Institutionen för folkhälsovetenskap / Department of Public Health Sciences
Abstract
Background: Tuberculosis (TB) is a global public health challenge. More
than 1.7 million deaths worldwide in 2007 were attributed to TB. Directly
Observed Therapy Short course (DOTS) is the globally recommended strategy
for TB control.
Context: The Sultanate of Oman, a middle-income country that has seen
substantial economic development during the last 25 years, has made
remarkable progress with regard to the control of infectious diseases
including TB. In 1996, TB elimination targets for the years 2005 and
2010, were set at three and one new smear positive cases per 100,000 in
the Omani national population, respectively. The 2005 target was not
reached, implying the need for additional TB control efforts, including
research on the various factors affecting TB incidence.
Aim: The main aim of this thesis is to study TB control in Oman and to
explore opportunities and challenges in relation to achieving the
specified TB elimination targets in Oman. The thesis also aims to give
recommendations to NTP to enhance TB control in the country.
Methods: The thesis is based on four studies. In study I, the official TB
notification rates for nationals and migrant workers during the period
1981 to 2005 were analyzed. Additional data on the Gross National Income
per capita during the same period and estimates of the socio-economic
status of 329 TB patients notified in 2004 and 2005 were also used. Study
II was a cross-sectional study. Questionnaires were used to evaluate the
level of suspicion and knowledge of TB among 257 private and public
general practitioners in the Muscat region. In study III, 17 qualitative
interviews were carried out with health care providers, to explore their
perceptions and experiences of TB control in Oman. Spoligotyping of 312
isolates of Mycobacterium tuberculosis from TB patients diagnosed during
2005-2007 was carried out in study IV.
Results: TB notifications declined by more than 85% from 1981 to 2005
(study I). In 2005, the highest notification rates for Omani nationals
were found among persons aged 60 years and over. Approximately 95% of the
329 Omani nationals with TB diagnosed in 2004 and 2005, were living in
households earning less than the gross national income per capita (Study
I). Studies II and III demonstrated inadequate suspicion and knowledge of
TB among general practitioners. The private health care sector providers
were found to be less aware of TB than the public health care providers,
and to be uninvolved in TB control (Studies II, III). Migrant workers
were perceived as disadvantaged by the repatriation policy that is
applied for persons diagnosed with TB (Study III). Study IV showed a
predominance of strains from the Indian subcontinent. Around 50% of the
migrant workers isolates were found in clusters also containing isolates
from Omani patients, suggesting possible transmission between the two
population groups.
Conclusion: Economic development and TB control measures have probably
contributed strongly to the reduced TB burden in Oman. To further improve
TB control and promote TB elimination, NTP in Oman need to: i) address
high-risk individuals, ii) increase awareness and knowledge of TB among
frontline health care providers, iii) involve and integrate private
providers within the TB control program, iv) review the repatriation
policy and consider other strategies to improve TB control among migrant
workers