Skiepai – veiksmingiausias būdas išvengti ligų. Tad kodėl jų vengiama?

Skiepai – veiksmingiausias būdas išvengti ligų. Tad kodėl jų vengiama?

Arvydas AmbrozaitisMokslas, faktai, statistika kalba, kad skiepai – veiksmingiausias būdas išvengti ligų. Nepaisant to, skiepų neretai bijoma labiau negu ligos. Tai rodo ir šalies gyventojų gripo skiepijimo mastas, ir tai, kad dalis tėvų vengia skiepyti vaikus. Net medicinos studentai, kurie ragina gyventojus skiepytis, patys vengia skiepų (2015 metais Vilniaus universiteto medicinos studentams buvo skirta 620 hepatito B skiepų dozių, tačiau pasiskiepijo vos 50).

Šią aktualią skiepų temą gvildename su Vilniaus universiteto Medicinos fakulteto Infekcinių, krūtinės ligų, dermatovenerologijos ir alergologijos klinikos vedėju, Vilniaus universiteto ligoninės Santaros klinikų Infekcinių ligų centro vadovu, Lietuvos infektologų draugijos pirmininku prof. Arvydu Ambrozaičiu.

 

Pasaulio sveikatos organizacijos (PSO) duomenimis, imunizacija – viena ekonomiškai efektyviausių visuomenės sveikatos veiklos sričių, leidžianti apsaugoti nuo ligų, jų komplikacijų ir mirčių vaikus ir suaugusiuosius. Šiandien vakcinomis galima kontroliuoti 28 ligas. PSO duomenimis, vakcinos kasmet išsaugo mažiausiai 2 mln. gyvybių. PSO tikslas – pasiekti, kad 90 proc. ir daugiau žmonių būtų pasiskiepiję nuo vakcinomis valdomų infekcijų. Prašome plačiau pakomentuoti skiepų padėtį Lietuvoje?

 

PSO duomenimis, 2016 metais pasaulyje apie 116,5 mln. naujagimių ir kūdikių buvo paskiepyti nuo difterijos, stabligės, kokliušo, tačiau apie 12,9 mln., t. y. beveik kas dešimtas, paskiepyti nebuvo. Neskiepijami naujagimiai ir vaikai susiduria su pavojumi užsikrėsti mirtinomis ligomis.

Lietuvoje, pagal Vaikų profilaktinių skiepijimų kalendorių, valstybės lėšomis naujagimiai, kūdikiai ir vaikai skiepijami nuo 12 infekcijų – tuberkuliozės, hepatito B, difterijos, stabligės, kokliušo, B tipo Haemophilus influenzae infekcijos, poliomielito, tymų, epideminio parotito, raudonukės, pneumokokinės ir žmogaus papilomos viruso (ŽPV) infekcijų.

2016 metais rugsėjo 1 dieną pradėtas 11 metų mergaičių skiepijimas valstybės lėšomis nuo ŽPV infekcijos. 2011–2016 metais per metus nuo ŽPV infekcijos pasiskiepydavo apie 300 mergaičių. 2016 metais, kai skiepai tapo finansuojami valstybės, nuo ŽPV infekcijos jau pasiskiepijo 3 890 mergaičių, o per 2017-ųjų pirmąjį pusmetį – 4 389.

Džiugu, kad vis daugiau žmonių skiepijasi savo lėšomis nuo B tipo meningokokinės infekcijos, erkinio encefalito, hepatito A, taip pat nuo rotavirusinės infekcijos. Užkrečiamųjų ligų ir AIDS centro (ULAC) duomenimis, 2017 matų pirmąjį pusmetį nuo rotavirusinės infekcijos paskiepyta daugiau naujagimių ir kūdikių negu praėjusiais metais per tą patį laikotarpį. Per minėtą laikotarpį daugiau paskiepyta ir nuo B tipo meningokokinės infekcijos, hepatito A ir erkinio encefalito, o nuo C tipo meningokokinės infekcijos ir vėjaraupių – mažiau. Tačiau 2017 metų pirmąjį pusmetį nuo tuberkuliozės, hepatito B, difterijos, stabligės, kokliušo, poliomielito, B tipo Haemophilus influenzae infekcijos, tymų, epideminio parotito, raudonukės, pneumokokinės infekcijos buvo paskiepyta mažiau asmenų nei per 2016 metų pirmąjį pusmetį. Nepaskiepyti vaikai rizikuoja užsikrėsti infekcinėmis ligomis, o tai gali lemti ligų protrūkius.

ULAC duomenimis, kasmet Lietuvoje atliekama daugiau nei 650 tūkst. vakcinacijos dūrių. Kalbant apie nepageidaujamas reakcijas, jų kasmet registruojama apie 50–80 (dažniausiai –paraudimas, patinimas, skausmingumas injekcijos vietoje). Tai sudaro 0,006–0,01 proc. visų per metus atliekamų injekcijų. 2016 metais daugiausia (22 proc.) nepageidaujamų reakcijų (limfadenitas) buvo stebėta po BCG vakcinos įskiepijimo.

ULAC duomenimis, per pirmąjį šių metų pusmetį Lietuvoje sergamumas pneumokokine infekcija padidėjo beveik 40 proc., palyginti su praėjusių metų tuo pačiu laikotarpiu. 2017 metais užregistruotas 51 pneumokokinės infekcijos atvejis, 2016-aisiais – 37. Pneumokokinė infekcija pasireiškia įvairiomis formomis. Dažniausi pneumokokinės infekcijos susirgimai tiek vaikams, tiek suaugusiesiems yra ausies ir plaučių uždegimai, kiek rečiau – sinusitai, pūliniai pleuritai, konjuktyvitai ir kt. Pavojingiausi yra meningitai, kuriems būdingas didelis mirštamumas. Didelė susirgimo rizika yra vaikams iki 5 metų ir vyresniems nei 65 metų suaugusiesiems. Taip pat asmenims, sergantiems lėtinėmis ligomis (cukriniu diabetu, širdies, plaučių, inkstų ir kepenų ligomis, vartojantiems alkoholio ir rūkantiems), ypač didelė – imunosupresiniams asmenims, t. y. sergantiesiems onkologinėmis, reumatinėmis ir kitomis ligomis, kuriems yra persodinti organai ar kaulų čiulpai, pašalinta blužnis, užsikrėtusiems ŽIV, hemodializuojamiems. Efektyviausia apsisaugojimo nuo pneumokokinės infekcijos priemonė – skiepai. Nuo 2015 metų gruodžio Lietuvoje valstybės lėšomis nuo šios infekcijos pradėti skiepyti vaikai ir suaugę, priklausantys rizikos grupėms.

ULAC duomenimis, įvedus nemokamus skiepus nuo pneumokokinės infekcijos, pasiskiepijusių vaikų ir suaugusių skaičius Lietuvoje didėja. Dauguma (60 proc.) suaugusiųjų, kurie pernai pasiskiepijo nuo pneumokokinės infekcijos, yra sergantieji onkologinėmis ligomis, o 75 proc. vaikų – sergantieji kvėpavimo takų ligomis. Vakcina nuo ligos sukėlėjo saugo visą gyvenimą.

Šeimos gydytojai dėl kompetencijos stokos dažnai nesiryžta pasiūlyti skiepų nuo pneumokokinės infekcijos ir gripo onkohematologinėmis ligomis sergantiems pacientams ir siunčiau juos pas onkohematologus, kurie neturi teisės skiepyti, nes tai nenumatyta jų specialybės medicinos normoje. Taigi dažnas onkohematologinis ligonis taip ir lieka nepaskiepytas.

 

Pastaraisiais metais daug kalbama apie tai, kad vakcinos tapo savo sėkmės įkaitėmis, kad ne tik visuomenė, bet ir medikai neretai abejoja vakcinų nauda. Kodėl vis dėlto skiepai nėra populiarūs?

 

Mūsų visuomenės problema – niekuo nepagrįstas įtarumas, nepasitikėjimas rekomendacijomis ir pačia vakcina, dėl ko nemažai žmonių, tarp kurių yra ir medikų, nesiskiepija nuo gripo. Maža to, kai kurie politikai ir šeimos gydytojai teigia, kad vakcinas gali pakeisti bendras imuniteto stiprinimas (bėgiojimas, grūdinimasis, česnakas). Kai apie tai kalba medicininio išsilavinimo neturintys politikai – tai jų nekompetencijos ir neatsakingumo prieš visuomenę požymis, bet kai bendrojo ir specifinio imuniteto, kurį gali sukurti tik vakcina, neskiria medikai ir savo mokslo įrodymais nepagrįstą nuomonę perša pacientams, dar daugiau – rodydami netinkamą pavyzdį visuomenei, į darbą eina sirgdami ir platindami ligos užkratą, tai jau rodo profesionalumo spragas, kurias privalėtų užpildyti tobulinimo kursuose.

Kalbant apie gripo vakciną, tenka apgailestauti, kad gripo skiepų ypač vengia medikai – maždaug tik 30 proc. jų kasmet pasiskiepija nuo gripo. Medikams vakcina veiksminga dar ir tuo, kad ne tik mažina tikimybę patiems susirgti gripu, bet kartu apsaugo ir jų pacientus, kuriuos jie gali užkrėsti. JAV yra keletas klinikų, kuriose palaipsniui įgyvendinamas privalomasis medicinos darbuotojų skiepijimas. Jeigu medikas yra nepasiskiepijęs, jam neleidžiama operuoti, konsultuoti ligonių ir pan. Iš darbo jo neatleidžia, bet įpareigoja vaikščioti po įstaigą su medicinine kauke, kad visi matytų, kad jis nepasiskiepijo. Žodžiu, toks moralinis kolektyvinis paskatinimas.

Skeptiškas požiūris Lietuvoje apskritai į skiepus, ypač į skiepus nuo gripo, kyla iš bendro nepasitikėjimo medicina, gydytojais, ekspertais, profesionalais. Posovietinius žmones, gyvenusius totalitarinėje valstybėje, veikia paranojinis mąstymas. Sovietų Sąjungoje viena buvo sakoma, kita – daroma, trečia – galvojama. Dauguma Lietuvos gyventojų tapo paranojinio mąstymo įkaitais. Toks mąstymas veda žmones prie sąmokslo teorijų kūrimo. Viena tokių byloja, kad skiepai yra farmacinių kampanijų išsigalvojimas siekiant pasipelnyti, o juos rekomenduojantys specialistai atitinkama yra papirkti ir kalba neteisybę. Tai provincialus mąstymas. Kita vertus, galime džiaugtis, kad gripo skiepų apimtys didėja. Padėtis keičiasi, tačiau per lėtai. Visuomenei turi būti aktyviau skleidžiama informacija, paremta įrodymais pagrįstos medicinos teiginiais ir tomis rekomendacijomis, kurias teikia nepriklausomos organizacijos, tokios kaip PSO, JAV ligų kontrolės ir Europos Sąjungos ligų kontrolės centrai.

 

Įvairiuose seminaruose, renginiuose, leidiniuose daug kalbate apie skiepų naudą, apie mokslo įrodytus faktus. Tačiau mitų apie skiepus vis dar yra. Kokius svarbiausius mitus norėtumėte dar kartą paneigti? Kokio bendradarbiavimo pageidautumėte, lauktumėte iš šeimos gydytojų, kurie yra arčiausiai žmonių ir galėtų labiausiai paveikti jų nuostatas dėl skiepų?

 

Mitų, deja, netrūksta. Pavardysiu dažniausius.

  • Geriau užsikrėsti natūraliu būdu ir taip įgyti imunitetą, nei skiepytis.

Teisinga manyti, kad neva natūrali infekcija dažnai sukelia geresnį imunitetą nei vakcinacija (Hib, pneumokokų ir stabligės vakcinos sukelia geresnį imunitetą nei infekcija). Natūrali infekcija dažniausiai sukelia imunitetą po vieno infekcijos epizodo, o vakcinos gali reikėti kelių dozių. Pavyzdžiui, difterijos, stabligės, kokliušo, hepatito B ir poliomielito vakcina yra skiriama mažiausiai 3 kartus. Tačiau skirtumas tarp vakcinacijos ir imunizacijos yra už imunitetą mokama kaina. Už vakcinaciją mokama kaina yra kelių injekcijų sukeltas nepatogumas ir kartais skaudanti ranka. Už kiekvieną natūralią infekciją mokama kaina dažniausiai yra gerokai didesnė. Natūralios poliomielito infekcijos sukeltas paralyžius, psichinio vystymosi sulėtėjimas po natūralios Hib infekcijos, kepenų sutrikimai po natūralios hepatito B infekcijos, kurtumas po natūralios parotito infekcijos ar pneumonija po natūralios vėjaraupių infekcijos – iš tiesų yra didelė natūralaus imuniteto kaina.

  • Pasitaiko atvejų, kad medikai, užuot raginę skiepytis nuo gripo nėščiąsias, ir toliau skleidžia mitus, kad skiepai gali paveikti vaisių. Nors realybė visai kitokia – ne skiepai, o gripo virusas gali pažeisti vaisių.
  • Susargdina pati vakcina. Netiesa, nes Lietuvoje vartojamoje inaktyvintoje gripo vakcinoje nėra gyvojo gripo viruso, jis yra padarytas nekenksmingas, t. y. joje yra tik antigenų, kurie negali sukelti pačios ligos.
  • Vakcina nesaugi, sukelia autizmą, išsėtinę sklerozę, kitus sutrikimus. Daug kalbėta, kad pandeminio gripo vakcina padidino narkolepsijos atvejų skaičių, ypač Šiaurės šalyse. Naujausi moksliniai tyrimai parodė, kad narkolepsijos tikimybė padidėjo tiems žmonėms, kurie sirgo pandeminiu gripu arba buvo nuo jo paskiepyti. Kodėl? Pasirodo, kad kalta ne vakcina, o antigenai, kurie buvo gyvojo pandeminio gripo viruso ar gripo vakcinos sudėtyje. Taigi narkolepsijos atvejų iš tikrųjų padaugėjo, bet ne nuo vakcinos, o dėl paties pandeminio gripo viruso antigenų poveikio, nes pandeminio gripo viruso antigenų yra ir pačiame gyvajame viruse, ir vakcinoje. Apie tai medikams tapo žinoma vėliau.
  • Neefektyvi, neapsaugo nuo ligos. 30 proc. žmonių iki 65 metų ir 70 proc. vyresnių kaip 65 metų žmonių gali susirgti gripu po vakcinacijos, tačiau visais atvejais jie serga lengviau, jiems nebūna komplikacijų, jie niekada nemiršta. Be to, skiepijimo nuo gripo esmė yra sumažinti sergamumą sunkiomis gripo formomis, komplikacijų dažnį ir mirštamumą.
  • Negalima skiepytis gripo sezono metu. Netiesa. JAV skiepai rekomenduojami iki gegužės 1 dienos. Be abejo, geriau skiepytis iki gripo sezono pradžios, t. y. rudenį. Kita vertus, ne visi iš karto užsikrečia. Pasiskiepijus imunitetas susidaro po 2 savaičių. Jokio pavojaus nėra, jeigu žmogus skiepijasi jau užsikrėtęs inkubacinio periodo metu.
  • Negalima skiepyti onkologinių ligonių, nes jų imuninė sistema ir taip nusilpusi, o vakcina dar labiau ją gali išreguliuoti. Onkologinėmis ligomis sergantys asmenys yra labiau jautrūs įvairioms infekcijoms dėl atsirandančių imunodeficitinių būklių skiriant specifinį gydymą ir, suprantama, dėl pačios ligos. Jie kaip tik priklauso rizikos grupei ir turėtų būti skiepijami kasmet nuo gripo ir vieną kartą nuo pneumokokinės infekcijos. Mokslo įrodyta, kad skiepai treniruoja nusilpusią onkologinių ligonių imuninę sistemą, padeda gydyti ir pagrindinę jų ligą.
  • Tymų, epideminio parotito ir raudonukės (MMR) vakcina gali sukelti autizmą. Dr. Andrew Wakefieldas 1998 metų žurnale The Lancet aprašė 8 klinikinius atvejus vaikų, kuriems, praėjus vienam mėnesiui po paskiepijimo MMR vakcina, išsivystė autizmas. Autorius straipsnyje nurodė, kad jis negali teigti, kad MMR vakcina sukėlė autizmą, nes nebuvo kontrolinės vaikų grupės. Tačiau jau kitą dieną, apsuptas sensacijų ištroškusios žiniasklaidos atstovų, jis pareiškė, kad labai tikėtina, jog ši vakcina sukėlė autizmą. Iš butelio buvo išleistas džinas. Daug triukšmo, ir dėl to smarkiai sumažėjo vaikų skiepijimų apimtys, padidėjo sergamumas tymais ir raudonuke. Vėliau buvo atlikta 14 didelės apimties kontroliuojamųjų tyrimų, bet jokio ryšio tarp skiepijimo MMR vakcina ir autizmo išsivystymo nenustatyta.
  • Kartais žiniasklaidoje pasakojama apie vaikus ir suaugusius asmenis, kuriems po skiepijimo išsivystė išsėtinė sklerozė ar neurologiniai sutrikimai. Jei vienas įvykis įvyksta anksčiau kito, tai nebūtinai reiškia, kad tą kitą sukėlė pirmesnis. Pavyzdžiui, išsėtinė sklerozė dažnai išsivysto paauglystėje ir ankstyvoje jaunystėje. Jeigu kuria nors vakcina yra skiepijami paaugliai ir jauni suaugusieji, kai kuriems jų po vakcinacijos išsivystys išsėtinė sklerozė. Kai kuriems išsėtinė sklerozė gali išsivystyti tuoj po vakcinacijos. Tuomet atrodys, kad šie įvykiai yra susiję. Tačiau vienintelis būdas nustatyti, ar vakcina sukelia išsėtinę sklerozę, būtų nustatyti šios ligos dažnį tarp tų, kurie buvo paskiepyti, ir tarp tų, kurie paskiepyti nebuvo. Siekiant atsakyti į šį klausimą, buvo atlikti keli tyrimai. Visuose buvo padaryta ta pati išvada: išsėtinės sklerozės dažnis tarp tų, kurie buvo paskiepyti, ir tarp tų, kurie paskiepyti nebuvo, buvo toks pat…

Daugiau skaitykite žurnale „Internistas“ Nr.8

Dėkojame už pokalbį.

Kalbėjosi Natalija Voronaja


130 minčių apie “Skiepai – veiksmingiausias būdas išvengti ligų. Tad kodėl jų vengiama?

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