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Clinical Investigations: TUBERCULOSIS |

Adverse Events and Treatment Completion for Latent Tuberculosis in Jail Inmates and Homeless Persons* FREE TO VIEW

Mark N. Lobato, MD; Randall R. Reves, MD, MSc; Robert M. Jasmer, MD; John C. Grabau, PhD; Naomi N. Bock, MD; Nong Shang, PhD; for the 2RZ Study Group
Author and Funding Information

Affiliations: *From the Division of Tuberculosis Elimination (Drs. Lobato, Bock, and Shang), National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention; the Denver Public Health Department (Dr. Reves), Denver, CO; the University of California-San Francisco (Dr. Jasmer), San Francisco, CA; and the Bureau of Tuberculosis Control (Dr. Grabau), New York State Department of Health, New York, NY.,  For a list of 2EZ Study Group members see the Appendix.

Correspondence to: Mark N. Lobato, MD, CDC, 1600 Clifton Rd, Mailstop E-10, Atlanta, GA 30333; e-mail: mnl0@cdc.gov



Chest. 2005;127(4):1296-1303. doi:10.1378/chest.127.4.1296
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Published online

Background: Recently, a short-course treatment using 60 daily doses of rifampin and pyrazinamide was recommended for latent tuberculosis (TB) infection (LTBI).

Study objectives: To determine the acceptability, tolerability, and completion of treatment.

Design: Observational cohort study.

Setting: Five county jails and TB outreach clinics for homeless populations in three cities.

Patients: Study staff enrolled 1,211 patients (844 inmates and 367 homeless persons).

Interventions: Sites used 60 daily doses of rifampin and pyrazinamide, an approved treatment regimen for LTBI.

Measurements: Types and frequency of drug-related adverse events and outcomes of treatment.

Results: Prior to treatment, 25 of 1,178 patients (2.1%) had a serum aminotransferase measurement at least 2.5 times the upper limit of normal. Patients who reported excess alcohol use in the past 12 months were more likely than other patients to have an elevated pretreatment serum aminotransferase level (odds ratio, 2.1; 95% confidence interval, 1.1 to 6.1; p = 0.03). Treatment was stopped in 66 of 162 patients (13.4%) who had a drug-related adverse event. Among 715 patients who had serum aminotransferase measured during treatment, 43 patients (6.0%) had an elevation > 5 times the upper limits of normal, including one patient who died of liver failure attributed to treatment. In multivariate analyses, increasing age, an abnormal baseline aspartate aminotransferase level, and unemployment within the past 24 months were independent risk factors for hepatotoxicity. Completion rates were similar in jail inmates (47.5%) and homeless persons (43.6%).

Conclusions: This study detected the first treatment-associated fatality with the rifampin and pyrazinamide regimen, prompting surveillance that detected unacceptable levels of hepatotoxicity and retraction of recommendations for its routine use. Completion rates for LTBI treatment using a short-course regimen exceeds historical rates using isoniazid. Efforts to identify an effective short-course treatment for LTBI should be given a high priority.

One priority of the national tuberculosis (TB) elimination strategy is to reduce the pool of persons infected with Mycobacterium tuberculosis in order to prevent future TB cases due to progression from latent TB infection (LTBI).1The Institute of Medicine report, Ending Neglect: The Elimination of Tuberculosis in the United States,2 specifically recommended testing for and treating LTBI among inmates in correctional facilities and homeless persons to prevent the development and transmission of TB. In addition to other medical conditions, LTBI and coinfection with the HIV are more common in these underserved populations than in the general population.35

Treatment of jail inmates and homeless persons for LTBI can be challenging. These populations have a high risk for TB and difficulty with adherence to clinic visits and treatment. One study6of inmates released before completion of therapy showed that only 43% ever made a single visit to the clinic after release. In another jail setting, a 3% rate of clinic visits after release was increased only to 23% using an educational intervention.7In the same city, adherence to an appointment by homeless patients with LTBI was 53% among those receiving standard care, and treatment completion using isoniazid (INH) was 26%.89

The short-course treatment of LTBI using 60 doses of daily rifampin and pyrazinamide (PZA) appeared to be a promising treatment option for populations such as jail inmates and homeless persons. Three prospective clinical trials1012 among approximately 1,500 patients with HIV infection demonstrated that the safety and efficacy of this regimen were similar to a 12-month regimen of INH. There were no significant differences in toxicity between the treatments, and adherence was greater among patients in the short-course treatment arm. As a result, the Centers for Disease Control and Prevention (CDC), the American Thoracic Society, and the Council of the Infectious Diseases Society of America recommended the use of daily rifampin and PZA with clinical and laboratory monitoring as an option for the treatment of LTBI in adults with and without HIV infection.13

In this article, we describe the results of an observational study conducted to demonstrate the acceptability, tolerability, and completion of treatment using a short-course regimen of rifampin and PZA in populations of jail inmates and homeless persons known to be at high risk for LTBI. This CDC-initiated, multicenter study detected the first fatality due to hepatotoxicity in patients being treated with the rifampin and PZA regimen. This finding prompted expanded surveillance that lead to the recognition that severe hepatotoxicity during treatment with rifampin and PZA occurred at a frequency that was higher than originally recognized.

Study Sites

This project was conducted between January 1, 2000, and November 21, 2001, through health departments that were implementing treatment of LTBI using rifampin and pyrazinamide as standard of care. Five city or county (central city) jails participated in this project: Duval County (Jacksonville, FL); Fulton County (Atlanta, GA); Harrison County (Gulfport, MS); Nassau County (Long Island, NY); and Rikers Island (New York, NY). The health departments of Denver, CO, San Francisco, CA, and Mobile, AL initiated the project in their homeless populations. These three health departments had existing systems of clinical services in place for treating TB and LTBI among the homeless. The institutional review boards at CDC and the participating institutions approved the protocol prior to initiating the study.

Social Risk and Medical Evaluation

Social risk factors for TB were determined, specifically drug use and homelessness within the past 12 months, unemployment in the past 24 months, and any prior jail incarceration. The definitions of these conditions were those used by CDC for national TB surveillance.14 All jail entrants and homeless persons without a documented positive tuberculin skin test (TST) result were tested with five tuberculin units (0.1 mL) of purified protein derivative applied by the Mantoux method. A trained health professional read the result 48 to 72 h after its application. Persons with a positive TST result or a documented prior positive result were evaluated for TB. Data were collected on demographics, risk factors for exposure to TB, symptoms of TB, and pertinent medical history including liver disease and current medications. Each patient underwent a physical examination, a chest radiograph, and pretreatment laboratory testing. Persons without documentation of a negative HIV antibody result were offered counseling about HIV testing and were tested for HIV if informed consent was obtained.

Those who were eligible based on the initial evaluation were enrolled into the project unless they declined treatment or preferred treatment with another regimen. Exclusion criteria included age < 17 years, active tuberculosis, previous treatment for TB or LTBI, a history of hypersensitivity to or intolerance of any treatment medication, pregnancy or attempting to become pregnant, a serum concentration of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 5 times the upper limits of normal.

Treatment and Monitoring

In the jails, a health professional administered treatment drugs by daily directly observed therapy (DOT). Among the homeless patients, treatment was administered by DOT; however, a combination of DOT and self-administered doses, particularly on weekends, was an acceptable treatment approach. For self-administered doses, patient reports of dosing and pill counts were used to determine if the doses were taken. If the patient missed doses, the course of treatment was extended to achieve 60 doses. Before starting treatment, patients received laboratory testing for serum concentration of AST and, in the majority, ALT and total bilirubin. The rifampin dose was 600 mg/d. PZA was administered at 15 to 20 mg/kg/d (maximum, 2 g).

Health-care workers supervising treatment were trained to identify possible adverse events related to treatment. Outreach workers delivering DOT in the field assessed symptoms and encouraged adherence. Clinical evaluation by a health-care provider and measurements of serum concentration of liver enzymes took place during treatment at weeks 4 and 8. In addition, patients were referred to the jail infirmary or public health TB clinic for clinical evaluation for any possible drug-related adverse event or for persistent symptoms. Treatment was held for serum AST or ALT levels > 5 times the upper limits of normal and was stopped if > 10 times the upper limits of normal. Subsequently, one patient’s death associated with the LTBI treatment regimen using rifampin and PZA in this study and similar deaths elsewhere resulted in the dissemination of revised recommendations for monitoring patients.1518 As a result, jail and public health staff monitored patient symptoms more closely and performed laboratory testing every 2 weeks for possible hepatotoxicity. For patients who had self-administered treatment, drug packets were limited to a 2-week supply.

Data Analysis

Completion of therapy was considered as 60 doses administered within 3 months. The type and timing of adverse events were assessed and categorized during visits for DOT and clinical evaluations. For this analysis, the highest observed AST or ALT concentration was used to define the extent of increase relative to the upper limits of normal for the laboratory at which the test was performed. Differences in the distribution of demographic and clinical variables between those who had an adverse event and those who did not were tested using the Yates corrected χ2 test; unless the variable was continuous, in which case the Student t test was used. Multivariate logistic-regression analyses using the backward stepwise selection procedure were performed to test association of potential risk factors for hepatotoxicity as well as for noncompletion of treatment. Because data were sparse for HIV status and hepatitis viruses B and C, these variables were not included in the multivariate analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported, with p < 0.05 considered significant.

Enrollment and Patient Characteristics

A total of 3,764 persons were evaluated for enrollment, and 1,246 persons (33.1%) were enrolled. The most common reason for nonenrollment was prior treatment for TB or LTBI (45.1%). Of 2,628 persons not previously treated, 499 persons (19.0%) declined treatment. Among those declining, 79.0% were from one site that targeted homeless persons. Of those persons enrolled, data were analyzed from 1,211 patients (844 jail inmates and 367 homeless persons). Not included in the analysis were data from 14 patients who had a pretreatment serum aminotransferase concentration that was greater than the exclusion criterion and were not treated. An additional 21 patients had three or fewer doses; their therapy was permanently stopped after their pretreatment serum aminotransferase concentrations were found to be > 5 times the upper limits of normal.

The median age of patients receiving treatment was 35 years (range, 17 to 71 years) and was less for those in jail than homeless patients (Table 1 ). Most patients (88.1%) were male, of African-American race, or Hispanic ethnicity (Table 1). Patients in jail were more likely to be born in the United States than patients who were homeless (63.4% vs 40.9%, p < 0.001). Only 57.9% of patients had a known HIV status. Twelve of 486 patients (2.5%) in jail who had a known HIV test result were seropositive, while 5 of 217 homeless patients (2.3%) were HIV seropositive. Social risk factors for LTBI were common in the study population; 88.4% of inmates (including 11% homelessness) had at least one social risk factor, as did 58.3% of homeless persons (other than homelessness). Either injection or noninjection drugs were used by almost half of patients. Excess alcohol use occurred in at least one fourth of patients. Unemployment was high among patients who were in jail or who were homeless, 19.5% and 30.4%, respectively. (Among patients in jail, homelessness was almost 11%.)

Pretreatment Laboratory Monitoring and Symptoms

Pretreatment AST and ALT concentrations were available for 1,178 patients (97%) and 631 patients (56%), respectively. One hundred twenty-eight patients (10.9%) had an AST or ALT greater than normal before the start of treatment; measurements of 25 patients were at least 2.5 times the upper limit of normal. Patients who reported excess alcohol use in the past 12 months were more likely than other patients to have an elevated pretreatment serum aminotransferase level (OR, 2.1; 95% CI, 1.1 to 6.1, p = 0.03). Patients were either previously known to be, or were screened and found infected with additional pathogens: hepatitis C virus (n = 28), hepatitis B virus (n = 8), and both hepatitis C and B viruses (n = 19). Before treatment was started, patients had complaints related to other conditions that can mimic adverse drug effects, including drug-induced hepatotoxicity. The most common complaints were headache (10.5%), abdominal pain (7.1%), dizziness (6.4%), rash (5.9%), loss of appetite (5.3%), fever (5.1%), nausea (3.9%), emesis (2.5%), and yellow eyes (1.3%).

Adverse Events

Overall, 162 patients (13.4%) had at least one drug-related adverse event, with 271 different medical conditions associated with these events. Patients in jail were more likely than homeless patients to have an adverse drug effect (6.4% vs 3.3%, p = 0.04). Hepatotoxicity was the most common adverse event occurring in 78 patients. Other common adverse events were related to skin conditions (56 rash, 17 pruritus), GI complaints (26 nausea, 16 emesis, 15 upset or pain, 10 anorexia), and other conditions (21 headache, 13 dizziness, 13 arthralgia, and 6 other).

Multivariate analyses were used to determine factors associated with developing a serum concentration of AST ≥ 2.5 times the upper limits of normal (Table 2 ). Increasing age, an abnormal baseline AST level, and unemployment within the past 24 months were independent risk factors for hepatotoxicity. Among 715 patients who had one or more serum aminotransferase measurements during treatment, 78 patients (10.9%) had a clinically significant elevated AST or ALT (3 patients also had elevated total bilirubin): 35 patients had levels between 2.5 and 5 times the upper limits of normal, 23 patients had levels > 5 to 10 times normal, and 20 had levels > 10 times normal. The majority (57.7%) of patients who had drug-induced hepatotoxicity were asymptomatic and diagnosis was made by routine laboratory monitoring; at least one third were symptomatic.

Fifteen patients with hepatotoxicity had AST levels > 500 U/L; 3 patients had a total bilirubin > 3 mg/dL, and 9 patients were symptomatic (Table 3 ). One patient was receiving acetaminophen, and one patient was receiving ibuprofen at usual treatment doses. Seven of the 15 patients were eventually able to complete treatment. Anorexia and lassitude progressing to liver failure and death in the fifth week of treatment developed in one HIV-seronegative inmate (patient 10) with a history of chronic alcohol use and normal liver test results.15 An elevated AST level was detected during treatment for patients with a viral coinfection among 0 of 7 patients (0%) with HIV, 1 of 6 patients (16.7%) with hepatitis B virus, 6 of 20 patients (30.0%) with hepatitis C virus, and 5 of 16 patients with hepatitis B and C viruses.

Completion of Treatment

Overall, 561 patients (46.3%) completed 60 doses of rifampin and pyrazinamide (Table 4 ). An additional 96 patients (7.9%) completed at least 80% of doses. The median numbers of doses received by incarcerated and homeless patients were 41 doses and 39 doses, respectively. Homeless patients received 45.6% of treatment doses by DOT. The percentage of homeless patients (43.6%) completing treatment did not differ significantly (p = 0.23) from those who were incarcerated (47.5%). Among 311 inmates released during treatment who did not move out of jurisdiction, 65 inmates (20.9%) completed treatment while receiving DOT by the local health department. An additional 34 inmates were transferred to another facility while receiving treatment; however, treatment outcomes are not known. Multivariate analysis showed predictors for noncompletion were female sex, Hispanic ethnicity, lack of employment, injection drug use within the past 12 months, or excessive use of alcohol (Table 5 ).

Of the 162 patients who experienced an adverse event, 66 patients (40.7%) had their treatment stopped permanently, 56 patients (34.6%) completed treatment, and 40 patients (24.7%) had other outcomes. Among the 78 patients with an AST level ≥ 2.5 times normal during treatment, 38 patients (48.7%) completed treatment, compared with 453 of 637 patients (71.1%) with an AST level < 2.5 times normal (p < 0.001). Patients who started treatment in jail were less likely to be unavailable for treatment (29.1% vs 40.1%, p < 0.001) than patients who started treatment out of jail. Patients in jail were more likely to end treatment owing to moving or transferring to another facility (5.1% vs 1.9%, p = 0.02). Highest completion rates were for black, non-Hispanic and US-born patients, 50.2% and 50.1%, respectively. Failure to complete treatment was highest for female patients (73.9%), who were more likely than were men to have adverse events and to refuse continued treatment, injection drug users (65.6%), and those dually infected with hepatitis B and C viruses (68.4%) or infected with HIV (64.7%).

This study doubles the number of patients whose treatment outcomes for LTBI using rifampin and PZA were previously published and contributes useful data for monitoring patients for adverse events and completion of therapy.1923 Although drug-related intolerance and adverse events were common (13.4%), almost half of patients who had hepatotoxicity and more than one third of patients who had any adverse drug event completed treatment. However, severe hepatotoxicity was considerably more frequent than that observed in patients using INH for the treatment of LTBI.24

One incarcerated patient with chronic excess alcohol use died of drug-induced liver failure.15 This death led CDC to initiate surveillance for liver injury related to the use of this regimen. From October 2000 to June 2003, national surveillance detected 48 patients receiving rifampin and PZA for treatment of LTBI who experienced severe liver injury requiring hospitalization; 11 patients died.18 As a result of these investigations, CDC and the American Thoracic Society now recommend that this regimen generally should not be offered for the treatment of LTBI for patients with and without HIV infection.18

In this study cohort, 2% of patients had increased baseline liver enzyme concentrations attributed by providers mostly to recent use of alcohol. In multivariate analysis, an elevated baseline AST was a risk factor for the development of hepatotoxicity during treatment, although in another urban population, hepatotoxicity due to this regimen was seemingly unrelated to alcohol use, although alcohol use was broadly defined as “any use.”20 Our data suggest that infection with hepatitis C virus alone or in combination with hepatitis B virus, but not hepatitis B virus alone, is a risk factor for developing hepatotoxicity during treatment with this regimen. Logistic regression identified other factors associated with hepatotoxicity, including increasing age and an abnormal baseline AST, probably related to excess alcohol use. While rates of hepatotoxicity during use of rifampin and pyrazinamide for the treatment of LTBI are variable, several studies establish that this regimen results in hepatotoxicity more frequently than does INH,20,22 and in some populations is as high as 35%.25

During an outbreak of tuberculosis in a state prison unit housing HIV-infected inmates, 18 of 225 patients (8%) [57% of whom were receiving treatment for HIV infection] receiving daily treatment for LTBI with PZA and rifabutin developed serum aminotransferase elevations > 5 times the upper limits of normal.26 However, researchers in Florida21 have reported the successful treatment of patients with HIV infection using biweekly PZA and either rifampin or rifabutin. Of the 135 patients who received this regimen, 17% of whom used illicit drugs and 7% of whom used alcohol excessively, hepatotoxicity developed in only 1 patient. Other investigators19 using PZA and rifampin to treat patient-inmates in an urban jail reported elevated AST levels developing in only 5 of 168 inmates during treatment. Another study22 among predominantly foreign-born adults found higher rates of toxicity; overall, 7.7% of patients had a significant elevation of serum aminotransferases, while nonhepatotoxic adverse events was 20%. Discontinuation of treatment owing to adverse events was almost twice as common in that study among foreign-born adults as in this study among jail inmates and the homeless (9.1% vs 5.5%).

This study was conducted under field conditions and, as such, had limitations. First, the study could not determine the optimal timing for clinical and laboratory monitoring for hepatotoxicity. Indeed, some patients were unavailable for follow-up and did not receive laboratory monitoring. Other patients were not discovered to have treatment-related hepatotoxicity until the end of treatment when routine measurements were done. Second, by using a short-course treatment, we were able to improve treatment completion among patients in jail and reach an equal or higher completion rate for homeless patients who were treated for LTBI using INH.27However, staff administering treatment did not know the HIV status of > 40% of these patients. From a practical public health perspective, the completion of treatment in patients coinfected with HIV has the greatest impact on preventing future TB cases and for ensuring that treatment for LTBI is a cost-effective intervention.28

Many TB experts believe that an efficacious, safe, and acceptably short regimen would achieve more satisfactory completion rates among patients at high risk for progressing from LTBI to TB.1 In the study discussed here, using a short-course regimen demonstrated a greater rate (46%) of treatment completion than expected from the experience using 6 months of INH. A short-course regimen for the treatment of LTBI may translate into an acceleration of the decline of TB in this country by preventing future infectious TB cases in high-risk populations. To this end, the CDC-funded TB Clinical Trials Consortium is currently enrolling patients in Study 26, a comparison of outcomes between 3 months of once-weekly INH plus rifapentine, a long-acting rifamycin, and 9 months of daily INH.

In summary, this study shows that treatment for LTBI with a combination of rifampin and PZA is associated with an increased risk of significant hepatotoxicity in up to 6% of patients. Treatment completion did exceed historical rates owing to the shorter length of therapy and the use of DOT. The judicious use of interventions to improve adherence for the treatment of TB such as DOT2930 and the use of incentives31 may improve treatment completion for LTBI.13

The 2RZ Study Work Group

New York State Department of Health: John C. Grabau (principal investigator), Elizabeth Foster, Stephen Hughes, Cheryl Kearns, Margaret J. Oxtoby; Nassau County Department of Health: Abby Greenberg.

Emory University School of Medicine: Naomi Bock (principal investigator), Jane Tapia, Tara Rogers.

Denver Public Health: Randall Reves (principal investigator), Susan Schoel.

Florida Bureau of TB & Refugee Health: Ellen Murray (principal investigator), Tara Creech; Max Solano, Duval County Pre-Trial Detention Center; Ozzie Renwick and Perry Faulk, Duval County Health Department; and John Rutherford, Sheriff, Duval County.

San Francisco Tuberculosis Control Section: Robert M. Jasmer (principal investigator), Dora Cotrim, Candace Box, Sheila Jackson, Tony Paz, Kry Tea, Robert Fallstad, Ron Steele.

New York City TB Control Program: Joseph N. Burzynski (principal investigator), Karen Granville, Debra Berg, Mathew Nwozuzu, Germaine Jacquette.

Mississippi TB Program: Mike Holcomb (principal investigator), David Daugherty.

Alabama Division of TB Control: Nancy Keenon (principal investigator), Jerry McClure, Eric Morgan.

CDC: Linda Leary (data manager).

Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; CDC = Centers for Disease Control and Prevention; CI = confidence interval; DOT = directly observed therapy; INH = isoniazid; LTBI = latent tuberculosis infection; OR = odds ratio; PZA = pyrazinamide; TB = tuberculosis; TST = tuberculin skin test

Support was provided by the CDC.

Table Graphic Jump Location
Table 1. Demographic and Clinical Characteristics of 1,211 Patients Receiving Rifampin and Pyarzinamide for the Treatment of LTBI*
* 

Data are presented as No. (%) unless otherwise indicated.

Table Graphic Jump Location
Table 2. Risk Factors for Abnormal AST Level Developing Among 715 Patients During Treatment for LTBI Using Rifampin and Pyrazinamide*
* 

AST level ≥ 2.5 times the upper limits of normal.

 

Computed based on the multiple logistic regression model selected through a stepwise regression procedure.

Table Graphic Jump Location
Table 3. Clinical and Laboratory Findings for 15 Patients With Severe Hepatotoxicity While Receiving Treatment With Rifampin and Pyrazinamide*
* 

COT = completion of therapy; HBV = hepatitis B virus; HCV = hepatitis C virus; AP = abdominal pain; ND = not determined.

 

Infection with hepatitis B or C virus or HIV.

Table Graphic Jump Location
Table 4. Treatment Outcomes for Patients Receiving Rifampin and Pyrazinamide for the Treatment of LTBI*
* 

Data are presented as No. of patients (%).

Table Graphic Jump Location
Table 5. Relationship of Demographic and Clinical Variables to Risk Factors of Not Completing Treatment
* 

Univariate analysis only done for HIV status and hepatitis viruses. NA = not applicable.

 

Difference tested by Fisher exact test.

We thank the staff from the jail systems, shelters, and health departments who generously participated in this study, and we thank Ann Lanner for editorial assistance.

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Figures

Tables

Table Graphic Jump Location
Table 1. Demographic and Clinical Characteristics of 1,211 Patients Receiving Rifampin and Pyarzinamide for the Treatment of LTBI*
* 

Data are presented as No. (%) unless otherwise indicated.

Table Graphic Jump Location
Table 2. Risk Factors for Abnormal AST Level Developing Among 715 Patients During Treatment for LTBI Using Rifampin and Pyrazinamide*
* 

AST level ≥ 2.5 times the upper limits of normal.

 

Computed based on the multiple logistic regression model selected through a stepwise regression procedure.

Table Graphic Jump Location
Table 3. Clinical and Laboratory Findings for 15 Patients With Severe Hepatotoxicity While Receiving Treatment With Rifampin and Pyrazinamide*
* 

COT = completion of therapy; HBV = hepatitis B virus; HCV = hepatitis C virus; AP = abdominal pain; ND = not determined.

 

Infection with hepatitis B or C virus or HIV.

Table Graphic Jump Location
Table 4. Treatment Outcomes for Patients Receiving Rifampin and Pyrazinamide for the Treatment of LTBI*
* 

Data are presented as No. of patients (%).

Table Graphic Jump Location
Table 5. Relationship of Demographic and Clinical Variables to Risk Factors of Not Completing Treatment
* 

Univariate analysis only done for HIV status and hepatitis viruses. NA = not applicable.

 

Difference tested by Fisher exact test.

References

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