PubMed Health⌕ Search

Biomedical subjects

S J Heymann

Publications and source records attributed to S J Heymann.

At least 19 recordsLinked to original sources
PubMed2001

Strategies to decrease tuberculosis in us homeless populations: a computer simulation model.

CONTEXT: The rate of tuberculosis (TB) among US homeless persons may be 20 times that of the general adult population. Studies suggest that the majority of urban homeless TB cases are attributable to ongoing transmission of TB. Optimal TB-control strategies in both chronically and transiently homeless populations are not known. OBJECTIVE: To examine the effects of TB-control strategies on projected TB cases and deaths in US homeless populations using a computer-based simulation model. DESIGN, SETTING, AND POPULATION: The US general population and a theoretical population of 2 million homeless individuals in 1995 were divided into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus (HIV) infection in a semi-Markov model. MAIN OUTCOME MEASURES: Prevalence of transiently and chronically homeless individuals with active TB and deaths from TB as a function of public health measures taken to control and eliminate TB, including improvement of treatment effectiveness, improvement in access to treatment, and vaccination with BCG. RESULTS: A 10% increase in access to treatment among homeless persons with active TB produced larger declines in predicted TB cases and deaths after 10 years (cases and deaths among chronically homeless persons decreased 12.5% and 19.8% and among transiently homeless persons dropped 35.9% and 32.4%, respectively) than improvements in the effectiveness of treatment programs (cases and deaths among chronically homeless persons declined 7.2% and 3.1% and among transiently homeless persons dropped 10.9% and 4.1%, respectively). A 10% increase in access to treatment among homeless persons with latent TB infection led to a 6.7% decline in TB among chronically homeless persons and a 5.7% decline among transiently homeless persons, while a 10% improvement in effectiveness of treatment for latent TB infection was associated with declines of 3.0% and 3.3%, respectively. When treatment for latent TB infection was modeled to be the same in vaccinated and nonvaccinated populations, BCG vaccination led to TB case declines of 15.4% and 21.5% in chronically and transiently homeless populations, respectively. CONCLUSIONS: Overcoming barriers faced by homeless individuals in accessing TB treatment programs will be crucial to reducing the burden of TB in this high-risk group. Increased treatment access, improvement in the effectiveness of treatment programs, and BCG vaccination of HIV-negative homeless individuals have the best chance to markedly decrease TB morbidity and mortality.

Antitubercular Agents↗
PubMed2000

Pediatric tuberculosis: what needs to be done to decrease morbidity and mortality.

OBJECTIVE: Tuberculosis (TB) control programs have been less successful among children than among adults in the United States. Between 1992 and 1997, the rate of decline of TB cases among 0- to 14-year-old children was less than the rate of decline among any other age group of US-born persons. Because of the higher prevalence of active TB among adults and their higher infectivity, most programs for TB in the United States have targeted adults. The inherent assumption has been that by targeting adults, from whom children may become infected, TB morbidity and mortality among children also will be reduced effectively. METHODS: Using a semi-Markov model that divided the US population into age groups <15 years old and >/=15 years old and into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus infection, we developed a computer-based simulation model to examine the effect of a range of potential TB control strategies on projected TB cases and deaths in children. We compare the impact of interventions targeted at children with the impact of interventions targeted at adults on pediatric morbidity and mortality. RESULTS: After 10 years, a 5% increase in the number of adults with TB who enter treatment would only lead to a.05% decline in TB cases among children, compared with predicted cases without this intervention. Improving treatment efficacy among those adults who are already receiving treatment for their TB leads to a smaller decline in cases among children of only.003%. In contrast, a 5% increase in the number of children who enter treatment leads to a 25% decline, after 10 years, in the number of TB cases among children and a 16% decline in the number of TB deaths. In the presence of immigration of tuberculin-positive children, the benefit of targeting programs directly at children is magnified. CONCLUSIONS: Marginal changes in programs targeted directly at children are significantly more effective at further reducing pediatric TB morbidity and mortality than the same changes in programs targeted at adults with the indirect goal of reducing spread to children. Marginal increases in the number of children who enter treatment are far more effective at decreasing morbidity and mortality than equivalent marginal increases in treatment effectiveness. Unfortunately, declining insurance coverage and increasing restrictions on services to immigrants have made it harder for those who are at greatest risk of TB to get medical care. Marginal increases in preventive therapy rates substantially reduce future pediatric TB cases and deaths among children with TB infection and human immunodeficiency virus.

Adolescent↗
PubMed1999

Working parents: what factors are involved in their ability to take time off from work when their children are sick?

BACKGROUND: A series of studies has demonstrated that sick children fare better when their parents are present. OBJECTIVE: To examine working conditions that determine whether parents can spend time with and become involved in the care of their children when they are sick. DESIGN: Survey with a multivariate analysis of factors influencing parental care of sick children. PARTICIPANTS: Mixed-income urban working parents aged 26 to 29 years participating in the Baltimore Parenthood Study. RESULTS: Only 42% of working parents in our sample cared for their young children when they became sick. A multivariate logistic regression analysis was conducted to predict which parents stayed at home when their children were sick. Those parents who had either paid sick or vacation leave were 5.2 times as likely to care for their children themselves when they were sick. Of parents with less than a high school education, 17% received paid leave, compared with 57% of parents with a general equivalency diploma, 76% of parents with a high school diploma, and 92% of parents with more than a high school education (P<.001). CONCLUSIONS: The finding that many parents were unable to care for their sick children themselves is important for pediatric care. While low-income children are more likely to face marked health problems and to be in need of parental care, they are more likely to live in households in which parents lack paid leave and cannot afford to take unpaid leave.

Adult↗
PubMed1999

The impact of welfare reform on parents' ability to care for their children's health.

OBJECTIVES: Most of the national policy debate regarding welfare assumed that if middle-income mothers could balance work while caring for their children's health and development, mothers leaving welfare for work should be able to do so as well. Yet, previous research has not examined the conditions faced by mothers leaving welfare for work. METHODS: Using data from the National Longitudinal Survey of Youth, this study examined the availability of benefits that working parents commonly use to meet the health and developmental needs of their children; paid sick leave, vacation leave, and flexible hours. RESULTS: In comparison with mothers who had never received welfare, mothers who had been on Aid to Families with Dependent Children were more likely to be caring for at least 1 child with a chronic condition (37% vs 21%, respectively). Yet, they were more likely to lack sick leave for the entire time they worked (36% vs 20%) and less likely to receive other paid leave or flexibility. CONCLUSIONS: If current welfare recipients face similar conditions when they return to work, many will face working conditions that make it difficult or impossible to succeed in the labor force at the same time as meeting their children's health and developmental needs.

Adolescent↗
PubMed1999

The breast-feeding dilemma and its impact on HIV-infected women and their children.

The rate of HIV transmission via breast-feeding ranges from 14% to 26%, depending on the timing of maternal infection. In settings where infant mortality rates from infectious diseases and malnutrition are low and relatively safe alternatives to breast-feeding are available, HIV-infected mothers should be advised not to breast-feed. Where breast-feeding by HIV-infected mothers and bottle-feeding both present serious risks of mortality, changing the conditions in which families live so that safe feeding alternatives become available must be a top priority. At the same time, these mothers need information about the relative risks and benefits of breast-feeding, early weaning, wet-nursing, and formula feeding. This article reviews the available research data and discusses critical gaps in current knowledge.

Bottle Feeding↗
PubMed1998

An effectiveness and cost analysis of presumptive treatment for Mycobacterium tuberculosis.

BACKGROUND: Delay in treatment of tuberculosis has contributed to both the spread of tuberculosis and its case fatality rate. METHODS: Decision analysis was used to examine the effectiveness and cost of presumptive treatment in patients evaluated for tuberculosis. RESULTS: Over a range of assumptions, empiric antituberculous therapy for acid-fast bacillus smear-positive persons lowers mortality and cost per person evaluated when available rapid diagnostic laboratory methods for tuberculosis are used. In contrast, the average cost per life saved by giving presumptive treatment to all acid-fast bacillus smear- and HIV-negative patients exceeds. $1 million. Empiric treatment for HIV-infected patients with acid-fast bacillus-negative smears decreases average mortality by 2% at an additional cost of $8000 per life saved. When the prevalence of multiple-drug resistance exceeds 9.6%, presumptive drug-resistant therapy for acid-fast bacillus smear-positive patients, rather than the initial four-drug regimen recommended for much of the United States, minimizes both mortality and costs. CONCLUSIONS: Empiric antituberculous therapy often minimizes average mortality and cost for patients evaluated for tuberculosis when rapid diagnostic methods are used.

Antitubercular Agents↗
PubMed1998

The influence of program acceptability on the effectiveness of public health policy: a study of directly observed therapy for tuberculosis.

OBJECTIVES: This study examined how patient acceptability influences the effectiveness of directly observed therapy for tuberculosis. METHODS: Decision and sensitivity analyses were used in assessing influences. RESULTS: If mandatory directly observed therapy discourages 6% of initial tuberculosis patients (range: 4% to 10%) from seeking care, then such therapy will be less effective than self-administered therapy. Directly observed therapy is more effective than repeated self-administered therapy for patients failing to complete initial treatment unless 32% (range: 27% to 38%) of patients avoid seeking care. CONCLUSIONS: Patient acceptability must be taken into consideration before selecting public health strategies.

AIDS-Related Opportunistic Infections↗
PubMed1997

Tuberculosis control in Asia and the western Pacific: a role for computer modelling.

Despite the availability of effective treatment, tuberculosis (TB) causes more deaths than any other infection. Most of the world's TB cases and deaths occur in Asia and the Western Pacific, and the growing prevalence of multiple drug-resistant TB and the spread of human immunodeficiency virus (HIV) present ever greater obstacles to effective TB control. The management of TB remains difficult, and epidemiologic studies to assess control programmes require significant time and expense and may not be generalizable to other regions. Computer models are powerful and relatively inexpensive tools for rapidly planning and evaluating TB control strategies. Models have demonstrated the value of targeted chemoprophylaxis strategies for the prevention of TB among HIV-infected individuals, and programmes to ensure that all HIV-infected individuals receive TB chemoprophylaxis should be considered in Asia and the Western Pacific. Though directly observed therapy (DOT) is effective when designed to be attractive to patients, modelling has shown that DOT, if poorly accepted by patients, may lead to fewer patients seeking care and thus to paradoxical rises in TB case rates. Models may be used to make accurate predictions of TB morbidity and programme costs using local epidemiologic and demographic inputs. The use of models in Asia and the Western Pacific offers a low-cost way to compare programmes, to improve the evaluation of programmes, to project future cases, and to examine programme needs while providing insights into TB control helpful to countries in and out of the region.

AIDS-Related Opportunistic Infections↗
PubMed1996

Evaluation of tuberculosis control policies using computer simulation.

OBJECTIVE: To develop more effective methods to assess tuberculosis (TB) control strategies so we can meet national goals for the elimination of TB in the United States. DESIGN: Using a semi-Markov model that divided the US population into 3 age groups and 18 clinical states based on disease status and risk for TB and human immunodeficiency virus (HIV) infection, we measured the effects of 5 changes in TB policy, introduced singly and in combination: (1) increased coverage and (2) improved efficacy of preventive therapy, (3) increased coverage and (4) improved efficacy of treatment, and (5) introduction of BCG vaccination. RESULTS: A BCG vaccination program that reached 10% of eligible children and 1% of eligible adults each year would produce a 17% reduction in cases and an 11% decline in deaths over 10 years. Preventive therapy programs among the general population would have little effect on the number of TB cases, but a program targeting HIV-infected patients would reduce HIV-associated TB cases and deaths 14% to 20%. A 10% improvement in the coverage and efficacy of both preventive therapy and treatment, coupled with the BCG vaccination program, would lead to a 47% decline in TB cases and a 50% decline in TB deaths relative to baseline over 10 years. CONCLUSIONS: Improvements in treatment coverage or effectiveness alone are unlikely to reach established national goals for the elimination of TB. These goals can be achieved through a combination of improvements in current programs with targeted preventive therapy and BCG vaccination programs.

Adolescent↗
PubMed1996

Parental availability for the care of sick children.

OBJECTIVE: Parents have always played a critical role in the care of sick children. Although parents' roles remain crucial to children's health, parental availability has declined during the past half century. The percentage of women with preschool children who work has risen almost fivefold in 45 years from 12% in 1947 to 58% in 1992. The percentage of women in the paid work force with school-aged children has almost tripled in the same period, from 27.3% to 75.9%. Research has examined the effects of a variety of parental work conditions on children. However, past research has not examined how working conditions affect the ability of parents to care for their sick children. In this article, we examine how often the children of working parents get sick and whether parents receive enough paid leave to care for their sick children. METHODOLOGY: This analysis makes use of two national surveys, which provide complementary information regarding the care of sick children. The National Longitudinal Survey of Youth is a longitudinal survey of a nationally representative probability sample of 12,686 men and women; the National Medical Expenditure Survey is a panel survey of 34,459 people. First, we estimated the family illness burden. Second, we looked in detail at the number of days of sick leave mothers had. Third, we examined whether mothers who had sick leave had it consistently during a 5-year period. Finally, we conducted a logistic regression to determine what factors were significant predictors of both lacking sick leave. RESULTS: More than one in three families faced a family illness burden of 2 weeks or more each year. Yet, 28% of mothers had sick leave none of the time they were employed between 1985 and 1990. Employed mothers of children with chronic conditions had less sick leave than other employed mothers. Thirty-six percent of mothers whose children had chronic conditions had sick leave none of the time they were employed. Although 20% of working parents who did not live in poverty lacked sick leave, 38% of parents who did live in poverty lacked sick leave. The problem is also more marked for nonwhite parents. Although 23% of working white parents lacked paid sick leave, 31% of nonwhite parents lacked sick leave. One in six families that lacked sick leave had to cover for more than 4 weeks of family illness during the year. CONCLUSION: In 1993, the US Congress passed the Family and Medical Leave Act (FMLA). However, by limiting the medical leave to the care of major illnesses, primarily those requiring hospitalization, the FMLA does not address the majority of children's sick care needs. For the common childhood illnesses that are not covered by the FMLA, employed parents often must rely on their sick leave if they are to care for their sick children themselves. Yet, we found that many employed parents lack sick leave. This is particularly true of parents of children with chronic conditions and poor and minority families.

Adult↗
PubMed1993

The infectious risks of transfusions in the United States: a decision-analytic approach.

INTRODUCTION: The development of AIDS as a result of HIV transmission and of cirrhosis as a result of chronic non-A, non-B hepatitis are the greatest infectious risks associated with transfusion in the United States. The goal of this study is to provide explicit quantitative guidelines to determine when the risk of death from all causes associated with transfusion exceeds the risk associated with anemia. METHODS: This study uses a decision-analytic model. RESULTS: On the basis of reported transfusion complication rates and an independent worst-case calculation of the risk of AIDS and non-A, non-B hepatitis, transfusion with red blood cells should be recommended as long as each unit received reduces the patient's risk of dying from anemia by at least 1/1100. DISCUSSION: Because of the relative safety of the blood supply as a result of universal screening and donor deferral, the overestimation in practice of fatal infectious complications, and the possible underestimation of the risk of anemia, undertransfusion has the potential to be as serious a problem in the United States as is overtransfusion. Although caution should be exercised not to undertransfuse when a patient has an appreciable risk of anemia-associated death, we must be wary not to overtransfuse for temporary relief of morbidity.

Acquired Immunodeficiency Syndrome↗