{"id":25421,"date":"2022-09-28T09:00:34","date_gmt":"2022-09-28T06:00:34","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25421"},"modified":"2022-09-28T10:31:48","modified_gmt":"2022-09-28T07:31:48","slug":"kizamigin-yeniden-ortaya-cikisi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/09\/28\/kizamigin-yeniden-ortaya-cikisi\/","title":{"rendered":"D\u00fcnyada ve \u00dclkemizde K\u0131zam\u0131\u011f\u0131n Yeniden Ortaya \u00c7\u0131k\u0131\u015f\u0131: Nedenler ve Sonu\u00e7lar"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

A\u015f\u0131lama yoluyla ba\u015far\u0131l\u0131 bir \u015fekilde kontrol alt\u0131na al\u0131nan eski ve olduk\u00e7a bula\u015f\u0131c\u0131 bir hastal\u0131k olan k\u0131zam\u0131k, eliminasyon ve eradikasyon hedeflerine ula\u015famadan b\u00fct\u00fcn d\u00fcnyada salg\u0131nlarla canlanma g\u00f6stermi\u015ftir. Bu derlemenin amac\u0131, hastanemizde \u00fc\u00e7 ayr\u0131 salg\u0131n d\u00f6neminde g\u00f6r\u00fclen k\u0131zam\u0131k olgular\u0131n\u0131n \u00f6zelliklerini de\u011ferlendirmek, a\u015f\u0131 karars\u0131zl\u0131\u011f\u0131n\u0131n k\u0131zam\u0131k olgu say\u0131s\u0131 art\u0131\u015f\u0131 \u00fczerindeki etkisine dikkat \u00e7ekmek ve hem \u00fclkemizde hem de d\u00fcnyada k\u0131zam\u0131k infeksiyonun ortaya \u00e7\u0131k\u0131\u015f\u0131n\u0131n neden ve sonu\u00e7lar\u0131n\u0131 irdelemektir. \u00a0<\/span><\/p>\n

Paramiksovirus ailesinin bir \u00fcyesi olan k\u0131zam\u0131k virusu, be\u015f ya\u015f\u0131ndan k\u00fc\u00e7\u00fck \u00e7ocuklar aras\u0131nda \u00f6nde gelen k\u00fcresel \u00f6l\u00fcm nedenlerinden biridir ve a\u015f\u0131yla \u00f6nlenebilir bir hastal\u0131\u011fa neden olur. K\u0131zam\u0131k infeksiyonunun s\u0131k g\u00f6r\u00fclen komplikasyonlar\u0131; solunum yolu mukozal y\u00fczeylerinin primer viral infeksiyonu ve bakteriyel s\u00fcperinfeksiyonlard\u0131r. Komplikasyonlar a\u011f\u0131rl\u0131kl\u0131 olarak be\u015f ya\u015f\u0131n alt\u0131ndaki \u00e7ocuklarda, ba\u011f\u0131\u015f\u0131k olmayan eri\u015fkinlerde, gebelerde ve imm\u00fcn sistemi bask\u0131lanm\u0131\u015f bireylerde ortaya \u00e7\u0131kar. Tipik komplikasyonlar; otitis media, laringotrakeobron\u015fit, pn\u00f6moni ve ishaldir. K\u0131zam\u0131k infeksiyonunun ge\u00e7 sekelleri, ciddi mukozal hasar ve virusun yaratt\u0131\u011f\u0131 imm\u00fcn bask\u0131lanmaya ba\u011fl\u0131d\u0131r. Akut infeksiyondan iyile\u015ftikten sonra bile, \u00e7ocuklarda persistan ishal ve geli\u015fme gerili\u011fi ile infeksiyondan aylar sonra mortalite riski olabilir. Latent t\u00fcberk\u00fcloz reaktive olabilir. K\u0131zam\u0131k infeksiyonundan hemen sonra t\u00fcberk\u00fcloz cilt testi daha az g\u00fcvenilir hale gelir. A vitamini eksikli\u011fi ve maln\u00fctrisyonun fazla oldu\u011fu pop\u00fclasyonlarda \u015fiddetli hastal\u0131k ve \u00f6l\u00fcmler artar. K\u0131zam\u0131ktan \u00f6l\u00fcme \u00e7o\u011funlukla viral pn\u00f6moni, sekonder bakteriyel pn\u00f6moni ve postviral ensefalit neden olur. Subakut sklerozan panensefalit; genellikle ergenlik d\u00f6neminde akut k\u0131zam\u0131k infeksiyonundan 7-10 y\u0131l sonra ortaya \u00e7\u0131kan, k\u0131zam\u0131\u011f\u0131n nadir, ge\u00e7 ve s\u0131kl\u0131kla fatal bir komplikasyonudur. Miyoklonik jerkler ve yava\u015f mental bozulma ile ba\u015flar; 1-3 y\u0131l i\u00e7inde ilerleyerek dejeneratif bir seyir ve \u00f6l\u00fcmle sonu\u00e7lan\u0131r (1).<\/p>\n

\u0130nfekte bir ki\u015finin; hava yoluyla, burun veya bo\u011faz salg\u0131lar\u0131yla, do\u011frudan temasla k\u0131zam\u0131\u011f\u0131 yayma kapasitesi ve virusun olduk\u00e7a bula\u015f\u0131c\u0131 olan do\u011fas\u0131 k\u0131zam\u0131k salg\u0131nlar\u0131na \u00f6nemli bir katk\u0131da bulunur (2). Viral dola\u015f\u0131m\u0131 durdurmak i\u00e7in %95\u2019in \u00fczerinde bir toplumsal ba\u011f\u0131\u015f\u0131kl\u0131k gereklidir. \u0130nsanlar\u0131n k\u0131zam\u0131k virusunun tek do\u011fal kona\u011f\u0131 olmas\u0131, virusun yaln\u0131zca bir serotipinin olmas\u0131 ve genetik olarak stabil olmas\u0131 nedeniyle, k\u0131zam\u0131k eradikasyonu biyolojik ve teknik olarak olas\u0131d\u0131r (3).<\/p>\n


\n<\/b>L\u0130TERAT\u00dcR DERLEMES\u0130 VE TARTI\u015eMA<\/h2>\n

D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc K\u00fcresel K\u0131zam\u0131k K\u0131zam\u0131k\u00e7\u0131k Eliminasyon Program\u0131<\/h3>\n

K\u0131zam\u0131k hastal\u0131k y\u00fck\u00fcn\u00fc k\u00fcresel d\u00fczeyde azaltmak amac\u0131 ile 1989 y\u0131l\u0131nda D\u00fcnya Sa\u011fl\u0131k Asamblesi\u2019nde ve 1990 y\u0131l\u0131nda D\u00fcnya \u00c7ocuk Zirvesi\u2019nde belirlenen hedefler kapsam\u0131nda a\u015f\u0131lama \u00f6ncesi d\u00f6neme g\u00f6re k\u0131zam\u0131k mortalitesinin %95 ve morbiditesinin %90 azalt\u0131lmas\u0131 hedeflenmi\u015ftir. Daha sonra D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6) taraf\u0131ndan, Amerika B\u00f6lgesi\u2019nde 2000, Avrupa B\u00f6lgesi\u2019nde 2010 ve Do\u011fu Akdeniz B\u00f6lgesi\u2019nde 2010 y\u0131l\u0131na kadar k\u0131zam\u0131k eliminasyonu hedeflenmi\u015ftir. K\u00fcresel k\u0131zam\u0131k eliminasyonu program\u0131na g\u00f6re; rutin a\u015f\u0131lamada iki doz k\u0131zam\u0131k a\u015f\u0131s\u0131 ile %95 kapsay\u0131c\u0131l\u0131k, duyarl\u0131 hedef gruplar\u0131n belirlenerek tamamlay\u0131c\u0131 a\u015f\u0131lar\u0131n yap\u0131lmas\u0131, laboratuvar destekli etkin s\u00fcrveyans sistemi kurulmas\u0131 ve k\u0131zam\u0131k olgular\u0131n\u0131n etkin klinik y\u00f6netimi planlanm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

Amerika Birle\u015fik Devletleri\u2019ndeki Durum<\/h3>\n

K\u0131zam\u0131k a\u015f\u0131s\u0131; Amerika Birle\u015fik Devletleri\u2019nde (ABD) y\u0131lda yakla\u015f\u0131k 3-4 milyon olgu, 48 000 hastane yat\u0131\u015f\u0131 ve 400-500 \u00f6l\u00fcm olgusunun oldu\u011fu 1963\u2019te kullan\u0131ma girmi\u015ftir (4, 5). \u0130zleyen 20 y\u0131lda, a\u015f\u0131n\u0131n yayg\u0131n olarak piyasaya s\u00fcr\u00fclmesinin ve yo\u011fun eliminasyon \u00e7abalar\u0131n\u0131n ard\u0131ndan k\u0131zam\u0131k insidans\u0131, a\u015f\u0131 \u00f6ncesi d\u00f6nemde 100 000 n\u00fcfus ba\u015f\u0131na 300\u2019den, 1982\u2019den 1988\u2019e kadar ortalama 1.3 olguya d\u00fc\u015fm\u00fc\u015ft\u00fcr. 1989\u2019dan 1992\u2019ye kadar, ABD de dahil olmak \u00fczere bir\u00e7ok \u00fclkede k\u0131zam\u0131k yeniden canlanm\u0131\u015ft\u0131r; bu durumun esas olarak okul \u00f6ncesi \u00e7ocuklar aras\u0131ndaki suboptimal a\u015f\u0131 kapsam\u0131na ve tek bir k\u0131zam\u0131k a\u015f\u0131s\u0131 dozundan sonra a\u015f\u0131 ba\u015far\u0131s\u0131zl\u0131\u011f\u0131na ba\u011fl\u0131 oldu\u011fu d\u00fc\u015f\u00fcn\u00fclm\u00fc\u015ft\u00fcr. Bu sonu\u00e7, s\u00f6z konusu ya\u015f grubundaki a\u015f\u0131 kapsam\u0131n\u0131 iyile\u015ftirmek i\u00e7in yo\u011fun bir halk sa\u011fl\u0131\u011f\u0131 \u00e7abas\u0131n\u0131 motive etmi\u015ftir. 1990\u2019larda ba\u015flayan ve ikinci doz k\u0131zam\u0131k a\u015f\u0131s\u0131n\u0131n resmi olarak uygulanmas\u0131n\u0131 i\u00e7eren \u00fc\u00e7\u00fcnc\u00fc bir eliminasyon \u00e7abas\u0131, k\u0131zam\u0131k insidans\u0131n\u0131 1997-1999\u2019a kadar bir milyon n\u00fcfusta bir olgunun alt\u0131na d\u00fc\u015f\u00fcrerek endemik olan k\u0131zam\u0131\u011f\u0131n 2000 y\u0131l\u0131na kadar ba\u015far\u0131l\u0131 bir \u015fekilde ortadan kald\u0131r\u0131lmas\u0131yla sonu\u00e7lanm\u0131\u015ft\u0131r (4). ABD Hastal\u0131k Kontrol ve Korunma Merkezleri (\u201cCenters for Disease Control and Prevention \u2013 CDC\u201d), hi\u00e7 \u00f6l\u00fcm\u00fcn olmad\u0131\u011f\u0131 ve sadece 86 olgunun kaydedildi\u011fi 2000 y\u0131l\u0131nda endemik k\u0131zam\u0131\u011f\u0131n elimine edildi\u011fini ilan etmi\u015ftir (5). ABD\u2019de 2000\u2019den beri k\u0131zam\u0131k endemik olmamas\u0131na ra\u011fmen salg\u0131nlar g\u00f6r\u00fclmeye devam etmi\u015f ve 2001-2012 y\u0131llar\u0131 aras\u0131nda \u00e7o\u011fu a\u015f\u0131lanmam\u0131\u015f ki\u015filerde olmak \u00fczere y\u0131ll\u0131k ortamala 60 olgu (37-220 olgu) bildirilmi\u015ftir (4, 6, 7). 2000-2011 y\u0131llar\u0131 aras\u0131nda ortaya \u00e7\u0131kan olgular\u0131n %88\u2019inin kayna\u011f\u0131 ABD d\u0131\u015f\u0131ndaki bir \u00fclkedir. K\u0131zam\u0131k geli\u015fen her \u00fc\u00e7 ki\u015fiden ikisi a\u015f\u0131s\u0131z veya a\u015f\u0131lanma durumu bilinmeyen hastalard\u0131r (2). ABD\u2019de 2013 y\u0131l\u0131nda CDC\u2019ye 187 olgu bildirilmi\u015ftir (8); 2014 y\u0131l\u0131nda ise olgular\u0131n %89\u2019undan sorumlu 23 salg\u0131n ve 667 olgu ile virusun eliminasyonundan itibaren en y\u00fcksek k\u0131zam\u0131k aktivitesi ya\u015fanm\u0131\u015ft\u0131r (2, 4, 8, 9). 23 May\u0131s 2014 itibariyle Ohio\u2019daki a\u015f\u0131lanmam\u0131\u015f Ami\u015fler (tutucu bir Hristiyan mezhebi) aras\u0131nda bildirilen 138 olgu, en b\u00fcy\u00fck salg\u0131nd\u0131r. S\u00f6z konusu salg\u0131n, 21 400\u2019den fazla olgunun bildirildi\u011fi b\u00fcy\u00fck bir k\u0131zam\u0131k salg\u0131n\u0131 ya\u015fayan Filipinler\u2019den Ami\u015f misyonerlerinin d\u00f6nmesinden sonra ba\u015flam\u0131\u015ft\u0131r. \u201cDisneyland\u201d olarak adland\u0131r\u0131lan salg\u0131nda 28 Aral\u0131k 2014 – 8 \u015eubat 2015 tarihleri aras\u0131nda 125 k\u0131zam\u0131k olgusu saptanm\u0131\u015ft\u0131r. Bunlardan 110\u2019u Kaliforniyal\u0131 olup hastalar\u0131n 39 (%35)\u2019u 17-20 Aral\u0131k tarihleri aras\u0131nda k\u0131zam\u0131\u011fa maruz kald\u0131klar\u0131 yer oldu\u011fu d\u00fc\u015f\u00fcn\u00fclen Disney tema park\u0131n\u0131 ziyaret etmi\u015ftir (8, 10). 2015\u2019te 188, 2016\u2019da 88, 2017\u2019de 120 ve 2018\u2019de 375 olgu bildirilmi\u015ftir (8). 2019 y\u0131l\u0131nda ise bildirilen olgu say\u0131s\u0131 daha da artarak 1282\u2019ye ula\u015fm\u0131\u015ft\u0131r (5).\u00a0<\/span><\/p>\n

Avrupa ve Di\u011fer K\u0131talardaki Durum<\/h3>\n

DS\u00d6 2015 y\u0131l\u0131na kadar Avrupa\u2019da k\u0131zam\u0131\u011f\u0131n ortadan kald\u0131r\u0131lmas\u0131n\u0131 planlam\u0131\u015f ancak bu hedefe ula\u015f\u0131lamad\u0131\u011f\u0131 gibi 2017\u2019de Avrupa b\u00f6lgesinde yakla\u015f\u0131k 25 500 olgu bildirilmi\u015ftir. Olgu say\u0131s\u0131 2018\u2019de 83 000\u2019le \u00fc\u00e7 kat\u0131na \u00e7\u0131km\u0131\u015ft\u0131r; \u00e7o\u011funlu\u011fu olu\u015fturan 54 000\u2019den fazla olgu Ukrayna\u2019dan bildirilmi\u015ftir. Ayr\u0131ca 2017-2018 y\u0131llar\u0131 aras\u0131nda olgu say\u0131s\u0131 Yunanistan\u2019da iki kat\u0131na ve Fransa\u2019da ise yakla\u015f\u0131k alt\u0131 kat\u0131na \u00e7\u0131km\u0131\u015ft\u0131r. \u0130talya\u2019da 2017 y\u0131l\u0131nda bildirilen 5000\u2019den fazla olgu aras\u0131nda en y\u00fcksek insidans oranlar\u0131 bebeklerde ve okul \u00f6ncesi \u00e7ocuklarda g\u00f6zlenmi\u015ftir. 2017\u2019de Venezuela\u2019dan da salg\u0131nlar bildirilmi\u015ftir. D\u00fcnya genelinde k\u0131zam\u0131k olgular\u0131 2019\u2019da artmaya devam etmi\u015ftir; y\u0131l\u0131n ilk \u00fc\u00e7 ay\u0131na ait veriler 2018\u2019in ayn\u0131 d\u00f6nemine g\u00f6re %300 art\u0131\u015f g\u00f6stermi\u015ftir. Esas olarak k\u00fc\u00e7\u00fck \u00e7ocuklar\u0131 etkileyen son k\u00fcresel salg\u0131nlar; Demokratik Kongo Cumhuriyeti, Etiyopya, G\u00fcrcistan, Kazakistan, K\u0131rg\u0131zistan, Madagaskar, Myanmar, Filipinler, Sudan, Tayland ve Ukrayna\u2019da ortaya \u00e7\u0131km\u0131\u015ft\u0131r. 2019\u2019da Madagaskar, Filipinler ve Brezilya\u2019dan salg\u0131nlar bildirilmi\u015ftir (5, 11). DS\u00d6 verilerine g\u00f6re ABD ve Avrupa d\u0131\u015f\u0131ndaki b\u00f6lgelerde ve \u00f6zellikle Afrika\u2019da 2019 ve 2020 y\u0131llar\u0131 aras\u0131nda y\u00fcksek k\u0131zam\u0131k olgu say\u0131lar\u0131 bildirilmi\u015ftir. 2020 y\u0131l\u0131 verilerine g\u00f6re Demokratik Kongo Cumhuriyeti\u2019nde 82 290, Nijerya\u2019da 8877, Angola\u2019da 1085, Hindistan\u2019da 5604, Banglade\u015f\u2019te 2410, Etiyopya\u2019da 1952 k\u0131zam\u0131k olgusu bildirilmi\u015ftir (13).<\/p>\n

K\u0131zam\u0131k, 1980\u2019de yayg\u0131n a\u015f\u0131lama ba\u015flamadan \u00f6nce, d\u00fcnya \u00e7ap\u0131nda her y\u0131l tahmini 2.6 milyon \u00f6l\u00fcme neden olurken, h\u0131zland\u0131r\u0131lm\u0131\u015f k\u00fcresel a\u015f\u0131lama programlar\u0131 \u00f6l\u00fcmlerin azalt\u0131lmas\u0131nda b\u00fcy\u00fck bir etkiye sahip olmu\u015ftur. DS\u00d6, 2000-2013 y\u0131llar\u0131 aras\u0131ndaki d\u00f6nemde a\u015f\u0131lama ile tahminen 15.6 milyon \u00f6l\u00fcm\u00fcn \u00f6nlendi\u011fini bildirmi\u015ftir. Bu b\u00fcy\u00fck d\u00fc\u015f\u00fc\u015f, ilk do\u011fum g\u00fcnlerinde bir doz k\u0131zam\u0131k a\u015f\u0131s\u0131 alan \u00e7ocuk oran\u0131n\u0131n 2000 y\u0131l\u0131nda %73 iken 2013 y\u0131l\u0131nda %84\u2019e y\u00fckselmesine ba\u011flanabilir. Ancak d\u00fcnya \u00e7ap\u0131nda k\u0131zam\u0131k \u00f6l\u00fcmlerinde %75 azalma ile sonu\u00e7lanan geli\u015fmi\u015f a\u015f\u0131lama kapsam\u0131na ra\u011fmen, 2013 y\u0131l\u0131nda d\u00fcnya genelinde 145 700 k\u0131zam\u0131ktan \u00f6l\u00fcm bildirilmi\u015ftir; kay\u0131p say\u0131s\u0131 2012\u2019ye g\u00f6re 23 700 daha fazlad\u0131r. Bu, ortalama olarak, bir g\u00fcnde yakla\u015f\u0131k 400 \u00f6l\u00fcm veya saatte 16 \u00f6l\u00fcm demektir. K\u0131zam\u0131ktan \u00f6l\u00fcm oran\u0131 ABD\u2019de %0.2-%0.3; geli\u015fmekte olan \u00fclkelerde ise %2-%15 aras\u0131ndad\u0131r (2, 5, 12).<\/p>\n

A\u015f\u0131 Teredd\u00fct\u00fc ve Reddi<\/h3>\n

Suboptimal a\u015f\u0131lama kapsam\u0131, bildirilen k\u0131zam\u0131k olgular\u0131n\u0131n \u00e7o\u011funda temel fakt\u00f6r olarak belirlenmi\u015ftir (2, 4, 5, 14, 15). D\u00fcnyada k\u0131zam\u0131k olgular\u0131ndaki art\u0131\u015f; k\u00fcresel istikrars\u0131zl\u0131k ve hareketlili\u011fin yan\u0131 s\u0131ra a\u015f\u0131 teredd\u00fct\u00fc veya reddi g\u00f6steren bireylerin ve topluluklar\u0131n say\u0131s\u0131n\u0131n art\u0131\u015f\u0131 ile ba\u011flant\u0131l\u0131d\u0131r. K\u0131zam\u0131k-kabakulak-k\u0131zam\u0131k\u00e7\u0131k (KKK) a\u015f\u0131s\u0131n\u0131n g\u00fcvenli\u011fi ve etkinli\u011fi, kan\u0131tlarla s\u00fcrekli olarak g\u00f6sterilmesine ra\u011fmen, a\u015f\u0131lama kar\u015f\u0131t\u0131 hareket g\u00fc\u00e7 kazanmaya devam etmektedir. DS\u00d6, 2019\u2019da a\u015f\u0131 teredd\u00fct\u00fcn\u00fc k\u00fcresel sa\u011fl\u0131\u011fa y\u00f6nelik en b\u00fcy\u00fck on tehditten biri olarak listeye alm\u0131\u015ft\u0131r (5). Sonu\u00e7lar\u0131 iyi bilinen a\u015f\u0131 reddi veya teredd\u00fct\u00fc, hem \u00e7ocuklar hem de toplum i\u00e7in potansiyel bir risk olup a\u015f\u0131lama yoluyla \u00f6nlenebilen hastal\u0131klar\u0131n \u00f6l\u00fcmle sonu\u00e7lanmas\u0131na veya hastaneye yat\u0131\u015flar\u0131n artmas\u0131na neden olabilir. Di\u011fer yanda, t\u0131bbi nedenlerle (\u00f6rne\u011fin bir a\u015f\u0131 bile\u015fenine \u015fiddetli alerjik reaksiyon, hematolojik malignite, solid t\u00fcm\u00f6rlerden dolay\u0131 ciddi imm\u00fcn yetmezlik, kemoterapi, konjenital imm\u00fcn yetmezlik, uzun s\u00fcreli imm\u00fcnos\u00fcpresif tedavi, insan imm\u00fcn yetmezlik vir\u00fcs\u00fc infeksiyonu, vb.) a\u015f\u0131laman\u0131n \u00f6nleyici etkilerinden yararlanamayanlar veya a\u015f\u0131 olma ya\u015f\u0131ndan k\u00fc\u00e7\u00fck olanlar da risk alt\u0131na girer (16).\u00a0<\/span><\/p>\n

A\u015f\u0131 teredd\u00fct\u00fc nedenleri ki\u015fiden ki\u015fiye ve toplumdan topluma g\u00f6re de\u011fi\u015f<\/span>mektedir. Bu nedenle a\u015f\u0131 teredd\u00fct\u00fc nedenleri anla\u015f\u0131lmal\u0131 ve bir s\u00fcreklilik i\u00e7inde ele al\u0131nmal\u0131d\u0131r. \u00d6rne\u011fin, bir ebeveyn b\u00fct\u00fcn a\u015f\u0131lar\u0131 reddedebilirken bir di\u011feri yaln\u0131zca belirli bir a\u015f\u0131 ile ilgili endi\u015felere sahip olabilir; bir ba\u015fkas\u0131 t\u00fcm a\u015f\u0131lara ku\u015fkuyla bakabilir ancak ayn\u0131 zamanda a\u015f\u0131laman\u0131n yararlar\u0131n\u0131n fark\u0131nda olabilir (17). \u0130nsanlar\u0131n a\u015f\u0131 yapt\u0131rmamay\u0131 tercih etme nedenleri karma\u015f\u0131kt\u0131r. \u0130stenmeyen etkilerle ilgili endi\u015felerden kaynaklanan a\u015f\u0131 g\u00fcvenli\u011fine olan inan\u00e7s\u0131zl\u0131k, temel fakt\u00f6rlerden biri olarak tan\u0131mlanm\u0131\u015ft\u0131r. Sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131n\u0131n, \u00f6zellikle birinci basamakta olanlar\u0131n, a\u015f\u0131 kararlar\u0131 \u00fczerindeki anahtar rolleri devam etmektedir. Bu nedenle, a\u015f\u0131larla ilgili g\u00fcvenilir ve kan\u0131ta dayal\u0131 bilgilere kolay eri\u015fim sa\u011flanmas\u0131n\u0131n desteklenmesi \u00f6nemlidir. Ebeveynlerin ve hastalar\u0131n a\u015f\u0131 g\u00fcvenli\u011fi konusunda sahip olduklar\u0131 endi\u015felerin en yayg\u0131n olanlar\u0131; al\u00fcminyum gibi adjuvanlar, civa gibi koruyucular, formaldehit gibi inaktive edici ajanlar, insan veya hayvan DNA fragmanlar\u0131 ve a\u015f\u0131 say\u0131s\u0131n\u0131n fazlal\u0131\u011f\u0131n\u0131n imm\u00fcn sistemi zay\u0131flat\u0131c\u0131 veya bozucu olabilece\u011fidir. Baz\u0131 ebeveynler a\u015f\u0131lar\u0131n otizme, diyabete, geli\u015fimsel gecikmelere, hiperaktiviteye ve dikkat eksikli\u011fi bozukluklar\u0131na neden oldu\u011fundan korkar. A\u015f\u0131 g\u00fcvenli\u011fi ile ilgili yayg\u0131n endi\u015felerin yanl\u0131\u015fl\u0131\u011f\u0131n\u0131 ortaya koyan \u00e7ok g\u00fc\u00e7l\u00fc bilimsel kan\u0131tlar vard\u0131r (16-20).\u00a0<\/span><\/span><\/p>\n

Yanl\u0131\u015f bilgilerin yayg\u0131nl\u0131\u011f\u0131, eri\u015filebilirli\u011fi ve korku uyand\u0131rma potansiyeli bir halk sa\u011fl\u0131\u011f\u0131 tehdidi olarak nitelendirilmi\u015ftir. Yanl\u0131\u015f bilgi ve belki de en endi\u015fe verici olan \u201ck\u00f6t\u00fc bilim<\/i>\u201d bir\u00e7ok formda ortaya \u00e7\u0131kar. Wakefield ve arkada\u015flar\u0131n\u0131n 1998 y\u0131l\u0131nda Lancet\u2019te yay\u0131nlanan a\u015f\u0131lar ve otizmle ilgili korkular\u0131 ate\u015fleyen makalesi (21), kal\u0131c\u0131 olarak etkili olan \u201ck\u00f6t\u00fc bilim<\/i>\u201de iyi bir \u00f6rnektir. Hileli bir \u00e7al\u0131\u015fmay\u0131 i\u00e7eren makalenin sayg\u0131n bir dergide yay\u0131nlanmas\u0131 ilk olarak me\u015fruiyet izlenimi vermi\u015ftir. Geri \u00e7ekilmesine ra\u011fmen, makalede yer alan iddialar hala baz\u0131 \u00e7evreler taraf\u0131ndan a\u015f\u0131-otizm ba\u011flant\u0131s\u0131n\u0131 destekleyen kan\u0131tlar olarak g\u00f6r\u00fcl\u00fcyor. Yanl\u0131\u015f bilgiler, a\u015f\u0131 tart\u0131\u015fmas\u0131n\u0131 s\u00fcrd\u00fcrmekten finansal veya siyasi kazan\u00e7 elde edecek ki\u015filer taraf\u0131ndan da yay\u0131l\u0131r. \u0130kincisine \u00f6rnek olarak; a\u015f\u0131 lehinde ve aleyhinde olanlar aras\u0131ndaki ayr\u0131m\u0131 derinle\u015ftirmeyi hedefleyen bir dil kullanan ve yanl\u0131\u015f bilginin yay\u0131lmas\u0131n\u0131 kontrol eden trol hesaplar ve ger\u00e7ek profil gibi g\u00f6r\u00fcnen ancak bir algoritma taraf\u0131ndan y\u00fcr\u00fct\u00fclen otomatik sosyal medya hesaplar\u0131 olan botlar verilebilir. Bu hesaplar sosyal medyay\u0131 kullanan di\u011fer a\u015f\u0131 konusunda teredd\u00fctl\u00fc ki\u015filere yanl\u0131\u015f bilgi yayar ve a\u015f\u0131 kar\u015f\u0131t\u0131 iddialar g\u00fc\u00e7lendirilir. \u201cYouTube\u201d ve benzeri platformlar, yanl\u0131\u015f bilgilerin yay\u0131l\u0131m\u0131nda di\u011fer \u00f6nemli ara\u00e7lard\u0131r. Kat\u0131l\u0131mc\u0131 a\u011f (\u201cparticipatory web\u201d) olarak da adland\u0131r\u0131lan ve sosyal medya k\u00fclt\u00fcr\u00fc i\u00e7inde yer alan pek \u00e7ok ortamda ki\u015filer inceleme ve ara\u015ft\u0131rma yapmadan i\u00e7erik \u00fcretebilir ve yay\u0131nlayabilir. A\u015f\u0131 kar\u015f\u0131t\u0131 video yay\u0131nlayanlar g\u00fcvenilirlik kazanmak i\u00e7in bilimsel bir dil kullan\u0131r veya \u201ctoksik\u201d gibi hedef kelimeleri se\u00e7er. Bu videolardan en \u00e7ok be\u011fenilirlik skorlar\u0131 olanlar, k\u0131zam\u0131k ve influenza a\u015f\u0131lar\u0131 ile ilgili olanlard\u0131r (22). A\u015f\u0131 teredd\u00fct\u00fcndeki e\u011filimlerin s\u00fcrveyans\u0131, i\u015fe yarayan ve yeni \u00f6nleyici tedbirlerin uygulanmas\u0131na olanak sa\u011flayan m\u00fcdahaleler hakk\u0131nda de\u011ferli veriler sunabilir. DS\u00d6, a\u015f\u0131 teredd\u00fct\u00fcn\u00fcn s\u00fcrekli olarak izlenmesini \u00f6nerir (23, 24).\u00a0<\/span><\/p>\n

\u00dclkemizdeki Durum ve Salg\u0131n D\u00f6nemlerinde \u0130zledi\u011fimiz K\u0131zam\u0131k Olgular\u0131n\u0131n \u00d6zellikleri<\/h3>\n
\"\"<\/a>

\u015eekil 1.<\/strong> Y\u0131llara G\u00f6re T\u00fcrkiye\u2019den DS\u00d6\u2019ye Bildirilen Do\u011frulanm\u0131\u015f K\u0131zam\u0131k Olgu Say\u0131lar\u0131 (K\u0131rm\u0131z\u0131 ile belirtilen y\u0131llarda hastanemize ba\u015fvuran hastalarla ilgili bilgiler metin i\u00e7erisinde verilmi\u015ftir.)<\/p><\/div>\n

T\u00fcrkiye\u2019de k\u0131zam\u0131k a\u015f\u0131s\u0131 1970\u2019den beri uygulanmaktad\u0131r. \u0130kinci a\u015f\u0131 dozu 1998\u2019de eklenmi\u015f ve ilkokul birinci s\u0131n\u0131f \u00e7ocuklar\u0131na uygulanmaya ba\u015flam\u0131\u015ft\u0131r. \u0130kinci dozun olumlu etkileri 2001 y\u0131l\u0131ndan itibaren g\u00f6zlenmeye ba\u015flam\u0131\u015ft\u0131r. 2002\u2019de \u00fclkemizde, DS\u00d6 Avrupa B\u00f6lgesi\u2019nin K\u0131zam\u0131k Eliminasyon Hedefi\u2019ne paralel olarak K\u0131zam\u0131kla M\u00fccadele Program\u0131 uygulanmaya ba\u015flanm\u0131\u015f; 2003\u2019te okullarda k\u0131zam\u0131k a\u015f\u0131lama g\u00fcnleri d\u00fczenlenmi\u015ftir. 2005\u2019te ikinci kez k\u0131zam\u0131k a\u015f\u0131lama g\u00fcnleri uygulamas\u0131 ba\u015flat\u0131lm\u0131\u015f ve 2007\u2019den 2011\u2019e kadar, olgu say\u0131s\u0131 be\u015fin alt\u0131nda kalm\u0131\u015f; 2008-2010 y\u0131llar\u0131 aras\u0131nda ise yurt i\u00e7i kaynakl\u0131 hi\u00e7bir olgu g\u00f6r\u00fclmemi\u015ftir. Ancak 2011 y\u0131l\u0131nda Suriye\u2019de \u00e7\u0131kan i\u00e7 sava\u015f\u0131n neden oldu\u011fu g\u00f6\u00e7ler ve Avrupa\u2019daki yetersiz a\u015f\u0131lama kapsam\u0131 nedeniyle ortaya \u00e7\u0131kan k\u0131zam\u0131k salg\u0131nlar\u0131 sonras\u0131nda, \u00fclkemizde hastal\u0131k oranlar\u0131 h\u0131zla artmaya ba\u015flam\u0131\u015f ve 2013\u2019te bir salg\u0131n ya\u015fanm\u0131\u015ft\u0131r (25). 1980-2019 aras\u0131nda T\u00fcrkiye\u2019den DS\u00d6\u2019ye bildirilen olgu say\u0131lar\u0131, \u015eekil 1\u2019de verildi (26).<\/p>\n

\u00dc\u00e7\u00fcnc\u00fc basamak bir e\u011fitim ve ara\u015ft\u0131rma hastanesi olan kurumumuzda yap\u0131lan \u00e7al\u0131\u015fmam\u0131zda, T\u00fcrkiye\u2019de 30 509 olgunun saptand\u0131\u011f\u0131 2001 y\u0131l\u0131nda; 59 (%74.7)\u2019u hastaneye yat\u0131r\u0131lan, 20 (%25.3)\u2019si ayaktan izlenen 1-180 ay aras\u0131nda 79 do\u011frulanm\u0131\u015f k\u0131zam\u0131kl\u0131 hasta incelendi. Bu hastane temelli \u00e7al\u0131\u015fmada; hastalar\u0131n 35 (%44)\u2019inin bebek oldu\u011fu, ortanca ya\u015f\u0131n 36 ay oldu\u011fu ve k\u0131zam\u0131k a\u015f\u0131s\u0131 \u00f6yk\u00fcs\u00fcn\u00fcn o tarihte T\u00fcrkiye\u2019de k\u0131zam\u0131k a\u015f\u0131s\u0131 i\u00e7in \u00f6nerilen ya\u015f olan 9 aydan b\u00fcy\u00fck bebeklerde %46.5 oldu\u011fu saptand\u0131. Yetmi\u015f \u00fc\u00e7 (%92.4) hastada komplikasyon geli\u015fti\u011fi, %75 ile en s\u0131k g\u00f6r\u00fclen komplikasyonun pn\u00f6moni oldu\u011fu ve bunu yedi hastada ortaya \u00e7\u0131kan ensefalitin izledi\u011fi saptand\u0131. \u00d6zellikle bebeklik d\u00f6neminde k\u0131zam\u0131k \u015fiddeti ve komplikasyon oran\u0131n\u0131n y\u00fcksek oldu\u011fu saptand\u0131. Kaybedilen \u00fc\u00e7 hastan\u0131n ikisi \u015fiddetli pn\u00f6moni geli\u015fen ve birinde maln\u00fctrisyon olan bebekler olup di\u011feri postmortem histopatolojik inceleme ile dev h\u00fccreli pn\u00f6moni tan\u0131s\u0131 konulan akut lenfositik l\u00f6semili \u00fc\u00e7 ya\u015f\u0131nda bir \u00e7ocuktu (27).<\/p>\n

\u00dclkemizde 2011\u2019de b\u00fcy\u00fck \u00e7o\u011funlu\u011fu \u0130stanbul\u2019da g\u00f6r\u00fclen ve yurt d\u0131\u015f\u0131ndan gelen (\u201cimporte\u201d) olgulardan kaynakland\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fclen lokal bir salg\u0131n bildirilmi\u015ftir. Ard\u0131ndan 4 \u015eubat 2013 tarihli Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131 verilerinde s\u0131kl\u0131k say\u0131s\u0131na g\u00f6re s\u0131ralanm\u0131\u015f olarak Ankara, Gaziantep, \u0130stanbul, Adana, Amasya, Batman, \u015eanl\u0131urfa ve Yozgat\u2019\u0131 kapsayan sekiz ilde toplam 816 olgunun yan\u0131 s\u0131ra 26 ilde dokuzdan az, 17 ilde de ikiden az olmak \u00fczere toplam 41 ilde k\u0131zam\u0131k olgular\u0131 bildirilmi\u015ftir. 2013\u2019te T\u00fcrkiye\u2019den bildirilen toplam olgu say\u0131s\u0131 daha \u00f6nceki y\u0131llara g\u00f6re belirgin art\u0131\u015f g\u00f6stererek 7405\u2019e ula\u015fm\u0131\u015ft\u0131r. Ayn\u0131 d\u00f6nemde, Aral\u0131k 2012-Nisan 2013 tarihleri aras\u0131nda hastanemize ba\u015fvuran, ya\u015flar\u0131 4-191 ay aras\u0131nda (ortalama 58.6\u00b159.5 ay) de\u011fi\u015fen 44 do\u011frulanm\u0131\u015f k\u0131zam\u0131kl\u0131 hasta incelendi. Hastanemize ilk ba\u015fvuran k\u0131zam\u0131kl\u0131 hasta (indeks olgu), Suriye\u2019li kom\u015fular\u0131 ile temas \u00f6yk\u00fcs\u00fc olan, k\u0131zam\u0131k a\u015f\u0131s\u0131 yap\u0131lmam\u0131\u015f, Gaziantep\u2019ten bir y\u0131l \u00f6nce g\u00f6\u00e7 etmi\u015f 12 ayl\u0131k bir k\u0131z \u00e7ocu\u011fuydu. Aral\u0131k\u2019ta 35 (%80), Ocak\u2019ta alt\u0131 (%14), \u015eubat\u2019ta iki (%4) ve Mart\u2019ta bir (%2) hasta saptand\u0131. Hastalar\u0131n, k\u0131zam\u0131k a\u015f\u0131s\u0131z oldu\u011fu veya a\u015f\u0131lanma durumunun bilinmedi\u011fi veya rutin a\u015f\u0131lama takvimine g\u00f6re a\u015f\u0131lama ya\u015f\u0131n\u0131n alt\u0131nda oldu\u011fu belirlendi. Hastalar\u0131n ba\u015fvurdu\u011fu d\u00f6nem boyunca, sa\u011fl\u0131k hizmeti ili\u015fkili infeksiyon olarak iki pediatri asistan\u0131nda ve di\u011fer nedenlerle muayene i\u00e7in ba\u015fvuran \u00fc\u00e7 hastada, temas\u0131 takiben k\u0131zam\u0131k ortaya \u00e7\u0131kt\u0131. K\u0131zam\u0131k tan\u0131s\u0131 alan iki doktorun da tek doz a\u015f\u0131l\u0131 oldu\u011fu ve bu a\u015f\u0131n\u0131n dokuzuncu ayda yap\u0131ld\u0131\u011f\u0131 tespit edildi. Komplikasyonlar nedeniyle 8 (%18) hasta hastaneye yat\u0131r\u0131lm\u0131\u015f olup s\u00f6z konusu komplikasyonlar d\u00f6rt hastada pn\u00f6moni, d\u00f6rt hastada oral s\u0131v\u0131 alamama\/dehidratasyondu. Hastalar\u0131n hepsi \u015fifa ile taburcu edildi (28).<\/span><\/p>\n

2019 y\u0131l\u0131 boyunca hastanemizde 20 do\u011frulanm\u0131\u015f k\u0131zam\u0131kl\u0131 hasta yatarak, be\u015f hasta ayaktan izlendi. Hastaneye yat\u0131r\u0131lan hastalar\u0131n ortanca ya\u015f\u0131 13.5 ay (2-184 ay) olarak bulundu. Sekiz (%40) hasta bir ya\u015f\u0131n alt\u0131nda, alt\u0131 (%30) hasta 1-4 ya\u015f aras\u0131nda, alt\u0131 (%30) hasta ise 4 ya\u015f\u0131ndan b\u00fcy\u00fckt\u00fc. 2020\u2019de g\u00fcncellenen Ulusal A\u015f\u0131 Program\u0131\u2019na g\u00f6re k\u0131zam\u0131k a\u015f\u0131s\u0131 \u00fclkemizde 12. ay ve 48. ayda olmak \u00fczere 2 doz olarak uygulanmaktad\u0131r. Hastalar\u0131n sekizi (%40) ilk a\u015f\u0131lama ya\u015f\u0131 olan 12 ay alt\u0131nda ve KKK ile a\u015f\u0131l\u0131 de\u011fildi. Di\u011fer 12 (%60) hastan\u0131n 12. ayda bir doz KKK ile a\u015f\u0131land\u0131\u011f\u0131 belirlendi. Bu 12 hastan\u0131n alt\u0131s\u0131nda daha \u00f6nceki Ulusal A\u015f\u0131 Program\u0131\u2019na g\u00f6re ilkokul 1. s\u0131n\u0131fta yap\u0131lan ancak yeni programda 48. ayda yap\u0131lmas\u0131 planlanan KKK a\u015f\u0131s\u0131n\u0131n yap\u0131lmad\u0131\u011f\u0131 saptand\u0131. \u0130ki doz KKK ile a\u015f\u0131lanm\u0131\u015f hi\u00e7 hasta yoktu. Hastalar\u0131n 11 (%55)\u2019inde k\u0131zam\u0131\u011fa ba\u011fl\u0131 en az bir komplikasyon geli\u015fti. Be\u015f (%25) hastada krup, d\u00f6rt (%20) hastada hiponatremi ve hiponatremi geli\u015fen hastalar\u0131n birinde ayr\u0131ca trombositopeni, bir (%5) hastada pn\u00f6moni, bir (%5) hastada keratit saptand\u0131. Hastanede yat\u0131\u015f s\u00fcresi ortanca 5 g\u00fcn (1-10 g\u00fcn) idi. En uzun s\u00fcre hastanede yatan hasta, pn\u00f6moni komplikasyonu geli\u015fen ve 10 g\u00fcn hastanede izlenen, 10 ya\u015f\u0131ndaki erkek hastayd\u0131. Komplikasyon geli\u015fen ve geli\u015fmeyen hastalar aras\u0131nda ya\u015f, cinsiyet, yak\u0131nmalar, ba\u015fvurdu\u011fu ay ve semptom s\u00fcresi benzerdi. Beyaz k\u00fcre say\u0131s\u0131 komplikasyon olan grupta olmayan gruba g\u00f6re daha d\u00fc\u015f\u00fck olarak saptand\u0131 (s\u0131ras\u0131 ile ortanca de\u011ferler 5.60 x103\/mm3<\/sup> ve 8.40 x103\/mm3<\/sup>; p=<\/i>0.025). Hastanede yat\u0131\u015f s\u00fcresi komplikasyon geli\u015fenlerde (ortanca 6 g\u00fcn, aral\u0131k 1-10 g\u00fcn) geli\u015fmeyenlere g\u00f6re (ortanca 4 g\u00fcn, aral\u0131k 1-6 g\u00fcn) daha uzun (p=<\/i>0.046) olarak bulundu.<\/p>\n

\"\"<\/a>

\u015eekil 2.<\/strong> Y\u0131llara G\u00f6re Hastanemize Ba\u015fvuran Do\u011frulanm\u0131\u015f K\u0131zam\u0131k Olgu Say\u0131lar\u0131<\/p><\/div>\n

T\u00fcrkiye\u2019den DS\u00d6\u2019ye bildirilen olgu say\u0131s\u0131, 2013\u2019ten sonra 2019\u2019da en y\u00fcksek say\u0131 olan 2904\u2019e ula\u015fm\u0131\u015ft\u0131r. 2000-2020 y\u0131llar\u0131 aras\u0131nda hastanemize ba\u015fvuran ve elektronik hasta veri sistemine \u201ckesin k\u0131zam\u0131k\u201d olarak girilen do\u011frulanm\u0131\u015f k\u0131zam\u0131k olgu say\u0131lar\u0131 belirlendi. Bu tarihler aras\u0131nda, y\u0131llara g\u00f6re k\u0131zam\u0131k olgu say\u0131lar\u0131 \u015eekil 2\u2019de g\u00f6sterildi. T\u00fcrkiye\u2019den bildirilen olgu say\u0131s\u0131n\u0131n art\u0131\u015f\u0131n\u0131n bir yans\u0131mas\u0131 olarak hastanemizde izlenen olgu say\u0131lar\u0131nda da art\u0131\u015f oldu\u011fu saptand\u0131.<\/p>\n

\u00dclkemizde, \u00f6nceleri \u00e7ok az say\u0131da olan a\u015f\u0131 reddi olgular\u0131n\u0131n 2015\u2019te a\u015f\u0131 uygulamas\u0131 i\u00e7in ebeveynden onam al\u0131nmas\u0131 ile ilgili bir davan\u0131n kazan\u0131lmas\u0131n\u0131n yan\u0131 s\u0131ra medyada artan a\u015f\u0131 kar\u015f\u0131t\u0131 s\u00f6ylemler nedeniyle artt\u0131\u011f\u0131 bildirilmi\u015ftir. \u00c7ocuklar\u0131na a\u015f\u0131 yapt\u0131rmak istemeyen ailelerin say\u0131s\u0131; 2011\u2019de 18, 2013\u2019te 980, 2015\u2019te 5400, 2016\u2019da 12 000, 2018\u2019de 23 000 olarak saptanm\u0131\u015ft\u0131r. K\u0131zam\u0131k insidans\u0131 2016\u2019da y\u00fcz bin n\u00fcfusta 0.01 iken, 2019\u2019da y\u00fcz binde 0.10 d\u00fczeyine y\u00fckselerek on kat art\u0131\u015f g\u00f6stermi\u015ftir (29).<\/p>\n

SONU\u00c7<\/h2>\n

\u00dclkemizde k\u0131zam\u0131k olgu say\u0131lar\u0131n\u0131n artt\u0131\u011f\u0131 iki d\u00f6nemde, hastanemizde izlenen hastalara ili\u015fkin iki \u00e7al\u0131\u015fman\u0131n yan\u0131 s\u0131ra en son art\u0131\u015f\u0131n oldu\u011fu 2019\u2019da izledi\u011fimiz olgular\u0131n de\u011ferlendirilmesini kapsayan bu derlemede, hastane bazl\u0131 olarak demografik veriler, hastalar\u0131n a\u015f\u0131lanma durumlar\u0131, komplikasyonlar ve prognoz vurguland\u0131. D\u00fcnyada ve \u00fclkemizde k\u0131zam\u0131\u011f\u0131n tekrar ortaya \u00e7\u0131kmas\u0131n\u0131n nedenleri olarak teredd\u00fctten, aksatma ve geciktirmeye ve hatta redde kadar de\u011fi\u015fen a\u015f\u0131 kabul spektrumunun fark\u0131ndal\u0131\u011f\u0131n\u0131n \u00f6nemli oldu\u011fu d\u00fc\u015f\u00fcn\u00fcld\u00fc. Sonu\u00e7 olarak, geni\u015f toplum kesimlerine KKK a\u015f\u0131s\u0131n\u0131n uygulanma gerek\u00e7esi ve g\u00fcvenilir oldu\u011fu anlat\u0131larak, bu konudaki sorular\u0131 yan\u0131tlayarak, a\u015f\u0131 uyumu ve a\u015f\u0131ya g\u00fcven art\u0131r\u0131lmal\u0131d\u0131r.\u00a0<\/span><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e A\u015f\u0131lama yoluyla ba\u015far\u0131l\u0131 bir \u015fekilde kontrol alt\u0131na al\u0131nan eski ve olduk\u00e7a bula\u015f\u0131c\u0131 bir hastal\u0131k olan k\u0131zam\u0131k, eliminasyon ve eradikasyon hedeflerine ula\u015famadan b\u00fct\u00fcn d\u00fcnyada salg\u0131nlarla canlanma g\u00f6stermi\u015ftir. Bu derlemenin amac\u0131, hastanemizde \u00fc\u00e7 ayr\u0131 salg\u0131n d\u00f6neminde g\u00f6r\u00fclen k\u0131zam\u0131k olgular\u0131n\u0131n \u00f6zelliklerini de\u011ferlendirmek, a\u015f\u0131 karars\u0131zl\u0131\u011f\u0131n\u0131n k\u0131zam\u0131k olgu say\u0131s\u0131 art\u0131\u015f\u0131 \u00fczerindeki etkisine dikkat \u00e7ekmek ve hem \u00fclkemizde hem de […]<\/p>\n","protected":false},"author":4,"featured_media":25591,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5127],"tags":[5099,3377,5495,5494],"class_list":["post-25421","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-derleme","tag-asi-reddi","tag-kizamik","tag-kizamik-eliminasyonu","tag-kizamik-kabakulak-kizamikcik-asisi"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25421","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=25421"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25421\/revisions"}],"predecessor-version":[{"id":25495,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25421\/revisions\/25495"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/25591"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25421"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25421"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25421"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}