Gio trnh Bnh nhim

407

ST BI LIT (Poliomyelitis : polio = xm, myelo=ty, itis : vim)

(ICD-10: A80.St bi lit , B91.Di chng st bi lit)

ThS.Bs. Hong Trng

ThS.Bs. V Th Thy H

Mc tiu:

1. Trnh by ngn gn c c im dch t hc st bi lit trn th gii v

Vit Nam.

2. Trnh by c c ch bnh sinh ca st bi lit.

3. M t c im lm sng ca th st bi lit in hnh .

4. K ra c cc yu t thun li xut hin lit trong st bi lit.

5. Chn on phn bit lit trong st bi lit vi cc bnh l gy lit khc.

6. Lit k cc nguyn tc iu tr v bin php hi sc trong cc th nng.

7. Trnh by c u v khuyt im ca hai loi vaccin st bi lit.

T kha : st bi lit tr em, lit mm ngoi vi cp n thun, hi chng sau

st bi lit, vaccin sabin ,vaccin salk thanh ton st bi lit.

Vit tt : OPV : Oral Poliovirus Vaccine, vaccin ba lit ung, IPV :

Inactivated Poliovirus Vaccine vaccin bi lit chch, VAPP : Vaccine-

Associated Paralytic Polio st bi lit lin quan vaccin.

I I CNG

1. nh ngha:

St bi lit, bnh Hein Medin,l bnh l nhim trng cp tnh c tnh sinh min

dch cao, do virus bi lit (poliovirus) gy ra. Bnh ly truyn qua ng tiu

ha v h hp,c c im lm sng l nhng biu hin do tn thng h thn

kinh vn ng ti sng trc ty sng v cht xm thn no.

2. Lch s:

Bnh st bi lit c m t rt sm khang 1600 nm trc cng nguyn

nhng mi n

1840 Jacob Von Hein ngi u tin m t chi tit v xp st bi lit thnh

mt bnh ring bit .Tuy nhin thi im by gi vn cn nhiu hn ch trong

hiu bit v bn cht t nhin cng nh cch phng nga st bi lit.

1890 Karl Oskar Medin ln u tin bo co v m t c din tin t nhin

v cc bin chng thn kinh do st bi lit gy ra sau mt v dch xy ra ti

Scandinavi .Nn sau st bi lit c thm tn gi l bnh Hein Medin.

1908 Karl Landstein, Erwin Popper tm ra virus bi lit.

1921 Frankin Delano Roosevelt tng thng M b mc bnh st bi lit.

Gio trnh Bnh nhim

408

1449 John Franklin Enders, Frederick Chapman Robbins v Thomas H Weller

nui cy thnh cng virus bi lit trn t bo bo thai ngi khng c ngun

gc thn kinh.

1955 Janas Salk pht minh ra Vaccin bt hat Salk dng chch. Chng trnh

tim nga vaccin bi lit ln u tin c tin hnh(ti M).

1960 Albert Sabin pht minh vaccin sng gim c lc Sabin dng ung, m ra

mt k nguyn mi trong vic phng chng st bi lit cho nhn lai.10,6

II DCH T HC

1. Mm bnh:

Virus st bi lit c tn l Poliovirus, thuc h Picornavirus, nhm

Enterovirus.L virus ARN khng v bc, kch thc nh.Virus bi lit c du

hiu di truyn c bit l du hiu nhit ,du hiu ny ni ln s khc nhau

gia virus c v khng c.Virus c tng trng nhit 36C v 40C,

virus vaccin ch tng trng nhit 36C. Chu k tng trng virus bi lit

l 6 gi.

Virus c tnh khng cao (l c tnh chung ca cc virus khng c v bc)

vi ngai cnh: sng rt lu nhit m 200C, vi ngy nhit 250C, 30

pht nhit 600C, virus bn vng pH t 2-10, trong phn ngi chng c

th sng c vi ngy, trong nc c th n 14 ngy. Nhng thuc st trng

thng thng nh cn, ether khng c tc dng.Virus d b tiu dit bi cc

cht st trng mnh,cht oxy ha mnh: nc javen, nc oxy gi, dung dch

chloramine v tia cc tm4

Hnh 1. Poliovirus

Poliovirus c 3 type khng nguyn khc nhau v khng c c min dch cho

gia cc nhm.Nn v mt l thuyt mt ngi c th 3 ln b mc bnh st bi

lit bi 3 type khc nhau:

Gio trnh Bnh nhim

409

Type I: in hnh l chng Brunhilde, ch yu gy bnh th in hnh (th

lit).

Type II: in hnh l chng Lansing, thng gy th khng triu chng.

Type III: in hnh l chng Lon, t gy bnh hn.

2. Ngun bnh:

Ngi c coi l ngun bnh duy nht.

Virus c phn lp hng v phn ngi bnh trong tun u ca bnh, virus

tip tc c thi ra ngai 1-4 tun qua ng h hp v ti 6 thng qua

phn5. Ngi lnh mang bnh chim t l rt thp, nhng y l ngun ly kh

quan trng, ngi ta ghi nhn c trng hp thi virus lin tc trong vng

20 nm sau khi khi bnh

3. ng ly truyn bnh:

Ly truyn bnh c th trc tip qua cht tit t ng h hp, qua ng

phn ming bi tay bn, hoc gin tip qua thc n, nc nhim bn5. Rui,

gin l trung gian truyn bnh quan trng.

4. C th cm th:

Mi la tui u c th b bnh trong 60-80% trng hp bnh gp la

tui t 2 dn 5 tui5, 2/3 trng hp phn lp c virus tr di 9 tui, nn

bnh st bi lit cn c tn gi khc l st bi lit tr em.

5. Tnh sinh min dch:

Sau khi b bnh bi lit bnh nhn thng c min dch bn vng him khi mc

li (type b nhim).

6. iu kin thun li xut hin st bi lit th lit:

Hin ti cha ai bit ti sao ch c mt s t l rt thp (khang 1/1000 tr

em) nhim Poliovirus dn ti lit.Tuy nhin cng c mt vi yu t nguy c

c ghi nhn8,6:

Nhim type I.

Nhim phi chng ang gy dch hin hnh.

Suy gim min dch: thai k, AIDS, ang s dng thuc c ch min dch

Gii nam.

Chn thng ti ch, tim chch.

Ct amidan d b st bi lit th hnh no hn.

Vn ng qu mc ngay trc khi v/hoc trong lc bnh khi pht.

Yu t di truyn.

7. Tnh hnh bnh st bi lit trn th gii v Vit nam:

St bi lit c mt khp mi ni.Vng nhit i v bn nhit i bnh xy ra

quanh nm.Vng n i bnh thng gp vo ma h v ma thu (thng 8-10).

Nh c vaccin st bi lit cng vi chin lc thanh tan bnh st bi lit trn

tan cu c t chc y t th gii pht ng t nm 1988, hu ht cc nc

c t chc y t th gii cng nhn han thnh mc tiu thanh ton st bi

Gio trnh Bnh nhim

410

lit.Vit nam c cng nhn thanh ton st bi lit vo nm 2000. Hin ti

ch cn mt s nc cha c cng nhn l n Nigeria, Pakistan v

Afganistan 12.

Tnh n thi im 15 thng 8 nm 2006 c th gii c 970 trng hp trong

gn 2/3 trng hp l Nigeria13.

III SINH L BNH:

T khi xm nhp vo c th n khi xm nhp vo h thn kinh trung ng gy

bnh cnh lit, virus st bi lit phi hai ln vo mu. Ta c th chia lm 3 giai

on chnh:

1. Giai on xm nhp, tng sinh ng tiu ha v hch lymph

Virus vo c th qua ng hu hng v tiu ha, trong 24 h u n cc

hch bch huyt su quanh hng v mng payer an cui rut non v bt

u tng sinh .Ta c th phn lp c virus t cht nhy mi hng v

phn trong giai an ny. Do virsu tng sinh trong cc hch lympho su nn

khng th IgG bt u xut hin rt sm ch vi ngy sau khi tip xc, trc khi

c biu hin lm sng. IgA tit t ng tiu ha c to ra trong giai an

ny v c vai tr quan trng ngn cn s xm nhp ca virus bi lit .

2. Giai on ni tng:

Virus t nim mc tiu ha vo mu ln th nht ri nhanh chng xm nhp

vo cc c quan cm th khng phi l h thn kinh trung ng (gan, lch, tim,

phi h hp, thng thn ,da nim ), tng sinh y v bt u gy ra cc

triu chng khi pht ca bnh ( triu chng ca th th s)

3. Giai on xm nhp v tng sinh h thn kinh trung ng (th nng)

Virus t ni tng vo mu ln hai (bt buc phi c trc khi xm nhp h thn

kinh trung ng) lu hn ln th nht v bt u xm nhp h thn kinh trung

ng , ty theo v tr v mc tn thng h thn kinh trung ng m ta c

biu hin th lm sng lit hoc khng lit.

C ch xm nhp h thn kinh trung ng vn cha c bit mt cch chnh

xc.C mt s gi thuyt c a ra6:

Virus xm nhp vo si trc nron ti nhng im yu ca hng ro mu

no.

T m c virus vt qua khp ni thn kinh c, vo si trc ri i ngc

dng ln nron.

c tnh hng (m) c (myotrophic) ca virus bi lit, tng t nh cc

enterovirus khc, c th gii thch triu chng au nhiu nhm c lin quan

trc khi tin trin ti yu lit8.

Gio trnh Bnh nhim

411

IV GII PHU BNH L:

1. V tr tn thng:

Thn kinh trung ng:

- Sng trc ty sng.

- Hnh ty: nhn tin nh,nhn dy thn kinh s v cc trung tm sinh tn.

- Tiu no.

- No gia.

- i th , h i.

- Cu nht.

Hch lymph su

Nim mc hu hng

Rut non (an cui)

Virus bi lit

Th lit (1%)

Vo mu ngn ngy

C quan cm th khng phi h thn kinh trung ng*

Vo mu di ngy

Xm nhp h thn kinh TW

Mng Payer

Th khng lit (1-

2%)

Ty sng

70%

Hnh ty 2%

No Thng kt hp vi cc th khc

Ty sng -Hnh ty

10-25%

Th khng triu chng

Th th s

(4-8%)

1-2%

Phn

Hi chng sau st bi lit (25%-40%) (30-40nm sau)

Hnh 2. S tm tt sinh l bnh hc ca st bi lit

Gio trnh Bnh nhim

412

- V no vn ng.

C quan khc:

C quan khc cng b tn thng : h hp, tim, gan, thn, tiu ha..nhng tn

thng nh v nhanh hi phc.

2. i th:

Mng no ty: ph n xung huyt.

Cht xm: mu hng, vng xm.

Cht trng: xung huyt, xut huyt ri rc.

Hnh 3. Tn thng ty trong bnh st bi lit

3. Vi th:

Th Nissl b tiu hy trong nguyn sinh cht ca nron, dn n tnh trng cc

nron b thai ha v phn ng vim mch mu, t chc m xung quanh

nron km ng thi vi s xm ln ca cc t bo vim.Hu qu cc hin trn

lm teo sng trc ty sng ,x ha t chc m v thnh mch.Tuy nhin

phn ln cc t bo s hi phc (han tan hoc mt phn), mt s nron khc

bi tn thng vnh vin v khng c kh nng hi phc (t bo nron khng c

kh nng ti sinh).

V LM SNG:

St bi lit c chia thnh cc th lm sng ch yu sau 7:

(1) Khng triu chng: 90-95%.

(2) Th bnh nh (minor illness) hay th th s (abortive form ): 4-8%.

(3) Th khng lit (non paralytic poliomyelitis) :1-2%.

(4) Th lit (paralytic poliomyelitis) :

Gio trnh Bnh nhim

413

A. Lm sng ca th in hnh hay th lit:

1. Thi k bnh:

Rt thay i t vi ngy ti mt thng, trung bnh 9-12 ngy.

2. Thi k tin lit (thi k khi bnh):

Ko di 3-7 ngy gm hai hi chng chnh:

Hi chng nhim siu vi ti ng h hp v tiu ha :

St: khi pht t ngt, a s st nh, mt s trng hp c st cao.

Vim long ng h hp.

Ri lon tiu ha.

Hi chng thn kinh:

au v co cng cc c l du hiu rt sm v ph bin. thng au

v co cng c vng c, thn mnh v sau i.

Ri lon phn x nng su: Cc phn x nng (phn x da bu, da

bng, phn x c mng hay c ct sng) thay i trc tin.Cc phn x su

thay i (phn x gn xng) xy ra 8-24 gi sau khi phn x nng thay i.

au c nhiu v nhng thay i phn x nng v su l nhng du hiu d

an nhm c lin quan s tin trin lit trong vng 12-24 gi.

Hi chng mng no:

Tr ln: tam chng mng no (nhc unn i-to bn), du kch

thch mng no (Kernig, Brudzinski) dng tnh.

Tr nh di 2 tui: thp phng, du Hoyne (du hiu c rt) dng

tnh.

Ri lon thn kinh thc vt: v m hi, nt mt lc ti lc ng ,

mch chm

Ri lon tm thn thn kinh: li b hoc vt v ,ku khc

Ri lon c vng dng b tiu.

Cc triu chng trn thay i mc v t l ty theo v dch.Tin trin sang

lit rt kh lng trc c.

3. Thi k lit (thi k ton pht):

Ko di khang 4-6 tun.

c im lit:

Khi pht : t ngt.

Din tin nhanh nng dn. T khi bt u lit n khi lit khng tin

trin na ch trong vng 48-72 gi.

Lit mm ngai vi, khng i xng v khng theo th t nht nh.

Mc rt thay i t yu nh mt nhm c ti lit han ton t chi.

Thng km theo ri lan vn mch.

Cc du hiu m tnh bt buc phi c:

Khng ri lon cm gic khch quan.

Khng c du hiu b thp (lit trung ng).

Gio trnh Bnh nhim

414

V tr lit:

Ty theo v tr tn thng trn h thn kinh trung ng ta c cc th sau 5:

a. Th ty sng: Chim khong 70% cc th lm sng c lit.

Ty c: lit c c, vai gy, chi trn, c hanh v c h hp gy suy h

hp, th ngc bng nghch chiu..

Ty tht lng: Lit c bng di, chi di.

Vng c hay b nht trong th ty sng l c delta, c t u i, nhm c

trc ngoi cng chn. Chi di thng b hn chi trn, gc chi b nhiu hn

ngn chi.

b. Th hnh ty n thun: chim khang 2% cc th lm sng c lit7.

Bnh nhn c th biu hin lit bt k dy thn kinh s no c nguyn y vng

hnh ty km theo hoc khng tn thng trung tm iu ha h hp vn mch

ti hnh ty.

Dy thn kinh s hay b tn thng l IX, X, XII gy biu hin cc triu

chng ca lit vm hu hng, li, dy thanh m nh :Nut kh, ng m

nht trong ming, tro nc bt, ni kh, ni ging mi,mt ting

Ri lon h hp: nc nhiu, kh th, ri lan nhp th

Ri lon tun han: huyt p dao ng, ri lan nhp tim, try mch

Ri lon thn kinh thc vt: st cao dao ng, v m hi, da tm ti.

y l th rt nng t l t vong cao (50-90%) c bit t vong do suy h hp.

c. Th ty sng hnh ty: Chim 15-25%

d. Th no: Thng kt hp vi hai th trn. t khi no n c, tin

lng xu, bnh din tin ko di v li nhiu di chng.

e. Cc biu hin khc:

Triu chng au c c th tng khi bt u lit ko di trong mt 1-2 ngy ri

sau gim dn, tng trng ci thin hn.

Thng ht st s xut hin lit i khi lit ri vn cn st 1-2 ngy.Cn st l

cn nguy c b lit.

f. Lit th West: Rt him gp vi biu hin u tin nht ca bnh l

lit xy ra rt t ngt khng h c cc triu chng bo trc.

4. Giai on lui bnh v di chng

Bnh bt u hi phc t tun th hai tr i. Tc v mc hi phc lit

khng ng u, lc u nhanh v sau chm dn. Nu lit cng ko di (trn 9

thng ) th kh nng din tin ti lit vnh vin s cng cao. Lit thng hi

phc nhng khng han tan , mt s t hi phc han ton mt s khc tip

tc lit v teo c.

Hi phc sm : Trong 6 tun u ca bnh, cc c b lit phc hi

nhanh, au c gim, sau ht hn, ch li mt s t c hoc nhm c

b lit han tan. Giai an ny tng ng vi thi im phc hi chc

nng ca cc nron b bt hat tm thi.

Gio trnh Bnh nhim

415

Hi phc mun : Sau 6 tun ti 2-3 nm, c b lit gim chm v khng

r rng, nhiu c b lit han tan.

Di chng : L nhng tn thng (lit) khng ci thin sau 3 nm.

Khi mt nron b h hi han ton, s gy ra mt s kch hat thn kinh

ln cc si c tng ng. Mc phc hi ph thuc vo6 :

S nron cn li sau giai an bnh.

S nhnh bng h t nron lnh ti phn b cho cc si c do cc

nron b h hi chi phi (Reinnervation through collateral sprouting).

Ph i b tr ca cc c cn li vng chi b nh hng nhm ci

thin sc c.

V c ch b tr hat ng kh hiu qu nn mt nhm c thm ch

vn cn duy tr c sc c gn nh bnh thng ngay c khi mt 50%

s si thn kinh chi phi . Nu ch mt s lng nh (

Gio trnh Bnh nhim

416

VI CN LM SNG:

1. Mu:

Bch cu mu bnh thng hoc c th tng trong vi ngy u sau nhanh

chng tr v bnh thng.

2. Dch no ty :

m tng c th 1-2g/l cao nht vo tun th 2-3 ca bnh ri tr v bnh

thng sau 1-2 thng.

ng bnh thng.

T bo tng cao 20-300/microlit, him khi no vt qu 1000 bch

cu/microlit, tng cao nht vo tun th 2-3 ca bnh v v bnh thng vo

tun th 4. Lc u ch yu bch cu a nhn, 12-48 gi sau th bch cu n

nhn nhanh chng chim u th.

3. Phn lp siu vi:

Trong mu: 3-5 ngy sau khi tip xc v ko di ti trc khi xut hin khng

th trung ha (khang ngy th 10 sau tip xc) trong mu8.

Trong dch tit mi hng: thng phn lp c trong tun u ca bnh .

Trong phn: vo tun u tin ca bnh v ko di ti khi khi bnh, i khi

lu hn c th ti 4 thng. Phn lp trong 10 ngy u ca bnh t l dng tnh

99%

Trong dch no ty : Ch thc hin nu bnh nhn c du hiu tn thng thn

kinh trung ng, phn lp trong giai on cp ca bnh v t l dng tnh rt

thay i 10-85%

4. Huyt thanh chn on:

Phn ng kt hp b th, phn ng trung ha vi hiu gi khng th ln hai

(cch ln u 1-2tun) gp 4 ln so vi ln 1, tn ti khong 2-6 thng.

VII CHN ON:

A. Chn on:

1. Dch t hc:

Tr t 2-8 tui sng ti a phng cha thc hin chng trnh tim chng

y , ti a phng c nhiu tr b tng t . Bn thn tr cha ung nga

bi lit.

2. Lm sng

L yu t quan trng nht. Chn an st bi lit th in hnh l chn an

lm sng.

St

au c

Lit nhanh, t ngt, lit mm ngoi vi khng km ri lai cm gic.

3. Cn lm sng

Ch c gi tr chn an i vi th khng in hnh hoc th khng triu

chng.

Gio trnh Bnh nhim

417

DNT: Vim mng no siu vi vi t bo tng 20-300/microlt.

Phn lp c siu vi t mu, cht tit ng h hp, phn, dch no

ty.

Huyt thanh chn an st bi lit dng tnh vi hiu gi khng th ln

2 gp 4 ln so vi ln u.

St bi lit phi c ngh n trc mt tr c yu t dch t nghi ng km

cc triu chng st khng c hiu, nhc u, au c, au lng ,lit mm

khng i xng, khng ri lan cm gic km t bo dch no ty tng va.

B. Chn on phn bit

(1) Th th s:

Khng th chn an phn bit trn lm sng vi cc bnh l nhim siu vi

khc c.

(2) Th khng lit:

a. Bnh cm v nhim virus ng h hp khc: Thng theo dch, tr

ung nga bi lit, din tin nhanh trong vng 7-10 ngy. Khng

km cc du hiu tn thng thn kinh trung ng: Ri lon phn xa

gn xng,hi chng mng no, ri lan tm thn, thn kinh thc vt,

c ng bt thng chi

b. Vim mng no m: V mt nhim trng, st cao lin tc km lnh

run, hi chng mng no xut hin sm v rm r hn, dch no ty c

ng gim, t bo ch yu bch cu a nhn, bch cu mu ngoi vi

tng cao ko di , bch cu a nhn chim a s.

c. Vim no mng no siu vi: Ri lan tri gic, co git, ch yu da

vo din tin thun li nhanh ca bnh sau 1-2 tun.

(3) Th lit :

a. Lit do cc virus ng rut khc:

Echovirus 6,9 v Coxackievirus A7, A9, B1-5 c th tn cng sng

trc ty sng v gy ra bnh cnh lit ging st bi lit.Tuy nhin

bnh cnh thng nh hn v him khi gy th lit hnh ty.

b. Hi chng Guillain Barr : vim a dy thn kinh ngoi bin, bnh

thng gp ngi ln hn l tr em, khng st, lit tin trin t t

,hng ln km theo ri lan cm gic kiu mang gng mang v. Dch

no ty c hin tng phn ly m t bo (m trong DNT tng cao

trong khi t bo bnh thng hoc rt t) ngc vi st bi lit.

c. Bnh l thn kinh ngoi vi do ng c (Toxic neurophathie):

Botulism (c t do Clostridium Botulium), Bch hu, Ng c ch

d. Gi lit trong vim khp,ct ty vim,chn thng, vim bao hot

dch..

e. Lit chu k do gim Kali mu: Thng gp tr em sau khi b tiu

chy, vn ng c qu mc (mi c), ba n nhiu carbohydrate (cht

Gio trnh Bnh nhim

418

bt ng), lit mm cp mt phn x gn xng, c tnh chu k v

tnh cht gia nh.

f. Nhc c trm trng (myasthenia gravis)

VIII IU TR:

Hin ti cha c thuc iu tr c hiu, ch iu tr triu chng.

a. Mc ch iu tr:

Ngn nga v hn ch di chng

Phc hi chc nng v tm l ti mc ti a c th cho bnh nhn.

b. Nguyn tc iu tr

iu tr ton din kt hp cht ch iu tr triu chng v nng cao sc

khng c th

Tch cc phng nga bin chng v di chng, to mi iu kin bnh nhn

phc hi chc nng v tm l.

Th th s:

iu tr triu chng bng thuc gim au,h st thng thng: Nhm

Acetaminophen

Ngh ngi n khi ht st vi ngy

Theo di v ti khm thn kinh c 2 thng sau pht hin cc biu hin nh

Giai on tin lit:

iu tr triu chng nh th th s.

Hn ch din tin ti lit:

Nm ngh trit ti ging trong 1-2 tun. Trnh mi hat ng lm mi c

nhiu.Trnh tim bp hoc gii phu vng mi hng.

Theo di st mc au v co cng cc c, phn x nng su d an

nhm c kh nng tin trin lit.

Theo di v ti khm thn kinh c 2 thng sau nhm pht hn cc biu hin

nh c th lm thay i t th tr trong nhng nm u.

Giai on lit:

Theo di st bnh nhn pht hin v phng cc bin chng c th xy

ra:

Sinh hiu: Nhit , mch, huyt p.

Lu theo di st tnh trng h hp phng v pht hin sm suy h hp nu

c iu tr h tr kp thi.

Theo di du hiu lit dy thn kinh s: B n, nut kh, sc , thay i ging

ni

Theo di cc biu hin lit c khc.

Chm sc tch cc phng nga v hn ch ti a cc bin chng v di

chng:

Hi sc tch cc h hp tun han nu cn (c bit l nhng tn thng nng

hnh ty).

Gio trnh Bnh nhim

419

Khng sinh chng bi nhim ng h hp v tit niu.

Bnh nhn nm t th sinh l thoi mi, d xoay tr chm sc, ging phng

cng.

p m cc chi au 2-4 gi/ln mi ln 15-30 pht.

V sinh rng ming.

Ty u cc cht tit ca bnh nhn, dng c nhn.

Nui dng y .

Vt l tr liu khi ht st 2-3ngy, khng nn ht au vi nhng bnh nhn

au nhiu thng teo c nhanh. Nn chia lm nhiu t mi t 10-15 ngy,

ko di khang 2 nm.

IX DIN TIN V TIN LNG

Hi phc vn ng bt u trong tun u sau khi khi bnh; i khi chm hn

tun th 3 - 4.

tr em b st bi lit th lit c khong: 3

30% hi phc han tan.

30% b di chng lit nh.

30% b di chng lit trung bnh hoc nng.

10% t vong .

T l t vong cao hn 15-30% (ty theo tui) tr ln, v tng ti 25-75%

th hnh ty7. T vong ch yu xy ra trong vng hai tun sau khi bnh khi

pht.

Mc phc hi v di chng lit cn ph thuc vo vic iu tr ng n v

kp thi c bit l vic duy tr t th c th ng, vn ng ch ng v chun

b tt tm l cho gia nh cng nh bnh nhn gip bnh nhn tr li ha nhp

vi cuc sng bnh thng.

HI CHNG SAU ST BI LIT:

Khong 30-45 nm sau b st bi lit th lit, 25-40% ngi bnh xut hin au

c, v yu lit c nng hn vng c b yu sn sn hoc yu lit c v tr

mi.

Gii n, st bi lit c di chng lit, khang thi gian sau st bi lit di (cng

lu th nguy c cng cao ) c cho l nhng yu t nguy c dn n hi chng

ny. C ch sinh bnh hin cha c bit r rng, c th c lin quan n s

yu nhm c ph i b tr trong giai an cp ca st bi lit7.

Hi chng sau st bi lit khng phi l mt tnh trng nhim trng nn bnh

nhn khng thi vi rus trong giai an ny7.

X D PHNG

y l bnh bo dch bt buc.

Ngun truyn bnh:

Bnh nhn c cch ly bnh vin t nht 2 -4 tun trong thi gian xy ra

dch.

Gio trnh Bnh nhim

420

Ty u, kh trng nhng cht thi, dng c lin quan n bnh nhn.

c im Vaccin bt hot Salk

(IPV)

Vaccin sng gim c lc Sabin

(OPV)

To khng th Trong mu (IgG) Trong mu (IgG) v nim mc

ng tiu ha (IgA)

Gy min dch ti rut Khng c.

Virus bi lit hoang di

vn c th tip tc truyn

bnh qua phn.

C.

Chng li c s xm nhp ca

virus hoang di , to c min

dch cng ng bi s chng

nga t nhin c c nh nhim

virus gim hat lc (vaccin sabin)

qua ng tiu ha t i tng

ung vaccin Sabin.

t bin thnh chng

virus c kh nng gy

bnh

Khng c.

Rt an tan.

Virus gim hat lc trong vaccin

c th bin i v tr nn gy bnh

cho ngi ung vacxin v c

nhng ngi xung quanh b nhim

chng virus ny. Lit mm cp sau

ung vaccin Sabin (t l 1/5 triu

liu) rt nguy him v nguy c lan

trn chng virus bin i ny vo

cng ng qua ng tiu ha.

i tng suy gim

min dch t bo

Dng an ton.

Chng ch nh.

ng dng Tim bp hoc tim mch. Ung.

Hn ch ti a vic tim chch

khng cn thit trong vng 1 thng

sau ung vaccin Sabin.

Tim nga nhc li L cn thit bo m

min dch lu di.

Hin nay vaccin Salk

thng c dng trong

chng trinh tim chng

cc nc pht trin khng

c dch st bi lit,

chng nga nhc li hoc

khi vaccin Sabin khng c

kt qu.

Min dch bn vng lu di.

Gi thnh t. Rt r.

Gio trnh Bnh nhim

421

ng truyn bnh:

Thc hin n chn ung si, v sinh ngun nc, v sinh c nhn, x l ngun

cht thi, rui, gin..

Khi cm th:

Dng vaccin l bin php phng nga hu hiu nht hin nay. Hin ti c hai

loi vaccin: Vaccin bt hat Salk dng ng chch v vaccin sng gim c

lc Sabin dng ng ung.

c im v u khuyt im cu hai loi vaccin c tm tt trong bng sau:

V phng din y t cng ng v dch t hc, vaccin Sabin c nhiu u im

hn ,gi thnh r nn c th a vo chng trnh tim chng quc gia ti cc

nc ang pht trin v hn ch c s lu hnh ca virus bi lit trong cng

ng.

Lch chng nga ung sabin cho tr ti nc ta:

3 ln lin tip vo thi im s sinh, thng th 2,3,4 sau sanh.

Nhc li ln 1sau 1 tui, ln 2 sau 2 tui.

Chng trnh thanh ton st bi lit trn ton cu

Nm 1988 T chc y t th gii pht ng khp cc quc gia chng trnh thanh

tan st bi lit trn ton cu vi mc tiu ra l nm 2005 s han thnh chung

trnh thanh tan st bi lit trn tan th gii. Kt qu t c rt kh quan t

350.000 trng hp st bi lit trn tan cu nm 1988 ti thng 9/ 2003 gim ch

cn 132 trng hp v 6 nc cha c cng nhn lai tr st bi lit : n ,

Pakistan.Afghanistan, Nigeria, Niger v Aicp. Mt vin cnh tt p cho vic loi

tr st bi lit vo nm 2005.

Tuy nhin vo u thng 11/2003 dch li bng pht li Nigeria nng tng s st

bi lit cui nm ln 638 ca, nguyn nhn do nhng tin n sai s tht, do s s hi

v thiu tin tng vo chnh ph ca cng ng hi gio ti Nigeria, sau chng

trnh tim chng ta nc ny b t lit sut c nm 2004 cho ti khi c s hp tc v

can thip ca th gii v cng ng hi gio. Mc tiu thanh tan st bi lit tan

cu c di li vo 2008.

Vin cnh tng lai ca chng trnh:

t vic thanh tan st bi lit vo 2008 phi t c 3 mc tiu sau:

1. Xc nhn lai tr han tan st bi lit trn tan cu.

2. Kim sat c virus hoang di.

3. Ngng s dng vaccin st bi lit.

Tuy nhin cn nhiu kh khn do:

S xut hin chng virus bi lit t vaccin ung (VDPV) c kh nng gy bnh v

lan truyn trong cng ng. c bit cc nc km pht trin c t l ph vaccin

thp v tnh trng v sinh km.

Nguy c khng b sinh hc bng virus bi lit v mc an tan ca vic lu tr

virus bi lit ti cc phng th nghim.

Gio trnh Bnh nhim

422

Lai b vaccin bi lit ung di s bo v ca vaccin chch l c th thc hin

cc nc pht trin, nhng vaccin chch li to khng th b mt IgA rt km , v

c bit cc nc ngho th thc hin rt kh khn do vn thiu kinh ph theo

ui ti cng. Global Alliance for Vaccins and Immunization (GAVI) v Vaccine

Found l hai qu h tr chnh cho chng trnh ny.

Chc chn VPO s c hu hon ton trong tng lai?

S dng VPI: chng no?

Ti Vit Nam14:

Sau hn 10 nm phn u (k t nm 1991), Vit Nam thnh cng trong vic thanh

ton bnh bi lit vo nm 2000. Chng trnh tim chng m rng quc gia t nm

1993 n 1999 t kt qu trn 99% tr di 5 tui ung 2 liu vc-xin bi lit.

T nm 1997 n nay, Vit Nam khng ghi nhn bt k trng hp bi lit no do vi-

rt bi lit hoang di gy ra, v c T chc Y t th gii (WHO) nh gi l mt

trong nhng quc gia thc hin thanh ton bi lit mt cch bi bn v hiu qu nht.

Vi-rt bi lit hoang di ang c kh nng xm nhp t nc cn lu hnh bnh ny

sang nhng nc thanh ton. Do , Vit Nam ang trin khai thc hin mt chin

lc hnh ng khn cp bo v thnh qu thanh ton bi lit.Theo B Y t, trong

cc nm ti, Vit Nam s chi khong 8,5 t ng bo v 2,3 triu tr em di 5

tui 30 tnh thnh khng b vi-rt bi lit tn cng.14

Gio trnh Bnh nhim

423

TI LIU THAM KHO

1. Abraham Morag Pearay L.Ogra. Enteroviruses. Nelson textbook of

pediatrie 2004. p956-64.

2. Benjamin Estrada. Poliomyelitis.

http://www.emedicine.com/ped/topic1843.htm . Internet 12/07/2006.

3. Bernard Seytre and Mary Shaffer. Poliomyelitis.

http://www.polio.info/polio-

eradication/front/templates/index.jsp?&lang=EN&codeRubrique=12 . Internet

06/06/2006.

4. B mn vi sinh i hc Y H Ni.Virus ng rut. Vi sinh y hc.Nh

xut bn y hc 2003.tr 325-327.

5. Bi i,Nguyn Vn Mi,Nguyn Hang Tun.Bnh st bi lit .Bnh hc

truyn nhim.Nh xut bn y hc 2002.tr 134-140.

6. Burk Jubelt and Judy Drucker. Poliomyelitis and the Post-Polio Syndrome.

http://www.ott.zynet.co.uk/polio/lincolnshire/library/jubelt/polioandthepps.htm

l .Internet 12/08/2006.

7. CDC. Poliomyelitis in Epidemiology & Prevention of Vaccine-Preventable

Diseases.

http://www.cdc.gov/nip/publications/pink/def_pink_full.htm . Internet

06/06/2006.

8. Jeffrey I.Cohen.Enterovirus. Harrison's Principles of Internal Medicine 6th

Edition CD-Rom. 2006.

9. John F.Modlin.Poliovirus.Principle and Practise of infectious diseases

2005.p2141-2146.

10. Ronald L.Huckstep. poliomyelitis - a guide for developing countries

including appliances and rehabilitation.

http://www.worldortho.com/database/polio/pg5.html . 2006. Internet

07/08/2006.

11. WHO. Fact sheet N114.

http://www.who.int/mediacentre/factsheets/fs114/en/index.html .Internet

04/2003.

12. WHO. Annual Report 2005.

http://www.polioeradication.org/content/publications/AnnualReport2005_ENG

.pdf .Internet 07/06/2006.

13. WHO. Global Polio Eradication Initiative.

http://www.polioeradication.org/casecount.asp .Internet 07/06/2006.

14. Website b y t Vit nam

http://www.moh.gov.vn/homebyt/vn/portal/InfoDetail.jsp?area=207&cat=1896

&ID=303

Gio trnh Bnh nhim

424

CU HI TRC NGHIM

1. St bi lit l bnh nhim trng :

A. Do vi trng gy ra

B. Tn thng h thn kinh cm gic v vn ng

C. Ngi l ngun bnh duy nht

D. To min dch tm thi.

2. Virus st bi lit :

A. Gm 3 type khc nhau

B. khng km vi ngoi cnh

C. Ly lan qua ng mu

D. Cu A v B ng

3. c im lit trong st bi lit :

A. Lit v ri lon cm gic thng bt u t ngn chi ri lan dn

ln

B. Lit cng trung ng

C. Lit mm ngoi vi din tin nhanh km ri lon cm gic

D. Lit mm, din tin nhanh, khng ng u v khng theo th t

nht nh

4. c im quan trng nht ca st bi lit l :

A. Lit khng ng u v khng i xng

B. Lit mm cp

C. Khng ri lon c vng

D. Teo c rt nhanh nhiu v sm

5. Chn cu ng

A. St khng phi l du hiu bt buc trong st bi lit

B. au c trong thi k tin lit lin quan cht ch n mc lit

c sau

C. au v hi chng mng no l cc biu hin thn kinh thng

gp trong thi k tin lit.

D. B v C ng

6. Th West trong st bi lit :

A. L th him gp

B. Xy ra t ngt khng triu chng bo trc

C. Lit l triu chng duy nht

D. Tt c u ng

7. Hi chng sau st bi lit

A. Xy ra sau khong 40 nm sau st bi lit

B. Nam nhiu hn n

C. C ch bnh sinh do ti hot virus bi lit

D. A v B ng