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Discussion
The use of RIF/PZA among immigrants in this out-break was associated with a high incidence of hepato-toxicity, a completion rate well below the CDC’s 85%target,（5） and cultural and financial barriers to treatment and monitoring.
The 17% of adults experiencing a drug-induced hepatitis is consistent with prior reports among non–HIV-infected persons.（10,14）The incidence of hepatotoxicity in clinical trials of non–HIV-infected persons is approximately 8%（14）; however, other health departments have reported higher rates.（15,16）Differences may be due to differences in patient populations, monitoring, and definitions of hepatitis. While this experience confirms the importance of close monitoring, the health department found that linguistic barriers and cultural beliefs about giving blood hindered monitoring and may have decreased adherence.
The key limitation to this study is the small number of subjects, which does not allow for population inferences, comparisons with clinical trials, or a full exploration of risk factors for hepatitis. Reliance on chartbased data and self-reports may have underestimated prevalence of comorbidities and alcohol use during treatment and contributed to the high rate of hepatotoxicity. While there were limited side effects and a high completion rate for children, 4 months of ri-fampin remains the standard of care in children exposed to isoniazid-resistant tuberculosis because of limited data on RIF/PZA in children.（5,13）The costs associated with RIF/PZA are underestimated because follow-up testing and interpreter time were not included.
This case study may assist healthcare providers facing similar decisions about tuberculosis prevention in recent immigrants. Resources should be directed toward improving the healthcare system’s ability to provide culturally appropriate care because this may improve adherence to current, less-toxic therapies.（4,17–19）Although mobile immigrants may benefit from short-course preventive therapy, potential benefits must be weighed against potential hepatotoxicity, cost, and cultural barriers.

We are grateful to Karen Grush, Jane Lux, and Ana Rodriguez at the DeKalb County Health Department, and Margaret Swartz and Vicki Biddle at the Illinois Department of Public Health for their gracious assistance and collaboration. We would also like to thank Marshall Chin and John Lantos at the University of Chicago for their helpful advice on the manuscript. This research was supported by a grant from the Robert Wood Johnson Foundation.

讨论
在此次（结核病）爆发中，使用RIF/PZA来治疗移民的原因是肝中毒的高发病率（CDC定下的完成率目标为低于85%）以及文化和经济因素对治疗和监测的障碍。
17%的成年人经历了药源性肝炎，这和之前的对于未受HIV感染的人群的报告结果一致。
对未受HIV感染人群的临床检验的肝炎发病率约为8%(参考文献14)；但是，其他卫生部门却曾经报告过比这要高的发病率（参考文献15，16）。区别可能在于病人的人数、监测、以及肝炎的定义。
虽然这次经验确认了密切监测的重要性，但是卫生部门发现对于抽血的语义理解上的障碍和文化信仰却阻碍了观测并可能导致依从性降低。
此项研究的关键局限性在于研究对象数量太少，使得无法执行人口推断、临床检验的比较、或者对肝炎风险因素的完整研究。
对基于图表的数据和自我报告的依赖，可能低估了并发症的流行和在治疗期间饮酒的情况，并因此导致（计算出了）较高的肝中毒发病率。
对儿童而言，产生的副作用很有限，完成率很高，但是由于缺乏对儿童采取RIF/PZA治疗的数据，所以4个月的利福平疗程仍然是对接触异烟肼抗性结核病的儿童的标准治疗方案（5，13）。
RIF/PZA的花费由于没有包括跟进测试和翻译时间而被低估。
这项病例研究可能有助于医疗工作者对近期移民的结核病预防工作作决策。
资源分配应倾向于提高医疗保险系统提供文化上适当的医疗的能力，因为这可能提高对于目前毒性较小的疗法的依从性。
虽然流动的移民可能受惠于短期预防性的疗法，但是相比潜在的肝中毒、花费、以及文化障碍，潜在的好处应该得到更多的考虑和重视。
我们感谢由DeKalb县卫生部的Karen Grush, Jane Lux，Ana Rodriguez，以及伊利诺公共卫生部的Margaret Swartz，Vicki Biddle的大方协助与合作。我们还感谢芝加哥大学的Marshall Chin和John Lantos对本文的有益的建议。本研究的支持资金来自于Robert Wood Johnson基金会。

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