2005 Georgia Tuberculosis Report 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 1 [This page intentionally left blank] 2 2005 Georgia Tuberculosis Report Georgia Department of Human Resources ............B. J. Walker Commissioner Division of Public Health.................................Stuart Brown, M.D. Director Epidemiology Branch.....................................Susan Lance, D.V.M., PhD. Director Tuberculosis Epidemiology Section....................Rose-Marie F. Sales, M.D., M.P.H. Section Chief Tuberculosis Program.....................................Beverly DeVoe-Payton, M.S.H. Program Manager Michael K. Leonard, Jr., M.D. Medical Consultant Acknowledgments: We thank the county health department staff, district health office TB coordinators, and state surveillance staff who collected and reported the data that were used in this annual report. 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 Suggested Citation: 2005 Georgia Tuberculosis Report, Georgia Department of Human Resources, Division of Public Health, Atlanta, Georgia. 3 [This page intentionally left blank] 4 Tuberculosis (TB) Epidemiology in Georgia In 2005, 504 tuberculosis cases (5.6 per 100,000 population) were reported in Georgia. This represents a 6% decrease from 537 cases reported in 2004, and a 44% reduction from the height of a resurgence in TB that occurred in Georgia from 1985 to 1992 (Figure 1). Georgia had the 6th highest number of reported TB cases and the 9th highest TB case rate among states in the U.S. in 2005. Geographic Distribution Five metropolitan Atlanta counties accounted for 51% of Georgia's TB cases in 2005. The counties that reported the highest number of cases in metropolitan Atlanta were: Fulton (88), DeKalb (79), Gwinnett (48), Cobb (29), and Clayton (15). Outside the metropolitan Atlanta area, Chatham (16 cases), Muscogee (14), Richmond (14), and Dougherty (12) counties reported the highest number of TB cases. DeKalb County had the highest TB case rate (11.6 per 100,000) in 2005 followed by Fulton County (9.6 per 100,000). Among Georgia's 18 Public Health Districts, Districts 4 (LaGrange) and 10 (Athens) had the lowest TB case rates (2.2 per 100,000) in 2005 (Figures 2-3). Sex and Age Distribution TB occurred predominantly (61%) among men and only a slight (0.6%) decrease in male cases was reported from 2004 to 2005. Among women, a 16% decrease was reported (from 209 cases in 2004 to 176 cases in 2005). The highest number of TB cases (187 cases) for both sexes by age group occurred in persons 25 to 44 years old, followed by persons in the 45-64 year old age group (127 cases) (Figure 4). TB case rates in these two age groups have been decreasing over the past five years (from 2001 to 2005) (Figure 5). In 2005, the highest case rate by age group was in persons 65 years old and older (8.6 per 100,000) while the lowest was in children 5 to 14 years old (0.9 per 100,000). Race/Ethnicity and TB Disparities TB disproportionately affects racial/ethnic minorities in Georgia. Racial/ethnic minorities represented 40% of the Georgia population but 83% of TB cases in 2005; 57% were non-Hispanic blacks, 18% were Hispanics, and 8% were Asians, while nonHispanic whites constituted 16% of cases (Figure 6). The highest TB case rate was in Asians (17.9 per 100,000) followed by Hispanics (13.9 per 100,000) and non-Hispanic blacks (10.8 per 100,000). The black case rate was seven times higher than the white rate (Figure 7). The TB case rate for black men was 4.5 times higher than for white men (17.4 vs. 3.9 per 100,000, respectively) while the case rate for black women was nine times higher than for white women (8.7 vs. 1 per 100,000 respectively). Over the past five years, TB case rates in all racial/ethnic groups in Georgia have been decreasing. 5 High-Risk Populations Foreign-born The number and proportion of TB cases among persons born outside of the United States increased from 159 cases (29%) in 2001 to 185 cases (37%) in 2005. Of these, 50% were diagnosed in the first three years of their arrival in the U.S. In 2005, most foreign-born cases came from Mexico (40 cases), Vietnam (17), Guatemala (15), Ethiopia (15), and India (12), countries where TB is an endemic disease (Figures 8-9). Refugees and Immigrants Of 173 refugees and immigrants who arrived in Georgia in 2005 with non- infectious TB diagnosed abroad in accordance with U.S. embassy procedures, 135 (78%) were re-evaluated by county health departments after their arrival. Seven (5%) were diagnosed with active TB and received TB treatment from public health clinics in Georgia. HIV co-infection Persons with HIV infection have a markedly high risk of acquiring TB soon after exposure to a patient with infectious TB. HIV co-infection was present in 69 (16%) of 437 TB cases whose HIV status was known. The number and proportion of TB cases coinfected with HIV decreased in the past five years while the rate of HIV testing has steadily improved (Figure 10). Among TB cases in adults aged 25-44 years old, 95% were tested for HIV in 2005 compared to 91% tested in 2001. Congregate Settings and Substance Abuse Persons residing in crowded congregate settings such as homeless shelters and prisons are at risk for acquiring TB. In 2005, 42 (8%) cases were homeless, 25 (5%) were residents of correctional facilities, and 8 (1%) were residents of long-term care facilities. This represents a small increase in the number of cases occurring among the homeless and residents of correctional facilities from the year before; however, cases in these high-risk settings have decreased over the past 5 years (by 33%, 24% and 61% among homeless cases, cases in correctional inmates and long-term care residents, respectively). Of the cases in correctional facilities, 13 were incarcerated in county jails while 12 were inmates of state prisons. Substance abuse of either drugs or alcohol was reported in 96 (19%) cases in 2005. The proportion of TB cases who were reported to be substance abusers over the past 5 years has ranged from 17% to 22% (Figure 11). Pediatric TB TB in children is considered a sentinel public health event because it indicates recent transmission from an infectious adult case. Potentially lethal forms of TB such as TB meningitis can develop in very young children. In 2005, children younger than 15 years old comprised 8% of Georgia TB cases; 30 cases were reported in children younger than 5 years old, 11 cases in children 5 to 14 years old. The major sites of disease among pediatric cases were pulmonary (78%), lymphatic (20%), and meningeal (2%). The case rate in children less than 5 years old and in children 5 to 14 years old was 4.3 per 100,000 and 0.9 per 100,000, respectively. 6 Drug Resistance Of 397 culture-confirmed cases with no previous history of TB, 392 (99%) were tested for drug susceptibility to the three first line anti-TB medications: isoniazid (INH), rifampin (RIF) and ethambutol (EMB). Of these tested isolates, 24 (6%) had primary resistance to INH, 3 (0.8%) to RIF, and 2 (0.5%) to EMB. One case (0.3%) had multidrug-resistant TB (MDR-TB) i.e., resistance to at least INH and RIF. Primary INH resistance has ranged from 5% to 8% in the past 5 years while an average of two MDRTB cases per year was reported over that time period (Figure 12). Indicators of Infectiousness Persons with pulmonary or laryngeal TB have the potential of infecting others with TB, and more so if they are sputum smear positive for acid-fast bacilli (AFB), culture positive for Mycobacterium tuberculosis, or have cavitary lesions on chest radiography. In 2005, 77% of cases had pulmonary TB, 50% of 443 cases whose sputum was tested for AFB had positive smears, 75% of 416 cases for which sputum culture was performed had positive Mycobacterium tuberculosis cultures, and 32% of 382 cases who underwent chest radiography showed radiographic evidence of cavitary lesions. Hospitalized TB Patients and Outpatient Follow-up In Georgia, most initial TB diagnoses are made in a hospital rather than in an outpatient clinic. In 2004-2005, 656 (63%) of 1,041 TB patients were initially reported to public health authorities by 114 different hospitals in Georgia. About a fourth of these hospitalized patients were admitted to Grady Memorial Hospital, a public tertiary referral hospital in Atlanta, Georgia. After hospital discharge, the majority (92%) of TB patients was followed-up and managed by county health departments that provided monthly evaluation and directly observed therapy. Only 8% of cases were cared for solely by a private physician. TB Mortality Thirty-one persons died of TB in GA in 2004, the most recent year with available mortality data. From 2000 to 2004, an average of 26 people died of TB per year (range = 15-32). The age-adjusted TB mortality rate was 0.4 per 100,000 in 2004 a slight increase from 0.2 deaths per 100,000 in 2003. TB Program Objectives: Objective 1: 90% of Georgia TB patients will complete a course of TB treatment within 12 months of starting treatment. Among 462 patients started on TB treatment in 2004, 92% completed their full course of treatment and 82% of patients eligible for a 12-month treatment course 7 completed treatment in 12 months. Timely treatment completion was lower than the state average of 82% among substance abusers (68%), homeless cases (69%), HIV infected cases (73%), and patients exclusively treated by private providers (75%). Timely treatment completion has improved since directly observed therapy became the standard of care for TB treatment in Georgia in 1994 (Figure 13). Objective 2: At least 95 percent of cases with sputum smears that are positive for acidfast bacillus will have contacts identified. Georgia achieved this goal in 2004, the most recent year with complete data on contact follow-up. Of 220 cases with sputum smears that were positive for acid-fast bacillus (an indicator of infectiousness), 209 (95%) had contacts identified by county health departments. Objective 3: At least 75 percent of persons with latent TB infection (LTBI) and started on treatment for latent TB infection will complete preventive LTBI therapy. Of 723 infected contacts started on LTBI therapy in 2004, 454 (63%) completed LTBI treatment. Of those who did not complete therapy, most (52%) chose to stop therapy on their own and 36% were lost to follow-up. Completion of LTBI therapy, though below the benchmark objective, has steadily improved from five years ago when it was only 54% (Figure 14). 8 Table 1. Number of TB Cases and TB Case Rates (per 100,000) by County, Georgia, 2004-2005 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 (excludes Augusta State Medical Prison) Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas 2004 Number of Case Rate cases <5 5.6 <5 12.5 0 0 0 0 <5 4.4 <5 6.4 0 0 6 6.9 0 0 0 0 10 6.4 <5 8.3 <5 12.9 <5 6.1 0 0 <5 4.9 <5 12.9 0 0 0 0 <5 2.2 0 0 8 7.8 <5 1.7 0 0 10 4.2 0 0 <5 7.5 <5 2.3 <5 2.9 0 0 1 4 5 .3 0 0 29 4.4 <5 5.1 <5 6.8 <5 2.0 2005 Number of Case Rate cases 0 0 <5 12.4 0 0 0 0 0 0 0 0 <5 3.3 6 6.7 0 0 0 0 9 5.8 0 0 0 0 0 0 0 0 <5 3.2 <5 12.9 0 0 0 0 <5 2.2 0 0 <5 2.8 <5 4.9 0 0 16 6.7 <5 6.8 <5 3.8 <5 1.6 <5 1.9 <5 30.8 15 5.6 0 0 29 4.4 <5 2.5 <5 4.6 <5 1.9 0 0 <5 6.1 <5 0.9 <5 0.9 0 0 0 0 <5 18.2 <5 18.2 <5 6.2 0 0 0 0 <5 5.1 0 0 <5 3.5 72 10.6 79 11.6 <5 5.1 <5 5.1 <5 25.8 <5 25.5 8 8.4 12 12.6 3 2.8 <5 0.9 9 COUNTY Early Echols Effingham 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 2004 Number of Case Rate cases <5 8.3 0 0 <5 8.9 <5 9.6 <5 9.0 <5 17.8 0 0 <5 2.9 6 6.4 <5 0.75 0 0 116 14.2 7 26.2 0 0 0 0 5 10.2 0 0 <5 6.4 42 6.0 0 0 6 3.7 0 0 0 0 <5 3.7 0 0 0 0 5 3.1 10 8.1 <5 20.1 <5 4.0 0 0 0 0 <5 5.9 0 0 0 0 <5 3.8 0 0 0 0 <5 2.1 0 0 <5 1.6 <5 11.9 0 0 5 5.2 0 0 <5 7.2 0 0 <5 14.1 0 0 <5 8.9 <5 4.4 2005 Number of Case Rate cases <5 8.3 0 0 <5 4.3 <5 4.8 <5 4.5 0 0 0 0 <5 1.0 7 7 .4 0 0 <5 4.6 88 9.6 <5 11 0 0 0 0 5 9.9 <5 4.1 <5 6.4 48 6.6 <5 7.6 10 6 0 0 0 0 <5 3.6 0 0 0 0 <5 1.8 8 6.3 0 0 <5 1.9 0 0 0 0 0 0 0 0 0 0 <5 3.7 <5 6.1 0 0 <5 4.3 <5 3.2 0 0 0 0 0 0 <5 4.1 0 0 <5 7.3 0 0 0 0 0 0 0 0 0 0 10 COUNTY Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington 2004 Number of Case Rate cases 0 0 6 25.1 <5 4.3 0 0 0 0 <5 2.5 20 10.9 0 0 0 0 0 0 <5 2.8 <5 4.0 0 0 0 0 <5 6.3 <5 2.5 0 0 <5 5.1 <5 81 0 0 0 0 9 4.6 <5 5.3 0 0 <5 19.6 <5 10.8 <5 3.3 0 0 0 0 <5 6.1 0 0 0 0 0 0 <5 11.1 0 0 <5 18.3 <5 2.3 <5 7.5 0 0 0 0 <5 14.2 <5 4.9 <5 10.6 <5 9.6 0 0 <5 3.6 <5 4.7 <5 5.6 <5 5.6 0 0 <5 4.7 2005 Number of Case Rate cases 0 0 <5 8.4 0 0 0 0 0 0 <5 2.4 14 7.6 <5 3.5 0 0 <5 7.3 <5 0.9 <5 8.1 0 0 0 0 0 0 <5 9.9 <5 10.3 <5 5 <5 81.1 0 0 0 0 14 7.2 7 8.9 0 0 <5 6.5 <5 10.8 <5 3.3 0 0 0 0 < 5 6.1 0 0 0 0 <5 4.3 <5 11.2 <5 7.6 0 0 <5 4.5 <5 2.4 <5 3.7 0 0 <5 14.8 <5 6.4 0 0 <5 9.7 0 0 <5 3.6 <5 6.3 <5 1.3 <5 8.7 0 0 <5 9.9 11 COUNTY Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth 2004 Number of Case rate cases 0 0 0 0 0 0 0 0 8 9.0 0 0 0 0 0 0 0 0 2005 Number of Case rate cases 0 0 0 0 0 0 <5 16.6 <5 3.3 <5 22.9 0 0 0 0 0 0 Table 2. Number of TB Cases and TB Case Rates by Health District, Georgia, 2004-2005 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/Augusta State Medical Prison 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens Total 2004 Number of cases 28 20 8 32 116 14 46 72 25 < 5 28 20/13 Case rate 4.9 5.2 1.5 4.2 14.2 5.2 5.3 10.6 3.5 2.8 5.6 4.6 35 9.9 12 5.1 22 6.1 17 3.3 13 3.9 12 2.9 537 6.0 2005 Number of cases 31 10 19 30 88 15 58 79 16 8 24 23/7 Case rate 5.3 2.5 3.5 3.9 9.6 5.6 6.5 11.6 2.2 5.6 4.8 5.3 30 8.4 6 2.5 23 6.4 19 3.7 9 2.7 9 2.2 5 04 5.6 12 Figure 1. TB Cases and Case Rates Georgia,1982-2005 Number 1000 Rate/100,000 16 900 14 800 12 700 600 504 10 500 8 400 6 300 4 200 100 2 0 0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 Year Number Case Rate 504 TB cases were reported in GA in 2005 a 6% decrease from 2004 Muscogee n=14 Figure 2. High TB Incidence Counties Georgia, 2005 Atlanta Richmond n=14 Cobb n=29 Fulton n=88 Gwinnett n=48 DeKalb n=79 Clayton n=15 51% of TB cases were reported from Metro Atlanta counties Chatham n=16 Dougherty n=12 13 Figure 3. TB Case Rates per 100,000 Health Districts, Georgia, 2005 1-2 2-0 Gordon 1-1Bartow Polk Paulding Haralson 3-1 3-2 3-4 3-5 3-3 Rockdale 10-0 4-0 5-2 6-0 7-0 5-1 9-1 8-2 Seminole Decatur 9-2 8-1 Health Districts: 1-1 Northwest (Rome) 1-2 North Georgia (Dalton) 2-0 North (Gainesville) 3-1 Cobb-Douglas 3-2 Fulton 3-3 Clayton (Morrow) 3-4 East Metro (Lawrenceville) 3-5 DeKalb 4-0 La Grange 5-1 South Central (Dublin) 5-2 North Central (Macon) 6-0 East Central (Augusta) 7-0 West Central (Columbus) 8-1 South (Valdosta) 8-2 Southwest (Albany) 9-1 Coastal (Savannah/Brunswick) 9-2 Southeast (Waycross) 10-0 Northeast (Athens) <= 3.5 (national target) 3.6 to 5.6 > 5.6 (state average) Figure 4. TB by Age Group and Sex Georgia, 2005 120 100 80 Number of TB Cases 60 40 20 0 < 5 5-14 15-24 25-44 45-64 >= 65 Age Group Male Female 14 Figure 5. TB Case Rates by Age Group Georgia, 2001-2005 Age Group < 5 yrs. 5-14 15-24 25-44 45-64 65 + 2001 3.4 0.7 4.5 8.9 8.3 9.7 2002 3.4 0.7 4.4 8.7 8.0 9.7 2003 5.0 0.8 4.7 7.4 7.7 9.6 2004 3.5 1.0 4.9 7 8.6 9 2005 4.3 0.9 5.6 6.6 6.1 8.6 Figure 6. TB Cases by Race/Ethnicity Georgia, 2001-2005 2005 2004 2003 2002 2001 0% 57 16 18 8 58 15 17 10 Black 58 15 16 9 White Hispanic 60 17 14 8 Asian 59 19 11 10 20% 40% 60% Percent 80% 100% Year 15 Case Rate/100,000 Figure 7. TB Case Rates in non-Hispanic Blacks and Whites, Georgia,1993-2005 35 30.6 30 25 20 15 10 5 3.7 0 10.8 1.5 93 94 95 96 97 98 99 01 02 03 04 05 Year Non-Hispanic White Non-Hispanic Black Black case rate is decreasing but was 7x higher than white rate Figure 8. US-born and Foreign-born TB Cases Georgia,1993-2005 Number 800 700 600 500 400 300 200 37% 100 0 93 94 95 96 97 98 99 00 01 02 03 04 05 Year US-born Foreign-born 16 Figure 9. Countries of Origin of Foreign-born TB Cases Georgia, 2005 12% 21% 39% 28% Latin America Africa Western Pacific Others Number Figure 10. HIV Status of TB Cases Georgia,1993-2005 900 800 700 600 500 400 300 200 100 0 16% HIV positive 93 94 95 96 97 98 99 00 01 02 03 04 05 Year Positive Negative Unknown 17 Figure 11. TB in Other High-Risk Populations Georgia, 2001-2005 120 100 80 Number 60 40 20 0 01 02 03 04 05 Year Substance abuse Homeless Correctionals Long-Term Care Small increases from the previous year among homeless and inmates during 2005 Figure 12. Drug Resistance and MDR-TB Georgia, 2001-2005 Number 35 30 25 22 20 15 10 5 22 0 01 30 22 02 20 22 03 Year 30 43 04 23 21 05 INH RIF MDR Primary INH resistance was reported in 6% of isolates tested in 2005 18 Figure 13. Timely Treatment Completion and Directly Observed Therapy (DOT) Georgia, 1993-2004 90 80 70 68% 60 50 40 30 20 DOT became standard of care 10 0 82% Completion in 12 months Totally DOT 93 94 95 96 97 98 99 00 01 02 03 04 Year Percent Percent Figure 14. Completion of Latent TB Infection Therapy, Georgia, 2000-2004 64 63 62 60 60 58 56 56 54 54 53 52 50 48 2000 2001 2002 2003 2004 Year Completed LTBI Therapy 19