MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

EDUCATIONAL INSTITUTION
«GRODNO STATE MEDICAL UNIVERSITY»

Department of General Hygiene and Ecology

I.A. Naumov
E.A. Moiseenok
S.P. Sivakova
T.I. Zimatkina

GENERAL HYGIENE
Training manual
for the Faculty of Foreign Students
(English medium)

Grodno 2013
3
 PREFACE
The training manual «General Hygiene» is made with the purpose of
adaptation of the educational materials stated in textbooks on General
Hygiene to the program of teaching General Hygiene in the Republic of
Belarus and simplification of self-preparation of the foreign students for
forthcoming practical classes and more successful development of practical
skills. The present training manual includes basic questions of General
Hygiene as medical science and covers main topics of Nutritional Hygiene,
Hygiene of Healthcare Institutions, Occupational Hygiene and Hygiene of
children and adolescents.
The manual is intended for the foreign students of medical
educational institutions with the education in the English language.

4
 1. THE PLACE OF HYGIENE IN THE SYSTEM OF MEDICAL
SCIENCES AND PROTECTION OF THE POPULATION HEALTH

HYGIENE -
a branch of preventative medicine which studies the influence of the
environment (living, working, studying, etc.) on human health, working
performance and life expectancy and creates the measures of prevention of
the diseases and providing optimal environment, preserving health and
active longevity.

Hygieinos – from ancient Greek language = providing health.

Sanitaria – system of hygienic measures aiming to improve

population health, to prevent diseases and to improve living conditions.

Sanitas – from ancient Latin language = health.

Epidemiology – a part of medicine, which studies the causes of

epidemies and their spread and creates the measures of their prevention and
control.

Epidemia – from ancient Greek language = mass disease.

Ecology – a science, which studies the relationships between the

organisms and environment. It is a science which studies the laws of
functioning of the biological systems.

Oikos – from ancient Greek language = home, birthplace.

Valeology – a science describing the patterns of health, mechanisms

and ways of maintenance, strengthening and preservation of health.

Valeo – from ancient Latin language = healthy.

5
 The relationship "biological-social"
social environment
Food

Clothes

Housing

Ecology

Technology

Medicine and drugs

Smoking and narcotics

Behavior and lifestyle

Computerization and radiations

Nature Biology
Climate Physiology

Definitions of health and disease. Risk factors. Health formula.

Health - WHO definition (1946): «Health is a state of complete

physical, mental and social wellbeing and not merely an absence of disease
or infirmity»

In narrow sense - health means: there is no obvious evidence of

disease; a person is functioning normally, i.e. conforming within normal
limits of variation to the standards of health criteria; organs of the body are
functioning adequately in relation to one another.
Public health – a system of social-economic and medical actions,
aiming to save and raise the level of health of each person and population
as a whole.
Public health is the most important economic and social potential of
the country, stipulated by the different environmental factors and life-style
of the population that allows to provide optimum level of quality and safety
of life.

6
 Physical
development

communicative
competence
Health

Disease – impaired organism state resulting from the impact of

extreme irritants (physical, chemical, biological and social environmental
factors) or the presence of birth defects, with partial offending of self-
regulation and homeostasis leading to the limitation of vital functions.

Disease  a physiological/psychological dysfunction.

Premorbidity – state of health, when physical and psychological

well-being is disturbed, but there are no obvious symptoms of disease.
Pre-morbid state – state of organism, when functional resources are
decreased, has 2 stages:
1 STAGE – nonspecific changes
2 STAGE – specific changes of organs and systems, their
resistance is impaired. Mechanisms of compensation postpone the onset of
disease.

7
 Risk factors – potentially dangerous factors for health; behavioral,
genetic, ecological, social factors raising probability of the diseases, their
progress and unfavorable upshot.

The influence of risk factors on the organism

Direct Indirect

Occur after a certain,

poisoning sometimes a long period of
injuries time or even after cessation
burns of exposure

• oncogenic, mutagenic and teratogenic substances

• formation of irreversible pathological changes in organs and
systems (eg, sclerosis)
• acceleration the aging process and reduction the life
expectancy

The order of the risk assessment

Identification of harmful
1 (dangerous) factor 6
Rating (justification) of
acceptable risk
Identification of adverse events (including legal requirements)
associated with detection
2
of harmful factor
7
Assessment of risk associated
with hazardous
Estimation of the (dangerous) factor
probability (P) (is a risk assumed?)
3 of undesirable events
5
The calculation of risk
Assessment of potential
(Р * С)
losses (С), associated with
4
the onset of adverse events

8
 Risk factors in the external medium.

External Internal medium

medium

Physical

Chemical

Biological

Psycho-
physiological

Social

Health Formula (the influence of risk factors on human health):

50% - lifestyle factors (nutrition, physical activity, work, bad habits, sexual
behaviour, etc.); 20% - genetical factors (heredity); 20% - environmental
factors (physical, chemical, biological, psycho-physiological factors); 10%
- medical service activity.

The main elements of a comprehensive

analysis
in the activities of a doctor:
collection of health information
hypotheses about the
relationship of environmental
factors with health
processing and analysis of
direct study of health information
environmental factors and
in-depth study of the
adoption of solutions to
characteristics of health
improve the environment for
Identification of the primary prevention of
quantitative relationships diseases
between environmental
verification of the implementation of
factors and health
characteristics effectiveness of decisions decisions

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 Structure of hygiene.

Hygiene includes the following parts:

Communal hygiene – studies the influence of native and social

factors on organism in the residential environment and creates hygienic
standards and measures to optimise the living environment. Consists of the
following chapters: hygiene of air media, climate and acclimatization,
hygiene of water, soil.
Nutritional hygiene – studies the influence of food substances and
diets, develops optimal balance of nutritional substances depending on
working and living conditions and measures of alimentary diseases
prevention.
Occupational hygiene and hygiene of work – studies manufacturing
activity and working environment from the point of their possible influence
on organism, develops recommendations on prevention of professional
diseases.
Hygiene of children and adolescents – studies the influence of
various factors on growing organism and creates measures, providing
optimal physical and mental development of children.
Radiation hygiene – studies the influence of radioactive substances
and ionising radiation, as factors of working environment on organism and
creates the measures of radiological protection.

Complex hygienic diagnostics. Hygienic pre-nosological diagnostics.

Complex hygienic diagnostics – complex research of native, social

environment and state of health with finding the rules of dependency of
health state from the quality of the environment.

Complex hygienic diagnostics includes:

Study of the intensity, duration and frequency of the factors impact on an
individual or a group of individuals;
Diagnostics of health status of individuals, groups of people, particularly
hypersensitive subgroups (children, elderly, etc.);

10
Determining the contribution of the factors in health disorders of the
individuals, groups of people and hypersensitive subgroups.

Hygienic pre-nosological diagnostics – assessment of the functional

state of the organism and its adaptive abilities in the period, when there are
no obvious sings of diseases.
Aims of pre-nosological diagnostics 
•Early detection of premorbid (pre-nosological) conditions as:
- tension of adaptive mechanisms,
- unsatisfactory adaptation,
- failed adaptation.
•Development and implementation of adequate measures of the prevention
of diseases.

Assessment of the state of adaptive systems includes the study of:

•Haematological and Immunological status;
•State of enzyme systems;
•Antioxidant systems and lipids peroxidation;
•Cardiovascular and respiratory systems reserve;
•Psychological testing.

Pre-nosological diagnostics reveals in otherwise healthy people:

in 40 % of cases - tension of adaptive mechanisms,
in 25 % - unsatisfactory adaptation,
in almost 9 % - failed adaptation.

Methods of hygienic researches:

Sanitary description of various objects of the environment, conditions
of work and life, quality of nutrition and related to this pathology.
Physical methods – instrumental, when physical parameters
(temperature, humidity, air ionisation, radiation) are studied with the help
of the devices.
Chemical methods – qualitative and quantitative analysis of products
and state of air and water media, content of soil.

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Modern physico-chemical methods include: spectrophotometry,
radiometric, dosimetry, luminescent analysis, etc.
Biological methods – bacteriological and helminthological.
Epidemiological method – while studying the indices of the morbidity, it
relates to sanitary-statistic – use of official information from reports and
monitoring documents.
Clinical studies - in pre-nosological diagnostics, for studying the
professional pathology and developing adequate methods of treatment and
prevention.
Method of hygienic experiment allows to investigate the influence of
various factors on organisms of humans and experimental animals.
Laboratory modelling is used for experimental establishing of maximal
permitted concentrations and levels, guide safe levels of impact, and other
indices called hygienic standards.

The purpose of hygiene as a science - to evaluate the nature of the

factor, the degree of harm (or benefit) of its impact on the organs and
systems of the body, as well as the time after which can manifest a
favorable or unfavorable effect of the factor
The purpose of hygiene as a scientific discipline - to participate in issues
of economic development through the development and scientific basis
of specific recommendations:
Creating favorable conditions for the normal development of the body, for
the full flowering of the physical and the spiritual forces of man, for the
high labor
Development of health legislation TASKS
Development of hygienic standards

Justification of hygienic measures to protect and improve

the environment, working conditions and rest

The health protection of children and adolescents

Participation in the development of hygienic basics of rational

nutrition, and sanitary inspection of the quality of food and
household goods

Scientific development of preventive and current sanitary

inspection

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 Aims of hygiene
harmoniously
developed

socially adapted

Healthy
Culture Health protection social welfare

PREVENTION
is a complex of state, social and medical measures aiming to preserve and
strengthen population health, to grow up healthy young generation, and to
extend the active longevity.

Medical prevention – a complex of measures aiming to remove the

causes and conditions resulting in the diseases.

Prevention can be primary, secondary and tertiary.

Primary prevention (radical) aims to eliminate the causes of the

disease by improvement of working and living environment.
Secondary prevention is carried among visibly healthy individuals in
order to reveal premorbid states in people with higher risk of the
development of the diseases. Secondary prevention aims to increase the
resistance of the organism (preventive nutrition, means of individual
protection, skills of safe life and work in unfavourable conditions).

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Tertiary prevention (rehabilitation) aims to prevent the complications
and recurrence of already existing diseases, and their transformation into
chronic forms.

Sanitary-epidemic wellbeing of the population.

Sanitary-epidemic wellbeing of the population – the state of

population health when unfavourable influence of environmental factors is
absent and favourable conditions for human life are created.

Sanitary-epidemic well-being is provided by:

 state sanitary-hygienic standardisation;
 following the hygienic standards and regulations;
 licensing of the activity potentially dangerous for human health;
 certification of products, work and services which are potentially
dangerous for human health;
 state sanitary-hygienic expertise;
 state hygienic regulation and registration;
 social-hygienic monitoring;
 implementation of state programs;
 economical interest in following hygienic and epidemiological
legislation;
 implementation of responsibility for breaches in hygienic and epidemic
legislation;
 reimbursement of damage to health and property of people as a result of
breach in hygienic and epidemic legislation;
 scientific development and implementation of its achievements in
providing sanitary-epidemic wellbeing of the population;
 informing of population about hygienic and epidemic state of the
environment and current preventative measures;
 developing high hygienic culture of population and formation of a
healthy lifestyle;
 system of the state and departmental hygienic supervision, manufacture
and public hygienic control.

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 Sanitary supervision and sanitary control.

State sanitary supervision – activity of state institutions targeting

the prevention of the diseases by prevention, revealing and suppression of
the breaches in sanitary legislation.
Sanitary rules and standards are statutory acts that install human or
harmlessness criteria of environmental factors as well as sanitary-hygienic
and antiepidemic requirements for provision of favorable vital activity
conditions.

Types of sanitary control:

 Preventive sanitary control is realized in relation to new
industrial, housing, communal objects during construction or
reconstruction, changing the profile and technologies of the production
process.

Preventive sanitary control provides:

 expert examination of design documentation;
 control for construction process;
 expert examination of the normative-technical documentation of raw
materials, products, technological processes, equipment, materials,
substances;
 control of the atmospheric air, water, soil for the sources of the
contamination.

 Current sanitary control is a systematic observation for

already existing objects to provide the affirmed sanitary rules and
standards.

Main directions of current sanitary control:

 hygienic estimation of the working environment: supervision of
working conditions, protection from sanitary hazards, organization of
preventive medical examinations, prevention of diseases and trauma,
educational work;
 supervision of the air ambience, state of water, soil, laboratory
control;
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 investigation of the disease incidence, prevention of diseases,
infection control, public health observation;
 supervision over health status and physical development of children
and adolescents, control of education process and daily regimen;
 organization of the rational nutrition, supervision over food safety;

Sanitary control at manufacture, including laboratory one, for the

purpose to improve conditions of work, education and rest, also over the
quality of manufactured products, with issuing documents certifying its
quality.
Public sanitary control carried out by public unions, which are
entitled to inform about the revealed breaches of sanitary rules institutions
of state or departmental sanitary control.

Sanitary-epidemiologic service in the Republic of Belarus.

Sanitary supervision and sanitary control as a key instrument to
achive sanitary-epidemic wellbeing of the population is performed by
sanitary-epidemiologic service.

Sanitary-epidemiologic service has the following main activities:

• gathering and assessment of information about sanitary-epidemic,
ecological and demographic situation;
• revelation of environmental factors and reasons influencing
population health;
• environmental factors standardization, regulation and registration;
• supervision over sanitary rules and standards compliance;
• suppression of sanitary legislation and rules violation.

Sanitary-epidemiologic service in the Republic of Belarus is headed

by the Chief state sanitary physician of the Republic of Belarus – Deputy
Minister of Health.
The main institutions of the sanitary-epidemiologic service are
republican (1), regional (6), town (22) and district (118) Centres of
Hygiene, Epidemiology and Public Health. Except Centres of Hygiene and
Epidemiology there are also Rebublican Scientific-Practical Centre of

16
Hygiene, sanitary departments and subdivisions of the Ministry of
Defence, Ministry of Internal Affairs, railway and air fleet.

Main functions of the Centres of Hygiene, Epidemiology and Public

Health:
 supervision over sanitary state of the region;
 monitoring of public health indices;
 systematic laboratory control of water, air, soil, food;
 preventive sanitary control;
 current sanitary control;
 prevention of AIDS and HIV;
 medical and hygienic education of the population.

The dynamics of mortality among persons 30

years and older from 1950 to 2002 in the United
States, Australia, England and Canada

USA
Australia
UK
Canada

Adverse tendencies in the state of Belarusian population health:

 decrease in average life expectancy;

 constantly rising level of average mortality, particularly at able-
bodied age;
17
 decrease in birth rate to the level, when average mortality is higher
than the birth rate;
 rise in socially dangerous diseases: venereal, active Tuberculosis,
professional diseases and trauma;
 rise in oncologic pathology, predominantly of endocrine system.

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 2. HYGIENIC PROBLEMS OF NUTRITION

Components of the nutritional hygiene.

Hygiene of nutrition is a science, which researches:

problems of rational, clinical and preventive nutrition, as well as
develops the measures providing safety of raw ingredients, food products
and processed food.

It consists of 2 parts:
•Hygienic problems of nutrition in different groups of population;
•Hygienic problems of food resources protection and providing safety of
food and food products.

Hygienic problems of nutrition:

•Planning of population nutrition;

•Meeting the requirements of different groups of population in food and
nutrient substances;
•Development of optimal nutritional regimens;
•Providing nutrition for organised collectives (hospitals, pre-school
institutions, military troops, etc.);
•Hygienic and educational work with population on topics of balanced
nutrition.

Hygienic problems of food and food products protection:

•Providing the quality and safety of food and food products;

•Development of hygienic regimens for manufacturing, delivery and use of
food products;
•Preventive and current hygienic supervision over the catering objects and
manufacturers of food products.

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 TYPES OF NUTRITION:
•Rational nutrition (balanced, correct, scientifically justified, optimal,
adequate).
•Clinical nutrition.
•Preventive nutrition.

Rational nutrition –
is a nutrition of a healthy individual, aiming to prevent alimentary, cardio-
vascular, allergic, stomach, bowel and other diseases.

Rationalis – from Latin = thoughtful, sensible, reasonable.

Rational nutrition provides:

•Stability of internal media (homeostasis);
•Living requirements (growth, development, activity of different organs
and systems) at a level, corresponding to the working and living
conditions.

Hygienic requirements for rational nutrition:

Energetic value of the daily ration should match the energy requirements
of the organism;
Physiological requirements of organism should be supplied with nutrients
in the most useful amounts and proportions;
Chemical structure of the food should correspond enzyme and digestive
systems of the organism;
Food consumption should be distributed correctly throughout the day;
Food should not possess risks for health.

Rational nutrition is based on physiological requirements.

Physiological requirements are the scientific background for:

•planning of manufacturing and consumption of food products;
•assessment of foodstuffs reserves;
•calculations and assessment of nutrition of organised collectives;
•assessment of individual nutrition;
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•preparation of advices on correction of rations.

Physiological nutritional requirements

 scientifically-proved requirements, providing full cover of
energetic losses and supplying organisms with all necessary substances in
required amounts and most optimal ratios.

2 sides of physiological requirements:

•Quantity, or calorie content of the rations;
•Quality – which substances provide the calories and which nutrients of no
calorie value should be supplied with food and in which amounts.

Dietary sources
The optimum ratio of protein, fat and carbohydrate
(by weight) in a daily ration is 1:1:4

Proteins Fats Carbohydrates

In foods of animal In meat, milk, In cereals,

origin lard, oily plants flour, starch

Energy loss consist of:

•Non-controllable loss (basic metabolism and specific dynamic impact –
SDI of food);
•Controllable loss (energy loss during working activity, sport, housework,
etc.)

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 Quality side of physiological requirements shows:
•How much of proteins, fats, carbohydrates, vitamins, mineral substances
should the ration contain;
•The ration of these components, as this may influence their digestion;
•What kinds of food products should supply the particular components of
food.

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 3. HYGIENIC CHARACTERISTICS OF MACRO- AND
MICRONUTRIENTS

A nutrient is a chemical that an organism needs to live and grow or a

substance used in an organism's metabolism which must be taken in from
its environment.

They are used to:

 build and repair tissues,
 regulate body processes
 be converted to and used as energy.

Organic nutrients include carbohydrates, fats, proteins (or their

building blocks, amino acids), and vitamins.
Inorganic chemical compounds such as dietary minerals and
water, may also be considered as nutrients.
A nutrient is said to be "essential" if it must be obtained from an
external source, ether because the organism cannot synthesize it or
produces insufficient quantities.
Nutrients needed in very small amounts are micronutrients and
those that are needed in larger quantities are called macronutrients. The
effects of nutrients are dose-dependent and shortages are called
deficiencies.

Macronutrients are defined as the classes of chemical

compounds humans consume in the largest quantities and which provide
bulk energy (carbohydrates, proteins, and fats). Water and
atmospheric oxygen also must be consumed in large quantities, but are not
always considered "food" or "nutrients".

The remaining vitamins, minerals or elements, are

called micronutrients because they are required in relatively small
quantities.

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 Substances that provide energy
 Carbohydrates are compounds made up of sugars. Carbohydrates
are classified by their number of sugar units: monosaccharides(such
as glucose and fructose), disaccharides (suchas sucrose and lactose), oligos
accharides, and polysaccharides (such as starch, glycogen, and cellulose).
 Proteins are organic compounds that consist of the amino acids
joined by peptide bonds. The body cannot manufacture some of the amino
acids (termed essential amino acids); the diet must supply these.
In nutrition, proteins are broken down through digestion by proteases back
into free amino acids.
 Fats consist of a glycerin molecule with three fatty acids attached.
Fatty acids are unbranched hydrocarbon chains, connected by single bonds
alone (saturated fatty acids) or by both double and single bonds
(unsaturated fatty acids). Fats are needed to keep cell
membranes functioning properly, to insulate body organs against shock, to
keep body temperature stable, and to maintain healthy skin and hair. The
body does not manufacture certain fatty acids (termed essential fatty acids)
and the diet must supply these.

Fat has an energy content of 9 kcal/g (~37.7

kJ/g); proteins and carbohydrates 4 kcal/g (~16.7 kJ/g). Ethanol (grain
alcohol) has an energy content of 7 kcal/g (~29.3 kJ/g).

Substances that support metabolism

 Dietary minerals are generally trace elements, salts, or ions such as
copper and iron. Some of these minerals are essential to human
metabolism.
 Vitamins are organic compounds essential to the body. They usually
act as coenzymes or cofactors for various proteins in the body.
 Water is an essential nutrient and is the solvent in which all the
chemical reactions of life take place.
 Nutrients are frequently categorized as essential or nonessential.
 Essential nutrients are unable to be synthesized internally (either at
all, or in sufficient quantities), and so must be consumed by an organism
from its environment.
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 Nonessential nutrients are those nutrients that can be made by the
body; they may often also be absorbed from consumed food. The majority
of animals ultimately derive their essential nutrients from plants, though
some animals may consume mineral-based soils to supplement their diet.
 For humans, these include essential polyunsaturated fatty acids,
essential amino acids, vitamins, and certain dietary
minerals. Oxygen and water are also essential for human survival, but are
generally not considered "food" when consumed in isolation.
 Humans can derive energy from a wide variety of
fats, carbohydrates, proteins, and ethanol, and can synthesize other needed
amino acids from the essential nutrients.
 Non-essential substances within foods can still have a significant
impact on health, whether beneficial or toxic. For example, most dietary
fiber is not absorbed by the human digestive tract, but is important in
digestion and absorption of otherwise harmful substances. Interest has
recently increased in phytochemicals, which include many non-essential
substances which may have health benefits.

The following play important roles in biological processes:

Dietary
RDA Category Insufficiency Excess
element

is a systemic electrolyte and is

essential in coregulating ATP with hyper
4700
Potassium sodium. Dietary sources hypokalemia
mg kalemia
include legumes, potato
skin, tomatoes, and bananas.

is needed for production of

hydrochloric acid in the stomach hypo hyper
2300
Chlorine and in cellular pump functions.
mg
Table salt (sodium chloride) is the chloremia chloremia
main dietary source.

25
 is a systemic electrolyte and is
essential in coregulating ATP with
1500 potassium. Dietary sources include hyper
Sodium hyponatremia
mg table salt (sodium chloride, the natremia
main source), sea vegetables, milk,
and spinach.

is needed for muscle, heart and

digestive system health, builds
bone, supports synthesis and
1000 function of blood cells. Dietary hypo hyper
Calcium
mg sources of calcium include dairy calcaemia calcaemia
products, canned fish with
bones (salmon, sardines), green
leafy vegetables, nuts and seeds.

is a component of bones and hyper

700 energy processing and many other hypo
Phosphorus phosphat
mg functions. In biological contexts, phosphatemia
usually seen as phosphate. emia

is required for processing ATP and hypo hyper

420 for bones. Dietary sources
Magnesium magnesemia, magnes
mg include nuts, soy beans, and cocoa magnesium
mass. deficiency emia

is pervasive and required for

11 several enzymes such as
zinc zinc
Zinc carboxypeptidase, liver alcohol
mg deficiency toxicity
dehydrogenase, and carbonic
anhydrase.

is required for many proteins and

Iron 8 mg enzymes, notably hemoglobin to anaemia iron
overload
prevent anemia. Dietary sources
26
 include red meat, leafy green disorder
vegetables, fish (tuna,
salmon), eggs, dried
fruits, beans, whole grains, and
enriched grains.

2.3 manganese
Manganese is a cofactor in enzyme functions. manganism
mg deficiency

900 is required component of many

copper copper
Copper redox enzymes, including
µg deficiency toxicity
cytochrome c oxidase.

is required not only for the

synthesis of thyroid hormones and
150 to prevent goiter, but also, probably
iodine
Iodine as an antioxidant, for extrathyroidal iodism
µg deficiency
organs as mammary and salivary
glands and for gastric mucosa and
immune system (thymus)

a cofactor essential to activity

55 selenium
Selenium of antioxidant enzymes like selenosis
µg deficiency
glutathione peroxidase.

Other elements
Many elements have been suggested as essential, but such claims
have usually not been confirmed. Definitive evidence for efficacy comes
from the characterization of a biomolecule containing the element with an
identifiable and testable function. One problem with identifying efficacy is
that some elements are innocuous at low concentrations and are pervasive,
so proof of efficacy is lacking because deficiencies are difficult to
reproduce.

27
 Vitamins

A vitamin is an organic compound required as a nutrient in tiny

amounts by an organism. In other words, an organic chemical compound
(or related set of compounds) is called a vitamin when it cannot
be synthesized in sufficient quantities by an organism, and must be
obtained from the diet. Thus, the term is conditional both on the
circumstances and on the particular organism. For example, ascorbic acid
(vitamin C) is a vitamin for humans, but not for most other animals,
and biotin and vitamin D are required in the human diet only in certain
circumstances.

Vitamins have diverse biochemical functions. Some have hormone-

like functions as regulators of mineral metabolism (e.g., vitamin D), or
regulators of cell and tissue growth and differentiation (e.g., some forms
of vitamin A). Others function as antioxidants (e.g., vitamin E and vitamin
C). The largest number of vitamins (e.g., B complex vitamins) function as
precursors for enzyme cofactors, that help enzymes in their work as
catalysts in metabolism. In this role, vitamins may be tightly bound
to enzymes as part of prosthetic groups: For example, biotin is part of
enzymes involved in making fatty acids.
Vitamins may also be less tightly bound to enzyme catalysts as
coenzymes, detachable molecules that function to carry chemical groups or
electrons between molecules. For example, folic acid carries various forms
of carbon group – methyl, formyl, and methylene – in the cell. Although
these roles in assisting enzyme-substrate reactions are vitamins' best-
known function, the other vitamin functions are equally important.

Vitamins are classified as either water-soluble or fat-soluble. In

humans there are 13 vitamins:
 4 fat-soluble (A, D, E, and K) and
 9 water-soluble (8 B vitamins and vitamin C).

Water-soluble vitamins dissolve easily in water and, in general, are

readily excreted from the body, to the degree that urinary output is a strong
predictor of vitamin consumption. Because they are not readily stored,
28
consistent daily intake is important. Many types of water-soluble vitamins
are synthesized by bacteria.

Fat-soluble vitamins are absorbed through the intestinal tract with

the help of lipids (fats). Because they are more likely to accumulate in the
body, they are more likely to lead to hypervitaminosis than are water-
soluble vitamins.

Each vitamin is typically used in multiple reactions, and, therefore,

most have multiple functions.

Recommended
Vitamin
dietary
generic Vitamer chemical Deficiency Overdose
allowances
descript name(s) disease disease
(male, age 19–
or name
70)

Retinol, retinal,
Night-blindness,
Vitamin four carotenoids Hypervitamino
900 µg Hyperkeratosis,
A including beta sis A
Keratomalacia
carotene

Drowsiness or
Beriberi, Wernick
Vitamin muscle
Thiamine 1.2 mg e-Korsakoff
B1 relaxation with
syndrome
large doses.

Vitamin
Riboflavin 1.3 mg Ariboflavinosis
B2

Liver damage
Vitamin Niacin, (doses >
16.0 mg Pellagra
B3 niacinamide 2g/day) and
other problems

29
 Diarrhea;
Vitamin
Pantothenic acid 5.0 mg Paresthesia possibly nausea
B5
and heartburn.

Impairment of
Pyridoxine, proprioception,
Vitamin Anemia periphera
pyridoxamine, 1.3–1.7 mg nerve damage
B6 l neuropathy.
pyridoxal (doses >
100 mg/day)

Vitamin Dermatitis, enterit

Biotin 30.0 µg
B7 is

Megaloblast and
Deficiency during
May mask
pregnancy is
Vitamin Folic acid, folinic symptoms of
400 µg associated with
B9 acid vitamin
birth defects, such
B12deficiency.
as neural
tube defects

Acne-like rash
Cyanocobalamin,
Vitamin Megaloblastic [causality is not
hydroxycobalamin, 2.4 µg
B12 anemia conclusively
methylcobalamin
established].

Vitamin Vitamin C
Ascorbic acid 90.0 mg Scurvy
C megadosage

Vitamin Ergocalciferol, Rickets and Hypervitamino

5.0 µg–10 µg
D cholecalciferol Osteomalacia sis D

15.0 mg Deficiency is very Increased

Vitamin Tocopherols,
rare; congestive

30
 E tocotrienols mild hemolytic heart failure
anemia in seen in one
newborn infants. large
randomized
study.

Increases
Vitamin phylloquinone, coagulation in
120 µg Bleeding diathesis
K menaquinones patients taking
warfarin.

In nutrition and diseases

Deficiencies of vitamins are classified as either primary or secondary.
A primary deficiency occurs when an organism does not get enough of
the vitamin in its food. A secondary deficiency may be due to an
underlying disorder that prevents or limits the absorption or use of the
vitamin, due to a “lifestyle factor”, such as smoking, excessive alcohol
consumption, or the use of medications that interfere with the absorption or
use of the vitamin. People who eat a varied diet are unlikely to develop a
severe primary vitamin deficiency.

31
 4. NUTRITION REQUIREMENTS FOR DIFFERENT GROUPS OF
POPULATION AND THEIR PHYSIOLOGICAL BACKGROUND

Nutrition requirements for particular groups of population are

indicated in Sanitary rules and standards «REQUIREMENTS IN
NUTRITION SUBSTANCES AND ENERGY CONSUMPTION FOR
DIFFERENT GROUPS OF POPULATION OF THE REPUBLIC OF
BELARUS» Instruction No. 16 from 14.03.2011.

The determining criteria of energy and nutritional substances

requirements:
•For unemployed population (children, teenagers, retired people) is their
age,
•For employed population – age and type of working activity.
Children population and, respectively, groups of nutrition
requirements are divided into 9 age groups:
 for children of infant age (3 groups),
 children of pre-school and school age (6 groups: 1-3 years, 4-6 years, 6
years (schoolchildren) 7-10 years (boys and girls), 14-17 years (boys and
girls).
Juvenile and youngsters groups are also divided by gender.

Special features in organisation of children’s nutrition.

Energetic values of the rations:

1 - 6 years - from 1300 to 2000 kcal,
7 - 17 years - 2100-2600 kcal.
Energy consumption:
From proteins 14-15 %,
From carbohydrates - 30-32 %,
From fats 54-56 %.

Ratio of proteins/ fats/ carbohydrates (p/f/c) in younger age groups –

1:1:3, in older – 1:1:4.
Sources of protein in younger groups – milk and dairy products (up to
500g), low fat meat and fish meal.
32
Animal proteins from 1 to 3 years should compound 70 %, from 3 to 6
years – 65 % from 7 years – 60 % of total protein.
In older age groups meat and fish dishes – are the main sources of
proteins, but milk and dairy products are included in ration in order to
provide at least 60-80% of daily requirements in calcium.
Rations include grouts, vegetable dishes and fruits. Fruits and vegetables
are preferably to be raw, unprocessed.
Frequency of meals in younger age groups is at least 5 per day, in older –
4 per day.

Features of the nutrition organisation for adult working population.

Adult active population is divided according to the intensity of

physical workload:
•5 groups for men,
•4 groups for women.

Each of these groups is divided according to age into 3 subgroups:

18-29 years, 30-39 years, 40-59 years.

•1 group – employees of mostly intellectual work;

•2 group – workers of light physical workload;
• 3 group – workers of intermediate physical workload;
•4 group – workers of heavy physical workload;
•5 group – workers of extra heavy workload.

1 group – employees of mostly intellectual work

•Managerial, engineering and technical staff, teachers, art workers,
planning and audit, clerks, controllers and operators, doctors (apart from
surgical specialities).
•Coefficient of physical activity - CPA (total energy losses divided by
basic metabolism) is 1.4.
•Daily energy value of the diets varies from 1800 to 2000 kcal for
women, from 2100 to 2450 kcal for men.

33
 2 group – workers of light physical load
•Engineering and technical work requiring some physical efforts, workers
of automated lines, radio-electronic industry, servicing personnel, traders,
workers of sewing industry, veterinary doctors, zootechnitians,
agronomists, medical nursing staff, physical training instructors and
trainers.
•CPA = 1.6
•Daily energy requirements vary from 2100 to 2200 kcal for women,
from 2500 to 2800 kcal for men.

3 group – workers of moderate physical load

•Machine-operators, metal-workers, tuners, chemists, textile worker and
drivers, railroad workers, water-transport workers, polygraph workers,
catering workers, traders at grocery stores, doctors of surgical specialities.
•CPA = 1.9
•Daily energy requirements are from 2500 to 2600 kcal for women, from
2950 to 3300 kcal for men.

4 group – workers of heavy physical workload

•Builders and most of agricultural workers, miners, workers in oil and gas
industry, manufacture of building materials, metallurgists and smelters,
workers in cellulose and paper and woodwork industry, carpenters.
•CPA = 2.2
•Daily energy requirements vary from 2850 to 3050 kcal for women,
from 3400 to 3850 kcal for men.

5 group – workers of extra heavy workload

•Machine service and workers in agriculture during sowing and harvesting
seasons, miners in underground works, steel makers, fellers, diggers,
bricklayers and concreters.
•CPA – over 2.5
•Daily energy requirements vary from 3750 to 4200 kcal for men.

34
 Special features of nutrition for intellectual work employees and
students.

Workload is characterised by minimal energy losses, hyperkinesias

and psycho-emotional tension.
Energy value of the diets should be adequate to energy losses (2000-2400
kcal).
Animal proteins should comprise at least 55% of total protein.
Ration is well balanced if p:f:c ratio is 1:1.1:4.7-4.9 for men and
1:1.1:4.4-4.7 for women.
Anti-cholesterol and lipotropic features are needed.
Requirements for group B vitamins are increased by 25-30%, for vitamin
С – by 30 %.
4 times per day nutritional regimen (25 %-20 %-35 %-20 %).
Increased requirements for wholemeal bread, vegetables, carrots,
fresh greens and fruits. Additional supplement with antioxidant vitamin
complex is advised.

Special features of elderly people nutrition organisation.

Is characterised by decreased metabolism, low motional activity,

endocrine disorders and slowed neuro-humoral regulation:
Energy value should be adequate to energy losses.
Protein requirements are 1g/kg of body weight, provided by dairy and
sour dairy food, fish and low fat meat.
Ration is balanced if p:f:c – 1:1.1:4.9-4.6 in men and 1:1:4.7-4.4 in
women).
Anti sclerosis (due to lecithin and other phosphotides, polyunsaturated
fatty acids, tocopherol, vitamins – choline, inosine, cyanocobalamine, folic
acid).
Food should stimulate activity of enzyme systems.
Ration should be diverse.
Amounts of sugar, pastry and animal fat are restricted, 25% of
carbohydrates are fruits and vegetables.
Nutrition is at least 4 times per day (energy distribution throughout the
day: 25-15-35-25 %).
35
Ration is enriched with vitamins-antioxidants, sour dairy products, dietary
fibre and pectin-containing products.

Special features of sportsmen nutrition organisation.

Sportsmen have high energy requirements during competitions

Up to 3500-4000 kcal for women and 4500-5000 kcal for men.
•Intensive muscular work is accompanied by high protein catabolism level,
so its requirements are calculated as 2 – 2.5 g/kg of body weight.
•1/3 of the ration should consist of easy digested mono - and disaccharides
in order to maintain sufficient glucose level.
•p:f:c – 1:0.7:4 in 4 times per day nutrition regimen.
•Consumption of fats is restricted, ration is supplemented with methionin
(cottage cheese, fish) to prevent fatty liver.
•To prevent acidosis food is enriched with higher pH products (milk, fruits
and vegetables – 15-20 % of ration energy value; Magnesium containing
products).
•Iron requirements are increased by 20 %.
•On the days of competitions and training no meals 3.5 hours before and
15-20 minutes after maximal loads.
•Ration is additionally enriched with high vitamin level products, or
multivitamin and mineral supplement.

Nutrition quality and safety are regulated by:

•Monitoring of quality and safety of raw food ingredients and food

products;
•Conduction of state policy in food quality and safety;
•Development of the measures aiming to prevent the use of low quality or
dangerous food products.

Food supplements and false products.

 food supplement – natural or artificial substances and their mixtures

specially added to food products during their processing or sale in order to
preserve the quality or achieve some properties;
36
 false products – raw ingredients and products in use with purposely
changed content and properties, in a way diminishing their nutritional
value, accompanied with incomplete or incorrect information.

Food quality.

Quality is a complex index, incorporating the following:

Nutritional value;
Biological value;
Consumption properties.

quality of food
Proteins The main building blocks of cells

Macroelements

Vitamins
Serve as body energy reserve
Fats

Microelements

Provide necessary energy for work

Carbohydrates

Nutritional value.

Nutritional value – complex of food features, providing physiological

requirements of a human being in energy and substances.
Biological value of food – ability to provide normal metabolism and
functional activity of the organism.
Consumption properties of food products determine possibility of
making various high quality tasty, well-digested and non-boring food out
of them.

37
 Food safety.
Safety – a complex of raw food ingredients, food products and
prepared food properties, due to which they are harmless and do not
possess any danger to life and health of current and future generations
under usual conditions of use.
The following are determined to detect food safety :
Degree of harmless;
Signs if spoilage/ damage.
Certification of quality and safety
Critical control point – stage of manufacturing or trade, when laboratory
technological control can be used.

Certification of quality and safety:

document, where legal person, or private entrepreneur certify the
compliance with quality and safety of a particular consignment of raw food
and food products to the requirements of legal documents of the Republic
of Belarus.

INFORMATION about the quality and safety of raw food and food
products can be placed on marking, label, pimple, etc. And should include:
Name of the product.
Reference to the legal document determining the requirements to quality
and safety.
Information about genetically modified ingredients / supplements.
Date of manufacture (expiry date, shelf life time).
Additional information about preventive properties of products is allowed
if relevant permission obtained from the Ministry of Healthcare of the
Republic of Belarus.

The state maintains food quality and safety by:

Development of standards and requirements;
Licensing and certification;
Hygienic regulation and registration;
State control, state supervision and quality control during manufacture,
Bringing to account guilty responsible persons.

38
 5. HYGIENIC BASICS OF THE CLINICAL AND PREVENTIVE
NUTRITION

Preventive nutrition is a group of specialized diets that give

protection for the health of people who work in the conditions of harmful
professional factors. Preventive nutrition is nutrition of HEALTHY man
who has daily contact with harmful factors at his work.

The aims of preventive nutrition:

•To increase health level.
•To increase organism resistance.
•To maintain high working capacity and lifetime.
•To reduce negative effects of the harmful substances.

The basics of preventive nutrition.

•Nutritional substances have protective properties against harmful factors
that can be used.
•Poisons should be promptly metabolized and removed from the body,
slowly absorbed in gastro-intestinal tract.
•Increase of the body resistance and functional capacity of the organs.
•Compensation of the higher requirements in biologically active substances
during poisons detoxication.

Main preventive nutritional factors - Proteins:

•bind toxic substances,
•raise antitoxic function of the liver,
•Sulfur-containing amino acids (methionine, cysteine) can produce
promptly metabolized and removed from the body complexes,

Main preventive nutritional factors - Fats:

•PUFA protect nervous system from chemicals (mercury, manganese).

Main preventive nutritional factors - Carbohydrates:

•raise antitoxic function of the liver,
•remove toxic substances from the body (dietary fiber, pectins).

39
 Main preventive nutritional factors – Vitamins and Minerals
•antioxidants (vitamins A, E, C) fight free radicals,
•increase body resistance,
•increase functional capacity of the organs (iron, calcium, magnesium).

Characteristics of the preventive diets:

Diet # 1
is administered for those working with radioactive substances and ionizing
radiation sources. Contains products enriched with lipotropic substances
(methionine, cysteine, lecytine) that raise antitoxic function of the liver.
Contains products of high biological value (milk, milk products, liver,
eggs) that increase general body resistance. Additionally – 150 mg of
ascorbic acid.

Characteristics of the preventive diets:

Diet # 2
is administered in chemical industry – production of the nitric and
sulphuric acids, chlorine, and phosphatic manures. Contains high quantity
of vegetables and cereals, full value animal proteins (milk, fish, meat),
PUFA (seed oil). Additionally – 150 mg of vitamin C, 2 mg of vitamin A.

Characteristics of the preventive diets:

Diet # 3
is administered in chemical industry – production of lead (Pb). Contains
high quantity of vegetables and fruits as a source of dietary fiber and
pectins. Additionally – 150 mg of ascorbic acid.

Characteristics of the preventive diets:

Diet # 4
is administered in chemical industry – production of the inorganic salts of
phosphorus, mercury, arsenic; organic products – benzol, phenol. Contains
milk, milk products, seed oils as a source of lipotropic substances. Meat
and fish dishes, mushroom soups, sauces are limited. Additionally – 150
mg of ascorbic acid, 4 mg of vitamin B1.

40
 Characteristics of the preventive diets:
Diet # 5
is administered in chemical industry - production of carbon disulfide,
acetaldehyde, and phosphoric poisonous chemicals. Contains eggs, PUFA
(seed oil), vitamin B1 and full value animal proteins for nervous system
and liver protection. Additionally – 150 mg of ascorbic acid, 4 mg of
vitamin B1.

People who work in the conditions of high temperature, infrared

radiation or in tobacco industry get vitamins as preventive nutrition.
People who work with weak acids and alkali or other chemical substances
get milk.

Vitamin supplement
 provided for individuals working in hot environment (smelt and
rolling metal, glass manufacture, bakery): Vit A 2 mg, Vit B1 3 mg, Vit
B2 3 mg , Vit PP 20 mg and Vit C 150 mg,
 workers at tobacco and nicotine manufactures – Vit B1 2 mg and Vit
C 150 mg.
Milk
provided daily during the working days, 0.5 l per day,
may be replaced with soured milk, kefir or colibacter (in antibiotics
manufacturing).

Clinical nutrition is scientific system of the nutrition organization

and differentiated use of certain food substances and their combinations for
treatment aims. Clinical nutrition is an important part of the complex
treatment of ILL man. Clinical diets have different modifications according
to severity of disease, indications and contraindications, concomitant
diseases, dietary and national habits.

The basics of clinical nutrition.

•To provide ill man with physiological requirements in nutritional
substances.
•To provide digestion in enzymatic pathology.
•Interaction of the nutritional substances in the gastro-intestinal tract.
41
•Modification of the dietary habits for the biochemical and physiological
processes training.
•Local influence of the food on organs of sense and gastro-intestinal tract.
Sparing diet: mechanic, chemical, thermal spare.
•Methods of training, reducing diets and contrast days.
•Food intake – 5-6 times per day, variety of dishes.

Characteristics of standard clinical diets

The basic diet - Diet B

Diet with a physiological content of proteins, fats and carbohydrates,
enriched with vitamins, minerals, fiber (vegetables, fruit). Nitrogenous
extractives, salt (6-8 g / day) are limited, spicy dressing, spinach, sorrel,
smoked food are excluded. Meals are cooked as boiled, steamed, or baked.
The temperature of hot dishes - not more than 60-65 ° C. Free fluid - 1.5-
2l. Meals 4-6 times a day.
Indications:
Diseases and conditions that do not require special medical diets.
Diabetes mellitus type 2.
Chemical content:
Protein - 90-95g (including animal - 40-45g).
Fat - 79-80g (including vegetable - 25-30g).
Carbohydrates - 300-330g, including mono-and disaccharides (30-
40g), refined carbohydrates are eliminated from the diet of patients with
diabetes mellitus type 2.
Energy - 2170-2400 kcal.
Vitamin C - 70 mg

Ration with mechanical and chemical spare - Diet P

Diet with physiological content of proteins, fats and carbohydrates,
enriched with vitamins, minerals, with a moderate restriction of chemical
and mechanical stimuli of mucosa receptor apparatus in gastrointestinal
tract. Tapas, condiments, spices are excluded, salt is limited (10 g / day).
Meals are cooked as boiled or steamed, mashed. Temperature of dishes -
from 15 to 60-65 ° C. Free fluid - 1.5-2l. Meals 5-6 times a day.

42
 Indications:
Diseases of the digestive system, requiring the appointment of a diet
with mechanical and chemical sparing. The period after the operations on
the internal organs.
Chemical content:
Protein - 85-90g (including animal - 40-45g).
Fat - 79-80g (including vegetable - 25-30g).
Carbohydrates - 300-350g, including mono-and disaccharides (50-
60g).
Energy value: 2170-2480 kcal.

A diet with a high protein content - DIET M (high-protein)

A diet rich in protein, a normal amount of fat, and carbohydrate
restriction. Salt is limited (6-8 g / day), chemical and mechanical spare.
Meals are cooked as boiled, stewed, baked, mashed. Temperature of dishes
- from 15 to 60-65 ° C. Free fluid - 1.5-2l. Meals 4-6 times a day.
Indications:
The diseases and conditions requiring the introduction of increased
amounts of protein (malabsorption, kidney disease with nephrotic
syndrome without complications, diabetes mellitus type 1, sepsis and other
serious bacterial infections, severe anemia).
Chemical content:
Proteins - 110-120 g (including animal - 45-60 g). Fat - 80-90 g
(including plant - 30 g).
Carbohydrates - 250-350 g, including mono-and disaccharides (30-40
g) refined carbohydrates are excluded for the patients with diabetes.
Energy - 2080-2650 kcal.
Vitamin C - 70 mg.

A diet with low protein content - Diet H (low protein)

Diet with protein restriction to 0.8 or 0.6 or 0.3 g / kg of ideal body
weight (60, 40 or 20 g/day) – depending on severity. Salt (2-3 g / day) and
liquid (0.8-1 l / day) are limited. Nitrogenous extractives, cocoa, chocolate,
coffee, salty snacks are excluded. The dishes are cooked without salt in
boiled form. A diet is enriched with vitamins and minerals. Meals 4-6
times a day.
43
 Indications:
Chronic glomerulonephritis with complications. Liver cirrhosis with
hepatic encephalopathy.
Chemical content:
Proteins - 20-60 g (including animal - 15-30 g).
Fat - 80-90 g (including plant - 20-30 g).
Carbohydrates - 350-400 g, including mono-and disaccharides (50-
100 g).
Energy - 2120-2650 kcal.
Vitamin C - 70 mg.

A diet with high protein and calorie content - Diet T (High-protein and
high-calorie)
A diet with a high content of proteins, fats and carbohydrates. Meals
are cooked as boiled, stewed, baked form. Temperature of dishes - from 15
to 60-65 ° C. Free fluid - 1.5 l. Sodium chloride – 15g. Meals 4-6 times a
day.
Indications:
Tuberculosis of the lungs. Burn disease.
Chemical content:
Proteins - 110-130 g (including animal - 70-80 g).
Fat - 100-120 g (including plant - 20-30 g).
Carbohydrates - 400-450 g
Energy - 3000-3400 kcal.
Vitamin C - 70 mg.

44
6. NUTRITIONAL AND BIOLOGICAL VALUE OF THE PRINCIPAL
FOODS

Classification of the foods by nutritive value:

•Milk and dairy products;
•Meat and meat products;
•Cereals;
•Vegetables and fruits;
•Fats, oils, sugar and sweeties.

Milk and dairy products are important as a source of:

•full-value proteins;
•easily absorbed Ca;
•Vitamins A, B2, B12.
•Limitation: fatty dairy products contain saturated fatty acids and
cholesterol.

Milk proteins:
•are easily absorbed,
•contain all essential amino acids,
•casein milk (75% and more of casein) – cow, goat,
•albumin milk (50% and less of casein) – mare milk.

Milk fats:
•triglycerides (98.2-99.5% of all fats),
•phospholipids,
•free fatty acids,
•sterols.

The carbohydrate in all milks is lactose.

45
 Nutritive value of cow milk:

Proteins 2.5-4.8 %

Fats 0-6 %

Carbohydrates 4-5,6 %

Vitamins and minerals About 1 %

Water 83-89 %

Energy value (3.2% fat) 60 kcal/ 100 g

Physical and chemical properties:

3
•Density, g/sm – 1.027 and more.
•Acidity, T, not more than 21.
•Milk can be additionally fortified with vitamin C in dose 10 mg per 100 g.

Milk can be a source of the various infections and food-borne diseases:

•Tuberculosis,
•Brucellosis,
•Streptococcal infections,
•Staphylococcal food poisoning,
•Salmonellosis,
•Enteropathogenic E. coli food poisoning,
•Decontamination - pasteurization or sterilization.

Bacteriological quality of the pasteurized milk:

•Coliform Count: Coliforms are absent in 1 ml of milk.
•Standard Plate Count: 50,000 bacterial count per 1 ml.
•Pathogenic bacteria: Salmonella is absent in 25 ml; Staphylococcus aureus
is absent in 1 ml.

46
 Meat products are important as a source of:
•full-value proteins;
•easily absorbed Fe;
•Zn;
•Vitamins group B, including B12.
•Limitation: some meat products contain high amounts of the saturated
animal fats.

Nutritional properties of meat:

•it contains proteins, fats and carbohydrates;
•proteins contain all essential amino acids;
•there are extractive substances that stimulate appetite – carnosine, purine
bases, glucose, lactic acid;
•proteins are easily absorbed;
•high assimilation;
•appetite saturation;
•can be consumed every day;
•various meals to cook;
•availability.

Composition of meat:
•muscle tissue (lysine, actin, globulin, myoglobin),
•fatty tissue (saturated fats),
•connective tissue (collagen, elastin),
•blood,
•bones.

47
 Nutritive value of meat:
Proteins 11-21 %
Fats 8-19 %
Carbohydrates only in fresh meat,
about 1%
Vitamins and minerals about 2 %
Extractive substances about 1 %

Water 68-74 %
Energy value (beef) 218 kcal/ 100 g

Intestinal parasitic infections

•Beef tapeworm infection (Taenia saginata),
•Pork tapeworm infection (Taenia solium),
•Trichinosis (Trichinella spiralis).

Beef tapeworm infection

•Eggs are ingested by cattle.
•The eggs hatch in the cattle, invade the intestinal wall and are carried by
the bloodstream to striated muscle, where they encyst.
•Humans ere infected by eating the cysts in raw or undercooked beef.

Trichinosis
•results from eating raw or inadequately cooked or processed pork or pork
products (rarely, meat of wild animals, especially bears), containing
encysted larvae (trichinae).

Sanitary inspection
•includes microscopic analysis of the meat samples.
•The samples of diaphragm, tongue, pectoral and intercostal muscles are
taken for the analysis.
•The detection of 1 trichinae in 24 samples or > 3 cysts of Taenia in 40 sm2
results in the utilization of the meat.
48
 Nutritional properties of poultry:
•it contains less connective tissue;
•muscle tissue does not contain much fat;
•proteins contain all the essential amino acids;
•fats contain unsaturated fatty acids;
•there are more extractive substances (up to 10%), especially in wild birds.

Fish
•Rich in proteins with good biological value.
•Satisfactory amino acid balance.
•Sea fish is a rich source of iodine and iron.
•The fat of fish is rich in unsaturated fatty acids, especially ω-3 group and
A and D vitamins.

49
Limitation: Fish has low appetite saturation and cannot be consumed
every day.

Nutritive value of the fish:

Proteins 10-25 %
Fats 2-10 %
Carbohydrates about 1%
Vitamins and minerals 1-3 %
Extractive substances 2-4 %
Water 57-83 %
Energy value 80-120 kcal/ 100 g

Tapeworm infection caused by Diphyllobotrium latum.

• The adult worm has several thousand proglottids and measures 4-9 m
in length.
• Eggs are released from the proglottid in the intestinal lumen. As the
egg hatches in fresh water, it releases the embryo, which is eaten by
small crustaceans. They may, in turn be ingested by fish.
• Humans are infected by eating raw or undercooked infected fish.
• Prevention: all freshwater fish should be thoroughly cooked or frozen
at -10 ˚C for 48 h.

Eggs

• Contain all the nutrients except carbohydrates and vitamin C.

• Proteins have all essential amino acids and are considered as the best
food proteins.
• Contains all fat-soluble and water-soluble vitamins in appreciable
amounts.
• Limitation: high content of cholesterol (250 mg/egg).
50
 Nutritive value of the egg:
Proteins 13 %
Fats 11.5 %
Carbohydrates 0,5 %
Vitamins and minerals 1%

Water 74 %
Energy value 157 kcal/ 100 g

The quality of the eggs

•is controlled by the shell condition and by ovoscopy.
•Microorganisms including pathogenic Salmonella penetrate a cracked
shell and enter the egg.
•Composition of the egg: shell, egg white, egg yolk.

Cereals are important as a source of:

•dietary fiber;
•starch (energy);
•vitamins group B;
•Fe and other minerals.

•There are almost no limitations for the cereals consumption if no fat and
sugar are added.

51
 Nutritive value of wheat:
Proteins 6-10 % deficient for the
essential amino acids
Fats About 1 %
Carbohydrates 45-50 %
Vitamins and minerals About 1 %
Water 30-40 %
Energy value 330 kcal / 100 g

Vegetables and fruits are important as a source of:

•dietary fiber;
•vitamin C;
•β-carotene;
•folic acid;
•K;
•water.
•Contain low amounts of fats, Na. Have low energy value.

Nutritive value of vegetables and

fruits :

Proteins 2-3 %
Fats absent
Carbohydrates 20-30 %
Vitamins and minerals About 1 %
Water 70-95 %
Energy value 10-80 kcal/ 100 g

52
 Fats and oils.
•vegetable oils,
•mayonnaise.
•Butter,
•animal fats.

Butter consists of:

•60-90% milk fat;
•0.002-0.008 mg vitamin D2;
•0.6 mg vitamin A;
•0.4 mg β-carotene;
•2-5 mg vitamin E;
•Energy value 700 kcal/ 100 g.

Food quality examination

•is based on the official state standards and includes the following indices:
•Organoleptic properties – taste, color, smell, appearance, consistence.
•Physical and chemical properties – fat content, acidity, density,
temperature, phosphotase (milk).
•Bacteriological quality - Coliform Count, Standard Plate Count,
Pathogenic bacteria (milk).

According to the quality all products can be divided in:

•Edible products have all properties according to the state standard. They
can be used without any limits.
•Conditionally edible – products have problems in their quality and have
to be additionally processed (for example – thermal cooking) to become
safe for the consumption.
•Reduced nutritive value products - have problems in their quality that
low nutritive value but are safe for the consumption.
•Faulty products – have artificially added properties that hide low quality
of the product.

53
 7. HYGIENIC ASSESSMENT OF THE NUTRITIONAL STATUS

Nutritional status is the balance between the intake of nutrients by

an organism and the expenditure of these in the processes of growth,
reproduction, and health maintenance. Because this process is highly
complex and quite individualized, nutritional status assessment can be
directed at a wide variety of aspects of nutrition:
 nutrient levels in the body,
 the products of their metabolism,
 the functional processes they regulate.

Nutritional status can be measured for individuals as well as for

populations. Accurate measurement of individual nutritional status is
required in clinical practice. Population measures are more important in
research. They can be used to:
 describe nutritional status of the group,
 identify populations or population segments at risk for nutrition-
related health consequences,
 evaluate interventions.

The choice of nutritional status assessment method must be made

mindful of the level at which one wants information, as well as of the
validity and reliability of the method. All methods have error. All methods
produce imperfect measures that are indirect approximations of the
process. Whatever method is chosen for assessment of nutritional status,
the data obtained must be compared with reference data to produce an
indicator of nutritional status. The quality of the available reference data
is, therefore, another factor that affects the assessment data.
Ideal methods are sensitive and specific. Unfortunately, it is difficult
to achieve both in the assessment of nutritional status. Sensitivity refers to
the ability of a technique to correctly identify those affected by a condition
(for example, undernutrition) as having that condition. Specificity refers to
the ability of a technique to correctly classify normal individuals as having
normal nutritional status.
Body mass index (wt/[ht]2) is a global measure of nutritional status
that illustrates the difference between these two constructs. Most persons
54
who consume insufficient energy have low body mass index, so the
measure is sensitive. However, there are other causes of low body mass
index, including genetics and disease, so body mass index is not specific to
nutritional status.

The assessment of nutritional status is commonly summarized by

the mnemonic "ABCD," which stands for:
 anthropometric measurement,
 biochemical or laboratory tests,
 clinical indicators,
 dietary assessment.

Anthropometric Approaches to Nutritional Status Assessment

Anthropometric approaches are, for the most part,

relatively noninvasive methods that assess the size or body composition of
an individual. For adults, body weight and height are used to evaluate
overall nutritional status and to classify individuals as at healthy or
nonhealthy weights. The emphasis for unhealthy weight is over-weight
and obesity. The standards for these have changed over time. The most
recent classification is to use body mass index (BMI, in kg/m2):
 normal at 18.5 to 25.0 kg/m2,
 overweight at 25.0 to 29.9 kg/m2,
 obese at over 30.0 kg/m2 .
In general BMI greater than 30 is assumed to be due to
excessive adiposity.

In children, growth charts have been developed to allow researchers

and clinicians to assess weight-and height-for-age, as well as weight-for-
height. For children, low height-for-age is considered stunting, while low
weight-for-height indicates wasting. In addition to weight and height,
measures of mid-arm circumference and skinfold measured over
the triceps muscle at the mid-arm are used to estimate fat and muscle mass.
Anthropometric measures of nutritional status can be
compromised by other health conditions. For
example, edema characteristic of some forms of malnutrition and other
55
disease states can conceal wasting by increasing body weight. Head
circumference can be used in children 36 months and younger to monitor
brain growth in the presence of malnutrition. Brain growth is better spared
than either height or weight during malnutrition.
To interpret anthropometric data, they must be compared with
reference data. Because well-nourished children in all populations follow
similar patterns of growth, reference data need not come from the same
population as the children of interest. It is of greater importance that
reference data be based on well-defined, large samples, collected in
populations that are healthy and adequately nourished.

Choosing a Dietary Approach to Nutritional Status Assessment

Several techniques exist for collecting dietary data with which to

estimate nutritional status. Because these techniques vary in cost for data
collection, burden on the respondent, and which aspects of diet they are
designed to measure, it is important to clearly articulate the goals of dietary
assessment of nutritional status before choosing an assessment strategy.
The primary consideration in choosing a dietary assessment method
is the specific type of data needed. Is the research intended to document
intake of "foods" or of "nutrients"? If the answer is foods, the method must
take account of the population's foodways:
 variability in food intake patterns (for example, day-today,
seasonal, ritual cycles);
 differences in food consumption by sex, age, and ethnicity;
 what items the population considers to be legitimate "food."

If the objective is to measure nutrient intake, the method must take

into account several additional factors:
 food preparation techniques, including the addition of
condiments and the effects of the technique on nutrient
composition of the food;
 sources of error in the determination of amounts of foods
consumed;
 differentiation distribution of nutrients among foods;

56
  the contribution of "non-food" consumption (such as betel
nut, laundry starch, and vitamin and mineral supplements) to
total nutrient consumption.

Another important consideration is the time period the data are

intended to represent. If the period is a relatively discrete one, it may be
possible to document diet quite precisely. However, if the interest is in
measuring "usual" diet, the methods must allow this abstract concept to be
estimated statistically.
Population measures of dietary status can be derived either from data
describing the entire population or population sub-group, or from data
describing samples of individuals. Population-wide data include food
availability figures, which allow the assessment of food balance - the
amount of food produced or imported by a population less that exported or
used as nonhuman food. Such measures are necessarily crude, as they do
not measure consumption directly. Another approach to measuring dietary
status of groups has been to focus on the household. Indirect data on
household food intake can be derived from records of foods brought into
the household or from pantry inventories. Because of variations in
intrahouse-hold distribution of foods, such techniques cannot be used to
estimate individual intakes.
By far the most precise way of measuring dietary intake is to gather
data on individuals. These methods depend on identifying a period of time
for which data are needed, measuring food quantities consumed, and then
translating these into nutrient amounts, either through direct chemical
analysis or (more commonly) using food composition tables.

Common Methods for Dietary Data Collection

The most valid, or accurate, dietary methods are prospective

methods. These involve keeping records of foods consumed over the
period of time of interest. This can be done by individuals themselves, or
by others observing them. Sometimes the foods are weighed before eating
and then plate waste is weighed and subtracted. A similar method is to
prepare two duplicate meals; one is consumed by the subject and the other
is analyzed for nutrient content. Another method is the dietary record, in
57
which the subject records estimated amounts of foods consumed. In any
case, these methods are highly reactive because individuals may alter usual
behavior to make their diet more socially desirable or to simplify the
process of record keeping.
Recall methods are the most widely used type of dietary data
collection method. They are less reactive, but also less accurate than record
methods. Twenty-four hour recalls, in which the previous day's intake is
queried in detail (for instance, foods, amounts, preparation techniques,
condiments) are easiest for individuals to complete. The data reported are
converted from foods to nutrients with the use of food composition tables.
Because a single day is not representative of usual intake, multiple twenty-
four hour recalls are frequently used. These multiple recalls can be thought
of as sampling from an individual's ongoing food behavior. The number
necessary to reliably measure diet depends on the nutrient of interest.
Nutrients widely distributed in food (such as carbohydrates) require fewer
days than nutrients not widely distributed (such as cholesterol). The
number of recalls needed also depends on the nature of the diet. In societies
where day-to-day and season-to-season food intake varies, more days are
needed than where diets are more monotonous.
The semiquantitative food frequency is a recall method in which an
individual summarizes the diet to produce a measure of usual intake. For a
list of foods commonly eaten, the individual estimates how frequently the
food has been eaten in the time period in question (often, one year) and in
what amount. Food composition tables are then used to estimate the usual
daily intake. This method combines low burden on the individual with low
cost. It has been widely used and studied, as it is the foremost method used
in nutritional epidemiology. Research has examined how best to formulate
a list of foods, how to present the foods to the subject, and whether portion
sizes should be included.
Because the act of estimating frequency of intake is assumed to be
based on cognitive processes, research has examined how best to maximize
reliability and validity of food frequency data by focusing on the cognitive
tasks experienced in the course of completing a food
frequency questionnaire. This includes questions such as whether a long
list of individual foods should be presented (for example, skim milk, 2
percent milk, whole milk) or whether foods should be nested (for example,
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questions about the presence or absence of milk in the diet separated from
the variety of milk). The results of these analyses have been mixed but
suggest that incorporation of formatting changes based on cognitive theory
will enhance the accuracy of reporting.
There has also been recent discussion of the actual task of
summarizing and estimating intake experienced by the subject. The
traditional explanation that persons completing a food frequency
questionnaire actually retrieve and integrate past behavior to achieve an
average dietary intake has been challenged by arguments that persons
answer food frequency questionnaires in terms of a composite image of
themselves and their diet, rather than a statistical estimate. If the latter is
the case, one might expect that attempts to minimize error will reach a
threshold of error that is unlikely to be crossed without a major conceptual
shift in dietary data collection techniques for nutritional status assessment.

Classification of the nutritional status

To the usual or optimal nutrition status is necessary to concern

persons with the fat contents in a body 12-18% or having BMI within the
limits of 20,0-25,0 kg /m2. At that functional and adaptable opportunities of
an organism provide optimal conditions of vital activity. Such nutrition
status takes place among the most young people accepting an adequate
diet.

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 The decreased status is characterized by fat quantity in a body 9-
12% or BMI from 18,5 up to 20,0 kg/m2. It can be caused by the
constitutional and adaptable features of the organism, an inadequate
nutrition, physical and nervous-and-emotional loadings. Preservation of
functional adaptable organism opportunities or their insignificant reduction
at inadequate nutrition take place.
People concern to the increased nutritional status with a fatty
component of body from 18 up to 21% (BMI - 25,0-27,5 kg/m2). Such
status is formed as a result of consumption of diets, at which energy
expenses of organism less then consumption. Essential changes of
functional and adaptable opportunities are not marked, though some
reduction takes place.
The insufficient nutritional status arises at quantitative or
qualitative inadequacy of nutrition, and also at reduction or full
impossibility of nutrients assimilation. Therefore the body structure,
functional both adaptable reserves and opportunities of organism can be
broken. Persons with such nutritional status (fat content in organism less
than 9%, BMI - not less than 18,5 kg/m2) are subject for medical inspection
and treatment. The insufficient nutritional status is subdivided on pre-
morbid (latent) and morbid.
Pre-morbid status is characterized by occurrence of microsymptoms
of nutrient’s insufficiency, deterioration of functions of the basic physical
systems, decrease of the general resistency and adaptable processes even in
usual conditions of vital activity. Morbid or the painful status is
characterized not only functional and structural infringements, but distinct
syndrome of nutrient insufficiency development.

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 8. ALIMENTARY (NUTRITIONAL) DISEASES AND FOOD
POISONING

Alimentary (nutritional) diseases are diseases associated with

deficiency or excess of the nutritional substances or bad quality food
consumption.

Diseases of the nutritional deficiency:

•Protein-energy malnutrition (PEM).
•Mineral deficiency.
•Vitamin deficiency.
•Amino acid and PUFA deficiency.

Alimentary anemia:
•Fe-deficient anemia.
•Other (vitamin B6, B12, folate-deficient).

Diseases of the nutritional excess:

•Obesity.
•Hypervitaminosis.
Food poisoning:
•Bacterial.
•Nonbacterial.
•Uncertain etiology.

Starvation (alimentary dystrophy) – structural and functional

changes due to inadequate intake of nutrients and energy sourсes.

Exogenous reasons:
•natural disasters,
•catastrophes,
•wars,
•voluntary starvation.

Endogenous reasons:
•Anorexia,
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•impaired digestion,
•disordered absorption,
•endocrine dysfunction,
•prolonged infections,
•surgical procedures,
•malignant tumors.

3 degrees of severity:
•Mild. Carbohydrates and fat are utilized. Hunger.
•Moderate. Body weight loss. Biochemical changes (protein catabolism,
electrolyte depletion, anemia).
•Severe. Total body fat loss. Anorexia. Muscular atrophy. Mental
disorders.

Prevention:
•Public – to provide with sufficient quantity of food.
•Individual – medical treatment.
A diet with excessive non protein calories from starch or sugar, but
deficient in total protein and essential amino acids results eventually in
Kwashiorkor. This is a disease of children aged 1-5 years in rural Africa.

Kwashiorkor is characterized by
•generalized edema,
•``flaky paint`` dermatosis,
•thinning and decoloration of the hair,
•enlarged fatty liver,
•retarded growth,
•generalized infections.

Obesity – the excessive accumulation of body fat. Obesity leads to

hypertension, atherosclerosis, MI, diabetes mellitus.

Etiology:
•imbalanced diet and low physical activity;
•genetic and developmental factors;
•social factors;
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•endocrine and metabolic factors;
•psychological factors and brain damage.

Food poisoning is any disease of the bacterial or toxic nature caused by or

thought to be caused by the consumption of food.

Bacterial food poisoning

•Occurs singly (sporadic cases) or in outbreaks where two or more cases
are related to food consumption.
•Has a short incubation period.
•Can`t be transmitted from man to man.
•Has a sudden onset, short duration of illness.

Bacterial food poisoning:

•infection type (E. coli, P. vulgaris, Cl. perfringens type А, Bac. cereus,
Str. faecalis and other).
•toxic type

Toxic type
•bacterial (Staph. aureus, Cl. botulinum),
•Mycotoxicosis (toxin-producing moulds Aspergillius, Fusarium,
Penicillium, Claviceps purpurea).

Prophylactic measures:
•Prevention of food contamination.
•Prevention of bacterial reproduction in food.
•Sufficient thermal treatment of food to kill bacteria.

Staphylococcal food poisoning – an acute syndrome of vomiting and

diarrhea caused by ingestion of food contaminated by staphylococcal
enterotoxin.

Prophylaxis
•Careful food preparation is essential to prevent these episodes. People
with Staphylococcal diseases should not prepare food.
•Prevention of bacterial reproduction in food.
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•Veterinary control of animals.

Botulism – neuromuscular poisoning by Clostridium botulinum

toxin. Botulism occurs in 3 forms: foodborne, wound and infant botulism.

Botulism. Clinical symptoms

•The incubation period is 12 to 36 hours;
•Dry mouth, dizziness, double vision (diplopia), loss of accommodation
and inability to open eyes fully (blepharoptosis);
•Bulbar paresis (dysarthria, dysphagia, nasal regurgitation);
•Nausea, vomiting and diarrhea.

Prophylactic measures
•Proper home and commercial canning and adequate heating of home-
canned food before serving are essential.
•Canned foods showing any evidence of spoilage should be discarded.
•Anyone known or thought to have been exposed to contaminated food
must be carefully observed.
Mycotoxicosis
•gangrene and convulsions (ergotism),
•renal disease (Balkan nephropathy),
•liver cancer (aflatoxicosis).

Nonbacterial food poisoning

Classification:
•Food poisoning of plant origin.
•Food poisoning of animal origin.
•Mushroom poisoning.
•Chemical poisoning.

Food poisoning of plant origin

•Many wild and domestic plants contain poisons in their leaves and fruit.
Common examples include yew, morning glory, nightshade, castor bean,
dieffenbachia (dumb cane), jequirity bean (`Indian bean`).

64
 Red kidney beans
•A number of toxic substances can be extracted from the beans, but current
evidence suggests that the haemagglutinin component is probably
responsible for diarrhea and vomiting. Much of this substance is leached
out by soaking beans for several hours, and thorough cooking will render
them safe.

Solanine
•Potatoes that are left to sprout or that are exposed to sunlight in such way
that the skin surface becomes green, will accumulate the alkaloid solanine
in skin and just below the surface. Peeling and washing will render them
safe, but jacket potatoes have caused some cases of poisoning.

Ciguatera poisoning
•can occur after ingestion  400 species of fish from the tropical reefs
where dinoflagellate supplies a toxin that accumulates in the marine
animals flesh. The fish flavor is unaffected and any processing procedures
are not protective.

Histamine poisoning
(scombroid fish)
•from tuna, skipjack and mackerel and, occasionally, herring and sardine
may become contaminated with spoilage organisms, which can convert the
amino acid histidine in the tissue to histamine.

Tetraodon poisoning
•from the puffer fish causes similar symptoms and signs, death may result
from respiratory paralysis.

Paralytic shellfish poisoning

From June to October mussels, clams, oysters and scallops may ingest a
poisonous dinoflagellate (red tide) that produces a neurotoxin resistant to
cooking.

Mushroom poisoning
•A. pantherina (false blusher)
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•A. muscaria (fly agaric)
•A. phalloides (death cap)
•A. virosa (destroying angel)

Prophylactic measures:
•Collect only known mushrooms.
•Adults should control children in collecting mushrooms.
•Only sorted mushrooms can be sold.
•Products in which mushrooms are cut and mixed can`t be sold.

Chemical poisoning
•may follow ingestion of unwashed fruits and vegetables sprayed with
arsenic, lead, or organic insecticides; liquids served in lead-glazed pottery;
or food stored in cadmium-lined containers.

Pesticides
•These substances are used to control pests of various kinds on wheat
seeds, fruit trees and vegetables. If ingested they are absorbed and
particularly affect the CNS. Mortality is about 8%.

Metals
•Mercurials discharged into the sea may be taken up by fish and cause
nephritis and CNS damage in people who ate them. Zinc leached from
galvanized pans when acid materials, such as fruit, are boiled in them is
toxic and causes acute abdominal symptoms.

Doctor`s actions in a food poisoning case:

•To organize medical aid.
•To prevent suspicious food consumption by other people.
•To inform sanitary service about food poisoning case.
•To organize biological materials collection (vomit and fecal mass, blood,
urine) for laboratory analysis.

Food poisoning investigation

Stage 1:
•Presumptive epidemiological diagnosis and its characteristics.
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 Stage 2:
•Inspection of the object connected with a food poisoning case.
•Microbiological analysis of the stuff and equipment.
•Laboratory analysis of the biological materials from the patients.
•Blood analysis for the serum diagnostics.
•Internal organs investigation in lethal cases.

Stage 3:
•Decryption of the food poisoning mechanism.

Stage 4:
•Dangerous food utilization.
•Infection source isolation.
•Object disinfection.
•Bacteria reproduction prevention.

Stage 5:
Compilation of the food poisoning investigation Act.

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9. HYGIENIC REQUIREMENTS FOR THE NUTRITION PROVISION
UNITS AND CATERING IN HOSPITALS

Nutrition provision unit structure:

•storage facilities,
•working area,
•personnel facilities,
•service space.

Storage facilities:
•freezing chambers (to store meat, fish, milk),
•storerooms (to store vegetables, flour, sugar, cereals).

Working area:
•vegetable processing room,
•meat processing room,
•fish processing room,
•kitchen or cookroom.

Personnel facilities:
•checkroom,
•shower,
•lavatory,
•personnel`s dayroom,
•offices.
Service space:
•washing chamber,
•daily food storeroom.

Main principles of the sanitary and epidemiological safety:

•producing sequence (sufficient quantity of the equipment, correct
planning);
•principle of division (different types of products should not contact each
other);
•commodity vicinity (different types of products should not influence on
the quality of each other).
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 Nutrition units equipment is classified as:
•mechanical (powered);
•unpowered;
•thermal;
•refrigerating.

Nutrition provision unit equipment:

Mechanical equipment Unpowered equipment

washing machine tables

potato peeler knives
vegetable slicer shelves
mincing machine bath
bread slicer cutting boards

Nutrition provision unit equipment:

Thermal equipment Refrigerating

equipment
gas-stove cooling chamber
frying pan cooling counter
frying machine refrigerator

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 Qualitative characteristics of the equipment materials fitness:
•should be harmless;
•taste property should not be worse;
•should have smooth surface;
•should provide with reliable protection against contamination;
•simple and effective treatment.

Materials that possess sanitary requirements:

•metals (stainless steel);
•wood;
•glazed pottery, porcelain and clay;
•glass;
•paper;
•polymer (polyethylene, rubber);
•combined materials (polyethylene film with paper, aluminum foil).

Sanitary requirements for the transport, reception and storage of food:

•separate storage and transport of the different kinds of food;
•storage conditions;
•expiry date;
•sanitary conditions of storage facilities, working area, transport,
equipment.

It is prohibited:
•to admit products with expired date of realization;
•to admit some kinds of the products (duck and goose eggs);
•to keep uncooked products together with cooked meal;
•to keep spoiled products;
•to keep inedible materials together with food.

Cooking process should provide the following:

•good organoleptic properties (taste, smell);
•sufficient nutritive value;
•food safety.

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 Cooking process consists of:
•primary processing;
•intermediate food processing (cold processing);
•thermal processing;
•cooked meal realization.

Cooked meal realization:

st
•1 course dishes should have temperature not lower than 75°С;
•2nd course dishes should have temperature not lower than 65°С;
•cold dishes temperature should be 7-14°С;
•cooked meal should be given to patients within 2 hours after cooking.

Nutrition unit’s documentation:

•Product invoices.
•Bills of fare.
•Personnel’s health register.
•Food quality-control register.
•Expiry date control register.
•Vitamin addition register.
•Nutrition unit’s sanitary state register.
•Personnel’s sanitary books.

Personnel’s medical examination:

•preliminary medical examination before the work;
•recurrent medical examination during the work.

Contraindications for the work in nutritional sphere:

•Enteric infections (typhoid fever, dysentery, salmonellosis).
•Bacteria carrying without clinical symptoms.
•Helminthic diseases.
•Venereal diseases (gonorrhea, lues).
•Tuberculosis.
•Skin diseases (scabies, pediculosis).
•Skin injures.
•Chronic inflammatory diseases of the eyes, skin, throat.
•Actinomycosis.
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•Fecal fistula.
•Putrefactive catarrh.

Catering in hospitals.
Head physician, General supervision
deputy head physician
Division Nutrition control in the
superintendent hospital departments
Dietarian, dietary nurse Medical and scientific
basics, direct
manufacturing
inspection
Assistant manager Providing with
products, equipment,
direct personnel’s
control

Catering in hospitals.
Doctor Prescribes the patient
clinical diet
Head nurse Arranges nutrition
orders
Dietary nurse Arranges bill of fare
based on nutrition
orders
Nutrition unit personnel Cooks the meal

Lunchroom personnel Serves meal to the

patients

Control for the parcels:

•the lists of the allowed and prohibited products;
•patient should be informed about the rules of parcel reception;
•nurse on duty controls rules of parcel storage;
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•products are stored in refrigerator.

The quality-control commission:

•administrative manager,
•dietarian or dietary nurse,
•cook,
•doctor on duty.

Nutrition sanitary control methods:

•organoleptic evaluation: taste, smell, color, consistence;
•calculating method: using tables or programs of chemical composition
we can count how much daily meal contains proteins, fats, carbohydrates
and so on.
•dishes weight and volume control;
•laboratory chemical analysis.

Reference data needed to arrange bills of fare:

•Clinical diets characteristics;
•Physiological nutrition regulations;
•Regulations of daily food quantity per one patient;
•Cookbooks.
•Tables or programs of chemical composition and energy value of diets;
•Production costs;
•Products trade off references;
•Product cooking loss, cooked dishes weight and volume.

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 10. HYGIENIC REQUIREMENTS FOR HEALTHCARE
INSTITUTIONS (HCI) PLACEMENT.
SITUATION AND GENERAL CONSTRUCTION PROGRAMMES

General hygienic requirements for healthcare institutions:

•Natural or anthropogenic factors must not produce negative effects on the
territory of HCI.
•A favourable for treatment environment and safe conditions for the staff
and visitors should be created in HCI.
•Institution should not be dangerous for people living nearby.

Situation construction programme of the HCI

Situation construction programme is allocation of a ground area
for institution aligned with:
built-up areas,
green plantations,
water sources,
communications,
other objects which may affect ecological, medical or epidemiological
conditions of the ground area.
The ground area is allocated aligned with local climate and nature
conditions.

Hygienic principles of building include:

correct choice of a geographical location;
plan of prophylactic measures on atmospheric air and soil, prevention of
harmful influences of noise, vibration, electromagnetic fields and other
negative factors;
possibility of arranging all modern facilities (sanitation, collection,
moving away and sterilization of hard waste, gas and electric supply, etc.);
functional zoning of the territory.

CORRECT CHOICE OF THE TERRITORY -

Healthcare institutions can be placed in residential area, green, or
suburban zones

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 Territories of HCI should be located away from:
railways, airports, motorways - sources of noise, vibration and other
physical factors;
industrial plants, sewage and hard waste treatment – sources of
atmospheric air pollution;
major sportive complexes – CROWDED PLACES (noise and biological
factors, risk of terrorism).

According to hygienic requirements, territory for building HCI should:

•be placed conveniently for inhabitants,
•not have natural and anthropogenic pollutions,
•have natural incline for diversion of rain water,
•not be subject to floods,
•be located nearby already existing systems of sanitation, water and gas
supply,
•have an access to external highways and railways, etc.

COMFORT FOR INHABITANTS:

surgeries, out-patient institutions and general hospitals are placed within
the settlements;
in suburban areas or outskirts, within the green zones, at least 1000m
distance from residential areas should be placed:
- specialized hospitals (CENTRES),
- hospitals for more than 1000 beds,
- special regimen hospitals for long term staying (psychiatric, TB, etc).

HCIs to be placed in the residential area:

•within a “walking distance” (1.5 – 2 km) out-patients institutions for local
residents;
•general hospitals (not closer than 30-50 m from residential buildings).
Placement of HCI is prohibited:
on the territories with organic, chemical, or other soil pollution,
on the territories previously being used as cemeteries, dumps, burial
grounds of cattle, etc.

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 Nature and climate factors:
Following climate factors have to be considered:

•Air temperature,
•Humidity,
•Predominant winds,
•Solar radiation,
•Local relief.

Air temperature
•Long-term data on a year average temperature, absolute minimal and
maximal temperatures are to be taken into account.
•Temperature characteristics are necessary for making a decision on depth
of foundation, thickness of walls, planning of heating, etc.

Humidity
Humidity has to be assessed together with precipitations,
nebulosity and fogs, because all these factors sufficiently affect the
following:
diversion of storm rainfall,
possibility of flooding in some areas,
dispersion of pollutions, getting in atmospheric air.
Value of hydrological factors:
Hydrological factors - water sources and level of subsoil waters.
•Water sources are used for household, drinking and healthcare purposes.
•Level of subsoil waters shows the probability of flooding and water
logging of the territory.

Planting of greenery
Value of green plants:
•changes in microclimate,
•noise reducing effect,
•protection against wind,
•protection against dust,
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•ability of some species to absorb gases, vapors and bacterial dredges,
•production of essential oils, wood resins.

Local relief:
•Influences conditions of insolation (solar irradiation of Earth surface).
All buildings, places on south side of a hill receive more solar radiation
than those in areas with a horizontal surface. Northern sides of hills receive
the least amount of heat.
•Calm relief providing conditions for drainage of atmospheric
precipitations is the most favourable. Incline should be within the limits of
1- 5 %. Incline up to 10 %, is permitted on short parts only.

TYPES OF HOSPITAL BUILDING UP:

centralized,
mixed,
decentralized (stage).
Centralized system.

•Treating, diagnostic, utility and auxiliary premises are located in the same
building.
•This system is the most compact and economical one.

77
•Although it is difficult to provide treating regimen and to prevent hospital
acquired infection.

Mixed system.
Most of wards and departments are located in the main building,
pediatric and obstetric wards, radiotherapy department and communicative
disease unit are located in the separate buildings.

Decentralized (stage) system:

Wards (medical, surgical, trauma, eye, etc) and departments are located in
separate buildings (30-80 beds each). Diagnostic departments and utility
services are located in separate buildings.

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 General plan of HCI.
•General plan – is a plan of institution’s territory including zoning, location
of buildings construction of services and siting to the particular area.
•Zoning – is a conventional division of a territory according to functional
purpose.

Functional zones of the territory:

•ward buildings for contagious and non-contagious patients,
•paediatric, psychiatric wards, radiotherapy departments and obstetric units,
•out-patient units,
•zone of vivarium and pathology building,
•recreational zone – territory for patients’ rest,
•utility zone for utility and engineering buildings.

Zoning is provided by:

conventional division of the territory into areas,
distance between buildings,
green plants,
separate entrances.
DISTANCES between wards and other buildings:
Distance between buildings with wards windows must be 2.5 x height of an
opposite building, but no less than 24 m.
Distance between wards and utility zone buildings must be no less than 30
m.
•Distance from wards to pathology building must be at least 30 m.
•Distance between radiotherapy unit and other buildings must be no less
than 25 m.

DISTRIBUTION OF THE TERRITORY:

•build up area – no more than 15-20 %;
•territory for patients’ walk and rest must be no less than 60% of territory,
25 m2 per bed;
•walking paths, roads – 20-25 %.

79
11. GENERAL HYGIENIC REQUIREMENTS FOR BUILDINGS AND
PREMISES OF HEALTHCARE INSTITUTIONS

General hygienic requirements for buildings and premises

Plan of buildings and premises should provide:
hygienic and appropriate treatment regimen;
prevention of hospitality infection;
favourable conditions for staying;
optimal condition of work and rest for the staff;
provision of the infected patients isolation;
hospitals, which are used for medical students training should additionally
have seminar rooms, study room for tutors and auxiliary premises (change
rooms, toilets) for tutors and students.

Organisation of admission unit:

•should provide order of priority for patients: entrance hall – waiting area –
examination room – admission department – hygienic inspection room -
ward.
•calculation of rotation number: 1 queue per 250 beds in paediatric and
general hospital, 1 queue per 150 patients – in emergency hospital.
•there should be 1 examination room and 1 hygienic inspection room per
each queue.

In large hospitals separate admission units should be:

•In obstetric, paediatric, infectious diseases, dermato-venerological and
psychiatric departments.
•All other departments can have one shared admission unit, which is
located either in the main hospital building, or in the building with the
greatest number of beds.
•Premises for hygienic inspection and for discharge may be located in each
building.

Sizes of admission unit:

2
•entrance hall – 12 m at least,
2
•registration office – 10 m at least,
2
•examination room – 12 m ,
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•1 bed box – 22 m2.

 Paediatric admissions require boxes and examination-admission

boxes.
 In infectious diseases hospitals admission units must have admission-
examination boxes. Their number depends on size of the hospital: hospitals
up to 60 beds should have 2 boxes, 60-100 beds – 3 boxes, if more, than
100 beds, number of boxes is equal to 3 % of hospital’s beds.
 Admission unit can have specialised boxes: operational,
resuscitation, X-ray.

Following actions are taken in admission department:

general examination, including screening for infectious diseases
(thermometry, skin, throat examination, etc.);
general screening for pediculosis and scabies, disinsection as required;
shower, hair and nail cut as required – if not contraindicated;
anthropometry and filling the admission information in patients
notes;
admission of a patient to a ward.

Patient is allowed to take following belongings to the ward:

 toiletries (toothbrush and toothpaste, soap, razor, etc.) and personal care
belongings.
 household clothes and slippers are allowed in medical wards.
 household clothes and slippers are prohibited in postoperative,
obstetric, infectious diseases and dermato-venereal diseases wards.

Hygienic requirements for admission department

Every patient, taking shower should use individual soap.
Use of disposable razors wherever shaving is required.
Non-disposable items (scissors, etc) must be disinfected after each use.
After shower and (if required) hair / nail cut each patient receives a clean
set of hospital clothes: night dress, pyjama (gown) and slippers.
Disposable gloves should be used by the staff for patient’s examination,
washing, etc.
Couch and used instruments have to be disinfected after each examination.
81
Staff should disinfect hands after contact with a patient.
Admission unit has to be cleaned with liquid disinfectants at least twice a
day.

Hygienic requirements for departments, wards and ward sections

•Department – the main functional element of the hospital. Its sizes may
vary from 30 to 120 beds.
•Ward section – main functional and structural unit of hospital building.
It is an isolated complex containing wards, diagnostic and treatment
premises, store rooms, auxiliary premises and a corridor (2.4-2.5 m
width), designed for the treatment of patients with similar diseases.
Number of beds in medical ward section should not be more than 30.
•Wards – premises, where patients stay.

Ward section premises’ sizes

2 2
Area per bed in a 2-bed ward -7 m , in a single bed ward – 9 m . Ward
capacity should not be more than 4 beds. Height of walls – at least 3 m;
cubic capacity – at least 20 m3 per bed.
Ward section, apart from wards, should have the following premises:
2
nurses station (6 m ),
2
doctor’s room (10 m ),
2 2
procedure room – 12 m (18 m – if gynaecological couch is in the room),

storage for a clean linen,

shower/ bathroom, toilet, room for washing and sterilisation of bedpans,

storage for cleaning equipment and for soiled linen,

still-room equipped for cleaning and disinfection of patients’ dishes and

dining room for patients,

2
patients lounge (0.8 m per bed).

Wards area to treatment and auxiliary premises area ratio should be 1:1.

Hygienic requirements for premises with special sterility regimen

Operation theatres:
Are placed in isolated block – separate building, or isolated sections
which are connected with the rest of the hospital by corridors, or passages.
Must be located as far as it is possible from vertical communications
(wells, refuse chutes, etc).
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Emergency operational theatres can be placed within the admission units.

Obstetric departments require:

Planning that divides wards clearly;
Admission and cleaning recurrence of the premises;
Systematised patients streams;
Optimal conditions for medical staff work.

Operational unit should have:

•Two separate entrances – staff entrance through the change room with
shower facilities, for patients – through locks.
•Two isolated, not connected departments – septic and aseptic; If
operational theatres are located on different levels, septic theatres must
be placed above the aseptic.
•Strict zoning of internal premises (sterile zone, zone of a strict regimen).
•Separate functional people streams:
–“sterile” – passage for surgeons and scrub nurses,
–“clean” – for bringing patients, passage for anaesthetists, junior and
auxiliary staff,
–“soiled” – for removal waste, used linen, etc.
•These streams must not get crossed.

In obstetric admission department pregnant women should be divided into

two queues:
“clean queue” – for uncomplicated pregnancy department and to
complicated pregnancy department;
“infected queue” – for observational department for observation and
treatment.

Scheme of queues should be approved by hygienic authorities.

•Observational departments, which are more infected, should be placed
on the top floor, above complicated pregnancy, uncomplicated pregnancy
and gynaecological departments, or on the ground floor, aside from the
main building.

83
 Hygienic requirements for working conditions of medical staff:
•Favourable microclimate and air conditions (temperature, humidity, speed
of air mobility, chemical and bacterial content) and sufficient air exchange
should be provided at the working places.
•Placement of equipment and its uses should be performed according to
the current safety requirements.

Premises for medical staff:

two cloakrooms –
for casual clothes;
for hospital clothes;
change rooms for medical staff;
shower and toilet facilities within the departments;
rest rooms.

Cloakrooms
2
•Sizes of cloakroom for casual clothes: at least 0.08 m per 1 hanger
(hook);
•Number of lockers in cloakrooms for casual and hospital clothes should be
equal to the number of staff, i.e. every member of staff should have own
locker;
•Clothes should be stored in double-doors, lockable, ventilated lockers.
Locker construction must provide separate storage of casual and hospital
clothes and shoes.

Staff change rooms:

•In operational departments change rooms should be separate for male
and female staff. Each change room consists of connected undressing,
dressing-up rooms (for change and storage of clothes) and shower room.
•Shower and dressing-up room are placed at theatre entrance (1 shower
cabin per 2-4 operational theatres).
•Obstetric, paediatric admission departments and observational
departments must have change rooms with cloakrooms and showers (1
shower cabin per 5 people per shift).

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 Auxiliary premises for staff:
Staff toilets must be separate for male and female staff;
Number of shower cabins depends on the type of a department.
Infectious diseases and tuberculosis departments should have 1 shower
cabin per 10 people, other departments should have 1 shower cabin per 15
people; if the number of staff is less than 10, there should be 1 shower
cabin per department;
For female staff there should be available personal hygiene rooms
equipped with bidet.

Staff rest rooms:

•Each structural unit should include staff rest rooms, equipped with a
fridge, electric boiler, hot and cold tap water supply.
•To provide hot meals for staff, hospitals should have canteens, or
cafeterias.

Safety at working place:

•Every member of medical staff undergoes medical examination according
to the state’s standards. Medical staff is checked at a time of employment,
and yearly thereafter. Obstetric and paediatric hospitals staff undergo
medical examination twice a year.
•At a time of employment and at least once a year thereafter every staff
member should go through instruction with further testing on hospital
infection control rules and requirements.

Hygienic and technical equipage of hospitals

Building and functioning HCI must be equipped with:
water pipe,
centralized hot tap water supply,
sewerage system,
central heating,
ventilation,
if required – air-conditioning systems,
two-stores and higher buildings should be equipped with lifts and refuse
chutes.

85
 Hygienic requirements to internal design of premises
 Wall and ceiling surfaces in the premises should:
 be integral,
 be smooth,
 not have traces of leakages, mould, etc.
 be easily accessible for wet cleaning and
disinfection.
 Flooring should:
 have no defects (gaps, crackles, holes, etc.);
 be smooth;
 match well the basement.
In the premises with “dry” regimen (wards, halls, doctor’s and
administration rooms, dining rooms, physiotherapy and other treatment and
diagnostic premises):
Walls are advised to be covered with water resistant paints. Areas of
basins, sinks, other similar equipment should be covered with tiles.
Ceilings can be painted with lime or water soluble emulsion. Use of
hanging ceilings allowed in premises not requiring aseptic and antiseptic
regimens only.
Floorings should be made of materials with higher thermo isolation
properties.
Floors in halls should be resistant to mechanical damage, so stronger
flooring should be used (tiles, marble, etc).

In premises with ”wet” regimen, as well as in premises with permanent

disinfection (operational and obstetric theatres, wound dressing change
rooms, anaesthetic and procedure rooms) and bathrooms, shower rooms,
toilets, enema rooms, premises for collection of used linen:
Walls should be covered with water resistant materials (tiles) up to
ceiling.
Ceiling should have no gaps and covered with water resistant paint.
Floors in operational and obstetric theatres, anaesthetic rooms and
similar premises should be waterproof, sparkless and antistatic.

86
 General hygienic requirements to furniture and equipment
Medical, technical, auxiliary and other furniture and equipment
used in the hospitals should:
•Be simple and convenient;
•Function properly;
•Be designed for frequent wet cleaning and disinfection.
Not permitted: use of malfunctioning equipment, furniture and
devices. Broken equipment, furniture and devices should be repaired or
replaced immediately.
Prohibited: placement and storage of unused equipment in functional
premises. Unused devices, furniture and equipment can be temporarily kept
in stockrooms.

General requirements to maintenance of premises, devices and

equipment in HCI :
•All premises, devices, medical and other equipment should be kept clean
and in working condition.
•Administration of HCI should organise preventive treatment of HCI
against insects and rodent.
•Winter preparations (check and repair of heating system, warming of
windows and doors, etc.) should be performed not later than 2 weeks
before the beginning of heating season.

Requirements to wet cleaning in HCI premises

 Personnel of specialised services (companies), having necessary
permit, can do cleaning in HCI.
Regimen of a current wet cleaning:
In surgical and obstetric institutions – at least 3 times a day, including
once a day – with disinfectants.
In departments – at least 2 times a day, use of disinfectants – after bed
linen change, and if there are epidemiological indications.
Premises with special requirements to sterility, aseptics and
antiseptics (intensive care, neonates and neonates intensive care wards,
procedure rooms, infectious boxes, boxes of bacteriological and viral
laboratories, dairy rooms, etc) should be decontaminated after each
cleaning.
87
Places of general use (halls, corridors, enquiries, etc.) should be cleaned
as required.

Regimen of general cleaning:

In the departments, studies, and premises of functional units general
cleaning should be done according to schedule, at least once a month. It
should include:
•Washing and disinfection of walls, floors and all equipment,
•Wet wipe of furniture, lights, blinds, etc.
General cleaning, including wet cleaning and disinfection of
operation theatres, would dressing change rooms, procedure rooms,
postoperative wards, intensive care units and premises of obstetric block
should be done once a week.
General cleaning in obstetric hospitals and terminal disinfection of
obstetric theatres is performed once in 3 days.

88
 12. HYGIENIC CHARACTERISTICS OF MICROCLIMATE,
HEATING AND VENTILATION IN HCI

Hygienic characteristics of microclimate:

•Microclimate is a set of physical factors, which includes temperature,
humidity, speed of air mobility and temperature of protecting surfaces
(walls), affecting heat exchange between the organism and environment.
•Microclimatic conditions – a sufficient part of treatment.

Patients in HCI have:

•Decreased compensatory thermoregulating abilities,
•Decreased protective and adaptive abilities,
•Increased sensitivity to negative environmental factors.
Most sensitive are patients suffering from cardiovascular,
neuropsychiatric diseases, thyrotoxicosis and common colds.
Air temperature – a degree of its heating, expressed in centigrades.

Air TEMPERATURE:
•True air temperature is a temperature level not affected by influence of
heat radiation on thermometer.
•Climatic temperature is a total value of air temperature and influence оf
heat radiation on thermometer.

Temperature regimen – evenness of heating at premises round the day.

Temperature regimen can de described using the following values:
•Average air temperature.
•Temperature drops over horizontal and vertical levels.
•24-hour temperature variations.
•Air-wall temperature drop.
Average air temperature.
•Is an average index of measurements
in 5 points –
in the centre and
in 4 corners
at a distance of 10-20 cm from the walls, and 1.5 m above the floor
level.
89
 Temperature drops over horizontal levels
•Measurements are performed at a distance of 10-20 cm from outer and
internal walls, and in the middle of a premise at 1.5 m above the floor
level.
Temperature drops over vertical levels
• Measurements are taken at 10 cm,
1 m and 1.5 m heights from floor level
(i.e. at the level of ankles, and at the level
of breathing in sitting and standing positions).

TEMPERATURE REQUIREMENTS IN HCI PREMISES:

•20 - 22о C – adult and paediatric wards, boxes, procedure and wound
о

dressing rooms, intensive care wards and doctor’s room.

•
25о C – burn and newborns’ wards, operational and obstetric theatres,
physiotherapy premises, bath/shower rooms.

Permitted air temperature drops:

•
over horizontal levels – up to 2оC;
•over vertical – up to 2.5оC per meter of height;
•24-hours temperature variations:
- with central heating ± 2-3оC;
- with furnace heating ± 4-6оC;
•air-wall temperature drop ± 3оC.

Air humidity:
•Absolute air humidity is the mass of water vapour in 1 m3 of air.
•Maximal humidity is the mass of water vapour required to saturate 1 m3
of air at a defined temperature.

Hygienic value of humidity

•Relative humidity – is the ratio of absolute humidity to the maximal
humidity, expressed as a percentage, or percentage of air saturation with
water vapour at a time of observation.
•Saturation deficit – difference between maximal and absolute humidity.

90
•Physiological humidity deficit - difference between maximal humidity at
37о C (body temperature) and absolute humidity at the time of
observation.

REGULATIONS FOR RELATIVE HUMIDITY

•Normal values of relative humidity –
30-60 %.
 Low air humidity (lower than 30%) results in mucosa dryness,
impairing barrier functions of mucosa.
 High air humidity increases body heat losses, and raises risk of local
and general hypothermia and number of common colds.
Air mobility is described by:
•Direction is the air move in open atmosphere.
•Wind rose is based on continuous observations over the wind direction;
•Speed is the distance, which air mass makes per unit of time (m/s).

Requirements for speed of air mobility:

Indoor environment:
•optimal speed – 0.1-0.15 m/s (comfortable),
•permitted speed – 0.2-0.3 m/s;
•still air - < 0.1 m/s,
•feeling of draught - > 0.4 m/s.
•speed, permitted in wards – 0.2-0.3 m/s;
•speed, permitted in operational, obstetric theatres, anaesthetic rooms,
intensive care wards – maximum of 0.15 m/s;
•speed, permitted at input ventilation valves – maximum of 1 m/s;

Outdoor environment:
•most favourable wind speed – 1-4 m/s,
•irritating effect of wind can be seen at 6-7 m/s.

Atmospheric pressure
Its variations within 10-30 mm limits impair general health feeling in
people suffering from rheumatoid arthritis, angina, hypertension, chest
and neurological conditions.
Normal are atmospheric pressure variations within the limits of:
91
 760 ± 20 mmHg, or
1013 ± 26.5 hPa

DEVICES for measuring air temperature: THERMOMETERS,

THERMOGRAPHS

DEVICES for measuring air humidity:

•Absolute humidity is measured by:
August psychrometer (wet and dry bulb thermometer).
Aspirational psychrometer.

•Relative humidity is measured directly by:

Hair hygrometer,
Hygrograph (continuous registration of changes in relative
humidity).
Thermobarohygrometer.
DEVICES for measuring speed of air mobility:
•Anemometers:
cap anemometer (to measure air mobility speed between 1 to 50 m/s);
revolving-vane analyzer (0.3 – 15 m/s);

•Katathermometers:
ball and cylindrical for measuring speed of air mobility in indoor
premises (if speed is lesser than 1 m/s).

Devices for measuring atmospheric pressure :

•Mercury – cistern and syphon barometers;
•Metal - aneroid;
•Barograph – for continuous observations on atmospheric pressure
changes.

Methods of complex hygienic microclimate assessment:

•katathermometry,
•effective temperatures,
•equivalent effective temperature,
•resultant temperatures.
92
 Katathermometry
•Value of air cooling ability “H” is calculated using katathermometer
cooling time:
Н= F (katathermometer factor – constant for the device)
Т (cooling time of katathermometer from 38°C to 35°C)
Optimal values of H at rest = 5.5 – 7 mcal*cm²/s

Effective temperatures (ET)

•Allow to assess complex effects of temperature, humidity and air
mobility on human organism;
•standardised air temperature is determined with a help of nomogram
based on levels of humidity and air mobility.

Equivalent effective temperature (EET)

•Conventional temperature shows the effect of heat feeling which depends
on simultaneous action of a certain ratio of temperature, humidity and air
mobility on human organism.
•Values of EET, at which 50 % of people feel good, are called comfort
zone. At rest levels of comfort zone vary between 17.2 to 21.7°С.
•Values of EET, at which 100% of people feel good, are called comfort
line. Comfort line values are between 18.1 – 18.9 °С.

Resultant temperatures (RT):

Resultant temperatures take into account complex effects of:
temperature +
humidity +
air mobility +
radiant energy.
Values are either measured with ball thermometer, or detected with
nomogram.

Mechanisms of body heat exchange with the environment

Chemical and physical thermoregulations are the main physiological
mechanisms of heat exchange between organism and environment.
Dynamic interaction of these two mechanisms provides the processes
of heat production and heat loss.
93
 Mechanisms of heat production
•Oxidation of nutrients;
•Heat release during muscle contractions;
•At lesser degree – solar radiation, heated objects and hot food.
An adult human produces on average 75-90 kcal/h, at rest, and 250 kcal/h
during hard physical work.

Mechanisms of heat loss:

•convection – heat donation from skin surface to contacting air layers
during their movement. Intensity of heat loss in this case depends on sizes
of exposed skin area, temperature gradient between organism and
environment, and speed of air mobility. Reinforced conventional flow
increases cooling of organism.
•conduction – direct heat losses during contact with surrounding objects.
•heat radiation takes place in the presence of objects and barriers of a
temperature lower, than a temperature of skin surface.
•evaporation – cooling due to sweat production and evaporation of water
from airways, skin and mucosa surfaces.
Average heat losses at rest:
radiation – 55.6 %
convection – 15.3 %
evaporation – 29.1 %

Quantitative levels of heat production are determined by :

•Age, type of activity, health condition, microclimate, and other factors.
•Healthy human is able to regulate intensity of heat production and heat
exchange. This provides constant body temperature, irrespectively on
changes of external microclimatic factors.
•Diseases and health disorders impair heat production and heat losses.
Heat production is grossly impaired in all patients suffering from endocrine
disorders, in patients with impaired fasting metabolism (oncological,
postoperative, etc). Changes in heat losses can be seen in patients with
vascular and blood pressure disorders.

94
Physiological and hygienic value of microclimate factors is due to their
influence on:
•heat balance of organism and processes of heat exchange;
•metabolism rate;
•physiological condition of the main functional systems;
•more prominent effect on sick organism;
Heat comfort promotes good outcome.

Systems of heating:
•Local heating: •Central heating:
•stoves with big heat capacity heat transmission from one
(holland stoves, temperature of their centralised source (boiler, or heat
surface should not be more than and power plant). With central
80°C), heating fuel combustion takes place
•stoves with medium heat capacity in a boiler. Resulting heat is sent to
(hold heat poorly, premises should heat carrier, which is delivered to
be heated twice a day), the premises via a system of pipe-
•stoves with small heat capacity lines.
(made of cast-iron, iron, small
ceramics – maintain the temperature
for 1-2 hours, can be used in
premises, where people stay
temporarily).
•Disadvantages:
•Large temperature variations during •Types of central heating according
a day (4-6°C). to a kind of heat carrier:
•Risk of air pollution with products •water
of incomplete fuel combustion, so •steam
fire-chambers should be located at •air
corridor site. •radiant.

Radiant heating:
•Heating elements (pipes or electric heaters), mounted in ceiling, walls or
floor: panel, overhead, floor heating.
•Temperature of heat-carrier should provide the following surface
temperatures : floors – 24-27°C, ceilings – 28-30°C, walls – 35-40°C.
95
 Advantages and disadvantages of radiant heating:
Advantages:
•Premises are heated more evenly.
•Almost absent dust raise, because of weak convectional flows.
•Due to higher temperature of barrier constructions heat losses from the
body surface are decreased, so good general feeling remains even at a
lower temperature (17-18°C).
•In summer time premises can be cooled by delivering cooling agent
through the pipes.
Disadvantages:
•Higher building expenses.
•Repair of heating elements is more complicated.
•Heating time of premises is prolonged.

Heating systems of HCI

Should:
•Provide air heating in the premises during the heating season.
•Exclude air pollution with toxic substances and smells.
•Not create noise above the permitted levels.
•Possess the regulating devices.
•Be convenient for use and repair.

Hygienic requirements to ventilation at HCI

•HCI should be equipped with combined extract and input ventilation
with mechanical impulse.
•External air collection should be performed in a clean zone, no lesser
than 1 m from ground surface. Air inlet should be protected with fender.
•External air should be purified with filters.
•Air, delivered to operational, obstetric theatres, anaesthetic, rooms,
intensive care, postoperative, post delivery and burn wards should be
treated with bactericide filters.
•Premises, where production of toxic substances and air pollution is likely,
should be equipped with local exhaust ventilation (aspirators, exhaust
hoods).

96
 Air conditioning should be installed in:
•Operation and obstetric theatres, anaesthetic rooms, postoperative, post
delivery and intensive care wards,
•One- and two-bed wards for burned patients,
•Neonatal wards.

97
 13. HYGIENIC ASSESSMENT OF AIR PURITY, LIGHTING AND
INSOLATION OF HOSPITAL’S PREMISES

Sources of air pollution in HCI premises:

1. Air gas content of indoor premises depends on atmospheric air content.
2. Products of vital functions of humans, including wound discharge.
3. Vapours of disinfectants, medications, substances excreted by polymers.

1. Effects of atmospheric air gas content

In the absence of purifying system for external air used for
ventilation, harmful substances get into the premise:
•Foul smelling substances (indole, skatole);
•Chemical pollution;
•Dust, more often of mineral origin, although can be of a mixed origin as
well;
•Radioactive or bacterial aerosols.

2. Products of human vital function, including wound discharge.

•Healthy human being produces during vital function processes over 70
various organic and non-organic substances including hydrogen sulphide,
indole, skatole, mercaptan, volatile fat acids, and ammonium.
•Airborne contamination increases in the presence of people.
•During breathing process carbon dioxide is secreted.
Healthy people develop headache, tiredness, decreased work
capacity after few hours of breathing with this mixture.

Air of indoor premises accumulates microflora secreted by people:

•through airways (talking, cough, sneezing),
•from skin and hair,
•from clothes and shoes.
The more people are there in the premise, the higher is the airborne
contamination, particularly with streptococcus.
For example, airborne contamination of the operational theatre
increases 6-7 times by the end of a day, and in the presence of students - 10
times.

98
 3. Vapours of disinfectants, medications and substances, secreted by
polymers.
HCI air may contain vapours of:
•Alcohol, aldehydes, phenols.
•Peroxides (hydrogen peroxide, peracetic acid).
•Halogens (chlorine and iodine containing substances).
•Quaternary ammonium compounds.
•Biguanidines.
•Polyhexanides.
•Antibiotics.
•Harmful chemicals produced by building materials, furniture, polymers.

Microorganisms presence in the air as bacterial aerosol:

(air is a dispersion medium and droplets or hard particles, containing
bacteria are a continuous phase)
There are 3 phases of bacterial aerosol:
•Coarse liquid phase (droplets diameter › 0.1mm),
•Fine liquid phase (droplets diameter ‹ 0.1mm),
•Phase of bacterial dust.

Viability of microorganisms is determined by:

►type of aerosol and
►resistance to drying.
in coarse phase low viable microorganisms survive (flu and measles
viruses),
in fine phase – streptococci, meningococci;
in bacterial dust phase – mycobacteria, bacterial spores, fungi.

Assessment of air cleanness in indoor premise

The main criteria of hospital’s premises air purity is the absence of
pollution, because air purity is assessed by:
Changes in air gas content,
Oxidation characteristics of air,
Microflora content,
Amount of harmful chemical pollution,
Effectiveness of ventilation.
99
 1. Changes in gas air content in premises during human’s staying
Carbon dioxide is excreted in air, and, if ventilation is
unsatisfactory, СО2 concentration increases in those premises where
people stay, because:
 Atmospheric air contains

О2 – 21 %, СО2 – 0.04 %,
 Expiration air concentrations of

О2 drops to 16.4 %,
СО2 raises up to 4 %.

Methods of air purity assessment

By Pettenkoffer:
3
•Air is clean, if it contains not more than 0.07 % СО2 , or 0.7 dm СО2 per
1m3;
•Slightly polluted – СО2 up to 0.15 %;
•Polluted - СО2 more than 0.15 %.
By Fluge:
3 3
•Air is clean, if it contains not more than 0.1 % or 1 dm СО2 per 1м of
air.

СО2 content is a preliminary index of air purity in premises

СО2 content may be insignificant in case of severe air pollution with
dust, harmful chemicals, or in the presence of pathogenic microorganisms.

Oxidation characteristics of air –amount of О2 in mg needed for oxidation

of organic substances in 1m3 of air.

Oxidation characteristics of air purity:

3
•Clean air – oxidation is up to 6.0 mg О2 per 1m ,
3
•Moderately polluted – oxidation is up to 10 mg О2 per 1m ,
3
•Polluted – oxidation ›10 mg О2 per 1m .

100
 Assessment of air purity using microflora
is based on:
3
•general amount of microorganisms per 1m of air;
•presence of hygienically and clinically important microorganisms –
haemolytic
streptococci and staphylococci.

Air purity assessment based on the amount of harmful chemicals:

•Most important premise’s air pollutants are carbon oxide, phenol,
formaldehyde, toluene, acetone, etc.
•Monitoring of pollution is performed by method of parallel probes – either
a number of tests are performed simultaneously, or a number of probes are
collected for further check of chemical air content in a laboratory.
•
Concentration of harmful substances must not exceed highest permitted
concentrations for atmospheric air.

Assessment of air purity

based on effectiveness of ventilation
Classification of ventilation:

By mechanism:
Input ventilation – ventilation devices deliver the air to the premise,
Exhaust ventilation – ventilation devices remove air from premises,
Combined extract and input ventilation.

Air exchange:
 input is marked (+),
 exhaust is marked (-).

Types of ventilation:
By nature of driving forces:
Natural ventilation;
Artificial ventilation;

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Natural ventilation is performed due to:
•temperature gradient between outside and inside air,
•impact of wind force.

Natural ventilation is divided into:

•Ventilation with unorganised air exchange,
•Ventilation with organised air exchange.

Natural ventilation with unorganised air exchange

Performed by infiltration
•Through pores in building materials of walls, tiny gaps in windows and
doors.
•As a result of pressure gradient between indoor and outdoor air.
•Depends on weather conditions.

Organised natural ventilation (air exchange) used in HCI

•aeration – natural ventilation of a premise, limited in time.
•airing – continuous natural ventilation.

Aeration can be angular and through.

Angular aeration
•performed with closed doors through window leafs, or transom.
Disadvantage – descending stream of cold air, which can affect staying
people.
The following regimen of aeration is used in wards:
•In the morning before patients wakening up.
•During cleaning of the premise.
•After morning and evening walks.
•After lunch and before going to sleep.
During aeration in patients presence doors should be shut, and
patients should be covered with blankets.

Angular and through aeration.

Through aeration is performed by opened windows and doors on the
opposite walls of the premise.
Through aeration is the short term natural air exchange:
102
 after 15–minute aeration air temperature decreases on average by
0
2 C.
Aeration is performed in the absence of people.

Airing
•is performed through intrawall channels;
•one end of the channel is opened in wards, auxiliary premises, corridors,
etc., whereas another end is opened on the roof;
•exhaust outlets are placed in the upper part of the wall, because warmed
air rises up;
•for better draught in channel special deflectors (“chimney with a cap”) are
placed on the roof.

Indices of effectiveness of natural ventilation

Considerations on effectiveness of ventilation can be made based on:
Its volume.
Air changes per hour.
Coefficient of air exchange.
•Volume of ventilation – amount of air, which is delivered to/ removed
from the premise per 1 hour.
•Air changes per hour – a number, which shows how many times per hour
air in the premise is replaced with outdoor air.

Aeration coefficient
A ratio of a glassed area of the window leaf or the transom to the floor
area.
Normal ratio = 1 : 50

Artificial ventilation
•General ventilation – air exchange takes place in a whole premise.
•Local ventilation – delivery or removal of air takes place within the
limited part of the premise (exhaust hood).

Hygienic requirements for artificial ventilation:

Ventilation volume:
Minimal volume – 40 - 50 m3/h per 1 bed.
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Optimal volume – 80 m3/h per 1 bed.
Air exchanges per hour:
In wards – output + 2, exhaust - 2,5
In operational and delivery theatres -
output + 6, exhaust - 5,
if air conditioners are installed -
output + 10, exhaust – 8.

Hygienic problems of lighting in HCI

Natural lighting is performed by:

•Direct solar radiation (isolation),
•Ambient light from sky,
•Light reflected from the surrounding objects and ground surface.

Natural lighting depends on:

•Latitude.
•Time of a year and of a day.
•Windows location.
•Darkening from buildings and green plants located nearby.
•Windows condition – sizes of windows openings, their construction,
quality and cleanness of window glass.
•Internal factors of the premise – internal planning, wall, floor and ceiling
paint, colour of furniture.

Features of internal planning affecting the lighting:

•Top margin of window should be at a distance of 20-30 cm from the
ceiling, because in this case light gets deeper in the premise.
•Height of window-sill should be 0.75 – 0.9 m.
•Depth of the premise – not more than 6 m.
•Optimal premise height – 3.2 – 3.5 m.
•Wall paint of wards looking south direction should be of cold colours
(mint, light blue), smoothening the sunshine;
•Wall paint of wards looking north should be of warm colours (yellow,
orange), replacing the absence of direct sun light.

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 Orientation of windows
•Wards windows in south (45° n. l.) and mid (45-55° n. l.) latitudes
should be oriented in south, south east and east, as this provide enough
lighting and insolation without overheating.
It is undesirable to place wards with windows looking west in south
latitudes, as this results in continuous and deep exposure to sun shine.

•Wards windows in north latitudes (55° n. l.) should look south, south-east
or south-west direction.
•Windows in operational theatres, wound dressing change, procedure,
resuscitation rooms should look north, north-west or north-east, as this
prevents dazzle from sun shine.

Insolation regimen of premises

There are 3 regimens of insolation in temperate climatic zone which
are determined by:
1. Orientation of windows by the sides of horizon.
2. Duration of insolation in hours.
3. Percentage of insolated floor area.
4. Amount of heat received through the window with solar radiation.

Types of insolation regimens

Maximal – recommended for -south-east or south-west
paediatric, trauma wards, wards for orientation;
convalescents. -Insolation time – 5 - 6 h;
-Insolating floor area - 80 %;
-Amount of heat > 500 kcal/m2.
Moderate – for medical, infection, -South or east orientation;
surgical wards. -Insolation time – 3 – 5 h;
-Insolating floor area – 40-60 %;
-Amount of heat = 500 kcal/m2.
Minimal – for operational theatres, -North-west or north-east
intensive care units, burn, orientation;
oncological, neurological wards. -Insolation time < 3 h;
-Insolating floor area <30 %;
-Amount of heat < 500 kcal/m2.
105
 Methods of natural lighting assessment:
Direct methods – by measuring of absolute and relative
illumination with light-meter.
Indirect methods:
•Light coefficient (ratio of glazed area to floor area). Hygienic requirement
for wards is 1:6;
•Location coefficient (ratio of distance from external to internal wall to the
distance from upper window margin to the floor). Hygienic requirement –
not more than 2.5;
•Light angle;
•Aperture angle.

Types of artificial lightening:

•Main, desired for lightening in the absence of natural light.
•Tell-tale light – night - small intensity for orientation at night.
•Emergency – provides uninterrupted lighting in operational and obstetric
theatres, resuscitation rooms, possesses independent energy supply.

Systems of artificial lightening:

•General – in premises, which do not require high level of illumination
(wards, doctor’s rooms, auxiliary premises).
•Local – desk, floor, or wall – in doctor’s rooms, at the top end of each bed
in wards, or on walls, apart from paediatric and psychiatric wards.
•Combined (general and local) – in operational theatres, wound dressing
change and procedure rooms.

Hygienic requirements for illumination in HCI:

Minimal illumination in wards:
•For incandescent bulbs – 75 lux,
•For luminescent lamps – 150 lux,
•Night – up to 3 lux.
In operational theatres:
•General lightening by luminescent lamps with illumination level of 400-
500 lux and local operating lamps, creating due to combined lightening
illumination of 3 000 lux to 10 000 lux on the operation field surface;

106
 14. WATER AS A FACTOR OF HEALTH. HYGIENIC
REQUIREMENTS TO WATER SUPPLY OF SETTLEMENTS

Water resources on Earth:

97 % of Earth water resources is salt water of seas and oceans.
3
Fresh water resources with mineralization up to 1 g/dm (standard for
drinking water) are distributed on the Earth in the following way:
rivers - no more than 1 %,
lakes – 0.009 %,
groundwater – 0.3 %,
atmospheric precipitates – 0.001 %,
glacier - 2- 3 %.
Over 10% of world population do not receive enough amount of purified
water.
The lack of not just fresh water, but PURE water becomes a real threat
for the future because of water sources pollution with domestic, industrial
and agricultural sewage.

Physiological role of water

Water is a universal solvent:
Blood, lymph, secretions and discharges are water solutions with
complicated chemical content.

Deficit in water impairs homeostasis:

deficit of 3 – 4 % in required water amount decreases work efficiency;
deficit of 10 % results in impaired metabolism,
deficit of more than 20 % leads to irreversible processes in organism.

Water is required for:

transportation of dissolved nutrients, including essential macro - and
microelements,
processes of assimilation and dissimilation take place in water,
maintenance of acid-base balance,
maintenance of water-electrolyte balance and permeability of cell
membranes,
removal of dissolved and colloid toxic products of metabolism,
107
evaporation – a mechanism of body temperature regulation.

Organism of 3-month fetus consists of about 80 % of water, adult

human - 50-70%, in elderly (› 70 years old) – less than 50%.
Hygienic importance of water
Water is used:
 To keep body, clothes and habitation clean;
 For accomplishment of cities and towns, water sources are elements
of settlements foundation and are important for architectural structures;
 Watering of green plantations;
 For heating, sewage system, etc.

Water plays an important role as a natural sanitary factor:

For increase in general resistance, swimming;
For sports and physical activity (rowing, sailing);
For treatment (salt baths, mineralized water);
Hydrotherapy together with thermal effect (steam bath);
Hydrotherapy together with mechanical component (hydromassage,
cascades, etc).

Role of water in spread of the diseases

Water may become a source of three groups of diseases:
epidemical,
endemic,
chronic intoxications due to increased residues of chemical substances in
water, as a result of water source pollution with industrial sewage, weed-
killers, pesticides, etc.

Epidemic diseases
Water becomes epidemiologically dangerous, if it gets contaminated
with secretions of carriers or sick people and animals.
Pathogenic microorganisms may contaminate open water sources
during:
burial of sewage from ships,
cattle watering,
washing of linen,
108
bathing,
washing away of garbage from soil surface by atmospheric sediments,
pollution with domestic and, particularly, hospital’s sewage water.

Epidemics of intestinal infections

The most important is cholera, classified as a special dangerous
infection. There were 6 pandemics in mankind history, when it spread
through out the world. 10 million people died.
The second most important infection transmitted with water is typhoid
and paratyphoid fevers. The biggest outbreak of typhoid was in
Barcelona in 1914: 300 cases of infection per each 10 000 of population.
The third most important is bacterial dysentery, but in this case water
factor is less important , as it can spread by other alimentary ways (food,
hands, dishes).

Viral infections:
Infectious hepatitis, polio, adenoviral, enteroviral.
Epidemically dangerous is infectious hepatitis, because a large number
of people may get infected through water before prevention measures are
taken.
Virus of polio remains viable for up to 100 days in tap water.
Enteroviruses retain pathogenicity in sewage water for months.

Zoonosis spread through water:

•Leptospirosis: rodent and live stock are the source of infection. The
disease is transmitted with excretions of sick animals, contaminating water
(infestant gets through damaged skin and mucosa). People living and
working in marshland are affected.
•Rabbit-fever and anthrax of water origin occur if rodent’s corps got into
operating wells.
•Brucellosis – domestic live stock is a reservoir of infection. Infestant
spreads through contact and by alimentary ways (including with water).

Pathogenic protozoa:
Water may be contaminated with protozoa (amoebas) and helminths
eggs (ascarids, threadworms).
109
Development cycle of biohelminths (tapeworms, opisthorchosis,
leishmania) takes place in water.
In unfavourable epidemic conditions there is a risk of infection,
particularly during use of local water sources (wells) and swimming pools.

Endemic diseases – biogeochemical epidemics

caused by water with chemical content changed due to increased or
decreased levels of minerals in soil of some geographical areas
(biogeochemical provinces).
Fluorine. Increased fluorine consumption leads to fluorosis,
phosphate-calcium metabolism changes, resulting in teeth enamel
destruction, brittle bones and bones deformities.
Low concentrations of fluorine causes dental caries.
Iodine. The diseases caused by diminished iodine intake play
important role. Natural deep-well water contains iodine, but food is the
main source: up to 60 % comes with vegetable food, about 30 % - with
meet and only 5 % comes with water. However, decreased water levels of
iodine cause endemic goitre.

Endemic diseases
Molybdenum possesses anti caries properties. Excessive intake
increases synthesis of uric acid leading to “molybdenic gout”.
Selenium. Deficit of selenium causes dystrophic changes in muscles,
including myocardium, and dystrophy of pancreas.
Beryllium – can cumulate. Its accumulation affects respiratory,
nervous and cardiovascular systems, suppresses erythropoesis.
Strontium. Concentrations over 2mg/dm3 cause changes in mineral
metabolism and enzymatic processes in bone tissue.

Water sources:
•For water supply purposes the following water sources can be used:
–Atmospheric water, ice, snow;
–Surface water (water of open sources – rivers, lakes, water reservoirs,
etc.);
–Groundwater.

110
 Atmospheric water
Used for domestic and drinking needs in tropical regions with high
atmospheric precipitants levels and in aridity regions.
In some areas (polar regions, mountain areas) ice and snow are used.

 Atmospheric waters are low mineralised, contain a large amount of

dissolved gases (nitrogen, oxygen, carbon dioxide), contaminated with
bacteria.
Chemical content depends on the degree of atmospheric air pollution
(acid precipitation).
Require purification and decontamination.

Surface water sources are characterised by:

large amount of suspension:
particles, decreased transparency,
increased chromaticity.
high mineralization,
seasonal changes in concentrations of chemical substances,
possibility of pollution with toxic substances (sewage water),
sufficient organic and bacterial pollution.
Require mandatory purification and decontamination.

Ground waters divide into:

Soil waters,
Subsoil waters,
Middle water (head water and non-pressure water).

Head ground water (deep-well water) meet the hygienic requirements.

Deep-well water is transparent, colourless, has no taste and smell, organic
substances and almost free from microorganisms, though can be used for
drinking without pretreatment.
Sometimes this water is highly mineralized (iron, carbonates).
Middle non-pressure waters are the next in terms of quality.
They are located between two waterproof layers and isolated from
atmospheric precipitants and superficial water.

111
They have constant chemical content, low bacterial contamination, often
highly mineralized.

SYSTEMS OF WATER SUPPLY

There are two main systems of settlements water supply:
centralised and decentralised.
Centralised system consists of headwork of water pipe and pipe
lines network.
Headwork of water pipe: water intake facilities, pumping stations,
treatment plant, reservoirs of purified water, where it is decontaminated
and water tower.
Water distribution is performed with the help of a network of
underground pipes made of galvanized iron or plastic.
Decentralised (local) water supply from local underground water
sources is used in rural areas with fairly low population density, in pioneer
camps, hospitals, on pastures. In this case it is necessary to have:
local water pipe,
tube well,
spring.

Hygienic requirements for water sources in Belarus:

The main source of drinking water supply in Belarus is groundwater.
•This water is low mineralized (200-500 mg/dm3) and with low hardness
(2-4 mmol/dm3).
•Water concentration of iron is increased – 1mg/dm3 and more, whereas
concentrations of fluorine, iodine, bromine and copper are insufficient.
•Water of tube wells contains increased levels of nitrates – up to 126
mg/l.
•In some areas concentrations of natural radioactive substances, including
radon, are increased.

WATER CONSUMPTION REQUIREMENTS IN BELARUS

-In cities, including water pipe, sewage system, centralised hot water
supply - 230 l/day per 1 person;
-In cities, including water pipe and sewage system –
160 l/day per 1 person;
112
- In rural areas with local water supply – 12 l/day per person.

Water consumption requirements for HCI

City hospitals - 250-300 l/ per 1 bed per day;
Rural hospitals - 100-120 l/ per 1 bed per day;
Out-patients hospitals - 15 l/ per 1 visit (per 1 person).

Natural improvement of water quality

One of the most important water qualities is its ability to self-
purification.
Flora and fauna of the water source participates in it. During this
process:
suspended mineral and organic particles, eggs of helminths and
microorganisms partially precipitate, water becomes more clear and
transparent;
organic substances get mineralised due to activity of water
microorganisms;
organic substances are oxidized by oxygen, dissolved in water;
pathogenic organisms die because of:
increasing lack of nutrients in water,
bactericidal effect of solar radiation,
effects of bacteriophages,
effects of antibiotic substances produced by antagonist bacteria.

If water is heavily polluted, and its ability to self-purification

is diminished, it should be purified artificially.
Ways of purification (improvement of water quality) can be classified
in the following way:
–physical-chemical,
–mechanical,
–chemical.
Methods of purification can be divided in the following way:
–clarification (elimination of water turbidity),
–decolouration (elimination of chromaticity),
–decontamination (elimination of pathogenic microorganisms and viruses),
–deactivation (removal of toxic substances).

113
 Special methods:
–distillation or demineralization (removal of salts),
–degassing (removal of dissolved gases),
–deferrization,
–fluoridation.

Stages of water purification:

1.Coagulation, sedimentation;
2. Filtration through slow acting sand filters;
3. Decontamination of water.

Coagulation and flocculation:

Physical-chemical methods of water purification are used at the first stage
of purification;
Target of coagulation and flocculation is to form colloid particles which
are able to grow quickly, to absorb on their surface fine suspended
particles, bacteria and algae, and to precipitate after that;
Performed to accelerate the processes of clarification and decolouration
of water;
There are 2 types of water treatment:
–Addition of coagulants and flocculants to water;
–Use of contact decolourises based on the effect of adhesive strength.

Coagulants and flocculants

 As coagulants are used: aluminium sulphate, ferrous sulphate, chloric
iron.
3
 Doses of coagulant: 30-200 mg/dm of water, depending on
chromaticity and turbidity.
 To increase the effectiveness of coagulation, flocculants, such as silica
acid, polyacrylamide (high molecular weight substances) are used over the
last years.
3
Low doses of flocculants – 0.5-2 mg/dm are able to accelerate and to
strengthen formation of hydrophobic colloid systems and due to this
sufficiently accelerate water purification.

114
 Water precipitation
The 2 types of precipitation tanks are used:
horizontal and vertical;
sedimentation of the suspension occurs due to abrupt slowing of water
current while moving from a narrow entering tube to the tank space;
moving slowly in precipitation tank, in 2-3 hours water partially gets free
from the suspension, which is mostly mineral, and partially – from bigger
microorganisms and eggs of helminths;
water transparency increases, chromaticity, amount of microorganisms
and eggs of helminths decrease as a result of precipitation.

Filtration
Physical-biological method of water treatment, which is
performed during the second stage of water purification.
Silica sand is used as a filtering substance;
In two-layered filters the lower layer is silica sand, and the upper layer is
crushed anthracite.
Filter should get mature, i.e. an active biological film, consisting of
sediment, bacteria and plankton should form on it surface. Mature filter
stops up to 80 % of water microorganisms.
There are 2 types of filtration:
3
 Filtration through slow filters (10-20 cm /h),
3
 Filtration through fast filters (5-12 m /h) – of a lower quality.

METHODS OF WATER DECONTAMINATION

Physical methods:
Ultraviolet radiation.
 Use of ultrasound.
 Use of pulsed electric discharge.
 Boiling.

Ultraviolet treatment.
Is performed with powerful high pressure mercury quartz lamps and
argon mercury lamps.
2 minute exposition is required. This is an effective and promising
method.
115
Ultraviolet radiation affects not only bacteria and eggs of helminths, but
also spore-forming microorganisms and viruses.
It does not change physical-chemical and organoleptic properties of
water.
Disadvantages: water should be very clear – of a low chromaticity and
should not contain suspended particles.

Boiling
Simple and reliable method of water decontamination.
Microorganisms which do not form spores, are killed after 20-30 seconds
of heating at a temperature of + 800С.
Water sterilization can be achieved after 30 minutes of boiling.
Disadvantages: gases evaporate, method can be used for decontamination
of a small amount of water, water can not be stored for more than 24 hours
at a room temperature, as it loses its ability to self-purification, and a fast
growth of microorganisms starts.

Chemical methods
Water chlorination with the help of:
Gaseous chlorine in a form of liquid;
Substances containing active chlorine:
– chloride of lime (active Cl – 25 - 36 %),

– chloramine (active Cl - 20 – 22 %).

Ozone treatment
Ozone simultaneously provides water decontamination, decolouration
and improves its organoleptic properties. This method does not require
supply with any substances.
3
Dose of 0.8-4 mg/dm (depends on water chromaticity and turbidity) in 3-
5 minutes provides marked decontaminating effect.
Ozone destroys spore-forming bacteria 300 times more actively than
chlorine.
WATER CHLORINATION
Advantages: affordable reagents (chlorine containing chemicals;
inexpensive method, effective; allows to monitor the effectiveness
detecting residual chlorine).
116
 Disadvantages: changes organoleptic properties of water, chemicals
are aggressive and unstable.
For water chlorination at waterworks gaseous chlorine is used.
Reaction of hydrolysis occurs after it is added to water:
Сl2 + H2O → HCl + HOCl (hypochloric acid),
HOCl → H+ + ОCl- (hypochlorite ion).
Hypochloric acid and hypochlorite ion are included in to a notion of
“active chlorine”.

WAYS OF WATER CHLORINATION

3 3
Usual doses of chlorine - 1-2 mg/dm - 5-6 mg/ dm of active chlorine
depending on degree of water pollution. Residual chlorine – 0.3-0.5
mg/dm3. This method is used for transparent (clear) water. Exposure time –
30 minutes.
3
Higher doses of chlorine (hyperchlorination) 10-20-100 mg/dm of
active chlorine. This method is used in unfavourable epidemic
environment, to decrease smell and chromaticity before coagulation; for
quick water disinfection. Advantages: exposure time is cut down to 15
minutes. This method is more reliable, technique of chlorination is more
simple, toxins are destroyed, microorganisms (except b. anthraces and eggs
of helminths) are killed.
Chlorination with preliminary ammonium treatment: before
chlorination ammonium is added to prevent persistent phenol smell, if
water has been polluted with oil products, or products of pharmaceutical
industry.

Indices of water quality

Standards of epidemiological water quality.
Indices characterising water quality by chemical content.
Indices of organoleptic properties of water.

Epidemiologically water safety is determined

by absence of pathogenic
bacteria, viruses and protozoa
•General microbial number – number of colony-forming bacteria per 1
cm3 of water. It characterises general amount of saprophitic
117
microorganisms able to survive at an optimal t - 37°C, i.e. in the intestine.
This index should be no more than 50 for drinking water.
•Heat tolerant coliform bacteria – index of faecal water pollution.
Bacteria are counted in 100 cm3 (100 ml) of water. Heat tolerant coliform
bacteria should be absent in 300 cm3 of water.
•
General coliform bacteria – another index of faecal water pollution.
General coliform bacteria should absent in 300 cm3.
3
•Coliphage. Presence of coliphage is determined per 100 cm , (100 ml) of
water. There should be no coliphage in drinking water.

Indices of chemical water

content characterise:
Substances most commonly seen in natural water on the territory of
Belarus and those ones resulting from global anthropogenic pollution;
Content of chemicals appearing in water as a result of its treatment in
water supply system;
Content of harmful chemicals getting in to water sources because of
economic activity.

Most common natural chemical substances can be detected with the

following indices:
Hydrogen ion concentration in open water sources:
6.5 – 8.0, in ground waters – 6.5 – 9.2 рН units.
General mineralization, or solid residue consists of a combination of
organic and mineral substances. In fresh water solid residue is 1000
mg/dm3; if ›1000 mg/dm3 water is mineralised.
Water hardness mostly depends on presence of Ca and Mg salts. Water
hardness can be general, removable and permanent. General water
hardness should not be more than 7 - 10 mmol/dm3.

Indices characterising water pollution with industrial, domestic and

agricultural sewage

Oxidation characteristic – amount of О2 required for oxidation of
organic substances in 1 dm3 (litre) of water. For tap water this index should
be no more than 5 mg/ dm3.
3
Oil products total – should be no more than 0.1 mg/dm .
118
Surfactant species, total – 0.5 mg/dm3.
Non-organic substances:
3
•Chlorine – max 350 mg/dm ,
3
•Sulphates – max 500 mg/dm ,
3
•Nitrates – max 45 mg/dm ,
3
•Iron – max 0.3 (1.0) mg/dm ,
3
•Fluorine – 1.5 mg/dm .

Microelements:
3
•Aluminium – 0.5 mg/dm .
3
•Lead – 0.03 mg/dm ,
3
•Selenium – 0.01 mg/dm ,
•
Mercury – 0.0005 mg/dm3.

Hygienic value of ammonium salts, nitrous and nitric acids:

Ammonium is the initial product of protein degradation, so its presence
means recent water pollution with organic substances of animal origin.
Presence of nitrites means that the first stage of ammonium
mineralization has passed.
Nitrates are the final product of mineralization of organic substances,
their presence means old pollution of a water source.
Presence of ammonium, nitrites and nitrates means constant and
continuous water pollution.
Chlorine. Presence of a large amount of chlorides in human and animal
urine and in economic water allows to use this as an index of water
pollution with sewage.
Simultaneous presence of ammonium and chlorides means water
pollution with urine and faeces.

Substances appearing in water during its treatment:

3
chlorine – residual free – 0.3-0.5 mg/dm or residual combined – 0.8-1.2
mg/dm3;
3
chloroform – during water chlorination – max 0.2 mg/dm ;
3
residual ozone – max 0.3 mg/dm ;
3
formaldehyde – during ozone treatment – max 0.05 mg/dm ;
3
residual aluminium after coagulation - 0.5 mg/dm ;
3
residual iron after coagulation – 0.3-1.0 mg/dm ;
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 Indices characterising organoleptic properties of water:

Water chromaticity - max 200;
Water transparency - 30 cm and more;
Water turbidity – 1.5-2 mg/dm3 or 2.6 units;
Taste and smell are described with a 5-points scale: 0 points – no taste or
smell, 1 point – if can be detected by an experienced laboratory assistant, 2
– weak smell and taste, 3 - noticeable, 4 – obvious, 5 – very strong.

Drinking water should have no more than 2 points.

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 15. INFECTION CONTROL IN HOSPITALS. HYGIENE OF
PATIENTS AND STAFF. HOSPITAL LINEN REGIMEN

Infection control in admission department

Patents with pediculosis (and a premise, if body louse is found) have
to undergo disinsection.
Linen used during patients admission is collected in a polyethylene or
rubber-coated bag and moved away to the used linen room immediately.
The following things should undergo decontamination after each
patient:
 used bast whisps,
 clippers,
 razors,
 manicure scissors,
 examination room coach,
 basin, bath and pan, if patients used them.

Infection control in wards

After patient’s discharge, death, or transfer to another ward
(department):
Bed, bed table and a bed pan stand have to be disinfected;
Bedding (mattresses, pillows, blankets) from infection diseases, surgical,
obstetric and, if epidemically indicated, from medical departments after
patient’s discharge should go for chamber disinfection;
Bed should be covered with beddings went through chamber disinfection
and a fresh linen.

Patient is offered individual personal care belongings: glass,

spittoon, bed pan; individual towel and soap;
Repeated examination of patients, underwent disinsection for lice, is
performed in a department, 7 days after the admission.
Hygienic care for patients:

Hygienic care after severely ill patient is performed after feeding, or in

case of body soiling, this care includes:
washing, or wiping the face,
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washing, or wiping the body,
mouthwash,
hair cut, shaving, etc.

Hygienic wash of other patients should be done at least once in 7

days, with making a relevant note in patient’s card.

Preoperative hygienic care for patients:

In surgical department patient undergoes hygienic treatment
before the surgery.
For elective surgery patients take a shower, or a bath with
antibacterial soap on the night before the operation. On the day of
operation patient receives fresh underwear. Notes of getting hygienic
treatment are made in patient’s cards.
In case of urgent operation patient’s skin is cleaned with disposable
hygienic, or antiseptic wipes.
Hair removal (haircut or depilation) in the area of operation field can
be performed:
 only by surgeon’s order,
 not earlier than 1 hour before the operation,
 after antiseptic skin treatment.

Hygiene of operation theatre staff

Working clothes used in theatres should be of a different colour, than the
ones, used in wards.
In scrub room:
•Hygienic hands wash and surgical antiseptics is performed;
•Surgical team members put on water resistant aprons or surgical sets with
water resistant impregnation.
In theatre:
•Medical staff put on sterile gowns, gloves and personal protective devices,
during this process scrub nurses assist doctors, following the rules of
aseptics.
•If the operation carries a high risk of vascular damage and spitting of
biological fluids, use of personal eye protecting devices (glasses,
protective screens) is mandatory.
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•Ifthe operation carries a high risk of glove damage (operations on bones,
etc), two pairs of sterile gloves should be put on.
Hygienic clothes and personal protective devices should be changed
after each operation.
If operation lasts for more than 3 hours, complete change of personal
airways protecting devices and gloves with repeated surgical antiseptic
hands washing should be done by surgeons.

Staff hygiene requirements for wound dressing change, procedure and

manipulation rooms, intensive care units
•Staff responsible for wound dressing change and those who work in
procedure and manipulation rooms changes gowns, caps and masks daily
before the beginning of the working day.
•Clothes has to be changed immediately if it gets soiled with biological
fluids or wound discharge.
•Medical staff participating in dressing change of infected wounds should
work in surgical (protective) gloves, mask and a cap. If required, a
protective apron should be applied.
•Protective gloves are mandatory in all cases, when there is a risk of a
contact with blood or other contaminated materials, mucosa, or damaged
skin.
•Gloves should be changed for a new ones before the beginning of each
procedure or dressing change.
•Disinfection of gloves with antiseptic (not taking them off the hands)
during work is prohibited.
•In a case of gloves damage they should be changed immediately with
repeated surgical antiseptic hands wash.

Hand hygiene of medical staff includes:

 hand wash,
 hygienic antiseptics,
 cosmetic hands care.
Hand hygiene of medical staff is one of the most important
measures of infection control.

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 Hands microflora
Consists of two types of microorgaisms: Permanent and transitory.

•Permanent microflora resides in corneal skin layer, sweat and oil glands,
hair follicles and consists of epidermal staphylococci, diphtheroids,
propionic bacteria, etc forming barrier skin function.
In periungual area and interdigital spaces, apart from the above
mentioned microorganisms Staphylococcus aureus, Pseudomonas, E. coli
and Klebsiella can be found.
The mentioned skin areas are the natural habitats for these groups of
bacteria.
•Transitory microflora gets onto skin as a result of a contact with infected
patients or contaminated objects and remains on hands skin for up to 24
hours.
It consists of obligate and elective pathogenic microorganisms (E.
coli, Klebsiella, Pseudomonas, Salmonella, Candida, adeno- and
rotaviruses, etc.).
Species composition of transitory microflora is characteristic for
certain profile of healthcare institution.

Skin disbacteriosis is the impairment of permanent microflora’s

population stability
Disbacteriosis manifests itself as a predominance of Gram negative
elective pathogenic microorganisms including hospital antibiotic-,
antiseptic- and disinfectant resistant strains in permanent microflora.
As a result of disbacteriosis, hands of medical staff may become not
just a factor of infection transmission, but also its reservoir.

Reasons for skin disbacteriosis:

Chemical and mechanical exposure of skin (hard brushes, alkaline
detergents, aggressive antiseptics),
Absence of softening components in alcohol based antiseptics.
Sterilization of hands skin is not just impossible, but also undesirable,
because preserving of corneal layer and relative stability of permanent
microflora prevents skin colonization by other, much more dangerous
microorganisms, particularly Gram negative bacteria.
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 Types of skin treatment for HCI staff
There are 2 kinds of hand washing:
 usual hand wash – using usual soap, which does not contain
antibacterial ingredients;
 antiseptic hand wash - using the soap, containing antibacterial
ingredients.
According to the degree of decontamination,
there are 2 types of hands antiseptic:
 surgical antiseptic,
 hygienic antiseptic.
Hand wash provides elimination of soiling and transitory microflora.

Hand wash is mandatory:

After taking off the undamaged gloves;
Before surgical antiseptic hand treatment.
The following sequence is recommended for hands wash:
rinse the hands under warm water;
rub the hands with soap over each other energetically for at least 15
seconds;
rinse the hands with water again;
dry them up with a disposable paper towel or with electric hand dryer.
Before surgical antiseptic hand treatment hands have to be dried up
with a help of a disposable paper towel / wipe only.
Any form of soap is permitted for a hand wash.
Hard soap can be used only in a form of a single-use pack.
If liquid soap is used, it should not be added to the half empty
dispenser. Before refilling dispenser must be emptied, washed and dried
up.

Hands antiseptic
Requires use of chemicals with antibacterial properties and designed for
skin decontamination.
Hand antiseptics should be easily available.
Dispensers with skin antiseptics should be placed:
•By operational theatre entrance,
•In intensive care and resuscitation wards,

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•In procedure rooms,
•In wound dressing change rooms,
•In manipulation rooms,
•In wards for patients with pyoinflammatory and septic infections.
Medical staff, involved in treatment and looking after the patients
should be provided with personal, pocket-size dispensers with antiseptic
solutions.
Antiseptics which are used for surgical hands antiseptic treatment
should provide persisting (continuous) effect.

Hygienic and surgical antiseptic hands treatment

Depending on aim and the required degree of decontamination, there
are 2 types: hygienic and surgical antiseptic hands treatment.
Hygienic antiseptic hand treatment provides elimination and killing of
transitory microflora.
Surgical antiseptic hands treatment provides elimination and killing of
transitory microflora and decrease in the amount of permanent microflora.

Hygienic antiseptic hand treatment is performed in the following cases:

before and after contact with a patient (measuring pulse, blood pressure,
transferring, etc.);
after contact with patients’ secretions or excretions (pus, blood, sputum,
excrements, urine, sweat, etc.), mucosa and wound dressings;
before and after manual and instrumental diagnostic and treatment
procedures, which do not require accessing sterile body cavities;
after contact with surrounding objects including medical devices and
equipment;
after visits to isolators, boxes and wards for infected patients including
pyoinflammatory and septic infections;
after using the toilets and before going home.

Surgical antiseptic hands treatment is required in the following cases:

diagnostic and treatment procedures, requiring the access to internal
sterile cavities and environment of the organism, including:
Surgical interventions,
Laparoscopic manipulations,
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Central veins catheterization,
Joints puncture, etc.

Cosmetic hands care:

Hand nails should be cut short.
Use of artificial nails and decorations (rings, bracelets), impairing
effective elimination of microorganisms is prohibited.
Hygienic lotions and creams should be provided for medical staff to
decrease the risk of contact dermatitis due to hands wash and antiseptic.
After completion of diagnostic, treatment procedures and operations
hygienic lotions or creams could be applied.
Use of hand care remedies is recommended after the hygienic
antiseptic hand treatment at the end of the working day.

Hospital linen regimen

Hospital linen regimen includes:
→ collection,
→ storage,
→ transportation,
→ disinfection,
→ laundry,
→ Ironing / pressing,
→ repairing,
→ utilization of hospital linen in HCI.
Hospital linen regimen includes the requirements targeting to
minimize the risk of appearance and spread of hospital acquired infections
(HAI) due to improvement of hospitals linen regimen management and use
of modern technologies of textile treatment.

Responsibility
•Senior sisters (matrons) of the departments are responsible for
maintenance of hospital linen regimen.
•Senior sister and matron are responsible for collection, storage and
transportation of soiled linen.

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 General requirements to hospital
linen regimen:
•Departments should maintain the sufficient stock of clean linen.
•Clean hospital linen should be stored in special premises – linen rooms.
•Hospital linen should be marked, storage of unmarked linen is not
allowed.
•Clean linen is kept packed (wrapped in pillow-cases or bed sheets) in sets
of 30-50 pieces.
•Hospital linen is given by matron. Before unpackaging, counting and
distribution matron washes her hands and puts on special gown and mask.
•Disposable linen should be used in operational theatres block, intensive
care and resuscitation units and in postoperative wards.
•Sterile disposable linen and drapes should be used in obstetric wards
and other premises with aseptic regimen (neonatal wards) and
operational theatres.
•Modern hygienic remedies (wipes, nappies, etc.) can be used.

Hospital linen change:

Patients linen should be changed regularly (no lesser than once in 7
days).
After operation patient’s linen should be changed as it gets soiled until
wound discharge discontinues.
In intensive care units linen is changed daily, or as required.
Linen soiled with excretions should be hanged immediately.
Women recently confined should get their bed linen changed once every
3 days, underwear and towels are to be changed daily, drapes – as required,
but at least 4 times per 24 hours during the first 3 days and at least twice
per 24 hours after.
Drapes used during newborn feeding are changed before each eating.
In diagnostic and treatment rooms separate linen is used for each
patient.

Sorting of dirty linen in the departments:

Degrees of linen soiling:
1. degree — new linen, with no visible soiling, delivered from storage;
2. degree — slightly soiled linen with some general soiling;
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3. degree — moderately soiled linen with spots and soiled areas;
4. degree — badly soiled linen, including slight soiling with biological
excretions (blood, urine, etc);
4a. degree — particularly badly soiled linen with biological excretions
(blood, pus, sputum, urine, faeces, etc.).
Degree of soiling determines the choice of laundry regimen, type
of laundry equipment, detergent and disinfectants.

Special requirements:
Hygienic clothes and textile means of personal protection
arriving from:
 Obstetric and neonatal,
 Infectious diseases,
 Skin and venereal diseases,
 Surgical infections,
 Tuberculosis
departments are treated as per regimen for IV degree soiled linen;
particularly badly soiled linen from these departments as per regimen for
IVa soiled linen.

Hygiene of staff working with soiled linen:

Medical staff providing patients care or involved in various
manipulations and investigations is not permitted to participate in
collection and transportation of soiled linen.
Staff working with dirty linen should be supplied with hygienic
clothes and textile means of individual protection:
 gown, kerchief,
 mask or respirator,
 special shoes,
 other means of individual protection (gloves).

After finishing with dirty linen staff is required:

to send the hygienic clothes and textile means of individual protection to
the laundry,
to decontaminate reusable gloves and respirators in disinfecting solution,
treat the shoes with disinfectant,

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wash the hands with a soap first and than to perform hygienic antiseptic
hands treatment.

Collection of dirty linen

All process related to transportation loading and unloading of linen should
be mechanized as much as possible.
Specially marked package – bags made of a strong fabrics or oilcloth,
containers with lids, linen trolleys, etc - should be used for collection of
dirty linen. After use they are washed and disinfected.
In wards/boxes dirty linen is collected in pedal containers or buckets with
lid and a bag placed. In these bags linen is delivered to departmental
sanitary room, or to the central soiled linen room.
The following is prohibited during collection of dirty linen:
To shake it and throw it on the floor,
To sort it out in the departments.
Wet clean with the use of disinfectants is performed in wards after the
linen change.

Sorting of dirty linen

In sanitary room linen, hygienic clothes and textile means of individual
protection are freed from foreign objects and packed in bags, made of a
strong fabrics, or polypropylene oilcloth. Packs weight should be not more
than 10 kg.
In sanitary room should be:
walls either covered with tiles for up to 1.5 m height, or painted with oil
paint for at least 2 m height,
exhaust ventilation,
bactericide exciter,
separate entrance,
basin for washing hands, soap, bath for soaking the linen,
gowns, masks, aprons, rubber gloves,
bags for dirty linen,
cleaning equipment and disinfectants,
Linen soiled with infected discharge, should undergo disinfection
immediately, in sanitary room. Wet disinfected linen is sent in water
resistant bags to the laundry.
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 Temporary storage (not longer than 12 hours) is permitted in sanitary
rooms in closed packs (metal or plastic disinfectable containers), away
from heating devices.

Transportation of soiled linen

 Packed dirty linen on marked “for soiled linen” trolleys, or by special
vehicles is delivered from the departments to:
either the premises for dirty linen collection,
or to HCI laundry,
or to central dirty linen room.
 Vehicles are disinfected after unloading the soiled linen.

Washing of hospital linen:

during treatment of hospital linen pathways for “dirty” and “clean”
linen should not get crossed.
Washing is performed:
In special hospitals laundry,

In city laundry, if there is no possibility of contacting hospital and non-

hospital linen.
Separate technological pathway is required for washing linen for
newborns and infants up to 1 year old. Children linen is washed with
boiling only (as per regimen for IV-IVa degree of soiling).
Linen from infectious and obstetric departments should be washed in
special laundry. If special laundry can not be provided, then this linen is
washed separately from other departments linen.
To avoid “clotting” during washing linen from obstetric, surgical and
other departments soiled with high protein substances (blood, milk, pus),
few cycles of pre-washing in water are used.
Linen from infectious departments and that soiled with biological
excretions is disinfected and washed in through-put washing machines with
2 openings – loading (“dirty”) and unloading (“clean”).
Non-infected linen is washed in ordinary washing machines.

Washing of staff’s working clothes

Washing of staff’s working clothes should be done centralised, in
laundry, separately from patients linen.
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Staff working clothes and textile means of individual protection must not
be washed at home.

Disinfection, drying and pressing of linen

Disinfection is achieved by washing with boiling and pressing at a
temperature of 160-180°С.
Drying of linen is performed in special tumble dryers and other special
equipment.
Pressing/ ironing is performed on pressing machines, ironing tables and
manikins of various productivity.
Worn, or damaged during washing linen has to be either repaired, or
discarded. Repair is performed in a special separate premise in laundry.
Pressed linen is packed in sets for each department. Prepared for
distribution linen is delivered to the linen storage. Giving the linen to the
departments is performed up to the schedule.

Transportation of hospital linen:

Transportation of the dirty linen to the laundry and of the clean linen to the
HCI should be performed:
by special transport, or in special closed wheeled containers;
packed clean linen (10 kg per clean linen bag) is delivered to the
departments;
package should be marked either for “dirty”, or for “clean” linen, use of
the same package for soiled and clean linen is prohibited;
washing fabric package (bags) should be performed at the same time as
washing the linen.
Vehicles should be disinfected after delivery of soiled linen.

Monitoring of washing quality

Monitoring of washing quality is based on detecting of the residues of
detergent and presence of hygienically important microorganisms in wash-
outs:
 Cleanness is assessed by whiteness and absence of spots and soils.
 Quality of rinse is checked with a few drops of 1 % phenolphthalein in
70 – 90 % ethanol, or with a help of litmus paper. Rinse is insufficient, if

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added phenolphthalein shows red-violet discoloration, or if litmus paper
changes colour to blue.
 Bacteriological investigations – linen treatment is effective, if there is no
hygienically important microflora growth.

Disinfection, pre-sterilization cleaning and sterilization of medical

equipment
is performed in order to prevent hospital acquired infections (HAI) in
patients and HCI staff.
Physical and chemical means, methods and equipment (cleaning
machines, sterilizers, etc) are used for disinfection, pre-sterilization
cleaning and sterilization.

Disinfection
All goods are needed to be disinfected after use
 Disinfection is performed in order to kill vegetative forms of
microorganisms: viruses, vegetative bacteria and dermatophytes.
 After disinfection goods are rinsed with tap water, dried up and either
used, or underwent pre-sterilization cleaning and sterilization.
Pre-sterilization cleaning and sterilization
Reusable goods require pre-sterilization cleaning in order to remove
protein, oily and mechanical soils, residues of drugs before sterilization.
Sterilization is performed in order to kill all kinds of microorganisms,
including spores.
Sterilization is required if goods contact with:
 wound surface,
 blood,
 solutions for injections,
 mucosa and if they can damage it.

Organization and performing epidemiological monitoring in HCI.

The aim of epidemiological monitoring is to reveal preconditions
and heralds of possible worsening of epidemiological situation and to
prevent that worsening.

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Chief doctor of HCI is responsible for organization and maintenance of
effective epidemiological monitoring, he organises and provides
microbiological monitoring of hospital strains.
Chief doctor should be notified about all detected disturbances of
epidemiological regimen in HCI and assumes the measures on their
correction.
Chief doctor is responsible for reliability of all cases of HAI monitoring,
and for prompt reporting of HAI cases to the Centre of Hygiene and
Epidemiology.

Epidemiological monitoring
The following things should be sterile and should undergo epidemiological
checks:
Instruments, damaging the skin and mucosa integrity (lancets, syringes).
Objects contacting with solution for injections (package, needles), or with
wound surface (dressing materials, surgical instruments).
Medical goods designed for manipulations on sterile areas of patients
bodies (endoscope equipment).
Surgical gloves.
Suturing and wound dressing material.
Remedies for care after patient’s mucosa.
Medications for injections, blood, blood substitutes.
Linen in operational theatres and wound dressing change rooms.
Catheters, gastric tubes, endotracheal tubes, etc.

Epidemiological monitoring of objects of HCI environment

Bacteriological investigation is required for:
objects of the environment, which may be possible sources of contact
infection transmission to skin, mucosa, wound surface;
objects of the environment which contribute to microbial contamination
with blood and solution for injections – medical gloves, instruments;
premises and equipment of operational theatres and wound dressing
change rooms before work;
air of the premises.

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 Backgrounds of epidemiological troubles:
Microorganisms are detected on those objects of the environment where
they should not be found (on medical instruments, in solutions for
injections, etc.).
Increased bacterial contamination of those objects where microflora is
normally detected (drinking water, air, etc.).
In the presence of the backgrounds which can affect hygienic and
epidemiological condition of the HCI, chief doctor implements measures to
reduce the use of the department until the detected defects are corrected.

Heralds of epidemiological troubles

Infection of patients and staff with organisms, but without clinical
manifestations of infection.
The following factors contribute to appearance of backgrounds and
heralds of epidemiological troubles:
interruptions in cold and hot water supply;
damage of water supply and sewage systems;
interruptions in linen supply;
disturbance in terms of decontamination of equipment;
interruptions in disinfectants supply, impair of their quality;
interruptions in heat and power supply;
interruption in work of technical equipment for air disinfection;
disturbance in use of ventilation and air conditioning systems;
overcrowded wards, breach of cyclic infill and disinfection regimen.

Epidemiologic trouble is an appearance of a case of infection with

clinical manifestations.
Staff actions in case of HAI:
Patients with pyoinflammatory septic or any other kind of HAI are
isolated into separate wards with UV bactericide exciters, other devices for
air decontamination approved for use in the presence of patients.
Bacteriological investigation of the environment, medical staff and
patients is performed in HCI.
Antiepidemic measures administered according to the results of
epidemiological investigations are implemented.

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 In case of finding HAI
People being in contact with HAI patient in a ward stay in the same ward
until discharge.
Admission of new arrived patients to the quarantine ward is prohibited.
Current cleaning in wards with HAI patients is performed with
disinfectants.
Cleaning of wards and patients care in HAI wards are performed after
disinfection of wards.
In wards with HAI patients medical staff works in specially marked
gowns and caps which are changed daily and in gloves changed when
moving from one patient to another.

Epidemiological investigation of HAI cases

In the first 24 hours since receiving of notification epidemiological
investigation of every case of HAI should be initiated in order to collect
information for the epidemiological diagnosis.
Epidemiological diagnostics and analysis are made by a specialist
appointed by chief doctor of HCI, who works in cooperation with CHE.
Close of the department or premise for unscheduled terminal disinfection
is performed according to the results of epidemiological investigation.
After discharge of all contacting patients in ward terminal disinfection is
performed.
Information regarding patients being in contact discharged from the
hospital is transferred to policlinic where they are observed during the
incubation period.

Bacteriological investigation
The following undergo bacteriological investigation:
Wound discharge (microbial contamination of the swab contacting with
wound and removed during the next dressing change is investigated).
Hands skin.
Nasal mucosa in medical staff and patients.
Faeces and other biological substrates of staff and patients organisms.

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 16. THE FUNDAMENTALS OF IONIZING RADIATION HYGIENE

Basic principles providing radiation safety

•Principle of substantiation,
•Principle of optimization,
•Principle of regulation,
•Principle of radiation-hygienic protection requirements: protection by
dose, time, distance, shield.

Principle of substantiation
is used at the stage of making decision
•during planning of new radiation objects,
•during approval of regulating technical documentation regarding use of
the sources of radiation,
•if conditions of work have been changed.

Principle of optimization
provides keeping individual and collective radiation doses on the
lowest possible level.

Principle of regulation
•Requires control of the approved limits of radiation doses.
•Should be followed by all organizations and authorities responsible for the
level of radiation exposure.

Assessment of radiation safety includes:

–Characteristics of the environmental radioactive pollution;
–Analysis of the standards, rules and hygienic requirements;
–Registration of people exposed to radiation over the allowed radiation
doses limits;
–Predicting the possibility of radiation accidents and their likely scale;
–Analysis of preparedness to effective elimination of radiation accidents
and consequences;
–Analysis of radiation doses received by certain groups of population from
all sources of ionizing radiation.

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 Radiation risk
Radiation risk is described by the total cumulative reacting dose
from all radioactive sources.
The value of each radiation source is detected by its contribution into
the total reacting dose.

Ways of the radiation safety

On the object radiation safety is achieved by:
–Obtaining the permission to work with the sources of ionizing radiation;
–Following the requirements of the state hygienic expertise for the
equipment and technologies under radiation factor;
–Following the requirements for technological systems;
–Protection of radiation sources;
–Radiation-hygienic literacy of the staff and measures providing staff
radiation safety;
–Presence of the radiation monitoring systems.

Radiation safety around the object is achieved by:

•Well-grounded choice of the area for the placement of radiation object;
•Quality of the radiation object plan;
•Zoning of the territory around and inside of the most dangerous objects;
•Following technological processes;
•Planning and carrying out the measures for the radiation safety of
population;
•Radiation-hygienic literacy of population.

Radiation safety of the staff is achieved by:

•Restrictions to work based on age, gender, general health condition, levels
of previous exposure to radiation;
•Knowing and following the rules of work with radiation sources;
•Maintaining the distance from the sources of radiation;
•Limits in working time with the sources of radiation;
•Use of collective means of protection;
•Use of individual means of protection;
•Providing radiation monitoring and maintaining the permitted control
levels;
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•Providing an information about radiation level.

Duties of the staff in following the requirements of radiation safety:

•To know and to follow the hygienic rules and requirements of radiation
safety;
•To undergo regular medical examinations and to follow the
recommendations of medical commission;
•To use the means of individual monitoring and protection;
•To follow the orders of the radiation safety service regarding safety
maintenance;
•To provide radiation protection of the patients during medical exposure;
•To follow the requirements of radiation accidents prevention and follow
the rules in a case of the accident;
•To inform the head of the object and the radiation safety service
immediately about all detected malfunctioning of the devices and
equipment.

Radiation safety of the population is achieved by:

•Providing safe conditions of life;
•Establishing the limits of doses from different sources;
•Planning and carrying out effective measures of protection;
•Organising the system of information about radiation environment.

Citizens of the Republic of Belarus and foreign citizens should:

•Follow the requirements of radiation safety;
•Take part in carrying out actions that provide radiation safety;
•Follow the requirements of the state institutions that perform monitoring
over radiation safety.

Regulation of the collective radiation exposure

•Decrease of the doses should be achieved by diminishing of a radiation
exposure for the critical groups of staff and population;
•Measures on the collective protection of people should be taken first on
those sources of radiation where the maximal decrease of the collective
radiation exposure can be achieved with minimal expenses.

139
 Monitoring over radiation safety
•Monitoring over radiation safety should be organised and performed on
the object.
•This monitoring is performed by a special service or a specially trained
person responsible for radiation safety.
•Plan of monitoring should be approved by local Centre of Hygiene and
Epidemiology.

Data of the monitoring over radiation safety is used for:

•Assessment of the radiation environment,
•Establishing control levels,
•Planning the measures of the radiation exposure doses decrease and
effectiveness assessment,
•For maintenance of radiation-hygienic log-book of the ionizing radiation
user.

Radiation-hygienic log-book of the object

 Results of the monitoring over radiation safety are recorded in
radiation-hygienic log-book of the object.
 Authorities performing state monitoring over providing of radiation
safety can suspend the work with sources of ionizing radiation (SIR) if
the breaches of rules and regulations on radiation safety have been
detected.

Radiation monitoring
The purpose of radiation monitoring is to obtain the information about
individual and collective radiation exposure doses of the staff, patients and
population.
The objects of the radiation monitoring are:
•Staff undergoing the impact of SIR in working environment;
•Patients during performing of medical radiological procedures;
•Population under effects of natural and artificial SIRs;
•Environment.

140
 Classification of the radiation objects according to their potential
danger
Potential danger of the radiation object is determined by its possible impact
on population.
According to the potential radiation danger there are 4 categories of
objects:
•I category are the objects where in a case of accident radiation impact on
population is possible.
•II category – radiation impact in a case of an accident is restricted to the
hygienic-protective zone.
•III category – radiation impact in a case of an accident is limited to the
territory of the object.
•IV category - radiation impact in a case of an accident is limited to the
premises where the work with sources of radiation is performed.

Placement of the radiation objects

Preferable areas for building of the radiation objects are:
•Non-flooded, with low density of population;
•With steady wind regimen;
•Whose that limit the possibility of radioactive substances spread over the
object’s territory due to topographic and hydro-geological conditions.
Radiation objects of the I and II categories should be placed with the
considerations on wind rose mostly on the lee side of the settlement areas,
health care institutions, children institutions, recreational places and
sportive buildings.

Zoning of the territories

•Hygienic-protective zone and zone of observation should be created
around the I and II categories objects.
•Borders of the hygienic-protective zone and zone of observation should be
approved by the Centres of Hygiene and Epidemiology.
•Territory of the hygienic-protective zone should be well equipped and
have green plantations.
•Radiation monitoring should be performed in the hygienic-protective zone
and zone of observation by radiation safety service of the object.

141
 Planning of the radiation objects should provide:
•Minimal staff radiation exposure;
•Maximal automatic control of operations;
•Absence of toxic and harmful substances;
•Minimal levels of noise, vibration and other harmful factors;
•Minimal spikes and fault of radioactive substances;
•Minimal amount of radioactive waste and reliable ways of its temporary
storage and processing;
•Sound and/or light breach of technological process alarm.

Requirements for the equipment used in work with radioactive substances:

•Reliable and convenient in use construction, adequate containment;
•Should be made of strong resistant materials, allowing easy
decontamination;
•External and internal surfaces of the equipment should be available for
decontamination.

Organisation of work with SIR, duties of the administration

Administration of the organisation:
•Approves the list of the staff allowed to work with radioactive substances;
•Is responsible for radiation monitoring, radiation safety, registration and
storage of SIR, for removal of radioactive waste;
•Provides the safety of radioactive sources;
•Creates and coordinates with the Centre of Hygiene and Epidemiology
instructions of radiation safety during work with SIR;
•Provides training of the staff.

Staff requirements:
•People allowed to work with sources of radioactivity should not be
younger than 18 years old and should not have medical contraindications.
•All workers should have training and knowledge testing about the rules of
safety before getting permission to work;
•Knowledge of the radiation safety rules should be tested before staff starts
to work and than regularly, no less than once a year, for managerial staff –
at least once in 3 years.
•Safety instruction should be performed at least twice per year.
142
•Staff should not be allowed to work if qualification requirements are not
satisfied.

Receiving, storage and transportation of the radiation sources

 Receiving of SIR is performed according to requests.
 Submission of requests is permitted only to organisations owning
radiation-hygienic log-books.
 Organisation should inform Centre of Hygiene and Epidemiology within
the 10 days after receiving SIR.
 Received SIR should be registered in a SIR receipt and consumption
log-book.
 Use of open radioactive nuclides is recorded in Acts.
 Commission administered by the head of the organisation performs
stock-taking of SIR yearly.

Storage of SIR
Out of use SIR should be stored in special places or equipped depositories.
Dose rate on the external surface of depository should not exceed 1.0
mcGr/h.
•Depository should be equipped with 24-hour exhaust ventilation.
•Radioactive substances that produce radioactive gases during storage
should be stored in exhaust hoods with purifying filters on ventilation
systems.
•Cooling system should be provided for storage of high activity radioactive
substances.
•Nuclear safety measures should be provided for the storage of fissionable
species.
•Measures of explosion and fire safety should be organized during storage
of easy inflammable or explosive substances.

Devices for SIR storage

•Construction of bays, wells and safes should prevent extra exposure to
radiation during storage and extraction of separate SIR.
•Section doors and radioactive nuclides packs (containers) should be
opened easily and be clearly marked (name of radioactive nuclide and its
activity).
143
 Transportation of SIR
SIR should be transported in containers and packs within the
premises and on the organisation’s territory.
Vehicles used for SIR transportation outside of the organisation
should have:
•Hygienic log-book,
•Specially equipped driver’s protection,
•Set of instruments and means of individual protection to be used in a case
of accident.

Work with closed SIR

•Closed sources of radioactivity belong to irreplaceable industrial products
that constantly spend its resource.
•After the end of determined expiry date SIR can not be repaired and its
work should be stopped.
•SIR containment should be monitored. SIR should not be used if
containment is damaged.
•SIR should be stored in protective devices resistant to mechanical,
chemical, thermal and other impacts, marked with radioactive danger sign.
•Remote control instruments should be used to remove closed SIR from
container.
•Protective shields and manipulators or protective devices (hoods, boxes)
with remote control should be used for a work with closed SIR.
•Working premises should be equipped with blocking systems and SIR
location alarm.
•Entrance door to the premise should be blocked with mechanism moving
the SIR in order to prevent accidental staff exposure to radiation.

Work with X-ray devices

•Working part of the stationary X-ray device should be placed in a separate
premise;
•Wall material and thickness should provide weakening of the primary and
sparse radiation in the adjacent premises and on the territory;
•Control panel should be placed in a separate premise.

144
 Work with open sources of radiation
Work with open SIR is divided into I, II and III classes depending on
radioactive danger of nuclides and it actual activity.
Measures of radiation safety during work with open SIR should:
•Provide staff protection from internal and external radiation;
•Limit pollution of air, working surfaces, skin and clothes;
•Minimize pollution of the environment – air, soil, green plants, etc.

Premises for work with open SIR are divided into three zones:
•1 zone – non-serviced premises, the main source of radioactive emanation
and radioactive pollution. Staff is not permitted to stay in non-serviced
premises when technological equipment is working;
•2 zone – periodically serviced premises used for equipment repair and
radioactive substances storage;
•3 zone – staff premises - for staff accommodation during the shift
(operator’s rooms, control panels, etc).

Requirements for the premises

Protective locks are built between zones of radioactivity to regulate the
spread of radioactive pollution.
Floors and walls of the I and II class premises should be covered with
low absorbing material resistant to washing detergents.
Different zones of radioactivity should be painted in different colours.
Margins of floorings should be lifted up and choked up flush with walls.
Floor should have incline if there is a trap.
2
Size of the I and II class premises should be not less than 10 m per
working person.

Requirements for the equipment

•Equipment and furniture should have smooth surface, simple construction
and low absorbing cover.
•Equipment, instruments and furniture should be marked and assigned to
the premises of each class. Moving them from one class premise to another
is prohibited.
•Distant tools should be used during the work in chambers and boxes.

145
•Trays and pans made of low absorbing materials should be used to
diminish working surfaces pollution.
•Disposable materials should be used – plastic films, filtering paper, etc.

Ventilation of the premises

•Construction of working premises, exhaust hoods and boxes should enable
direct air stream from non-polluted areas to polluted ones.
•Removed air should be purified before ejection into atmosphere.
•Filters should be placed directly in boxes or hoods to diminish pollution.
•Air supply to the hose isolating individual means of protection (pressure
suits, hose gas-masks) should be available in the I and II class premises.

Water supply and sewerage system

•Organisations should have cold and hot water supply and sewerage
system.
•Water taps in I and II class premises should have mixers and be opened
with a help of pedal, elbow or contact-free device.
•Sinks for discharge radioactive solutions should be connected to a special
sewerage system. Their construction should eliminate spraying of the
solutions.
•Toilet flush should be performed with pedal water flush.
•Basins should have a built-in electric hand dryers.
•Special sewerage system should provide decontamination of sewage
water. Sewage disposal plant should be placed in a special premise on the
territory of the object.

Means of individual protection

Staff working with sources of radiation should be supplied with the means
of individual protection, including:
Basic set of individual protection means.
 Additional working clothes.
Basic set of individual protection means includes:
•Special underwear,
•Socks,
•Overall or suit (trousers, jacket),
•Special shoes,
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•Cap or helmet,
•Gloves,
•Towels and disposable handkerchiefs,
•Means of airway protection (depends on degree of air pollution).
Change of basic working clothes and underwear should be done at least
once in 10 days.

Means of individual protection for HCI staff

For class II and some works of class III staff should be provided with:
•gowns,
•caps,
•gloves,
•light shoes,
•means of airways protection, if required.
Means of individual protection should either be made of easily
decontaminated materials or be disposable.

Personal hygiene of the staff

The following is prohibited in the premises for work with open SIR:
•Presence of the staff without necessary means of individual protection;
•Eating, smoking, use of cosmetics;
•Storage of food and tobacco products;
•Storage of domestic clothes, cosmetics and other belongings not related to
work.

Medical provision of radiation safety includes:

•Medical examinations,
•Prevention of diseases,
•If required – treatment and rehabilitation of people with health
impairments.
Staff working with SIR should undergo preliminary and regular health
screening.
Staff is not allowed to work without medical permission.

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 17. OCCUPATIONAL HYGIENE. HYGIENE, PHYSIOLOGY AND
PSYCHOLOGY OF WORK. WORKING ENVIRONMENT

Occupational Hygiene
is a part of hygiene studying:
 working environment,
 nature of work,
effects of working environment and nature of work on functional state
and health of human beings,
this field of hygiene creates scientific background and practical
prevention of adverse effects due to working environment and nature of
work.

Occupational hygiene consists of:

Physiology of work;
Psychology of work;
Hygiene of work in functional overstrain;
Occupational hygiene for work in unfavourable microclimate;
Occupational hygiene for electromagnetic fields and radiation exposure;
Occupational hygiene for vibro-acoustic exposure;
Occupational hygiene for work under ionising radiation exposure;
Occupational hygiene for different branches of industry and agriculture.

Comprehensive hygienic assessment of working environment and nature

of work
INCLUDES:
 distinctive features of manufacture;
 hygienic working environment;
 nature of manufacturing process;
 changes in physiological functions occurred during the work;
 hygienic efficacy of the group protective equipment;
 efficacy of the individual protective equipment;
 staff’s health condition.

Distinctive features of manufacturing include:

►manufacturing process (technology);
148
► manufacture equipment,
► raw and processed materials,
► accumulating waste products,
►technical hygienic condition of manufacture (technical hygienic
condition depends on group and individual protective equipment used).

Staff protective equipment

Group protective equipment:
 technical (ventilation, lightening),
 general use premises, facilities, devices and equipment;

Individual protective equipment:

Working clothes,
Special shoes,
Protective glasses and screens,
Respirators,
Protective helmets, etc.

Types of working activity:

Involving sufficient physical activity.
Mechanical work.
Semiautomatic work.
Automatic work.
Conveyer work (group type).
Work with remote control over the manufacture cycle.
Mental work.

Types of mental work:

operator,
management,
creative labour,
work of healthcare personnel,
pupils/ students labour.

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 Workload and tension of work
Workload – description of the working process reflecting its load on
muscular-skeletal system and systems, providing its performance
(cardiovascular, respiratory).
Tension of work – description of working process reflecting the load on
central nervous system, senses and emotional sphere.
Measurements and calculation of workload and tension of work are
performed according to the methods used in physiology and occupational
hygiene.

Workload is described by:

value of dynamic load,
value of static load,
weight of lifting and moving load,
total number of stereotype working movements,
type of the working position, degree of body inclination,
amount of moves around the area.

Tension of work is described by:

intellectual, sensor and emotional loads,
degree of monotony of the loads,
working regimen (pattern).
Physiology of work:
STUDIES THE ORGANISM’S FUNCTIONAL STATE IN A PROCESS
OF WORK AND WORKS OUT THE WAYS TO INCREASE
EFFICIENCY OF WORK

Physiological classification of physical labour:

1 CATEGORY – light physical activity
- 1А (up to 139 Wt) – sitting labour;
- 1B (140-174 Wt) – standing labour;
2 CATEGORY – medium physical activity
- 2А (175-232 Wt) – labour involving walk or moving weights up to 1 kg;
- 2B (233-290 Wt) - labour involving walk or moving weights up to 10 kg;
150
3 CATEGORY – heavy physical labour - (over 290 Wt) - labour
involving walk or moving weights over 10 kg.

Main physiological criteria of organism’s state:

•Oxygen requirements (oxygen demands / deficiency)
•State of CVS – increase of heart rate and minute volume;
•State of RS – increase of respiratory rate;
•Blood content – morphological (erythrocytosis, leucocytosis) and
chemical (blood sugar and lactate ratio).

Physiology of mental work.

The loads are mostly on:
•Functional state of CNS,
•Cardiovascular system,
•Mechanisms of blood supply self-regulation,
•Emotional sphere,
•Sympato-adrenal and hypothalamic-hypophysis systems,
•Vegetative nervous system and metabolism.

Concomitant adverse factors:

•Hyperkinesias and hypodynamia,
•Overweight,
•Bad habits.

CNS and working efficiency.

•Initial starting stage.
•Stage of stable working efficiency.
•Stage of decreased efficiency at pre-lunch period.
•Second starting stage.
•Second stage of stable working efficiency.
•Second stage of decreased efficiency 1-2 hours before the end of the
working time.
•Short period of increased efficiency against a background of tiredness.
The pattern of functional changes in CNS state manifests during the
working day and throughout the working week.

151
 Effects of work and leisure on functional states of human organism

Adverse
change in the
functional Area of harmful working conditions
state of the
human
organism

Area of permissible working

conditions
Mo Tue We Thu Fr Sa Su Mo Tue We Thu Fr Sa Su Mo

Adverse
change in the
functional
state of the
human Area of harmful working conditions
organism

Area of permissible working

conditions

1 2 3 4 5 6 7 8 9 10 11 vac 1 2 3

Psychology of work
New chapter of occupational hygiene uses the achievements in
general psychology for professional orientation, professional training,
increase of working efficiency and improvement of working environment
and interpersonal relationships in a working group.
Includes the following:
Psychological expert examination.
Psychology of professional training.
Engineering psychology (ergonomics).
Psychological rationalization of the work (based on psychometric
results).
Psycho-physiological pre-nosological diagnostics.

Stress within the working environment:

•The effect of the extreme factor (in terms of workload or tension).
•Result of the emotional overload (responsibility).
•Excess of information.
•The consequence of insufficient training (lack of training or
professionalism).

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 Tiredness
– physiological process based on protective inhibition. It develops in
CNS and reflects the ratio of the processes of excitation and inhibition in
brain cortex (dominance of protective inhibition).
•Quickly developing tiredness is the result of either overload or load
inadequate to organism's functional capacity.
•Slowly developing tiredness is the result of a continuous or monotonous
work
Over fatigue – pathological condition resulting from widespread
inhibition or over excitation of the brain cortex.
Unlike the tiredness in over fatigue the rest period does not
restore the functions.
Over fatigue is a base of general and professional morbidity.

Working conditions
 Working conditions is the sum of factors of the working environment,
affecting the efficiency of work.
 Efficiency of work is a physical state of a human, which describes
ability to perform certain amount of work over a certain time interval.
 Ability to work is a condition which considers a sum of physical,
intellectual and emotional abilities of a human to perform certain amount
of work over a time interval.

Working conditions are divided into 4 classes:

optimal,
bearable (favourable, safe),
harmful,
dangerous (unfavourable).
Safe working conditions
•Optimal working conditions (1 class) – environment which preserves
worker’s health and creates the conditions for maintenance of a high level
of working efficiency.
•Bearable working conditions (2 class) – manufacturing factors do not
exceed the hygienic standards and changes in functional state of the
153
organism return back to normal during the rest period or by the beginning
if the nest shift and do not possess adverse effects neither in near nor in far
future on the heath of staff and their descendants.
Optimal and bearable working conditions are classified as safe.
Safe working conditions – environment where dangerous or
harmful factors are either absent or their effects do not exceed the
permissible levels.

Harmful working conditions can be distinguished into 4 degrees:

•1st degree (3.1) – working conditions cause functional changes which
return back to normal after the contact with harmful factors is stopped;

•2nd degree (3.2) – persistent functional changes leading in increase of

professional morbidity, development of mild forms of professional
diseases often following 15 and more years of working experience;
•3rd degree (3.3) – working conditions resulting in mild to moderate
forms of the professional diseases;
•4th degree (3.4) – working conditions which may lead to sever
professional diseases.

Sources of risks in manufacture

manufacturing process

Devices and
Equipment
instruments
Technology Industrial medium Management

Production risks

Professional risks

Qualification, Responsibility,
State of health
experience self-discipline

Worker

154
 International risk assessment methodology

1. Detection and identification of hazards:

goals, objectives
and specific solutions are defined

2. Exposure assessment:
dose, exposure and
intensity of factor, its frequency,
duration of
the impact in past, present and future are set

3. The establishment of "dose - effect“ connection:

the dependence of health indicators
From the level of exposure is revealed

4. Risk profile:
data analysis and calculation of individual
and group risks, a comparison of risks
with tolerable levels.
The aim of a phase – identification of the risks
that must be eliminated
or reduced to the lowest possible level

5. Risk management: transfer of the data to the

authorities responsible for risk management, which must
develop measures to reduce
or prevent the risk
and control public health

6. Risk notification: distribution of the information about the risks,

their sources and effective prevention
at national, regional and individual levels

The following is required for a work in harmful environment:

 special permission,
 use of group and personal protective equipment and remedies,
 use of other measures to minimize adverse effects of harmful factors of
working environment (protection by time, screen, distance).
155
 Morbidity resulting from manufacturing activity and professional
diseases – diseases related to certain working activity
•Morbidity resulting from manufacturing activity – morbidity which
includes common diseases of various origin, not considered as
professional, it tends to increase with the longer working experience and
remains higher than in professional groups, not contacting with harmful
factors.
•Professional disease (acute or chronic) – disease of a staff member
resulting from effects of harmful and/or dangerous factor of working
environment and causes damage to health.

Dangerous working conditions

‼ Dangerous (extreme) working conditions
(4th class)- are characterised by levels of working factors resulting
in:
risk for life,
danger of the development of acute professional damage.
Work under dangerous conditions is not permitted, apart from the
liquidation of major accidents and their prevention.
Work under dangerous conditions should be performed in appropriate
personal protective remedies and should strictly follow the regimens
created for this kind of work.

Manufacturing factors
•The leading manufacturing factor is the factor which effect on organism
is the most prominent in a case of combined influence.
•Harmful manufacturing factor is the factor which effect on working
person may result in professional disease, decreased working efficiency or
affect negatively the descendants.
•Dangerous manufacturing factor is the factor which effect on working
person results in injury, acute poisoning other sudden abrupt health
deterioration or death.
Dependently on level concentration and duration of exposure,
harmful manufacturing factor may become dangerous.

156
 Hygienic criteria – indices allowing to assess the degree of
deviation of certain parameters of working environment and
manufacturing process from the current hygienic standards.

Dangerous and harmful manufacturing factors

Dangerous manufacturing factor harmful manufacturing factor

Influence on human organism
Death Disease The negative impact on the
Acute poisoning or other health of offspring
Trauma sudden health deterioration
decreased performance

Physical Chemical
moving machinery; By nature of the impact on the body
high or low temperature; Toxic Irritating Sensitizing
increased noise at the workplace;
Carcinogenic Mutagenic
increased level of vibration;
high voltage electrical circuit; Affecting the reproductive function
insufficient illumination of the working area; By way of penetration into the human body
sharp edges, burrs and roughness By Inhalation Through GIT
on the surface of workpieces, tools and equipment.
Through the skin and mucous membranes

Biological
pathogenic microorganisms (bacteria, viruses, ...) and their macroorganisms (animals and plants)
metabolic products
Psychophysiological
Physical overload Mental Overload
mental strain monotony of work
static
analyzers overstrain emotional overload
dynamic

Classification of the (harmful) manufacturing factors

The following may be the harmful manufacturing factors:
•Workload and work tension;
•Temperature, humidity, rate of air move, heat irradiation;
•Non-ionising electromagnetic fields and radiation (including UV and
laser);
•Manufacturing noise, ultrasound and infrasound;
•Vibration (local and general);
•Lightening;
•Electrically charged air particles – air ions;
•Aerosol (dust);
•Chemical factors;

157
•Biological factors;
•Ionising radiation.

Hygienic regulation of working conditions:

- maximal permissible concentrations,
- maximal permissible levels.
Values (amounts) of harmful manufacturing factors which in a case
of a daily work for no more than 40 h per week (maximal working week)
do not cause any diseases or deviation in health detected by modern
methods of investigation throughout all working experience during work or
in a far future of the present and next generations.
Metrological measurement of the maximal permissible
concentrations
The upper confidence limit of the
measurement result The result of a single
measurement
The average value Accuracy of
(expectation) single
measurement
measurement

The lower
Result of

confidence limit of
the measurement
result

Measurement or time
1 2 3 4 5 6 7
The uncertainty of the
Field of "actual" values
measurement result

Temporary reference safe levels of impact (TSLI) and reference

permissible levels (RPL) are set up:
With the help of computer data bases,
Information-predictive systems,
Mathematic modelling of correlations between chemical structure,
physical and chemical properties and toxicity of potentially harmful
substances,

158
By revelation of correlation between indices of toxicity found in short-
term researches and effects of chronic impact.
With the use of cell culture, isolated tissues and organs, biological objects
of various complexity.

Methodology of hygienic
regulation Unacceptable
harmful
Extremely
Very
Not Harmful harmful
harmful
harmful

NOT HARMFUL HARMFUL

>10
10

6
3
1
The ratio of the factor to the MPL or MPC

Risk of
pathogenic
effects
healthy
1

Intoxication in 1-2
month 3-5
times
MPC Intoxication
in 2-4 weeks 10 times

Intoxication in 1-2
100 times
weeks

ORGANISM Acute poisoning or

> 100 times
death

Exceeding MPC in water

159
The main regulating documents in occupational hygiene in Belarus are
Hygienic Rules and Standards.
Normative documents must be used :
 On all manufactures, irrespectively on the type of property;
 For obtaining full and complete information about working
conditions at a time of staff recruitment;
 By state supervising bodies;
 By medical staff of occupational health departments, out-patient
clinics, surgeries, departments of professional diseases;
 By national insurance staff.

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 18. NOISE AS MANUFACTURING FACTOR

Oscillations of solids, liquids and gases can be described by:

amplitude – magnitude of deviations from the balance point;
frequency – number of deviations per time,
(1 Hz – 1 deviation per 1 second);
rate of oscillating wave spread in physical or biological surrounding,
including human body.
There are 3 ranges of oscillations frequency:
infrasonic – up to 20 Hz;
sonic, perceived by ear as sounds — from 20 Hz to 20 kHz;
ultrasonic – over 20 kHz.

Sound
 is a mechanical oscillation of a bumping (air) medium at
frequency from
20 Hz to 20 kHz.
Sonic wave carries:
sonic pressure, measured in Pa or N/m2;
sonic energy, measured in Wt/m2.

Noise
is a sum of a sounds of various rates and intensity, disorderly
combining and changing in time.
Noise is characterised by spectre (frequency content):
low frequency noise – up to 350 Hz;
medium frequency noise – 350-800 Hz;
high frequency noise – over 800 Hz.

Types of noise:
 domestic – elevators, technical hygienic facilities (air conditioners,
water supply), objects of general use, trade, catering which are placed in
living buildings;
 street – motor vehicles;
 manufacturing.

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 Noise regulations
Frequency characteristics: sound spectre is divided into 9 octave stripes
with the following medium geometric frequencies:
31.5 Hz; 63 Hz; 125 Hz; 250 Hz; 500 Hz; 1000 Hz; 2000 Hz; 4000
Hz;8000 Hz.

 Intensity of noise (strength of noise) is assessed by the level of sound

pressure which is evaluated in logarithmic units – decibels (dB).
Zero decibel corresponds to the sound pressure of 2х105 Pa. The maximal
sound which human ear is able to detect is 140 times stronger. The range of
sound measurements varies from 0 to 140 dB.

Maximal permissible street noise

 Motorways - 87 dB.
 City highways with permanent traffic - 85 dB.
 City highways with regulated traffic - 82 dB.
 District high streets - 81 dB.

Manufacturing noise
Elevated noise levels are typical for many modern manufactures:
In manufacturing of reinforced concrete units noise levels reach 105-120
dB.
In woodworking industry - 85-105 dB.
In spinning and weaving manufacture - 92-110 dB.

Factors that influence noise effects on human body:

 distance to the source of noise;
 duration of noise;
 restraint of the working space;
 intensity of physical activity;
 simultaneous effects of other harmful manufacturing factors.

Effects of noise on human body

Specific effect of noise manifests as hearing disorders.

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Noise disease is complicated symptom complex of functional and
organic disorders in the organism developing simultaneously to hearing
disorders.

Hearing disorders.
1st stage – hearing adaptation: under influence of noise the hearing
threshold increases by 10-15 dB. Hearing threshold returns back to normal
in 3-5 minutes after noise is over.
2nd stage – hearing fatigue: adaptation time is prolonged.
3rd stage – cochlear neuritis or occupational deafness: persistent
decrease of sensitivity to different tones and whistling.
4th stage – occupational hearing loss: constant capillary spasm results in
acoustic papilla atrophy.

Noise disease:
General effects of noise on CNS:
Slowing of all neural responses;
Shortening of the active attention duration;
Decrease in working efficiency and performance.
Higher nervous activity disorders:
Changes in respirations and cardiac contractions rhythm;
Increase of systolic and diastolic blood pressure;
Hyper secretion of some endocrine glands;
Increase in sweating particularly of palms and feet.
Changes in motor and secretion activity of the digestive system.
Metabolism disorders, particularly in lipid metabolism, raise of
cholesterol levels due to endogenous hypercholesterolemia.

Noise disease is accompanied by:

 hypertension, 50-60 % raise comparing to noise free manufacture.
Female workers suffer twice more often than male;
 common colds and communicative diseases due to suppressed
immune response and functions;
 headaches, vertigo, sleeping disorders;
 suppression of all psychic functions, particularly memory.

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 Prevention of noise disorders
With the help of the following:
 Introduction and following hygienic standards for maximum
permissible noise levels with consideration of work intensity and workload.
 Technical support.
 Management measures.
 Medical protection.

Maximum permissible noise levels with

consideration to work intensity and workload

Categories
of work Categories of workload
intensity
light moderate hard 1st. hard 2nd. hard 3rd.

80 dB 80 dB 75 dB 75 dB 75 dB
light

moderate 70 dB 70 dB 65 dB 65 dB 65 dB

Intensive 60 dB 60 dB
1st.
Intensive 50 dB 50 dB
2nd.

Ways to decrease the noise

Most effective way is to diminish noise at its source:
Acoustic isolation of equipment and instruments;
Acoustic isolation of protecting construction, special coating of walls and
ceilings;
Use of silencers in ventilating systems;
Diminishing of noise from technique and hygienic equipment of
buildings (elevators, water supply).
Use of the cabins with acoustic isolation and remote control.
Properly arranged working pattern to limit the duration of noise
exposure.
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 Use of personal protective devices (headphones, earplugs and
helmets).
Medical prevention: preliminary and periodical health screenings for
early diagnostics of occupational disorders.

Infrasound
 acoustic vibrations in the range of up to 20 Hz frequency not
detectable my human ear.
Manufacturing infrasound varies in frequency from 1.6 to 20 Hz
and has four octave stripes with average geometric frequencies of 2, 4,
8 and 16 Hz.
According to the spectre infrasound noises can be:
tonal, when one of the frequency spectre compound overwhelm the
levels of the rest frequencies by 10 dB or more;
wideband, when frequency spectre consists of a number of octave
infrasound stripes.

Infrasound as a factor of manufacturing environment

In modern manufacture and transport sources of ultrasound are
compressors, air conditioners, turbines, industrial ventilators, vibrating
platforms, blast and open hearth furnaces, heavy machinery with spinning
parts, aircrafts and helicopters engines, diesel engines of ships and
submarines, motor vehicles.

Effects of infrasound:
Headache and dizziness,
Nausea,
Shakes and shivering,
Aches during swallowing, mouth dryness,
Numbness of palate and facial skin,
Nervous and psychic disorders (fear, anxiety, senestopathy),
Various vegetative reactions.

Prevention of infrasound effects

Infrasound spreads over sufficient distances
Complex of measures is required for protection:
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•constructive measures, decreasing infrasound at its source,
•Planning solutions,
•Management and administrative measures,
•Medical prevention,
•Personal protection devices.

Hygienic standards for infrasound

No Types of premises Levels of sound pressure (dB)

2 Hz 4 Hz 8 Hz 16 Hz

1 Manufacturing premises
for:
works of various
workload,
100 95 90 85
works of various intensity 95 90 85 80
2 Area of dwelling building
up 90 85 80 75
3 Dwellings and public
buildings premises 75 70 65 60

Ultrasound
 Bumping oscillations and waves with a frequency of over 20 kHz,
non-detectable by human ear.
Use of low-frequency (up to 100 kHz) ultrasound waves, spreading by
contact and through air – for cleaning, purification, degreasing, welding,
soldering and thermal treatment of materials, in medicine – ultrasonic
surgical equipment, sterilization of instruments.
Use of high-frequency (100 kHz - 100 MHz and higher) ultrasound,
spreading only through direct contact, for non-invasive control and
measurements, also in medicine for diagnostics and treatment.

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 Biological effects of ultrasound
specialists in USG diagnostics, physiotherapists and surgeons are exposed
to effects of ultrasound with a frequency of 18 kHz - 20 MHz and intensity
of 50-160 dB.
Effects of ultrasound on hearing are less than those from high-
frequency noise, however, its effects on vestibular apparatus are more
prominent.
Low-intensity ultrasound promotes faster metabolism, light tissue heating
and micro massage.
Medium-frequency ultrasound causes reversible reactions of suppression,
first of all, in nerve tissue.
High-frequency ultrasound causes irreversible suppression, progressing
into complete tissue destruction.

High-frequency contact ultrasound

Affects only at the direct contact between the source of
ultrasound and body surface.
Continuous work with ultrasound due to contact transmission on
hands results in peripherial neurovascular disorders, the severity of
disorders depends on ultrasound intensity, duration of contact and size of
the contact area, other unfavourable factors of the working environment
such as local and general hypothermia.

Effects of contact ultrasound

Local effects:
Hand paraesthesia;
Increased cold sensitivity;
Hands weakness and aches at night;
Decrease in tactile sensation;
Palm sweating.

General effects:
Headaches;
Dizziness;
Tinnitus;
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General fatigue;
Palpitations;
Chest pain.

Maximum permissible levels of

ultrasound on working places

Air ultrasound Contact ultrasound

Medium Levels of sound Medium geometric Levels of sound

geometric pressure, dB frequencies, kHz pressure, dB
frequencies, kHz

12.5 80 8-63 100

16 90 125-500 105
20 100 > 500 110
25 105
31-100 110

Individual and manufacturing professional risk factors:

Individual risk factors:

Inherited risk of cardiovascular diseases,
Astenic constitution,
Cold allergy,
Injuries and frostbite of extremities in the past medical history,
Continuous working experience in similar speciality.

Manufacturing professional factors:

High levels of contact and air ultrasound,
Transmission of ultrasound through liquid medium,
Large contact surface with the sources of ultrasound,

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Soilingof hands with contact lubricants,
Concomitant hands hypothermia or cooling microclimate in the premises,
Work in a forced posture or static load on fingers and wrists muscles.

Medical prevention
Clinical examination of the staff,
Regular health screening,
Physiotherapy: warming air procedures with massage and warming
hydromassage for hands, massage of upper extremities,
Physical exercises,
Balanced diet, vitamins,
Psycho-physiological relief.
Personal protection devices:
Use of two pairs of thick cotton gloves - to prevent the spread of
ultrasound through solid medium;
A pair of thick rubber gloves over a pair of cotton gloves – to prevent the
spread of ultrasound in liquid medium.

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 19. THE EFFECTS OF VIBRATION ON HUMAN HEALTH
Vibration is the mechanical oscillations of an object about an
equilibrium point.
The oscillations may be:
 regular such as the motion of a pendulum or
 random such as the movement of a tire on a gravel road.
The study of health effects of vibration require measures of the
overall "pressure waves" that are generated by vibrating equipment.

Vibration enters the body from the organ in contact with vibrating
equipment. When a worker operates hand-held equipment such as a chain
saw or jackhammer, vibration affects hands and arms. Such an exposure is
called hand-arm vibration exposure. When a worker sits or stands on a
vibrating floor or seat, the vibration exposure affects almost the entire body
and is called whole-body vibration exposure.
The risk of vibration induced injury depends on the average daily
exposure. An evaluation takes into account
 the intensity and frequency of the vibration,
 the duration (years) of exposure and
 the part of the body which receives the vibration energy.

Characteristics of vibration
If we could watch a vibrating object in slow motion, you could see
movements in different directions. Any vibration has two measurable
quantities. How far (amplitude or intensity), and how fast (frequency)
the object moves helps determine its vibrational characteristics. The terms
used to describe this movement are frequency, amplitude and acceleration.

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 Frequency
A vibrating object moves back and forth from its normal stationary
position. A complete cycle of vibration occurs when the object moves from
one extreme position to the other extreme, and back again. The number of
cycles that a vibrating object completes in one second is called frequency.
The unit of frequency is hertz (Hz). One hertz equals one cycle per second.

Amplitude
A vibrating object moves to a certain maximum distance on either
side of its stationary position. Amplitude is the distance from the stationary
position to the extreme position on either side and is measured in metres
(m). The intensity of vibration depends on amplitude.

Acceleration (measure of vibration intensity)

The speed of a vibrating object varies from zero to a maximum
during each cycle of vibration. It moves fastest as it passes through its
natural stationary position to an extreme position. The vibrating object
slows down as it approaches the extreme, where it stops and then moves in
the opposite direction through the stationary position toward the other
extreme. Speed of vibration is expressed in units of metres per second
(m/s).
Acceleration is a measure of how quickly speed changes with time.
The measure of acceleration is expressed in units of (metres per second)
per second or metres per second squared (m/s2). The magnitude of
acceleration changes from zero to a maximum during each cycle of
vibration. It increases as vibrating object moves further from its normal
stationary position.

Resonance
Every object tends to vibrate at one particular frequency called the
natural frequency. The measure of natural frequency depends on the
composition of the object, its size, structure, weight and shape. If we apply
a vibrating force on the object with its frequency equal to the natural
frequency, it is a resonance condition. A vibrating machine transfers the
maximum amount of energy to an object when the machine vibrates at the
object's resonant frequency.
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 Vibration exposure
Contact with a vibrating machine transfers vibration energy to a
person's organ. We know that vibration affects the organ in contact such as
the hands. But we do not fully understand how vibration may affect other
parts of the worker's body or only a selected particular organ. The effect of
vibration exposure also depends on the frequency of vibration. Each organ
of the body has its own resonant frequency. If exposure occurs at or near
any of these resonant frequencies, the resulting effect is greatly increased.

Segmental vibration exposure affects an organ, part or "segment" of

the body. The most widely studied and most common type of segmental
vibration exposure is hand-arm vibration exposure which affects the hands
and arms. Exposed occupational groups include operators of chain saws,
chipping tools, jackhammers, jack leg drills, grinders and many other
workers who operate hand-held vibrating tools.

Whole body vibration energy enters the body through a seat or the
floor, and it affects the entire body or a number of organs in the body.
Exposed groups include operators of trucks, buses, tractors and those who
work on vibrating floors.

Examples of occupational vibration exposure

Industry Type of Vibration Common Source of Vibration
Agriculture Whole body Tractors
Boiler making Hand-arm Pneumatic tools
Construction Whole body Heavy equipment vehicles

Hand-arm Pneumatic tools, Jackhammers

Diamond cutting Hand-arm Vibrating hand tools
Forestry Whole body Tractors

Hand-arm Chain saws

Foundries Hand-arm Vibrating cleavers

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 Furniture manufacture Hand-arm Pneumatic chisels
Iron and steel Hand-arm Vibrating hand tools
Lumber Hand-arm Chain saws
Machine tools Hand-arm Vibrating hand tools
Mining Whole body Vehicle operation

Hand-arm Rock drills

Rivetting Hand-arm Hand tools
Rubber Hand-arm Pneumatic stripping tools
Sheet Metal Hand-arm Stamping Equipment
Shipyards Hand-arm Pneumatic hand tools
Shoe-making Hand-arm Pounding machine
Stone dressing Hand-arm Pneumatic hand tools
Textile Hand-arm Sewing machines, Looms
Transportation Whole body Vehicles

The health effects of hand-arm vibration

Vibration induced health conditions progress slowly. In the beginning
it starts as a pain. As the vibration exposure continues, the pain may
develop into an injury or disease. Pain is the first health condition that is
noticed and should be addressed in order to stop the injury.
Vibration-induced white finger (VWF) is the most common
condition among the operators of hand-held vibrating tools. Vibration can
cause changes in tendons, muscles, bones and joints, and can affect the
nervous system. Collectively, these effects are known as Hand-Arm
Vibration Syndrome (HAVS). The symptoms of VWF are aggravated
when the hands are exposed to cold.

Workers affected by HAVS commonly report:

 attacks of whitening (blanching) of one or more fingers when
exposed to cold
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 tingling and loss of sensation in the fingers
 loss of light touch
 pain and cold sensations between periodic white finger attacks
 loss of grip strength
 bone cysts in fingers and wrists
The development of HAVS is gradual and increases in severity over time.
It may take a few months to several years for the symptoms of HAVS to
become clinically noticeable.

The symptoms of hand-arm vibration syndrome (HAVS)

Hand-arm vibration exposure affects the blood flow (vascular effect)
and causes loss of touch sensation (neurological effect) in fingers. One of
the earliest methods used for identifying the severity of these symptoms
was the Taylor-Pelmear classification method. This classification was
widely used in the past.

Taylor-Pelmear classification of vibration-induced white finger by stages

Stage Symptom
1 Occasional, 1 or More Finger Tips
2 Occasional, Distal & Middle Finger
3 Frequent Attacks All / Most Fingers
4 Same as 3 With Skin Change in Finger Tips

A common method that is used to classify VWF is the Stockholm

Workshop classification scale.
The Stockholm Workshop classification scale
for cold-induced vascular (blood flow) symptoms
in fingers with hand-arm vibration syndrome
Stage Grade Description
0 (none) No attacks
1 Mild Occasional attacks affecting only the tips of one or more fingers

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 Occasional attacks affecting finger tips and middle of the finger
2 Moderate
and rarely also the finger parts close to the palm
3 Severe Frequent attacks affecting most fingers
Very Same symptoms as in stage 3 with degenerate skin changes in the
4
Severe finger tips.

The Stockholm Workshop classification scale for sensorineural

changes in fingers due to hand-arm vibration syndrome
Stage Symptoms
OSN Exposed to vibration but no symptoms
1SN Intermittent numbness, with or without tingling
2SN Intermittent or persistent numbness, reduced sensory perception
Intermittent or persistent numbness, reduced tactile discrimination and/or
3SN
manipulative dexterity

The severity of hand-arm vibration syndrome depends on several

other factors, such as the characteristics of vibration exposure, work
practice, personal history and habits.

Factors that influence the effect of vibration on the hand

Physical Factors Biodynamic Factors Individual Factors
Grip forces - how hard the worker Operator's control of
Acceleration of vibration
grasps the vibrating equipment tool
Surface area, location, and mass
Frequency of vibration of parts of the hand in contact Machine work rate
with the source of vibration
Hardness of the material being
Duration of exposure each contacted by the hand-held tools, Skill and
workday for example metal in grinding and productivity
chipping

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Years of employment Individual
Position of the hand and arm
involving vibration susceptibility to
relative to the body
exposure vibration
Smoking and use of
drugs.
Texture of handle-soft and
State of tool maintenance Exposure to other
compliant versus rigid material
physical and
chemical agents.
Protective practices and
Medical history of injury to Disease or prior
equipment including
fingers and hands, particularly injury to the fingers
gloves, boots, work-rest
frostbite or hands
periods.

Raynaud's phenomenon of occupational origin

Hand-arm vibration syndrome is also known as Raynaud's
phenomenon of occupational origin. Vibration is just one cause of
Raynaud's phenomenon. Other causes are connective tissue diseases, tissue
injury, diseases of the blood vessels in the fingers, exposure to vinyl
chloride, and the use of certain drugs. The resulting reduced blood flow can
produce white fingers in cold environments.

The health effects of whole-body vibration

Whole-body vibration can cause
 fatigue,
 insomnia,
 stomach problems,
 headache and
 "shakiness" shortly after or during exposure.

The symptoms are similar to those that many people experience after
a long car or boat trip. After daily exposure over a number of years, whole-
body vibration can affect the entire body and result in a number of health
disorders. Sea, air or land vehicles cause motion sickness when the
vibration exposure occurs in the 0.1 to 0.6 Hz frequency range. Studies of
bus and truck drivers found that occupational exposure to whole-body
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 vibration could have contributed to a number of circulatory, bowel,
respiratory, muscular and back disorders. The combined effects of body
posture, postural fatigue, dietary habits and whole-body vibration are the
possible causes for these disorders.
Studies show that whole-body vibration can increase heart rate,
oxygen uptake and respiratory rate, and can produce changes in blood and
urine. East European researchers have noted that exposure to whole-body
vibration can produce an overall ill feeling which they call "vibration
sickness."
Many studies have reported decreased performance in workers
exposed to whole-body vibration.

Vibration exposure accumulation

As in all occupational exposures, individual sensitivity to vibration
varies from person to person.
Three important factors affect the health effects that can result from
exposure to vibration:
 the threshold value or the amount of vibration exposure that results in
no adverse health effects
 the dose-response relationship (how the severity of the ill health
effects is related to the amount of exposure)
 latent period (time from first exposure to appearance of symptoms

The threshold value of vibration is the level below which there is no

risk of vibration syndrome. In other words, it is the maximum intensity of
vibration to which most healthy workers can be exposed every workday for
their entire full-time employment without developing numbness, paleness
or chill of fingers. Workers will not develop vibration-related injuries or
disease if their exposure to vibration is maintained at sufficiently low
levels.
What has been observed is that the number of affected people
increases as the intensity and duration of vibration exposure increases. This
type of exposure-response relationship indicates a possible link between
health effects and the total amount of vibration energy entering the hands
or body. Depending on the intensity of exposure, the symptoms may
appear months or years after the start of the exposure.
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 The latent period for VWF is the time from the first occupational
exposure to hand-arm vibration until the onset of symptoms. The latent
period depends on the intensity of exposure. The higher the intensity, the
shorter the latent period.

Average latent periods for vibration-induced

diseases in different occupations
Latency
Occupation Stage of VWF
(years)
Tingling 1.8
Foundry worker Numbness 2.2
Blanching 2.0
Tingling 9.1
Shipyard worker Numbness 12.0
Blanching 16.8
Chain saw operator Numbness 4.0
Grinder Blanching 13.7

Diagnostics of vibration related diseases

The acceptance of vibration syndrome as an industrial disease is
hindered mainly because:
 Not every physician is trained to diagnose vibration-induced white
finger (VWF) or other vibration-related diseases.
 The causes of VWF cannot always be identified.
 There are no objective clinical tests to measure the impairment.
 The disease progresses for years before the symptoms become severe
enough to affect a worker's ability to do her or his work.

The combined effect of noise and vibration

Since most vibrating machines and tools produce noise, a vibration-
exposed worker is likely to be exposed to noise at the same time. Studies of
hearing loss among lumberjacks revealed that, for equal noise exposure,

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those with vibration-induced white finger (VWF) had greater hearing loss
than those without VWF. The reason for this effect is not clear.
Studies of the effect of separate and simultaneous exposure to noise
and whole-body vibration have concluded that whole-body vibration alone
does not cause hearing loss. However, simultaneous exposure to noise and
vibration produces greater temporary hearing loss than noise alone.

Exposure standards for vibration

Workplaces should try to maintain exposures as much below the
limits as possible.

Maximal permissible levels of local

vibration
Frequencies of octave bands, dB
Hz
8 115
16 109
31,5 109
63 109
125 109
250 109
500 109
1000 109

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 MPL of whole-body vibration in accommodation,
hospital wards, schools and reading rooms of
libraries

Frequencies of octave dB
bands, Hz
2 76
4 71
8 67
16 67
31,5 67
63 67

In some international jurisdictions, the exposure limit is also given as

threshold limit and exposure limit. Threshold limit is lower than exposure
limit and warrants the initiation of control measures. Following is an
example of such limits.

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 Prevention
Good practice in industrial health and safety management requires
that worker vibration exposure is assessed in terms of
acceleration amplitude and duration. Using a tool that vibrates slightly for a
long time can be as damaging as using a heavily vibrating tool for a short
time. The duration of use of the tool is measured as trigger time, the
period when the worker actually has their finger on the trigger to make the
tool run, and is typically quoted in hours per day. Vibration amplitude is
quoted in metres per second squared, and is measured by
an accelerometer on the tool or given by the manufacturer. Amplitudes can
vary significantly with tool design, condition and style of use, even for the
same type of tool.

Recommendations to prevent vibration disease

If you use vibrating equipment on a regular basis you are at risk for
developing vibration white finger. There are some preventative measures
you can take to ward of this syndrome.
 Use sound ergonomic equipment that reduce vibration transference to
the hands.
 Use vibration absorbing gloves or pads. Gel padding is better than
foam padding for protecting against vibration.
 Hold equipment loosely.
 Work in short durations with frequent breaks. Take at least one 10
minute break every hour.
 Keep hands warm to keep blood flowing.
 Avoid smoking or other drugs or substances that inhibit blood flow.
Maintain a Healthy Body
You need to stay healthy and fit. Maintain a healthy weight. Strong
bodies are more resilient against the stressors that cause vibration white
finger.
Maintain good cardiovascular health. Good blood flow to the hands is
crucial.

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 20. HYGIENE OF CHILDREN AND ADOLESCENTS. PHYSICAL
DEVELOPMENT AND HEALTH STATUS OF CHILDREN AND
ADOLESCENTS

Hygiene of children and adolescents

Hygiene of children and adolescents is a field of preventative medicine:
studying children’s environment,
studying influence of the environment on health and functional state of
growing organism,
developing scientific basis and practical measures in order to preserve
and improve state of health, support the optimal level of functions and
optimal development of children and adolescents.

Hygiene of children and adolescents consists of the following parts:

•Pre-school hygiene (pre-school age children).
•School hygiene (children and adolescents, pupils of general schools
(including boarding schools, schools with extended day), colleges, etc.).
•Hygiene of youth (students of high school and working young people).

Hygiene of children and adolescents. Target and aims.

TARGET: to provide growth and development of a healthy
generation.
AIMS:
Protection and improvement of the health of children and adolescents;
Scientific backgrounds development of tutoring and training, including
permissible educational and physical loads during tutoring and professional
education;
Assessment of environmental factors, i.e. hygienic standards and
requirements for institutions, using belongings, clothes, toys, text books,
etc.;
Regular monitoring of hygienic standards and requirements maintenance
in the places of living and temporal accommodation of children and
adolescents.

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 General directions of research
1. Assessment and analysis of health status and physical development.
2. Hygienic requirements, rules and standards for physical training.
3. Hygienic requirements, rules and standards for educational process.
4. Hygienic requirements, rules and standards for working activity.
5. Hygienic requirements and hygienic accomplishment of institutions.

Healthy lifestyle – the way for high level of health

Optimal level of physical Regular medical

activity examinations

Preventive activities Positive ecological

activities

Rational nutrition Mental and emotional

stability

Regimen of work and Sexual education

rest

Personal hygiene Safe behavior

Factors which form health status

•Parental health as due to harmful habits, unbalanced life style, presence of
chronic diseases may negatively affect intrauterine development.
According to WHO, hereditary diseases are responsible for 4-8 % of
paediatric pathology worldwide.
•Nature and climate factors as features of climate sufficiently determine the
nature of morbidity. For instance, in cold climate, particularly in winter
number of colds increases whereas in hot climate with high level of
insolation number of skin problems is increased.
•Nutrition as a health forming factor can be shown particularly clearly in
economic crisis and stratification of population according to incomes. In
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this situation the number of teenagers with lowered nutritional status
increases.

3 groups of indices used for health status assessment

1. Medical indices: physical development, morbidity, total and paediatric
mortality, invalidity.
2. Indices of social well being: demographic situation, state of
environmental factors, lifestyle, level of medical care.
3. Indices of mental health: psychiatric morbidity, frequency of neurotic
disorders and psychopaties.

4 health groups of children population.

st
•1 group – children who do not have any chronic diseases; not being ill or
being ill for a short time only over the observation period; with normal-for-
age physical and neuro-psychic development (healthy children without any
deviations).
nd
• 2 group – children with absence of chronic diseases (healthy, but with
decreased resistance (subgroup 2A) and morphological deviations
(subgroup 2B)).
rd
• 3 group – children with chronic diseases or hereditary problems, with
rare and relatively benign exacerbations of chronic diseases, with no
obvious impairment of general being.
th
• 4 group – children with severe decompensated chronic diseases, with
sufficient decrease of functional capacities.

For children of the first health group:

•There are no limitations in organisation of educational, working and
sportive activity.
•Paediatric health checks are normal routine.
•Medical recommendations usually include measures for general health.

Children and teenagers of the second health group:

Those with functional and morphological deviations, being sick often (4
times per year and more), or for a long time (more than 25 days per case)
require more medical attention.

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 They need a complex of health improving measures to increase the
organism resistance with non-specific remedies:
1) optimal motion activity;
2) tempering with native factors of nature;
3) rational daily regimen,
4) additional vitamin supplement, etc.
Schedule of health follow-up is set individually by the doctor with
considerations to trend of deviations in health status and the degree of
organism resistance.

Children and teenagers of 3rd and 4th health groups:

They are constantly observed and followed up by doctors of different
specialities, receive medical and preventive care according to presenting
pathology and degree of compensation.
Sparring daily regimen, prolonged resting period and night sleep is
implemented for them in children institutions as well as restricted amount
and intensity of physical load, etc.
If required they are referred to special children and adolescents
institutions where treatment and tutoring are implemented with regards to
features of a particular pathology.

Assessment of growth and development

General patterns of growth and morphological features of a growing
organism
Physical development of children and adolescents
•“Physical development” means the state of morphological and functional
properties and features of organism as well as the level of biological
development – biological age.
•Physical development of a child during each period of life is a complex of
morpho-functional properties characterising the age of achieved biological
development and physical efficiency of an organism.
•At the same time, physical development is a process of age-determined
changes in body size, appearance, muscular strength and efficiency of child
organism.

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 Age period
Human maturing is divided into several age periods.
“Age period” includes period of time during which processes of
growth and development as well as physiological features of organism are
similar and responses to stimulus are more or less the same.
At the same time, age period is a time required for completion of a
certain stage of morpho-functional development of the organism and
achievement of a child’s preparedness for a certain type of activity.

7 periods in human ontogenesis:

•Newborn period 1 – 10 days;
•Breast feeding age 10 days – 1 year;
•Toddler – 1 – 3 years;
•First childhood (infants) – 4 – 7 years;
•Second childhood – boys 8 – 12 years;
girls 8 – 11 years;
6. Adolescence - boys 13 – 16 years;
girls 12 – 15 years;
•Youth age – youngsters – 17 – 21 years;
girls – 16 – 20 years.

Patterns of growth and development

•Growth and development rate irregularity (the younger is organism the
processes of growth and development are more intensive);
•Non-simultaneity of growth and development of different systems;
•Gender determination of growth and development (sexual dimorphism);
•Genetic determination of growth and development;
•Determination of growth and development by environmental factors;
•Acceleration of growth and development.

Assessment of physical development

Individualising method – systematic observation over physical
development of a particular child allows individual assessment of the
development.
Generalizing method – mass medical check up of children and adolescents
in the same settlement allows:
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1) To find the deviations in physical development of children resulting
from the social factors;
2) To achieve after statistical treatment average indices of physical
development in each age-gender group – age standards.

Age standards
 Reflect the level of physical development of certain groups of children
and adolescents which are formed according to age, gender, place of
residence, inheritance, ethnicity, social and economical state of the
population, ecological and other factors.
 Local (regional) standards of physical development are used by doctors
for individual assessment of physical development.

Indices of physical development

Somatometric indices: body mass and length, chest circumference;
Somatoscopic indices: shape of chest, back, feet, posture, state of
muscles, fat deposition, skin elasticity, pubescence;
Physiometric indices: lungs vital capacity (VC), hand strength
(dynamometry).

Methods of physical development individual assessment

•Detection of deviations in main indices of physical development from the
average values for the age-gender group with graphical imaging of the
profile (graph) of individual development.
•Assessment of physical development with the help of assessment tables.
•Complex assessment of physical development.

Assessment of physical development

With the help of body mass value, height, chest circumference
and muscular strength morpho-functional state can be described as:
Harmonic,
Disharmonic, or
Badly disharmonic.
•Harmonic – body mass and chest circumference are appropriate for the
body height or within 1 sigma out of standard range (М ± 1).

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•Disharmonic – body mass and chest circumference are out of standard
range for more than 1 sigma (М ± 1.1 – 2.0).
•Badly disharmonic - body mass and chest circumference are out of
standard range for more than 2 sigma (М ± 2.1 – 3.0).

Health assessment of children and adolescent groups

The following indices are used to assess the health of different groups:
1. Overall morbidity.
2. Transmissible diseases morbidity.
3. Health index – the percentage of continuously ill children.
4. Spread and structure of chronic diseases.
5. Percent of children with normal physical development and with mental
and physical development disorders.
6. Distribution over the health groups.

Acceleration of growth and development.

Rate of growth and development of children and adolescents faster
than the one of the previous generation is called acceleration.
It has been found that biological maturing of modern generation
completes slightly earlier than in previous. Acceleration can be seen from
early age but it is most prominent during adolescence.
Apart from increased developmental rate some other changes occurred:
life expectancy extended, longer lasting reproductive period, bigger
definitive (final) body sizes, morbidity structure changed.
Changes occurring over whole human life are called “circular trend».

Main theories explaining the reasons of acceleration

Physical and chemical:
1) Heliogenic (influence of solar radiation);
2) Radiofrequency, magnet (influence of electromagnetic field);
3) Space radiation;
4) Increased CO2 concentration due to increased manufacture;
Influence of certain environmental factors:
•Alimentary;
•Nutritive;
•Increased information.
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Genetic:
•Cyclic biological changes;
•Heterosys (mixing of populations);
Theories of complex environmental factors:
•Urban influence;
•Complex social-biologic factors.

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 21. FUNCTIONAL PREPAREDNESS FOR SYSTEMATIC
EDUCATION. HYGIENIC ASSESSMENT OF CLASSES AND DAILY
ROUTINE IN GENERAL SCHOOL

FUNCTIONAL PREPARADNESS FOR SYSTEMATIC

EDUCATION
•From the positions of hygiene, teaching and psychology, the success of
education, efficiency and adaptation of children to educational load depend
on the correct assessment of functional preparedness of children for regular
study at an educational institution.
•Assessment of preparedness for school is performed by a doctor of pre-
school educational institution or (if a child does not attend kinder garden)
by out patient paediatrician considering medical and psycho-physiological
indices.
•Assessment of preparedness consists of 2 stages during which program of
health correction is prepared and conducted to correct the development of
functions, essential for education.

Medical criteria of preparedness for education:

•Level of biological development;
•Health status during examination;
•Acute illnesses morbidity over the previous year.

Psycho-physiological criteria of development:

•Results of test, consisting of 3 tasks: to draw a man, to copy a short
phrase, to copy a group of dots;
•Quality of pronunciation (presence of defects);
•Results of motometric test “cutting a round”.

Medical indications for postponing the education of 6-years old

children
It is decided during the repeated medical examination before entering
the school (April-May), whether the child will start to study at school in
time or not.
Beginning of education is postponed in 6-years old children if they
suffered an acute illness (hepatitis, pyelonephritis, diffuse
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glomerulonephritis, miocarditis, meningitis, tuberculosis, rheumatic fever
or blood diseases).
Children with sub- and decompensated chronic diseases (neuro-
circulatory dystony, heart malformations and valve diseases, chronic
bronchitis, bronchial asthma, stomach ulcer, palate tonsils enlargement or
3rd degree adenoids, neurosis, endocrine problems. In all other cases
decision is made by a medical commission.
Children with biological retardation (body length is lower than М-l σ of
the local standards of physical development, less than 4 cm increase in
body length over the last year; complete absence of permanent teeth).
Those who failed the 3 tasks of the test and with defects of pronunciation.

Special features of school education

School education requires:
•Activation of numerous functional systems responsible for active brain
performance. It has been found that 5-7 years old children can keep active
attention for 15 min, 8-10 years old - 20 min, 11-12 years old - 25 min, 12-
15 years old - 30 min;
•Continuous maintenance of the required working position creates
sufficient load on child’s muscular-skeletal system. Maintenance of a
sitting position at school desk is a tiring static work accompanied by
functional disorders in CVS, peripheral and central nervous system. Static
tension results in impaired oxygen blood supply.

Tiredness of school children

•Tiredness is a condition developing as a result of activity. It manifests by
a feeling of tiredness, neuro-muscular tension, coordination disorders,
disturbed work of various functional systems.
Double biological meaning of tiredness:
It is protective reaction, preventing over exhaust of the organism.
It stimulates recovery process and increases functional limits.

Tiredness  is a reversible process:

termination of activity can treat it and recover the level of organism’s
functions.

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Tiredness usually is accompanied by a feeling of restlessness. However
tiredness and restlessness may not come at the same time. When work is
interesting and accompanied by positive emotions children do not feel
restlessness over a long period of time although objectively they are
already tired. And vice versa, in a case of monotonous, boring work
restlessness comes much earlier than decrease in functions.
Development of tiredness relates to a sophisticated mixing of processes in
the neural centres and peripheral viscera. In some cases the leading role
belongs to neural centres, in other cases – to peripheral organs. For
instance, in heavy motion load tiredness first develops in muscles as a
result of switching off fast tiring motion units whereas in activity with light
loads, performed by low-tiring motion units – in nervous centres. In a case
of medium load there is a sophisticated combination of the tiredness
events.

Signs of tiredness in schoolchildren

Decrease of efficiency (increased number of mistakes and incorrect
answers, time required to complete the task);
Weakening of internal inhibition (manifests with motion disturbance,
frequent derivations, distraction of attention);
Impaired regulation of physiological functions (cardiac rhythm and
coordination disorders);
Feeling of restlessness.

Recovery of mental efficiency of pupils

Tiredness is a natural response to a more or less continuous or intensive
work.
Tiredness itself is not dangerous as the signs of tiredness are of a
functional nature and accompanying it psychological, biochemical and
physiological changes are reversible.
Signs of tiredness in schoolchildren quickly disappear after rest during
break, after returning back from school, sometimes in more sufficient
tiredness – after sleep or sufficiently long time of rest.

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 Overwork
Cumulating state of tiredness which signs do not disappear neither
with daily nor with weekly rest.
Signs of overwork are not reversed not only after a short rest but even
after normal duration night sleep.
More continuous rest is required for complete recovery of the efficiency,
elimination of neuro-psychic disturbances and regulatory processes
disorders, sometimes – complex treatment with the use of medicines,
physiotherapy and treating exercises.

Signs of overwork
Initial signs of overwork:
•Changes in pupils behaviour,
•Impaired progress in studying,
•Loss of appetite,
•Functional neuro-psychic disorders (irritability, etc.),
•Various vegetative disorders, particularly of cardio-vascular system.
Prominent signs of overwork:
•Sudden and continuous drop in mental and physical efficiency;
•Neuro-psychic disorders (sleeping disorders, feeling of fear, hysteria);
•Steady changes in regulation of vegetative functions (dysrhythmia, neuro-
vascular dystony);
•Decreased resistance against unfavourable factors and pathogenic
microorganisms.

Hygienic standards of schoolchildren activity

They are required to prevent activity from causing overwork but to
trigger positive impact on growth and development of a child.
To establish the standards (the highest permissible loads) average morpho-
functional data of age period are used; however, not only age, but also
individual features of schoolchildren have to be considered.
Hygienic standards consider as a main landmark duration of recovery
period which allows to bring organism back into normal state.

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 Physiology of the decreased functional state recovery
Recovery period consists of 2 phases:
1 – restoration of functional level and
2 – strengthening of achieved recovered state.
If the rest is limited to the 1st phase only, i.e. restoration of efficiency
the expected results can not be achieved. Any new load, even
unremarkable, quickly brings the organism back to the state of impaired
efficiency.
That’s why the duration of rest depends on degree of functional
impairment, nature and intensity of the job performed.

HYGIENIC REQUIREMENTS TO EDUCATIONAL PROCESS

ORGANISATION IN GENERAL EDUCATIONAL INSTITUTIONS
Adequacy of educational load to age and individual features;
Scientific organisation of educational process;
Providing optimal conditions of studying.
Following these requirements prolongs the period of steady
efficiency, postpones development of tiredness and prevents
development of overwork.

It is essential to follow the standards and keep educational loads

appropriate for age and individual features of schoolchildren because:
Functional systems important for education (CNS, visual and hearing
analyzers) are still immature in children.
Functional capacities of cortex neural cells are relatively low, so hard
mental loads cause their exhaustion.
Steady concentration of attention is vital for successful education,
whereas in children, particularly of a younger age, imbalanced state of
neural processes is typical, overwhelming of excitation along with fairly
weak processes of active internal inhibition. That is why it is so difficult
for a child to concentrate and to keep attention during the lesson.

Principles of scientific organisation of educational process in school.

Educational process in school is organised with considerations to
physiological patterns of efficiency changes in schoolchildren.
The curve of efficiency includes:
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Period of beginning of work,
Period of a steady high efficiency,
Period of decreasing efficiency, or tiredness.
These patterns mean that the beginning of a lesson, week, or a study
year should be relatively easier.
It is reasonable to explain new and most difficult information and to
give tests in the period of a steady high efficiency when efficiency reaches
the highest level, the most of educational load should be planned for the
mid of study week, study quarter and study year.
Intensive educational loads should be excluded during the period of
decreasing efficiency because energetic potentials of the organism become
exhausted and extensive load may have an adverse impact on health.

Hygienic requirements to the lesson

Hygienic requirements determine duration of lesson and duration of
certain types of educational activity during the lesson (reading, writing,
counting, watching movies, etc.).
Standard scheme of lesson divides it into 3 parts — introductory, main
and finishing.
For mid and older years pupils optimal lesson duration is 45 minutes, for
younger pupils – 35 minutes.
Duration of uninterrupted writing for 6-years old children should not be
more than 2 minutes, for 14-15-years old pupils it can be as long as 20
minutes.
In the primary school short physical exercises are needed during the
lesson to treat static muscular tension.

Distribution of a weekly educational load (time table)

st th
Mandatory number of studying hours increases from 1 to 11 year from
18 to 32 hours.
For pupils whishing to advance their knowledge in certain subjects with
facultative studies duration of studies can be extended during 6-9th years by
2 hours, during 10-11th years – by 3-4 hours per week.
Pupils efficiency is the highest on Tuesday and Wednesday, whereas from
Thursday and throughout Friday to Saturday tiredness cumulates. Because

195
of low efficiency control testing and control questioning must not held on
Friday, also there is no sense in starting new material on this day.
Hygienic requirements to timetable take into consideration dynamics of
changes of physiological functions and efficiency of pupils throughout
working day and week.
Most difficult and tiring subjects should be placed in a timetable on days
of high efficiency.
It is advised not to organize on the same day lessons on subjects requiring
lot of time for preparing home tasks.
Scales of subjects difficulty are used for hygienic assessment of the school
timetable (max - 10 points – mathematics, min – 1 point - singing). For this
purpose sum of points per day is calculated.

Prevention of overwork in schoolchildren

•Following the daily regimen.
•Appropriateness of mental and physical load to children age capacities,
with consideration to their functional state.
•Correctly organised educational process at school.
•Rational planning of studies during the study day and study week.
•Standardised number of lessons during the day, week, quarter.
•Regulation of lessons and breaks duration.
•Number and duration of holidays.
•Sufficient for children motion activity.

Hygienic requirements to daily regimen are based in building dynamic

stereotype.
Due to formation of conditioned reflexes, every previous activity
becomes a conditional trigger or signal for further actions:
Eating during certain established hours provides good appetite and
normal digestion;
Going to bed persistently at the same time provides faster falling asleep
and longer sleeping in children;
Doing studying / working always at the same time of a day results in
better efficiency during the beginning period and better absorbance of
knowledge and skills.

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 Principles of daily regimen planning
Regimen should first allow the required time for sleeping, feeding, being
in open air, activity games, and only after this time can be planned for
education.
Duration of certain types of rest should be determined by age.
Some types of activity, comprising the daily regimen, should cause some
tension of corresponding organs and systems as it would promote their
training and prepare organism for moving on the next level of the dynamic
stereotype.

3 types of regimen for children and adolescents

1. Part load, or pampering.
2. Exhausting.
3. Stimulating, or training-tempering.

3 types of regimen for children and adolescents

With part load regimen there is a lack of irritants, they are monotonous
and of insufficient intensity. One of the consequences of this regimen is
physical and neuro-psychic retardation, higher morbidity and mortality.
In exhausting regimen child is constantly under too numerous, too
various and too intensive irritants. This may result into over tension of
adaptation in various organs and systems with their gradual exhaustion and
retardation, increased morbidity and neurosis.
With stimulating regimen there are various factors acting with steady and
gradually increasing intensity. This causes persistent gradual changes in
organism resulting in development of compensating adaptive mechanisms,
increasing efficiency and strengthening health.

Hygienic role of the surrounding conditions of education and tutoring

Sensitivity of the child’s organism to most of the environmental factors is
higher than in adults and reflects on general feeling, mood and efficiency.
Daily regimen, motion activity, organisation of feeding, studies and rest,
comprehensive physical training and tempering grossly depends on
accomplishment and hygienic state of those institutions.

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 o
By the end of the study day air temperature is 3-5 C higher, CO2
concentration, content of organic substances and microorganisms may
increase 3 times and more.

Hygienic requirements to the territory of

pre-school institution
•It is organised for children from 2 months to 7 years, groups are formed
according to age: nursery groups for children up to 3 year old, pre-school
groups – for 3-7 years old.
•Day nurseries and kinder gardens are planned for various number of
groups (2-24), with number of places from 25 to 660.
•Serving area should not be more than 0.3 km, the best placement option is
one inside the quarter blocks.
•The rule of group isolation must be implemented in pre-school
institution. It requires presence of separate groups of children, isolated
from each other on the play ground and in the building in order to prevent
the spread of transmissible diseases.
•Percent of building on the territory should not be more than 10-12 %,
area of green plantations in total should be 50 % at least.

Hygienic requirements to the building of the pre-school institution

Building of the pre-school institution - block (or stage) planning, should
not be more than 1-store high.
Rule of a group isolation – every group should be provided with the full
set of premises (group unit), for conducting tutoring process and fulfilling
all domestic needs of children. It is permitted to use 1 building entrance
per 2 - 3 groups.
Modern projects provide advanced set of premises: room for musical
classes, swimming pool, winter garden.
Kitchen must be placed on a ground level and should have separate
entrance.
Medical station is placed on the ground floor and includes examination
room and an isolation bay.
Apart from the rule of group isolation, pre-school institutions should also
follow the rule of individual isolation: every child should have own locker

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for street and change clothes, bed with linen, chamber pot in the toilet,
towel, tooth brush and a comb in a personal cell.

Hygienic requirements to the territory of general school

•Educational institution should have own plot of land with at least 25 m
distance between road and a school building. Sizes of plot depend on the
type of the institution and its capacity, it should be at least 40-50 m2 per
pupil.
•The plot should be divided into the following zones: sportive and physical
exercising, educational-experimental, recreational, auxiliary.
•Green plantations should comprise at least 50% of the territory.
•Building should be of a block planning - few 1-2 stores building
connected together with heated corridors.

Hygienic requirements to the building of general secondary school

•Pupils of I step (primary classes) should study in secured for each class
premises.
•Pupils of II and III step (medium and senior years) should study by class-
study system which provides studying in a class-room, equipped with
studying materials and technical educational equipment.
2
•Study area is calculated as 2.5 m per 1 pupil.
•Gym should be placed on a ground floor. Gyms should have: equipment
room, change rooms for boys and girls with showers and toilets and
instructors room.
•School should have either 2 workshops or it may have one combined
premise equipped with machines for wood and metal work. Area of
workshops is calculated as 6 m2 per pupil.
•Auxiliary premises are: cloakrooms, recreational premises, library, hall,
canteen, medical station, toilets and administrative and maintenance
premises.

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