Българско списание за обществено здраве, том 3, кн. 1-2,...

1Òîì 3 Êí.1-2 ÁÚËÃÀÐÑÊÎ ÑÏÈÑÀÍÈÅ ÇÀ ÎÁÙÅÑÒÂÅÍÎ ÇÄÐÀÂÅ 2011 BULGARIAN JOURNAL OF PUBLIC HEALTH Vol.3 ¹ 1-2

ÑÚÄÚÐÆÀÍÈÅ

ÕÐÀÍÈ È ÕÐÀÍÅÍÅ

Íîâ áúëãàðñêè õëÿá çà äèàáåò è ìåòàáîëèòíèíàðóøåíèÿÄ. Ïîïîâà, Ñ. Ïåòðîâà , Ê. Êîïðèâàðîâà, Á.Ñòðàõèëîâà, Ä. Âúíäåâà , À. Áåäðàí , Ð. Ìèõàéëîâ

Æåëåçåí äåôèöèò è æåëÿçîäåôèöèòíà àíåìèÿ ïðèäåöà îò 1 äî 5 ãîäèíè â ãðàä Ñîôèÿ (áèîõèìè÷íèìàðêåðè íà õðàíèòåëåí ïðèåì íà æåëÿçî)Ë. Ðàíãåëîâà, Ñ. Ïåòðîâà, Ê. Öà÷åâ, Á. Àòàíàñîâà

ÁÅÇÎÏÀÑÍÎÑÒ ÍÀ ÕÐÀÍÈÒÅ

Îïàñåí ëè å áèñôåíîë À?Ïîñëåäíè çàêëþ÷åíèÿ íà åâðîïåéñêèÿ îðãàí ïîáåçîïàñíîñò íà õðàíèòåÃ. Æåêîâà, Ò. Âðàá÷åâà

Ìèêðîáíè êîíòàìèíàíòè â áóòèëèðàíè âîäèË. ×èïèëñêà, Â. Ãåîðãèåâà

ÒÐÓÄÎÂÀ ÌÅÄÈÖÈÍÀ

Ïñèõîôèçèîëîãè÷íè ïîêàçàòåëè èðàáîòîñïîñîáíîñò íà ðàáîòåùè ñ êîìïþòðè âòúðãîâñêè îáåêòèÁ. Êàâàëäæèåâà, Ò. Äèìèòðîâà, Ä. Íàéäåíîâà

ÇÄÐÀÂÍÀ ÏÎËÈÒÈÊÀ È ÏÐÀÊÒÈÊÀ

Åëåêòðîííî çäðàâåîïàçâàíå- ñúñòîÿíèåè ïåðñïåêòèâèÂ. Öåêîâ

Ñúâðåìåííî ñúñòîÿíèå íà íåêîíâåíöèîíàëíèòåìåòîäè â ìåäèöèíàòà ó íàñÈ. ßíåâà-Áàëàáàíñêà

Ìóëòèíàöèîíàëíî ïðîó÷âàíå çà îöåíêàíà êà÷åñòâîòî, ðàçõîäèòå è ðàâíîïîñòàâåíîñòòà ïðèïúðâè÷íàòà ìåäèöèíñêà ïîìîù, QUALICOPCÏ. Ñàë÷åâ, W. Schäfer, W. Boerma, P. Groenewegen

ÍÎÂÈ ÊÍÈÃÈ

ÍÎÂÈÍÈ

CONTENTS

FOODS AND NUTRITION

New Bulgarian bread for diabetes and metabolicdiseasesD. Popova, S. Petrova, K. Koprivarova, B. Strahilova,D. Vundeva, A. Bedran, R. Michaylov

Iron deficiency and iron deficiency anemia in children1 to 5 years in Sofia (Biochemical markers of dietaryintake of iron)L. Rangelova, S. Petrova, K. Tzatchev, B. Atanasova

FOOD SAFETY

How dangerous is Bisphenol A?Final conclusions of the European Food SafetyAuthority (EFSA)G. Zhekova, T. Vrabcheva

Microbial contaminants in bottled waterL. Chipilska, V. Georgieva

OCCUPATIONAL HEALTH

Psycho-physiological indexes and working-ability inpersons working with computers in trading centers(objects)B. Kavaldzieva, T. Dimitrova, D. Naidenova

HEALTH POLICY AND PRACTICE

E-Health system – status and perspectivesV. Cekov

Non-conventional medicine in Bulgaria: currentstatusI. Yaneva-Balabanska

QUALICOPC, a multi-country study evaluatingquality, costs and equity in primary care

P. Salchev, W. Schäfer, W. Boerma, P. Groenewegen

NEW BOOKS

NEWS

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2 Òîì 3 Êí.1-2 ÁÚËÃÀÐÑÊÎ ÑÏÈÑÀÍÈÅ ÇÀ ÎÁÙÅÑÒÂÅÍÎ ÇÄÐÀÂÅ 2011 BULGARIAN JOURNAL OF PUBLIC HEALTH Vol.3 ¹ 1-2

ÍÎÂ ÁÚËÃÀÐÑÊÈ ÕËßÁ ÇÀ ÄÈÀÁÅÒÈ ÌÅÒÀÁÎËÈÒÍÈ ÍÀÐÓØÅÍÈß

Äàíèåëà Ïîïîâà1, Ñòåôêà Ïåòðîâà2 , ÊàëèíêàÊîïðèâàðîâà3, Áèñåðêà Ñòðàõèëîâà1, Äèàíà Âúíäåâà1 ,

Àëè Áåäðàí 4 , Ðîñåí Ìèõàéëîâ4

1Óíèâåðñèòåòñêà ìíîãîïðîôèëíà áîëíèöà çà àêòèâíîëå÷åíèå „Öàðèöà Éîàííà-ÈÑÓË”, Êëèíèêà ïî

ìåòàáîëèòíî-åíäîêðèííè çàáîëÿâàíèÿ è äèåòåòèêà;2 Íàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè;3 Óíèâåðñèòåòñêà ñïåöèàëèçèðàíà áîëíèöà çà àêòèâíîëå÷åíèå íà äåòñêè áîëåñòè, Êëèíèêà ïî åíäîêðèíîëîãèÿ,

äèàáåò è êëèíè÷íà ãåíåòèêà;4 Óíèâåðñèòåòñêà ìíîãîïðîôèëíà áîëíèöà çà àêòèâíî

ëå÷åíèå „Öàðèöà Éîàííà-ÈÑÓË”,Îòäåëåíèå ïî êëèíè÷íàëàáîðàòîðèÿ

Ðåçþìå

Äèåòàòà å âàæåí ôàêòîð â ïðîôèëàêòèêàòà èêîìïëåêñíîòî ëå÷åíèå íà äèàáåòà è ìåòàáîëèòíèòåíàðóøåíèÿ. Õëÿáúò å îñíîâíà õðàíà çà áúëãàðñêîòîíàñåëåíèå. Âêëþ÷âàíåòî íà ïîäõîäÿù õëÿá â õðàíåíåòîíà áîëíè îò òåçè øèðîêîðàçïðîñòðàíåíè çàáîëÿâàíèÿå îò ñúùåñòâåíî çíà÷åíèå çà äèåòîòåðàïèÿòà.

Öåë: Äà ñå íàïðàâè ìåòàáîëèòíà è äåãóñòàöèîííàîöåíêà íà íîâ áúëãàðñêè õëÿá, ïðåäíàçíà÷åí çà ïðåâåíöèÿè òðåòèðàíå íà ëèöà ñ äèàáåò è ìåòàáîëèòåí ñèíäðîì.

Äèçàéí è ìåòîäè: Ïðîâåäåíî å êëèíè÷íî êîíòðîëèðàíîïðîó÷âàíå âúðõó 38 âúçðàñòíè áîëíè (22 ñ äèàáåò òèï2 è 16 ñ ïðåäèàáåò) è ïðè 6 äåöà ñ äèàáåò òèï 1.Åôåêòúò íà íîâèÿ áúëãàðñêè õëÿá „Äåà” å èçñëåäâàí âóñëîâèÿòà íà åäíîêðàòåí ñóòðåøåí ïðèåì íà 75 ã õëÿá ñ÷àé, êàòî çàêóñêà ïðè âúçðàñòíèòå ïàöèåíòè è âêëþ÷åíêúì îáåäíîòî ìåíþ íà äåöàòà ñ äèàáåò â èíäèâèäóàëíîêîëè÷åñòâî (îò 40 äî 100 ã). Â àêðåäèòèðàíàëàáîðàòîðèÿ å èçâúðøåí àíàëèç íà õèìè÷íèÿ ñúñòàâ íàõëÿáà, âêëþ÷èòåëíî ìàêðîíóòðèåíòè, îáùè èðàçòâîðèìè âëàêíèíè, íàòðèåâ õëîðèä, åíåðãèéíàñòîéíîñò. Çà îöåíêà åôåêòà íà õëÿá „Äåà” íà ëèöàòàñà èçâúðøåíè àíòðîïîìåòðè÷íè èçìåðâàíèÿ, êëèíèêî-ëàáîðàòîðíè èçñëåäâàíèÿ - íèâà íà ãëþêîçà âúâ âåíîçíàêðúâ, ñåðóìåí îáù õîëåñòåðîë, òðèãëèöåðèäè,âèñîêîïëúòíîñòåí õîëåñòåðîë, èìóíîðåàêòèâåíèíñóëèí. Èç÷èñëÿâàí å èíäåêñ íà èíñóëèíîâàðåçèñòåíòíîñò. Íàïðàâåíà å äåãóñòàöèîííà îöåíêà íàõëÿáà îò èçñëåäâàíèòå ëèöà.

Ðåçóëòàòè: Ïðè âñè÷êè ïàöèåíòè íà âòîðèÿ ÷àñ îòïðèåìà íà õëÿáà ëèïñâà çíà÷èìî ïîâèøåíèå íàãëèêåìèÿòà, êàòî ïðè ïàöèåíòèòå ñ ïðåäèàáåò èíåèíñóëèíîçàâèñèì äèàáåò êðúâíàòà çàõàð ñïàäàçíà÷èìî, à ïðè ïàöèåíòèòå ñ èíñóëèíîçàâèñèì äèàáåòíå ñå ïðîìåíÿ ñúùåñòâåíî. Óñòàíîâÿâà ñå òåíäåíöèÿ êúì

NEW BULGARIAN BREAD FORDIABETES AND METABOLIC DISEASES

Daniela Popova1, Stefka Petrova2, KalinkaKoprivarova3, Biserka Strahilova1, Dyana Vundeva1,

Ali Bedran4, Rosen Michaylov4

1University Hospital Queen Giovanna-ISUL, Clinic ofmetabolic diseases and dietetics;

2National Center of Public Health and Analyses;3University Children Hospital, Clinic of

endocrinology, diabetes and clinic genetics;4 University Hospital Queen Giovanna-ISUL,

Department of Clinical laboratory

Abstract

Diet is an important factor in the prevention and com-plex treatment of diabetes and metabolic disorders. Breadis a main food for the Bulgarian population; thereforethe inclusion of bread that seems to be the most benefi-cial for the diet of patients suffering from these widespread diseases is of vital importance for the diet therapy.

Aim: To perform metabolic and degustation assessmentof a new Bulgarian bread that is good for preventionand treatment of persons with diabetes and metabolicsyndrome.

Design and methods: A clinically controlled study on38 adult diabetics (22 diabetics with type 2 diabetesand 16 prediabetics) and on 6 children with type 1 dia-betes. The effects of new Bulgarian bread “Dea” wasestimated under the conditions of one single intake inthe morning of 75 g Dea bread as breakfast with herbaltea and included in the lunch of diabetic children (from40 to 100 g). At an Accredited laboratory an analysis onthe chemical composition of bread was performed in-cluding on macronutrients, total and soluble fiber, so-dium chloride, energy value. For the estimation of ef-fects of Dea bread on the patients were conducted an-thropometric measurements, clinical and laboratoryexaminations – glucose level in venous blood, serumand total cholesterol, triglycerides, high density choles-terol, immunoreactive insulin. The index of insulin resis-tance was calculated. Degustation estimation of thebread was performed by examined individuals.

Results: In all patients after 2 hours of the bread intakelack of significant glycemic increase has been estab-lished, whereas in patients with prediabetes and non-insulin dependent diabetes the glucose level has shownsignificant decrease and no significant changes werefound in insulin dependent diabetics. A tendency of se-

ÕÐÀÍÈ È ÕÐÀÍÅÍÅ FOODS AND NUTRITION


ïîíèæàâàíå íà èíñóëèíåìèÿòà è íàìàëÿâàíå íàèíñóëèíîâàòà ðåçèñòåíòíîñò, êàêòî è ïîíèæàâàíå íàñåðóìíèòå òðèãëèöåðèäè. Ïðè äåöàòà ñ äèàáåò ñåðåãèñòðèðà ïîäîáðåí èíäèâèäóàëåí ìåòàáîëèòåíîòãîâîð ïðè ïðèåìà íà íîâèÿ õëÿá, â ñðàâíåíèå ñ ïðèåìíà ñòàíäàðòåí õëÿá „Äîáðóäæà”. Äåãóñòàöèîííàòàîöåíêà ïîêàçà, ÷å 86,48% îò âúçðàñòíèòå ïàöèåíòèíàïúëíî îäîáðÿâàò õëÿáà, 8,11% - íå ìíîãî è ñàìî 5,41%íå ãî îäîáðÿâàò. Äåöàòà ñ äèàáåò äàâàò äîáðàäåãóñòàöèîííà îöåíêà.

Çàêëþ÷åíèå: Íîâèÿò õëÿá å ôóíêöèîíàëíàâúãëåõèäðàòíà õðàíà ñ íèñúê ãëèêåìè÷åí èíäåêñ,áëàãîïðèÿòíè ìåòàáîëèòíè åôåêòè è ìíîãî äîáðàäåãóñòàöèîííà îöåíêà. Òîé ñå ïðåïîðú÷âà çà õðàíèòåëíàïðåâåíöèÿ è äèåòîòåðàïèÿ ïðè äèàáåò è ìåòàáîëèòíèíàðóøåíèÿ, êàêòî è çà çäðàâîñëîâíî õðàíåíå.

Êëþ÷îâè äóìè: íîâ õëÿá „Äåà”, äèàáåò, ïðåäèàáåò,ãëèêåìè÷åí èíäåêñ

Âúâåäåíèå

Õðàíèòåëíàòà ïðåâåíöèÿ è äèåòîòåðàïèÿòà ñà îñíîâíèôàêòîðè â ñúâðåìåííèÿ êîíòðîë íà äèàáåòà, êîèòî ìîãàòñúùåñòâåíî äà ñúäåéñòâàò çà íàìàëÿâàíå íà áîëåñòíîñòòàîò äèàáåò è çàáàâÿíåòî íà ïðîãðåñèÿòà íà äèàáåòíèòåóñëîæíåíèÿ (1,2). Âàæíà ðîëÿ â õðàíèòåëíèÿ ðåæèì ïðèäèàáåò ñå îòðåæäà íà âúãëåõèäðàòíèòå õðàíè ñ íèñúêãëèêåìè÷åí èíäåêñ (3). Âúïðåêè ðàçëè÷íèòå çàêëþ÷åíèÿíà ïðîâåäåíèòå èçñëåäâàíèÿ (ñòóäèè) îòíîñíî ñòåïåíòàíà çíà÷èìîñò íà ãëèêåìè÷íèÿ èíäåêñ, âúâ âñè÷êèñúâðåìåííè äèåòè÷íè ïðåïîðúêè çà õîðàòà ñ äèàáåò åâêëþ÷åíà ïðåïîðúêàòà çà êîíñóìàöèÿ íà äîñòàòú÷íîêîëè÷åñòâî âúãëåõèäðàòè äî 55-60 åíåðãèéíè %,ïðåäñòàâåíè ïðåäèìíî îò ïúëíîçúðíåñòè õëåáíè èçäåëèÿ,äîñòàòú÷íî ôèáðè è õðàíè ñ íèñúê õèïåðãëèêåìè÷åíïîòåíöèàë (4,5,6,7). Ñúâðåìåííèòå ïðåïîðúêè çàçäðàâîñëîâíî õðàíåíå ñúùî íàñî÷âàò êúì êîíñóìàöèÿíà ïðåäèìíî êîìïëåêñíè ïîëèçàõàðèäè è ïúëíîçúðíåñòõëÿá. Ïðîèçâîäñòâîòî è ïðèëîæåíèåòî íà íîâèçäðàâîñëîâíè è äèåòè÷íè õðàíè òðÿáâà äà áúäå ñúùåñòâåíåëåìåíò îò íàöèîíàëíàòà õðàíèòåëíà ïîëèòèêà (1,8).

Öåë íà íàñòîÿùîòî ïðîó÷âàíå å äà ñå íàïðàâèìåòàáîëèòíà è äåãóñòàöèîííà îöåíêà íà íîâèÿ áúëãàðñêèõëÿá çà äèàáåòèöè „Äåà” è äà ñå äàäàò ïðåïîðúêè çàíåãîâîòî ïðèëîæåíèå.

Ìàòåðèàë, ãðóïè ïàöèåíòè, ìåòîäè èäèçàéí íà ïðîó÷âàíåòî

Íîâèÿò õëÿá çà äèàáåòèöè, ïîä òúðãîâñêàòà ìàðêà „Äåà”,å ïðîèçâåäåí îò áúëãàðñêàòà ôèðìà „Íèëàíà” ïîîðèãèíàëíà àâñòðèéñêà ðåöåïòà íà õëÿá „Êàéçåð Ôðàíö”,ñåðòèôèöèðàí êàòî äèåòè÷íà õðàíà çà äèàáåòèöè îòèíñòèòóòà „Áèîòàñê”, Ãåðìàíèÿ. Íåãîâèÿò ñúñòàâ âêëþ÷âàïúëíîçúðíåñòî áðàøíî îò äèâîðàñòÿùà ïøåíèöà – ñïåëò,ðúæåíî áðàøíî, å÷åìè÷åí ìàëöîâ åêñòðàêò, êàðòîôåíè

rum insulin and insulin resistance decreasing and alsoserum triglycerides decreasing has been proved. Thefavorable individual metabolic effect in children hasbeen shown when they took the new bread in compari-son to the intake of standard bread “Dobrudzha”. Thedegustation estimation showed that with good toler-ance to new bread are 86,48% of patients, satisfied –8,11% and only 5,41% - negative. The diabetics chil-dren have been demonstrated a good degustation toler-ance.

Conclusion: New bread has been estimated as functionalcarbohydrate food with low glycemic index, favorablemetabolic effects and good degudtation assessment. Itis useful in medical practice for nutrition preventionand dietary therapy in diabetes, metabolic disorders aswell as for healthy nutrition.

Key words: new bread “Dea” , diabetes, pre-diabetes, low glycemic index

Introduction

Nutritional prevention and dietary therapy have beenshown to be main factors that can improve diabetescontrol; moreover they may significantly contribute todecreased diabetes prevalence and might retard theprogression of diabetic complications (1,2).Carbohydrate-containing foods with low glycemic indexplay an important role in diabetes diet in managing thedisease (3). Despite different conclusions of the studiesconducted concerning the category of food on theglycemic index in all current dietary recommendationsfor the diabetics, the recommendation included for theconsumption of sufficient carbohydrate amount is up to55-60 energy % represented mainly by whole-wheatbread products, sufficient fiber and foods with lowhyperglycaemic potential (4,5,6,7). Currentrecommendations for healthy nutrition are also orientedto the consumption of predominantly complexpolysaccharides and whole-wheat bread. The productionand application of new healthy and dietetic foods shouldbe an essential part of the national nutrition policy (1,8)

The aim of the current study is to perform a metabolicand degustation assessment of the new Bulgarian bread“Dea” for diabetics and to make recommendations forits application.

Material, groups of patients, methods anddesign of the study

The new bread for diabetics under the trademark “Dea”was produced by the Bulgarian company “Nilana”through the original Austrian bread recipe “Kaizer Franz”that is certified as a dietetic food for diabetics by theInstitute „Biotack”, Germany. The ingredients includedare whole-grain flour from wild wheat – spelt, rye flour,



ëþñïè, ñóõî ðúæåíî ìàåíî òåñòî. Õðàíèòåëíîòîñúäúðæàíèå ñå ñúñòîè îò 5,28% áåëòúöè; 38,7%âúãëåõèäðàòè è 184 êêàë íà 100 ã ãîòîâ ïðîäóêò. Îò íÿêîëêîãîäèíè õëÿáúò „Êàéçåð Ôðàíö”, êîéòî ñå ïðèãîòâÿ îòñúùàòà óíèêàëíà êîìáèíàöèÿ áðàøíî, å óñïåøåí ïðîäóêòâ Ãåðìàíèÿ è Àâñòðèÿ êàêòî çà õîðàòà ñ äèàáåò, òàêà è çàçäðàâîñëîâíî õðàíåíå.

Ñúãëàñíî ïðåäñòàâåíà ïðîäóêòîâà ñïåöèôèêàöèÿ õëÿá„Êàéçåð Ôðàíö”, êîéòî ñå èçãîòâÿ îò ñìåñ çà ïå÷åíå íàôèðìà „Ïôàíåë Áàêìèòåë ÃìáÕ” ïî ñúîòâåòíà ðåöåïòà,îòãîâàðÿ íà ðàçïîðåäáèòå íà íåìñêàòà Íàðåäáà çàäèåòè÷íèòå õðàíè îò 28 àïðèë 2005 ã., èçìåíåíà íà30.01.2008 ã. çà èçèñêâàíèÿòà çà äèåòè÷íè õðàíè çàäèàáåòèöè:

1. Ñúäúðæàíèåòî íà ìàçíèíè èëè àëêîõîë íå òðÿáâà äà åïî-âèñîêî îò òîâà íà ñðàâíèìèòå õðàíè çà îáùàêîíñóìàöèÿ.

2. Ãëþêîçàòà, èíâåðòíàòà çàõàð, äèçàõàðèäèòå,ìàëòîäåêñòðèíèòå è ãëþêîçíèÿò ñèðîï íå òðÿáâà äàïðèñúñòâàò êàòî äîáàâêè.

3. Õëÿáúò òðÿáâà äà èìà õðàíèòåëíà ñòîéíîñò îòìàêñèìóì 840 êÄæ èëè 200 êêàë íà 100 ã.

Ïðîáè îò ïðîèçâåäåíèÿ õëÿá „Äåà” ñà òåñòâàíè äâóêðàòíîâ àêðåäèòèðàíà ëàáîðàòîðèÿ çà èçñëåäâàíå íà õèìè÷íèÿñúñòàâ íà õðàíèòå â ÍÖÎÎÇ (ñåãà ÍÖÎÇÀ) ïîñòàíäàðòèçèðàíè è âàëèäèðàíè âúòðåøíî-ëàáîðàòîðíèìåòîäè ïî ÁÄÑ çà îïðåäåëÿíå íà ïîêàçàòåëèòå:ñúäúðæàíèå íà ñóõî âåùåñòâî, âëàãà íà ñðåäèíàòà, áåëòúê,ìàçíèíè, ïåïåë, âëàêíèíè – îáùè, íåðàçòâîðèìè,ðàçòâîðèìè (ïî ÀÎÀÑ), êèñåëèííîñò, íàòðèåâ õëîðèä,âúãëåõèäðàòè, åíåðãèéíî ñúäúðæàíèå.

Íîâèÿò õëÿá å àïðîáèðàí ïðè ãðóïà îò 38 ïàöèåíòè,õîñïèòàëèçèðàíè â Êëèíèêàòà ïî ìåòàáîëèòíèçàáîëÿâàíèÿ è äèåòåòèêà ïðè Óíèâåðñèòåòñêàòà áîëíèöà„Öàðèöà Éîàííà-ÈÑÓË” â Ñîôèÿ – 22 ñ äèàáåò, 16 ñïðåäèàáåò, îò êîèòî îáùî 22 æåíè è 16 ìúæå, íà âúçðàñòîò 20 ã. äî 74 ã., ïðè ñðåäíà âúçðàñò íà æåíèòå 49 ã. è íàìúæåòå - 51 ã. Â ãðóïàòà íà áîëíèòå ñ äèàáåò 15 ñà ñíåèíñóëèíîçàâèñèì äèàáåò íà ïåðîðàëíà òåðàïèÿ (7 æåíèíà ñðåäíà âúçðàñò 55 ã.,8 ìúæå íà ñðåäíà âúçðàñò 58 ã.,êàòî âñè÷êè ïîëó÷àâàò áèãâàíèä, à ïðè 4 –ìà (26,66%)ïåðîðàëíàòà òåðàïèÿ å êîìáèíèðàíà - áèãâàíèä èñóëôàíèëóðååí ïðåïàðàò. Ñ èíñóëèíîçàâèñèì äèàáåò ñà 7ïàöèåíòè (5 æåíè íà ñðåäíà âúçðàñò 60 ã. è 2-ìà ìúæå íàñðåäíà âúçðàñò 55 ã.), êàòî ïðè 5 îò òÿõ (71,4%)èíñóëèíîëå÷åíèåòî ñå êîìáèíèðà ñ áèãâàíèä.Èíñóëèíîâîòî ëå÷åíèå å ñ äâó- è òðèêðàòíè àïëèêàöèè íàêîíâåíöèîíàëíè èíñóëèíè è/èëè èíñóëèíîâè àíàëîãîâèñìåñè ïðè äîáúð è çàäîâîëèòåëåí ãëèêåìè÷åí êîíòðîë. Âãðóïàòà íà áîëíèòå ñ ïðåäèàáåò 10 ñà æåíè íà ñðåäíàâúçðàñò 40 ã. è 6 ñà ìúæå íà ñðåäíà âúçðàñò 39 ã., êàòî ïðè37,6% (6) êúì äèåòîëå÷åíèåòî å äîáàâåíà ìåäèêàìåíòîçíàòåðàïèÿ ñ áèãâàíèä, ïîðàäè èçðàçåíà èíñóëèíîâàðåçèñòåíòíîñò.

barley malt extract, potatoes flakes, rye sourdough withactive dry yeast. The nutritional content consists of 5,28%proteins; 38,7% carbohydrates and 184 kcal per 100 g ofready product. Over the last few years the “Kaizer Franz”bread prepared by the same unique combination of flouris a successful food item in Germany and Austria bothfor the diabetics and for the healthy nutrition.

According to a product specification presented the KaizerFranz bread that is made from a baking mixture of theCompany Pfahnl Backmittel GmbH following a certainrecipe was found to correspond to the regulations of theGerman Ordinance for dietetic foods as of 28 April 2005amended on 30.01.2008 adjusted for the requirements fordietetic foods for diabetics.

1. The content of fats or alcohol should not be higherthan that of the comparable foods for generalconsumption.

2. Glucose, inverted sugar, disaccharides, maltodextrinesand glucose syrup should not be present asadditives.

3. The bread should have nutritional value of maximum840 kJ or 200 kcal of 100 g.

Samples of the produced bread „Dea” were tested twiceat an Accredited laboratory for investigation of foodchemical composition in the National Center of PublicHealth Protection by using standardized and validatedinternal-laboratory methods according BDS for measuringthe following indicators: content of dry substance,moisture of bread crumb, protein, fats, ash, fiber – general,insoluble, soluble (by ÀÎÀÑ), acidity, sodium choride,carbohydrates, energy content.

The new bread was approbated in a group of 38 patients,hospitalized in the Clinic of metabolic diseases anddietetics at the University Hospital Queen Giovanna-ISUL in Sofia – 22 with diabetes, 16 with prediabetes, ofthem a total of 22 women and 16 men, aged from 20 to 74years with a median age of 49 for women and a medianage of 51 for men. In the group of diabetics 15 patientshave non-insulin dependent diabetes with per oraladministration /7 women at median age of55 years, 8 menat median age of 58/, as all of them receive biguanide, andin 4 (26,66%) patients the per oral administration wascombined – biguanide and sulfa nitrile preparation. Sevenpatients have insulin dependent diabetes (5 women atmedian age of 60 years and 2 men at median age of 55), asin 5 of them (71,4%) the insulin therapy is combined withbiguanide. The insulin therapy is with two and threeapplications of conventional insulin and/or insulinanalogous mixtures with good and fair glycemic control.In the group of prediabetic patients 10 are women with amedian age of 40 years and 6 are men with a median ageof 39 years, as in 37,6% (6). medicinal therapy withbiguanide due to the expressed insulin resistance wasadded to the diet therapy.



Êîíòðîëíàòà ãðóïà âêëþ÷âà 7 ïàöèåíòè, 4 æåíè íà ñðåäíàâúçðàñò 50 ã. è 3-ìà ìúæå íà ñðåäíà âúçðàñò 27 ã., îò êîèòî1 ñ íåèíñóëèíîçàâèñèì äèàáåò òèï 2 è 6 - ñ ïðåäèàáåò.Âñè÷êè ïðîâåæäàò äèåòîëå÷åíèå, à ïðè 4-ìà (57,1%) åâêëþ÷åí è áèãâàíèä.

Âñè÷êè ïàöèåíòè ñà àíêåòèðàíè ñúñ ñïåöèàëíîðàçðàáîòåíà àíêåòíà êàðòà è ñà èçñëåäâàíèàíòðîïîìåòðè÷íî è êëèíèêî-ëàáîðàòîðíî ñúññúîòâåòíèòå ðóòèííè ìåòîäè. Â ïðîáè âåíîçíà êðúâ íààâòîìàòè÷åí àíàëèçàòîð Architect 8000 ñà îïðåäåëÿíèíèâàòà íà ãëþêîçà ÷ðåç îêèñëèòåëíî-ðåäóêöèîíåí ìåòîä,íà îáù õîëåñòåðîë è òðèãëèöåðèäè -÷ðåç åíçèìíèôîòîìåòðè÷íè ìåòîäè, íà âèñîêîïëúòíîñòåí õîëåñòåðîë- ÷ðåç äèðåêòåí ìåòîä, íà èìóíîðåàêòèâåí èíñóëèí - ÷ðåçåíçèìåí èìóíîàíàëèç – MEIA íà Axym. Èç÷èñëÿâàí åèíäåêñ íà èíñóëèíîâà ðåçèñòåíòíîñò. Ïîëó÷åíèòå äàííèñà îáðàáîòåíè ñúñ ñòàòèñòè÷åñêè ìåòîäè: ÷åñòîòåí àíàëèçíà êà÷åñòâåíè ïðîìåíëèâè, êîéòî âêëþ÷âà àáñîëþòíè èîòíîñèòåëíè ÷åñòîòè (%); âàðèàöèîíåí àíàëèç íàêîëè÷åñòâåíè ïðîìåíëèâè; t-òåñò çà ñðàâíåíèå íà ñðåäíèñòîéíîñòè íà äâå ãðóïè. Ñòàòèñòè÷åñêàòà îáðàáîòêà íàäàííèòå å èçâúðøåíà ñúñ ñòàòèñòè÷åñêè ïàêåò SPSS 15.0.

Â îòäåëåíèåòî ïî äèàáåò íà Óíèâåðñèòåòñêàòà áîëíèöàïî äåòñêè áîëåñòè â Ñîôèÿ ïðè 15 äåöà ñ äèàáåò åïðîâåäåíà äåãóñòàöèÿ íà íîâèÿ õëÿá, à â êëèíè÷åíåêñïåðèìåíò ñà âêëþ÷åíè 6 äåöà ñ äèàáåò òèï 1, ñ äàâíîñòíà çàáîëÿâàíåòî îò 2 äî 6 ãîäèíè, íà âúçðàñò îò 5 äî 15 ã.,íà èíòåíçèôèöèðàíî èíñóëèíîâî ëå÷åíèå ñ òðèêðàòíààïëèêàöèÿ íà áúðçîäåéñòâàù èíñóëèí è ÷åòâúðòàèíæåêöèÿ â 22 ÷. ñ èíòåðìåäèåðåí èíñóëèí.

Ðåçóëòàòè è îáñúæäàíå

Â ñåêöèÿ „Õèìè÷åí ñúñòàâ íà õðàíèòå” – Èçïèòâàòåëåíöåíòúð „Çäðàâå” íà ÍÖÎÎÇ (ñåãà ÍÖÎÇÀ) äâóêðàòíî åèçâúðøåí õèìè÷åí àíàëèç íà ïðîáè õëÿá, ïðîèçâåäåíè èïðåäîñòàâåíè îò ôèðìà „Íèëàíà” ÎÎÄ, Ñîôèÿ, ïîñúîòâåòíè ñòàíäàðòíè ìåòîäèêè, ñ öåë îïðåäåëÿíå íàðåàëíèÿ õèìè÷åí ñúñòàâ è ñúîòâåòíî åíåðãèéíîñúäúðæàíèå íà íîâèÿ áúëãàðñêè õëÿá çà äèàáåòèöè. ÍàÒàáë.1. ñà ïðåäñòàâåíè ðåçóëòàòèòå îò àíàëèçà íà „Äåà”.Ïðè ïúðâèÿ àíàëèç ñå óñòàíîâÿâàò ìàëêî ïî-âèñîêîñúäúðæàíèå íà áåëòúöè (7% ñðåùó 5,28%) è âúãëåõèäðàòè(40,15% ñðåùó 38,7%) â ñðàâíåíèå ñ îáÿâåíàòà ðåöåïòà,êîåòî îáà÷å íå ñå îòêëîíÿâà îò èçèñêâàíèÿòà çà ñúñòàâàíà äèåòè÷íèòå ïðîäóêòè çà äèàáåòèöè. Âòîðèÿò àíàëèçïîêàçâà ïîäîáðåí è îïòèìèçèðàí ñúñòàâ íà õëÿáà ïðèñúîòâåòíî ïîâèøåíî ñúäúðæàíèå íà îáùèòå èðàçòâîðèìèòå âëàêíèíè (ñúîòâåòíî 13,88% ñðåùó 11,55%è 4,59% ñðåùó 1,01% ñïðÿìî ïúðâàòà ïðîáà) è èçâåñòíîíàìàëÿâàíå íà îáùèòå âúãëåõèäðàòè (32,76% ñðåùó 40,15%ñïðÿìî ïúðâàòà ïðîáà). Õàðàêòåðèñòèêàòà íà õëåáíèÿïðîäóêò å çàïàçåíà ïðè íàëè÷íà åíåðãèéíîñò ïîä 200 êêàëíà 100 ã ïðîäóêò, îïòèìàëíî ñúäúðæàíèå íà âëàêíèíè(âúãëåõèäðàòíè åäèíèöè ìåæäó 3 è 4, à õëåáíè åäèíèöèñðåäíî - 3 íà 100 ã ïðîäóêò).

The control group includes 7 patients, 4 women with amedian age of 50 years and 3 men with a median age of 27years, of them 1 has non-insulin dependent type 2diabetes and 6 have prediabetes. All are under diettherapy, and in 4 (7,1%) biguanide is included.

All patients were inquired by specially developedquestionnaire card and investigated anthropometricallyand by clinical-laboratory with the relevant routinemethods. In samples of venous blood at automaticanalyzer Architect 8000 the glucose levels were measuredby oxy-reduction method, of total cholesterol andtriglycerides by enzymatic photometric methods, of highdensity cholesterol method by a direct method, ofimmuno-reactive insulin by an enzymatic immuneanalysis– MEIA of Axym. The index of insulin resistancewas calculated. Descriptive statistics, correlation andregression analyses parametric and non-parametricinferential statistics and multiple linear logistic regressionanalysis have been applied for data processing.

In the Department of diabetes at the University PediatricHospital in Sofia degustation of the new bread wasperformed by 15 diabetic children, while in a clinicalexperiment were included 6 children, aged 5 to 15 years,with type 1 diabetes with a disease duration that rangedfrom 2 to 6 years, at intensifying insulin program withtriple-therapy regimen of fast-acting insulin and fourthinjection at 22 h with intermediate-acting insulin.

Results and discussion

In the section „Chemical food composition” – Test Center„Zdrave” of the NCPHP a chemical analysis of samplesof the bread produced and placed at disposal by theCompany “Nilana” Ltd, Sofia, using appropriate standardmethods in order to determine the real chemicalcomposition and respective energy content of the newbread for diabetic people. The results obtained from theanalysis of Dea bread are shown in Table 1. In the firstanalysis a little bit higher amount of proteins (7% against5.28%) and carbohydrates (40.15% against 38.7%) wereestablished in comparison to the recipe declared;however, it is not deviated from requirements for dieteticproduct composition beneficial for diabetics. The secondanalysis shows improved and optimal food compositionat appropriately increased content of total and solublefiber (respectively 13,88% against 11,55% and 4,59%against 1,01% versus the first sample) and certaindecrease of total carbohydrates (32,76% against 40,15%versus the first sample). Properties of the bread productare preserved at available energy content below 200 kcalper 100 g of a product, optimal content of fiber,carbohydrate units between 3 and 4, and bread units onaverage 3 per 100 g of a product.



Table 1. Chemical and energy composition of Dea breadÒàáëèöà 1. Õèìè÷åí è åíåðãèåí ñúñòàâ íà õëÿá „Äåà” *

* Ðåçóëòàòèòå îò àíàëèçà ñå îòíàñÿò ñàìî çà èçïèòâàíàòàïðîáà. Ïðè àíàëèçà íà ïðîáèòå ñ òå÷íîõðîìàòîãðàôñêàìåòîäèêà ïî ËÌÈ:ÈÖÇ íå ñå îòêðèâà çàõàðîçà.

Ðàçðàáîòåíèÿò íîâ àñîðòèìåíò õëÿá „Äåà” ïðåäñòàâëÿâàíîâ ïðîäóêò, êîéòî ñå îòëè÷àâà ñ ïîäîáðåíè õðàíèòåëíèêà÷åñòâà è îïòèìàëåí ñúñòàâ. Òîé å ñúçäàäåí íà îñíîâà íàïúëíîçúðíåñòî áðàøíî îò ðúæ è äèâîðàñòÿùà ïøåíèöà èå åñòåñòâåí èçòî÷íèê íà ðàñòèòåëíè âëàêíèíè, à çàåäíî ñòîâà è íà ìèíåðàëè, âèòàìèíè, ðàñòèòåëíè ìàçíèíè. „Äåà”ñå îòëè÷àâà ñ íàìàëåíî åíåðãèéíî ñúäúðæàíèå èîïòèìèçèðàíî âúãëåõèäðàòíî ñúäúðæèìî.

Õðàíèòåëíàòà ñòîéíîñò íà íîâèÿ õëÿá îòãîâàðÿ èçöÿëî íàèçèñêâàíèÿòà çà õëåáíî èçäåëèå, à âëîæåíèòå ñóðîâèíè èêîìáèíèðàíîòî óíèêàëíî áðàøíî, îáîãàòåíî ñ âëàêíèíè,îïðåäåëÿò íåãîâèòå îïòèìàëíè ìåòàáîëèòíè åôåêòè.

Âúç îñíîâà íà ðóòèíåí êëèíè÷åí ïðåãëåä è ñúîòâåòíèêëèíèêî-ëàáîðàòîðíè èçñëåäâàíèÿ å íàïðàâåíàõàðàêòåðèñòèêà íà ãðóïàòà îò 38 ïàöèåíòè îòÌåòàáîëèòíàòà êëèíèêà, âêëþ÷åíè â îïðåäåëÿíåòî íàìåòàáîëèòíà è äåãóñòàöèîííà îöåíêà íà íîâèÿ õëÿá.

* The results obtained from the analysis are only referred tothe tested samples. In the analysis of samples usingHPLC, no saccharosis was found.

The developed new type of bread “Dea” of the Company“Nilana” is a new bread product, which is distinguished byits improved nutritional qualities and optimal composition.It was produced on the basis of whole grain flour from ryeand wheat and it is a natural source of plant fiber alongwith minerals, vitamins and plant fats. “Dea” isdistinguished by its decreased energy content and modifiedcarbohydrate content.

The nutritional value of the new bread corresponds as awhole to the requirements for bread product, and theincorporated raw materials and combined unique fiber-richflour determine its modified metabolic effect.

On the basis of a routine clinical check-up and relevantclinical and laboratory examination, characterization wasperformed within the group of 38 patients from theMetabolic clinic, who were included in the determinationof metabolic and degustation assessment of the new bread.



Êàêòî å äîáðå èçâåñòíî, äèàáåò òèï 2 ñå ñú÷åòàâà ñíàäíîðìåíî òåãëî. Â ãðóïàòà íà íåèíñóëèíîâèòåäèàáåòèöè 14 èëè 93,33% èìàò çàòëúñòÿâàíå è ñàìî 1(06,64%) å ñ íîðìàëíî òåãëî. Âñè÷êè ïàöèåíòè ñà ñàðòåðèàëíà õèïåðòîíèÿ. 9 îò òÿõ (60,0%) ñà ñ ïîâèøåí îáùõîëåñòåðîë, 10 (66,66%) ñà ñ íèñúê õîëåñòåðîë âëèïîïðîòåèíèòå ñ âèñîêà ïëúòíîñò, à 8 (53,33%) îòïàöèåíòèòå ñà ñ õèïåðòðèãëèöåðèäåìèÿ. Òðèìà /20,00%/ñúîáùàâàò çà õðîíè÷åí ãàñòðîäóîäåíèò. Ñ ðàçâèòèå íàäèàáåòíè óñëîæíåíèÿ ïî òèïà íà äèàáåòíàïîëèíåâðîïàòèÿ ñà 9 ïàöèåíòè (60,0%) è ñ äèàáåòíàíåôðîïàòèÿ ñà 4-ìà (26,66%).

Â ãðóïàòà íà èíñóëèíîâèòå äèàáåòèöè âñè÷êè ïàöèåíòèèìàò çàòëúñòÿâàíå ñ ÈÒÌ íàä 30 (òåãëî (êã)/ðúñò (ì2)).Ñúðäå÷íîñúäîâè çàáîëÿâàíèÿ (àðòåðèàëíà õèïåðòîíèÿ èÈÁÑ) èìàò 6 ïàöèåíòè (85,7%), à 2-ìà (28,6%) èìàòõðîíè÷åí ãàñòðèò. Äèàáåòúò å óñëîæíåí ïðè âñè÷êè ñäèàáåòíà ïîëèíåâðîïàòèÿ è ïðè 2-ìà (28,6%) èìàóñòàíîâåíà äèàáåòíà íåôðîïàòèÿ. Óñòàíîâåíè ñà èâòîðè÷íè ëèïèäíè íàðóøåíèÿ. Ïðè 4-ìà ïàöèåíòè (57,1%)- ïîâèøåí îáù õîëåñòåðîë, ïðè 5 (51,4%) - ïîíèæåíõîëåñòåðîë â ëèïîïðîòåèíèòå ñ âèñîêà ïëúòíîñò, ïðè 4(57,1%) - ïîâèøåíè òðèãëèöåðèäè.

Â ãðóïàòà íà ïàöèåíòèòå ñ ïðåäèàáåò ïðåîáëàäàâàò ëèöàòàñúñ çàòëúñòÿâàíå – 14 (87,5%). Îáùî ïðè âñè÷êè èìàìåòàáîëèòåí ñèíäðîì, êàòî ïîâèøåí îáù õîëåñòåðîë ñåíàìèðà ïðè 9 äóøè (56,3%), ïîíèæåí õîëåñòåðîë âëèïîïðîòåèíèòå ñ âèñîêà ïëúòíîñò - ïðè 13 (81,3%),ïîâèøåíè íèâà íà òðèãëèöåðèäè – ïðè 7 (43,7%). Îáùîïðè 9 ïàöèåíòè (56,3%) ñå óñòàíîâÿâàò àðòåðèàëíàõèïåðòîíèÿ è ÈÁÑ; ïðè 7 (43,7%) - õðîíè÷åí ãàñòðèò, àïðè åäèí - õîëåöèñòåêòîìèÿ.

Êîíòðîëíàòà ãðóïà ïàöèåíòè èìà ñõîäíà êëèíè÷íàõàðàêòåðèñòèêà. Ñúñ çàòëúñòÿâàíå ñà 71,4%, ïðè 57,1% èìààðòåðèàëíà õèïåðòîíèÿ è ÈÁÑ è ïðè 14,3% - õðîíè÷åíãàñòðèò. Ëèïèäíèòå íàðóøåíèÿ ñà ñúùî ÷åñòè – ñ ïîâèøåíîáù õîëåñòåðîë ñà 42,9%, ñ ïîíèæåí âèñîêîïëúòíîñòåíõîëåñòåðîë ñà 57,1%, ñ ïîâèøåíè íèâà íà òðèãëèöåðèäèòåñà 42,9%.

Äèåòîòåðàïèÿòà å îñíîâíà òåðàïèÿ çà ïàöèåíòèòå ñ äèàáåò.Àíêåòíîòî ïðîó÷âàíå óñòàíîâè, ÷å 60% îòíåèíñóëèíîâèòå äèàáåòèöè (9 ïàöèåíòè) ñïàçâàò äèåòè÷åíðåæèì, à 40% -6 äóøè ñúîáùàâàò, ÷å íå ãî ñïàçâàò. Âàæåíôàêòîð çà äèåòîëå÷åíèåòî ïðè äèàáåò å îáó÷åíèåòî íàïàöèåíòèòå çà ïðàâèëåí äèåòè÷åí ðåæèì. Ïàöèåíòèòå,ñïàçâàùè äèåòè÷íèÿ ðåæèì,ñà áèëè îáó÷åíè çà òîâà, àòåçè, êîèòî íå ãî ñïàçâàò ñúîáùàâàò, ÷å íå ñà îáó÷åíè.Íà÷èíúò íà îáó÷åíèå å ðàçëè÷åí – 4-ìà ïàöèåíòè (26,66%)ñà îáó÷åíè â ãðóïîâî îáó÷åíèå â êëèíèêà, 3-ìà (20,0%)ñà îáó÷åíè îò èíòåðíåò è ëèòåðàòóðà, 1 ïàöèåíò (6,66%) åîáó÷åí îò ëè÷åí ëåêàð è 1 (6,66%) - îò ñïåöèàëèñò.Ñúùåñòâåí åëåìåíò íà äèåòè÷íèÿ ðåæèì å îïðåäåëÿíåòîíà õëåáíèòå åäèíèöè. Îêàçà ñå, ÷å âúïðåêè îáó÷åíèåòî,ñàìî 3-ìà îò ïàöèåíòèòå (20,0%) çíàÿò êîëêî õëåáíèåäèíèöè äíåâíî òðÿáâà äà ïðèåìàò, à îñòàíàëèòå 12ïàöèåíòè (80,0%) íå çíàÿò òîâà.

As it is well known, type 2 diabetes is strongly associatedwith being overweight. In the group of non-insulin diabetics14 or 93,33% are overweight and only 1 diabetic (06,64%) isnormal weight patient. All patients have arterialhypertension, 9 (60,0%) have increased total cholesterol,66,66% (10) have low cholesterol in the high densitylipoproteins, 53,33% (8) of patients havehypertriglyceridemia and 3 of then (20,00%) have reportedchronic gastroduodenite. With the development of diabeticcomplications by the type of diabetic polynephropathyare 60,0% (9) of the patients and with diabetic nephropathyare 26,66% (4) of the patients.

In the group of insulin diabetics all patients are overweightwith BMI above 30 kg/m2. 85,7% /6/ have cardio-vasculardiseases (arterial hypertension and coronary heart disease),and 2 (28,6%) have chronic gastritis. Diabetes iscomplicated in all with diabetic polynephropathy and in 2(28,6%) a diabetic nephropathy was established. Secondarylipid disorders were found as follows: in 4 patients (57,1%)- increased total cholesterol, in 5 (51,4%) - decreasedcholesterol in high density lipoproteins, in 4 (57,1%) -increased triglycerides.

In the group of patients with prediabetes prevail theindividuals with obesity– 87,5% (14). Totally, in all patientsis revealed metabolic syndrome, as increased totalcholesterol was found in 9 (56,3%), decreased cholesterolin high density lipoproteins in 13 (81,3%), increasedtriglyceride levels – in 7 (43,7%). Totally, in 9 patients (56,3%)was found arterial hypertension and coronary heart diseaseand in 7 (43,7%) - chronic gastritis and in 1 –cholecystectomy.

The control group of patients has similar clinicalcharacteristics. 71,4% of them are obese, 57,1% of patientshave arterial hypertension and coronary heart disease and14,3% have chronic gastritis. The lipid disorders are alsofrequently met – with increased total cholesterol are 42,9%,with decreased high density cholesterol are 57,1% and withelevated triglyceride levels are 42,9%.

Diet therapy plays a very important role in the treatment ofdiabetes. It was established by using questionnaires that60% of non-insulin diabetics (9) follow diet therapy, and40% (6) have reported that they did not follow it. Animportant factor for the diet therapy in diabetes is to trainpatients for an appropriate dietary regimen. The patientsthat followed the dietary regimen (9/)were trained for doingthis, while those who did not follow it (6) have reportedthat they were not trained. The way of being trained is different– 4 patients (26,66%) participated in group-based training inthe clinic, 3 patients were trained (20,0%) through the Internetand scientific literature, 1 patient (6,66%) was given training bya GP and 1 patient (6,66%) was given training by a medicalspecialist. An essential element of the dietary regimen is thedetermination of the bread units. It can be seen that despite thetraining only 3 of the patients (20,0%) know how many breadunits daily should be delivered, while the rest 12 patients (80,0%)did not know anything about this.



Âúïðåêè ïî-ñåðèîçíîòî ëå÷åíèå ïðè èíñóëèíîâèòåäèàáåòèöè, àíêåòíèòå äàííè ïîêàçâàò, ÷å äèåòàòà ñå ñïàçâàñòðèêòíî ñàìî ïðè 2-ìà (28,6%), ïîíÿêîãà – ïðè 4-ìà(57,15), à åäèí âúîáùå íå ÿ ñïàçâà. Îáó÷åíè çà äèåòè÷íèÿðåæèì ñà 4-ìà ïàöèåíòè (57,1%) è òå çíàÿò êîëêî õëåáíèåäèíèöè ñà èì íåîáõîäèìè. Îñòàíàëèòå íå ñà çàïîçíàòè ñòîâà.

Â ãðóïàòà íà ïàöèåíòèòå ñ ðèñê îò äèàáåò ïðåäïèñàíèÿòäèåòè÷åí ðåæèì ñå ñïàçâà ïðè òâúðäå ìàëêî ïàöèåíòè -ñàìî äâàìà (12,5%), ïîíÿêîãà – îò 9 (56,3%) è íå ñå ñïàçâàîò îñòàíàëèòå 5 (31,2%). Îêàçà ñå, ÷å ïîâå÷åòî îò òÿõ íå ñàè îáó÷åíè çà òîâà. Ñàìî 4-ìà ïàöèåíòè îò ãðóïàòà (25,0%)ñà èíôîðìèðàíè çà ïðàâèëíàòà äèåòà , îò êîèòî 3-ìà ÷ðåçãðóïîâî îáó÷åíèå â êëèíèêàòà è 1 – îò èíòåðíåò èëèòåðàòóðà. Ñúîòâåòíî ñ íåîáõîäèìèòå èì õëåáíèåäèíèöè ñà çàïîçíàòè ñàìî 2-ìà ïàöèåíòè (12,5%).

Ñúâðåìåííèòå äèåòè÷íè ïðåïîðúêè çà äèàáåò èçèñêâàòäîñòàòú÷íî ïðèåì íà âúãëåõèäðàòè êàòî 55-60% îò äíåâíèÿåíåðãèåí ïðèåì. Ðåçóëòàòèòå îò àíêåòàòà ïîêàçâàò, ÷åðåäîâíî ïðèåìàò õëÿá 13 îò ïàöèåíòèòå ñíåèíñóëèíîçàâèñèì äèàáåò (86,66%), à ñ íåðåäîâåí ïðèåìíà õëÿá ñà ñàìî 2 ïàöèåíòè (13,33%), êàòî ñðåäíèÿò ïðèåìíà õëÿá å 4 è ïîëîâèíà ñòàíäàðòíè ôèëèè äíåâíî.Ïàöèåíòèòå ñå íàñî÷âàò êúì êîíñóìàöèÿ íà ïðåäèìíîòúìíè, ïúëíîçúðíåñòè õëÿáîâå. Äåâåò (60,0%) îò òÿõñïîäåëÿò, ÷å ïðèåìàò ïðåäèìíî òèïîâ õëÿá, 4-ìà (26,66%)- ïúëíîçúðíåñò õëÿá è äâàìà (13,34%) - ÷åðåí õëÿá.

Ïîäîáíè ñà îòãîâîðèòå è íà ïàöèåíòèòå ñèíñóëèíîçàâèñèì äèàáåò. Îò òÿõ ðåäîâíî ïðèåìàò õëÿáïîâå÷å îò ïîëîâèíàòà – 71,4% , ïðè ñðåäåí ïðèåì íà 4ñòàíäàðòíè ôèëèè äíåâíî. Â 57,1% ñå ïðåäïî÷èòà òèïîâõëÿá, ïðè 28,6% - ÷åðåí õëÿá, à 14,3% ïðèåìàò õëÿá„Äîáðóäæà”.

Â ãðóïàòà íà ïàöèåíòèòå ñ ïðåäèàáåò ïî-ãîëÿìàòà ÷àñòñúùî ðåäîâíî ïðèåìàò õëÿá – 62,5%, íåðåäîâíî – 31,3%è 1 ïàöèåíò íå ïðèåìà õëÿá. Ñðåäíèÿò ïðèåì íà õëÿá å 4,8ñòàíäàðòíè ôèëèè äíåâíî. Êîíñóìàöèÿòà íà õëÿá å ïî-ðàçíîîáðàçíà – 25% ïðèåìàò òèïîâ õëÿá, 31,3% ïðèåìàòïúëíîçúðíåñò õëÿá, 25% - áÿë õëÿá è 18,7% - ðúæåí õëÿá.

Â êëèíè÷íè óñëîâèÿ ïàöèåíòèòå ñà ïîëó÷èëè åäíîêðàòíîêàòî ñóòðåøíà çàêóñêà ñàìî 75 ã õëÿá „Äåà” (2 ÕÅ) - ñðåäíî2 îðèãèíàëíè ôèëèéêè, çàåäíî ñ ÷àé, ïðè êîåòî åèçâúðøåíà äåãóñòàöèîííà è ìåòàáîëèòíà îöåíêà íà õëÿáà.Êîíòðîëíàòà ãðóïà ïàöèåíòè å ïðèåëà åäíîêðàòíî ñúùîòîêîëè÷åñòâî 75 ã ñòàíäàðòåí õëÿá „Äîáðóäæà”. Íà âñè÷êèïàöèåíòè ñà ïðîñëåäåíè ìåòàáîëèòíè êðúâíè ïîêàçàòåëèïðåäè è íà 120-òà ìèíóòà îò ïðèåìà íà õëÿáà â ïðîáèâåíîçíà êðúâ, à íà 60-òà - â êëèíèêàòà „Accuchek Active” ñãëþêîìåð å îïðåäåëåíà êðúâíàòà çàõàð â êàïèëÿðíà êðúâ.

Äàííèòå çà ìåòàáîëèòíèòå ïðîìåíè ïðè îòäåëíèòå ãðóïèïàöèåíòè ñà ïðåäñòàâåíè íà òàáë. 2,3,4,5. Ìåòàáîëèòíàòàõàðàêòåðèñòèêà íà îòäåëíèòå ãðóïè å ðàçëè÷íà âñúîòâåòñòâèå ñúñ ñòåïåíòà íà íàðóøåíèÿòà âúââúãëåõèäðàòíèÿ ìåòàáîëèçúì. Ðàçëè÷íè ñà èìåòàáîëèòíèòå îòãîâîðè íà ïðèåìà íà õëÿáà, êîéòî å

Despite the more serious treatment for insulin diabetics, thequestionnaires show that the diet was strictly followed onlyby 2 patients (28,6%), sometimes – by 4 patients (57,15),while 1 patient has never followed it. Four patients (57,1%)were educated for the dietary regimen and they know howmany bread units are needed, while the rest patients werenot acquainted with this.

In the group of patients being at risk for diabetes theprescribed dietary regimen was followed by few patients –only 2 (12,5%), sometimes – by 9 (56,3%) patients and wasnot followed by the rest 5 patients (31,2%). It was foundthat most of them were not trained for this. Only 4 patientsof the group (25,0%) were well informed for the proper diet,of them 3 acquired information through group training inthe Clinic and 1 – through the Internet and scientificliterature. Only 2 patients (12,5%) were acquainted with thebread units relevant for them.

Current dietary recommendations for diabetes requiresufficient intake of carbohydrates as 55-60% of the dailyenergy intake. Results of the questionnaire show that86,66% (3) of the patients with non-insulin diabetes eatbread on a regular basis, while only 2 patients (13,33%) eatbread irregularly, as the average bread intake is 4 and a halfstandard slices per day. Patients are predominantly orientedto the consumption of brown, whole-grain breads and 60,0%(9) of them share their opinion that eat mainly brown, 26,66%(4) - whole-wheat bread and 13,34% (2) - rye bread.

The answers of the patients with insulin-dependent diabeteswere similar, too. Of them most of the half eat bread on aregular basis – 71,4% (5), on average intake of 4 standardslices per day. 57,1% (4) of the patients prefer brown bread,28,6% (2) eat rye bread and 1 (14,3%) patient consumes thebread “Dobrudzha”.

In the group of prediabetic patients the most part of themeat also bread on a regular basis – 10 (62,5%), on an irregularbasis – 5 (31,3%) and 1 patient does not eat bread. Theaverage intake of bread is 4,8 standard slices of bread daily.The bread consumption is more diverse – 25% (4) of thepatients eat brown bread, 31,3% (5) of the patients eat whole-wheat bread, 25% (4) of the patients – white bread and18,7% (3) of the patients consume rye bread.

Under clinical conditions the patients were delivered onceas breakfast only 75 g of bread „Dea” (2 ÕÅ) - on average 2original slices along with tea, as in parallel a degustationand metabolic assessment of the bread is performed. Thecontrol group of patients took once the same quantity of 75g of standard bread “Dobrudzha”. All patients were tracedfor the metabolic blood indicators before and at the 120th

minute from the intake of bread in samples of venous blood,and the glucose level in capillary blood was determined atthe 60th minute through the glucomeasurer in the clinicAccuchek Active.

Data for metabolic changes in the different group of patientsare presented in Tables 2,3,4,5. Metabolic characteristic ofthe different groups is distinguished by the degree of



ïðåäèìíî âúãëåõèäðàòíà õðàíà ñ ïîëèçàõàðèäíîñúäúðæàíèå è ïî-íèñúê õèïåðãëèêåìè÷åí ïîòåíöèàë.

Òàáëèöà 2. Ìåòàáîëèòíè ïðîìåíè ïðè ïàöèåíòèòå ñïðåäèàáåò ñëåä ïðèåì íà õëÿá „Äåà” (n=16).

* Ñòàòèñòè÷åñêè äîñòîâåðíà ðàçëèêà íà ñðåäíàòà ñòîéíîñò íàïîêàçàòåëÿ â ñðàâíåíèå ñ óñòàíîâåíàòà ñòîéíîñò ïðåäèêîíñóìàöèÿòà íà õëÿáà (ð<0,05).

Òàáëèöà 3. Ìåòàáîëèòíè ïðîìåíè ïðè ïàöèåíòèòå ñíåèíñóëèíîçàâèñèì äèàáåò ñëåä ïðèåì íà „ Äåà” ( n=15).

* Ñòàòèñòè÷åñêè äîñòîâåðíà ðàçëèêà íà ñðåäíàòà ñòîéíîñò íàïîêàçàòåëÿ â ñðàâíåíèå ñ óñòàíîâåíàòà ñòîéíîñò ïðåäèêîíñóìàöèÿòà íà õëÿáà (ð<0,05)

disorders in the carbohydrate metabolism. Metabolic repliesto the intake of bread that is predominantly carbohydratefood with polysaccharide content and lower hyperglycemicpotential.

Table 2. Metabolic changes in patients with prediabetes aftereating Dea bread ( n=16).

* Statistically significant difference of the mean value ofindicator in comparison to the value established before thebread consumption (p<0,05).

Table 3. Metabolic changes in patients with non-insulindependent diabetes after the intake of Dea bread (n =15).

* Statistically significant difference of the mean value ofindicator in comparison to the value established before thebread consumption (p<0,05)



Òàáëèöà 4. Ìåòàáîëèòíè ïðîìåíè ïðè ïàöèåíòèòå ñèíñóëèíîçàâèñèì äèàáåò ñëåä ïðèåì íà õëÿá „Äåà”( n=7).


Òàáëèöà 5. Ìåòàáîëèòíè ïðîìåíè ïðè êîíòðîëíàòà ãðóïà ñïðåäèàáåò ñëåä ïðèåì íà õëÿá „Äîáðóäæà” ( n=7).


Âúïðåêè ìåòàáîëèòíèòå ðàçëè÷èÿ è ïðè òðèòå ãðóïèïàöèåíòè, òåñòâàíè ñ „Äåà”, íå ñå óñòàíîâÿâà çíà÷èìîïîâèøåíèå íà ãëèêåìèÿòà íà âòîðèÿ ÷àñ îò ïðèåìà íàõëÿáà. Ïðè ïàöèåíòèòå ñ ïðåäèàáåò è ñ íåèíñóëèíîçàâèñèìäèàáåò ñå ðåãèñòðèðà çíà÷èìî ïîíèæåíèå íà ãëèêåìèÿòàíà 120-òà ìèí. ñïðÿìî èçõîäíàòà é ñòîéíîñò íà ãëàäíî –ñúîòâåòíî ñðåäíî ñ îêîëî 0,5 mmol/l èëè ñúñ 7,59% ïðèïðåäèàáåò è ñðåäíî ñ 0,96 mmol/l èëè ñ 12,03% ïðèíåèíñóëèíîçàâèñèìèòå äèàáåòèöè. Ïðè ïàöèåíòèòå ñèíñóëèíîçàâèñèì äèàáåò òàçè ïðîìÿíà ñå èçðàçÿâà ñðåäíîñ 0,56 mmol/l èëè ñ 4,80%, íî ïîðàäè ïî-ìàëêèÿ áðîéïàöèåíòè òàçè ðàçëèêà íå å ñòàòèñòè÷åñêè çíà÷èìà (Ôèã.1).

Table 4. Metabolic changes in patients with insulin-dependentdiabetes after the intake of Dea bread.


Table 5. Metabolic changes in the control group withprediabetes after the intake of Dobrudzha bread (n=7).


Despite the metabolic differences and in the three groupsof patients tested with Dea bread, no significant increasewas established in the glycemia at the second hour after thebread intake. In the patients with prediabetes and with non-insulin dependent diabetes a significant decrease in theglycemia at the 120th minute was registered versus its initialvalue on an empty stomach – respectively on average withabout 0,5 mmol/l or with 7,59% in prediabetes and on averagewith 0,96 mmol/l or with 12,03% in non-insulin dependentdiabetics. In the patients with insulin dependent diabetesthis change is manifested on average with 0,56 mmol/l orwith 4,80%, but due to the lower number of patients thisdifference is not statistically significant (Fig.1).



Ôèã. 1. Íèâà íà êðúâíà çàõàð ïðè ïàöèåíòè ñ ïðåäèàáåò,íåèíñóëèíîçàâèñèì è èíñóëèíîçàâèñèì äèàáåò ïðåäè èñëåä ïðèåì íà õëÿá „Äåà” è ïðè êîíòðîëíà ãðóïà ñïðåäèàáåò ïðåäè è ñëåä ïðèåì íà õëÿá „Äîáðóäæà”.

ËåãåíäàÏðåäèàáåò – ïàöèåíòè ñ ïðåäèàáåòÍÈÇÇÄ – ïàöèåíòè ñ íåèíñóëèíîçàâèñèì çàõàðåí äèàáåòÈÇÇÄ - ïàöèåíòè ñ èíñóëèíîçàâèñèì çàõàðåí äèàáåòÊîíòðîëà - ïàöèåíòè ñ ïðåäèàáåò

Òåçè ðåçóëòàòè ïîêàçâàò ÿñíî íàëè÷èå íà íèñúêãëèêåìè÷åí èíäåêñ íà íîâèÿ õëÿá, ëèïñà íà çíà÷èìîïîâèøåíèå íà êðúâíàòà çàõàð è äîðè ïîäîáðÿâàíå íàõèïåðãëèêåìèÿòà ñëåä íåãîâèÿ ïðèåì. Ïðîìåíèòå íàãëèêåìèÿòà íà êîíòðîëíèòå ïàöèåíòè, òåñòâàíè ñ õëÿá„Äîáðóäæà”, ïîêàçàõà ïîâèøåíèå íà êðúâíàòà çàõàð,ñðåäíî ñ 0,95 mmol/l èëè ñ 16,46% íà âòîðèÿ ÷àñ ñëåäïðèåìà, êîåòî ïðåäñòàâëÿâà åäèí î÷àêâàí ìåòàáîëèòåíîòãîâîð ñïðÿìî òîçè ñòàíäàðòåí õëÿá (9), ïðèãîòâåí îòïî-ðàôèíèðàíî áðàøíî áåç ôèáðè (Ôèã.2).

Ôèã.2. Íèâà íà èìóíîðåàêòèâåí èíñóëèí (ÈÐÈ/) ïðè ïàöèåíòèñ ïðåäèàáåò è íåèíñóëèíîçàâèñèì äèàáåò ïðåäè è ñëåäêîíñóìàöèÿ íà õëÿá „Äåà” è ïðè êîíòðîëíà ãðóïà ïàöèåíòèñ ïðåäèàáåò ïðåäè è ñëåä ïðèåì íà õëÿá „Äîáðóäæà”.

ËåãåíäàÏðåäèàáåò– ïàöèåíòè ñ ïðåäèàáåòÍÈÇÇÄ– ïàöèåíòè ñ íåèíñóëèíîçàâèñèì çàõàðåí äèàáåòÊîíòðîëà – ïàöèåíòè ñ ïðåäèàáåò

Fig.1. Blood sugar levels in patients with prediabetes, non-insulin dependent and insulin dependent diabetes mellitusbefore and after intake of „Dea” bread and in control groupwith prediabetes before and after intake of “Dobrudja” bread.

LegendPrediabetes - individuals with prediabetesNIDDM - patients with non-insulin dependent diabetesmellitusIDDM - patients with insulin dependent diabetes mellitusControl group - Control group patients with prediabetes

These results show significant presence of low glycemicindex of the new bread, lack of significant increase inglucose level and even improvement of the hyperglycemiaafter the bread intake. Changes in glycemia of the controlpatients tested with Dobrudzha bread showed increasein the glucose level on average with 0,95 mmol/l or with16,46% at the second hour after the intake, which presentsan expected metabolic answer versus this standard bread(9), prepared by more refined flour without fiber (Fig. 2)

Fig. 2. Levels of immunoreactive insulin (IRI) in patientswith prediabetes and non-insulin dependent diabetesmellitus before and after intake of „Dea” bread and incontrol group before and after intake of “Dobrudja” bread

LegendPrediabetes -patients with prediabetesNIDDM - patients with non-insulin dependent diabetesmellitusControl group - patients with prediabetes



Ðàçëè÷íè ïî ñòåïåí, íî åäíîïîñî÷íè ñà è ïðîìåíèòå âèíñóëèíåìèÿòà è èíñóëèíîâàòà ðåçèñòåíòíîñò ïðèïàöèåíòèòå ñ ïðåäèàáåò è íåèíñóëèíîçàâèñèì äèàáåò âóñëîâèÿòà íà òåñòà. Âúïðåêè ÷å èíñóëèíåìèÿòà îñòàâàâèñîêà, íà âòîðèÿ ÷àñ îò ïðèåìà íà õëÿáà ñå ðåãèñòðèðàòåíäåíöèÿ êúì íåéíîòî ïîíèæàâàíå, êàêòî è èçâåñòíîíàìàëÿâàíå íà èíñóëèíîâàòà ðåçèñòåíòíîñò, êîåòî ñúùî åáëàãîïðèÿòåí ìåòàáîëèòåí åôåêò (ôèã.3). Íàé-âåðîÿòíîòåçè ðåçóëòàòè ñå äúëæàò íà îïòèìèçèðàíèÿ ñúñòàâ íà„Äåà”, â êîéòî ñà âêëþ÷åíè äîñòàòú÷íî êà÷åñòâåíè ôèáðèè áàâíîóñâîÿâàùè ñå âúãëåõèäðàòè (10).

Ôèã.3. Èíäåêñ íà èíñóëèíîâà ðåçèñòåíòíîñò (ÍÎÌÀ –ÈÐ) ïðèïàöèåíòè ñ ïðåäèàáåò è íåèíñóëèíîçàâèñèì äèàáåò ñëåäêîíñóìàöèÿ íà õëÿá „Äåà” è ïðè êîíòðîëíà ãðóïà,ïðèåìàëà õëÿá „Äîáðóäæà”.

ËåãåíäàÏðåäèàáåò– ïàöèåíòè ñ ïðåäèàáåòÍÈÇÇÄ– ïàöèåíòè ñ íåèíñóëèíîçàâèñèì çàõàðåí äèàáåòÊîíòðîëà – ïàöèåíòè ñ ïðåäèàáåò

Ïðîñëåäÿâàíåòî íà ëèïèäíèòå ïîêàçàòåëè â óñëîâèÿòàòåñòà ïîêàçà, ÷å â íèâîòî íà õîëåñòåðîëåìèÿòà íå ñåíàáëþäàâàò çíà÷èìè ïðîìåíè ïðè âñè÷êè ãðóïè, äîêàòîñåðóìíèòå òðèãëèöåðèäè ñå ïîíèæàâàò çíà÷èìî ñ 0,35mmol/l èëè ñ 15,90% ïðè ïðåäèàáåò è ñ 0,4 mmol/l èëè ñ20,83% ïðè èíñóëèíîçàâèñèì äèàáåò. Îáðàòíî, â ãðóïàòàíà êîíòðîëèòå, ïðèåìàëè „Äîáðóäæà”, ñå óñòàíîâÿâàïîâèøåíèå íà ñåðóìíèòå òðèãëèöåðèäè ñð. ñ 0,38 mmol/lèëè ñ 23,89%, âåðîÿòíî â ñúîòâåòñòâèå ñ ïîêà÷âàíåòî íàêðúâíàòà çàõàð è èíñóëèíîâàòà ðåçèñòåíòíîñò íà âòîðèÿ÷àñ (Ôèã.4).

Different by their degree, but in the same direction arethe changes in the insulinemia and insulin resistance inpatients with prediabetes and non-insulin dependentdiabetes under the test conditions. Although theinsulinemia remains high, a tendency to its decrease wasregistered at the second hour after the bread intake aswell as certain reduction of the insulin resistance, whichis also a beneficial metabolic effect (Fig.3). Most likelythese results are due to the optimized composition of theDea bread, in which sufficient qualitative fiber and low-digestible carbohydrates were included (10).

Fig. 3. Index of insulin resistance (HOMA-IR) in patientswith prediabetes and non-insulin dependent diabetesmellitus before and after intake of „Dea” bread and incontrol group before and after intake of “Dobrudja” bread.

LegendPrediabetes -patients with prediabetesNIDDM - patients with non-insulin dependent diabetesmellitusControl group - patients with prediabetes

Tracking out the lipid indicators under the test conditionsshowed that no significant changes were observed in allgroups in the cholesterolemia level, while the serumtriglycerides were decreased significantly with 0,35 mmol/l or with 15,90% in prediabetes and with 0,4 mmol/l orwith 20,83% in insulindependent diabetes. On thecontrary, in the group of controls taken “Dobrudzha”bread an increase in the serum triglycerides wasestablished on average with 0,38 mmol/l or with 23,89%,probably in conformity with the elevation of glucose leveland insulin resistance at the second hour (Fig. 4).



Ôèã.4. Íèâà íà îáù õîëåñòåðîë è òðèãëèöåðèäè (mmol/l) âêðúâåí ñåðóì ïðè ïàöèåíòè ñ ïðåäèàáåò, íåèíñóëèíî-çàâèñèì è èíñóëèíîçàâèñèì äèàáåò ïðåäè è ñëåäïðèåì íà õëÿá „Äåà” è ïðè êîíòðîëíà ãðóïà, ïðèåìàëàõëÿá „Äîáðóäæà”

ËåãåíäàÏðåäèàáåò – ïàöèåíòè ñ ïðåäèàáåòÍÈÇÇÄ – ïàöèåíòè ñ íåèíñóëèíîçàâèñèì çàõàðåí äèàáåòÈÇÇÄ - ïàöèåíòè ñ èíñóëèíîçàâèñèì çàõàðåí äèàáåòÊîíòðîëà - ïàöèåíòè ñ ïðåäèàáåò

Õëÿáúò ïðèíàäëåæè êúì ãðóïàòà íà âúãëåõèäðàòíèòåõðàíè, êîèòî ïî ïðàâèëî íàòîâàðâàò êîíòðîëà íàêðúâíàòà çàõàð è çàòîâà âèíàãè â äèåòàòà íà õîðàòà ñäèàáåò ñòðîãî ñå îïðåäåëÿ äîïóñòèìîòî êîëè÷åñòâî èâèäúò íà ïðèåìàíèòå âúãëåõèäðàòè (11). Àïðîáèðàíèÿòõëÿá „Äåà” ïîêàçà îïòèìàëåí ìåòàáîëèòåí îòãîâîð ïðèïàöèåíòè ñ äèàáåò â óñëîâèÿòà íà ãîðåïîñî÷åíîòîåäíîêðàòíî êëèíè÷íî íàáëþäåíèå.

Ïî÷òè âñè÷êè ïàöèåíòè, ó÷àñòâàùè â êëèíè÷íèÿåêñïåðèìåíò, îäîáðÿâàò âêóñà íà äåãóñòèðàíèÿ õëÿá,êàòî ñàìî 5,41% íå ãî îäîáðÿâàò, à 8,11% íå ãîîäîáðÿâàò ìíîãî (ôèã.5). Âúíøíèÿò âèä ñå âúçïðèåìàèçöÿëî îò 81,09% è íå ìíîãî – îò 18,91% . Ïðèåìúò íàõëÿáà íå å ñúïðîâîäåí îò íåæåëàíè åôåêòè ïðè ïî÷òèâñè÷êè ïàöèåíòè – 94,59% è ñàìî ïðè äâàìà ïàöèåíòè/5,41%/ ñà íàáëþäàâàíè ëåêè ãîðíîäèñïåïòè÷íèîïëàêâàíèÿ íà ôîíà íà íàëè÷åí è íåëåêóâàí õðîíè÷åíãàñòðîäóîäåíèò, âåðîÿòíî âúâ âðúçêà ñ ïîâèøåíîòîñúäúðæàíèå íà ôèáðè â õëÿáà. Ñëåä ïðîâåäåíèÿêëèíè÷åí òåñò çíà÷èòåëíà ÷àñò îò ïàöèåíòèòå – 26(70,27%) èçðàçèõà ãîòîâíîñò äà êîíñóìèðàò ðåäîâíîõëÿá „Äåà”, 9 (24,32%) - ïîíÿêîãà è ñàìî äâàìà (5,41%)íå èçðàçÿâàò æåëàíèå äà ãî âêëþ÷àò â äèåòè÷íèÿ ñèðåæèì.

Fig. 4. Levels of total holesterol and triglycerides (mmol/l) inblood serum of patients with prediabetes, non-insulindependent and insulin dependent diabetes mellitusbefore and after intake of „Dea” bread and in controlgroup before and after intake of “Dobrudja” bread

LegendPrediabetes - individuals with prediabetesNIDDM - patients with non-insulin dependent diabetes mellitusIDDM - patients with insulin dependent diabetes mellitusControl group - Control group patients with prediabetes

Bread belongs to the group of the carbohydrate foods,which as a rule burden the control of glucose level; thusin the diet of people with diabetes the recommendedquantity and type of carbohydrates taken are strictlydefined (11). The approbated Dea bread showed anoptimal metabolic answer in diabetic patients under theconditions of the above-mentioned single clinical survey.

Almost all of the patients that participated in the clinicaltrial approve the taste of the degustated bread, as only5,41% (2) do not like it as a whole, and 8,11% (3) do notaccept it too much (Fig.5). The outward appearance istotally approved by 81,09% (30) and to a certain degree– by 18,91% (7). The intake of bread is not followed byundesired effects in almost all patients – 94,59% (35)and only in 2 patients (5,41%) mild upper dyspepticcomplains were observed at the background of availableand untreated chronic gadtroduodenite, most likely inrelation to the elevated fiber content in bread. Afterconducting the clinical test a significant part of patients–70,27% (26) showed willingness to consume Dea breadon a regular basis, 24,32% (9) - wanted to eat breadsometimes and only 5,41% (2) do not like to have includedthe bread in their dietary regimen.



Ôèã.5. Äåãóñòàöèîííà îöåíêà íà õëÿá „Äåà”.

Â îòäåëåíèåòî ïî äèàáåò íà Óíèâåðñèòåòñêàòà áîëíèöàïî äåòñêè áîëåñòè â Ñîôèÿ å ïðîâåäåíà êëèíè÷íààïðîáàöèÿ íà íîâèÿ õëÿá ïðè 6 õîñïèòàëèçèðàíè äåöà ñäèàáåò òèï 1 íà èíòåíçèôèöèðàíî èíñóëèíîâî ëå÷åíèå.Ïúðâèÿ äåí íà îáÿä å ñåðâèðàí ñòàíäàðòåí õëÿá„Äîáðóäæà”, à íà ñëåäâàùèÿ äåí ñúùîòî êîëè÷åñòâî õëÿáå çàìåíåíî ñ åêñïåðèìåíòèðàíèÿ õëÿá „Äåà”, êàòîîáåäíàòà äîçà èíñóëèí îñòàâà íåïðîìåíåíà ïðåç äâàòàäíè. Îïðåäåëåíèòå õëåáíè åäèíèöè ïðè îòäåëíèòå äåöà ñàðàçëè÷íè ñïîðåä òåõíèòå ìåòàáîëèòíè íóæäè, íî åäíàêâèçà äâàòà äíè ïðè âñÿêî äåòå, êàêòî è ïî îòíîøåíèå íàãëèêåìè÷íèÿ èíäåêñ – ïúðâèÿ äåí îáÿä - çåëåí ãðàõ ñïèëåøêî, ñúîòâåòíî íà âòîðèÿ äåí - ïðÿñíî çåëå ñ ïèëåøêî,ñàëàòà äîìàòè è êðàñòàâèöè è äåñåðò ÿáúëêà è â äâàòà äíè(áåç ñóïà). Ñúîòâåòíî ïðè 2 äåöà å íàçíà÷åí 100 ã õëÿá âîáåäíîòî äèåòè÷íî ìåíþ, ïðè 2 – 75 ã, ïðè 1 – 50 ã è ïðè1 – 40 ã. Äåöàòà íå ñà èìàëè ôèçè÷åñêà àêòèâíîñò ïðåäè èïî âðåìå íà îáåäíèÿ èíòåðâàë, ñ êîåòî å èçêëþ÷åíîíåéíîòî âëèÿíèå âúðõó íèâîòî íà êðúâíàòà çàõàð.Êðúâíàòà çàõàð å îïðåäåëåíà ïî ñòàíäàðòíèÿ ìåòîä íàãëàäíî ïðåäè ïîñòàâÿíå íà îáåäíèÿ èíñóëèí è 2 ÷àñà ñëåäïðèêëþ÷âàíå íà îáÿäà. Íà Òàáë.6. ñà ïðåäñòàâåíèèíäèâèäóàëíèòå ðåçóëòàòè íà äåöàòà.

Òàáëèöà 6. Èíäèâèäóàëíè íèâà íà êðúâíàòà çàõàð ïðåäè è 2÷àñà ñëåä îáåäåí ïðèåì íà õëÿá „Äåà” è õëÿá „Äîáðóäæà”ïðè äåöà ñ äèàáåò òèï 1(n =6).

Ïðè âñè÷êè äåöà å íàëèöå ïîâèøåíèå íà êðúâíàòà çàõàðñëåä ïðèåì íà õëÿá „Äîáðóäæà” îò 0,1 äî 1,0 ììîë/ë,äîêàòî ñëåä ïðèåì íà íîâèÿ õëÿá „Äåà” îáðàòíî –

Fig. 5. Taste assessment of “Dea” bread.

In the Department of diabetes at the University PediatricHospital in Sofia a clinical approbation of the new breadwas conducted by 6 hospitalized children with type 1diabetes at intensifying insulin treatment. The first day atlunch a standard bread “Dobrudzha” was served, and onthe following day the same amount of bread was replacedby the experimental “Dea” bread as the noon insulin doseremains unchanged during both days. The determined breadunits in different children are distinguished according totheir metabolic needs, but equal for both days for eachchild as in relation to the glycemic index – first day forlunch at noon – green peas with chicken, respectively onthe second day – cabbage with chicken, tomato andcucumber salad and an apple as dessert and in both days(without soup). Respectively 2 children were given 100 g ofbread in the lunch diet menu, 2 children received 75 g, 1child received 50 g and 1 child was given 40 g. Children didnot have any physical activity before and during the lunchinterval, with which its effect on the glucose level wasexcluded. The glucose level was determined by a standardmethod on an empty stomach before the noon insulininjection and 2 hours after completing the lunch. Theindividual results of the children are presented in Table 6.

Table 6. Individual glucose level before and 2 hours afterlunch intake of bread “Dea” and bread “Dobrudzha” inchildren with type 1 diabetes (n =6).

In all children an increase in the glucose level wasestablished after the intake of Dobrudzha bread from 0,1to 1,0 mmol/l, while after the intake of the new Dea bread



íàáëþäàâà ñå íàìàëåíèå íà êðúâíàòà ãëþêîçà îò 0,1 äî0,6 ììîë/ë. Ìàêàð ÷å íÿìà ñòàòèñòè÷åñêè çíà÷èìàðàçëèêà â íàìàëåíèåòî íà ãëèêåìèÿòà, ïîðàäè ìàëêèÿáðîé ïàöèåíòè, íàëèöå å áåçñïîðíà òåíäåíöèÿ çàñíèæåíèå íà ãëèêåìèÿòà ñëåä ïðèåì íà íîâèÿ õëÿá„Äåà”.

Âñè÷êè äåöà ïðèåìàò âêóñîâî ìíîãî äîáðå íîâèÿ õëÿá èíå ñúîáùàâàò çà ðàçëèêà â çàñèòåíîñòòà è äåôåêàöèÿòà.

Äåãóñòàöèÿòà íà íîâèÿ õëÿá, ïðîâåäåíà ïðè äðóãà ãðóïàîò 15 äåöà ñ äèàáåò, ïîòâúðäè ìíîãî äîáðàäåãóñòàöèîííà îöåíêà è âúçïðèåì÷èâîñò.

Ãîðåïîñî÷åíèòå ðåçóëòàòè îò åäíîêðàòíîòî êëèíè÷íîíàáëþäåíèå íè äàâàò îñíîâàíèå çà ïðîâåæäàíå íàêëèíè÷íî ïðîó÷âàíå íà õëÿáà â êîìáèíèðàí äèåòè÷åíðåæèì ïðè äúëãîòðàéíî ïðèëîæåíèå.

Èçâîäè

1. Õèìè÷íèÿò àíàëèç íà íîâèÿ õëÿá „Äåà” óñòàíîâÿâàîïòèìàëíî ñúäúðæàíèå íà ïîëèçàõàðèäíèâúãëåõèäðàòè, âëàêíèíè è äîñòàòú÷íà õðàíèòåëíàñòîéíîñò.

2. Äèåòàòà íå ñå ñïàçâà ïðè ïîâå÷å îò ïîëîâèíàòà îòïàöèåíòèòå ñ äèàáåò è ïðåäèàáåò è òå íå ñà äîñòàòú÷íîîáó÷åíè çà ïðàâèëíèÿ õðàíèòåëåí ðåæèì èíåîáõîäèìèÿ âúãëåõèäðàòåí ïðèåì, âúïðåêè ÷åäèåòîòåðàïèÿòà å îñíîâåí ìåòîä íà ëå÷åíèå.

3. „Äåà”, ïðèåò êàòî åäíîêðàòåí ñóòðåøåí ïðèåì îò 75 ãâ êëèíè÷íè óñëîâèÿ, ïðè ïàöèåíòè ñ ïðåäèàáåò èäèàáåò, îêàçâà çíà÷èìè áëàãîïðèÿòíè ìåòàáîëèòíèåôåêòè âúðõó ïîêàçàòåëèòå íà âúãëåõèäðàòíà èëèïèäíà îáìÿíà.

4. „Äåà”, âêëþ÷åí â îáåäíîòî ìåíþ íà äåöà ñ äèàáåò ïðèêëèíè÷íè óñëîâèÿ, ïîêàçâà äîáðà âúçïðèåì÷èâîñòè ïîíèæàâàù ãëèêåìèÿòà åôåêò.

5. Íîâèÿò õëÿá „Äåà” å ôóíêöèîíàëíà âúãëåõèäðàòíàõðàíà ñ íèñúê ãëèêåìè÷åí èíäåêñ è ìíîãî äîáðàäåãóñòàöèîííà îöåíêà.

Çàêëþ÷åíèå

Íîâèÿò áúëãàðñêè õëÿá „Äåà” ïðèòåæàâàõàðàêòåðèñòèêàòà íà óíèêàëåí òèï õëÿá, êîéòî ñåîòëè÷àâà ñ âèñîêà õðàíèòåëíà ñòîéíîñò, îïòèìàëíîêîëè÷åñòâî ðàçòâîðèìè è íåðàçòâîðèìè âëàêíèíè èíèñúê ãëèêåìè÷åí èíäåêñ. Íåãîâèòå áëàãîïðèÿòíèìåòàáîëèòíè åôåêòè è ìíîãî äîáðà äåãóñòàöèîííàîöåíêà ñà êëèíè÷íî äîêàçàíè. Âúç îñíîâà íà íåãîâèÿñúñòàâ è ñâîéñòâà òîé ñëåäâà äà áúäå âêëþ÷åí â ãðóïàòàíà ôóíêöèîíàëíèòå è çäðàâîñëîâíè õðàíè.”Äåà” ñåïðåïîðú÷âà êàòî ìíîãî ïîäõîäÿù õëÿá çà äèåòè÷íî èïðîôèëàêòè÷íî õðàíåíå ïðè äèàáåò, ïðåäèàáåò,ìåòàáîëèòíè íàðóøåíèÿ è íàäíîðìåíî òåãëî, êàêòî èçà çäðàâîñëîâíî õðàíåíå ïðè âúçðàñòíè è äåöà.

on the contrary – a reduction of the glucose level from0,1 to 0,6 mmol/l wad observed. Although no statisticallysignificant difference was found in the decrease ofglycemia due to the small number of patients, anundoubted tendency is observed for reduction of theglycemia after the intake of the new “Dea” bread.

All children liked the new bread and did not report forany problems with satiation and defecation.

Degustation of the new bread conducted in other groupof 15 diabetic children confirmed the very gooddegustational assessment and susceptibility.

The above-mentioned results from the single clinicalsurvey give us reasons for conducting follow up of clinicalsurvey on the bread in combined dietary regimen at long-term use.

Outcomes

1. Chemical analysis of the new bread “Dea” establishedan optimal amount of polysaccharides, fiber andsufficient nutritional value.

2. The diet was not observed in most of the half ofpatients with diabetes and prediabetes and they werenot trained sufficiently for the proper nutritional dietand necessary carbohydrate intake, although the diettherapy is a main treatment method.

3. Dea bread, received as a single breakfast iïtake of 75g under clinical conditions in patients with diabetesand prediabetes, has significant metabolic effectson the indicators of carbohydrate and lipid exchange.

4. Dea bread, included in the lunch menu of the childrenwith diabetes under clinical conditions, shows a goodsusceptibility and decreasing glycemic effect.

5. The new bread “Dea” is a functional carbohydratefood with low hlycemic index and very gooddegustation assessment.

Conclusion

New Bulgarian bread “Dea” has the characteristics ofunique type of bread, which is distinguished by itsnutritional value, optimal quantity of soluble andinsoluble fiber and low glycemic index. Its beneficialmetabolic effects and very good degustation assessmentare clinically proved. On the basis of its compositionand properties it should be included in the group offunctional and healthy foods. “Dea” bread isrecommended as very suitable bread product for dieteticand preventive nutrition in diabetes, prediabetes,metabolic disorders and overweight, as well ad forhealthy diet in adults and children.



Êíèãîïèñ / References

1. Ïîïîâà Ä., Ìàñëàðñêà Ò.. Êëèíè÷íî ïðèëîæåíèå íà íîâèèíñòàíòíè ïúëíîçúðíåíè õðàíè ïðè îáìåííèçàáîëÿâàíèÿ. Â: Íàóêàòà çà õðàíåíå ïðåä íîâèâúçìîæíîñòè è ïðåäèçâèêàòåëñòâà.Ïîä ðåä.Á.Ïîïîâ.Ñîôèÿ, Áúëãàðñêî äðóæåñòâî ïî õðàíåíå è äèåòåòèêà,2008, 304-306.

2. Foster-Powell K. et al. International table of glycemic indexand glycemic load values:2002. Am.J.Clin.Nutr.,76,2002,5.

3. Valensi, P., Schwarz P., Hall M. et al. Pre-diabetesessential action:a European perspective. DiabetesMetab., 2005, 31, 606-620.

4. Ïîïîâà Ä. Ôóíêöèîíàëíè õðàíè è ìåòàáîëèçúì.Â:Ôóíêöèîíàëíè õðàíè, õðàíèòåëíè äîáàâêè,õðàíèòåëíèòåõíîëîãèè. Ïîä ðåä.Á.Ïîïîâ. Ñîôèÿ,Ôèëâåñò,2006,20-25.

5. ADA. Nutrition recommendations and interventions fordiabetes /position statement/. Diab.care, 30,2007,S48.

6. Beaser R.,. Campbell A. The Joslin guide to diabetes. AFireside book, New York, London, Toronto, Sydney,Simon & Shuster, 2005.

Àäðåñ çà êîðåñïîíäåíöèÿ:

Äîö.ä-ð Äàíèåëà Ïîïîâà, äìÓíèâåðñèòåòñêà áîëíèöà “Öàðèöà Éîàííà-ÈÑÓË”Óë.”Áÿëî ìîðå” ¹8, Ñîôèÿ 1527

Å-mail: [email protected]

7. Brand-Miller J . et al. Low-glycemic index diets inthe management of diabetes: a meta-analysis ofrandomized controlled trials. Diab. care, 26, 2003,2261.

8. Evidence-based nutrition principles andrecommendations for the treatment and prevention ofdiabetes and related disorders.Diab.Care, 2002, 25,148-98

9. Rizkalla S.W. et al. Improved plasma glucosecontrol, whole-body glucose utilization and lipidprofile on a low-glycemic index diet in type 2diabetic men. Diab.care, 2004, 27, 1866.

10. Escott-Stump S. Type I and type II diabetesmellitus. In:Nutrition and diagnosis-related care.Philadelphia,London,Lea&Febiger,1992,279-284.

11. Diet recommended for people with type 1 and type2 diabetes by EASD,ADA and Diabetes UK /2002 -2005/.www.easd.org, www.diabetes.org,www.eufic.org

Address for correspondence:

Assoc. Prof. Daniela Popova, MD, PhDUniversity Hospital Queen Giovanna-ISUL8, Byalo more Street, Sofia 1527 BULGARIA

Å-mail: [email protected]



ÆÅËÅÇÅÍ ÄÅÔÈÖÈÒ È ÆÅËßÇÎ-ÄÅÔÈÖÈÒÍÀ ÀÍÅÌÈß ÏÐÈ ÄÅÖÀ ÎÒ1 ÄÎ 5 ÃÎÄÈÍÈ Â ÃÐÀÄ ÑÎÔÈß(ÁÈÎÕÈÌÈ×ÍÈ ÌÀÐÊÅÐÈ ÍÀÕÐÀÍÈÒÅËÅÍ ÏÐÈÅÌ ÍÀ ÆÅËßÇÎ)

Ëàëêà Ðàíãåëîâà1, Ñòåôêà Ïåòðîâà1,Êàìåí Öà÷åâ2, Áèñåðà Àòàíàñîâà2

1Íàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè2 Ìåäèöèíñêè Ôàêóëòåò, Êàòåäðà ïî êëèíè÷íà

ëàáîðàòîðèÿ è êëèíè÷íà èìóíîëîãèÿ, ÌåäèöèíñêèÓíèâåðñèòåò – Ñîôèÿ

Ðåçþìå

Öåë: Äà ñå îöåíè íàëè÷èåòî íà æåëåçåí äåôèöèò ïðèäåöà îò 1 äî 5 ãîäèíè â ãðàä Ñîôèÿ è íåãîâàòà âðúçêà ñðàñòåæà è çäðàâåòî íà äåöàòà.

Ìåòîäè: Ïðåç 2007 ã. å ïðîâåäåíî òðàíñâåðçàëíî èðåòðîñïåêòèâíî åïèäåìèîëîãè÷íî ïðîó÷âàíå íàõðàíåíåòî è õðàíèòåëíèÿ ñòàòóñ íà ïðåäñòàâèòåëíàèçâàäêà îò 671 äåöà îò 0 äî 5 ãîäèíè â ãð. Ñîôèÿ.Àíåìèÿòà ïðè äåöàòà å îöåíåíà ÷ðåç èçñëåäâàíå íàõåìîãëîáèí â ïåðèôåðíà êðúâ. Íà ïîäèçâàäêà îò 189äåöà îò 1 äî 5 ãîäèíè ñà èçñëåäâàíè ñëåäíèòåïîêàçàòåëè: 1. îöåíêà íà ñòàòóñà íà æåëÿçî (ñåðóìíîFe,TIBC, ñåðóìåí Ferritin, sTf; ïúëíà êðúâíà êàðòèíà); 2.Ñ-ðåàêòèâåí ïðîòåèí (CRP); 3. ñåðóìíè íèâà íà vitaminA, Zn, Se. Íà âñÿêî äåòå ïî ñòàíäàðòíà ìåòîäèêà ñàèçìåðåíè òåëåñíà ìàñà è ðúñò. Îöåíêàòà íàõðàíèòåëíèÿ ñòàòóñ å èçâúðøåíà íà áàçààíòðîïîìåòðè÷íè èíäåêñè ðúñò-çà-âúçðàñò, òåãëî-çà-âúçðàñò, òåãëî-çà-ðúñò, èíäåêñ íà òåëåñíà ìàñà-çà-âúçðàñò.

Ðåçóëòàòè: ×åñòîòàòà íà àíåìèÿ ïðè èçñëåäâàíèòåäåöà îò 1 äî 5 ãîäèíè å 5,29%. Ñúãëàñíî êðèòåðèèòå íàÑÇÎ ÷åñòîòàòà íà àíåìèÿòà å ñ íèñêà ñòåïåí íàçíà÷åíèå çà îáùåñòâåíîòî çäðàâå.

Ðàçïðîñòðàíåíèåòî íà æåëåçåí äåôèöèò (ÆÄ) ïðèäåöàòà îò 1 äî 5 ãîäèíè å 20,1% (Ïðåëàòåíòíèÿò ÆÄ-6,35%, Ëàòåíòíèÿò ÆÄ-8,47% è 5,29% -Æåëÿçîäåôèöèòíà àíåìèÿ (ÆÄÀ).

ÆÄ ïðè èçñëåäâàíèòå äåöà å ñòàòèñòè÷åñêè çíà÷èìîñâúðçàí ñ ïðèåì íà ñóïëåìåíòè, ñúäúðæàùè âèòàìèíèè ìèíåðàëè è çíà÷èì ïðèåì íà æåëÿçî îò æèâîòèíñêèïðîèçõîä. Äâà ïúòè å ïî-âèñîêà ÷åñòîòà íà ïîäíîðìåíîòåãëî è ïîâèøåíà çàáîëåâàåìîñò îò îñòðèðåñïèðàòîðíè çàáîëÿâàíèÿ ïðè äåöàòà ñ ÆÄ, ñïðÿìîòåçè áåç äåôèöèò.

IRON DEFICIENCY AND IRONDEFICIENCY ANEMIA IN CHILDREN 1TO 5 YEARS IN SOFIA(BIOCHEMICAL MARKERS OFDIETARY INTAKE OF IRON)

Lalka Rangelova1, Stefka Petrova1,Kamen Tzatchev2, Bisera Atanasova2

1Department Public Health Nutrition, NationalCentre of Public Health and Analyses

2 Medical Faculty, Department of Clinical Laboratoryand Clinical Immunology, Medical University - Sofia

Abstract

Background: Iron deficiency is widespread worldwide,affecting particularly children. The aim of the study is toassess the prevalence of iron deficiency in children aged1 to 5 years in Sofia and its relation to growth andhealth of children.

Methods: In 2007 a cross-sectional and retrospectiveepidemiological study on nutrition and nutritional sta-tus of a representative sample of 671 children aged 0 to5 years in Sofia was conducted. Anemia in children hasbeen assessed by measurement of hemoglobin in periph-eral blood. In a sub-sample of 189 children aged 1 to 5years the following indicators have been investigated:1.evaluation of iron status (serum Fe, TIBC, serum Fer-ritin, sTfR; complete blood count), 2. C-reactive protein(CRP); 3.serum levels of vitamin A, Zn, Se. Using a stan-dard methodology body weight and height of every childhave been measured. The assessment of nutritional sta-tus has been carried out on the bases of anthropometricindices: height-for-age, weight-for-age, weight-for-height and body mass index-for-age.

Results: The prevalence of anemia in the studied chil-dren aged 1 to 5 years is 5.29%. According to WHOcriteria, the incidence of anemia is of low public healthsignificance.

Iron deficiency (ID) prevalence in children aged 1 to 5years was 20.1%. Pre-latent iron deficiency is 6.35%,latent iron deficiency - 8.47% and iron deficiency ane-mia (IDA) - 5.29%.

Iron deficiency in the studied children was significantlyassociated with the intake of supplements containingvitamins and minerals and the significant intake of hemeiron. The prevalence of underweight and of acute respi-ratory diseases in children with ID has been twice ashigh versus those without ID.



Çàêëþ÷åíèå: Äåöàòà îò 1 äî 5-ãîäèøíà âúçðàñò â ãðàäÑîôèÿ ñà ðèñêîâà ïîïóëàöèîííà ãðóïà çà ÆÄ è ÆÄÀ.Îñèãóðåíè ñà íàäåæäíè äàííè çà ÷åñòîòàòà, òåæåñòòàè íåãàòèâíîòî âëèÿíèå íà ÆÄ âúðõó çäðàâåòî è ðàñòåæàíà äåöàòà îò ãðàä Ñîôèÿ - áàçà çà åôåêòèâíàõðàíèòåëíà ïîëèòèêà.

Êëþ÷îâè äóìè: æåëåçåí äåôèöèò, äåöà îò 1 äî 5ãîäèíè

Âúâåäåíèå

Æåëåçíèÿò äåôèöèò (ÆÄ) å øèðîêîðàçïðîñòðàíåí â öåëèÿñâÿò. Òîé çàñÿãà èçêëþ÷èòåëíî äåöàòà è áðåìåííèòå æåíè âðàçâèâàùèòå ñå ñòðàíè, êúäåòî 40-45% îò äåöàòà íà âúçðàñòîò 0 äî 5 ãîäèíè ñòðàäàò îò æåëÿçîäåôèöèòíà àíåìèÿ (ÆÄÀ)(1; 2).

Æåëåçíèÿò äåôèöèò ñå õàðàêòåðèçèðà ñ íåäîñòèã íà æåëÿçîçà ïîääúðæàíå íà íîðìàëíèòå ôèçèîëîãè÷íè ôóíêöèè íàòúêàíèòå - êðúâ, ìîçúê, ìóñêóëè. Ïîñëåäíèÿò ñòàäèé íà ÆÄå ñâúðçàí ñ ïîÿâàòà íà ÆÄÀ (2; 3; 4). Æåëÿçîäåôèöèòíàòààíåìèÿ ñå õàðàêòåðèçèðà ñ íèñúê õåìîãëîáèí è õåìàòîêðèò,ñ ïðîìåíè â åðèòðîöèòíàòà öèòîëîãèÿ è ìîðôîëîãèÿ(ìèêðîöèòîçà è õèïîõðîìèÿ), íàðóøåíèÿ íà êèñëîðîäíèòåòðàíñïîðòíè ìåõàíèçìè (5; 6). Ïðè æåëÿçîäåôèöèòíàåðèòðîïîåçà èíäèâèäóàëíàòà êîíöåíòðàöèÿ íà õåìîãëîáèíâ êðúâòà ñïàäà ïîä äîëíàòà ðåôåðåíòíà ãðàíèöà çàïîïóëàöèÿòà îò ñúîòâåòíàòà âúçðàñò è ïîë, êîÿòî æèâåå ïðèñúùàòà íàäìîðñêà âèñî÷èíà (2).

Îñíîâíè ïðè÷èíè çà ÆÄ ñà èç÷åðïâàíå íà æåëåçíèòå çàïàñèîò ðàæäàíåòî, íàìàëÿâàíå íà ïðèåìà íà æåëÿçî, óâåëè÷àâàíåçàãóáèòå íà îðãàíè÷íî æåëÿçî, íàìàëÿâàíå íà àáñîðáöèÿòàè óâåëè÷àâàíå íà ïîòðåáíîñòè îò åëåìåíòà (7).

Àäåêâàòíèÿò ïðèåì íà æåëÿçî îò áðåìåííàòà æåíà, îñîáåíîïðåç òðåòèÿ òðèìåñòúð íà áðåìåííîñòòà, îñèãóðÿâàäîñòàòú÷íî êîëè÷åñòâî æåëÿçî çà ðàçâèòèå íà ïëîäà (3).Çàïàñèòå îò æåëÿçî íà íîâîðîäåíîòî ñå âëèÿÿò ñúùåñòâåíîîò êîëè÷åñòâîòî êðúâ, êîåòî ïðåìèíàâà îò ïëàöåíòàòàíåïîñðåäñòâåíî ñëåä ðàæäàíåòî, ìàëêî ïðåäè óìáèëèêàëíàòàâåíà äà áúäå ïðåêúñíàòà (8; 9).

Çäðàâèòå, äîíîñåíè ñ íîðìàëíî òåãëî ïðè ðàæäàíåòî, äåöàèìàò äîñòàòú÷íî çàïàñè îò æåëÿçî, êîèòî ìîãàò äà îñèãóðÿòðàñòåæà ïðåç ïúðâèòå 4-6 ìåñåöà îò æèâîòà (10; 11). Ñëåäòîçè ïåðèîä íåîáõîäèìîòî æåëÿçî ñå íàáàâÿ îò çàõðàíâàùèòåõðàíè.

Êúì íàñòîÿùèÿ ìîìåíò ñà íàëèöå îãðàíè÷åíè äàííè çà÷åñòîòàòà íà ÆÄ ïðè äåöàòà îò 0 äî 5 ãîäèíè â Áúëãàðèÿ. Ïðèïðîó÷âàíå íà õðàíåíåòî ïðåç 1987 ãîäèíà å óñòàíîâåíà ÆÄÀîò 9,7%, 11,8% è 5,2 %, ñúîòâåòíî çà äåöàòà íà âúçðàñò 1-2, 2-3 è 4-6 ãîäèíè (12). Ïðè ïðîâåäåíî ïðåç 1999 ã. íàöèîíàëíîïðîó÷âàíå íà õðàíåíåòî íà èíñòèòóöèîíàëèçèðàíè (îòäîìîâå “Ìàéêà è äåòå”) êúðìà÷åòà è äåöà äî 3-ãîäèøíà âúçðàñòå óñòàíîâåíî øèðîêî ðàçïðîñòðàíåíèå íà àíåìèÿ - 32,3%, êàòîïðè äåöàòà íà âúçðàñò 6-12 ìåñåöà àíåìèÿòà å íàé-âèñîêà -49,5% (13). Ïðè èçñëåäâàíå ïðåç 2004 ã, âêëþ÷âàùî

Conclusion: Children aged 1 to 5 years in Sofia are arisk population group as to ID and IDA. Reliable dataon the prevalence, magnitude and negative impact of IDon the health and growth of children from Sofia havebeen provided as a basis for an effective nutritionalpolicy.

Key words: iron deficiency, children aged 1 to 5years

Introduction

Iron deficiency (ID) is widespread worldwide, affectingparticularly children and pregnant women indeveloping countries where 40-45% of children aged 0to 5 years suffer from iron deficiency anemia (IDA) (1,2).

Iron deficiency is characterized by not sufficient ironto maintain normal physiological functions of tissues- blood, brain, muscles. The last stage of ID isassociated with the occurrence of IDA (2, 3, 4). Iron-deficiency anemia is characterized by low hemoglobin(Hb) and hematocrit , changes in erythrocytemorphology and cytology (microcytosis andhypochromia), impaired oxygen transport mechanisms(5, 6). In iron deficiency erythropoiesis, the bloodconcentration of Hb falls below the lower referencelimit for the population of corresponding age and sex,living at the same altitude (2).

The main reasons for ID are depletion of iron stores atbirth, decrease of dietary iron intake, increase oforganic iron losses, reduced absorption and increasedrequirements of iron in the body (7).

Adequate dietary intake of iron in pregnant women,especially during the third trimester, provides sufficientiron for fetal development (3). Iron stores in thenewborn are affected significantly by the amount ofblood that passes from the placenta immediately afterbirth, shortly before the umbilical vein is cut off (8, 9).

Healthy, full-term, normal birth weight children havesufficient stores of iron, securing growth in the first 4-6 months of life (10, 11). After this period the necessaryiron comes from complementary foods.

There are limited data on the prevalence of ID inchildren aged 0 to 5 years in Bulgaria at present. In anutritional study in 1987 IDA has been found in 9.7%,11.8% and 5.2% respectively for children aged 1-2, 2-3and 4-6 years (12). A 1999 national nutrition survey ofinstitutionalized (of “Mother and Child” homes) infantsand children under 3 years of age found a highprevalence of anemia - 32.3%, the highest - 49.5%-being in children aged 6-12 months (13). A 2004 studyinvolving evaluation of hemoglobin in 116 childrenaged 1 to 3 years has found a 23.3 % prevalence ofanemia (14).



îïðåäåëÿíå íà õåìîãëîáèí ïðè 116 äåöà îò 1 äî 3-ãîäèøíàâúçðàñò , å óñòàíîâåíà 23,3% ÷åñòîòà íà àíåìèÿòà (14).

Öåëòà íà íàñòîÿùåòî ïðîó÷âàíå å äà ñå îöåíè íàëè÷èåòîíà ÆÄ ïðè äåöà îò 1 äî 5 ãîäèíè â ãðàä Ñîôèÿ è íåãîâàòàâðúçêà ñ ðàñòåæà è çäðàâåòî íà äåöàòà, êàòî ÷àñò îòîáøèðíî èçñëåäâàíå íà õðàíåíåòî è õðàíèòåëíèÿ ñòàòóñíà äåöà äî 5-ãîäèøíà âúçðàñò îò ñòîëèöàòà.

Ìàòåðèàë è ìåòîäè

Ïðîâåäåíî å òðàíñâåðçàëíî è ðåòðîñïåêòèâíî ïðîó÷âàíå íàõðàíåíåòî, õðàíèòåëíèÿ ñòàòóñ è ðèñêîâè ôàêòîðè, ñâúðçàíèñ òÿõ íà ïðåäñòàâèòåëíà èçâàäêà îò 671 äåöà îò 0 äî 5 ãîäèíè âãðàä Ñîôèÿ. Îáåìúò íà èçâàäêàòà (ìèíèìàëåí áðîé îò 289äåöà âúâ âñÿêà ãðóïà) å îïðåäåëåí ïðè ñïàçâàíå íà ñëåäíèòåóñëîâèÿ è ñòîéíîñòè: Î÷àêâàíà ÷åñòîòà (Anticipatedpopulation proportion) íà õàðàêòåðèñòèêàòà (çàáîëÿâàíå èëèñúñòîÿíèå) â ïîïóëàöèÿòà – 25%.

Äîâåðèòåëíî íèâî (Confidence level) – 95%; Àáñîëþòíàïðåöèçíîñò (Absolute precision) – 0,05 (èëè 5%).

Ïðèëîæåíà å äâóñòåïåííà ñëó÷àéíà èçâàäêà. Ïî ìåòîäà íàñëó÷àéíèÿ ïîäáîð îò ñïèñúêà íà âñè÷êè îáùîïðàêòèêóâàùèëåêàðè â Ñîôèÿ ñà èçáðàíè 43 îáùîïðàêòèêóâàùè ëåêàðè,êîèòî ïîïàäíàõà â 9 ðàéîíà íà ñòîëèöàòà. Îò òÿõ, 39 ñåñúãëàñÿâàò äà ó÷àñòâàò â ïðîó÷âàíåòî (91% response rate). Îòñïèñúöèòå ñ ïàöèåíòè íà ëåêàðèòå ÷ðåç ñëó÷àåí ñèñòåìàòè÷åíïîäáîð (âñÿêî òðåòî äåòå îò ñïèñúêà) ñà âêëþ÷åíè äåöà, êîèòîîòãîâàðÿò íà èçèñêâàíèÿ ïî îòíîøåíèå íà âúçðàñò, ïîë èçäðàâåí ñòàòóñ.

Ïðîó÷âàíåòî (èíòåðâþ íà ìàéêèòå, èçìåðâàíèÿ íà äåöàòà) åîñúùåñòâåíî â êàáèíåòèòå íà ëè÷íèòå ëåêàðè íà äåöàòà.Ëè÷íèòå ëåêàðè ïîêàíâàõà ìàéêèòå çà ó÷àñòèå â ïðîó÷âàíåòîè ãè èíôîðìèðàõà äåòàéëíî çà ïðîó÷âàíåòî, çà ñâúðçàíèòå ñíåãî íåóäîáñòâà, âúçìîæíè ðèñêîâå è ïîëçè. Äåöàòà ñàâêëþ÷âàíè â ïðîó÷âàíåòî ñëåä ïîäïèñâàíå îò ìàéêèòå íàïèñìåíà äåêëàðàöèÿ çà ñúãëàñèå. Ïîâå÷åòî îò ïîêàíåíèòåìàéêè (604) ñå ñúãëàñèõà äà ó÷àñòâàò â èçñëåäâàíåòî ñ äåöàòàñè (90 % response rate).

Â ïðîó÷âàíåòî íå ñà âêëþ÷âàíè äåöà ñúñ ñëåäíèòå çäðàâíèïðîáëåìè: âðîäåíè ìàëôîðìàöèè è òåæêè õðîíè÷íèçàáîëÿâàíèÿ, êîèòî ïîâëèÿâàò õðàíåíåòî è õðàíèòåëíèÿ ñòàòóñíà äåöàòà (âðîäåíè ñúðäå÷íè ïîðîöè, áúáðå÷íà íåäîñòàòú-÷íîñò, äèàáåò è äð.), à ñúùî è äåöà, êîèòî ñà ïðåêàðàëè îñòðèèíôåêöèîçíè è äèàðè÷íè çàáîëÿâàíèÿ äî 1 ìåñåö ïðåäèîïðåäåëåíîòî èçñëåäâàíå, äåöà ñ äîêàçàíà àíåìèÿ, íåñâúðçàíàñ õðàíåíåòî.

Ïðîó÷âàíåòî è èçïîëçâàíèòå ìåòîäè è àíêåòíè êàðòè,èíôîðìàöèÿ çà ðîäèòåëèòå è äåêëàðàöèÿ çà èíôîðìèðàíîñúãëàñèå çà ó÷àñòèå â èçñëåäâàíåòî, ñà ïðåäñòàâåíè ïðåäÊîìèñèÿ ïî ìåäèöèíñêà åòèêà êúì ÍÖÎÎÇ (ñåãà ÍÖÎÇÀ) èñà îäîáðåíè ñ ïðîòîêîë ¹3 îò 29.01.2007 ãîäèíà.

Çà ñúáèðàíå íà íåîáõîäèìàòà èíôîðìàöèÿ ïî ïðîó÷âàíåòîñà ðàçðàáîòåíè 7 àíêåòíè êàðòè, ñ âàðèàíò çà èçñëåäâàíåíà êúðìà÷åòà îò 0 äî 12 ìåñåöà è ñ âàðèàíò çà èçñëåäâàíå íàäåöà îò 1 äî 5 ãîäèíè. Äàííèòå ñà ïîëó÷åíè ÷ðåç àêòèâíî

The purpose of this study was to assess theprevalence of ID in children aged 1 to 5 years in Sofiaand its relation to growth and health of children aspart of an extensive study on nutrition and nutritionalstatus of children less than 5 years of age from Sofia.

Materials and Methods

A cross-sectional and retrospective study has beenconducted on nutrition, nutritional status and relatedrisk factors in a representative sample of 671 childrenaged 0 to 5 years in Sofia. Sample size (minimum numberof 289 children in each group) is defined under thefollowing conditions and values: Anticipated populationproportion of the characteristic (disease or condition) inthe population - 25%, Confidence level - 95%, Absoluteprecision - 0,05 (or 5%).

A two-stage random sampling has been implemented.From the list of all GPs in Sofia, 43 GPs have at randombeen selected falling in 9 regions of the Sofia. Thirtynine of these agreed to participate in the study (91%response rate). From the GPs’ lists of patients, using asystematic random selection (every third child from thelist) children who met the requirements for age, genderand health status have been included.

The study (interview of mothers plus measurements ofchildren) was carried out in the GPs’ consultancy rooms.The GPs invited mothers to participate in the study andinformed them in details of the study, of associateddisadvantages, possible risks and benefits. A child wasincluded in the study after a signing by the mother of aninformed consent form. Most of the mothers invited (604)agreed to participate in the study with their children (90%response rate).

Some criteria for exclusion from the study groups havebeen applied: children with birth defects and seriouschronic diseases that affect nutrition and nutritionalstatus (congenital heart defects, kidney failure, diabetes,etc.) as well as children who had had acute infectiousand diarrhea diseases up to a month before the study,children with proven anemia unrelated to nutrition havebeen excluded.

All study methods and questionnaires, information forparents and the informed consent form to participate inthe study were presented to the Committee on MedicalEthics NCPHP and approved by the ¹ 3 Protocol of29.01.2007.

To collect the necessary information for the study sevenquestionnaires had been developed, with an option for thestudy of infants aged 0 to 12 months and an option for thestudy of children aged 1 to 5 years. Data were obtainedthrough an active interview with the mother, from the child’smedical record and from its personal physician.



èíòåðâþ íà ìàéêàòà, îò ìåäèöèíñêèÿ êàðòîí íà äåòåòî è îòëè÷íèÿ ìó ëåêàð.

Õðàíåíåòî å îöåíÿâàíî çà äâà íåïîñëåäîâàòåëíè äíè ïðåçïðîëåòíî-ëåòíèÿ ñåçîí íà 2007 ãîäèíà. Èçïîëçâàí å ìåòîäúòíà 24-÷àñîâî âúçïðîèçâåæäàíå ïî ïàìåò íà õðàíèòåëíèÿïðèåì (êîëè÷åñòâî íà êîíñóìèðàíèòå õðàíè, ïðèåì íàåíåðãèÿ è õðàíèòåëíè âåùåñòâà) çà ïðåäøåñòâàùîäåíîíîùèå èëè 24-h recall.

Çà îöåíêà íà õðàíèòåëíèÿ ñòàòóñ íà âñÿêî äåòå ñà èçìåðåíèïî ñòàíäàðòíà ìåòîäèêà òåëåñíà ìàñà (ñ òî÷íîñò äî 10 ã), ÷ðåçêàëèáðèðàíà åëåêòðîííà âåçíà “Giordany”, ïðåäíàçíà÷åíà çàêúðìà÷åòà è ìàëêè äåöà, ðúñò - ÷ðåç ñòàíäàðòåí ñòàäèîìåòúð (ñòî÷íîñò äî 0,1 ñì). Îöåíêàòà íà õðàíèòåëíèÿ ñòàòóñ å èçâúðøåíàíà áàçà àíòðîïîìåòðè÷íè èíäåêñè ðúñò-çà-âúçðàñò (ÐÂ), òåãëî-çà-âúçðàñò (ÒÂ), òåãëî-çà-ðúñò (ÒÐ), èíäåêñ íà òåëåñíà ìàñà-çà-âúçðàñò (ÈÒÌ), ïðèëîæåíè â ñúîòâåòñòâèå ñ äèñêðèìèíàòèâíèòåêðèòåðèè íà ÑÇÎ çà îöåíêà íà õðàíèòåëåí ñòàòóñ íà äåöà îò 0 äî5 ãîäèíè.

Íà êúðìà÷åòàòà è ÷àñò îò äåöàòà, ó÷àñòâàùè â ïðîó÷âàíåòî,å èçñëåäâàí õåìîãëîáèí â ïåðèôåðíà êðúâ. Çà öåëòà åèçïîëçâàí ñúâðåìåíåí ïðåíîñèì ôîòîìåòúð „Hemocue”(2007 ã.), ñúãëàñíî èçèñêâàíèÿòà íà ÑÇÎ ïðèåïèäåìèîëîãè÷íè èçñëåäâàíèÿ. Íà 189 äåöà íà âúçðàñò îò 1äî 5 ãîäèíè å âçåòà âåíîçíà êðúâ è ñà èçñëåäâàíè êðúâíèïîêàçàòåëè çà îöåíêà íà õðàíèòåëíèÿ è çäðàâíèÿ ñòàòóñ.

Êðúâíà êàðòèíà – îïðåäåëÿíè ñà Íb, År, Hct, ÌÑV, MCH,MCHC – ÷ðåç àâòîìàòè÷åí êóëòîâ àíàëèçàòîð Coulter HmXHematology Analyzer-Roche Diagnostic.

Ïîêàçàòåëè íà æåëåçåí ñòàòóñ – èçñëåäâàíè ñà Fe, ÒIBC, sTfr,F, CRP ñ àâòîìàòè÷åí Cobas Integra 400- Roche Diagnostics.

Èçïîëçâàíè ñòàòèñòè÷åñêè ìåòîäè: äåñêðèïòèâíè ìåòîäè- ÷åñòîòåí àíàëèç íà êà÷åñòâåíè ïðîìåíëèâè, âàðèàöèîíåíàíàëèç íà êîëè÷åñòâåíè ïðîìåíëèâè; ïàðàìåòðè÷íè ìåòîäè -t-òåñò çà ñðàâíåíèå íà ñðåäíè ñòîéíîñòè íà äâå ãðóïè(íåçàâèñèìè èçâàäêè), äèñïåðñèîíåí àíàëèç ÀNOVA çàñðàâíåíèå íà ïîâå÷å îò äâå ãðóïè, ïðè íîðìàëíî ðàçïðåäåëåíèåíà äàííèòå, ïðèëàãàíå íà Post Hoc òåñòîâå çà ìíîæåñòâåíèñðàâíåíèÿ; íåïàðàìåòðè÷íè ìåòîäè: Mann-Whitney U òåñò,Kruskal–Wallis òåñò; ëîãèñòè÷eí ðåãðåñèîíåí àíàëèç (multiplelinear logistic regression analysis) å èçïîëçâàí çà óñòàíîâÿâàíåçàâèñèìîñò ìåæäó äèõîòîìíà çàâèñèìà ïðîìåíëèâà èìíîæåñòâî íåçàâèñèìè ïðîìåíëèâè.

Ñòàòèñòè÷åñêàòà îáðàáîòêà íà äàííèòå å èçâúðøåíà ñúññòàòèñòè÷åñêèÿ ïàêåò SPSS for Windows 11.0. Çà òàáëè÷íîè ãðàôè÷íî ïðåäñòàâÿíå íà ðåçóëòàòèòå å èçïîëçâàí MSEXCEL 2007.

Ðåçóëòàòè

Íà áàçàòà íà èçñëåäâàíèòå áèîõèìè÷íèòå èíäèêàòîðè íàæåëåçåí ñòàòóñ, ïðè äåöàòà îò 1 äî 5 ãîäèíè â ãðàä Ñîôèÿñå óñòàíîâè 20,1% æåëåçåí äåôèöèò. Îò íåãî:

Êëèíè÷íî ïðîÿâåíèÿò æåëåçåí äåôèöèò (IV ñòàäèé, ò.å.ÆÄÀ) å ñ ÷åñòîòà 5,29 % (Ôèãóðà 1).

Nutrition was assessed for two non-consecutive daysduring the spring-summer season of 2007. The method usedis a 24-hour recall of nutritional intake (quantity of foodsconsumed, intake of energy and nutrients) for the previousday.

The nutritional status was assessed by measuring for everychild of the weight (±10 g) by a standard method usingcalibrated electronic scales “Giordany”, designed for infantsand young children, as well as height using a standardgrowth stadiometer (±0.1 cm). The evaluation of nutritionalstatus was carry out on the base of anthropometric indices:height -for-age (HA), weight-for-age (WA), weight-for-height (WH), body mass index-for-age (BMI), according todiscriminative WHO criteria for assessing the nutritionalstatus of children aged 0 to 5 years.

In infants and some children in the study, hemoglobin inperipheral blood (a prick blood sample) was studied. Forthis purpose, a portable photometer “Hemocue” (2007) wasused as required by the WHO in epidemiological studies.

In 189 children aged 1 to 5 years venous blood was takenand blood tests were performed to assess the nutritionaland health status.

Blood count - Hb, Er, Hct, MSV, MCH, MCHC weredetermined – by an automatic analyzer Coulter HmXHematology Analyzer-Roche Diagnostic.

Indicators of iron status – serum Fe, TIBC, sTfR, serumFerritin, CRP were investigated by an automatic CobasIntegra 400 - Roche Diagnostics.

Statistical methods used: descriptive methods - frequencyanalysis of qualitative variables, variation analysis ofquantitative variables, parametric methods - t-test tocompare averages of two groups (independent samples),dispersion analysis of variance ANOVA for comparing morethan two groups, at normal distribution of data, applicationof Post Hoc tests for multiple comparisons, nonparametricmethods: Mann-Whitney U test, Kruskal-Wallis test;logistic regression analysis (multiple linear logisticregression analysis) was used to establish correlationbetween a dichotomous dependent variable and multipleindependent variables.

Statistical data processing was carried out with the statisticalpackage SPSS for Windows 11.0. For tabular and graphicpresentation of results MS EXCEL 2007 is used.

Results

20.1% iron deficiency was found in children aged 1 to 5years from Sofia, based on the tested biochemical indicatorsof the iron status of the children. There of:

Pre-latent iron deficiency (Hb>110 g/L; Ferritin<20.0 ìg/l; sTfR>5.4 mg/L; CRP<3.7 mg/L), associated withdepletion of iron stores, was found in 6.35% of thechildren in the study group.



Ïðåëàòåíòíèÿò æåëåçåí äåôèöèò (Íb>110 g/L;Ferritin<20,0 µg/l; sTfr>5,4mg/L; CRP<3,7 mg/L),ñâúðçàí ñ èç÷åðïâàíå íà æåëåçíèòå çàïàñè âîðãàíèçìà, ñå óñòàíîâè ïðè 6,35% îò èçñëåäâàíèòåäåöà.

Ëàòåíòíèÿò æåëåçåí äåôèöèò ïðè äåöàòà (Íb>110 g/L;Ferritin<12,0 µg/l; sTfr >5,4mg/L; CRP<3,7 mg/L;HCT<32,9; MCV <73,4fl; MCH <26,1pg; MCHC<336,2g/L; Fe <8,7ìmol/L; GSK >69,6 ìmol/L) å ñ ÷åñòîòà 8,47%.

Ôèãóðà 1. Îòíîñèòåëåí äÿë íà äåöà îò 1 äî 5 ãîäèíè, ñïîðåäñòàäèÿ íà æåëåçåí äåôèöèò (ÆÄ)

Ôèãóðà 2. Îòíîñèòåëåí äÿë íà äåöà îò 1 äî 5 ãîäèíè ñïîäíîðìåíî è ñâðúõòåãëî, îöåíåíî ÷ðåç ÈÒÌ ïðèíàëè÷èå/ëèïñà íà æåëåçåí äåôèöèò (ÆÄ)

Îòíîñèòåëíèÿò äÿë íà äåöà îò ñòîëèöàòà ñ ïîäíîðìåíîòåãëî è ÆÄ å ïðåäñòàâåí íà Ôèãóðà 2. Ïî÷òè äâà ïúòè åïî-ãîëÿìà ÷åñòîòàòà íà ïîäíîðìåíî òåãëî ïðè äåöà ñ ÆÄ,â ñðàâíåíèå ñ äåöà áåç äåôèöèò.

Ñðåäíîäíåâíèÿò ïðèåì íà åíåðãèÿ ïðè äåöàòà îò 1 äî 5ãîäèíè, áåç è ñ ÆÄ, ïîêàçâà ìíîãî áëèçêè ñðåäíèñòîéíîñòè (ð>0,05) (Òàáëèöà 1).

Ïðè ñðàâíÿâàíå íà ñðåäíèÿ åíåðãèåí ïðèåì íà äåöà ñÆÄ è äåöà áåç ÆÄ, ãðóïèðàíè ñïîðåä ñâîÿàíòðîïîìåòðè÷åí ñòàòóñ, íå ñå óñòàíîâè ñòàòèñòè÷åñêèçíà÷èìà ðàçëèêà ìåæäó ñðåäíèòå ñòîéíîñòè íà ïðèåòàòàåíåðãèÿ ïðè äåöà (áåç ÆÄ è ñ ÆÄ) è ñ ïîäíîðìåíî òåãëî,îöåíåíî íà áàçà íÿêîëêî àíòðîïîìåòðè÷íè èíäåêñà: (ÒÂ<-2Z, ð=0,303); (ÈÒÌ<-2Z, ð=0,548); (ÒÐ<-2Z, ð=0,482).

Latent iron deficiency in children (Hb>110 g/L;Ferritin<12.0 ìg/l; sTfR>5.4 mg/L; CRP<3.7 mg/L;HCT<32.9; MCV<73.4 fl; MCH<26.1 pg; MCHC<336.2g/L; Fe<8.7 ìmol/L; TIBC>69.6 ìmol/L) has aprevalence of 8.47%.

Clinically manifested iron deficiency (IV stage - IDA) -5.29% (Figure 1).

Figure1. Relative distribution of children aged 1 to 5 years onthe base of differentiated stage of iron deficiency (ID)

Figure 2. Relative rate of children aged 1 to 5 years withunderweight and overweight, assessed with BMI in thepresence of/lack of iron deficiency (ID)

The relative rate of underweight and ID in children fromSofia is presented in Figure 2. The incidence ofunderweight children with ID compared to childrenwithout a deficit is two times higher.

The average daily energy intake in children from 1 to 5years with and without ID shows very similar model(p>0.05) (Table 1).

When comparing the average daily energy intake ofchildren with and without ID, grouped according to theiranthropometric status, no a statistically significantdifference is obtained between the average energy intake(with and without ID) and underweight, evaluated onthe basis of the anthropometric indices: (WA<-2Z, p =0.303) (BMI<-2Z, p = 0.548) (WH<-2Z, p = 0.482).



Òàáëèöà 1. Ñðåäíîäíåâåí åíåðãèåí ïðèåì (êêàë) ïðè äåöà íàâúçðàñò îò 1 äî 5 ãîäèíè, äèôåðåíöèðàíè ïî âúçðàñò, ïîëè æåëåçåí ñòàòóñ

Âðúçêàòà ìåæäó ñîöèàëíî-äåìîãðàôñêè, áèîëîãè÷íèôàêòîðè è ÆÄ, ïðè äåöàòà íà âúçðàñò îò 1 äî 5 ãîäèíè,ó÷àñòâàùè â èçñëåäâàíåòî, å ïðåäñòàâåíà íà Òàáëèöà 2.

Òàáëèöà 2. Âðúçêà ìåæäó ñîöèàëíî-äåìîãðàôñêè, áèîëîãè÷íèôàêòîðè è æåëåçåí äåôèöèò ïðè äåöà íà âúçðàñò îò 1 äî 5

ãîäèíè (Îòíîøåíèå íà øàíñîâå = Odds ratio).

Ref – ðåôåðåíòíà ïîïóëàöèîííàãðóïà

† (êðèòåðèé íà Fisher)

Table 1. Average daily energy intake (kcal) in children aged 1to 5 years, differentiated by age, sex and iron status

The relationship between social-demographic,biological factors and ID in children aged 1 to 5 years ispresented in Table 2.

Table 2. Relationship between social-demographic,biological factors and iron deficiency in children aged 1to 5 years (odds Ratio = Odds ratio).

ef – referent population group

† (Fisher criterion)



Îòíîñèòåëíèÿò äÿë äåöà ñúñ ñðåäíîäíåâåí ïðèåì íàåíåðãèÿ ïîä ïðåïîðú÷èòåëíèÿ å 13,2% ïðè äåöà ñ ÆÄ,ñïðÿìî 18,7% - ïðè äåöà áåç ÆÄ (ð=0,296).

Ñòàòèñòè÷åñêè çíà÷èìî ïî-íèñúê å ïðèåìúò íà æåëÿçîîò æèâîòèíñêè ïðîèçõîä ïðè äåöàòà íà 1-2 ãîäèíè ñ ÆÄ,â ñðàâíåíèå ñ òîçè íà äåöàòà áåç ÆÄ (ð=0,036), íî íå ñåóñòàíîâè òàêàâà çàâèñèìîñò â ïðèåìà íà æåëÿçî îòæèâîòèíñêè ïðîèçõîä ïðè äåöà íà 3-4 ãîäèíè (ð=0,678),êàêòî è íå ñå óñòàíîâè çàâèñèìîñò â ïðèåìà íà îáùîæåëÿçî è ÆÄ è ïðè äâåòå âúçðàñòîâè ãðóïè (ð=0,370 èð=0,876). Ñàìî 2 äåöà íà 1-4 ãîäèíè ñ ÆÄ ñà ñúññðåäíîäíåâåí ïðèåì íà æåëÿçî ïîä ÅÀR, êîåòî íåïîçâîëÿâà äà ñå äîêàæå ñòàòèñòè÷åñêè çíà÷èìà âðúçêàìåæäó ÆÄ è ïðèåìà íà æåëÿçî ïîä ÅÀR (ð=0,642).

Ñðåäíîäíåâíèÿò ïðèåì íà öèíê å ìíîãî áëèçúê ïðè äåöàíà 1-2 ãîäèíè áåç ÆÄ (5,3 ìã) è äåöà ñ ÆÄ (5,0 ìã) (ð=0,379).Ñõîäíè äàííè ñå íàáëþäàâàò è ïðè äåöà íà 3-4 ãîäèíè áåçÆÄ (6,7ìã) è äåöà ñ ÆÄ (6,9 ìã) (ð=0,494). Â èçâàäêàòà íåñà ïîïàäíàëè äåöà ñ ÆÄ è ïðèåì íà öèíê ïîä ÅÀR(ð=1,000).

Íå ñå óñòàíîâè ðàçëèêà â ïðèåìà íà áåëòúê,âúãëåõèäðàòè è ìàçíèíè, âèòàìèí À, âèòàìèí Ñ ïðèèçñëåäâàíèòå äåöà ñ èëè áåç ÆÄ. Ñòàòèñòè÷åñêè çíà÷èìîïî-âèñîêà å îáà÷å ÷åñòîòàòà íà ÆÄ ïðè äåöà, êîèòî ñàïðèåìàëè õðàíèòåëíè äîáàâêè ïî-ìàëêî îò 10 äíè(âèòàìèíè è ìèíåðàëè) (19,8%) îò òåçè, êîèòî ñà ïðèåìàëèïîâå÷å îò 10 äíè (10,2%) (ð=0,048).

Îòíîñèòåëíèÿò äÿë äåöà îò 1 äî 5 ãîäèíè ñ ÆÄ, áîëåäóâàëèîò îñòðè ðåñïèðàòîðíè çàáîëÿâàíèÿ íàä 4 ïúòè ïðåçïîñëåäíàòà ãîäèíà, å 17,2 %, ñïðÿìî áîëåäóâàëè 7,9% äåöàáåç ÆÄ îò ñúùàòà ãðóïà.

Îáñúæäàíå

×åñòîòàòà íà àíåìèÿ ïðè èçñëåäâàíèòå äåöà îò 1 äî 5ãîäèíè (Íb <110 ã/ë) å 5,9%. Ñúãëàñíî êðèòåðèèòå íà ÑÇÎ,÷åñòîòàòà íà àíåìèÿòà å ñ íèñêà ñòåïåí íà çíà÷åíèå çàîáùåñòâåíîòî çäðàâå (2).

Èçñëåäâàíåòî íà êðúâíè è áèîõèìè÷íè ïîêàçàòåëè íàæåëåçåí ñòàòóñ íà ïîäèçâàäêà îò 189 äåöà â ãð. Ñîôèÿïîêàçà, ÷å ñ Íb<110 ã/ë ñà 7,4 % îò äåöàòà.

Ïî ëèòåðàòóðíè äàííè 90% îò àíåìèÿòà â äåòñêà âúçðàñòå ÆÄÀ (2). Çà äà íàìàëèì âúçìîæíîñòòà çà àíåìèÿ, êîÿòîñå äúëæè íà äðóãè ïðè÷èíè, ïðåäâàðèòåëíî çàëîæèõìåóñëîâèå çà èçêëþ÷âàíå íà äåöà ñ äîêàçàíà àíåìèÿ îòíåõðàíèòåëåí ïðîèçõîä (òàëàñåìèÿ è äð.) (15). Âúïðåêè÷å ïîäáîðúò íà äåöàòà èçèñêâàøå äà íå ñà áîëåäóâàëèïðåç ïîñëåäíèÿ ìåñåö îò îñòðè âúçïàëèòåëíèçàáîëÿâàíèÿ, íàïðàâåíîòî èçñëåäâàíå íà ñ-ðåàêòèâåíïðîòåèí äàäå âúçìîæíîñò çà äîïúëíèòåëíîðàçãðàíè÷àâàíå íà äåöà ñ Íb<110 ã/ë, ñâúðçàí ñâúçïàëèòåëíè ïðîöåñè â îðãàíèçìà, îò àíåìèÿ, êîÿòî ñå

The relative rate of children with average daily energyintake below the recommendations is 13.2% in childrenwith ID, compared to 18.7% in children without ID (p =0.296).

The daily intake of heme iron in children aged 1-2 yearswith ID compared with children without ID (p = 0.036)was statistically significantly lower, but not suchdependence in heme iron intake in children aged 3-4 years(p = 0.678) was established, moreover there was nodependence on the intake of total iron and ID in both agegroups (p = 0.370 and p = 0.876).

Only 2 children aged 1-4 years with ID have average dailyiron intake below the EAR, which does not make it possibleto demonstrate statistically significant relationshipbetween ID and iron intake below the EAR (p = 0.642).

The average daily intake of zinc is very similar in childrenof 1-2 years without ID (5.3 mg) and children with ID (5.0mg) (p = 0.379). Similar data were obtained in children of3-4 years without ID (6.7 mg) and children with ID (6.9mg) (p = 0.494).

The representative sample did not include children withID and zinc intake below EAR (p = 1.000).

No difference was found in the intake of protein,carbohydrates and fats, vitamin A and vitamin C in thestudied children with or without ID. However, theincidence of ID in children who received supplements atleast 10 days (vitamins and minerals) (19.8%) wasstatistically significantly higher than that in the groupwho received more than 10 days (10.2%) (p = 0.048).

The relative rate of children aged 1 to 5 years with ID anda history of respiratory tract infections over 4 times inthe last year was 17.2%, compared to 7.9% without ID inthe same group.

Discussion

The prevalence of anemia in the studied children aged 1to 5 years (Hb<110 g/L) was 5.9%. According to WHOcriteria, the prevalence of anemia is of low public healthsignificance (mild public health significance 5.0 - 19.9%)(2). The study of blood and biochemical indicators forthe iron status of a sub-sample of 189 children in Sofiashowed that 7.4% of the children had Hb<110 g/l.

According to bibliographic data 90% of cases with anemiain childhood are IDA (2). To reduce the possibility ofanemia that might be due to other causes, preliminaryconditions were set for elimination of children with aproven anemia of non nutritional origin (thalassemia andothers.) (15). Although the selection of children in theexcluded those with acute inflammatory diseases in thelast month, the evaluation of CRP allowed furtherdifferentiation of children with Hb<110 g/l, associatedwith inflammatory processes in the body from anemiadue to inadequate dietary intake of iron. Increased CRP( 3.7 mg/L), proving inflammatory processes in the body



äúëæè íà íåàäåêâàòåí õðàíèòåëåí ïðèåì íà æåëÿçî.Óâåëè÷åí CRP ( 3,7 mg/L), äîêàçâàù âúçïàëèòåëíèïðîöåñè â îðãàíèçìà, ñå óñòàíîâè ïðè 4 äåöà ñ íèñêèñòîéíîñòè íà õåìîãëîáèí. Ñëåä èçâàæäàíå äà äåöàòà ñâèñîêè ñòîéíîñòè íà CRP (2,1%) îò áðîÿ íà äåöàòà ñíèñúê õåìîãëîáèí ñå óñòàíîâè, ÷å äåöàòà ñ âúçìîæíàÆÄÀ ñà 5,29%. Äîêàçâàíåòî íà ïîñëåäíàòà å óñòàíîâåíî÷ðåç èçñëåäâàíå íà îñíîâíè áèîõèìè÷íè èíäèêàòîðè çàæåëåçåí ñòàòóñ, êîèòî ïîêàçàõà ñúîòâåòíèòå çà ÆÄîòêëîíåíèÿ îò íîðìàëíèòå ãðàíèöè íà ïîêàçàòåëèòå:ñòîéíîñòè ïîä äîëíà ðåôåðåíòíà ãðàíèöà - HCT<32,9;MCV <73,4fl; MCH <26,1pg; MCHC<336,2g/L; Fe <8,7ìmol/L; Ferritin<20.0 µg/l è ñòîéíîñòè íàä ãîðíà ðåôåðåíòíàãðàíèöà - sTfr >5,4mg/L è TIBC >69,6ìmol/L. Îáùèÿò ÆÄïðè èçñëåäâàíèòå â íàøåòî ïðîó÷âàíå äåöà å 20,1 %,ñïðÿìî ñðåäíî 12,5% çà äåöàòà íà 0-4 ãîäèíè â Åâðîïà è14,2% çà äåöàòà íà ñúùàòà âúçðàñò â Àìåðèêà (16).Èç÷åðïâàíåòî íà æåëåçíèòå çàïàñè (6,35%) èëè ÆÄ (I-IIñòàäèé) ñå íàáëþäàâà â åâðîïåéñêèòå ñòðàíè ñ ÷åñòîòà îò2% äî 48%, äèôåðåíöèðàíî â ðàçëè÷íè âúçðàñòîâèïåðèîäè çà äåöàòà îò 0 äî 6-ãîäèøíà âúçðàñò: Íàïðèìåðâúâ Ôðàíöèÿ çà äåöà íà âúçðàñò 2 ãîäèíè òàçè ÷åñòîòà å38%, à çà äåöà íà âúçðàñò 4 ãîäèíè å 17% (17). ×åñòîòàòà íàÆÄÀ ñðåä äåöàòà îò ãðàä Ñîôèÿ íà 1-2 ãîäèíè å 16,1% èëèäâà ïúòè ïî-âèñîêà ñïðÿìî äåöàòà îò ñúùàòà âúçðàñò âîáëàñò Òåñàëèÿ, Ãúðöèÿ (7,9%) (18), ÷åòèðè ïúòè ïî-âèñîêàîò èçñëåäâàíàòà âúâ Ôðàíöèÿ (4,2%) (17) è çíà÷èòåëíî ïî-íèñêà îò óñòàíîâåíàòà â íÿêîé ðàçâèâàùè ñå ñòðàíè, êàòîÏàêèñòàí - 65% (19) è Áðàçèëèÿ - 64,2% (20).

Æåëåçíèÿò äåôèöèò è ÆÄÀ îêàçâàò âëèÿíèå âúðõóôèçè÷åñêîòî ðàçâèòèå íà ìàëêîòî äåòå. Ëèòåðàòóðíèòåäàííè ïîêàçâàò íàëè÷èå íà ïðàâî ïðîïîðöèîíàëíà âðúçêàñ ïîäíîðìåíîòî òåãëî è èçîñòàâàíåòî â ðúñòà ïðèçàñåãíàòèòå äåöà (11).

Îòíîñèòåëíèÿò äÿë íà äåöà îò ñòîëèöàòà ñ ïîäíîðìåíîòåãëî è ÆÄ ïîêàçà, ÷å ïî÷òè äâà ïúòè å ïî-ãîëÿìà÷åñòîòàòà íà ïîäíîðìåíî òåãëî ïðè äåöà ñ æåëåçåíäåôèöèò â ñðàâíåíèå ñ äåöà áåç äåôèöèò.

Âëèÿíèåòî íà æåëåçíèÿ äåôèöèò âúðõó ðàñòåæà íà äåöàòà,ïðåäñòàâåíî ÷ðåç îñíîâíè àíòðîïîìåòðè÷íè èíäåêñè,ïîêàçâà èçðàçåíà òåíäåíöèÿ, íî íå è ñòàòèñòè÷åñêèçíà÷èìà âðúçêà (ð>0,05).

Èçñëåäâàíèòå â ïðîó÷âàíåòî ñîöèàëíî-èêîíîìè÷åñêèôàêòîðè: âúçðàñò è îáðàçîâàíèå íà ìàéêàòà è ñðåäåí äîõîäíà äîìàêèíñòâîòî, íå îêàçâàò çíà÷èìî âëèÿíèå âúðõó÷åñòîòàòà íà ÆÄ ïðè äåöàòà îò 1 äî 5 ãîäèíè.

Ñðåäíîäíåâíèÿò ïðèåì íà åíåðãèÿ, áåëòúê, âúãëåõèäðàòèè ìàçíèíè, âèòàìèí À, âèòàìèí Ñ ïðè äåöàòà îò 1 äî 5ãîäèíè, ñ èëè áåç ÆÄ, íå ïîêàçà ñòàòèñòè÷åñêè çíà÷èìàðàçëèêà, íî ñòàòèñòè÷åñêè çíà÷èìî ïî-íèñúê å ïðèåìúòíà æåëÿçî îò æèâîòèíñêè ïðîèçõîä ïðè äåöàòà íà 1-2ãîäèíè ñ ÆÄ, â ñðàâíåíèå ñ òîçè íà äåöàòà áåç ÆÄ (ð<0,05).Òàçè çàâèñèìîñò íå ñå óñòàíîâè â ïðèåìà íà æåëÿçî îòæèâîòèíñêè ïðîèçõîä ïðè äåöà íà 3-4 ãîäèíè (ð>0,05),êàêòî è íå ñå óñòàíîâè çàâèñèìîñò â ïðèåìà íà îáùîæåëÿçî è ÆÄ è ïðè äâåòå âúçðàñòîâè ãðóïè äåöà (ð>0,05).

was found in 4 children with low levels of Hb. After theexclusion of children with high levels of CRP (2.1%)from the group with low Hb, children with possibleIDA were found to be 5.29%. The latter was proved byassessment on the basic biochemical indexes of ironstatus, which showed relevant abnormal levels ofindicators for ID: values below the lower reference limit- HCT<32.9; MCV<73.4 fl; MCH<26.1 pg; MCHC<336.2g/L; Fe<8.7 ìmol/L; Ferritin<20.0 ìg/l and valuesabove upper reference limit - sTfR>5.4 mg / L andTIBC>69.6 ìmol/L. In total ID in studied children was20.1%, compared to an average 12.5% for children of0-4 years in Europe and 14.2% for children of same agein America (16). Depletion of iron stores (6.35 %) or ID(I-II stage) were observed in European countries withan incidence of 2% to 48%, variable in different ageperiods for children 0 to 6 years of age: for example inFrance for children aged 2 years, this rate is 38% andfor children aged 4 years is 17% (17). The prevalenceof IDA for children from Sofia aged 1-2 years is 16.1%or twice as high for children of that age in the Thessalyprovince, Greece (7.9%) (18), four times higher thanthe incidence of IDA studied in France (4.2%) (17) andsignificantly lower than that established in somedeveloping countries such as Pakistan - 65% (19) andBrazil - 64.2% (20).

Iron deficiency and IDA affect the physicaldevelopment of the infants. Literature data indicatethe presence of directly proportional relationship withunderweight and lack of growth (stunting) in affectedchildren (11).

The proportion of children underweight in Sofia andID showed that nearly two times greater incidence ofunderweight in children with ID than children withouta deficit.

The influence of ID on child growth, evaluated byanthropometric indices showed tendency but nostatistically significant difference (p>0,05).

In the study socio - economic factors: maternal age,education of the mother and the average householdincome has no significant influence on the frequencyof ID in children 1 to 5 years.

The average daily intake of energy, protein,carbohydrates and fats, vitamin A, vitamin C in childrenfrom 1 to 5 years with or without ID showed nostatistically significant difference, but statisticallysignificant lower intake of heme iron in children 1-2years with ID compared with children without ID(p<0,05). This relationship is not established in theaverage daily heme iron intake in children of 3-4 years(p>0,05), and it is not established dependence on theintake of total iron and ID in both age groups ofchildren (p>0,05).

In the presence of inadequate daily iron intake fromfoods supplementation by vitamins and minerals has



Ïðè íàëè÷èå íà íåàäåêâàòíî ñúäúðæàíèå íà æåëÿçî âõðàíàòà ïðèåìúò íà õðàíèòåëíè äîáàâêè ñ âèòàìèíè èìèíåðàëè îêàçâà ïðîòåêòèâåí åôåêò ïî îòíîøåíèåðàçâèòèåòî íà ÆÄ. Ñòàòèñòè÷åñêè çíà÷èìî ïî-íèñêà å÷åñòîòàòà íà ÆÄ ïðè äåöàòà îò 1 äî 5 ãîäèíè, êîèòî ñàñóïëåìåíòèðàíè ñ âèòàìèíè è ìèíåðàëè ïîâå÷å îò 10äíè, â ñðàâíåíèå ñ òåçè, êîèòî ñà ïðèåìàëè ïî-ìàëêî îò10 äíè (ð<0,05).

Æåëåçíèÿò äåôèöèò ïðè äåöàòà å ñâúðçàí ñ ïîâèøåíàçàáîëåâàåìîñò. Ïðè íàøåòî ïðîó÷âàíå îòíîñèòåëíèÿòäÿë äåöà îò 1 äî 5 ãîäèíè ñ ÆÄ, áîëåäóâàëè îò îñòðèðåñïèðàòîðíè çàáîëÿâàíèÿ íàä 4 ïúòè (17,2 %), å ïî-ãîëÿì,ñïðÿìî áîëåäóâàëèòå (7,9%) äåöà áåç ÆÄ. Ñïîðåä íÿêîèàâòîðè ÆÄ ïîòèñêà èìóííàòà ñèñòåìà è óâåëè÷àâà ðèñêàîò ãàñòðîèíòåñòèíàëíè è ðåñïèðàòîðíè èíôåêöèè,äîêàòî äðóãè òâúðäÿò, ÷å èìóííàòà ñèñòåìà íå ñå ïîâëèÿâàîò ÆÄ (21; 22, 23). Äîïóñêà ñå, ÷å àíåìèÿòà åíåñïåöèôè÷åí èìóíîëîãè÷åí çàùèòåí ìåõàíèçúì, âîòãîâîð íà ìèêðîáíàòà èíâàçèÿ (24).


1. Äåöàòà îò 1 äî 5-ãîäèøíà âúçðàñò â ãðàä Ñîôèÿ ñàðèñêîâà ïîïóëàöèîííà ãðóïà çà æåëåçåí äåôèöèò èæåëÿçîäåôèöèòíà àíåìèÿ.

1. Ñúãëàñíî êðèòåðèèòå íà ÑÇÎ, ÷åñòîòàòà íà àíåìèÿòà å ñíèñêà ñòåïåí íà çíà÷åíèå çà îáùåñòâåíîòî çäðàâå.

2. Îñèãóðåíè ñà íàäåæäíè äàííè çà ÷åñòîòàòà, òåæåñòòà èíåãàòèâíîòî âëèÿíèå íà æåëåçíèÿ äåôèöèò âúðõóçäðàâåòî è ðàñòåæà íà äåöàòà îò ãðàä Ñîôèÿ - áàçà çàåôåêòèâíà õðàíèòåëíà ïîëèòèêà.


1. Ramakrishnan U (Edit). Nutritional Anemias, CRC Pess LLC, Florida,2001

2. WHO. Assessment, Prevention and Control. A guide for programmemanagers. In: Iron Deficiency Anaemia. Geneva: WHO, 2001: 97-100

3. Oski FA. Iron deficiency and childhood. N Engl J Med 1993; 329: 190-194

4. Stopler T. Medical Nutrition Therapy for Anemia. In: Krause’s Food,Nutrition& Diet Therapy. USA, Elsevier, 2005: 838-847

5. Dallman PR, Reeves JD. Laboratory diagnosis of iron deficiency andiron. In: Iron nutrition in infancy and childhood.( Stekel A, editor.)Nestle Nutrition Workshop Series, 4. New York: Raven Press; 1984 :11-44

6. Domell f M, L nerdal B, Abrams SA, Hermell O. Iron absorbtion inbreast-fed infants. Effect of age, iron status, iron supplements andcomplimentary foods. Am J Clin Nutr 2002; 76: 198-204

7. Hercberg S, Galan P. Nutritional anaemias. Baillieres Clin Haematol1992, 5: 143-468

8. Aggett PJ, Agostoni C, Axelsson I, Bresson JL,Goulet O, Hernell O,Koletzko B, Lafeber HL, Michaelsen KF, Micheli JL, Rigo J, SzajewskaH, Weaver LT. Iron metabolism and requirements in early childhood:Do we know enough? A commentary by the ESPGHAN Committee onNutrition. J Pediatr Gastro Nutr 2002; 34: 337-345

a protective effect against the development of ID.Statistically significantly lower was the prevalence ofID in children 1 to 5 years supplemented by vitaminsand minerals more then 10 days than in those whowere not supplemented (p<0,05).

Iron deficiency in children is associated with increasedmorbidity. In our study the proportion of children 1 to5 years with ID, suffered from acute respiratorydiseases over 4 times (17.2%) is higher compared to(7.9%) children without ID. The opinion of relationbetween ID and immune defense is controversial.According to some authors ID suppresses the immunesystem and increases the risk of gastrointestinal andrespiratory infections, while others argue that theimmune system is not affected by ID (21, 22, 23). Someauthors have suggested that anemia is a non-specificimmunological defense mechanism in response tomicrobial invasion (24).

Conclusion

1. Children aged 1 to 5 years in Sofia are a populationgroup at risk for iron deficiency and iron deficiencyanemia.

2. According to WHO criteria, the prevalence of anemiais of mild public health significance.

3. Data provided on the prevalence, magnitude andnegative impact of iron deficiency on the health andgrowth of children from Sofia - a basis for aneffective nutritional policy.

9. Pisacane A. Neonatal prevention of iron deficiency. BMJ 1996;312: 136-137

10. Dallman PR, Yip R. Changing characteristics of childhoodanemia. J Pediatr 1989; 114: 161-164

11. Dangour AD, Hill HL, Ismail SJ. Height, weight andhaemoglobin status of 6 to 59 – month – old Kazakh childrenliving in Kzyl – Orda region, Kazakhstan. Europ J Clin Nutr2002; 56: 1030 – 1038

12. Ãàòåâà. Ïðîó÷âàíå íà æåëÿçîäåôèöèòíèòå ñúñòîÿíèÿ ïðèäåöà (äèàãíîñòèêà, ÷åñòîòà, ïðîôèëàêòèêà) Äèñåðòàöèîíåíòðóä çà ïðèñúæäàíå íà îáðàçîâàòåëíà è íàó÷íà ñòåïåí „ä.ì.í.”,Ñîôèÿ, 1987 /Gateva. Study of iron deficiency states in children(diagnosis, incidence, prevention) Dissertation for the award ofeducational and scientific degree of D.Sc., Sofia, 1987/.

13. Èâàíîâà Ë, Ê Àíãåëîâà, Â Äóëåâà, Ä Îâ÷àðîâà, Ê Âàòðàëî-âà, Ì Âóêîâ, Á Áîåâà. Íàöèîíàëíî ïðîó÷âàíå íà àíòðîïî-ìåòðè÷åí õðàíèòåëåí ñòàòóñ ïðè èíñòèòóöèîíàëèçèðàíèäåöà íà âúçðàñò 0 äî 3 ãîäèíè. Õèãèåíà è çäðàâåîïàçâàíå2000; XLIII, 5-6: 43 – 46 / Ivanova L, Angelova K, C Duleva, EOvcharova, Vatralova K, M Vukov, B Boeva. National study ofanthropometric nutritional status in institutionalized children aged 0to 3 years. Hygiene and Public Health 2000; XLIII, 5-6: 43-46.



14. ÌÇ. Íàöèîíàëåí ïëàí çà äåéñòâèå „Õðàíè è õðàíåíå” 2005-2010. ÌÇ, 2005 / Ministry of Health. National Action Plan for Foodand Nutrition 2005-2010. MH, 2005.

15. Pusic M, Dawyduk B and Mitchell D. Opportunistic screening foriron-deficiency in 6-36 month old children presenting to thepaediatric emergency department. BMC Pediatr 2005; 5: 42

16. WHO. Regional Publications, Europian Series, ¹ 87; Feeding andnutrition of infants and young children. 2000

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18. Tympa-Psirropoulou E, Vagenas C, Psirropoulou D, Dafni O,Matala A, Skopouli F. Nutrition risk factors for iron-deficiencyanemia in children 12-24 months old in the area of Tessalia inGreece. Int J Food Sci Nutr 2005; 56 (1): 1-12

19. Sultan AN, Zuberi RW. Late weaning: the most significant riskfactor in the development of iron deficiency anemia at 1-2 years ofage. Eur J Clin Nutr 2003; 15:3-7


Ãë. àñ. ä-ð Ëàëêà ÐàíãåëîâàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçèÑîôèÿ, áóë. „Àêàä. Èâàí Ãåøîâ 15”

Òåë.: 8056264

20. Assiss AM. Childhood anemia prevalence and associatedfactors in Salvador, Bahia, Brasil. Cad Saude Publica 2004;20: 1633-1641

21. Hershko C. Iron, infection and immune function. Proc NutrSoc 1993; 52: 165-174

22. Reeves JD, Yip R, Kiley VA, Dallman PR. Iron deficiency ininfants: the influence of mild antecedent infection. J Pediatr1984;105(6): 874-879

23. Jansson LT, Kling S, Dallman PR. Anemia in children withacute infections seen in a primary care pediatric outpatientclinic. Pediatr Infect Dis 1986;4:424-427

24. Kent S, Weinberg ED, Stuart-Macadan P. The etiology ofanemia of chronic disease and infection. J Clin Epidemiol1994; 47: 23-33


Assist. Prof. Lalka Rangelova, MD, PhDNational Centre of Public Health and Analyses

E-mail: [email protected]



ÎÏÀÑÅÍ ËÈ Å ÁÈÑÔÅÍÎË À?ÏÎÑËÅÄÍÈ ÇÀÊËÞ×ÅÍÈß ÍÀÅÂÐÎÏÅÉÑÊÈß ÎÐÃÀÍ ÏÎÁÅÇÎÏÀÑÍÎÑÒ ÍÀ ÕÐÀÍÈÒÅ

Ãàáðèåëà Æåêîâà, Òåðè Âðàá÷åâàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè

Ðåçþìå

Áèñôåíîë À å îðãàíè÷íî ñúåäèíåíèå, êîåòî ñå èçïîëçâàãëàâíî êàòî ìîíîìåð ïðè ïðîèçâîäñòâîòî íàïîëèêàðáîíàò - âèä ïðîçðà÷íà òâúðäà ïëàñòìàñà, ñïðèëîæåíèå â ïðîèçâîäñòâîòî íà ñúäîâå çà õðàíè èíàïèòêè, ïðåäíàçíà÷åíè çà ìíîãîêðàòíà óïîòðåáà. Ìàëêèêîëè÷åñòâà îò íåãî ìîãàò äà ïðîíèêíàò â õðàíàòà îòñúäà èëè îïàêîâêàòà, â ñëåäñòâèå íà êîåòî äà áúäàòïîãúëíàòè îò ÷îâåêà. Ïîíàñòîÿùåì ñå ñìÿòà, ÷åîñíîâíèÿò ïúò íà åêñïîçèöèÿ å îðàëíèÿò – ÷ðåç äèåòàòà.Íàé-âèñîêà å åêñïîçèöèÿòà â ãðóïàòà íà êúðìà÷åòàòàîò 3 äî 6-ìåñå÷íà âúçðàñò, õðàíåíè ñ ïîëèêàðáîíàòíèøèøåòà. Áèñôåíîë À å ñìÿòàí çà „åíäîêðèíåí íàðóøèòåë”,ñ ìåõàíèçúì íà äåéñòâèå êàòî êñåíîåñòðîãåí, ïîðàäèêîåòî ïðåäèçâèêâà ãîëÿì èíòåðåñ ïðåç ïîñëåäíèòå ãîäèíè.Ïîâå÷å îò 400 ñòàòèè ìåñå÷íî ðàçèñêâàò (è â ïîâå÷åòîñëó÷àè ñå ñúìíÿâàò) íåãîâàòà áåçâðåäíîñò. Åâðîïåéñêàòàêîìèñèÿ ïîñòàíîâè óïîòðåáàòà íà BPA â ïðîèçâîäñòâîòîíà øèøåòà çà õðàíåíå íà êúðìà÷åòà è ïóñêàíåòî íà ïàçàðàíà ïîëèêàðáîíàòíè øèøåòà çà õðàíåíå íà êúðìà÷åòà äàáúäàò âðåìåííî çàáðàíåíè äî ïîëó÷àâàíåòî íàäîïúëíèòåëíè íàó÷íè äàííè. Òå òðÿáâà äà èçÿñíÿòòîêñèêîëîãè÷íàòà çíà÷èìîñò íà íÿêîè åôåêòè íà BPA,íàáëþäàâàíè â ïðîó÷âàíèÿ âúðõó æèâîòíè, ñ îñîáåíîâíèìàíèå ïî îòíîøåíèå íà áèîõèìè÷íèòå ïðîìåíè â ìîçúêà,èìóíîìîäóëàòîðíèòå åôåêòè è ïîâèøåíàòàïðåäðàçïîëîæåíîñò êúì ðàçâèòèå íà òóìîðè íà ãúðäàòà.

Êëþ÷îâè äóìè: áèñôåíîë À, ïîëèêàðáîíàòè,åíäîêðèííè íàðóøèòåëè, êñåíîåñòðîãåíè, øèøåòàçà õðàíåíå íà êúðìà÷åòà.

Áèñôåíîë À - õàðàêòåðèñòèêà

Áèñôåíîë À (4,4'-äèõèäðîêñè-2 ,2-äèôåíèëïðîïàí; 4,4'-(ïðîïàí-2-èëèäåí)äèôåíîë; p, p'-çîïðîïèëèäåíáèñôåíîë;4,4'-èçîïðîïèëèäåíäèôåíîë ) å îðãàíè÷íî ñúåäèíåíèå,êîåòî ñå èçïîëçâà ãëàâíî êàòî ìîíîìåð ïðè ïðîèçâîäñòâîòî

HOW DANGEROUS IS BISPHENOLA? FINAL CONCLUSIONS OF THEEUROPEAN FOOD SAFETYAUTHORITY (EFSA)

Gabriela Zhekova, Terry VrabchevaNational Center of Public Health and Analyses

Abstract

Bisphenol A (BPA) is an organic compound mainlyused as a monomer in the manufacture of polycar-bonate – a kind of highly transparent durable plas-tics, which is used to make some types of food anddrink containers. Trace amounts of BPA can enterthe food through food containers or packages, as aresult of this it can be swallowed by human beings.Bisphenol À is considered to be “endocrinedisruptor” with a mechanism of action asxenoestrogen, due to which BPA is still of great in-terest during the last years. More than 400 articleshave discussed monthly (as in most cases there aredoubts) its safety. The European Commission estab-lished the use of BPA in the manufacturing of feedingbottles for infants and the launch of polycarbonateinfants feeding bottles to the market to be tempo-rarily banned until receiving additional scientificdata that will clarify the toxicological significanceof some observed effects of BPA, in particular, for thebiochemical changes in the brain,immunomodulatory effects and increased predispo-sition to the development of breast cancer.

Key words: Bisphenol A, polycarbonates,endocrine disruptors, xenoestrogens, infantsfeeding bottles.

Bisphenol A - properties

Bisphenol À (4,4'-Dihydroxy-2,2-diphenylpropane; 4,4'-(propane 2,2-diyl) diphenol; p,p'-isopropylidenebisphenol;4,4' -isopropilidendiphenol) is an organic compound, whichis mainly used as a monomer in the manufacture of

ÁÅÇÎÏÀÑÍÎÑÒ ÍÀ ÕÐÀÍÈÒÅ FOOD SAFETY


íà ïîëèêàðáîíàòè è åïîêñèäíè ñìîëè, â ñèíòåçà íàïîëèñóëôîíè è ïîëèåòåðíè êåòîíè. Íàìèðà ïðèëîæåíèå êàòîàíòèîêñèäàíò â íÿêîè ïëàñòèôèêàòîðè è êàòî èíõèáèòîð íàïîëèìåðèçàöèÿòà â ïîëèâèíèëõëîðèäà (PVC). Çà íåãî ñåñúîáùàâà çà ïúðâè ïúò ïðåç 1891 ã. îò Äèàíèí â „Æóðíàëüðóññêîãî ôèçèêî-õèìè÷åñêîãî îáùåñòâà”. Áèñôåíîë À(BPA) å ïðîäóêò îò êîíäåíçàöèÿòà íà åäíà ìîëåêóëà àöåòîíè äâå ìîëåêóëè ôåíîë. Ïðåç ïîñëåäíèòå 50 ãîäèíè ÂÐÀ ñåóïîòðåáÿâà ìàñîâî â ïðîèçâîäñòâîòî íà ïîëèêàðáîíàò,âèä ïðîçðà÷íà òâúðäà ïëàñòìàñà, êîÿòî íàìèðàïðèëîæåíèå â ïðîèçâîäñòâîòî íà ñúäîâå çà õðàíè èíàïèòêè, ïðåäíàçíà÷åíè çà ìíîãîêðàòíà óïîòðåáà:áóòèëêè çà íàïèòêè , øèøåòà çà õðàíåíå íà êúðìà÷åòà,ïîñóäà (÷èíèè è ÷àøè), ñúäîâå çà ìèêðîâúëíîâà ôóðíà èñúäîâå çà ñúõðàíåíèå. Îñòàòú÷åí BPA ñå íàìèðà è âåïîêñèäíèòå ñìîëè, êîèòî ñå èçïîëçâàò êàòî çàùèòíèïîêðèòèÿ íà ìåòàëíèòå êîíñåðâíè êóòèè è êîíòåéíåðè çàñúõðàíåíèå íà õðàíè è íàïèòêè. Ñïåöèôè÷íà ñôåðà íàïîòåíöèàëíî ïðèëîæåíèå íà ÂÐÀ ñå ÿâÿâàò ìàòåðèàëèòåâ êîíòàêò ñ ïèòåéíàòà âîäà. Ïîëèêàðáîíàòèòå ñå èçïîëçâàòè çà íàïðàâàòà íà âîäîïðîâîäíè òðúáè, à åïîêñèäíèòåñìîëè ñëóæàò êàòî ïîâúðõíîñòíè ïîêðèòèÿ è íà âîäíèòåðåçåðâîàðè (1).

ÂÐÀ ïðåäèçâèêâà ãîëÿì èíòåðåñ ïðåç ïîñëåäíèòå ãîäèíè.Ïîâå÷å îò 400 ñòàòèè ìåñå÷íî ðàçèñêâàò (è â ïîâå÷åòîñëó÷àè ñå ñúìíÿâàò) íåãîâàòà áåçâðåäíîñò.

×îâåøêàòà åêñïîçèöèÿ íà áèñôåíîë À

Â Åâðîïåéñêèÿ ñúþç BPA å ðàçðåøåí çà èçïîëçâàíå âìàòåðèàëè, ïðåäíàçíà÷åíè çà êîíòàêò ñ õðàíè. Ìàëêèêîëè÷åñòâà îò íåãî ìîãàò äà ïðîíèêíàò â õðàíàòà îò ñúäàèëè îïàêîâêàòà, â ñëåäñòâèå íà êîåòî äà áúäàò ïîãúëíàòèîò ÷îâåêà. Ñ Äèðåêòèâà íà Åâðîïåéñêàòà êîìèñèÿ 2002/72/ÅÑ, îò 6 àâãóñò 2002, îòíàñÿùà ñå äî ïëàñòìàñè èïðåäìåòè, ïðåäíàçíà÷åíè çà êîíòàêò ñ õðàíè, ñà çàäàäåíèãðàíèöè íà ñïåöèôè÷íà ìèãðàöèÿ îò 0,6 mg/kg õðàíà.Ïîíàñòîÿùåì ñå ñìÿòà, ÷å îñíîâíèÿò ïúò íà åêñïîçèöèÿå îðàëíèÿò.

Ïðîâåäåíè ñà äâå èçñëåäâàíèÿ, îöåíÿâàùè íèâàòà íàåêñïîçèöèÿòà íà BPA ïðè ìàëêè äåöà. Ïúðâîòî îò òÿõâêëþ÷âà ñàìî 9 äåöà è å ïðîåêòèðàíî äà ïðîó÷è òÿõíàòàïîòåíöèàëíà åêñïîçèöèÿ â äîìà è â äåòñêàòà ãðàäèíà (5).ÂÐÀ å îòêðèò â ïðîáè îò âúçäóõà â ïîìåùåíèÿòà èàòìîñôåðíèÿ âúçäóõ, ïðîáè îò ïðàõòà ïî ïîäà, îò ïî÷âàòàíà ïëîùàäêèòå çà èãðà, â ñõîäíè êîíöåíòðàöèè è íà äâåòåìåñòà. Îòêðèò å è â ïðîáè îò òâúðäà è òå÷íà õðàíà êàêòî âäîìà, òàêà è â äåòñêàòà ãðàäèíà. Âúç îñíîâà íà òîâàèçñëåäâàíå, àâòîðèòå çàêëþ÷àâàò, ÷å ñðåäíîòî íèâî íàåêñïîçèöèÿ ïðè ìàëêè äåöà å 42.98 ng/kg òåëåñíà ìàñàäíåâíî. Âòîðî ïðîó÷âàíå íà ñúùèÿ êîëåêòèâ èçñëåäâàåêñïîçèöèÿòà íà BPA ïðè 257 äåöà â ïðåäó÷èëèùíàâúçðàñò (6). Òîâà ïðîó÷âàíå ïîòâúðæäàâà, ÷å BPA ìîæå äàáúäå îòêðèò â íàä 50% îò ïðîáèòå îò âúçäóõà â ïîìåùåíèÿòà,êúðïèòå çà áúðñàíå íà ðúöå, òâúðäàòà è òå÷íàòà õðàíà.Àâòîðèòå ñòèãàò äî çàêëþ÷åíèåòî, ÷å 99% îò åêñïîçèöèÿòàíà áèñôåíîë À ñå äúëæè íà äèåòàòà. Íèâàòà íà åêñïîçèöèÿ


polycarbonate plastic and epoxy resins, in the synthesisof polysulfones and polyether ketones. Another use forbisphenol A is as an antioxidant in some plasticizers, andas a polymerization inhibitor in polyvinyl chloride (PVC).It was first announced by the Russian chemistA.P.Dianin in 1891 in the “Zhurnal russkogo fiziko-khimicheskogo obshchestva”. Bisphenol A (BPA) isproduced by condensation of acetone with two phenolequivalents. Over the last 50 years BPA is used tomanufacture polycarbonate plastics. This type of plasticsis used to make some types of food and drink containersthat are meant for multiple use: plastic beverage bottles,plastic baby bottles, plastic dinnerware (plates andglasses), plastic containers produced for use in microwaveovens and food storage containers. Unavoidable tracelevels of BPA (so-called free or residual BPA can also befound in the epoxy resins that are used for safe coatingsof metal cans and food and drink storage containers. Aspecific area of the potential application is the use of BPAin materials in contact with drinking water. Polycarbonatesare used as well to produce drinking water pipes, whileepoxy resins serve as surface coatings of water reservoirs (1).

There has been growing debate and public concernaround the substance bisphenol A or BPA over the lastyears. More than 400 articles have discussed monthly(as in most cases there are doubts) its safety.

Human exposure to bisphenol A

In the European Union BPA is permitted for use in certainfood contact materials. Trace amounts of BPA can enterthe food through food containers or packages, as aresult of this it can be swallowed by human beings. ByCommission Directive 2002/72/EC of 6 August 2002relating to plastic materials and articles intended to comeinto contact with foodstuffs were set out specificmigration limits of 0,6 mg/kg food. Nowadays it hasbeen considered that the most common route ofexposure is the oral route.

Two studies have been carried out to assess BPAexposure levels in young children. The first of themincluded just 9 children and was designed to studytheir potential exposure at home and in the kindergarten(5). ÂÐÀ was detected in ambient (outdoor) and indoorair sampling locations, floor dust and playground soilin both locations at similar levels. It was also found insamples of solid and liquid foods both at home and inthe kindergarten. Having in mind this study the authorsdrew the conclusion that the average BPA exposurelevel for young children is 42.98 ng/kg body mass perday. The second study of the same authors’ teaminvestigated bisphenol exposures in 257 preschool agedchildren (6). This study confirmed the fact that BPAcould be detected in more than 50% of samples ofindoor air, hand wipe towels, solid and liquid foods.Authors conclusions suggested that 99% ofexposures of preschool children originated in the


îò õðàíèòåëíè èçòî÷íèöè ñå îöåíÿâàò íà 52–74 ng/kg òåëåñíàìàñà äíåâíî, à íèâàòà íà åêñïîçèöèÿ îò âäèøâàíèÿ âúçäóõ ñåîöåíÿâàò íà 0.24–0.41 ng/kg òåëåñíà ìàñà äíåâíî.

Çäðàâíè åôåêòè íà ÂÐÀ

Áèñôåíîë À å ñìÿòàí çà „åíäîêðèíåí íàðóøèòåë”(endocrine disrupter). Áèîõèìè÷íè èçñëåäâàíèÿ äîêàçâàòàôèíèòåòà íà ÂÐÀ êúì åñòðîãåííèòå ðåöåïòîðè (ER) èîòêðèâàò, ÷å òîé ñå ñâúðçâà êàêòî ñ ER-àëôà , òàêà è ñ ER-áåòà, ñ ïî÷òè 10-ïúòè ïî-ñèëåí àôèíèòåò êúì ER-áåòà(7,8,9). BPA èìà 10 000 – 100 000 ïúòè ïî-ñëàá àôèíèòåòêúì ðåöåïòîðèòå, îòêîëêîòî åñòðàäèîëà è ïîðàäè òîâàäúëãî âðåìå ñå å ñìÿòàëî, ÷å èìà 10 000–100 000 ïúòè ïî-ñëàá åôåêò. Ïîíàñòîÿùåì, ïðîó÷âàíèÿ íà ìîëåêóëÿðíèòåìåõàíèçìè íà äåéñòâèå íà BPA ðàçêðèâàò ìíîæåñòâîïúòèùà, ïî êîèòî BPA ìîæå äà ïðåäèçâèêà êëåòú÷åíîòãîâîð â ìíîãî íèñêè êîíöåíòðöèè (10), â äîïúëíåíèåêúì åôåêòèòå, ïðåäèçâèêàíè îò ñâúðçâàíåòî ìó êúìêëàñè÷åñêèòå íóêëåàðíè è ãåíîìíè åñòðîãåííèðåöåïòîðè. Ñúâðåìåííè èçñëåäâàíèÿ äåìîíñòðèðàò âðàçëè÷íè òúêàíè, ÷å BPA å ñ åêâèâàëåíòíà íà åñòðàäèîëàìîùíîñò, êàòî ïðîìåíèòå â êëåòú÷íàòà ôóíêöèÿ ñàíàáëþäàâàíè ïðè äîçè îò 1 pM (0.23 pg/ml êëåòú÷íàêóëòóðà), ïî ìåõàíèçìè, êîèòî ñå ñ÷èòàò çà „íå-ãåíîìíè”è âêëþ÷âàò ìåìáðàííî àñîöèèðàíè ôîðìè íàåñòðîãåííèòå ðåöåïòîðè (11).

Ïðåç îêòîìâðè 2007 ã., åêèï îò ÿïîíñêè áèîõèìèöèðàçêðèâà ìåõàíèçìà íà äåéñòâèå íà ÂÐÀ êàòîêñåíîåñòðîãåí. Òå äîêàçâàò, ÷å ÂÐÀ ñå ñâúðçâà ñ âèñîêàôèíèòåò êúì åñòðîãåí-ñâúðçàíèÿ ðåöåïòîð-ãàìà (ERR-gama: estrogen-related receptor-gama). Òîçè ðåöåïòîð-ñèðàê (åíäîãåííèÿò ëèãàíä å íåèçâåñòåí) ïðåäñòàâëÿâàñòðóêòóðåí àêòèâàòîð íà òðàíñêðèïöèÿòà. Çà ðàçëèêà îòER, âðúçêàòà íà ÂÐÀ ñ ERR-gama e ìíîãî ñèëíà (êîíñòàíòàíà äèñîöèàöèÿ 5,5 nM). Ñâúðçâàíåòî ñ ÂÐÀ ñúõðàíÿâàáàçàëíàòà ñòðóêòóðíà àêòèâíîñò íà ERR-gama. Òîéïðåäïàçâà ðåöåïòîðà îò äåàêòèâàöèÿ îò ñåëåêòèâíèÿìîäóëàòîð íà å ñòðîãåíîâèòå ðåöåïòîðè 4-õèäðîêñèòàìîêñèôåí (12).

Êàòî „íèñêè äîçè” çà åíäîêðèííèòå íàðóøèòåëè ñå ñìÿòàòäîçèòå ïîä NOAEL (13), êîèòî çà BPA ñà äîçè ïî-íèñêè îò50 mg/kg òåëåñíà ìàñà äíåâíî. Ïóáëèêóâàíèòå äàííè îòíàä 150 ïðîó÷âàíèÿ ïîêàçâàò åôåêòè íà íèñêè äîçè ÂÐÀïðè æèâîòíè, êàòî õèïåðïëàçèÿ è ðàê íà ïðîñòàòàòà, ðàêíà ìëå÷íàòà æëåçà, åôåêòè âúðõó õèïîòàëàìóñà, ñïîñëåäâàùè íàðóøåíèÿ â ñåêñóàëíèÿ äèìîðôèçúì,ìåíñòðóàëíèÿ öèêúë è ðàíåí ïóáåðòåò, îòêëîíåíèÿ âòåëåñíàòà ìàñà, ãåíèòàëíè ìàëôîðìàöèè è äð. (14). Ïðèïîâå÷å îò 40 îò òåçè ïðîó÷âàíèÿ ñà íàáëþäàâàíè ïîäîáíèåôåêòè ïðè äîçè ïî-íèñêè îò ðåôåðåíòíàòà äîçà çà BPA îò0,50 mg/kg òåëåñíà ìàñà äíåâíî.

Òåçè ðåçóëòàòè ñà îñíîâàíèå çà çàãðèæåíîñò, ïðåäâèäåïèäåìèîëîãè÷íèòå òåíäåíöèè ïðè ÷îâåêà. Ïîðàäè ñâîåòîøèðîêî ðàçïðîñòàíåíèå è åñòðîãåííàòà ñè àêòèâíîñò,ïðîÿâåíà in vitro è in vivo, ÂÐÀ ñå ñ÷èòà çà âúçìîæåíïðè÷èíèòåë íà ìíîæåñòâî âðåäíè åôåêòè çà ÷îâåøêîòî

diet. The estimated exposure from dietary sources was52-74 ng/kg per day, and estimated inhalation exposurewas 0.24-0.41 ng/kg per day.

Effects of bisphenol A on human health

Bisphenol À is considered to be “endocrine disruptor”.Biochemical studies showed the affinity of BPA toestrogen receptors (ER) and found that it could be boundboth to ERá or ERâ homodimers; furthermore, bisphenolA receptor-binding activity was ten times stronger forERâ than for ERá (7,8,9). The affinity of BPA for ERs wasreported to be 10 000 – 100 000 fold weaker than that ofthe estradiol; historically, BPA has been considered toact primarily as a weak estrogen. Nowadays, studies onmolecular mechanisms of BPA effects have shown avariety of pathways through which BPA can stimulatecellular response at very low concentrations (10) inaddition to the effects caused by its binding to classicalnuclear genomic ERs.

Recent studies have shown in different tissues that BPAis with potency equivalent to that of estradiol as thechanges in cellular function were observed at doses of 1pM (0.23 pg/ml cell culture), using mechanisms whichwere considered for “non-genomic’ and includemembrane associated forms of ERs (11).

In October 2007 team of Japanese biochemists reveal themechanism of action of BPA as xenoestrogen. They provethat BPA is bound with high affinity to the ERR-gama(ERRã - estrogen-related receptor-gama). This “orphan”receptor (the endogenous ligand is unknown) oftencontains a transcriptional activation function, In contrastto ER, BPA binds to ERRã very strongly [dissociationconstant (Kd) = 5.5 nM]. The binding activity of ÂÐÀmaintains the basal structural activity of ERRã. It preventsthe receptor from deactivation by the selective estrogenreceptor modulator 4-hydroxytamoxifen (12).

For “low doses” for endocrine disruptors are considereddoses below “no observable adverse effect level”(NOAEL) (13), which for BPA are doses lower than 50 mg/kg body mass daily. The data published of more than 150studies show effects of lower doses of BPA in animals ashyperplasia and prostate cancer, breast cancer, effectson the hypothalamus with follow-up disorders in the sexualdimorphism, menstrual cycle and early puberty, deviationsin the body mass, genital malformations etc, (14). In morethan 40 of these studies are considered similar effects indoses lower than the referent BPA dose 0,50 mg/kg bodymass daily.

These results should be the subject of concern, havingin mind the epidemiological tendencies for human beings.Due to its wide-spread use and estrogenic activity showedin vitro è in vivo BPA is considered to be the possiblecausing agent of a variety of adverse effects for the humanhealth (15,16,17,18). There are hypotheses according towhich the exposure to xenoestrogens like BPA mainly




çäðàâå (15,16,17,18). Ñúùåñòâóâàò õèïîòåçè, ñïîðåä êîèòîåêñïîçèöèÿòà íà êñåíîåñòðîãåíè êàòî BPA, îñîáåíî ïîâðåìå íà ðàííîòî ðàçâèòèå (ïðå- è ïîñòíàòàëíî), ìîæå äàñå îêàæå ïðè÷èíàòà çà íàðàñòâàùèòå ñëó÷àè íà áåçïëîäèå,ìàëôîðìàöèè íà ãåíèòàëèèòå, îòêëîíåíèÿ â ïîëîâîòîðàçâèòèå è ðàê íà ìëå÷íàòà æëåçà, íàáëþäàâàíè ñðåä÷îâåøêèòå ïîïóëàöèè â Åâðîïà è ÑÀÙ ïðåç ïîñëåäíèòå50 ãîäèíè (19, 20, 21).

Ðîëÿ íà Åâðîïåéñêèÿ îðãàí ïî áåçîïàñíîñòíà õðàíèòå (EFSA)

Ïúðâîíà÷àëíîòî íîðìèðàíå íà ÂÐÀ â ìàòåðèàëèòå èïðåäìåòèòå îò ïëàñòìàñè, ïðåäíàçíà÷åíè çà êîíòàêò ñ õðàíèñå èçâúðøâà ïðåç 1986 ã. îò Íàó÷íèÿ êîìèòåò ïî õðàíèòå(SCF – Scientific Committee on Food). Êîìèòåòúò îïðåäåëÿñòîéíîñòòà çà ïîíîñèì äíåâåí ïðèåì (TDI – tolerable dailyintake) îò 0.05 mg/kg òåëåñíà ìàñà äíåâíî çà òîâà âåùåñòâî.Òàçè ñòîéíîñò ñå îñíîâàâà íà 90-äíåâíî èçñëåäâàíå íàïëúõîâå è ìèøêè, ïðèåìàëè ÂÐÀ ñ õðàíàòà. Êàòîîêîí÷àòåëíà íàé-ãîëÿìà äîçà, íåïðåäèçâèêâàùà âðåäåíåôåêò (NOAEL - no observed adverse effect level), åîïðåäåëåíà äîçàòà îò 25 mg/kg òåëåñíà ìàñà äíåâíî. Êúìíåÿ ñå ïðèëàãà ôàêòîð íà íåñèãóðíîñò 500 (UF – uncertaintyfactor), ïîðàäè íåäîñòàòú÷íèòå äàííè.

Ïðåç 2002 ã. SCF ïðàâè ïðåîöåíêà. Îêîí÷àòåëíàòà îðàëíàNOAEL çà áèñôåíîë À ñå îöåíÿâà íà 5 mg/kg òåëåñíàìàñà äíåâíî. Îïðåäåëåí å âðåìåíåí TDI îò 0,01 mg/kgòåëåñíà ìàñà äíåâíî. Èçïîëçâàíèÿò UF îòíîâî å 500 (100çà ìåæäó- è âúòðåâèäîâèòå ðàçëè÷èÿ, óìíîæåí ïî 5,ïîðàäè íåïúëíàòà áàçà äàííè).

Ïðåç 2006 ã., EFSA ïóáëèêóâà îöåíêà íà çäðàâíèÿ ðèñêïðè åêñïîíèðàíè íà áèñôåíîë À õîðà. Â òîçè äîêóìåíòîêîí÷àòåëíî e äåôèíèðàíà ñòîéíîñòòà çà ïîíîñèì äíåâåíïðèåì (TDI) îò 0.05 mg/kg òåëåñíà ìàñà äíåâíî çà òîâàâåùåñòâî (22). Òàçè îöåíêà íà ðèñêà ñå îñíîâàâà íà òåñòîâåçà òîêñè÷íîñò, ïðîâåäåíè âúðõó îïèòíè æèâîòíè.Åêñïåðòíàòà ãðóïà ïî äîáàâêè â õðàíèòå, àðîìàòè,ñïîìàãàòåëíè ñðåäñòâà çà îáðàáîòêà è ìàòåðèàëè, êîèòîâëèçàò â êîíòàêò ñ õðàíè (AFC), ñìÿòà ðåçóëòàòèòå îò äâåòåèçñëåäâàíèÿ íà íÿêîëêî ïîðåäíè ïîêîëåíèÿ ïëúõîâå (23) èìèøêè (24) çà äîñòàòú÷íî àâòîðèòåòíè, çà äà ïîñëóæàò çàîïðåäåëÿíå íà íàé-ìàëêàòà íàáëþäàâàíà åôåêòèâíà äîçà(LOAEL - lowest observed adverse effect level) êàòî 50 mg/kg òåëåñíà ìàñà äíåâíî è NOAEL îò 5 mg/ kg òåëåñíà ìàñàäíåâíî. Òîâà ñòàâà, ñëåä êàòî å èãíîðèðàí äîáàâåíèÿò UF5.

Ðåâèçèÿòà íà ôàêòîðà íà íåñèãóðíîñò å ðåøåíà ïîðàäèîïèñàíèòå âèäîâè ðàçëè÷èÿ â òîêñèêîêèíåòèêàòà íà ÂÐÀìåæäó ãðèçà÷èòå è ÷îâåêà. ÂÐÀ ñå àáñîðáèðà áúðçî âãàñòðî-èíòåñòèíàëíèÿ òðàêò, ñëåä êîåòî ñå ãëþêóðîíèðà â÷åðíèÿ äðîá è òîâà îáðàçóâàíå íà áèñôåíîë À – ãëþêóðîíèäñå ÿâÿâà îñíîâíèÿò ïúò íà áèîòðàíñôîðìàöèÿ ïðè ïðèìàòèòå(âêë. ÷îâåêà) è ãðèçà÷èòå. Ãëþêóðîíèðàíåòî ïðåäñòàâëÿâàðåàêöèÿ íà äåçàêòèâàöèÿ, çàùîòî áèñôåíîë À – ãëþêóðîíèäúòíå ïðèòåæàâà åíäîêðèííà àêòèâíîñò. Ñâîáîäíèÿò ÂÐÀ ìîæåäà áúäå èíàêòèâèðàí ñúùî ÷ðåç ñóëôàòèðàíå. Ïúòèùàòà íàåëèìèíèðàíå ïðè ïðèìàòèòå è ïðè ãðèçà÷èòå ñà ðàçëè÷íè.

during early development (pre- and postnatal), can bethe cause for growing numbers of sterility, malformationsof genitals, deviations in the sexual development andbreast cancer, observed in the human populations inEurope and in the USA over the past 50 years (19, 20,21).

Role of the European Food Safety Authority(EFSA)

The primary standardization of BPA in the materials andplastic issues designed for contact with foods wasperformed in 1986 by the Scientific Committee on Food(SCF). The Committee has defined the value for tolerabledaily intake (TDI) 0.05 mg/kg body weight daily for thissubstance, whose value is based on 90-day survey onrats and mice that took BPA with food. As a final oneand the biggest NOAEL dose is that of 25 mg/kg bodyweight daily. To this dose is applied uncertainty factor(UF) of 500, due to insufficient data availability

In 2002 SCF made a reassessment. The final oral NOAELfor BPA was assessed to be 5 mg/kg body weight perday. The temporary daily intake (TDI) of 0,01 mg/kg bodyweight daily was determined. The used standarduncertainty factor (UF) again is 500 (100 for inter- andintraspecies differences, multiplied by 5 due toincomplete data bases).

In 2006 EFSA published a health risk assessment forpeople’s exposure to BPA. In this document finally wasdefined the value for TDI of 0.05 mg/kg body weightdaily for this substance (22). This risk assessment wasbased on tests for toxicity performed on experimentalanimals. The expert Panel on Food Additives,Flavourings, Processing Aids and Materials in Contactwith Food (AFC) has considered the results from bothstudies on serial generations of rats (23) and mice (24)for sufficiently authoritative in order to serve for thedetermination of the - lowest observed adverse effectlevel (LOAEL) as 50 mg/ kg body weight daily andNOAEL of 5 mg/ kg body weight per day. This happenedafter ignoring the added UF 5.

The revision of UF was settled due to described speciesdifferences in the toxicokinetics of BPA between rodentsand humans. BPA is rapidly absorbed in the gastro-intestinal tract, after that it is glucoronized in the liverand this form of BPA – glucuronide appears to be themain route for biotransformation in primates (includinghuman being) and rodents. The glucuronidation is areaction of deactivation because BPA glucuronide doesnot have endocrine activity. Free BPA could beinactivated through sulfatation. Paths for eliminationin primates and human beings are different. In humanbeins 80% of the absorbed BPA is excreted by urine inthe next 5 hours. In rodents there has been observedenterohepatitic circulation (deglucuronidation to freeBPA and again glucuronidation) and significantlyslower elimination by feces. Having in mind these



Ïðè õîðàòà 80% îò ïîãúëíàòèÿ ÂÐÀ ñå åêñêðåòèðà ñ óðèíàòàâ ñëåäâàùèòå 5 ÷àñà. Ïðè ãðèçà÷èòå ñå íàáëþäàâàåíòåðîõåïàòàëíà öèðêóëàöèÿ (äåãëþêóðîíèðàíå äî ñâîáîäåíÂÐÀ è îòíîâî ãëþêóðîíèðàíå) è çíà÷èòåëíî ïî-áàâíîåëèìèíèðàíå ñ ôåöåñà. Ïðåäâèä òåçè ðàçëèêè è íèñêàòàñèñòåìíà êîíöåíòðàöèÿ íàìåðåíà ó õîðà, â ñðàâíåíèå ñïëúõîâåòå, AFC îïðåäåëÿ ôàêòîð íà íåñèãóðíîñò 100.Åêñïåðòíàòà ãðóïà ñúùî òàêà çàêëþ÷àâà, ÷å ïðèåìúò íà ÂÐÀñ õðàíèòå è íàïèòêèòå å ìíîãî ïî-íèñúê îò TDI, äîðè ïðèêúðìà÷åòàòà è ìàëêèòå äåöà (22).

Ïðåç þëè 2008 ã., ïîðàäè íàëè÷èå íà íîâè äàííè îòïðîó÷âàíèÿ, èçâúðøåíè ñúãëàñíî óêàçàíèÿòà çà Äîáðàëàáîðàòîðíà ïðàêòèêà íà OECD (Îðãàíèçàöèÿòà çàèêîíîìè÷åñêî ñúòðóäíè÷åñòâî è ðàçâèòèå), EFSA èçâúðøâàïî-ïîäðîáíà îöåíêà íà âúçðàñòîâèòå ðàçëè÷èÿ âòîêñèêîêèíåòèêàòà ïðè æèâîòíè è õîðà è òÿõíîòîïðèëîæåíèå çà îöåíêà íà ðèñêà è îïàñíîñòòà îò ÂÐÀ âõðàíèòå. Ïðåäâèä ìàé÷èíèÿ êàïàöèòåò çà êîíþãàöèÿ, AFCñ÷èòà åêñïîçèöèÿòà íà ÷îâåøêèÿ ôåòóñ íà ñâîáîäåí ÂÐÀ çàíåçíà÷èòåëíà, çà ðàçëèêà îò ôåòóñèòå íà ïëúõà, êîèòî ñàåêñïîíèðàíè íà ñâîáîäåí ÂÐÀ îò ìàé÷èíîòîêðúâîîáðàùåíèå. Ïàíåëúò çàêëþ÷àâà, ÷å íîâîðîäåíèòå äåöàïðèòåæàâàò äîñòàòú÷åí êàïàöèòåò äà áèîòðàíñôîðìèðàò ÂÐÀäî õîðìîíàëíî íåàêòèâíè ôîðìè ïðè íèâàòà íà åêñïîçèöèÿ,äîêëàäâàíè îò EFSA ïðåç 2006 ã. è â Äîêëàäà çà îöåíêà íàðèñêà íà Åâðîïåéñêèÿ ñúþç îò 2003 ã. (25) è îò 2008 ã. (26) (EURAR). Ïðåäâèä îïèñàíèòå ðàçëè÷èÿ â òîêñèêîêèíåòèêàòà èòåõíèÿ åôåêò âúðõó òîêñè÷íîñòòà, ïðè äàäåíà åêâèâàëåíòíàäîçà ÂÐÀ, òÿ áè áèëà ïî-âèñîêà ïðè ïëúõîâåòå îò âñÿêà âúçðàñò,â ñðàâíåíèå ñ õîðàòà. Ïàíåëúò ðåøàâà, ÷å âúçðàñòîâèòå ðàçëè÷èÿâ òîêñèêîêèíåòèêàòà íà ÂÐÀ ïðè æèâîòíè è õîðà íÿìàòçíà÷åíèå çà îöåíêàòà íà ðèñêà è ïðåïîòâúðæäàâà TDI (27).

Íà 15.10.2009 ã. Åâðîïåéñêàòà êîìèñèÿ îòïðàâÿ èñêàíå êúìEFSA çà íîâà îöåíêà íà ðèñêà, âñëåäñòâèå íà ïîëó÷åíè íîâèíàó÷íè äàííè çà âðåäíè åôåêòè íà áèñôåíîë À. Ñòàíîâèùåòîíà Åêñïåðòíàòà ãðóïà ïî ìàòåðèàëèòå, êîèòî âëèçàò â êîíòàêòñ õðàíè, åíçèìèòå, äîáàâêèòå â õðàíèòå, àðîìàòèçàíòèòå èñïîìàãàòåëíèòå ñðåäñòâà çà îáðàáîòêà, å îáÿâåíî ïðåçñåïòåìâðè 2010 ã. Ìåæäóâðåìåííî ñà àíàëèçèðàíè âñè÷êèïðîó÷âàíèÿ ïî ïðîáëåìà, âñè÷êè íàëè÷íè íàó÷íèäîêàçàòåëñòâà, íàä 800 ïóáëèêàöèè. Â ñâîåòî ñòàíîâèùåÅêñïåðòíàòà ãðóïà ñòèãà äî çàêëþ÷åíèåòî, ÷å, âúç îñíîâà íàäåòàéëíàòà îöåíêà íà ïîñëåäíèòå äàííè çà òîêñè÷íîñò ïðèõîðàòà è æèâîòíèòå, íå ñå íàìèðà íîâî ïðîó÷âàíå, êîåòî äàèçèñêâà ïðåðàçãëåæäàíå íà äîñåãàøíèòå ñòîéíîñòè çà TDIîò 0,05 mg/kg òåëåñíà ìàñà äíåâíî.

Â „ìíåíèå íà ìàëöèíñòâîòî“, âñå ïàê åäèí îò ÷ëåíîâåòå íàÅêñïåðòíàòà ãðóïà çàêëþ÷àâà, ÷å åôåêòèòå, íàáëþäàâàíè ïðèîïðåäåëåíè ïðîó÷âàíèÿ è ïðåäèçâèêàëè ñúìíåíèÿ, ñà èçâúíîáõâàòà íà íàñòîÿùèÿ TDI, êîéòî ïîðàäè òîâà ñëåäâà äà ñåñ÷èòà çà âðåìåíåí äî ïîëó÷àâàíåòî íà ïî-íàäåæäíè äàííè âîáëàñòèòå, â êîèòî ñúùåñòâóâà íåñèãóðíîñò. Åêñïåðòíàòàãðóïà îòáåëÿçâà, ÷å íÿêîè ïðîó÷âàíèÿ, ïðîâåäåíè âúðõóíåçàâúðøèëè ñâîåòî ðàçâèòèå æèâîòíè, äîïóñêàòâúçìîæíîñòòà çà íàëè÷èå íà äðóãè âèäîâå òîêñè÷íè åôåêòè,ñâúðçàíè ñ BPA, â ÷àñòíîñò áèîõèìè÷íè ïðîìåíè â ìîçúêà,èìóíîìîäóëàöèÿ è ïîâèøåíà ïðåäðàçïîëîæåíîñò êúì

differences and the low systematic concentrationfound in humans in comparison to the rats, AFC hasdetermined UF 100. The Panel also draw the conclusionthat the intake of BPA with foods and beverages issignificantly lower than the TDI, as well revealed forinfants and young children (22).

In July 2008 due to the presence of new data obtainedfrom studies peãformed according to the guidelinesfor Good laboratory practice of the Organization foreconomic collaboration and development (OECD).EFSA has performed more detailed assessment of theage differences in the toxicokinetics in animals andhumans and their application for assessing the riskand threat from BPA in foods. Having in mind themother’s capacity for conjugation AFC Panelconsiders the exposure of the human fetus to freeBPA for insignificant in contrast to the fetuses of rat,which are exposed to free BPA from the mother’scirculation. The Panel made the conclusion thatnewborns have significant capacity to biotransformBPA to hormonal inactive forms in the exposure levelsreported by EFSA in 2006 and in the Report for riskassessment of the European Union in 2003 (25) and in2008 (26) (EU RAR). Having in mind the differencesdescribed in toxicokinetics and their effect on toxicityat a certain equivalent dose of BPA it would be higherin rats of all ages in comparison to humans. The Paneldesided that the age differences in the toxicokineticsof BPA in animals and humans are not significant forthe risk assessment and reaffirmed the TDI (27).

On October 15th 2009 the European Commission madea request to EFSA for a new risk assessment due tonew scientific data received for the adverse effects ofBPA. The statement of the expert Panel on FoodAdditives, Flavourings, Processing Aids andMaterials in Contact with Food (AFC) was announcedin September 2010 as in between all studies on theproblem were analyzed and all available scientificevidence was made accessible including 800publications. In its statement the expert Panel arrivedat a conclusion that on the basis of a detailedassessment on the last data for toxicity in humansand animals it was not found a new study that couldrequire a reconsideration of the existing values forTDI of 0,05 mg/kg bw/day.

In the opinion of 2010 a Panel member expressed a“minority opinion” that the effects observed in certainstudies and provoked doubts are outside the rangeof the current TDI, which should be considered fortemporary one until receiving new more reliable datain the fields where uncertainties exist. The expert Panelmentioned that some studies performed on immatureanimals have assumed the opportunity for presenceof other types of toxic effects related to BPA inparticular biochemical changes in the brain,ummunomodulation and increased predisposition tothe development of breast cancer. According to the


ðàçâèòèå íà òóìîðè íà ãúðäàòà. Ñïîðåä åêñïåðòèòå òåçèïðîó÷âàíèÿ èìàò ðåäèöà íåäîñòàòúöè è ïîíàñòîÿùåì íåìîæå äà áúäå îöåíåíî äîêîëêî òåõíèòå ðåçóëòàòè èìàòîòíîøåíèå êúì ÷îâåøêîòî çäðàâå. Â ñëó÷àé, ÷å â áúäåùåñòàíàò èçâåñòíè íîâè äàííè, êîèòî ñà îò çíà÷åíèå,Åêñïåðòíàòà ãðóïà ùå ïðåðàçãëåäà ñòàíîâèùåòî ñè (28).

Ìíåíèåòî íà ìåæäóíàðîäíàòà íàó÷íàîáùíîñò

Ìåæäóâðåìåííî ñà ïóáëèêóâàíè ñúîáùåíèÿ çà ïîâå÷åîò 40 èçñëåäâàíèÿ, ïðîâåäåíè îò ðàçëè÷íè íàó÷íè åêèïè,ïðè êîèòî ñà óñòàíîâåíè òîêñè÷íè åôåêòè âúðõó ãðèçà÷è,ïðè ïåðîðàëåí ïðèåì íà äîçè îò 0,05 mg/kg òåëåñíà ìàñàäíåâíî è ïî-íèñêè (29). Èçñëåäâàíè ñà ìîðôîëîãèÿòà íàðåïðîäóêòèâíèòå îðãàíè, ðàçâèòèåòî íà íåðâíàòàñèñòåìà, ïîâåäåíèåòî, ðåïðîäóêòèâíîòî çäðàâå íàìúæêèòå æèâîòíè è èìóíèòåòà. Îöåíêàòà íà EFSA îò2006 ã. (22) è Äîêëàäúò çà îöåíêà íà ðèñêà íà Åâðîïåéñêàòàêîìèñèÿ îò 2008 ã. (26) ïîñòàíîâÿâàò, ÷å íèòî åäíî îò òåçèïðîó÷âàíèÿ íà íèñêîäîçîâèòå åôåêòè íà ÂÐÀ íå ìîæå äàïðåäñòàâè êà÷åñòâåíè äàííè çà îöåíêà íà ðèñêà èïîëó÷åíèòå îò òÿõ ðåçóëòàòè ñà ïðåíåáðåãíàòè.Ïðîòèâîïîëîæíî íà ïîâå÷åòî ñòðàíè-÷ëåíêè, íÿêîèñåâåðíè ñòðàíè (Äàíèÿ, Øâåöèÿ è Íîðâåãèÿ) ïðèçíàâàò 4èçñëåäâàíèÿ çà åôåêòèòå íà ÂÐÀ âúðõó íåðâíàòà ñèñòåìàè ïîâåäåíèåòî êàòî âàëèäíè çà îöåíêà íà ðèñêà (30, 31,32, 33).

Ñ öåë ïðåðàçãëåæäàíå íà îöåíêàòà íà ðèñêà íà FDA (Foodand Drug Administration), Íàó÷íèÿò êîìèòåò íà òîçèðåãóëàòîðåí îðãàí ïðåç 2008 ã. ñúçäàâà ïîäêîìèòåò, êîéòîäà ðåøè ïðîáëåìà. Òîçè ïîäêîìèòåò îñòðî êðèòèêóâàFDA êàòî, â ÷àñòíîñò, èçðàçÿâà íåñúãëàñèå ñíåâêëþ÷âàíåòî íà ãîëÿì áðîé èçñëåäâàíèÿ, êîèòî íå ñàïðîâåäåíè ñúãëàñíî GLP, â òàçè îöåíêà. Ó÷åíèòå ñìÿòàò,÷å òåæåñòòà íà íàó÷íèòå äîêàçàòåëñòâà å äîñòàòú÷íà, çàäà áúäå çàäàäåíà êàòî NOAEL ñòîéíîñò îò åäèí èëèïîâå÷å ïîðÿäúêà ïî-íèñêà îò çàäàäåíàòà îò FDA 5 mg/ kgòåëåñíà ìàñà äíåâíî.

Ìåæäóíàðîäíà ðàáîòíà ñðåùà âúðõó îöåíêàòà íàáèñôåíîë À (30-31 ìàðò 2009 ã.), ïðîâåäåíà ïîä åãèäàòàíà Ãåðìàíñêàòà ôåäåðàëíà àãåíöèÿ ïî îêîëíàòà ñðåäà(UBA) çàêëþ÷è, ÷å òðÿáâà äà áúäàò ðàçãëåäàíè âñè÷êèíàëè÷íè äàííè, âêëþ÷èòåëíî ïîëó÷åíèòå îò èçñëåäâàíèÿ,íåïðîâåäåíè ñúãëàñíî íàðú÷íèöèòå çà GLP. Íåîáõîäèìîå äà áúäàò èçïîëçâàíè âñè÷êè íàëè÷íè äàííè èðåãóëàòîðíèòå îðãàíè íå òðÿáâà äà îòäàâàò çíà÷åíèå íàìàëêîòî èçñëåäâàíèÿ, ïðîâåäåíè ñúãëàñíî Äîáðàòàëàáîðàòîðíà ïðàêòèêà, èãíîðèðàéêè ñòîòèöèòå, ïðîâåäåíèïî èíèöèàòèâà íà ñàìèòå èçñëåäîâàòåëè. Èçâåäåíè ñà ñúùîè íÿêîè êðèòåðèè çà êà÷åñòâî, íà êîèòî òðÿáâà äà îòãîâàðÿòïðîó÷âàíèÿòà (34). Íà ñúùàòà ðàáîòíà ñðåùà Rochelle Tyl,àâòîð íà äâåòå èçñëåäâàíèÿ, èçïîëçâàíè îò EFSA ïðåç 2006ã.è îò FDA ïðåç 2008 ã. êàòî äîêàçàòåëñòâà çà áåçîïàñíîñòòàíà ÂÐÀ, çàÿâÿâà, ÷å òåçè èçñëåäâàíèÿ íå ïðåòåíäèðàò, ÷å ÂÐÀå áåçîïàñåí, çàùîòî íå ïîêðèâàò âñè÷êè àñïåêòè íà íåãîâîòîâúçäåéñòâèå. Òèë ïðèçíàâà, ÷å â äîêëàäà íà FDA îò 2008 ã.,

experts these studies have a variety of disadvantagesand up to now it could not be assessed whether theirresults have any effects on the human health. In casethere have been known new data which are importantfor this case the expert Panel will reconsider itsstatement (28).

Views of the international scientificcommunity

Meanwhile, there have been published announcementsfor more than 40 studies, carried out by different researchteams, in which toxic effects on rodents were establishedin peroral administration of doses of 0,05 mg/kg bw/dayand lower ones (29). There have been investigated themorphology of the reproductive organs, developmentof the nervous system, behavior, reproductive health ofmale animals and immunity. Both the assessment of EFSAperformed in 2006 (22) and the Report of the EuropeanCommission for risk assessment published in 2008 (26)confirm that neither of these studies on low BPA dosesreveal qualitative data for the risk assessment and theresults obtained from them were neglected. In contrastto more of the EU’s member states some several countries(Denmark, Sweden and Norway) recognize four studiesfor BPA effects on the nervous system and behavior asvalid for the risk assessment (30, 31, 32, 33).

In order to reconsider the risk assessment of the Foodand Drug Administration (FDA) the EFSA Scientificcommittee in 2008 created a subcommittee that shouldfind a resolution to the problem. This subcommitteesharply criticized FDA as, in particular, expresseddisagreement with the non-inclusion of a great deal ofstudies which were not performed according to the goodlaboratory practice (GLP). The researchers consider thatthe weight of scientific evidence is sufficient to be putas a NOAEL value at least an order of magnitude lowerthan the value of 5 mg/ kg bw/day selected by FDA.

The international workshop on the BPA assessment (30-31 March 2009) performed under the auspices of theGerman Federal Environmental Agency (UBA) concludedthat there should be considered all data availableincluding those received from studies that were notcarried out according to the manuals for GLP. For thegoals of the regulation it is necessary to use all the dataavailable and the regulatory bodies should not attachimportance to the few studies performed according toGLP principles, thus ignoring about hundreds ofstudies fulfilled on the own initiative of the researchers.There have been drawn some quality criteria thatshould be met by the studies (34). At the sameworkshop Rochelle Tyl, author of both studies usedby EFSA in 2006 and by FDA in 2008 as evidence forthe safety of BPA, made a statement that these studiesdid not pretend that BPA was safe because they donot cove all the aspects of its effect. Tyl has



ñïîíñîðèðàí îò American Chemistry Council, òúðãîâñêààñîöèàöèÿ íà ïðîèçâîäèòåëèòå íà ÂÐÀ, ñà íàëèöå ìíîãîãðåøêè è ïðîòèâîðå÷èÿ (35).

Äðóã èçòî÷íèê íà ïðîòèâîðå÷èÿ å ðåàëíàòà âúòðåøíàåêñïîçèöèÿ íà õîðàòà. Çà áèîëîãè÷íî àêòèâåí ñå ñ÷èòàåäèíñòâåíî ñâîáîäíèÿò áèñôåíîë À, òîâà íå âàæè çà íåãîâèòåìåòàáîëèòè. Ïðè áèîìîíèòîðèíãîâè ïðîó÷âàíèÿ âÃåðìàíèÿ (36) è ÑÀÙ (37), â êðúâòà íà ìàéêèòå ñà èçìåðåíèíèâà îò 4-6 ng/ ml ñâîáîäåí ÂÐÀ. Âúïðåêè èçïîëçâàíèòåðàçëè÷íè òåõíèêè, ðåçóëòàòèòå îò èçñëåäâàíèÿòà ñàèäåíòè÷íè. Ìåæäóâðåìåííî, â êðúâòà íà äåâåòèìàäîáðîâîëöè, ïðèåëè öåëåíàñî÷åíî äîçà îò 5 mg ïåðîðàëíî,íå å íàìåðåí ñâîáîäåí ÂÐÀ (38). Òîâà å åêñïåðèìåíòúò, âúðõóêîéòî EFSA îñíîâàâà ñâîÿòà îöåíêà íà ðèñêà, äîïóñêàéêè÷å â êðúâòà íà õîðàòà íå ñå îòêðèâàò íèêàêâè êîíöåíòðàöèèíà ÂÐÀ, êîèòî áèõà ìîãëè äà èìàò ïðàêòè÷åñêî çíà÷åíèå.Íàëèöå å ãîëÿìî íåñúãëàñèå ìåæäó åêñïåðòèòå ïî âúïðîñàçà PBPK (Physiologically-based pharmacokinetic modeling –ìåòîä íà ìàòåìàòè÷åñêî ìîäåëèðàíå, ïîçâîëÿâàùåêñòðàïîíèðàíåòî íà ïîëó÷åíèòå ðåçóëòàòè îòåêñïåðèìåíòàëíè æèâîòíè êúì õîðà) ìîäåë íà BPA çà õîðàòà.Åôåêòèòå íà ÂÐÀ âúðõó îðãàíèçìà çàâèñÿò îò òîâà êàêâî åíàëè÷íîòî êîëè÷åñòâî íà ñâîáîäåí ÂÐÀ è çà êàêúâ ïåðèîä îòâðåìå êëåòêèòå ñà èçëîæåíè íà äåéñòâèåòî ìó. Åäèí íàñêîðîïóáëèêóâàí îáçîð øèðîêî äèñêóòèðà ïðèëîæèìîñòòà íàèçìåðâàíèÿòà íà ñâîáîäíèÿ è êîíþãèðàí áèñôåíîë À â÷îâåøêà êðúâ (39). Ìíîãî ïåðèôåðíè îðãàíè, âêëþ÷èòåëíîïëàöåíòàòà, èìàò âèñîêà àêòèâíîñò íà ãëþêóðîíèäàçè èñóëôàòàçè, êîèòî ñà ñïîñîáíè äà äåêîíþãèðàò íåàêòèâíèòåìåòàáîëèòè äî ñâîáîäíàòà è ìåòàáîëèòíî àêòèâíà ôîðìà.Ïðèñúñòâèåòî â êðúâòà åäèíñòâåíî íà êîíþãèðàí áèñôåíîëÀ íå ãàðàíòèðà, ÷å ñóáñòàíöèÿòà å áèîëîãè÷íî íåàêòèâíà èâ òúêàíèòå. Ïðåäïîëîæåíèåòî íà EFSA, ÷å áúðçàòà êîíþãàöèÿïðåäïàçâà õîðàòà îò âðåäíè åôåêòè íå å â ñúîòâåòñòâèå ñïîëèòèêàòà íà Åâðîïåéñêèÿ ñúþç çà õèìè÷íèòå âåùåñòâà, â÷àñòíîñò ñ ïðèíöèïà íà ïðåäîõðàíèòåëíèòå ìåðêè (40).

Äðóã ïðîáëåì å âçàèìîäåéñòâèåòî íà ÂÐÀ ñ äðóãèñóáñòàíöèè â îðãàíèçìà. Èçñëåäâàíå, ïðîâåäåíî ïðåç 2009ã., äîêàçâà, ÷å íÿêîè øèðîêîóïîòðåáÿâàíè ìåäèêàìåíòè -êàòî ñàëèöèëîâà êèñåëèíà, êàðáàìàçåïèí, íàïðîêñåí è äð.,ìîãàò çíà÷èòåëíî äà èíõèáèðàò ãëþêóðîíèðàíåòî íà ÂÐÀ invitro(41). Ïîâå÷åòî îò ïóáëèêóâàíèòå íàó÷íèáèîìîíèòîðèíãîâè ïðîó÷âàíèÿ ïîñëåäîâàòåëíî îòêðèâàòçíà÷èòåëíè íèâà íà ñâîáîäåí áèñôåíîë À â ÷îâåøêàòà êðúâ.Íàñêîðî îïîâåñòåí îáçîð íà áèîìîíèòîðèíãîâèòåïðîó÷âàíèÿ çàêëþ÷àâà: „Íàëè÷íèòå äàííè îòáèîìîíèòîðèíãîâèòå ïðîó÷âàíèÿ ÿñíî ïîêàçâàò, ÷åîñíîâíàòà ïîïóëàöèÿ å åêñïîíèðàíà íà ÂÐÀ è õîðàòà ñà âðèñê îò âúòðåøíî åêñïîíèðàíå ñ íåêîíþãèðàí ÂÐÀ. Äâåòåòîêñèêîêèíåòè÷íè èçñëåäâàíèÿ (23,24), êîèòî èçêàçâàòïðåäïîëîæåíèåòî, ÷å ÷îâåøêàòà åêñïîçèöèÿ íà ÂÐÀ åíåçíà÷èòåëíà, èìàò ñúùåñòâåíè íåäîñòàòúöè, äèðåêòíî ñåîïðîâåðãàâàò îò ïðîó÷âàíèÿ, îñíîâàíè íà õèïîòåçè è ïîðàäèòàçè ïðè÷èíà íà òÿõ íå ìîæå äà ñå ðàç÷èòà çà öåëèòå íàîöåíêàòà íà ðèñêà .” (42)

recognized that in the FDA Report since 2008 sponsoãedby the American Chemistry Council, a trade associationof the producers of BPA, there were lots of mistakesand contradictions (35).

Other source of contradictions is the real internalexposure of humans. For biologically active one isconsidered only free BPA, while this is not valid for itsmetabolites. In biomonitoring studies performed inGermany (36) and USA (37), in the blood of mothersthere were measured free BPA levels of 4-6 ng/ ml.Despite the different techniques used the resultsreceived from the studies are identical. Meantime, inthe blood of ninth volunteers who intentionally took aperoral dose of 5 mg free BPA was not found (38). Thisis the experiment on which EFSA based its riskassessment with the admission that in the blood ofhumans no BPA concentrations were found whichcould have any practical significance. There is a greatdisagreement among the experts on the issue for PBPK(physiologically-based pharmacokinetic modeling () –a method of mathematical modeling, allowing thetransponation of results received from experimentalanimals to humans) model of BPA for human beings.BPA effects on the organism depends on the availablequantity of free BPA and on the time period for whichcells are being exposed to it. Recently published reviewhas widely discussed the applicabili ty of themeasurements of free and conjugated BPA in humanblood (39). Lots of peripheral organs, includingplacenta, have a high activity of glucuronidases andsulfatases, which are free to disconjugate the inactivemetabolites of the free and metabolic active form. Thepresence in blood of only conjugated BPA does notguarantee that the substance is biologically inactivein the tissues, too. The supposition of EFSA that rapidconjugation prevents people from adverse effects isnot in accordance with the policy of the EuropeanUnion for chemical substances, in particular, theprecautionary principle (40).

Another problem arisen is the interaction of ÂÐÀ withother substances in the organism. An in vitro studyconducted in 2009 showed that some widely usedmedications as salicylic acid, carbamazepine, naproxenetc., could significantly inhibit the glucuronidation ofBPA (41). Most of the published scientificbiomonitoring studies have found significant levels offree BPA in human blood. A recently released reviewof biomonitoring studies has concluded: „The availabledata from biomonitoring studies clearly show that themain population is exposed to BPA and people are atrisk of internal exposure to non-conjugated BPA. Bothtoxicokinetic studies (23,24), which make a guess thatthe human exposure to BPA is insignificant, haveessential disadvantages, have been directly denied bystudies based on hypotheses and due to this it cannotbe relied on them for the goals of the risk assessment.”(42)



Ïîçèöèÿ íà ïðàâèòåëñòâàòà è èíäóñòðèÿòà

Ïðàâèòåëñòâîòî íà Êàíàäà îáÿâè ÂÐÀ çà îïàñåí ïðåç 2008ã. è â ìîìåíòà òîé å â ñïèñúêà íà òîêñè÷íèòå âåùåñòâà.Ìèíèñòåðñòâàòà íà çäðàâåîïàçâàíåòî è íà îêîëíàòà ñðåäàïðåäïðèåõà ìåðêè çà îãðàíè÷àâàíå íà âíîñà, ïðîäàæáèòåè ðåêëàìàòà íà áåáåøêè áóòèëêè, ïðîèçâåäåíè îòïîëèêàðáîíàòíè ïëàñòìàñè. Ïðåç ñúùàòà ãîäèíà âåðèãàòàWal-Mart èçëåçå ñ èçÿâëåíèå, ÷å íåçàáàâíî ïðåêðàòÿâàïðîäàæáèòå íà êîíòåéíåðè çà õðàíà, áóòèëêè çà âîäà èáåáåøêè áóòèëêè, ÷àøè ñúñ ñëàìêè è çàëúãàëêè,ñúäúðæàùè ÂÐÀ âúâ âñè÷êè ñâîè ìàãàçèíè â Êàíàäà, êàòîùå èçòåãëè ïîñòåïåííî áåáåøêèòå áóòèëêè, ñúäúðæàùèÂÐÀ è îò ìàãàçèíèòå ñè â ÑÀÙ ïðåç ïúðâèòå ìåñåöè íà2009 ã. Ïðåç 2009 ã. øåñòòå íàé-ãîëåìè êîìïàíèè â ÑÀÙ,ïðîäàâàùè áåáåøêè áóòèëêè, ðåøèõà äà ñïðàò äàèçïîëçâàò ÂÐÀ â ñâîèòå ïðîäóêòè (43). Nalgene îáÿâè, ÷åùå ñïðå óïîòðåáàòà íà õèìèêàëà â ñâîèòå ïðîäóêòè, âïîñëåäñòâèå Toys-R-Us ñúùî çàÿâèõà, ÷å ïðåêðàòÿâàòïðîäàæáèòå íà áåáåøêè áóòèëêè, ñúäúðæàùè ÂÐÀ. Ïðåç2009 ã. Sunoco, ïðîèçâîäèòåë íà áåíçèí è õèìèêàëè, îòêàçàäà ïðîäàâà ÂÐÀ íà êîìïàíèè, ïðîèçâåæäàùè êîíòåéíåðèçà õðàíè è íàïèòêè çà äåöà ïîä 3 ãîäèíè. Ïúðâèòå ùàòè,êîèòî çàáðàíèõà ÂÐÀ â äåòñêèòå ïðîäóêòè (áåáåøêèøèøåòà è ÷àøè ñúñ ñëàìêè), áÿõà Ìèíåñîòà è Èëèíîèñ(ÿíóàðè 2010 ã.). Êúíåêòèêúò ñòàíà ïúðâèÿò ùàò, êîéòîçàáðàíè ÂÐÀ â îïàêîâêèòå íà âñè÷êè âèäîâå õðàíè çàêúðìà÷åòà, êàêòî è â êîíòåéíåðèòå çà õðàíè è íàïèòêè,ïðåäíàçíà÷åíè çà ìíîãîêðàòíà óïîòðåáà.

Ïðåç îêòîìâðè 2009 ã. Ãåðìàíñêàòà Ôåäåðàëíà àãåíöèÿïî îêîëíàòà ñðåäà (Bund für Umwelt und NaturschutzDeutschland) èçèñêà çàáðàíà íà BPA â ïðîäóêòèòå çà äåöà,îñîáåíî çàëúãàëêèòå è ìàòåðèàëèòå è ïðåäìåòèòå âêîíòàêò ñ õðàíè. Â îòãîâîð íà òîâà èñêàíå, íÿêîèïðîèçâîäèòåëè äîáðîâîëíî èçòåãëÿò îò ïàçàðàïðîáëåìíèòå çàëúãàëêè. Ïðåç íîåìâðè 2009 ã. ÑÇÎ (FAO)îáÿâè, ÷å ïðåç 2010 ã. ïðåäñòîè äà áúäå ñâèêàí êîíñèëèóìîò åêñïåðòè, êîèòî äà îöåíÿò áåçîïàñíîñòòà íà ÂÐÀ (44).Êîíñèëèóìúò ñå ñúñòîÿ íà 1-5 íîåìâðè 2010 ã. â Îòàâà,Êàíàäà. Â çàêëþ÷åíèåòî îò ñðåùàòà åêñïåðòèòåïîä÷åðòàâàò, ÷å óñòàíîâÿâàíåòî íà áåçîïàñíî íèâî íàåêñïîçèöèÿ çà áèñôåíîë À ïðîäúëæàâà äà áúäåâúçïðåïÿòñòâàíî îò íåäîñòèãà íà äàííè, âñëåäñòâèå íàìàëêèÿ áðîé åêñïåðèìåíòàëíè ïðîó÷âàíèÿ âúðõóæèâîòíè, êîèòî ñà ïîäõîäÿùè çà îöåíêà íà ðèñêà. Ïîâå÷åòîïðîó÷âàíèÿ ñòðàäàò îò íåäîñòàòúöè íà äèçàéíà èìåòîäèêàòà, êîèòî îãðàíè÷àâàò òÿõíîòî ïðèëîæåíèå çàöåëòà. Âúïðåêè òîâà, íÿêîè èçñëåäâàíèÿ âúðõó ÂÐÀ èíåãîâîòî âëèÿíèå âúðõó ñåêñóàëíèÿ äèìîðôèçúì,ïðåíåîïëàñòè÷íèòå ïðîìåíè â ìëå÷íèòå æëåçè èïðîñòàòàòà ïðè ïëúõîâå è ñïåðìàòîãåíåçàòà, ïîêàçâàòâðúçêà ñ åêñïîçèöèÿòà íà íèñêè äîçè, êîåòî äîêàçâàíóæäàòà îò áúäåùè èçñëåäâàíèÿ ïî ïðîáëåìà (45).

Äàíèÿ çàáðàíè èçïîëçâàíåòî íà ïëàñòìàñè, ñúäúðæàùèÂÐÀ, çà ïðîèçâîäñòâîòî íà áåáåøêè áóòèëêè ïðåç ìàðò2010. Ïðåç ñúùèÿ ìåñåö â Áåëãèÿ, ñåíàòîðúò PhilippeMahoux ïðåäëîæè çàêîíîäàòåëñòâîòî äà çàáðàíèèçïîëçâàíåòî íà ÂÐÀ â ìàòåðèàëèòå çà êîíòàêò ñ õðàíè. Íà

Reaction of the governments and industry

The federal government of Canada declared that BPA isdangerous in 2008 and it was placed in the toxicsubstances list. The Ministries of Health and of theEnvironment underwent measures for restriction of theimport, sales and advertisements of babies bottlesproduced by polycarbonate plastics. In the same year,the Wal-Mart Stores, Inc. announced immediatecanceling of the sales of containers for food, waterbottles and baby bottles, cups with straws and trinketsthat contain BPA in all of the stores in Canada and willwithdraw gradually the baby bottles containing BPA fromthe stores in the USA in the first months of the 2009. In2009 sixth of the biggest companies in the USA sellingbaby bottles decided to stop the use of BPA in theirproducts (43). Nalgene declared that it would suspendthe use of the chemical in their products; later on Toys-R-Us also declared that they would suspend the sales ofbaby bottles that contain BPA. In 2009 Sunoco ,manufacturer of gasoline and chemicals, refused to sellBPA to companies producing containers for food andbeverages for children below 3 years. The first statesthat banned BPA in kids products (baby bottles and cupswith straws) were Minnesota and Illinois (January 2010).Connecticut became the first state that banned ÂÐÀ inthe packages of all types of foods for infants as well as inthe multi-use food and beverages containers.

In October 2009 the German’s Federal EnvironmentAgency (Bund für Umwelt und Naturschutz Deutschland)requested to implement a ban on BPA in child products,especially trinkets and materials and issues coming intocontact with food. In reply to this request somemanufacturers voluntarily withdrew from the market thementioned trinkets. In November 2009 the World HealthOrganization (WHO) and the Food and AgricultureOrganization (FAO) declared that in 2010 would beconvene a council of experts who should assess the BPAsafety (44). The Joint FAO/WHO Expert meeting was heldon 1-5 November 2010 in Ottawa, Canada. In theconclusions of the meeting the experts pointed out thatthe establishment of safe level of BPA exposure continuesto be hindered from the insufficiency of data, as a resultof low number of experimental studies on animals thatwere convenient for the risk assessment. Most of thestudies have some flaws in relation to the design andmethods, which restrict their application to defined goal.Nevertheless, some studies on BPA and its effect on thesexual dimorphism, preneoplastic changes inmammalian glands and prostate in rats andspermatogenesis, revealed a relation to the exposureto low doses, which showed the necessity from futureexaminations on the problem (45).

Denmark banned the use of plastics containing BPAfor the production of baby bottles in March 2010. Atthe same month in Belgium the senator PhilippeMahoux proposed legislation banning BPA in materialscoming into contact with food. On 24 March 2010 with



24 ìàðò 2010 ã. Ôðåíñêèÿò Ñåíàò åäèíîäóøíî îäîáðèïðîåêòîçàêîí çà çàáðàíà íà ÂÐÀ â áåáåøêèòå áóòèëêè.

Ðåãóëàòîðíèòå îðãàíè íà äðóãè ñòðàíè, êàòî Øâåéöàðèÿ,Àâñòðàëèÿ è Íîâà Çåëàíäèÿ, èçëèçàò ñ èçÿâëåíèÿ, ÷åíàñòîÿùàòà åêñïîçèöèÿ íà ÂÐÀ îò àëèìåíòàðíè èçòî÷íèöèíå ïðåäñòàâëÿâà ðèñê çà íàñåëåíèåòî, íî âúïðåêè òîâàïðèçîâàâàò êúì ïðàâèëíà óïîòðåáà íà áåáåøêèòå áóòèëêè,è ïðåäëàãàò èçïîëçâàíåòî íà àëòåðíàòèâè íàïîëèêàðáîíàòíèòå áóòèëêè (íàïðèìåð ñòúêëåíè).

Â çàêëþ÷åíèå ìîæå äà ñå êàæå, ÷å íà íàñòîÿùèÿ åòàïíàó÷íèòå èçñëåäâàíèÿ âúðõó áåçâðåäíîñòòà íà ÂÐÀ çàêúðìà÷åòà, åêñïîíèðàíè ïîñðåäñòâîì ïîëèêàðáîíàòíèòåøèøåòà çà õðàíåíå, áóäÿò íÿêîè ñúìíåíèÿ, êîèòî ñå íàëàãàäà áúäàò èçÿñíåíè. Âúâ âðúçêà ñ òîâà Åâðîïåéñêàòà êîìèñèÿñå ïîçîâà íà ïðèíöèïà íà ïðåäîõðàíèòåëíèòå ìåðêè,ïðåäâèäåí â ÷ëåí 7 íà Ðåãëàìåíò (ÅÎ) ¹ 178/2002, ïðèëîæèìâ ñëó÷àèòå íà ñúùåñòâóâàùà íåñèãóðíîñò, äîðè êîãàòî ÿâåíðèñê çà ÷îâåøêîòî çäðàâå âñå îùå íå å íàïúëíî äîêàçàí.Åâðîïåéñêàòà êîìèñèÿ ïîñòàíîâè óïîòðåáàòà íà BPA âïðîèçâîäñòâîòî íà øèøåòà çà õðàíåíå íà êúðìà÷åòà èïóñêàíåòî íà ïàçàðà íà ïîëèêàðáîíàòíè øèøåòà çà õðàíåíåíà êúðìà÷åòà äà áúäàò âðåìåííî çàáðàíåíè, äî ïîëó÷àâàíåòîíà äîïúëíèòåëíè íàó÷íè äàííè. Òåçè äàííè òðÿáâà äà èçÿñíÿòòîêñèêîëîãè÷íàòà çíà÷èìîñò íà íÿêîè íàáëþäàâàíè åôåêòèíà BPA, ñ îñîáåíî âíèìàíèå ïî îòíîøåíèå íàáèîõèìè÷íèòå ïðîìåíè â ìîçúêà, èìóíîìîäóëàòîðíèòååôåêòè è ïîâèøåíàòà ïðåäðàçïîëîæåíîñò êúì ðàçâèòèå íàòóìîðè íà ãúðäàòà. Î÷àêâà ñå âñè÷êè øèøåòà çà õðàíåíå íàêúðìà÷åòà, ñúäúðæàùè BPA, äà áúäàò èçòåãëåíè îò ïàçàðàíà ÅÑ äî ñðåäàòà íà 2011 ã.


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the consent of the French national assembly a Draftlaw for banning the use of BPA in baby bottles wasapproved.

Regulatory authorities of other countries likeSwitzerland. Australia and New Zealand declared thatthe current exposure to BPA from alimentary sourcesdoes not pose risk for the population, however, theyappealed to the proper use of baby bottles andproposed the use of alternatives to the polycarbonatebottles (for example made of glass).

Thus, as a final conclusion, it can be said that nowadaysscientific studies on BPA’s safety for infants exposed toBPA through polycarbonate feeding bottles arousesuspicion that should be clarified. In relation to this theEuropean Commission has relied on the precautionaryprinciple laid down in Article 7 of the Regulation(ÅC) ¹ 178/2002, applicable in the cases of existinguncertainty; although the risk appeared, particularly forhuman health, has not yet been fully proven. TheEuropean Commission established the use of BPA in themanufacturing of feeding bottles for infants and thelaunch of polycarbonate infants feeding bottles to themarket to be temporarily banned until receiving additionalscientific data that will clarify the toxicological significanceof some observed effects of BPA, in particular, for thebiochemical changes in the brain, immunomodulatoryeffects and increased predisposition to the developmentof breast cancer. It is expected that all bottles for infantfeeding containing BPA should be withdrawn from themarket of the EU by the middle of 2011.

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21. Tyl, R.W. et al. Two-generation reproductive toxicity study ofdietary bisphenol A in CD-1(swiss) mice. Toxicol Sci.; 104 (2), pp362-384

22. European Commission, 2003. European Union Risk AssessmentReport. Bisphenol A, CAS ¹ 80-05-7. Institute for Health andConsumer Protection, European Chemicals Bureau, EuropeanCommission Joint Research Centre, 3rd Priority List, Luxembourg:Office for Official Publications of the European Communities.Available online

23. European Commission, 2008. Updated Risk Assessment Reportof 4’-Isopropylidendiphenol (Bisphenol A). Office for OfficialPublications of the European Communities, Luxembourg) Availableonline

24. EFSA, 2008. Scientific Opinion of the Panel on Food Additives,Flavourings, Processing Aids and Materials in Contact with Food(AFC) on a request from the Commission on the toxicocinetics ofBisphenol A. The EFSA Journal 759, 1-10

25. EFSA Panel on food contact materials, enzymes, flavourings andprocessing aids (CEF). Scientific Opinion on Bisphenol A:evaluation of a study investigating its neurodevelopmental toxicity,review of recent scientific literature on its toxicity and advice on theDanish risk assessment of Bisphenol A. EFSA Journal 2010;8(9):1829

26. Gies A. 2007. Problems in assessing low dose effects of endocrinedisruptors. In: Reproductive Health and the EnvironmentNicolopoulou-Stamati P, Hens L, Howard CV, editors, Springer,283-296

27. Negishi T, et al. Behavioral alterations in response to fear-provoking stimuli and tranylcypromine induced by perinatalexposure on bisphenol A and nonyphenol in male rats. EnvironHealth Perspect 2004 , 112: 1159-1164

28. Carr R, et al. Effect of neonatal rat bisphenol a exposure onperformance in the Morris water maze. J Toxicol Environ Health A.2003 ; 66: 2077-2088

29. Ryan BC, Vandenbergh JG. Developmental exposure toenvironmental estrogens alters anxiety and spatial memory infemale mice. Horm Behav 2006; 50:85-93


Àñ. ä-ð Ã. ÆåêîâàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè


30. Adriani W, et al. Altered profiles of spontaneous noveltyseeking, impulsive behaviour and response to D-amphetaminein rats perinatally exposed to bisphenol A. Environ HealthPerspect 2003; 111: 395-401. Errratum in Environ HealthPerspect 113 A368 ( 2005)

31. Gies A, et al. (2009). Bisphenol A Workshop of the GermanFederal Environment Agency – March 30-31, 2009: WorkGroup Report: Public Health Issues of Bisphenol A.International Journal of Hygiene and Environmental Health 212(6): 693-696

32. Scientists: FDA’s Assertion of BPA Unreliable And IncompletePosted by Chrissie Cole, Tuesday, April 14, 2009 9:45 AMEST; Read more: http://www.injuryboard.com/national-news/scientists-fdas-assertion-of-bpa-unreliable-and-incomplete.aspx?googleid=261002#ixzz0kkZFHc2G Available10 March 2010

33. Shonfelder G, et all. (2002) Parent bisphenol a accumulationin the human maternal-fetal-placental unit. Environ HealthPerspect, 110 (11), pp. A703-A707

34. Padmanabhan V, et all. (2008) Maternal bisphenol A levels atdelievery: A looming problem? Journal of Perinatology; 28:258-263

35. Volkel W, et all.(2002) Chem Res Toxicol. Metabolism andkinetics of bisphenol A in humans at low doses following oraladministration. 15: 1281-1287

36. Ginsberg G, Rice DC (2009) Does Rapid Metabolism EnsureNegligible Risk to Bisphenol A? Environ Health Perspect 117:1639-1643

37. EU (2000), Communication from the commission on theprecautionary principle COM 1. Brussels: Commission of theEuropean Communities

38. Verner, M et al. (2009). “High concentrations of commonlyused drugs can inhibit the in vitro glucuronidation of bisphenola and nonylphenol in rats”. Xenobiotica February 2010, Vol.40, No. 2 : Pages 83-92

39. Vandenberg, L. N et al. (2010). “Urinary, Circulating andTissue Biomonitoring Studies Indicate Widespread Exposure toBisphenol A”. Environmental Health Perspectives. doi:10.1289/ehp.0901716.

40. „No BPA For Baby Bottles In U.S. 6 Makers AnnounceDecision on Chemical „- By Lyndsey Layton, March 6, 2009;Page A06, Washington Post

41. “BISPHENOL A (BPA) - Current state of knowledge and futureactions by WHO and FAO”. 27 November 2009. http://www.who.int/entity/foodsafety/publications/fs_management/No_05_Bisphenol_A_Nov09_en.pdf. Retrieved 10 March 2010.

42. FAO/ WHO 2010. Joint FAO/WHO Expert Meeting to ReviewToxicological and Health Aspects of Bisphenol 1–5 November2010 Ottawa, Canada A. Summary Report including Report ofStakeholder Meeting on Bisphenol A . Available online.


Assist. Prof. G. Zhekova, MDNational Center of Public Health and Analyses

[email protected]



ÌÈÊÐÎÁÍÈ ÊÎÍÒÀÌÈÍÀÍÒÈ ÂÁÓÒÈËÈÐÀÍÈ ÂÎÄÈ

Ëèëÿíà ×èïèëñêà, Âåñåëà ÃåîðãèåâàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè

Ðåçþìå

Â ïîñëåäíèòå ãîäèíè â Áúëãàðèÿ ñå íàáëþäàâà íàðàñòâàíåíà ïîòðåáëåíèåòî íà áóòèëèðàíè âîäè (ìèíåðàëíè,èçâîðíè, òðàïåçíè). Êà÷åñòâîòî èì å ðåãëàìåíòèðàíî îòåâðîïåéñêîòî è áúëãàðñêîòî çàêîíîäàòåëñòâî. Âíîðìàòèâíèòå äîêóìåíòè ñå äåôèíèðà äîïóñòèìîñòòàíà òðåòèðàíå íà âîäèòå â çàâèñèìîñò îò òÿõíàòàêàòåãîðèÿ. Íå ñå äîïóñêà àíòèìèêðîáíîòî òðåòèðàíå íàìèíåðàëíèòå è èçâîðíèòå âîäè. Òîâà å ïðîòåêòîðåíìåõàíèçúì çà íåíàðóøàâàíå àâòåíòè÷íîñòòà íà òåõíèÿóíèêàëåí ñúñòàâ è ìèêðîôëîðà. Âàæíî å äà ñå ñúõðàíèåñòåñòâåíàòà ïðèðîäíà ÷èñòîòà íà âîäèòå è â ïðîöåñàíà òÿõíîòî áóòèëèðàíå. Ìèêðîáèîëîãè÷íèÿò êîíòðîë èìàçà öåë äà îáåêòèâèçèðà ìèêðîáíîòî ñúñòîÿíèå íà âîäèòåñëåä òÿõíîòî áóòèëèðàíå è ñúõðàíåíèå, çà äà ãàðàíòèðàáåçîïàñíîñòòà èì ïðè óïîòðåáà.

Â íàñòîÿùèÿ ëèòåðàòóðåí îáçîð ñå ðàçãëåæäàòèçîëèðàíè îò ìèíåðàëíè è èçâîðíè âîäè ìèêðîáíèêîíòàìèíàíòè, êîìåíòèðà ñå òåõíèÿò èçòî÷íèê èâúçìîæåí çäðàâåí ðèñê. Íÿêîè êîíòàìèíàíòè (êîëèôîðìè,E.coli åíòåðîêîêè è ñòàôèëîêîêè) ïîïàäàò âúâ âîäàòàîò îêîëíàòà ñðåäà èëè ñà ðåçóëòàò îò ëîøà õèãèåíà íàïåðñîíàëà, äðóãè -Aeromonas spp. è Pseudomonas spp.,êîëîíèçèðàò â áóòèëèðàùèòå ëèíèè êàòî áèîôèëì è ñåÿâÿâàò èçòî÷íèê íà âòîðè÷íî çàìúðñÿâàíå. Áèîëîãè÷íèêîíòàìèíàíòè ñà è âîäîðàñëèòå - êðåìú÷íè, ÷èéòîèçòî÷íèê ñà ïîâúðõíîñòíè âîäè, íàâëèçàùè â ñîíäàæíèòåèíñòàëàöèè, à ñúùî òàêà çåëåíè è ñèíúî-çåëåíè âîäîðàñëèîò ïî÷âàòà. Ïðè íåïðàâèëíî ñúõðàíåíèå (íàïð.èçòî÷íèêíà ñâåòëèíà, íåïîäõîäÿùà òåìïåðàòóðà) ïðèñúñòâèåòîíà àâòîõòîííè è àëëîõòîííè âîäîðàñëè êîìïðîìåòèðàêà÷åñòâîòî íà áóòèëèðàíèòå âîäè.

Ïðîáëåìèòå ñà ðàçðåøèìè ÷ðåç ñïàçâàíå íà äîáðàïðîèçâîäñòâåíà ïðàêòèêà, ñòðîéíà ñèñòåìà íàäåçèíôåêöèÿ íà îáîðóäâàíåòî è ñèñòåìåí ïîñòîÿíåíêîíòðîë.

Êëþ÷îâè äóìè: ìèêðîáíî çàìúðñÿâàíå,àâòîõòîííà, àëëîõòîííà ôëîðà,áóòèëèðàíèìèíåðàëíè âîäè, èçâîðíè âîäè, ìèêðîáèîëîãè÷íèêðèòåðèè.

Â ïîñëåäíèòå ãîäèíè â Áúëãàðèÿ ñå íàáëþäàâà íàðàñòâàíåïîòðåáëåíèåòî íà áóòèëèðàíè âîäè. Â èíäóñòðèÿòà íàáåçàëêîõîëíè íàïèòêè òîâà å ïðîäóêòúò ñ íàé-áúðçîíàðàñòâàù òåìï íà êîíñóìèðàíå. Êà÷åñòâî íà

MICROBIAL CONTAMINANTSIN BOTTLED WATER

Liliana Chipilska, Vesela GeorgievaNational Center of Public Health and Analyses

Abstract

Over the recent years, the consumption of bottled(mineral, spring, table) water has increased in Bul-garia. Quality of bottled water is regulated by bothEuropean and Bulgarian legislations. Regulationsallow water treatment according to its category. An-timicrobial treatment is not allowed for mineral andspring waters as it is a protective mechanism for theirauthentic unique composition and microflora. It isimportant to preserve the natural purity of waterduring bottling process. Microbiological controlaims at identifying microbiological content ofbottled and stored water in order to guarantee safeconsumption.

The present literature review deals with microbialcontaminants, being isolated from mineral springwater, with respect to its source and possible healthrisk. Some contaminants (Coliforms, E.coli, Entero-cocci and Staphylococci) get into water from theenvironment or as a result from staff ’s poor hygiene,while others -Aeromonas spp. and Pseudomonas spp.colonize as a biofilm bottling lines, becoming asource of secondary contamination. Biological con-taminants include also algae - diatoms, whose sourceis surface water entering the drilling installations,as well as green and blue-green algae coming fromthe soil. Inappropriate storage (for example, near alight source, at inappropriate temperature) and thepresence of autochthanous and allochthanous al-gae compromise the quality of bottled water.

Problems could be solved by good manufacturingpractice, coherent disinfection system of equipmentand continuous monitoring system.

Keywords: microbial contamination, indigenous,autochthanous and allochthanous flora, bottledmineral water, spring water, microbiologicalcriteria.

Over the recent years, the consumption of bottled watershas increased in Bulgaria. It is the product with thefastest growing consumption in the soft drink industry.



áóòèëèðàíèòå âîäè å ðåãëàìåíòèðàíî îò åâðîïåéñêîòî èáúëãàðñêîòî çàêîíîäàòåëñòâî. Èìà òðè îñíîâíè êàòåãîðèèáóòèëèðàíè âîäè – íàòóðàëíè ìèíåðàëíè, èçâîðíè èòðàïåçíè, êàòî ðàçëèêèòå ìåæäó òÿõ ñà äåôèíèðàíè âÍàðåäáàòà çà áóòèëèðàíèòå âîäè (1). Òàçè Íàðåäáàîïðåäåëÿ äîïóñêàíå èëè íå íà îïðåäåëåíî âúçäåéñòâèåâúðõó òÿõíàòà ìèêðîôëîðà, â çàâèñèìîñò îò êàòåãîðèÿòàíà âîäàòà, êîÿòî ñå áóòèëèðà.

Íàòóðàëíèòå ìèíåðàëíè âîäè îáèêíîâåíî ñà îò äúëáîê,çàùèòåí ïîäçåìåí âîäîèçòî÷íèê, ïîðàäè êîåòî ñå ñ÷èòà,÷å â òÿõ íÿìà îïàñíè ìèêðîîðãàíèçìè. Òåçè âîäè òðÿáâàäà îòãîâàðÿò íà îïðåäåëåíè ìèêðîáèîëîãè÷íè êðèòåðèèêàêòî ïðè âîäîèçòî÷íèêà, òàêà è ñëåä áóòèëèðàíåòî èì.Çà íàòóðàëíèòå ìèíåðàëíè âîäè íå ñå äîïóñêà êàêâîòî éäà áèëî òðåòèðàíå, öåëÿùî ïîñòèãàíå íàìèêðîáèîëîãè÷íèòå êðèòåðèè.

Èçâîðíèòå âîäè ñúùî ïðîèçõîæäàò îò ïîäçåìåí,åñòåñòâåíî çàùèòåí âîäåí îáåêò è ñå ïîä÷èíÿâàò íà ñúùèòåìèêðîáèîëîãè÷íè êðèòåðèè, êàêòî è ìèíåðàëíèòå âîäè.È ïðè èçâîðíèòå âîäè íå ñå äîïóñêà êàêâàòî è äà åîáðàáîòêà, öåëÿùà äåçèíôåêöèÿ íà âîäàòà.

Òðàïåçíèòå âîäè ìîãàò ñà êàêòî îò ïîäçåìíè, òàêà è îòïîâúðõíîñòíè âîäîèçòî÷íèöè. Âîäèòå îò òåçè âîäîèçòî÷íèöèòðÿáâà äà îòãîâàðÿò íà èçèñêâàíèÿòà íà Íàðåäáàòà ¹9 (2),ðåãëàìåíòèðàùà êà÷åñòâîòî íà âîäàòà, ïðåäíàçíà÷åíà çàïèòåéíî-áèòîâè öåëè (íî íå îòãîâàðÿò íà èçèñêâàíèÿòà çàâîäîèçòî÷íèöèòå çà íàòóðàëíè ìèíåðàëíè è èçâîðíè âîäè)è ìîãàò äà áúäàò òðåòèðàíè, çà äà ïîñòèãíàò èçèñêâàíèÿòà çàìèêðîáèîëîãè÷íî êà÷åñòâî.

Êîè ñà ìèêðîáèîëîãè÷íèòå êðèòåðèè, íàêîèòî òðÿáâà äà ñå ïîä÷èíÿâàòáóòèëèðàíèòå âîäè?

Îáù áðîé æèçíåñïîñîáíè ìèêðîîðãàíèçìè,îáîçíà÷åíè êàòî ÊÎÅ/cm3 :

- ðàñòÿùè ïðè ( 20±2) 0Ñ çà 72 ÷àñà : íå ïîâå÷å îò 20 ïðèâîäîèçòî÷íèêà è íå ïîâå÷å îò 100 ñëåä áóòèëèðàíåòî;

- ðàñòÿùè ïðè( 37±1) 0Ñ çà 24 ÷àñà : íå ïîâå÷å îò 5 ïðèâîäîèçòî÷íèêà è íå ïîâå÷å îò 20 ñëåä óòèëèðàíåòî.

Êîëèôîðìè: 0/250 cm3

Å. êîëè: 0/250 cm3

Ôåêàëíè ñòðåïòîêîêè: 0/250 cm3

Ñóëôèòðåäóöèðàùè ñïîðîâè àíàåðîáíè áàêòåðèè: 0/50 cm3

Ï. àåðóãèíîçà: 0/250 cm3

Òðàïåçíèòå âîäè, çà ðàçëèêà îò íàòóðàëíèòå ìèíåðàëíè èèçâîðíèòå âîäè, íå ñå èçëåäâàò çà îáù áðîéæèçíåñïîñîáíè ìèêðîîðãàíèçìè ïðè âîäîèçòî÷íèêà, íîïî îñòàíàëèòå ìèêðîáèîëîãè÷íè êðèòåðèè òå òðÿáâà äàîòãîâàðÿò íà ñúùèòå èçèñêâàíèÿ, êàêòî è äðóãèòåáóòèëèðàíè âîäè.

Quality of bottled water is regulated by both Europeanand Bulgarian legislations. There are three maincategories of bottled water - natural mineral, springand table, the differences between them beingspecified by the Regulation on bottled water (1). TheRegulation allows or not a particular effect on theirmicroflora depending on the category of bottled water.

Natural mineral waters usually come from deeper,protected underground water source and thereforethey are considered to be free of dangerousmicroorganisms. These waters should meet certainmicrobiological criteria at water source and afterbottling. Natural mineral waters should not be treatedin order to meet microbiological criteria.

Spring waters also come from underground, naturalprotected water source, being subject to the samemicrobiological criteria as mineral water. They shouldnot be treated for disinfection purposes.

Table water may come from both underground andsurface water sources and should meet therequirements of Regulation ¹ 9 (2) concerning thequality of water intended for drinking and householdpurposes (but not those for natural mineral and springwaters) and therefore is allowed to be treated to meetrequirements for microbiological quality.

What are microbiological criteria to be metby bottled water?

Òotal number of viable microorganisms, designatedas CFU/cm3 :

- growing at (20 ± 2) 0C for 72 hours: less than 20 atwater source and less than 100 after bottling

- growing at (37 ± 1) 0C for 24 hours: less than 5 atwater sources and less than 20 after bottling

Coliform bacteria: 0/250 cm3

E. coli: 0/250 cm3

Faecal streptococci: 0/250 cm3

Sulphite-reducing spore anaerobic bacteria: 0/50 cm3

Ps. aeruginosa: 0/250 cm3

Unlike natural mineral and spring waters, table water isnot tested for the total number of viable microorganismsat source, but as bottled water, it should meet therequirements for the other microbiological criteria.



Èçòî÷íèöè íà ìèêðîáèîëîãè÷íî çàìúðñÿâàíå

Èìà äâà îñíîâíè èçòî÷íèêà íà ìèêðîîðãàíèçìè âáóòèëèðàíèòå âîäè è òåõíèòå õàðàêòåðèñòèêè ñà ìíîãîðàçëè÷íè. Âñÿêà âîäà, äîðè è òàçè, êîÿòî èäâà îò äúëáîêïîäçåìåí âîäîèçòî÷íèê, ñúäúðæà ìèêðîîðãàíèçìè – òîâàå òàêà íàðå÷åíàòà àâòîõòîííà, ñîáñòâåíà ìèêðîôëîðà. Ïîâðåìå íà ïðîöåñà íà áóòèëèðàíå ìîãàò äà áúäàò âíåñåíèêàòî çàìúðñÿâàíå îò îáîðóäâàíåòî è îêîëíàòà ñðåäà äðóãèìèêðîðãàíèçìè – àëëîõòîííà ôëîðà.

Àâòîõòîííàòà ôëîðà å ïðåäñòàâåíà îáèêíîâåíî îòñàïðîôèòíè ìèêðîîðãàíèçìè, ãëàâíî ãðàì-îòðèöàòåëíèáàêòåðèè, âêëþ÷âàùè âèäîâå îò ðîäîâåòå Pseudomonas,Flavobacterium è Moraxella, êîèòî íîðìàëíî îáèòàâàòâîäàòà. Òå ÷åñòî ñà â ”ãëàäíî” ñúñòîÿíèå è ìîãàò äàïðèñúñòâàò âúâ âîäàòà êàòî óëòðà êëåòêè – ìíîãî ìàëêèáàêòåðèàëíè êëåòêè, ñïîñîáíè äà ïðåìèíàâàò ïðåç ôèëòðèòå.Òîâà å âèä àäàïòàöèÿ êúì íèñêèòå íèâà íà õðàíèòåëíèâåùåñòâà â òåçè âîäè (3). Àâòîõòîííàòà ìèêðîôëîðà íà âîäàòàíå å ïðèñïîñîáåíà äà æèâåå â òåëàòà íà òîïëîêðúâíèòåîðãàíèçìè, ïîðàäè êîåòî å áåçâðåäíà çà ÷îâåêà, äîðè è òîãàâà,êîãàòî ïðèñúñòâà âúâ âèñîêè êîíöåíòðàöèè. Ñúùåñòâóâàîáà÷å îïàñíîñò ïðè òåæêî áîëíè õîðà èëè ëèöà ñêîìïðîìåíòèðàíà èìóííà ñèñòåìà.

Íåäîáðå çàùèòåíèòå âîäîèçòî÷íèöè îáà÷å, ìîãàò äà áúäàòêîíòàìèíèðàíè îò îòòè÷àùè ñå îò ïîâúðõíîñòòà âîäè èòîãàâà ñúäúðæàò äðóãè âèäîâå áàêòåðèè, âêëþ÷èòåëíî èðàçíîîáðàçíè ïàòîãåííè, îñîáåíî, àêî å íàëèöå ôåêàëíîçàìúðñÿâàíå. Àëëîõòîííàòà ôëîðà ìîæå äà âêëþ÷âà øèðîêñïåêòúð îò ìèêðîîðãàíèçìè, êîéòî îòðàçÿâà õàðàêòåðà íàçàìúðñÿâàíåòî. Áàêòåðèè îò ðîäîâåòå Pseudomonas,Flavobacterium è Aeromonas ìîãàò äà êîëîíèçèðàòáóòèëèðàùèòå ëèíèè è äà îáðàçóâàò áèîôèëì, êîéòî ñå ÿâÿâàèçòî÷íèê íà âòîðè÷íî çàìúðñÿâàíå. Äðóãè áàêòåðèè, êàòîñòàôèëîêîêè è êîëèôîðìè, ìîãàò äà íàâëÿçàò âúâ âîäàòà îòîêîëíàòà ñðåäà èëè äà ñà ðåçóëòàò îò ëîøà õèãèåíà íàïåðñîíàëà. Ïëàñòìàñîâèòå áóòèëêè è êàïà÷êè îáèêíîâåíîñúäúðæàò ìíîãî ìàëúê áðîé áàêòåðèè, ïîðàäè êîåòî íåñúçäàâàò ïî ïðàâèëî ïîäîáíè ïðîáëåìè (3).

Ñëåä áóòèëèðàíå

Áúëãàðñêîòî çàêîíîäàòåëñòâî ðåãëàìåíòèðà äâå ñòîéíîñòèçà ñúäúðæàíèåòî íà æèçíåñïîñîáíèòå ìèêðîîðãàíèçìè âíàòóðàëíèòå ìèíåðàëíè âîäè - ïðè âîäîèçòî÷íèêà è äî 12÷àñà ñëåä áóòèëèðàíåòî, ïðè äâå òåìïåðàòóðè: íà 220Ñ çà 72÷àñà è íà 370Ñ çà 24 ÷àñà (1). Ñ÷èòà ñå, ÷å òåìïåðàòóðàòà îò370Ñ å ïîäõîäÿùà çà êóëòèâèðàíåòî íà ïî-áúðçî ðàçâèâàùèòåñå áàêòåðèè, êîèòî ñà ïî-áëèçêè äî ïàòîãåííèòå, à 220Ñ åïîäõîäÿùà òåìïåðàòóðà çà êóëòèâèðàíåòî íà õàðàêòåðíèòå çàâîäàòà áàêòåðèè (àâòîõòîííèòå), êîèòî ñå ðàçâèâàò ïî-áàâíî.

Ïî âðåìå íà ñúõðàíåíèåòî íà ìèíåðàëíèòå áóòèëèðàíè âîäèíàñòúïâàò çíà÷èòåëíè ïðîìåíè â òåõíèòå áàêòåðèàëíèïîïóëàöèè. Òîçè ïðîáëåì íå ñå íàáëþäàâà ïðè ãàçèðàíèòåâîäè ïðåç öåëèÿ ïåðèîä íà ïðåñòîÿ èì â òúðãîâñêàòà ìðåæà

Sources of microbial contamination

These are the two principal sources of microorganismsin bottled waters, and their characteristics may be quitedifferent. Even water, which is drawn off from anunderground source, contains microorganisms – socalled autochthanous flora. During the bottlingoperation, other microorganisms may be introducedas contaminants from equipment and the environment(allochthanous flora).

The autochthanous flora is generally saprophyticmicroorganisms, mainly Gram negative bacteriaincluding species of Pseudomonas, Flavobacterium,Cytophaga, and Moraxella, which normally inhabitwater. They are often in a ‘starved’ state, and can bepresent as ultramicrocells, very small bacterial cellsthat may pass through filters. This is an adaptation tolow nutrient levels.(3) Autochthanous microflora inwater is not adapted to live in warm-blood organisms,thus being harmless to humans even at highconcentrations. They can be however hazardous incase of severe diseases or compromised immunesystem.

However, inadequately protected sources may becontaminated by run-off from the surface and thencontain other species, including a variety ofpathogens, especially if faecal contamination ispresent. The allochthanous flora may include a veryvaried range of microorganisms as a result from thecharacter of pollution. Organisms such asPseudomonas, Flavobacterium and Aeromonas spp.may colonize the pipes of the bottling plant, and maybuild up as biofilms, which act as sources of secondarycontamination. Other bacteria, such as staphylococciand coliforms, may enter the water from the generalenvironment or as a result of poor hygiene bypersonnel. Plastic bottles and caps usually have verylow levels of bacteria, thus not creating similarproblems (3)

After bottling

Bulgarian legislation provides for two values for thecontent of viable microorganisms in natural mineral waters- at water source and up to 12 hours after bottling, at twotemperatures: 22oC for 72 hours and 37oC for 24 hours(1). It is considered that the temperature of the 37oC issuitable for the cultivation of fast-growing bacteria thatare closer to pathogenic, while 22oC is appropriate forthe cultivation of typical water bacteria (autochthanous)that develop more slowly.

Bottled mineral water undergoes significant changes inits bacteria population during storage. This problem doesnot occur in aerated water during its whole stay in retail(shelf life) as saturation with carbon dioxide acts as apreservative (4).



(ñðîê íà ãîäíîñò), òúé êàòî íàñèùàíåòî ñ âúãëåðîäåíäèîêñèä äåéñòâà êàòî êîíñåðâàíò (4).

Ñëåä áóòèëèðàíå àâòîõòîííàòà ôëîðà çàïî÷âà äà ñåðàçìíîæàâà è ìîæå äà äîñòèãíå íèâà îò 104 – 105 ÊÎÅ/ cm3, àäîðè è ïîâå÷å –106 – 107 ÊÎÅ/cm3 (5,6). Íà äàäåí åòàï áðîÿòíà ìèêðîîðãàíèçìèòå ïðåñòàâà äà íàðàñòâà è ñå çàïàçâàïîâå÷å èëè ïî-ìàëêî ïîñòîÿíåí çà äúëúã ïåðèîä îò âðåìå /äî 6 ìåñåöà/. Íÿêîè àâòîðè ïðåäïîëàãàò, ÷å àâòîõòîííèòåáàêòåðèè, â ñðàâíåíèå ñ àëëîõòîííèòå, ñà ïî-äîáðåàäàïòèðàíè êúì îëèãîòðîôíèòå óñëîâèÿ â áóòèëèðàíàòà âîäàè çàòîâà òåõíèÿò áðîé áúðçî íàðàñòâà ñëåä áóòèëèðàíå (3,6).Äðóãè ïðåäïîëàãàåìè ïðè÷èíè, êîèòî îòêëþ÷âàò ðàñòåæàíà áàêòåðèèòå â áóòèëèðàíèòå ìèíåðàëíè âîäè, ñà íèñêàòàêîíöåíòðàöèÿ íà ðàçòâîðåíèÿ âúãëåðîä â ìèíåðàëíàòà âîäà,óâåëè÷åíàòà ïîâúðõíîñò íà áóòèëêèòå è ïîâèøàâàíåòåìïåðàòóðàòà ïî âðåìå íà ñúõðàíÿâàíåòî èì (6).Îïðåäåëÿùèÿò ôàêòîð íà ðàñòåæà âñå ïàê ñà íèñêèòå íèâàíà õðàíèòåëíè âåùåñòâà â áóòèëèðàíèòå âîäè. Áàêòåðèàëíàòàïîïóëàöèÿ íàðàñòâà äîêàòî íàëè÷íèòå õðàíèòåëíè âåùåñòâàñå èç÷åðïÿò, ñëåä êîåòî êëåòêèòå çàïî÷âàò äà îòìèðàò.Óìðåëèòå êëåòêè ëèçèðàò, õðàíèòåëíèòå âåùåñòâà ñå âðúùàòâúâ âîäàòà è òîâà ïðåäèçâèêâà ïîñëåäâàùî ðàçìíîæàâàíå.Òîçè öèêúë ïîçâîëÿâà äà ñå ïîääúðæà åäíà ïîñòîÿííàïîïóëàöèÿ (6). Ïî-èíòåíçèâåí ðàñòåæ ñå íàáëþäàâà âïëàñòìàñîâèòå áóòèëêè, îòêîëêîòî â ñòúêëåíèòå. Àâòîðèòåîáÿñíÿâàò òåçè äàííè ñ èíõèáèðàíå ðàñòåæà îò ñëåäèòå íàèçìèâàùèòå õèìèêàëè ïî ïîâúðõíîñòà íà ñòúêëåíèòåáóòèëêè, êàêòî è ñúñ ñòèìóëèðàíå íà ðàñòåæà îòðàçòâîðåíèòå îðãàíè÷íè õðàíèòåëíè âåùåñòâà îòïëàñòìàñîâèòå áóòèëêè, ÷èÿòî ïîâúðõíîñò å ïî-ïîäõîäÿùàçà êîëîíèçèðàíå íà áàêòåðèèòå (3).

Îáèêíîâåíî ãîëÿìà áàêòåðèàëíà ãúñòîòà ñå íàáëþäàâà âïðîáèòå áóòèëèðàíà âîäà, ñúõðàíÿâàíè íà ñòàéíàòåìïåðàòóðà (7). Ñúõðàíåíèåòî â õëàäèëíèê èëè íà äðóãîõëàäíî ìÿñòî íå ñïèðà, íî çàáàâÿ ðàçìíîæàâàíåòî íàáàêòåðèèòå â íàòóðàëíèòå ìèíåðàëíè âîäè (4,6,8). Âèçëîæåíèòå íà ïðÿêà ñëúí÷åâà ñâåòëèíà ïðîáè ñúùåñòâóâàâåðîÿòíîñò äà ñå îáðàçóâàò êàíöåðîãåííè âåùåñòâà îòìàòåðèàëèòå, îò êîèòî ñà íàïðàâåíè ïëàñòìàñîâèòå áóòèëêè.Çàòîâà ñå ïðåïîðú÷âà áóòèëèðàíèòå âîäè äà ñå ñúõðàíÿâàòíà òúìíî, õëàäíî è ñóõî ìÿñòî, çà äà ñå èçáåãíå îïàñíîñòòàîò ðàçâèòèåòî íà ìèêðîáíè êîíòàìèíàíòè, à ñúùî âåùåñòâàîò õèìè÷åí ïðîèçõîä ñ îïàñíîñò çà çäðàâåòî íà ÷îâåêà (8).

Óâåëè÷åíèÿò áðîé íà õåòåðîòðîôíèòå áàêòåðèè å êðèòåðèéçà îáùîòî áàêòåðèàëíî çàìúðñÿâàíå íà âîäàòà.Õåòåðîòðîôíèòå áàêòåðèè íå ñà çàäúëæèòåëíî îïàñíè çàçäðàâåòî, íî òå ìîãàò äà èíäèêèðàò çà ïðèñúñòâèåòî íàïàòîãåííè áàêòåðèè è ñå èçïîëçâàò êàòî îñíîâåí èíäèêàòîðçà ñàíèòàðíèòå ìåðîïðèÿòèÿ, êîèòî ïîëçâà áóòèëèðàùàòàêîìïàíèÿ (9).

Àëëîõòîííàòà ôëîðà, îáðàòíî íà àâòîõòîííàòà, îòìèðàïî âðåìå íà ñúõðàíÿâàíåòî/ïðåñòîÿ íà áóòèëèðàíèòå âîäè.Èìà ìíîãî ïóáëèêàöèè çà ïðåæèâÿåìîñòòà íà ðàçëè÷íèáàêòåðèè – ïîâå÷åòî ïàòîãåííè, â áóòèëèðàíè âîäè è ìàêàð÷å ñúîáùàâàíèòå äàííè ñå ðàçëè÷àâàò ïîìåæäó ñè, ïðèâñè÷êè òÿõ ñå óñòàíîâÿâà çíà÷èòåëíî ïîíèæàâàíå áðîÿ íàáàêòåðèèòå ñëåä íÿêîëêî ñåäìèöè. Èçêëþ÷åíèå îò òîâàïðàâèëî å èçîëèðàíåòî íà P. aeruginosa îò âîäà è ñëåä 5ãîäèíè (3).

After bottling, the autochthanous flora begin tomultiply, and may eventually reach levels of 104-105

per ml, or even more. At this point, the numbers stopincreasing, and stay more or less constant for longperiods (up to 6 months). Some researchers supposethat autochthtanous microorganisms better adapt tooligotrophic environment of bottled water thanallochthanous and that is why they quickly begins toincrease in number after bottling. (3,6). Othersuggested factors that tr igger the growth ofmicroorganisms in mineral bottled waters, are: low levelof carbon dissolved into mineral waters, greatersurface of bottles and higher temperature duringstorage (6). The limiting factor on growth is the lownutrient level in bottled waters. The bacterialpopulation increases until the available nutrients areexhausted, and then cells begin to die. As they die,the cells lyse and release nutrients back to the water,thus allowing further growth. This cycle allows aconstant population to be maintained (6). More growthseems to occur in plastic bottles than in glass ones.Researchers see an explanation in the inhibition ofgrowth by traces of cleaning chemicals on the surfaceof glass and the stimulation of growth by organicnutrients leaching from plastic, whose surfaces aremore suitable for bacterial colonization(3).

Usually high bacterial density is observed in samplesof bottled water, stored at room temperature (7). Storagein a refrigerator or other cool place does not stop butslows down the growth of microorganisms in naturalmineral waters (4,6,8). Carcinogenic substances arelikely to be released from materials, from which plasticbottles are made, in samples exposed to direct sunlightsamples. Therefore, it is recommended the bottledwater to be stored in a dark, cool and dry place toavoid health hazards from microbial and chemicalcontaminants (8).

The increased number of heterotrophic bacteria is acommon criterion for bacterial contamination of water.Heterotrophic bacteria are not necessarily hazardousto health, but they can indicate the presence ofpathogenic bacteria and are used as a primary indicatorof the sanitary measures taken by the bottling company(9).

The allochthanous flora, by contrast, tends to dieout during storage/stay of bottled waters. Manyreports have been published on the survival of variousbacteria (mostly pathogens) in bottled waters, andalthough results are very variable, a significant declinein numbers is usually apparent after a few weeks. Oneexception to this pattern is Pseudomonas aeruginosa,which was reported to persist for up to five years.(3)



Êàêâè ïðåäñòàâèòåëè íà àâòîõòîííàòà èàëëîõòîííàòà ìèêëîôëîðà ñà èçîëèðàíè îòáóòèëèðàíè âîäè è êàêúâ çäðàâåí ðèñêïðåäñòàâëÿâàò òå?

Áàêòåðèàëíîòî ñúîáùåñòâî â áóòèëèðàíèòå ìèíåðàëíèâîäè å ïðåäñòàâåíî ïðåîáëàäàâàùî îò ãðàì-îòðèöàòåëíèìèêðîîðãàíèçìè. Àâòîðèòå ñà åäèíîäóøíè, ÷å íàé-÷åñòîèçîëèðàíèòå ìèêðîáè â ìèíåðàëíèòå âîäè ïðèíàäëåæàòêúì ðîäîâåòå Pseudomonas, Acinetobacter, Alcaligenes,Aeromonas, à êàòî ïî-ðÿäêî ñðåùàíè îïðåäåëÿò ðîäîâåòåComamonas, Burkholderia, Ralstonia, Stenotrophomonas,Sphingomonas, Acidovorax, Brevundimonas, Paucimonas,Serratia , Moraxella, Flavobacterium (3,10,11).

Ñïîðåä íÿêîè àâòîðè (10) 40 % îò èçîëèðàíèòå ùàìîâå îòìèíåðàëíè âîäè ñà âèäîâå îò ðîä Pseudomonas. Íå âñè÷êèïñåóäîìîíàäèòå, îáà÷å, ñà îïðåäåëåíè êàòî P.aeruginosa(9). Îñâåí òîçè âèä îò ìèíåðàëíè âîäè ÷åñòî ñå èçîëèðàòè âèäîâåòå P. fluorescens è P. ðutida (10).

Ñúîáðàçíî Äèðåêòèâàòà íà ÅÑ (12), êàêòî è ñïîðåäáúëãàðñêîòî çàêîíîäàòåëñòâî, áóòèëèðàíèòå ìèíåðàëíèâîäè íå òðÿáâà äà ñúäúðæàò P. aeruginosa â 250 cm3 ïðîáà(1). Ïðèñúñòâèåòî íà P. aeruginosa å íåäîïóñòèìî, çàùîòîòîçè âèä å ïàòîãåíåí è ñ íåãî ñå ñâúðçâàò çàáîëÿâàíèÿ îòâîäåí è õðàíèòåëåí ïðîèçõîä (10).

P. aeruginosa ìîæå äà àäàïòèðà ìåòàáîëèçìà ñè è äàîöåëÿâà çà äúëúã ïåðèîä â ìèíåðàëíèòå âîäè, âúïðåêèòåõíèÿ áåäåí ñòàòóñ íà õðàíèòåëíè âåùåñòâà (3). Íåùîïîâå÷å, P. aeruginosa å ñïîñîáåí äà ñå ðàçìíîæàâà âòàêèâà âîäè ñ íèñêî ñúäúðæàíèå íà õðàíèòåëíè âåùåñòâà(10) è çàåäíî ñ äðóãè ïñåóäîìîíàäè è áàêòåðèè îò ðîäAeromonas, ìîæå äà êîëîíèçèðà áóòèëèðàùèòå ëèíèè,êîåòî îáóñëàâÿ âàæíîñòòà íà åôåêòèâíàòà õèãèåíà èïî÷èñòâàíå íà îáîðóäâàíåòî (3,9). Ìíîãî îò èçîëèðàíèòåùàìîâå P.aeruginosa. ñà ðåçèñòåíòíè êúì íàé-÷åñòîïðèëàãàíèòå àíòèìèêðîáíè àãåíòè (8,13).

Áàêòåðèèòå îò ðîä Aeromonas ñà ÷åñòà íàõîäêà âáóòèëèðàíèòå ìèíåðàëíè âîäè, ïðåäèìíî ïðåäñòàâåíèîò âèäîâåòå A.hydrophila è A.caviae. Áàêòåðèèòå îò ðîäAeromonas ñà èçâåñòíè êàòî ïðè÷èíèòåëè íà ðàíåâè èãàñòðîèíòåñòèíàëíè èíôåêöèè, íî ñà è øèðîêîðàçïðîñòðàíåíè â ïîâúðõíîñòíèòå âîäè è ìîãàò äàêîíòàìèíèðàò ìèíåðàëíèòå âîäè ïîðàäè ëîøà õèãèåííàïðàêòèêà íà ïðîèçâîäèòåëèòå. Ïîäîáíî íà P. aeruginosa,òÿõíîòî ïðèñúñòâèå â áóòèëèðàíèòå âîäè íàñî÷âà çàôåêàëíî çàìúðñÿâàíå è îòòóê íåãîâîòî çíà÷åíèå êàòîôåêàëåí èíäèêàòîð (10).

Â îïèòèòå äà ñå óñòàíîâè ïðè÷èíàòà çà ÷åñòîòàòà íàèçîëèðàíå íà áàêòåðèè Pseudomonas spð. è Aeromonasspð. îò ìèíåðàëíèòå âîäè, àâòîðèòå ïîñî÷âàò íèñêîòîíèâî íà îðãàíè÷åí âúãëåðîä, íåîáõîäèì çà òÿõíîòîðàçâèòèå. Äîêàçàíî å, ÷å íåîáõîäèìèòå êîëè÷åñòâàîðãàíè÷åí âúãëåðîä çà ðàñòåæà íà A. hydrophila ñà 10ìg/l-1, è 25ìg/l-1 çà P. aeruginosa (10).

What types of autochtonous andallochthanous microflora have beenisolated in bottled waters and what is thehealth risk resulting from them?

With respect of bacterial community in bottled waters,Gram negative microorganisms are most frequentlyidentified. Researchers unanimously report that the mostfrequently isolated microbes in mineral waters belong togenera Pseudomonas, Acinetobacter, Alcaligenes,Aeromonas, while genera Comamonas, Burkholderia,Ralstonia, Stenotrophomonas, Sphingomonas,Acidovorax, Brevundimonas, Paucimonas, Serratia ,Moraxella, Flavobacterium are less frequently identified(3,10,11).

Some studies reported (10) that 40% of strains isolatedfrom mineral water was Pseudomonas species. Howevernot all Pseudomonas have been identified asP.aeruginosa (9). P. fluorescens and P. ðutida have beenfrequently reported as other species isolated from mineralwaters were (10).

According to EC Directive 98/83/EO (12) and Bulgarianlegislation, mineral bottled waters should be free of P.aeruginosa in a sample of 250 cm3 (1). The presence ofPsd. aeruginosa is unacceptable because this species isa pathogen, which has been implicated in foodborne andwaterborne diseases (10).

Psd.aeruginosa can be adapted metabolically andsurvive for long time in the mineral water although theirpoor status of nutrients (3). Furthermore, Psd.aeruginosais also capable of multiplying abundantly in low-nutrientwater (10) and together with other Pseudomonas andbacteria from the species Aeromonas, can colonizebottled waters that makes effective hygiene and cleaningof equipment important (3,9). A lot of isolated strainsP.aeruginosa are resistant to the most commonantimicrobial agents (8,13).

Bacteria of species Aeromonas are frequently found inmineral bottled waters and especially the strainsA.hydrophila and A.caviae. Aeromonas are known ascausative agents of wound and gastrointestinalinfections, but they are also widespread in surface watersand may contaminate surface and mineral waters due topoor hygienic practice of producers. As withPsd.aeruginosa, their presence in these situations isindicative of induced faecal pollution and therefore is asignificant quality indicator (10).

In attempting to understand the frequent occurrence ofcertain bacteria such as Pseudomonas spp andAeromonas spp in mineral water, studies have shownthe low level of organic carbon needed for their growth.It has been found that level needed of organic carbonfor the growth of Aeromonas hydrophila was 10ìg/l-1,and 25ìg/l-1 for Psd.aeruginosa (10).

Concerning isolates from bottled waters, of moreconcern are some of the emerging pathogens, such as



Îò íàõîäêèòå â áóòèëèðàíà âîäà îñîáåíî âíèìàíèåçàñëóæàâàò óñëîâíî-ïàòîãåííèòå áàêòåðèè E.coli 0157,êîèòî ñà ïî-óñòîé÷èâè îò äðóãèòå E.coli è ïðåæèâÿâàò âáóòèëèðàíà âîäà äî 63 äíè. Òúé êàòî ñàìî íÿêîëêî êëåòêèîò E.coli 0157 ñà äîñòàòú÷íè äà ïðè÷èíÿò çàáîëÿâàíå -ãàñòðîåíòåðèò, îïàçâàíåòî íà ïîäçåìíèòå èçòî÷íèöè íàíàòóðàëíè ìèíåðàëíè âîäè å îò îñîáåíî çíà÷åíèå. Èìàíÿêîëêî âçðèâà â Ñåâåðíà Àìåðèêà, êîèòî ñå ñâúðçâàò ñêîíòàìèíèðàíå íà èçâîðè (3).

Acinetobacter sðp. ñà ñúùî ñðåä ÷åñòî èçîëèðàíèòåìèêðîáè â áóòèëèðàíèòå ìèíåðàëíè âîäè.Òîâà ñàïàòîãåííè áàêòåðèè, èçâåñòíè êàòî åòèîëîãè÷íè àãåíòèïðè èíôåêöèè íà îòäåëèòåëíàòà ñèñòåìà, ïíåâìîíèè,âòîðè÷íè ìèíèíãèòè è èíôåêöèè íà ðàíè. Îò äðóãà ñòðàíàîáà÷å, Acinetobacter spp. ñà ïîâñåìåñòíè îáèòàòåëè íàïî÷âàòà, âîäàòà è îòïàäíèòå âîäè, îòêúäåòî ìîãàò äàïîïàäíàò â ìèíåðàëíèòå âîäè (3).

Ïðè èçîëèðàíåòî íà Alcaligenes spð. îò ìèíåðàëíè âîäè ñíàé-ãîëÿìà ÷åñòîòà å A.faecalis (10).

Ïðåîáëàäàâàùàòà ÷àñò îò ïî-ðÿäêî èçîëèðàíèòå áàêòåðèèîò ìèíåðàëíè âîäè ñà ÷àñò îò àâòîõòîííàòà ìèêðîôëîðàíà òåçè âîäè. Íàïðèìåð âèäúò Sph. paucimobilis îò ðîäSphingomonas å àâòîõòîííà ôëîðà â ïðèðîäíè ìèíåðàëíèâîäè. Àíàëîãè÷åí å ñëó÷àÿò ñ Com. àcidovora îò ðîäComamonas, ñ ïðåäñòàâèòåëèòå íà ðîä Acidovorax, ðîäBrevundimonas è ðîä Flavobacterium sðp (10).

Áàêòåðèè Moraxella spð., ïðè÷èíÿâàùè èíôåêöèè íà î÷èòåè ãîðíèòå äèõàòåëíè ïúòèùà, ñå ðàçãëåæäàò è êàòî ñúñòàâíà÷àñò íà àâòîõòîííàòà ôëîðà íà áóòèëèðàíèòå âîäè è ñåèçîëèðàò îò ìèíåðàëíè âîäè(10).

Serratia spð. ñà èäåíòèôèöèðàíè êàòî S. fonticola. Òîâà ñàïñèõðîòðîôíè ìèêðîáè, øèðîêî ðàçïðîñòðàíåíè âúââîäíàòà ñðåäà è â ïîâå÷åòî ñëó÷àè ïðîèçõîæäàò îò çåëåí÷óöèèëè ìàëêè æèâîòíè (10).

Îò íàòóðàëíèòå ìèíåðàëíè âîäè ñå èçîëèðàò è ãðàì-ïîëîæèòåëíè áàêòåðèè, íî òå íå ñà ñúñòàâíà ÷àñò íààâòîõòîííàòà ôëîðà íà ìèíåðàëíèòå âîäè. Òÿõíîòîïðèñúñòâèå òðÿáâà äà ñå ðàçãëåæäà êàòî çàìúðñÿâàíå îòâúíøåí èçòî÷íèê – íàïð. îáîðóäâàíåòî íà áóòèëèðàùèòåêîìïàíèè, îêîëíàòà ñðåäà èëè õîðàòà, çàåòè ñïðîèçâîäñòâîòî, òúé êàòî ãîëÿìà ÷àñò îò èçîëèðàíèòåìèêðîáè ñà ÷àñò îò íîðìàëíàòà ÷îâåøêà ìèêðîôëîðà.Äîêàòî åäíè àâòîðè (6,13) äîêëàäâàò çà èçîëèðàíåòî íà ðîäîâåBacillus sp, Staphylococcus sp è Micrococcus sp îò ìèíåðàëíèâîäè, äðóãè àâòîðè óñòàíîâÿâàò âèäîâå îò ðîäîâåòåArthrobacter è Corynebacterium (10). Âñè÷êè âèäîâåñòàôèëîêîêè ñà áèëè èäåíòèôèöèðàíè êàòî S.epidermidis èâñè÷êè âèäîâå Micrococcus – êàòî M.luteus, äîêàòî çà äðóãèòåòðè ðîäà - Corynebacterium, Arthrobacter è Bacillus,èçîëèðàíèòå ùàìîâå íå ñà îïðåäåëåíè äî âèä.

Åäèíè÷íî ñúîáùåíèå òðåòèðà çàìúðñÿâàíåòî íà áóòèëèðàíèìèíåðàëíè âîäè ñ ïëåñåíè, êîèòî ñå ïîñî÷âàò êàòî èçòî÷íèêíà çàìúðñÿâàíåòî â ïúëíà÷íîòî ïîìåùåíèå, ÐÅÒ áóòèëêèòåè êàïà÷êèòå. Èçìåðåíèÿò áðîé íà ïëåñåíèòå âúâ âúçäóõà íàïúëíà÷íîòî ïîìåùåíèå å ïî-âèñîê ïðåäè ïúëíåíåòî,

Aeromonas, which are more resistant than other E.coliand are able to survive in bottled water up to 63 days.Since only a few cells of E. coli O157 are enough tocause illness, protection of underground sources ofnatural mineral water is of great importance. There havealready been several outbreaks associated withcontaminated wells (3).

The Acinetobacter spp. are also isolated from mineralbottled waters. They are known as pathogens that maycause urinary tract infections, pneumonia, andsecondary meningitis and wound infections. However,Acinetobacter spp. are ubiquitous inhabitants of soil,water and sewage environments and thus can entermineral waters (3).

Of strains of Alcaligenes spp. isolated from mineralwaters, Alc.faecalis is the most frequent one. (10).

Less frequently bacteria isolated from mineral watersbelong to autochthonous flora. For example, the speciesSph.paucimobilis belongs to the autochthons flora ofnatural mineral waters. Same is the case of Com.àcidovora of the species Comamonas , andrepresentatives of genera Acidovorax, Brevundimonasand Flavobacterium sðp (10)

Although Moraxella spp can cause infections of theeye and upper respiratory tract, it is considered asconstituent of the autochthonous flora of bottled waterand has been isolated from mineral waters (10).

Serratia spp were identified as Serratia fonticola. Thesepsychrotrophic microbes are widely distributed in waterand mostly originate from vegetable or small animalsources (10).

Gram-positive bacteria have been also isolated fromnatural mineral waters, but they are not considered asconstituents of autochthonous flora of mineral water.Therefore, they are thought to be due to the pollutioncaused by external sources, like bottling plant equipment,for instance, its employees or the environment, becausethey are mostly considered as normal inhabitants ofhuman beings. Some studies have reported that generaBacillus, Staphylococcus and Micrococcus were isolatedfrom mineral waters, while others have reported speciesbelonging to genera Arthrobacter and Corynebacterium(10). All species Staphylococcus have been identifies asS.epidermidis and all genera Micrococcus as M.luteus,while the isolated strains for the other three generaCorynebacterium, Arthrobacter è Bacillus have notbeen identified.

One study has dealt with the contamination of bottledmineral waters by moulds, where the filling room, thePET bottles and the caps were identified ascontamination sources. The mould count measured inthe air of the filling room before filling was higher thanthat measured 3 hrs. after filling, because the HEPA filterwas contaminated by mould. The PET bottles werewashed in 0.3 ppm ozone water or 10 ppm chlorine water,



îòêîëêîòî 3 ÷àñà ñëåä ïúëíåíåòî, òúé êàòî ÍÅÐÀ ôèëòúðúò åáèë êîíòàìèíèðàí ñ ïëåñåíè. ÐÅÒ áóòèëêèòå ñà èçïëàêíàòè ñ0,3 ppm îçîíèðàíà âîäà èëè ñ 10 ppm õëîðèðàíà âîäà, íîõèãèåííèÿò åôåêò íå å áèë ïî-äîáúð îò èçìèâàíåòî èì ñúññòåðèëíà âîäà. Çàïóøàëêèòå ñà îáðàáîòåíè ñ 1 è 2 ppm îçîí- ãàç çà 30 ìèíóòè, êîåòî ñúùî íå å áèëî äîñòàòú÷íî, çà äà ñåî÷èñòÿò îò ïëåñåíèòå. Òå ñà èäåíòèôèöèðàíè êàòî Penicilliumcitrinum, Neosartorya fischeri, Aspergillus terreus, Curvulariaborreriae, Cladosporium cladosporiodes, and Alternariaalternate (14).

Ïðîó÷âàíèÿòà çà çàìúðñÿâàíåòî íà áóòèëèðàíè èçâîðíèâîäè ñà ìíîãî ïî-ìàëêî.Ñúîáùàâà ñå çà íàëè÷èå íàêîëèôîðìè è äèàòîìåè â áóòèëèðàíà èçâîðíà âîäà.Äîêàçâàíåòî íà êîëèôîðìèòå â îêîëíàòà ñðåäà å èíäèêàòîðçà ïîòåíöèàëíîòî ïðèñúñòâèå çà äðóãî çàìúðñÿâàíå âúââîäàòà. Óñòàíîâÿâàíåòî íà äèàòîìåè âúâ âîäàòà ïúê åèíäèêàòîð, ÷å íåòðåòèðàíè èëè ÷àñòè÷íî ïðå÷èñòåíèïîâúðõíîñòíè âîäè ñà çàìúðñèëè èçïîëçâàíèÿ çà áóòèëèðàíåâîäåí èçòî÷íèê (15).

Áàêòåðèàëíîòî çàìúðñÿâàíå â ðàçïðåäåëèòåëíàòàáóòèëèðàùà ñèñòåìà íà èçâîðíà âîäà å ïðåäñòàâåíîïðåîáëàäàâàùî îò Bacillus spð., Enterobacteriaceae(Escherichia sðp., Shigella boydii), Pseudomonas sðp. èStaphylococcus sðp.(16).

Ìèêðîîðãàíèçìúò, êîéòî å íàé-÷åñòî â ïðÿñíà èçâîðíà âîäàè ñå èçîëèðà îò íåÿ, å P. fluorescens è íå ñå ðàçãëåæäà êàòîçàìúðñÿâàíå. Íî, êîãàòî òîçè ìèêðîîðãàíèçúì áúäåèçîëèðàí îò ìåñî, òîé ñå ñ÷èòà êàòî ïîòåíöèàëíî ïàòîãåíåíè å ïîâîä çà ðàçìèñúë (17).

Ïðè èçñëåäâàíå íà 34 òúðãîâñêè ìàðêè áóòèëèðàíè (â òîâà÷èñëî è èçâîðíè) âîäè îò ðàçëè÷íè ðàéîíè íà Øðè Ëàíêà, âïåðèîäà 1-3 ìåñåöà ñëåä äàòàòà íà ïðîèçâîäñòâî èì ïðèñúõðàíÿâàíå íà òåìïåðàòóðà (27±10Ñ), ñå èçîëèðàò ïëåñåíèîò ðîäîâåòå Trichoderma, Aspergillus, Alternaria, Penicillium.,Mucor è äðîæäè â ïî-ãîëÿìà ÷àñò îò ïðîáèòå, äîêàòîâîäîðàñëè íå ñà èçîëèðàíè îò íèòî åäíà ïðîáà. Â 15 % îòïðîáèòå ñå óñòàíîâÿâàò ôåêàëíè êîëèôîðìè, êîåòî ïîñòàâÿïîä âúïðîñ êà÷åñòâîòî íà áóòèëèðàíàòà âîäà â Øðè Ëàíêà èèçñêâà ïî-çàñèëåí êîíòðîë êúì áóòèëèðàùàòà èíäóñòðèÿ (18).

Àâòîðè îò Òåêñàñêèÿ Þæåí óíèâåðñèòåò (19) ñà èçñëåäâàëèçà áàêòåðèàëíà êîíòàìèíàöèÿ 35 ìàðêè áóòèëèðàíè âîäè.Îò 16 âèäà èçâîðíè âîäè, 6 ñà ïîêàçàëè ìèíèìàëíîáàêòåðèàëíî êîíòàìèíèðàíå. Îò 11 ïðîáè ïðå÷èñòåíè èîáîãàòåíè âîäîïðîâîäíè âîäè, 3 ñà êîíòàìèíèðàíè. Îòêðèòèñà ñëåäíèòå êîíòàìèíàíòè:

Ralstonia pickettii – ìàêàð ÷å òîçè âèä áàêòåðèÿ íåïðè÷èíÿâà ÷åñòî çàáîëÿâàíèÿ ó õîðàòà, èìà äàííè çàáîëíè÷íè èíôåêöèè îò Ralstonia pickettii â òåæêî áîëíèïàöèåíòè ñ êèñòîçíè ôèáðîçè è äð. Òàçè áàêòåðèÿ îáèòàâàïî÷âàòà è ìîæå äà áúäå îòêðèòà â åçåðà è ðå÷íè âîäè.

Agrobacterium Rhizogenes å íàé-÷åñòî ñðåùàíà â ïî÷âàòà,êàêòî ìíîãî äðóãè âèäîâå áàêòåðèè, êîèòî èìàò îòðèöàòåëíîâúçäåéñòâèå âúðõó èíñòàëàöèèòå. Äîêëàäâàíî å çà çàðàçåíèõîðà ñ îòñëàáåíà èìóííà ñèñòåìà.

but the sanitizing efficiency were not better than ofwashing with by sterilized water. The caps treated with 1and 2 ppm ozone gas for 30 min. were not sufficientlysterilized to be free of mould on it. Moulds have beenidentified to be Penicillium citrinum, Neosartoryafischeri, Aspergillus terreus, Curvularia borreriae,Cladosporium cladosporiodes, and Alternariaalternate(14).

Studies of polluted bottled spring waters were lessfrequent. They have reported coliforms diatoms inbottled spring water. The identification of coliforms inthe environment was an indicator for potential otherpollution of water. The identification of diatoms in waterpointed out that the water source used for bottling hasbeen polluted by nontreated or partially purified surfacewaters (15).

The bottled spring water in the distribution system wasmostly polluted by Bacillus spð., Enterobacteriaceae(Escherichia sðp., Shigella boydii), Pseudomonas sðp.è Staphylococcus sðp.(16).

P. fluorescens was most frequently identified and isolatedfrom fresh spring water, without being considered as apollutant. However when it was isolated from meat, itwas considered as potentially pathogenic and givesreason for concern (17).

34 brands of bottled waters (including spring waters)from different regions of Sri Lanka, being stored at2727±10Ñ, have been studied from 1 to 3 months afterthe date of production. The study reported mouldsbelonging to genera Trichoderma ., Aspergillus ,Alternaria, Penicillium., Mucor as well as yeast, whichhas been isolated in most samples, but not algae. FecalColiforms have been identified in 15% of samples, whichcompromised the quality of water in Sri Lanka, requiringa stronger control over bottling industry (18).

In Texas Southern University study (19), 35 brands weretested for biological contamination. Of the 16 types ofspring water, six showed minor bacterial contamination.From the 11 purified and fortified tap water bottles, threewere contaminated. The following contaminants werefound:

Ralstonia Pickettii - although this type of bacteria doesnot usually cause diseases in human beings, there havebeen hospital reports in which Ralstonia pickettiiinfections were found in critically ill patients with cysticfibrosis and other diseases. These bacteria are abundantin soil, and thus can be commonly found in lake andriver water.

Agrobacterium Rhizogenes is most commonly foundin soil, like various other types of bacteria, that has anegative impact on plants. It has been reported to infectpeople who have a weakened immune system.

Klebsiella Terrigena is generally found in water becauseof its abundance in soil, but this bacteria’s ability to



Klebsiella Terrigena îñíîâíî ñå îòêðèâà âúâ âîäàòà, ïîðàäèèçîáèëèåòî ìó â ïî÷âàòà, íî íåãîâàòà ñïîñîáíîñò äàïðè÷èíÿâà çàáîëÿâàíèÿ ó õîðàòà íå å ïîçíàòà. Òîâà ñå äúëæèíà ôàêòà, ÷å òîçè ìèêðîîðãàíèçúì å èçîëèðàí ìíîãî ðÿäêîîò õîðà.

Acidovorax Temperans ñå íàìèðà îáè÷àéíî â óòàéêèòå íàïðå÷èñòâàòåëíèòå ñòàíöèè íà âîäè êàòî íîðìàëåí êîìïîíåíòíà àêòèâíàòà óòàéêà.

Îò 1980 ã. , êîãàòî âëèçà â ñèëà íîâîòî åâðîïåéñêîçàêîíîäàòåëñòâî, íÿìà îòáåëÿçàíè ñëó÷àè íà áîëåñòè,äúëæàùè ñå íà êîíñóìàöèÿòà íà áóòèëèðàíà âîäà â Åâðîïà.Èìà ñèãíàëè çà çàìúðñÿâàíå ñ êîëèôîðìè, îñíîâíî â Àíãëèÿè Íîðâåãèÿ, íî íÿìà äîêóìåíòèðàíè íèêàêâè ñëó÷àè íàðàçáîëÿâàíå äîñåãà (3).

Îò çäðàâíà ãëåäíà òî÷êà å âàæíî äà ñå îòáåëåæè, ÷å ÑÇÎ (20)ðàçãëåæäà ñëåäíèòå âèäîâå ìèêðîîðãàíèçìè êàòîïðè÷èíèòåëè íà çàáîëÿâàíèÿ ñ âîäåí ïðîèçõîä: P. aeruginosa,A. hydrophilia, Burkholderia cepacia, Stenotrophomonasmaltophilia, S. marcescens, F. meningosepticum,A.calcoaceticus. Íÿìà äàííè îáà÷å çà çàáîëÿâàíèÿ, äúëæàùèñå íà âèñîêè êîíöåíòðàöèè íà õåòåðîòðîôíè áàêòåðèè âáóòèëèðàíèòå âîäè (10).


1. Íàðåäáà çà èçèñêâàíèÿòà êúì áóòèëèðàíèòå íàòóðàëíèìèíåðàëíè, èçâîðíè è òðàïåçíè âîäè, ïðåäíàçíà÷åíè çàïèòåéíè öåëè (îáí., ÄÂ, áð.68 îò 2004ã; èçì. è äîï., áð.66îò 2008ã). /Regulation about requirements to bottled naturalmineral, spring and potable water, intended for drinkingpurposes (publication in State newspaper, issue 68 of 2004,amendment and addition , issue 66 of 2008)/.

2. Íàðåäáà ¹9 îò16.03.2001ã çà êà÷åñòâîòî íà âîäàòà,ïðåäíàçíà÷åíà çà ïèòåéíî-áèòîâè öåëè. /Regulation ¹9 of16.03.2001 about quality to the water, intended for publicdrinking purposes/.

3. Lawley, Richard - Jan2007. Water, water, everywhere.http://www.foodsafetywatch.com/public/157print.cfm

4. Korzeniewska Ewa, Zofia Filipkowska, Sylwia Domeradzka,Kamil Wlodkowski. Microbiological Quality of Carbonated andNon-Carbonated Mineral Water Stored at Different Temperature.Polish Journal of Microbiology, 2005, vol.54, Suppl., 27-33.jmhttp://www.p.microbiology.pl/archive/vol54suppl20052

5. Ehlers, Marthie M., Walda B. van Zyl, Dobromir N. Pavlov andEtienne E. Müller. Random survey of the microbial quality ofbottled water in South Africa. Department of Medical Virology,Institute of Pathology, University of Pretoria, PO Box 2034,Pretoria, 0001, South Africa. Water SA Vol. 30 No.2 April 2007http://www.ajol.info/index.php/wsa/article/viewFile/5065/12656

6. Leclerc, H. and Moreau, A. (2002). Microbiological safety ofnatural mineral water. FEMS Microbiol Rev. 26:207–222.

7. Lacroix, B. and Powell, D.A., 2001.The Microbiological Safetyof Bottled Water in Canada.http://www.foodsafety.ksu.edu/articles/468/micro_sfty_bottled_water_canada.pdf

cause diseases in humans is unknown. This is due tothe fact that it is only rarely isolated from humans.

Acidovorax Temperans is constantly found in the sludgewater of water treatment plants because it is considereda normal component of activated sludge treatmentsystems.

Since 1980, when new European regulations wereimplemented, there were no recorded cases of diseaseassociated with consumption of bottled water in Europe.There have been some recalls because of coliformcontamination mainly in UK and Norway, but there wereno documented cases of illness to date. (3)

It has to be stressed that WHO (2) considers the followingspecies to be agents of waterborn diseases: P.aeruginosa, A. hydrophilia, Burkholderia cepacia,Stenotrophomonas maltophilia, S. marcescens, F.meningosepticum,A.calcoaceticus . However, there isno evidence about diseases due to high concentrationsof heterotrophic bacteria in bottled waters (10).

8. Osman, G.A., M.S.Ali, M.M.Kamel, A.Z. Al-Herrawy.Assessment of Bottled Water Quality Using MicrobialIndicators (Pseudomonas and Bacillus). Middle – EastJournal of Scientific Research 4(4): 341-347, 2009.http://www.idosi.org/mejsr/mejsr4(4)/19.pdf

9. http://www.nrdc.org/water/drinking/bw/chap3.asp BottledWater Pure Drink or Pure Hype? This is the online versionof NRDC’s March 1999 petition to the FDA. NRDC = NaturalResources Defense Council

10. Daood, N. (2008). Bacterial diversity of local and importedbottled mineral water in Syria. Damascus University Journalfor Basic Sciences (Vo.24, No2.61-80). http://damascusuniversity.sy/mag/asasy/images/stories/61-80e.pdf

11. Daood, N. Risk Assessment of Heterotrophic Bacteria fromBottled Mineral Water Consumed in Syria. DamascusUniversity Journal for Basic Sciences (Vol. 25, No 1, 2009)Department of Botany, Faculty of Sciences, TishreenUniversity, Syria.http://damascusuniversity.sy/mag/asasy/images/stories/21-42%20e.pdf

12. Äèðåêòèâà 98/83/ÅÎ îòíîñíî êà÷åñòâîòî íà âîäèòå,ïðåäíàçíà÷åíè çà êîíñóìàöèÿ îò ÷îâåêà

13. Ogan, M. (1992), Microbiological quality of bottled watersold in retail outlets in Nigeria. Journal of AppliedMicrobiology, 73: 175–181. doi: 10.1111/j.1365-2672.1992.tb01706.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.1992.tb01706.x/abstract

18. Abayasekara C. L., W.H.M.A.T. Herath, N.K.B. Adikaram,R. Chandrajith ,S.C. Illapperuma, A.D. Sirisena and S.G.Rajapura.



14. Huang Chin Cheng; Lung Sham Mam; Peng Jui Sen.Identification of floating microorganisms in bottled mineralwater and contamination caused by equipment and theenvironment. Taiwanese Journal of Agricultural Chemistryand Food Science 2000 Vol. 38 No. 4 pp. 361-366. http://www.cabdirect.org/abstracts/20003029990.html

15. http://www.bio-medicine.org/medicine-news/Bottled-Water-Contains-Coliform-Bacteria- and-Diatoms-8846-1/Bottled water contains coliform bacteria and diatoms[Outline] [RSS & Subscription] Bio-Medicine.

16. Behardien, Latiefa, “Investigation into the bacterialcontamination in a spring water distribution system and theapplication of bioremediation as treatment technology”(2008). CPUT Theses & Dissertations. Paper 28. CapePeninsula University of Technology http://dk.cput.ac.za/td_cput/28/

17. http://www.frequencyrising.com/water_bottled.htm BottledWater Cleanliness.


Äîö. ä-ð Ë.×èïèëñêà, äìÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçèÁóë.”Àêàä. Èâàí Ãåøîâ” ¹15, Ñîôèÿ 1431Òåë.: 80-56-298

Å-ïîùà: [email protected]

Microbiological Quality of Bottled Water in Sri Lanka: APreliminary SurveyProceedings of the Peradeniya University ResearchSessions, Sri Lanka, Vol.12, Part I, 30thNovember 2007.http://www.pdn.ac.lk/purse/purse07/papers/021.pdf

19. Gauthier, Cristina . Types of Bacteria in Bottled Water.eHow Contributor updated: November 16, 2010.http://www.ehow.com/list_7505176_types-bacteria-bottled-water.html.

20. The world health report 2002 - Reducing Risks,Promoting Healthy Lifehttp://www.who.int/whr/2002/en/


Assoc. Prof. L. Chipilska, MDNational Center of Public Health and AnalysesAcad. Ivan Geshov Blvd. 15, Sofia 1431Tel: 8056 298

Email: chipilska@gmail. com



ÏÑÈÕÎÔÈÇÈÎËÎÃÈ×ÍÈÏÎÊÀÇÀÒÅËÈ È ÐÀÁÎÒÎÑÏÎÑÎÁÍÎÑÒÍÀ ÐÀÁÎÒÅÙÈ Ñ ÊÎÌÏÞÒÐÈ ÂÒÚÐÃÎÂÑÊÈ ÎÁÅÊÒÈ

Áîðÿíà Êàâàëäæèåâà, Òåîäîðà Äèìèòðîâà,Äàðèíà Íàéäåíîâà

Êàòåäðà “Õèãèåíà è áåäñòâåíè ñèòóàöèè” –ÌÓ Âàðíà

Ðåçþìå

Öåë íà íàñòîÿùàòà ðàáîòà å ïðîó÷âàíå íàðàáîòîñïîñîáíîñòòà íà ëèöà, ðàáîòåùè ñ êîìïþòðè âòúðãîâñêè îáåêòè, ñ îãëåä íåîáõîäèìîñòòà îò ñúçäàâàíåíà ðàöèîíàëíè ðåæèìè íà òðóä è ïî÷èâêà – çàïðîôèëàêòèêà íà óìîðàòà è ïîâèøàâàíå íàïðîèçâîäèòåëíîñòòà íà òðóäà.

Èçñëåäâàíè ñà 39 ÷îâåêà (àäìèíèñòðàòèâåí ïåðñîíàë èêàñèåðè) íà ñðåäíà âúçðàñò 29,95±1,1ã., ðàáîòåùèîñíîâíî íà êîìïþòúð â òúðãîâñêè îáåêòè. Ëèöàòà ñàðàçäåëåíè â òðè ãðóïè â çàâèñèìîñò îò ðàáîòíîòî âðåìå:² (ñóòðåøíà ñìÿíà), ðàáîòåùè îò 8 äî 14,30÷; ²²(ñëåäîáåäíà), ðàáîòåùè îò 14,30 äî 21,00÷ è ²²² (ðåäîâíà),ðàáîòåùè îò 9,00 äî 17,00 ÷. Èçñëåäâàíèÿòà ñà ïðîâåäåíèòðè äíè â ñåäìèöàòà (ïúðâè, òðåòè è ïåòè äåí),òðèêðàòíî – â íà÷àëîòî, ñðåäàòà è êðàÿ íà ðàáîòíèÿ äåí.Îïðåäåëåíè ñà ïóëñîâà ÷åñòîòà è àðòåðèàëíî íàëÿãàíå,âðåìå íà çðèòåëíî-ìîòîðíà ðåàêöèÿ ÷ðåç êîìïþòúðíàïðîãðàìà “Reflection test” è îáåì, ñêîðîñò è òî÷íîñò íàïðåðàáîòåíàòà èíôîðìàöèÿ ñ òàáëèöà íà Ëàíäîëò.Èç÷èñëåíè ñà âåãåòàòèâåí èíäåêñ íà Êåðäî è êîåôèöèåíòíà èçäðúæëèâîñò. Çà ñòàòèñòè÷åñêà îáðàáîòêà ñàïðèëîæåíè âàðèàöèîíåí, àëòåðíàòèâåí è íåïàðàìåòðè÷åíàíàëèç íà ïàêåòà SPSS PC.

Ðåçóëòàòèòå îò íàøèòå èçñëåäâàíèÿ íàïñèõîôèçèîëîãè÷íèòå ïîêàçàòåëè â äíåâíà è ñåäìè÷íàäèíàìèêà ïîêàçâàò èçâåñòíè ïðîìåíè âðàáîòîñïîñîáíîñòòà. Ïî-èçðàçåíè ñà èçìåíåíèÿòà âñúðäå÷íîñúäîâèòå ïîêàçàòåëèòå è òåçè, ñâúðçàíè ñïðèåìàíå è ïðåðàáîòêà íà èíôîðìàöèÿ ïðè ðàáîòåùèòå² è ²² ñìÿíà, êîåòî áè ìîãëî äà ñå ñâúðæå ñ âëèÿíèåòî íàìîíîòîíèÿòà âúðõó îðãàíèçìà íà ðàáîòåùèòå. Äàííèòåîò ñåäìè÷íàòà äèíàìèêà íà ðàáîòîñïîñîáíîñòòàïîòâúðæäàâàò ñòàíîâèùåòî çà ïî-ðàííî ðàçâèòèå íàíåðâíî-ñåíçîðíà óìîðà ïðè ðàáîòåùèòå ñ êîìïþòúð.

Êëþ÷îâè äóìè: ïñèõîôèçèîëîãè÷íè ïîêàçàòåëè,ðàáîòîñïîñîáíîñò, óìîðà, ìîíîòîííîñò.

Îñíîâíà ïðè÷èíà çà èçìåíåíèÿòà â ðàáîòîñïîñîáíîñòòà åâèäúò íà èçâúðøâàíàòà ðàáîòà. Ñïåöèôè÷íà îñîáåíîñò ïðè

PSYCHO-PHYSIOLOGICAL INDEXESAND WORKING-ABILITY INPERSONS WORKING WITHCOMPUTERS IN TRADING CENTERS(OBJECTS)

Boryana Kavaldzieva, Teodora Dimitrova, DarinaNaidenova

Department of Hygiene and medicine of disasters –MU Varna

Abstract

The study of the work ability of those working withcomputers in the retail sector has great importancein necessitating the creation of a sensible work-restbalance to prevent fatigue and increase work pro-ductivity.

39 administrative personnel and cashiers from theretail sector, with an average age of 29.95+1.1 yearsand who work mostly with computers, have been ex-amined. The subjects were divided in three groupsaccording to their work schedules: group I (morningshift) working from 8 am to 2:30 pm; group II (after-noon shift) working from 2:30 pm to 9 pm; and groupIII (regular shift) working from 9 am to 5 pm. Studieshave been conducted three days a week (first, thirdand fifth day), three times a day – at the start, middleand end of the workday. The following indicators weremeasured: heart rate, blood pressure, eye-hand co-ordination using a computer software, and amount,speed and accuracy of information internalizationusing a Landolt table. The vegetative index of Kerdoand the coefficient of resistance have been calculated.The statistical analysis includes variable, alterna-tive and non-parametric analysis using SPSS.

The results of the study of the psycho-physiologicalindicators show certain changes in work ability. Morepronounced are the changes in the cardio-vascularand information internalization indicators amongstthose in groups I and II, which could be connectedwith the effect of monotony on the body. The data ofthe weekly dynamics of work ability confirms the state-ment of earlier development of neurosensory fatigueamongst those working with computers.

Key words: psycho-physiological indexes ,working-ability, fatique, monotony

The main reason for the changes in the working-abilityis the type of the performed work. In the contemporaryconditions as a specific characteristic of the usage ofcomputers in the service area is the monotony, which

ÒÐÓÄÎÂÀ ÌÅÄÈÖÈÍÀ OCCUPATIONAL HEALTH


èçïîëçâàíåòî íà êîìïþòðè â îáñëóæâàùàòà ñôåðà åìîíîòîííîñòòà, êîÿòî âîäè ïî-áúðçî äî íåáëàãîïðèÿòíèïñèõîôèçèîëîãè÷íè ïîñëåäèöè è âëîøàâàíå íàðàáîòîñïîñîáíîñòòà, äàâàùà îòðàæåíèå è âúðõóïðîèçâîäèòåëíîñòòà íà òðóäà.

Èçó÷àâàíåòî íà ôóíêöèîíàëíîòî ñúñòîÿíèå, âúâ âðúçêà ñîöåíêàòà íà ðàáîòîñïîñîáíîñòòà íà ëèöà, ðàáîòåùè âòúðãîâñêè îáåêòè, å âàæåí âúïðîñ, ñ îãëåä íåîáõîäèìîñò-òà îò ñúçäàâàíå íà ðàöèîíàëíè ðåæèìè íà òðóä è ïî÷èâêà,à ñúùî – è çà ïðîôèëàêòèêà íà óìîðàòà è ïîâèøàâàíå íàðàáîòîñïîñîáíîñòòà.

Ïîñòàíîâêà è ìåòîäè

Èçñëåäâàíè ñà 39 ÷îâåêà (àäìèíèñòðàòèâåí ïåðñîíàë èêàñèåðè) íà ñðåäíà âúçðàñò 29,95±1,1ã., ðàáîòåùèîñíîâíî ñ êîìïþòúð â òúðãîâñêè îáåêòè. Ëèöàòà ñàðàçäåëåíè â òðè ãðóïè â çàâèñèìîñò îò ðàáîòíîòî âðåìå:² (ñóòðåøíà ñìÿíà), ðàáîòåùè îò 8 äî 14,30÷; ²²(ñëåäîáåäíà), ðàáîòåùè îò 14,30 äî 21,00÷ è ²²² (ðåäîâíà),ðàáîòåùè îò 9,00 äî 17,00 ÷. Ðàáîòåùèòå ðåäîâíà ñìÿíà ñàëèöà îò ñ÷åòîâîäíî-ìåíèäæúðñêèÿ åêèï, äîêàòî òåçè îò ²è ²² ñìÿíà – îñíîâíî êàñèåðè. Èçñëåäâàíèÿòà ñà ïðîâåäåíèòðè äíè â ñåäìèöàòà (ïúðâè, òðåòè è ïåòè äåí), òðèêðàòíî– â íà÷àëîòî, ñðåäàòà è êðàÿ íà ðàáîòíèÿ äåí. Îïðåäåëåíèñà ïóëñîâà ÷åñòîòà è àðòåðèàëíî íàëÿãàíå, âðåìå íàçðèòåëíî-ìîòîðíà ðåàêöèÿ ÷ðåç êîìïþòúðíà ïðîãðàìà“Reflection test” è îáåì, ñêîðîñò è òî÷íîñò íàïðåðàáîòåíàòà èíôîðìàöèÿ ñ òàáëèöà íà Ëàíäîëò.Èç÷èñëåíè ñà âåãåòàòèâåí èíäåêñ íà Êåðäî è êîåôèöèåíòíà èçäðúæëèâîñò ïî ôîðìóëàòà íà Êâàñ (1,3).

Çà ñòàòèñòè÷åñêà îáðàáîòêà ñà ïðèëîæåíè âàðèàöèîíåí,àëòåðíàòèâåí è íåïàðàìåòðè÷åí àíàëèç íà ïàêåòà SPSS PC.

Ðåçóëòàòè è îáñúæäàíå

Ðåçóëòàòèå îò èçñëåäâàíèòå ëèöà ïîêàçâàò òåíäåíöèÿ êúìïîíèæàâàíå íà ïóëñîâàòà ÷åñòîòà â êðàÿ íà ðàáîòíèÿ äåíè â òðèòå äíè (Ôèã.1.), êàòî â ñðåäàòà íà ðàáîòíàòà ñåäìèöàòî å ñòàòèñòè÷åñêè äîñòîâåðíî (ð <0,04). Ïîäîáíè ñàòåíäåíöèèòå çà ñèñòîëíîòî è äèàñòîëíîòî íàëÿãàíå, íîñàìî â ² –ÿ äåí ïîíèæåíèåòî çà äèàñòîëíîòî íàëÿãàíå ñåïîòâúðæäàâà ñòàòèñòè÷åñêè (ð < 0,047).

Èçõîæäàéêè îò èçâåñòíèÿ ôàêò, ÷å ïðîìåíèòå â ïóëñà ñà âñúîòâåòñòâèå ñ èçìåíåíèÿòà âúâ ôóíêöèîíàëíîòîñúñòîÿíèå íà íåðâíàòà ñèñòåìà, òî íàøèòå ðåçóëòàòèïîòâúðæäàâàò òîâà. Ïðè ðàáîòåùè ñúñ ñëàáî ôèçè÷åñêîíàòîâàðâàíå è ñåäÿùà ðàáîòíà ïîçà, õàðàêòåðíî çà òåçèïðîôåñèîíàëíè ãðóïè, çàáàâÿíåòî íà ñúðäå÷íèòåñúêðàùåíèÿ å ðåçîííî. Ðàçãëåæäàéêè òîçè ïîêàçàòåë ïîãðóïè, ñå îòáåëÿçâà, ÷å ïðè ² ñìÿíà ïóëñîâàòà ÷åñòîòà âïîñëåäíèÿ äåí îòáåëÿçâà äîñòîâåðåí ñïàä (ð<0,046), à ïðè²² – ïðåç âñè÷êèòå òðè äíè íà èçñëåäâàíåòî (ð<0,05).Ñèñòîëíîòî íàëÿãàíå ïîêàçâà çíà÷èì ñïàä ñàìî âïîñëåäíèÿ äåí (ð<0,034). Äèàñòîëíîòî íàëÿãàíå íÿìàçíà÷èìè ïðîìåíè â îòäåëíèòå ãðóïè.

faster leads to unfavorable psycho-physiologicalconsequences and worsening of working-ability,reflecting also the productivity of labor.

Studying of the functional condition connected withassessment of the working-ability of persons, working intrading centers is an important question, in accordanceto the necessity of creation of rational regimes of workand rest, and also – for prophylaxis of tiredness andincrease in the working-ability.

Design and methods

Thirty nine persons are studied (administrative staff andcashiers) at average age 29,95±1,1 year, working mainlywith a computer in trading centers. They are divided intothree groups according to their working time: I-st (morningshift), working form 8 to 14,30 p.m.; II-nd (afternoon shift),working form 14,30 to 21,00 p.m. and III-rd (regular shift),working from 9 to 17,00 p.m. Workers from the regularshift are people from the accounting-manager staff, whilethose from I-st and II-nd shift – mainly cashiers. Theexaminations are performed in three days of the week(first, third and fifth), threefold – in the beginning, in themiddle and at the end of the working day. Tested are thepulse rate and blood pressure, time for visual-motorreaction by computer program “Reflection test” andvolume, speed and accuracy of the processed informationwith Landolt’s table. Calculated are the vegetative Kerdoindex and coefficient of tenacity by the Kvas formula (1,3).

For the statistic processing are used variation, alternativeand nonparametric analysis by SPSS PC.

Results and discussion

The results form the tested people show tendency oflowering of the pulse rate at the end of the working dayfor all three days (Fig.1), as in the middle of the work-week it is statistically reliable (p<0,04). Similar are thetendencies for the systolic and diastolic pressure, butonly in the I-st day the lowering of the diastolic pressureis confirmed statistically (p<0,047).

Assuming the known fact that the changes in the pulseare in correlation with the changes in the functionalcondition of the nerve system, our results confirm that.In workers with mild physical loading and sitting workingposition, which is characteristic for these professionalgroups, the lowering of the heart cuts is reasonable.Looking at this index for the different groups, is foundthat in I-st shift the pulse rate in the last day has a reliabledrop (p<0,046), and for II-nd – in all three days of theinvestigation (p<0,05). The systolic pressure show asignificant drop only in the last day (p<0,034). Thediastolic pressure has no significant changes in thedifferent groups.



Ôèã.1. Äèíàìèêà â ñòîéíîñòèòå íà ïóëñîâàòà ÷åñòîòà

Âåãåòàòèâíèÿò èíäåêñ íà Êåðäî å ñ òåíäåíöèÿ êúìïîíèæàâàíå â êðàÿ íà ðàáîòíàòà ñìÿíà. Â íà÷àëîòî íàðàáîòíàòà ñåäìèöà 33,7% îò èçñëåäâàíèòå èìàò îòðèöàòåëåíèíäåêñ è 66,3% - ïîëîæèòåëåí. (Ôèã.2) Â ñðåäàòà è êðàÿ íàñåäìèöàòà îòðèöàòåëåí èíäåêñ ñå íàáëþäàâà ïðè 24% îòèçñëåäâàíèòå, ïðè � 0,05. Çà ²² ñìÿíà ñå íàáëþäàâà â êðàÿíà ðàáîòíàòà ñåäìèöà è ðàáîòíèÿ äåí ðÿçúê ñïàä (ð<0,03),êàòî ïðîöåíòúò íà ëèöàòà ñ îòðèöàòåëåí èíäåêñ îò 11,1% âíà÷àëîòî íà ðàáîòíèÿ äåí ñå ïîêà÷âà äî 40,0%. Èçâåñòíî å,÷å îòðèöàòåëíèòå ïîêàçàíèÿ íà âåãåòàòèâíèÿ èíäåêñ íàÊåðäî å óêàçàíèå çà âêëþ÷âàíå íà ïàðàñèìïàòèêîâàòà íåðâíàñèñòåìà, îñîáåíî ïðè âúçñòàíîâÿâàíå, ñëåä ñúñòîÿíèå íàïðîäúëæèòåëíî íàòîâàðâàíå.

Ôèã.2. Äèíàìèêà â ðàçïðåäåëåíèåòî íà ëèöàòà ñ îòðèöàòåëíèñòîéíîñòè íà âåãåòàòèâíèÿ èíäåêñ íà Êåðäî

Êîåôèöèåíòúò íà èçäðúæëèâîñò íà Êâàñ ïîêàçâàñðàâíèòåëíî âèñîêè ñðåäíè ñòîéíîñò (20 – 24 óñëîâíèåäèíèöè) è îáùà òåíäåíöèÿ êúì íàìàëåíèå â êðàÿ íàïúðâèÿ è òðåòèÿ äåí, êàòî â ïîñëåäíèÿ äåí ñå çàïàçâà íàåäíî íèâî. (Ôèã.3) Ïðè ðåäîâíà, ² è ²² ñìÿíà òåíäåíöèÿòà


Figure 1. Dynamics in the value of pulse rate

The vegetative index of Kerdo is with tendency oflowering at the end of the working shift. At the beginningof the working week 33,7% of the tested have a negativeindex and 66,3% - positive. In the middle and at the endof the week, the negative index is found in 24% of thetested at p 0,05. (Fig.2) The II-nd shift has a significantdrop at the end of the working week and working day(p<0,03), as the percentage of the people with negativeindex from 11,1% increases to 40%. It is known that thenegative results of the vegetative index of Kerdo showsthe inclusion of the parasympathetic nerve system,especially in recovery, after continuous loading.

Figure 2. Dynamics in the distribution of persons withnegative value of the vegetative index of Kerdo (%)

The coefficient of tenacity of Kvas shows relatively highaverage values (20 – 24 conditional unit) and generaltendency to lowering at the end of the first and third day,as in the last day it stays at the same level. (Fig.3) Inregular, I-st and II-nd shift, the tendency is the same, asin the last day for II-nd shift the tendency is for lowering,



å ñúùàòà, êàòî â ïîñëåäíèÿ äåí çà ²² ñìÿíà òåíäåíöèÿòà å êúìíàìàëåíèå, à çà ðåäîâíà – êúì óâåëè÷åíèå. Íàáëþäàâàíèòåòåíäåíöèè íå ñå äîêàçâàò ñòàòèñòè÷åñêè (ð 0,05). Èçõîæäàéêèîò ôàêòà, ÷å áîëøèíñòâîòî îò èçñëåäâàíèòå ëèöà ñà â ìëàäàâúçðàñò, à ðàáîòàòà â ïî-ãîëÿìàòà ÷àñò îò âðåìåòî ñå èçâúðøâàâ ñåäÿùà ïîçà, ïî-âèñîêèÿò êîåôèöèåíò íà èçäðúæëèâîñò,êîéòî îáèêíîâåíî å ïîêàçàòåë çà îòñëàáåíè âúçìîæíîñòè íàñúðäå÷íîñúäîâàòà ñèñòåìà, ìîæå äà ñå ñâúðæå ñ ìîíîòîííèÿòðóä.

Ôèã. 3. Äèíàìèêà íà ñòîéíîñòèòå íà êîåôèöèåíòàíà èçäðúæëèâîñò

Âúç îñíîâà íà äëúæíîñòíàòà õàðàêòåðèñòèêà íàèçñëåäâàíèòå ëèöà è íà ðåçóëòàòèòå îò èçñëåäâàíèòåïîêàçàòåëè – ïóëñîâà ÷åñòîòà è ñèñòîëíî è äèàñòîëíîíàëÿãàíå, ìîæå äà ñå ãîâîðè çà äåéíîñò ñ íèñêà äâèãàòåëíààêòèâíîñò ñ ïðåîáëàäàâàùà ìîíîòîííî ñò. Êàòîäîïúëíèòåëíè ôàêòîðè ìîãàò äà ñå ïîñî÷àò, ïðè ïî-ãîëÿìàòà ÷àñò îò èçñëåäâàíèòå (íàïð. êàñèåðè) – ñåäÿùàòàðàáîòíà ïîçà è ëèïñàòà íà ïàóçà, ïðåç êîÿòî ìîæå äà ñåñòàíå è äà ñå ïðîìåíè ïîëîæåíèåòî íà òÿëîòî. Òå, îò ñâîÿñòðàíà, çàñèëâàò õèïîêèíåçèÿòà êàòî íàìàëÿâàòàôåðåíòíàòà ñòèìóëàöèÿ íà öåíòðàëíàòà íåðâíà ñèñòåìàîò ïðîïðèîðåöåïòîðèòå íà äâèãàòåëíèÿ àïàðàò.

Êàòî ñå èìà ïðåäâèä, ÷å îáñëóæâàíåòî íà ñúâðåìåííàòàòåõíèêà, â ñëó÷àÿ – êîìïþòðè, èçèñêâà ñúñðåäîòî÷âàíå, áúðçîïðåâêëþ÷âàíå, óñòîé÷èâîñò íà âíèìàíèåòî, ïàìåò, óìñòâåíîíàïðåæåíèå, å öåëåñúîáðàçíî äà ñå èçñëåäâàò ïîêàçàòåëèòåçà ôóíêöèîíàëíîòî ñúñòîÿíèå íà öåíòðàëíàòà íåðâíàñèñòåìà. Äàííèòå îò íàøèòå èçñëåäâàíèÿ çà ïðîìåíèòå âñåíçîìîòîðíàòà ðåàêöèÿ è ïðîìåíèòå âúâ âíèìàíèåòî ñåõàðàêòåðèçèðàò ñ îïðåäåëåíà äèíàìèêà.

Íàé-îáùî â íà÷àëîòî è ñðåäàòà íà ðàáîòíàòà ñåäìèöà îáåìúòè ñêîðîñòòà íà ïðèåòàòà è ïðåðàáîòåíà èíôîðìàöèÿ íàìàëÿâàâ êðàÿ íà ñìÿíàòà ( ð < 0,05 ñàìî çà ñðåäàòà íà ñåäìèöàòà).(Ôèã.4) Â êðàÿ íà ðàáîòíàòà ñåäìèöà è íà ðàáîòíàòà ñìÿíàñå íàáëþäàâà òåíäåíöèÿ êúì ïîâèøàâàíå íà ïîêàçàòåëèòå

and for regular - for increase. The observed tendenciesare not statistically approved (p 0,05). Assuming the factthat most of the studied persons are at young age, andthe work in most of the time is performed in sittingposition, the higher coefficient of tenacity, which usuallyis an index for lowered abilities of the cardio-vascularsystem, can be connected with the monotony work.

Figure 3. Dynamics in the value of the coefficient of tenacityduring the fifth day

According to the job description of the studied personsand to the results of the studied indexes – pulse rate andsystolic and diastolic pressure, we can talk about activitywith low motive activity with predominant monotony. Asadditional factors in most of the studied (cashiers forexample) can be found – fixed working position and nopause, during which they can stand and change the bodyposition. These factors on their side increase thehypokinesia and lower the afferent stimulation of thecentral nervous system from the proprioreceptors of themotive apparatus.

As it is known that the maintenance of the contemporarytechnique, in our case – computers, requires concentration,fast switching, stability of attention, memory, mentaltension, it is important to test the indexes of the functionalcondition of the central nervous system. The data of ourtests for the changes in the sensomotor reaction andchanges in attention are characterized with certaindynamics.

Generally at the beginning and in the middle of the workingweek, the volume and speed of the accepted andprocessed information lowers at the end of the shift (asp<0,05 only in the middle of the week) (Fig.4). At the endof the working week and working shift is found a tendencyof increase of the indexes (p 0,05). (Fig.5) Similar is the



(ð 0,05). (Ôèã.5) Ïîäîáíà å òåíäåíöèÿòà çà âðåìåòî çàðåàêöèÿ è çà èç÷èñëåíèòå êîåôèöèåíòè íà ïðîäóêòèâíîñò èòî÷íîñò. (Ôèã.6) Â çàâèñèìîñò îò ñìåííîñòòà íà ðàáîòàñå îòáåëÿçâà çíà÷èìî íàìàëÿâàíå íà îáåìà íàïðåðàáîòåíàòà èíôîðìàöèÿ ïðè ðàáîòåùèòå ² ñìÿíà âñðåäàòà è êðàÿ íà ðàáîòíàòà ñåäìèöà (ð<0,05) è íàñêîðîñòòà – â êðàÿ íà ðàáîòíèÿ äåí ïðè âñè÷êè èçñëåäâàíèäíè (ð<0,05). Ïðè ²² ñìÿíà òåíäåíöèÿòà å ïîäîáíà (ïðèð 0,05). Çà ðàáîòåùèòå ðåäîâíà ñìÿíà â ñðåäàòà íàðàáîòíàòà ñåäìèöà ñå îòáåëÿçâà çíà÷èìî íàìàëÿâàíå íàîáåìà è ñêîðîñòòà íà ïðåðàáîòåíàòà èíôîðìàöèÿ â êðàÿíà ðàáîòíèÿ äåí (ð<0,05).

Ôèã.4. Äèíàìèêà â îáåìà íà ïðåðàáîòåíàòà èíôîðìàöèÿ

Ôèã.5. Äèíàìèêà â ñêîðîñòòà íà ïðåðàáîòåíàòà èíôîðìàöèÿ

tendency for the time of reaction and the calculatedcoefficients of productivity and accuracy. (Fig.6)Examined according to the shifts of work, there is asignificant lowering of the volume of the processedinformation of the workers I-st shift in the middle and atthe end of the working week (p<0,05) and the speed – atthe end of the working day for all the studied days(p<0,05). For II-nd shift the tendency is similar (atp 0,05). For workers at regular shift in the middle of theworking week is found significant lowering of the volumeand speed of the processed information at the end ofthe working day. (ð<0,05).

Figure 4. Dynamics in the volume of the processed information

Figure 5. Dynamics in the speed of the processed information



Figure 6. Dynamics in the time of reaction

Our data confirm that the changes in the functionalcondition of the persons working with computers in asignificant level is determined by changes mainly in thecognitive sphere (2, 7), as an earlier development ofnerve-sensor tiredness is observed.(4). With thehypokinesia and monotony, probably, can be connectedthe tendencies in the changes of the cardio-vascularindexes, as the reaction to the uniformity of the irritatorsmanifests with increase of the parasympathetic influence(5,9,11), which leads to lowering of the pulse rate andblood pressure. This is especially indicative for I-st andII-nd shift and in milder level for the regular shift, whichfinds its logical explanation in the fact that for theaccounting-manager staff the monotony can be overcomeby higher liberty of organization of work and in this way– more successful overcoming the consequences of themonotony.

The inter-shift differences in our results supports thedata of other authors (8,10), that the control over theorganization of working time and ability of usage ofspontaneous micropauses are main factors formaintenance of stable working ability in coming tirednessat the end of the working cycle.

Explanation of the variability of the studied indexes inthe separate shifts can be also the different hours of theperformed tests during the day and the connected withthis natural dynamics of the working ability.

On its side the monotony is characterized with paralleldevelopment of inhibitor processes at another level ofmanagement, connected with the accepting andprocessing of information. In our examinations theevidence for this are the lowered volumes and speed ofthe processed information and the coefficients ofaccuracy and productivity.

Ôèã.6. Äèíàìèêà íà âðåìåòî íà ðåàêöèÿòà

Íàøèòå äàííè ïîòâúðæäàâàò, ÷å ïðîìåíèòå âúâôóíêöèîíàëíîòî ñúñòîÿíèå íà ðàáîòåùèòå ñ êîìïþòðè âçíà÷èòåëíà ñòåïåí ñå îïðåäåëÿò îò ïðîìåíè îñíîâíî âêîãíèòèâíàòà ñôåðà (2, 7), êàòî ñå íàáëþäàâà ïî-ðàííîðàçâèòèå íà íåðâíî-ñåíçîðíà óìîðà (4). Ñ õèïîêèíåçèÿòà èìîíîòîííîñòòà, ïî âñÿêà âåðîÿòíîñò, ìîæå äà ñå ñâúðæàòòåíäåíöèèòå â èçìåíåíèÿòà íà ñúðäå÷íîñúäîâèòå ïîêàçàòåëè,òúé êàòî ðåàêöèÿòà íà åäíîîáðàçèåòî íà äðàçíèòåëèòå ñåïðîÿâÿâà â çàñèëâàíå íà ïàðàñèìïàòèêîâîòî âëèÿíèå (5, 9,11), êîåòî âîäè äî íàìàëÿâàíå íà ïóëñîâàòà ÷åñòîòà èàðòåðèàëíîòî íàëÿãàíå. Òîâà å îñîáåíî ïîêàçàòåëíî çà ² è ²²ñìÿíà è â ïî-ìàëêà ñòåïåí – çà ðåäîâíà ñìÿíà, êîåòî íàìèðàñâîåòî ëîãè÷íî îáÿñíåíèå âúâ ôàêòà, ÷å ïðè ñ÷åòîâîäíî-ìåíèäæúðñêèÿ ïåðñîíàë ìîíîòîííîñòòà ìîæå äà áúäåäîíÿêúäå ïðåîäîëÿíà ÷ðåç ïî-ãîëÿìàòà ñâîáîäà íàîðãàíèçàöèÿ íà ðàáîòàòà è ïî òîçè íà÷èí - ïî-óñïåøíîïðåîäîëÿâàíå íà ïîñëåäèöèòå îò ìîíîòîííîñòòà.

Ìåæäóñìåííèòå ðàçëèêè â íàøèòå ðåçóëòàòè ïîäêðåïÿòäàííèòå è íà äðóãè àâòîðè ( 8,10), ÷å êîíòðîëúò âúðõóîðãàíèçàöèÿòà íà ðàáîòíîòî âðåìå è âúçìîæíîñòòà çàèçïîëçâàíåòî íà ñïîíòàííè ìèêðîïàóçè ñà îñíîâåí ôàêòîðçà ïîääúðæàíåòî íà óñòîé÷èâà ðàáîòîñïîñîáíîñò è íàé-âå÷åçà çàïàçâàíåòî íà ðàáîòîñïîñîáíîñòòà ïðè íàñòúïâàùà âå÷åóìîðà â êðàÿ íà ðàáîòíèÿ öèêúë.

Îáÿñíåíèå çà âàðèàáèëíîñòòà íà èçñëåäâàíèòå ïîêàçàòåëè âîòäåëíèòå ñìåíè ìîæå äà ñà è ðàçëè÷íèòå ÷àñîâå íàèçñëåäâàíå îò äåíîíîùèåòî è ñâúðçàíàòà ñ òîâà åñòåñòâåíàäèíàìèêà íà ðàáîòîñïîñîáíîñòòà.

Îò ñâîÿ ñòðàíà ìîíîòîííîñòòà ñå õàðàêòåðèçèðà ñ ïàðàëåëíîðàçâèòèå íà çàäðúæíè ïðîöåñè íà äðóãî íèâî íà óïðàâëåíèå,ñâúðçàíî ñ ïðèåìàíåòî è ïðåðàáîòâàíåòî íà èíôîðìàöèÿ.Ïðè íàøèòå èçñëåäâàíèÿ çà òîâà ñâèòåòåëñòâàò íàìàëåíèòåîáåì è ñêîðîñò íà ïðåðàáîòåíàòà èíôîðìàöèÿ èêîåôèöèåíòèòå íà òî÷íîñò è ïðîäóêòèâíîñò.


Â çàêëþ÷åíèå, ðåçóëòàòèòå îò íàøèòå èçñëåäâàíèÿ íàïñèõîôèçèîëîãè÷íèòå ïîêàçàòåëè â äíåâíà è ñåäìè÷íàäèíàìèêà ïîêàçâàò èçâåñòíè ïðîìåíè âðàáîòîñïîñîáíîñòòà.

Ïî-èçðàçåíèòå èçìåíåíèÿ â ñúðäå÷íîñúäîâèòåïîêàçàòåëèòå è òåçè, ñâúðçàíè ñ ïðèåìàíå è ïðåðàáîòêàíà èíôîðìàöèÿ ïðè ðàáîòåùèòå ² è ²² ñìÿíà, áèõà ìîãëèäà ñå ñâúðæàò ñ âëèÿíèåòî íà ìîíîòîíèÿòà âúðõóîðãàíèçìà íà ðàáîòåùèòå.

Ñåäìè÷íàòà äèíàìèêà íà ðàáîòîñïîñîáíîñòòàïîòâúðæäàâà ñòàíîâèùåòî çà ïî-ðàííî ðàçâèòèå íàíåðâíî-ñåíçîðíà óìîðà ïðè ðàáîòåùèòå ñ êîìïþòúð.


1. Êèñåëåâ, Ë.Â. Àäàïòèâíûå âîçìîæíîñòè è ôèçè÷åñêàÿïîäãîòîâëåííîñòü ñåëüñêèõ øêîëüíèêîâ, Ãèã. è ñàí.,1985, ¹4,51-54.

2. Ìîðãóíîâ, Å.Á. Àêòèâàöèÿ, óòîìëåíèå è äðóãèå ñîñòîÿíèÿðàáîòíèêà, ÝÑÌ, 29.03.2005, Ì,2004

3. Ñàíþêåâè÷, Â.È., Ë.È.Ñàíþêåâè÷, Ë.Ï.Ìîëîäîâà.Àðòåðèàëüíîå äàâëåíèå è âåãåòàòèâíàÿ ðåãóëÿöèÿ ñåðäöà óñòóäåíòîâ â ïðîöåññå ó÷åáíîé äåÿòåëüíîñòè, Ãèã. èñàí.,1985,¹6,35-39.

4. Ñòåôàíîâ, Á. Ìèêðîêîìïþòúðúò è çäðàâåòî, 1998

5. Ôåòèñêèí, Í.Ï. Ñèñòåìíîå èññëåäîâàíèå ìîíîòîíèè âïðîôåññèîíàëüíîé äåÿòåëüíîñòè, Àâòîðåô. Äèñ., ÑÏá, 1993

6. Pickering TG, Devereux RB, James GD, Environmental influenceson blood pressure and the role of job strain., J Hypertens Suppl.1996 Dec;14(5):S179-85.

7. Sluiter JK, Frings-Dresen MH, Meijman TF, Reactivity andrecovery from different types of work measured by catecholaminesand cortisol: a systematic literature overview., Occup Environ Med.2000 May;57(5):298-315.

.


Äîö. ä-ð Áîðÿíà Êàâàëäæèåâà, äì Ðúêîâîäèòåë êàòåäðà “Õèãèåíà è áåäñòâåíè ñèòóàöèè”ÌÓ – Âàðíà 9002Óë. “Ìàðèí Äðèíîâ” ¹55


In conclusion, the results of out studies of the psycho-physiological indexes in daily and weekly dynamics showcertain changes in the working ability.

The more expressed changes in the cardio-vascularindexes and those connected with perception andprocessing of information for the workers I-st and II-ndshift can be connected with the influence of themonotony over the organism of the workers.

Assuming the weekly dynamics of the working ability, itis confirmed the statement for early development ofnerve-sensor tiredness in people working with acomputer.

8. Steptoe A, Evans O, Fieldman G., Perceptions of control overwork: psychophysiological responses to self-paced andexternally-paced tasks in an adult population sample., Int JPsychophysiol. 1997 Apr;25(3):211-20.

9. Steptoe A, Fieldman G, Evans O, Perry L, Cardiovascular riskand responsivity to mental stress: the influence of age, genderand risk factors. J Cardiovasc Risk. 1996 Feb;3(1):83-93.

10. Van den Berg TI, Robroek SJ, Plat JF, Koopmanschap MA,Burdorf A., The importance of job control for workers withdecreased work ability to remain productive at work, Int ArchOccup Environ Health. 2010 Oct 16. [Epub ahead of print]Vögele C, Steptoe A., Emotional coping and tonic bloodpressure as determinants of cardiovascular responses to mentalstress., J Hypertens. 1992 Sep; 10(9):1079-87


Assoc. Prof. Dr Boryana Kavaldzhieva, MD, PhDHead of Department of Hygiene and Medicine of disastersMedical University - Varna 900255 “Marin Drinov” Str.




ÅËÅÊÒÐÎÍÍÎ ÇÄÐÀÂÅÎÏÀÇÂÀÍÅ -ÑÚÑÒÎßÍÈÅ È ÏÅÐÑÏÅÊÒÈÂÈ

Âàëåðè ÖåêîâÓïðàâèòåë íà „Áúëãàðñêî ñäðóæåíèå ïî èíîâàòèâíàìåäèöèíà” , ãë.àñèñòåíò ÌÓ Ïëîâäèâ - ²² êàòåäðà ïî

âúòðåøíè áîëåñòè

Ðåçþìå

Â êðàÿ íà 20-è è íà÷àëîòî íà 21-âåê åëåêòðîííîòîçäðàâåîïàçâàíå (ÅÇ) ïîñòåïåííî ñå ïðåâúðíà â òåðìèí,êîéòî ñå ñâúðçâà ñ øèðîêîòî íàâëèçàíå íàèíôîðìàöèîííèòå è êîìóíèêàöèîííèòå òåõíîëîãèè(ÈÊÒ) â ñåêòîðà íà çäðàâåîïàçâàíåòî. Íÿêîè àâòîðèèçïîëçâàò òîçè òåðìèí, çà äà äåôèíèðàò èçïîëçâàíåòîíà äèãèòàëíèòå òåõíîëîãèè çà íóæäèòå íà êëèíè÷íàòàìåäèöèíà, ìåäèöèíñêîòî îáðàçîâàíèå è çäðàâíàòààäìèíèñòðàöèÿ. Äðóãè àâòîðè èìàò ïðåäâèä ïî òåñíèÿìó ñìèñúë íà èçïîëçâàíå íà Èíòåðíåò â ìåäèöèíñêàòàïðàêòèêà. Â ñòàòèÿòà ñå ïðàâè àíàëèç íà íàä 50 âèäàäåôèíèöèè çà ÅÇ, èçïîëçâàíè â íàó÷íàòà ëèòåðàòóðà. Âïðåîáëàäàâàùàòà ÷àñò îò äåôèíèöèèòå òåðìèíúò ÅÇñå ñâúðçâà ñ ïðåäîñòàâÿíåòî íà ìåäèöèíñêè äåéíîñòè,êàòî åäâà ïðè 25% îò äåôèíèöèèòå ñå íàáëÿãà íàïîäîáðÿâàíåòî íà ñúîòíîøåíèåòî „ðàçõîäè-åôåêòèâíîñò” ïðè çäðàâíîòî îáñëóæâàíå èëèïîâèøåíàòà åôåêòèâíîñò íà ïðîöåñèòå.Äåìîãðàôñêèòå ïðîöåñè â åâðîïåéñêèòå äúðæàâè,íàðàñòâàùàòà ìèãðàöèÿ è î÷àêâàíèÿòà çàâèñîêîêà÷åñòâåíè è äîñòúïíè çäðàâíè óñëóãè, â ðàìêèòåíà Åâðîïåéñêèÿ ñúþç (ÅÑ), èçïðàâÿò çäðàâíèòå ñèñòåìèïðåä âñå ïî-ãîëåìè ïðåäèçâèêàòåëñòâà. ÈíèöèàòèâàòàeEurope, îáÿâåíà îò Åâðîïåéñêàòà êîìèñèÿ (ÅÊ) ïðåç1999 ãîäèíà, îòáåëÿçà íà÷àëîòî íà ìîùíî íàâëèçàíå íàèíôîðìàöèîííè ïðèëîæåíèÿ â çäðàâíèÿ ñåêòîð â Åâðîïà.Òîâà ïîâäèãà ðåäèöà âúïðîñè, ñâúðçàíè ñúñçàêîíîäàòåëíèòå àñïåêòè ïðè èçïîëçâàíåòî èì âìåäèöèíñêàòà ïðàêòèêà è íàóêà. Ïîñòèãàíå íàñåìàíòè÷íà èíòåðîïåðàáèëíîñò, ñòàíäàðòèçàöèÿ,ñåðòèôèêàöèÿ è îáùè çà ÅÑ èçèñêâàíèÿ êúìåëåêòðîííèòå äîñèåòà íà ïàöèåíòà ñå ðàçãëåæäàò âñòàòèÿòà êàòî îñíîâíè åëåìåíòè çà ïîñòèãàíå íàîïåðàòèâíà ñúâìåñòèìîñò (èíòåðîïåðàáèëíîñò) íàèíôîðìàöèîííèòå èíôðàñòðóêòóðè è ñèñòåìè âçäðàâåîïàçâàíåòî íà ñòðàíèòå îò ÅÑ. Òåçè âúïðîñè ñàïðåäìåò íà ïúðâèÿ çà ÅÑ Ïëàí çà äåéñòâèå çà Åâðîïåéñêàîáëàñò íà ÅÇ. Òîé î÷åðòàâà ñòúïêèòå çà âúâåæäàíå íàÈÊÒ â çäðàâåîïàçâàíåòî è óñêîðÿâà èçïîëçâàíåòî íàøèðîêîëåíòîâèÿ, âèñîêîñêîðîñòåí Èíòåðíåò âçäðàâíèòå ñèñòåìè. Â èçïúëíåíèå íà ïëàíà âñè÷êèäúðæàâè-÷ëåíêè íà ÅÑ ïðèåìàò íàöèîíàëíè ñòðàòåãèèçà ÅÇ. Ìíîãî îò òÿõ âíåäðÿâàò íàöèîíàëíè çäðàâíè

E-HEALTH SYSTEM – STATUS ANDPERSPECTIVES

Valeri CekovSenior Manager of the Bulgarian

Association of Innovative MedicineChief Assistant, Medical University – Plovdiv

Second Department of Internal Diseases

Abstract

At the end of the 20th century and in the beginning ofthe 21st one electronic health (e-Health) has graduallybecome a term that was associated with the broad imple-mentation of information and communication technolo-gies (ICTs) in the field of healthcare. Some authors makeuse of this term in order to define the utilization of digi-tal technologies for the needs of clinical medicine, medi-cal education and healthcare management. Other au-thors take into consideration its more narrow sense withregard to the Internet use in the medical practice. In thearticle an analysis was performed of more than 50 defi-nitions for e-Health used in the scientific literature. Inmost part of the definitions the term e-Health was re-lated to the delivery of medical services as nearly 25%of definitions have emphasized on the improvement ofthe ratio “expenditures – effectiveness” in thehealthcare or on the increased effectiveness of the pro-cesses.

Demographic processes in the European countries, grow-ing migration and expectations for high quality andaccessible health services within the European Union(EU) have faced the healthcare systems towards greaterchallenges. The initiative e-Europe was established inDecember 1999 by the European Commission and indi-cated the beginning of a powerful use of informationtechnologies in the European health sector. This raisesquestions related to the legislative aspects in their us-age in the medical practice and science. The achieve-ment of semantic interoperability, standardization, cer-tification and general EU requirements for the electronicpatient records were considered in the article as keyelements for gaining operative compatibility(interoperability) of information infrastructures andsystems within the EU. These problems were the maintopic of the first Action plan for a European e-HealthArea. It outlined the steps for implementation of ICTs forthe healthcare and boosted the use of broadband highspeed Internet in the health systems. In the realization ofthe plan all Member-states adopted national strategiesfor e-Health. Many of them have integrated the nationalhealth portals, electronic patient records, electronicprescriptions and telemedical applications. Large-scaleprojects have been realized for the achievement of op-

ÇÄÐÀÂÍÀ ÏÎËÈÒÈÊÀ È ÏÐÀÊÒÈÊÀ HEALTH POLICY AND PRACTICE


ïîðòàëè, åëåêòðîííè çäðàâíè äîñèåòà, åëåêòðîííèçäðàâíè êàðòè, åëåêòðîííè ðåöåïòè è òåëåìåäèöèíñêèïðèëîæåíèÿ. Ðåàëèçèðàò ñå ìàùàáíè ïðîåêòè íà ÅÑ çàïîñòèãàíå íà îïåðàòèâíà ñúâìåñòèìîñò íàèíôîðìàöèîííè ïðèëîæåíèÿ è ñèñòåìè. Ïîÿâÿâà ñå èïîðòàëúò íà ÅÑ „Îáùåñòâåíî çäðàâå”. Ñëåäïðèåìàíåòî íà Íàöèîíàëíàòà ñòðàòåãèÿ çà åëåêòðîííîçäðàâåîïàçâàíå ïðåç 2006 ãîäèíà â Áúëãàðèÿ ñúùî ñåçàñèëèõà ïðîöåñèòå íà âíåäðÿâàíå íà ÈÊÒ â ñèñòåìàòàíà çäðàâåîïàçâàíåòî. Ðåàëèçèðàíè ñà ðåäèöà ñèñòåìèçà òåëåìåäèöèíà, êàêòî è íÿêîëêî ïèëîòíè ïðîåêòà, âò. ÷. çà åëåêòðîííè çäðàâíè êàðòè, åëåêòðîííè äîñèåòà,íàöèîíàëåí çäðàâåí ïîðòàë. Ñúçäàäåíè ñà ìíîæåñòâîíàöèîíàëíè ðåãèñòðè è å âúâåäåíà â äåéñòâèåèíòåãðèðàíàòà èíôîðìàöèîííà ñèñòåìà íàÍàöèîíàëíàòà çäðàâíà êàñà.

Êëþ÷îâè äóìè: åëåêòðîííî çäðàâåîïàçâàíå,èíôîðìàöèîííè è êîìóíèêàöèîííè òåõíîëîãèè,åëåêòðîííî äîñèå íà ïàöèåíòà,èíòåðîïåðàáèëíîñò.

1. Ñúñòîÿíèå íà ïðîáëåìà âìåæäóíàðîäåí àñïåêò

Îò íà÷àëîòî íà 21 âåê âñå ïî-÷åñòî ñå ïèøå è ãîâîðè çàåëåêòðîííî çäðàâåîïàçâàíå (ÅÇ). Ïðåäè 1999 ã. òîçè òåðìèíå ñðàâíèòåëíî ðÿäêî óïîòðåáÿâàí è å ñâúðçâàí íàé-îáùî ñêîìïþòðè è ìåäèöèíà. Èçïîëçâàí å ïðåäèìíî îòèíäóñòðèàëöè è ñïåöèàëèñòè ïî ìàðêåòèíã. Áóðíîòîðàçâèòèå íà Èíòåðíåò ñúçäàâà íîâè âúçìîæíîñòè èïðåäèçâèêàòåëñòâà ïðåä òðàäèöèîííàòà èíäóñòðèÿ çàèíôîðìàöèîííè è êîìóíèêàöèîííè òåõíîëîãèè (ÈÊÒ) âîáëàñòòà íà çäðàâåîïàçâàíåòî è ïðåâðúùà èçïîëçâàíåòî íàòîçè òåðìèí â åæåäíåâèå. “Íîâèòå” ïðåäèçâèêàòåëñòâà ñåñúñòîÿò âúâ âúçìîæíîñòòà çà ïîòðåáèòåëèòå äàâçàèìîäåéñòâàò îíëàéí ñ áèçíåñ ñèñòåìè (Â2Ñ = “businessto consumer” èëè ÁÊÏ = “áèçíåñ êúì ïîòðåáèòåë”);ïîäîáðåíè âúçìîæíîñòè çà ïðåäàâàíå íà äàííè îòèíñòèòóöèÿ êúì èíñòèòóöèÿ (B2B = “business to business”èëè ÁÊÁ = “áèçíåñ êúì áèçíåñ”); íîâè âúçìîæíîñòè çàêîìóíèêàöèè ìåæäó ñàìèòå ïîòðåáèòåëè (C2C = “consumerto consumer” èëè ÏÊÏ = “ïîòðåáèòåë êúì ïîòðåáèòåë”)( G.Eysenbach, 2001) (1).

Ñïîðåä Journal of Medical Internet Research òåðìèíúò„åëåêòðîííî çäðàâåîïàçâàíå” òðÿáâà äà îñòàíå â ñôåðàòàíà áèçíåñà è ìàðêåòèíãà è äà ñå èçáÿãâà â íàó÷íàòàìåäèöèíñêà ëèòåðàòóðà. Òåðìèíúò, îáà÷å, âå÷å å íàâëÿçúëâ íàó÷íàòà ëèòåðàòóðà, íî, êàêòî ñå öèòèðà â ñïèñàíèåòî,“äà ïîñòàâèø äåôèíèöèÿ íà íåùî êàòî ÅÇ å êàòî äàïîñòàâèø äåôèíèöèÿ íà “Èíòåðíåò”, òúé êàòî òîâà åäèíàìè÷íà, íåïðåêúñíàòî äâèæåùà ñå ñðåäà”.

Ñïîðåä Àéçåíáàõ “Åëåêòðîííîòî çäðàâåîïàçâàíå åâúçíèêâàùà îáëàñò â ñå÷åíèåòî íå ìåäèöèíñêàòàèíôîðìàòèêà, îáùåñòâåíîòî çäðàâå è áèçíåñà, îòíàñÿùàñå äî çäðàâíîòî îáñëóæâàíå è èíôîðìàöèÿòà,ïðåäîñòàâÿíà èëè ðàçøèðÿâàíà ÷ðåç Èíòåðíåò è

erative compatibility of the information technologiesand systems. The portal of the EU Public Health ap-peared, too.

After the adoption of the National strategy for electronichealth in 2006 in Bulgaria the processes for implemen-tation of ICT in the healthcare have also strengthened.A series of systems for telemedicine have been conductedas well as some pilot projects, including electronic healthcards, electronic records, national health portal. Plentyof national registries were created and the integratedinformation system of the National Health InsuranceFund was also implemented

Key words: Electronic health, information andcommunication technologies, electronic patientrecord, interoperability.

1. International aspects of the problem

Since the beginning of the 21st century it has been writtenabout electronic health (e-Health). Before 1999 this termwas rarely used and related to computers and medicine.It was used mainly by industrial leaders and marketingspecialists. The rapid development of Internet has createdplenty of possibilities and challenges toward thetraditional industry for information and communicationtechnologies (ICTs) in the field of healthcare system andit turned to be a routine daily used term. The “new”challenges consist of the possibility for the consumersto interact online with business systems (Â2Ñ =“business to consumer”); improved opportunities fortransmission of data from institution to institution (B2B= “business to business”); new capacities forcommunications among the consumers (C2C = “consumerto consumer (G. Eysenbach, 2001) (1).

According to the Journal of Medical Internet Researchthe term e-health should be left in the domain of businessand marketing and to be avoided in the scientific medicalliterature, but as it was cited in the Journal “to make adefinition for something as e-health is to place a definitionof the “Internet” as this is a dynamic constantly movingenvironment”.

According to Eysenbach “E-health is an emerging fieldin the intersection of medical informatics, public healthand business, referring to health services andinformation delivered or enhanced through the Internetand related technologies. In a broader sense, the termcharacterizes not only a technical development, but alsoa state-of-mind, a way of thinking, an attitude, and acommitment for networked, global thinking, to improvehealth care locally, regionally, and worldwide by using



ñâúðçàíèòå ñ íåãî òåõíîëîãèè. Â ïî-øèðîê ñìèñúëòåðìèíúò õàðàêòåðèçèðà íå ñàìî òåõíè÷åñêîòîðàçâèòèå, íî è ñúñòîÿíèå íà óìà, íà÷èí íà ìèñëåíå,îòíîøåíèå è ðåøåíèå çà ìðåæîâî, ãëîáàëíî ìèñëåíå çàïîäîáðÿâàíå íà çäðàâåîïàçâàíåòî íà ëîêàëíî, ðåãèîíàëíîè ñâåòîâíî íèâî ÷ðåç èçïîëçâàíå íà èíôîðìàöèîííè èêîìóíèêàöèîííè òåõíîëîãèè”. Òàçè äåôèíèöèÿ åäîñòàòú÷íî øèðîêà, ìîæå äà ñå ïðèëàãà êúì äèíàìè÷íàñðåäà è ïîêàçâà, ÷å åëåêòðîííîòî çäðàâåîïàçâàíå íå îáõâàùàñàìî “Èíòåðíåò è ìåäèöèíà”.

Áóêâàòà “å” â “e-health” íå îçíà÷àâà ñàìî “åëåêòðîííî”, àâêëþ÷âà è ìíîãî äðóãè “å”, êîèòî çàåäíî íàé-äîáðåõàðàêòåðèçèðàò êàêâî å “åëåêòðîííî çäðàâåîïàçâàíå” (èëèêàêâî òðÿáâà äà áúäå).

10-òå“å” â “åëåêòðîííî çäðàâåîïàçâàíå”

1. (Efficacy) Åôèêàñíîñò- åäíî îò îáåùàíèÿòà íàåëåêòðîííîòî çäðàâåîïàçâàíå å äà ïîâèøèåôèêàñíîñòòà â çäðàâåîïàçâàíåòî ñ íàìàëÿâàíå íàðàçõîäèòå. Åäèí âúçìîæåí íà÷èí çà íàìàëÿâàíå íàðàçõîäèòå áè áèë ÷ðåç èçáÿãâàíå íà äóáëèðàíè èëèíåíóæíè äèàãíîñòè÷íè èëè òåðàïåâòè÷íèèíòåðâåíöèè ÷ðåç ïîäîáðåíè êîìóíèêàöèîííèâúçìîæíîñòè ìåæäó çäðàâíèòå çàâåäåíèÿ è ÷ðåçàíãàæèðàíå íà ïàöèåíòèòå.

2. (Enhancing quality of care) Ïîäîáðÿâàíå íàêà÷åñòâîòî íà îáñëóæâàíå- ïîâèøàâàíåòî íàåôèêàñíîñòòà âêëþ÷âà íå ñàìî íàìàëÿâàíå íàðàçõîäèòå, íî è ïîäîáðÿâàíå íà êà÷åñòâîòî âñúùîòî âðåìå. Åëåêòðîííîòî çäðàâåîïàçâàíå ìîæåäà ïîäîáðè êà÷åñòâîòî íà çäðàâíèòå ãðèæèíàïðèìåð, ÷ðåç ïîçâîëÿâàíå íà ñðàâíåíèå ìåæäóðàçëè÷íèòå äîñòàâ÷èöè íà ìåäèöèíñêî îáñëóæâàíå,âêëþ÷âàíå íà ïîòðåáèòåëèòå êàòî äîïúëíèòåëíàñèëà çà ãàðàíòèðàíå íà êà÷åñòâîòî è íàñî÷âàíå íàïàöèåíòîïîòîöèòå êúì äîñòàâ÷èöèòå, îñèãóðÿâàùèíàé-äîáðî êà÷åñòâî.

3. (Evidence based) Îñíîâàíî íà íàó÷íè äàííè -èíòåðâåíöèèòå íà åëåêòðîííîòî çäðàâåîïàçâàíåòðÿáâà äà áúäàò áàçèðàíè íà íàó÷íè äàííè âñìèñúë, ÷å åôåêòèâíîñòòà è åôèêàñíîñòòà èìòðÿáâà äà áúäàò äîêàçàíè ÷ðåç ïðåöèçíà íàó÷íàîöåíêà. Â òàçè îáëàñò ïðåäñòîè ìíîãî ðàáîòà.

4. (Empowerment of consumers and patients)Ðàçøèðÿâàíå íà âúçìîæíîñòèòå íà ïîòðåáèòåëèòå èïàöèåíòèòå - îñèãóðÿâàíå íà äîñòúï äî íàó÷íèòåìåäèöèíñêè ïîçíàíèÿ ÷ðåç Èíòåðíåò, êîåòî îòâàðÿíîâè ïúòèùà çà ìåäèöèíà, öåíòðàëèçèðàíà îêîëîïîòðåáèòåëÿ è äàâà âúçìîæíîñò çà èçáîð íàïàöèåíòà, îñíîâàí íà íàó÷íè äîêàçàòåëñòâà.

5. (Encouragement) Íàñúð÷àâàíå íà íîâè îòíîøåíèÿìåæäó ïàöèåíòà è çäðàâíèÿ ïðîôåñèîíàëèñò,îòíîøåíèÿ íà ïàðòíüîðñòâî, êúäåòî ðåøåíèÿòà ñåâçåìàò çàåäíî.


information and communication technology. Thisdefinition is sufficiently wide and could be applied to adynamic sphere and shows that the e-health does notonly encompass “Internet and medicine”.

The letter “å” in “e-health” does not only indicate“electronic”, but it also covers a number other “å’s”,which together best identifies what e-health “electronichealth” is all about (or it should be).

10 “e’s” of e-Health

1. Efficacy - one of promises of e-health is toincrease efficiency in healthcare system, thusdecreasing the costs. One of the possible waysof decreasing costs would be by staying awayfrom duplicative or unnecessary diagnostic ortherapeutic interventions through improvedcommunication possibilities between health careestablishments and through patientparticipation..

2. Enhancing quality of care – increasing efficiencyimplies not only reducing cost, but at the sametime boosting quality. E-health may improve thequality of healthcare system for example bypermitting comparisons between differentproviders of healthcare, involving theconsumers as additional force for qualityassurance and conducting patient streams to thebest quality providers.

3. Evidence based – e-health interventions shouldbe evidence based in the sense that theireffectiveness and efficiency should be provedby rigorous scientific evaluation. Too muchwork has to be done in this domain.

4. Empowerment of consumers and patients –providing an access to the scientific medicalknowledge over the Internet, which opens newavenues for patient centered medicine andallows evidence based choice.

5. Encouragement – of a new relationship betweenthe patient and health professional, towards agenuine partnership, where decisions are madein a mutual manner

6. Education – of physicians through onlinesources (continuing medical education) andconsumers (health education, specially tailoredpreventive information).


6. (Education) Îáðàçîâàíèå íà ëåêàðèòå ÷ðåç îíëàéíèçòî÷íèöè (ïðîäúëæàâàùî ìåäèöèíñêîîáðàçîâàíèå) è íà ïîòðåáèòåëèòå (çäðàâíîîáðàçîâàíèå, ñïåöèàëíî ïîäãîòâåíà èíôîðìàöèÿ çàïðîôèëàêòèêà).

7. (Enabling) Äàâàíå íà âúçìîæíîñò çà îáìåí è êîìóíèêàöèÿíà èíôîðìàöèÿ ìåæäó çäðàâíèòå çàâåäåíèÿ ïîñòàíäàðòèçèðàí íà÷èí.

8. (Extending) Ðàçøèðÿâàíå îáõâàòà íà çäðàâíèòå ãðèæè èçâúíêîíâåíöèîíàëíèòå ãðàíèöè. Òîâà îáõâàùà êàêòîãåîãðàôñêèÿ, òàêà è êîíöåïòóàëíèÿ ñìèñúë.Åëåêòðîííîòî çäðàâåîïàçâàíå äàâà âúçìîæíîñò íàïîòðåáèòåëèòå ëåñíî äà ïîëó÷àâàò çäðàâíî îáñëóæâàíåîíëàéí îò ñâåòîâíè äîñòàâ÷èöè. Òåçè óñëóãè ìîãàò äàâàðèðàò îò ïðîñòè ñúâåòè äî ïî-ñëîæíè èíòåðâåíöèèèëè ïðîäóêòè, íàïðèìåð ôàðìàöåâòè÷íè ïðîäóêòè.

9. (Ethics) Åòèêà - åëåêòðîííîòî çäðàâåîïàçâàíå âêëþ÷âàíîâè ôîðìè íà âçàèìîäåéñòâèåòî ïàöèåíò-ëåêàð èïîñòàâÿ íîâè ïðåäèçâèêàòåëñòâà è çàïëàõè êúì åòè÷íèòåïðîáëåìè, òàêèâà êàòî ïðîôåñèîíàëíà ïðàêòèêà îíëàéí,èíôîðìèðàíî ñúãëàñèå, ïîâåðèòåëíîñò èðàâíîïîñòàâåíîñò.

10. (Equity) Ðàâíîïîñòàâåíîñò - åäíî îò îáåùàíèÿòà íàåëåêòðîííîòî çäðàâåîïàçâàíå å äà íàïðàâè çäðàâíîòîîáñëóæâàíå ïî-ðàâíîïîñòàâåíî, íî â ñúùîòî âðåìå èìàçíà÷èòåëíà îïàñíîñò äà ñå ðàçøèðè ïðîïàñòòà ìåæäó“èìàì” è “íÿìàì”. Õîðà, êîèòî íÿìàò ïàðè, óìåíèÿ èäîñòúï äî êîìïþòðè è ìðåæè, íå ìîãàò äà ñå âúçïîëçâàòîò òàçè âúçìîæíîñò. Â ðåçóëòàò íà òîâà, òåçè ãðóïèïàöèåíòè (êîèòî âñúùíîñò íàé-ìíîãî áèõà ñïå÷åëèëèîò çäðàâíà èíôîðìàöèÿ) ñ íàé-ìàëêà âåðîÿòíîñò áèõàñïå÷åëèëè îò íàïðåäúêà â èíôîðìàöèîííèòåòåõíîëîãèè, îñâåí, àêî ñ ïîëèòè÷åñêè ìåðêè íå ñåîñèãóðè ðàâåí äîñòúï çà âñè÷êè. Ãðàíèöàòàïîíàñòîÿùåì ìèíàâà ìåæäó ãðàäñêî - ñåëñêî íàñåëåíèå,áîãàòè - áåäíè, ìëàäè - âúçðàñòíè, ìúæå - æåíè è ìåæäóðåäêè - øèðîêî ðàçïðîñòðàíåíè çàáîëÿâàíèÿ (Öèò. ÏîÃ. Àéçåíáàõ, 2001) (1).

Ñèñòåìàòèçèðàí ïðåãëåä íà äåôèíèöèèòå

Òåðìèíúò ÅÇ îáõâàùà ìíîæåñòâî ðàçíîîáðàçíè ïîíÿòèÿ,âêëþ÷âàùè çäðàâå, òåõíîëîãèÿ è òúðãîâèÿ. Èçïîëçâàéêèðåäèöà áàçà äàííè çà òúðñåíå íà òåðìèíà “åëåêòðîííîçäðàâåîïàçâàíå” íà àíãëèéñêè åçèê (Medline è Premedline(1966 - þíè 2004), EMBASE (1980 - ìàé 2004), InternationalPharmaceutical Abstracts (1970 - ìàé 2004), Web of Science(âñè÷êè ãîäèíè), Information Sciences Abstracts (1966 - ìàé2004), Library Information Sciences Abstracts (1969 - ìàé2004) è Wilson Business Abstracts (1982 - ìàðò 2004) è äð.,Õàíñ Îõ, Êàðëîñ Ðèçî, Ìúðè Åíêèí, Àëåõàíäðî Õàäàä (2)îòêðèâàò 51 äåôèíèöèè. Âúïðåêè âñå ïî-øèðîêîòîíàâëèçàíå íà òîâà ïîíÿòèå â ñúâðåìåííàòà íàóêà èïðàêòèêà, ëèïñâà èçÿâåí êîíñåíñóñ çà çíà÷åíèåòî ìó.Êàêòî è ïîâå÷åòî íåîëîãèçìè, òî÷íîòî çíà÷åíèå íà“åëåêòðîííî çäðàâåîïàçâàíå” (ÅÇ) âàðèðà ñ ïîäòåêñòà, âêîéòî ñå èçïîëçâà òåðìèíúò. (Òàáëèöà 1)


7. Enabling giving a possibility for informationexchange and communication in a standardizedway between healthcare establishments.

8. Extending – the scope of healthcare beyondits conventional boundaries. Thisencompasses both a geographical senseand a conceptual sense. E-health enablesconsumers to easily obtain healthcareservices online from global providers.These services can range from simpleadvise to more complicated interventions orproducts such a pharmaceuticals.

9. Ethics – e-health involves new forms ofpatients-physician interaction and offers newchallenges and threats to ethical issues suchas online professional practice, informedconsent, privacy and equity issues.

10. Equity – one of the promises of e-health is tomake the healthcare more equal in rights forpeople, but at the same time there exists athreat to deepen the gap between the “haves’and ‘have-nots’. People, who do not have themoney, skills, and access to computers andnetworks cannot use this possibil i tyeffectively. As a result , these patientpopulations (which would actually benefit themost from health information) are the leastlikely to benefit from advances in informationtechnology, unless political measures ensureequitable access for all. The boundarycurrently divides between rural vs, urbanpopulations, rich vs. poor, young vs. old, malevs. female people, and between neglected/rarevs, common diseases. (Citation by G.Eysenbach, 2001) (1).

Systematic review of the definitions

The term e-health covers a variety of notionsincluding health, technology and trade. Using aseries of data bases for searching of the term “e-health” in English (Medline and Premedline (1966 -June 2004), EMBASE (1980 - May 2004), InternationalPharmaceutical Abstracts (1970 - May 2004), Webof Science (all the years), Information SciencesAbstracts (1966 - May 2004), Library InformationSciences Abstracts (1969 - May 2004) and WilsonBusiness Abstracts (1982 - March 2004) etc. theauthors Hans Och, Carlos Rizo, Murrey Enkine,Alejandro Hadad (2) found 51 definitions. Despitethe wider involvement of this term in the currentscience and practice, there is a lack of consensuson its sense. As more of the neologisms the correctsense of ‘e-health’ (EH) varies within the subtext inwhich the term is used (Table 1)


Òàáëèöà 1. Äåôèíèöèè çà “åëåêòðîííî çäðàâåîïàçâàíå”,ïðåäñòàâåíè â õðîíîëîãè÷åí ðåä


Table 1. Definitions (verbatim quotations) of “e-health”,presented in chronological order



Note: In the qualitative analysis below in quadratic parentheses are giventhe numbers of authors, indicated in the column No.2 in the .

Çàá.: Â êà÷åñòâåíèÿ àíàëèç ïî-äîëó â ïðàâè ñêîáè ñà ïîñî÷åíèíîìåðàòà íà àâòîðèòå, îòáåëÿçàíè â êîëîíà ¹2 íà òàáëèöàòà.


Îò ñêàíèðàíèòå 1209 ðåçþìåòà è ïðåãëåäàíè 430öèòèðàíèÿ îò áèáëèîãðàôñêèòå áàçè äàííè àâòîðèòåñà ñúáðàëè 10 ðàçëè÷íè äåôèíèöèè çà òåðìèíà “ÅÇ”.Îò ïðåãëåäàíèòå â Google 1158 ñàéòà ñà èäåíòèôèöèðàíè41 äîïúëíèòåëíè óíèêàëíè äåôèíèöèè ñ äúëæèíà îòòðè (3) äî 74 äóìè (4).

Êà÷åñòâåíèÿò àíàëèç ïîêàçâà, ÷å âñè÷êè äåôèíèöèè(áåç äâå - 3,5) ëîãè÷íî âêëþ÷âàò òåìàòà „çäðàâå”. Â íàé-îáù ñìèñúë, äóìàòà „çäðàâå” å èçïîëçâàíà âúâ âðúçêàñ îñèãóðÿâàíå íà çäðàâíî îáñëóæâàíå (íàïðèìåðçäðàâíè ãðèæè (1, 6 - 33), çäðàâíà ñèñòåìà (34-36),çäðàâåí ñåêòîð (11, 17, 37-39) èëè çäðàâíà èíäóñòðèÿ (4,40-42), êîåòî ïîäñêàçâà, ÷å ÅÇ ìîæå äà ñå îòíàñÿ ïîâå÷åäî îáñëóæâàíåòî è ñèñòåìèòå, îòêîëêîòî äî çäðàâåòîíà õîðàòà. Áëàãîïîëó÷èåòî (â ñìèñúë äîáðî ñúñòîÿíèå)êàòî êîíöåïöèÿ å èçïîëçâàíî ñàìî 5 ïúòè, à èìåííî,áëàãîïîëó÷èå (äîáðî ñúñòîÿíèå) (1), îáùåñòâåíîçäðàâå (21), çäðàâå è áëàãîïîëó÷èå (äîáðî ñúñòîÿíèå)(43), çäðàâå è áëàãîïîëó÷èå (44) è ïðîìîöèÿ íàçäðàâåòî (8).

Íàðåä ñ òîâà âñè÷êè äåôèíèöèè ñå îòíàñÿò è äîòåõíîëîãèÿòà, åêñïëèöèòíî èëè èìïëèöèòíî. Äóìàòà„Èíòåðíåò” å åêñïëèöèòíî óïîòðåáåíà â 27 îò 51äåôèíèöèè (1, 4, 6, 8, 9, 11-13, 15-19, 21-24, 26, 29, 33, 35,40-42, 44-46); 4 îò òÿõ èçïîëçâàò Èíòåðíåò êàòîïðèëàãàòåëíî (Èíòåðíåò-ñâúðçàíè (8), Èíòåðíåòòåõíîëîãèè (22, 46) èëè Èíòåðíåò ïðèíöèïè (22)), à íåêàòî ñúùåñòâèòåëíî. Íÿêîè àâòîðè èçáðîÿâàòñïåöèôè÷íè òåõíîëîãèè, òàêèâà êàòî èíòåðàêòèâíàòåëåâèçèÿ (18), ëè÷íè öèôðîâè ïîìîùíèöè (23), CD-ROMs/DVD (23) èëè Èíòåðíåò òåëåôîíèÿ (11). Äðóãèñå îòíàñÿò êúì òåõíîëîãèÿòà ñ ïî-îáùè òåðìèíè(íàïðèìåð íîâè ìåäèè (47)), ÈÊÒ (14, 15, 17, 24, 25, 27,28, 30, 31, 34, 36-39, 43, 48, 49), è òåõíîëîãèè, ñâúðçàíè ñÈíòåðíåò (1, 6, 13, 21, 22, 29). Ñàìî åäíà äåôèíèöèÿèçïîëçâà äóìàòà “èíòåãðèðàíå” (33). Â 11 äåôèíèöèè(1, 7, 16, 22, 23, 37, 32, 40-42, 51) ÅÇ å ñïîìåíàòî â ñìèñúëíà òúðãîâèÿ, ïîäñêàçâàéêè, ÷å ÅÇ å “çäðàâíàòàêîìïîíåíòà íà áèçíåñà ïî Èíòåðíåò” (40),“ïðèëîæåíèåòî íà åëåêòðîííàòà òúðãîâèÿ â çäðàâíèòåãðèæè è ôàðìàöåâòè÷íèòå ïðåïàðàòè” (7) èëè êàòî“íîâè áèçíåñ ìîäåëè, èçïîëçâàùè òåõíîëîãèè” (32).Äðóãè àñîöèèðàò ÅÇ ñ äåéíîñòè êàòî óïðàâëåíèå (17),îáðàçîâàíèå (34), óðåæäàíå (17), ñâúðçâàíå (34),ïðèäîáèâàíå (29), äîñòàâÿíå (28), ïðåäåôèíèðàíå (23),ïîäêðåïÿíå(28), èçïîëçâàíå (37), ïîäïîìàãàíå (32) èäîñòúï (46). Êëþ÷îâèòå èãðà÷è, êîèòî ñå ñïîìåíàâàòíàé-÷åñòî, ñà äîñòàâ÷èöèòå íà çäðàâíî îáñëóæâàíå(ëåêàðè (22, 31), ïðîôåñèîíàëèñòè ïî çäðàâíè ãðèæè(29, 34), çäðàâíè ðàáîòíèöè (46), ìåíèäæúðè (34) èîáãðèæâàùè (35)). Îáùåñòâîòî å ñïîìåíàòî êàòîîáùåñòâî (46), ïàöèåíòè (12, 20, 22, 29, 34, 48),ïîòðåáèòåëè (9, 16, 20, 34), íåïðîôåñèîíàëèñòè (9, 16,41) è ãðàæäàíè (48). Ïðàâèòåëñòâàòà (34),ðàáîòîäàòåëèòå (22) è ïëàùàùèòå (22) ñà èçáðîåíè êàòîïîòåíöèàëíî ïå÷åëåùè îò ÅÇ.


From the scanned 1209 abstracts and reviews 430quotations from bibliographic data bases the authorscollected 10 different definitions of the term “e-Health”.From the reviewed 1158 sites in Google 41 additionalunique definitions were identified, which were as shortas three words (3) or as long as 74 words (4).

The qualitative analysis showed that all definitions(without two - 3,5) logically encompass the term“health”. In the most common sense, the word “health”was used in relation to health services delivery (eg,health care(1, 6 - 33), health system(34-36), healthsector (11, 17, 37-39) or health industry(4, 40-42)),which suggests that e-Health may refer more toservices and systems rather than to the health ofpeople. Wellness as a concept was used only fivetimes (namely, wellness (1), public health (21), healthand wellness (43), health and well-being (44), andhealth promotion (8)).

Along with this all definitions referred to thetechnology, either explicitly or implicitly. The wordInternet was explicitly mentioned in 27 out of the 51definitions (1, 4, 6, 8, 9, 11-13, 15-19, 21-24, 26, 29, 33,35, 40-42, 44-46); 4 of them employed Internet as anadjective (Internet-related (8), Internet technologies(22, 46) or Internet principle (22)) rather than as a noun.Some authors pointed out specific technologies suchas interactive television (18), personal digitalassistants (23), CD-ROMs/DVD (23) or Internettelephony (11). Others mentioned technology in moregeneral terms (eg, new media (47)), information andcommunication technologies (14, 15, 17, 24, 25, 27, 28,30, 31, 34, 36-39, 43, 48, 49), and Internet-relatedtechnologies (1, 6, 13, 21, 22, 29). Only one definitionobserved the term “integration” (33). In 11 definitions(1, 7, 16, 22, 23, 37, 32, 40-42, 51) e-Health was mentionedin terms of commerce, suggesting that e-Health is“health care’s component of business over theInternet” (40), the “application of e-commerce to healthcare and pharmaceuticals” (7) or as “new businessmodels using technology” (32). Others associated e-Health with activities such as managing (17), educating(34), arranging (17), connecting (34), obtaining (29),providing (28), redefining (23), supporting(28), using(37), assisting (32) and accessing (46). The stakeholdersmost frequently referred to were health care providers(doctors (22, 31), health care professionals (29, 34),health workers (46), managers (34) and caregivers (35)).The public was mentioned as public (46), patients (12,20, 22, 29, 34, 48), consumers (9, 16, 20, 34), non-professionals (9, 16, 41), and citizens (48). Governments(34), employers (22) and payers (48) are also listed aspotentially benefiting from e-Health.


Äîêàòî ïîâå÷åòî äåôèíèöèè ñå êîíöåíòðèðàò âúðõóïðîöåñà íà ãðèæè, îêîëî åäíà ÷åòâúðò îò òÿõ ñåñúñðåäîòî÷àâàò âúðõó î÷àêâàíèòå ðåçóëòàòè. Òåçèäåôèíèöèè ñå ñïèðàò íà ïîäîáðÿâàíåòî íà „ðàçõîäè-åôåêòèâíîñò” íà çäðàâíîòî îáñëóæâàíå (4) èïîäîáðÿâàíåòî íà åôåêòèâíîñòòà íà ïðîöåñèòå (9, 20, 21).Äðóãè ïðåäïîëàãàò, ÷å ÅÇ ìîæå äà ðàçðåøè ïðîáëåìè,ñâúðçàíè ñ ãðèæè, ðàçõîäè, êà÷åñòâî è äîñòúïíîñò íàçäðàâíîòî îáñëóæâàíå (4).

Äðóãè àâòîðè ñ÷èòàò, ÷å ÅÇ ïðåäñòàâëÿâà íîâà ïåðñïåêòèâàïðåä çäðàâíèòå ãðèæè. Åäèí àâòîð îïèñâà ÅÇ êàòî “ñúñòîÿíèåíà óìà, íà÷èí íà ìèñëåíå, îòíîøåíèå è îòäàäåíîñò çàìðåæîâî, ãëîáàëíî ìèñëåíå” (1). Â äðóã èçòî÷íèê ÅÇ ñåîïèñâà êàòî „ìîäåë, öåíòðèðàí âúðõó ïîòðåáèòåëÿ, â êîéòîêëþ÷îâèòå èãðà÷è ñè ñúòðóäíè÷àò” (17).

Çäðàâåòî, êàêòî å èçïîëçâàíî â òåçè äåôèíèöèè,îáèêíîâåíî ñå îòíàñÿ åêñïëèöèòíî êúì çäðàâíèòå ãðèæèïîâå÷å êàòî ïðîöåñ, îòêîëêîòî êúì çäðàâåòî êàòî ðåçóëòàò.Òîâà å î÷àêâàíî. Íÿìà êîíñåíñóñ çà çíà÷åíèåòî íà äóìàòà„çäðàâå” êàòî òàêàâà, äåôèíèöèèòå íà êîÿòî âàðèðàò îò„îáðàòíî íà áîëåñò èëè íåðàçïîëîæåíèå èëè êîãàòîîòñúñòâà áîëåñò èëè íåðàçïîëîæåíèå” (50), äîâñåîáõâàòíîòî îïðåäåëåíèå íà Ñâåòîâíàòà çäðàâíàîðãàíèçàöèÿ “çäðàâåòî å ñúñòîÿíèå íà ïúëíî ôèçè÷åñêî,ïñèõè÷íî è ñîöèàëíî áëàãîïîëó÷èå, à íå ñàìîîòñúñòâèåòî íà áîëåñò èëè íåðàçïîëîæåíèå” (52).

Â äåôèíèöèèòå íà ÅÇ, òåõíîëîãèÿòà ñå ðàçãëåæäà êàòîñðåäñòâî çà ðàçøèðÿâàíå, ïîäïîìàãàíå èëè ïîâèøàâàíåíà ÷îâåøêèòå äåéíîñòè, âìåñòî êàòî òåõåí çàìåñòèòåë.

Ïðåîáëàäàâàùîòî ðàçáèðàíå íà ÅÇ îòðàçÿâà îïòèìèñòè÷íàíàãëàñà. Âñè÷êè äåôèíèöèè èìàò ïîçèòèâåí ñìèñúë èâêëþ÷âàò òåðìèíè êàòî ïîëçà (4), ïîäîáðÿâàíå (1, 15, 18, 21,22), ðàçøèðÿâàíå (29, 30, 43), åôåêòèâíîñò (1, 20) è äàâàíå íàâúçìîæíîñò (15, 18, 20, 22, 31). Åäíà äåôèíèöèÿ ïîäñêàçâà, ÷åÅÇ ïîçâîëÿâà íà ïàöèåíòèòå è ïðîôåñèîíàëèñòèòå „äàíàïðàâÿò òîâà, êîåòî å áèëî íåâúçìîæíî” (9).

Íèòî åäíà îò ïóáëèêóâàíèòå äåôèíèöèè íå ïðåäïîëàãà, ÷åÅÇ ìîæå äà èìà âðåäíè, îòðèöàòåëíè, îïàñíè èëèíåáëàãîïðèÿòíè åôåêòè.

Íàé-÷åñòî öèòèðàíàòà äåôèíèöèÿ â Èíòåðíåò å òàçè íàÀéçåíáàõ (1).

2. Åëåêòðîííî çäðàâåîïàçâàíå â Åâðîïà

Ôàêòúò, ÷å íàñåëåíèåòî íà Åâðîïà çàñòàðÿâà, å øèðîêîèçâåñòåí. Ñúùåâðåìåííî åâðîïåéöèòå âñå ïîâå÷å ìèãðèðàòâ ðàìêèòå íà ÅÑ ñ öåë òóðèçúì, ó÷åíèå, ðàáîòà. Ãðàæäàíèòåè ïàöèåíòèòå èñêàò äà èìàò ïî-çäðàâîñëîâåí íà÷èí íà æèâîòè äà èì áúäàò ïðåäîñòàâåíè âèñîêîêà÷åñòâåíè è äîñòúïíèçäðàâíè ãðèæè. Òåçè î÷àêâàíèÿ íå ñàìî îêàçâàò çíà÷èòåëåííàòèñê âúðõó íàöèîíàëíèòå çäðàâíè èíñòèòóöèè è çäðàâíàòàïîëèòèêà, íî äàâàò âúçìîæíîñòè íà åâðîïåéñêàòà èíäóñòðèÿäà ïîìîãíå çà ñúçäàâàíå íà àäåêâàòåí åâðîïåéñêè ïàçàð âîáëàñòòà íà çäðàâåòî è çäðàâíèòå òåõíîëîãèè (G. Comyn) (4).


While most of the definitions concentrated on the processof care, about one quarter of them focused on the resultsto be expected. These definitions mentioned improvingand increasing the “cost-effectiveness” of health care(4) and making processes more efficient (9, 20, 21). Otherssuggested that e-Health could solve problems related toaccess to care, cost, quality, and access of health careservices (4).

Some authors suggest that e-Health represents a newviewpoint on health care. One author describes eHealthas a “state-of-mind, a way of thinking, an attitude, and acommitment for networked, global thinking” (1). Anothersource describes eHealth as a “consumer-centered modelof health where stakeholders collaborate” (17).

Health, as used in these definitions, usually mentionedexplicitly health care as a process, rather than health as aresult. This is expected; there is no consensus on themeaning of the word health, the definitions of which rangefrom a narrowly construed “converse of disease orinfirmity or when disease or infirmity is absent” (50) tothe all encompassing World Health Organization’s “healthis a state of complete physical, mental, and social wellbeing and not just the absence of disease or infirmity”(52).

In the definitions of e-Health, the technology was viewedas a vehicle to broaden, to support, or to enhance humanactivities, rather than as a substitute for them.

The overspreading understanding of e-Health shows anattitude of optimism. All definitions had positiveconnotations and covered terms such as benefits (4),improvement (1, 15, 18, 21, 22), enhancing (29, 30, 43),efficiency (1, 20), and enabling (15, 18, 20, 22, 31). Onedefinition suggests that e-Health allows patients andprofessionals to “do the previously impossible” (9).

None of the published definitions suggests that e-Healthmay have any adverse, negative, harmful, ordisadvantageous effects.The most frequently quoted definition in theInternet is that of Eysenbach (1).

2. e-Health in Europe

The fact that the European population is aging is well-known.In fact, Europeans increasingly move from, to and withinthe EU for a host of reasons – tourism, education, seekingjob. Citizens and patients focus on achieving a healthierlifestyle and want to have accessible, affordable and highquality health care. These expectations not only have effectson the national health institutions but also give possibilitiesto the European industry to help create adequate Europeanmarket in the field of health and health technologies (G.Comyn) (4).


Ïðåç 1999 ã. Åâðîïåéñêàòà êîìèñèÿ (ÅÊ) çà ïúðâè ïúòîáÿâÿâà èíèöèàòèâàòà å-Åâðîïà ñ ïóáëèêóâàíå íàñúîáùåíèåòî eEurope - èíôîðìàöèîííî îáùåñòâî çàâñè÷êè (5). Ïðåç ñëåäâàùèòå ãîäèíè ïàçàðúò çàòåõíîëîãè÷íè ïðèëîæåíèÿ â ìåäèöèíñêàòà îáëàñò âÅâðîïà ðàñòå íåïðåêúñíàòî, âúïðåêè ëèïñàòà íàçàêîíîäàòåëíà ÿñíîòà è ñèãóðíîñò. Ñúîáùåíèåòî íà ÅÊîò 2002 ã. ïîòâúðæäàâà íàëè÷èåòî íà „íåñèãóðíîñò çàîòãîâîðíîñòòà è çàùèòàòà íà äàííèòå, çà çàêîííîñòòà ïðèäàâàíå íà online ñòàíîâèùà ïî ìåäèöèíñêè âúïðîñè,êàêòî è online ôàðìàöåâòè÷íà èíôîðìàöèÿ è ñíàáäÿâàíåñ ïðîäóêòè”. Òîçè âúïðîñ å ïîâäèãíàò îòíîâî â Ïëàíà çàäåéñòâèå (2004) çà Åâðîïåéñêà îáëàñò íà ÅÇ (6), ïîðàäèíàëè÷èåòî íà ïðîáëåìè, ñâúðçàíè ñúñ çàùèòà íà äàííèòå,åëåêòðîííèÿ ïîäïèñ, åëåêòðîííàòà òúðãîâèÿ,äèñòàíöèîííîòî äîãîâàðÿíå è ñúùåñòâóâàùîòî ïî òîâàâðåìå çàêîíîäàòåëñòâî ïî Îáùà îòãîâîðíîñò çà ïðîäóêòèè ìåäèöèíñêà àïàðàòóðà. Îò÷èòà ñå è çíà÷èòåëíàíåñèãóðíîñò â çàêîíîäàòåëíèòå àñïåêòè ïðè èçïîëçâàíåòîíà èíñòðóìåíòèòå, óñëóãèòå è êëèíè÷íèòå ïðèëîæåíèÿòàíà ÅÇ. Ïëàíúò çà äåéñòâèå, êîéòî îáõâàùà âñè÷êî, îòåëåêòðîííèòå ðåöåïòè è çäðàâíè êàðòè, äî íîâèèíôîðìàöèîííè ñèñòåìè (ÈÑ), íàìàëÿâàùè âðåìåòî çà÷àêàíå è ãðåøêè, ïðåäëàãà äî 2009 ÅÊ äà îñèãóðè ðàìêàçà ïî-ãîëÿìà çàêîíîäàòåëíà ñèãóðíîñò íà ïðîäóêòèòå èóñëóãèòå íà ÅÇ. Ïëàíúò îïðåäåëÿ ñòúïêèòå, íåîáõîäèìèçà øèðîêîòî âúâåæäàíå íà òåõíîëîãèè çà ÅÇ â öåëèÿ ÅÑ äî2010 ã. Áúðçî âíåäðÿâàíå íà âèñîêîñêîðîñòåí èíòåðíåòäîñòúï, íà êîéòî ñå îñíîâàâàò òîëêîâà ìíîãî îòèíñòðóìåíòèòå íà ÅÇ, å ïîñî÷åí êàòî ðåøàâàù çàðàçâèòèåòî íà ÅÇ. Îòäåëíè ãðóïè â îáùåñòâîòî, êàòîíàïðèìåð âúçðàñòíè õîðà, èíâàëèäè èëè áåçðàáîòíè,÷åñòî èìàò íàé-ãîëÿìà íóæäà îò çäðàâíè óñëóãè, àåäíîâðåìåííî èìàò è çàòðóäíåí äîñòúï äî èíòåðíåò. Òîâàå ïðè÷èíàòà íàñúð÷àâàíåòî íà äîñòúïíîñòòà íà óñëóãèòåíà ÅÇ, îñîáåíî çà óÿçâèìèòå ãðóïè, äà å îñíîâåí ïðèîðèòåòíà ïëàíà çà äåéñòâèå. Ïëàíúò ïðåäâèæäà äúðæàâèòå-÷ëåíêè äà ðàçâèâàò àäåêâàòíè íàöèîíàëíè è ðåãèîíàëíèñòðàòåãèè çà ÅÇ, êîèòî äà ïîñðåùíàò òåõíèòå ñïåöèôè÷íèíóæäè. Ó÷àñòèåòî íà âñè÷êè ñòðàíè îò ÅÑ â èçïúëíåíèåòîíà ïëàíà íàñúð÷àâà âñè÷êè çäðàâíè îðãàíè äà ñå ó÷àò îòîïèòà íà äðóãèòå. Ñïîäåëÿíåòî íà èäåè è îïèò â öÿëàÅâðîïà äàâà âúçìîæíîñò íà âñè÷êè äà ñå âúçïîëçâàò ïî-áúðçî îò åôåêòèâíè è íàäåæäíè ñèñòåìè çà ÅÇ. (6)

Ïðåç 2011 ãîäèíà ÅÊ ïóáëèêóâà äîêëàä (7), îöåíÿâàùäåéñòâèÿòà ïî èçïúëíåíèå íà ïëàíà. Äîêëàäúò ðàçâèâàòåçàòà, ÷å âåðîÿòíî Ïëàíúò çà äåéñòâèå íå å óñïÿë äàïîñòèãíå âñè÷êè öåëè â òåñíèÿ ñìèñúë íà äóìàòà, íî åóñïÿë â ñúçäàâàíåòî íà çíà÷èòåëíî íàñëåäñòâî îòêîíêðåòíè ðàçðàáîòêè, êîèòî ìîãàò äà ñå ïðåâúðíàò âîñíîâàâà íà ïî-íàòàòúøåí íàïðåäúê. Àíàëèçúò íàñúñòîÿíèåòî íà ÅÇ â äúðæàâèòå-÷ëåíêè (Ä×) íà ÅÑ ïîêàçâà,÷å:

âñè÷êè èìàò ðàçðàáîòåíè ñòðàòåãèè çà ÅÇ;

ðàçðàáîòåíè ñà ñòàíäàðòè çà åëåêòðîííè çäðàâíèäîñèåòà (EHRs): íÿêîè äúðæàâè-÷ëåíêè ñëåäâàò


In 1999 for the first time the European Commission (ÅC)launched the e-Europe initiative through releasing aCommunication: e-Europe - An Information Society ForAll (5). In the next years the market for technologicalapplications in the clinical domain in Europe wasconstantly growing despite the lack of legal clarity andcertainty. The European Commission formally issued theCommunication eEurope 2002 where the presence of“uncertainty persists in the health telematics relatedindustry about responsibility and data protection, thelegality of providing on-line medical opinions as well ason-line pharmaceutical information and product supply.”This topic was reconsidered again in the 2004 ActionPlan for a European e-Health (6) due to considerableproblems with data protection, electronic signature,electronic commerce, distance contracting and existing,at that time, legislation on General Product Liability andon Medical Devices. Considerable uncertainty on thelegal aspects of the use of e-Health applications, toolsand services still continues. The Action Plan that coversall issues from electronic prescribing and electronic healthrecords to new Information systems, decreasing the timefor waiting and error, proposed until 2009 the EuropeanCommission to ensure a legal framework for greatercertainty for goods and services of e-Health. The Plandefined steps necessary for broad implementation oftechnologies for e-Health within the EU by the end of2010. The rapid implementation of access to high speedInternet on which are based so many e-Health tools waspointed out as a crucial one for the development of e-Health. Different target groups from the public eg seniorcitizens, disabled or unemployed people often have thegreatest need of health services and at the same timethey face difficult access to the Internet. This is thereason that enhances the access to e-Health services, inparticular for the vulnerable groups, to be a main priorityin the Action Plan. The Plan foresees the Member-statesto develop adequate national and regional strategies fore-Health, which should meet their specific needs. Theparticipation of all countries within the EU in the planrealization boost all health authorities to learn themselvesfrom the experience of others participants. Sharing ideasand experience within Europe gives a possibility to all totake advantages rapidly from effective and reliablesystems for e-Health (6).

In 2011 the EC published a report (7) that assessed theprogress of the e-Health Action Plan for the period 2004– 2010. The report adopted the thesis that although theAction Plan may not have managed to achieve some ofits targets in the strict sense, it has succeeded in creatinga strong legacy of concrete developments that can beused for further progress. The analysis on the currentstate of e-Health in the Member-states showed that:

All countries have elaborated strategies on e-Health

Standards for Electronic Health Records (EHRs)have been developed: some Member States follow


òåçè ñòàíäàðòè, à â ÷åòèðè ñòðàíè ñå èçïîëçâàòïîäìíîæåñòâà íà çàïèñè, (ïàöèåíòñêè ðåçþìåòà);

åëåêòðîííè ðåöåïòè ñå èçïîëçâàò íà íàöèîíàëíî íèâî,â òðè Ä×, à â äðóãè ïîäîáíè óñëóãè ñà â ïðîöåñ íàïîäãîòîâêà;

òåëåìåäèöèíà ñå ïðèëàãà ðåãèîíàëíî íà ïèëîòíî íèâî,îñíîâíî â ñêàíäèíàâñêèòå ñòðàíè, è ñå ïîäêðåïÿïîëèòè÷åñêè îò ñïåöèàëåí ïëàí çà äåéñòâèå (2008);

ïðàâíèòå ðàìêè íà ÅÇ ñà â ïðîöåñ íà ïîäãîòîâêà âíÿêîè ñòðàíè è ïîä âíèìàíèå â ïî-ãîëÿìà ÷àñò îòîñòàíàëèòå;

ðåàëèçèðàò ñå ìàùàáíè îáùîåâðîïåéñêè (epSOS)ïèëîòíè âíåäðÿâàíèÿ íà ÷àñòè÷íî åëåêòðîííîïàöèåíòñêî äîñèå (EHR);

åëåêòðîííè êàðòè çà Åâðîïåéñêàòà çäðàâíîîñèãóðè-òåëíà óñëóãà ñà ðåàëèçèðàíè âúç îñíîâà ïèëîòíèïðîåêòè (íÿêîè â êîíòåêñòà íà ïðîåêòà NETC@RDS);

ðàçïðîñòðàíåíèåòî íà íàé-äîáðèòå ïðàêòèêè ñåïðåâúðíà â îíëàéí ðåñóðñ (ePractice.eu ïîðòàë);

ðåàëèçèðàí å ïîðòàëúò íà ÅÑ „Îáùåñòâåíî çäðàâå”;

ñúçäàâàíåòî íà ïàçàð çà ïðîäóêòè è óñëóãè íà ÅÇ ñåïðåâúðíà â åäíà äúëãîñðî÷íà ïîëèòè÷åñêà öåë (÷ðåçÈíèöèàòèâàòà çà âîäåùè ïàçàðè è íåéíèÿ ïëàí çàäåéñòâèå).

Íèòî åäèí îò ïîñî÷åíèòå åëåìåíòè íà ÅÇ íå ñúùåñòâóâàïðåäè 2004 ãîäèíà. Âñè÷êè òå ñà êîíêðåòíè èíôðàñòðóêòóðíèðåçóëòàòè íà äåéñòâèÿòà, ïðåäïðèåòè â èçïúëíåíèå íà ïëàíà.Áëàãîäàðåíèå íà òîâà Åâðîïà íàòðóïà áîãàò îïèò è çíàíèÿîòíîñíî òðóäíîñòèòå, êîèòî ñå ñðåùàò ïðè îáùèòå äåéñòâèÿíà äúðæàâèòå-÷ëåíêè è çíà÷åíèåòî íà ôóíêöèîíèðàíåòî íàåâðîïåéñêî ðàâíèùå. (7)

Ïðåç ïåðèîäà ìàðò-ìàé 2011 ã. Åâðîïåéñêàòà êîìèñèÿïðîâåäå ïóáëè÷íî äîïèòâàíå (7) îòíîñíî ñúçäàâàíå íà íîâïëàí çà äåéñòâèå çà åëåêòðîííîòî çäðàâåîïàçâàíå (eHAP)2012-2020. Òîçè âòîðè ïëàí çà äåéñòâèå ùå äàäå âúçìîæíîñòçà êîíñîëèäèðàíå íà äåéñòâèÿòà, êîèòî êúì äíåøíà äàòà ñàáèëè àäðåñèðàíè, äà î÷åðòàå ñëåäâàùè âúçìîæíè ñòúïêè èäà îñèãóðè ïî-äúëãîñðî÷íà âèçèÿ çà åëåêòðîííîòîçäðàâåîïàçâàíå â Åâðîïà, â êîíòåêñòà íà ñòðàòåãèÿòà “ÅÑ2020”, Ïðîãðàìàòà â îáëàñòòà íà öèôðîâèòå òåõíîëîãèè íàÅÑ, Ñúþçà çà èíîâàöèèòå è ñâúðçàíîòî ñ íåãî Åâðîïåéñêîèíîâàòèâíî ïàðòíüîðñòâî çà àêòèâíî è çäðàâîñëîâíîñòàðååíå. Íîâèÿò ïëàí çà äåéñòâèå ïîñòàâÿ ñåðèÿ îò öåëè,êîèòî òðÿáâà äà áúäàò èçïúëíåíè â ãîäèíèòå äî 2020.

ÅÇ å íåäåëèì êîìïîíåíò íà „Ïðîãðàìàòà â îáëàñòòà íàöèôðîâèòå òåõíîëîãèè çà Åâðîïà íà ÅÑ”, êîÿòî ñå ôîêóñèðàâúðõó âúçìîæíîñòèòå íà ÈÊÒ çà íàìàëÿâàíå íàïîòðåáëåíèåòî íà åíåðãèÿ, çà ïîäêðåïà æèâîòà íàçàñòàðÿâàùèòå ãðàæäàíè, çà ðåâîëþöèÿ â çäðàâíèòå óñëóãèè ïîäîáðÿâàíå íà îáùåñòâåíèòå óñëóãè. ÅÊ ïðåäâèæäàøåäà ïðèåìå íîâèÿ ïëàí äî êðàÿ íà 2011 ã., íî ñå íàëîæèîòëàãàíå çà 2012 ãîäèíà ïîðàäè íÿêîëêî åâðîïåéñêèèíèöèàòèâè, ñâúðçàíè ñ ÅÇ, êîèòî ñå î÷àêâà äà äàäàò ïúðâèòå


these, while in four countries the use of subsetsof records (Patient Summaries) are underway

E-Prescription services at a national-level are areality in three states and are in a process ofpreparation in others

Telemedicine is regionally applied at a pilot levelmainly in the Nordic countries, and is politicallysupported by a specially dedicated action plan(2008)

Legal frameworks are under preparation in somecountries and under consideration in most ofthem

Large-scale pan-European pilot implementationson partial EHRs are progressing (through largescale pilots such as European Patients - Smartopen Services (epSOS.)

Electronic European Health Insurance Cardsservices have been implemented on a pilot basis(in the context of the NETC@RDS project)

Dissemination of best practices has become anonline resource (ePractice.eu portal)

An EU Public Health portal is a reality

The creation of a market on e-Health productsand services has become a long-term politicalaim (via the Lead Market Initiative and its actionplan).

None of the above mentioned facts existed before 2004.They all are concrete infrastructural results of the drivewhich the plan itself provided. Thanks to those, Europeansare richer in experience and knowledge. They have becomeaware of the difficulties which common action by all MemberStates presents and have gained an appreciation of theimportance of functioning at European level. (7)

Over the period of March – May 2011 the EuropeanCommission launched a public consultation on a new e-Health Action Plan (e-HAP) for the period 2012-2020.This second new action plan’s aim is to consolidate theactions which have been undertaken so far under theprevious Action Plan, take them a step further whileproviding for a longer term vision for e-Health in Europe,in the context of the EU 2020 Strategy, the Digital Agendafor Europe, Innovation Union and its associatedEuropean Innovation Partnership on Active and HealthyAgeing. In this sense, the public consultation sought tovalidate a set of proposed objectives that need to berealized in the next years up to 2020.

E-health is a part of the European Commission’s DigitalAgenda for Europe, which focused on the possibilitiesof the ICT for decreasing the energy consumption, forsupporting the living of elder citizens, for revolution inthe healthcare services and improvement of the publicprocurement. The implementation of the relevantactions had initially been foreseen for the end of 2011.


ñè ðåçóëòàòè äî íÿêîëêî ìåñåöà. Òàêà íàïðèìåðèíèöèàòèâàòà „Åâðîïåéñêî ïàðòíüîðñòâî çà èíîâàöèè çààêòèâíî è çäðàâîñëîâíî ñòàðååíå” ïðèå ñâîÿ Ñòðàòåãè÷åñêèïëàí çà âíåäðÿâàíå íà 7 íîåìâðè 2011. Èíèöèàòèâàòà„Óïðàâëåíèå ÷ðåç ÅÇ” ïðåäñòîè äà ïðåäëîæè ñâîÿ äîêóìåíòñ ïðèîðèòåòè è âúçìîæíè êîíêðåòíè ïðåïîðúêè ïðåç ìàé2012 ã. „Öåëåâàòà ãðóïà çà ÅÇ” (Task Force on eHealth)ïðåäñòîè äà ïðèåìå ñâîÿ îêîí÷àòåëåí äîêëàä ïðåç ïðîëåòòàíà 2012. Îñâåí òîâà, „Ìðåæàòà íà ÅÇ”, ñúçäàäåíà ïî ñèëàòàíà äèðåêòèâàòà çà ïðàâà íà ïàöèåíòèòå íà òðàíñãðàíè÷íèçäðàâíè óñëóãè, ùå áúäå ñúçäàäåíà â íà÷àëîòî íà 2012 ã. (17)Îò äðóãà ñòðàíà îòëàãàíåòî ùå ãàðàíòèðà ïî-äîáðîâçàèìîäåéñòâèå íà âñè÷êè çàèíòåðåñîâàíè ñòðàíè èäîïúëâàíå íà ñïîìåíàòèòå èíèöèàòèâè, òàêà ÷å âñè÷êèïðåïîðúêè è ðåçóëòàòè äà ìîãàò äà áúäàò àäåêâàòíî îòðàçåíèâ íîâèÿ ïëàí çà äåéñòâèå çà ÅÇ. Òîâà å êëþ÷îâ äîêóìåíò,êîéòî ñå î÷àêâà äà ïðîïðàâè ïúò íà ÅÇ â Åâðîïà, çàòîâà å îòñúùåñòâåíî çíà÷åíèå äà ñå îñíîâàâà íà êîíñîëèäèðàíè èäîáðå îáîñíîâàíè âúçãëåäè, è ïðåäëîæåíèÿ îòïðåäñòàâèòåëè íà äúðæàâèòå-÷ëåíêè, çàèíòåðåñîâàíèòåñòðàíè è åêñïåðòèòå, êîåòî ùå ãàðàíòèðà âèñîêî êà÷åñòâî,åôåêòèâíîñò è ïî-äîáðî èçïúëíåíèå íà äåéñòâèÿòà,çàëîæåíè â íåãî.

Ñòðàòåãè÷åñêà ðàìêà íà ÅÇ â ÅÑ è î÷àêâàíèïîëçè

Ñòðàòåãè÷åñêàòà èíèöèàòèâà i2010 å èíèöèàòèâà çà ðàñòåæ èçàåòîñò. Òÿ ñå îñíîâàâà íà ïîëèòèêèòå, íàó÷íèòå èçñëåäâàíèÿè èíîâàöèèòå â îáëàñòòà íà ÈÊÒ, çà äà ñïîìîãíå çà ïîñòèãàíåíà öåëèòå íà Ëèñàáîíñêàòà ñòðàòåãèÿ. Èíèöèàòèâàòà i2010èìà çà öåë äà ñòèìóëèðà èçãðàæäàíåòî íà åâðîïåéñêîòîèíôîðìàöèîííî îáùåñòâî è äà íàñúð÷àâà ïðåäîñòàâÿíåòîíà ïî-äîáðè îáùåñòâåíè óñëóãè, âêëþ÷èòåëíî ÅÇ.

Åäíà îò ãîëåìèòå áàðèåðè çà øèðîêî âúâåæäàíå íà ÅÇ åôðàãìåíòàðíîñòòà íà çäðàâíèòå ñèñòåìè è ëèïñàòà íàòåõíè÷åñêà ñúâìåñòèìîñò (èíòåðîïåðàáèëíîñò) íàèíôîðìàöèîííèòå ïðèëîæåíèÿ. Ñòàíäàðòèçàöèÿòà íàèíôîðìàöèîííèòå ñèñòåìè (ÈÑ) â çäðàâåîïàçâàíåòî å îòèçêëþ÷èòåëíî âàæíî çíà÷åíèå, çà äà ñå ïîñòèãíå òåõíè÷åñêàè ñåìàíòè÷íà ñúâìåñòèìîñò, áåç êîÿòî òðàíñãðàíè÷íàòàèíòåðîïåðàáèëíîñò ñúùî å íåìèñëèìà. Ñòàíäàðòèçàöèÿòàáè ìîãëà äà îñèãóðè íåïðåêúñíàòîñò íà çäðàâåîïàçâàíåòî èëå÷åíèåòî, êîåòî ïúê ùå ïîâèøè áåçîïàñíîñòòà íàïàöèåíòèòå, ùå ïîäîáðè ëå÷åíèåòî è ùå ïðîïðàâè ïúò êúìåôåêòèâíî è èíòåðàêòèâíî çäðàâåîïàçâàíå.

Âúâåæäàíåòî íà èíòåðîïåðàáèëíè ðåøåíèÿ â îáëàñòòà íàÅÇ ÷ðåç ñúòðóäíè÷åñòâî è êîîðäèíàöèÿ â Åâðîïà ñå íóæäàåîò óñêîðÿâàíå ïîðàäè íÿêîëêî îñíîâíè ïðè÷èíè:

óâåëè÷åíàòà ìîáèëíîñò íà åâðîïåéñêèòå ãðàæäàíè,òåõíèòå î÷àêâàíèÿ è íóæäè, êàêòî è òåíäåíöèÿòà çàïî-ãëîáàëíè çäðàâíè ïàçàðè;

âúçìîæíîñòòà çà ïîäîáðÿâàíå íà ãðèæèòå çàïàöèåíòèòå, íàìàëÿâàíå íà ëåêàðñêèòå ãðåøêè èèêîíîìè÷åñêèòå ðàçõîäè, ÷ðåç èíòåãðèðàíå íàäàííèòå;


However, the Commission postponed the adoption ofmeasures related to the e-Health Action Plan to 2012 due tothe launch of a number of initiatives relevant to thedevelopment of the e-Health agenda, which might give theirfirst result in the coming few months. For instance, theinitiative European Innovation Partnership on Active andHealthy Ageing adopted a Strategic Implementation Plan(SIP) at its meeting of 7 November 2011. The e-HealthGovernance Initiative8 will propose its priority documentand possible specific recommendations in May 2012. TheTask Force9 on e-Health will agree on its final report inspring 2012. Furthermore, the e-Health network set up underthe Directive on patients rights for cross border care will beestablished early 2012 (7). On the other hand, thepostponement is considered essential to guarantee that allrelevant synergies and complementarities can be achievedand that all the initiatives mentioned above and any relevantrecommendations and results can be adequately reflectedin the new e-Health Action Plan. The Plan is a key documentwhich is expected to pave the way forward for e-Health inEurope; therefore, it is essential that it builds on wellconsolidated views and visions from Member Statesrepresentatives, stakeholders and experts. This is welljustified as it will increase the quality, the effectiveness andultimately strengthen the implementation of the actionsproposed in the Plan.

Strategic e-Health framework within the EUand expected benefits

The strategic initiative i2010 is an initiative for growthand employment. It is based on information andcommunication technology policies, research andinnovation to help achieve the goals of the LisbonStrategy. The i2010 initiative encourages the buildingof European information society and boostsenhancement of public services, including e-Health.Major barriers to implementation of e-Health on a largescale in the Community are a fragmentation withinhealthcare systems and a lack of technicalcompatibility (interoperability) of informationapplications. Standardizing the information systems(IS) of healthcare systems is of vital importance toachieve technical and semantic compatibility,otherwise the cross border interoperability isinconceivable, too. The standardization would ensurecontinuity of healthcare and treatment, thus improvingpatient safety, health treatment while paving the wayto cost effective and interactive healthcare.

The main reasons for boosting the introduction ofinteroperable e-Health solutions in a collaborative andcoordinated way in Europe are:

The increasing mobility of European citizens,their outlooks and needs as well as the growingtrend towards more global health markets;


ïîñòîÿííîòî íàðàñòâàíå íà èçèñêâàíèÿòà êúìçäðàâíèòå è ñîöèàëíè ãðèæè;

îñèãóðÿâàíå íà ïî-äîáðè ðåçóëòàòè ïîðàäè ïî-äîáðàèíôîðìèðàíîñò;

âúçìîæíîñòòà çà îáìåí íà äàííè çà îñèãóðÿâàíå íàêà÷åñòâî è áåí÷ìàðêèíã, ðåèìáóðñèðàíå, ïî-äîáúðìåíèäæìúíò è êîíòðîë, íàáëþäåíèå íà áîëåñòèòå èãîòîâíîñò çà ñïåøíè ñëó÷àè, ïîäêðåïà íà ðåøåíèÿ,ìîíèòîðèíã íà çäðàâåîïàçâàíåòî, ãåíåðèðàíå íàçíàíèÿ è íàó÷íè èçñëåäâàíèÿ;

íåîáõîäèìîñòòà îò óïðàâëåíèå íà çäðàâíèÿ ðèñê âúâ èèçâúí ìåäèöèíñêèòå çàâåäåíèÿ è ïîäîáðÿâàíåòî íàáåçîïàñíîñòòà íà ïàöèåíòà.

Èìåííî ïîäîáðÿâàíåòî íà áåçîïàñíîñòòà íà ïàöèåíòà,óñïîðåäíî ñ îñèãóðÿâàíå öÿëîñòíàòà ïîñëåäîâàòåëíîñò íàçäðàâíèòå ãðèæè, å ïðèîðèòåòåí âúïðîñ â çäðàâíèòåñòðàòåãèè íà ïîâå÷åòî ñòðàíè-÷ëåíêè è ÅÑ. Äðóãè ïîëçè ñàïîäîáðÿâàíå íà äîñòúïà (óëåñíÿâàíå íà èíôîðìàöèÿòà çàïàöèåíòèòå è çäðàâíèòå ïðîôåñèîíàëèñòè, ïîäîáðÿâàíå íàêîíòàêòèòå ñ è ìåæäó ìåäèöèíñêèòå ñïåöèàëèñòè èèçáÿãâàíåòî íà íåíóæíîòî òðàíñïîðòèðàíå), êà÷åñòâîòî(îñèãóðÿâàíå íà ñúîòâåòíà ìåäèöèíñêà èíôîðìàöèÿ çàïðîôèëàêòèêà è äèàãíîñòèöèðàíå, èçáÿãâàíå íà ãðåøêè âëå÷åíèåòî ïîðàäè ëèïñà íà èíôîðìàöèÿ) è íàìàëÿâàíå íàðàçõîäèòå (èçáÿãâàíå íà äóáëèðàíå íà ðåíòãåíîëîãè÷íè èëàáîðàòîðíè èçñëåäâàíèÿ è ò.í.) (5, 8, 9, 100, 11, 12, 13).

Ïðåäñòîÿùè ñòúïêè çà ïîñòèãàíå íàèíòåðîïåðàáèëíîñò â Åâðîïà

Íàé-îáùî êàçàíî èíòåðîïåðàáèëíîñòòà (îïåðàòèâíàòàñúâìåñòèìîñò) å ïðåíîñ íà èíôîðìàöèÿ ìåæäó çäðàâíèòåñèñòåìè çà ïîñòèãàíå íà êëèíè÷íà öåë. Âñÿêî íèâî íàèíòåðîïåðàáèëíîñò èçèñêâà ïðåäâàðèòåëíîñïåöèôèöèðàíå íà êëèíè÷íèÿ êîíòåêñò, àíàëèçèðàíå íàðàáîòíèÿ ïîòîê, îïðåäåëÿíå íà èíôîðìàöèÿòà, êîÿòîòðÿáâà äà ñå óïðàâëÿâà è ïðåäàâà è, íàêðàÿ, îïðåäåëÿíåíà òåõíè÷åñêèòå ðåøåíèÿ çà ïðåäàâàíå íà òàçèèíôîðìàöèÿ. Ñúòðóäíè÷åñòâîòî íà çäðàâíèòåïðîôåñèîíàëèñòè ïðè äåôèíèðàíå íà êëèíè÷íèÿ êîíòåêñòå îò ðåøàâàùî çíà÷åíèå çà åôåêòèâíîñòòà íà âñÿêîðåøåíèå. Óïðàâëÿåìèòå ãðèæè çà ïàöèåíòà íàëàãàòèçêëþ÷èòåëíà êîìóíèêàöèÿ.

Êîìóíèêàöèÿòà è ñúòðóäíè÷åñòâîòî ìåæäó çäðàâíèòåçàâåäåíèÿ è ìåæäó îðãàíèçàöèèòå è òåõíèòå ïàöèåíòè ñàïîä÷èíåíè íà ðàçëè÷íè ðàìêè è ðàáîòÿò íà ðàçëè÷íèíèâà, êîèòî íå ñà ïîäðîáíî èçñëåäâàíè: þðèäè÷åñêî èëèðåãóëàòîðíî íèâî; åòè÷íî-êóëòóðíî-ñîöèàëíî-ìåäèöèíñêî íèâî; àäìèíèñòðàòèâíî (âêë. ôèíàíñîâî) èîðãàíèçàöèîííî íèâî è ðàìêà íà òåõíè÷åñêàèíòåðîïåðàáèëíîñò. Âñÿêà âúçíèêíàëà ïðå÷êà, íà êîåòî èäà å íèâî, ìîæå äà ïðîâàëè öÿëàòà êîìóíèêàöèÿ.

Opportunities for improving patients’ care,decreasing medical errors and reduction of coststhrough data integration;

Continuously rising demands on health andsocial care; healthcare through ICT could lead tobetter results due to better information flow;

The opportunity for data exchange for deliveringquality assurance and benchmarking,reimbursement, better management and control,disease surveillance and emergencypreparedness, decision support, knowledgegeneration and research;

The necessity to handle health risks both withinand outside clinical establishments and toimprove patient safety.

Promoting patient safety along the full continuum ofcare is now a priority issue on the international healthpolicy agenda in the most Member-states and the EU.Other benefits gained are in terms of access (facilitatinginformation for patients and health professionals,improving contacts with the health professionals, andavoiding useless transportation), quality (makingappropriate medical information available forprevention and diagnostic, avoiding treatment errorsdue to lack of information) and reduction of costs(avoiding duplication of laboratory and radiologyexaminations, and so on) (5, 8, 9, 10, 11, 12, 13).

Next steps for achieving interoperability inEurope

In general, interoperability (operative compatibility) isa transfer of information between health systems toachieve a clinical goal. Any interoperability levelrequires prior specifying clinical context, analyzingoperative flow, identifying information to be managedand transmitted, and finally specifying technicalsolutions for data transmission. Cooperation of healthprofessionals in defining the clinical context is crucialfor the effectiveness of any decision. Managedpatient’s care requires high level communication.

Communication and collaboration between hospitals,on the one hand, and between organizations and theirpatients, on the other hand, are established withindifferent frameworks and at different levels, which arenot studied in detail: at legal or regulatory level; atethical, cultural and socio-medical level; atadministrative (including financial) and organizationallevel within the framework for technicalinteroperability. Each obstacle, which has occurred atany level, can disrupt the communication as a whole.

The concept of EH interoperabili ty and itsimplementation in everyday medical practice is a majorchallenge for the relationship physician-patient,



Êîíöåïöèÿòà çà èíòåðîïåðàáèëíîñò íà ÅÇ è âíåäðÿâàíåòîé â åæåäíåâíàòà ìåäèöèíñêà ïðàêòèêà å ãîëÿìîïðåäèçâèêàòåëñòâî çà âçàèìîîòíîøåíèÿòà ìåæäó ëåêàðè ïàöèåíò, ëåêàð è èíñòèòóöèÿ è ìåæäó èíñòèòóöèèòå. Âòðàäèöèîííèÿ ìîäåë íà îñèãóðÿâàíå íà çäðàâíè ãðèæè,äîñòúïúò íà ïàöèåíòà äî ñèñòåìàòà íà çäðàâíàòà ïîìîùïîíÿêîãà å îãðàíè÷åí äî ïðåäâàðèòåëíî çàäàäåíè âõîäíèòî÷êè (íàïð. ÎÏË). Äâèæåíèåòî íà ïàöèåíòà ïðåçñèñòåìàòà å îòíîñèòåëíî ëèíåéíî è ÷åñòî ñå äèêòóâà îòñúîòâåòíàòà ñèñòåìà íà ðåèìáóðñèðàíå, ðàçëè÷íà çàðàçëè÷íèòå ñòðàíè. Àíàëîãè÷íî, ïðîöåñèòå, êàòîäèàãíîñòèöèðàíå, ëå÷åíèå è îáãðèæâàíå, âêëþ÷âàòôèçè÷åñêî ïðèñúñòâèå è ëè÷íî âçàèìîäåéñòâèå ìåæäóïàöèåíòè è èçïúëíèòåëè íà ìåäèöèíñêà ïîìîù, êàòîïîòðåáèòåëèòå ïëàùàò ïðÿêî èëè íåïðÿêî çà çäðàâíàòàèíôîðìàöèÿ, ëå÷åíèå è îáãðèæâàíå, ÷ðåç äàíúöè èëèñîöèàëíî-îñèãóðèòåëíè ñèñòåìè èëè ÷ðåç ïî-ñëîæíèñèñòåìè çà ðåèìáóðñèðàíå. ÅÇ, îáà÷å, å îñíîâàíî íàñúâñåì íîâ îïèò íà ïàöèåíòèòå, çà êîèòî îãðàíè÷åíèÿòàíà âõîäíèòå òî÷êè è ñòðóêòóðè èëè òðàäèöèîííèòå êàíàëèçà îñèãóðÿâàíå íà èíôîðìàöèÿ èëè ãðèæè ìîãàò äàîòïàäíàò.

Íåîáõîäèìîñòòà îò îñèãóðÿâàíå íà åôåêòèâíî èóñòîé÷èâî çäðàâåîïàçâàíå íàëàãà îáìèñëÿíå íàèçèñêâàíèÿòà çà èíòåðîïåðàáèëíîñò íà ÅÇ. Ïîäèíòåðîïåðàáèëíîñò ñå ðàçáèðà ñèñòåìè è óñëóãè, êîèòîñà ñâúðçàíè è ôóíêöèîíèðàò åôåêòèâíî ñúâìåñòíî, êàòîñå çàïàçâà àíîíèìíîñòòà íà ïàöèåíòà è ñïåöèàëèñòà, íàëè÷íèòå äàííè è áåçîïàñíîñòòà, ñ öåë ïîäîáðÿâàíå íàäîñòúïà, êà÷åñòâîòî, áåçîïàñíîñòòà è öåíàòà íà çäðàâíèòåóñëóãè, â ñúîòâåòñòâèå ñ Ëèñàáîíñêàòà ñòðàòåãèÿ.

Â òàçè âðúçêà ïúðâèÿò ïëàí çà äåéñòâèå íà Åâðîïåéñêàòàêîìèñèÿ (ÅÊ) èìà çà öåë ïîñòèãàíå íà èíòåðîïåðàáèëíîñòíà ÅÇ, ðàçøèðåíî èçïîëçâàíå íà ÅÇ äîñèåòà, îí-ëàéíóñëóãè, å-ðåöåïòè, ñòàíäàðòèçèðàíå è âñè÷êè äðóãèïîäïîìàãàùè äîáðè ïðàêòèêè (7).

Ïðåç 2007 ãîäèíà ÅÊ ïóáëèêóâà ñúîáùåíèåòî“Èíèöèàòèâà çà âîäåùè ïàçàðè â Åâðîïà” (COM(2007)860 final), êîåòî öåëè ñúçäàâàíåòî è ïóñêàíåòî íà ïàçàðàíà èíîâàòèâíè ïðîäóêòè è óñëóãè âúâ âîäåùèïðîìèøëåíè è ñîöèàëíè îáëàñòè, âêëþ÷èòåëíîåëåêòðîííîòî çäðàâåîïàçâàíå. Åäíà îò îñíîâíèòå öåëèíà ïðåäëîæåíàòà èíèöèàòèâà å äà ïîâèøè îïåðàòèâíàòàñúâìåñòèìîñò íà ñèñòåìèòå çà åëåêòðîííè çäðàâíèäîñèåòà, òúé êàòî èçïîëçâàíèòå ïîíàñòîÿùåì âäúðæàâèòå-÷ëåíêè çäðàâíè èíôîðìàöèîííè èêîìóíèêàöèîííè ñèñòåìè è ñòàíäàðòè ÷åñòî ñàíåñúâìåñòèìè, êîåòî ïðåäñòàâëÿâà áàðèåðà çàâúçíèêâàíåòî íà èêîíîìè÷åñêè åôåêòèâíè èèíîâàòèâíè ðåøåíèÿ çà çäðàâåîïàçâàíåòî, âúç îñíîâàíà ÈÊÒ. Íà 23 ìàé 2007 ã. Åâðîïåéñêèÿò ïàðëàìåíò ïðèåðåçîëþöèÿ (2006/2275 (INI)), ñ êîÿòî ïðèêàíè ÅÊ äàíàñúð÷è äúðæàâèòå-÷ëåíêè àêòèâíî äà ïîäêðåïÿòâúâåæäàíåòî íà åëåêòðîííîòî çäðàâåîïàçâàíå è íàòåëåìåäèöèíàòà, îñîáåíî ÷ðåç ðàçðàáîòâàíå íàîïåðàòèâíî ñúâìåñòèìè ñèñòåìè, ïîçâîëÿâàùè îáìåííà èíôîðìàöèÿ çà ïàöèåíòèòå ìåæäó äîñòàâ÷èöèòå íàçäðàâíè óñëóãè â ðàçëè÷íè äúðæàâè-÷ëåíêè (16).

physician- institution and between institutions. Thetraditional model of health care provision offerssometimes a patient’s access to health care system,which is limited to a predefined entry points (eg. GPs).Patient’s movement through the system is relativelylinear and is often dictated by country-specificreimbursement system. Similarly, processes such asdiagnosis, treatment and provision of care include aphysical presence and personal interaction betweenpatients and health care providers. Consumers paydirectly or indirectly for health information, treatmentand care through taxes or social security systems ormore complex reimbursement systems. However, EHis based on a completely new experience for patients,where limitations at the entry points and structures ortraditional channels to provide information or care andmay be removed.

The need to ensure effective and sustainable healthrequires specifying the requirements for EHinteroperability. The term interoperability meanssystems and services that are linked and functioneffectively together, keeping the patient, specialist andpersonal data anonymous and ensuring safety in orderto improve access, quality, safety and cost of healthcare according to the Lisbon Strategy .

With respect to this, the first action plan of theEuropean Commission (EC) was aimed at achievinginteroperability of EH, extensive use of EH records,online services, e-prescriptions, standardization andusing all other supporting practices. (7)

In 2007 the EC published a communication entitled “ Alead market initiative for Europe” (COM (2007) 860final), which aims at creating and marketing innovativeproducts and services in leading industrial and socialareas, including e-Health. One of the main objectivesof the proposed initiative is to promote theinteroperability of electronic health records as healthinformation and communication systems andstandards, currently used in Member States, are oftenincompatible, which is an obstacle to cost-effectiveand innovative solutions in public health area, basedon the ICT. On May 23, 2007, the European Parliamentadopted a Resolution (2006/2275 (INI)), inviting theCommission to encourage Member States to activelysupport the introduction of e-Health and telemedicine,particularly by developing interoperable systemsallowing the exchange of patient information betweenhealthcare providers in different Member States (16)



Íåîáõîäèìîñò îò ñåìàíòè÷íàèíòåðîïåðàáèëíîñò

Ñåìàíòè÷íàòà èíòåðîïåðàáèëíîñò êàñàå ïðèëîæíèÿêîíòåêñò, â êîéòî òðÿáâà äà ñå ïîñòèãíå èíòåðîïåðàáèëíîñò.Ïúðâî ñå îïðåäåëÿ êëèíè÷íèÿò êîíòåêñò è ðàáîòíèÿò ïîòîê,ñëåä êîåòî ñå äåôèíèðà èíôîðìàöèÿòà îò ðàçëè÷íè ÷àñòèíà ïðîöåñà íà îáñëóæâàíå ïî íà÷èí, êîéòî ìîæå äà ñåèçïîëçâà è ðàçáèðà îò äðóãè ó÷àñòíèöè. Êàòî ïðåäïîñòàâêàòðÿáâà äà áúäàò ãàðàíòèðàíè ðàçáèðàíåòî è òîëåðàíòíîñòòàíà êîìïîíåíòèòå íà îáñëóæâàíåòî, õàðìîíèçèðàíå íàïðîöåäóðèòå, èçáÿãâàíå íà íåïðàâèëíî èíòåðïðåòèðàíå,êîìáèíèðàíî ñ íàäåæäíîñò, ðàçäåëåíà ìåæäó âñè÷êèó÷àñòíèöè - âêëþ÷èòåëíî è ïàöèåíòà. Îïèñàíèåòî íàïðîöåñà, îáóñëàâÿùèòå ìîäåëè è êîíöåïöèè,òåðìèíîëîãèÿòà è îíòîëîãèÿòà íà ïðåäñòàâÿíåòî íà çíàíèÿòàòðÿáâà äà ñà íåäâóñìèñëåíî ñïîäåëåíè. Òîâà èçèñêâà èõàðìîíèçèðàíå íà òåõíè÷åñêèòå ñðåäñòâà, âêëþ÷èòåëíîïîääúðæàùèòå ñèñòåìè çà çäðàâíà èíôîðìàöèÿ èêîìóíèêàöèÿ. Íàïîñëåäúê àâòîìàòè÷íîòî ëèíãâèñòè÷íîîáðàáîòâàíå è èíòåëèãåíòíîòî òúðñåíå íà èíôîðìàöèÿî÷åðòàâàò íåîáõîäèìîñò îò îðèãèíàëíà ñåìàíòè÷íàèíòåðîïåðàáèëíîñò, òîåñò ãàðàíöèÿ, ÷å âñåêè åçèê âìíîæåñòâî îò äàííè å íåäâóñìèñëåí è èìà ñúùîòî çíà÷åíèåçà âñåêè ïîñëåäâàù ïîòðåáèòåë íà ñèñòåìàòà. Òî÷íîòîçíà÷åíèå òðÿáâà äà áúäå îïèñàíî ôîðìàëíî - çà äà áúäåîáðàáîòåíî îò ìàøèíà - è òðàíñôîðìèðàíî, âúç îñíîâà íàïðåäâàðèòåëíî ñúçäàäåíè ïðàâèëà, çà äà ñå ðàçáåðå îòïîòðåáèòåëèòå íà ñèñòåìàòà.

Íåîáõîäèìîñò îò ñòàíäàðòèçèðàíå

Ñòàíäàðòèçèðàíåòî å íåäåëèìà ÷àñò îò ïîëèòèêàòà íà ÅÑ çàïîâèøàâàíå íà êîíêóðåíòîñïîñîáíîñòòà íà ïðåäïðèÿòèÿòàè ïðåìàõâàíå íà ïðå÷êèòå ïðåä òúðãîâèÿòà (14). Â îáëàñòòàíà ÅÇ Åâðîïåéñêèÿò êîìèòåò ïî ñòàíäàðòèçàöèÿ ïîä÷åðòàâà,÷å ñòàíäàðòèòå çà çäðàâíà èíôîðìàöèÿ ñà îò îñîáåíîçíà÷åíèå çà ïîñòèãàíå íà öåëèòå íà ÅÇ â Åâðîïà. Êîìèòåòúòïðåïîðú÷âà ñúçäàâàíåòî íà ïëàòôîðìà çàèíòåðîïåðàáèëíîñò, êîÿòî äà äàäå îáùîåâðîïåéñêè ïîãëåäâúðõó èçèñêâàíèÿòà çà ÅÇ, ñòàíäàðòèçèðàíåòî è ïðèëàãàíåòîìó, â ñúòðóäíè÷åñòâî ñúñ ñòàíäàðòèçàöèîííèòå îðãàíèçàöèè,âúç îñíîâà íà èíôîðìàöèÿ îò êëþ÷îâè èãðà÷è.

Çà ãàðàíòèðàíå íà ñåìàíòè÷íà èíòåðîïåðàáèëíîñòñèñòåìèòå è ðåøåíèÿòà òðÿáâà äà áúäàò ïðîåêòèðàíèïðàâèëíî, âúç îñíîâà íà îïðåäåëåíà àðõèòåêòóðà. Òîâà åîñîáåíî âàæíî çà ñèñòåìèòå çà åëåêòðîííè çäðàâíè äîñèåòà.Ñåìàíòè÷íàòà è òåõíè÷åñêàòà èíòåðîïåðàáèëíîñò ìîãàò äàáúäàò ïîäïîìîãíàòè ÷ðåç ñòàíäàðòèçèðàíå íà òåõíè÷åñêèÿèíòåðôåéñ, ïðîòîêîëè, ñúîáùåíèÿ è äîêóìåíòè, áèçíåñïðîöåñèòå, êëèíè÷íè ïðîöåäóðè è ïúòåêè. Â òîçè àñïåêò ñàïîäõîäÿùè ñòàíäàðòè çà àïàðàòóðà, ïðîòîêîëè, ñúîáùåíèÿ,äîêóìåíòè, ïðîöåñè, àðõèòåêòóðà, äèçàéí è ìîäåëèðàíå,êàêòî è ñòàíäàðòè çà èíôðàñòðóêòóðà è èíôðàñòðóêòóðíîîáñëóæâàíå, ñ àêöåíò âúðõó ñèãóðíîñòòà, áåçîïàñíîñòòà èêîíôèäåíöèàëíîñòòà.

Need for semanticinteroperability

Semantic interoperability refers to the applicationcontext, in which it should be achieved. The clinicalcontext and workflow should be first specified andthen the information from different parts of the serviceprocess should be defined in order to be used andunderstood by other participants. It is a prerequisiteto ensure understandable service components,harmonized procedures, to avoid misinterpretations,to ensure reliability of all stakeholders, includingpatients. They should agree knowledge that requiresharmonization of technical means, including supportsystems for health information and communication.Recent automatic linguistic processing and intelligentsearch of information reveal a necessity for originalsemantic interoperability, i.e. to guarantee that everylanguage in the data set is unambiguous, having thesame meaning for each subsequent system user. Theright meaning must be perceived in a way so that itcould be formally described in order to be processedand transformed according to already specified rulesand finally to be understood by system users.

A need for standardisation

Standardisation is an integral part of EU policy toincrease the competitiveness of enterprises and toremove barriers to trade (14). European Committee forStandardization stresses that the health informationstandards are essential for achieving objectives of EHin Europe. The Committee recommends developing aplatform for interoperability in order to make a pan-European overview of the requirements for EH, itsstandardization and implementation in cooperationwith the standardization organizations on the basisinformation from the main stakeholders.

Systems and solutions should be properly designedin compliance with specific architecture requirements,which is especially important for electronic healthrecord systems in order to ensure a semanticinteroperabili ty. Semantic and technicalinteroperabilities could be supported by standardizingtechnical interface, protocols, reports and documents,business processes, clinical procedures andpathways. Therefore it is recommended to useappropriate standards for equipment, records, reports,documents, processes, architecture, design andmodeling as well as standards for infrastructure andinfrastructure services focused on safety, security andconfidentiality.



Åëåêòðîííî äîñèå íà ïàöèåíòà

Ðåøàâàíåòî íà íàñòîÿùè è áúäåùè ïðîáëåìè íàåâðîïåéñêèòå çäðàâíè ñèñòåìè å âúçìîæíî, ïîíå ÷àñòè÷íî,÷ðåç ïðèëàãàíåòî íà èçïèòàíè ðåøåíèÿ âúç îñíîâà íà ÈÊÒ(ò.å. ÷ðåç åëåêòðîííîòî çäðàâåîïàçâàíå). Îñíîâíàïðåäïîñòàâêà çà èçâëè÷àíå íà ïîëçà îò ÅÇ å ïîäîáðåíàòàîïåðàòèâíàòà ñúâìåñòèìîñò ìåæäó ñèñòåìèòå èïðèëîæåíèÿòà çà ÅÇ. Ñèñòåìèòå çà åëåêòðîííè çäðàâíèäîñèåòà ïðåäñòàâëÿâàò îñíîâíà ÷àñò íà ñèñòåìèòå çà ÅÇ.Ñúâìåñòèìîñòòà íà ñèñòåìèòå çà åëåêòðîííè çäðàâíè äîñèåòàíà òåõíè÷åñêî íèâî å íàé-âàæíàòà ïðåäïîñòàâêà çàîïåðàòèâíî ñúâìåñòèìè ñèñòåìè çà åëåêòðîííè çäðàâíèäîñèåòà. (16)

Ðàçðàáîòåíè ñà òðè âèäà ñöåíàðèè çà èçïîëçâàíå íàåëåêòðîííî çäðàâíî äîñèå íà ïàöèåíòà (åëåêòðîíåí çäðàâåíçàïèñ - ÅÍR). Òå èíòåðïðåòèðàò:

åäèíè÷åí îñòúð ñëó÷àé (íåïðîãíîçèðàí äîñòúï äîêëèíè÷íà èíôîðìàöèÿ);

òàêà íàðå÷åíèÿ “íîðìàëåí” ñëó÷àé íà ïàöèåíò (adhoc âçàèìîäåéñòâèÿ ìåæäó ïðîôåñèîíàëèñòè) è

õðîíè÷åí ñëó÷àé (ñïîäåëÿíå íà èíôîðìàöèÿ ïîïðåäâàðèòåëíî îïðåäåëåí äîãîâîðåí ïëàí).

Âñåêè ñöåíàðèé ïðåäâèæäà ïðåäàâàíå íà èíôîðìàöèÿìåæäó ðàçëè÷íè ïàðòíüîðè â ñèñòåìàòà íà çäðàâåîïàçâàíåòîçà îñèãóðÿâàíå íà ïðàâèëíî ïîñëåäâàùî ëå÷åíèå è çàïîäîáðÿâàíå íà óïðàâëåíèåòî.

Òåçè ñöåíàðèè íå ñà ðàçðàáîòåíè çà îïðåäåëÿíå íàèíôîðìàöèÿòà çà ñàìîòî äîñèå íà ïàöèåíòà, à çà ðàçêðèâàíåè èçñëåäâàíå íà äðóãè óñëîâèÿ è èçèñêâàíèÿ, êîèòî òðÿáâàäà ñå óäîâëåòâîðÿò ïðè èçïîëçâàíå íà äîñèåòî. Äåôèíèðàíèñà ïåò îñíîâíè èçèñêâàíèÿ:

1. Èäåíòèôèöèðàíå íà àêòüîðèòå è îðãàíèçàöèèòå âúââñè÷êè ñòðàíè-÷ëåíêè, íà îñíîâàòà íà îáùîïðèåòàþðèäè÷åñêà ðàìêà. Èíèöèàòèâàòà âêëþ÷âà ò. íàð.ìåòàäàííè - àâòîðúò íà äàäåí äîêóìåíò, âðúçêàòà ñíåãî, äàòàòà íà ñúçäàâàíå íà äîêóìåíòà, äàííè îòïðîòîêîëà çà âðúçêà, êîé èìà äîñòúï è êîé å ïîëó÷èëäîñòúï äî ñúäúðæàíèåòî è äð.

2. Áàçà äàííè çà ñïåøíè ñëó÷àè.

3. Èíôðàñòðóêòóðà. Ïðåäàâàíåòî íà äîñèåòî èçâúíãðàíèöèòå íà çäðàâíàòà èíñòèòóöèÿ ñúùî èçèñêâàèíòåðîïåðàáèëíîñò íà èíôðàñòðóêòóðàòà íàèíôîðìàöèîííàòà è êîìóíèêàöèîííàòà òåõíîëîãèÿ âñòðàíèòå-÷ëåíêè.

4 Ïðàâî íà äîñòúï (àâòîðèçàöèÿ) - äàííèòå òðÿáâà äàáúäàò äîáðå óïðàâëÿâàíè. Îòãîâîðíîñòòà çà äàâàíå íàäîñòúï äî äàííèòå íà ïàöèåíòà å íàñî÷åíà êúì òîçèèíäèâèä èëè èíñòèòóöèÿ, êîÿòî ìîæå äà ãàðàíòèðàñèãóðíî ñúõðàíåíèå è äîñòúï äîèäåíòèôèêàöèîííèòå äàííè.

5. Óñòîé÷èâîñò íà ôèíàíñîâèÿ ìîäåë. ×åñòîîðãàíèçàöèÿòà, êîÿòî òðÿáâà äà èíâåñòèðà â ÅÇ, íå å

Electronic patient record

It is possible to address, at least partly, current andfuture problems of European health systems byapplying reliable ICT-based solutions (i.e. through e-health). The main prerequisite for taking advantage ofEH is the improved operative compatibility betweensystems and applications for EH. Electronic healthrecord systems are an essential part of EH systems.Compatibility of electronic health record systems atthe technical level is the essential prerequisite forinteroperable electronic health records. (16)

Three types of scenarios for the use of electronicmedical patient record (electronic health record - ENR)have been developed. They deal with:

A single acute case (unexpected access toclinical information)

So-called “normal” case (ad hoc interactionsbetween professionals) and

Chronic case (sharing information on the basis apreviously agreed plan).

Each scenario foresees the transmission of informationbetween different partners in the healthcare system toensure proper follow-up treatment and improvedmanagement.

These scenarios were not developed for identifyinginformation for patient record, but for identifying andinvestigating other conditions and requirements to bemet when using the record. Five basic requirementshave been set:

1. Identification of stakeholders and organizationsin all Member States on the basis of generallyaccepted legal framework. The initiative includesthe so-called metadata: author of a document,contact information, issue date of the document,data from the communications protocol, who hasaccess to it and who has been given access tothe content and others.

2. Database of emergency cases.

3. Infrastructure. The transmission of the fileoutside the health institution also requiresinteroperability of ICT infrastructure in MemberStates.

4. Right of access (authorization) - data should beproperly managed. The responsibility forproviding access to patient data should beassigned to an individual or institution that canensure reliable storage and access toidentification data.

5. Sustainability of financial model. Often, theorganization, which should invest in the EH, isdifferent from that to benefit from investment.This sometimes delays introduction of ED



ñúùàòà, êîÿòî ùå èìà ïîëçà îò èíâåñòèöèèòå. Òîâàïîíÿêîãà çàáàâÿ âúâåæäàíåòî íà ðåøåíèÿ ïî ÅÇ.Âúïðåêè ÷å ïèëîòíèòå ïðîåêòè ÷åñòî ïîêàçâàòïîëçè, íÿìà óñòîé÷èâ ôèíàíñîâ ìîäåë çàèíòåðîïåðàáèëíîñò íà ÅÇ, îñâåí, àêî íå ñå âúâåäàòíîâè ìîäåëè çà ôèíàíñèðàíå, òàêèâà êàòîïóáëè÷íî-÷àñòíî ïàðòíüîðñòâî.

Íåîáõîäèìîñò îò ñåðòèôèöèðàíå

Èíòåðîïåðàáèëíîñòòà íà ÅÇ èçèñêâà îáù ïðîöåñ íà àíàëèç,ñïåöèôèêàöèÿ, ïðèëîæåíèå è ðàçïðîñòðàíåíèå íàêîíöåïòóàëíè ìîäåëè, îáùè êîíöåïöèè, ðàìêîâààðõèòåêòóðà è íåéíèòå ïðèîðèòèçèðàíè ðåøåíèÿ è çàèíôðàñòðóêòóðíè åëåìåíòè è óñëóãè. Ïðîöåñúò çàïðèëîæåíèå, îöåíêà è åòèêåòèðàíå íà ñúâìåñòèìîñòòà ñ òåçèèçèñêâàíèÿ, èçâúðøâàí îò îòîðèçèðàí îðãàí, ñå íàðè÷àñåðòèôèöèðàíå. Ñåðòèôèêàöèîííèòå óñëóãè ìîãàò äà áúäàòïðèëîæåíè ïî öåíòðàëèçèðàí - èëè îùå ïî-äîáðå - ïîéåðàðõè÷íî äåöåíòðàëèçèðàí íà÷èí.

Óòâúðæäàâàíåòî íà ïðåäïîëàãàåìà ñúâìåñòèìîñò ñúñ çàêîíòðÿáâà èëè äà áúäå âåðèôèöèðàíà îò íåçàâèñèìà òðåòàñòðàíà, èëè äà ñå óñòàíîâÿò ÿñíè ïðàâèëà, ïðè êîèòî ìîæåäà ñå ïðåäïðèåìå ñàìîñåðòèôèêàöèÿ.

Èìà ìíîãî ìàëúê îïèò ñúñ ñåðòèôèöèðàíå íà âèñîêè(ñåìàíòè÷íè) íèâà â îáëàñòòà íà ÅÇ. Ïðàêòè÷åñêè îïèò(íàïðèìåð ñ DICOM (15) èëè ñ Èíòåãðèðàíå íà çàâåäåíèÿòàçà çäðàâíè ãðèæè) ïîêàçâà, ÷å ïðåòåíöèèòå çà ñúâìåñòèìîñòîò èíäóñòðèÿòà, çàåäíî ñ äîáðîâîëíè ñåñèè çà òåñòâàíå èèíñòðóìåíòè çà òåñòâàíå â îáùåñòâåíèÿ äîìåéí, ñà ìíîãîåôåêòèâíè è åôèêàñíè.

3. Ñúñòîÿíèå íà ïðîáëåìà â Ðåïóáëèêà Áúëãàðèÿ

Âíåäðÿâàíåòî íà åëåêòðîííîòî çäðàâåîïàçâàíå å âàæåíêîìïîíåíò íà èíôîðìàöèîííîòî îáùåñòâî è å èçâåäåí êàòîåäèí îò îñíîâíèòå ïðèîðèòåòè â åâðîïåéñêèòå ïëàíîâå çàðàçâèòèå â èçïúëíåíèå íà Ëèñàáîíñêàòà ñòðàòåãèÿ.Ïîñëåäíàòà îòäåëÿ çíà÷èòåëíî ìÿñòî íà âúâåæäàíåòî íàåëåêòðîííè çäðàâíè êàðòè è åäèííà èíôîðìàöèîííàñèñòåìà, êàòî íåäåëèìà ÷àñò îò ñúâðåìåííîòî ìîäåðíîçäðàâåîïàçâàíå. Ïî ïúòÿ êúì ïðèîáùàâàíåòî íè êúì Åâðîïàè â îòãîâîð íà ïðåäèçâèêàòåëñòâàòà íà ãëîáàëèçàöèÿòà,âúïðîñèòå íà åëåêòðîííîòî çäðàâåîïàçâàíå çàåìàò âîäåùîìÿñòî â ïðèîðèòåòèòå íà áúëãàðñêîòî ïðàâèòåëñòâî. Ïðåçïîñëåäíèòå 10 ãîäèíè ñå íàáëþäàâà ïîñòîÿíåí ïðîöåñ íàðàçøèðÿâàíå èçïîëçâàíåòî íà ÈÊÒ â ñèñòåìàòà íàçäðàâåîïàçâàíåòî ó íàñ.

Ïðåç ïåðèîäà 2004-2011 ã. ñå íàáëþäàâà çíà÷èòåëíî ðàçâèòèåíà îñíîâíèòå åëåìåíòè íà ÅÇ. Ïî íÿêîè îò îñíîâíèòåïîêàçàòåëè, ñâúðçàíè ñ èçïîëçâàíåòî íà Èíòåðíåò èåëåêòðîííèòå òåõíîëîãèè çà îò÷èòàíå íà ìåäèöèíñêèòåäåéíîñòè êúì 2010 ãîäèíà, Áúëãàðèÿ äîáëèæàâà ìíîãî îòñòðàíèòå â Åâðîïåéñêèÿ ñúþç. Ìíîãî îò ëå÷åáíèòå çàâåäåíèÿçà áîëíè÷íà ïîìîù ðàçïîëàãàò ñ áîëíè÷íè ÈÑ.

decisions. Although pilot projects often showbenefits, there is not sustainable financial modelfor the interoperability of EH, unless new modelsfor funding such as public-private partnershipare introduced.

A need for certification

Interoperability of EH requires a common process ofanalysis, specification, implementation and disseminationof conceptual models, common concepts, frameworkarchitecture, its prioritized solutions for infrastructureelements and services. Certification means the processof meeting, evaluating and labeling the compliance withthese requirements, performed by an authorized body.Certification services can be provided in a centralized -or even better - a hierarchical decentralized way.

Confirmation of presumed compliance with the lawshould be either be verified by an independent thirdparty or clear rules for self-certification should beestablished.

There is a very limited experience in certifying high(semantic) levels in the field of EH. Practice (related,for instance, to DICOM (15) or to the integration ofhealth care establishments) shows claims forcompatibility from industry as well as voluntary testingsessions and testing tools in the public domain to bevery effective and efficient.

3. The situation in the Republic of Bulgaria

Implementation of e-health is an important componentof information society, being one of the main prioritiesof European development plans to achieve Lisbonstrategy targets. Lisbon strategy pays a great attentionto the introduction of electronic health records andintegrated information system as an integral part ofmodern health care system. On the way of integratingBulgaria in Europe and facing globalization challenges,issues of e-Health range among the first priorities ofBulgarian government. Over the past 10 years therehas been an ongoing process of expanding the use ofICT in the healthcare system in our country.

During 2004-2011 took place a significant developmentof the main elements of EH. Bulgaria is close to manlyMember States when it comes to some of the basicindicators for the use of Internet and e-technologiesfor reporting of medical activities by 2010. A lot ofhospitals have their own IS. Telemedicine applicationsare gradually becoming common tools for providinghealth care. (17). By 2011, broadband, high speedInternet is available almost everywhere in Bulgaria.According to the Ministry of Health (18), by the endof 2010 100% of GPs, physicians providing specializedoutpatient care, medical diagnostic laboratories,



Òåëåìåäèöèíñêèòå ïðèëîæåíèÿ ïîñòåïåííî ñå ïðåâðúùàòâ îáè÷àéíè èíñòðóìåíòè çà ïðåäîñòàâÿíå íà ìåäèöèíñêèãðèæè. (17). Êúì 2011 ãîäèíà ãîëÿìà ÷àñò îò òåðèòîðèÿòà íàñòðàíàòà å ïîêðèòà ñ øèðîêîëåíòîâ, âèñîêîñêîðîñòåíÈíòåðíåò. Ñïîðåä äàííè íà ÌÇ(18), êúì êðàÿ íà 2010ã. 100%îò ÎÏË, ëåêàðèòå - èçïúëíèòåëè íà ñïåöèàëèçèðàíàèçâúíáîëíè÷íà ïîìîù, ìåäèêîäèàãíîñòè÷íèòåëàáîðàòîðèè, àïòåêèòå è âñè÷êè ëå÷åáíè çàâåäåíèÿ çàáîëíè÷íà ïîìîù, êîèòî èìàò ñêëþ÷åíè äîãîâîðè ñ ÍÇÎÊ,ñå îò÷èòàò ïî åëåêòðîíåí ïúò ñ åëåêòðîííè îò÷åòíè ôàéëîâåâ îïðåäåëåí, (ïðåäåôèíèðàí) ôîðìàò. Âúâåäåíà åâúçìîæíîñò è çà îí-ëàéí îò÷èòàíå íà äåéíîñòòà íà ÎÏË èëåêàðèòå-ñïåöèàëèñòè, êàòî óñëóãàòà ñå èçïîëçâà îò 6% îòÎÏË. Íà ïðàêòèêà âñè÷êè èçïúëíèòåëè íà ìåäèöèíñêèóñëóãè, ðàáîòåùè ïî äîãîâîð ñ ÍÇÎÊ, ðàçïîëàãàò ñêîìïþòúðíè êîíôèãóðàöèè è ðàçëè÷íè ïî ñëîæíîñò ëîêàëíèÈÑ ñ áàçè äàííè è èìàò äîñòúï äî Èíòåðíåò. (18).

Âúïðåêè ìíîæåñòâîòî ðåàëèçèðàíè ïèëîòíè ïðîåêòè èïîñòèãíàòèÿ íàïðåäúê, Áúëãàðèÿ âñå îùå èçîñòàâà â ïðîöåñàíà èíòåãðèðàíî âúâåæäàíå íà ÈÊÒ â çäðàâåîïàçâàíåòî. Ñàìîìàëêà ÷àñò îò çäðàâíàòà èíôîðìàöèÿ íà ïàöèåíòà ñåñúõðàíÿâà â çäðàâíè äîñèåòà, à èíòåãðèðàíîòî çäðàâíîîáñëóæâàíå âñå îùå íå å ñòàíäàðò âúâ âñè÷êè ëå÷åáíèçàâåäåíèÿ. Òîâà âúçïðåïÿòñòâà îáìåíà íà çäðàâíàèíôîðìàöèÿ ïî åëåêòðîíåí ïúò, òàêà ÷å ïðè ñëåäâàù ïðåãëåäëåêàðÿò äà èìà íà ðàçïîëîæåíèå äàííèòå îò ïðåäõîäíè âèçèòè.Ëèïñàòà íà êîìóíèêàöèîííà ñðåäà çà èíòåãðèðàíî çäðàâíîîáñëóæâàíå è ñîôòóåðíè ïðîäóêòè, êîèòî äà îñèãóðÿâàòâðúçêà â ðåàëíî âðåìå ìåæäó èçïúëíèòåëèòå íà ìåäèöèíñêàïîìîù â öÿëîñòíà ñèñòåìà, èçèñêâàò ïîñëåäîâàòåëíèïîëèòèêè è ñòðàòåãèè çà âúâåæäàíå íà êîìïîíåíòèòå íà ÅÇíà íàöèîíàëíî íèâî. Ïðèåìàíåòî íà Íàöèîíàëíàòà ñòðàòåãèÿçà åëåêòðîííî çäðàâåîïàçâàíå ïðåç 2006 ãîäèíà å âàæíîïîëèòè÷åñêî ðåøåíèå çà âúâåæäàíå íà èíôîðìàöèîííèòå èêîìóíèêàöèîííèòå òåõíîëîãèè (ÈÊÒ) â çäðàâåîïàçâàíåòî íàíàöèîíàëíî íèâî. Ñòðàòåãèÿòà å îñíîâàíà íà àíàëèç íàáúëãàðñêèÿ è ñâåòîâåí îïèò ïðè âíåäðÿâàíå íà ÈÊÒ âçäðàâåîïàçâàíåòî, íà ñúñòîÿíèåòî íà çäðàâíàòà ñèñòåìà âÁúëãàðèÿ è îáùåñòâåíèòå ïîòðåáíîñòè îò ïîëçâàíå íàåëåêòðîííè óñëóãè â ñôåðàòà íà çäðàâåîïàçâàíåòî. ÂÑòðàòåãèÿòà ÅÇ ñå ðàçãëåæäà êàòî „ñúâêóïíîñò îò ïðèëîæåíèÿ,èçãðàäåíè íà áàçàòà íà ìîäåðíè èíôîðìàöèîííè èêîìóíèêàöèîííè òåõíîëîãèè, áàçèðàíè íà îðãàíèçàöèîííàè ïðàâíà ðàìêà, îáõâàùàùè öåëèÿ àñïåêò íà ôóíêöèîíèðàíåíà çäðàâåîïàçâàíåòî - îò ïîñòàâÿíåòî íà äèàãíîçàòà, äîìîìåíòà íà çàâúðøâàíå íà ëå÷åíèåòî è çàïëàùàíåòî çàíåãî”.(19) Àêöåíò ñå ïîñòàâÿ âúðõó êà÷åñòâîòî íàïðåäîñòàâÿíèòå óñëóãè, êîåòî å íåâúçìîæíî áåç ïðàâèëíîóïðàâëåíèå íà èíôîðìàöèÿòà è èíôîðìàöèîííèòå ïîòîöè.

Åâîëþöèÿòà íà ïîëèòèêèòå çà „åëåêòðîíèçàöèÿ” íà ïðîöåñèòåâ çäðàâåîïàçâàíåòî íåìèíóåìî ùå äîâåäå äî ñíèæàâàíå íàðàçõîäèòå çà çäðàâåîïàçâàíåòî ÷ðåç ïîäîáðÿâàíå íàïëàíèðàíåòî, îò÷åòíîñòòà è êîíòðîëà ïðè çàïëàùàíå íàèçâúðøåíèòå è îò÷åòåíè ìåäèöèíñêè äåéíîñòè, êàêòî èïîâèøàâàíå êà÷åñòâîòî è áåçîïàñíîñòòà íà óñëóãèòå, ÷ðåçóâåëè÷àâàíå íà ìåäèöèíñêàòà è çäðàâíàòà èíôîðìàöèÿ, ñêîÿòî ðàçïîëàãàò ñïåöèàëèñòèòå è ïàöèåíòèòå.

pharmacies and all hospital care establishments, thathave contracts with the NHIF, give account by sendingelectronic reporting files with a specified (predefined)format. There is a possibility for on-line reporting ofactivities, performed by GPs and physicians withspecialty, the service being used by 6% of GPs. In factcomputer configurations, various complex local IS withdatabases and Internet access are available to allhealth care providers, working under contract with theNHIF (18).

Despite many pilot projects and progress, Bulgaria isstill behind integrated introduction of ICT in healthsystem as only a small part of the patient healthinformation is stored in health records, while integratedhealth care provision is still not a standard in all medicalestablishments. This impedes electronic exchange ofhealth information that makes available to thephysician data from previous visits. The lack ofcommunication media for integrated health servicesand software, which provide a real time connectionbetween medical care providers in the overall system,requires consistent policies and strategies forintroducing EH components at national level. Theadoption of the National Strategy for e-Health in 2006was an important political decision for introducinginformation and communication technology in thenational health system. The strategy is based on theanalysis of Bulgarian and world experience inimplementing ICT in health system, the state ofBulgarian healthcare system and social needs for usinge-health services. The strategy defines EH as “a set ofapplications, based on modern information andcommunication technologies and organizational andlegal framework, which cover all functional aspects ofthe health system - from the diagnosis to the end ofthe treatment and payment for it” (19). It emphasizeson the quality of services provided, which is could beensured only through sound management ofinformation and information flows.

The evolution of policies for “computerization” ofhealth care processes will inevitably lead to lowerhealth care costs through better planning, reportingand monitoring of payments of performed and reportedmedical activities as well as through higher qualityand safety of services by increasing the amount ofmedical and health information available toprofessionals and patients, respectively.




1. Eysenbach G. What is e-health? J Med Internet Res 2001 Jun18;3(2):e20 http://www.imir.org/2001/2/e20/

2. Oh, , Hans, C. Rizo, M. Enkin, A. Jadad, - (J Med Internet Res,2005 Jan-Mar; 7 (1): e1

3. Marcus E, Fabius R. What is E-health? http://www.acpenet.org/Forums/Topical/Ehealth/Primer.htm

4. Comyn, G. - Connected Health: Quallity and Safety for EuropeanCitizens. Report of the Unit ICT for health in collaboration with thei2010 sub-group on eHealth and the eHealth stakeholders’ group,2006, 34 p.

5. Wennberg, et al. Geography and the Debate over Medicare Reform,Health Affairs, 02/13/02. W96-W14;

6. COM(2004) 356(final)& e-Health - making healthcare better forEuropean citizen: An action plan for a European e-health area.

7. Ioannis Kotsiopoulos Diane Whitehouse, Assessing the progressof the eHealth Action Plan for the period 2004 - 2010, August 2011

8. Institute of Medicine (IOM) Report (2000). To err is human:Building a safer health system. http://books.nap.edu/books/0309068371/html/index.html

9. Casalino et al. External Incentives, Information Technology, andOrganized Processes to Improve Health Care Quality for PatientsWith Chronic Diseases -JAMA 2003;289:434-441.

10. Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, andGary Fanjiang, Editors (2005) Building a Better Delivery System: ANew Engineering/Health Care Partnership. Committee onEngineering and the Health Care System, National AcademiesPress, 276 p. http://www.nap.edu/catalog/11378.html

11. IOM Report (2006). Preventing Medical Errors. Report available athttp://www.iom.edu/Object.File/Master/35/943/medication%20errors%20new.pdf


Ä-ð Âàëåðè Öåêîâ - Óïðàâèòåë íà „Áúëãàðñêî ñäðóæåíèå ïîèíîâàòèâíà ìåäèöèíà” ,ãë.àñèñòåíò â ÌÓ Ïëîâäèâ - ²² êàòåäðà ïî âúòðåøíèáîëåñòè


12. National Audit Office (NAO) (2005) A Safer Place for Patients:Learning to improve patient safety, November 3, 2005,Department of Health, 86 p., http://www.nao.org.uk/publications/nao reports/05-06/0506456.pdf , p.1

13. Jan Walker, Eric Pan, Douglas Johnston, Julia Adler-Milstein,David W. Bates, and Blackford Middleton, The value of HealthCare Information Exchange and Interoperability., Health Affairsno. (2005):January 19, 2005 http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.10v1

14. COM(2004) 674 final - Communication on the Role ofEuropean standardization in the Framework of Europeanpolicies and legislation.

15. DICOM stands for the Digital Imaging and Communications inMedicine (DICOM) standard - http://medical.nema.org/.

16. EC, 2008 Commission Recommendation of 2 July 2008 oncross-border interoperability of electronic health recordsystems (notified under document number C(2008) 3282)

17. Ãåí÷î Íà÷åâ, Òåëåìåäèöèíà â ñïåøíàòà ïîìîù., 5òàÍàöèîíàëíà êîíôåðåíöèÿ „å- Çäðàâåîïàçâàíå - îòèíâåñòèöèÿòà äî êà÷åñòâåíàòà ïðîìÿíà”, 17 ôåâðóàðè,2010 ã., õîòåë Øåðàòîí, Ñîôèÿ. http://www.ehealth-bg.org/images/EH Presentation St Ekaterina.pps ;

18. Áëàãîé Ìèðîâ, Íàñîêè çà ðàçâèòèå íà çäðàâíî-èíôîðìàöèîííà ìðåæà â Áúëãàðèÿ., 6-òà ðåãèîíàëíàêîíôåðåíöèÿ „Å-çäðàâåîïàçâàíå - åâðîïðîåêòè èèíôîðìàöèîííè ñèñòåìè çà åôåêòèâíà çäðàâíà ãðèæà” (10ôåâðóàðè, 2011 ã., õîòåë Øåðàòîí, Ñîôèÿ) http://www.ehealth-bg.org/images/Blagoy%20Mirov-MH.pdf ;

19. ÑÒÐÀÒÅÃÈß ÇÀ ÂÍÅÄÐßÂÀÍÅ ÍÀ ÅËÅÊÒÐÎÍÍÎÇÄÐÀÂÅÎÏÀÇÂÀÍÅ Â ÁÚËÃÀÐÈß http://www.mh.government.bg/Articles.aspx?lang=bg-BG&pageid=419


Valeri Tzekov, MD – Senior Manager of the BulgarianAssociation of Innovative MedicineChief Assistant, Medical University – PlovdivSecond Department of Internal Diseases




ÑÚÂÐÅÌÅÍÍÎ ÑÚÑÒÎßÍÈÅ ÍÀÍÅÊÎÍÂÅÍÖÈÎÍÀËÍÈÒÅ ÌÅÒÎÄÈ ÂÌÅÄÈÖÈÍÀÒÀ Ó ÍÀÑ

Èëèÿíà ßíåâà-ÁàëàáàíñêàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè

Ðåçþìå

Â ñòàòèÿòà ñå ïðàâè ïðåãëåä, âúç îñíîâà íà ñúùåñòâóâàùàèíôîðìàöèÿ â ðåãèîíàëíèòå öåíòðîâå ïî çäðàâåîïàçâàíå– ÐÖÇ (ñåãà Ðåãèîíàëíè çäðàâíè èíñïåêöèè - ÐÇÈ), íàçàêîííî ïðåäëàãàíèòå ó íàñ íåêîíâåíöèîíàëíè óñëóãè âñèñòåìàòà íà çäðàâåîïàçâàíåòî, êàêòî è íà ÷îâåøêèòåðåñóðñè â îáëàñòòà íà „íåêîíâåíöèîíàëíîòî”çäðàâåîïàçâàíå, êàòî àêöåíò å ïîñòàâåí âúðõóñúùåñòâóâàùèòå ïðîáëåìè. Âúïðåêè ÷å çà ïåðèîäà 2008-2010 ã. ñå íàáëþäàâà òåíäåíöèÿ çà íàðàñòâàíå íà áðîÿ íàðåãèñòðèðàíèòå â ÐÇÈ ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè çà áëàãîïðèÿòíî âúçäåéñòâèåâúðõó èíäèâèäóàëíîòî çäðàâå (ÍÌ), êúì 15.05.2010 ã. òåñà èçêëþ÷èòåëíî íåäîñòàòú÷íî – 166 ëèöà. Îò òÿõ 98 ñàìàãèñòðè ïî ïðîôåñèîíàëíî íàïðàâëåíèå „Ìåäèöèíà” èëè„Äåíòàëíà ìåäèöèíà” è 68 ñà ëèöà ñ äðóãà ñïåöèàëíîñòîò ñèñòåìàòà íà çäðàâåîïàçâàíåòî. Íåäîñòàòú÷íî åîñèãóðÿâàíåòî íà ãðàæäàíèòå è ïî îáëàñòè â ñòðàíàòàñúñ çàêîííè äîñòàâ÷èöè íà íåêîíâåíöèîíàëíè çäðàâíèóñëóãè. Êúì 15.05.2010 ã., â 9 ðåãèîíàëíè öåíòðîâå ïîçäðàâåîïàçâàíå â ñòðàíàòà (ïî÷òè 1/3 îò îáàñòèòå âÐÁúëãàðèÿ) íå ñà ñå ðåãèñòðèðàëè ëèöà çà óïðàæíÿâàíåíà ÍÌ, êàòî â öåëèÿ Þãîçàïàäåí ðàéîí íå å îñúùåñòâåíàíèòî åäíà ðåãèñòðàöèÿ íà ëèöå, óïðàæíÿâàùîíåêîíâåíöèîíàëíè ìåòîäè. Íàé-äîáðî å îñèãóðÿâàíåòî íàíàñåëåíèåòî â ñòðàíàòà ñ äîñòàâ÷èöè íà õîìåîïàòè÷íèÿìåòîä (êúì 31.12.08 ã. - 1666 ìàãèñòðè ïî „Ìåäèöèíà” è„Äåíòàëíà ìåäèöèíà” ñà ïðåìèíàëè îáó÷åíèå ïîõîìåîïàòèÿ), êîèòî çà óïðàæíÿâàíå íà ìåòîäà íå ñàçàäúëæåíè äà ñå ðåãèñòðèðàò â ÐÖÇ. Âîäåùî ìÿñòî ïîáðîé ðåãèñòðèðàíè ëèöà, â ÐÖÇ-òà çà óïðàæíÿâàíå íàÍÌ, çàåìàò ìåòîäèòå „íåêîíâåíöèîíàëíè ôèçèêàëíèìåòîäè”, „àêóïóíêòóðà è àêóïðåñóðà” è „èçïîëçâàíå íàíåëåêàðñòâåíè ïðîäóêòè îò îðãàíè÷åí ïðîèçõîä”. Áðîÿòíà ìàãèñòðèòå ïî „Ìåäèöèíà” è „Äåíòàëíà ìåäèöèíà”,ðåãèñòðèðàíè â ÐÖÇ-òà çà óïðàæíÿâàíå íà ÍÌ, ñèçêëþ÷åíèå íà ìåòîäà „íåêîíâåíöèîíàëíè ôèçèêàëíèìåòîäè,” ïðåîáëàäàâà íàä áðîÿ íà îñòàíàëèòåìåäèöèíñêè ñïåöèàëèñòè. Ïðåç 2008ã. â 3 ÐÖÇ â ñòðàíàòàñà ðåãèñòðèðàíè 4 ëèöà çà óïðàæíÿâàíå íà íåðàçðåøåíèçà ïðèëàãàíå ó íàñ ÍÌ. Ó íàñ íå å ïðåäâèäåíî çàäúëæèòåëíîîáó÷åíèå ïî ïðèëàãàíåòî íà îòäåëíèòå ÍÌ. Â íàñòîÿùèÿåòàï ëèöàòà áåç ìåäèöèíñêî îáðàçîâàíèå, ò.í. „ëå÷èòåëè”,íÿìàò ïðàâî äà óïðàæíÿâàò ÍÌ ó íàñ. Òå ãè óïðàæíÿâàòíà òîçè åòàï íåçàêîííî, êàòî áðîÿò íà ãðàæäàíèòå,

NON-CONVENTIONAL MEDICINE INBULGARIA: CURRENT STATUS

Iliana Yaneva-BalabanskaNational Center of Public Health and Analyses

Abstract

The aim of the current article is to make an overview, basedon the existing information in regional health centers(RHCs), on both of non-conventional services legally pro-posed within healthcare system and of human resourceswithin the field of non-conventional healthcare as a majoremphasis is placed on the existing problems. Despite thatover the period of 2008-2010 there was a tendency forgrowth in the number of practitioners registered in RHCfor practicing non-conventional medicine methods thathave a reasonable effect on human health, their numberby 15th September 2010 was extremely insufficient – 166practitioners, of them 98 are Master’s in Medicine or Den-tal Medicine, while 68 are practitioners gaining otherspeciality within the healthcare system. The delivery ofnon-conventional services by legal providers to citizensin the country still remains insufficient. By 15 May, 2010in 9 RHCs within the country (approximately one third ofthe regions in Bulgaria) no practitioners were registeredfor practicing non-conventional medicine, at the same timein the whole southwest region no registration of individu-als practicing non-conventional methods was done. Thebest provision to the population in the country with pro-viders of the homeopathic method (by the end of December2008 1666 masters in Medicine and Dental Medicine ac-quired training in homeopathy), who are not obliged tobe registered in RHC for method practicing. A leadingplace according to the number of registered practitionersin RHC for using non-conventional medicine occupy meth-ods like “non-conventional physical methods”, “acupunc-ture and acupressure” and “using non-medicinal prod-ucts of organic origin”. The number of masters in Medi-cine and in Dental medicine, which is registered in RHCfor non-conventional practice, with the exception of “non-conventional physical methods”, prevails above the num-ber of other medical specialists. In 2008 in 3 RHCs 4 indi-viduals were registered for practicing of non-conventionalmedicine methods that are not allowed to be applied inour country. In Bulgaria it is not foreseen the compulsorytraining on the application of different non-conventionalmethods. At the present moment practitioners without medi-cal education, so-called “healers” do not have the rightto practice non-conventional treatments that is why theyhave practiced them illegally as the number of citizenswho make an appointment and go to their practices is



êîèòî ãè ïîñåùàâàò, å çíà÷èòåëåí. Ëèïñâàò äàííè çàðàçõîäèòå, íàïðàâåíè îò íàñåëåíèåòî çà„íåêîíâåíöèîíàëíî” çäðàâåîïàçâàíå. Çà äà îòãîâîðè íàïîòðåáíîñòèòå íà áúëãàðñêîòî íàñåëåíèå îòîñèãóðÿâàíåòî ìó ñ íåêîíâåíöèîíàëíè óñëóãè, êàñàåùèçäðàâåòî è çà äà ñå ãàðàíòèðà íà ãðàæäàíèòå ñèãóðíîñòè áåçîïàñíîñò ïðè ïîëçâàíåòî íà òåçè óñëóãè, å íåîáõîäèìîçàêîíîäàòåëÿò äà ïðåäïðèåìå äåéñòâèÿ ïî èçìåíåíèå èäîïúëíåíèå íà çàêîíîäàòåëíàòà óðåäáà çà ïðèëàãàíåòîíà íåêîíâåíöèîíàëíèòå ìåòîäè ó íàñ.

Êëþ÷îâè äóìè: íåêîíâåíöèîíàëíè ìåòîäè,áúëãàðñêî çäðàâåîïàçâàíå, ÐÖÇ

1. Âúâåäåíèå

Øèðîêîòî èçïîëçâàíå íà íåêîíâåíöèîíàëíèòå ìåòîäè âìåäèöèíàòà ó íàñ è â äðóãè ñòðàíè âñå ïîâå÷å ïðèâëè÷à êúìñåáå ñè âíèìàíèåòî íà ãîñïîäñòâàùèòå ñèñòåìè íàçäðàâåîïàçâàíå.

Ñïîðåä áúëãàðñêîòî çàêîíîäàòåëñòâî êðèòåðèèòå çàîïðåäåëÿíå íà “íåêîíâåíöèîíàëíè ìåòîäè çà áëàãîïðèÿòíîâúçäåéñòâèå âúðõó èíäèâèäóàëíîòî çäðàâå” (ÍÌ) ñà äâà -íåâêëþ÷âàíå íà èçó÷àâàíåòî èì â ó÷åáíèòå ïðîãðàìè íàâèñøèòå ìåäèöèíñêè ó÷èëèùà è - ïðèëàãàíåòî èì ñ öåëáëàãîïðèÿòíî äà ïîâëèÿâàò çäðàâåòî (1). Òåçè ìåòîäè âðàçëè÷íèòå ñòðàíè ñà îïðåäåëåíè êàòî àëòåðíàòèâíè,êîìïëåìåíòàðíè, íàðîäíè, òðàäèöèîííî-íàðîäíè è äð. (2).Çà îçíà÷àâàíåòî èì ÑÇÎ âúçïðèåìà òåðìèíèòå ÑÀÌ/ÒÌ(êîìïëåìåíòàðíà è àëòåðíàòèâíà ìåäèöèíà/òðàäèöèîííàìåäèöèíà), (3). Âñúùíîñò èçáðîåíèòå ïîíÿòèÿ ñå ÿâÿâàòñèíîíèìè íà åäíî è ñúùî ÿâëåíèå – ìåäèöèíñêè äåéíîñòè,êîèòî ñà èëè íå ñà ÷àñò îò òðàäèöèèòå íà ñàìàòà ñòðàíà,íàïúëíî, ÷àñòè÷íî èëè íå ñà èíòåãðèðàíè âãîñïîäñòâàùàòà çäðàâíà ñèñòåìà, â ïîâå÷åòî ñëó÷àèèçó÷àâàíåòî èì íå å âêëþ÷åíî â çàäúëæèòåëíèòå ó÷åáíèïðîãðàìè íà âèñøèòå ìåäèöèíñêè ó÷èëèùà.

Ðàçðåøåíèòå çà ïðèëàãàíå â ÐÁúëãàðèÿ îò 01.01.2005 ã.íåêîíâåíöèîíàëíè ìåòîäè çà áëàãîïðèÿòíî âúçäåéñòâèåâúðõó èíäèâèäóàëíîòî çäðàâå (ÍÌ) âêëþ÷âàò ñëåäíèòå 7ðàçäåëà (1, 4):

1. Èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îò îðãàíè÷åíïðîèçõîä (íàòóðàëíè, èçñóøåíè òåðìè÷íî è/èëèìåõàíè÷íî îáðàáîòåíè ðàñòåíèÿ, èçâëåöè îòðàñòåíèÿ; íàòóðàëíè, èçñóøåíè, òåðìè÷íî è/èëèìåõàíè÷íî îáðàáîòåíè æèâîòèíñêè îðãàíè, òúêàíè,òåëåñíè òå÷íîñòè, êîíêðåìåíòè è åêñêðåìåíòè èèçâëåöè îò òÿõ; ñèíòåòè÷íè èëè ïîëóñèíòåòè÷íèîðãàíè÷íè ïðîäóêòè);

2. Èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îòìèíåðàëåí ïðîèçõîä (õèìè÷íè âåùåñòâà, òåõíèñúåäèíåíèÿ, ðàçòâîðè èëè ñìåñè);

3. Èçïîëçâàíå íà íåòðàäèöèîííè ôèçèêàëíè ìåòîäè(íåêîíâåíöèîíàëíè êîíòàêòíè ìàñàæè íà òÿëîòî èëèíà íåãîâè ÷àñòè; òîïëèííè èçòî÷íèöè çà âúçäåéñòâèåâúðõó îòäåëíè ó÷àñòúöè îò êîæàòà; âåíäóçè; ìàãíèòíîïîëå, ñúçäàâàíî îò ïîñòîÿííè ìàãíèòè)

4. Õîìåîïàòèÿ;

significant. There are no data available for the costs madeby the population for this “non-conventional” healthcare.In order to respond to the needs of the Bulgarian popula-tion with regard to the provision with non-conventionalmethods influencing human health and to guarantee safetyand certainty to the citizens by providing them with theseservices it is necessary for the law-makers to undergoactions for the amending and supplementing of the legis-lative organization for the application of non-conven-tional methods in the country.

Key words: non-conventional treatments, Bulgarianhealthcare system, regional health centers

1. Introduction

The more wide-spread use of non-conventional medicinemethods in Bulgaria and in other countries the moreattracted attention to these treatments on behalf of theoverwhelming healthcare systems.

According to the Bulgarian legislation there have beendetermined two criteria for “the non-conventionaltreatments for favorable reasonable effect on the humanhealth”), namely: non-inclusion in the curricula of thehigher medical institutes and application of methods withregard to favorable influence on the human health (1).These methods in different countries were defined asalternative, complementary, folk, traditional-folk etc, (2).For the classification the WHO adopts the terms ÑÀÌ/ÒÌ (complementary and alternative medicine/traditionalmedicine) (3). In fact, the mentioned terms appear to besynonyms of one and the same event– medical activitiesthat are or are not a part of traditions of the countryherself, which are completely, partially or are not beingintegrated in the prevailing healthcare system, in mostcases their learning is not included in obligatory schoolcurricula of the higher medical institutions.

Non-conventional methods for favorable effect on thehuman health allowed to be used in the Republic ofBulgaria from 1st January 2005 encompass the following7 sections (1, 4):

1. Use of non-medicinal products from organicorigin (natural, thermally dried and/ormechanically processed animal organs, tissues,body fluids, concrements and excrements andextractions of them; synthetic or semi-syntheticorganic products);

2. Use of non-medicinal products from mineralorigin (chemical substances, their compounds,solutions or mixtures);

3. Use of non-traditional physical methods (non-conventional contact massages of the body orof its parts, thermal sources for influencing ondifferent parts of the skin, cupping glasses,magnetic field, created by permanent magnets);

4. Homeopathy;

5. Acupuncture and acupressure;



5. Àêóïóíêòóðà è àêóïðåñóðà;6. Èðèñîâè, ïóëñîâè è àóðèêóëàðíè ìåòîäè íà

èçñëåäâàíå;

7. Äèåòèêà è ëå÷åáíî ãëàäóâàíå.

Íà òîçè åòàï ó íàñ òåçè ìåòîäè, ñ èçêëþ÷åíèå íàõîìåîïàòè÷íèÿ ìåòîä, çàêîííî ñå ïðèëàãàò ñàìî îò ëèöà,ïðèòåæàâàùè îáðàçîâàòåëíî-êâàëèôèêàöèîííà ñòåïåí“Ìàãèñòúð” ïî ñïåöèàëíîñòèòå “Ìåäèöèíà”, “Äåíòàëíàìåäèöèíà” (ïî-íàòàòúê ùå ãè íàðè÷àìå „äîêòîðè”),„Ôàðìàöèÿ” èëè îáðàçîâàòåëíî êâàëèôèêàöèîííà ñòåïåí„Ñïåöèàëèñò” èëè „Áàêàëàâúð” ïî ñïåöèàëíîñò îòïðîôåñèîíàëíî íàïðàâëåíèå “Çäðàâíè ãðèæè” (ïî-íàòàòúê ùå ãè íàðè÷àìå „äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî”). Õîìåîïàòè÷íèÿò ìåòîä ìîæå äà ñåïðèëàãà ñàìî îò ìàãèñòðè ïî “Ìåäèöèíà” èëè “Äåíòàëíàìåäèöèíà”. Ëèöàòà ìîãàò äà óïðàæíÿâàò òåçè ìåòîäè ñëåäðåãèñòðèðàíå â ÐÖÇ ïî ìÿñòîòî íà óïðàæíÿâàíå.Õîìåîïàòè÷íè ïðîäóêòè ìîãàò äà ñå íàçíà÷àâàò ñàìî îòëèöà-ìàãèñòðè ïî “Ìåäèöèíà” èëè “Äåíòàëíà ìåäèöèíà”,ðàáîòåùè â ëå÷åáíî çàâåäåíèå, áåç äà ñå èçèñêâàçàäúëæèòåëíà ðåãèñòðàöèÿ â ÐÖÇ (4).

2. Èçëîæåíèå

Ïðîó÷åíè ñà ðåãèñòðèòå â èíòåðíåò ñòðàíèöèòå íà ÐÖÇ âñòðàíàòà ïî îòíîøåíèå íà çàêîííî ïðåäëàãàíèòå ó íàñíåêîíâåíöèîíàëíè óñëóãè â ñèñòåìàòà íà çäðàâåîïàçâàíåòî,êàêòî è íà ÷îâåøêèòå ðåñóðñè â îáëàñòòà íà„íåêîíâåíöèîíàëíîòî” çäðàâåîïàçâàíå (êîëè÷åñòâî èñòðóêòóðà íà ëèöàòà, ðåãèñòðèðàíè â ÐÖÇ çà óïðàæíÿâàíåíà ÍÌ êúì 15.09.2009 ã è êúì 15.05.2010 ã).

Çàêîííî ïðàêòèêóâàùèòå äîñòàâ÷èöè íàíåêîíâåíöèîíàëíè çäðàâíè óñëóãè â ñòðàíàòà êúì31.12.08ã. (5) ïî äàííè îò ðåãèñòðèòå íà ÐÖÇ, ñà 130 ëèöà,ðåãèñòðèðàíè â 17 ÐÖÇ, êàòî 31 îò òÿõ ñà ïîñî÷èëè, ÷åïðàêòèêóâàò õîìåîïàòè÷íèÿ ìåòîä.

Ðåãèñòðèðàíèòå â ÐÖÇ ëèöà ñå ðàçïðåäåëÿò ïî îáëàñòèêàêòî ñëåäâà: â ÐÖÇ Ïëîâäèâ – 25 ëèöà, Ñîôèÿ-ãðàä – 23,Âàðíà – 20, Áóðãàñ – 16, Ñòàðà Çàãîðà – 12, Äîáðè÷ –8,Ñìîëÿí-5, Øóìåí – 4, Ïëåâåí è Ñëèâåí– ïî 3, Âèäèí,Ãàáðîâî, Õàñêîâî, Âðàöà – ïî 2, Òúðãîâèùå, ÂåëèêîÒúðíîâî, Ëîâå÷ – ïî 1. Â 11 îò öåíòðîâåòå, êúì 31.12.08 ã.(Ïåðíèê, Ñîôèÿ-îáëàñò, Ðàçãðàä, Êþñòåíäèë, Ïàçàðäæèê,Ñèëèñòðà, ßìáîë, Ðóñå, Áëàãîåâãðàä, Ìîíòàíà,Êúðäæàëè), íÿìà ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàÍÌ.

Ïî äàííè íà îðãàíèçàöèè, êîèòî ïðîâåæäàò îáó÷åíèå óíàñ ïî ïðèëàãàíå íà õîìåîïàòè÷íèÿ ìåòîä, ìàãèñòðèòåïî ïðîôåñèîíàëíè íàïðàâëåíèÿ “Ìåäèöèíà “ è“Äåíòàëíà ìåäèöèíà”, ïðåìèíàëè îáó÷åíèå ïîõîìåîïàòèÿ êúì 31.12.08 ñà 1666 ëèöà.

Êúì 15.09.2009 ã. ëèöàòà, ðåãèñòðèðàíè â ÐÖÇ â ñòðàíàòàçà óïðàæíÿâàíå íà ÍÌ, ñà 152, êàòî îò òÿõ 65 ñà „äðóãèëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî”5, à 87 ñà ìàãèñòðèïî „Ìåäèöèíà” èëè „Äåíòàëíà ìåäèöèíà”, êîèòî çàêðàòêîñò ïî-íàòàòúê ùå íàðè÷àìå „äîêòîðè”. Â îñåì ÐÖÇâ ñòðàíàòà íÿìà ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàÍÌ – â îáëàñòèòå Ïåðíèê, Ñîôèÿ-îáëàñò, Ðàçãðàä,Êþñòåíäèë, Ïàçàðäæèê, Ñèëèñòðà, ßìáîë, Ðóñå (6-30).


6. Iris, pulse and auricular methods for examination;

7. Dietetics and fasting.

At this stage in Bulgaria these methods with the exceptionof homeopathic method are legally applied only bypractitioners acquiring educational-qualification degree“Master” in the specialties of Medicine and DentalMedicine (from now on they will be referred to as“doctors”), “Pharmacy” or educational-qualificationdegree of “specialist” or “bachelor” within theprofessional field “Health care” (from now on they willbe referred to as “other practitioners: within the healthcaresystem”). The homeopathic method can be applied onlyfrom masters in Medicine or Dental medicine. Theindividuals can practice these methods after registrationin the RHC at the place of the conduction of activitiessince only masters in Medicine and Dental Medicineworking in a medical establishment, without requiringobligatory registration in the RHC, could prescribehomeopathic products (4).

2. Presentation

The registries from the Internet websites of RHCsthroughout the country with regard to the legally proposednon-conventional services within the health system as wellas of human resources in the non-conventional healthcare(quantity and structure of registrants in RHCs for practicingnon-conventional medicine methods by September 15, 2009and by May 15, 2010) .

The legally practicing providers of non-conventionalservices in the country by the end of December 2008 (5)according to data of the RHCs registries, are 130 practitionersas of them 31 pointed out that had practiced the homeopathicmethod.

The practitioners registered in RHCs are distributed by regionsas follows: in the RHC of Plovdiv – 25 practitioners, Sofia-city –23, Varna – 20, Burgas – 16, Stara Zagora – 12, Dobrich –8,Smolyan - 5, Shumen – 4, Pleven and Sliven – by 3, Vidin, Gabrovo,Haskovo, Vratsa – by 2, Targovishte, Veliko Turnovo, Lovech– by 1. In 11 of the RHCs within the country by the end ofDecember 2008 (Pernik, Sofia-district, Razgrad, Kyustendil,Pazardzhik, Silistra, Yambol, Russe, Blagoevgrad, Montana,Kardzhali) there are no registered individuals for practicing non-conventional medicine.

Having in mind data of organizations, which conduct training inour country for applying the homeopathic method, the Mastersin Medicine and Dental medicine, who underwent a training inhomeopathy by 31 December 2008 are a total of 1666 practitioners.

By September 15, 2009 the registrants in RHCs for practicingnonconventional medicine were 152, as of them 65 are „otherpractitioners within the healthcare system”, while a total of 87are the Masters in Medicine or Dental medicine, who for briefannotation from now on we will mention as “doctors”. In eightof the RHCs in the country there are no registered practitionersfor practicing NCM in the regions of Pernik, Sofia-district,Razgrad, Kyustendil, Pazardzhik, Silistra, Yambol, Russe (6-30).

By September 15, 2009 in 9 of the RHCs within the country(Pernik, Sofia-district, Razgrad, Kyustendil, Pazardzhik,


Êúì 15.05.2010 ã. â 9 ÐÖÇ (Ïåðíèê, Ñîôèÿ-îáëàñò, Ðàçãðàä,Êþñòåíäèë, Ïàçàðäæèê, Ñèëèñòðà, ßìáîë, Áëàãîåâãðàä,Òúðãîâèùå) íå ñà ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàÍÌ. Ïðåç 2010 ã. ÐÖÇ-Ðóñå ðåãèñòðèðà ëèöà çàóïðàæíÿâàíå íà ÍÌ, íî ïúê òàêèâà ðåãèñòðàöèè ñåçàëè÷àâàò â ÐÖÇ - Áëàãîåâãðàä è Òúðãîâèùå. Êúì15.05.2010 ã. ðåãèñòðèðàíèòå â ÐÖÇ ëèöà, êîèòî ïðàêòèêóâàòíåêîíâåíöèîíàëíè ìåòîäè ñà 166, îò òÿõ 98 ñà „äîêòîðè”,à 68 ñà „äðóãè ëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî”.Áðîÿò íà ðåãèñòðèðàíèòå ëèöà â ÐÖÇ â ñòðàíàòà çà 2009 è2010 ã. å ïðåäñòàâåí íà Òàáëèöà 1.

Òàáëèöà 1. Áðîé ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè çà áëàãîïðèÿòíî âúçäåéñòâèåâúðõó èíäèâèäóàëíîòî çäðàâå â ÐÖÇ çà 2009 è 2010 ã.

Silistra, Yambol, Blagoevgrad, Targovishte) there are noregistered practitioners for practicing NCM, In 2010 the RHCof Russe registered practitioners for using NCM, but at thesame time registrations were erased in the RHCs –Blagoevgrad and Targovishte. By September 15, 2010 thepractitioners registered in the RHCs, who have practicedNCM were 166, as of them 98 were „Doctors”, and 68 were„other practitioners within the healthcare system”. Thenumber of the registered practitioners in the different RHCsfor the 2009 and 2010 are presented in the Table 1.

Table 1. Number of registrants in the RHCs of the country forpracticing NCM for favorable effects on the human healthover the period of 2009 and 2010.



Êúì 15.05.2010 ã. ïî áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ âñòðàíàòà çà óïðàæíÿâàíå íà ÍÌ, îáëàñòèòå ñå ïîäðåæäàòêàêòî ñëåäâà – Ñîôèÿ –ãðàä -34 ÷îâåêà, Ïëîâäèâ – 30, Âàðíà– 26 , Áóðãàñ – 24, Ñòàðà Çàãîðà – 13, Äîáðè÷ – 9. Êúì15.09.09 ã. â ÐÖÇ â ñòðàíàòà ñà çàëè÷åíè 9 ðåãèñòðàöèè – 5íà äîêòîðè è 4 íà äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî, à êúì 15.05.2010 ã. ñà çàëè÷åíè 2ðåãèñòðàöèè, êàòî è äâåòå ëèöå ñà îò êàòåãîðèÿòà „äðóãèëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî”.

Áðîÿò íà ðåãèñòðèðàíèòå ëèöà â ÐÖÇ â ñòðàíàòà êúì15.09.2009 ã. è êúì 15.05.2010 ã. çà óïðàæíÿâàíå íà îòäåëíèíåêîíâåíöèîíàëíè ìåòîäè å ïðåäñòàâåí â Òàáëèöè 2 - 7.

Òàáëèöà 2. Áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèÿ ìåòîä „Èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò îðãàíè÷åí ïðîèçõîä” êúì 15.09.2009 ã. è15.05.2010 ã.

30,2% (46 ÷îâåêà) îò ðåãèñòðèðàíèòå â 12 ÐÖÇ êúì15.09.2009 ã. ñà ïîñî÷èëè, ÷å óïðàæíÿâàòíåêîíâåíöèîíàëíèÿ ìåòîä „Èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò îðãàíè÷åí ïðîèçõîä”, êàòî 24 îò òÿõ ñàäîêòîðè è 22 - äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî. Êúì 15.05.2005 ã. áðîÿò íà ëèöàòà,óïðàæíÿâàùè òîçè ìåòîä å íàðàñíàë íà 39,63% îò îáùèÿáðîé ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íà ÍÌ.

By 15 May 2010 by the number of registered practitioners in theRHCs in the country for practicing NCM, the regions wereranked as follows – Sofia City --34 practitioners, Plovdov – 30,Varna – 26, Burgas – 24, Stara Zagora – 13, Dobrich – 9. By 15September 2009 in the RHCs in the country there were erased 9registrations – 5 of “Doctors” and 4 of “other practitionerswithin the healthcare system”, and by 15.May 2010 were erased2 registrations.

The numbers of the registered practitioners in the RHCs in thecountry by 15 September 2009. and by 15 May 2010 forpracticing of different non-conventional methods are presentedin the Tables 2 - 7.

Table 2. The number of registrants in RHCs for practicingNCM “Using non-medicinal products from animal origin”by 15 September 2009 and 15 May 2010.

30,2% (46 individuals) of the registered practitioners in 12RHCs by 15 September.2009 pointed out that they practicedthe non-conventional method “Using the non-medicinalproducts from organic origin” as of them 24 are “Doctors”and 22 are “other practitioners within the healthcare system”(in the same year one registration of “other person withinthe healthcare system” was erased. By 15 May 2005 thenumber of practitioners practicing this method was increasedby 39,63% of the total number of registered practitioners forpracticing NCM in the RHCs throughout the country.



Òàáëèöà 3. Áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèÿ ìåòîä „Èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò ìèíåðàëåí ïðîèçõîä” êúì 15.09.2009 ã. èêúì 15.05.2010 ã

29 ëèöà (19,07%) îò ðåãèñòðèðàíèòå â 12 ÐÖÇ êúì 15.09.2009ã. ñà ïîñî÷èëè, ÷å óïðàæíÿâàò íåêîíâåíöèîíàëíèÿ ìåòîä„Èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îò ìèíåðàëåíïðîèçõîä”. Îò òÿõ 18 ñà äîêòîðè è 11 - äðóãè ëèöà îòñèñòåìàòà íà çäðàâåîïàçâàíåòî. Êúì 15.05.2010 ã. òåõíèÿòáðîé ñå å óâåëè÷èë (28 äîêòîðè è 15 äðóãè ëèöà îòñèñòåìàòà íà çäðàâåîïàçâàíåòî â 11 ÐÖÇ) – 25,5% îòîáùèÿ áðîé ðåãèñòðèðàíè ëèöà. Ïðåç 2009 ã. å çàëè÷åíàåäíà ðåãèñòðàöèÿ íà „äðóãî ëèöå îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî”.

Íà òàáëèöà 4 è òàáëèöà 5 å ïðåäñòàâåí áðîÿò íàðåãèñòðèðàíèòå ëèöà ó íàñ êúì 15.09.2009 ã. è êúì15.05.2010 ã. çà óïðàæíÿâàíå íà íåêîíâåíöèîíàëíèÿ ìåòîä„èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè”(ÍÔÌ), êîèòî âêëþ÷âàò - íåêîíâåíöèîíàëíè êîíòàêòíèìàñàæè íà òÿëîòî èëè íà íåãîâè ÷àñòè (ÍÊÌ); òîïëèííèèçòî÷íèöè çà âúçäåéñòâèå âúðõó îòäåëíè ó÷àñòúöè îò

Table 3. The number of practitioners registered in RHCs forpracticing NCM “Using non-medicinal products frommineral origin” by 15 September 2009 and by 15 May 2010.

19,07% (29 practitioners) of the registered individuals in 12 RHCsby 15 September 2009 pointed out that they practiced the non-conventional method “Using of the non-medicinal productsfrom mineral origin” as 18 practitioners were “Doctors” and 11practitioners were “other practitioners within the healthcaresystem”. By 15 September 2010 their number was increased (28were “Doctors” and 15 were “other practitioners withinhealthcare system” from 11 RHCs) – 25,5% of the total numberof registered practitioners. In 2009 one registration of “otherpractitioner within the healthcare system” was stricken off thelist.

In Table 4 and in Table 5 are presented the numbers ofthe registered practitioners by 15 September 2009 andby 15 May 2010 for practicing the non-conventionalmethod “using non-conventional physical methods”(NCPM), which include non-conventional contactmassages of the body or of its parts (NCCM); thermalsources for the effect on different skin parts (TSE),



êîæàòà (ÒÈÂ); âåíäóçè; ìàãíèòíî ïîëå, ñúçäàâàíî îòïîñòîÿííè ìàãíèòè (ÌÏ).

Òàáëèöà 4. Áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ â ñòðàíàòà êúì15.09.2009 ã. è êúì 15.05.2010 ã. çà óïðàæíÿâàíå íàâñåêè îòäåëåí íåêîíâåíöèîíàëåí ìåòîä îò ðàçäåëà„Èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíèìåòîäè”.

cupping glasses, magnet field, created by permanentmagnets (MF).

Table 4. umber of practitioners registered in the RHCs of thecountry by 15 September 2009 and by 15 May 2010 forpracticing of each non-conventional method of the section“Using non-conventional physical methods”.



Table 5. Total number of the registered practitioners within thecountry by 15.09.2009 and by 15.05.2010 for practicing ofeach individual non-conventional method from the section“Using the nonconventional physical factors”.

By 15.09.2009 in 20 RHCs were registered 66 practitioners,(26 doctors and 40 are “other practitioners within thehealthcare system”), consisting 43,42% of the total numberof registrants for practicing non-conventional medicine fromthe section “Using non-conventional physical methods”.By 15.05.2010 the registries were 91 practitioners from 19RHCs throughout the country (41 “doctors” and 50 “otherpractitioners within the healthcare system”). For applyingthe methods “cupping glasses”, “magnetic field created bypermanent magnets” and “thermal sources for influencingon individual skin segments” there are no practitionersregistered. For practicing all methods of this section wereregistered as follows - – by 15.09.2009 in 12 RHCs - 59practitioners, of them 25 are “doctors” and 34 are “otherpractitioners within the healthcare system”, by 15.05.2010in 12 RHCs - 80 practitioners, of them 39 are “doctors” and41 are “other practitioners within the healthcare system”.The practicing of the methods “magnetic field created bypermanent magnets” and “non-conventional massages ofskin and its parts” was indicated by 1 practitioner that was“other person within the healthcare system” In 2009 oneregistry of “other person within the healthcare system” waserased.

Òàáëèöà 5. Îáù áðîé ðåãèñòðèðàíè ëèöà â ñòðàíàòà êúì15.09.2009 ã. è êúì 15.05.2010 ã. çà óïðàæíÿâàíå íà âñåêèîòäåëåí íåêîíâåíöèîíàëåí ìåòîä îò ðàçäåëà„Èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè”.

Êúì 15.09.2009 ã. â 20 ÐÖÇ ñà ðåãèñòðèðàíè 66 ëèöà, (26äîêòîðè è 40 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), ñúñòàâëÿâàùè 43,42% îò îáùèÿ áðîéðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íà ÍÌ îò ðàçäåëà„Èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè”.Êúì 15.05.2010 ã. òå ñà 91 ëèöà â 19 ÐÖÇ (41 äîêòîðè è 50äðóãè ëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî). Çàïðèëàãàíå ñàìî íà ìåòîäèòå „âåíäóçè”, „ìàãíèòíî ïîëå,ñúçäàâàíî îò ïîñòîÿííè ìàãíèòè” è „òîïëèííè èçòî÷íèöèçà âúçäåéñòâèå âúðõó îòäåëíè ó÷àñòúöè îò êîæàòà” íÿìàðåãèñòðèðàíè ëèöà. Çà óïðàæíÿâàíå íà âñè÷êè ìåòîäè îòòîçè ðàçäåë ñà ñå ðåãèñòðèðàëè êàêòî ñëåäâà – êúì15.09.2009 ã. â 12 ÐÖÇ - 59 ëèöà ( 25 äîêòîðè è 34 äðóãè ëèöàîò ñèñòåìàòà íà çäðàâåîïàçâàíåòî), êúì 15.05.2010 ã. - 80ëèöà (39 äîêòîðè è 41 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî). Óïðàæíÿâàíåòî íà ìåòîäèòå „ìàãíèòíîïîëå, ñúçäàâàíî îò ïîñòîÿííè ìàãíèòè ”è„íåêîíâåíöîíàëíè ìàñàæè íà òÿëîòî è íà íåãîâè ÷àñòè” åïîñî÷åíî îò 1 äðóãî ëèöå îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî. Ïðåç 2009 ã. å çàëè÷åíà åäíàðåãèñòðàöèÿ íà äðóãî ëèöå îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî çà óïðàæíÿâàíå íà òîçè ìåòîä.



Õîìåîïàòè÷íèÿò ìåòîä ìîæå äà ñå ïðèëàãà ñàìî îò ëèöà,êîèòî ïðèòåæàâàò ìàãèñòúðñêà ñòåïåí ïî „Ìåäèöèíà”èëè „Äåíòàëíà ìåäèöèíà” (4).

Òàáëèöà 6. Áðîé ðåãèñòðèðàíè „äîêòîðè” çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèÿ ìåòîä „õîìåîïàòèÿ” êúì 15.09.2009ã. è êúì 15.05.2010 ã.

Ïðåç 2009 ã. çà óïðàæíÿâàíå íà õîìåîïàòè÷íèÿ ìåòîä óíàñ ñà ðåãèñòðèðàíè 29 äîêòîðè (42,5% îò îáùèÿ áðîéðåãèñòðèðàíè äîêòîðè) â 12 ÐÖÇ , à ïðåç 2010 ã. òå ñà 40(42,8% îò îáùèÿ áðîé ðåãèñòðèðàíè äîêòîðè),ðåãèñòðèðàíè â 13 ÐÖÇ.

Êúì 15.09.09ã. ñà çàëè÷åíè 3 ðåãèñòðàöèè íà äîêòîðè â çàïðèëàãàíå íà õîìåîïàòè÷íèÿ ìåòîä.

The homeopathy can be applied only by practitioners acquiringthe master’s degree in “Medicine” or “Dental medicine” (4).

Table 6. Number of registered “doctors” for practicing the non-conventional method “homeopathy” by 15.09.2009 and by15.05.2010.

In 2009 for practicing homeopathy in the country wereregistered 29 “Doctors” (42,5% of the total number ofregistered doctors) in 12 RHCs, and in 2010 they were 40practitioners(42,8% of the total number of registereddoctors) are registered in 13 RHCs in the country.

By 15.09.2009 were erased 3 registries of “Doctors” in 2RHCs for the application of the homeopathic method.



Êúì 15.09.2009 ã. â 14 ÐÖÇ â ñòðàíàòà ñà ðåãèñòðèðàíè73 ëèöà (39 äîêòîðè è 34 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), êîåòî å 48,03% îò îáùèÿ áðîéðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíà ëíèòå ìåòîäè „àêóïóíêòóðà”,„àêóïðåñóðà” è „àêóïóíêòóðà è àêóïðåñóðà”. Êúì15.05.2010 ã. òå ñà 91 ëèöà (53 äîêòîðè è 38 äðóãè ëèöàîò ñèñòåìàòà íà çäðàâåîïàçâàíåòî) â 15 ÐÖÇ. Çàïðèëàãàíå ñàìî íà ìåòîäà „àêóïóíêòóðà” ñà ñåðåãèñòðèðàëè êàêòî ñëåäâà – êúì 15.09.2009 ã. â 4 ÐÖÇ -13 ëèöà ( 12 äîêòîðè è 1 äðóãî ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), êúì 15.05.2010 ã.- 15 ëèöà ( 13 äîêòîðèè 2 äðóãè ëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî). Çàïðèëàãàíå ñàìî íà ìåòîäà „àêóïðåñóðà” ñà ñåðåãèñòðèðàëè êàêòî ñëåäâà – êúì 15.09.2009 ã. â 5 ÐÖÇ–16 ëèöà ( 3-ìà äîêòîðè è 13 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), à êúì 15.05.2010 ã.- 19 ëèöà ( 7äîêòîðè è 12 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî). Çà ïðèëàãàíå è íà äâàòà ìåòîäà„àêóïóíêòóðà” è „àêóïðåñóðà” ñà ñå ðåãèñòðèðàëè êúì15.09.2009 ã. â 13 ÐÖÇ 44 ëèöà ( 24 äîêòîðè è 20 äðóãèëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî), à êúì 15.05.2010ã. â 14 ÐÖÇ òå ñà 57 ëèöà, îò òÿõ 33-ìà äîêòîðè. Êúì15.09.09ã. ñà çàëè÷åíè äâå ðåãèñòðàöèè â 2 ÐÖÇ çàóïðàæíÿâàíå íà ìåòîäèòå „àêóïóíêòóðà è àêóïðåñóðà”.

Êúì 15.09.2009 ã. â 12 ÐÖÇ ñà ðåãèñòðèðàíè 49 ëèöà (32äîêòîðè è 17 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), êîèòî ñúñòàâëÿâàò 32,23% îò îáùèÿáðîé ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèòå ìåòîäè íà èçñëåäâàíå „èðèñîâ”,„ïóëñîâ”, „àóðèêóëàðåí”, „èðèñîâ è ïóëñîâ”; „èðèñîâè àóðèêóëàðåí”. Êúì 15.05.2010 ã. òå ñà 68 ëèöà (47äîêòîðè è 21 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî).

Çà ïðèëàãàíå íà „èðèñîâ” ìåòîä ñà ðåãèñòðèðàíè –êúì 15.09.2009 ã. 12 ëèöà (10 äîêòîðè è 2 äðóãè ëèöà îòñèñòåìàòà íà çäðàâåîïàçâàíåòî), à êúì 15.05.2010 ã. - 14ëèöà, îò òÿõ 11 äîêòîðè. Çà ïðèëàãàíå íà „ïóëñîâ” ìåòîäíà èçñëåäâàíå ñà ðåãèñòðèðàíè è çà äâåòå ãîäèíè ïîåäíî ëèöå – äîêòîð.

Çà ïðèëàãàíå íà „àóðèêóëàðåí” ìåòîä ñà ðåãèñòðèðàíèêúì 15.09.2009 ã. 9 ëèöà, à êúì 15.05.2010 ã. - 10 ëèöà. Çàïðèëàãàíå íà òðèòå ìåòîäà íà èçñëåäâàíå „èðèñîâ,ïóëñîâ è àóðèêóëàðåí” ñà ðåãèñòðèðàíè êúì 15.09.2009ã. 20 ëèöà (14 äîêòîðè è 6 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), à êúì 15.05.2010 ã. - 29 ëèöà, îò òÿõ22-ìà äîêòîðè.

By 15.09.2009 in 14 RHCs in the country there have beenregistered 73 practitioners (39 “Doctors” and 34 “otherpractitioners within the healthcare system”), covering48,03% of the total number of registered practitioners forpracticing non-conventional methods “acupuncture”,“acupressure” and “acupuncture and acupressure”, by15.05.2010 they are 91 practitioners (53 “Doctors” and 38“other practitioners within healthcare system”) in 15 of theRHCs in the country. For the application of acupuncturewere registered – by 15.09.2009 in 4 RHCs - 13 practitioners,of them 12 are “doctors” and 1 is “other person within thehealthcare system”, by 15.05.2010- in 4 RHCs - 15practitioners, of them 13 are “doctors” and 2 are “otherpractitioners within the healthcare system”. For applyingthe method “acupressure” were registered – by 15.09.2009in 5 RHCs – 16 practitioners, of them 3 are “doctors” and 13ñà “other practitioners within the healthcare system”, andby 15.05.2010 were registered in 5 RHCs - 19 practitioners,of them 7 are “doctors” and 12 are “other practitioners withinthe healthcare system”. For practicing both methods“acupuncture” and “acupressure” were registered by15.09.2009 in 13 RHCs - 44 practitioners, of them 24 are“doctors” and 20 individuals are “other practitioners withinthe healthcare system”, and by 15.05.2010 were registeredin 14 RHCs - 57 practitioners, of them 33 are “doctors” and24 are “other practitioners within the healthcare system”.By 15.09.09 ” in 2 RHCs were erased two registries forpracticing methods “acupuncture and acupressure– oneperson was a “doctor” and one person was from “otherpractitioners within the healthcare system”.

By 15.09.2009 in 12 RHCs of the country were registered 49practitioners (32 are “doctors” and 17 are “other practitionersin the healthcare”), consisting of 32,23% of the total numberof registrants for practicing non-conventional medicineutilizing “iris method”, “pulse method” and “auricularmethod”. By 15.05.2010 they are.68 (47 “doctors” and 21“other practitioners in the healthcare”) within 12 RHCs ofthe country. For applying the “iris method”: by 15.09.2009within 6 RHCs of the country - 12 were registeredpractitioners, of them 10 are “doctors” and 2 are “otherpractitioners in the healthcare”; by 15.05.2010 within 6 RHCsof the country - 14 practitioners, of them 11 are “doctors”and 3 are “other practitioners in the healthcare”. Forapplying the “pulse method” by 15.09.2009 were registeredas follows - 1 practitioner is “doctor” and by 15.05.2010. aswell 1 practitioner is “doctor”. For applying the “auricular”method by 15.09.2009 within 4 RHCs of the country 9practitioners were registered, of them 3 are “doctors” and 6are “other practitioners in the healthcare”, and by 15.05.2010within 4 RHCs were registered 10 practitioners, of them 4are “doctors” and 6 are “other practitioners in thehealthcare”. For applying the three methods for examination– “iris, pulse and auricular” by 15.09.2009within 7 RHCswere registered 20 practitioners, of them 14 are “doctors”and 6 are “other practitioners in the healthcare”; and by15.05.2010 within 7 RHCs the registrants were 29, of them 22are “doctors”



Òàáëèöà 7. Îáù áðîé ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèòå ìåòîäè „äèåòèêà è ëå÷åáíîãëàäóâàíå” â ñòðàíàòà êúì 15.09.2009 ã. è êúì 15.05.2010 ã.

Êúì 15.09.2009 ã. â 11 ÐÖÇ ñà ðåãèñòðèðàíè 34 ëèöà (22äîêòîðè è 12 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî), ñúñòàâëÿâàùè 23,27% îò îáùèÿ áðîéðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíèòå ìåòîäè „äèåòèêà”, „ëå÷åáíîãëàäóâàíå” è „äèåòèêà è ëå÷åáíî ãëàäóâàíå”. Êúì15.05.2010 ã. òå ñà 46 ëèöà, îò òÿõ 29 äîêòîðè.Çà ïðèëàãàíåñàìî íà ìåòîäà „äèåòèêà” êúì 15.09.2009 ã. ñàðåãèñòðèðàíè – 7 ëèöà, à êúì 15.05.2010 ã.- 8 ëèöà ( 4-ìàäîêòîðè è 4 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî). Çà ïðèëàãàíå ñàìî íà ìåòîäà „ëå÷åáíîãëàäóâàíå” íÿìà ðåãèñòðèðàíè ëèöà êúì 15.09.2009 ã. è15.05.2010 ã. Çà ïðèëàãàíå íà ìåòîäèòå „äèåòèêà” è„ëå÷åáíî ãëàäóâàíå” ñà ñå ðåãèñòðèðàíè êúì 15.09.2009 ã.27 ëèöà, îò òÿõ 18 ñà äîêòîðè, à êúì 15.05.2010 ã. - 38 ëèöà,îò êîèòî 25 äîêòîðè (òàáëèöà 7).

Òàáëèöà 8. Áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ-òà â ñòðàíàòà çàóïðàæíÿâàíå íà íåðàçðåøåíè çà ïðèëàãàíåíåêîíâåíöèîíàëíè ìåòîäè â ÐÁúëãàðèÿ

1 ÍÌÁÂÈÇ – íåêîíâåíöèîíàëíè ìåòîäè çà áëàãîïðèÿòíîâúçäåéñòâèå âúðõó èíäèâèäóàëíîòî çäðàâå

2 ÍÌË – íåêîíâåíöèîíàëíè ìåòîäè íà ëå÷åíèå

Table 7. Total number of registrants for practicing non-conventional medicine methods of “dietetics and fating”in the country by 15.09.2009 and by 15.05.2010.

By 15.09.2009 in 11 RHCs 34 practitioners were registered(22 are “doctors” and 12 are “other practitioners in thehealthcare”), consisting 23,27% of the total number ofregistrants for practicing non-conventional methods of“dietetics”, “fasting” and “dietetics and fasting”, by15.05.2010 they are 46 (29 “doctors”). For only applying themethod of “dietetics” by 15.09.2009 the registrants in 4 RHCswere 7, of them 4 are “doctors” and 3 are “other practitionersin the healthcare”; by 15.05.2010 the registrants in 4 RHCswere 8, of them 4 are “doctors” and 4 are “other practitionersin the healthcare”. For only applying the method of “fasting”no registrants were found. For applying both methods of“dietetics” and “fasting” 27 practitioners, of them 18 are“doctors” and 9 are “other practitioners in the healthcare”,were registered by 15.09.2009 in 10 RHCs; by 15.05.2010 38practitioners, of them 25 are “doctors” (Table 7).

Table 8. Number of registrants in the RHCs in the country forpracticing non-conventional medicine methods not-allowed for application in the Republic of Bulgaria

1 NMMFIHH - Non-conventional medicine methods for favorableimpacts on human health

2 NMMT Non-conventional medicine treatments



Òàáëèöà 9. ÐÖÇ, êîèòî íå ñà ñïàçèëè èçèñêâàíèÿòà ïðèðåãèñòðèðàíå íà ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè ó íàñ êúì 15.09.2009 ã.

Â 3 îò ÐÖÇ íå ñà îïèñàíè îòäåëíèòå íåêîíâåíöèîíàëíèìåòîäè, êîèòî ëèöàòà óïðàæíÿâàò, â 2 ÐÖÇ â ðåãèñòðèòåñà îòðàçåíè - „êàáèíåò ïî èçòî÷íà ìåäèöèíà” è „êàáèíåòïî ðåõàáèëèòàöèÿ”, êàòî íå ñà ñïàçåíè èçèñêâàíèÿòà íà÷ë.170 îò Çàêîíà çà çäðàâåòî çà ïîäðîáíî îïèñâàíå íàâñåêè ïðèëàãàí ÍÌ.

Êúì 15.09.2009 ã. ëèöàòà, ðåãèñòðèðàíè ñàìî ïî 1íåêîíâåíöèîíàëåí ìåòîä, ñà 66 ( 41 äîêòîðè), à êúì15.05.2010 ã. òå ñà 71, îò êîèòî 40 äîêòîðè. Çà óïðàæíÿâàíåíà 7 íåêîíâåíöèîíàëíè ìåòîäà ïðåç 2009 ã. ñàðåãèñòðèðàíè 4 äîêòîðè, à êúì 15.05.2010 ã. – 8 äîêòîðè.

III. Îáñúæäàíå

Ó íàñ ðåãèñòðèðàíåòî â ÐÖÇ íà ëèöàòà, æåëàåùè äàóïðàæíÿâàò ÍÌ, ñòàðòèðà îò 15.03.2005 ã., ñëåäïóáëèêóâàíåòî íà íàðåäáà ¹47 íà ÌÇ çà èçèñêâàíèÿòàêúì äåéíîñòòà íà ëèöàòà, óïðàæíÿâàùè òåçè ìåòîäè. Íàáàçàòà íà èíôîðìàöèÿòà, ïîëó÷åíà îò ïðîó÷âàíå íàðåãèñòðèòå íà ÐÖÇ â ñòðàíàòà, ñå óñòàíîâÿâà, ÷å êúì15.05.2010 ã. îñèãóðÿâàíåòî íà ãðàæäàíèòå ïî îáëàñòè óíàñ, ñúñ çàêîííè äîñòàâ÷èöè íà íåêîíâåíöèîíàëíèçäðàâíè óñëóãè, å êðàéíî íåäîñòàòú÷íî. Êúì 31.12.2008 ã.â 11 öåíòúðà íå ñà ðåãèñòðàíè ëèöà çà óïðàæíÿâàíå íàÍÌ. Êúì 15.09.2009 ã. òåõíèÿò áðîé å íàìàëÿë äî 8, íî êúì15.05.2010 ã. íàðàñòâà äî 9. Âúïðåêè ÷å ñå íàáëþäàâàòåíäåíöèÿ çà íàðàñòâàíå íà áðîÿ íà îáëàñòèòå, â êîèòî ñåðåãèñòðèðàò ëèöà çà óïðàæíÿâàíå íà ÍÌ â ïåðèîäà 2008-2010 ã., òî 5 ãîäèíè ñëåä ïóáëèêóâàíåòî íà íîðìàòèâíèòåäîêóìåíòè, ðåãëàìåíòèðàùè ïðèëàãàíåòî èì, ïî÷òè â 1/3îò îáëàñòèòå â ÐÁúëãàðèÿ íå å ðåãèñòðèðàíî íèòî åäíîëèöå çà óïðàæíÿâàíå íà ÍÌ. Òîâà ñà îáëàñòè êàòî Ñîôèÿ,Ïåðíèê, Êþñòåíäèë, Áëàãîåâãðàä, îáõâàùàùè öåëèÿÞãîçàïàäåí ðàéîí íà ñòðàíàòà. Îò äðóãà ñòðàíà,

Table 9. RHCs that did not meet requirements for practitionersusing non-conventional methods in the country by15.09.2009.

In 3 RHCs there are no individual non-conventional methodsdescribed for practicing, in 2 of the RHCs in the registrieswere indicated “Chinese medicine practice” and“rehabilitation practice” as requirements by Art. 170 of theHealth Law for detailed description of each applied non-conventional medicine method were not met.

By 15.09.2009 practitioners that were registered only for 1non-conventional method are 66, of them “doctors” are 41individuals, and by 15.05.2010 they are 71 practitioners, ofthem “doctors” are 40 individuals. For practicing of 7 non-conventional methods in 2009 were registered 4 “doctors”,and by 15.05.2010 – 8 “doctors”.

III. Discussion

In Bulgaria the registration in the RHCs of thepractitioners that wanted to practice NCM started since15 May 2005 after the publication of the Ordinance ¹47of the Ministry of Health for the requirements towardthe activity of individuals practicing these methods. Onthe basis of this information obtained from a survey onthe registries of RHCs in the country it was establishedthat by 15 May 2010 the delivery to citizens by regionswith legal providers of non-conventional healthcareserviced is extremely insufficient. By 31.12.2008 in 11 ofthe RHCs there were no registrations of practitionerspracticing NCM, by 15.09.2009 their number wasdecreased to 8, but by 15.05.2010 their number increasedto 9. Despite the tendency for growth of the number ofregions where practitioners practicing NCM wereregistered over the period 2008-2010, after 5 years fromthe publication of the documents regulating theirapplying, facts have shown that almost in 1/3 of theregions in the Republic of Bulgaria neither one wasregistered for practicing NCM and this refers to regions



íåäîñòàòú÷åí å è áðîÿò íà ëèöàòà, ðåãèñòðèðàíè çàóïðàæíÿâàíå íà ÍÌ. Êúì 31.12.2008 ã. òå ñà 130 ëèöà,êúì 15.09.2009 ã. – 152, êúì 15.05.2010 ã. - 166 ëèöà.

Íàé-äîáðî å îñèãóðÿâàíåòî íà íàñåëåíèåòî â ñòðàíàòàñ äîñòàâ÷èöè íà õîìåîïàòè÷íèÿ ìåòîä (êúì 31.12.08 ã.1666 ìàãèñòðè ïî „ìåäèöèíà” è „äåíòàëíà ìåäèöèíà”ñà ïðåìèíàëè îáó÷åíèå ïî õîìåîïàòèÿ), êîèòî çàóïðàæíÿâàíå íà ìåòîäà íå ñà çàäúëæåíè äà ñåðåãèñòðèðàò â ÐÖÇ. Ïðåç 2008 ã. âîäåùî ìÿñòî ïî áðîéðåãèñòðèðàíè ëèöà â ÐÖÇ çà óïðàæíÿâàíå íà ÍÌ çàåìàÐÖÇ-Ïëîâäèâ -25 ëèöà, ñëåä íåãî ñå íàðåæäà ÐÖÇ Ñîôèÿ– ñ 23 ëèöà, ÐÖÇ-Âàðíà – 20, ÐÖÇ-Áóðãàñ – 16, ÐÖÇÑòàðà Çàãîðà – 12, ÐÖÇ Äîáðè÷ – 8, ÐÖÇ Ñìîëÿí – 5,ÐÖÇ Øóìåí – 6 è ò.í. Êúì 15.05.2010 ã. âîäåùîòî ìÿñòîïî áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ çà óïðàæíÿâàíå íàÍÌ çàåìà ÐÖÇ Ñîôèÿ-ãðàä – 34 ëèöà, ÐÖÇ Ïëîâäèâ ñåíàðåæäà íà âòîðî ìÿñòî – 30 ðåãèñòðèðàíè ëèöà.Íàáëþäàâà ñå òåíäåíöèÿ íà ñëàáî óâåëè÷àâàíå íà áðîÿíà ðåãèñòðèðàíèòå â ÐÖÇ ëèöà, óïðàæíÿâàùè ÍÌ çàïåðèîäà 2008-2010 ã.

Åäíà îò îñíîâíèòå ïðè÷èíè çà ñëàáàòà îñèãóðåíîñò íàíàñåëåíèåòî ñúñ çàêîííè äîñòàâ÷èöè íàíåêîíâåíöèîíàëíè çäðàâíè óñëóãè å ëèïñàòà íàîáó÷åíèå ïî îòäåëíèòå íåêîíâåíöèîíàëíè ìåòîäè óíàñ, îò êîåòî èçêëþ÷åíèå ïðàâè ñàìî õîìåîïàòè÷íèÿòìåòîä. Äðóãà ïðè÷èíà å, ÷å ïîâå÷åòî äîñòàâ÷èöè íàíåêîíâåíöèîíàëíè óñëóãè íà òîçè åòàï ãè äîñòàâÿòíåçàêîííî è çàòîâà çà òÿõ ëèïñâà áàçà äàííè.

Ñåäåìòå ðàçäåëà, â êîèòî ñà ãðóïèðàíè ÍÌ, îïèñàíè âíà÷àëîòî íà ñòàòèÿòà, ñå íàðåæäàò ïî áðîéðåãèñòðèðàíè â ÐÖÇ ëèöà, êàêòî ñëåäâà: êúì 15.09.09 ã.âîäåùî ìÿñòî çàåìà ðàçäåëúò “aêóïóíêòóðà èàêóïðåñóðà” ñúñ 73 ðåãèñòðèðàíè ëèöà (îò òÿõ 39 ñàäîêòîðè); ñëåäâà ðàçäåëúò „íåêîíâåíöèîíàëíèôèçèêàëíè ìåòîäè” ñ 66 ðåãèñòðèðàíè ëèöà (îò òÿõ 26äîêòîðè), íà òðåòî ìÿñòî ñå íàðåæäà ðàçäåëúò “èðèñîâè,ïóëñîâè è àóðèêóëàðíè ìåòîäè íà èçñëåäâàíå” – ñ 49ðåãèñòðèðàíè ëèöà, îò êîèòî 32 ñà äîêòîðè è íàòàòúêñëåäâàò ðàçäåëåëèòå - “èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò îðãàíè÷åí ïðîèçõîä - ñ 46 ðåãèñòðèðàíèëèöà (îò êîèòî 24 äîêòîðè), õîìåîïàòèÿ” – ñ 39 äîêòîðè;„äèåòèêà è ëå÷åáíî ãëàäóâàíå” – 34, îò êîèòî 22 ñàäîêòîðè; “èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îòìèíåðàëåí ïðîèçõîä” – 29, îò êîèòî 18 äîêòîðè. Êúì15.05.2010 ã. êàðòèíàòà â ñòðàíàòà å ïîäîáíà – âîäåùîìÿñòî çàåìàò ðàçäåëèòå –“àêóïóíêòóðà è àêóïðåñóðà”è “èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíèìåòîäè” ñ ïî 91 ðåãèñòðèðàíè ëèöà, íî ñëåä òÿõ ñåíàðåæäà ðàçäåëúò “èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò îðãàíè÷åí ïðîèçõîä – ñ 66 ðåãèñòðèðàíèëèöà. Êàòî öÿëî ñå çàïàçâà òåíäåíöèÿòà çà íàðàñòâàíåíà áðîÿ íà ðåãèñòðèðàíèòå ëèöà çà óïðàæíÿâàíå íàÍÌ, çà ïåðèîäà 2008-2010 ã., êîåòî ïðè ïîâå÷åòîðàçäåëè å ñ îêîëî 20-30%.

like Sofia-district, Pernik, Kyustendil, Blagoevgrad,covering the whole southwest region. On the one hand,the number of regions in which there is a lack of provisionof legally practicing providers of non-conventionalservices to the population, on the other hand, the numberof the registered practitioners that practice NCM in theRHCs throughout the country is insufficient – by31.12.2008 they were 130 practitioners, by 15.09.2009 theywere 152 individuals and by 15.05.2010 their number wasincreased up to 166 practitioners. The delivery withproviders of homeopathic method to the population isthe best (by 31.12.08 1666 masters in: Medicine andDental medicine gained a training in homeopathy), sincethey were not obliged to be registered in the RHCs forpracticing this method. In 2008 the leading place in thenumber of registered practitioners in RHCs for practicingNCM occupied the RHC of Plovdiv - 25 registries, after itcomes the RHC of Sofia – with 23 registries, Varna RHC– 20, Burgas RHC – 16, Stara Zagora RHC – 12, DobrichRHC – 8, Smolyan RHC – 5, Shumen RHC – 6 etc. By15.05.2010 the leading place in the registries for practicingNCM occupies Sofia City– 34, Plovdiv RHC is at thesecond place – 30%. A tendency for light increase in thenumber of registries was observed in the country for theperiod 2008-2010. One of the main reasons for the slightdelivery with legal providers of non-conventionalservices to the population is the lack of training on thedifferent non-conventional methods, of which only thehomeopathic method makes an exception. Other reasonis that majority pf providers make their deliveries illegallyand due to this there is a lack of databases.

The seven sections for grouping the NCM described in thebeginning of the article were ranked by the number ofregistries as follows - by 15 September.2009 the leadingplace was for the section ‘acupuncture and acupressure”with 73 registries (of them 39 are “Doctors”), the followingis the section “non-conventional physical methods” with66 registries (of them 26 are “Doctors”), at the third placecomes the section “iris. Pulse and auricular methods ofinvestigation” – with 49 registries, of them 32 are “Doctors”and the units that come are as follows – “using non-medicinal products from organic origin” with 46 registries(of them 24 are “Doctors”), “homeopathy” – with 39“Doctors”; “dietetics and fasting” – with 34 registries, ofthem 22 are “Doctors”; “using non-medicinal products frommineral origin”– with 29 registries, of them 18 are “Doctors”.By 15 Mat 2010 the picture in the country is similar – theleading place is occupied by the sections – “acupunctureand acupressure” and “using non-conventional physicalmethods” with 91 registries, but after them come the section“using non-medicinal products from organic origin – with66 registries, the sectionñ “iris, pulse and auricular methodsof studying” - with 61 registries, “dietetics and fasting” –with 46 registries, “using non-medicinal products frommineral origin” – with 43 registries, at the last place is the“homeopathic method” – with 41 “Doctors”. As w wholethe tendency for increase in the number of registeredpractitioners for practicing NCM over the period 2008-2010is still kept, which for the most sections is about 20-30%.



Òàáëèöà 10. Áðîé ðåãèñòðèðàíè â ÐÖÇ ó íàñ ëèöà êúì15.09.2009 ã.çà óïðàæíÿâàíå íà íåêîíâåíöèîíàëíè ìåòîäè ïîðàçäåëè.

1 ÍÏÎÏ- èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îò îðãàíè÷åíïðîèçõîä

2 ÍÏÌÏ - èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îò ìèíåðàëåíïðîèçõîä

Òàáëèöà 11. Áðîé ðåãèñòðèðàíè â ÐÖÇ ëèöà êúì 15.05.2010 ã. çàóïðàæíÿâàíå íà íåêîíâåíöèîíàëíè ìåòîäè ïî ðàçäåëè

Êàêâà å ñèòóàöèÿòà îòíîñíî áðîÿ ëèöà, ðåãèñòðèðàíè âÐÖÇ, çà óïðàæíÿâàíå íà ÍÌ îò îòäåëíèòå ðàçäåëè? Âîäåùîìÿñòî êúì 15.09.09 ã. çàåìàò ìåòîäèòå „íåêîíâåíöèîíàëíèôèçèêàëíè ìåòîäè” (59 ëèöà, îò êîèòî 29 äîêòîðè); ñëåäâàòìåòîäúò „èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòè îòîðãàíè÷åí ïðîèçõîä ( 46 ëèöà, îò êîèòî 24 äîêòîðè);ìåòîäèòå „àêóïóíêòóðà è àêóïðåñóðà” ( 44, îò êîèòî 24äîêòîðè); ìåòîäúò „õîìåîïàòèÿ” - 39 äîêòîðè; „èçïîëçâàíåíà íåëåêàðñòâåíè ïðîäóêòè îò ìèíåðàëåí ïðîèçõîä ( 29,îò êîèòî 24 ñà äîêòîðè); „äèåòèêà è ëå÷åáíî ãëàäóâàíå ( 27ëèöà, îò êîèòî 18 äîêòîðè); è ò.í. Íàé-ãîëÿì å áðîÿò íàäîêòîðèòå, êúì 15.09.09 ã., êîèòî ñà ðåãèñòðèðàíè çàóïðàæíÿâàíå íà õîìåîïàòè÷íèÿ ìåòîä, à ïðè äðóãèòåëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî, êúì 15.09.09 ã.,íàé-ãîëÿì å áðîÿò íà ðåãèñòðèðàíèòå çà óïðàæíÿâàíå íà„âñè÷êè íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè” (34 ëèöà).

Êúì 15.05.10 ã. êàðòèíàòà â ñòðàíàòà å ïîäîáíà. Âîäåùîìÿñòî îò íåêîíâåíöèîíàëíèòå ìåòîäè ïî áðîéðåãèñòðèðàíè ëèöà çàåìàò „âñè÷êè íåêîíâåíöèîíàëíè

Table 10. Number of registrants in the RHCs for practicingnon-conventional methods by sections by 15 September2009.

1 NMPOO – using non-medicinal products from organic origin2 NMPMO – using non-medicinal products from mineral origin

Table 11. Number of registrants in the RHCs for practicingnon-conventional methods by sections by 15 May 2010

What is the situation about the registries in the RHCs forpracticing non-conventional methods by the differentsections? The leading place for the number of registries inthe RHCs by 15 September 2009 is for the methods like“non-conventional physical methods” – with 59 registries,of them 29 are “Doctors”, the following is the method “usingnon-medicinal products from organic origin” (with 46registries, of them 24 are “Doctors”), the methods‘acupuncture and acupressure” (with 44 registries, of them24 are “Doctors”), the method “homeopathy” (with 39“Doctors” registered), “using non-medicinal products frommineral origin (with 29 registries, of them 24 are “Doctors”),“dietetics and fasting” (with 27 registries, of them 18 are“Doctors”). The biggest number is that of the “Doctors”by 15.09.09, who were registered for practicing thehomeopathic method, and the biggest number is that of the“other practitioners within the healthcare system” by 15September 2009, who were registered for practicing “allconventional physical methods” (34 practitioners).



By 15 September 2010 the picture in the country is similar. Theleading place among the non-conventional methods by thenumber of registries are being occupied by “all non-conventionalphysical methods” (with 80 registries in the RHCs, of them 39are “Doctors”).

With regard to the number of registered “doctors” in the RHCsfor practicing non-conventional methods the leading place by15 May 2010 is that of the homeopathic method, as the biggestnumber is that of “other persona within the healthcare system”,who were registered for practicing ll non-conventional physicalmethods (total of 41). The method “acupuncture andacupressure” by the number of registered “other practitionerswithin the healthcare system” (24 individuals) is at the “secondplace”, the third place is for the method “using non-medicinalproducts from organic origin” (23 registries). Comparing bygroups the registered “doctors” and “other practitioners withinthe healthcare system” it was established that the group of“doctors” prevail with. .By 15 May 2010 “doctors” are 98practitioners (versus 68 “other persona within the healthcaresystem”). The number of “doctors” prevail above the numberof “other persona within the healthcare system” in the practicingof all sections of non-conventional medicine, excluding thesection of “using non-conventional-physical methods”. In thepracticing of non-conventional medicine in our country at thisstage the monopoly of the medical speciality has been observed.

The conclusion is made that in our country the leading placeby the number of registered practitioners in the RHCs forpracticing non-conventional methods is occupied by bothmethods of “non-conventional physical methods” and “usingnon-medicinal products from organic origin”, which can beexplained by the inherited Bulgarian tradition for using differentmassage vehicles, cupping glass, medicinal plants, as well asbee products from the Bulgarian folk medicine. The ranking ofthe method “acupuncture and acupressure” (methods of thetraditional Chinese medicine) at the leading positions by thenumber of registered practitioners in the RHCs could beexplained by the great interest in theses methods, appeared inour country mainly over the last decade of the 20th century, withthe possibilities that arose for training in the application ofthese methods as well as the wide-spread use of literaturelaunched at our market.

As it was mentioned the number of practitioners registered inthe RHCs for practicing non-conventional methods is verysmall. For example their number by 31 December 2008 – 130registered practitioners in comparison to the registered numberof GPs in the country by 31 December 2008 (4894 GPs1), withwhom the National Health Insurance Fund (NHIF) concludedan agreement is too small and they consisted of nearly 2,66% ofthe doctors entering into agreement with the NHI and deliveringprimary healthcare. Practitioners practicing homeopathicmethod at that time consist of 34,67% of the total number ofthe GPs, concluding agreement with the NHIF. Whereas oneGP has approximately 1554 individuals from the population,one practitioners registered for practicing non-conventionalmedicine has on average 58512 individuals from thepopulation, having in mind that in 11 of the regions in thecountry there are no registered practitioners for practicing

ôèçèêàëíè ìåòîäè” (ñ 80 ëèöà, îò êîèòî 39 äîêòîðè),ñëåäâàò ìåòîäúò „èçïîëçâàíå íà íåëåêàðñòâåíè ïðîäóêòèîò îðãàíè÷åí ïðîèçõîä ( 66 ëèöà, îò êîèòî 38 äîêòîðè),ìåòîäèòå „àêóïóíêòóðà è àêóïðåñóðà” (ñ 57 ëèöà, îò êîèòî33 äîêòîðè) è ò.í.

Ïî áðîé ðåãèñòðèðàíè äîêòîðè â ÐÖÇ çà óïðàæíÿâàíå íàÍÌ âîäåùî ìÿñòî, êúì 15.05.10 ã., çàåìà õîìåîïàòè÷íèÿòìåòîä, à íàé-ãîëÿì å áðîÿò íà äðóãèòå ëèöà îò ñèñòåìàòàíà çäðàâåîïàçâàíåòî, êîèòî ñà ñå ðåãèñòðèðàëè çàóïðàæíÿâàíå íà „âñè÷êè íåêîíâåíöèîíàëíè ôèçèêàëíèìåòîäè” - 41 ëèöà. Ìåòîäúò „àêóïóíêòóðà è àêóïðåñóðà”ïî áðîé ðåãèñòðèðàíè äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî (24 ëèöà) çàåìà âòîðî ìÿñòî, íà òðåòîìÿñòî ñå íàðåæäà ìåòîäúò „èçïîëçâàíå íà íåëåêàðñòâåíèïðîäóêòè îò îðãàíè÷åí ïðîèçõîä ( 23 ëèöà). Ñðàâíÿâàéêèïî ãðóïè ðåãèñòðèðàíèòå äîêòîðè è äðóãèòå ëèöà îòñèñòåìàòà íà çäðàâåîïàçâàíåòî ñå óñòàíîâÿâà, ÷åïðåîáëàäàâà ãðóïàòà íà äîêòîðèòå, êúì 15.09.2009 ã òå ñà87, ñïðÿìî 65 äðóãè ëèöà îò ñèñòåìàòà íàçäðàâåîïàçâàíåòî. Êúì 15.05.2010 ã. äîêòîðèòå ñà 98 ëèöà,ñïðÿìî 68 äðóãè ëèöà îò ñèñòåìàòà íà çäðàâåîïàçâàíåòî.Áðîÿò íà äîêòîðèòå ïðåîáëàäàâà íàä áðîÿ íà äðóãèòå ëèöàîò ñèñòåìàòà íà çäðàâåîïàçâàíåòî ïðè óïðàæíÿâàíåòî íàâñè÷êè ðàçäåëè „ÍÌ”, ñ èçêëþ÷åíèå íà ðàçäåëà„èçïîëçâàíå íà íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè”.Ïðè óïðàæíÿâàíåòî íà ÍÌ ó íàñ íà òîçè åòàï èìàìîíîïîë íà ëåêàðñêàòà ïðîôåñèÿ.

Ìîæå äà ñå íàïðàâè çàêëþ÷åíèåòî, ÷å ó íàñ âîäåùî ìÿñòîïî áðîé ðåãèñòðèðàíè ëèöà â ÐÖÇ, çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè, çàåìàò ìåòîäèòå„íåêîíâåíöèîíàëíè ôèçèêàëíè ìåòîäè” è „èçïîëçâàíåíà íåëåêàðñòâåíè ïðîäóêòè îò îðãàíè÷åí ïðîèçõîä”. Òîâàìîæå äà ñå îáÿñíè ñ íàñëåäåíàòà áúëãàðñêà òðàäèöèÿ çàèçïîëçâàíå íà ðàçëè÷íè ìàñàæíè ïîõâàòè, âåíäóçè,ëå÷åáíè ðàñòåíèÿ, êàêòî è ï÷åëíè ïðîäóêòè â áúëãàðñêàòàíàðîäíà ìåäèöèíà. Çàåìàíåòî íà åäíà îò ÷åëíèòåïîçèöèè íà ìåòîäà “àêóïóíêòóðà è àêóïðåñóðà” (ìåòîäèíà òðàäèöèîííàòà êèòàéñêà ìåäèöèíà) ïî áðîéðåãèñòðèðàíè ëèöà â ÐÖÇ, ìîæå äà ñå îáÿñíè ñ ìàñîâèÿèíòåðåñ êúì òåçè ìåòîäè, âúçíèêíàë ó íàñ ãëàâíî ïðåçïîñëåäíîòî äåñåòèëåòèå íà 20-è âåê, ñúñ ñúçäàëèòå ñåâúçìîæíîñòè çà îáó÷åíèå ïî ïðèëàãàíåòî íà òåçè ìåòîäè,êàêòî è ñ øèðîêîòî íàâëèçàíå íà íàøèÿ ïàçàð íàñïåöèàëèçèðàíà ïî òåìàòà ëèòåðàòóðà.

Êàêòî âå÷å ñòàíà äóìà ðåãèñòðèðàíèòå ó íàñ ëèöà çàóïðàæíÿâàíå íà ÍÌ ñà èçêëþ÷èòåëíî ìàëêî. Áðîÿò èìêúì 31.12.2008ã. å 130 ëèöà, â ñðàâíåíèå ñ ðåãèñòðèðàíèÿáðîé îáùîïðàêòèêóâàùè ëåêàðè â ñòðàíàòà êúì 31.12.2008ã. (4894 ÎÏË - îáùîïðàêòèêóâàùè ëåêàðè), ñ êîèòî ÍÇÎÊå ñêëþ÷èëà äîãîâîð. Òå ñúñòàâëÿâàò åäâà 2,66% îò áðîÿëåêàðè, îñèãóðÿâàùè ïúðâè÷íà ìåäèöèíñêà ïîìîù. Ëèöàòà,óïðàæíÿâàùè õîìåîïàòè÷íèÿ ìåòîä êúì ñúùèÿ ïåðèîä,ñúñòàâëÿâàò 34,67% îò îáùèÿ áðîé ÎÏË, ñêëþ÷èëè äîãîâîðñ êàñàòà. Äîêàòî íà åäèí ÎÏË ñå ïàäàò ñðåäíî 1554 ÷îâåêàíàñåëåíèå, òî íà 1 ëèöå, ðåãèñòðèðàíî çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè, ñå ïàäàò ñðåäíî 58512 ÷îâåêà îòíàñåëåíèåòî. Òðÿáâà äà ñå èìà ïðåäâèä, ÷å â 11 îò îáëàñòèòå




non-conventional methods. Of the practitioners.Practicing the homeopathic method 1 doctor has anumber of 4482 individuals from the population.

According to data from pilot surveys carried out withcitizens in our country dated toward 20003., the providersof non-conventional healthcare services (herbalists,bone-settlers and sorceresses) were visited by 57,27%of the inquired citizens (42,4% of them are women and14,96% - men), and mediums were visited by 59,4% ofthe requested practitioners, of them 41,4% are womenand 18% are men (31). The biggest percentage of 18,38%is that of the citizens, aged 31-40 yrs, seeking for helpfrom mediums, followed by practitioners aged 41-50 yrs.– 15,38% of the inquired citizens.

Based on the data from pilot surveys conducted in ourcountry we can draw a final conclusion that these non-conventional methods are illegally practiced. The populationdelivers these services from illegal practitioners so-called“witch doctors” who have not gained medical educationand do not possess the right to practice non-conventionalmedicine in our country.. Having in mind the advertisementsin media for different witch doctors treating “101 diseases”etc., who take unfair advantage of people’s faith theconclusion made is that these practitioners are not familiarwith the regulations or on the contrary – they know theregulations but neglect the consequences that could arise.It is necessary to realize that the RHCs to strengthen thecontrol on the non-conventional methods practiced in thecountry in order not to admit the damaging of people’shealth by incompetent individuals. A disadvantage of theregulations for practicing the non-conventional methodsis the lack of mandatory training for applying of theindividual non-conventional methods in Bulgaria.Practitioners that applied different non-conventionalmethods on their own are trained as havind gained coursesorganized by different organizations, including privatecompanies which cannot guarantee high quality of thetraining proposed. Only training on homeopathy can beguaranteed by internationally adopted standards. Thehomeopathists in the country by 31 December 2008 as itwas mentioned are 1666 individuals; moreover, they aremasters in “Medicine” and “Dental medicine” having passeda training on the application of homeopathy. Thus, citizensthat are consumers of this method can be guaranteed safeand high-quality services delivered.

A survey conducted by Reader’s Digest for the healthof population in 11 European countries in 2008 (Belgium,Czech Republic, Finland, France, Germany, theNetherlands, Poland, Portugal, Russia, Switzerland, theUnited Kingdom) showed that 12% of the respondentson average have resorted to the services proposed byalternative therapists. The biggest number is inSwitzerland – 21% of the respondents, followed by Belgium– 15%; France, Germany, the Netherlands – 13%; CzechRepublic and the United Kingdom - 12%; Finland – 11%,Portugal – 10%, Russia – 8%, Poland – 4% (32). These datacompared versus the data obtained from the surveys in

â ñòðàíàòà íÿìà ðåãèñòðèðàíè ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè. Îò ëèöàòà, óïðàæíÿâàùèõîìåîïàòè÷íèÿ ìåòîä, 1 äîêòîð ñå ïàäà íà 4482 ÷îâåêà îòíàñåëåíèåòî.

Ïî äàííè îò àíêåòíè ïèëîòíè ïðîó÷âàíèÿ, ïðîâåäåíè ñãðàæäàíè ó íàñ, äàòèðàíè êúì 2000 ã., äîñòàâ÷èöè íàíåêîíâåíöèîíàëíè óñëóãè â ìåäèöèíàòà, (áèëêàðè,êîñòîïðàâè, áàÿ÷êè) ñà ïîñåùàâàíè îò 57,27% îòàíêåòèðàíèòå ãðàæäàíè (42,4% - æåíè è 14,96% - ìúæå), àåêñòðàñåíñè ñà ïîñåùàâàíè îò 59,4% îò àíêåòèðàíèòåãðàæäàíè. Îò òÿõ 41,4% ñà æåíè è 18% - ìúæå (31). Íàéãîëÿì å ïðîöåíòúò íà ãðàæäàíèòå, îáðúùàëè ñå êúìåêñòðàñåíñè, è êúì äðóãè äîñòàâ÷èöè íàíåêîíâåíöèîíàëíè óñëóãè íà âúçðàñò ìåæäó 31 è 40 ã.(18,38%), ñëåäâàíè îò ëèöàòà íà âúçðàñò ìåæäó 41 è 50 ã. –15,38%. Òúé êàòî ðåãèñòðèðàíèòå ëèöà çà óïðàæíÿâàíåíà ÍÌ â ÐÖÇ ó íàñ ñà èçêëþ÷èòåëíî ìàëêî, à â ãîëåìèðàéîíè, êàòî íàïðèìåð â Þãîçàïàäíèÿ ðàéîí íà ñòðàíàòà,íÿìà íèòî åäíî ðåãèñòðèðàíî ëèöå êúì 15.05.2010 ã., ìîæåäà ñå íàïðàâè èçâîäúò, ÷å òåçè ëèöà íå ìîãàò äà çàäîâîëÿòïîòðåáíîñòèòå íà íàñåëåíèåòî îò íåêîíâåíöèîíàëíèóñëóãè.

Áàçèðàéêè ñå íà äàííèòå îò ïèëîòíèòå àíêåòíèïðîó÷âàíèÿ, ïðîâåäåíè ñ ãðàæäàíè ó íàñ, ñå ñòèãà äîèçâîäà, ÷å òåçè íåêîíâåíöèîíàëíè ìåòîäè ó íàñ, âïîâå÷åòî ñëó÷àè, ñå óïðàæíÿâàò íåçàêîííî. Íàñåëåíèåòîñè äîñòàâÿ òåçè óñëóãè ãëàâíî îò ò.í. “ëå÷èòåëè”, êîèòîíÿìàò ìåäèöèíñêî îáðàçîâàíèå è íà òîçè åòàï íÿìàòïðàâî äà óïðàæíÿâàò ÍÌ ó íàñ. Òåçè ëèöà íå ïîçíàâàòíîðìàòèâíàòà óðåäáà èëè ïúê íàïðîòèâ – ïîçíàâàò ÿäîáðå, íî íåõàÿò çà ïîñëåäñòâèÿòà, êîèòî ìîãàò äàíàñòúïÿò. Íåîáõîäèìî å ÐÖÇ äà çàñèëÿò êîíòðîëà ñè âúðõóóïðàæíÿâàíèòå â ñòðàíàòà íåêîíâåíöèîíàëíè ìåòîäè, çàäà íå ñå äîïóñêà óâðåæäàíå íà çäðàâåòî íà ãðàæäàíèòå îòíåêîìïåòåíòíè ëèöà. Íåäîñòàòúê íà íîðìàòèâíàòà óðåäáà,êàñàåùà óïðàæíÿâàíåòî íà ÍÌ ó íàñ, å íåèçèñêâàíåòî íàçàäúëæèòåëíî îáó÷åíèå ïî ïðèëàãàíåòî íà îòäåëíèòå ÍÌ.Ëèöàòà, êîèòî ïðèëàãàò îòäåëíè ÍÌ, ñàìè ñå ãðèæàò çàîáó÷åíèåòî ñè. Òå ïðåìèíàâàò ïðåç êóðñîâå,îðãàíèçèðàíè îò ðàçëè÷íè îðãàíèçàöèè, â òîâà ÷èñëî èîò ÷àñòíè ôèðìè, êîèòî íå ìîãàò äà ãàðàíòèðàò âèñîêîêà÷åñòâî íà ïðåäëàãàíîòî îáó÷åíèå. Åäèíñòâåíî çàîáó÷åíèåòî ïî õîìåîïàòèÿ â ñòðàíàòà íà òîçè åòàï ìîæåäà ñå ãàðàíòèðà „îáó÷åíèå ïî ìåæäóíàðîäíî ïðèåòèñòàíäàðòè”. Õîìåîïàòèòå â ñòðàíàòà, êúì 31.12.2008 ã., ñà1666 ëèöà, ïðè òîâà ìàãèñòðè ïî “Ìåäèöèíà” è “Äåíòàëíàìåäèöèíà”. Òå ñà ïðåìèíàëè îáó÷åíèå çà ïðèëàãàíå íàõîìåîïàòè÷íèÿ ìåòîä è íà ãðàæäàíèòå, ïîòðåáèòåëè íàòîçè ìåòîä â ñòðàíàòà, ìîæå äà ñå ãàðàíòèðà áåçîïàñíà èêà÷åñòâåíà óñëóãà.

Ïðîó÷âàíå, ïðîâåäåíî îò ñïèñàíèåòî Reader’s Digest çàçäðàâåòî íà íàñåëåíèåòî â 11 åâðîïåéñêè ñòðàíè çà 2008 ã.(Áåëãèÿ, ×åõèÿ, Ôèíëàíäèÿ, Ôðàíöèÿ, Ãåðìàíèÿ,Íèäåðëàíäèÿ, Ïîëøà, Ïîðòóãàëèÿ, Ðóñèÿ, Øâåéöàðèÿ,Âåëèêîáðèòàíèÿ) ïîêàçâà, ÷å êúì óñëóãè íà àëòåðíàòèâíèëå÷èòåëè ñà ïðèáÿãâàëè ñðåäíî 12% îò àíêåòèðàíèòå ëèöà.Íàé-ãîëÿì å òåõíèÿò áðîé â Øâåéöàðèÿ - 21%, ñëåäâàò Áåëãèÿ



Bulgaria show that in our country the number of practitionersseeking help from the providers of alternative health servicesis higher than the mentioned countries, although the numberof legally practicing therapists delivering these services islower.

A tendency for growth of the consumption of herbal nutritionsupplements by the population has been observed both inthe EU and in Bulgaria (a survey conducted from the Reader’sDigest Magazine in 2008 showed that on average foã the11th European countries included herbal supplements weretaken on a regular basis by 23% of the respondents, as thebiggest number is in the Czech Republic – 43%, followed byPoland – 29%, Switzerland – 25%; Finland – 24%; Russia –22%; Belgium – 21%; the Netherlands – 20%; Portugal andthe United Kingdom – by 19%; France and Germany – by18% (32). The same tendency was observed in our country,too. For example by data from consolidating report for theactivities of Sopharma Company for the first six months ofthe 2008 it was pointed out that the world tendency forincrease in the consumption of food supplements has alreadybeen observed at the Bulgarian pharmaceutical market (33).

By 15 May .2010 in our country the Bulgarian legislation didnot correspond to the real needs of the population withregard to the provision of non-conventional methodspermitted in the country. In order to observe the principlefor freedom of choosing health services by the patient andto guarantee the safety, quality and effectiveness of theseservices for the citizens, it is necessary that the Bulgarianlegislation to include all applied in the country non-conventional methods in the “permitted list” since at themoment illegally practicing practitioners have provided thesemethods to the Bulgarian citizens. Urgently the problem forimplementing the training needed by the Health Law for theindividuals without having medical education for practicingnon-conventional methods should be handled. Thesepractitioners for the moment have practiced illegally andour legislation cannot guarantee the safety of the citizensthat use this kind of services. There is no official informationconcerning the expenditures made by the Bulgarian citizensin using the non-conventional healthcare services by healersfor whom there exist data that 2-3-5 times and more prevailthe paid healthcare services delivered by medicalpractitioners..

On the other hand, there is a tendency for ignoring theessence of the individual non-conventional methods byexperts in the RHCs. Thus, in 9 RHCs by 15 September.2009in the country there have been existed malpractices in theregistration of practitioners for practicing non-conventionalmethods relating to the registry of methods non-allowed forapplication in the Republic of Bulgaria (RHCs – Sofia City,Varna, Blagoevgrad); in the RHCs of Plovdiv and Burgasfor practicing the homeopathic method were registeredpractitioners for whom was nor clearly pointed out that theywere “doctors”; in the RHCs of Dobrich, Vratsa andTargovishte were not described the non-conventionslmethods applied; in the RHCs of Sofia City, Targovishteand Sliven an error was done in the indication of the name of

– 15%; Ôðàíöèÿ, Ãåðìàíèÿ, Íèäåðëàíäèÿ – ñ ïî 13%; ×åõèÿè Âåëèêîáðèòàíèÿ - 12%; Ôèíëàíäèÿ – 11%, Ïîðòóãàëèÿ –10%, Ðóñèÿ – 8%, Ïîëøà – 4% (32). Òåçè äàííè, ñðàâíåíè ñäàííèòå îò ïðîó÷âàíèÿòà â Áúëãàðèÿ, ãîâîðÿò, ÷å ó íàñ áðîÿòíà ëèöàòà, îáðúùàùè ñå êúì äîñòàâ÷èöè íà àëòåðíàòèâíèìåäèöèíñêè óñëóãè å ïî-ãîëÿì, âúïðåêè ÷å çàêîííîðàáîòåùèòå äîñòàâ÷èöè íà òåçè óñëóãè ó íàñ ñà ìàëêî.

Â åâðîïåéñêèòå ñòðàíè è ó íàñ ñå íàáëþäàâà òåíäåíöèÿ çàíàðàñòâàíå íà ïîòðåáëåíèåòî íà áèëêîâè õðàíèòåëíèäîáàâêè. Ïðîó÷âàíå, ïðîâåäåíî îò ñïèñàíèåòî Reader’sDigest çà 2008 ã., ïîêàçâà, ÷å ñðåäíî çà âêëþ÷åíèòå 11åâðîïåéñêè ñòðàíè, ðåãóëÿðíî ïðèåìàíå íà áèëêîâè äîáàâêèñå íàáëþäàâà ïðè 23% îò àíêåòèðàíèòå ëèöà. Íàé-ãîëÿì åáðîÿò èì â ×åõèÿ – 43%, ñëåäâàíà îò Ïîëøà – 29%,Øâåéöàðèÿ – 25%; Ôèíëàíäèÿ – 24%; Ðóñèÿ – 22%; Áåëãèÿ –21%; Íèäåðëàíäèÿ – 20%; Ïîðòóãàëèÿ è Âåëèêîáðèòàíèÿ –ïî 19%; Ôðàíöèÿ è Ãåðìàíèÿ – ïî 18% (32). Ñúùàòàòåíäåíöèÿ ñå íàáëþäàâà è ó íàñ. Ïî äàííè íà êîíñîëèäèðàíäîêëàä çà äåéíîñòòà íà ãðóïà „Ñîôàðìà”, çà ïúðâîòîïîëóãîäèå íà 2008 ã, å ïîñî÷åíî, ÷å âå÷å è â áúëãàðñêèÿôàðìàöåâòè÷åí ïàçàð ñå çàáåëÿçâà ñâåòîâíàòà òåíäåíöèÿ çàóâåëè÷àâàíå íà ïîòðåáëåíèåòî íà õðàíèòåëíè äîáàâêè (33).

Êúì 15.05.2010 ã. áúëãàðñêîòî çàêîíîäàòåëñòâî íå îòãîâàðÿíà îáåêòèâíèòå ïîòðåáíîñòè íà íàñåëåíèåòî ïî îòíîøåíèåíà îñèãóðÿâàíåòî ñ ðàçðåøåíè çà ïðèëàãàíå â ñòðàíàòàíåêîíâåíöèîíàëíè ìåòîäè. Çà äà ñå ñïàçè ïðèíöèïúò çàñâîáîäà íà èçáîð íà çäðàâíè óñëóãè îò ïàöèåíòà è çà äà ñåãàðàíòèðà íà ãðàæäàíèòå áåçîïàñíîñò, êà÷åñòâî èåôåêòèâíîñò íà òåçè óñëóãè, å íåîáõîäèìî áúëãàðñêîòîçàêîíîäàòåëñòâî äà âêëþ÷è â “ðàçðåøåíèÿ ñïèñúê” âñè÷êèïðèëàãàíè â ñòðàíàòà íåêîíâåíöèîíàëíè ìåòîäè. Ñåãàáúëãàðñêèòå ãðàæäàíè ñè ãè äîñòàâÿò îò íåçàêîííîïðàêòèêóâàùè ãè ëèöà. Ñïåøíî òðÿáâà äà ñå ðåøè âúïðîñúòñ âúâåæäàíåòî íà èçèñêâàíîòî îò Çàêîíà çà çäðàâåòîîáó÷åíèå çà ëèöàòà áåç ìåäèöèíñêî îáðàçîâàíèå,ïðàêòèêóâàùè íåêîíâåíöèîíàëíè ìåòîäè ó íàñ. Òåçè ëèöà âíàñòîÿùèÿ ìîìåíò ïðàêòèêóâàò íåçàêîííî èçàêîíîäàòåëñòâîòî íè íå ìîæå äà ãàðàíòèðà áåçîïàñíîñòòàíà ãðàæäàíèòå, ïîëçâàùè òåçè óñëóãè. Ó íàñ ëèïñâàîôèöèàëíà èíôîðìàöèÿ çà ðàçõîäèòå, íàïðàâåíè îòáúëãàðñêèòå ãðàæäàíè, ïðè ïîëçâàíåòî íàíåêîíâåíöèîíàëíè çäðàâíè óñëóãè îò ëå÷èòåëè. Ïîíåîôèöèàëíè äàííè òåçè ðàçõîäè ñà 2-3-5 ïúòè ïîâå÷å îòïëàòåíèòå çäðàâíè óñëóãè, îêàçâàíè îò ìåäèöèíñêèñïåöèàëèñòè.

Îò äðóãà ñòðàíà, ó íàñ ñå íàáëþäàâà íåïîçíàâàíå íàñúùíîñòòà íà îòäåëíèòå ÍÌ îò åêñïåðòè â ÐÖÇ. Íàïðèìåðâ 9 ÐÖÇ, êúì 15.09.2009 ã., ñà äîïóñíàòè íàðóøåíèÿ ïðèðåãèñòðèðàíåòî íà ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè, îòíàñÿùè ñå äî: ðåãèñòðèðàíåíà ìåòîäè, çàáðàíåíè çà ïðèëàãàíå â Ð Áúëãàðèÿ (ÐÖÇ –Ñîôèÿ-ãðàä, Âàðíà, Áëàãîåâãðàä); â ÐÖÇ Ïëîâäèâ è Áóðãàñçà óïðàæíÿâàíå íà õîìåîïàòè÷íèÿ ìåòîä ñà ðåãèñòðèðàíèëèöà, çà êîèòî íå å ïîñî÷åíî, ÷å ñà äîêòîðè. Â ÐÖÇ Äîáðè÷,Âðàöà è Òúðãîâèùå íå ñà îïèñàíè ïðèëàãàíèòåíåêîíâåíöèîíàëíè ìåòîäè; â ÐÖÇ Ñîôèÿ-ãðàä, Òúðãîâèùåè Ñëèâåí å äîïóñíàòî íàðóøåíèå ïðè îçíà÷àâàíå íà èìåòî


the register of practitioners practicing non-conventionalmethods. This imposes the need of implementation of atraining of the experts from the RHCs throughout thecountry in order to familiarize them the nature of the non-conventional methods allowed for using in the Republic ofBulgaria.

IV. Conclusions:

1. No recognition was made by the Bulgarian legislationto all non-conventional methods practiced in thecountry; that is why, they are practiced illegally atthe present moment.

2. It is not well known the number of all non-conventional methods used in the country.

3. At the present moment non-conventional methods inmedicine are being used legally by practitioners thathave an educational qualification degree “Master”in Medicine, Dental medicine, Pharmacy or thosewho gained educational qualification degree of“specialist” or “bachelor” in the field of healthcare.No resources have been assigned for thedevelopment of cadres that delivered non-conventional healthcare services.

4. Practitioners without medical education i.e. healers atthis moment could not practice non-conventionalmethods as they did not gained the training requiredby the Health Law. At the present moment the so-called healers apply non-conventional treatmentsillegally in the country. The healers in the countrymainly use the non-allowed non-conventionalmethod “bioenergytherapy”. The exact number ofthe healers practicing NCM is not known..

5. There is a great number of citizens who request non-conventional services from providers including fromthe so-called “psychics”.

6. There is a lack of legally requested training on thedifferent non-conventional methods.

7. Databases of NCM practitioners and the appliedpreparations on a plant etc basis are insufficient withregard to the consumers of non-conventionalmethods in the country, which can be seen in theOrdinance No.7 of the Ministry of Health.

8. There are malpractice admitted by the RHCs in theregistration of practitioners for using non-conventional methods relating to the registration ofmethods banned for application in the Republic ofBulgaria (RHC – Sofia City, Varna); in the RHCs ofPlovdiv and Burgas for practicing the homeopathicmethod were registered practitioners for whom wasnot pointed whether they were physicians; in the RHCsof Dobrich,. Vratsa, and Targovishte there were nodescribed the different non-conventional methodsemployed by practitioners.

íà ðåãèñòúðà íà ëèöàòà, ïðàêòèêóâàùè íåêîíâåíöèîíàëíèìåòîäè. Òîâà íàëàãà âúâåæäàíå íà îáó÷åíèå çà åêñïåðòèòåîò ÐÖÇ â ñòðàíàòà, ñ öåë çàïîçíàâàíåòî èì ñ åñòåñòâîòî íàíåêîíâåíöèîíàëíèòå ìåòîäè, ðàçðåøåíè çà ïðèëàãàíå â ÐÁúëãàðèÿ.

IV. Èçâîäè

1. Íå ñà ïðèçíàòè îò áúëãàðñêîòî çàêîíîäàòåëñòâî âñè÷êèïðàêòèêóâàíè â ñòðàíàòà íåêîíâåíöèîíàëíè ìåòîäè,ïîðàäè êîåòî, â íàñòîÿùèÿ ìîìåíò òå ñå ïðàêòèêóâàòíåçàêîííî.

2. Íå å èçâåñòåí áðîÿò íà âñè÷êè èçïîëçâàíè ó íàñíåêîíâåíöèîíàëíè ìåòîäè.

3. Íåêîíâåíöèîíàëíè ìåòîäè â ìåäèöèíàòà ó íàñ ñåóïðàæíÿâàò ëåãàëíî îò ëèöà, ïðèòåæàâàùèîáðàçîâàòåëíî-êâàëèôèêàöèîííà ñòåïåí “Ìàãèñòúð”ïî ïðîôåñèîíàëíè íàïðàâëåíèÿ “Ìåäèöèíà”,“Äåíòàëíà ìåäèöèíà”, “Ôàðìàöèÿ” èëè - ïðèòåæàâàùè,îáðàçîâàòåëíî-êâàëèôèêàöèîííà ñòåïåí “Ñïåöèàëèñò”èëè “Áàêàëàâúð” ïî ïðîôåñèîíàëíî íàïðàâëåíèå“Çäðàâíè ãðèæè”. Íå ñà îòäåëåíè ðåñóðñè çà ðàçâèòèåíà êàäðè, äîñòàâÿùè íåêîíâåíöèîíàëíè çäðàâíè óñëóãè.

4. Ëèöàòà áåç ìåäèöèíñêî îáðàçîâàíèå, ò.í. ëå÷èòåëè, íàòîçè åòàï âñå îùå íå ìîãàò äà óïðàæíÿâàòíåêîíâåíöèîíàëíè ìåòîäè, òúé êàòî íå ñà ïðåìèíàëèèçèñêâàíîòî, îò Çàêîíà çà çäðàâåòî, îáó÷åíèå. Âíàñòîÿùèÿ ìîìåíò ò.í. ëå÷èòåëè ïðèëàãàòíåêîíâåíöèîíàëíè ìåòîäè â ìåäèöèíàòà ó íàñíåçàêîííî. Òå óïðàæíÿâàò îñíîâíî íåðàçðåøåíèÿíåêîíâåíöèîíàëåí ìåòîä “áèîåíåðãîòåðàïèÿ”. Íå åèçâåñòåí áðîÿò íà ëå÷èòåëèòå, óïðàæíÿâàùèíåêîíâåíöèîíàëíè ìåòîäè â ñòðàíàòà íè.

5. Ãîëÿì å áðîÿò íà ãðàæäàíèòå, êîèòî ñå îáðúùàò êúìäîñòàâ÷èöè íà íåêîíâåíöèîíàëíè óñëóãè âìåäèöèíàòà, â òîâà ÷èñëî è êúì “åêñòðàñåíñè”.

6. Ëèïñâà çàêîíîâî èçèñêâàíî îáó÷åíèå ïî îòäåëíèòåíåêîíâåíöèîíàëíè ìåòîäè.

7. Íåäîñòàòú÷íà å ôàêòè÷åñêàòà áàçà-äàííè ïî îòíîøåíèå:íà ïîòðåáèòåëèòå íà íåêîíâåíöèîíàëíè óñëóãè âñòðàíàòà, íà ïðàêòèêóâàíèòå â ñòðàíàòàíåêîíâåíöèîíàëíè ìåòîäè è íà ïðèëàãàíèòå ñðåäñòâàíà ðàñòèòåëíà è äð. îñíîâà, îïèñàíè â íàðåäáà ¹7 íàÌÇ.

8. Îò ÐÖÇ â ñòðàíàòà ñà äîïóñíàòè íàðóøåíèÿ ïðèðåãèñòðèðàíåòî íà ëèöà çà óïðàæíÿâàíå íàíåêîíâåíöèîíàëíè ìåòîäè, îòíàñÿùè ñå ãëàâíî äî:ðåãèñòðèðàíå íà ìåòîäè, çàáðàíåíè çà ïðèëàãàíå â ÐÁúëãàðèÿ (ÐÖÇ – Ñîôèÿ-ãðàä, Âàðíà); â ÐÖÇ Ïëîâäèâ èÁóðãàñ çà óïðàæíÿâàíå íà õîìåîïàòè÷íèÿ ìåòîä ñàðåãèñòðèðàíè ëèöà, çà êîèòî íå å ïîñî÷åíî, ÷å ñà ëåêàðè;â ÐÖÇ Äîáðè÷, Âðàöà è Òúðãîâèùå íå ñà îïèñàíèïðèëàãàíèòå íåêîíâåíöèîíàëíè ìåòîäè è äð.



9. Ëèöàòà, ðåãèñòðèðàíè çà ïðàêòèêóâàíå íàíåêîíâåíöèîíàëíè ìåòîäè ó íàñ, ñà îòíîñèòåëíî ìàëêîíà áðîé – 166 ëèöà êúì 15.05.2010 ã. Òå íå áèõà ìîãëè äàçàäîâîëÿò ïîòðåáíîñòèòå íà íàñåëåíèåòî îòíåêîíâåíöèîíàëíè óñëóãè. Èçêëþ÷åíèå ïðàâèõîìåîïàòè÷íèÿò ìåòîä, ïî ÷èåòî ïðèëàãàíå îáó÷åíèåñà ïðåìèíàëè 1666 ëèöà, êúì 31.12.08 ã.

10. Ëèïñâà èíôîðìàöèÿ çà ðàçõîäèòå, íàïðàâåíè îòáúëãàðñêîòî íàñåëåíèå, ïðè íàçíà÷àâàíåòî èëèñàìîíàçíà÷àâàíåòî íà õðàíèòåëíè äîáàâêè, ñúäúðæàùèðàñòåíèÿ.Çà äà îòãîâîðè íà ïîòðåáíîñòèòå íà áúëãàðñêîòîíàñåëåíèå îò îñèãóðÿâàíåòî ìó ñ íåêîíâåíöèîíàëíèóñëóãè, êàñàåùè çäðàâåòî è çà äà ñå ãàðàíòèðà íàãðàæäàíèòå ñèãóðíîñò è áåçîïàñíîñò ïðè ïîëçâàíåòîíà òåçè óñëóãè, å íåîáõîäèìî çàêîíîäàòåëÿò äàïðåäïðèåìå äåéñòâèÿ ïî:Âêëþ÷âàíå îò áúëãàðñêîòî çàêîíîäàòåëñòâî “âðàçðåøåíèÿ ñïèñúê” íà âñè÷êè íåêîíâåíöèîíàëíèìåòîäè, êîèòî â òîçè ìîìåíò ó íàñ ñå óïðàæíÿâàòíåçàêîííî.Ïî òîçè íà÷èí ùå ñå îñèãóðè äîñòúï äî ðàçëè÷íèíåêîíâåíöèîíàëíè óñëóãè, êîèòî ñà ïðåäïî÷èòàíè îòáúëãàðñêèòå ãðàæäàíè, çà äà íå ñè ãè äîñòàâÿò òå îòíåçàêîííî ïðàêòèêóâàùè ãè ëèöà.

11. Îðãàíèçèðàíå è ïðîâåæäàíå íà èçèñêâàíîòî îò Çàêîíàçà çäðàâåòî îáó÷åíèå çà ëèöàòà ñ íåìåäèöèíñêîîáðàçîâàíèå, ò.í. „ëå÷èòåëè”, êîèòî æåëàÿò äàóïðàæíÿâàò íåêîíâåíöèîíàëíè ìåòîäè.

12. Âúâåæäàíå íà çàäúëæèòåëíî îáó÷åíèå ïî îòíîøåíèå íàïðàêòèêóâàíèòå íåêîíâåíöèîíàëíè ìåòîäè çà âñè÷êèëèöà, êîèòî æåëàÿò äà ãè óïðàæíÿâàò.

13. Îðãàíèçèðàíå è ïðîâåæäàíå íà îáó÷åíèå çà åêñïåðòè îòÐÖÇ â ñòðàíàòà ïî îòíîøåíèå íà åñòåñòâîòî íàíåêîíâåíöèîíàëíèòå ìåòîäè.


1. Íàðåäáà ¹7 îò 01.03.2005 ã. çà èçèñêâàíèÿòà êúì äåéíîñòòà íàëèöàòà, êîèòî óïðàæíÿâàò íåêîíâåíöèîíàëíè ìåòîäè çàáëàãîïðèÿòíî âúçäåéñòâèå âúðõó èíäèâèäóàëíîòî çäðàâå, îáí.ÄÂ, áð.22 îò 15.03.2005 ã.Ordinance No. 7 as of 1st March, 2005 for the requirements for theactivities of practitioners who practice non-conventional methodsfor favorable effects in the human health, published in the StateGazette, No. 22 of 15th March 2005.

2.Council of Europe. Legislation and administrative regulations on theuse by licensed health service personnel of non-conventionalmethods of diagnosis and treatment of illness, Strasburg, 1984

3. WHO Traditional Medicine Strategy 2002-2005, WHO, Geneva

4. Çàêîí çà çäðàâåòî (ïóáë. ÄÂ áð.70 îò 10.08.2004 ã.)Health Law (published in State Gazette No. 70 dated 10 August2004)

5. Äîêëàä çà çäðàâåòî íà íàöèÿòà ïðåç 2008 ã.Report for the nation’s health in 2008

9. Practitioners registered for using non-conventionalmethods in our country by 31.12.2008 are only in 17 ofthe RHCs as they are relatively small in number – 130practitioners, and by 15.05.2010 they are 166 individuals.They could not satisfy the needs of the populationfrom non-conventional healthcare services. The onlyexception was done for the homeopathic method onwhich application 1666 practitioners acquired trainingby 31.12.2008.

10. There is a lack of information concerning the costs madeby the Bulgarian population in the administration orself-prescription of food additives containing plants. In order to meet the needs of the Bulgarian populationwith the provision of non-conventional treatmentsinfluencing the human health and to guarantee thesafety and certainty of the citizens when using theseservices the following measures should be undertakenby legislators, namely:Including by the Bulgarian legislation in “the permittedlist” of all non-conventional methods which at thismoment are practiced illegally in our country. Thus, anaccess will be provided to different non-conventionalservices, which are preferred by the Bulgarian citizensin order to get rid of illegally practicing healers..

11. Organizing and conducting of the training required bythe Health Law for all the practitioners with non-medicaleducation – so-called healers, who are keen onpracticing non-conventional methods.

12. Implementation of obligatory training with regard to thepracticing of non-conventional methods for allpractitioners that desire to employ them.

13. Organizing and conducting of a training for the expertsfrom the RHCs of the country concerning the characterof non-conventional methods.

6.Ðåãèñòðè, Available at www.rczbl.orgq, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rczbl.orgq, Accessed May, 15,2010, September 15, 2009

7. Ðåãèñòðè, Available at www.rcz-bourgas.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-bourgas.com, Accessed May, 15,2010, September 15, 2009

8. Ðåãèñòðè, Available at www.rcz-varna.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-varna.com, Accessed May, 15,2010, September 15, 2009

9. Ðåãèñòðè, Available at www.rczvidin.hit, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rczvidin.hit, Accessed May, 15,2010, September 15, 2009



10. Ðåãèñòðè, Available at www.rcz-vtarnovo.info, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-vtarnovo.info, Accessed May, 15,2010, September 15, 2009

11. Ðåãèñòðè, Available at www.rcz-dobrich.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-dobrich.org, Accessed May, 15,2010, September 15, 2009

12. Ðåãèñòðè, Available at www.rcz-kardzhali.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-kardzhali.com, Accessed May, 15,2010, September 15, 2009

13. Ðåãèñòðè, Available at www.rcz-kn.net, Accessed May, 15, 2010,September 15, 2009Registries. Available at www.rcz-kn.net, Accessed May, 15, 2010,September 15, 2009

14. Ðåãèñòðè, Available at www.rcz-lovech.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-lovech.com, Accessed May, 15,2010, September 15, 2009

15. Ðåãèñòðè, Available at www.rcz-montana.hit.bg, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-montana.hit.bg, Accessed May, 15,2010, September 15, 2009

16. Ðåãèñòðè, Available at www.rcz-pz.com, Accessed May, 15, 2010,September 15, 2009Registries. Available at www.rcz-pz.com, Accessed May, 15, 2010,September 15, 2009

17. Ðåãèñòðè, Available at www.rcz-pernik.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-pernik.com, Accessed May, 15, 2010,September 15, 2009

18. Ðåãèñòðè, Available at www.rcz-pleven.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-pleven.com, Accessed May, 15,2010, September 15, 2009

19. Ðåãèñòðè, Available at free.hit.bg/rczpd, Accessed May, 15, 2010,September 15, 2009Registries. Available at free.hit.bg/rczpd, Accessed May, 15, 2010,September 15, 2009

20. Ðåãèñòðè, Available at rczrazgrad.my.contact.bg, Accessed May, 15,2010, September 15, 2009Registries. Available at rczrazgrad.my.contact.bg, Accessed May, 15,2010, September 15, 2009

21. Ðåãèñòðè, Available at www.rcz.hit.bg, Accessed May, 15, 2010,September 15, 2009Registries. Available at www.rcz.hit.bg, Accessed May, 15, 2010,September 15, 2009

22. Ðåãèñòðè, Available at www.rcz-silistra.com, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-silistra.com, Accessed May, 15,2010, September 15, 2009


Äîö. ä-ð Èëèÿíà ßíåâà-ÁàëàáàíñêàÍàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçèÒåë.: 02 8056340

Email [email protected]

23.Ðåãèñòðè, Available at www.rcz.sliven.info, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz.sliven.info, Accessed May, 15,2010, September 15, 2009

24.Ðåãèñòðè, Available at www.rcz-smolyan.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-smolyan.org, Accessed May, 15,2010, September 15, 2009

25.Ðåãèñòðè, Available at www.rczsofia.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rczsofia.org, Accessed May, 15,2010, September 15, 2009

26.Ðåãèñòðè, Available at www.rczsofob.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rczsofob.org, Accessed May, 15,2010, September 15, 2009

27.Ðåãèñòðè, Available at www.rcz-starazagora.org, Accessed 15May 2010, 15 September 2009Registries. Available at www.rcz-starazagora.org, Accessed 15May 2010, 15 September 2009

28.Ðåãèñòðè, Available at www.rcz-targovishte.com, Accessed May,15, 2010, September 15, 2009Registries. Available at www.rcz-targovishte.com, Accessed May,15, 2010, September 15, 2009

29.Ðåãèñòðè, Available at www.rcz-haskovo.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-haskovo.org, Accessed May, 15,2010, September 15, 2009

30.Ðåãèñòðè, Available at www.rcz-yambol.org, Accessed May, 15,2010, September 15, 2009Registries. Available at www.rcz-yambol.org, Accessed May, 15,2010, September 15, 2009

31.ßíåâà-Áàëàáàíñêà, È. Íåêîíâåíöèîíàëíè ìåòîäè çàäèàãíîñòèêà è ëå÷åíèå â Áúëãàðèÿ, Èçäàòåëñòâî “Èëèíäà-Åâòèìîâ”, Ñ., 2006.Yaneva-Balabanska, I. Non-conventional methods for diagnosticsand treatment in Bulgaria. Publishing Office “Ilinda-Evtimov”,Sofia, 2006

32.Europe Health 2008; Reader’s Digest; Available at http://www.rdtrustedbrands.com/health/, Accessed May 15, 2010Êîíñîëèäèðàí äîêëàä çà äåéíîñòòà íà ãðóïà Ñîôàðìà çàïúðâîòî ïîëóãîäèå íà 2008 ã Available at http://209.85.135.132/search?q=cache:WxIZDxaL0QgJ: www.investor.bg/bull/upload/=lang_bg, Accessed September, 15, 2009Consolidated report for the activities of the group Sopharma for thefirst six months of the 2008. Available at http://209.85.135.132/search?q=cache:WxIZDxaL0QgJ: www.investor.bg/bull/upload/=lang_bg, Accessed September, 15, 2009


Assoc. Prof. Iliana Yaneva-BalabanskaNational Center of Health Protection and AnalysesTel.: 02 8056340

Email [email protected]



ÌÓËÒÈÍÀÖÈÎÍÀËÍÎ ÏÐÎÓ×ÂÀÍÅÇÀ ÎÖÅÍÊÀ ÍÀ ÊÀ×ÅÑÒÂÎÒÎ, ÐÀÇÕÎ-ÄÈÒÅ È ÐÀÂÍÎÏÎÑÒÀÂÅÍÎÑÒÒÀ ÏÐÈÏÚÐÂÈ×ÍÀÒÀ ÌÅÄÈÖÈÍÑÊÀÏÎÌÎÙ, QUALICOPC

Ïåòêî Ñàë÷åâ 1, Willemijn Sch fer2, Wienke Boerma2,Peter Groenewegen3

1Íàöèîíàëåí öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçè,Áúëãàðèÿ

2NIVEL, Netherlands Institute for Health Servicesesearch, Utrecht, The Netherlands

3Department of Sociology and Department of HumanGeography, Utrecht University, Utrecht, The Netherlands

Ðåçþìå

Äíåñ, óêðåïâàíåòî íà ïúðâè÷íàòà ìåäèöèíñêà ïîìîù âñâåòîâåí ìàùàá å âúâ ôîêóñà íà äíåâíèÿ ðåä íà ó÷åíè èïîëèòèöè, ïîâå÷å îò âñÿêîãà (1). Ïúðâè÷íàòà ìåäèöèíñêàïîìîù ñå î÷àêâà äà áúäå åäèí åôåêòèâåí îòãîâîð íàïîñëåäèöèòå îò íàñòîÿùàòà èêîíîìè÷åñêà êðèçà âúðõóçäðàâåòî è çäðàâåîïàçâàíåòî. Ñòðàòåãèÿòà âïîëèòèêàòà êúì óêðåïâàíåòî íà ïúðâè÷íàòà ìåäèöèíñêàïîìîù ÷åñòî ñå îñíîâàâà íà èäåÿòà, ÷å åäíà ñèëíà ñèñòåìàíà ïúðâè÷íà çäðàâíà ïîìîù å îò ïîëçà çà çäðàâåòî íàíàöèÿòà è ñúîòâåòíî - çà çäðàâíàòà ñèñòåìà.Ïúðâè÷íàòà ìåäèöèíñêà ïîìîù (ÏÌÏ) èìà ïîòåíöèàëàäà äîïðèíåñå çà öÿëîñòíîòî ðàçâèòèå íà çäðàâíàòàñèñòåìà è ïîäîáðÿâàíå íà çäðàâåòî íà íàñåëåíèåòî (2,3).

Ïðåç 2010 ã. çàïî÷íà ïðîåêòúò QUALICOPC (Quality andCosts of Primary Care in Europ / Êà÷åñòâî è ðàçõîäè âïúðâè÷íàòà ìåäèöèíñêà ïîìîù â Åâðîïà). Öåëòà íàïðîåêòà è ïðîó÷âàíåòî å äà ñå îöåíè êà÷åñòâîòî,ðàçõîäèòå, åôåêòèâíîñòòà è ðàâíîïîñòàâåíîñòòà âïúðâè÷íàòà ìåäèöèíñêà ïîìîù â åâðîïåéñêèòå ñòðàíè.Èçñëåäîâàòåëèòå, âêëþ÷åíè â òîâà ïðîó÷âàíå, ñå îïèòâàòäà äàäàò îòãîâîð íà âúïðîñà, êàêâè ñà ïîëçèòå îòïúðâè÷íàòà ìåäèöèíñêà ïîìîù è êàêúâ å åôåêòúò íà ÏÌÏâúðõó ñèñòåìèòå íà çäðàâåîïàçâàíå. Ïðîó÷âàíåòî ñåôèíàíñèðà îò Åâðîïåéñêàòà êîìèñèÿ ïî ò.í. “Ñåäìàðàìêîâà ïðîãðàìà” è ñå îñúùåñòâÿâà îò êîíñîðöèóì îò6 èçñëåäîâàòåëñêè èíñòèòóòà îò Áåëãèÿ, Ãåðìàíèÿ,Èòàëèÿ, Õîëàíäèÿ è Ñëîâåíèÿ. Êîîðäèíèðà ñå îò NIVEL,Õîëàíäèÿ - Èíñòèòóò çà íàó÷íè èçñëåäâàíèÿ âçäðàâåîïàçâàíåòî. Â òàçè ñòàòèÿ å îïèñàíà îñíîâàòà èäèçàéíúò íà ïðîåêòà QUALICOPC è ïðîó÷âàíåòî.

Êëþ÷îâè äóìè: ïúðâè÷íà ìåäèöèíñêà ïîìîù,ïðîó÷âàíå, åôåêòèâíîñò, ðàçõîäè

QUALICOPC, A MULTI-COUNTRYSTUDY EVALUATING QUALITY,COSTS AND EQUITY INPRIMARY CARE

Petko Salchev3, Willemijn Sch fer1, WienkeBoerma1, Peter Groenewegen2

1NIVEL, Netherlands Institute for Health ServicesResearch, Utrecht, The Netherlands

2Department of Sociology and Department of HumanGeography, Utrecht University, Utrecht, The Netherlands

3 National Center of Public Health and Analyses, Sofia,Bulgaria

Àbstract

Today, strengthening primary care is worldwide prob-ably higher than ever on the agenda of scientist andpolicy makers (1). Primary care is expected to be aneffective response to effects of the current economiccrisis on health and health care. The policy strategytowards primary care reinforcement is often basedon the notion that a strong primary care system ben-efits a nation’s health and health care system. PC hasthe potential to contribute to overall health systemperformance and health (2)(3).

In 2010 the QUALICOPC (Quality and Costs of Pri-mary Care in Europe) study started. The aim of thisstudy is to evaluate quality, costs and equity of pri-mary care in European countries. The researchers ofthis study are trying to give an answer to the ques-tion what the benefits of primary care are and whateffect the strength of a primary care system has on theperformance of health care systems. The study isfunded by the European Commission under the so-called “Seventh Framework Programme” and is car-ried out by a consortium of 6 research institutes fromBelgium, Germany, Italy, the Netherlands andSlovenia. The study is coordinated by NIVEL, theNetherlands Institute for Health Services Research.In this article the background and design of theQUALICOPC study is described.

Key words: Primary care, study, effectiveness,costs



Introduction

Prior studies have shown a relationship betweenprimary care and outcomes such as costs, quality andaccessibility of care (3-7). This currently availableevidence should be considered with care due to thelimited generalisability of the results to the Europeancontext. Previous studies have usually only includeda selection of EU countries. Moreover, little is knownabout the relation between structural arrangementsof primary care (such as the payment system) and theperformance of care. This would demand a deeperinsight in professional behaviour of health careworkers and the expectations and actions of patients.

The QUALICOPC study responds to this byevaluating the effects of strong primary care on theperformance of health systems. To this end, thestructure of primary care at the national level will berelated to indicators of quality at the practice leveland quality as experienced by patients. The study isaimed at six themes: quality of the process of care,experiences of patients, costs of primary care, equity,avoidable hospitalisation and examples of ‘goodpractices’.

Methods

QUALICOP started in 2010 and will run until May 2013.Data will be collected in 31 European countries (27countries of the EU, Iceland, Norway, Turkey andSwitzerland). Furthermore, research departments/institutes from Australia, Israel and New Zealandjoined the study. The data collection is being done atthree levels: the health care system, the GP practiceand the level of the patient. Information at the practice-and patient level is being collected trough surveysamong GPs and their patients. With the questionnairesinsight is gained in professional behaviour of GPsand the expectations and actions of patients. Further,data from a European study from 1993 on the taskprofiles of GPs are being used. Data on the level ofthe health care system, the national level, are derivedfrom existing sources such as the “Primary Health CareActivity Monitor Europe” (PHAMEU) database.

GP and patient surveys

In each country the aim is to realize a response of 220GPs. In Cyprus, Iceland, Luxembourg and Malta thedesired response is lower (around 75). In everycountry a nationally representative sample is drawn.Only one GP per practice will be included. This is toavoid the inclusion of multiple GPs which are subjectto the same practice variables.

The questionnaires will be distributed among patients(above the age of 18) of the participating GPs. Thepatients will be invited by a fieldworker in the waiting

Âúâåäåíèå

Ïðîó÷âàíèÿ ïîêàçâàò âðúçêàòà ìåæäó ïúðâè÷íàòàìåäèöèíñêà ïîìîù è ðåçóëòàòèòå, êàòî ðàçõîäè, êà÷åñòâîè äîñòúïíîñò íà ãðèæèòå (3,7). Òåçè íàëè÷íè â ìîìåíòàíàó÷íè ôàêòè è äîêàçàòåëñòâà ñëåäâà äà ñå ðàçãëåæäàò ñïîâèøåíî âíèìàíèå, ïîðàäè îãðàíè÷åíîòî èìãåíåðàëèçèðàíå â åâðîïåéñêè êîíòåêñò. Ïðåäèøíèèçñëåäâàíèÿ âêëþ÷âàò ñàìî ïîäáðàíè ñòðàíè îò ÅÑ. Íåùîïîâå÷å, ìàëêî ñå çíàå çà âðúçêàòà ìåæäó ñòðóêòóðíèäîãîâîðåíîñòè ïðè ïúðâè÷íàòà ìåäèöèíñêà ïîìîù(íàïðèìåð íà÷èíè çà ïëàùàíå), êàêòî è ïðåäîñòàâÿíåòîíà çäðàâíèòå ãðèæè è èçïúëíåíèåòî íà ñúîòâåòíèòåäåéíîñòè. Òîâà èçèñêâà ïî-äúëáîêî âíèêâàíå âïðîôåñèîíàëíîòî ïîâåäåíèå íà çäðàâíèòåïðîôåñèîíàëèñòè, êàêòî è â î÷àêâàíèÿòà è äåéñòâèÿòà íàïàöèåíòèòå.

Ïðîó÷âàíåòî QUALICOPC îòãîâàðÿ íà òåçè âúïðîñè ÷ðåçîöåíêà íà âúçäåéñòâèåòî íà ñèëíàòà ïúðâè÷íàìåäèöèíñêà ïîìîù ïðè ôóíêöèîíèðàíåòî íà çäðàâíèòåñèñòåìè. Çà òàçè öåë, ñòðóêòóðàòà íà ïúðâè÷íàòàìåäèöèíñêà ïîìîù íà íàöèîíàëíî íèâî ùå áúäå ñâúðçàíàñ ïîêàçàòåëè çà êà÷åñòâî íà íèâî ïúðâè÷íà ìåäèöèíñêàïðàêòèêà è êà÷åñòâîòî, ñâúðçàíî ñúñ ñúîòâåòíèÿ îïèò îòñòðàíà íà ïàöèåíòèòå ïðè êîíòàêòèòå ñîáùîïðàêòèêóâàùèòå ëåêàðè. Ïðîó÷âàíåòî å íàñî÷åíîêúì øåñò òåìè: êà÷åñòâî íà ïðîöåñà íà ãðèæèòå, îïèò èîòíîøåíèå íà ïàöèåíòèòå ïðè êîíòàêòà èì ñ ïðàêòèêàòà,ðàçõîäè çà ïúðâè÷íà ìåäèöèíñêà ïîìîù, åôåêòèâíîñò èðàâíîïîñòàâåíîñò, íåíóæíà õîñïèòàëèçàöèÿ è ïðèìåðèçà “äîáðè ïðàêòèêè”.

Ìåòîäè

QUALICOP çàïî÷âà ïðåç 2010 ã. è ïðîäúëæàâà äî ìàé 2013ã. Äàííèòå ñå ñúáèðàò â 31 åâðîïåéñêè ñòðàíè (27 ñòðàíèîò ÅÑ, Èñëàíäèÿ, Íîðâåãèÿ, Òóðöèÿ è Øâåéöàðèÿ). Êúìïðîó÷âàíåòî ñà ïðèñúåäèíåíè è èçñëåäîâàòåëñêè îòäåëè/ èíñòèòóòè îò Àâñòðàëèÿ, Èçðàåë è Íîâà Çåëàíäèÿ.Ñúáèðàíåòî íà äàííè ñå èçâúðøâà íà òðè íèâà: íà íèâîñèñòåìà íà çäðàâåîïàçâàíåòî, íà íèâî ïðàêòèêà íà ÎÏË èíà íèâî ïàöèåíò. Èíôîðìàöèÿòà íà íèâî ïðàêòèêà è íàíèâî ïàöèåíò ñå ñúáèðà ÷ðåç ïðîó÷âàíèÿ ñðåäîáùîïðàêòèêóâàùèòå ëåêàðè è òåõíèòå ïàöèåíòè. ×ðåçâúïðîñíèöèòå ñå öåëè äà ñå îöåíè ïðîôåñèîíàëíîòîïîâåäåíèå íà ÎÏË, êàêòî è î÷àêâàíèÿòà íà ïàöèåíòèòå.Îñâåí òîâà ñå èçïîëçâàò äàííè îò åâðîïåéñêî ïðîó÷âàíåîò 1993 ã. îòíîñíî ïðîôèëà íà äåéíîñòèòå íàîáùîïðàêòèêóâàùèòå ëåêàðè. Äàííèòå íà íèâî ñèñòåìàòàíà çäðàâåîïàçâàíåòî - íàöèîíàëíî íèâî, ñà èçâëå÷åíè îòñúùåñòâóâàùè èçòî÷íèöè, íàïðèìåð “Ìîíèòîð íàäåéíîñòèòå â ïúðâè÷íàòà ìåäèöèíñêà ïîìîù â Åâðîïà“(PHAMEU) áàçà äàííè.

Ïðîó÷âàíå íà îáùîïðàêòèêóâàùèòå ëåêàðèè ïàöèåíòèòå



room to anonymously fill in a questionnaire. Afieldworker visits the practice and invites patients until10 people have agreed to participate. Nine of thesepatients will be asked to fill in a questionnaire abouttheir experiences with primary care and one patientfills in a questionnaire about what he/she findsimportant. Per country about 2200 patients will fill in aquestionnaire. In each country the questionnaires willbe available in the national language(s). In manycountries the patient questionnaires are also availablein the languages of the largest groups of ethnicminorities, to also include these patients in the study.

The data collection in [Your country] is organised by[Your organisation].

Content of the questionnaires

For this study new questionnaires have beendeveloped based on a systematic literature review ofexisting questionnaires and expert opinion. To test thequestionnaires a pilot has been held in Slovenia,Belgium and the Netherlands. The questionnairesinclude questions which can measure the variety ofprimary care in European countries. The survey amongGPs includes self-reported involvement in curative andpreventive tasks and questions on the type andorganisation of the practice, integrated provision ofservices and aspects of workload and use of time.

The patients experiences questionnaire containsquestions about the patients’ backgrounds, distanceto the PC practice, choice of doctor, copayments forservices, time for the patients, availability of healtheducation, experiences with services of the practice orcentre, experiences with their own doctor and aspectsof care coordination. In order to weigh the answersabout patients’ experiences a separate questionnairehas been developed about what patients find important(the patients values questionnaire).

Finally, a questionnaire for the fieldworkers visitingthe GP practices has been developed. Thisquestionnaire contains questions about practicecharacteristics in general, such as the availability of aparking space for with disability.

Analyses

The gathered data will be analysed with statisticalmultilevel models. With these analyses it can beexplored to what extend the variation in outcomes (e.g.variation in quality of care between practices) can berelated to the influence of the country, or differencesbetween individual practices. Apart from studyinggeneral patterns and trends ‘good practices’ will beidentified, which in a statistical sense are the outliersin the analyses. An important aspect of the studydesign is that the questionnaires of the patients canbe linked to the questionnaires of their GPs.

Öåëòà å âúâ âñÿêà ñòðàíà, ó÷àñòâàùà â ïðîó÷âàíåòî, äà ñåâêëþ÷àò îáùî ïî 220 îáùîïðàêòèêóâàùè ëåêàðè. Â Êèïúð,Èñëàíäèÿ, Ëþêñåìáóðã è Ìàëòà æåëàíèÿò áðîé ðåñïîíäåíòèå ïî-íèñúê (îêîëî 75). Âúâ âñÿêà ñòðàíà å ñúñòàâåíàíàöèîíàëíà ïðåäñòàâèòåëíà èçâàäêà. Ñàìî åäèí GP îòïðàêòèêà ìîæå äà áúäå âêëþ÷åí. Öåëòà å äà ñå èçáåãíåâêëþ÷âàíåòî íà íÿêîëêî îáùîïðàêòèêóâàùè ëåêàðè, êîèòîñà ïîä âëèÿíèåòî íà åäíè è ñúùè ôàêòîðè (ïðîìåíëèâè) âïðàêòèêàòà.

Âúïðîñíèöèòå ñà ðàçïðåäåëåíè ñðåä ïàöèåíòè (íàä 18-ãîäèøíà âúçðàñò) íà ó÷àñòâàùèòå â ïðîó÷âàíåòîîáùîïðàêòèêóâàùè ëåêàðè. Ïàöèåíòèòå, èçðàçèëè ñúãëàñèåäà ó÷àñòâàò â ïðîó÷âàíåòî (îáùî äî 10 ïàöèåíòè îòïðàêòèêà), ñå êàíÿò îò àíêåòüîð â ÷àêàëíÿòà íà ïðàêòèêàòà äàïîïúëíÿò àíîíèìíî âúïðîñíèêà. Äåâåò îò òåçè ïàöèåíòèïîïúëâàò âúïðîñíèê îòíîñíî ñâîÿ îïèò è âçàèìîîòíîøåíèÿñ ïúðâè÷íàòà ìåäèöèíñêà ïîìîù (ïðàêòèêàòà). Åäèíïàöèåíò ïîïúëâà âúïðîñíèê çà òîâà, êîåòî òîé íàìèðà çàâàæíî. Î÷àêâà ñå âúâ âñÿêà ñòðàíà îêîëî 2200 ïàöèåíòè äàïîïúëíÿò âúïðîñíèöèòå. Òå ñà ïðåäîñòàâåíè íà íàöèîíàëíèÿåçèê (åçèöèè) íà ñúîòâåòíàòà ñòðàíà. Â íÿêîè ñòðàíèâúïðîñíèöèòå çà ïàöèåíòèòå ñà ïðåäîñòàâåíè íà åçèöèòå íàíàé-ãîëåìèòå ãðóïè îò åòíè÷åñêè ìàëöèíñòâà, ñ öåëâêëþ÷âàíåòî è íà òåçè ïàöèåíòè â ïðîó÷âàíåòî.

Ñúáèðàíåòî íà äàííè â Áúëãàðèÿ ñå îðãàíèçèðà îòÄèëèäæåíòèñ ÅÎÎÄ, ñúñ ñúäåéñòâèåòî íà ñîöèîëîãè÷åñêààãåíöèÿ „ÍÎÅÌÀ“.

Ñúäúðæàíèå íà âúïðîñíèêà

Çà öåëèòå íà òîâà ïðîó÷âàíå ñà ðàçðàáîòåíè íîâèâúïðîñíèöè, âúç îñíîâà íà ñèñòåìàòè÷åí ïðåãëåä íàëèòåðàòóðàòà îòíîñíî ñúùåñòâóâàùè âúïðîñíèöè è íàåêñïåðòíî ìíåíèå. Â Ñëîâåíèÿ, Áåëãèÿ è Õîëàíäèÿ åïðîâåäåíî ïèëîòíî ïðîó÷âàíå çà òåñòâàíå íà âúïðîñíèöèòå.Â òÿõ ñà âêëþ÷åíè âúïðîñè, êîèòî äàâàò âúçìîæíîñò äà ñåèçìåðè è îöåíè ðàçíîîáðàçèåòî â ïúðâè÷íàòà ìåäèöèíñêàïîìîù â åâðîïåéñêèòå ñòðàíè. Â ïðîó÷âàíåòî ñðåäîáùîïðàêòèêóâàùèòå ëåêàðè å âêëþ÷åíî èçñëåäâàíå çàó÷àñòèåòî íà ðåñïîíäåíòèòå â ëå÷åáíè è ïðåâàíòèâíè çàäà÷èè âúïðîñè îòíîñíî âèäà è îðãàíèçàöèÿòà íà ïðàêòèêàòà, âêîÿòî ðàáîòÿò, èíòåãðèðàíîòî ïðåäîñòàâÿíå íà óñëóãè èàñïåêòè, ñâúðçàíè ñ íàòîâàðâàíå è èçïîëçâàíå íà âðåìåòîíà îáùîïðàêòèêóâàùèÿ ëåêàð.

Âúïðîñíèêúò çà îïèòà è âçàèìîîòíîøåíèÿòà íà ïàöèåíòèòåñ ïðàêòèêàòà ñúäúðæà ñëåäíèòå âúïðîñè: âúçðàñò èîáðàçîâàíèå íà ïàöèåíòèòå; ðàçñòîÿíèå äî ïúðâè÷íàòàìåäèöèíñêà ïðàêòèêàòà; èçáîð íà ëåêàð; èìà ëè ïëàùàíèÿçà óñëóãè; âðåìå, îòäåëåíî â ïðàêòèêàòà çà ïàöèåíòèòå;íàëè÷èå íà çäðàâíî-îáðàçîâàòåëíè ïðîãðàìè;âçàèìîîòíîøåíèÿ ñ ïðàêòèêàòà èëè çäðàâíèÿ öåíòúð;âçàèìîîòíîøåíèÿ ñ ëè÷íèÿ ëåêàð è àñïåêòè íàêîîðäèíàöèÿòà ïðè çäðàâíèòå ãðèæè. Ñ öåë äà ñå îöåíÿò èïðåòåãëÿò ïî âàæíîñò îòãîâîðèòå çà îïèòà èâçàèìîîòíîøåíèÿòà íà ïàöèåíòèòå ñ ïðàêòèêàòà å ðàçðàáîòåíîòäåëåí âúïðîñíèê îòíîñíî àñïåêòèòå, êîèòî ïàöèåíòèòåíàìèðàò çà âàæíè (âúïðîñíèê çà âàæíîñòòà).



Finally

Europe and some countries beyond are the laboratory ofthe QUALICOPC study. The study will considerablycontribute to this base of evidence on the benefits ofstrong primary care. Therefore data will be analysed atdifferent levels of care: the national level, but also dataon the level of the GP practice and patients. Because theresearch includes 34 countries, variants of primary carefrom these countries can be included in the study. Theoutcomes of the study will be used to inform the EuropeanCommission, WHO and national authorities to contributeto effective health care policies.

Ðàçðàáîòåí å è âúïðîñíèê çà àíêåòüîðèòå, ïîñåùàâàùè GPïðàêòèêè. Òîçè âúïðîñíèê ñúäúðæà âúïðîñè, ñâúðçàíè ñïðàêòè÷åñêè õàðàêòåðèñòèêè êàòî öÿëî, íàïðèìåð, íàëè÷èåòîíà ìÿñòî çà ïàðêèðàíå çà ïàöèåíòè ñ óâðåæäàíèÿ.

Àíàëèçè

Ñúáðàíèòå äàííè ñå àíàëèçèðàò ñúñ ñòàòèñòè÷åñêèìíîãîñòåïåííè ìîäåëè. Ñ òåçè àíàëèçè ìîæå äà ñå îöåíè äîêàêâà ñòåïåí ïðîìÿíàòà ïî îòíîøåíèå íà ðåçóëòàòèòå (íàïð.ðàçëè÷èÿ â êà÷åñòâîòî íà ãðèæèòå ìåæäó ïðàêòèêè) ìîæå äàáúäå ñâúðçàíà ñ âëèÿíèåòî íà îñîáåíîñòèòå â ñúîòâåòíàòàñòðàíà èëè ðàçëèêèòå ìåæäó îòäåëíèòå ïðàêòèêè. Îñâåíèçó÷àâàíå íà òåíäåíöèè ïðè îáùèòå ìîäåëè, ñåèäåíòèôèöèðàò è „äîáðèòå ïðàêòèêè - ïðèìåðè“, êîèòî âñòàòèñòè÷åñêè ñìèñúë ñà îòêëîíåíèÿòà (outliers)-ãîëåìèòåðàçëè÷èÿ îò ñðåäíèòå ñòîéíîñòè â àíàëèçèòå. Âàæåí àñïåêòîò äèçàéíà íà ïðîó÷âàíåòî å, ÷å âúïðîñíèöèòå, ïîïúëâàíèîò ïàöèåíòèòå, ìîæå äà áúäàò ñâúðçàíè ñ âúïðîñíèöèòå íàòåõíèòå îáùîïðàêòèêóâàùè ëåêàðè.


Åâðîïà è íÿêîè ñòðàíè èçâúí íåÿ ñà ò.í. ëàáîðàòîðèÿ íàQUALICOPC ïðîåêòà. Ïðîó÷âàíåòî ùå äîïðèíåñå çàñúçäàâàíå íà áàçà çà äîêàçàòåëñòâà îòíîñíî ïîëçèòå îòñèëíà ïúðâè÷íà ìåäèöèíñêà ïîìîù. Ïîðàäè òîâà äàííèòåñå àíàëèçèðàò íà ðàçëè÷íè íèâà íà çäðàâíèòå ãðèæè: íàíàöèîíàëíî íèâî, íà íèâî ïðàêòèêà è íèâî ïàöèåíòè íàîáùîïðàêòèêóâàùèòå ëåêàðè. Òúé êàòî èçñëåäâàíåòîâêëþ÷âà 34 ñòðàíè, âñè÷êè âàðèàíòè íà ïúðâè÷íàòàìåäèöèíñêà ïîìîù îò òåçè ñòðàíè ìîãàò äà áúäàòâêëþ÷åíè â ïðîó÷âàíåòî. Ðåçóëòàòèòå îò ïðîó÷âàíåòî ùåáúäàò èçïîëçâàíè, çà äà ñå èíôîðìèðàò Åâðîïåéñêàòàêîìèñèÿ, ÑÇÎ è íàöèîíàëíèòå âëàñòè è ùå äîïðèíåñàò çàïðèåìàíåòî íà åôåêòèâíè ïîëèòèêè â îáëàñòòà íàçäðàâåîïàçâàíåòî.


Ïðîó÷âàíå – Áúëãàðèÿ

1. Ïåðèîä íà ñúáèðàíå íà äàííè - 15.10.2011-15.12.2012 ã.

2. Èíôîðìàöèÿ îòíîñíî ðåñïîíäåíòèòå:

- Áðîé íà îáùîïðàêòèêóâàùèòå ëåêàðè â Áúëãàðèÿ -4131 ëåêàðè; 3091 èíäèâèäóàëíè ïðàêòèêè è 230ãðóïîâè ïðàêòèêè (Èçòî÷íèê: Íàöèîíàëíàçäðàâíîîñèãóðèòåëíà êàñà (2010);

- Áðîé íà îáùîïðàêòèêóâàùèòå ëåêàðè îáùî,ïîêàíåíè äà ó÷àñòâàò â òîâà ïðîó÷âàíå – 350ëåêàðè.

- Èçâàäêàòà å ñòðàòèôèöèðàíà ïî áðîÿ íàîáùîïðàêòèêóâàùèòå ëåêàðè âúâ âñÿêà îò 28-òåîáëàñòè â ñòðàíàòà. Çà âñÿêà îáëàñò èçâàäêàòà åñëó÷àéíà.

3. Àíêåòèðàíå - ïîëåâàòà ðàáîòà. Ñîöèîëîãè÷åñêààãåíöèÿ “Íîåìà” - ïðîôåñèîíàëíè íòåðâþèðàùè- 103 äóøè.

Data collection in BULGARIA

1. The period of data collection – 15.10.2011-15.12.2011

2. Information on the sample – who can expect tobe included?

- Number of GPs in Bulgaria - 4131 GPs - 3091individual practices and 230 group (Source:National Health Insurance Fund ( 2010)

- Number of GPs in total invited to participate in thisstudy – 350

- The sample is stratified by number of GPs in each ofthe 28 districts in the country. For each district thesample is random.

3. FieldworkPooling agency “Noema” - professionalinterviewers – 103 people

4. National coordinator – Assoc.prof. Petko Salchev

5. Supporting bodies - Ministry of health

6. Other details interesting to know for GPs

The patients were more wishful to participate in thesurvey, rather than GPs.

The general feedback is that too many studies werebeen made among GPs, mainly conducted byPharmaceutical Companies which incentives areoften valuable and expensive. Therefore, theconduction of the present study was a bit difficultand the need of a large number of interviewers wasdetermined.


5. Kerssens JJ, Groenewegen PP, Sixma HJ, Boerma WG, van derEijk I: Comparison of patient evaluations of health care qualityin relation to WHO measures of achievementin 12 European countries. Bull World Health Organ 2004, 82:106-114.

6. De Maeseneer JM, De Prins L, Gosset C, Heyerick J: Providercontinuity in family medicine: does it make a difference for totalhealth care costs? Ann Fam Med 2003, 1: 144-148.

7. Delnoij D, Van Merode G, Paulus A, Groenewegen P: Doesgeneral practitioner gatekeeping curb health care expenditure? JHealth Serv Res Policy 2000, 5: 22-26.

This article is based on:

Schäfer, W.L.A.; Boerma, W.G.W.; Kringos, D.S.; Maeseneer,J. de; Gress, S.; Heinemann, S.; Rotar-Pavlic, D.; Seghieri,C.; Svab, I.; Berg, M.J. van den; Vainieri, M.; Westert, G.P.;Willems, S.; Groenewegen, P.P. QUALICOPC, a multi-countrystudy evaluating quality, costs and equity in primary care.BMC Family Practice, vol. 12, (2011), nr. 115


Assoc. Prof. Pretko Salchev, MD, PhDNational Center of Public Health and AnalysesAcad. Ivan Geshov Blvd. 15, Sofia 1431For correspondence about the QUALICOPC project inBulgaria: [email protected]

For correspondence about the QUALICOPC project ingeneral: [email protected]

Êíèãîïèñ/ References

1. World Health Org. The World Health Report 2008: Primary HealthCare - Now More Than Ever. 2008. Geneva, World HealthOrganisation.

2. World Health Org. The Financial Crisis and Global Health: Report ofa High-Level Consultation, 19 January 2009. 2009. Geneva, WorldHealth Organization.

3. Kringos DS, Boerma WG, Hutchinson A, van der Zee J,Groenewegen PP: The breadth of primary care: a systematicliterature review of its core dimensions. BMC Health Serv Res 2010,10: 65.

4. Starfield B, Shi L, Macinko J: Contribution of primary care to healthsystems and health. Milbank Q 2005, 83: 457-502.

Òàçè ñòàòèÿ ñå áàçèðà íà:

Schäfer, W.L.A.; Boerma, W.G.W.; Kringos, D.S.; Maeseneer,J. de; Gress, S.; Heinemann, S.; Rotar-Pavlic, D.; Seghieri,C.; Svab, I.; Berg, M.J. van den; Vainieri, M.; Westert, G.P.;Willems, S.; Groenewegen, P.P. QUALICOPC, a multi-countrystudy evaluating quality, costs and equity in primary care.BMC Family Practice, vol. 12, (2011), nr. 115

Aäðåñ çà êîðåñïîíäåíöèÿ:

Äîö. ä-ð Ïåòêî Ñàë÷åâÑîôèÿ, áóë.”Àêàä. Èâàí Ãåøîâ” 15Íàöèîíàëåí öåíòúð çà îáùåñòâåíî çäðàâå è àíàëèçèÇà êîðåñïîíäåíöèÿ îòíîñíî QUALICOPC ïðîåêòà âÁúëãàðèÿ: [email protected]

Çà êîðåñïîíäåíöèÿ îòíîñíî QUALICOPC ïðîåêòà îáùî:[email protected]


4. Íàöèîíàëåí êîîðäèíàòîð -äîö. ä-ð. Ïåòêî Ñàë÷åâ.

5. Ïîäêðåïÿùè îðãàíè -Ìèíèñòåðñòâî íà çäðàâåîïàçâàíåòî.

6. Äðóãè ïîäðîáíîñòè, êîèòî áèõà çàèíòåðåñóâàëèîáùîïðàêòèêóâàùèòå ëåêàðè:

Ïàöèåíòèòå ñà ïî-ïîëîæèòåëíî íàñòðîåíè äà ó÷àñòâàò âïðîó÷âàíåòî, îòêîëêîòî îáùîïðàêòèêóâàùèòå ëåêàðè.

Îáðàòíà âðúçêà îò îáù õàðàêòåð, ïîëó÷åíà ÷ðåçàíêåòüîðèòå, ïîñî÷âà, ÷å ñðåä îáùîïðàêòèêóâàùèòåëåêàðè ñà ïðîâåæäàíè ìíîãî èçñëåäâàíèÿ, ãëàâíî îòôàðìàöåâòè÷íè êîìïàíèè, ÷èèòî ñòèìóëè ÷åñòî ñàñêúïè. Åòî çàùî, ïðîâåæäàíåòî íà íàñòîÿùîòîèçñëåäâàíå å áèëî çàòðóäíåíî, êîåòî îïðåäåëèíåîáõîäèìîñòòà îò ïî-ãîëÿì áðîé íà èíòåðâþèðàùèòe.


PRIMARY HEALTH CARE INBULGARIA – FACTS AND

ANALYSES

2011, Open Society Institute – SofiaISBN 978-954-2933-12-03

Authors:Assoc. Prof. Petko Salchev,

Assoc. Prof. Lidia Georgieva,Nikolai Hristov,

Òîäîð Kundurdzhiev,Dessislava Dimitrova

Editors: P. Salchev

In recent years the academic community did not performany studies (save for a few sociological studies onpatient satisfaction) on the efficiency and quality of thenew model of primary health care functioning. This wasthe challenge to the collective – to collect and analysethe available data on GP activities in the country andassess what is achieved so far.

Based on the available data from NHIF the collectivefocused on presenting a momentous picture of theorganization, functions, activities and efficiency ofprimary health care, provided by GPs in Bulgaria. Theyear 2009 was chosen due to the following considerations– available comprehensive data, a sufficiently long periodafter the onset of the reforms and stabilization of thesystem, accumulated experience in the analysis of thesystem, etc.

The monograph is arranged in the following manner:

Presented first is a general description of the socio-economical and political state of

the country, as well as the health status of the populationfor the respective year and a brief depiction of thenational health system of Bulgaria.

The second chapter presents the legal frame andorganizational forms of primary health care, the basicpackage of delivered health services and the paymentmechanisms for GPs.

The next chapter presents and analyses the state offunding, manpower availability, and performed activitiesby GPs.

The last chapter presents the results of the applicationof a specific model for efficiency assessment of GPactivities, where as main units of comparison we usedthe administrative regions. We deemed impossible theperformance of individual GP assessment due to thescarcity of data and limitations in the methods of analysis.

ÏÚÐÂÈ×ÍÀÒÀ ÇÄÐÀÂÍÀ ÏÎÌÎÙÂ ÁÚËÃÀÐÈß – ÔÀÊÒÈ ÈÀÍÀËÈÇÈ

2011, Èíñòèòóò „Îòâîðåíî îáùåñòâî” – ÑîôèÿISBN 978-954-2933-12-03ÿ / Primary Hea lth Care in BulgariaÀâòîðñêè êîëåêòèâ:Äîö. ä-ð Ïåòêî Ñàë÷åâ,Äîö. ä-ð Ëèäèÿ Ãåîðãèåâà,Ä-ð Íèêîëàé Õðèñòîâ,Òîäîð Êóíäóðäæèåâ,Äåñèñëàâà ÄèìèòðîâàÏîä ðåäàêöèÿòà íà äîö. ä-ð Ï. Ñàë÷åâÈÍÑÒÈÒÓÒ “ÎÒÂÎÐÅÍÎ ÎÁÙÅÑÒÂÎ”/

Â ïîñëåäíèòå ãîäèíè îò ñòðàíà íà íàó÷íàòà îáùíîñò íå ñàïðîâåäåíè ïî÷òè íèêàêâè ïðîó÷âàíèÿ (ñ èçêëþ÷åíèå íàîïðåäåëåíè ñîöèîëîãè÷åñêè èçñëåäâàíèÿ îòíîñíîóäîâëåòâîðåíîñòòà íà ïàöèåíòèòå) çà îöåíêà íàåôåêòèâíîñòòà è êà÷åñòâîòî íà íîâèÿ ìîäåë â ïúðâè÷íàòàçäðàâíà ïîìîù. Òîâà å è ïðåäèçâèêàòåëñòâîòî ïðåäàâòîðñêèÿ êîëåêòèâ íà ìîíîãðàôèÿòà – äà ñå ñúáåðàò èàíàëèçèðàò äîñòúïíèòå äàííè çà äåéíîñòòà íàîáùîïðàêòèêóâàùèòå ëåêàðè â ñòðàíàòà è äà ñå íàïðàâèîöåíêà íà ïîñòèãíàòîòî äî ìîìåíòà. Íà áàçàòà íà äîñòúïíàòàèíôîðìàöèÿ îò ÍÇÎÊ àâòîðèòå ïðåäñòàâÿò ìîìåíòíàêàðòèíà îòíîñíî îðãàíèçàöèÿòà, ôóíêöèèòå, äåéíîñòòà èåôåêòèâíîñòòà íà ïúðâè÷íàòà çäðàâíà ïîìîù, îñèãóðÿâàíàîò îáùîïðàêòèêóâàùèòå ëåêàðè (ÎÏË) â Áúëãàðèÿ. Èçáðàíàå 2009 ãîäèíà ïîðàäè ñëåäíèòå ôàêòîðè – íàëè÷íà ïúëíàèíôîðìàöèÿ, äîñòàòú÷íî ãîëÿì ïåðèîä ñëåä ïðîâåæäàíåòîíà ðåôîðìàòà è ñòàáèëèçèðàíå íà ñèñòåìàòà, íàòðóïàí îïèòçà àíàëèç íà ñèñòåìàòà è ò.í.

Ìîíîãðàôèÿòà å ïîäðåäåíà ïî ñëåäíèÿ ðåä:

Íà ïúðâî ìÿñòî – îáùî îïèñàíèå íà ñîöèàëíî-èêîíîìè÷åñêàòà è ïîëèòè÷åñêàòà îáñòàíîâêà â ñòðàíàòà èçäðàâíîòî ñúñòîÿíèå íà íàñåëåíèåòî â ñúîòâåòíàòà ãîäèíà,êðàòêî îïèñàíèå íà çäðàâíàòà ñèñòåìà íà Áúëãàðèÿ.

Âúâ âòîðàòà ãëàâà å ïðåäñòàâåíà ïðàâíàòà ðàìêà èîðãàíèçàöèîííè ôîðìè íà ïúðâè÷íàòà çäðàâíà ïîìîù,îñíîâåí ïàêåò íà ïðåäîñòàâÿíèòå çäðàâíè óñëóãè è íà÷èí íàçàïëàùàíå íà ÎÏË.

Â ñëåäâàùàòà ãëàâà ñà ðàçãëåäàíè è àíàëèçèðàíè ñúñòîÿíèåòîíà ôèíàíñèðàíåòî, íàëè÷íèòå êàäðè, èçâúðøåíèòå äåéíîñòèîò ñòðàíà íà îáùîïðàêòèêóâàùèòå ëåêàðè.

Â ïîñëåäíàòà ãëàâà å ïðèëîæåí ñïåöèôè÷åí ìîäåë íà îöåíêàíà åôåêòèâíîñòòà íà äåéíîñòòà íà îáùîïðàêòèêóâàùèòåëåêàðè, êàòî îñíîâíè åäèíèöè çà ñðàâíåíèå ñà ïîäáðàíèðàçëè÷íèòå ðåãèîíè.

Àâòîðèòå íå ïðåäñòàâÿò ñàìî ôàêòèòå, à ïðàâÿò àíàëèç íàðåàëíèòå ÿâëåíèÿ â ñôåðàòà íà ïúðâè÷íàòà çäðàâíà ïîìîù.

ÍÎÂÈ ÊÍÈÃÈ NEW BOOKS


A DECADA OF REGIONALCOOPERATION ON PUBLIC HEALTH

IN SOUTH-EASTERN EUROPE

THERD HEALTH MINISTERS’ FORUM:

HEALTH IN ALL POLICIES IN SOUTH-

EASTERN EUROPE – A SHARED

GOAL AND RESPONSIBILITY

2011, World Health Organization,Regional office for Europe

A decade of regional cooperation on public health insouth - eastern Europe tells the story of SEEHN from itsfounding in 2001 until today It describes a unique processof regional cooperation in public health, involving thehealth ministries of the nine countries in the region, theRegional Office, the Council of Europe and the Councilof Europe Development Bank, initially under the aegis ofthe Stability Pact for South Eastern Europe and then theRegional Cooperation Council.

The process started with the First Health Ministers Forum,held in Dubrovnik, Croatia, in 2001. a breakthrough forumwhere the founding document of the cooperative enterise,the Dubrovnik Pledge, was signed (Annex 1] (WHORegional Office for Europe. 2001] This document set outa new, ambitious vision for regional partnership andcooperation on better health. What had been envisionedas a transitional mechanism to promote reconciliation andregional stability rapidly proved to be a model of regionalcooperation. The Second Health Ministers’ Forum, heldin 2005 in Skopje, the former Yugoslav Republic ofMacedonia, confirmed and expanded the vision, goalsand aims of SEEHN in a new document, the Skopje Pledge/Annex 2/.

(WHO Regional Office for Europe, 2005). Today, six yearslater, SFEHN is an established, highly valued actor in thepromotion of public health in the region. Il has apermanent seat in Skopje, and it is expanding by addingnew Member Stales and partner states, as well as bysteadily widening the scope of its activities The currentreport is being pub-lished to coincide with the ThirdHealth Ministers Forum, which is being held in October2011 in Banja Luka, Bosnia and Herzegovina.

The development of 5FFHN has been shaped by the inputand engagement of a wide variety of long-term partners,including different national government sectors, theRegional Cooperation Council, the Regional Office, theCouncil of Europe, the Council of Europe DevelopmentBank and the Northern Dimension Partnership in PublicHealth and Social Well-being, as well as by newer,

ÄÅÑÅÒÃÎÄÈØÍÎ ÐÅÃÈÎÍÀËÍÎÑÚÒÐÓÄÍÈ×ÅÑÒÂÎ Â ÎÁËÀÑÒÒÀ ÍÀÎÁÙÅÑÒÂÅÍÎÒÎ ÇÄÐÀÂÅÎÏÀÇÂÀÍÅÂ ÞÃÎÈÇÒÎ×ÍÀ ÅÂÐÎÏÀ

ÒÐÅÒÈ ÔÎÐÓÌ ÍÀ ÌÈÍÈÑÒÐÈÒÅ ÍÀ

ÇÄÐÀÂÅÎÏÀÇÂÀÍÅÒÎ ÍÀ ÒÅÌÀ

“ÇÄÐÀÂÅÒÎ ÂÚÂ ÂÑÈ×ÊÈ ÏÎËÈÒÈÊÈ Â

ÞÃÎÈÇÒÎ×ÍÀ ÅÂÐÎÏÀ - ÎÁÙÀ ÖÅË È

ÎÒÃÎÂÎÐÍÎÑÒ”

2011 ã., Ñâåòîâíà çäðàâíà îðãàíèçàöèÿ,Ðåãèîíàëåí îôèñ çà Åâðîïà

Èçäàíèåòî å ïîñâåòåíî íà èñòîðèÿòà íà çäðàâíàòà ìðåæà âÞãîèçòî÷íà Åâðîïà (SEEHN) îò îñíîâàâàíåòî é ïðåç 2001 ã., äîäíåñ. Ïðåäñòàâåíî å óíèêàëíî ïî ðîäà ñè ðåãèîíàëíîñúòðóäíè÷åñòâî â îáëàñòòà íà îáùåñòâåíîòî çäðàâåîïàçâàíå ñó÷àñòèåòî íà çäðàâíèòå ìèíèñòåðñòâà íà äåâåò ñòðàíè îòðåãèîíà, Ðåãèîíàëíèÿ îôèñ, Ñúâåòà íà Åâðîïà è Ñúâåòà íàÅâðîïåéñêàòà áàíêà çà ðàçâèòèå, êîåòî ïúðâîíà÷àëíî ñåîñúùåñòâÿâà ïîä åãèäàòà íà Ïàêòà çà ñòàáèëíîñò çà Þãîèçòî÷íàÅâðîïà è íà Ñúâåòà çà ðåãèîíàëíî ñúòðóäíè÷åñòâî.

Ïúðâèÿò ôîðóì íà ìèíèñòðèòå íà çäðàâåîïàçâàíåòî å âÄóáðîâíèê, Õúðâàòèÿ, ïðåç 2001 ã., êúäåòî ñå ïîäïèñâàäîêóìåíò çà ó÷ðåäÿâàíå íà ñúòðóäíè÷åñòâîòî. Òîé ïðåäëàãàíîâà, àìáèöèîçíà âèçèÿ çà ðåãèîíàëíî ïàðòíüîðñòâî èñúòðóäíè÷åñòâî ñ öåë ïî-äîáðî çäðàâå. Â íà÷àëîòî ñåâúçïðèåìà êàòî ïðåõîäåí ìåõàíèçúì çà ïîìèðåíèå èðåãèîíàëíà ñòàáèëíîñò, íî ìíîãî ñêîðî ñå ïðåâðúùà âóñïåøåí ìîäåë çà ðåãèîíàëíî ñúòðóäíè÷åñòâî. Âòîðèÿòôîðóì íà ìèíèñòðèòå íà çäðàâåîïàçâàíåòî ïðåç 2005 ã. âÑêîïèå, Ìàêåäîíèÿ, ïîòâúðæäàâà è ðàçøèðÿâà âèçèÿòà,öåëèòå è çàäà÷èòå íà SEEHN ñ íîâ ïðîãðàìåí äîêóìåíò.

Äíåñ, øåñò ãîäèíè ïî-êúñíî, SFEHN å óòâúðäåí è âèñîêîöåíåí ó÷àñòíèê â ðàçâèòèåòî íà îáùåñòâåíîòîçäðàâåîïàçâàíå â ðåãèîíà. Ïîñòîÿííîòî ñåäàëèùå íàìðåæàòà å â Ñêîïèå. Òÿ ñå ðàçðàñòâà ÷ðåç ïðèñúåäèíÿâàíåíà íîâè äúðæàâè è ïàðòíüîðè è ïîñòîÿííî ðàçøèðÿâàíå íàîáõâàòà íà äåéíîñòòà.

Íàñòîÿùèÿò äîêëàä å ïóáëèêóâàí âúâ âðúçêà ñ Òðåòèÿ ôîðóìíà ìèíèñòðèòå íà çäðàâåîïàçâàíåòî ïðåç îêòîìâðè 2011 ã. âÁàíÿ Ëóêà, Áîñíà è Õåðöåãîâèíà.

Ðàçâèòèåòî íà ìðåæàòà ñå äúëæè íà ïðèíîñà èàíãàæèðàíîñòòà íà øèðîê êðúã äúëãîñðî÷íè ïàðòíüîðè,ìåæäó êîèòî ðàçëè÷íè ïðàâèòåëñòâåíè ñåêòîðè, Ñúâåòúò çàðåãèîíàëíî ñúòðóäíè÷åñòâî, Ðåãèîíàëíèÿò îôèñ, Ñúâåòúòíà Åâðîïà, Ñúâåòúò íà Åâðîïåéñêàòà áàíêàòà çà ðàçâèòèå èÑêàíäèíàâñêîòî ïàðòíüîðñòâî â îáëàñòòà íà îáùåñòâåíîòîçäðàâå è ñîöèàëíîòî áëàãîïîëó÷èå, êàêòî íà ïî-íîâè,ðàçâèâàùè ñå ïàðòíüîðñòâà ñ Ìåæäóíàðîäíàòà îðãàíèçàöèÿïî ìèãðàöèÿ, EuroHealthNet è Åâðîïåéñêàòà êîìèñèÿ. Íà



evolv-ing partnerships with the InternationalOrganization for Migration, EuroHealthNet and theEuropean Commission. In turn. SFFHN has helped shapethe actions of these organizations in SEE while helpingdefine core public health development functions in theregion and beyond.

The purpose of this report is to:

• introduce the South-Eastern Europe HealthNetwork ISEEHN], a unique, innovativepartnership in public health, to south easternEurope [SEE], the European health community andthe general public;

• describe the impact that SEEHN has had onpublic health through its regional projects andprogrammes;

• trace SEEHN’s development over the pastdecade from a tool for promoting peace andstability to one for enhancing economicdevelopment and building an intersectoralapproach to public health,

• utilize SEEHN’s achievements to advocate publichealth as a viable instrument of health diplomacy,

• outline SEEHN’s capacity as a major advocate ofbetter public health in SEE and beyond,

• show how SEEHN provides a forum for itsmember countries to prepare tor Europeanintegration through convergence with EU policiesand legislation; and

• present SEEHN as an open initiative in publichealth that reaches beyond its initial historical andgeographical boundaries to establish newpartnerships and initiatives for better health.


ñâîé ðåä ìðåæàòà äîïðèíàñÿ çà êîíêðåòèçèðàíå íàäåéñòâèÿòà íà òåçè îðãàíèçàöèè â Þãîèçòî÷íà Åâðîïà, êàêòîè çà îïðåäåëíå íà îñíîâíèòå ôóíêöèè çà ðàçâèòèå íàîáùåñòâåíîòî çäðàâåîïàçâàíå â ðåãèîíà è èçâúí íåãî.

Äîêëàäúò âêëþ÷âà:

• ïðåäñòàâÿíå íà SEEHN êàòî óíèêàëíî, èíîâàòèâíîïàðòíüîðñòâî â îáëàñòòà íà îáùåñòâåíîòîçäðàâåîïàçâàíå â Þãîèçòî÷íà Åâðîïà;

• âëèÿíèåòî íà SEEHN âúðõó îáùåñòâåíîòî çäðàâå÷ðåç ðåãèîíàëíè ïðîåêòè è ïðîãðàìè;

• ïðåãëåä íà ðàçâèòèåòî íà ìðåæàòà ïðåç ïîñëåäíîòîäåñåòèëåòèå îò èíñòðóìåíò çà íàñúð÷àâàíå íà ìèðàè ñòàáèëíîñòòà, â òàêúâ çà àêòèâèçèðàíå íàèêîíîìè÷åñêîòî ðàçâèòèå è èçãðàæäàíå íàìåæäóñåêòîðåí ïîäõîä êúì îáùåñòâåíîòî çäðàâå;

• èçïîëçâàíå íà ïîñòèæåíèÿòà íà SEEHN â ïîäêðåïàíà îáùåñòâåíîòî çäðàâå êàòî íàäåæäåíäèïëîìàòè÷åñêè èíñòðóìåíò;

• ïðåäñòàâÿíå íà êàïàöèòåòà íà SEEHN êàòî îñíîâåíçàñòúïíèê çà ïî-äîáðî îáùåñòâåíî çäðàâå âÞãîèçòî÷íà Åâðîïà è èçâúí íåÿ;

• ôîðóìà, ïðåäîñòàâÿí îò SEEHN íà ÷ëåíóâàùèòå âíåÿ ñòðàíè, çà äà ñå ïîäãîòâÿò çà èíòåãðèðàíå âÅâðîïà ÷ðåç ñáëèæàâàíå ñ ïîëèòèêèòå èçàêîíîäàòåëñòâîòî íà ÅÑ;

• ïðåäñòàâÿíå íà SEEHN êàòî îòâîðåíà èíèöèàòèâà âîáëàñòòà íà îáùåñòâåíîòî çäðàâå, êîÿòî èçëèçàèçâúí ïúðâîíà÷àëíèòå èñòîðè÷åñêè è ãåîãðàôñêèãðàíèöè è ñúçäàâà íîâè ïàðòíüîðñòâà èèíèöèàòèâè çà ïî-äîáðî çäðàâå.


NEWS

According to the Ordinance ¹ 145 of the Council ofMinisters as of 26.05.2011 for structural changes withinhealthcare system, published in the State Gazette ¹ 41of 31.05.2011, the National Center of Public HealthProtection and the National Center for Health Informationwere merged in the National Center of Public Health andAnalyses.

Dr. Ivailo Vaklinov has been appointed as director of theNational Center of Public Health and Analyses (NCPHA),by order of the Minister of Health dated 06.06.2011.

The NCPHA is an institution within the nationalhealthcare system, conducting the following activities:public health protection, health promotion and diseaseprevention, information provision to healthcareadministration. Its mission is to perform these diverseactivities with the aim of achieving better health for theoverall population. All efforts of the academic staff,experts and technical personnel are directed to theapplication of modern technologies within the publichealth and playing a leading role in the Nationalhealthcare system. Information about NCPHA activitiescan be found at the site http://ncpha.government.bg.

The Bulgarian Journal of Public Health continues tobe issued. The Journal will keep its conception andobjectives, and will popularize modern information andcommunication technologies within the public healthcaresystem.

The Journal’s team wishes every success to the newBoard of Directors of the NCPHA.

The authors aim to present only facts and to analyze theevents happening in the domain of primary health care .

ÍÎÂÈÍÈ NEWS

ÍÎÂÈÍÈ

Ñ ïîñòàíîâëåíèå ¹ 145 íà ÌÑ îò 26.05.2011ã. çàñòðóêòóðíè ïðîìåíè â ñèñòåìàòà íà çäðàâåîïàçâàíåòî,îáíàðîäâàíî â ÄÂ, áð.41 îò 31.05.2011ã., Íàöèîíàëíèÿòöåíòúð ïî îïàçâàíå íà îáùåñòâåíîòî çäðàâå èÍàöèîíàëíèÿò öåíòúð ïî çäðàâíà èíôîðìàöèÿ ñàïðåîáðàçóâàíè, ÷ðåç ñëèâàíå, â Íàöèîíàëåí öåíòúðïî îáùåñòâåíî çäðàâå è àíàëèçè (ÍÖÎÇÀ).

Ñúñ çàïîâåä íà Ìèíèñòúðà íà çäðàâåîïàçâàíåòî, îò06.06.2011ã., çà äèðåêòîð íà Íàöèîíàëíèÿ öåíòúð ïîîáùåñòâåíî çäðàâå è àíàëèçè å íàçíà÷åí ä-ð ÈâàéëîÂàêëèíîâ.

Íàöèîíàëíèÿò öåíòúð ïî îáùåñòâåíî çäðàâå è àíàëèçèå ñòðóêòóðà íà íàöèîíàëíàòà ñèñòåìà íàçäðàâåîïàçâàíåòî è îñúùåñòâÿâà äåéíîñòè ïî:îïàçâàíå íà îáùåñòâåíîòî çäðàâå, ïðîìîöèÿ íàçäðàâåòî è ïðîôèëàêòèêà íà áîëåñòèòå,èíôîðìàöèîííî îñèãóðÿâàíå íà óïðàâëåíèåòî íàçäðàâåîïàçâàíåòî. Ìèñèÿòà íà öåíòúðà å äà ñú÷åòàâàòåçè ðàçíîîáðàçíè äåéíîñòè â èíòåðåñ íà ïî-äîáðîòîçäðàâå íà íàñåëåíèåòî. Âñè÷êè óñèëèÿ íà ðàáîòåùèòåâ Öåíòúðà õàáèëèòèðàíè ëèöà, åêñïåðòè è òåõíè÷åñêèïåðñîíàë ñà íàñî÷åíè êúì ïðèëàãàíåòî íàñúâðåìåííèòå òåõíîëîãèè â îáëàñòòà íà îáùåñòâåíîòîçäðàâåîïàçâàíå è çàåìàíåòî íà âîäåùî ìÿñòî âÍàöèîíàëíàòà çäðàâíà ñèñòåìà.

Àêòóàëíà èíôîðìàöèÿ çà äåéíîñòòà íà ÍÖÎÇÀìîæåòå äà ÷åòåòå íà ñàéòà http://ncpha.government.bg.

Ïðîäúëæàâà äà èçëèçà Áúëãàðñêî ñïèñàíèå çàîáùåñòâåíî çäðàâå. Ñïèñàíèåòî ùå çàïàçè ñâîÿòàêîíöåïöèÿ, ùå ïðîäúëæè äà èçïúëíÿâà çàëîæåíèòåöåëè è ùå ïîïóëÿðèçèðà ñúâðåìåííèèíôîðìàöèîííè è êîìóíèêàöèîííè òåõíîëîãèè âîáëàñòòà íà îáùåñòâåíîòî çäðàâåîïàçâàíå.

Åêèïúò íà ñïèñàíèåòî ïîæåëàâà óñïåõ íà íîâîòîðúêîâîäñòâî íà ÍÖÎÇÀ.


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Bulgarian Journal of Public Health is a multidisciplinaryjournal, which covers the following fields of public health:health policy, health management and economics,epidemiology of noncommunicable and communicablediseases, population / women’s/ children’s health, healthpromotion and disease prevention, environmental health,foods and nutrition, occupational health, mental health,public health and disasters.

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ÓÊÀÇÀÍÈß ÇÀ ÀÂÒÎÐÈÒÅ

“Áúëãàðñêî ñïèñàíèå çà îáùåñòâåíî çäðàâå” åìíîãîïðîôèëíî ñïèñàíèå, êîåòî âêëþ÷âàïóáëèêàöèè â îáëàñòòà íà çäðàâíàòà ïîëèòèêà, çäðàâåíìåíèäæìúíò è èêîíîìèêà, åïèäåìèîëîãèÿ íàíåèíôåêöèîçíèòå è çàðàçíèòå áîëåñòè, çäðàâåòî íàíàñåëåíèåòî /æåíèòå/äåöàòà/, ïðîìîöèÿ íà çäðàâåòîè ïðîôèëàêòèêà íà áîëåñòèòå, îêîëíà ñðåäà è çäðàâå,õðàíè è õðàíåíå, òðóäîâà ìåäèöèíà, ïñèõè÷íî çäðàâå,êðèçèñíè ñèòóàöèè è îáùåñòâåíî çäðàâå. Ìàòåðèàëèòåñå îòïå÷àòâàò íà áúëãàðñêè è àíãëèéñêè åçèê. Âñïèñàíèåòî ñå ïóáëèêóâàò:

- Íàó÷íè ñòàòèè (äî 12 ñòð.): Ñòàòèèòå âêëþ÷âàòÂúâåäåíèå, Öåë, Ìàòåðèàë è ìåòîäè, Ðåçóëòàòè,Îáñúæäàíå, Çàêëþ÷åíèå è Êíèãîïèñ.

- Îáçîðè (äî 12 ñòð.): Îáçîðèòå òðÿáâà äà ïðåäñòàâÿòçíà÷èìè òåìè â îáëàñòòà íà îáùåñòâåíîòî çäðàâå.

- Äèñêóñèÿ, ïîçèöèè (äî 6 ñòð.) - çàñÿãàò âñÿêà îáëàñòíà îáùåñòâåíîòî çäðàâå.

- Ìíåíèÿ, ñúáèòèÿ (äî 1 ñòð.) - ïðåäñòàâÿò àêòóàëíè,çíà÷èìè èëè äèñêóñèîííè ïðîáëåìè è âàæíèñúáèòèÿ.

- Ïðåäñòàâÿíå íà íîâè êíèãè èëè ñîôòóåð (äî 1ñòð.)

Îòãîâîðíîñò íà àâòîðà. Âñè÷êè ïðåäñòàâåíè çàïóáëèêóâàíå ìàòåðèàëè òðÿáâà äà áúäàò îðèãèíàëíèðàçðàáîòêè, êîèòî íå ñà ïóáëèêóâàíè äî òîçè ìîìåíòè íå ñà ïîäàäåíè çà ïóáëèêóâàíå äðóãàäå. Ïðèåòèòåðúêîïèñè íå ìîãàò äà áúäàò ïóáëèêóâàíè ñëåä òîâà âäðóãè èçäàíèÿ â ñúùèÿ âèä, èçöÿëî èëè íà ÷àñòè è íàêàêúâòî è äà áèëî åçèê, áåç ñúãëàñèåòî íà “Áúëãàðñêîñïèñàíèå çà îáùåñòâåíî çäðàâå”. Àâòîðèòå îòãîâàðÿòçà âñè÷êè ÷àñòè îò ìàòåðèàëà ñè.

Íàó÷íà åòèêà. Îòãîâîðíîñò íà àâòîðèòå å äàóäîñòîâåðÿò, ÷å âñÿêî èçñëåäâàíå âúðõó õîðà å áèëîîäîáðåíî îò êîìèñèÿ ïî ìåäèöèíñêà åòèêà.

Ïîäàâàíå íà ðúêîïèñèòå. Ìàòåðèàëèòå òðÿáâà äàáúäàò ïîäàâàíè â åëåêòðîíåí âèä (ïî åëåêòðîííà ïîùàèëè íà CD/äèñêåòà) è êàòî ïå÷àòíî êîïèå (2 êîïèÿ,ôîðìàò À4). Ìàòåðèàëèòå îò áúëãàðñêèòå àâòîðèòðÿáâà äà áúäàò íà áúëãàðñêè è àíãëèéñêè åçèê, à íààâòîðèòå îò ÷óæáèíà íà àíãëèéñêè åçèê.

Ïîäãîòîâêà íà ðúêîïèñà

Ïðèäðóæèòåëíî ïèñìî: Ðúêîïèñúò òðÿáâà äà áúäåïðèäðóæåí ñ ïèñìî, óäîñòîâåðÿâàùî, ÷å ìàòåðèàëúòè äàííèòå èëè ÷àñòè îò òÿõ íå ñà áèëè ïóáëèêóâàíèäîñåãà (îñâåí êàòî ðåçþìå), êàêòî è ÷å ìàòåðèàëúò íåå ïîä ïå÷àò è íå å âúçëîæåí çà ðåöåíçèðàíå â äðóãîèçäàíèå.

Çàãëàâíà ñòðàíèöà:

- Âèä íà ðúêîïèñà (îðèãèíàëíà ñòàòèÿ, îáçîð è äð.)


- Title, Authors names and affiliations at the time thework has been created

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- Acknowledgements, including colleagues whocontributed to the research.

Directions: Use SI units of measure. Avoid acronymsunless they are widely recognized. Define acronyms andabbreviations at first mention in text. Provide submittedmanuscript files in a Microsoft Word processing format.Format the manuscript files for A4 size paper with 2.5 cmmargin on all sides. Use 12-point Times New Roman, 1.5spaced. Align text only on the left side.

Abstract: For research articles, provide a structuredabstract, with headings for Background, Methods,Results, and Conclusions. Unstructured abstracts areallowed for papers of different kind (eg, methodologypapers). Abstracts are limited to 250 words.

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References: References should be numberedconsecutively in order of appearance in the text, andlisted immediately after the main text. Reference numbersin the text should be in parenthesis. 1,5 space thereferences.

- Çàãëàâèå, èìåíà íà àâòîðèòå è ìåñòîðàáîòà ïîâðåìå íà èçãîòâÿíå íà ìàòåðèàëà

- Èìå è ïúëåí àäðåñ íà êîðåñïîíäèðàùèÿ àâòîð,òåëåôîí, åëåêòðîííà ïîùà

- Áëàãîäàðíîñòè êúì ëèöà è êîëåãè ñ ïðèíîñ çàèçñëåäâàíåòî.

Óêàçàíèÿ çà îôîðìëåíèå íà ìàòåðèàëèòå: Èçïîëçâàòñå ìåðíè åäèíèöè íà ìåæäóíàðîäíàòà ñèñòåìà SI. Äàñå èçáÿãâàò àêðîíèìè, îñâåí àêî íå ñà îáùîïðèåòè.Àêðîíèìèòå è ñúêðàùåíèÿòà ñå äåôèíèðàò ïðèïúðâàòà èì óïîòðåáà â òåêñòà. Ôàéëîâåòå íà ðúêîïèñàñå ïîäàâàò âúâ ôîðìàò íà Microsoft Word. Ôîðìàòúòíà ñòðàíèöèòå òðÿáâà äà áúäå À4 ñ ïîëåòà îò 2,5 cm îòâñè÷êè ñòðàíè, øðèôòúò 12-point Times New Roman ñ1,5 èíòåðâàë ìåæäó ðåäîâåòå. Òåêñòúò ñå ïîäðàâíÿâàñàìî îò ëÿâî.

Ðåçþìå: Çà íàó÷íè ñòàòèè ñå ïîäãîòâÿ ðåçþìå ñúññëåäíàòà ñòðóêòóðà è ïîäçàãëàâèÿ: Îáîñíîâêà, Öåë,Ìåòîäè, Ðåçóëòàòè è Çàêëþ÷åíèå. Ïðè ìàòåðèàëè áåçñòðóêòóðà (íàïðèìåð, ìåòîäîëîãè÷íè ìàòåðèàëè) ñåäîïóñêàò ðåçþìåòà, íåñòðóêòóðèðàíè ïî ãîðíèÿíà÷èí. Ðåçþìåòî òðÿáâà äà ñúäúðæà íå ïîâå÷å îò 250äóìè.

Êëþ÷îâè äóìè: Ïðåäñòàâÿò ñå ñëåä ðåçþìåòî.

Òàáëèöè: Òàáëèöèòå òðÿáâà äà èìàò ÿñíè çàãëàâèÿ èïðè íåîáõîäèìîñò îáÿñíèòåëíè áåëåæêè ïîä ÷åðòà.

Ôèãóðè: Âñÿêà ôèãóðà ñå ïîäàâà êàòî îòäåëåíäîêóìåíò/ôàéë. Ôèãóðèòå ñå íîìåðèðàò ïî ðåäà íàöèòèðàíåòî èì â òåêñòà. Âñÿêà ôèãóðà òðÿáâà ñåïðèäðóæàâà ñ êðàòêà ëåãåíäà íà îòäåëíà ñòðàíèöà,êîÿòî ñëåäâà Êíèãîïèñà è å ÷àñò îò òåêñòîâèÿ ôàéë. Âìàòåðèàëèòå íà áúëãàðñêèòå àâòîðè çàãëàâèÿòà èòåêñòúò êúì ôèãóðèòå òðÿáâà äà áúäàò íà áúëãàðñêè èàíãëèéñêè åçèê.

Êíèãîïèñ: Öèòèðàíèòå èçòî÷íèöè ñå íîìåðèðàò ïîðåäà íà ïîñî÷âàíåòî èì â òåêñòà è ñå îïèñâàòíåïîñðåäñòâåíî ñëåä îñíîâíèÿ òåêñò. Â òåêñòà íîìåðúòíà öèòèðàíèÿ èçòî÷íèê ñå ïîñòàâÿ â ñêîáè.

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