industrial centre the emissions of metallurgical plants enter, such as oxides of sulfur, nitrogen, metals which negatively affect a health condition of population. The action of these harmful factors is characterized as *A. combined. B. complex. C. integral. D. isolated. E. mixed.

3. The excess of MPC of toxic substance in atmospheric air makes up 100. What changes in a health condition of population should be expected? A. fatal poisonings of children and elderly people *B. acute poisonings C. changes in a health condition by separate parameters D. chronic poisonings

4. Which of the following does not refer to parameters of acute toxicity of industrial poisons? A. DL 16 B. DL 50 C. C cum. D. Lim ac. *E. Lim ch. Problem Solving 1. What kind of work does a hygienist do at making periodic medical examinations at industrial enterprises? 2. Introduction of toxic substance into animals was carried out daily in doses equal to 1/20 of DL50. Thus at a 5-time-a week introduction during 4 months each animal received totally 10.5 doses of toxic substance equal to DL 50. Determine the factor of cumulation and give its estimation. 3. At doing electrical welding works the aerosols containing oxides of iron, manganese, carbon, chrome and silicon are emitted into the shop atmosphere. In welders the lesion of the nervous system (chronic intoxication) is diagnosed. What can cause chronic intoxication?

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Standard Answers 1. He determines the list of persons for physical examination. 2. Factor of cumulation is a ratio of total LD 50 to a dose at a single introduction (LD50). So, C cum = 10.5/5 since in the task 1/20 of DL50 is taken; C cum = 2.1, that is expressed cumulation. 3. Manganese oxides.

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HYGIENE OF CHILDREN AND TEENAGERS

Theme No 21. Subject and Tasks of Hygiene of Children and Teenagers (HCT)

The Physical Development of Children and Teenagers as a Criterion of Health

Subject and Tasks of Hygiene of Children and Teenagers (HCT) HCT is a section of hygiene studying the action of environmental factors on a growing organism and developing preventive measures to maintain and strengthen the health of children and teenagers. The primary goals of HCT are: studying the physical development, elaboration of hygienic requirements to children‘s preschool and school institutions, to training, physical training of children, to children's toys, hygiene of work of schoolchildren and teenagers, hygiene of children‘s nutrition, medical-professional consulting at school. Basic Methods of Research in HCT  Epidemiological method (studying the health state of children's contingents depending on environmental factors);  Method of sanitary description (sanitary inspection of children's preschool institutions, schools, etc.);  Method of sanitary examination (examination of children's toys, etc.);  Methods of laboratory experiments (for example, studying the effect of harmful factors on a growing organism in experiments on laboratory animals). Laws of Growth and Development of Children  Irregularity of growth and development of organism depending on age – the younger the organism is, the more intensive these processes are;  Irregularity of growth and development of different organs and systems at different age;  Connection of growth and development with sex - unequal rates of growth and development in boys and girls;  Influence of genetic factors, environmental factors and social conditions, disease incidence on growth and development;  Influence of acceleration. Acceleration as an Actual Problem of HCT Acceleration is a speeded up physical development of children and teenagers as compared with anthropometric parameters of children many years ago. For the recent 10-15 years rates of acceleration have noticeably decreased and even deceleration is observed, i.e. decreasing of physical development of children and teenagers in comparison with anthropometric parameters of children 10-15 years ago. Theories (Reasons) of Acceleration Up to now the universal reason of acceleration is not established in view of great amount of factors influencing physical development. The basic theories of acceleration are:  Alimentary theory – improvement of qualitative and quantitative parameters of nutrition of the population;  Medical theory – decrease of disease incidence, gynecologic pathology due to development of medicine;  Heliogenic theory - influence of cyclic changes of solar activity and levels of UVR;  Ecological theory - growth of СО2 content in atmosphere, increase of intensity of electromagnetic fields, elevation of level of natural radioactive background;

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 Theory of heteresis – increase of mixed marriages of different races and nationali- ties. Medical and Social Consequences of Acceleration Medical unfavourable effects:  rejuvenation of many diseases (oncological, cardiovascular, etc.);  functional disorders of organ and system development;  the problem of a large fetus in obstetrics due to intrauterine acceleration;  the necessity of revision of hygienic norms (norms of nutrition, size of school furniture, standards of physical development);  gynecologic pathology due to early pregnancy and abortions. Social consequences are caused by delay of mental development as compared with physical one: increase in teenage crime, growth of divorce number and number of children without care of parents, etc. Schemes of Age Periodization The biological periodization accepted in HCT includes:  the period of new-born (1-10 days);  infancy - till 1 year;  early childhood - 1-3 years;  the first childhood - 4-7 years;  the second childhood - boys of 8-12; girls - 8-11 years;  teenage age - boys of 13-16; girls - 12-15 years;  youthful age - young men of 17-21; girls - 16-20 years. The social age periodization includes:  day nursery age - till 3 years;  preschool age - 3-7 years;  junior school age - 7-10 years;  middle school age - 11-14 years;  senior school age - 15-18 years. Physical Development of Children and Teenagers Physical development is a complex of morphological and functional signs determining growth, formation of child‘s organism, resources of its vital energy, tolerance and activity. Physical development is one of the major parameters characterizing the health state of population and influence of various factors on it. For estimation of health of children's contingents this parameter is most frequently used in connection with disease incidence. The purposes of research of physical development are the following:  revealing the laws of growth and development;  estimation of individual and population level of health;  studying the effect of environmental, social, genetic factors;  estimation of efficiency of medical-prophylactic measures. Methods of Research of Physical Development The requirements to research methods are the following:  application of simple and accessible techniques,  carrying out researches at one and the same time (better in the morning after sleep),  sufficient accuracy of measurements. The research methods are subdivided into:  Somatometric (anthropometric) - measuring height, body mass and circumference of the chest.  Somatoscopic - the description of the form of skeleton, spinal cord, chest, legs, development of muscles, state of skin, sexual development by criteria of Tanner.  Physiometric - measuring vital capacity of the lungs, chest excursion, muscle strength, arterial blood pressure, pulse rate.

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Methods of Estimation of Physical Development  Method of indexes, for example, Brock‘s index: height in cm - 100 cm = ideal weight in kg (with age correction). For children this method is rarely used.  Method of sigma deviations Sigma in statistics means a standard deviation. There are standard tables of physical development of children and teenagers according to age and sex on the basis of statistical researches of big contingents in which average indices of height, body mass and chest circumference with their sigma are included. After determination of somatometric parameters of a concrete child, the average values from the table are subtracted from them, and difference is divided into the given sigma. For example, a boy aged 10 has body mass of 45 kg, in the table for boys of this age the average body mass equals to 40 kg, sigma +- 2.5. Estimation: 45 – 40 kg = 5 kg/2.5 = + 2. If quotient of division is from +1 up to –1, the development is average (it corresponds to the age norm); if it is +1 - + 2 - the development is above average; -1 - 2 - below average; more than +2 or below -2 - high or low. The disadvantage of this method consists in the fact that each parameter is estimated separately, without interrelation with other parameters, and it is impossible to estimate harmonicity of physical development. To eliminate this disadvantage the further development of method of sigma deviations has been suggested, i.e. drawing a diagram (profile) of physical development.

Fig 21. The Diagram (Profile) of Physical Development

The diagram graphically represents the data received according to each parameter, if all quotients by 3 parameters are within the limits of 1σ the development is proportional (harmonious), up to 2 σ - disharmonious, more than 2 σ - sharply disharmonious.

Method of regression scales (regression sigma) shows on the basis of statistical researches what body mass and chest circumference should correspond to the given height. From the received parameters of body mass and chest circumference of the given child we deduct the average indices corresponding to the given height (from tables with estimated figures) and difference is divided into regression sigma, showing within what limits the range of mass and chest circumference in relation to height is possible at harmonious development. Variants of estimation: development is harmonious within the limits of +1 up to -1 sigma; disharmonious - from +2 up to -2 σ and sharply disharmonious - more than +2 or less than -2 σ.

Method of centile lines (centiles). It is an American method mostly used in pediatrics. For research not less than 100 children are necessary ranged according to increase of each parameter (height, weight, chest circumference), thus the first child is 1 centile, the last one - 100 centiles. The development is considered average between 16 and 84 centiles (+ - 2 σ for 100 observations). More often in pediatrics the range of 25-75 centiles is used. The drawbacks of this method are: the interrelation of parameters and harmonicity of development are not estimated, and besides a great number of children are necessary for researches.

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Recommendations for Practical Classes on the Theme

Key Questions 1.Anthropometric, anthroposcopic, physiometric methods of studying physical development of children and teenagers. 2.Methods of estimation of physical development of children and teenagers: Method of indexes Method of sigma deviations and profile of physical development Method of regression scales Method of centile lines A complex method of estimation of physical development. 3.Determination of children‘s health groups. 4.Determination of groups for physical training classes. 5.Method of comparison of physical development in various children collectives. 6.Laws of growth and development of a child‘s organism. 7.Biological and social schemes of age periodization. 8.Acceleration. Theories, essence, consequences of deceleration phenomenon. Self Test 1. Identify a centile range which testifies to a child’s height appropriate to his age? *A. 25-75 B. 5-95 C. 16-84 D. 20-80 E. 3-97 2. How many health groups of children are known? A. 2 B. 3 *C. 5 D. 4 E. 6 Problem Solving 1. On medical examination of a schoolboy aged 14 chronic tonsillitis and caries are revealed. On inspection – his height is average, physical development is harmonious. Determine the group of health. 2. Evaluate the physical development of Tanya L., aged 14 by method of scales of re- gress. Height of the child is 120 cm (+0.5 sigma regression), body weight - 20 kg (+0. 8 σR), chest circumference - 90 cm (+0.4σR).

Standards Answers: 1. The 3rd group of health, as the child has chronic tonsillitis. 2. Differences between all regression sigmas are not more than 1; therefore the physical development is harmonious.

Theme No 22.

Hygienic Requirements to Children's Preschool Institutions and Schools

Hygienic Requirements to Children's Preschool Institutions (CPI) Types of CPI are: kindergarten (for children of 3-7 years), day nursery (till 3 years), children's center (day nursery + kindergarten), children's home, preschool children's home, specialized CPI for children with disorders of development, preschool health-improving institutions for summer vacation. Requirements to Choice of Site for CPI  Accessibility for population - radius of service in microdistrict is 300 m;  Optimal hygienic conditions on the site (optimal microclimate, absence of air pollution by chemical and physical factors, presence of green plantations).

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Requirements to Site of CPI  The site area is 30-40 m2 per child;  There should be 2 entrances – the main and economic; the form of the site should be rectangular;  There should be special functional zones on the site based on principle of group and age isolation: zone of building; zone of group playgrounds; zone of sports grounds; economic zone; zone of green plantations. Requirements to Functional Zones on CPI Site

Zone of Building up Systems of CPI building up may be:  Centralized (it is not optimal from the hygienic point of view as all groups and economic premises are in one building);  A pavilion type of building up (it requires a lot of place, the construction is expensive);  Block building up (modern projects include blocks of, for example, day nursery, kindergarten, gymnasium, economic block). The building should be located not closer than 25 m from the site border, be surrounded with green plantations (trees - not closer than 10 m, bushes – 5 m from the building to preserve the normal natural light exposure).

Zone of Group Playgrounds The area of group playgrounds should be 7.2 m2 per child, a shadow canopy - 40 m2, game and sports equipment should correspond to age. Calculation of the necessary number of playgrounds should be made proceeding from one playground per two day nursery groups or four kindergarten groups. The playgrounds are separated by a zone of green plantations.

Zone of Sports Grounds There should be 2 sports grounds with area of 150-250 m2 - separately for junior and senior age groups, equipped with racetracks, other sports facilities.

Economic Zone It should be located in a distant part of the site, closer to economic entrance; it should be separated by green plantations.

Zone of Green Plantations It should occupy not less than 50 % of the site area. Plants with prickles producing irritating and allergenic action, poisonous wild-growing plants should be excluded.

Requirements to Layout of CPI The major principle of layout is the principle of group isolation which provides:  prevention of infectious diseases;  possibility to carry out quarantine measures;  different day regimen in different age groups;  prevention of traumatism at getting children of different age together. There should be not more than 2 floors in the building, including the basic groups of premises, such are: group sections, premises for general use, medical and administrative premises. Hygienic Requirements to a Group Section A group section is the basic functional unit of CPI; it is a set of premises intended for staying of one group of children. A group section includes: a reception-locker room, a group room (or separately a room for playing, bedroom, dining room), buffet, lavatory, verandah (for day nursery groups). The reception-locker room has the area of 18 m2, cupboards for outer clothing, benches, racks for toys used during walks. In day nursery groups there should also be tables for swad- dling and feeding children by their mothers. A group room is a common room which can be divided into a room for playing and a

197 bedroom. The total area is 4 m2 per child. The hygienic requirements are as follows: Microclimate: the air temperature is 21-22ºC (in a day nursery) or 18-20ºC (in a kindergarten), air humidity - 40-60 %, speed of air movement – 0.1-0.3 m/sec. 3 Ventilation: frequency rate is 3, volume of ventilation per child is 20 m /h, CO2 content - up to 0.1 %. Illumination: natural - LC 1/4-1/5, CNI – 1.5 %, light angle on desks - 27º, corner of aperture – 5º. Artificial common illumination - 150 lux. Premises for general use: gymnasium and music hall (75 m2 each), methodical room; additional premises: a swimming pool, hall, study for hand work and drawing. Medical premises: a medical room, medical treatment room, isolator. Administrative premises: manager‘ office with a hall for holding meetings with parents, cloakroom and shower room for personnel, laundry and ironing room, nutrition unit. Hygienic Requirements to CPI Equipment

Hygienic Requirements to Children's Furniture The following should be observed:  conformity to the anthropometric sizes of children,  trauma safety,  it should be made of non-toxic materials (better from wood),  it should be covered with non-toxic paint, smell of paint is not more than 1 point. Hygienic Requirements to Toys in CPI The following requirements are set to toys in children‘s preschool institutions:  Weight of toys for children till 3 years - up to 100 g, 3-7 years – 400 g, over 7-10 years – 800 g.  The size of small details of toys for children till 3 years - not less than 3 cm (to avoid inspiration of small details).  Material for toys is food types of rubber and plastic. Paints should be non-toxic, steady to disinfection, smell of paints for children before till 3 years - 1 point, from 3 to 7 years - 2 points.  Application of toys which are badly subjected to disinfection (soft toys) is not recommended.  Electric voltage in electric toys is up to 12 V. Hygienic Requirements to Schools

Requirements to School Location  Accessibility (radius of service is 1.5 km in a city and 3 km in the country);  Optimal hygienic conditions in the place of future school site. Requirements to a School Site The area is 20-50 m2 per pupil, the site should be of a rectangular form. Functional zones of school site include: zone of building up (of school building); zone of rest; training-experiential zone; sports zone; economic zone; zone of green plantations. Zone of building up – a building should be not closer than 25 m from borders of the site surrounded with a green plantation shelter belt (not closer than 5-10 m from the building to preserve natural illumination on the ground floor). Zone of rest - two grounds for outdoor games for junior and senior classes, a ground for a quiet rest, benches. Training-experiential zone – a garden, vegetable garden, greenhouses, educational workshops, etc. Sports zone – a stadium with racetracks and pits for jumps, grounds for volleyball, sports apparatuses, etc. Economic zone should be located at the end of a school site, closer to economic entrance and separated by green plantations. Zone of green plantations should occupy not less than 40-50 % of the site area.

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Requirements to School Building The systems of school construction may be:  centralized (all premises are in one building; it is an old project which causes high level of infections, noise, air pollution),  a pavilion type (there are many small buildings, it is accepted now for schools of a sanatorium type),  a block type (blocks for junior, middle, senior classes, for gymnasium, kitchen). The basic groups of premises at school include: Educational sections, general-purpose premises (vestibule, cloakroom, dining room, sports hall, assembly hall, library, etc.), offices (director‘s office, teachers‘ room, a first-aid post, nutrition unit). The basic functional unit at school is an educational section including some classrooms or studies, a recreation zone (hall, corridor), lavatory. A one-sided design of a school corridor with windows and halls is the most optimal. Hygienic Requirements to a School Classroom The area should be 1.25 m2 per pupil, on the whole not less than 50 m2. Microclimate should be the same as for usual premises, air changes per hour - 4, venti- 3 lation volume - 20-30 m /h/pupil, CO2 concentration in the air is not more than 0.1 %. Requirements to illumination are very important. It should be:  natural: LC 1/4-1/5, CNI – 1.5 %, light angle - 27º, ventiduct angle– 5º;  artificial: common illumination - 150 lux (luminescent lamps - 300 lux). Requirements to school desks (school tables): In a classroom the desks should be of not less than 3 sizes, placed in 3 rows, with distance of 0.7 m between rows, 2.5m to the blackboard, and 0.5m to the walls. Hygienic Requirements to Educational Laboratories Chemistry, physics, biology laboratories. Their area should be 70-100 m2, they should have an additional room of 6 m2; it is better to locate them on the top floors of a school building where airing is better; they should be equipped with artificial ventilation, water-pipe for washing utensils and equipment.

Advantages and Disadvantages of Laboratory System of School Education The advantages are the following: it is easier to concentrate the equipment and didactic material in 1-2 studies and not move them to different classes. The disadvantages include the following: big counter-current flows of pupils during breaks (infections), reduction of recreation time, non-correspondence of furniture to anthropometrical parameters of pupils of different age. Requirements to School Sports Hall It is better to have it on the ground floor, at block system of construction - in a separate block as noise interferes with classes in other classrooms. Its area is 4 m2 per 1 pupil, height – 4.5-6 m; there should be a locker room and a room for keeping sports stock. The feature of microclimate is the air temperature of 16ºC not to cause overheating of children at intensive physical activity; air changes per hour are 4-5. Common Hygienic Requirements to School Furniture They include the following:  correspondence to the anthropometrical sizes of children (prevention of disorders of the musculoskeletal system and organs of vision);  prevention of traumatism;  non-toxicity of materials and dyes, their stability to disinfection;  light or green colouring of tables.

Size of School Desks (Tables) In each classroom there should be desks of not less than 3 sizes, at schools the desks of 6-12 sizes are used having multi-coloured marking for a teacher. At the beginning of classes

199 the teacher should distribute the pupils according to their size (by Flerov‘s ruler or by Listov‘s formula: № of school desk = 2 first figures of height - 5).

Hygienic Standards of School Furniture These include:  Differention – a vertical distance from a table to chair – it should be equal to 1/7-1/8 of height or to the distance from the lowered elbow to sitting.  Distance of sitting – a horizontal distance between the edge of the table and edge of sitting – it should be 4–5 cm.  Distance of chair back – a horizontal distance from the edge of table up to back of sitting = the anterior-posterior section of body + 3-5 cm.  Height of sitting - length of leg + 2 cm.

A B C

Fig. 22. Distance of sitting: A - negative, B - zero; C - positive.

Medical-professional consultation and orientation at school are carried out by doctors, teachers and experts of youth employment centers with the purpose of choosing the future professions and recommendation to schoolboys in respect to professions suitable for their health state. Professional orientation includes: information service about availability of vacant occupations, psychological consultations in view of type of the nervous system activity. Medical-professional consultation is carried out twice:  in the 5th form for children with abnormalities of physical development, for the rest - in the 7th form;  in the 10-11th form. For the first time it is carried out for early revealing and treatment of diseases limiting capacity for work, for the second time – for the final determination of range of professions. While medical professional consultations the medical documentation for a schoolboy is used, evaluation of physical development and physical examination are carried out, if necessary – a thorough medical examination in hospital is done. From the medical point of view all professions are divided into 4 groups:  professions not connected with difficult working conditions;  professions connected with action of harmful factors;  professions connected with constant effect of harmful factor complex;  professions connected with difficult and harmful working conditions. Hygienic Requirements to Vocational Schools They should be located close to the basic industrial enterprises or in the suburbs of inhabited locality. The size of a site should be 20 m2 per pupil. Functional zoning: industrial practical training zone (a building for theoretical course and training workshops), sports zone (it is increased in comparison with school), economic, residential area (hostel), green plantations. At block system of building up the corresponding blocks should be present. The requirements to a hostel are the following: the area is 6 m2 per person, availability of the first-aid station.

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Recommendations for Practical Classes on the Theme

Key Questions 1.The hygienic requirements to the site of CPI. Functional zoning of the site. 2.The hygienic requirements to a group section in CPI (lay-out, illumination, microclimate). 3.The hygienic requirements to children's toys, clothes and footwear. 4.The hygienic requirements to a day regimen of children of different age. 5.Organization of physical training and its control. 6.Adaptation of children to training at school. 7.Estimation of children‘s readiness to school training. 8.Estimation of "school maturity" according to Kern-Ierasik test. 9Medical indications to postponing admission to school of six-year-old children. 10.The hygienic requirements to location and area of a school site. 11.The hygienic requirements to layout and building up of school site; functional zoning of site. 12.Systems of school construction. The hygienic requirements to a school building. 13.The hygienic requirements to the basic functional groups of school premises. 14.The hygienic requirements to a classroom. 15.The hygienic requirements to a sports hall, rational arrangement of a physical training lesson. 16.The hygienic requirements to school furniture. 17.The hygienic requirements to the equipment of school workshops. 18.The hygienic requirements to school time-table. 19.Organization of health services at school. 20.Organization of medical-professional consultations at school. Self Test 1. How many 5-year-old children is one group section in CPI designed for? *A. 20 children B. 10 children C. 5 children D. 30 children E. 25 children

2. What is a group section in CPI? A. a room for games B. a room for walks *C. a set of rooms for staying one group of children D. a set of rooms for all children in CPI E. a set of rooms for children‘s medical care

3. Identify the amount of air per one pupil in a classroom. *A. 3.75 m3 B. 4.75 m3 C. 1.25 m3 D. 1.0 m3 E. 5.0 m3

4. A training section at school is: A. a set of rooms for staying pupils of one form B. a classroom *C. a set of rooms for staying children of the same age of three forms or children of 2 forms of adjacent age groups (2 and 3 forms) with a common recreation room D. a block at school with a block layout E. a set of rooms for children of the 1st–10th forms Problem Solving 1. On the ground of CPI there are the following zones: green plantations, playgrounds for groups, economic area, a building site. The area of the ground per one child is 10 m2. Ra- dius of service of CPI is 500 m. What hygienic standard is broken in this case? 2. Before going to school Tanya‘s readiness for training at school was checked by Kern- Ierasik‘s test. Thus, the total number of received points was 5. Is she ready to start training at school? 3. In the city on the ground plot of a rectangular configuration having area of 4.4 hec-

201 tares (44,000 m2) the construction of a comprehensive school for 40 classes is planned. The borders of the site are at a distance of 55 meters from blocks of flats and municipal buildings. On the ground area there are green plantations, such as white acacia, oak, pine, wild grapes. Give the sanitary-hygienic estimation of the ground area. Solve the problem on the opportunity of using the available green plantations on the school site. 4. Give the sanitary-hygienic estimation to location of various premises of comprehensive school. The building of the school is of a block type, has three floors. On the ground floor of the building there is: a tambour, vestibule–cloakroom, corridor, teachers‘ room, 5 classrooms for fifth forms, 2 chemistry laboratories, library, lavatory for pupils and personnel of the school. On the first floor there are 3 English language studies, 2 drawing and fine art studies, 3 mathematics studies, 3 physics studies, the Russian language and literature study, 2 chemistry studies, the director‘s office, recreation hall, lavatory rooms. On the second floor there are 3 biology studies, doctor‘s consulting room, teachers' room.

Standard Answers: 1. The area of the ground of CPI per one child is reduced (normally it should be 40 m2). 2. She is not ready to study at school (normally the minimal result of the test should be 9). 3. The area of the ground is sufficient. The cultivation of wild grapes on a school site is forbidden. 4. The chemistry study should be located on the top (here 2nd) floor, the doctor‘s consulting room - on the ground or first floor.

Independent Work of Students-Pediatricians:

Sanitary Inspection of Comprehensive Schools and Children's Preschool Institutions

Learning Objectives 1) The hygienic requirements to location of CPI and schools. 2) The rules of drawing up the act of sanitary inspection of schools and CPI.

Plan of the Lesson The lesson is arranged as an independent work on sanitary inspection of CPI or schools of Simferopol under supervision of the teacher or doctor of SES according to the given schemes (see Appendix No. 1 and Appendix No. 2). Then each student makes up the act of sanitary inspection of the object and hands it in to the teacher during the next lesson.

Appendix No. 1 The Scheme of Sanitary Inspection of Children’s Preschool Institutions (CPI) 1. Surnames of supervisory members and those present at inspection. 2. Name of CPI, its address, date of inspection. 3. Area of the ground plot in square meters per one child. Availability of all functional zones on the site. 4. Zone of green plantations: percent of total area of site, distance of trees and bushes location from borders of the site. 5. Zone of group playgrounds: number of groups per one group playground, availability of any equipment, awning. 6. Zone of sports grounds: their number, equipment. 7. Economic zone: its location, what is included into it, whether it is separated from other zones by green plantations. 8. Zone of building up: location of building (in meters) from borders of the site, system of building up, number of floors. Scheduled number of places in CPE. Location of day nursery and preschool group sections in the building. 9. Structure and equipment of premises (rooms) of a group section: reception room-

202 checkroom, group room, buffet, lavatory, verandah. 10. The observance of hygienic requirements to children's furniture: correspondence to age and growth, safety, colouring, smell, material of production. 11. Toys available in a group room (their weight, material, smell, colouring). 12. Number of children in one group section. 12. Microclimate and illumination (artificial and natural) in a group room. 13. Availability of premises (room) for general use: a gymnasium, music hall, methodical study, their equipment and location. 14. Location and equipment of medical premises (medical room, procedure unit, isolator) 15. Location of administrative premises (rooms) (manager‘s office, laundry, nutrition unit) 16. Catering services for children:  Presence of cold and hot running water;  Supply with refrigerating equipment, kitchen utensils, their marking;  Sanitary state of nutrition unit premises, availability of detergents and disinfectants;  Availability of complete staff, sanitary cards, timely physical examinations. 17. The conclusion about sanitary state of PCI 18. Specify all revealed drawbacks. 19. Recommendations and terms of their liquidation. Date:______Signature:______

Appendix No 2 The Scheme of Sanitary Inspection of School 1. Surnames of supervisory members and those present at inspection. 2. Name of school, address, telephone, date of inspection. 3. Area of the ground plot, its green plantations, availability of game and sports grounds, their equipment. 4. Type of building: typical, specially constructed or adapted. 5. Planned number of places at school. 6. Number of pupils in classes. 7. Number of shifts at school, amount of pupils studying in the first and second shifts. 8. Amount of classrooms, studies, their area. 9. Average number of pupils in the 1-3, 5-8 and 9-11 forms, area in classrooms per one pupil. 10. Supply of school with desks, their marking, number of non-standard desks by the example of one-two classes. 11. Seating pupils at desks according to their height and health condition. 12. Presence of a sports gymnasium, its area, equipment, availability of cloakrooms, shower rooms, lavatory at a sports gymnasium. Subdivision of pupils into sports groups. 13. Availability of industrial workshops, their area, equipment, location of machine tools, size of passages, presence of supports to machine tools, used in workshops tools, conformity of their size to age of pupils. 14. Illumination at school (classooms, studies, workshops, sports gymnasium). Natural, artificial illumination (luminescent or incandescent lamps). Artificial illumination, amount of electric points, name of electric armature, capacity of lamps (W/m2). 15. Heating of school (central, furnace). An air-thermal regimen in premises, air temperature in classrooms, workshops, gymnasium. Regimen of premise airing. Presence of mechanical ventilation. 16. A drinking regimen, availability of drinking fountains. 17. Sewerage system of school, sanitary-technical condition of lavatories. 18. A study system of training, presence of studies for two age groups. 19. A hygienic estimation of time-table of lessons in junior, middle and senior classes (by

203 the example of one class in these age groups). 20. Presence of breaks between lessons and shifts. 21. A sanitary-hygienic condition of school, quality of the current tidying up. 22. Organization and control of self-service. 23. Catering services for children:  Availability of a canteen, buffet, amount of seats in them;  Availability of cold and hot running water;  Supply with refrigerating equipment, kitchen utensils, their marking;  A sanitary state of canteen premises, presence of detergents and disinfectants;  Availability of complete staff, sanitary cards, timely physical examinations. 24. Number of groups for prolonged staying at school. Availability of premises for such groups. 25. Personal hygiene of pupils. 26. Health services:  Full name of a doctor, nurse, medical establishment, which serves school;  Availability of a medical room and its equipment; presence of a separate room for a dentist;  Medical control over a sanitary state of school, canteen, hygienic conditions of training, health state of pupils. 27. Availability of popular medical literature in school library. 27. Hygienic training of school staff. 28. The conclusion about sanitary state of school. 29. Specify all revealed drawbacks. 30. Recommendations and terms of their liquidation coordinated with school authorities. Date:______Signature______

Appendix No 3 Estimation of a Difficulty Scale of School Subjects Range scale of difficulty of school subjects (in points) Mathematics, Russian 11 Foreign languages 10 Physics, chemistry 9 History 8 Literature, native language 7 Biology, geography 6 Physical training 5 Labour training 4 Drawing 3 Painting 2 Singing 1

Theme No 23.

Hygienic Requirements to Training, Physical Training and Hardening of Children and Teenagers. Hygiene of Children’s Nutrition

Hygienic Requirements to Training of Children and Teenagers The basic problem of training is the necessity to perceive a lot of information, which is doubled every 10 years. Therefore at development of hygienic requirements to training it is necessary to solve two problems:  To provide a child with knowledge and skills necessary for professional work;  To maintain thus children‘s health, not allowing overfatigue. The basic ways of solving this problem (at any educational establishment, including

204 higher school) are:  To increase the duration of training – but it is already impossible by physiological opportunities of organism;  Optimization of training – the use of new intensive forms of training, rational elaboration and revision of educational programs, optimization of training and rest-time regimen. In a complex process of children‘s training 2 main stages may be distinguished:  Development of skills of long sitting, writing, reading, concentration of attention – a preschool stage (in preschool institutions, at home etc.);  Stage of knowledge accumulation, development of logic and abstract thinking –at school, vocational school, higher school. It is the most difficult stage. Ways of Adaptation to Training at School A gradual change of dynamic stereotype, i.e. child‘s day regimen takes place:  In 3-5 years - 2 lessons for 15-20 min each as a game;  In preschool group - 4 days per week with 4 lessons every day by total duration of 1 hour 50 min per day;  In the 1st form - up to 20 lessons per week 35 min each (not more than 4 lessons a day). Age of Starting Training at School It is determined not by calendar age, but by psychophysiological features of a child, his physical development, health state. This problem is of great importance for pediatricians. There are some psychophysiological tests for definition of readiness for training at school (for example, Kern-Ierasik test). Exhaustion and Overfatigue of Pupils and Its Prevention At improper organization of educational process the signs of exhaustion and overfatigue among schoolboys are rather often observed resulting in subsequent disturbances of health. Signs of exhaustion of pupils include the following:  Decrease in work efficiency (increase in number of mistakes and decrease of volume of the processed information at correcting work);  Weakening of internal inhibition (diminished attention, distractable attention, excitation);  Deterioration of regulation of physiological functions (disturbance of cardiac rate and coordination of movements);  Occurrence of fatigue. Usually these signs quickly disappear during breaks and after school, but their long preservation testifies to development of overfatigue which is manifested by:  Sharp and long decrease of capacity for work;  Neuropsychic disorders (disturbance of sleep, feeling of fear, hysterics);  Stable disturbance of regulation of vegetative functions (arrhythmias, vegetovascular dystonia, disturbance of inner organ function);  Decrease of resistibility to infections and othe adverse factors. Prevention of Exhaustion in Pupils This includes:  Providing with optimal hygienic conditions for training, i.e. normal illumination, ventilation, microclimate, observance of MPL of noise and other harmful factors.  Optimization of training regimen, i.e. a correctly planned schedule of lessons, a correct organization of a lesson, effective use of breaks, optimal day regimen;  Optimization and revision of educational programs. Hygienic Requirements to School Schedule  Restriction of number of lessons per week: in the 1st form - up to 20 lessons by 35 min, 2nd form - up to 22 by 45 min, 3-4 form - 24, 5-8 form - 30, 9-11 form - 31 lessons per week;  Arrangement of lessons by complexity within a day and week using a scale of difficul-

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ty of school subjects: the exact sciences - 11 points, singing - 1 point. Requirements: it is impossible to put 2 difficult lessons together, at the beginning and at the end of the day and week. The maximally difficult lessons must be on Tuesday and Wednes- day, i.e. in the middle of the week. It corresponds to dynamics of capacity for work.

Hygienic Requirements to Structure of the Lesson Researches of pupils‘ capacity for work have revealed that the in-working stage lasts first 5 min of the lesson, phase of working excitation - 5-25 min, then goes the phase of incipient exhaustion. Hence recommendations for arrangement of the lesson: the introduction before the lesson (interrogation) must be 10 mines, the basic part (explanation of new material) - up to 25 min, then - revision. Application of sports intervals, game elements etc. should be provided.

Rational Use of School Breaks A break after each lesson must be 10 min, after the second lesson – a big break for 30 min or two breaks for 20 min after the 2nd and 3d lesson. The use of breaks for other purposes is forbidden. During breaks the maximal stay of children in the open air should be provided. Hygienic Requirements to a Day Regimen of Children and Teenagers The main principles of hygienic requirements are:  correspondence to daily biorhythms of a child;  the maximal maintenance of a dynamic stereotype, if necessary - its gradual change (a new regimen should be introduced gradually);  a rational arrangement of the basic components of a day regimen (sleep, training, games, staying in the open air, meals, personal hygiene) within a day and their alternation;  correspondence to capacity for work limits and to psychophysiological opportunities of a child.

The Basic Components of a Day Regimen of Children and Teenagers 1. Sleep. In a newborn age sleep is excessive – 16. 5 h. Day sleep: at the age of 1.5-2 years – 2.5-3 h. At the age from 3 to 6-7 years - 2-1.5 h. Night sleep: at the age from 1 to 7 years – 10 h 40 min-10 h 15 min. From 8 years sleep is only at night: at the age of 8-10 years - 10 h, 11-14 years – 9.5-9 h, 15-17 years - 9-8 h. 2. Staying in the open air Till 1.5 years staying in the open air is at day sleep. At the age of 2-3 years - not less than 4.5-5h per day (2 walks before going to sleep in PCI and at home) At the age of 4-6 years – 4.5-3.5 h At the age of 7-10 years – 3.5 h At the age of 11-14 years - 3 h At the age of 15-17 years – 2.5 h 3. Educational activities At the age of 1.5-2 years - some activities per week for 8-10 min. At the age of 3-4 years -10 kinds of activities for 10-15 min At the age of 4-5 years - 10 kinds of activities for 20 min At the age of 5-6 years - 15 kinds of activities for 20-25 min At the age of 6-7 years - 19 kinds of activities for 25-30 min At school: 1st form - 20 kinds of activities for 35 min, 2nd form - 22 kinds of activities for 45 min, 3-4 form - 24 kinds of activities, 5-8 form - 30 kinds of activities, 9-11 form - 31 kinds of activities per week. 4. Game activity or rest At a preschool age – 4.0-5 h, for pupils – 1.5-4.0 h. 5. Meals and personal hygiene. 2.5-4 hours a day (taking a shower and a bath, morning exercises, getting dressed,

206 meals).

Hygienic Requirements to Motion Activity and Physical Training of Children Motion activity is a necessary condition of normal development of a child‘s organism. It is measured by locomotions. At disturbance of physiologically caused necessity of a child‘s organism in movement 2 states may occur:  hypodynamia (low motion activity) - asthenovegetative syndrome, syndrome of de- training, excessive weight. The reasons are improper day regimen, diseases, climatic conditions, social factors;  b) hyperkinesia (high motion activity, which does not correspond to organism abilities) - myocardiodysthrophy, stable arterial hypertension. The reasons are intensive physical training, a strong desire of fatty children to lose weight. Hygienic Requirements to Physical Training of Children They include:  individuality;  adequacy to a health state and abilities of organism;  systematic character;  gradual increase of physical activity under medical care;  favourable psychoemotional and environmental conditions. Estimation of Adequacy of Physical Activity It is made:  by external signs: reddening of face, respiration rate, perspiration rate, etc.;  by methods of studying the physical capacity for work: by time of development of physical exhaustion;  by pulse rate: it is measured before the lesson (the initial level) and every 5 min during the lesson of physical training. Criteria: the increase of pulse rate at a single measurement - up to 90 % from the initial one, on the average within a lesson - up to 50 %. Requirements to Duration of Motion Activity in a Day Regimen The motion component of a day regimen should make up 50 % of day time, including 70 % of regular forms of physical training and 30 % of independent motion activity. Units of Motion Activity 1. As a unit of motion activity the number of movements (number of steps) per day is taken. H = 1.3 n, where: H – a necessary number of steps per day (in thousand steps) n - age in years 2. Duration of motion activity. T = 6.5 – 0.2 n, where: T - duration of motion activity per day (in hours) n - age in years Note: At usage of these formulas a standard deviation from a daily norm may be not more than 10 %. For the girls-teenagers (13-15 years) the estimated values of daily amount of steps and time of locomotion should be diminished by 15 % in connection with physiological decrease of dynamic activity at this age. Hygienic Requirements to Hardening of Children The purposes of hardening are:  Development and perfection of organism thermoregulation (basically due to training a tone of peripheral vessels). Features of thermoregulation in children include: the increased heat production because of high basal metabolism; high heat emission due to big body surface, lability of vessels;

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 Adaptation to change of climatic conditions;  Decrease of sensitivity to catarrhal diseases. Principles of hardening are the same as for physical training (see above). Features of Hygiene of Children’s Nutrition The main feature is high intensity of metabolism in a child‘s organism, thus nutrition should not only compensate losses of energy, but also provide synthetic processes of growth and development of organism. Therefore the caloric content of nutrition per kg of body mass in children should be 1.5-2 times higher than in adults and it should exceed energy losses. Differences in the 2 principle of balanced diet is the ratio of proteins, fats and carbohydrates: it is not 1: 1: 4 as for adult, but 1 : 1 : 3, i.e. a relative increase of protein and fat content in a diet is marked. Features of Protein Nutrition in Children  A greater amount of proteins per kg of body mass as compared to adults;  Animal proteins, especially dairy proteins, prevail, making up 60-75 %;  The compulsory availability of conditionally irreplaceable amino acids arginine and histidine, as well as irreplaceable amino acids lysine and tryptophan (factors of growth). Features of Fatty Nutrition  A greater amount of fats per kg of body mass;  A lot of animal fats, not more than 10 % of vegetative fats, otherwise inhibition of growth, lack of vitamins A and D occur. Features of Carbohydrate Nutrition  A relatively great necessity per kg of body mass (energy);  As compared with adults‘ nutrition, children‘s food should contain more unprotected carbohydrates (up to 20 %) and pectins, less superprotected carbohydrates (vegetative cellulose). Features of Mineral Substances and Vitamins in Children’s Nutrition Because of intensive growth of bones an increased consumption of Са and Р takes place, because they participate in bone formation. A sufficient amount of magnesium - 12-13 mg/day is necessary. The basic foods of children's nutrition - dairy foods - do not meet the requirements of organism in Fe, therefore additional sources of its supply are necessary. Vitamins. In view of intensive growth a great amount of vitamins is necessary, especially vitamins A, D and group B. Artificial vitaminization in winter-spring period is necessary. Diet Regimen. The smaller the child, the more frequent meals are necessary: for preschool children 5 times a day with a 3-hour interval, for pupils - 4 times a day every 4-5 hours. A more equal distribution of food caloricity by meals is recommended in comparison with adults. Recommendations for Practical Classes on the Theme

Key Questions 1.Concept of a day regimen, distribution of its components within day at various age and its physiological bases (sleep, staying in the open air, studies, game activity and rest for choice, nutrition and personal hygiene) 2.Concept of motion activity. Units of measurement of motion activity. 3.Hypodynamia. The reasons, signs, prevention. 4.Basic reasons, manifestation and prevention of hyperkinesia. 5.Basic methods of physical training of pupils. Hygienic requirements to arrangement of physical training lessons. The hygienic requirements to physical training lessons at schools. 6.Basic principles of hardening children and teenagers. The basic kinds of hardening. 7.Organization of hardening children and pupils. 8.Estimation of children‘s readiness to training at school.

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9.Estimation of "school maturity" of children by Kern-Ierasik test 10.Medical indications to delay of admission of 6-year-old children to school. Self Test 1. To irreplaceable amino acids for only children the following refer *A. arginine. *B. histidine. C. methionine. D. cystine. E. valine.

2. An average level of pulse rate at physical training lessons should exceed the initial one by A. 30 % B. 40 % *C. 50 % D. 80 % E. 90 % Problem Solving 1. Natasha С., aged 16, is of middle height, her body weight is higher than average due to fat deposits, the functional parameters are decreased, 7 times a year she was ill with acute respiratory diseases. Every day she has classes at school for 7 hours, does her homework for 3 hours, attends extra classes in physics and chemistry for 2 hours, watches TV for 3 hours. She does not attend physical training. She has 5 meals a day; the ratio of proteins, fats and carbohydrates is 1 : 1: 4, a daily caloricity of food is 2,600 Kcal. What is the basic reason of the given symptoms? 2. Schoolboy C., aged 16, has morphologic and functional parameters higher than average. He goes in for athletics. During sports competitions he takes first places. On medical examination myocardiodystrophy and arterial hypertension were revealed. 10 days before the examination he had been ill with acute respiratory disease. Identify the probable reason of the given changes.

Standard Answers: 1. Hypodynamia 2. Hyperkinesia

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HYGIENE OF HOT CLIMATE

Theme No 25. Hygienic Characteristics of Hot Climate and Its Effect on a Human Organ- ism.

Hygiene of Nutrition, Hygiene of Work, Personal Hygiene under Conditions of Hot Climate

Characteristics of Hot Climate The climate of south countries can be conditionally divided into 2 types: tropical climate and climate of deserts. Tropical Climate Its feature is constant high air temperature with insignificant daily and annual fluctuations (1-6ºC). The level of solar radiation is rather high (100 Kcal\cm2 and over). The next feature is high humidity of air - 80-90%, sometimes 100 % (at night). The level of annual atmospheric precipitation is usually high; there are 2 periods of rains per year (totally about 7 months). The combination of high temperature and humidity of air at its insufficient circulation leads to formation of fogs, activation of putrefactive processes in fallen foliage that results in increase of СО2 content in the air up to 0.3-0.4 %. Climate of Deserts It is characterized by a small amount of atmospheric precipitation and low humidity of air - up to 5 %. As against tropical climate, the air temperature in deserts may be much higher, with significant fluctuations within a day (in Northern Sahara in December the temperature at night is –14ºC, in the daytime +25-30ºC). Strong winds and high dustiness of air (sandy storms) are characteristic. The above-listed features of 2 types of climate considerably affect a human organism and processes of thermoregulation; when a person moves into such climatic conditions from other climatic zone, the processes of acclimatization become sharply expressed. At acclimatization the complex processes of reorganization of organ and system functioning takes place in a human organism, breaking of established "dynamic stereotype", i.e, a mobile balance of organism with the environment is marked and the establishment of new balance in accordance with changed climatic conditions occurs. This process takes different time in different people depending on health state, adaptable abilities, age, etc. The first phase of acclimatization is adaptation (partial acclimatization) which lasts from several hours till 14 days; the 2 phase is full acclimatization which takes some months or a year, sometimes even more. In the course of acclimatization, especially in the 1 phase, the astenovegetative syndrome, increase of morbidity, decrease of capacity for work are observed. Influence of Hot Climate on Thermoregulation System of Organism The major factors influencing thermoregulation in hot climate are high temperature and humidity of air. The system of human thermoregulation provides maintenance of temperature of man‘s internal environment in the narrow constant range. The increase of body temperature by 2-3º C essentially influences the function of CNS, cardiovascular and urinary systems, but its increase for a long term by 4-5ºC and over is incompatible with life. Thermoregulation is a complex process, consisting of heat production (chemical thermoregulation) and heat emission (physical thermoregulation). Heat production is provided due to biochemical exchange processes (thus at easy work in a human organism about 3000 Kcal of heat per day are formed). In hot climate organism receives additional amount of heat (up to 200-400 Kcal/h) from the environment. The level of heat production in organism basically de-

210 pends on air temperature; the zone of indifference is 15-25ºC, at higher temperature heat production is decreased. Heat emission consists in conducting heat to the air (convection), thermal radiation of IR-beams and perspiration. In conditions of hot climate at high temperature and humidity of air these processes are decreased that may cause overheating of organism and disturbance of thermoregulation: heatstroke, thermal spasms, thermal fainting, thermal exhaustion by water and salt losses, thermal hypostasis of feet. Factors Causing Organism Overheating  High temperature and humidity of air, small speed of air movement;  Hard muscular work increases heat production;  Multilayer clothes;  Insufficient water consumption by organism – deterioration of sweat secretion. A heatstroke more often occurs in people with cardiovascular diseases (atherosclerosis, hypertension, heart valvular diseases), endocrine diseases (adiposity, hyperthyrosis). Over- heating easily occurs in children before a year. Depending on prevalence of these or those symptoms some forms of heatstroke are distinguished:  cardiovascular  pulmonary (atelectatic)  brain  shock  delirious According to degree of severity a mild, moderate and severe form is distinguished. Influence of Hot Climate on Water and Mineral Metabolism Under conditions of hot climate water-salt metabolism has a number of features connected with participation of water in thermoregulation and its secretion through the skin in the form of sweat. The investigations have revealed that at usual temperature of 20ºC water is secreted through kidneys, skin, lungs and gastrointestinal tract in the ratio of 6 : 2 : 2 : 1. At a high air temperature water is basically (up to 70-80 %) secreted through skin as sweat. Water losses with sweat at temperature of 37.8ºC make up 0.3 l/h and at temperature rise by every 0.5ºC they are increased by 20 ml. Under conditions of hot climate in weakened people at hard physical work the daily water losses can reach 12 l - hence dehydration of organism of different degree of severity may occur. Thus blood plasma suffers primarily, as at dehydration of organism by 11 % of body mass plasma loses water 2.7 times more than organism as a whole). Consequently blood viscosity, hemoglobin content sharply increase, volume of circulating blood decreases causing reduction of blood circulation speed, reduction of stroke volume, increase of heartbeat rate. A considerable loss of water from organism is called dehydration exhaustion, which symptoms depend on volume of water loss. Thus, at water loss of about 5 % of body mass the feeling of malaise, sleepiness, irritability occurs; at water loss of 6-10 % - dizziness, headache, dyspnea, tingling in extremities, termination of salivation, dysarthria; over 10 % - visual and hearing impairment, speech disturbance, unconsciousness, delirium. Then all phenomena progress and a person dies of irreversible disorders of CNS, blood circulation and cardiac activity. Death can occur at water loss of 15 % of body weight and temperature above 30ºC, or at lower temperature and water loss of 25 % of body weight. Water deficit in organism is accompanied by a subjective feeling of thirst. True thirst (at dehydration of organism) and conditioned-reflex thirst (at absence of water deficiency in organism) are distinguished. The feeling of thirst has some inertness and is eliminated not imme- diately after drink but some time later - in 10-12 minutes. Under conditions of hot climate in weakened people at hard physical work a peculiar condition of thirst can occur: the more the person drinks, the more water he would like. If such condition is not eliminated, a severe stage – drinking illness or water intoxication - can occur which is manifested by salivation, nausea, vomiting, increased diuresis, disorder of movement coordination. Changes of Salt Metabolism under Conditions of Hot Climate The disturbance of sodium chloride (NaCL) metabolism is of particular importance. At slight perspiration of total NaCL lost by organism daily (15-20g) 2-6 g/day is lost with sweat. At significant perspiration NaCL losses reach great values (sweat contains 0.3-0.6 % NaCL) and

211 cause serious disturbances of salt metabolism, not compensated even at full replacement of water loss. The compensation reactions of organism to prevent salt deficiency are: decrease of chloride content in sweat up to 0.1 %, decrease of diuresis up to minimum (360-400 ml/day). Oliguria (decrease of diuresis) is a characteristic reflex directed not so much at maintenance of water in tissues, but at maintenance of Na in organism. The addition of NaCL to food is not required, as food completely covers the needs for salt, and excessive NaCL causes potassium elimination with urine and occurrence of its deficiency in organism. In some cases at large losses of salt with sweat a serious condition - salt exhaustion - can occur with the following symptoms: severe gastric spasms, vomiting, apathy, fainting, cramps (increase of muscle excitability at decrease of chlorides in plasma). For treatment additional introduction of NaCL is required. In conditions of hot climate some restrictions of water consumption are necessary. For example, while working at +39-40ºC a person needs 6 l/day of water in divided portions 100- 150 ml each. Hygiene of Nutrition in Conditions of Hot Climate.

Features of Nutrition in Hot Climate At long action of high temperature and humidity of air the decrease of basic metabolism up to 10 % is marked due to effect of heat on vegetative nervous system. There can be decrease of appetite (especially to meat food), salivation, gastric secretion and motility. In a diet of population of some regions with hot climate (Africa, Southeast Asia, South America) significant deficiency of proteins of animal origin with prevalence of vegetable carbohydrates (carbohydrate monophagia) is marked. It is connected to a low standard of life of the population, religious and traditional factors. A large content of cellulose in food causes constant mechanical irritation of intestines, especially large intestine, and development of colitis. High temperature and carbohydrate nutrition results in activation of fermentative processes in intestines, especially in children, causing toxic dyspepsia. Only carbohydrate nutrition with deficiency of irreplaceable amino acids, animal fats and some vitamins results in occurrence of specific diseases, such as:  Kvashiorcor (in translation - "the red boy") – a severe children‘s disease after wean- ing, i.e. deprivation of breast milk and commencement of nourishment with carbohydrate food (deficit of animal protein, methionine, fat-soluble vitamins) that causes growth inhibition, delay in weight, edemas, dermatoses and skin depigmentation, mental retardation, fatty liver infiltration, atrophy of pancreas, hypochromic anemia.  Spru – a severe chronic disease characterized by persistent diarrhea, gastritis, anemia, atrophy of mucous membrane of stomach and intestines, disturbances in bone marrow and liver; gradually general cachexia develops (big loss of body masses).  A specific food poisoning of tropic climate is heliotropic toxicosis (heliotropic hepatitis) which occurs at use of cereals with admixture of heliotrope weed. The disease starts with gastroenteritis and in 1-2 weeks proceeds to ascites, atrophy of liver, decrease of proteins in blood, anemia, leukopenia. The disease may quickly lead to death at hepatic insufficiency or in 1-2 years to development of liver cirrhosis. In tropic climate there are good conditions for development of microbes in food, therefore food poisonings of microbe etiology (toxicoinfections, bacterial toxicoses) are rather common there (see theme ―Food poisonings‖). Prevention of Alimentary Diseases in Hot Climate It is based on principles of a rational diet, especially balanced in proteins, fats, carbohydrates, minerals and vitamins. It is of particular importance to provide nutrition with proteins which are responsible for processes of biosynthesis in organism. It is necessary to use animal fats – up to 60-70 % of total amount. Carbohydrate monophagia should be eliminated, and amount of vitamins C, В1, В2, В6, РР, etc should be increased. Feature of this diet is taking meals (up to 40-50 % of a daily diet) in cooler time of the day, i.e. in the morning or in the evening. Hygiene of Work in Conditions of Hot Climate The primary goal is the prevention of overheating and disturbances of water-salt meta-

212 bolism. For this purpose work should be carried out in cooler periods of the day – to begin work earlier, having a break from 12 a.m. till 6 p.m. During work a 10-15-minute break every hour is necessary for rest in a cool place and for taking shower. For prevention of toxic effect of occupational harmful factors in conditions of hot climate such processes as automatization, hermetic capsulation, ventilation at manufacture, as well as mechanization of hard physical work are of great significance. Requirements to work wear: not multilayered, of light natural fibers, light colouring, free style. At work in the open uninhabited area the clothes should maximally protect all parts of the body from action of direct solar beams and dust; for protection of eyes obscure glasses should be used. Personal Hygiene in Conditions of Hot Climate It is recommended to get up early in the morning, often to take a shower (for 15 min not more to prevent overcooling) and to do the washing of clothes (dirty clothes worsen heat exchange), to keep the body clean (high temperature and humidity of air may cause intertrigo, dermatites, fissures of the skin), to go in for sports at cool period of the day, to have sufficient sleep at night and in the daytime. Hygiene of Living Quarters in Hot Climate The basic purpose is protection of rooms from overheating. The optimal parameters of microclimate in premises under the conditions of hot climate (at air temperature outside the premise 30ºC and over) should be the following: temperature is 24-25ºC, humidity - 45-55 %, speed of air movement – 0.1-0.2 m/sec. At environmental temperature over 35ºC it is impossible to achieve such parameters only by aeration (airing), that is why the application of air conditioning of premises is necessary. The complex building and sun-protection measures are necessary, i.e. apartment houses should be built near green plantations and reservoirs, orientation of windows - to the north, building materials should be heatproof made of wood, brick, foam concrete, pise materials. Building with an attic having good isolation and aeration is necessary. It is expedient to increase the size of rooms and their height. Colouring of external walls is recommended to be light for reflection of solar radiation; special sheds, Venetian blind above windows are also recommended. Recommendations for Practical Classes on the Theme

Key Questions: 1.Concept of ―tropical illnesses‖. 2.Concept of climate. The climate-forming factors. 3.The basic parameters of climate. 4.The basic classifications of climate. 5.The climate characteristic of tropical zone. 6.Influence of tropic climate on working conditions and life of population, its health. 7.Influence of hot climate on thermoregulation of human organism. Types of thermoregulation disturbances in person under such conditions, their pathogenesis, manifestations and prevention. 8.Influence of hot climate on water-salt metabolism of human organism. Pathogenesis, manifestations and prevention of disturbances. 9.Alimentary disease and food poisonings characteristic of hot climate, their reasons, manifestations and prevention. 10.Features of nutrition hygiene in hot climate. 11.Features of occupational hygiene, personal hygiene, hygiene of inhabited buildings in conditions of hot climate. Self Test 1. Identify mechanisms which prevent overheating of human organism under the following conditions of environment: air temperature - 45º С, relative humidity - 40 %. *A. convection and perspiration B. heat radiation and perspiration C. heat conduction and convection

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D. heat radiation and convection E. heat radiation and conduction

2. Identify the symptoms which are observed at sunstroke. A. dryness of integuments B. stomachaches *C. general weakness, dizziness *D. vomiting *E. epileptiod attacks Problem Solving 1. In conditions of hot climate the population spends the greater part of the day in the street, among the green plantations, therefore the construction of their houses is to a great extent aimed at a wide use of open space in front of the houses. What is constructed with this purpose? 2. Explain the difference: city Bordeaux (France) and Vladivostok (Russia) are on the same latitude, both are located on the sea coast, the average January temperature in Bor- deaux is + 5ºC, and in Vladivostok - -13.5 º C, i.e. 18.5º lower. Why is it so? 3. When does an expressed adaptation of human organism occur under the conditions of hot climate at action of high temperature? at moderately hard work?

Standard Answers: 1. Half-opened space is widely used, namely internal gardens, verandas, balconies; besides fountains and swimming-pools are built. 2. The difference is explained by the fact that in Bordeaux in winter the south-east winds prevail, which bring warm air from the Atlantic Ocean and in Vladivostok the north-east winds prevail at this time of the year, which bring cold air from Siberia. 3. The adaptation is formed during the 1 month. For stable adaptation more time is necessary.

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FINAL CONTROL ON GENERAL HYGIENE AND MEDICAL ECOLOGY

Key Questions: 1.Subject and basic sections of hygiene. History of hygiene development. 2.Basic laws of hygiene and their significance for maintaining health of population and protection of the environment. 3.Basic methods of hygienic researches, examples. 4.Interrelation and difference of hygiene and ecology and other medical sciences. 5.Concept of environment and biosphere, their components. 6.Classification of the environmental factors in hygiene and ecology. 7.The basic criteria of quality (level of pollution) of the environment. 8.Concept of hygienic specification of harmful factors in the environment, its variants, examples. 9.Basic principles of hygienic regulation of harmful factors in the environment. 10.Features of hygienic regulation of pollutants in the air and water, limiting attributes of harmful action. 11.Features hygienic regulation of pollutants in food products and soil, limiting attributes of harmful action. 12.Principles of hygienic regulation of bacterial pollution in objects of the environment, examples of such specifications. 13.Principles of hygienic estimation of the environmental objects at combined pollution in view of type of combined action. 14.Structure of sanitary-epidemiologic services of Ukraine, of sanitary-epidemiologic station. Types of state sanitary supervision and forms of its realization. 15.Subject and tasks of ecology, interrelation and difference of ecology and hygiene. 16.Classification of ecological factors, types of their influence on organisms. 17.Laws of action of ecological factors on organism (law of ecological optimum, zones of pessimum). Concepts of ecological valency and spectrum of species. 18.Concept of trophic chain in ecology, importance of its investigation for hygiene. 19.Ecosystems and biocenosis, their basic characteristics and features. 20.Concept of "health of population", major factors influencing health of population. Significance of hygiene in improvement of health of population. 21.Basic parameters of health of population, their use for investigation of effect of the environmental quality. 22.Concept of environmental diseases, their main groups. 23.Direct and indirect negative effect of the environmental pollution on health of population and conditions of its life, examples. 24.Methods of study of influence of environmental quality on health of population. Rules of choice of supervision zones. 25.Basic sources and factors of environmental pollution, protection of biosphere from anthropogenous pollution. Hygienic measures in this area. 26.State sanitary supervision in the field of hygiene of nutrition, its kinds and examples of realization. 27.Sanitary examination of foodstuff. Cases when it is necessary. Methods of sanitary examination of foodstuffs and examples of its realization. 28.Rules of food sampling for laboratory research. Classification of foodstuff quality, examples. 29.Hygienic characteristics of milk and dairy products. Methods of sanitary examination of milk: main parameters, devices and standards. 30.Basic sections of nutrition hygiene. The purpose and tasks of rational, preventive, clinical- prophylactic and clinical (dietary) nutrition. 31.Standards of population nutrition, parameters which are taken into account at their drawing up. Modern nutrition problems of population in Ukraine. 32.Classification of alimentary and alimentary-conditioned diseases, their diagnostics and

215 treatment. 33.Classification of primary alimentary diseases: examples, treatment and prevention. 34.Basic principles of rational nutrition (balanced diet) of a healthy man. 35.Methods of control of observing the principles of a balanced diet by a person. 36.Functions of proteins in nutrition. Signs of high-grade proteins and examples of proteins different in value. 37.Irreplaceable amino acids for the adult and for children: representatives, importance in nutrition, products–suppliers. 38.Concept of protein norm and protein minimum, estimation of protein minimum. Protein problem and ways of its solving. 39.Importance of fats in nutrition. Classification and hygienic characteristics of fatty acids. 40.Polyunsaturated fatty acids of оmega-3 and оmega-6 families: representatives, products- suppliers, role in a human organism. 41.Phospholipids: representatives, products-suppliers, role in оrganism. 42.Cholesterol: products-suppliers, significance for human оrganism. 43.Alimentary antisclerotic factors: representatives, products-suppliers, application in preventive and clinical nutrition. 44.Importance of carbohydrates in nutrition. Chemical and hygienic classification of carbohydrates. Significance of unprotected (rafined) carbohydrates. 45.Importance of superprotected carbohydrates and pectin substances in nutrition; their application in clinical nutrition. 46.Importance of vitamins in nutrition. Classification of vitamins. Significance of vitamin C, daily need, products–suppliers. Measures on preserving vitamin C in cooked food. 47.Role of vitamin D, ways of its getting into оrganism, manifestations of D-avitaminosis, its prevention. Manifestations and reasons of D-hypervitaminosis. 48.Role of vitamin A, products-suppliers. Manifestations of A-avitaminosis and A- hypervitaminosis. 49.Exogenic and endogenic factors increasing the need of оrganism for vitamins and their estimation in nutrition. 50.Artificial vitaminization of cooked food and rules of its realization. The control of vitamin value of a diet. 51.Importance of mineral substances in nutrition. Classification of the basic groups of mineral substances and its criteria. 52.Importance of Са and P in оrganism, daily need, products-suppliers, condition of their absorption. 53.Significance of microelements in nutrition, for example fluorine, iodine, iron. The reasons and manifestations of diseases caused by changes of their content in nutrition. 54.Microelementoses: the reasons, classification, manifestations and prevention. 55.The main principles of preventive nutrition of working people. Usage of different nutrients in it. 56.Main principles of medical nutrition (dietetic therapy). Kinds of diet at different diseases. 57.Dietetic therapy at overweight and adiposity. 58.Dietetic therapy at atherosclerosis and cardiac diseases. 59.Concept of food poisoning, basic reasons of its occurrence and classification. 60.Food poisoning of a microbe etiology: versions, causative agents, pathogenesis, reason of occurrence and prevention. 61.Toxicoinfections: causative agents, products-sources, conditions of occurrence, clinical forms, prevention. 62.Bacterial toxicosis, its versions. Staphylococcal toxicosis: products-sources, condition of occurrence, symptoms and prevention. 63.Botulism. Features of causative agent, products-sources, pathogenesis, symptoms, treatment and prevention. 64.Food poisonings with poisonous mushrooms: representatives, toxins, symptoms and prevention. 65.Food poisonings with poisonous plants: representatives, toxins, symptoms and prevention. 66.Food poisonings with products sometimes or partially poisonous: representatives, toxins, symptoms and prevention. 67.Food poisonings with zinc and copper: reasons, pathogenesis, symptoms and prevention.

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68.Food poisonings with lead, mercury: reasons, pathogenesis, symptoms and prevention. 69.Food poisonings with pesticides: reasons, pathogenesis, prevention. 70.Food poisonings with nitrates: reasons, pathogenesis, symptoms, prevention. 71.Micotoxicoses: versions, reason of occurrence, prevention. Ergotism: reasons of occurrence, toxins, clinical forms, prevention. 72.Fusariose and alimentary-toxic aleukia: reasons of occurrence, symptoms, prevention. 73.Aflatoxicoses: reasons of occurrence, symptoms, prevention. A problem of aflatoxicoses in the southern countries. 74.Food poisonings of insufficiently investigated etiology: versions, clinical manifestations. 75.Tactics of the doctor at suspicion of food poisoning in patient. 76.Rules of documents registration in case of food poisoning: names, contents and purpose of the basic documents.

MUNICIPAL HYGIENE

Key Questions: 1. Concept of municipal hygiene, its main divisions and tasks. 2.Concept of climate and microclimate. Climate-forming factors. Factors of microclimate. 3.Influence of microclimate factors on the human thermoregulation system. 4.Influence of climatic factors on a human organism. Problems of acclimatization. 5.Methods of measurement of microclimate factors. Devices, specifications for various premises and their substantiation. 6.Types of thermoregulation disturbances of man in conditions of hot climate, their mechanisms and prevention. 7.Methods of complex estimation of microclimate and their application. Norms of parameters and ways of their estimation. 8.The basic weather-forming factors and their influence on man. Medical estimation and classifications of weather. 9.Heliometeotropic reactions of man, their manifestations. Diseases accompanied by such reactions. Prevention of such reactions. 10.Structure of atmospheric air; effect of its components on the man. 11.Pathogenesis, symptoms and prevention of mountain (high-altitude) and decompression (Caisson) illnesses. 12.Content of CO2 in atmosphere, its dynamics and reasons. Effect of various CO2 concentrations on the man. MPC of CO2 in the air of premises and its substantiation. 13.Basic sources and factors of atmosphere pollution, ways of its autopurification. 14.Factors affecting the level of pollution in certain region. Types of air-cleaning structures. 15.Direct and indirect negative effect of atmospheric pollution on health of people and conditions of their life, its versions and examples. 16.Protection of atmosphere from anthropogenic pollution: the basic directions and examples. Standartization of harmful substances in atmospheric air. 17.Significance of solar radiation. The reasons, manifestations and prevention of solar starvation.  Biological effect of ultraviolet irradiation, its mechanism. Concept of a biodose of ultraviolet irradiation, method of its estimationtion.  Structure of solar light on the Earth surface. Effect of components of solar light on a human organism.  The hygienic requirements to natural illumination in inhabited, educational and hospital premises, its indicators, methods of estimation and specifications.  The hygienic requirements to artificial illumination, types and systems of such illumination, methods of estimation and specifications in various premises (rooms).  The hygienic characteristics of sources of water supply. Zones of sanitary protection of water sources and their purpose.  The main types of water consumption, hygienic requirements to quality of water,

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structure of water pipe.  The hygienic requirements to quality of drinking water. Organoleptic parameters of drinking water, their significance, methods of definition and norms.  The hygienic requirements to chemical structure of water, diseases caused by its change, their reasons, manifestations and prevention.  Epidemic significance of water, signs of water epidemics, parameters of epidemic safety of water.  Methods of improvement of water quality. Methods of water purification, control of its efficiency.  Methods of water disinfection, its hygienic estimation and control of its efficiency.  Chemical methods of water disinfection, their hygienic estimation and control of their efficiency.  Chlorination of water, its types, scheme, parameters of efficiency. Drawbacks of this method of water disinfection.  The basic sources and factors of reservoir pollution, ways of reservoirs autopurification.  Protection of reservoirs from anthropogenic pollution. Hygienic standartization of pollutants in water.  Hygienic significance of soil, its basic parameters. The basic pollutants and ways of soil autopurification.  Endemical significance of soil: endemic diseases, their reasons, manifestations, prevention.  The signs of harm at standartization of harmful substances in the soil. Protection of soil from anthropogenic pollution.  Urbanization and its hygienic estimation. The modern town-planning factors and their significance for development of cities.  Hygienic estimation of systems of city and residential quarters building. Functional zones in cities.  The hygienic requirements to premises (microclimate, ventilation, illumination).  Methods of cleaning of populated places from solid wastes. Methods of destruction of solid household and industrial wastes.  Methods of sewage clearing. Natural and artificial methods of sewage clearing.

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Hygiene of Work and Hospital Hygiene

Key Questions

Key Questions:

Hygiene of Work 1)Concept of capacity for work, its dynamics during and after work, reasons of changes. 2)Methods of studying man‘s capacity for work. 3) Changes in organism during work. Exhaustion, reasons of its development (theories of exhaustion). Overfatigue. Prevention of exhaustion in manufacture. 4) Occupational harmful factors and occupational diseases. Classification. Physical examinations of working people: types, purposes and arrangement. 5) Registration and investigation of acute and chronic occupational diseases and intoxications. Prevention of such diseases. 6) Noise, its classifications, action on organism. Noise illness, its diagnostics and prevention. Maximum permissible level of noise and it substantiation for various premises. 7) Electromagnetic fields, their basic types and sources, effect on organism. Microwave syndrome: manifestations and prevention. 8) Vibration, effect on organism. Symptomatology and prevention of vibration illness. 9) Industrial poisons, their classification by level of toxicity, specific effect and ability to cumulation. Factors influencing toxic effect of industrial poisons. 10) Basic parameters of acute, subacute and chronic toxicity of industrial poisons and methods of their study in experiment. 11) Specific and remote effects of industrial poisons and methods of their study. 12) Ways of entry and removal of industrial poisons. Ways of detoxication of poisons in organism. Detoxication system of organism and its parameters. 13) Combined effect of industrial poisons, its types, methods of study and significance for sanitary estimation of industrial environment. 14) Types of harmful effect of industrial poisons on working people, prevention of occupational poisonings. 15) Causes and manifestations of poisonings with industrial poisons of irritating action (CO, ammonia, chlorine, nitric oxides). 16) Causes and symptoms of occupational poisonings with heavy metals (lead and mercury); clinical and hygienic confirmation of diagnosis. 17) Industrial dust, classification, action on organism, maximum permissible concentration of dust of different structure. Diagnostics and prevention of pneumoconioses. 18) Features of work in agriculture and their effect on organism of working people. Basic occupational diseases, their causes and prevention. 19) Pesticides, their purpose and classifications by toxicity, function and chemical structure. Ecological estimation of pesticides by stability and toxicity. 20) Toxicological characteristics of basic groups of pesticides (phosphorus-organic, chlorine-organic, carbamates, mercury-organic). Indicator enzymes. 21) Hygiene of work at storage, transportation and application of pesticides. Preventive measures against poisonings of working people and population with pesticides. 22) Toxicological characteristics of mineral fertilizers (nitric and phosphoric). Hygiene of work at their application. Radiation Hygiene 23) Concept of radioactivity, hygienic characteristics of types of radiation, screening materials. Natural and artificial sources of radiation. 24) Mechanisms of radiation effect on organism, types of biological effect of radiation. 25) Radiosensitivity of organs and tissues (Bergonie‘s law). Groups of critical organs. Limiting doses of external and internal radiation. 26) Hygiene of work with closed sources of radiation. Ways of protection of medical personnel from radiation damage.

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27) Hygiene of work with open sources of radiation. Hygienic requirements to radiologic laboratories. 28) Natural radiation background, its structure, levels, sources and dynamics. Influence of anthropogenic sources on its increase. 29) Effect of Chernobyl accident on health of population living in polluted territories, early and remote effects. Features of population nutrition in radioactive-polluted territories. Hospital Hygiene 30) Concept of medical-protective regimen in hospital and its basic components. The hygienic requirements to location of hospitals of different type. 31) Hygienic requirements to a hospital site. Functional zones of hospital site. Historical types of hospital construction. 32) Hygienic estimation of different systems of hospital construction. The basic directions of prevention of intrahospital infections. 33) Hygienic requirements to internal layout of hospital. A typical ward section and its layout. 34) Hygienic requirements to hospital ward (layout, microclimate, ventilation, illumination). 35) Hygienic requirements to a reception ward of hospital. Its functions and structure. 36) Hygienic requirements to infectious department. Features of ward layout and their reasons. 37) Hygienic requirements to a surgery unit and operating room (layout, microclimate, illumination, ventilation). 38) Concept of intrahospital infections, reasons of their growth, structure, basic sources and ways of transmission. Prevention of such infections. 39) Hygiene of work of surgeons and anaesthesiologists. Basic occupational harmful factors and prevention of occupational diseases. Hygiene of Children and Teenagers 40) Subject and tasks of hygiene of children and teenagers. Laws of growth and development of children. Schemes of age periodization. Problems of acceleration. 41) Physical development of children and teenagers as a criterion of individual health and health of children's contingent as a whole. Methods of research of physical development. 42) Methods of estimation of physical development of children and teenagers. Methods of estimation of harmonicity of physical development. 43) Hygienic requirements to location, layout of site and building of children's preschool institutions. Functional zones of site. A principle of group isolation. 44) Hygienic requirements to a group section in children's preschool institutions. Standards of layout, microclimate, illumination in a game room. 45) Hygienic requirements to toys in children's preschool institutions. 46) Principles of hardening and physical training of children. The control of adequacy of physical load. The basic reasons, manifestations and prevention of hypodynamia and hyperkinesias. 47) Hygienic requirements to a daily regimen of preschool age children and pupils. Ways of adaptation to training at school. Requirements to school time-table. 48) Medical-professional consultation at school, its tasks and organization at school and polyclinic. Health groups of children and basic groups of occupations. 49) Hygienic requirements to location of schools and school site. Zones of site. Characteristics of school construction systems. Layout of school building. 50) Hygienic requirements to layout, microclimate, illumination of classrooms and studies at school. Advantages and disadvantages of study system of education. 51) Hygienic requirements to school furniture, basic parameters and norms. Methods of selection and marking of school furniture, requirement to placement of desks in classrooms. 52) Features of nutrition hygiene of children and teenagers. The reasons of difference from nutrition of adult people.

Hygiene of Hot Climate

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53) Types of climate in hot countries and its influence on person. Features of tropical climate. Features of desert climate. 54) Influence of climate of hot countries on organism thermoregulation (on processes of heat production). 55) Influence of climate of hot countries on organism thermoregulation (on processes of heat emission). 56) Acclimatization of organism to conditions of hot climate. Prevention of adverse manifestations of acclimatization to conditions of hot climate. 57) Types of disturbances of organism thermoregulation in conditions of hot climate, their reasons and pathogenesis. 58) Influence of hot climate on water metabolism. Drinking illness, symptoms, prevention. Dehydration of organism in conditions of hot climate, its reasons and prevention. 59) Alimentary diseases in conditions of hot climate (kvashiorcor, spru), their reasons, symptoms and prevention. 60) Food poisonings of a microbe etiology in hot climate. Influence of hot climate on occurrence of food poisonings of a microbe etiology. Prevention. 61) Food poisonings of non-microbe etiology, characteristic of conditions of hot climate (heliotropic toxicosis, aflotoxicosis). 62) Hygiene of work in conditions of hot climate. Influence of hot climate on occurrence of occupational poisonings and their prevention. 63) Methods of improvement of microclimatic factors in manufacture under conditions of hot climate and control of their efficiency. 64) Epidemic significance of water in conditions of hot climate, signs of water epidemics. 65) Control of epidemic safety of water in conditions of hot climate. 66) Hygienic requirements to inhabited premises in conditions of hot climate.

An Example of Test 1. A patient with a body overweight visited the doctor. The patient's diet contained a lot of bread products, cream products, pork, cheese, cottage cheese, carrot, cabbage, fruit. The endocrine disorders in the patient are absent. Give recommendations as to correction of his diet. А. To restrict protein products (cheese, cottage cheese) in the diet *В. To restrict carbohydrates and fat products (bread, cream, pork) С. To restrict the use of vegetables D. To restrict the use of fruit Е. To include macaroni products in a ration 2. In a 55-year-old patient the expressed atherosclerosis is revealed. From his words, he prefers fatty and sweet food: fatty meat, sugar, candies. What is the role of meal in this disease? А. Etiological *В. A risk factor С. Pathogenesis D. Factor of transmission Е. Secondary 3. A patient came to the doctor with complaints of stomatorrhagia, nasal bleedings, swelling of lower extremities. Objectively: the reduced resistance of capillaries, hypochromic anemia in the blood. The diet of this patient includes bread, meat canned food, concentrates from various cereals. What are your recommendations on prophylaxis of similar diseases? *А. Satisfaction of physiological requirements in vitamin C В. Inclusion of products, rich in vitamin В1 in a diet С. Enrichment of ration with vitamin РР D. Usage of fish fat Е. UV irradiation 4. The patient complains of increased fatigability and worsening of vision. On examination the signs of vitamin insufficiency are detected: adipose seborrhea near nostrils, in nasolabial folds, in the area of forehead and ears; anguiitis and pericorneal dilation of

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vessels. These manifestations are most probably associated with А. polyhypovitaminosis. В. В6–hypovitaminosis. С. РР–hypovitaminosis. D. В1–hypovitaminosis. *Е. В2-hypovitaminosis. 5. A 25-year-old suckling woman‘s diet contains 1,000 mg of calcium, 1,300 mg of phosphorus and 20 mg of iron lactate per day. How should the content of mineral substances in her diet be modified? *А. To increase the content of phosphorus B. To reduce the content of calcium С. To increase the content of calcium D. To decrease the content of phosphorus Е. To increase the content of iron lactate 6. A high level of cardiovascular pathology is registered in children and women of fertile age in the region during many years. There are the following clinical signs: asthenovegetative syndrome, extrasystole, disorder of atrioventricular conductivity, diffuse-sclerotic, metabolic disorders and hypertrophy of myocardium, increasing activity of blood glutationperoxidase and gastric acidity. What microelement deficiency in foodstuff caused this disease? *А. Selenium В. Manganese С. Copper D. Zinc Е. Cobalt 7. A 35-year-old patient has acute hepatitis in the phase of recovery with disorder of hepatic function and bile ducts without accompanying diseases of stomach and intestine. To normalize the functions of the liver and bile ducts, cholesterol and fat metabolism the diet should be enriched with А. protein. B. extractives. C. fat. *D. lipotropic substances. Е. carbohydrates. 8. An 8-month child has mental and physical developmental retardation. What amino acid is necessary to eliminate from the child‘s diet? А. Tyrosine B. Leucine C. Tryptophan *D. Phenylalanine Е. Histidine 9. A 32-year-old woman with the complaints of menstrual cycle disorders, frequent diarrhea, edema around the eyes visited the doctor. OD: pale skin, hypochromic anemia, reticulocytosis. The woman said that she followed the vegetarian diet. These clinical manifestations are associated with deficiency of *A. copper. B. iron. C. manganese. D. magnesium. E. iodine. 10. A daily ration of a 29-year-old doctor-surgeon contains 90 g of proteins (including 39 g of animal origin), 101 g of fats, 412 g of carbohydrates. The daily caloricity is 3,000 kcаl. Give recommendation as for modifying the diet? *A. To increase the content of animal proteins B. To increase a calory content of the ration C. To increase the content of carbohydrates D. To increase the content of proteins E. To decrease the content of fats

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11. In autumn 20 schoolchildren of a village school were poisoned with food. The poisoning was characterized by subfebrile temperature, nausea, vomiting, colic pains (spasms) in the abdomen. These manifestations occurred in 1-3 hours after breakfast (pancakes with sour cream). The cause of the disease became home-made sour cream bought at a rural inhabitant. What microorganism could have become the reason of the disease? *А. Staphylococcus В. Streptococcus С. Bacterium of a Proteus type D. Pathogenic strains of E. Coli Е. Cl. perfringens 12. On investigation of alimentary poisoning the diagnosis of poisoning with amanita palloides (toadstools) was established. What toxicant contained in mushroom could have become the reason of poisoning? А. Gelvelic acid *В. Amanitotoxin С. Girometrin D. Solanine Е. Fasin 13. Among the pupils of a boarding-school the case of common alimentary poisoning was detected. According to epidemiological anamnesis, the reason was the use of cakes with cream. These cakes were stored at the nutrition unit with the disturbed temperature regimen. Which of the enumerated methods is the most effective in prophylaxis of staphylococcal toxicosis? А. Elimination of staphylococcal carrier among the workers of the nutrition unit В. Elimination of staphylococcal carrier among animals *С. Prevention of staphylococcal reproduction in foodstuffs and production of toxin D. Exclusion of foodstuff contamination by staphylococci Е. Following the methods of thermal processing of foods 14. The onset of disease in the kindergarten was sudden, 2-3 hours after the consumption of curds, not subjected to heat processing. All had abundant multiple vomiting, abdominal pain, liquid stool, paleness of skin, some of them had a slight fever (up to 37˚C). The clinical manifestations were controlled within a day. What is the most probable diagnosis? А. Poisoning with salts of heavy metals В. Bacterial toxicosis С. Acute intestinal infection D. Mycotoxicosis *Е. Alimentary toxinfection Municipal Hygiene 1. The research of water taken from the mine well is carried out. The following is found out: transparence–18 cm, color–15°, smell –3 points, hardness–12 mg/equivalent, oxidability – 4 mg/l, the content of nitrogen – 0.2 mg/l, nitrogen oxide – 0.05 mg/l, sodium chloride – 80 mg/l, coli titer – 80, coli index – 12. Give hygienic estimate of drinking water quality. A. Water does not meet hygienic requirements B. Water meets hygienic requirements C. Water does not meet hygienic requirements, it needs purification *D. Water does not meet hygienic requirements, it needs disinfection E. Water does not meet hygienic requirements, it needs deactivation 2. Before removing sewage of infectious hospital into a city sewer net, it is cleaned and disinfected on local construction including a lattice, airtank, sand collector, contact tank, dehelmintizator. Which of the following is used for biological purification of sewage? A. Dehelmintizator B. Sand collector C. Contact tank D. Lattice *E. Airtank 3. In the inhabitants of settlement A., situated in 3 climatic zones, there is a mass affection of teeth with fluorosis. At what concentration of F-ion in drinking water can fluorosis occur?

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*B. 1.5 С. 1.0 D. 0.3 E. 0.1 4. Diseases of children with methemoglobinemia are registered in the baby's house. On examination it has been revealed that those children‘s alimentary admixtures are diluted with drinking water. Identify chemical substance which excess in drinking water can cause this disease? A. Chloride B. Sulfate *C. Nitrate D. Lead E. Mercury 5. On hygienic estimation of conditions of garbage dump in a reservoir of 1st category of water use it has been determined that conditions of dump do not correspond to hygienic requirements for biological consumption of oxygen (BCO). What standard of BCO of reservoir water quality was used in that case? 3 *A. No more than 3 mg of О2/dm 3 B. No more than 2 mg of О2/dm 3 C. No more than 4 mg of О2/dm 3 D. No more than 5 mg of О2/dm 3 E. No more than 6 mg of О2/dm 6. The typhoid epidemic of water origin is registered in settlement NN. Which of the following is not characteristic of the given epidemic? A. An epidemic tail (loop) B. A sharp rise of disease curve *C. A three-phase character of disease curve D. A falling level of disease after liquidation of waterpipe failure E. The contingent of fallen ill population lives in one microdistrict 7. A man, aged 28, a citizen of Kiev, has the diagnosis of "chronic gastritis with reduced secretory and acidogenetic function of the stomach with frequent aggravations, the phase of remission‖. He receives the necessary therapy at aggravations, follows a diet. Suggest the most expedient gastroenterological sanatorium with mineral waters. A. Sanatorium in Mirgorod *B. Sanatorium in Essentuky C. Sanatorium in Druskeeninkai (Baltic) D. Sanatorium in Staraya Russa E. All above mentioned 8. On laboratory analysis of potable water from an artesian borehole it is established that the transparency makes up 50 cm; chromaticity –200; turbidity–0.5 mg/l; smell and smack–1 point; general water hardness–12.5 mg/l; fluorine–1.5 mg/l; oxidability–0.7 mg/l; coli titer –500 mg/l; coli index –2; microbic number–10. Which method of purification is necessary for improvement of potable water quality? A. Disinfection B. Deodorization C. Defluorization *D. Softening E. Purification 9. The settlement receives potable water from an artesian borehole. The water has passed a full work cycle of water preparation. Results of potable water analysis are: transparency – 30 cm, chromaticity – 20, smell – 1 point, dry residue – 1,000 mg/dm3, dry residue – 5.5 mg/dm3, nitrates – 20 mg/dm3, fluorine – 4.0 mg/dm3, coli titer – 300 ml, microbic number – 100. Identify the disease which incidence will be influenced by the use of this water? A. Urolithic illness *B. Fluorosis C. Chronic gastritis D. Water-nitrogen mеthemoglobinemia

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E. Iron-deficiency anemia 10. The investigation of potable water quality in city A. is carried out. It has been determined that organoleptic parameters are lower than properties of water, hardness does not exceed the norm, and nitrates and coli titer are higher than the norms specified in State Standard "Drinking Water". What can the use of this water cause? A. Urolithiasis B. Infectious disease of intestinal group C. Cholelithiasis *D. Меthemoglobinemia E. It is unpleasant to drink 11. In a hospital ward sized 5 х 3.5 m2 there are two windows. The aeration of the ward is carried out by repeated opening of window leaves within a day. The estimation of carbon dioxide content is carried out by the passing of air through Petry's absorber with an alkaline solution. Identify the allowable content of carbon dioxide in the ward air (in %). A. 0.04 *B. 0.1 C. 0.01 D. 0.15 E. 0.20 12. At estimation of effect of atmospheric air quality on health of population a degree of danger of atmospheric air impurity is taken into account. At what degree of atmospheric air pollution is it possible to expect the increase of incidence of specific and nonspecific deseases, acute poisoning, death rate? A. Slightly dangerous B. Moderately dangerous C. Dangerous *D. Very dangerous E. Rather dangerous 13. For disinfection of air in operating room a source of ultraviolet radiation is planned to be used. To establish the necessary regimen of irradiation, 5 regimens have been tested. The estimation of efficiency of air disinfection has been carried out with the help of Krotov's device. The efficiency of sanitation (in %) has been designed. Identify the optimal dose. A. 55 % B. 85 % C. 75 % D. 65 % *E. 95 % 14. At laboratory research of air in settlement M. it has been found out that concentration of some chemical substances exceeds the maximum permissible concentration by 5 times. What changes are expected in a health state of population? A. Changes of some functional parameters B. Specific and nonspecific mobidity *C. Expressed physiological disturbances D. Acute poisonings E. Lethal poisonings 15. At laboratory research of the air environment quality of a ward it has been established in summer that bacterial contamination makes up 4 cells/m3, hemolytic streptococcus – 25 colonies per 1 m3, content of carbon dioxide – 0.1 %. Estimate the degree of air clearness. A. Very clear B. Clear C. Polluted *D. Satisfactorily clear E. Very polluted 16. Patient with thyrotoxicosis is in a 2-bed hospital ward of therapeutic department. The area of the ward is 18 m2, its height – 3 m, ventilation rate – 2.5/h. Air temperature is 20˚С, relative humidity – 45%, air movement speed – 0.3 m/sec, light coefficient – 1/5, noise

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level – 30 dB. Make hygienic assessment of the conditions. *A. discomfortable microclimate B. non-effective ventilation C. poor lighting D. a high level of noise E. all conditions are comfortable 17. By order of the doctor the nurse has taken measurements necessary for estimation of microclimatic conditions of the ward of therapeutic department. The results of measurements are the following: the average temperature of air makes up 20°С, air movement speed – 0.02 m/sec, relative humidity of air – 58 %. Make hygienic assessment of the ward microclimate. A. Discomfortable microclimate of a heating type B. Discomfortable microclimate of a cooling type *C. Microclimate is comfortable D. Microclimate is discomfortable due to increased humidity of air E. Microclimate is discomfortable due to increased air movement 18. In the departments of infectious hospital the instrumental control over the general work of ventilation system and keeping the optimal parameters of microclimate is planned. The following devices are prepared for this purpose: Krotov's device, anemometer, thermograph, catathermometer, Assman's aspirational psychrometer. Which of the listed devices are intended for measuring air movement speed in hospital premises? A. Assman's aspirational psychrometer B. Anemometer *C. Catathermometer D. Krotov's device E. Thermograph 19. The doctor-cardiologist in Chernigov has received the urgent report of weather forecast: "Due to chromospheric flash on the Sun a great magnetic storm is expected". Give recommendation as for changes in treatment of patients with chronic ischemic heart disease in the hospital. A. To continue the treatment administered before B. To administer hypotensive preparations C. To administer bed regimen *D. To strengthen spasmolytic and anticoagulant therapy E. To cancel serious medical-diagnostic procedures administered the day before 20. In a classroom sized 6 х 10 m2 six light points are fixed, equipped with filament lamps having capacity 150 W each. The illumination intensity on workplaces ranges within the limits of 70 – 80 lux. Make the hygienic estimate of artificial illumination in the classroom. A. Artificial illumination of the classroom is uniform and sufficient: illumination intensity on workplaces is low. B. Artificial illumination of the classroom is uniform: illumination intensity on workplaces is low. C. Artificial illumination of the classroom is non-uniform, but sufficient: illumination intensity on workplaces is sufficient. D. Artificial illumination of the classroom is uniform and sufficient: illumination intensity on workplaces is sufficient. *E. Artificial illumination of the classroom is non-uniform and insufficient: illumination intensity on workplaces is low. Hygiene of Work 1. In a thermal shop of a machine-building factory the excess of obvious heat makes up 81 kkal/m3 per year. The air temperature changes from 25C up to 30 C (normal–18–20 C), heat emission — up to 1800 kkal/m2 a year, relative humidity –40–60 % (normal – 40–60 %), speed of air movement–0.5–0.7 m/sec (normal–0.2 m/sec). Which of the above factors can cause an eye disease such as cataract? А. Speed of air movement В. Convection warmth

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С. Air temperature D. Relative humidity of air *Е. Heat emission 2. An electric welder of a mechanical workshop performs operations on welding and kerf of metal accompanied by intensive UV-radiation on a welding post supplied with effective mechanical cooling. What occupational disease is most probable to develop in him? *А. Electrophthalmia B. A dust disease C. Chronic overheating D. A vegetovascular dystonia Е. Thermal shock 3. On a workplace of a worker the power of electrical and magnetic fields form electromagnetic field, created by high-frequency generator located at a distance of 3 m from the workplace. What zone of exposure is the workplace located in? *A. Induction B. Undulatory C. Interference D. Alienation E. Reverberation 4. Student B. and student M. of the medical faculty were given the task to make a hygienic estimation of noise at a plant shop, namely: to research a noise level /for student B./ and its effect on organism /for student M/. What instrument should student М. use to make the research? *A. Audiometer B. Actinometer C. Radiometer D. Noise-vibration-meter E. Noise spectrum analyzer 5. A constant noise from the external sources penetrates into the hospital wards and doctors' consulting rooms in the daytime. Identify the permissible level of noise in the daytime for the hospital wards. *A. 35 dB B. 45 dB C. 85 dB D. 60 dB E. 75 dB 6. In a tool shop the currents of high frequency are used. The working conditions are characterized by exceeding the limited noise levels, EMF, content of dust (iron, molybdenum, silicon dioxide), eyestrain. On examination of a worker neurasthenia, disorders of endocrine regulation are diagnosed. The etiological factor is: *A. EMF B. Noise C. Iron dust D. Molybdenum dust E. Silicon dioxide 7. In a mechanical shop a turner at a lathe is exposed to a high level of noise. In 6–8 years of work by speciality the decrease of hearing can develop in him. Identify the most significant preventive measures. *A. Measures of technological character B. Layout measures C. Measures of technical character D. Measures of individual protection E. Measures of medical prophylaxis 8. The drivers of heavy haulers are subjected to effect of low-frequency transport vibration. In 5–8 years of work by speciality such illnesses can occur in them as radiculitis and ishialgia, dysfunction of a vestibular analyzer, and early fatigue. Identify the most significant preventive measures. *A. the decrease of vibration intensity of the source (at the expense of design

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improvement) B. means of external protection from vibration C. decrease of working hours D. a rational regimen of work and rest E. elimination of immediate contact with vibrant equipment 9. On receiving an appointment of announcer in the regional broadcasting company citizen Н. was directed to medical-prophylactic establishment to undergo the initial medical examination. The medical brigade should include the following doctors-specialists: *A. Therapeutist, neuropathologist B. Therapeutist, otolaryngologist C. Therapeutist, ophthalmologist, neuropathologist D. Therapeutist, otolaryngologist, ophthalmologist E. Therapeutist, urologist, neuropathologist 10. On initial medical examination of a person, who arrived to work with the source of noise and vibration, otosclerosis with unfavorable prognosis was detected. The working conditions are connected with effect of numerous harmful production factors of a physical nature. Contraindication to work by the given speciality is A. local industrial vibration. B. ultrasound. *C. industrial noise. D. infrasound. E. electromagnetic fields. 11. In a city some unfavorable factors simultaneously act: atmospheric contamination, noise, electromagnetic radiation and some others. The effect of these harmful factors is characterized as A. complex. *B. associated. C. combined. D. mixed. E. additive.

Radiation Hygiene 1. After an accident on atomic power station people take iodine drugs. What is the purpose of this measure? А. To maintain regular processes В. To strengthen a bactericidal action of tissues *С. To prevent hypoplasia of the thyroid gland D. To increase the resistance of organism Е. To strengthen a protective effect 2. At the enterprise demanding a particular observance of measures of ecological safety, there was a serious accident accompanied with ignition, explosion, considerable contamination of the environment with products dangerous to life. In casualties the following signs were observed: excitement, headache, instability of vegetative functions, erythropenia, leukopenia, thrombocytopenia, decrease of cytophagous activity and formation of antibodies, bleeding, vomiting, diarrhea, inflammation of the tongue and gums, necrotic angina, pneumonia and other disturbances. What is the main etiological factor of the described syndrome? А. Damage caused by blast wave В. Damage caused by high temperature С. Toxic and chemical substances in the air and nutrition D. Mental stress * Е. Radiation damage 3. Mr. S, 45 years old, living on radioactively-contaminated territory, addressed the doctor after the advice to use vegetables removing radionuclides from organism. Give recommendations as for chemical composition of vegetables and their content in a diet. А. Sweet pepper *В. Carrots

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C. Potatoes D. Tomatoes Е. Watermelon 4. The gamma-radiography with the help of a cobalt defectoscope is used for a qualitative control of details. Identify the type and danger of the used source for workers. A. Open B. Non-radioactive С. Alpha radiation D. Dangerous at internal exposure *Е. Closed, causing the external exposure 5. In the radiological department for intracavitary therapy the gamma-ray irradiation device "Agat" is used with the source of cobalt isotope, which is in a steel ampoule. Which of the following ways of staff protection from effect of ionizing radiation should be used primarily in view of type of source? *А. Screening of the source and workplace В. Capsulation of installation С. Layout measures (zones of location) D. Equipment of department with effective ventilation Е. Use of means of individual protection and cleansing staff 6. Specify a maximum permissible dose per year for a category A (person, permanently or temporarily working with immediate sources of ionizing radiation) according to norms of radiation safety (NRS–97). *А. 2 rem/year B. 4 rem/year С. 0.2 rem/year D. 1 rem/year Е. 0.5 rem/year 7. Citizen A. (aged 28 years, body height–175 cm, body mass –74 kg), working at the establishment with radiation, received 2 maximum permissible doses of radiation during a local radiation accident. He was referred to a medical commission to solve the problem on possibility of further work with industrial sources of ionizing radiation. On medical examination citizen A. did not have any complaints concerning his health. The experts, who carried out the examination, considered him to be practically healthy. Evaluate the possibility of further work of citizen A. with sources of ionizing radiation. *А. The exposure is admitted without any limitations В. The exposure is admitted conditionally with limitation of a dose С. The exposure is admitted conditionally with limitation of time D. The exposure is admitted conditionally with limitation of work with open sources Е. The exposure is admitted only to closed sources 8. Farmer А. addressed the radiological department with the request to make the analysis of potatoes as for the content of radionuclides and to draw the hygienic conclusion on possible use of complete product. The results of the analysis showed that the content of radioactive substance cesium–137 in the potatoes were equal to 40 Bq /kg, and strontium–90 – 8 Bq/kg. Identify the most probable variant of the conclusion. А. The potatoes can be used only as forage to cattle *В. The potatoes can be used without limitations С. The potatoes can be utilized for production of ethanol D. The potatoes can be utilized for production of amylum Е. The potatoes can be utilized for production of chips Hygiene of Children and Teenagers 1. The girl, aged 14 years, has deviations in physical development. Her body height is below average, excess of body mass is of II degree. In the anamnesis: adenoid disease, rheumatic disease with infrequent exacerbations. Recently she has had complaints of colicy pains in the epigastric area, feeling of gravity, dryness in the mouth, nausea, vomiting, sometimes repeated. The diagnosis of gastritis has been established. What health group does this child refer to? *А. 3rd

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B. 1st C. 2nd D. 4th Е. 5th 2. The estimation of degree and harmonicity of physical development of children and teenagers is carried out by anthropometric, physiometric and somatoscopic researches. What parameters refer to physiometric indexes of physical development? *А. Vital capacity of the lungs B. Body weight С. Form of legs and thoracic cavity D. Body length Е. Secondary sexual signs 3. To common measures of hardening the following refers: А. Physical training, walk, rubdown В. Gargle of the throat, physical training, proper clothes С. Rational nutrition for energy supply, physical training *D. Creation of the optimal thermal regimen, proper clothes, walk, physical training Е. Creation of the optimal thermal regimen in groups, physical training 4. In a classroom sized 6 х 10 m2 six light sources are placed equipped with filament lamps 150 W each. The illumination on the workplaces changes within the limits of 70–80 lux. Make the hygienic estimation of artificial lighting. *А. Artificial lighting of the classroom is irregular and poor: illumination on the workplaces is low В. Artificial lighting of the classroom is uniform: illumination on the workplaces is low С. Artificial lighting of the classroom is irregular, but sufficient: illumination on the workplaces is sufficient D. Artificial lighting of the classroom is uniform and sufficient: illumination on the workplaces is sufficient Е. Artificial lighting of the classroom is uniform and sufficient: illumination on the workplaces is low 5. The girl, aged 8 years, has a body height of 135 cm (+1.5), body mass –38.5 kg (+2), size of the thoracal cavity –67 cm (+1.2). Make the estimation of body height and harmonicity of the child's development. А. The child is high and harmonic В. The child is of average body height, and harmonic *С. The child is low and harmonic D. The child is of average body height and disharmonic Е. The child is high and disharmonic 6. A school classroom is equipped with desks of "E" group. The schoolboys of the class have a body height of 148–160 cm. Estimate and justify the appropriateness of school desks for this class. А. They fit perfectly В. The group desks "E" correspond to body height of 146–160 cm С. The group desks correspond to body height of 161–174 cm *D. The class is equipped with inappropriate desks, since desks of group "E" correspond to body height of children up to 130 cm, Е. Desks of group "E" are necessary for body height of 131–145 cm 7. The regimen of children in a middle group was characterized by the following: 1) alternation of activities — sleep, meals, wake, 2) a 2-hour day sleep, 3) two walks. Does this regimen correspond to the age possibilities of children? *А. Yes, it does В. No, it doesn't due to alternation of activities С. No, it doesn't due to duration of day sleep D. No, it doesn't due to number of walks Е. No, it doesn't due to duration of walks 8. By results of medical-pedagogical control of the physical training lesson in the 9th form a physiological curve was drawn describing a step-by-step increase of pulse rate at the beginning of the lesson, increase of pulse rate by 80 % during the main part of the

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lesson. Make estimatation of organization of a physical training lesson. А. The lesson is arranged correctly B. Physical load is poor С. Physical load is excessive D. Physical load is sufficient *Е. There are long intervals between exercises 9. For estimation of school maturity of 6–7-year-old children the assessment of level of mental development is carried out on the basis of morphologic and functional psychophysiological criteria. What parameters determine the level of mental development of children? А. Biological age В. State of the central nervous system С. State of health *D. Kern-Iracek test Е. Interrelation of exitation and inhibition processes in the brain 10. In the spontaneous market the desks of handicraft production are suggested. The desks are made of mild types of wood, the cover has a regulated declination (from 1 up to 45˚), height of desktop is 0.8 m, height of seat – 0.5 m, distance of seat is positive. What pathology can occur in children who will use this desk for home studies? *А. Left-side scoliosis В. Right-side scoliosis С. Platypodia D. Anemia Е. Hypermetropia

Examples of Situational Tasks

TASK 1 On interrogation of patient A., aged 26 years, a plasterer, it has been revealed that he has breakfast and supper at home, but dinner — in the dining-room of the building company. The patient stated that on 11 June, two hours after dinner he felt bad and went home. At home pains occurred in the stomach area, he had vomiting, weakness. The patient paid attention to the fact that taste of juice, which he had drunk at dinner was not good. Objective information: body temperature is 37, pulse rate — 76/min., breathing — without features. The stomach is soft. There is slight morbidity in the stomach area. Diarrhea is not present. The patient feels nausea and notes astringent taste in the mouth. Make and substantiate the diagnosis of the disease. How to confirm the diagnosis? What documents should the doctor process in this case? Identify the hygienic measures for prophylaxis of similar diseases. TASK 2 On examination of patient I. the following has been revealed: he is a collective farmer, aged 30, has meals at home. He gets foodstuffs, including flour, in the collective farm. On 10 May, approximately at 12 o'clock, he felt somnolence, numbness of fingers, sense of crawling of small ants, difficulty of unbending hands and feet. Then the twitch of facial muscles, difficulty of swallowing appeared. Objective information: the body temperature is 36.8˚C; pulse and breathing are without features; convulsive twitch of leg muscles; slight pain in the stomach; nausea, dizziness. For the last 2 months 3 cases of similar disease occurred in his village. Make and substantiate the diagnosis of the disease. How to confirm the diagnosis? What documents should the doctor process in this case? Identify the hygienic and prophylactic measures in this case. TASK 3 On examination of child T., aged 5 years, the following has been revealed: on 20 June, after dinner the middle group of kindergarten went for a walk to the field with their nursery governess and picked flowers there. The walk lasted for 1.5 hours. Having come back, the

231 nursery governess noticed the child's face sharply turning red, hoarseness of voice and dilated pupils. Objective information: face turning red, temperature — 38˚C, pulse rate — 140; frequent breathing, dry mucous membrane of the oral cavity, hoarseness of voice, strongly dilated pupils. The child is excited, restless, having visual hallucinations. Make and substantiate the diagnosis of the disease. How to confirm the diagnosis? What documents should the doctor process in this case? What prophylactic measures should be carried out in the nursery school? TASK 4 On examination of patient A., the following has been revealed in order to render the first aid: the patient is 18 years old, a student, has meals in a students' canteen. From conversation with the patient it has been found out that on 18 May, he felt dryness in the mouth, difficulty of swallowing, blurring of vision. Disturbances of stool were absent. Objective information: body temperature is 36.8˚C, pulse — 70, full. The stomach is painless, soft on palpation. Pupils are dilated; there is slight ptosis, dryness of oral mucous membrane. Voice is hoarse; there is slight lowering of soft palate. Make and substantiate the diagnosis of the disease. How to confirm the diagnosis? What documents should the doctor process in this case? Identify medical and prophylactic measures in this case. Task 5 The child, aged 3 months, with body mass of 6 kg is fed artificially by mixture "Kid". With the purpose of rickets prophylaxis the doctor administered vitamin D. The mother did not follow the prescription strictly; instead of 3 drops she gave 10 drops a day during 3 months. The mother stated that her child had become languid, ate badly, had periodic vomiting after feeding, drank greedily; once or twice there was liquid stool. On examination the skin integument is pale, clean, the turgor of tissues is decreased, the anterior fontanelle is 1.5x1.5 cm, the mucous membranes are dry. The pathologies of internal organs are not revealed. At laboratory research a big content of calcium salts is revealed in the urine. Identify the reason of child's state. Specify a daily dose of vitamin D. Give the necessary recommendations. How to prevent rickets in this case? TASK 6 A group of students residing in a hostel applied to the doctor of policlinic with complaints of general weakness, somnolence, rapid fatigability, slight swelling of the gums. On inquiring it was found out that students do not have regular meals, often take canned goods and concentrates for meals. On examination the presence of gum haemorrage was revealed. Make the initial diagnosis. What objective adequate methods of research for these students can you offer? What methods can be applied for mass examination of all students living in the hostel? Give recommendation for prophylaxis of similar diseases. Task 7 A patient, aged 63 years, a pensioner, addressed the doctor with complaints of surplus body mass. He had the expressed signs of atherosclerosis of coronary vessels, high blood pressure. On inquiring it was found out that the patient had meals 3 times a day, avoided fatty and spicy food. The analysis of his diet revealed that the content of proteins made up 70 g, fats — 50 g, carbohydrates — 400 g a day. As for vitamin and mineral content, his ration corresponded to the norm. Estimate the adequacy of patient's nutrition to basic principles of rational diet. What are the reasons of overweight? What group of alimentary diseases does this pathology belong to? What recommendations relating to correction of nutrition of antisclerotic orientation are necessary in this case? Task 1 In town N. a high level of morbidity of population with arterial blood pressure and caries is marked as compared to middle indexes in the region. To find out the reasons of this pathology growth, the researches of drinking-water are conducted. The analysis of water from an artesian well supplying the town with water revealed the following: organoleptic indexes —

232 normal, a dry residue – 2,300 mg/l, content of chlorides – 670 mg/l, sulfates – 750 mg/l, nitrates – 42 mg/l, iron – 0.2 mg/l, fluorine – 0.8 mg/l. Make the hygienic estimation of water. Is there any connection between the increase of these diseases with quality of drinking water? What other diseases are possible in this town? How to reduce the level of these diseases among the population? Task 2 On analysis of morbidity of population in district T. the increased level of acute intestinal infections is revealed. On analysis of superficial water sources in this period the following is found out in the district: the smell of water is 2–3 points, taste is 1–2 points, turbidity– 1–2 mg/l, dry residue – 800 mg/l, oxidation of water – 5–6 mg O2/l, coli titr – 150–200. Could the quality of water be the reason of growth of acute intestinal infections? What are the possible reasons of changes of water quality? What indexes of water should be investigated additionally? Identify the necessary measures for improvement of water quality in this district. Task 3 In town K. for the last few years there was a sharp growth of morbidity of population with respiratory diseases. To find out the reasons of this phenomenon the local SES conducted the researches of the air. In mid air of the town a number of pollutants were found out, including nitrogen oxides at a level of 0.8 MPC, carbon oxide in the concentration of 0.6 MPC. At combined effect on organism these substances produce an additional effect (summation). Make the hygienic estimation of degree of air pollution in the town. Can the air pollution in the town affect the increase of this pathology? What other risk factors have the influence on the increase of morbidity of population? What hygienic measures are necessary to decrease the air pollution? Task 4 On analysis of water from an artesian well supplying the city with water, the following has been revealed: organoleptic indexes — normal, a dry residue is 1,300 mg/l, content of chlorides – 570 mg/l, sulfates – 550 mg/l, nitrates – 20 mg/l, iron –0.2 mg/l, fluorine – 0.8 mg/l. Make the hygienic estimate of water. What diseases can relate to the quality of drinking- water? How to reduce the level of these diseases among the population? Task 5 On analysis of water of the rural plumbing the following is found out: smell – 2 points, taste – 3 points, turbidity – 1 mg/l, dry residue – 2,000 mg/l, sulfates – 500 mg/l, Oxidation – 7 mg O2/l, fluorine – 0.7 mg/l, nitrates – 5 mg/l, microbe number – 80, coli index – 5. Make the hygienic estimate of water. Is it possible to use this water for drinking? If not, what methods of improvement of water quality are required? What health disorders can the use of this water cause? Task 6 On research of microclimate in the living quarters it has been revealed that time of cooling of katathermometer is 100 sec, factor of katathermometer – 600, effective temperature – 16.5˚EТ. Make estimate of microclimate. What devices were used for researches? How to improve the microclimate in this room? Task 7 On sanitary inspection of a habitable room it was found out that in a room sized 2.5 m x 4 m x 5 m two persons live; due to natural ventilation 40 m3 air per hour enter the room. The temperature of air is 21˚C, speed of its movement is 0.1 m/sec, effective temperature – 22.5˚EТ. Make estimate of the conditions in the room. What index should be investigated additionally? Task 8

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In a hospital operating block there is an operating room with 2 tables (area is 54 m2). Ventilation is input-extract (+4, –5). Luminosity of the operating field – 1,500 lux. General luminosity – 200 lux. The air temperature during operation is 26˚C, relative humidity – 80%. Content of CO2 – 0.15%, general microbe number in the air before the operation – 1,000 per m3. Make the hygienic estimate of the operating block. How to improve the hygienic conditions in the operation room? Task 9 In a nursery group room with the area of 45 m2 there are 25 children. On measuring microclimate the following has been found out: the air temperature is 18°C, relative humidity of air – 75%, the speed of air movement is 0.4 m/sec, effective temperature – 16° ET. Indexes of luminosity: coefficient of natural illumination (CNI) – 1.0%, light coefficient (LC) – 1:7, luminosity with luminescent lamps – 200 lux. Frequency rate of ventilation is once per hour. Content of CO2 – 0.23%. Make the hygienic estimate of a group room. Give recommendation on optimization of conditions in a nursery group room. Task 10 For building a hospital for 120 beds a site is offered with the area of 120 x 80 m, located in the residential area at a distance of 80 m from the nearest dwelling houses; the radius of policlinic service does not exceed 2 km. At a distance of 40 m from the area border there is a district motorway. A sound level in the area makes up in the daytime – 60, and at night 50 dB, in the wards – 30 dB. Estimate the fitness of this area for building a hospital; give recommendations on layout of functional zones in the area of hospital.

Task 1 A worker of a chemical enterprise, aged 35 years, addressed the doctor of policlinic with complaints of bad health state, sleeplessness, defective memory, sense of anxiety and fear. Record of service in this enterprise is 5 years. On examination the asthenovegetative syndrome, asymmetrical tremor of hands, gingivitis and stomatitis in the oral cavity, black edge of the gums are revealed. In the blood lymphocytosis and monocytosis are revealed. Make the diagnosis and stage of occupational disease. What harmful occupational factor caused the disease and why? What documents must be processed by the doctor in this case? What rehabilitation and prophylactic measures are required for the worker and the chemical enterprise on the whole? Task 2 In a classroom with the area of 40 m2 forty pupils study. All school desks have a yellow marking. Differention of desks and chairs makes up 1/5 growth of children, distance of seat +2 cm. Light coefficient is 1/10, coefficient of natural illumination–1%, general artificial illumination–100 lux. Give the hygienic estimation of the classroom. What functional disturbances or diseases can occur in children at such conditions? How to improve the hygienic conditions in the classrooms? Task 3 In the hospital operating block there is an operating room for 2 tables with the area of 54 m2. Ventilation is input-extract (+4, –5). Local luminosity of the operating field–1,500 lux. General artificial luminosity –200 lux. The air temperature during operation is 26˚C, relative humidity –80%. Content of CO2–0.15%, general microbe number in the air before the operation is 1000 per m3. Give the hygienic estimation of the operating block. How to improve the hygienic conditions in the operation room? Task 4

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At the annual prophylactic medical examination in a district policlinic the worker of agricultural chemical storehouse of agricultural enterprise complained of headaches, weakness, tenderness in the area of liver, unsteady stool, nausea. The asthenovegetative syndrome and symptoms of hepatitis were revealed in the worker. The analysis of blood in the hospital biochemical laboratory revealed the decrease of cholinesterase activity by 45%, erythropenia and leucopenia, lymphocytosis. Make the diagnosis and stage of occupational disease. What harmful occupational factor caused the disease and why? What documents must be processed by the doctor in this case? What rehabilitation and prophylactic measures are required for the worker and storage of agrochemicals on the whole? Task 5 On sanitary inspection of the working conditions of medical personnel in the x-ray room of policlinic it was found out that the dose of external irradiation of personnel made up 150 mRem per week, which corresponds to 7.5 Rem per year. Give the hygienic estimation of the working conditions of medical personnel in the x-ray room. What occupational diseases are possible in personnel under these conditions? What remote effects of radiation can occur, what are their manifestations? What measures of radiation protection should be strengthened in the x-ray room? Task 6 A hospital ward of a general type for 4 beds has the area of 20 m2. In the ward there is 1 window with the glazed area of 5m2, CNI–0.75%. A sound level at night –25 dB. Common artificial illumination –50 lux, local –80 lux. Frequency of natural ventilation is 1.5/h, concentration of CO2–0.15 %. Make the hygienic estimation of the ward. Name the necessary measures for creation of optimal conditions in a hospital ward for patients. Task 7 A nursery school is in the center of microdistrict. The site area of the nursery school is 20 m2 per child. 50% of the area are occupied by green plantations. The area of a group room is 60 m2 per 30 children of preschool age. CNI is 1.5 %, light coefficient–1:5, luminosity with luminescent lamps–200 lux. The air temperature is 24˚C, humidity –70%. Give the hygienic estimation of nursery school. What is your recommendation for optimization of hygienic conditions in the nursery school? Task 8 Estimate the physical development of a girl, aged 10 years, 125 cm in height, with a body mass of 41.1 kg. According to information of age table the normal physical development (average+- sigma) makes up: height–134.0±2.5 cm; body mass –35.1±2.2 kg. The Turner's criteria are normal. What are the causes of these deviations in physical development? What other methods can be applied to estimate the physical development of the girl? Task 9 To carry out the current sanitary supervision, the doctors of SES have studied the working conditions of factory workers. It has been found out that the content of dust in the air of the working area is 35 mg/m3, CO –3 mg/m3; the level of high-frequency noise is 88 dB, air temperature –25 ˚C, humidity –80%. Draw the hygienic conclusion about the working conditions. What occupational diseases of workers can occur at these conditions, what are their diagnostics and prophylaxis? Task 10 For construction of hospital per 120 beds the site is offered sized 120 x 80 m, located in relation to a residential area in such a way that the nearest dwelling houses are at a distance of 80 m, the radius of policlinic service does not exceed 2 km. At a distance of 40 m from the site border there is a district motorway. A noise level on the site makes up in the daytime –60, and at night –50 dB, in hospital wards –30 dB.

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Estimate the appropriateness of this site for building the hospital. Give recommendations on placing the functional zones on the hospital area. Task 11 A woman-worker of agricultural hothouse addressed the doctor with complaints about permanent headaches, sleeplessness. On examination the astenovegetative syndrome, signs of peptic ulcer of the stomach, the decrease of cholinesterase activity in the blood by 30% were revealed in the woman. Make the diagnosis of occupational disease? What harmful factor influenced the organism? How to confirm the diagnosis by the conditions of work? What documents must be processed by the doctor in this case? What rehabilitation and prophylactic measures are required for the worker and the hothouse economy on the whole?

LITERATURE

1. Books in Inglish

1. Lectures on common hygiene and medical ecology. S.Shibanov. — Simferopol, 2003.— 160 p.

2. Park‘s textbook of Preventive and Social medicine. India.— 23th edition.— 660 p. 3.Hygiene and Ecology. V.G.Bardov et al. – Винница, 2009. – 688с. 4. Short textbook of Hygiene and Ecology for foreign students. Pivovarov Y.P., Alsabounchi A.A. – Moscow> 1999, 2002, 2006. 5. Mahajan & Gupta. Textbook of Preventive and Social Medicine. – India. 4 th edition. 6. Jekels Epidemiology, Biostatistics and Preventive Medicine & Public Health. 7. Influence of environment on health of the man. Reports of WHO.— Geneva, 1976 — 2014.

2. Books in Russian

Гигиена окружающей среды. / Ред. Г. И. Сидоренко.— Москва, 1985. Руководство к практическим занятиям по общей гигиене и медицинской экологии. / Под ред. Проф. С. Э. Шибанова.— Симферополь, 2003.— 260с. Журнал " Гигиена и санитария " 1980-2017гг. В. А. Покровский. Гигиена. Москва, ―Mедицина‖.— 1979.— 495с. А. А. Минх. Методы гигиенических исследований.— Москва, ―Медицина‖.— 1971.— 584с. Г. Н. Новожилов, О. П. Ломов. Гигиеническая оценка микроклимата.— Ленинград,1987.— 110с. Никберг И.И. Гигиена больниц.— Киев, 1993.— 235с. Румянцев Г.И. Общая гигиена.— Москва, 1998.— С. 253-328 I.I.Даценко, Р.Д.Габович. Профiлактична медицина.— Київ, Здоров'я, 1999.— 694с. Е.И.Гончарук, В.Г.Бардов Г.И.Румянцев. Общая гигиена. Київ, " Вища школа", 2000 652с. Е.И.Гончарук. Руководство к практическим занятиям по коммунальной гигиене.— Москва, 1990.— 236с. Р.Д.Габович. Гигиена.— Киев, 1983.— 320с. В.Войффен. Больничная гигиена. Минск, 1984 Р.П.Венцель. Внутрибольничные инфекции.— Москва, 1970 Д.Лошинци. Внутрибольничные инфекции.— Москва, 1978

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Маненко А.К., Сахновская Н.И. Гигиена медицинских учреждений.— Киев, 1982 В.К. Овчарова. Работа и здоровье медицинских работников.— Москва, 1985 В.Ф.Кириллов и др. Руководство к практическим занятиям по радиационной гигиене.— Москва, 2001.— 223с. Кириллов В.Ф. и др. Радиационная гигиена.— Москва, 1988.— 237с. Ильин Л.А., Кириллов В.Ф. Радиационная гигиена.— Москва, 1999.— 384с. Ильин Л.А., Кириллов В.Ф. Радиационная безопасность и защита.— Москва, 1996.— 336с. Г. Н. Сердюковская и др. Гигиена детей и подростков.— Москва, 1986.— 420с. В. И. Берзинь и др. Руководство к практическим занятиям по гигиене детей и подрост- ков.— Киев, 1989.— 120с. Шибанов С.Э., Михайлов В.В. Руководство по гигиене жаркого климата.— Симферополь, 2000.— 50 с. Лысенко А.Я. Руководство по тропическим болезням.— Москва, 1983. Кошелев Н.Ф. Гигиена водоснабжения и питания в условиях жаркого климата.— Ленин- град, 1975.— С. 5-19.

Attachment 1

Students’ Independent Work N 1. Evaluation of adequacy of an individual nutrition Evaluation of adequacy of an individual nutrition (according to the tables made at home in advance: a kind of activity, diet), assessment of own energy consumption according to the offered and made at home tables, taking into account sex, age, kind of activity, body weight (see Appendices). Methodical Recommendations for Students’ Independent Work I. Evaluation of the daily energy consumption A. Basal metabolism is estimated according to Table 12. B. Energy consumption for digestion of nutrition — 10 % of basal metabolism. C. Energy consumption for all kinds of activity: 1. Estimate basal metabolism per hour. Basal metabolism per hour = Basal metabolism: 24 hours. 2. Estimate energy consumption for all kinds of activity: energy consumption for activity = (Basal metabolism per hour) x (duration of activity) x (coefficient of activity). The coefficient of activity is indicated in Table 13. 3. Sum up all the energy consumption for the activity (for all twenty-four hours) — (Table 3). D Daily energy consumption = energy consumption for digestion of nutrition + energy consumption for all kinds of activity Table 12 Basal Metabolism Age (in years) Basal metabolism (00) kcal of energy Men 10-18 (16.6 х W) + (77 х H) + 572 18-30 (15.4 х W) + (27 х H) + 717 30-60 (11.3 х W) + (16 х H) + 901 older than 60 (8.8 х W) + (1128 х H) + 1071 Women 10-18 (7.4 х W) + (482 х H) + 217 18-30 (13.3 х W) + (334 х H) + 35

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30-60 (8.7 х W) + (25 х H) + 865 older than 60 (9.2 х W) + (637 х H ) — 302 Note: W- weight in kilograms, H — height in metres

Table 13 Coefficient of Activity Kind of activity Coefficient of activity Women Men I. Studies 1.1. Practical classes: Classes at theoretical departments 1.9 1.8 Classes in a clinic 2.3 2.2 1.2. Work with a computer 1.7 1.6 1.3. Attendance of lectures 2.0 1.9 1.4. Preparation for classes: 1.6 1.6 II. Personal hygiene: Washing 1.4 1.6 Shower 1.6 1.7 Dressing, undressing 1.5 1.8 Meals 1.5 1.3 III. Household activity: Tidying up 2.7 2.7 Sweeping the floor 3.5 3.5 Washing 2.5 3.3 Washing up 1.6 1.5 Cooking 1.8 2.2 Washing the floor 3.5 3.7 IV. Movement: Walking around a house 2.5 2.4 Slow walk 2.8 3.0 Moderate walk 3.2 3.4 Fast walk 4.7 4.7 Walk upstairs and downstairs 6.2 6.1 Going by transport 1.7 1.5 V. Going in for sports: Morning exercises 3.3 2.2 Playing chess 2.2 2.1 Playing billiards 2.2 4.4 Aerobics (light) 3.1 3.2 Aerobics (heavy) 7.3 7.2 Playing rugby, basketball 5.5 5.6 Playing volleyball 3.6 3.8 Playing cricket 7.0 7.1 Gymnastics (light) 3.5 3.5 Gymnastics (heavy) 7.0 6.6 Running moderate 7.0 7.1 Running fast 11.0 11.0

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Swimming (at average speed) 2.9 3.0 Swimming (at high speed) 6 6 Ping-pong 3-4 3-3.9 Football 6.8 6.6 Application of sports equipment 8.0 7.6 IX. Rest: Sitting calmly 1.2 1.2 Watching TV 1.4 1.4 Dancing (in a middle tempo) 3.0 3.0 Dancing (in a quick tempo) 6.0 5.8 Singing 1.6 1.6 Reading 1.7 1.7 Sewing 2.1 2.2 Knitting 1.9 2.0 X. Sleep 1 1

Sum up all the energy consumption for the activity (during the whole twenty-four hours)

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Table 14 № Activity Duration of ac- Coefficient of Basal meta- Energy consump- tivity activity bolism per tion for (per hour ) hour the activity 1 2 3 Total Note: 1 minute = 0.016 hour 3 minutes = 0.05 hour 5 minutes = 0.083 hour 7 minutes = 0.12 hour 20 minutes = 0.33 hour 25 minutes = 0.42 hour 30 minutes = 0.5 hour

Task A man aged 20 is 60 kg in weight, 1.7 m in height. His work during the whole twenty-four hours is as follows: classes in a clinic — 5 hours, attendance of lectures — 3 hours, going by transport — 2 hours, work on a computer — 1 hour, preparation for classes — 4 hours, sleep — 9 hours. Calculate his energy consumption for twenty-four hours. Solution 1. Calculation of the basal metabolism (Table 12). The basal metabolism = (15.4 х W) + (27 х H) + 717 = 924 + 45.9 + 717 = 1686.9 kcal. Basal metabolism per hour = 1686.9 kcal: 24 hours = 70.29 kcal per hour. 2. Calculation of the energy consumption for all kinds of activity (Tables 13, 14).

№ Activity Duration of Coefficient Basal metabol- Energy consump- № activity of activity ism per hour tion for the activity (in hours) (kcal per hour) 1. Classes in a 5 2.2 70.3 52.270.3 = 773.3 clinic 2. Attendance of 3 1.9 70.3 31.970.3 = 400.7 lectures 3. Going by 2 1.5 70.3 21.570.3 = 210.9 transport 4. Work on a 1 1.6 70.3 11.670.3 = 112.4 computer 5. Preparation for 4 1.6 70.3 41.670.3 = 449.9 classes 6. Sleep 9 1 70.3 9170.3 = 632.7 Sum up all the energy consumption for the activity (for the whole twenty-four hours) = 773.3 + 400.7 + 210.9 + 112.4 + 449.9 + 632.7 = 2579.9 kcal

3. Daily energy consumption = energy consumption for digestion of nutrition + energy consumption for all kinds of activity. Daily energy consumption = 168.69 + 2579.9 = 2748.6 kcal The answer: The daily energy consumption = 2748.6 kcal

II. Evaluation of the necessary quantity of nutrients according to the amount of the daily energy consumption Caloric content of protein makes up 12-14 % of common caloric content of nutrition. 1 gram of protein gives 4.1 kcal of energy. Caloric content of fats makes up 25-30 % of common caloric content of nutrition, and 1 gram of fats gives 9.3 kcal of energy. Caloric content of carbohydrates makes up 56 % of common caloric content of nutrition, and 1 gram

240 of carbohydrates gives 4.1 kcal of energy. Task A man aged 20 has a body weight of 60 kg, body height — 1.7 m. The daily energy consumption = 2748/6 kcal. How many protein, fat, carbohydrate calories are necessary for him? Solution 1. Protein a) Caloric content of protein makes up 12-14 % of common caloric content of nutrition. 100% of common caloric content — 14 % of caloric protein content 2748.6 kcal of common caloric content — X caloric content of protein X = (2748.6 x 14) : 100 = 384.8 kcal of protein content b) 1 gram of protein gives 4.1 kcal of energy. 1 gram of protein — 4.1 kcal X — 384.8 kcal X = (384.8 x 1) : 4.1 = 93.8g protein 2. Fats a) Caloric content of fats makes up 25-30 % of common caloric content of nutrition, and 1 gram of fats gives 9.3 kcal of energy. 100% common caloric content — 30 % of caloric content of fats 2748.6 kcal of common caloric content — X of caloric content of fats X = (2748.6 x 30) : 100 = 824.6 kcal of protein content b) 1 gram of fats gives 9.3 kcal of energy. 1 gram of fats — 9.3 kcal X — 824.6 kcal X = (824.6 x 1) : 9.3 = 88.7g fats 3. Carbohydrates a) Caloric content of carbohydrates makes up 56 % of common caloric content of nutrition 100% of common caloric content — 56 % of caloric content of carbohydrates 2748.6 kcal of common caloric content — X of caloric content of protein X = (2748.6 x 56) : 100 = 1539.2 kcal of carbohydrates content b) 1 gram of carbohydrates gives 4.1 kcal of energy. 1 gram of carbohydrates — 4.1 kcal X -1539.2 kcal X = (1539.2 x 1) : 4.1 = 375.4 gram of carbohydrates The answer: 93.8g proteins, 88.7g fats, 375.4g carbohydrates are necessary.

III. Evaluation of the Daily Consumption of Proteins, Fats, Carbohydrates Estimation of the nutritive value of a daily ration is made with the help of the suggested table of nutritive value of foods. A student fills in the appropriate columns of Table 15. Table 15 Estimation of Nutritive Value of Foods № Foods Weight (g) Protein (g) Fats (g) Carbohydrate (g) Kca l Soup 1. Cabbage soup 500 4.9 11.1 33.6 260 2. Fowl soup 500 7.1 9.3 19.3 196 3. Tomato soup 500 17.6 19 33.1 373 4. Cream soup 500 10.3 1.0 42.5 139 5. Milk soup 500 10.2 18.8 50.9 330 6. Fish soup 500 9.8 7.5 19.6 220 Main Courses 1. Fried fish 100 15.8 9.8 3.4 168 2. Rissole pork 60 20 33 46 484 3. Rissole beef 60 14 31 28 450 4. Roast Chicken 100 18 18 15 340

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5. Fried fowl 100 36 32 28 410 6. Steak 50 19 21 18 370 7. Beef casserole 100 19 18 15 435 8. Boiled eggs (2 eggs) 100 9 9.7 0.3 127 9. Fried eggs (2 eggs) 100 9.0 14.3 0.9 174 10 Fried bacon and 100 29 35 1.0 270 . eggs (2 eggs) 11 Sausage 100 10.2 16.1 1.3 162 . 12 Smoked sausage 100 19.2 38.4 1.9 285 . Porridge 1. Oatmeal porridge 100 5 3 25 120 2. Buckwheat porridge 100 4 2.8 28 178 3. Rice (rice porridge) 100 8 5 29 230 4. Semolina porridge 100 2.6 3.2 14 103 Vegetables 1. Boiled potatoes 100 1.8 0.5 18.2 91 2. Fried potatoes 100 1.5 6.2 15.8 137 3. Chips 30 1.4 4.3 14.1 73 4. Green salad 100 2.0 8.9 12.2 125 5. Tomatoes 100 1.1 0 4.1 280 6. Cucumbers 100 0.8 0 3,2 14 7. Cabbage salad 100 1.8 0.9 5.1 35 8. Carrot salad 100 1.3 0.7 8.5 36 Dairy products 1. Milk 100 2.8 3.2 4.8 58 2. Curds 100 14 2.8 3.8 232 3. Sour cream 100 2.8 20 3.2 206 4. Cheese 100 26.8 0 360 5. Kefir 100 2.8 3.2 4.8 58 Fats 1. Oil 100 0 99.9 0 899 2. Butter 100 0.6 825 0.9 748 3. Margarine (Rama) 100 0.3 82.3 1.0 739 Cereals and Grains 1. White bread 100 7.6 0.9 50 220 Black bread 100 5.5 1.0 31 157 3. Roll 100 7.9 1.0 65 250 4. Meat patty 50 5.2 1.9 17 102 5. Potatoes patty 50 3.6 18 25 126 6. Pastry 50 2.7 2.8 31 142 7. Boiled Macaroni 100 12.3 3.1 65 322 Fruits 1. Apples 100 0.4 - 1.2 34 2. Oranges 100 1.0 - 9.8 39 3. Strawberries 100 0.8 - 10.4 31 Drinks 1. Tomato juice 100 1.0 - 3.4 18 2. Apple juice 100 0.3 - 11.9 48

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3. Grapes juice 100 0.4 0 16.5 68 4. Tea 100 2.0 - 8.5 99 5. Coffee 100 13.9 14.4 15.2 223

Task A man aged 20 has a body weight of 60 kg, a body height — 1.7 m. His meal includes: rice — 50g, steak — 170 g, white bread — 25 g, tea — 60g. How many calories does he get with proteins, fats, carbohydrates? Solution (according to Table 4) 1. Amount of calories consumed: a) 100 g rice — 230 kcal 50 g rice — X kcal X = (50 x 230) : 100 = 115 kcal b) 50 g steak — 370 kcal 170 g steak — X kcal X = (170 x 370) : 50 = 1,258 kcal c) 100 g white bread — 220 kcal 25 g white bread — X kcal X = (25 x 220) : 100 = 55 kcal d) 100 g tea — 99 kcal 60 g tea — X kcal X = (69 x 99) : 100 = 68 kcal e) Amount of calories: 115 + 1258 + 55 + 68 = 1,496 2. Proteins consumed: a) 100 g rice — 8 g proteins 50 g rice — X g proteins X = (50 x 8) : 100 = 4 g proteins b) 50 g steak — 19 g proteins 170 g steak — X g proteins X = (170 x 19) : 50 = 64 g proteins c) 100 g white bread — 7.6 g proteins 25 g white bread — X g proteins X = (25 x 7,6) : 100 = 1.9 g proteins d) 100 g tea — 2 g proteins 60 g tea — X g proteins X = (69 x 2) : 100 = 1.4 g proteins e) Amount of proteins: 4 g + 64 g + 1.9 g + 1.4 g = 71.3 g 3. Fats consumed: a) 100 g rice — 5 g fats 50 g rice — X g fats X = (50 x 5) : 100 = 42.5 g fats b) 50 g steak — 21 g fats 170 g steak — X g fats X = (170 x 21) : 50 = 71 g fats c) 100 g white bread — 0.9 g fats 25 g white bread — X g fats X = (25 x 0.9) : 100 = 0.2 g fats d) 100 g tea — 0 g fats 60 g tea — X g proteins X = (69 x 0) : 100 = 0 g fats e) Amount of fats: 42.5 g + 71 g + 0.2 g = 113.7 g 4. Carbohydrates consumed: a) 100 g rice — 29 g carbohydrates 50 g rice — X g carbohydrates X = (50 x 29) : 100 = 14.5 g carbohydrates b) 50 g steak — 18 g carbohydrates 170 g steak — X g carbohydrates X = (170 x 18) : 50 = 61.2 g carbohydrates c) 100 g white bread — 50 g carbohydrates 25 g white bread — X g carbohydrates X = (25 x 50) : 100 = 12.5 g carbohydrates d) 100 g tea — 8.5 g carbohydrates 60 g tea — X g carbohydrates X = (69 x 8.5) : 100 = 5.8 g carbohydrates e) Amount of carbohydrates: 14.5 g + 61.2 g + 12.5 g + 5.8 g = 94 g The answer: The food contains: calories — 1496, proteins — 71.3 g, fats — 113.7 g, carbohydrates 94 g.

Table 16 Physiological Daily Nutrition Need for Adult (Russia) Group Coefficient Age Energy Protein Fats Carbohydrate Total Includinganimal protein 1 2 3 4 5 6 7 8 Men I 1.4 18-29 2450 72 40 81 358 30-39 2300 68 37 77 335 40-59 2100 65 36 70 303 II 1.6 18-29 2800 80 44 93 411

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30-39 2650 77 42 88 387 40-59 2500 72 40 83 366 III 1.9 18-29 3300 94 52 110 484 30-39 3150 89 49 105 462 40-59 2950 84 46 98 432 IV 2.2 18-29 3850 108 59 128 566 30-39 3600 102 56 120 528 40-59 3400 96 53 113 499 V 2.5 18-29 4200 117 64 154 586 30-39 3950 115 61 144 550 40-59 3750 104 57 137 524 Women I 1.4 18-29 2000 61 34 67 289 30-39 1900 59 33 63 274 40-59 1800 58 32 60 257 II 1.6 18-29 2200 66 36 73 318 30-39 2150 65 36 72 311 40-59 2100 63 35 70 305 III 1.9 18-29 2600 76 42 87 378 30-39 2550 74 41 85 372 40-59 2500 72 40 83 366 IV 2.2 18-29 3050 87 48 102 462 30-39 2950 84 46 98 432 40-59 2850 82 45 95 417

5. Conclusion (variants)  A daily energy consumption exceeds (corresponds to, is lower than) caloric content of nutrition per day, therefore it is necessary to increase (maintain, decrease) the caloric content of nutrition by ______Kcal.  The ratio of proteins, fats, carbohydrates in nutrition makes up ______, but 1:1:4 ratio is required; so it should be increased (decreased) (to specify by what nutrients).  The regimen of nutrition meets (does not meet) the demands of a balanced diet (to specify the available malnutrition), therefore it is necessary ______(references, recommendations for change of a nutrition regimen are given). For correction of nutrition it is necessary to ______(to specify the necessary changes in nutrition).

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Attachment 2 Symptoms of poisoning by Lead and Mercury

Blood picture at Lead poisoning

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Lead border on gums at lead poisonong

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Mercury trembling of hands

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