Paediatric malaria case-management with artemether-lumefantrine in Zambia: a repeat cross-sectional study

BACKGROUND:Zambia was the first African country to change national antimalarial treatment policy to artemisinin-based combination therapy - artemether-lumefantrine. An evaluation during the early implementation phase revealed low readiness of health facilities and health workers to deliver artemether-lumefantrine, and worryingly suboptimal treatment practices. Improvements in the case-management of uncomplicated malaria two years after the initial evaluation and three years after the change of policy in Zambia are reported.METHODS:Data collected during the health facility surveys undertaken in 2004 and 2006 at all outpatient departments of government and mission facilities in four Zambian districts were analysed. The surveys were cross-sectional, using a range of quality of care assessment methods. The main outcome measures were changes in health facility and health worker readiness to deliver artemether-lumefantrine, and changes in case-management practices for children below five years of age presenting with uncomplicated malaria as defined by national guidelines.RESULTS:In 2004, 94 health facilities, 103 health workers and 944 consultations for children with uncomplicated malaria were evaluated. In 2006, 104 facilities, 135 health workers and 1125 consultations were evaluated using the same criteria of selection. Health facility and health worker readiness improved from 2004 to 2006: availability of artemether-lumefantrine from 51% (48/94) to 60% (62/104), presence of artemether-lumefantrine dosage wall charts from 20% (19/94) to 75% (78/104), possession of guidelines from 58% (60/103) to 92% (124/135), and provision of in-service training from 25% (26/103) to 41% (55/135). The proportions of children with uncomplicated malaria treated with artemether-lumefantrine also increased from 2004 to 2006: from 1% (6/527) to 27% (149/552) in children weighing 5 to 9 kg, and from 11% (42/394) to 42% (231/547) in children weighing 10 kg or more. In both weight groups and both years, 22% (441/2020) of children with uncomplicated malaria were not prescribed any antimalarial drug.CONCLUSION:Although significant improvements in malaria case-management have occurred over two years in Zambia, the quality of treatment provided at the point of care is not yet optimal. Strengthening weak health systems and improving the delivery of effective interventions should remain high priority in all countries implementing new treatment policies for malaria.

Application-Level Document Caching in the Internet

With the increasing demand for document transfer services such as the World Wide Web comes a need for better resource management to reduce the latency of documents in these systems. To address this need, we analyze the potential for document caching at the application level in document transfer services. We have collected traces of actual executions of Mosaic, reflecting over half a million user requests for WWW documents. Using those traces, we study the tradeoffs between caching at three levels in the system, and the potential for use of application-level information in the caching system. Our traces show that while a high hit rate in terms of URLs is achievable, a much lower hit rate is possible in terms of bytes, because most profitably-cached documents are small. We consider the performance of caching when applied at the level of individual user sessions, at the level of individual hosts, and at the level of a collection of hosts on a single LAN. We show that the performance gain achievable by caching at the session level (which is straightforward to implement) is nearly all of that achievable at the LAN level (where caching is more difficult to implement). However, when resource requirements are considered, LAN level caching becomes much more desirable, since it can achieve a given level of caching performance using a much smaller amount of cache space. Finally, we consider the use of organizational boundary information as an example of the potential for use of application-level information in caching. Our results suggest that distinguishing between documents produced locally and those produced remotely can provide useful leverage in designing caching policies, because of differences in the potential for sharing these two document types among multiple users.