Hygiene & Sanitation

hygienic journal of general profile

Hygienic Journal of the General scope publishes articles on all sections of hygiene science and sanitary practice. The main attention pay to environmental and human health, human ecology, child and adolescent hygiene and radiation hygiene, occupational health, nutrition and social hygiene and health risk assessment. The Journal publishes original and review articles.


Topic number
№ 4 . 2020
ENVIRONMENTAL HYGIENE

Justification of the priority controlled sanitary-microbiological parameters to ensure the safety of hospital environment, medical organizations stationary type, regardless of their functional purpose

Annotation

Introduction. The work is devoted to evaluating the results of our own research of sanitary-microbiological monitoring of environmental objects in diversified treatment-and-prophylactic institutions of stationary type and of the analysis both of domestic and foreign data in order justify of the list of priority controlled sanitary-microbiological indices of air and surfaces to ensure the safety of hospital environment, medical organizations stationary type, regardless of their functional purpose.

Material and methods. The survey was conducted in various premises in the medical-prophylactic institutions of stationary type for two years. Studies included determination of microbial contamination of the air environment, working surfaces, hands of personnel with the detection of bacteriological, virological, and mycological parameters, followed by macroscopic and microscopic identification of microorganisms and identification using automated systems with the method of time-of-flight matrix-assisted laser mass spectrometry platform MALDI-TOF, based on the study of the mass spectra of ribosomal proteins in the range of 1000-10000 Daltons and bioinformatic comparison of the obtained spectrum with database reference spectra and PCR.

Results. As a result, the research of surface washings in the premises of a multidisciplinary clinic revealed microbial contamination with conditionally pathogenic gram-positive cocci, including S.aureus, gram-positive and gram-negative bacteria posing a serious epidemiological danger to patients in these wards regardless of the MOST profile and requires mandatory monitoring taking into account of the used disinfectants.

Conclusion. Our own research and analysis of domestic and foreign literature showed that it is not enough to monitor the air in the MOST premises only in terms of total microbiological contamination. In the operating, procedural and dressing blocks, as well as in the wards, physiotherapeutic, diagnostic, laboratory rooms and auxiliary units, it is also necessary to take into account other sanitary and microbiological indices: total microbes count, gram-positive rods and cocci, including S.aureus, fungi, adeno-, entero-, astroviruses, coliphages.

Leading air pollution related reasons of death

Annotation

The aim of this study was to analyze the effect of air pollution on the structure of reasons of death from major non communicable diseases in cities of the Russian Federation

Material and methods. The study analyzed the mortality of people of working age (with stratification by gender and causes of death) in pairs of cities, with matching the cities of each pair by the climatic and socio-economic conditions, but the level of air pollution in one city significantly exceeded the level of pollution in another. The following pairs of cities were formed (“dirty” - “relatively clean”): Bratsk-Kirov; Nizhny Tagil-Kirov; Novokuznetsk-Tomsk; Chita-Tomsk; Magnitogorsk - Orenburg, Cherepovets-Vologda. The analysis included data on the mortality from diseases of the circulatory system, respiratory system, and oncological diseases, since according to WHO, air pollution primarily affects mortality from coronary heart disease, stroke, chronic obstructive pulmonary disease, and lung cancer.

Results. The mortality rate of people of working age from diseases of the circulatory system, primarily from cardiovascular diseases, is significantly higher in cities with a high level of pollution compared with cities with a lower level of pollution and similar climatic and socioeconomic conditions. The mortality rate of men from cerebrovascular diseases in the group of dirty cities is higher than in compared cities in 4 out of 6 studied pairs. Moreover, differences in the mortality rate in women were less pronounced, they were revealed in 2 out of 6 compared pairs. The differences in mortality from oncological diseases were detected in 4 out of 6 comparison pairs for women and 2 out of 6 compared pairs for men.

Conclusion. An analysis of the mortality used pairwise comparison of cities showed air pollution to most affect on the mortality from diseases of the circulatory system.

Developing GIS portal to ensure sanitary and epidemiological surveillance of transferring radio engineering objects

Annotation

In recent years, in the Russian Federation there has been an increase in the levels of radiofrequency electromagnetic fields in residential areas, including due to an increase in the number of base stations (BS). The purpose of sanitary and epidemiological surveillance at the stages of placement and commissioning of base stations (BS) is to prevent their adverse effects on public health. The increase in the number of base stations, together with the advent of new electronic equipment and antennas, provide opportunities for improving the processes of their accounting at the stage of placement and monitoring of the levels of radiofrequency electromagnetic fields at the operation stage. This automation tool can be a geo-information portal for providing sanitary and epidemiological surveillance of cellular base stations. The prototype of the geo-information portal allows both calculating the size of sanitary protection zones (PZ) and building restriction zones (RZ) from the BS in online mode, displaying the results of calculations in graphical form and issuing sanitary and epidemiological conclusions for the placement and operation of base stations. The geo-information portal has the ability to synchronize with the data of the radio frequency center. Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing will be able to receive up-to-date analytical data. There will be completely automated processes of collecting, processing and storing information on BS.

Information hygiene: modern approaches to hygienic evaluation of content and physical signals of information carriers

Annotation

The increasing flow of information affects health. The prevalence of information as an environmental factor is considered. With the growth of traditional information-dependent morbidity according to ICD-10, a new pathology appears as follows: computer syndrome, television addiction, depression from social networks, Internet addiction, ludomania, nomophobia, Internet suicides. There is presented a conceptual framework of prevention trends: information hygiene, ecology, ethics, digital-, cyber-, internet-hygiene. Information hygiene is a branch of medical science that studies the regularities of the impact of information on the mental, physical and social well-being of a person, his working capacity, life expectancy, public health of society, developing standards and measures to improve the information environment and optimize intellectual activity. There was analyzed the existing hygienic regulation of physical signals and perspectives of hygienic assessment activities with pronounced information loads. The shortcomings of the existing dosimetry, modern diagnostic devices for the dose-effect methodology are considered. There is discussed the importance of informational hygiene for content limits, targeting boundaries and specialization in the dissemination of information for the prevention of infopandemics, accompanied by virusophobia, quarantinomania, radiophobia, mysophobia. There are provided the scientific trends of multi-disciplinary mega-projects of the study of intelligence for the new hygienic approaches to optimize mental health. Taking into account the strategies of the national project “Education”, the digital development of the information society in Russia, as well as prevention of info-epidemics, the development of a textbook on information hygiene can be relied upon the principles outlined in the axiomatics of information ecology. There is proposed expediency of adequate responses from hygienists, preventive medicine and the state sanitary service for consideration. In social and communal hygiene – the study of mental statistics, public health, prediction, prevention infopandemics. In the hygiene of children and adolescents there is considered the development of recommendations and standards for gadgets and the time of their use, the assessment of the phenomena of clip-thinking, the transition to electronic textbooks, “blinkers” on the quality and volume of information in the search for knowledge. In occupational health – determination of the limits of intelligence from neuroscience, intensification of brain-computer interfaces, “dose-effects” and maximum permissible levels of carrier signals, optimization of information cooperation.

Comparative analysis of the prevalence of congenital malformations of the brain in children of the radioactively contaminated territories of the Bryansk region after the Chernobyl disaster (1999-2014)

Annotation

Purpose of the study. Based on the official statistics for 1999-2014, we carried out a comparative analysis of the incidence of congenital brain malformations in children resided in the radiation-contaminated areas of the Bryansk region after the Chernobyl disaster with different densities of Cesium-137 and Strontium-90.

Material and Methods. Student’s t-test, Pearson chi-square test, Pearson correlation test, linear regression.

Results. As a result of the study, no statistically significant excess in the frequency of anencephaly, hydrocephalus and encephalocele in children in more radiation-contaminated south-western territories (SWT) was found compared to the average regional data. However, in the SWT, the prevalence of microcephaly is statistically significant (p<0,05) above the average regional values (5.8 times). While the maximum values are recorded in the most radioactively polluted areas of the region when high statistically significant correlations are detected with the density of radioactive contamination with Cesium-137 (r=0.69; p=0.040) and Strontium 90 (r=0.70; p=0.037), while there are no significant dependencies for other brain defects of the brain. A statistically significant decrease in the long-term trend in the prevalence of microcephaly throughout the region without SWT in the period 1999-2014, and an increase in the radiation-contaminated SWT, was found.

Conclusions. The results obtained presumably indicate to the influence of the radiation factor on the increased incidence of microcephaly in SWT relative to the average regional values without SWT for a sixteen-year period (1999-2014). The further studies are needed to analyze the incidence of various types of congenital malformations in order to determine a strategy for preventing birth of children with congenital anomalies.

Assess of contamination of the snow cover for detecting the zones of inhalation chemical risk

Annotation

Introduction. On the territory with a resistant snow cover, atmospheric pollution accumulates over several months; solid precipitation in the form of snow is an indicator object for assessing the state of the urban environment.

Materials and methods. The sampling of snow was carried out on trial plots close to the monitoring points of atmospheric air and reflecting the influence of various stationary and mobile sources of pollution. The methods of gas chromatography-mass spectrometry and the atomic absorption spectrometry were used.

Results. The results were obtained on the content of polycyclic aromatic hydrocarbons (PAHs) and heavy metals in snow cover to identify risk zones in the city of Ulan-Ude of the Republic of Buryatiya. The widest range of metals is recorded at points located near a major traffic interchange and in a residential area near the low-rise buildings of the private sector. The determined PAHs in large quantities were established to be contained in the solid sediment of snow samples.

Discussion. Snow cover is a depositing and transit component of the environment. Its study gives important information about the chemical state of industrial ecosystems. About 30 thousand tons of chemical impurities enter the air basin of Ulan-Ude from stationary sources per year. Emissions of the total amount of hydrocarbons averaged of 1,741.96 tons over the study period, soot - 822.41 tons, which is by tens and hundreds times higher than that of other toxic substances, therefore, the PAH content in snow samples is higher than that of heavy metals.

Conclusion. The accumulation of chemicals of 13 priority PAHs, of which 60–80% of the total amount falls on 3-,4- nuclear counterparts (phenanthrene, anthracene, fluoranthene, pyrene, benzo(a)anthracene, chrysene) occurs in accumulating media. PAHs are associated with water-insoluble (solid phase) PAHs, which indicates to the unity of the main source of pollution (vehicle exhaust gases).

Effect of pollutants on biochemical properties of microorganisms

Annotation

Introduction. The development of different ways of identifying hazard of substances, polluting the environment, that are alternative to routine methods for assessing health of different professional groups of people, as well as to tests on laboratory animals, has been assessed and summarized in a number of papers, and there is a growing volume of actual data on this issue. The analyzing pathogenic properties of microflora, isolated from polluted habitats or changed under the effect of pollutants, allows both assessing the risk of diseases with microbial etiology and identifying the influence of modifying factors on this process.

Materials and methods. The research was performed on 150 cultures of Klebsiella pneumoniae, exposed to diethanolamine, phenol, sulfuric and nitric acids, taken at the level of their threshold limit value. The same cultures incubated without pollutants were used as a control group. Pathogenic factors were determined with the use of traditional methods, our modified methods (RNAase activity) and standard agents, kits and media.

Results. The contact with all the pollutants resulted in a fair increase in adhesive, anti-Ig, lysozyme, anti-lysozyme and RNAase activities of microorganisms, their resistance to antibacterial action of blood serum, as well as to damaging action of lactoferrin. The bacteria increased their ability to synthesize a substance, immunologically similar to human lactoferrin. At the same time, there was a decrease in lipase activity, primarily referred to factors determining the bacterial ability to survive in the environment.

Discussion. Therefore, the paper results can be presented as follows: being an independent and holistic section of modern microbiology, bacterial biochemistry unites the issues appeared to be far from each other – changes in factors of pathogenicity and persistence of microorganisms and technogenic changeability of the environment. Being quite urgent today, this problem may become aggravated in the course of further technological progress.

Questions on the role of biofilms for the adaptation of microorganisms to unfavorable environmental factors by the example of P. aeruginosa

Annotation

Pseudomonas aeruginosa is a widely represented species of bacteria possessing of a pathogenic potential. This infectious agent is causing wound infections, fibrotic cystitis, fibrosing pneumonia, bacterial sepsis, etc. The microorganism is highly resistant to antiseptics, disinfectants, immune system responses of the body. The responses of a quorum sense of this kind of bacteria ensure the inclusion of many pathogenicity factors. The analysis of the scientific literature made it possible to formulate four questions concerning the role of biofilms for the adaptation of P. aeruginosa to adverse environmental factors: Is another person appears to be predominantly of a source an etiological agent or the source of P. aeruginosa infection in the environment? Does the formation of biofilms influence on the antibiotic resistance? How the antagonistic activity of microorganisms is realized in biofilm form? What is the main function of biofilms in the functioning of bacteria? A hypothesis has been put forward the effect of biofilms on the increase of antibiotic resistance of bacteria and, in particular, P. aeruginosa to be secondary in charcter. It is more likely a biofilmboth to fulfill the function of storing nutrients and provide topical competition in the face of food scarcity. In connection with the incompatibility of the molecular radii of most antibiotics and pores in biofilm, biofilm is doubtful to be capable of performing a barrier function for protecting against antibiotics. However, with respect to antibodies and immunocompetent cells, the barrier function is beyond doubt. The biofilm is more likely to fulfill the function of storing nutrients and providing topical competition in conditions of scarcity of food resources.

OCCUPATIONAL HYGIENE

Sudden death from diseases of the circulatory system of employees of enterprises of the Republic of Bashkortostan

Annotation

Introduction. Over the past decade, in Russia and abroad, there has been a clear trend towards an increase in cases of sudden death in the workplace from the disease of the circulatory system.

Material and methods. During the study, there were studied the databases of the State Labor Inspectorate in the Republic of Bashkortostan in 2014-2018, including accident investigation reports, information on a special assessment of working conditions, medical examinations, forensic medical examinations and other materials.

Results. Diseases of the circulatory system (DSC) were the main cause of sudden death in the workplace in more than 90% of cases. The maximum number of cases of sudden due to DSC was recorded in the age group of 56-60 years. The overwhelming majority of the deceased cases were represented by working occupations - 82.8%, drivers of transport were in 13.7% of cases. The vast majority of deaths occurred in the morning (from 6 to 12) and daytime (from 12 to 18) hours. The working conditions of deceased DCS workers in most cases (59.8%) corresponded to the permissible class (class 2); under harmful conditions (subclass 3.1 - 3.3) 24.9% cases worked. Most often, some form of acute coronary heart disease (CHD) was mentioned as the immediate cause of death (64.0%). Among acute forms of coronary heart disease in medical documents in more than 50% of cases the code I 24.8 “Other forms of acute coronary heart disease” was established. “Acute myocardial infarction” was verified in 11.1% of cases and was the main cause of death in men. In the group “Cerebrovascular Diseases”, “Intracerebral hemorrhage” was most often diagnosed.

Conclusion. The obtained results substantiate the need to develop measures to prevent sudden death in the workplace, aimed primarily at preventing the development, progression and early diagnosis of DSC.

POPULATION HEALTH

Effectiveness of drug and non-drug treatment of tobacco dependence among physicians and nurses

Annotation

Introduction. The article is devoted to assessing the effectiveness of drug and non-drug treatment of tobacco dependence in health care workers.

Material and methods. The study included 621 medical workers (237 men and 384 women) working in hospitals in Moscow, at the average age of 48.3 ± 5.6 years, including 207 doctors and 414 nurses. The medical workers were divided into 2 groups depending on the antismoking program used. The first group consisted of 316 medical workers who received non-drug methods of treatment: psychosocial support, using cognitive aspects; psychotherapy; breathing exercises; acupuncture; increase physical activity. The second group consisted of 305 medical workers who, in addition to non-drug methods (described above), received Varenicline treatment (Champix® - tablets) and, if necessary, nicotine replacement therapy.

Results. In medical workers from the 2nd group, besides non-pharmacological therapy, received the drug Varenicline, 195 out of 305 (64%) persons completely stopped smoking; In the 1st group of Medical workers receiving non-drug therapy, 177 out of 316 (56% ) cases completely quit smoking (OR= 1.40; 95% CI: 1.01-1.93; р=0.0423). 6 months after the end of the treatment program, in the first group 84 (26.7%) medical workers) in the 2nd group - 31 medical workers (10.2%) restarted smoking, (OR=3.02, 95% CI: 2.05-5.02; р<0.00001).

Conclusion. Thus, the antismoking program, including drug Varenicline and, if necessary, nicotine-replacement therapy, as well as non-drug effects, including psycho-social support; psychotherapy; breathing exercises; acupuncture; an increase in physical activity showed higher efficacy compared with the antismoking program without Varenicline, moreover, high efficacy remained even after the treatment carried out for 6 months.

HYGIENE OF CHILDREN AND ADOLESCENTS

Comparative characteristics of the functional state of the Autonomous and Central nervous systems depending on the presence and degree of myopia in students

Annotation

Introduction. In children and adolescents myopia in some countries already reached epidemic levels due to the growing prevalence is an urgent need for new approaches to management and search for screening indics of its development risk and key points in its stabilization. Taking into account the development and progression of myopia may be associated with autonomous influences of the nervous system, it becomes relevant to study the features of the autonomous status formation in children, depending on the presence and degree of myopia.

Material and methods. The functional state of the autonomic nervous system in 380 5-10 grades students with low degree myopia (group 1), moderate myopia (group 2), and without myopia (group 3) was assessed by heart rate and central nervous system variability and mental performance using variation chronoreflexometry.

Results. The maximum number (40%) was recorded in eighth grade of myopia students, 39.4% cases - in fifth grade students. An imbalance in the autonomic nervous system in schoolchildren was established to increase with growing myopic refraction. Thus, vagotonia occurred in 42.8% of students with low degree myopia, eutonia - in 42%, and sympathicotonia only in 15.2%. While in students with moderate myopia in 75% of cases the constraint of regulation systems was revealed due to excessive tone of the sympathetic part of the autonomic nervous system, which leads to uneconomic work of the cardiovascular system and a sharp decrease in the functional reserves of the body in 50% -70% of students.

Conclusion. Consideration of the relationship of myopia with the autonomous status and functional state of the сentral nervous system offers new directions to the existing concepts of myopia management in children and adolescents of school age, which can be a starting point for solving the problem of prevention of myopia and its progression.

Morphofunctional indices and motor qualities in younout g students with different levels of body mass deficit

Annotation

Introduction. The body weight of the person characterizes features of the exchange, power, hormonal, etc. the processes happening in a human body. Deviations from normal parameters of body weight affects somatic, physical, mental human health. The analysis of morfofunctsional characteristics and motive features of youth students with insufficient body weight is relevant in connection with insufficient study of the matter.

Material and methods. 1514 students of the Irkutsk University at the age of 17-21 years are examined. Anthropometrical and physiometric examination was preformed, the maintenance of muscle and fatty bulk in a body was determined, motive qualities of young men with the normal body weight and deficiency of weight with gradation “below an average” and “low” are considered.

Results. The deficiency of body weight is revealed at 209 examined young men (13.8%), out of them 134 students (64.1%) have gradation of deficiency of body weight “below an average” and value of an index in the range of a sigma deviation from M = -1 σ to M = -2 σ and 75 young (35.9%) men - gradation “low” where value of an index less than A M = -2 σ. Reliable differences between morfofunctional indices and results in motive tests of the students having deficiency of body weight and normal weight students are established. Indices of anthropometrical and physiometric characteristics, motive tests, the maintenance of muscle and fatty bulk in a body of all young men having deficiency of body weight are lower in comparison with indices of the young men having normal body weight (р <0.05). The dependence between decrease in the level of development of motive qualities and reduction of body weight of students is noted.

Conclusions. The received results allow correcting educational process on valeological and physical training of students of higher education institution with the use of integrative pedagogical methods and methods of training.

Hygienic assessment of learning environment conditions (by the example of higher educational institutions of the city of Ufa)

Annotation

Introduction. The important factors affecting health and performance of young people are the conditions of education, in particular, a comfortable microclimate in the classrooms of higher educational institutions.

Materials and methods. In view of the urgency of this problem, an analysis was made of the microclimate parameters of educational organizations of different profiles (Ufa city, the Republic of Bashkortostan). 294 classrooms were studied in 22 buildings of 4 leading universities in Ufa. A total of 3,822 measurements were taken to determine the parameters of the microclimate. The analysis of ionizing radiation in the aerial environment of classrooms. There was performed determination of radon and its affiliated products content. In order to assess the conditions and lifestyle of students of 4 higher educational institutions of the city of Ufa, we conducted an anonymous survey of 1,820 students of I and IV years of education.

Results. The average temperature in the classrooms of all universities studied was 23.9±0.09 C. The average relative humidity in all classrooms was 34.2 ± 0.42%. Analysis of ionizing radiation (radon and its daughter products decay) in the aerial environment of the classrooms and sports halls located in the basement determined that the average annual equivalent equilibrium volumetric activity of the radon daughter products (EROA ± Δ222Rn) ranged from 28 ± 14 to 69 ± 34.5 meter, which meets the requirements established by SanPiN.

Conclusion. The hygienic assessment of the microclimate parameters of educational institutions of various profile revealed a number of deviations from the regulated norms. The results indicate the need to control the parameters of the microclimate, both from the administration of universities, and from the professors. According to the results of the study, recommendations were prepared for the management of higher educational institutions in Ufa.

PREVENTIVE TOXICOLOGY AND HYGIENIC RATING

Iron Metabolism in the Human Body and its Hygienic Limits for Drinking Water. Review. Part 1

Annotation

Iron is an essential element indispensable for the growth, division, differentiation and functioning of any living cell in the body. for humans iron is vitally important and dangerous at the same time, because with excessive accumulation it causes oxidative stress with the formation of highly active oxygen radicals and reactive forms of nitrogen that can destroy cell membranes, proteins, nucleic acids, reduce cell viability, which, according to modern concepts, can contribute to the development of many diseases (cardiovascular, rheumatic, gastrointestinal, neurodegenerative, oncological, metabolic and others), and also accelerate the aging process. This review discusses the issues of iron metabolism in humans, including its regulation at the cellular and systemic levels, the intake, transport, use, accumulation and export of iron in cells, the role of the labile iron pool in the cytoplasm of cells and plasma non-transferrin bound iron. There are provided data on the causes, prevalence iron overload in the formation of free radicals, the development of oxidative stress and related common diseases, as well as information on ferroptosis, a new type of iron-dependent regulated cell death. Attention is paid to the works of domestic authors, where it was found that prolonged use of drinking water with a high iron content is unfavorable for the population and leads to an increase in the overall incidence, the development of diseases of the blood, skin and subcutaneous tissue, musculoskeletal system, digestive system, urogenital system, and allergic diseases. There are cited separate publications on the possibility of a negative effect of iron at concentrations in water at a level of 0.3 mg/l and lower. The materials of the review emphasize the preventive value of a cautious attitude to regulating iron in the water of the Russian Federation, where 1/3 of the population uses iron-containing water for drinking, and substantiate the feasibility of establishing a hygienic standard for iron in water not higher than 0.3 mg/l, without inclusion in regulatory documents level of 1 mg/l as permissible.

EXPERIMENTAL INVESTIGATIONS

Assessment of the mutagenicity of the technical product of N-(1-ethylpropyl)-2,6-dinitro -3,4-xylidinen

Annotation

Introduction. Evaluation of genotoxicity of the pesticide technical products is one of the mandatory requirements for their toxicological and hygienic assessment. The data about mutagenic property is ambiguous for some pesticides. This may be due to the use of various active ingredients of technical products of the pesticide for testing, as they may have different profiles of relevant impurities, some of which may be potentially genotoxic.

Material and methods. A technical product of N-(1-ethylpropyl)-2,6-dinitro-3,4-xylidine was tested using the bacterial reverse mutation method with Salmonella typhimurium (Ames test) and the in vivo mammalian micronucleus analysis in mouse bone marrow erythrocytes.

Results. Statistically significant dose-dependent mutagenic effects of the technical product of N-(1-ethylpropyl)-2,6-dinitro-3,4-xylidine were revealed for TA97 (+S9 / -S9); TA100 (+S9 / -S9); TA102 (+S9 / -S9) and TA98 (+S9 / -S9) strains. In all cases, the fold increase of the revertant numbers mediated by the tested substance compared with the concurrent negative control was > 2 except TA98 in the presence of S9. In the micronucleus test, the technical product did not induce a statistically significant increase in the frequency of the micronucleated polychromatophilic erythrocytes in CD-1 mouse bone marrow up to 2000 mg/kg bw.

Conclusion. The data suggest all technical products of pesticides entering the market should be tested for the potential genotoxicity. In such a case it is necessary to use at least two methods on different test systems for obtaining reliable results.

CHIEF EDITOR
CHIEF EDITOR
Yuri A. Rahmanin
MD, Ph.D., professor, Honored Scientist of the Russian Federation, chief scientific consultant of the Centre for Strategic Planning, Russian Ministry of Health
Medicine today

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