Malaria: symptoms, diagnosis, treatment, prevention

Malaria is caused by parasites of the genus Plasmodium. These parasites are transmitted to humans through the bites of infected female Anopheles mosquitoes, which are called "malaria vectors." There are five species of parasites that cause malaria in humans, and two of these species, P. falciparum and P. vivax, are the most dangerous.

• In 2022, P. falciparum was estimated to account for approximately 99.7% of malaria cases in the WHO African Region, 50% of cases in the WHO South-East Asia Region, 71% of cases in the Eastern Mediterranean Region and 65% in the Western Region. parts of the Pacific Ocean.
• P. vivax is the predominant parasite in the WHO Region of the Americas, where it accounts for 75% of malaria cases.

Symptoms

Malaria is an acute febrile disease. In a person who is not immune, symptoms usually appear 10 to 15 days after being bitten by an infected mosquito. The first symptoms—fever, headache, and chills—may be mild, making malaria difficult to detect. If treatment is not started within the first 24 hours, P. falciparum malaria can develop into a severe illness that is often fatal.

Children with severe malaria often develop one or more of the following symptoms: severe anemia, respiratory failure due to metabolic acidosis, or cerebral malaria. Adults also often experience multiple organ failure. In areas where malaria is endemic, people may develop partial immunity, in which infections occur without symptoms.

Preventive measures

To avoid contracting malaria, persons who travel to areas with unfavorable epidemiological conditions must take special medications:

• Chloroquine. Adults - 14 days before departure, 300 mg once a week. It is necessary to continue taking it for another 4-6 weeks after returning. Children are prescribed at the rate of 5 mg per 1 kg of body weight per week, the course of administration is similar to adults;
• Mefloquine. Adults - 7 days before departure and another four weeks after return. Dosage – 250 mg once a week. In children, the dosage depends on weight: from 15 to 19 kg - 0.25 tablets, from 20 to 30 kg - 0.5 tablets, from 31 to 45 kg - 0.75 tablets, over 45 kg - 1 piece.

If there are contraindications to taking special medications, then you can take Doxycyline at a dosage of 100 mg. One dose per day is enough, one or two days before departure and for a month after returning.

You should avoid mosquito bites and use protective equipment - creams, aerosols, mosquito nets.

Who is at risk?

In 2022, nearly half the world's population was at risk of malaria. Most malaria cases and deaths occur in sub-Saharan Africa. However, WHO regions such as South-East Asia, the Eastern Mediterranean, the Western Pacific and the Americas are also at risk.

The risk of contracting malaria and developing severe disease is significantly higher among some groups of the population. These groups include infants, children under five years of age, pregnant women and people with HIV/AIDS, as well as non-immune migrants, mobile populations and travelers. National malaria control programs need to take special measures to protect these populations from malaria infection, taking into account their specific circumstances.

Burden of disease

According to the latest edition of the World Malaria Report, released in November 2022, 229 million people worldwide were affected by malaria in 2022, up from 228 million in 2018. An estimated 409,000 people died from malaria in 2022 up from 411,000 in 2022

The WHO African Region continues to bear a disproportionate share of the global malaria burden. In 2019, the region accounted for 94% of all malaria cases and deaths.

In 2022, approximately half of all malaria deaths worldwide occurred in six countries: Nigeria (23%), Democratic Republic of the Congo (11%), United Republic of Tanzania (5%), Burkina Faso (4%), Mozambique ( 4%) and Niger (4%).

Children under five years of age are especially susceptible to malaria; in 2022, they accounted for 67% (274,000) of all malaria deaths worldwide.

• World Malaria Report 2022 – in English

Consequences and complications

If correct and timely treatment of the disease has not been carried out, in the case of three-day malaria the disease can last about two years, with four-day malaria - several years, with tropical - about a year.

The consequences of the illness include dysfunction of internal organs, the central nervous system, and prolonged disability.

The most serious complications of malaria are:

• coma;
• splenic rupture;
• acute nephritis;
• hemoglobinuric fever;
• psychosis.

If a patient develops a malarial coma , he falls into a deep sleep from which he cannot be awakened. In this case, convulsive seizures, fecal and urinary incontinence, and a characteristic appearance are noted.

When the spleen ruptures, there is a sharp pain in the abdomen, fainting, tension of the abdominal muscles in the left hypochondrium, and the presence of a painful tumor in this place. In this case, urgent surgery is necessary.

With hemoglobinuric fever, chills develop sharply, the temperature can rise to 41 degrees. There is a severe headache, vomiting, and body aches. Urine becomes dark red, almost black, and jaundice develops. Severe thirst. The attack lasts several hours or several days, but already on the first or second day the person may die.

The most common complication of the tropical form is cerebral malaria . Three stages of this condition develop: somnolence, stupor and coma. At the somolent stage, headache, lethargy, photophobia, hyperesthesia , and intracranial hypertension . In the stage of stupor, all symptoms worsen; convulsions and convulsive twitching of different muscle groups are possible. The skin color is gray with an earthy tint, the mucous membranes are dry. Tachycardia , tachypnea , and hypotension develop . The patient falls into deep sleep. During the coma stage, the patient remains unconscious and does not respond to stimuli. Without treatment, this complication is fatal.

It is important to realize that the tropical form, with late treatment or its absence, leads to the death of the patient.

Transmission of infection

Most cases of malaria are transmitted through the bites of female Anopheles mosquitoes. There are over 400 different species of Anopheles mosquitoes; about 30 species are significant vectors of malaria. All significant vector species bite at dusk and dawn. The intensity of transmission depends on factors related to the parasite, the vector, the human host and the environment.

Anopheles mosquitoes lay eggs in water, which hatch into larvae that eventually develop into adult mosquitoes. Female mosquitoes need blood to lay eggs. Each Anopheles mosquito species has its own aquatic habitat; some, for example, prefer small, shallow accumulations of fresh water, such as puddles and hoof marks, which are abundant during the rainy season in tropical countries.

Transmission occurs more intensely in places where mosquitoes have a longer lifespan (giving the parasite enough time to complete its development in the mosquito) and where the vector prefers to bite people rather than animals. For example, the long lifespan of African vector species and the fact that they consistently prefer to bite humans are the main reasons why approximately 90% of all malaria deaths occur in Africa.

Transmission of infection also depends on climate features, such as rainfall patterns, temperature and humidity, which also affect the number and survival of mosquitoes. In many places, transmission is seasonal and peaks during and immediately after the monsoon seasons. Malaria epidemics can occur when climatic and other conditions suddenly become favorable for transmission in areas where people have little or no immunity to malaria. In addition, epidemics can occur when people with weak immune systems enter areas with intense malaria transmission, for example to seek work or as refugees.

Another important factor is human immunity, especially among adults in areas with moderate to intense transmission. Partial immunity develops over several years of exposure, and although it never provides complete protection, it reduces the risk of developing severe illness in the event of a malaria infection. For this reason, most malaria deaths in Africa occur among young children, while in areas with less intense transmission and low immunity, all age groups are at risk.

Kinds

There are four types of malaria:

• tropical. It is the most common and dangerous - it causes complications more often than others. More than 90% of cases are of this type;
• four-day. It is named so because acute attacks of the disease most often occur after 72 hours;
• three-day. In this case, attacks will occur more often - on average every 40-48 hours;
• ovale malaria. The cycle of attacks is similar to the previous version.

It is important to understand that after illness and recovery, immunity to re-infection is not developed. Such immunity can develop after a year or after several infections, however, even in this case it is not very effective, since it can only act on certain types of parasites and does not provide complete protection, but only reduces symptoms.

Prevention

The main way to prevent and reduce malaria transmission is vector control. Sufficiently high coverage of a particular area with vector control measures provides some protection from infection to the entire population of the area.

To protect all people at risk of malaria, WHO recommends effective vector control measures. To do this, two methods can be effectively used in a wide variety of conditions - insecticide-treated mosquito nets and spraying residual insecticides indoors.

Insecticide treated mosquito nets

The use of insecticide-treated mosquito nets (ITNs) during sleep may reduce the likelihood of mosquito-human contact through both the presence of a physical barrier and exposure to the insecticide. Mass eradication of mosquitoes in areas where such nets are widely available and actively used by local residents can provide protection to the entire population.

In 2022, insecticide-treated nets in Africa protected about 46% of all people at risk of malaria, up from 2% in 2000. However, ITN coverage has shown little growth since 2016.

Spraying residual insecticides indoors

Another effective way to rapidly reduce malaria transmission is indoor residual spraying (IRID). Insecticide spraying inside residential areas is carried out once or twice a year. To achieve effective protection of the population, a high level of RIODVP coverage must be ensured.

Globally, the rate of use of RADI for protection has decreased from a peak of 5% in 2010 to 2% in 2022 in all WHO regions except the Eastern Mediterranean Region. The decline in MRV coverage occurs as countries shift from using pyrethroid pesticides to more expensive alternatives to address pyrethroid resistance in mosquitoes.

Treatment with folk remedies

The use of folk remedies to treat this disease is only possible if they are used as additional methods for the general restoration of the body. In no case should such treatment be substituted for taking anti-malaria drugs, as this can lead to fatal consequences.

To treat this disease, the following folk remedies are used:

• Orange peel. Crush dry orange peel and apply half a teaspoon of this powder three times a day.
• Willow bark. 2 tsp pour crushed willow bark into 1.5 cups of water and keep the product on low heat until the amount of liquid is reduced to one cup. You need to drink the decoction in the morning on an empty stomach, adding a little honey to it.
• Mustard and wine. Pour 100 ml of wine into a ladle of a teaspoon of mustard and add a little salt. Drink three times a day. This remedy helps reduce the symptoms of fever.
• Garlic. The head of garlic needs to be peeled so that the cloves are without peel. Grind them and add 1 glass of water. Leave to infuse for 12 hours. Drink the prepared infusion throughout the day in small sips.
• Star anise root. 4 tsp crushed root, pour a glass of boiled water and cook for several minutes. Drink 3 tbsp. three times a day.
• Parsley juice with vodka. Pass 2 kg of parsley through a meat grinder, squeeze out the juice and mix it with 150 ml of vodka. Drink 100 ml morning and evening.
• Black radish juice. 50 g of fresh radish juice should be mixed with 50 g of vodka. Divide the product into three parts and drink them throughout the day. On the second day, it is recommended to drink the entire portion in the morning.
• Basil. Pour 200 g of leaves into half a liter of water, add a little cardamom powder and black pepper and boil for 20 minutes. After 2 hours, mix with a small amount of honey and drink 3 tbsp. three times a day.
• Grapefruit. Half the fruit should be poured with 500 ml of water and boiled for several minutes. Strain and drink a glass 2 times a day.
• Cinnamon. 1 tsp cinnamon with a small pinch of pepper, pour half a liter of water and boil for 5 minutes. Cool, add a spoonful of honey and drink 100 g 2 times a day.

Antimalarial drugs

Antimalarial drugs can also be used to prevent malaria. Prevention of malaria among travelers can be achieved through chemoprophylaxis, which suppresses the blood stage of malaria infection, thereby preventing the disease from developing. Among pregnant women living in areas of moderate to intense transmission, WHO recommends at least 3 doses of intermittent sulfadoxine-pyrimethamine prophylaxis at each scheduled antenatal visit after the first trimester of pregnancy.

Similarly, intermittent preventive therapy with three doses of sulfadoxine-pyrimethamine as part of routine vaccination is recommended for infants living in areas of Africa with high transmission rates.

Since 2012, WHO has recommended seasonal malaria chemoprophylaxis in areas of the Sahel subregion as an additional malaria prevention strategy. This strategy involves administering monthly courses of amodiaquine plus sulfadoxine-pyrimethamine to all children under five years of age during the high transmission season.

List of sources

• Baranova AM Modern problems of imported malaria and preventing the consequences of importation // ZNiSO.- M., 1995.-No. 2.-P.1-4.
• Voskresentsev V. A. Current problems of detection and prevention of malaria [Text] / V.
• A. Voskresentsev // Medical statistics and organizational and methodological work in institutions
• healthcare. - 2014. - No. 9. - P. 74-78.
• Litvinov, S.K. Vaccination against malaria: reality and prospects [Text] / S.K.
• Litvinov, A. M. Bronshtein, E. N. Morozov // Epidemiology and infectious diseases. —
• 2017. - No. 3. - P. 153-156.
• Lysenko, A. Ya. Malaria: parasitology, epidemiology, prevention and immunity: Center. Institute of Improvement doctors: lecture / A. Ya. Lysenko, A. E. Belyaev. - M.: TSOLIUV, 1981. - 42 p.

Insecticide resistance

Since 2000, progress in malaria control has been achieved largely through increased coverage of vector control interventions, particularly in sub-Saharan Africa. However, these achievements are under threat due to the increasing resistance of Anopheles mosquitoes to insecticides. According to the latest edition of the World Malaria Report, mosquito resistance to at least one of the four most common classes of insecticides was reported in 73 countries between 2010 and 2022. In 28 countries, mosquito resistance to all major classes of insecticides was observed.

Despite the rise and spread of mosquito resistance to pyrethroids, insecticide-treated nets continue to provide significant levels of protection in most areas of human activity. This was confirmed by the results of a large study coordinated by WHO in five countries between 2011 and 2016.

Despite the encouraging results of this study, WHO continues to reiterate the urgent need for new and improved tools to combat malaria worldwide. WHO also emphasizes the urgent need for all countries where malaria transmission continues to develop and implement effective strategies to combat insecticide resistance to prevent the decline in the effectiveness of the most common vector control tools.

Diagnosis and treatment

Early diagnosis and treatment of malaria helps reduce the severity of the disease and prevent death. These measures also help reduce the intensity of malaria transmission. The most effective existing treatment regimen, especially for P. falciparum malaria, is artemisinin combination therapy (ACT).

WHO recommends that in all cases of suspected malaria, the diagnosis be confirmed using a diagnostic test to identify the parasite (microscopic examination or rapid diagnostic test) before starting treatment. The period for obtaining parasitological confirmation is up to 30 minutes. The decision to carry out treatment based solely on clinical symptoms can only be made in cases where establishing a parasitological diagnosis is impossible. More detailed recommendations are available in the third edition of the WHO Malaria Treatment Guidelines, published in April 2015.

Malaria (synonyms for the disease: fever, swamp fever) is an acute infectious protozoal disease, which is caused by several species of Plasmodium, transmitted by mosquitoes of the genus Anopheles and is characterized by primary damage to the system of mononuclear phagocytes and erythrocytes, manifested by attacks of fever, hepatolienal syndrome, hemolytic anemia, and a tendency to relapse.

Historical data of malaria

As an independent disease, malaria was isolated from the mass of febrile diseases by Hippocrates in the 5th century. BC e., however, the systematic study of malaria began only in the 17th century. Thus, in 1640, the doctor Juan del Vego proposed an infusion of cinchona bark to treat malaria. The first detailed description of the clinical picture of malaria was made in 1696 by the Genevan physician Morton. The Italian researcher G. Lancisi in 1717 linked cases of malaria with the negative effects of evaporation from swampy areas (translated from Italian: Mala aria - spoiled air).

The causative agent of malaria was discovered and described in 1880 p. A. Laveran. The role of mosquitoes from the genus Anopheles as carriers of malaria was established in 1887 p. R. Ross. Discoveries in malariology that were made in the 20th century. (Synthesis of effective antimalarial drugs, insecticides, etc.), studies of the epidemiological features of the disease made it possible to develop a global program for the elimination of malaria, adopted at the VIII session of WHO in 1955. The work carried out made it possible to sharply reduce the incidence in the world, however, as a result of the emergence of resistance of certain strains of Plasmodium to Due to specific treatment and vectors for insecticides, the activity of the main foci of invasion has remained, as evidenced by the increase in the incidence of malaria in recent years, as well as the increase in the importation of malaria into non-endemic regions.

Etiology of malaria

The causative agents of malaria belong to the phylum Protozoa, class Sporosoa, family Plasmodiidae, genus Plasmodium. There are four known species of Plasmodium falciparum that can cause malaria in humans:

• P. vivax - three-day malaria,
• P. ovale - three-day ovalemalaria,
• P. malariae - four-day malaria,
• P. falciparum - tropical malaria.

Infection of humans with zoonotic Plasmodium species (about 70 species) is rare. During their life, plasmodia go through a development cycle, which consists of two phases: sporogony - the sexual phase in the body of the female Anopheles mosquito and schizogony - the asexual phase in the human body.

Sporogony

Mosquitoes of the genus Anopheles become infected by sucking the blood of a patient with malaria or a carrier of Plasmodium. At the same time, male and female sexual forms of plasmodium (micro- and macrogametocytes) enter the mosquito’s stomach, which transform into mature micro- and macrogametes. After the fusion of mature gametes (fertilization), a zygote is formed, which later turns into an ookinete.

The latter penetrates the outer lining of the mosquito's stomach and turns into oocysts. Subsequently, the oocyst grows, its content is divided many times, resulting in the formation of a large number of invasive forms - sporozoites. Sporozoites are concentrated in the salivary glands of the mosquito, where they can be stored for 2 months. The rate of sporogony depends on the type of plasmodium and the ambient temperature. Thus, in P. vivax at the optimal temperature (25 ° C), sporogony lasts 10 days. If the ambient temperature does not exceed 15 ° C, sporogony stops.

Schizogony

Schizogony occurs in the human body and has two phases: tissue (pre- or extra-erythrocyte) and erythrocyte.

Tissue schizogony occurs in hepatocytes, where sporozoites successively form tissue trophozoites, schizonts, and an abundance of tissue merozoites (in P. vivax - up to 10 thousand per sporozoite, in P. falciparum - up to 50 thousand). The shortest duration of tissue schizogony is 6 days in P. falciparum, 8 in P. vivax, 9 in P. ovale and 15 days in P. malariae.

It has been proven that in case of four-day and tropical malaria, after the end of tissue schizogony, merozoites completely exit the liver into the blood, and in case of three-day and oval malaria, due to the genetic heterogeneity of sporozoites, tissue schizogony can occur both immediately after inoculation (tachysporozoites) and after 1. 5-2 years after it (brady or hypnozoites), which is the cause of long incubation and distant (real) relapses of the disease.

Erythrocyte schizogony. After the end of tissue schizogony, merozoites enter the blood and penetrate erythrocytes. When examining affected red blood cells under a microscope, three stages of parasite transformation are detected:

1. the merozoite ring increases, a vacuole is formed at its core, which squeezes the core to the periphery, and the parasite is shaped like a ring,
2. amoeboid schizont (adult form),
3. morulae - when the schizont reaches a large size, it takes on an oval shape, its nucleus and cytoplasm begin to divide, resulting in the formation of 6 to 24 erythrocyte merozoites.

Red blood cells are destroyed and merozoites enter the blood plasma, where one part of them dies, and the second penetrates into other red blood cells, and the cycle of erythrocyte schizogony is repeated. The duration of one cycle of erythrocyte schizogony is 48 hours in P. vivax, P. ovale and P. falciparum and 72 hours in P. malariae. Already from the first days, and in tropical malaria from the 8-10th day of illness, part of the merozoites in erythrocytes turns into immature male and female germ cells (micro- and macrogametocytes).

In P. vivax, P. ovale and P. malariae, erythrocyte schizogony occurs in the erythrocytes of the circulating blood, so all stages of parasite development can be detected in smears, while P. falciparum - in the capillaries of internal organs, so in peripheral blood it is possible detect only the initial and final stages of plasmodia (ring trophozoites and gametocytes), and intermediate forms - only in cases of malignant disease.

Epidemiology of malaria

The source of infection in malaria are patients or parasite carriers whose blood contains sexual forms of malarial plasmodia (gamonts). The amount of gamonts in the blood increases sharply during relapses of the disease, so such patients pose a greater epidemiological danger than patients with primary malaria. Parasite carriage, which is the main source of the disease in the inter-epidemic period, can be provoked by inadequate treatment or resistance of parasites to etiotropic drugs

The mechanism of transmission of malaria is transmissible. The carrier is the female Anopheles mosquito (about 80 species). In endemic regions, transmission also often occurs transplacentally or from mother to child during childbirth. Cases of transmission of infection through blood transfusions have been described, especially with four-day malaria due to frequent long-term (tens of years) parasite carriage. If the rules of asepsis are violated, plasmodia can also be transmitted through medical instruments (syringes, needles, etc.). Mosquitoes breed in shallow water bodies that warm up well. In them, mosquitoes develop from eggs through the phases of larvae, pupa into imago (winged form) in 2-4 weeks. At air temperatures below 10 °C, the development of larvae stops. The period of transmission of plasmodium by mosquitoes (depending on the ambient temperature) in temperate climate zones lasts up to 2 months, subtropical - up to 6 months, tropical - year-round.

Susceptibility to infection is high, especially in young children. Carriers of abnormal hemoglobin-S (HbS) are relatively resistant to malaria. Seasonality in regions of temperate and subtropical climates is summer-autumn; in countries with a tropical climate, cases of malaria are recorded throughout the year.

Today, malaria is rarely observed in zones with a temperate climate, but is widespread in the countries of Africa, South America, and Southeast Asia, where stable foci of the disease have formed. In endemic regions, about 1 million children die each year from malaria, which is the leading cause of death, especially at an early age. The degree of spread of malaria in individual endemic regions is characterized by the splenic index (SI) - the ratio of the number of people with an enlarged spleen to the total number of those examined (%)

According to WHO recommendations, this index distinguishes four types of malaria cells:

1. hypoendemic - SI in children from 2 to 9 years old reaches 10%,
2. mesoendemic - SI in children of the same age - 11-50%,
3. hyperendemic - SI in children of the same age is above 50%, in adults it is also high,
4. holoendemic - SI in children of the indicated age is above 75%, in adults it is low (African type) or high (New Guinea type), and in infants it is constantly above 75%. The risk of infection in hyper- and holoendemic areas is very high, especially among the non-indigenous, non-immune population.

After suffering from malaria, type-specific and unstable immunity remains. In endemic regions, due to frequent recurrence

Infection levels of herd immunity among the adult population may be high.

Pathogenesis and pathomorphology of malaria

Depending on the method of infection, malaria occurs in the form of sporozoite or schizont invasion. When bitten by an infected mosquito, sporozoites enter the bloodstream with saliva, and sporozoite invasion develops. It begins with a phase of tissue schizogony, corresponding to the incubation period of the disease without noticeable clinical manifestations. In some cases of schizont invasion (for example, during blood transfusion, childbirth), erythrocyte forms of plasmodium enter the blood. Schizont malaria is characterized by a shortened incubation period due to the absence of the pre-erythrocytic stage of parasite development.

Clinical manifestations of malaria are associated with the phase of erythrocyte schizogony and are a consequence of the release into the blood plasma of both the products of destruction of erythrocytes and the protein products of the parasite's vital activity. Paroxysms of fever develop only when parasitemia reaches a pyrogenic level, depending on the type of pathogen, several tens or hundreds of parasites in 1 μl of blood. In the initial period of erythrocyte schizogony in the blood there are schizonts of several generations at different stages of development, which leads to fever of the wrong type, but after 2-3 days synchronization of the stages of development of the parasite occurs with periodic attacks of fever, depending on the duration of erythrocyte schizogony: with tertian and oval malaria - after 48 hours, for four days - after 72 hours. Despite the fact that in tropical malaria the schizogony cycle lasts 48 hours, attacks of fever can be repeated daily or several times a day due to the entry of a new generation of tissue merozoites from the liver into the blood and the beginning of a new phase of erythrocyte schizogony. Repeated disintegration of affected red blood cells leads to progressive hemolytic anemia and the development of autoimmune processes, which is the cause of agglutination and hemolysis of part of the red blood cells affected by Plasmodium, an increase in the amount of biogenic amines (including histamine and serotonin), activation of the kalikreinin system, microcirculation disorders, and in severe cases, tropical malaria - infectious-toxic shock.

The presence of erythrocyte breakdown products in the blood leads to activation and hyperplasia of the reticuloendothelium of the spleen, liver and bone marrow against the background of inhibition of leukopoiesis and thrombocytopoiesis. In severe cases (tropical malaria), microcirculation in the brain is disrupted, parasitic blood clots form, which leads to malarial coma, and massive hemolysis of red blood cells leads to hemoglobinuric fever.

Due to the inferiority of the initial immunity, in some cases early relapses of the disease are possible within two months. With four-day malaria, long-term parasite carriage often develops, which, against the background of weakened immunity, can cause distant relapses of the disease even after decades. Late relapses (after 1-2 years) in tertian and oval malaria are associated with activation of the “hypnozoite” tissue phase of schizogony. In tropical malaria, after the end of the period of early relapses, the body is radically freed from the pathogen.

Pathomorphologically, significant dystrophic changes in the internal organs are detected. The liver and especially the spleen are significantly enlarged, slate-gray in color due to pigment deposition, and foci of necrosis are detected. Necrobiotic changes and hemorrhages are found in the kidneys, myocardium, adrenal glands and other organs.

During a malarial coma, Dirk granulomas form in the brain - around capillaries filled with many invaded red blood cells (parasitic blood clots), with foci of edema, necrosis and hemorrhages in the substance of the brain and its membranes, proliferation of oligodendroglycocytes and glial macrophages occurs, i.e. specific meningoencephalitis develops.

Malaria clinic

The incubation period for three-day malaria is 10-14 days, for oval malaria - 7-21 days, for tropical - 8-16 days, for four-day malaria - 25-40 days.

Three-day malaria

Three-day malaria is more common. The disease begins acutely with chills and increased body temperature, only in some cases short-term malaise, weakness, and headache are observed. A triad of symptoms is characteristic: fever, anemia, splenomegaly. In the first 2-3 days of illness, fever is of a remitting or irregular type (initial fever). A typical attack of malaria in most cases begins suddenly on the 3rd-5th day of illness and has three successive phases: chills, fever, sweat. More often in the first half of the day, a sharp (shaking) chill appears, the body temperature rises, the patient is forced to go to bed, and cannot warm up under the blanket. There is pain in the head and lower back, nausea, and sometimes vomiting. The skin is pale, goose bumps, cold extremities, acrocyanosis. The chill phase lasts 1-2 hours, at the end of which the body temperature reaches 40-41 ° C and remains at a high level for 5-8 hours. Currently, facial hyperemia, scleral injection, dry mucous membranes are detected, the tongue is covered with a white coating. Heart sounds are muffled, tachycardia. After 6-8 hours from the onset of the attack, the body temperature drops sharply to normal or subnormal levels, profuse sweating is observed, and the patient’s condition gradually improves. The duration of the attack is from 2 to 14 hours. During the period of apyrexia, patients may feel satisfactory and remain functional. Repeated attacks of three-day malaria occur every other day (on the 3rd day).

After the first attacks, patients develop subicteric sclera and skin, the spleen and liver become enlarged (splenohepatomegaly), which acquire a dense consistency. Blood tests reveal a decrease in the number of red blood cells, hemoglobin, leukopenia with relative lymphocytosis, thrombocytopenia, and an increase in ESR.

In primary malaria, the number of paroxysms can reach 10-14. If the course is favorable, from the 6th-8th attack the body temperature during paroxysms gradually decreases, the liver and spleen contract, the blood picture normalizes and the patient gradually recovers.

Early relapses (1-2 months after recovery) are initially characterized by the frequency of attacks and the absence, as a rule, of initial fever. Signs of intoxication are weaker than at the beginning of the disease, the duration of paroxysms is shorter. A characteristic sign of recurrent malaria is the rapid enlargement of the liver and especially the spleen, even larger than in primary malaria. Late relapses (6-14 months from the onset of the disease), which sometimes develop with three-day malaria, are characterized by a benign course, but severe cases are also possible. Duration of three-day malaria - 2-3 years

Tropical malaria

Chills and sweating are less pronounced than in other forms of the disease, but the fever is prolonged (up to 24 hours) and has an irregular character. The condition of patients is often severe, consciousness is clouded, intense headache and vomiting are observed. Often there is pain in the epigastric region, sometimes diarrhea (feces without pathological impurities). There is no frequency of attacks. The periods of apyrexia are not clearly defined. The spleen and liver quickly enlarge. The algic form of tropical malaria, which is very rare, from the first days has a course with signs of infectious-toxic shock, thrombo-hemorrhagic syndrome against the background of normal or low body temperature. In non-immune individuals, especially against the background of immunodeficiency, tropical malaria has a malignant course, causing death in 96-98% of all fatal cases from malaria. In the case of a benign course, the disease lasts about a year.

Quartan

Initial fever is observed less frequently than with three-day malaria. The attacks recur after 2 days (on the 4th day). Double attacks are possible (two days in a row followed by apyrexia for one day). The disease is characterized by long-term clinical activity, parasitemia does not reach a high level, and hepatosplenomegaly develops more slowly. Treatment is effective, but without the use of adequate etiotropic drugs, submicroscopic parasitemia is often observed with the possibility of distant relapses. Relapses of four-day malaria have been described 30-40 years after infection.

Ovale malaria

More often than with other forms, attacks begin in the evening and at night; in most cases there is no initial fever. The attacks are repeated every other day (on the 3rd day). The level of parasitemia is low. The course is milder than with other forms of malaria, spontaneous recovery is possible after the 3-5th attack of fever. Early and late relapses have a benign course, and deaths are rare. The duration of the disease is 1-2 years.

Malaria in children

In young children, the course of the disease is severe, typical attacks are rare, and there is no chills. More often they begin with pallor, general cyanosis, coldness of the extremities; at high body temperatures, convulsions and vomiting are possible. Body temperature often stays at high levels only at the beginning of the disease, and then becomes low-grade. Sweating is not typical; when body temperature drops, the head and neck sweat moderately. Diarrhea and abdominal pain are often observed, anemia develops quickly, the liver and especially the spleen become enlarged and painful.

Malaria in pregnant women

In pregnant women, the course of malaria is severe, with frequent development of anemia, jaundice, edema, and various complications. Malaria aggravates the course of pregnancy; in the tropical form, it contributes to the development of eclampsia, fetal death, and a 2-fold increase in mortality.

Congenital malaria

Intrauterine (through a damaged placenta) infection of the fetus in the first half of pregnancy can lead to miscarriage. In other cases and with intrauterine infection in the second half of pregnancy, children are often born premature, with severe malnutrition, anemia, hepatolienal syndrome, and sometimes jaundice. Attacks of the disease often occur without fever and are characterized by cyanosis, convulsions, anxiety, diarrhea, and hiccups. If infection occurs during childbirth, the disease begins after the incubation period, its course is the same as in children under one year old.

Complications of malaria

In severe cases, malarial coma, hemoglobinuric fever, and splenic rupture may develop.

Malarial coma develops in malignant forms of the disease, more often in primary tropical malaria. First, against the background of high body temperature, an unbearable headache and repeated vomiting appear.

A disturbance of consciousness develops rapidly and goes through three successive phases:

1. somnolence - adynamia, drowsiness, sleep inversion, the patient is reluctant to make contact,
2. stupor - consciousness is sharply inhibited, the patient reacts only to strong stimuli, reflexes are reduced, convulsions, meningeal symptoms are possible,
3. coma - fainting, reflexes are sharply reduced or not evoked.

Hemoglobinuric fever develops as a result of intravascular hemolysis, more often during treatment of patients with tropical malaria with quinine. This complication begins suddenly: a sharp chill, a rapid increase in body temperature to 40-41 ° C. Soon the urine becomes dark brown, jaundice increases, signs of acute kidney failure, and hyperazotemia appear.

Mortality is high. The patient dies due to manifestations of azotemic coma. More often, hemoglobinuric fever develops in individuals with a genetically determined deficiency of glucose-6-phosphate dehydrogenase, which leads to a decrease in erythrocyte resistance.

Rupture of the spleen occurs suddenly and is characterized by dagger-like pain in the upper abdomen spreading to the left shoulder and scapula. There is severe pallor, cold sweat, tachycardia, thread-like pulse, and blood pressure decreases. Free fluid appears in the abdominal cavity. If emergency surgery is not performed, patients die from acute blood loss due to hypovolemic shock.

Other possible complications include malarial algid, pulmonary edema, disseminated intravascular coagulation, hemorrhagic syndrome, acute renal failure, etc.

The prognosis with timely adequate treatment is favorable. The overall mortality rate is about 1% due to severe complicated forms of tropical malaria.

Diagnosis of malaria

The main symptoms of the clinical diagnosis of malaria are an acute onset, paroxysmal intermittent fever (with severe chills, fever, sweating), which repeats after 48 or 72 hours, splenohepatomegaly, hemolytic anemia. It is important that the patient stayed in endemic regions for two years before the onset of the disease; data on blood transfusion or parenteral intervention during the last 2-3 months are taken into account.

Specific diagnosis of malaria

Among laboratory methods, microscopy of thick drops and blood smears has become widely used. Blood from patients must be taken before specific treatment begins and the studies must be repeated during treatment. Microscopy evaluates both the massiveness of the invasion (the number of parasites in 1 ml of blood), which is easier to detect in a thick drop, and the qualitative characteristics (identification of the type of plasmodium and stages of schizogony) when examining a smear. There are more parasites in the blood at the height of fever, after the 2-3rd attack, although the results of the study are often positive during the period of apyrexia. If the microscopic examination is negative, the diagnosis of malaria cannot be rejected. Research should be repeated many times.

Microscopic examination of blood for malaria should be carried out not only in patients with suspected malaria, but also in all patients with fever of unknown origin.

Serological methods are of auxiliary importance: RIGA, fluorescent antibody reaction (FA), which are more often used in the retrospective diagnosis of malaria, as well as for the purpose of identifying parasite carriage in donors.

Differential diagnosis of malaria

The clinical course of malaria can often resemble other infectious and non-infectious diseases (as a result, malaria was called the “great simulator”), therefore it should be differentiated with sepsis, influenza, leptospirosis, visceral leishmaniasis, typhoid fever, brucellosis, meningitis, blood diseases, acute pyelonephritis, lobar pneumonia...

• During sepsis, an acute increase in body temperature with chills, sweating, myalgia, and lower back pain is often observed, but, unlike malaria, there are no long periods of apyrexia, significant hemorrhagic syndrome, an enlarged liver of soft consistency, often septic foci, neutrophilic leukocytosis.
• Significant fever with chills, signs of intoxication, aching joints also occur with influenza, but there are catarrhal changes in the upper respiratory tract, dry cough, splenohepatemegaly, and anemia are not observed.
• Leptospirosis begins acutely with chills, an increase in body temperature to 39-40 ° C, accompanied by muscle pain, facial flushing, injection of scleral vessels, but, unlike malaria, there is typical myalgia in the calf muscles, kidney damage with kidney failure is more often observed, severe jaundice due to an increase in the level of direct (in malaria - indirect) bilirubin, significant hemorrhagic syndrome, neutrophilic leukocytosis with a shift in the leukocyte formula to the left.
• The clinical picture of visceral leishmaniasis is in many ways reminiscent of malaria (fever, noticeable enlargement of the liver and spleen, significant anemia, lymphocytopenia), but the onset of the disease is gradual, the fever is prolonged, of an irregular wave-like type, there is lymphadenopathy, cachexia, and often the primary affect is at the site of a mosquito bite.
• In patients with typhoid fever, there may be high body temperature, enlarged liver and spleen, lymphatic enlargement, but, unlike malaria, the onset of the disease is gradual, the fever is more often of a constant nature, relative bradycardia, typhoid tongue, roseola rash on the skin, the phenomenon of palpable crepitus, flatulence are observed.
• In some cases, it is difficult to differentiate malaria from brucellosis, in which remitting and intermittent fever with profuse sweat, enlargement of the liver and spleen, and leukopenia are often observed, but brucellosis is characterized by the absence of significant intoxication at high temperatures, constant sweating, pain, and relatively frequent damage to the musculoskeletal system. and support with the formation of fibrositis, the reproductive system. Epidemiological history and laboratory tests are of decisive importance.
• Acute meningitis is characterized by a sudden onset, chills, and a sharp increase in body temperature, but, unlike malaria, repeated vomiting, positive meningeal symptoms, and corresponding changes in the cerebrospinal fluid are typical. Treatment of malaria All patients with malaria are subject to mandatory hospitalization in the infectious diseases department.

Etiotropic treatment is used for the purpose of:

1. cessation of acute attacks of illness,
2. neutralization of tissue schizonts in three-day and oval malaria (radical treatment),
3. neutralization of gametocytes (for tropical malaria).

During acute attacks, hemoschizotropic drugs are prescribed (against erythrocyte schizonts). The most widely used is hingamine (delagil, chloroquine, resokhin), which is prescribed as early as possible in a single dose of 1 g (4 tablets of 0.25 g), after 6-8 hours - again 0.5 g. In subsequent days - 0 .5 g per day once. For three-day and oval malaria, the course of treatment lasts 3 days, for tropical and four-day malaria - 5 days. For children on the first day, hingamine is prescribed per day: up to 1 year - 0.05 g, 1-6 years - 0.125, 6-10 years - 0.25, 10-15 years - 0.5 g. Subsequently, the daily dose halved. Quinine, chloridine (pyrimethamine), mefloquine, bigumal (proguanil), quinine, sulfonamide drugs, and tetracyclines also have a hemoschisotropic effect. If P. falciparum is resistant to quinamine, prescribe quinine hydrochloride 0.65 g 3 times a day for 7 days, fanzidar (chloridine + sulfadoxine) 3 tablets per day for 3 days, maloprim (chloridine + diaphenylsulfone) 1 tablet 1 time per week. For patients with malignant forms of tropical malaria, quinine hydrochloride is administered intravenously (20 mg/kg per day in three doses), and when the condition improves, they proceed to oral administration of the drug.

If in case of tropical and tetrad malaria with the help of hemoschizotropic drugs it is possible to completely free the body from schizonts, then for radical treatment of tetrad malaria and oval malaria a one-time prescription of drugs with a histoschizotropic effect (against extra-erythrocytic schizonts) is required. Primaquine is used at a dose of 0.027 g per day (15 mg base) in 1st dose for 14 days or quinocide at a dose of 30 mg per day for 10 days. This treatment is effective in 97-99% of cases.

Chloridine and primaquine have a gamontotropic effect. For three-day, oval and four-day malaria, gamontotropic treatment is not carried out, since in these forms of malaria the gamonts quickly disappear from the blood after the cessation of erythrocyte schizogony.

In addition to etiotropic treatment, pathogenetic treatment is widely used, especially in the case of tropical malaria. Intravenous infusions of colloid and crystalloid solutions are performed. Glycocorticoids, antihistamines, diuretics, and, if necessary, cardiotonic drugs are prescribed. In case of acute kidney failure, hemosorption and hemodialysis are used.

Prevention of malaria

Prevention involves timely identification and treatment of patients with malaria and parasites, epidemiological surveillance of endemic regions, chemoprophylaxis, a wide range of measures to kill mosquitoes (the use of larvicidal agents in mosquito breeding areas, imagocidal agents in residential and business premises, biological methods of controlling mosquito larvae - breeding of larval fish, etc.).

Patients are discharged from the hospital after completing the course of etiotropic treatment, subject to a three-fold negative result of parasitoscopy examination of a thick drop and blood smear.

Persons traveling to endemic areas are given individual chemoprophylaxis. For this purpose, hemoschizotropic drugs are used, most often khingamine 0.5 g once a week, and in hyperendemic areas - 2 times a week. The drug is prescribed 5 days before entering an endemic zone, during stay in the zone and for 8 weeks after departure. Among the population of endemic areas, chemoprophylaxis begins 1-2 weeks before the appearance of mosquitoes. Chemoprophylaxis of malaria can also be carried out with bigumal (0.1 g per day), amodiaquine (0.3 g once a week), chloridine (0.025-0.05 g once a week), etc. The effectiveness of chemoprophylaxis increases in case of alternating two or three drugs every one to two months. In endemic foci caused by hingamine-resistant strains of malarial plasmodia, for the purpose of individual prevention, fanzidar, metakelfin (chloridine-bsulfalene) are used. Persons arriving from three-day malaria cells are given seasonal relapse prevention with primaquine (0.027 g per day for 14 days) for two years. To protect against mosquito bites, repellents, curtains, etc. are used.

Antimalarial drug resistance

The problem of resistance to antimalarial drugs continues. Resistance of the malaria parasite P. falciparum to previous generations of drugs such as chloroquine and sulfadoxine-pyrimethamine (SP) became widespread in the 1950s and 1960s, weakening efforts to control malaria and erasing gains in child survival rates.

Ensuring the effectiveness of antimalarial drugs is critical to malaria control and elimination. Regular monitoring of drug effectiveness is required to develop treatment strategies for malaria-endemic countries and to ensure timely detection and control of drug resistance.

In 2013, WHO adopted the Greater Mekong Subregion Artemisinin Resistance Emergency Response Plan (ERERP), a comprehensive proactive plan to contain the spread of drug-resistant parasites and provide life-saving supplies to all populations at risk of malaria. However, already in the process of this work, other, independent centers of resilience emerged in other geographical areas of the subregion. In parallel, there have been reports that in some cases the resistance of the infection to “partner” components in artemisinin-combination therapy is increasing. Changing trends in malaria incidence have created a need for a different approach.

At the World Health Assembly in May 2015, WHO adopted the Greater Mekong Subregion Malaria Elimination Strategy (2015–2030), which was endorsed by all countries in the subregion. The strategy aims to eliminate all types of human malaria across the region by 2030 and includes a series of immediate actions, particularly in areas where multidrug-resistant malaria is widespread.

All countries in the subregion, with technical support from WHO, have developed national malaria elimination plans. WHO, together with partners, is providing ongoing support to countries' efforts to eliminate malaria through the Mekong Malaria Elimination Programme, a new initiative that is a continuation of the EMER.

Classification

Depending on the causative agent of malaria, the symptoms, course of the disease and prognosis differ. The life cycle of the malaria pathogen also depends on the variety. The causative agent of malaria is several types of Plasmodium:

• Plasmodium vivax is the causative agent of tertian malaria. The duration of the incubation period is from 1 to 3 weeks, in some cases up to 14 months. The attacks occur every other day. The pathogen is one of the most common.
• Plasmodium malariae – This species causes quadrant malaria. The incubation period lasts from 3 to 6 weeks. Recurrence of attacks - after 2 days.
• Plasmodium falciparum causes tropical malaria. The duration of the incubation period is from 9 to 16 days. Recurrence of attacks every other day, if the form is severe, they last from a day to a day and a half, while periods of normal temperature are very short. This type of disease can lead to impaired brain function and the development of cerebral malaria. The temperature rises to 40 degrees, the head hurts severely, and the patient may become delirious. Every fifth case is fatal. This is the most common form of the disease.
• Plasmodium ovale - causes malaria ovale. The duration of the incubation period is 10-20 days. Recurrence of attacks – every other day.

The answer to the question that malaria is caused by the amoebas trypanosomes, plasmodia and ciliates is clear - this disease is provoked by plasmodia.

You can examine in detail photos and pictures dedicated to the characteristics of different forms of pathogens in the corresponding presentations.

Surveillance

Surveillance involves monitoring cases of disease, systematically responding, and making decisions based on the findings. Currently, many countries with a high malaria burden have weak surveillance systems and are unable to assess the distribution and trends of the disease, making it difficult to optimize responses and respond to outbreaks.

Effective surveillance is needed at all stages of the progress towards malaria elimination. Strengthening malaria surveillance programs is urgently needed to ensure a timely and effective response to malaria in endemic regions, prevent outbreaks and re-emergence of the disease, monitor progress and hold governments and other global actors in the fight against malaria accountable.

In March 2022, WHO released guidance on surveillance, monitoring and evaluation of malaria cases. The guide provides information on global surveillance standards and recommendations for strengthening country surveillance systems.

Elimination

Malaria elimination is defined as the interruption, through targeted action, of local transmission of a specific species of malaria parasite within a defined geographic area. Preventing resurgence of transmission requires continued efforts. Malaria elimination is defined as the global incidence of malaria caused by human malaria parasites being achieved through targeted action at all times. The fact that malaria has been eliminated eliminates the need for further anti-malarial measures.

Elimination is expanding around the world, and more countries are moving closer to the goal of reducing malaria incidence to zero. In 2022, the number of countries reporting fewer than 100 cases of local transmission was 27, up from 6 in 2000.

Countries that have not reported a single local case of malaria for at least three consecutive years meet the criteria to apply to WHO for malaria elimination certification. Over the past 20 years, 10 countries have been certified as malaria-free by the WHO Director-General: United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010), Armenia (2011), Sri Lanka (2016), Kyrgyzstan (2016), Paraguay (2018), Uzbekistan (2018), Algeria (2019) and Argentina (2018). The WHO Malaria Elimination Framework (2017) provides a comprehensive set of tools and strategies to achieve and sustain elimination.

Vaccines against malaria

To date, RTS,S/AS01 (RTS,S) is the first and only vaccine demonstrated to significantly reduce the incidence of malaria and life-threatening severe malaria in African young children. It works against P. falciparum, the world's deadliest malaria parasite and the most common in Africa. In a large, four-year clinical trial in children who received four doses of the vaccine, it prevented malaria in 4 out of 10 cases.

Leading WHO advisory bodies on malaria and immunization, given the high public health importance of this vaccine, have jointly recommended its phased introduction in parts of sub-Saharan Africa. In 2022, three countries (Ghana, Kenya and Malawi) began introducing the vaccine in selected areas with moderate to high intensity malaria transmission. Vaccination is carried out as part of the national routine immunization program of each country.

The vaccine pilot program will provide answers to a number of outstanding questions regarding its use in public health. This will be important in understanding the optimal administration schedule for the four recommended doses of RTS,S; the potential role of vaccines in reducing child mortality; and its safety during routine vaccinations.

The program is being coordinated by WHO, together with the ministries of health of Ghana, Kenya and Malawi, as well as a number of national and international partners, including the non-profit organization PATH and (GSK), the vaccine developer and manufacturer.

Funding for the vaccine development program was provided through a collaboration between three of the world's largest health financing organizations: the Vaccine Alliance GAVI, the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNITAID.

Pathogenesis

The causative agent of malaria is protozoa of the genus Plasmodium ( plasmodia ). Infection occurs when a female malaria mosquito injects sporozoites (this is the name of one of the stages of the life cycle of the pathogen). This happens when the mosquito sucks blood.

After entering the blood, Plasmodium sporozoites end up in liver hepatocytes, provoking the onset of the preclinical exoerythrocytic (liver) stage of the disease. In liver cells, sporozoites multiply (schizogony), resulting in the formation of liver merozoites. After a few weeks, they penetrate the blood again.

If the infection was caused by P.falciparum and P.malariae, the liver stage is completed. If the disease is caused by another type of malarial plasmodium, “dormant” liver stages (hypnozoites) remain in the body. They can cause parasites to escape into the blood and cause relapses of the disease months and years after infection.

The next stage of malaria - clinical or erythrocyte - begins when merozoites that enter the blood attach to specific receptors on the membranes of erythrocytes.

Mechanism of transmission of malaria

By the way, scientists in the process of research have proven that plasmodia, when they enter a victim, stimulate the body to secrete those substances that attract mosquitoes.

Therefore, the sequence of occurrence of malaria is as follows: after a mosquito bite, plasmodium enters the human blood, later penetrates the liver, multiplies, then destroys red blood cells, after which the person develops a fever. This is precisely the answer to the question of establishing the sequence of occurrence of malaria.

WHO activities

WHO global technical strategy for malaria control 2016–2030.

Adopted by the World Health Assembly in May 2015, the WHO Global Technical Strategy for Malaria Control 2016–2030. sets technical parameters for work in all malaria-endemic countries. It aims to guide and support regional and national programs as they work to control and achieve malaria elimination.

This strategy sets ambitious but achievable global goals, including:

• reducing the incidence of malaria by at least 90% by 2030;
• reducing malaria mortality rates by at least 90% by 2030;
• eliminating malaria in at least 35 countries by 2030;
• preventing the re-emergence of malaria in all malaria-free countries.

The strategy was the result of a broad consultative process over two years involving more than 400 technical experts from 70 Member States.

Global Malaria Program

The WHO Global Malaria Program coordinates WHO's international efforts to control and achieve malaria elimination through:

• developing, communicating and promoting their adoption of norms, standards, policies, technical strategies and guidelines;
• independent assessment of global progress;
• developing approaches to strengthen capacity, improve systems and conduct surveillance;
• identifying factors that threaten effective malaria control and elimination, as well as finding new areas of action.

The Program is supported and advised by a Malaria Policy Advisory Committee (MPAC), composed of malaria experts appointed through open nominations. The mandate of the ACPM is to provide policy advice and technical advice on all aspects of malaria control and elimination through a transparent, flexible and credible rule-making process.

"A heavy burden requires high efficiency"

At the World Health Assembly in May 2022, WHO Director-General Dr Tedros Adhanom Ghebreyesus called for a new proactive approach to accelerate progress in the fight against malaria. A new initiative, High Burdens Call High Performance, implemented with the active participation of countries, was launched in November 2022 in Mozambique.

Currently, 11 countries with the highest burden of disease are participating (Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, India, Mali, Mozambique, Niger, Nigeria, Uganda and the United Republic of Tanzania). The main elements of the initiative are:

• mobilizing political will to reduce the burden of malaria;
• providing strategic information to achieve real change;
• improving guidelines, policies and strategies;
• coordinated efforts to combat malaria at the national level.

The High Burden Means High Impact initiative, carried out with the active participation of WHO and the WOM Partnership to End Malaria, is based on the principle that no one should die from a disease that is preventable and diagnosable and completely curable with existing medicines.

Diet

Diet 13 table

• Efficacy: therapeutic effect after 4 days
• Time frame: no more than 2 weeks
• Cost of products: 1500-1600 rubles per week

Diet 9th table

• Efficacy: therapeutic effect after 14 days
• Timing: constantly
• Cost of products: 1400 - 1500 rubles per week

Nutrition for malaria depends on the stage of the disease and its form. During attacks of fever, it is recommended to adhere to the principles of Diet 13 table , and in case of quinine-resistant forms of the disease - Diet 9 table .

When eating on the 13th table, it is recommended to include the following products in the menu:

• wheat bread crackers;
• low-fat broths from meat and fish;
• soups with cereals, puree soups;
• meat soufflés and steamed dishes;
• boiled lean fish;
• viscous porridge;
• egg white omelet;
• fermented milk dishes, cottage cheese;
• vegetable stew;
• purees and fruit drinks from berries and fruits;
• honey, marmalade, etc.

During fever, it is important to drink plenty of fluids. During the acute course of the disease, the consumption of fatty and fried foods, alcohol, legumes, fatty dairy products, and radishes is strictly prohibited. A detailed presentation of the diet is in its description.