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Multilevel Modeling of Household Contextual Determinants of Tuberculin Skin Test Positivity among Contacts of Infectious Tuberculosis Patients, Umerkot, Pakistan

This cross-sectional study sought to identify household contextual determinants that might be associated with Mycobacterium tuberculosis infection as assessed by tuberculin skin test (TST) positivity among familial contacts of index patients of infectious pulmonary tuberculosis (TB) while controlling for the effects of individual-level factors. We analyzed data on TST results on 359 household contacts of 77 index cases of acid-fast bacilli (AFB) sputum smear-positive pulmonary TB using multilevel logistic regression analysis with characteristics of household contacts at the first level and that of households at the second level. The prevalence of M. tuberculosis infection as assessed by TST positivity among household contacts of index TB patients was 49.9% (179/359). After taking into account the individual-level risk factors, household-level contextual determinants significantly associated with contact’s TST positivity were gender of index TB patient (adjusted odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.3–3.9%) and density of AFB sputum smear (adjusted OR = 3.2; 95% CI: 1.9–5.5%). Household variances in multilevel models indicated significant inter-household heterogeneity in TST positivity among contacts. This study provided the evidence for substantive effects of household-level contextual variables on the TST positivity among contacts of index TB patients. Thus, both individual-level and household-level characteristics need to be taken into account while prioritizing contacts for investigations to improve TB control and prevention in resource-constrained countries such as Pakistan.

Received June 30, 2008. Accepted for publication December 1, 2008.

Acknowledgments: We thank the many individuals who have helped in this study with particular gratitude to Shaheena Qayyum, Rano Mal, Majid Memon, and the staff of UATA clinic. We also thank the referees of the journal for their thoughtful comments that have improved the presentation of the manuscript.

Financial support: The study was supported by Umerkot Anti-tuberculosis Association and the Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.

^* Address correspondence to Saeed Akhtar, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait. E-mail: saeed.akhtar{at}hsc.edu.kw

Authors’ addresses: Saeed Akhtar, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait, E-mail: saeed.akhtar{at}hsc.edu.kw. Suresh K. Rathi, Department of Community Health Sciences, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.