2001 Georgia Tuberculosis Report Georgia Department of Human Resources | Division of Public Health Epidemiology Branch | Prevention Services Branch Pub. No. DPH02.140 [THIS PAGE LEFT BLANK INTENTIONALLY] 2001 Georgia Tuberculosis Report Georgia Department of Human Resources ............Jim Martin Commissioner Division of Public Health.................................Kathleen E. Toomey, M.D., M.P.H. Director Epidemiology Branch.....................................Paul A. Blake, M.D., M.P.H. Director Tuberculosis Epidemiology Section....................Rose-Marie F. Sales, M.D., M.P.H. Chief Tuberculosis Control Section............................Beverly DeVoe, M.S.H. Program Manager Acknowledgments: TB Epidemiology Section: Pamela Clarke-Alleyne, PhD.: Data Manager Sean Willis TB Surveillance/Medical Records: Lanetta Culver: Supervisor Kimberly Davis Betty Jones De-lon Tanner Katrina Williams Graphics and Design: Jimmy Clanton Further information on this report can be obtained by contacting: Rose-Marie F. Sales, M.D., M.P.H. Georgia Department of Human Resources Division of Public Health, TB Epidemiology Section 2 Peachtree St., NW Atlanta, GA 30303 Phone: (404) 657-2634 Fax: (404) 463-3460 E-mail: rfsales@dhr.state.ga.us Introduction Since the period of tuberculosis (TB) resurgence in the United States that occurred from 1985 to 1992, the number of TB cases reported in the U.S. has decreased each year reaching a record low of 15,991 in 2001. The reduction in TB cases has been attributed to a substantial rebuilding of the public health infrastructure for TB services, enabling state and local TB control programs to promptly identify TB cases, initiate appropriate therapy, and assure that therapy is completed. Some of the highest TB case rates in the country are in the Southeast region where Georgia is second to Florida in TB case rates and contributes 4% to the national TB burden. The 2001 Georgia TB Report describes the current distribution of TB cases among residents of Georgia and analyzes trends in TB morbidity and mortality, drug-resistance levels, and TB program outcome measures. The report may be used for planning TB control activities at the state, county, and institutional levels. Current Epidemiology of TB in Georgia Demographic Distribution of Cases In 2001, 575 TB cases were reported in Georgia, representing a 17% decrease from 696 cases reported in 2000 (Figure 1). Georgia ranked seventh in the nation in TB case rates (6.9 per 100,000 persons) and continues to have higher case rates than the national average (5.6/ 100,000) (Figure 2). TB cases in Georgia are predominantly male (63%) and African American (59%) (Figure 3, 4). The largest proportion of cases among age groups (40%, 233 cases) occurred in the 25-44 years old age group (Figure 5). The highest TB case rate among age groups (11/100,000 in 2000) occurred among persons 65 years and older while the lowest rate among age groups was in children 5-14 years old (0.2/100,000). TB case rates for all age groups have been decreasing over the past decade (Figure 6). 4 | 2001 Georgia Tuberculosis Report Figure 1. Number of Reported TB Cases Georgia, 1981-2001 Number of Cases 1000 900 800 700 600 500 400 300 200 100 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 Year Figure 2. TB Case Rates U.S. and Georgia, 1981-2001 Case Rate 18 16 14 12 10 8 6 4 2 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 Year US Rate GA Rate Figure 3. TB Cases by Race/Ethnicity Georgia, 2001 Asian 10% Hispanic 11% Non-Hispanic White 20% 59% Non-Hispanic Black Figure 4. TB Cases by Race/Ethnicity Georgia, 1993-2001 700 Number 600 500 Non-Hispanic White Non-Hispanic Black Hispanic Asian 400 300 200 100 0 93 94 95 96Year97 98 99 00 01 Figure 5. TB Cases by Age Group Georgia, 2001 > = 65 yrs. 15% 15-24 yrs. 4% < 5 yrs. 1% 15-24 yrs. 8% Distribution in High-Risk Populations TB disproportionately affects African-Americans in Georgia. While African Americans make up 29% of the population in Georgia, they accounted for 61% of TB cases (425 of 698 cases) in 2000 and 59% (336 of 573) in 2001. In 2000, the TB case rate for African-Americans in Georgia (18.3 per 100,000 population) was seven times higher than the case rate for non-Hispanic whites (2.5 per 100,000 population). Fulton County has one of the highest proportions of TB cases that are African-American compared with other counties in the state. African-Americans represent 45% of Fulton County's population yet accounted for 81% (109/135) of the county's TB cases in 2001. Georgia has achieved some success in narrowing the disparities between racial/ethnic groups. Between 1993 and 2001, a 42% decrease was seen in the number of newly reported African-American TB cases compared with a 38% decrease in non-Hispanic whites (Figure 4). 45-64 yrs. 32% 25-44 yrs. 40% Figure 6. TB Case Rates by Age Group Georgia, 1993-2001 Age Group < 5 1996 7.7 1997 5.6 1998 5.8 1999 6.6 2000 4.2 5-14 2.6 1.8 2 2 0.2 15-24 5.3 5.8 4.4 6 3.8 25-44 13 12.4 9.6 9.9 8.8 45-64 14.6 11.6 13.2 11.6 10.5 65 + 20.5 15.7 17.5 12.5 11 2001 Georgia Tuberculosis Report | 5 The rising trend in the proportion of TB cases in the foreign-born population continues - increasing from 5% (40 cases) in 1993 to 28% (159 cases) in 2001 (Figure 7). In 2001, foreign-born TB cases were mostly reported from metropolitan Atlanta Health Districts, e.g., DeKalb (43 cases, 57% of District cases), Cobb (22 cases, 56%), Fulton (21 cases, 16%) and Lawrenceville (16 cases, 76%). Outside of the metropolitan Atlanta area, the Health Districts reporting most of the foreign-born cases were Augusta (9 cases, 16% of District cases), Savannah (7 cases, 48%) and Waycross (6 cases, 24%). Foreign-born cases are primarily seen in persons from the high incidence countries of Mexico (35 cases), India (21), Vietnam (12), Guatemala (12) and the Philippines (11). Nearly half (46%) of foreign-born TB cases reported in 2001 were diagnosed with TB within 5 years of their arrival in the U.S. In 2001, 223 refugees and immigrants with a B1 (active, non-infectious TB) or B2 (inactive, non-infectious TB) overseas classification resettled in Georgia. Of 2,309 refugees who arrived in Georgia in 2001, 1,950 were skin tested for TB and 1,112 (57%) were skin test positive. Sixty-three percent (1,455/2,309) of newly arrived refugees resettled in DeKalb County. The resurgence of TB in the United States in the mid80s to early 90's is largely attributed to the sharp increase in the number of persons diagnosed with HIV/ AIDS during that period. TB cases co-infected with HIV have been decreasing in Georgia - from 140 (42%) of cases with known HIV status in 1993 to 83 (18%) cases with known HIV status in 2001 (Figure 8). Of TB cases with available information on HIV status in 2001, co-infection with HIV is predominant among African Americans (86%), males (72%), and in adults aged 2544 (66%). Reporting of HIV infection status among TB cases has considerably improved. In 1993, when monitoring for HIV status was first included in the expanded TB surveillance system, the status of HIV infection was reported in only 41% of TB cases. In 2001, reporting of HIV status had increased to 79%. Among TB cases age 25-44 years, reporting of HIV status increased from 59% (209/353) in 1993 to 89% (207 of 233) in 2001. Figure 7. US- and Non-US Born TB Cases, Georgia, 1993-2001 Number 800 769 700 672 654 695 600 579 511 533 548 500 416 400 300 200 100 40 68 81 96 116 119 137 155 159 0 93 94 95 96 97 98 99 00 01 Year US-Born NonUS-Born Figure 8. HIV Status of TB Cases Georgia, 1997-2001 Number 800 700 600 233 500 241 212 165 88 130 400 100 69 87 83 300 200 362 320 370 445 364 100 0 97 98 99 00 01 Year Negative Positive Unknown 6 | 2001 Georgia Tuberculosis Report Figure 9. TB in Congregate Settings Georgia, 1997-2001 Number 80 73 70 60 50 45 40 30 23 20 67 31 20 65 21 16 50 38 21 63 31 21 10 0 97 98 99 00 01 Year Homeless CorrectioYnaealsr Long-Term Care In 2001, TB cases living in congregate settings where infection is easily transmitted included 63 (11%) homeless persons, 31 (5%) cases from correctional facilities, and 21 (4%) persons living in long-term care facilities (Figure 9). Twenty-three percent of TB cases reported abuse of illegal drugs and/or alcohol. A 26% increase in homeless TB cases in 2001 from the previous year was reported after 5 consecutive years of decline in homeless cases. Based on targeted TB skin test screenings done in selected homeless shelters in Fulton County in 2000 and 2001, the prevalence of latent TB infection in the homeless ranges from 7% to 23% compared to a background prevalence rate of 2%-3% estimated from school-based screenings of low-risk students. Two recent epidemiologic investigations involving homeless TB cases indicated that TB transmission had occurred among the homeless and between homeless persons and non-homeless community residents. Of 17,662 TB skin tests (TST) readings from inmates at the Fulton County jail in 2001, 2,109 (12%) inmates were TST positive. Geographical Distribution of Cases The metropolitan Atlanta area accounted for 50% of all TB cases reported in Georgia in 2001. The top five counties in the state reporting the highest number of TB cases were: Fulton (135 cases), DeKalb (76), Cobb (36), Richmond (30), and Gwinnett (20). Fulton County, which includes the capital city of Atlanta, had a TB case rate of 16.5 per 100,000 population in 2001 three times higher than the U.S. case rate. Some urban poor neighborhoods in Fulton have TB case rates approaching 100/100,000 population. Of 159 counties statewide, 49 (31%) had case rates higher than the state average, 62 (39%) did not report a single TB case, and 81 (51%) attained the interim target TB elimination goal of <= 3.5 cases/100,000 population in 2001 which represents an improvement over case rates reported in 2000 when 78 (49%) counties attained the target goal. (Table 1). Seventeen of 19 health districts reported decreases in TB case rates (Table 2). 2001 Georgia Tuberculosis Report | 7 Table 1. Number of TB Cases and TB Case Rates (per 100,000) by County Georgia, 2000-2001 COUNTY Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham 2000 Number of cases <5 <5 0 0 <5 0 <5 <5 <5 <5 13 <5 <5 <5 0 <5 <5 <5 0 <5 0 7 6 0 20 0 <5 <5 7 0 23 <5 38 5 <5 15 0 7 0 7 0 0 <5 86 0 <5 9 0 0 0 <5 Case rate 11.5 52.6 0 0 2.2 0 4.3 2.6 11.4 12.3 8.4 17.1 6.8 6.1 0 7.1 9.0 5.1 0 2.3 0 8.0 11.3 0 8.6 0 3.9 2.1 6.9 0 9.7 14.5 6.2 13.4 9.5 16.8 0 7.8 0 31.8 0 0 7.1 12.9 0 34.7 9.4 0 0 0 5.3 2001 Number of cases < 5 < 5 < 5 0 0 0 < 5 5 < 5 < 5 7 0 < 5 < 5 < 5 < 5 < 5 0 < 5 < 5 < 5 < 5 < 5 0 15 0 < 5 < 5 < 5 0 15 < 5 36 < 5 < 5 25 < 5 < 5 0 < 5 0 0 0 76 < 5 < 5 10 < 5 0 0 < 5 Case rate 5.7 13.2 10 0 0 0 6.1 6.2 11.6 6.2 4.6 0 6.7 6.1 4.1 3.5 17.7 0 31.7 4.5 10.5 3.3 7.2 0 6.5 0 3.9 0.7 3.9 0 6.1 14.6 5.7 10.6 7.1 27.0 12.6 1.1 0 18.1 0 0 0 11.4 5.2 17.2 10.4 3.1 0 0 2.5 8 | 2001 Georgia Tuberculosis Report Table 1. Continued COUNTY Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe 2000 Number of cases <5 0 0 0 <5 11 0 <5 183 <5 0 5 <5 <5 0 40 0 6 <5 0 <5 <5 0 <5 9 <5 <5 0 0 <5 <5 0 0 0 <5 5 0 <5 0 <5 <5 <5 <5 <5 <5 0 0 <5 0 12 0 Case rate 9.8 0 0 0 1.1 12.1 0 4.9 22.4 8.5 0 7.4 2.3 12.7 0 6.8 0 4.3 19.8 0 4.2 4.3 0 3.4 8.1 10.1 2.4 0 0 5.8 23.3 0 0 0 0 11.1 0 6.5 0 9.7 2.2 4.8 7.1 3.9 28.0 0 0 13.3 0 50.1 0 2001 Number of cases < 5 < 5 0 0 0 9 < 5 0 135 < 5 0 0 6 < 5 0 20 < 5 < 5 0 0 0 0 0 5 < 5 0 < 5 < 5 < 5 < 5 0 0 0 0 0 5 < 5 0 0 0 6 < 5 0 < 5 0 0 0 < 5 0 6 0 Case rate 9.7 4.6 0 0 0 9.9 1.8 0 16.5 4.1 0 0 13.2 12.7 0 3.2 8.1 1.4 0 0 0 0 0 3.8 3.5 0 6.8 8.4 7.8 17.6 0 0 0 0 0 11.0 7.8 0 0 0 6.5 4.6 0 3.8 0 0 0 4.4 0 24.9 0 2001 Georgia Tuberculosis Report | 9 Table 1. Continued COUNTY 2000 Number of cases Montgomery 0 Morgan 0 Murray <5 Muscogee 12 Newton <5 Oconee <5 Oglethorpe 0 Paulding <5 Peach <5 Pickens <5 Pierce 0 Pike 0 Polk 5 Pulaski 0 Putnam <5 Quitman 0 Rabun 0 Randolph 0 Richmond 22 Rockdale <5 Schley 0 Screven 0 Seminole <5 Spalding <5 Stephens <5 Stewart 0 Sumter 0 Talbot 0 Taliaferro <5 Tattnall <5 Taylor 0 Telfair <5 Terrell <5 Thomas <5 Tift <5 Toombs 5 Towns <5 Treutlen 0 Troup <5 Turner <5 Twiggs 0 Union 0 Upson <5 Walker <5 Walton 0 Ware 5 Warren 0 Washington <5 Wayne <5 Webster 0 Wheeler 0 White 0 Whitfield 8 Wilcox 0 Wilkes 0 Wilkinson 0 Worth <5 Case rate 0 0 2.7 6.4 3.2 3.8 0 2.4 4.2 4.4 0 0 13.1 0 38.5 0 0 0 11.0 1.4 0 0 10.7 1.7 7.9 0 0 0 48.1 13.4 0 8.5 27.3 7.0 10.4 19.2 10.7 0 5.1 10.5 0 0 10.9 4.9 0 14.1 0 9.4 15.1 0 0 0 9.6 0 0 0 4.6 10 | 2001 Georgia Tuberculosis Report 2001 Number of cases 0 0 0 9 < 5 0 0 < 5 5 < 5 < 5 0 < 5 0 0 0 < 5 < 5 30 0 < 5 < 5 0 < 5 < 5 < 5 < 5 0 0 < 5 < 5 0 < 5 < 5 < 5 < 5 0 0 < 5 < 5 0 0 < 5 < 5 < 5 < 5 < 5 < 5 < 5 0 0 0 7 0 < 5 < 5 < 5 Case rate 0 0 0 4.9 1.5 0 0 2.2 20.7 8.1 12.7 0 2.6 0 0 0 6.5 13.1 15.1 0 25.5 19.8 0 3.4 7.8 19.4 3.0 0 0 4.5 11.3 0 18.3 2.3 5.2 7.7 0 0 3.4 10.4 0 0 7.2 4.8 1.5 8.4 15.9 19.0 14.8 0 0 0 8.2 0 9.4 19.4 4.6 Table 2. Number of TB Cases and TB Case Rates (per 100,000) by Health District Georgia, 2000-2001 HEALTH DISTRICT 1.1 Rome 1.2 Dalton 2.0 Gainesville 3.1 Cobb 3.2 Fulton 3.3 Clayton 3.4 Lawrenceville 3.5 DeKalb 4.0 LaGrange 5.1 Dublin 5.2 Macon 6.0 Augusta ASMP 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Savannah 9.2 Waycross 9.3 Brunswick 10 Athens 2000 Number of cases 31 15 12 38 177 23 43 86 29 8 28 30 13 30 14 38 22 34 11 14 Case rate 6.1 4.6 2.6 6.2 22.4 9.7 6.8 12.9 4.9 5.9 5.9 10.1 8.5 6.2 10.8 8.2 10.6 5.1 3.8 2001 Number of cases 31 11 11 39 135 15 21 76 16 6 23 52 16 20 15 30 16 25 < 5 14 Case rate 5.7 3.2 2.3 5.4 16.5 6.5 2.8 11.4 2.5 4.4 4.8 12.1 5.7 6.2 8.8 5.9 7.8 1.4 3.7 Percent change in number of cases 0 -27 -8 +3 -24 -35 -51 -12 -45 -25 -18 +73 -33 +7 -21 -27 -26 -73 0 2001 Georgia Tuberculosis Report | 11 Primary Drug Resistance and Multi-Drug Resistant TB (MDR-TB) Drug susceptibility results were reported for 414 of 420 (99%) isolates from culture-positive cases in 2001. Primary drug resistance to the first line anti-TB drugs: isoniazid (INH), rifampin (RIF), ethambutol, and streptomycin, was reported in 22 (6%), 2 (0.5%), 2 (0.5 %) and 9 (8%) cases, respectively (Figure 10). Two cases (0.5%) of multi-drug resistant tuberculosis (resistance to at least INH and RIF) were reported. Relative to other states with large metropolitan areas, the incidence of multidrug resistant tuberculosis (MDR-TB) in Georgia has been low. Between 1993 and 2001, 37 MDR-TB cases have been reported, most of which were reported by DeKalb District (12 cases, 32%) and Cobb District (6 cases, 16%). Twenty-two (60%) of the MDR-TB cases were foreign-born. Mexico, India, and Vietnam were the countries of origin of most of the foreign-born MDRTB cases, accounting for 15 cases during that time period. Figure 10. Primary TB Drug Resistance and MDR-TB Number 40 35 32 30 25 20 15 10 87 5 0 97 Georgia, 1997-2001 34 30 26 22 7 4 56 98 99 00 Year INH RIF MDR 22 22 01 TB Mortality Thirty-two persons died of TB in Georgia in 2000, the year for which the most recent mortality data is available. The age-adjusted TB mortality rate was 0.47 per 100,000 persons in 2000 compared to 1.11 per 100,000 in 1999. TB Program Outcome Measures A. Completion of TB therapy within 12 months for TB cases (National TB Elimination goal: 90%) Of newly diagnosed TB cases in 2000 who were eligible for treatment of one year or less, 85% completed therapy within 12 months - lower than the 90% treatment completion rate achieved in 1999 but still higher than in preceding years (Figure 11). Five of 19 health districts achieved 90% or higher completion of therapy rates in 12 months: District 1.2 (Dalton), 3.2 (Fulton), 3.5 (DeKalb), 8.1 (Valdosta), and 10 (Athens). Improvements in treatment completion have been mainly attributed to increased treatment adherence as a result of directly observed therapy (DOT) Fig. 11. Completion of TB Treatment in 12 months* and Directly Observed Therapy, Georgia, 1994-2000 Percent 100 90 80 70 60 50 40 30 20 10 0 94 95 96 97 98 99 00 Year Completion of therapy in 12 mos. Directly observed therapy *Excludes cases with rifampin resistance and cases < 15 yrs. old with miliary, meningeal, bone or joint TB that require > 12 months treatment 12 | 2001 Georgia Tuberculosis Report (Figure 12). Before DOT became the standard of care in Georgia in 1995, completion of TB therapy within 12 months was only 66% in 1994. Lower treatment completion within 12 months was noted in populations at-risk for treatment nonadherence 71% among persons who abused illegal drugs, 78% among homeless persons, and 78% among residents of correctional facilities. B. Completion of Latent TB Infection treatment of TB contacts (National TB Elimination goal: 85%) In 2000, 5,561 contacts to TB cases were completely evaluated for TB disease and infection. Of the contacts evaluated, 1,723 (31%) had latent TB infection (LTBI) and 114 (2%) had active TB disease (Figure 13). Preliminary data of contacts started on treatment for LTBI show 583 (53%) infected contacts completing LTBI treatment (Figure 14). Figure 12. Directly Observed Therapy (DOT) Georgia, 1993-2000 Percent 120 100 11 80 12 14 23 32 33 35 60 49 52 40 52 51 50 20 54 0 30 30 21 16 15 93 94 95 96 97 98 Year Self-Administered (SA) only DOT only 30 21 57 66 11 9 99 00 DOT + SA Note: Unknowns not included in graph Figure 13. Contact Investigation Results Georgia, 2000-2001 Number 2000 1800 1600 1400 1200 1000 800 600 400 200 0 1723 114 2000 * preliminary data Year 723 34 2001 * Latent TB Infection Active TB Disease Figure 14. Contact Follow-up Results Georgia, 2000 Contact Follow-up Results No Contacts Identified Sputum Smear + Sputum Smear - Cases Culture + Cases n = 282 n = 142 9% 17% Contacts Evaluated 61% 63% Infected Contacts 64% 58% Treated Infected Contacts that 53% 53% Completed Treatment 2001 Georgia Tuberculosis Report | 13 Data Implications for TB Elimination in Georgia While the Georgia TB Program has made steady progress toward achieving national TB control and elimination objectives, many challenges still remain. The remarkable efforts made by public health workers to attain a high coverage for directly observed therapy made a notable impact on rates for completion of therapy and reducing TB numbers yet this could plateau and weaken without stable support of the public health infrastructure. TB programs must be strengthened for populations with difficult life circumstances such as poverty, HIV infection, homelessness, and substance abuse for which adherence to TB treatment is frequently problematic and health-seeking behavior is often delayed. TB programs will need to accelerate their out-reach work in populations where disparities in TB incidence persist which requires consistent investment in human resources needed to get the job done. TB program activities should actively seek out collaboration with community-based organizations and community health care/social service providers to implement grass-roots interventions and improve access to care. Counties with a high proportion of foreign-born TB cases must implement culturally competent, effective, and affordable strategies to overcome social barriers to care. Legislation is required to prohibit contagious TB cases from boarding airplanes and other means of public transportation until they are rendered clinically non- infectious by appropriate TB treatment to prevent further TB transmission. Skills and competencies of public health staff in areas of low TB incidence need to be sustained. Screening for new TB cases and persons with latent TB infection (LTBI) is a very labor-intensive public health activity that warrants judicious prioritization of public health resources expenditures. Among populations selected for TB screening, contacts recently exposed to an active TB case and newly arrived refugees (especially those who arrive with a B1 or B2 TB condition) yield the highest prevalence of latent TB infection. To prevent future TB cases, thorough evaluation for LTBI and follow-up of LTBI treatment completion in these populations is a cost-effective strategy. Homeless shelters and jails are also suitable sites for targeted TB screening. However, the unstable social situations and mobility of persons in these settings make monitoring of LTBI treatment exceptionally difficult, necessitating special interventions to ensure that appropriate LTBI treatment is started and completed. Routine TB screening procedures for employees and residents in these settings should be developed if none exist. 14 | 2001 Georgia Tuberculosis Report TB Case Rates by County Georgia, 2001 TB Case Rate 0 to 6.9 >6.9 (state average) TB Case Rates by District Georgia, 2001 1.2 2 1.1 3.1 3.4 10 3.2 3.3 4 6 3.5 5.2 TB Case Rate 0 to 6.9 >6.9 (state average) 7 5.1 8.2 9.2 8.1 9.1 9.3 2001 Georgia Tuberculosis Report | 15 2001 Tuberculosis Report Georgia Department of Human Resources | Division of Public Health Epidemiology Branch | Prevention Services Branch