IDRlD HEALTH ORGANIZATION EN/TB/84 Reg~onal Off~ce for the EH/sT/26 Eastern Me~terranean

TUBERCULOSIS PREVALENCE SURVEY IN THE HASHEMITE KINGOOM OF JORDAN

April 1960 - WHO EMRO EM/TB/84 EM/ST/26 page i

TABLE OF COFTENT&

I INTroDUCTION 4/1 ...... ~ • ••••• •• •••• 1.

II BDPULATION ••••••••••••.••••.••..•••••.•. , ••••••••••••• ~..... 1

III SAMPLING METHODS ••••••••••••••••••••.••.•••••••••••••••••••• 2

IV METHODS OF EXAMINATION

1, Tubercul1n Test1ng •••.•••••••••••••.•••.•.•••••••••••• ~ J 2, X-ray Exam~nat~on ••.••••••••••••••••••••••• ~ ••••••••••• 3 3. Bacter~olog~cal Exam~at~on of Sputum •••••••••••••••••• 4 v SAMPLE POPULATION •...... •...... •..••.•...... •• 4 VI RESULTS

1. Tubercul1TI Teat1ng •••••.• , •••••••••••••••••••••••••••• 4 X-ray Exam1nat1on •••••.•••••••.•••••••••••.••••••••••• 6 Bacter101og~cal Exam~nat1on •••••••....•••..•.•.•••••.• 7 VII CONCLUSIVE RESULTS OF THE TI-Kl SURVEYS ...... 7

VIII S~ ...... 8

ANNEX I

Table 1 Sample Populatlon, Exa~natlons done and Extent of Part~clpations

Table 2 The Sample Populatlon by Age and Sex

Table 3 Tempo~ry Abs~ntees DlStrlbutl0n by 11.ge and Sex Table 4 Reason for Absenteelsm by Age and Sex

Table 5 D~strlbut~on by S~ze of Reactlon to Mx 1 TU In specrl~ed age-group

Table 6 D~str~butl0n by Slze of Reactlon to ~~ 1 TU In spec~fled Age-group EM/TB/54 WHO EMRO EM/ST/26 page J.i

TABLE OF CONTENTS (cont'd)

Table 7 - DJ.strJ.butJ.on by ~ze of ReactJ.on to r-Ix 1 TU J.n specJ.fJ.ed Age-group

Table 8 - Percentage DistrJ.butJ.on by SJ.ze of ReactJ.or t-Q Mx 1 TU by Age-gro\lp

Table 9 - Percenta~~ ~+$tr+bvt+oo by SJ.ze of ReactJ.on to Mx 1 TU by Age-group

Table 10 - Percentage DJ.2trJ.butJ.on by SJ.ze of ReactJ.OI) to }r~ 1. '.[U by Age-group

iable 11 - Estimated Preval~nce of Tuberculous InfectJ.~n by Age and Sex Total PopulatJ.on

Table 12 - EstJ.mated Prev2lenc6 of Tuberculous Infectl0n by ~ge, Sex and Place of ResJ.dence

Table 13 Scars from preVJ.ous EGG Vacclnatl0n

Table 14 - SJ.ze of Tuberculln Reactlon among Persons WJ.th defJ.nJ.te or doubful Scars, J.DdJ.catJ.pg preVJ.ous BCG VaccJ.natJ.on

Table 15 - Type of Tubercul~n ~eact~on and 1t.s. Relatlon to Re~ctlon Slze - Total S~mple Populatl0n

Table 16 - Results of X-Ray ExaID1natJ.on by S~3mple Group

Table 17 - Results of X-Ray Ex~mJ.natlon by Age ond Sex Table. 18 - X-Ray Flnd1ngs by Slze of Tuberoulin ReactJ.on

Table 19 - X-Ray Flnd1ngs by Slze of ReactJ.on to the Mx 1 TU Teat - Urban and Rural Areas

Table 20 - Estlmated Prevalence of Tuberculous Infectl0n by Sex and Age - Jllml~n Survey and NatJ.onal Survey

Table 21 - X-Ray Flndlngs by Slze of Tuberculln Reoctlon - Beth Surveys WHO EMRO EH/TB/84 EM/ST/26 page l.ll

TABLE OF 'XlNTENTS (cont'd)

ANNEX II

Fl.gure 1 - Frequency Dl.strl.butl.on of Sl.ze of Tubercull.n Reaction by Sex - All Groups

Fl.gure 2 - Frequency Distrl.butl.on of Sl.ze of Tubercull.D Reaction by Aee - Total Population

Flgure J - Age Infectl.on Curve for the Total Sample Populatlon, by Sex (Infected Persons - Tubercull.D Reactl.on of 10 mm or more)

Fl.gure 4 - Age Infection Curve by Sex and Place of Resldence

Fl.gure 5 - Type of X-Ray Flndl.ng b,y Sl.ze of Tubercull.n Reactl.on WHO EMRO EM/TB/84 FJ!!./ST/26 page 1

I INTRODUCTICN

A country-~~de tuberculos~s prevalence survey has been conducted ~ the Hashe~te K1ngdom of Jordan from to July 1961. The survey was carrled out under the directlon of the Mlnlstry of Health and ~th technlcal ass~stance from WHO. Ass1stance was glven by UNICEF ~ the form of eqUlpment and supplles.

The a1m of the survey was to collect lnformat10n on the prevalence of pulmonary tuberculos1S and of tuberculous 1nfect10n in the Country.

The survey conslsted of the exammation by three standarcb.zed cl:Lagnost~c tests of a sample of the Jord2nlan populatlcm. The samp11ng Tias done accord1ng to a ran~om procedure wh~ch 1n pr1nclple gave all the mhab~tants the same chance of bemg lnc1ude~ thus ensuring that the sample would be representat1ve of the populatlon from ..Inch it was drawn.

The survey was carr~ed out m two phases. The f~rst phase cons~sted of the overall plannlng and the examlnat~on of e~ght groups selected ~n Amman d1str~ct (mclud~g Amman town) and was Conducted by the Reg~onal Tuberculos~s Survey Team of the 1'IHO Reg~onal Off~ce for the Eastern MedJ.terranean. The second phase cons1sted of the examlnat10n of t huty-three selected groups an d was carr1ed out by the Rat~onal Tuber~ulos1s Prevalence Survey Team who had been tra1ned in all aspects of survey work by the Reg~onal Tuberculos1S Survey Team durmg the first phase of the survey. The procedures followed are the same for both phases of the survey whlch makes the obtained results directly ccml3Brable. For conven~ence the fp'st phase of the survey Tn:!.l be referred to In thlS report as the Amman Survey, and the second phase u1ll be referred to as the Nat10nal Survey.

The results obta1ned In the Amman Survey have been presented m the report "TuberculoslS Survey m Amman, The Hashem~te Klngdom of the Jordan", Alexan dna, Un1ted Arab Repubhc (), and 1-I'ill be dealt inth only bneily here. Th1S report Wlll present the results obta1'ned m the Nat10nal Survey and also glve some overall estlmates.

II FOPULATION

Jordan bas a populatlon of approXlmately 1,400,000 of unlcb about 600,000 are 11Vlng m urban areas. These f1eures lnclude some 500,000 Palest~ne refugees of whom 38% 11ve In camps. The moving bedoUln populatlon 1S about 30 - ~,OOO. The pr~nc~pal towns are Amman and Arab Jerusalem. A'T\ITlan lS the capl tal and has about 170,000 mhabitants. Arab Jerusa'lem, for the llost part tbe old C1ty, has a populatlon of about 100,000. ENjTB/84 WHO Et·rRD Fl'J./ST/26 page 2

III S.JIlvIPLING l"lETHODS

The P~lest~ne refugees l~~ng ~n camps are under separ~te adm~n~str~t~on and have been excluded from the survey. Excluded were also people l~~g ~ m~l~tary establ~shments.

Jordan ~s adm~n~str~t~vely ~~ded ~to e~ght d~str~cts. Groups were allocated to the d~ferent ~str~cts accord~ng to population. No ~str~ct was allocated less than two groups. W~th~n each d~striot groups were ~str~buted between urban and rural ~reas accord~g to populat~on. A total of forty-one groups were selecte~ twenty-one ~n urban ~nd twenty ~ rural areas ..

The procedure for select~g groups ~ rural ~reas ~ns~de a d~str~ct was as follows:

The l~st of ~llages from the last census (1952) was obt~~n6d and ~th the ~elp of local author~t~es checked and adJusted ~n order to make ~t as up-to-date ::s pos~ble. Sm311 Vl.llages were comb~ed ~th ne~ghbour~g ~llages so that no ~llage or group of Vl.llages had less than 500 ~nhab~tants.

As a f~rst-stage sampl~n~ the requ~red number of ~113ges were randomly selected from the Vl.llage l~st us~g the populat~cn f~gures as we~ghts.

F~nally, as a second-stage sampll.ng, one household was randomly selected from the l~st of households to ~n~cate the f~rst household to be exa~ned. The survey team's census takers started reg~strat~on ~n the selected household and e6ntLnued ~ the houses w~th consecut~vely h~gher numbers ~ the l~st of households unt~l approx~atcly 300 persons had been reached. All persons l~~g ~ the last household were reg~stered ~rrespect~ve of number.

The select~on of groups ~n urben areas w~th~n a d~str1ct was performed in the follo~ng way:

In ~str~cts ~th more than one tOlm, the groups were d~stnbuted between the towns accord~ng to the number of ~nhab~tants. For each town where one or more groups were to be selecte~ a llst of houses was obta~ned from the tax collector together ·nth a map on wh~ch quarters or blocks were marked.

As a f~rst-stage sampl~g, the reCluued number of quarters or blocks were randomly selected us~ng the number of hcuses ~n e~ch quarter or block as we~ght.

F~nally as [),' IiIBoond-stClge sampl~ng, one house was randomly selected ~ each selected quo.rter or block from the l~st of houses. The survey team's census takers started reg~strat~on ~n the selected house 3nd cont~nued in the houses W1th consecuuvely h~ghcr numbers ~ the l~st of houses, unt~l appro~ately 300 persons had been reached. All persons ~n the last house were reg~stered ~rrespect~ve of number. w.:-ro EHRD EM/TB/84 BlI/ST/26 page 3

All persons belong~ng to the selected households were reg~stered. Temporar~ly present persons, ~.e. ~s~tors who expected to sleep actually dur~ng the night prior to the f~rst exam~nation day slept ~n the househol~ 1..rere also regl.stered and ~ncluded 1n the sample. Persons reported tempo­ rar~ly absent, 1.e. those who l-rere expected to be absent durwg the entlre survey per~od but who habltually slept In the house and ~ntended to return, were reg~stered but eXCluded from the sample. The temporar~ly absent persons Nere reg~stered ~n order to ascerta~n to what extent the populatl0n actually present dl.ffered from the res~dent populatlon. Infants of less than one month of age were also ree lstered but excluded from the sample as 1t was decl.d~d not to examlne them.

IV METOODS OF EXAMINATION

1. Tubercul1n Testl.ng

All persons attendl.ng were glven a Mantoux test w1th a dose of one tubercuhn Un1t (Mx 1 TU). The tubercuhn used was a PPD, batch RT 23, ~th Tween 80 adde~ prepared by Stat ens Serum Instltut, Copenhagen, The test was glven l.ntracutaneously w the ffi1ddle dorsal area of the left forearm. The transverse d~ameter of the result1ng 1ndurat1cn was measured w m11~eters after three days. The reader made no attempt to class1fy the react10ns as pos1t~ve or negat~ve.

2. X-ray Exam~nat10n

1\10 70 mIn photofluorogtams were taken of all persons attendwg whose age was ten years or more. One exPosure was made W1th the camera and X-ray tube pos~tl0ned aoout 4 cm h~gher than W1th the other exposure. The photofluorograms were read ~ndeT'endent ly by hm readers, and the abnormal shadows formed were descrlbed by t=~e and S1ze and classlf~ed as follows:

No pulmonary abnormahty 0 S~ngle or mult~ple calc1f1catLon (s) 1 F1brotl.c changes (scars) of an apparently cl~nically l.nsl.gnlf~cant nature 2 So11tary 1nfl.ltratl.on w1thout ca~ty 3 Hultlple lnf1ltratl.ons Wl.thout CBVlty 4 Slngle caVlty $ Mult~ple cavlt~es 6 Abr;(rmall.t~es vlh~ch could have poss1bly been caused by or res~lted from a tuberculous d~sease (e.g. pleur1sy ~ sequelae, hllar aden~t1s, thoracoplasty, pneumothorax etc. ) 7 Abnorma11tles not l~kely caused by or related to tuberculos1S (e.g. cysts, emphysema, heart and vessel abnormal~t~es etc.) 8 EM/TB/84 vlHO ZM 0 El-!/ST/26 pnge 4

3. Bacter~ologLcDl Ex~nat~on of Sputum.

A sputum spec1men vas collected from nIl persons attend~g 'mose age ,v2S 10 years or more. Ecch eA 'm~nee vms asRed to cough Vl.gorously and to sp~t ~to a small plastic conta~ner 'whatever 'vas present ~n the mouth 3fter th~ cough. A smecr was wade 1n all 1nst_nce~ str1ned by the Z1ehl-Neelsen method and exam~ed by dl.rect "l.croscopy US1.ng an Apochromate, a:;.erture 1,30, 100x 01.1 1mmerSl.on W1.th 8x compensnt1.on oculars. The technl.cl.an counted the aCl.d-fast bacl.lll. l.n eac~ f1.~ld of focus along two horl.zontal 11.nes extendl.ng from the edge of the sll.de to the ml.ddle ll.ne and two vert~cal lines extendl.ng from edge to edge. ~ach sll.de was read for 10 ~utes or as long as was necessary to detect Dnd count 3nd crunt 100 aCl.d-fast rods.

V Sl'IMPLE FOFULATIDN

The sample populahon (No.t1.onal Survey) cons1.sted of t 'Hty-tnree groups (10426 persons) of wh1.ch seventeen were selected ~ urban areas and s1Xteen J.n rural areas. Deta on the m.unbcr of persons reg1stered and exam~ed as well as the COVErage obtalDea for each type of examJ.natl.on are gl.vsn by group J.n table 1. The age and sex dJ.strl.butl.on of the sample populatl.on l.S presented :in table 2.

Excluded from the sample were 351 persons who were temporarl.ly absent, and 39 l.Pfants of less than one month of age. Trus 390 person~ or 3.6% of all persons repstered, were eXCluded from the sample, thus decreasl.ng the number of Males ~ the sample with 5.3% and the m.unber of females Wl.th 2.0%. The age Dnd sex dl.strl.butl.on of the temporarl.ly absent persons can be seerr£rom table 3, 'lnd the reason for theH absenteel.sm from t 2ble 4. It l.S noted that about 75% of the temporarl.ly absent cersons were males, and that about 65% of these were absent beciluse of work elser-there.

A total of 97.7% of the sample ~opulat~on was tubErcul~n teste~ and thel.r reac~l.on measured. X-ray examJ.natl.on was carrl.ed out among ge.~ of the sample po;,>ulat1.on t en years of age or rere, and 87.7% of the same populilt1on had thE.H sputum exam~ed by dl.rect ml.croscopy. VI RESULTS 1. Tubercull.n Testl.ng The results of tubercull.n test~ng are presented l.n tables 5-10. The frequency dJ.strl.butl.on by sue of reachen tot he I1x 1 TU test l.S s 'own lD fl.gure 1 by sex and l.n fl.g~re 2 by age groups. It Wl.Il be seen that l.n all age groups as well as l.n the populatl.on as a 'mole, the reactl.ons seem to fall ~to two groups, small reactlons ;nd Iprge reactl.C'ns. 1'he small reactl.ons are dJ.strl.buted nth a mode at 0 J1l171, and t he frequency decreases lnth l.ncreasl.ng age. The mode 1n the dl.stnbutl.on of large reactl.ons 1.S at 20 - 21 nun, and 1'HO DIDO EM/TB/84 EH/ST/26 page 5

the f~equ3ncy 10creases wlth ~ncreaslng abe. The two groups presuma~ly re­ present tl-J.ose not 10fected and t,oose 1nfected W1th the tubercle b:::Cllll.

A relatlvely clear scparatlcn bfot.reen the t.,TO groups of reactlonb lS seen 10 all age groups as Nell as ln the populatl0n as a whole. Some overlapPlllg occurs m;;klng lt JJIlposslble completely to elim1nate errors ,\-Then classlfYJ.ng the llldlV1dual reactlons 111to pCSltl'Ve and negatlve reactions. However, the error made by settlng tl'e hmlt between the negatlve and POSltlve reactlons at 10mm ll1curatlcn lS small, as the number of negatlve reactlcns classlfled as posltlve W111 be small and to some extent balance the posltlve react lens claSSllled as ncgetlve. Persons W1th a tubercullO react Lon of 10 mm or more are 111 tne folloWlng referred to as reactors.

A remarkably hlgh percentage or persons Wl.th reactlons of 26 mID or morw lS seen 10 all age groups. 1 aXJ.InUlll lS reached mth 16.5% l.D females in the age group 40 - 49 years. SlX and a half per cent of all- females and 3.5% of all males have lnduratlons measurlng 26mm or more. The correspondlOg percentages found 10 che Amman Survey were 0.7% and 0.6% respectlvely.

T~e age 1nfectlon curve has been constructed on the assumptlOD that the percentage of reactors among all persons tuberculln tested can be used as a ~easure of the prevalence of tuberculous infect lon, see flgure 3 and kble 11.

A steep rlse lS seen for both ~ales and females l.D the abe group 0-14 years lndlcatlOg a r.lgh rlsk of 1Ofectlon 1.D recent years. After the age of 1::; years the curve for ma]es conhnues to nse rapldly untll the age of 50, vrhen 78.8% are lnfected. The curve for females nses some,mat more slowly afcer the age of 15, end rcec~es lts "JanmUlll Tnth 71.4% at the age group 50 - ifJ years. One of the "OSSJ ble explanatlons of the 10irer rlsk of 1nfecilOn for females after the age of IS yearn could be theu rc::luced chance of mcctJ.ng sources of lnfectl0n outslde the~r aim faml1y, belng restrlcted by soclal customs. As the soclsl customs are more strlctly kept In urban t~an In rural areas, vmere wOIllen have to \fork ~ the fleld, fO to the T-roll or rlvers, etc., where they .neet "lIore people outslde theu own household, the lmver rlsk of lnfectlon for females Should be more pronounced ln urban than l.D rural &reas. However, the small Slze of the ma ccrlal does not allow for supportUlg thlS statement by statlstlcal tests. The dJ.fferences observed In the rates of lnfectJ..ons shoWlng h~gher rates for males than for females are stJtJ.stlcally sl~nJ.flcant both In urban and L~ rural areas. (See table 12 and flgure 4). rable 12 ~lso shows that che male lnfection rate lS h1gher ln the urban than lD the rural areas, and that tOls holds true for most of the age groups. Also for females the urban rates are GLgher than the rural rates In most of the age groups. It has nrt been rosslble to demonstrate a statlstlcally slgn~lcant dlfference between these lemale status. The overall prevalence of tuberculous lnfectlon lS e;tlnated to be 34.9%. ElI/TB/84 EN/ST/26 page 6

Dur~g the tubercul~ testln~ the left deltcld regl0n was exam~ed for scars posslbly resultlng from preVlcus BGG vacclnation. Such scars .rere reported for 22.7% of the exemlnec persons ( see tables 13 and 14). It lS note'l-Torthy that 70% of these persons exhlblted tubercul~ reactl0ns of less than lOmm. ThlS low post-vacclnatl0n allergy could have many causes. It could for lnstance be, that the effect of the BOG vacclnatlon had ,.. aned off, or that the OOG vaCCl""e for scme reason had lest lts potency, or that the orlg1n of the scars had been mlslnterpreted.

Comphcations ca::urred J.n the form of veslcula or bullae only. Two persons were reported to have developed veslcula and 117 had developed bullae. It WJ.ll be seen frcm table 15 that no comphcatlcns occurred ~ persons m.t\-l a tuberc1.il~ reactl0n of less than 16 mm.

2. X-ray ExamJ..nation

The results of X-ray eXamLnatlon are presented by sample groups ln table 16 and by age and sex J.n table 17. A total of 6873 persons ,ere eXamJ ned, and abnormal lung shadows Fere found ~ 3022 (44.0%). Calc1f'led or f1brotlc lesJ.ons were found ~ 2139 (31.1%~ lung shadows poss1bly related to tuberculosJ.s In 163 (2.4%), and 644 (9.4%) had pulmonary pat:'ology that was unhkely to b" related to tuberc~loslS. Lung sradows lnterpreted as J.nfJ.ltrates WJ.thout caVlties were found ~ 64 (0.9%) persons, and 12 (0.2%) had caVlty lesJ.ons.

The dJ.stributJ.on by sue of reactJ.on to Mx 1 TU of persons l11th and W1thout pulmonary pathology 15 presented In table 18 and fJ.gure 5. It 1S observed that 28.9% of the pers0ns 'ntb lnfiltrates (mth or TJnthout cavitary lesions ) have an lndurat2cn of less than 10 mm. It lS known that some tUJerculous cases do not react to tuberculin, but tbJ.s lS only 1n rare L~stances and cannot explaln the substa~tlal proportlon of ron-reactors among persons 111th lrfJ.ltrates ln tels watetlal. It has already been s~own that the Ex 1 TU test clearly separ_tos the populDtlon lnto reactors a.'d non-reactors. It must therefore be assumed that the J.nflltrates found ln non-reactors are of non-tube culous orlg~n. Thus only ~he 54 reactors }nth lnfl1trates, 1.e. 0 .. 8% of all persons examined by X-ray, sr.ould be regarded as cases of pulmcrwry tuberct,loslS. Tras flgure can at be censldered accurate £:s some of the lJ:1flltratEs fc·und ln non-reactors rr~[,ht be of tubfrculous orJ.gJ.n. On the ot' er hand lt could ~lso be th~l :ome of the inf11trates found ln reactors we-re of non-tuberculous orlgln. As trese cases cannot be 1de tlfled, hov,ever, they can lot be removed from tne res~ectlve gr0up~ and no correctlon can be made.

It was found ln the Amman Survey, that actlve pulmonary t.lOerculos1S 1S ~ore prevalent ln rural than 1n urban areas, 4.4% aga1nst 1.2% res~ect1vely (excludlng non-reactors). The Natlonal Survey glves an lndlcatlon of the same, ra~ely 1.0% ~ rural and 0.6% 1n urban areas (see teble 19), and th1s J.n splte of the fact t at thE h1ghest rate of tuberculous lnrect~on lS found 1n t~e urbaJ:1 areas. One explanatJ.on of thlS apparent dJ.screpancy could EM/TB/84 EM/ST/26 page 7 poss1b1y be found 10 the eX1stence of better overall nealth services 1n urban areJs, glV1ng cases of tuberculos1S a better chance of be1ng trontad. Tr~s 1S espec1ally 1n Amman, where there lS a concentrat10n of ~OS91tals and cl1n1cs ana W1th the pr1nc1pal Tuberculos1S Centre 1n the ccuntry rece1ved a slgn1f1cant number of referrals from med1cal practitl0ners and 1nst1tut1ons. The lower percentage (28%) of 1nact1ve tuberculos1S (calclficatl0ns ond flbrosis) In urban areas aga1nst 34% In rural area~ should tren posslbly indicate th~t many cases have b2en treated early enough so as not to leave any calcl£icatlons or f1brosls.

3. BDcterl01og1cal ~lnatlon

Altogether 6126 sputum speClIDens were collected and examlOed by dlrect l1ll.croscopy. The results should, accorct1Dg to the protocol used, be recorded as a three dlglt code number 1ndlcatlng the number of aCld-fast bacl11l detected and the tlme spent In readlng. No flndlOgs were however reported In thlS way. Twenty-nlne speclmens were reported to co JtalO "red rodsll or 1I1lke red ::-ods lI • It has been decl.ded not to accept these .l.1rdlngs as POSltlV3, and t' lS declslon lS relnforced by the fact that none of the 29 ~ersons sho.red any relevant chest X-ray shadows.

VII CONCLUSIVE RESULTS OF THZ J:'ilO STJrlVSYS

The Natlonal Survey was c0nducted In the same ;18Y as the Amman Survey, the protocol used was the same, and the Jordan Natlonal Team was tralned by the Wi-IO Reglcnal Team. It should therefore be allowed, duectly to add up the ~esults of the two surveys, alloWlng of crurse for personal factors such as dlfferences In tre tubercul~n test readers' readlOgs and the doctors' lnterpretatlon of X-ray shadows. There is rowever no reason to· belleve that personal factors have had a considerable lnfluence on the results.

'rhe lOfectlon rate lS presented by age and sex for both surveys 10 table 20. It Wlll be seen that the rates for the two surveys together are only sllghtly.hlgRer than for the Natl0nal Survey alone. There lS no Qlfference In the lnfectlon rate for the two sexes In the age group 0 - 14 years, but males have a hlgher rate than females from the a~e of 15 years ana up. Abcut 30% are lnfected at the ~ge of 12 - 13 Years irre~pectlve of sex. 60% of the males are lnfected before the age of 30 and 6c%~of the females before the age of 40. The overall lnfect10n rate lS est1ffiated at 36.1%. The X-ray flndlngs are presented for both surveys In table 21. It Wlll be seen that 126 (1.5%) of the 8337 Jersons examlned had lung shadows lnter­ preted .:s lnflltrates Wlth or -'l.thout cantles. Out of the 126, only 94 shoued a reachon of 10 mm or mote Lo the Mx 1 TU test, and only Lhese 94 (1.1%) can be regarded as C3seS of pulmonary tuberculoslS. !!M/TB/84 IlHO ::.:t1RO :&IjST/26 page 8

VIII S Ulli.:ARY

A country~~de tube£culos~s rrevalence survey has been crnducted kn the Hash€m~te K~ngdom of Jordan. The survey has been carrled out kn two ph~ses, the flrst phase (the Amman Survey) was conducted by the Regl0na1 Tubercu1os~s Survey Team of the w::n .aeg~onal Offlce for the EasterI' Me~terranean and the sec0nd Dhase (the Nat~onal Survey) by the Jordan Nat~ona1 Tuberculos~s Survey Team.

The results obtJlned ~ the Amman Survey have bEen publ~shed ~n the ~IRO report "Tuberculos~s Survey ~ Anman, the Hashem~te Kl.ngdom of Jordan". The present report deals ma~nly ~th the results of the Nat~onal Survey and presents some overall estlIDates.

The NatlOna1 Survey compr~sed 33 groups (10426 persons) selected by . random sampl1ng. All persons selecl.ed uere examined by three sttmdlirdized ~2gnost~c tests.

It nes found that about 35% of the total po"pu1ahon were .l.I1fected by tubercle bac~ll~. 50% of the males were ipfected before the age of 25 and 50% of the females before the o?e of 35 years. A steep rlse kn the lnfect~on r~te kn the age group 0 - 14 years 1S seen for males as well as for females ln~catlng a h~gh rlsk of lnfectlon L~ recent years. Aft~r the age of 15 females ~re less lnfected than males.

Abnormal lung shadows 'Here found ~ 44.0% of the 6873 persons examned by chest X-ray. CBlc~f~ed or llbrotlc les~ons were found in 31.1% and lung shadows poss~bly related to tuber(uloS1S In 2.4%. Lung shadows lnterpreced es lnfl1trates wlth or Wlthout cBVltles were fcund In 1.1%. About 70% of those lI~th ~flltrates wlth or 'Nlthout cantles s:'owed a rcactlon to the Mx 1 TU of 10 rom or Mcre, and vnly these can be c~ns~dered cases of pulmonary tuberculos~s. The total number of caseS found was 54 (0.8%).

Add~g up the results of the two surveys ~t can be estl.mated that about 36% of the total population of the Country are ~nfected by tubercle bacJ.ll~. The age infeot1on r~te 1nd1c~tes that 30% are lnfected before the age of about 13 years and 60% before the age of about 35 years. The ~fectl.on rate ~ncreases more rrpldly by age ~ males than In females. It can be est~ted that 1.1% of the populatlon has actlve pulmonary tuberculoslS. WO Et1RO Table 1 E}JTB/84 F1If/Sl,/26 Sample l)0p..ul.~tJ.~1. exam], atl.ons ':!one and extent of partlclpatl0!1~ Annex I page i

- .,------~ -- • I Sam 1e ]'0. of per~ons -- Tuberculln I l!.xalll1ned Coverage obta1ned p lncl. In sample j Sputum Group All ages !1.0 vears T A tested &read by examl.ned IrUberC'!llj '{-rayJ'Jputum No. &. over (llX 1. TU) X-ray t"st d no e ,n~r1 ------t- +------" Et !;U!.a!!ll.""" _~a.m~ 09 308 j 203 18 292 200 195 94.8! 93.5 ! 96.1 10 291 209 1'- 36! ____ 275____ 1- ___20~ 209 94.5 _~ _ 9_S:1-jlOO.O 11 301 ~~~_; 23 i 297 _ 195 ____19~ _ ~a.7 _ 98.0 l ~8:~_ 12 309 199 ' 16! 300 196 193 97.1 9tl.5; 99.5 13 311 - -..... - 205 --t- -1-4 - .! -----3-0-2------2"01-- r-199----97.-1- t--9d-:-or-97-.1- ---I ------1---. ----- 14 318 212 11 291 20b 208 91.5 913.1 98.1' ------1------15 310 201 22 296 IuS 201 95.5 93.5 100.0 I t-- 16 --i5 - 21.4 + -U--~----306-- -- 212--- 211 -+ --97:1. ----99-:-;- 98.6 ------r------17 316 261 1.1, 305 259 250 96.5 99.2 95.tI '------r------18 310 1.97 12 301 195 172 97.1 99.0 87.3 - --+--- - 1------.------1.9 31.5 217 13 307 216 200 97.5 99.5 92.2- 20 f , 317 --+_21-8__ --7_l- __ 315 ~ --=~~o 200_ 99.4----100.0: 91.7 r -t- ______21 J 320 226 7 320 221 210 100.0 97.e 92.9 ~ ~---+------_. i 1 ' ' r 22 I 319 219 6 313 218 201 98.1. 99.5 91.tl • 23 322 207 5 I 320 204 Id8 99.4 98.6 90.8 0- -+- - -- - 1---. I 24 316 212 10 311 209 188 98.4 9d.6 88.7------f--.--- I I -~ ----- ._- 25 322 239 7 313 233 206 97.2 97.5 86.2

* Excludlng TAe and l11fants of less than one m'lnth of age. ../ .. WHO EMRO EN/TB/84 Table 1 (cont'd) EN/ST/26 Annex I Sample ;oopulat:LOn, exarunatlors done and extent' of nartlclpatlons page II

r------r------,-"------~------~------~- -~------~--~ Sample No. of persons Tuberculln E d Coverage obtalned * I xaInlne . lncl. In sample tested & sputum 1----.1--- Group TAdf ' All a es 10 years rea by examJ..ned Tube rcul In X-ray Sputum No. _ g .~_a:r..e_r:.__ (YJX 1 T1T) X-ray tested examlned eXCfl\J..ned

26 323 212 5 322 205 185 99.7 96.7 87.3 27 322 214 4 316 205 - 174 98"1-95.~-,---er:Jl 28- 324 237 3 315' 233 201 97~2 r~~ to 29 321 216 ==r 3 320 215 - 176 990---99.5 1-- 8in =30 -. 325_ 226" I 4 322 _ _ 221 ~_9~~~~ - n:tJJ 86n I- 31 308 217 18 298 213! -~l 96.8 -"I-- 90 ~ . . - 32 320 199 I 2 I --w;- 196 -I 160- -)--98,4---"9b 33 --321 200· 5 I - 319 - 200! 169 'L-- -99~4-- ""''lGo t------+-- . -~ ----0-- J -:-----=-.;- L 34 318 199 7__ J 310 -t- 196 I _' . '-I'{.';;~. . ~, 156 . - _._. - I 'jJ , tth __ 99.1 - --- 2: -I 3~ 204 .. 321 J 2==--'__ 6 4", ..:.~_ l 99.0 t_ 99.0 - 7 .5--1 36"1313 197 16 310 196 J-. -r- 0 1 --97.5 _99, 8'2 37 322 205 7 _ 314 201 L_-=-~ 141 __-, , ~ 98 0 +--- - 2-1 .~_ I 97.8 . 1 Jo.5 t.--:~ 322 194 8 L. 315 ~_ 192 ! _ 96.b- 39 I 315 203 12 I 305 I 199 I 15~"- 40 314 220 14 309 r 218 '.~;----_ .. 41 314 206 6 310 -203--' -- -- TOT~ 10426 6987 351 ____ ..~~~~5__ _~ __~b 73 l 6126 < Exc1udlng TAs and lnfants of less than one month of age. WHO EMRO EM/T3/84 EM/ST/26 Annex I page U.1 Ta)le 2

The Sample Populat10n oy Age and Sex

Percentage Age Group Both Sexes Males Females (years) Males Females

0-4 1830 953 t 877 19.1 16.1

5-9 1609 I 826 783 16.6 14.4

10-14 1572 811 761 16.3 14.0

15-19 1088 524 564 10.5 10.4

20-29 1313 517 796 10.4 14.6

30-39 1011 393 618 7·9 11.3

l.iO- 49 724 318 406 6.4 ---7.4

50-59 523 258 265 5.2 4.9

60 + 756 379 377 7.6 6.9

TOTAL 1.0426 4979 5447 100.0 100.0 , WHO EMRO Eh/TB/84 EH/ST/26 Annex I page ~v Table 3

Temporary Aosentees * D~str~but~on by age and sex

Percentage Age Croup Both Sexes Nales Females (years-) I Hales F8l'lales

0-4 17 8 9 , 3.1 9·9

5-9 18 9 9 3-4 9·9

10-14 31 I 20 11 7.7 12.1 , 15-19 I 17 15.0 18.7 - 56 39

I I 20-29 I 85 70 15 26.9 16.5 1 , .30-39 50 41 9 15.~ 9.9

40-49 48 38 10 14.6 10·9

50-59 27 20 7 7.7 7.7

- {jJ + 19 15 4- rf;,8 -L .L,

TOTAL .351 260 91 100.0 100.0 I

* Exclud~ng 39 1nfants of less ~han one month of age, 20 males and 19 fe"'lales. ~!/'IB/84 EM/ST/26 Annex I nage v

TO-ble 4

Reo.son for absenteelsm sy age ~nd sex*

Age REA S ON F OR A BSE}"T EEl S 1 Sroup Sex Worlnng PbysJ..c~~ HospJ..t-::.- VJ..sltlng IDncoope- Unknown TOTAL (yrsf elsewhere IJ..zed uni'J..t r~tJ..ve reason

m .. 6 2 8 0-4 - -- f - - 9 - - - 9 m - .. - 9 -- - 9 / 5-9 1 f - 1 8 - - - 9 m II - 9 - -- 20 10-14 f J - 8 - - - 11 , m 25 L',. - - 39 15-19 - - f 2 1 JL - -- 17 - - m 49 , - I 2C - - 1 70 20-29, f 1 ~ 11, - - - 15 , I'\ 30 - 11 - -- 41 30-39 f - 1 8 - - - 9 m 35 - 3 - - - 38 "0-49 f 2 1 7 10 - . - - - m 14 - 6 - - - 20 50-§9 - I f 1 1 5 - - - 7 I

m 10 ~ 15 I 5 - - - .! I 60 & I more f - - 4 - -- 4 Sub m 169 - H8 - - 3 259 Totd f 9 5 7? - - . 91 :;;:::::======~===~==l====="",======.=::::..::======-= ;=~===:====r===:==== F=~===9 TOTAL 178 5 165 3 350

* Excludlng 39 lnf~nts of 1QSS th~n one Month of o.ge. Table 5 WHOEMRO EN/'fB/04 Dlstr1but1on by S1ze of react10n to ~~ 1 ru ~ speclfied age-group E:·1jST/26 1,nnex I MALES Indurat10n ~n rom page V1 Total Not Age 1 2 4 5 6 7 B 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 te stt.U tes- Group 0 3 + & read ted (yr&') - - 1 1 2 932 Pl 0-4 769 IG 94 26 -6 2 2 - 1 3 1 - - 1 1 - 1 1 - 1 1 - - , - - ~ 2 2 020 6 5-9 469 15 164 51 12 13 10 3 7 2 4 1 5 5 3 5 7 6 9 7 6 3 2 3 4 - 16 23 17 21 11 9 9 6 11 12 800 11 10-1~ 215 12 136 56 27 19 16 7, 17 12 9 9 21 11 12 9 17 - 11 17 501 23 15-l9 104 3 64 49 23 19 d 7 6 3 16 S 1S 10 11 17 12 12 19 14 16 14 10 9 7 --f--- 11 11 29 4B6 31 20-29 107 -3 5± 23 -12 4 13 7 4 5 12" 6 ,- 8 8 20 15 12 19 15 12 35 9 20 15 , , d 6 1 4 2 6 4 6 6 13 13, 23 27 32 14 27 11 19 17 20 363 30 30-39 50 3 21 11 5 3 3 , - - -- - 1 ' 1 ' 9 8 11 12 21 24 14 25 16 20 15 13 19 25 306 12 40-49 20 - 14 9 7 3 3 4 4 4 , 4 , I cl 1 6 4 1 5 10 13 12 7 15 l.8 If 26 15 U 6 11 6 21 251 7 50-59 18 - 4 4 5 3 7 , , ------1tl 12 12 12 31 364 15 60 + 29 1 14 14 3 6 9 3 4 6 12 7 12 10 17 Itl 19 15 23 17 24 13 ------80 84 87 169 4823 156 TOTll1 1841- 55 562 247 102 70 69 42 51 3d 68 33 81 62 91 94 98 122 155 12Q Id6 93 fL23 I - -- Table 6 WHO EMRO EH/TB/84 DlStrlbutlon by Slze of reachon to I1x 1 TU In spcclfled aec-£irou£ El"I/ST/26 Anrex I FE.IlJ.lU,E S Indurntlon In mm page Vll ---r- Age - rr otcl Not 26 fl-csteu tes Group 0 1 2 3 4 5 6 7 v 9 10 11 12 13 14 15 16 17 10 19 20 21 22 23 24 25 - rend ted (yrs) + -- --1----f- 2 - - 1 2 4 I 863 0-4 715 13 101 11 5 2 - 1 - - 2 1 1 1 - - - 11 - - - , 1,41

6 I 6 6 6 5-9 432 It! 149 53 19 B 7 7 4 5 1 3 2 2 - 3 12 6 6 5 5 4 4 4 777 I - 10-14 225 8 133 65 35 26 12 14 15 9 9 5 17 11 7 I 9 6 14 23 10 29 10 19 9 7 12 14 753 8 - - '------' .., I, 8 14 10 12 14 31. 560 4 L)-19 108 7 III 60 25 20 9 5 6 6 8 3 15 11 -.> 3 10 16 7 18 -- 10. 20-29 184 8 130 75 25 IJ 11 6 9 5 114 1 9 6 12 15 3 13 2l 1.6 40 16 18 15 1.5 20 62 780 . -- 9 69 5 80 55 17 23 10 9 9 3 11 2 5 1 9 11 6 13 21 14 33 17 25 19 33 31 78 609 I I 30-39 I - 1------40-49 31 1 33 22 12 10 9 3 5 4 3 4 3 6 4 10 8 9 17 141 30 19 24 16 16 1.6 65 394 12 - - , 2 6 6 8 8 8 17 13 10 14 29 259 6 50-59 16 2 14 18 5 9 4 2, 3 1 12 5 5 9 111 22 , - -- - '- 8 10 367 10 60 + 34 - 24 17 17 17 10 11 4 6 6 6 9 8 11 9 11 15 16 9 13 17 10 1.2 57 - - TOTAL 1814 62 789 376 160 133 72 58 55 39 66 27 66 52 67 69 47 91 /134 87 193 100 132- 99 105 123 346 5362 85 I r-tl;b1e 7 \'lli0 ENRO E~1/TB(()4 D~str~but~on by s~zc of re~t~on to MX 1 TU ~ spec~f~ed age-group EN/ST/26 , , ' rorr-I SE.XES Annex I Induro.t~on ~n mm- age Vl.~~ Age Total' Not Group 0 1 2 3 4 5 6 7 B 9 110 11 12 13 14 15 16 17 13119 20 21 22 23 24 25 26 tostec tcs- , + (yrsl , I & H.(lC ted i - , 0-4 14el4 31 195 37 11 2 2 3 - 1, 5 , 2 1 1 1 1 - 2 1 - 3 1 - 1 1 3 0 1795 35 I ' I ~ 5-5 901, 33 313 104 31 21 17 1.0 11 I, 51 4 7 7 9 11 7 9 21 13 12 8 7 6 6 7 10 1597 12 , 10-14 500 20 269 121 62 i 1.5 2tl 21 32 211 18 14 ' 38 22 19 1ll 22 31 46 27 50 21 2d ,118 13 23 26 1553 19 - - - l5-19 212 10 181 109 4tj 39 17 121 12 9 24 8 30 21 24 20 1,.6 22 35 2l 34 20 21 i 2l 4lJ 1061 27 - 1---- -j~~ f--- t--.L--1-- 20-29 291 11 1::;9 90 37 22 24 11 13 10 26 7 17 14 32 30 15 37 36 28 75 25 3[3 30 26 1 31 91- 1266 47 - 30-39 119 d 10l 66 '25 20 13 15 12 4 15 4 11 5 15 17 19 26 44- I~ 65 31 52 I 30 5'2 415 106 972 39 -- ,-1---1- 40-49 51 1 47 31 19 13 12 7 9 5 7 5 12 10 12 2l 20 30 41 28 55 35 44- 31 2>' 35 90 700 24 , - - - I , 50-59 34 2 1:3 26 9 10 9 5 9 8 16 3 10 16 1el ]8 16 23 26 23 40 23 ,30 119 21- 50 510 1-3 201 - - - 1 I 60 + 63 1 3tl 31 20 23 19 14 8 12 18 13 2l 18 20 27 30 33 39 26 37 30 28 24 20 221 88 731 25 i I - - , TOTAL 3655 117 lJ51 623_~ ~~~2:4=- 100 =-~6_.'!2 ~~. _~1.47 ~14 tl5~ 163 :45 213 28~2071379 :~~ ~55 ~79 189 21~~1! ,10185 241 - I-- T'1ble 8

Percenta§6 Dl.S'j;rlhu"tJ..on by 6J..Z6 of react:lon to Hx 1 'lU by .'lge-group WHO ENRO .3l"1/TB/d4 :MALES J!.,Jl/ST/26 l.nn€x I Jla~ge IX Age o 2 4 % 6 % 8, % 10 % 12 % 16, % 18 % \20 26 ctaJ:..-] Groun % % 1 1 1 % 141 % 1241 % t I 1 1 3 5 7 9 II 13 15 17 19 21 % ~; 25 + ~v·te . (yr,) ) &. z 2 0- 4 1787 ~20 2.9" 6D.? 40.4 10.1 40.4 -' - I 21°·2 U~"r'l:112 '.2 - -rt' I ~'2'F~ .~S4 (59.0 F15 26.2 25/3.0 I 13 1.6 .9 1.1 5 0.6/ 10 L; r- 8 ,1.0 t I~J.6 161;.~- 9 -,1 o.5T-5 0,6 ~).5 ;; ~I_"" !J5.9 ~92 "".~ F I;;-L::\2-:91~~l': ~3 !32 E~_k2112.61!!f~l~ [~32 - i.j; 2~J l7 [1 i]:,~5 BOO , 25 2 r ~5.19:::'? , 21, J IUJ 1: . -" ',s '-!-::) e.fP"·a )''-IV i 2'J j :':.l':::~~ '.;:'"+31 t~'_". '-'--t L: ~G I: ::..1.:" t' ,', , '::" 7 ~9" 110 :'2.~ .:'f·: ,r 16 ~~~'~=- 9t::. i'B 13: 1.16 13~ _3:1::(: 'j "::" , ':I' ~~ ?':..:' j ~ '_I '_2J 4·:yt~J~:. I13 7 ~39, j3 1l4.61:Ti b 92.51 41-~L 6 fl:6bJ 2.7 .c2 !3.3 t~!, .2 !~o hed 146 ~' 1.'0". r" :J.!".l ~ 9~-'=f' _~:J ~D-49 :0 6.5 23 ?5l'-~J~::L7 2.3 5l.~~ 1:.:: 13 r:;- 19,:6.2' :?2.f~!~ 41~+:}:.'"j!'lo.ji 2:l8:~_ .. :G6 I ~O:-~9___ J!8 7'?_r-~?'-~~~~ 3~.2 13 5.2 1200 l5_ ..6.0 25:9 91 22 13q'I' ;WIll:': -41116.3 19 L~.. b 17608_.-==_ -251 pO + 30 8.2 28 7.7 9 2.5 12 3.3 10 2.8 19 5.2 22 6.0 35 9.6 3710.2 40111.0 37 10.2 ~o fS02 24 6.6 31 8.5 364 ~"'''''''======~======"'=, === =="'~======f======1======~=F======--" ===, ====, === -======, === ="'''======TCYrA.L 1896 39.3 e09 16.8 172 3.6 III 2.3 89 1.8 101 2.1~.3 3 ..0 IS5 3.8 2204.6 -'2751-,5--.7 2!79 5.8 203 4.2 171 3.5 169 3.5 4823 Table 9

pepcentage D~str~butr0n qy 's~ze of reaction to MX 1 TO Br ~ge-group WHQ EMRO El"'/TB/84 FENi..LES ElM/ST/20 Annex I page x 8 12 18 20 Age I 0 % 2 % 4) % 6 % % ,10 I % % 141 % 16, % 22, % 24, % 26 %~Tota1 Group 1 1 % % ested , 5 7 9 11 13 15 17 19 21 23 25 + , (.vrr. r readl 0- 4 728184.41 112113.0 710.. 8 110.1. - 31 0.4 2 10.2 110.1 2 0.2 1 0.1 I 2 0.21 41 0.51 863 I -;1-~ 5- 9 27 3.5 14 1.8 9 1.2 4 0.5 4 0.5 12 1.5 3 0.4 18 2.31 11 1.4 9 1.2 I 8 1.0 6, o.Oj 7?7 10-14 61 8.1 26 ~.4?L 3.2 14 1.9 28 3.7 16 2.1 20 2,7 33 -'~.4 .39 5:2' 28!;:;/I9I' ?sl~~11.91 '153- I I I I I I 2 ----+-~ I l??bl,~l 4518.0 14 2.5L _2~i -:.~ ~.31~2.9L1~:L 23 I Z=. u :~r ~~t4~3-1 ~6r4.61-3~1 >~6 560_

213j27031 431).SI ~~2~~~_~1<; L.L.9 IS 1.9 f 2'713~l::j2.:....I~~J 4.~~L~h.21 ~~I~~.2j ]514_~_ 6:L~~t-?80 - 13s122<21 40 6.61 1913.l\12 .2.0113! 2.1 6 1 {) ~p 31'=9jJ.J 35 r~·'7t~~J 8'~L ~-=l~~L :~I.~~~L~]:~1._609 . 55113091 22 5.61 12 1300 9 2.3 7 ':,8 9 2'311413,61'~403 31l2.9]4::,~2.{~~.2 L32~:,LL5116.51 "94 , 5q-59 +- ~-:-_l __ J-_"_,-5~4 _,11, 4.2 f;14.2 1'716.6 '1917.;f;o ~61 c.3otu.6! 24 9.J pO + 34 9.3 4111.2 34 9.3 21~.7 10 2.712 3.3 17 4.6 205.4 267.1 25t6'8130 8.2 22l6.0 184.9 5715.5 387 ~;~~ F~~;~ ;;:~ F~:; ;~:;= F;;; ;~; ~;~= ;:: ;:= =~~; ;;: =~~;= ~~= F;:;' ~;: ;:; ~;; ;:~= F;;i ,::i ;~;=~_;_:; ;;~I ::;; F;;; "::; ;: =::;F;;:;= Table 10

M£O ,rno Percentage D~str~but~on by SJze of react10n to }~ 1 TU qy age-group EJ'!/TB/84 1l'1/S1' /26 BOTH SEXES Annex I page XJ. o 2 4 6 8 20 24 26 Total Age I % % % % % 10. % 121 % 141 % 16 % 18 % % 221 % % Group 1 1 % I tested I 1 II 17 21 23 25 (yrs) 3 5 7 9 13 15 19 + & read

0- 41 1515184.41 232112,9J 13/0.71 510.31 110.11 7/0.41 210.~ 210.11 210.11 110,11 41 0.21 110.11 41 0.21 61 O.~ 1795 5- 9 i 934 58.5 417 26.1 52 3.3 27 1.7 1.8 1.1 9 0.5 14 0.9 20 1.3 16 1.0 34 2.1 20 1.3 13 0.8 13 0.81-~0 0.6 1597 I --1- 1 --- - ~. 10-141 52033Q5 390 25.1 107 6.9 493.1 53 3.4 32 2.0 603.9 37 2.4 1407 71 4.6 46 3,01 36 2 J __ ~J:.L'L~~ 1 =- _L~ ~~~ 15-19 222 2M 290 2'7.3 b7 8.2 29 2.7 21 2.0 32 ~~,. :: If"~! 44l~ 2 3b~~1 5\ i5 .3t~J I-,.~ _.':'. ~' 'l:~2 L4_0. I,S 1.. 5 ) 06" 20-29 302 23G9 287 22.~ 594.7 37 2.9 23 L8 33 2.6 3112.41 621~.9L5~t<1' 6/'1.~:0!10;r 7.9 6~15c4j 5'7l~1 9:' ;::~--=26S 30-39 12'7 13.1 167 17.2 53 5.5 29 2.9 16 ).6 19 2.0 16 ,.6f 32~ ',1 4514.61st .E ~.9 8218.4 100 1O.31,06 10.~ 972 40-49 52 7.4 78 11.1 324.6 19 2.7 14 2.0 12\107 2213.1 3314.71 50 7.1l 69 9.9l 9012.9 75Pn7 64 9.2 9011209\ 700 50-59 I 3617.11 4418.611913.711412.811713.31 19p.71 2615.11 3617.113917.714919.6171113.914919.61411 8.015019.81 510

60 + I 6418.81 6919.414315.913314.512012.713114.313915.31 5517.516318.616518.916719.215217.11421 5.8188112.01 731 ~=====~====t====~====4====4===+===~===t===i===~===4===~===4=~=f===t===t===t===t===4===~===f===t====t===+===t===~=====4===4====t=~==== TOTALI3772137.011974/19.4146514.6124112.411.8311.8/194~.91261/2.6/321/3.1135813.51496/4.9/572/5.6 /43414.313991 3.9151515.0110185 Ej!:/TB/el.,. El-I/ST/2.6 'Annex I ~ge Xll

Table 11

EstlJllated prtvalence of tubE'l'r'ulous lnfectl.on EY <'ge and sex Total populatlon

MAlES FEI.w:.ES I;ICJ.ItH SEXES, Age . No. of t--Pers~ns with a No. of Persons with .:l. Ho. of Persons wlth a Group persons' tu~erculln perSO'16 tubcrcul1n persons tubercul1n tested reaqt:Lon of' tested reactJ.on of ,tested react:LOIl of (years) 10 mnl ana. more 10 mp and more lO mm and more N9 r',- No r' No. % " - .

0-4 932 ]);.. ~.5 863 15 17 1795 29 1.6

5-9 820 74 9 0 777 '"[5 9 7 ,1597 149 9 3

10-14 800 ·223 2( 9 753 211 28 0 11553 434 27 9

15-19 501 215 42 9 S60 197 3::' 2 1061 )+12 )88

20-29 486 25( 52.9 780 ::"{)1 38.6 ;1.266 558 44.1

30-)9 363 252 69.4 60g 329 54.0 972 581 59.8

40-49 306 241 72.8 394 264 67.0 ,700 505 72.1

50-59 251 195 77.7 259 185 714 510 380 74.5

60+ 364 275 75.5 367 227 61.9 731 p02 68.7 - TOTAL 4823 1746 36.2 '5362 1804 35 6 10185 3550 34 9 WHO EMRO EM/m/84 EM/ST/26 Annex I page XLii Table 12

Estlmated Prevalence of Tuberculous Infectlon by age, sex and place of resldence

Age MAIE::: Ft'EMAIES BCYT'H SEXF.

0-4 0.4 2.5 1 5 0.5 3 0 1 7 0.5 2.7 1 6

5-9 8.3 9.7 9.0 6 3 12.6 9.7 7.4 11.1 9.3

10-14 27.8 28.0 27 9 31 2 23.9 28.0 29.5 26.1 27.9

15-19 46.9 37.2 42 9 42.5 26 8 35 2 44 7 31 4 38.8

20-29 59.4 43.5 52.9 Jw 6 36) 38.6 48 4 38.8 44.1

30-39 74 0 63 2 69 4 56 7 51.8 54.0 64 2 55.4 59.8 -

-4<>-49 80.3 77 2 78 i3 61 5 72'T G7 0 69.9 74 4 72.1

50-59 75.8 79.4 77 7 71 9 710 71.4 73.7 75.3 74.5

60+- 73 8 76 7 75 5 64.4 59.8 61.9 689 68.5 68.7

Total 37.8 34.5 36.2 34.6 32.7 33.6 36.1 33.6 34.9

Total No. 2494 2329 4823 2691 2671 5362 5185 5000 10185 tested WHO EM1lD EM/'lB/84 EM/fJr/26 Atmex I page xiv Table 13

Scars from prevlous BeG Vaccinatlon

Sample Definite or %persons group doubtful tIo vlslb1e Not TOT A L with No scars scar recorded scars

09 28 268 12 308 9 5

10 62 221 8 291 21.9

11 31 200 10 301 lO7

12 71 232 6 309 23 4

13 85 220 6 311 27 9

14 8'2 214 22 318 27.7

15 92 214 4 310 30.1

16 121 190 4 315 389

17 96 206 I 14 316 31.8 ------18 108 195 7 310 356 ,

19 94 214 ( )15 30·5

20 80 233 4 317 25.6 i I 21 70 249 ;L 320 21.9

22 90 223 6 319 28 8

23 74 246 2 322 23.1

24 94 220 2 316 29·9

25 101+ 207 11 322 33.4

26 75 247 1 323 23.3 l·rno EMRO EH/TB/84 FJIl./ST/26 Annex I page xv TobIe 13 (cont1d)

Scars from prev~ou6 BeG Vaccination

Sample Definite or % persons group doubtful No v~sib1e Not TOT A L with No. scars scar recorded scars

27 60 258 4 322 18·9

28 97 224 3 324 30.2 29 101 216 4 321 31.9

30 76 242 7 325 23.9

31 96 2U3 9 308 32 1 32 64 256 - 320 20 0 33 21 295 5 321 6.6

34 38 277 3 318 12.1

35 59 260 5 324 18.5

36 49 253 11 313 16.2 , , 37 66 247 9 322 21.1 38 46 ::>68 8 322 14 6 - 39 48 265 2 315 15.3

40 21 289 .'[ 314 6.8

41 18 293 3 314 5 8

TOrAL 2317 7905 204 10.426 22.7 vTHO El1PD E11/TB/84 EM/ST/26 Annex I Table 14 page xvi

S~ze of t~berc~l~n react~on among persons w~th def~~te or doub1 ~ul scars, lnd~cat~g preV10us BeG vaccinat~on * All sample groups .------rj--·------r-I------~------, React~on I I ReaCT.lOn Percentage Nu:.be:::" I Nllr.'ber s~ze, rom i : SJze, rom D~str~but~on o i -----·--,------;------'-r------1,)(,2 1 0-1 582 \----...;..---\:--'---1i 25.5 1 I 20 I I t--~2~---'1:---::.~;7') -j 2-3 I 622 27.2 3 __. ______-+I ______~------~ 4 106 I i 4-5 191 5 I P5.ji -+------~------~------; 6 I 63 ! 1---'-';7::"'---1 ~- 46 I 6-7 109

8 I 51 I 8-9 80 9 , 29 10 1.2 I .-J 10-11 72 11 30 I 12 12-13 109 4.8 13 : 45 I 14 I 56 11 -15 98 4 3 r-~15::...---I·~-~42~-~i------rr!------+------·------~ t-__l...;;6 ____ :, __...... ::;3..;.9 __ : 16-~.N • r9 3.9 t---'1~7____ ~ __~50 ___ rl------__ ~:------_~------; 1--__19'-- __ {__ ~7a_, ~8 :!.9 I 1 ') Ji 5.2 ]('l I 41 I I 1-_2.;.O___ ~ __ 5~ ,1------_;;--1---- 'l7 I 20 ?1 -t ?~ I I ! ~------:.-- i ------~:------~,------~ 1----",2.;;;.2 __'! 2'3 ---l ':2 -23 I 59 2.6 1--.....:;;24::.---~r---J~q~-+--2-4-_~·:---44----:----1~::-9---T23 1 31 '1_ I

1--__25~ __~,~--2-6.---1------+,------;_------_; 26 + J Jl i 26 + L 31 1.4 --=====,======*,======~======4I I TO':'1.!. I 2283 I 2283 100.0 I i ,

* Exclud~g 34 person3 not tested ltJHO EHRO Eh/TB/04 .t;.H/ST/26 Annex I page xvu. Table 15

Type of tuberculln reactlon ani lts relatlon to reactlon Slze - Total sample pouulatlon

Induratlon ~nd ~Induratlon Induratlon - TOTAL Cmm) only VeSlcula Bulla Pustulll Ulcus

o - 9 6635 - - - - 6635

10 - 15 776 - - - - 776

16 - 17 353 - 5 - - 358

18 - 19 487 - I 9 - - 496

~ 20 - 21 557 2 13 - - 57? - 22 - 23 421 - 13 -- 434 -

24 - 25 381 - 18 - - 399

26 + 456 - 59 - - SIS

TOl'£,1 10066 2 117 - - 10185 ~I/TB/84 EM/ST/26 Annex I page XVJ.U. TablCl 16

Results of X-ray eX'I'l'natlon oy sample group

No. of Percent- Sa'ilple persons X-ray Code Total Not age Slg- group ellp- * exam- exa- mfl.cant ITo. ole for 0 2 lned ml.ned Aonor. exa.'ill.n. 1 3 4 5 6 7 8 (codtlJ-6' 09 203 165 26 - - 4 - - - 5 - 200 3 2.0 10 209 138 36 - - 3 ; - 12 16 205 4 1.5 n 199 96 74 - 6 - 2 - - 9 8 195 L. 1.0 12 199 112 65 4 - 1 - - 1- 13 196 3 0.5 13 205 156 30 . _1 - - - - 1 13 201 4 - 14 212 171 24 - -- - - 1 12 208 4 - - 15 201 167- =tg - rt - 1 1 188 13 • , - - - - I 16 214 175 29 - - 1 - .J 4 212 "to 0.5 , - - - 17 261 215 31 ? 2 1 - - 1 7 259 2 1.2 18 197 169 20 -:. - 2 - - 2 2 195 2 1.0 19 217 135 71 1 - - - 1 1 7 216 1 0.5 - 20 218 128 71 3 - 3 - 1 7 5 218 -- 1.8 21 226 87 120- - 1 1 2 - - 7 3 221 5 1.4 22 219 96 105 - 1 1 - - 4 11 218 1 0.9 23 207 105 PO 7 - - - - 7 5 20l.! 3 - 24 212 115 90 2 2 209 J ------25 239 R2 128 - - 8 .. - 11. )-1 2JJ 6 3.h

• .,1 •• ~ For lnterpretatl.on of X-ray code see pa~e. 3 WHO EMRO EH/TB/84 El1/ST/26 Annex I ;Jage nx

Table 16 (cont1d)

No. of Percent- Sample persons X-ray Code Total Not age Slg- group ehgl.- exam- e~ m. fic ant 1'-10. ole for l.., c: lned med Abnormal. 0 1 2 3 -' 6 7 8 eXB.' 'In. [(code 3.. 6 '

26 212 102 BO 1 - 4 1 - 11 6 205 7 2.4 27 214 131 53 2 1 3 - - 11 4 205 9 2.0 28 237 103 92 3 - 1 .. - 11 23 233 4 Q.4 29 216 104 52 19 - 2 - 1 4 33 215 1 1,11 30 226 117 39 6 - 3 - 1 - 55 221 5 _I 1.8 , 31 217 105 53 2 - - - - 2 51 213 4 .. ,... 32 199 99 50 6 - - 1 3 II 23 196 3 2.,_0 33 200 56 74 29 - 2 -- 4 35 200 - 1.0 34 19J 46 92 6 - 2 -- 1 49 196 3 1,0 35 204 63 64 10 - 2 - - 7 36 202 2 1.0 36 197 89 32 1 - - - - 6 68 196 1 - 3';' 205 68 67 1 - 1 - 1 4 59 201 4 1.0

38 194 38 97 2;3 2 2 -- 5 25 192 2 2.1 .. 39 203 130 25 7 - 1 - - 1 35 199 4 0.5 4:> 220 129 36 17 2 3 - - 7 24 218 2 2.3 41 206 159 14 22 - 1 2 - - .5 203 3 1.5 70TAL 6987 3851 1958 181 9 5S 4 8 ,163 644 6873 114 1.1 I I

" For lnterprctatJ on of X-ray code see page.3 EM/TB/84 EM/ST/2.6 Annex I page :xx Tacle 17

Resu1 ts of X-ray eXaffi'l nahon )y age and sex

Percentage Age X-ray Code ·-c Tota" Not S l.e;n1.f1.cant Sex exam- eY3l"- A')t1.orna11.- r~~) lned lned t:L8S 0 1 2 3 I 4 5 6 7 8 (code 3-6) , I . m 472 259 4 2 I - 1 37 1 32 807 4 O.L 10-14 - , t f 488 21.6 4 2 3 - - 26 116 755 6 0.7 j 1 I I ; ill .3.31 162 8 2 I 522 2 0.4 - I - - 7 i 12 I I 15-19 I J> I i .J. 394 144 3 1 2 - - - 19 563 ,I 1 0.5 m :302- 169 11 1 3 - 1 3 21 511 6 I 1.0 , 20-29 ; 530 185 9 2 7 1 - 2 49 78 '5 11 1.3

~ I"l 2-12 132 12 1 - - 9 24- 390 -" 0.3 .30-39 - f 358 157 13 - 3 1 1 11. 61 I 6]5 1.3 0-.8 m 1 LiD 105 25 - :5 - - 6 '35 316 2 1.6 40-49 f 194 112 20 1 1 1 - I 7 64 LiDo 6 o.B I -1 i I I"l 1 2 U8 71 14 1 , 3 1 !, 7 i 40 256 z.3 50-59 f 108 71 n 1 ' 4 - 1 ! 8 i 56 262 .3 2.3 I I m 94 ,4 36 - 10 - ~ 22 107 366 1.3 3.6 60+ I " - ~':1~ - 2-;1- f -11:0- 81- 9 9 18 108 .)~ 42 I - - - , Suo- m 1669 J92 :no 2 26 1 tJ 91 271 3168 32 1.1 4, Total f- 2182 ,66 n 7 29 3 2 72 373 3705 22 To1 - TOTAL 3551. L?58 ilin. 9 55 1.. 8 i!-fl3 644 -fl-873 llLJ 1.1

* For l.nterpretatlcr of X-rar code see paee.3 ",THO EJvIR.O Er/:m/84 ID/Srr/26 .AnnefC I page XlCl. TablE' 18

X~ray f~nu~ngs by s~ze of tubercul~n rpact~on

I Tubercul~n No 3.onor- CalcJ.f~ca- lnf ~lT.. ra- O~her abnor- Ca:v:tty TOTAL I react~on r:12'J.ty " ~()Il,f~bros~s tl.on 'llall.tl.es l liTo. l _N9 •• __ . Ii mm ~ I,To. % No~ % rOo! % % 0- 1 770 20.5 406 19.5 7 10.9 1 8.3 121 15.4 1305

2- .3 845 22.5 372 17.9 7 10.9 1 8.3 89 11.3 1314 4- 5 245 6.5 111 5.3 2 3.1 -- 38 4.8 396 I - - - 6- 7 120 3.2 55 "2~6- -1 1.6 - , - 27 - J.4, 203 8- 9 103 2.8 48 2.3 .3 4.7 - - 10 :t.3 164 86 10-11 2.3 51 2.4 2 J .. 1 - - 31 3~9, 170 12-13 124 3.3 81 3.9 2 3.1 35 4~4i 242 - - I 14-15 153 4.1 95 4.6 3 1 8.3 40 5'11 -292 4.7 ,r I 16-17 180 4.8 106 5.1 4 6.3 - - - 44 -- ~.6: 334 241 6.4 132 6 •.3 9 14.1 2 16.7 65 8.3 449 t 08-19 ::>0-21 266 7.1 189 9.1 7 10.9 4 33.3 , 77. 9.8 ' 543 ~2-23 213 5.7 141 6.8 6 9.4 1 8.3 58- 7.4 419 I '4-25 181 4.8 125 6.0 2 3.1 2 16.7 65 8.3 375 - 21) + 226 6.0 170 8.2 ? 14.1 - - ~7 11.0 492 I =z.==; ::::;:11=== ==;;;;;::::=~=~== =~=; F======*= =-===== :=====~ ==""=-=== rT:~:~=;:;: i ted J753 100.0 2082 100.0 64 100.0 12 00.0 787 lOO.O 6698 98 57 - - 20 175 I ===::t:= ,,==>=> ===:::t=::::::a ====~ F~:~~:~: F======;======F",,==e= =:::::r.======0== 1=:=== I===~:='=----I, Grand Total 38s'l 2139 64 12 807 6873 I I I WhO EhRO "S!1/TB/84 ill'I/ST/26 Table 19 Annex I page XX11 X-r~ flndlngs b.r Slze of react10n to the Mx 1 TU test Urban and Rural Areas

PerceI.tage of Inf1ltrat1ons iI. No lnflltrat1911 Other Calcll1c~t1on w:i...th or "luthout Cav1ty In R Calcif1Co.tJ.on TOTAL all examlned by X-ray and E Induratlon abnorma- wi.th (,1' or F1broS1S l,";i:lhcu:t; abnorma- Mx 1 TU A F'J.bros1s EXI'..MD1ED 1n percen t of (nnn) 11t1e9 Iltles Annnan CavJ.t.y all exrun1ned NatlOnal Survev Survey U 0-9 1115 441 11 149 1716 25.7 o .3 0.7 R 10 and over 960 5.38 22 265 1785 .30.1 0.6 1.2 B Not tested 66 A .39 - 12 117 .33 •.3 ...... N Total 2141 1018 33 426 3618 28.1 0.9 1.9

R o - q 968 551 11 136 1666 .33.1 0.3 0.4 U 10 and over 710 552 32 237 1531 36.1 1.0 4.4 R I-- Not tested 18 8 58 31.0 A 32 - ......

, L ToW 1710 1121 4.3 .381 .3255 34.4 1.3 4.9 ,

-~ -- WHO EMRO EH/m/84 EH/ST/26 .mnex I page XXJ..U Table 20

Est:unated ,prevalence of tuberculous infect~on by sex and age. Amman Survey and National Survey

Age Amr

I , - 0- 4 2.0 3.9 2.9 1.5 1.7 1.6 1.6 . 2 .. 2 1.9 , 5- 9 16.0 17.4 16.7 9.0 9.7 9.3 10.3 I 1l~0 10 6

10 .. U 47.1 38.8 42.7 27.9 28.0 ?:.7_.9' - 30.4 29.7 30.0 15':'19 61.3 52.4 56.3 42.9 35.2 38.8 45.4 37.9 4104 20-29 59.2 46.7 51.1 52.9 38.6 44.1 54.2 40.5 45.7 - 30-39 72.1 64.3 68.1 69.4 54.0 59.8 70.1 55.9 61.6 , 40-49 84.9 72.1 79.1 73.8 67.0 72.1' 79.9 67.7 73.3

50-59 82.7 79.5 81.3 77.7 71.4 74.5 78.5 72.5, 75.5 , 60 + 86.8 80.6 83.5 75.5 61.9 68.7 77.0 70.7 F======~ ======;======f======p======-===== ~===== -"=~:~== p===== Total 43.1 40.2 41.6 36.2 33.6 34.9 37.5 34.8 36.1

Total No.tes- 1084 ll73 2257 4823 5362 lO1.85~ 5907 6535 124112 ted , , , J WHO EHRO ]~1/TB/84 El"1/ST/26 Table 21 jlnneX I page XX1V Xiray fln~ngS by Slze of[tub~rcul~n renct+on BOl'H SURVEYS InduratlOIl No InflltratlOrl Calclilcatlon other Total Inflltratlon Wlth or (nun) abnormall- ,.IJ. th or Wl th- or Pulmonary Number Wlthout caVl ty m tles out cavlty flbrosls Pathology- examilled - percent of all examlned 0- 9 520 8 22 2 552 0.5

Al1lImn 10 or more 702 lt~ 93 23 858 2.7 Survey Not tested 46 2 :3 3 54 0.1 Total 1268 50 liB 28 1464 3.4 0- 9 2083 22 992 285 3382 0.3 Natlonal 10 or more 1670 54 1090 502 3316 0.8

Survey Not tested 98 57 20 175 - - i

Total 3851 76 2139 8Cf7 6873 1.1 , I 0- 9 2603 30 1014 287 3934 0.4 ------10 or more 2372 94 liB3 525 4174 1.1 TOTAL [ Not tested 144 2 60 23 229 0.02 Total 5119 . 126 2257 835 8337 1.5 1'lli0 EMRO EM/TB/84 Fl-IjST/26 Fl.g. 1 AN};EX II page ~

Frequenci D~str~but~on of S~ze of Tubercul~n React~on

by sex AU groups t.o ,.....- Males

20

! i 0'-- ....1-.__ ,_-_-_- -L.._...J-l'-'-::...... "''-',~...:..-..J!'--·--) -. 1--=:L__ -1'----"1_-_J.:,-===....,.,

Ju l Females

20

Both Sexes

2

I I - I -j-- ~ :::~ C- T~_l~-:-- ~ d l_ --- --_ --l-_ - 1-: _ - -, --.r--, 0 2 4 6 8 10 12 14 16 18 20 22 24 26 ? 1 .-' 5 7 9 11 13 15 17 19 21 23 25 +

Indurat~on l-n rom E!'f!T:l!84 F::t.g. 2 EM/ST 26 Frequency ;)lstrlbutlon of Slze of Tubercul1n ANNEX II reactlon, by age Total Populatlon page 1.i

1

o - 4 years

01 i.-.__ ::...-~

20 : I - I I 5 - 9 years 1~1

______L ______.... ::.~_

10 - 14 years

1-- 1 -.::~

20 15 - 19 years ~ , ~ ~ 10 I ~ I ;2 ~ 0 ----f-- p.. J . -

20, -- I 20 - 29 years 1DI I 0 1

r--- 30 - 39 years 10 ----i 01 .1<,- ___ --- J 40 - 49 "cars

- 1 , 1-- --' 51 !- , I 0- 50 - 59 years le ~_ ,'"'- - -t

0 ~ _ J {jJ years and more

~o _.- - -"1 ,---1 1---- I 1• C I 1 ( I 0 2 ...1 6 8 10 12 lL 16 18 20 22 24 26 ~ 1 ..) S 7 9 11 13 1.5 17 19 21 23 25 + Induratlon In rom. WHO llMRO EM/TB/84 FJ!I/ST/26 Annex II page hi

F1.g. 3

8a, /~--- \ - - ... ------... .

,/ "- • 7~ .- .... I I, I -.

601 / I I I ,•

Q) llD <11 +' , ~ Q) I / / 0 ..Q) P-. (OJ ~.

Males ------... Females , ! I I I I / l~ 1 , I , I J .... o - / ---- -50---~-- 0 5 10 15 20 30 ---L6-- Age l.n years WHO EMRO EM/T.:l/84 El"jST/26 Annex II page l.V

F1.g. h

Age uu'echon curve by sex and place of residence

, ' . , -. - - - 7

!! / . I '/ , '

-- - - Males Urban Hales Rural Females Urban - ~ - -- Females Rural 20

10

Age l.n years WHO EMRO EM/TB/S4 FM/ST/26 Flog. 5 ANNEX II page v Type of X-ray f~nd~r~ oy s~ze of tvoercu1ln react~on

20 ~ I No abnorrnal1ty

o

Calclflcat10n, flbrosls 20 10 - ... --, - ,-- - - I ,- - i f --,-----,-, o ..J __ ~ __"___-l._ ... ____ ~ ______-1...._ 1 _ _ __

Infl1trd:.on -, 1C ~-, t o 1_ I GaVlty

,-ijc, ~~ F' , , D r~ Ie ~ I 0 - ____• _. ______! ...1-_---<1-.

Other abno~lltles 10 I - - ,-- (- r-- i ,__ ,--I o .. - ---~- ---'- .. 1 I '--14 I -i6!-"'---::-l"::"'S 26 024 - --6 --S -10 ·12 -""'20- --"'2C":2...l.....2r I 1 3 :, 7 9 11 13 15 17 19 21 23 25 + Indurat"Lon lU rnm.