Georgia epidemiology report, Vol. 24, no. 10 (Oct. 2008)

October 2008

volume 24 number 10

Challenges to Tuberculosis Elimination in Gwinnett County, Georgia

The epidemiology of tuberculosis (TB) in Gwinnett County, Georgia, is unique

Figure 1. TB Cases and Case Rates,

Number of Cases Rate/100,000

among the 159 counties in Georgia in two respects: 1) the county reported steadily increasing numbers of TB cases between 2001 and 2006; and 2) foreign-born persons accounted for more than 75% of the county's TB cases each year for the past 8 years. This article summarizes important epidemiologic TB trends and challenges to TB elimination in Gwinnett County a county 30 miles northeast of Atlanta and one of the fastest-growing counties in the United States [1].
Overview

70 60

Gwinnett County, 1996 - 20077.8

9 8

6.8

6.7

6.8 7

50

40 4.3

4.4 4

30

2.9

5 3.2

6 5.4

6 5 4

3

20

2

10

1

The national TB elimination goal for the United States is to achieve an incidence of

0

0

<1 case per 1,000,000 population by the year 2010 and an interim goal of 3.5 cases per

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

100,000 for the year 2000 [2]. Georgia and Gwinnett County have not yet achieved

Year

this goal, however, Gwinnett County's TB case rates steadily increased during 2001 to 2006 (from 3.2 cases per 100,000 population to 7.8 per 100,000) while Georgia's

Number Case Rate

TB case rates were declining (from 6.9 to 5.0 per 100,000) over the same time period [Figures 1-2]. The number of TB cases in Gwinnett County increased 195% from

Figure 2. TB Cases and Case Rates,

2001 to 2006 (from 20 to 59 cases, Figure 1), outpacing the growth in Gwinnett

Georgia, 1996 - 2007

County's population, which increased 20% from 2001 to 2006 (from 622,512 to 749,836 persons) [3]. In contrast, there was a 12% decrease in TB cases in Georgia over the same time period [Figure 2]. The numbers of foreign-born (FB) TB cases and US-born cases tripled from 2001 to 2006 with a 25% and 27% average annual increase among FB and US-born cases respectively [Figure 3]. Gwinnett County has ranked third among counties in Georgia in TB case numbers and case rates since

Number of Cases

Rate/100,000

900 10.7

12

800

9.5

700

8.3 8.5 8.5

10

600 500 400

6.9 6.2

6.1

6.0

5.5 5.4

8
5.0 6

300

4

1993, when expanded surveillance for TB started in Georgia, with only DeKalb and 200

2

100

Fulton Counties reporting more cases and higher rates. All three counties are located 0

0

in populous metropolitan Atlanta. Nearly two-thirds of TB cases in Gwinnett County over the past 5 years resided in the cities of Lawrenceville and Norcross.

1996

1997

1998

1999

2000

2001 2002
Year

2003

2004

2005

2006

2007



Number Case Rate

Foreign-born TB Cases

From 1996 to 1999, foreign-born TB cases accounted for 56%-67% of all TB cases in Gwinnett County. In 2000, the proportion of foreign-born TB cases of all TB cases in Gwinnett County increased to 82%, and foreign-born TB cases accounted for 75% or more of all TB cases in the county from 2001 to 2007 [Figure 3]. This increase in the numbers and proportion of foreign-born TB cases coincided with a 92% increase in the number of foreign-born residents (from 99,518 to 190,805 persons) and an increase in the proportion of the foreign-born population (17% to 25%) in Gwinnett County from 2000 to 2007 [4].
In 2007, among 43 foreign-born cases in Gwinnett County, 46% were in Asians and 28% were in Hispanics, though Asians and Hispanics made up only 9% and 17% of

Number of Cases

Figure 3. US-born and Foreign-born TB Cases, Gwinnett

County, 1996 - 2007

50

47

45

43

40

38

35

33

33

30

25 27

25

20 15 10

12 8

14 13

10

10 10

5

5

16 7
4

7

8

9

9 12 10

0

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

the county's population, respectively. More than half (57%) of foreign-born TB cases in Gwinnett County were reported in persons from four countries: Vietnam (9 cases), Mexico (7), Honduras (4), and India (4). Ten foreign-born cases had a TB condition

Year Foreign-born US-born

(either non-infectious active TB or not clinically active TB) diagnosed before entering

the U.S. as part of the federal government's refugee and immigrant medical screening to foreign-born parents with TB also contributed to Gwinnett

process. The majority (53%) of foreign-born TB cases in Gwinnett County were

County's TB morbidity in 2007; of 10 U.S.-born cases in 2007,

diagnosed within 8 years after their arrival in the U.S. U.S.-born children exposed

three were children with at least one foreign-born parent who was

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originally from a country with a high TB prevalence. Regardless of country of origin, TB case rates in Gwinnett County were highest among Asians (29.7 per 100,000) followed by Hispanics (10.6/100,000), non-Hispanic blacks (6.9/100,000) and non-Hispanic whites (1.5/100,000).
TB in Children TB in children younger than 5 years old is considered a sentinel public health event because it can be a marker for recent transmission from an adult source case and because infected young children have a higher risk for rapid progression to active TB disease that may further progress to potentially lethal forms of TB [5]. The risk for developing active TB is also increased among adolescents and young adults with a positive tuberculin skin test [5]. In Gwinnett County in 2007, the lowest TB case rate (0.9/100,000) among age groups was in children 5 to 14 years old while the highest rate (11.2/100,000) was among persons 15 to 24 years old. In 2007, three cases were reported among children under five years old but none developed severe forms of TB; two were identified by contact investigations of adult relatives with active TB who lived in the same household as the child. A spike in the number of TB cases among Gwinnett County school children occurred in 2007 which generated considerable media attention; seven student cases were reported that year compared to only two student cases reported per year in the three preceding years. The median age of the seven student cases in 2007 was 15 years old (range: 719), five were high school students, and four were foreign-born students who originated from four different regions of the world.
TB Treatment Completion Treatment for patients with drug susceptible TB takes at least six to nine months to complete with a combination of several anti-TB antibiotics [6]. County health departments (CHDs) go to great lengths to ensure that patients complete TB treatment. Public health staff make home visits to provide directly observed therapy (DOT) to TB patients, supply transportation tokens and fast food coupons for indigents, give temporary shelter for homeless patients, and even pursue legal court orders compelling non-adherent infectious patients to comply with a TB treatment plan. From 1996-2000, more than 90% of TB patients in Gwinnett County completed their treatment, putting the county on par with state averages for treatment completion. During 2001 and 2003 however, and for the past two consecutive years that have complete data on treatment outcomes, TB treatment completion in Gwinnett County fell below 90% (83% in 2005 and 87% in 2006). The 15 cases that did not complete treatment during those two years were all foreign-born; nine were Hispanic, three were Asian, and three were black. Ten cases did not complete treatment in Gwinnett County because they were lost to follow-up (six returned to their country of origin without a forwarding address) and five were uncooperative or refused treatment.
Directly Observed Therapy The American Thoracic Society and the U.S. Centers for Disease Control (CDC) recommends that TB treatment should be given by directly observed therapy (DOT), in which public health staff watch TB patients ingest every dose of their medications to ensure treatment adherence [6]. However, the percentage of TB patients in Gwinnett County who received TB treatment exclusively by DOT throughout the entire duration of their treatment is declining. During 2000-2003, the percent of TB patients per year who received DOT for the entire duration of their TB treatment was 79% (30 of 38), 59% (10 of 17), 62% (18 of 29), and 71%

(25 of 35). In contrast, during 2004-2005, only 57% of 86 TB patients in Gwinnett County received TB treatment entirely by DOT, and in 2006, only 46% of 54 TB patients received TB treatment entirely by DOT; 48% of patients in 2006 had treatment that was partially by DOT and partially self-administered, and 6% self-administered all their TB medications. During 2004-2006, of seven patients who self-administered all their TB medications, four were exclusively under the care of private providers and two were managed by both the CHD and a private provider. CHD staff reported that at least two private providers were not supportive of their patients being on DOT.
Contact Investigation and Latent TB Infection (LTBI) Therapy CHD staff conduct contact investigations routinely for every TB case, regardless of whether the case is managed by a public or private provider. Contacts with a positive tuberculin skin test (TST) but a normal chest radiograph and no TB signs or symptoms have latent TB infection (LTBI). Persons with LTBI are not ill or contagious but they have a 10% chance of developing active TB over their lifetime if they do not complete LTBI therapy [2]. LTBI is generally treated with isoniazid for nine months to prevent active TB disease from developing [6]. Among 266 contacts to TB cases in Gwinnett County that were evaluated in 2006 (this excludes school contacts evaluated during post-exposure mass screenings), 83 (31%) had LTBI and 5 (2%) had active TB, which is higher than the state average for contacts with LTBI (22%) and active TB (1%). Among 50 infected contacts started on LTBI therapy, 35 (70%) completed therapy, which exceeds the state's 56% LTBI treatment completion rate for 2006. Among the 15 infected contacts that did not complete LTBI therapy; nine chose to stop therapy on their own, four were lost to follow-up, one had an adverse reaction to the medication, and one contact's provider decided to stop the medication.
Health Care Resource Capacity In 2007, the majority (59%) of TB patients in Gwinnett County were initially reported from a hospital (21 patients were admitted to Gwinnett Medical Center, a private hospital in Lawrenceville). After hospital discharge, TB patients are typically referred to the Gwinnett CHD and health centers for follow-up. Over the past five years, the Georgia TB Program funded positions in Gwinnett County for four nurses and one outreach worker with state grant-in-aid monies, and a county pharmacist position through a federal grant. Federal, state, and county funding for health care personnel, however, has not increased to keep up with the county's increased TB client workload. Despite the preponderance of TB cases that are foreign-born, there is only one bilingual TB case manager (fluent in Spanish and English) for Gwinnett County.
Community Outreach To address the increase in TB cases among Hispanics in Gwinnett County, the Georgia TB Program and the Gwinnett CHD sponsored 10 interviews with health care providers serving the local Hispanic community, seven patient interviews, and two focus groups that were conducted by an Emory University graduate student to assess the knowledge, attitude, and perceptions of the Hispanic population about TB and access to health services. These interviews revealed gaps in knowledge about TB transmission, a preference for Spanish-speaking private providers for primary health care, instances of delayed diagnosis of TB by private providers, inadequate interpreter services at CHDs, satisfaction with

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John M. Horan, M.D., M.P.H. State Epidemiologist
Director, Epidemiology Section http://health.state.ga.us/epi
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Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
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the health care provided by CHD TB clinic staff, but a perception that Hispanics would receive poor customer service during intake at CHDs. Health care providers stated that some of their patients avoided seeking care at the CHD for fear of deportation. In addition, many of their patients suffered from low literacy, limited financial resources, and lack of health insurance. Health care providers were not aware of the services provided by CHDs and they felt that CHDs should work closely with Hispanic-serving clinics to improve the health of Hispanics in Gwinnett County. These results were presented at a meeting with key stakeholders and providers of services to the Hispanic community in Gwinnett County. As an outcome of this meeting, the state and district TB programs are collaborating with community organizations to plan educational outreach activities for the Hispanic community.
Discussion and Conclusions Gwinnett County's rapidly-growing population and rise in foreign-born TB cases present unique challenges for TB elimination in the county. Due to budgetary shortfalls, state and federal funding streams have not been able to provide the county with more resources to cope with the increase in their TB client load. In the current environment of diminishing resources, it will become even more important to establish priority activities and focus interventions to attain national and state TB program objectives.
As Gwinnett County, along with the rest of Metropolitan Atlanta, becomes more of an international community linked to a global economy, the area's population can be expected to become increasingly culturally diverse. Culturally competent and bilingual staff can help to improve communication with non-English speaking foreign-born patients. The Southeastern National TB Center, a regional resource facility located in Gainesville, Florida, which is funded by CDC, has developed communication tool kits targeting foreign-born patients that can be used to impart key messages about TB. Some of these products were distributed at the Latin American Association Headquarters in Atlanta, when the focus group and interview findings were presented to key stakeholders of Gwinnett County's Hispanic community. Community educational campaigns to raise TB awareness may need to include information that patient encounters for public health assistance to test and treat communicable diseases are exempt from recent state legislation that requires verification of lawful presence in the United States from persons applying for local public services, and thus this legislation should not be a potential barrier to health care access and TB clinic services.
Gwinnett County's TB treatment completion rate is negatively impacted by the return of foreign-born patients to their home countries during treatment. If patients inform CHD staff of their impending departure and they meet the World Health Organization (WHO) criteria of TB patients who may travel, the state TB Program will mail a notification form to TB control personnel in the patient's country of destination using the National TB Program contact information list provided in CDC's Division of TB Elimination website [7, 8]. The state TB Program can refer patients who move to Latin American countries to TBNet or CureTB, two federally funded agencies that monitor treatment completion of TB patients who travel back and forth between Latin America and the U.S [9,10]. CHDs can advise patients on the importance of completing treatment and give them a referral form, preferably translated in their native language, to present to their primary care providers in their home countries for continuation of treatment.
Gwinnett County authorities have raised the question of whether routine school entrance TB screening should be performed countywide due to sporadic spikes in the number of student TB cases. However, routine TB screening in a student population is not advisable because of the low prevalence of TB among children and the enormous public health resources it would take to annually screen a huge but low-risk population (the Gwinnett Public School System is the largest school system in Georgia with

114 schools and a projected 2008-09 enrollment of 159,000-plus students) [11]. In addition, a sizeable proportion of the TST positive results in screenings of low-risk populations may be false positive results caused by nonspecific reactivity or exposure to nontuberculous mycobacteria in the environment [13,14]. In such a setting, LTBI treatment may be given needlessly to a substantial number of students with false positive TSTs. To reduce the number of false-positive TST results in such a population, the optimal approach recommended by CDC is administration of a screening questionnaire (similar to that used by the Georgia Health Check program, Georgia's preventive health care program for children) that assesses risk factors for TB so that only children with specific risk factors for LTBI would be given a TST [12, 14].
Evidence-based, priority strategies that guide TB programs in the U.S. include: 1) early identification of TB cases and completion of TB treatment; 2) contact evaluation and treatment of LTBI to prevent disease; and 3) targeted testing and LBTI treatment among high-risk populations [14]. To overcome barriers to implementing these strategies in Gwinnett County, adequate resources are needed to support the county's public health infrastructure to ensure that all patients complete treatment by DOT, that non-adherent patients are managed as allowed by state TB laws, that thorough contact investigations are performed, public health staff are culturally competent, and more bilingual staff are hired. Partnering with community-based organizations to promote awareness about TB and CHD TB services, while educating community health care providers about TB diagnosis and management would complement these key strategies to protect Gwinnett County communities from TB.
This article was written by Rose-Marie Sales, M.D., M.P.H.1, Alana Sulka2, William Blomenkamp2, Lisa Watson3, and Beverly DeVoe-Payton, M.H.S.1
1Division of Public Health, Georgia Department of Human Resources 2Health District Office 3.4 (East Metro, Lawrenceville) 3Emory University Rollins School of Public Health
References: 1. U.S. Census Report [serial on the Internet]. Available from http://www.
census.gov/popest/counties/tables/CO-EST2007-08.csv 2. CDC. TB Elimination Revisited: Obstacles, Opportunities, and a Renewed
Commitment. MMWR 1999;41(No.RR-09):1-30. 3. U.S. Census Report [serial on the Internet]. Available from http://www.
census.gov/popest/counties/tables/CO-EST2007-01-13.csv 4. Federation for American Immigration Reform [page on the Internet].
Available from http://www.fairus.org/site/PageServer?=research_ researc6e9_sup 5. Comstock, G. W., V. T. Livesay, and S. F. Woolpert. 1974. The prognosis of a positive tuberculin reaction in childhood and adolescence. Am. J. Epidemiol. 99:131--138. 6. CDC. Treatment of Tuberculosis. MMWR 2003;52(No.RR-11):1-77. 7. WHO. Tuberculosis and Air Travel: Guidelines for Prevention and Control. Second edition, 2006. p.1-47. 8. CDC Division of TB Elimination [page on the Internet]. Available from http://www.cdc.gov/tb/pubs/international/internat_proces.htm 9. TBNet [homepage on the Internet]. Available from http://www. migrantclinician.org/services/tbnet.html 10. CureTB [page on the Internet]. Available from http://www2.sdcounty. ca.gov/hhsa/ServiceDetails.asp?ServiceID=437 11. Gwinnett County Public School System [page on the Internet]. Available from http://www.gwinnett.k12.ga.us/gcpsmainweb01.nsf/pages/ Schools2~MainPage 12. CDC. Targeted Tuberculin Testing and Treatment of Latent TB Infection. MMWR;49(No.RR-06):1-54. 13. Starke JR. Universal screening for tuberculosis infection. School's out! JAMA 1995;274:652--3. 14. CDC. Controlling Tuberculosis in the United States. MMWR 2005;54(No.RR-12):1-81.

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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

October 2008

Volume24Number10

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for July 2008

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for July 2008
2008 108 224 22
4 98 170 12 3 15 2 5 2 0 6 0 346 55 5 29 25 65 0 37

Previous 3 Months Total Ending in July

2006

2007

2008

170

252

258

10280

11122

1753

54

54

53

17

8

18

168

155

199

5459

4758

760

27

22

31

19

22

9

55

34

49

13

10

7

5

8

13

2

4

6

3

0

1

8

6

9

0

0

0

548

496

771

291

633

339

28

27

28

112

150

124

112

114

85

247

327

245

1

2

1

143

120

137

Previous 12 Months Total Ending in July

2006

2007

2008

573

662

701

38119

42428

32116

202

271

268

43

32

55

694

677

711

18907

19202

12978

116

120

150

85

70

47

188

166

159

36

46

38

8

10

18

15

20

27

5

0

2

32

26

19

0

0

0

1915

1896

2264

948

1821

1418

136

106

108

473

553

617

403

424

410

990

1123

1164

8

10

8

524

493

478

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period
Latest 12 Months

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

HIV, non-AIDS 18

3,000

3,018

Percent Female MSM

28

25

Risk Group Distribution %

IDU

MSM&IDU HS

Unknown Perinatal White

2

1

4

67

1

18

Race Distribution %

Black

Hispanic Other

77

4

1

9/07-8/08

AIDS

2

1,826

1,828

28

29

3

1

7

60

<1

17

77

5

1

Five Years Ago:**

HIV, non-AIDS -

-

-

-

-

-

-

-

-

-

-

-

-

-

9/03-8/04

AIDS

11

1,663

1,674

29

34

7

2

16

39

1

18

76

5

1

Cumulative: HIV, non-AIDS 219

12,626

12,845

31

28

6

2

10

53

2

21

74

4

1

07/81-8/08 AIDS

239

32,959

33,198

20

43

14

5

14

23

1

30

67

3

1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period

***HIV, non-AIDS was not collected until 12/31/2003

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