疟疾:修订间差异

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{{medical}}
{{Infobox_Disease
{{Infobox_Disease
| Name = 疟疾
| Name = 疟疾
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| MeshNumber = C03.752.250.552 |
| MeshNumber = C03.752.250.552 |
}}
}}



<!-- 定義與症狀 -->
<!-- 定義與症狀 -->
'''瘧疾'''({{Lang-en|Malaria}})是一種 [[蚊子傳播的疾病|蚊媒病]],由寄生性的[[原生生物界]](一種單細胞 [[微生物]])[[瘧原蟲]]屬<ref name=WHO2014>{{cite web|title=Malaria Fact sheet N°94|url=http://www.who.int/mediacentre/factsheets/fs094/en/|website=WHO|accessdate=28 August 2014|date=March 2014}}</ref>引起,人類及其他動物的全球性急性[[寄生蟲]][[傳染病]]。瘧疾引起的典型症狀有[[發燒]]、{{Link-en|倦怠不適|Malaise}}、[[嘔吐]]以及 [[頭痛]]。在嚴重的病例中會引起[[黃疸]] 、{{Link-en|癲癇發作|Epileptic_seizure}}、[[昏迷]]或 [[死亡]]<ref name=EBMED2014>{{cite journal|last=Caraballo|first=Hector|title=Emergency Department Management Of Mosquito-Borne Illness: Malaria, Dengue, And West Nile Virus|journal=Emergency Medicine Practice|date=May 2014|volume=16|issue=5|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=405}}</ref>。這些症狀通常在被蚊子叮咬後十到十五天內開始出現,沒有受到適當治療的病人(但症狀緩解)可能於數個月後會再次出現這些症狀<ref name=WHO2014/>。而在瘧疾倖存者中,再次感染通常引起的症狀通常較輕微。如果沒有持續暴露在瘧疾環境中,這種少量的{{Link-en|抵抗力|Immunity}}會在數月至數年間消失[2]
'''瘧疾'''({{Lang-en|Malaria}})是一種[[蚊子傳播的疾病|蚊媒病]],由寄生性的[[原生生物界]](一種單細胞 [[微生物]])[[瘧原蟲]]屬<ref name=WHO2014>{{cite web|title=Malaria Fact sheet N°94|url=http://www.who.int/mediacentre/factsheets/fs094/en/|website=WHO|accessdate=28 August 2014|date=March 2014}}</ref>引起,人類及其他動物的全球性急性[[寄生蟲]][[傳染病]]。瘧疾引起的典型症狀有[[發燒]]、{{Link-en|倦怠不適|Malaise}}、[[嘔吐]]以及 [[頭痛]]。在嚴重的病例中會引起[[黃疸]] 、{{Link-en|癲癇發作|Epileptic_seizure}}、[[昏迷]]或 [[死亡]]<ref name=EBMED2014>{{cite journal|last=Caraballo|first=Hector|title=Emergency Department Management Of Mosquito-Borne Illness: Malaria, Dengue, And West Nile Virus|journal=Emergency Medicine Practice|date=May 2014|volume=16|issue=5|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=405}}</ref>。這些症狀通常在被蚊子叮咬後十到十五天內開始出現,沒有受到適當治療的病人(但症狀緩解)可能於數個月後會再次出現這些症狀<ref name=WHO2014/>。而在瘧疾倖存者中,再次感染通常引起的症狀通常較輕微。如果沒有持續暴露在瘧疾環境中,這種少量的{{Link-en|抵抗力|Immunity}}會在數月至數年間消失<ref name="Caraballo 2014"/>


<!--成因與診斷-->
<!--成因與診斷-->
一般來說,瘧疾是透過受感染的雌性[[瘧蚊]]叮咬來傳播的。寄生蟲瘧原蟲會透過瘧蚊叮咬從蚊子的唾液中傳入至人類的[[血液]]中<ref name=WHO2014/>,接著瘧原蟲會隨血液移動至肝臟,在肝臟細胞中發育成熟及繁殖。瘧原蟲屬中有五種是可藉由感染人類進行散播<ref name=EBMED2014/>,多數死亡案例由[[恶性疟原虫|惡性瘧]]、{{Link-en|間日瘧|Plasmodium vivax}}及{{Link-en|卵形瘧|Plasmodium_ovale}}所造成,而{{Link-en|三日瘧|Plasmodium_malariae}}則產生較輕微的瘧疾症狀<ref name=WHO2014/><ref name=EBMED2014/>。另外,{{Link-en|猴瘧蟲(諾氏瘧蟲)|Plasmodium_knowlesi}}較少在人類身上造成疾病<ref name=WHO2014/>。診斷瘧疾主要透過顯微鏡檢驗{{Link-en|血液抹片|Blood_film}}或是加上{{Link-en|快速瘧疾抗原診斷測試|Malaria_antigen_detection_tests}}<ref name=EBMED2014/>。近年發展[[聚合酶鏈式反應]]來偵測瘧原蟲的[[DNA]],但目前因為成本及複雜性,而沒有廣泛地應用在瘧疾[[地方性流行|盛行地區]]<ref name="Nadjm 2012">{{Cite journal |author=Nadjm B, Behrens RH |title=Malaria: An update for physicians |journal=Infectious Disease Clinics of North America |year=2012 |volume=26 |issue=2 |pages=243–59 |pmid=22632637 |doi=10.1016/j.idc.2012.03.010}}</ref>。
一般來說,瘧疾是透過受感染的雌性[[瘧蚊]]叮咬來傳播的。寄生蟲瘧原蟲會透過瘧蚊叮咬從蚊子的唾液中傳入至人類的[[血液]]中<ref name=WHO2014/>,接著瘧原蟲會隨血液移動至肝臟,在肝臟細胞中發育成熟及繁殖。瘧原蟲屬中有五種是可藉由感染人類進行散播<ref name=EBMED2014/>,多數死亡案例由[[恶性疟原虫|惡性瘧]](''P.&nbsp;falciparum'')、{{Link-en|間日瘧|Plasmodium vivax}}(''P.&nbsp;vivax'')及{{Link-en|卵形瘧|Plasmodium_ovale}}(''P.&nbsp;ovale'')所造成,而{{Link-en|三日瘧|Plasmodium_malariae}}(''P.&nbsp;malariae'')則產生較輕微的瘧疾症狀<ref name=WHO2014/><ref name=EBMED2014/>。另外,{{Link-en|猴瘧蟲|Plasmodium_knowlesi|猴瘧蟲}}''P.&nbsp;knowlesi'',又稱諾氏瘧蟲)較少在人類身上造成疾病<ref name=WHO2014/>。診斷瘧疾主要透過顯微鏡檢驗{{Link-en|血液抹片|Blood_film}}或是加上{{Link-en|快速瘧疾抗原診斷測試|Malaria_antigen_detection_tests}}<ref name=EBMED2014/>。近年發展[[聚合酶鏈式反應]]來偵測瘧原蟲的[[DNA]],但目前因為成本及複雜性,而沒有廣泛地應用在瘧疾[[地方性流行|盛行地區]]<ref name="Nadjm 2012">{{Cite journal |author=Nadjm B, Behrens RH |title=Malaria: An update for physicians |journal=Infectious Disease Clinics of North America |year=2012 |volume=26 |issue=2 |pages=243–59 |pmid=22632637 |doi=10.1016/j.idc.2012.03.010}}</ref>。


<!--預防與治療-->
<!--預防與治療-->
避免瘧蚊叮咬能夠降低感染瘧疾的風險,透過使用[[蚊帳]]以及[[防蚊液|驅蟲劑]] 或其他{{Link-en|控制蚊蟲生長|Mosquito contro}}的方法,像是噴灑[[殺蟲劑]]以及清除積水<ref name=EBMED2014/>。前往瘧疾盛行區的旅客可以使用幾種藥物來{{Link-en|預防瘧疾|Malaria_prophylaxis}},而瘧疾好發地區的[[嬰兒]]及過了[[妊娠#.E6.87.B7.E5.AD.95.E5.88.9D.E6.9C.9F|懷孕初期第一妊娠期]]的[[孕婦]]也建議適量使用{{Link-en|周效磺胺/比利美胺|Sulfadoxine/pyrimethamine}}。20世紀中期以後也出現了一些新的藥物,中國科學家研製的 [[青蒿素]] 有很好的抗瘧疾效果。儘管有所需求,但瘧疾尚無[[疫苗]],目前相關研究正在進行中<ref name=WHO2014/>。瘧疾的建議治療是併用[[青蒿素]]及另一種[[抗疟药|抗瘧疾藥物]]<ref name=WHO2014/><ref name=EBMED2014/>,包括{{Link-en|甲氟喹|Mefloquine}}、{{Link-en|苯芴醇|Lumefantrine}}或{{Link-en|周效磺胺/比利美胺|Sulfadoxine/pyrimethamine}}<ref name=WHO2010>{{cite book|last1=Organization|first1=World Health|title=Guidelines for the treatment of malaria|date=2010|publisher=World Health Organization|location=Geneva|isbn=9789241547925|page=ix|edition=2nd ed.}}</ref>。如果青蒿素無法取得,則可使用[[奎寧]]加上[[去氧羥四環素]]<ref name=WHO2010/>。由於擔心[[抗藥性]]的增加,建議在瘧疾盛行地區儘可能確診為瘧疾後再開始治療。目前瘧疾逐漸對於幾種藥物發展出抗藥性,例如:具有{{Link-en|氯化奎寧/氯喹|chloroquine}}抗藥性的惡性瘧已經散布到多數的瘧疾地區,另外青蒿素抗藥性問題在部分東南亞地區日益嚴重<ref name=WHO2014/>。
避免瘧蚊叮咬能夠降低感染瘧疾的風險,透過使用[[蚊帳]]以及[[防蚊液|驅蟲劑]] 或其他{{Link-en|控制蚊蟲生長|Mosquito contro}}的方法,像是噴灑[[殺蟲劑]]以及清除積水<ref name=EBMED2014/>。前往瘧疾盛行區的旅客可以使用幾種藥物來{{Link-en|預防瘧疾|Malaria_prophylaxis}},而瘧疾好發地區的[[嬰兒]]及過了[[妊娠#.E6.87.B7.E5.AD.95.E5.88.9D.E6.9C.9F|懷孕初期第一妊娠期]]的[[孕婦]]也建議適量使用{{Link-en|周效磺胺/比利美胺|Sulfadoxine/pyrimethamine}}。20世紀中期以後也出現了一些新的藥物,中國科學家研製的 [[青蒿素]] 有很好的抗瘧疾效果。儘管有所需求,但瘧疾尚無[[疫苗]],目前相關研究正在進行中<ref name=WHO2014/>。瘧疾的建議治療是併用[[青蒿素]]及另一種[[抗疟药|抗瘧疾藥物]]<ref name=WHO2014/><ref name=EBMED2014/>,包括{{Link-en|甲氟喹|Mefloquine}}、{{Link-en|苯芴醇|Lumefantrine}}或{{Link-en|周效磺胺/比利美胺|Sulfadoxine/pyrimethamine}}<ref name=WHO2010>{{cite book|last1=Organization|first1=World Health|title=Guidelines for the treatment of malaria|date=2010|publisher=World Health Organization|location=Geneva|isbn=9789241547925|page=ix|edition=2nd ed.}}</ref>。如果青蒿素無法取得,則可使用[[奎寧]]加上[[去氧羥四環素]]<ref name=WHO2010/>。由於擔心[[抗藥性]]的增加,建議在瘧疾盛行地區儘可能確診為瘧疾後再開始治療。目前瘧疾逐漸對於幾種藥物發展出抗藥性,例如:具有{{Link-en|氯化奎寧|chloroquine}}(氯喹)抗藥性的惡性瘧已經散布到多數的瘧疾地區,另外青蒿素抗藥性問題在部分東南亞地區日益嚴重<ref name=WHO2014/>。


<!--流行-->
<!--流行-->
瘧疾普遍存在於[[熱帶]]及[[亞熱帶]]地區,位於[[赤道]]周圍的寬大帶狀區域<ref name=EBMED2014/>。主要流行地區是 [[非洲中部]]、[[南亞]]、[[東南亞]]及 [[南美洲|南美]]北部的熱帶地區,這其中又以 [[非洲]] 的疫情最甚。就中國而言,瘧疾主要的流行地帶為[[華中]][[華南]]的叢林多山地區,但疫情遠較非洲為輕。[[世界衛生組織]]預估2012年,將會有二億七百萬例瘧疾案例,同時也預估該年因患瘧疾死亡人數介於四十七萬三千人至七十八萬九千人之間,多數為非洲的孩童<ref name=WHO2014/>。瘧疾與貧困息息相關,造成[[經濟發展]]相當大的負面影響<ref name="IftSoL">{{Cite report |author=Gollin D, Zimmermann C |title=Malaria: Disease Impacts and Long-Run Income Differences |date=August 2007 |publisher=[[Institute for the Study of Labor]] |url=http://ftp.iza.org/dp2997.pdf |format=PDF}}</ref><ref name="Worrall 2005">{{Cite journal |author=Worrall E, Basu S, Hanson K |title=Is malaria a disease of poverty? A review of the literature |journal=Tropical Health and Medicine |year=2005 |volume=10 |issue=10 |pages=1047–59 |doi=10.1111/j.1365-3156.2005.01476.x |pmid=16185240}} {{open access}}</ref>。非洲預估每年損失一百二十億美元,因為健康照護的花費增加,勞動力減少,以及瘧疾對觀光旅遊業造成的影響<ref name="Greenwood 2005">{{Cite journal |author=Greenwood BM, Bojang K, Whitty CJ, Targett GA |title=Malaria |journal=Lancet |year=2005|volume=365 |issue=9469 |pages=1487–98 |pmid=15850634 |doi=10.1016/S0140-6736(05)66420-3}}</ref>。
瘧疾普遍存在於[[熱帶]]及[[亞熱帶]]地區,位於[[赤道]]周圍的寬大帶狀區域<ref name=EBMED2014/>。主要流行地區是 [[非洲中部]]、[[南亞]]、[[東南亞]]及 [[南美洲|南美]]北部的熱帶地區,這其中又以 [[非洲]] 的疫情最甚。就中國而言,瘧疾主要的流行地帶為[[華中]][[華南]]的叢林多山地區,但疫情遠較非洲為輕。[[世界衛生組織]]預估2012年,將會有二億七百萬例瘧疾案例,同時也預估該年因患瘧疾死亡人數介於四十七萬三千人至七十八萬九千人之間,多數為非洲的孩童<ref name=WHO2014/>。瘧疾與貧困息息相關,造成[[經濟發展]]相當大的負面影響<ref name="IftSoL"/><ref name="Worrall 2005"/>。非洲預估每年損失一百二十億美元,因為健康照護的花費增加,勞動力減少,以及瘧疾對觀光旅遊業造成的影響<ref name="Greenwood 2005"/>。根據[[世界衛生組織]]的統計,2013年全世界的瘧疾病例共有1.98億例。<ref name=who2014/><ref>{{cite journal |author=GBD 2013 Mortality and Causes of Death Collaborators |title=Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 |journal=Lancet |date=17 December 2014 |pmid=25530442 |doi=10.1016/S0140-6736(14)61682-2 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(14)61682-2 |volume=385 |issue=9963 |pages=117–171 |pmc=4340604}}</ref>造成584,000至855,000人死亡,當中有90%是在非洲發生<ref>{{cite web|title=Factsheet on the World Malaria Report 2014|url=http://www.who.int/malaria/media/world_malaria_report_2014/en/|publisher=World Health Orgnization|accessdate=2 February 2015|date=2014}}</ref><ref name=who2014>{{cite book|last1=WHO|title=World Malaria Report 2014|date=2014|publisher=World Health Organization|location=Geneva, Switzerland|isbn=978-92-4156483-0|pages=32-42|url=http://www.who.int/entity/malaria/publications/world_malaria_report_2014/en/index.html}}</ref>。


== 主要病徵 ==
== 主要病徵 ==
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== 参考文献 ==
== 参考文献 ==
{{Reflist}}
{{Reflist}}
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<ref name="WHO Indoor Residual Spraying">{{Cite report |author= |url=http://whqlibdoc.who.int/hq/2006/WHO_HTM_MAL_2006.1112_eng.pdf |format=PDF |title=Indoor Residual Spraying: Use of Indoor Residual Spraying for Scaling Up Global Malaria Control and Elimination. WHO Position Statement |publisher=World Health Organization |year=2006}}</ref>

<ref name="whqlibdoc">{{Cite book |author=World Health Organization |chapter=Malaria |title=The First Ten Years of the World Health Organization |year=1958 |url=http://whqlibdoc.who.int/publications/a38153_(ch12).pdf |format=PDF |publisher=World Health Organization |pages=172–87}}</ref>

<ref name="Williams 1963">{{Cite journal |author=Williams LL |title=Malaria eradication in the United States |journal=American Journal of Public Health and the Nation's Health |year=1963 |volume=53 |issue=1 |pages=17–21 |pmid=14000898 |pmc=1253858 |doi=10.2105/AJPH.53.1.17}} {{open access}}</ref>

<ref name="Wilson 2012">{{Cite journal |author=Wilson ML |title=Malaria rapid diagnostic tests |journal=Clinical Infectious Diseases|year=2012 |volume=54 |issue=11 |pages=1637–41 |doi=10.1093/cid/cis228 |pmid=22550113}}</ref>

<ref name="Wongsrichanalai 2008">{{cite journal |author=Wongsrichanalai C, Meshnick SR |title=Declining artesunate-mefloquine efficacy against falciparum malaria on the Cambodia–Thailand border |journal=Emerging Infectious Diseases |volume=14 |issue=5 |pages=716–9 |year=2008 |pmid=18439351 |pmc=2600243 |doi=10.3201/eid1405.071601 |url=http://www.cdc.gov/eid/content/14/5/716.htm}}</ref>

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<ref name="Worrall 2005">{{Cite journal |author=Worrall E, Basu S, Hanson K |title=Is malaria a disease of poverty? A review of the literature |journal=Tropical Health and Medicine |year=2005 |volume=10 |issue=10 |pages=1047–59 |doi=10.1111/j.1365-3156.2005.01476.x |pmid=16185240}} {{open access}}</ref>

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<ref name="Yangzom 2012">{{Cite journal |author=Yangzom T, Gueye CS, Namgay R, Galappaththy GN, Thimasarn K, Gosling R, Murugasampillay S, Dev V |title=Malaria control in Bhutan: Case study of a country embarking on elimination |year=2012 |volume=11 |page=9 |pmid=22230355 |pmc=3278342 |doi=10.1186/1475-2875-11-9 |journal=Malaria Journal}} {{open access}}</ref>

}}

;引用文章
* {{Cite report |author=WHO |title=Guidelines for the Treatment of Malaria |edition=2nd |year=2010 |publisher=World Health Organization |isbn=978-9-2415-4792-5 |url=http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf |format=PDF |ref=harv}}
* {{Cite report |author=WHO |title=Guidelines for the Treatment of Malaria |edition=2nd |year=2010 |publisher=World Health Organization |isbn=978-9-2415-4792-5 |url=http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf |format=PDF |ref=harv}}
* {{Cite book |author=Schlagenhauf-Lawlor P |title=Travelers' Malaria |year=2008 |publisher=PMPH-USA |isbn=978-1-55009-336-0 |url=http://books.google.com/books?id=54Dza0UHyngC |ref=harv}}


== 外部連結 ==
== 外部連結 ==
{{commons category}}
{{Wikivoyage|Malaria}}
{{Wiktionary|malaria}}
*[http://smallcollation.blogspot.com/2013/02/protozoa-plasmodium.html 寄生蟲學-protozoa(原蟲)-Plasmodium(瘧原蟲屬)]
*[http://smallcollation.blogspot.com/2013/02/protozoa-plasmodium.html 寄生蟲學-protozoa(原蟲)-Plasmodium(瘧原蟲屬)]
* [http://www.cdc.gov.tw/sp.asp?xdurl=disease/disease_content.asp&id=771&mp=1&ctnode=1498 中華民國疾病管制局-瘧疾防治]
* [http://www.cdc.gov.tw/sp.asp?xdurl=disease/disease_content.asp&id=771&mp=1&ctnode=1498 中華民國疾病管制局-瘧疾防治]
* [http://www.map.ox.ac.uk 疟疾地图计划]
* [http://www.map.ox.ac.uk 疟疾地图计划]
* {{dmoz|Health/Conditions_and_Diseases/Infectious_Diseases/Parasitic/Malaria}}
* [http://www.emro.who.int/entity/malaria-control-and-elimination/ WHO site on malaria]
* [http://www.unhco.org/malaria/ UNHCO site on malaria]
* [http://www.rollbackmalaria.org/gmap/ Global Malaria Action Plan](2008年)
* [http://doctorswithoutborders.org/news/issue.cfm?id=2395 Doctors Without Borders/Médecins Sans Frontières – ''Malaria''] information pages
* [http://www.wehi.edu.au/other_domains/MalDB/who.html Who/TDR Malaria Database]
* [http://www.antimalariaomd.org/en/index.php Anti malaria and sustainable development]
* [http://www.wwarn.org Worldwide Antimalarial Resistance Network (WWARN)]

==延伸閱讀==
* {{Cite book |author=Packard RM |title=The Making of a Tropical Disease: A Short History of Malaria |url=http://books.google.com/books?id=B_V1Xj6wH7IC |year=2007 |publisher=JHU Press |isbn=978-0-8018-8712-3 |series=Johns Hopkins Biographies of Disease}}
* {{Cite book |author=Shah S |title=The Fever: How Malaria Has Ruled Humankind for 500,000 Years |url=http://books.google.com/books?id=4jUjPh64X9UC |year=2010 |publisher=Macmillan |isbn=978-0-374-23001-2}} [http://www.amazon.com/Fever-Malaria-Ruled-Humankind-Years/dp/0374230013/ excerpt and text search]
* {{Cite book |author=Bynum WF, Overy C |title=The Beast in the Mosquito: The Correspondence of Ronald Ross and Patrick Manson |url=http://books.google.com/books?id=5BXbsSJLaToC |year=1998 |publisher=Rodopi |isbn=978-90-420-0721-5 |series=Wellcome Institute Series in The History of Medicine}}

{{malaria}}
{{Diseases of Poverty}}
{{Chromalveolate diseases}}


{{Authority control}}
[[Category:頂複門]]
[[Category:疟疾| ]]
[[Category:疟疾| ]]
[[Category:]]
[[Category:动物病]]
[[Category:热带病]]

2015年5月20日 (三) 11:19的版本

疟疾
Malaria.jpg
人体血液中的恶性疟原虫环状体和配子母细胞
症状intermittent fever[*], periodic fever[*], 肝腫大, 贫血, 脾腫大[*], 黄疸, 昏迷, 發冷
肇因恶性疟原虫, 间日疟原虫, 三日瘧, 卵形瘧, 猴瘧蟲
診斷方法血膜[*], 光学显微镜, 聚合酶链式反应
治療抗疟药, 解熱劑, intravenous fluid replacement[*], 对症治疗
盛行率729、​22、​2、​1,974、​881,730、​343,527、​31,479、​21,309、​177,767、​3,769,051、​500,000,000、​4,114
死亡數445,000、​627,000
醫學專科傳染病學、​熱帶醫學、​寄生虫学


瘧疾(英語:Malaria)是一種蚊媒病,由寄生性的原生生物界(一種單細胞 微生物瘧原蟲[1]引起,人類及其他動物的全球性急性寄生蟲傳染病。瘧疾引起的典型症狀有發燒倦怠不適英语Malaise嘔吐以及 頭痛。在嚴重的病例中會引起黃疸癲癇發作昏迷死亡[2]。這些症狀通常在被蚊子叮咬後十到十五天內開始出現,沒有受到適當治療的病人(但症狀緩解)可能於數個月後會再次出現這些症狀[1]。而在瘧疾倖存者中,再次感染通常引起的症狀通常較輕微。如果沒有持續暴露在瘧疾環境中,這種少量的抵抗力會在數月至數年間消失[3]

一般來說,瘧疾是透過受感染的雌性瘧蚊叮咬來傳播的。寄生蟲瘧原蟲會透過瘧蚊叮咬從蚊子的唾液中傳入至人類的血液[1],接著瘧原蟲會隨血液移動至肝臟,在肝臟細胞中發育成熟及繁殖。瘧原蟲屬中有五種是可藉由感染人類進行散播[2],多數死亡案例由惡性瘧P. falciparum)、間日瘧P. vivax)及卵形瘧P. ovale)所造成,而三日瘧P. malariae)則產生較輕微的瘧疾症狀[1][2]。另外,猴瘧蟲英语Plasmodium_knowlesiP. knowlesi,又稱諾氏瘧蟲)較少在人類身上造成疾病[1]。診斷瘧疾主要透過顯微鏡檢驗血液抹片英语Blood_film或是加上快速瘧疾抗原診斷測試英语Malaria_antigen_detection_tests[2]。近年發展聚合酶鏈式反應來偵測瘧原蟲的DNA,但目前因為成本及複雜性,而沒有廣泛地應用在瘧疾盛行地區[4]

避免瘧蚊叮咬能夠降低感染瘧疾的風險,透過使用蚊帳以及驅蟲劑 或其他控制蚊蟲生長英语Mosquito contro的方法,像是噴灑殺蟲劑以及清除積水[2]。前往瘧疾盛行區的旅客可以使用幾種藥物來預防瘧疾英语Malaria_prophylaxis,而瘧疾好發地區的嬰兒及過了懷孕初期第一妊娠期孕婦也建議適量使用周效磺胺/比利美胺英语Sulfadoxine/pyrimethamine。20世紀中期以後也出現了一些新的藥物,中國科學家研製的 青蒿素 有很好的抗瘧疾效果。儘管有所需求,但瘧疾尚無疫苗,目前相關研究正在進行中[1]。瘧疾的建議治療是併用青蒿素及另一種抗瘧疾藥物[1][2],包括甲氟喹苯芴醇周效磺胺/比利美胺英语Sulfadoxine/pyrimethamine[5]。如果青蒿素無法取得,則可使用奎寧加上去氧羥四環素[5]。由於擔心抗藥性的增加,建議在瘧疾盛行地區儘可能確診為瘧疾後再開始治療。目前瘧疾逐漸對於幾種藥物發展出抗藥性,例如:具有氯化奎寧(氯喹)抗藥性的惡性瘧已經散布到多數的瘧疾地區,另外青蒿素抗藥性問題在部分東南亞地區日益嚴重[1]

瘧疾普遍存在於熱帶亞熱帶地區,位於赤道周圍的寬大帶狀區域[2]。主要流行地區是 非洲中部南亞東南亞南美北部的熱帶地區,這其中又以 非洲 的疫情最甚。就中國而言,瘧疾主要的流行地帶為華中華南的叢林多山地區,但疫情遠較非洲為輕。世界衛生組織預估2012年,將會有二億七百萬例瘧疾案例,同時也預估該年因患瘧疾死亡人數介於四十七萬三千人至七十八萬九千人之間,多數為非洲的孩童[1]。瘧疾與貧困息息相關,造成經濟發展相當大的負面影響[6][7]。非洲預估每年損失一百二十億美元,因為健康照護的花費增加,勞動力減少,以及瘧疾對觀光旅遊業造成的影響[8]。根據世界衛生組織的統計,2013年全世界的瘧疾病例共有1.98億例。[9][10]造成584,000至855,000人死亡,當中有90%是在非洲發生[11][9]

主要病徵

感染疟原虫后8-25天会发病,病人可能会有如下症状:忽冷忽热、头痛发热顫栗关节痛呕吐溶血反应、疟原性贫血、黄疸尿血视网膜损害、抽搐等。最典型的症状为忽冷忽热循环——先发冷、打冷颤,然后发热、出汗。这是因为疟原虫生活周期具有明显的生理节奏(circadian rhythm),如間日疟原虫(Plasmodium vivax)导致的疟疾发热周期为48小时,因而病患的发烧症状也呈现周期性。如果疟原虫侵入脑部血管,则会导致最为严重的脑部疟疾,这通常会造成病者昏迷。由于早期迹象与流行性感冒有相似之处,许多对该疾病不熟悉的外来旅游者容易将疟疾误认为感冒,从而因为没有得到及时的药物治疗而使得病情恶化。

按照疟疾病征的严重程度不同,疟疾可以分为非重症疟疾(uncomplicated malaria)和重症疟疾(complicated / severe malaria),能有效治疗这两类疟疾的药物不太相同。

如果没有得到及时和有效的治疗,疟疾患者的死亡率会非常高。这也是非洲疟疾肆虐的主要原因之一,由于战乱和经济发展问题,处于疫区的非洲国家公共卫生和医疗状况通常非常恶劣,这使得这些地方疟疾的感染和死亡率一直居高不下。

病原

瘧疾疫區,2006年。[12]
    氯喹及多重耐药性疟疾高发区     氯喹抗药性疟疾发生区     无抗药性疟疾发生区     无疟疾

瘧疾的致病源是瘧原蟲(疟原虫属,Plasmodium spp.),这是一类单细胞真核生物,属于细胞内寄生蟲,它们以瘧蚊蚊子的其中一個屬,瘧蚊屬的部分種類)作為传病媒介,通过雌蚊叮咬吸血来傳播病原体。

疟原虫属生物是顶复合器门(Apicomplexa)的原生生物,这一门的生物几乎都是寄生虫。大部分脊椎动物都可以作为疟原虫的主要宿主,比如啮齿动物,蝙蝠,蜥蜴,鸟等等。这也使得生物学家可以通过建立生物模型(比方说,用老鼠做疟疾病理研究)的方式来研究人类疟疾。

只有四种疟原虫能够感染人类,这包括恶性疟原虫(Plasmodium falciparum)、三日疟原虫(Plasmodium malariae)、卵形疟原虫(Plasmodium ovale)及间日疟原虫(Plasmodium vivax)。其中恶性疟原虫是非洲流行疟疾的主要病原体,亦是造成患者死亡率最高的疟原虫。

中国以间日疟与恶性疟最为常见,三日疟少见,卵形疟极少发生。恶性疟主要发生在西南与海南。间日疟发生在东北、华北、西北。

生命周期

疟原虫的生命周期很复杂。雌按蚊叮咬人时,唾液中的疟原虫的长梭形的子孢子进入人体内,随血液运移到肝脏,侵入肝细胞。子孢子在肝细胞内部吸收营养,长大成熟后分裂生殖形成很多小的裂殖子。裂殖子成熟后,破坏肝细胞进入体液、血液中,一部分再侵入肝细胞重复上述循环,一部分侵入红细胞

在红细胞内,裂殖子逐渐吸收血红蛋白作为营养长大,成为像个戒指的环状体。环状体进一步长大,向四周伸出伪足,称为阿米巴样体或大滋养体。大滋养体进一步发育形成裂殖体,裂殖体成熟后放出很多裂殖子,破坏红细胞后进入血液,继续感染其他红细胞。由于人体内的疟原虫的裂殖子同时破坏大量红细胞进入血液,人体会产生疟疾的典型症状,如发冷发热。如果宿主环境不利,一些裂殖子进入红细胞后可形成大、小配子母细胞。这些配子母细胞在人体中不再进一步发育,如果不能被蚊子吸血时吸走,配子母细胞在人体内可存活60天。

当蚊子吸取受感染人体的血液后,雄,雌配子母细胞进入蚊子胃内,发育成配子并进行有性繁殖。合子穿透蚊子的胃壁,在胃壁下形成卵囊(oocyte)。卵囊中疟原虫进行无性繁殖,最终形成子孢子(sporozoite)。成熟后,卵囊破裂,子孢子进入蚊子体腔,穿透各种组织,进入蚊子唾液腺。蚊子唾液腺中的子孢子可达20万。子孢子在蚊子体内存活70天。准备感染新的脊椎动物宿主。

病理分段

根据疟原虫所处的环境和自身形态的不同,疟原虫的生命周期可以大致分为三个阶段:

  1. 红血球外阶段(Pre-erythrocytic stage):从寄生虫的孢子体进入宿主体内到其侵入红血球为止,这个过程一般需要8~9天,这一阶段患者无明显症状。这一阶段抗疟药对疟原虫没有作用。
  2. 无性血内阶段(Asexual blood stage):寄生虫在红血球内不断扩殖,这一阶段病人呈现显著的疟疾临床症状。由于疟原虫具有很明显的生理节奏,每隔一定的时间所有寄生在红血球中的寄生虫就会一同离开受感染细胞,寻找新的宿主细胞,这是造成疟疾患者高烧具有周期性的主要原因。另外,疟原虫可以改造受感染细胞的表面蛋白结构,使之可以贴附在血管内壁表面,免于受感染细胞在经过脾脏时受宿主免疫系统攻击而死亡。这一行为能够造成微细血管的阻塞,如果阻塞发生在脑部血管,患者很容易陷入昏迷状态。
  3. 有性繁殖阶段(Sexual stage),疟原虫在红血球内形成配子体,进而经蚊子吸食血液进入蚊子体内完成有性繁殖,再由蚊子叮咬进入新的宿主。对疾病传播的控制主要针对的就是这一阶段。

预防与治疗

人体免疫反应

疟原虫生活史

人体对疟原虫有一定的免疫反应。先天免疫系统可以发现病原体和受感染的细胞并加以杀死。人体还可以产生抗体来对抗疟原虫和受感染细胞,这些免疫反应是造成病人病理反应的部分原因。实际上,人体对疟疾的抵抗能力是有一定效果的,疟疾死者多为10岁以下免疫功能并不完善的儿童。然而,疟原虫具有一套非常复杂的遗传系统,在宿主的免疫反应压力下,疟原虫可以通过基因重组的方式迅速改变它们及所寄生细胞的表面抗原,从而使得寄生虫在血液内不容易被根除。许多病人在病理特征减轻后进入寄生虫血症(Parasitaemia)阶段,此时免疫系统很难完全消灭疟原虫,病情进入慢性期。

疫苗

研究瘧疾疫苗的難度很高,現時有一些試驗中的疫苗。

药物

治療疟疾的藥物稱為抗瘧藥,會依疟疾的種類及嚴重程度選用不同的藥物。和解熱劑英语Antipyretic一起服用的效果還不是很明確 [13]

抗疟疾最著名的药物是奎宁。口服和肌肉注射都有效。1969年-1972年间,屠呦呦领导的523课题组发现并从黄花蒿中提取了青蒿素[14],是由菊科植物黄花蒿[15]所提煉出來的倍半萜內酯化合物,是治療恶性疟原虫所引发的瘧疾的特效藥。

非重症的疟疾可以用口服藥物治療,最有效的療法是青蒿素配合其他抗瘧藥一起服用(稱為青蒿素聯合療法,簡稱ACT),可以減輕對單一藥物的抗藥性[16]。其他的抗瘧藥包括阿莫地喹英语amodiaquine本芴醇、甲氟喹(mefloquine)或磺胺多辛/乙胺嘧啶英语sulfadoxine/pyrimethamine[17]。另一建議的聯合療法是双氢青蒿素喹哌英语piperaquine[18][19]。若用在非重症疟疾,青蒿素聯合療法有效的比率約有90%[20]。若是治療孕婦的疟疾,世界衛生組織建議在懷孕初期(前三個月)用奎寧克林黴素,在中後期則用青蒿素聯合療法[21]在2000年左右,在東南亞已經出現對青蒿素有抗藥性的疟疾[22]

传播途径

一种冈比亚按蚊,是疟原虫的最终宿主

雌按蚊叮人传播疟疾,但並非所有蚊都能传播疟疾,大部分蚊抗疟原虫,只有按蚊属(Anopheles spp.)下的部分种类,易受疟原虫。

預防方法

填平濕地及破壞原始森林是一種預防方法,但是此種破壞生態的方法會造成更多問題,在這些地區的瘧蚊(按蚊)是難以根治的,人類避免受瘧疾感染,主要是避免受蚊子的叮咬。

  • 避免在原始森林和河澗逗留。
  • 使用DDT等殺蟲劑,但是要小心破壞生態及蚊蟲抗藥性等問題。
  • 到瘧疾肆虐地區之前應該先做好防疫措施,例如請醫師開立奎寧類藥物服用預防。
  • 若需要到郊外或森林,盡量避免在晨早或黃昏時按蚊活躍期間。
  • 穿著淺色長袖衣服、長褲、帽子,減少皮膚外露。
  • 使用蚊帳、蚊香等滅蚊措施;浸泡過殺蟲劑的蚊帳效果更好。
  • 使用含DEET水劑的防蚊液,塗在外露皮膚上,出汗後需要再次塗上。
  • 在滅絕按蚊的幼蟲孑孓方面,可以將河道的雜草清除,和將部份河道的障礙物如石頭移走,令河道的流量加快。
  • 在室內可將滅蚊劑噴在房間的牆壁。因為蚊習性於叮人血後依附在牆上休息消化,殘留在牆壁上的滅蚊劑可以殺掉蚊子。
  • 若到外地旅遊,應詳盡紀錄所到地方,以防當自己懷疑染疾時可向醫護人員提供可靠資料。
  • 东南亚虽然是仍然存在疟疾的地理区域,但疫情主要集中在中南半岛内陆山区和马来群岛偏远岛屿,新加坡曼谷吉隆坡清迈等大都市以及巴厘岛普吉岛吴哥窟等热门旅游景点并无疟疾疫情,若不是进行丛林探险的背包客则不必在出发前接种疫苗。
  • 南亚次大陆撒哈拉以南的非洲大陆为最易感染疟疾的地理区域,即便是前往孟买拉各斯金沙萨等大城市也有必要在出发前接种疟疾疫苗。
  • 南美洲的疟疾疫情主要集中在纬度和海拔较低的圭亚那苏里南和巴西东北部,库斯科马丘比丘里约热内卢科隆群岛等热门旅游景点均无疟疾疫情,无须在行前接种疫苗。
  • 多米尼加共和国的贫民区及海地共和国外,其余的加勒比岛国均无疟疾疫情。

參見

参考文献

  1. ^ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Malaria Fact sheet N°94. WHO. March 2014 [28 August 2014]. 
  2. ^ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Caraballo, Hector. Emergency Department Management Of Mosquito-Borne Illness: Malaria, Dengue, And West Nile Virus. Emergency Medicine Practice. May 2014, 16 (5). 
  3. ^ 引用错误:没有为名为Caraballo 2014的参考文献提供内容
  4. ^ Nadjm B, Behrens RH. Malaria: An update for physicians. Infectious Disease Clinics of North America. 2012, 26 (2): 243–59. PMID 22632637. doi:10.1016/j.idc.2012.03.010. 
  5. ^ 5.0 5.1 Organization, World Health. Guidelines for the treatment of malaria 2nd ed. Geneva: World Health Organization. 2010: ix. ISBN 9789241547925. 
  6. ^ 引用错误:没有为名为IftSoL的参考文献提供内容
  7. ^ 引用错误:没有为名为Worrall 2005的参考文献提供内容
  8. ^ 引用错误:没有为名为Greenwood 2005的参考文献提供内容
  9. ^ 9.0 9.1 WHO. World Malaria Report 2014. Geneva, Switzerland: World Health Organization. 2014: 32–42. ISBN 978-92-4156483-0. 
  10. ^ GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 17 December 2014, 385 (9963): 117–171. PMC 4340604可免费查阅. PMID 25530442. doi:10.1016/S0140-6736(14)61682-2. 
  11. ^ Factsheet on the World Malaria Report 2014. World Health Orgnization. 2014 [2 February 2015]. 
  12. ^ CHU Hôpitaux de Rouen. Fréquence et origine des cas de paludisme. .chu-rouen.fr. [2010-08-24]. 
  13. ^ Meremikwu MM, Odigwe CC, Akudo Nwagbara B, Udoh EE. Meremikwu, Martin M , 编. Antipyretic measures for treating fever in malaria. Cochrane Database of Systematic Reviews. 2012, 9: CD002151. PMID 22972057. doi:10.1002/14651858.CD002151.pub2. 
  14. ^ 米勒·路易斯(Louis H. Miller)和苏新专(Xin-zhuan Su). 青蒿素:源自中草药园的发现. 《细胞》 (CAMBRIDGE, MA 02139, USA: Cell Press). 2011-09-16, 146 (6): 855–858. ISSN 0092-8674. PMID 21907397. doi:10.1016/j.cell.2011.08.024. 
  15. ^ 方舟子. 青蒿素和中药有多大的关系?. 2011-09-23 [2011-09-26]. 
  16. ^ Kokwaro G. Ongoing challenges in the management of malaria. Malaria Journal. 2009, 8 (Suppl 1): S2. PMC 2760237可免费查阅. PMID 19818169. doi:10.1186/1475-2875-8-S1-S2.  开放获取
  17. ^ WHO 2010,第75–86頁
  18. ^ WHO 2010,第21頁
  19. ^ Keating GM. Dihydroartemisinin/piperaquine: A review of its use in the treatment of uncomplicated Plasmodium falciparum malaria. Drugs. 2012, 72 (7): 937–61. PMID 22515619. doi:10.2165/11203910-000000000-00000. 
  20. ^ Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J, Blakemore A, Bull AM, Car J, Conteh L, Cooke GS, Ford N, Gregson SA, Kerr K, King D, Kulendran M, Malkin RA, Majeed A, Matlin S, Merrifield R, Penfold HA, Reid SD, Smith PC, Stevens MM, Templeton MR, Vincent C, Wilson E. Technologies for global health. The Lancet. 2012, 380 (9840): 507–35. PMID 22857974. doi:10.1016/S0140-6736(12)61127-1. 
  21. ^ Manyando C, Kayentao K, D'Alessandro U, Okafor HU, Juma E, Hamed K. A systematic review of the safety and efficacy of artemether-lumefantrine against uncomplicated Plasmodium falciparum malaria during pregnancy. Malaria Journal. 2011, 11: 141. PMC 3405476可免费查阅. PMID 22548983. doi:10.1186/1475-2875-11-141.  开放获取
  22. ^ Fairhurst RM, Nayyar GM, Breman JG, Hallett R, Vennerstrom JL, Duong S, Ringwald P, Wellems TE, Plowe CV, Dondorp AM. Artemisinin-resistant malaria: research challenges, opportunities, and public health implications. American Journal of Tropical Medicine and Hygiene. 2012, 87 (2): 231–41. PMC 3414557可免费查阅. PMID 22855752. doi:10.4269/ajtmh.2012.12-0025.  开放获取

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引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用
引用错误:带有group属性""的脚注列表区没有在文中使用

引用错误:带有group属性""的脚注列表区没有在文中使用
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