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.

Mistreatment in Distributed Caching Groups: Causes and Implications

Although cooperation generally increases the amount of resources available to a community of nodes, thus improving individual and collective performance, it also allows for the appearance of potential mistreatment problems through the exposition of one node’s resources to others. We study such concerns by considering a group of independent, rational, self-aware nodes that cooperate using on-line caching algorithms, where the exposed resource is the storage of each node. Motivated by content networking applications – including web caching, CDNs, and P2P – this paper extends our previous work on the off-line version of the problem, which was limited to object replication and was conducted under a game-theoretic framework. We identify and investigate two causes of mistreatment: (1) cache state interactions (due to the cooperative servicing of requests) and (2) the adoption of a common scheme for cache replacement/redirection/admission policies. Using analytic models, numerical solutions of these models, as well as simulation experiments, we show that online cooperation schemes using caching are fairly robust to mistreatment caused by state interactions. When this becomes possible, the interaction through the exchange of miss-streams has to be very intense, making it feasible for the mistreated nodes to detect and react to the exploitation. This robustness ceases to exist when nodes fetch and store objects in response to remote requests, i.e., when they operate as Level-2 caches (or proxies) for other nodes. Regarding mistreatment due to a common scheme, we show that this can easily take place when the “outlier” characteristics of some of the nodes get overlooked. This finding underscores the importance of allowing cooperative caching nodes the flexibility of choosing from a diverse set of schemes to fit the peculiarities of individual nodes. To that end, we outline an emulation-based framework for the development of mistreatment-resilient distributed selfish caching schemes.

Notes on the Effect of Different Access Patterns on the Intensity of Mistreatment in Distributed Caching Groups

In this report, we extend our study of the intensity of mistreatment in distributed caching groups due to state interaction. In our earlier work (published as BUCS-TR-2006-003), we analytically showed how this type of mistreatment may appear under homogeneous demand distributions. We provided a simple setting where mistreatment due to state interaction may occur. According to this setting, one or more "overactive" nodes generate disproportionately more requests than the other nodes. In this report, we extend our experimental evaluation of the intensity of mistreatment to which non-overactive nodes are subjected, when the demand distributions are not homogeneous.