MALARIA TREATMENT AND PREVENTION IN PREGNANCY - INDICATIONS FOR USE AND ADVERSE EVENTS ASSOCIATED WITH USE OF CHLOROQUINE OR MEFLOQUINE

In sub-Saharan Africa, women frequently report a variety of symptoms d uring pregnancy, some of which indicate possible illness. Given the ad verse impact of malaria in pregnancy, these events may be important fo r at least two reasons: it may be possible to use reported fever illne ss as a determinant of which women need an antimalarial intervention, and, it is possible that adverse symptoms following the antimalarial i ntervention may be important determinants of continued adherence to th e prevention regimen. In a cohort of pregnant women enrolled at first antenatal clinic visit in rural Malawi, we evaluated reported fever, d etermined parasitemia, and placed the women on antimalarial regimens c ontaining chloroquine (CQ) or mefloquine (MQ). We then systematically evaluated reported symptoms following antimalarial drug use after init ial therapeutic doses and subsequent prophylactic doses, and monitored women throughout their pregnancy and at delivery. Among 4,187 enrolle d women, 1,048 (25%) reported at least one febrile episode during preg nancy before their first antenatal clinic visit. Factors associated wi th this reported fever included low parity, enrollment in the rainy se ason, human immunodeficiency virus seropositivity, use of antimalarial prophylaxis before enrollment, high socioeconomic status, normal (com pared to low) maternal height and weight, and literacy. Fever before t he first antenatal clinic visit was reported by 24.4% of parasitemic w omen and 25.4% of aparasitemic women; the sensitivity and specificity of fever to identify parasitemic women was 24% and 71%, respectively. In contrast, the sensitivity and specificity of first or second pregna ncy to identify parasitemic women was 71% and 57%, respectively. Among women on a CQ or MQ regimen, approximately 60% reported side effects (e.g., itching, dizziness, and gastrointestinal disturbances) after a treatment dose and approximately 25% reported side effects after a pro phylactic dose; rates and types of symptoms reported were similar in t he CQ and MQ groups. Few serious side effects were observed and rates of fetal loss were low and similar in the groups. Reliance on fever il lness will be wholly inadequate to identify parasitemic women; therefo re, our findings support existing World Health Organization recommenda tions that presumptive treatment and prevention regimens should be off ered to all pregnant women. When resources are inadequate to offer ant imalarial prophylaxis to all pregnant women, women in their first or s econd pregnancy may be a more appropriate target group than pregnant w omen with reported fever. Education regarding expected minor side effe cts may reduce rates of poor compliance and improve the effectiveness of the prevention effort.