Factors associated with typical enteropathogenic Escherichia coli infection among children <5 years old with moderate-to-severe diarrhoea in rural western Kenya, 2008-2012.

Typical enteropathogenic Escherichia coli (tEPEC) infection is a major cause of diarrhoea and contributor to mortality in children <5 years old in developing countries. Data were analysed from the Global Enteric Multicenter Study examining children <5 years old seeking care for moderate-to-severe diarrhoea (MSD) in Kenya. Stool specimens were tested for enteric pathogens, including by multiplex polymerase chain reaction for gene targets of tEPEC. Demographic, clinical and anthropometric data were collected at enrolment and ~60-days later; multivariable logistic regressions were constructed. Of 1778 MSD cases enrolled from 2008 to 2012, 135 (7.6%) children tested positive for tEPEC. In a case-to-case comparison among MSD cases, tEPEC was independently associated with presentation at enrolment with a loss of skin turgor (adjusted odds ratio (aOR) 2.08, 95% confidence interval (CI) 1.37-3.17), and convulsions (aOR 2.83, 95% CI 1.12-7.14). At follow-up, infants with tEPEC compared to those without were associated with being underweight (OR 2.2, 95% CI 1.3-3.6) and wasted (OR 2.5, 95% CI 1.3-4.6). Among MSD cases, tEPEC was associated with mortality (aOR 2.85, 95% CI 1.47-5.55). This study suggests that tEPEC contributes to morbidity and mortality in children. Interventions aimed at defining and reducing the burden of tEPEC and its sequelae should be urgently investigated, prioritised and implemented.

Vibriosis, not cholera: toxigenic Vibrio cholerae non-O1, non-O139 infections in the United States, 1984-2014.

Toxigenic strains of Vibrio cholerae serogroups O1 and O139 have caused cholera epidemics, but other serogroups - such as O75 or O141 - can also produce cholera toxin and cause severe watery diarrhoea similar to cholera. We describe 31 years of surveillance for toxigenic non-O1, non-O139 infections in the United States and map these infections to the state where the exposure probably originated. While serogroups O75 and O141 are closely related pathogens, they differ in how and where they infect people. Oysters were the main vehicle for O75 infection. The vehicles for O141 infection include oysters, clams, and freshwater in lakes and rivers. The patients infected with serogroup O75 who had food traceback information available ate raw oysters from Florida. Patients infected with O141 ate oysters from Florida and clams from New Jersey, and those who only reported being exposed to freshwater were exposed in Arizona, Michigan, Missouri, and Texas. Improving the safety of oysters, specifically, should help prevent future illnesses from these toxigenic strains and similar pathogenic Vibrio species. Post-harvest processing of raw oysters, such as individual quick freezing, heat-cool pasteurization, and high hydrostatic pressurization, should be considered.

Cholera in the United States, 2001-2011: a reflection of patterns of global epidemiology and travel.

US cholera surveillance offers insight into global and domestic trends. Between 2001 and 2011, 111 cases were reported to the Centers for Disease Control and Prevention. Cholera was associated with international travel in 90 (81%) patients and was domestically acquired in 20 (18%) patients; for one patient, information was not available. From January 2001 to October 2010, the 42 (47%) travel-associated cases were associated with travel to Asia. In October 2010, a cholera epidemic started in Haiti, soon spreading to the Dominican Republic (Hispaniola). From then to December 2011, 40 (83%) of the 48 travel-associated cases were associated with travel to Hispaniola. Of 20 patients who acquired cholera domestically, 17 (85%) reported seafood consumption; 10 (59%) ate seafood from the US Gulf Coast. In summary, an increase in travel-associated US cholera cases was associated with epidemic cholera in Hispaniola in 2010-2011. Travel to Asia and consumption of Gulf Coast seafood remained important sources of US cholera cases.

Sporadic paediatric diarrhoeal illness in urban and rural sites in Nyanza Province, Kenya.

OBJECTIVE: Investigate differences in the infectious aetiology, health seeking behaviour, and provider practices with regard to diarrhoeal illness among children presenting to urban versus rural clinics in Western Kenya. DESIGN: Laboratory-based, passive surveillance. SETTING: The urban portion of the study was conducted at the paediatric outpatient clinic of Nyanza Provincial Hospital in Kisumu. The rural portion of the study was conducted at four outpatient clinics in the Asembo Bay community approximately 20 kilometers west of Kisumu. SUBJECTS: Children aged less than five years presenting to medical facilities for the treatment of diarrhoea from October 2001-October 2003 at the urban site and May 1997-April 2003 for the rural sites. RESULTS: Among the 1303 urban and 1247 rural specimens collected, 24% of specimens yielded a bacterial pathogen (24% urban, 25% rural). Campylobacter was the predominant bacterial pathogen (17% urban, 15% rural), followed by Shigella and nontyphoidal Salmonella (both 4% urban and 5% rural). In both communities, susceptibilities of these pathogens to the most commonly prescribed antibiotics was low (< or = 50%); 70% of all episodes of diarrhoea were prescribed antibiotic treatment. Urban health practitioners prescribed fewer antibiotics, chose drugs more likely to be effective, and were more likely to prescribe oral rehydration therapy for bloody diarrhoea. CONCLUSION: Most characteristics of diarrhoeal disease and their causes were similar in paediatric patients presenting to urban and rural clinics. Urban providers were more compliant with WHO recommendations.

Evaluating the functional utility of congregate day treatment activities for adults with severe disabilities.

Many adults with severe disabilities spend considerable amounts of time in segregated day programs. We evaluated the degree to which these programs support purposeful and age-appropriate activity. Observations in 100 congregate community and institutional program sites indicated that approximately half of consumer time was spent in purposeful activity, 75% of which was age-appropriate. In 20% of the sites, though, most activity was age-inappropriate. These results, which were similar across community and institutional settings, are discussed in terms of respective program administrators evaluating their supports through comparisons with activity involvement in other programs and the need for changes in programs providing primarily age-inappropriate activities.

Evaluating and improving residential treatment during group leisure situations: a program replication and refinement.

The authors attempted to replicate and refine a program for evaluating and improving residential treatment services during group leisure periods in living units. In Study 1, an active treatment program was implemented using a consultant model in two living units serving persons with severe handicaps. Similar to previous research, the program was accompanied by decreases in nonadaptive client behavior in both units during leisure periods. In addition, a time-efficient monitoring system was developed which suggested that two staff-related variables, provision of leisure materials, and interactions with clients were related to the program's success. Study 2 evaluated more thoroughly the relationship of these variables to client nonadaptive behavior in 20 residential units in four states. Significant predictive relationships again were found between nonadaptive behavior and material availability, and between nonadaptive behavior and staff interactions with clients. Results of Study 2 also indicated that three living unit supervisors readily learned to use the evaluation system. Results are discussed regarding the importance of simple and efficient monitoring systems for routinely evaluating and improving residential services.

Training basic teaching skills to community and institutional support staff for people with severe disabilities: a one-day program.

Shortcomings in the technology for training support staff in methods of teaching people with severe disabilities recently have resulted in calls to improve the technology. We evaluated a program for training basic teaching skills within one day. The program entailed classroom-based verbal and video instruction, practice, and feedback followed by on-the-job feedback. In Study I, four undergraduate interns participated in the program, and all four met the mastery criterion for teaching skills. Three teacher aides participated in Study 2, with results indicating that when the staff applied their newly acquired teaching skills, students with profound disabilities made progress in skill acquisition. Clinical replications occurred in Study 3, involving 17 staff in school classrooms, group homes, and an institution. Results of Studies 2 and 3 also indicated staff were accepting of the program and improved their verbal skills. Results are discussed regarding advantages of training staff in one day. Future research suggestions are offered, focusing on identifying means of rapidly training other teaching skills in order to develop the most effective, acceptable, and efficient technology for staff training.

Supervisory training for teachers: multiple, long-term effects in an education program for adults with severe disabilities.

We evaluated a means of training special education teachers in supervisory strategies for improving specific teaching-related performances of their paraprofessional, teacher assistants. Using classroom-based instruction and on-the-job monitoring and feedback, seven teachers were trained to systematically observe the data collection and teaching performances of their assistants as well as to provide contingent feedback. The supervisory training for teachers, evaluated using a multiple-probe design across groups of assistants, was accompanied by improvements in data collection performances among seven of eight assistants. Improvement in other teaching skill applications also occurred. The improved performance among the assistants was maintained across a 17-month follow-up period. The supervisory training seemed to have multiple benefits in that the teachers' own teaching-related performances improved once teachers were trained to systematically observe and provide feedback to their assistants. The need for continued research is discussed to evaluate the benefits of supervisory training to improve and maintain other important areas of staff performance.

Assisting older adults with severe disabilities in expressing leisure preferences: a protocol for determining choice-making skills.

We evaluated a protocol involving two types of choice presentations for assessing leisure choice-making skills of seven older adults with severe disabilities. Initially when presented with pairs of objects representing choices, choice making was validated through demonstration of an object preference. A more complex choice-presentation format was then employed, involving pictures to represent choices. If the preference identified with objects was not demonstrated using pictures, a replication of the object format occurred to ensure changes in choice making using pictures was not due to a preference change. Five participants demonstrated choice-making skills using objects and two demonstrated choices using pictures. These results reflect the importance of assessing choice-making skills prior to presenting choice opportunities. Suggestions for future research focus on expanding the assessment protocol to include a wider array of choice-making skills and training staff to provide choices in a format commensurate with an individual's skill level.

Reducing job coach assistance for supported workers with severe multiple disabilities: an alternative off-site/on-site model.

Adults with severe multiple disabilities constitute a very small percentage of individuals in supported work. When these persons do obtain community jobs, considerable assistance is usually required. We evaluated an off-site/on-site program for reducing job coach assistance provided for three adults with severe multiple disabilities in a part-time community job. Following observations of the supported workers' job performance in a publishing company, the job support reduction program was implemented while the individuals received more traditional day services when not at work. The program involved assessing the amount and type of assistance provided for each step in a worker's job tasks, and then reducing the assistance through environmental adaptations and instruction. After implementation in the nonwork setting, the adaptations and instruction were extended to the work site. Immediate reductions occurred in the amount of assistance provided by job coaches for each supported worker while on the job. No adverse effects on productivity were observed. These results suggest that an off-site/on-site approach to reducing work assistance represents a viable alternative to current supported work models. Social validity observations in 10 job sites highlighted the need to demonstrate ways to reduce work assistance provided for workers with severe multiple disabilities. Future research areas are noted, focusing on evaluating other models for enhancing supported work opportunities for people with highly significant disabilities.

Comparing choice and questionnaire measures of the acceptability of a staff training procedure.

We compared questionnaire and choice measures of acceptability while evaluating effects of staff familiarity versus unfamiliarity with the system used to monitor performance during a training program. Staff members rated both monitoring formats equally favorably on the questionnaire, whereas when given a choice, they frequently chose the familiar format and never chose the unfamiliar format. These results suggest that traditional questionnaire evaluations may not be sufficiently sensitive measures of acceptability relative to choice measures.

Assessing food preferences among persons with profound mental retardation: providing opportunities to make choices.

Increased attention has been directed recently to assisting persons with severe handicaps to express preferences concerning events in their lives. We evaluated a program for assessing choice-making skills to provide opportunities for persons with profound mental retardation to express food and drink preferences. In Experiment 1, the assessment procedure involving repeated, paired-item presentations resulted in active choice making and the identification of preferences for all 5 participants. Results also indicated that caregiver opinion was not predictive of participant food and drink preferences. A survey of service providers supported the importance of meal-related choices in this population. In Experiment 2, the practicality of the assessment procedure was supported by demonstrating that (a) routine caregivers could apply the procedure with appropriate supervision to provide choice opportunities, and (b) results of the procedure were predictive of participant choices when a less structured and more normal opportunity to express a preference was provided during regular mealtimes. Results are discussed in terms of extending the developing technology of preference and reinforcer identification to other important areas for persons with severe disabilities.

Training residential supervisors to provide feedback for maintaining staff teaching skills with people who have severe disabilities.

We evaluated procedures for training supervisors in a residential setting to provide feedback for maintaining direct-service staff members ' teaching skills with people who have severe disabilities. Using classroom-based instruction and on-the-job observation and feedback, 10 supervisors were initially trained to implement teaching programs themselves. The training improved supervisors' teaching skills but was insufficient to improve the quality of feedback they provided to direct-service staff regarding the staff members' teaching skills. Subsequently, classroom-based instruction and on-the-job observation and feedback that targeted supervisors' feedback skills were provided. Following training in provision of feedback, all supervisors met criterion for providing feedback to their staff. Results also indicated that maintenance of teaching skills was greater for direct-service staff whose supervisors had received training in providing feedback relative to staff whose supervisors had not received such training. The need for analysis of other variables that affect maintenance of staff performance, as well as variables that affect other important areas of supervisor performance, is discussed.

Improving residential treatment services: implementation and norm-referenced evaluation of a comprehensive management system.

Ensuring effective service delivery by direct-care personnel in institutional living units for persons with developmental disabilities historically has been a difficult process, despite considerable attention from researchers, service providers, and governmental regulatory agencies. In this investigation, we conducted a normative evaluation of the extent and quality of treatment services currently provided in residential living units and evaluated a comprehensive management system designed to improve such services. Results of the first experiment, encompassing 22 living units in three states, indicated that on the average two thirds of observed resident behavior did not involve any therapeutic activity. The results also provided social validity for the criteria used to evaluate the quality of treatment provision based on opinions of mental retardation professionals. Results of the second experiment indicated that a behavioral management program implemented during 23 separate time periods across five living units was accompanied by consistent and durable decreases in resident nontherapeutic activity as well as increases in specifically designated habilitative activity. The results provide support for the successful incorporation of behavioral management technology into human service settings on a large-scale, long-term basis.

Training support staff to embed teaching within natural routines of young children with disabilities in an inclusive preschool.

We evaluated a program for training 4 support staff to embed instruction within the existing activities of 5 children with disabilities in an inclusive preschool. The program involved classroom-based instruction, role playing, and feedback regarding how to effectively prompt, correct, and reinforce child behavior. Descriptions of naturally occurring teaching opportunities in which to use the teaching skills were also provided. Following classroom training, brief on-the-job training was provided to each staff member, followed by on-the-job feedback. Results indicated that each staff member increased her use of correct teaching procedures when training was implemented. Improvements in child performance accompanied each application of the staff training program. Results are discussed in terms of using effective staff training as one means of increasing the use of recommended intervention procedures in inclusive settings. Areas for future research could focus on training staff to embed other types of recommended practices within typical preschool routines involving children with disabilities.

Effects of chosen versus assigned jobs on the work performance of persons with severe handicaps.

We evaluated the effects of several choice-related variables on the work performance of adults with severe handicaps. After assessing client work preferences, three choice-related situations were presented: (a) providing clients with the opportunity to choose a work task, (b) assigning a preferred task, and (c) assigning a nonpreferred task. Results indicated that clients attended to work tasks almost twice as much when they chose their tasks and when assigned to work on preferred tasks versus when assigned to work on nonpreferred tasks. Results are discussed regarding the need to assess systematically the effects of choice-related variables.

Identifying work preferences among individuals with severe multiple disabilities prior to beginning supported work.

We evaluated a prework assessment for predicting work-task preferences among workers with severe multiple disabilities prior to beginning supported work. The assessment involved comparing worker selections from pairs of work tasks drawn from their future job duties. Results of workers' choices once they began their jobs in a publishing company indicated that the assessment predicted tasks that the workers preferred to work on during their job routines. Results are discussed regarding other possible means of determining preferred types of supported work.

Increasing one aspect of self-determination among adults with severe multiple disabilities in supported work.

We attempted to increase one aspect of self-determination among 3 supported workers with multiple disabilities. Following Baer's (1998) self-determination conceptualization, the workers were exposed to two conditions that involved working more versus less independently based on availability of assistive devices. Next, their condition preferences were assessed and honored. All participants consistently chose the more independent condition. Results reflect how self-determination may be enhanced by giving workers increased control over work situations.

Expanding the impact of behavioral staff management: a large-scale, long-term application in schools serving severely handicapped students.

Experimental evaluations of behavioral staff management procedures usually have been limited to relatively small-scale demonstration studies. We evaluated a large-scale, long-term application of a staff management program designed to improve the functional utility of educational services for severely handicapped persons. The intervention, involving a brief in-service program followed by supervisory prompts and feedback, was implemented by three principals in four schools involving 21 classrooms. Implementation of the management procedures was consistently accompanied by increases in student involvement in functional educational tasks in each classroom. Further, the improved services continued throughout a 2-year follow-up period. Staff responses to a questionnaire indicated a high degree of staff acceptance of the management program. Results are discussed in terms of expanding the use of behavioral supervisory procedures from experimental demonstrations to actual adoption by existing human service agencies.

Evaluation of components of residential treatment by Medicaid ICF-MR surveys: a validity assessment.

We evaluated the proficiency of the federal Medicaid program's survey process for evaluating intermediate care facilities for the mentally retarded. In Study 1, an observational analysis of active treatment during leisure times in living units suggested that these surveys did not discriminate between certified and noncertified units. In Study 2, a reactivity analysis of a survey indicated that direct-care staff performed differently during the survey by increasing interactions with clients and decreasing nonwork behavior. Similarly, results of Study 3 showed increases in client access to leisure materials during a survey. In Study 4, questionnaire results indicated considerable variability among service providers' opinions on the consistency, accuracy, and objectivity with which survey teams determine agency standard compliance. Results are discussed regarding effects of the questionable proficiency of survey processes and the potential utility of behavioral assessment methodologies to improve such processes.