2007 Georgia Tuberculosis Report Georgia Department of Human Resources | Division of Public Health 2007 Georgia Tuberculosis Report | 1 Pub. No. DPH08.327HW 2007 Georgia Tuberculosis Report Georgia Department of Human Resources ............B. J. Walker Commissioner Division of Public Health.................................S. Elizabeth Ford, M.D., M.B.A. Acting Division Director Health Information, Policy, Strategy, and Accountability ............................................. Martha Okafor, Ph.D. Division Deputy Director Office of Epidemiology, Evaluation and Health Information........................................ Dafna Kanny, Ph.D. Senior Director Epidemiology Section...........................................John Horan, M.D., M.P.H. Director Tuberculosis Epidemiology Team.............................Rose-Marie F. Sales, M.D., M.P.H. Team Leader 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 TB surveillance staff that collected and reported the data that were used in this annual report. Thanks to Jimmy Clanton for the design and graphics of this 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 Team 2 Peachtree St., NW, Atlanta, GA 30303 Phone: (404) 657-2634 E-mail: rfsales@dhr.state.ga.us Suggested Citation: 2007 Georgia Tuberculosis Report, Georgia Department of Human Resources, Division of Public Health, Atlanta, Georgia, October 2008. Publication No:DPH08.327HW 2007 Georgia Tuberculosis Report | 1 Table of Contents TB Surveillance in Georgia........................................................................................................................................................3 Current Epidemiology of TB in Georgia....................................................................................................................................4 High-Risk Populations................................................................................................................................................................6 Drug Resistance..........................................................................................................................................................................7 Indicators of Infectiousness........................................................................................................................................................8 Initial Diagnosis, Health Provider Data, and Directly Observed Therapy.................................................................................................................................................8 TB Mortality...............................................................................................................................................................................8 TB Contact Investigations and Latent TB Infection...................................................................................................................8 TB Program Objectives..............................................................................................................................................................9 Morbidity Trends and Program Performance Tables..................................................................................................................10 Graphs of TB Morbidity Trends by Health District, 1995-2007................................................................................................20 2007 Georgia Tuberculosis Report | 2 Tuberculosis (TB) Surveillance in Georgia TB is a reportable disease in Georgia. All Georgia physicians, laboratories, and other health care providers are required by law to immediately report clinical and laboratory confirmed TB cases under their care to Georgia public health authorities. TB cases may be directly reported to a County Health Department, a District Health office, or to the state TB Program and TB Epidemiology Team of the Georgia Department of Human Resources, Division of Public Health (GA DHR-DPH), which is responsible for the systematic collection of all reported TB cases in the state. Immediate reporting of TB cases enables appropriate public health follow-up of patients, including administration of directly observed therapy, monitoring TB treatment until completion, evaluating and screening contacts exposed to a TB case, and outbreak investigation and control. TB cases in Georgia can be reported electronically through the State Electronic Notifiable Disease Surveillance System (SendSS), a secure web-based surveillance software developed by GA DHR's Division of Public Health, or by calling, mailing or faxing a report to public health authorities. Hospital infection practitioners as well as public health nurses, outreach staff, epidemiologists, and communicable disease specialists involved in disease surveillance are encouraged to report TB through SendSS and register to become a SendSS user by logging into the system's website at: https://sendss.state. ga.us then selecting TB from the list of reportable diseases. Public health authorities collect data on reported TB cases that include demographic, clinical, risk factor, and contact information, which are analyzed to describe the distribution of the disease among Georgia's population, identify high risk groups and TB clusters, describe trends in morbidity, mortality and drug resistance patterns, treatment outcomes, and infection rates among contacts to TB cases. The data are used at state and local levels to guide policy and decision making, set priorities for program interventions, evaluate program performance for the prevention and control of TB in Georgia, and educate key stakeholders and the general public on TB. Georgia's TB surveillance data are transmitted electronically to the U.S. Centers for Disease Control and Prevention and become part of the national TB surveillance database. What's new in this edition of the Georgia Tuberculosis Report: Table on Percentage of Latent TB Infection Among Contacts Exposed to a TB Case by Health District, Georgia, 2005-2006 Table on Reasons Why Infected Contacts Stop Latent TB Infection Therapy, Georgia, 2002-2006 Graphs of Tuberculosis Incidence Trends by Health District, Georgia, 1995-2007 2007 Georgia Tuberculosis Report | 3 Current Epidemiology of Tuberculosis (TB) in Georgia In 2007, 473 tuberculosis (TB) cases were reported in Georgia, representing a 7% decrease from 507 TB cases reported the year before, and a 48% reduction in cases from the height of a resurgence in TB that occurred in Georgia in the early 1990s (Figure 1). Despite the declining incidence of cases, however, Georgia's TB case rate of 5 cases per 100,000 population is still higher than the national average of 4.4 cases per 100,000, and Georgia has the ninth highest TB case rate among the 50 states of the United States. Georgia is also one of 24 states with a case rate higher than the 2000 national interim target TB case rate of 3.5 per 100,000 population. Figure 1. TB Cases and Case Rates Georgia,1982-2007 Number of Cases 1000 900 800 700 600 500 400 300 200 100 0 Rate/100,000 16 14 12 10 8 6 4 2 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Number Case Rate Geographic Distribution Among 159 counties in Georgia, the counties that reported the highest number of TB cases in 2007 were: Fulton (78), DeKalb (72), Gwinnett (53), and Cobb (27). All four counties are in the metropolitan Atlanta area and accounted for 49% of Georgia's TB cases. Only four other counties reported more than 10 TB cases in 2007: Chatham (16 cases), Columbia (16), Clayton (15) and Muscogee (11) counties that are all outside of the metropolitan Atlanta area except for Clayton County. Eighty-one counties did not report a single case of TB, 60 counties reported fewer than 5 cases, and ten counties reported between 5-7 cases in 2007 (Table 1, Figure 2). Figure 2. High TB Incidence Counties Georgia, 2007 Atlanta Columbia n= 16 Cobb n=27 Fulton n=78 Gwinnett n=53 DeKalb n=72 Clayton n=15 Chatham n=16 Number of TB Cases: >= 15 cases < 15 cases Among Georgia's 18 Public Health Districts, DeKalb Health District had the highest TB case rate (9.8/100,000) while Athens Health District had the lowest case rate (1.8/100,000) in 2007 (Table 2). The number of TB cases increased in five Health Districts from the previous year while the number of cases decreased in 10 Health Districts. Seven Health Districts achieved the national target incidence rate for TB elimination of <=3.5/100,000. Seven Health Districts had higher case rates than the state average (Figure 3). Figure 3. TB Case Rates by Health Districts Georgia, 2007 1-2 G ordon 2-0 1-1 B artow P olk P aulding Harals on 3-1 3-2 3-4 3-5 R oc k da le 3-3 10-0 Case rates/100,000 population: <= 3.5 (national target) 3.6 to 5.0 > 5.0 (state average) 4-0 6-0 5-2 7-0 8-2 S eminole Dec a tu r 5-1 9-1 9-2 8-1 2007 Georgia Tuberculosis Report | 4 Sex and Age Distribution TB occurred predominantly among men (64%) while the highest number and proportion of TB cases by age group occurred among persons 25-44 years old (170 cases, 36%) (Figure 4). Figure 4. TB Cases by Age Group and Sex Georgia, 2007 120 100 80 Number 60 40 20 0 < 5 5-14 15-24 25-44 45-64 >= 65 Age Group (years) Male Female The highest case rate by age group was among persons 65 years and older (7.4 per 100,000) while the lowest was in children 5-14 years old (0.8 per 100,000) (Figure 5). Figure 5. TB Case Rates* by Age Group 2002-2007, Georgia Age Group 2003 < 5 yrs. 5.0 5-14 yrs. 0.8 15-24 yrs. 4.6 25-44 yrs. 7.3 45-64 yrs. 7.6 65+ yrs. 9.6 2004 3.5 1 4.9 6.9 8.5 8.9 2005 4.3 0.7 5.6 6.6 6.1 8.6 2006 4.1 0.8 5.1 6.9 6.6 6.1 2007 3.5 0.8 4.3 6.0 6.0 7.4 *Rates are per 100,000 population Race/Ethnicity Distribution and TB Disparities TB disproportionately affects racial/ethnic minorities in Georgia. In 2007, non-Hispanic blacks, Hispanics, and Asians accounted for 51%, 20% and 14% of TB cases in Georgia while representing 30%, 8% and 3% of Georgia's population respectively (Figure 6). Non-Hispanic whites constituted 15% of cases in 2007. The highest TB case rate among race/ethnic groups was in Asians (21.5 per 100,000), followed by Hispanics (12.9 per 100,000), and non-Hispanic blacks (8.3 per 100,000). Case rates for all race/ethnic groups were lower than the year before (Figure 7). The nonHispanic black case rate has been steadily decreasing but was still seven times higher than the non-Hispanic white rate (1.2 per 100,000) in 2007 (Figure 8). Figure 6. TB Cases by Race/Ethnicity Georgia, 1997 and 2007 Asian 6% White 20% Hispanic 6% 1997 Black 67% Asian 14% White 15% Black 51% Hispanic 20% 2007 Figure 7. TB Case Rates* by Race/Ethnicity Georgia, 2003-2007 Race/ Ethnicity Asian, non-Hispanic Hispanic, All races Black, non-Hispanic White, non-Hispanic 2003 2004 2005 2006 2007 22.8 22.4 17.8 26.4 21.5 15.1 15.3 13.6 16.5 12.9 12.2 12 10.8 9.0 8.3 1.5 1.5 1.5 1.3 1.2 *Rates are per 100,000 population Figure 8. TB Case Rates in non-Hispanic Blacks and Whites, Georgia, 1993-2007 Non-Hispanic Black Non-Hispanic White Case Rate/100,000 35 30.6 30 25 20 15 10 8.3 5 3.7 1.2 0 1993 1995 1997 1999 2001 2003 2005 2007 Year 2007 Georgia Tuberculosis Report | 5 High-Risk Populations Foreign-born The number of TB cases among persons born outside of the United States increased fivefold from 1993 to 2007 (from 40 to 194 cases). In 2007, foreign-born TB cases made up 41% of TB cases in Georgia compared to only 5% in 1993. Most foreign-born cases reported in 2007 came from Mexico (28%), India (11%), Guatemala (9%), and Vietnam (9%), countries where TB is an endemic disease (Figures 9 & 10). Of these foreign-born cases, 48% were diagnosed in the first five years of their arrival in the U.S. Foreign-born persons represented >=50% of TB cases in five Health Districts: Lawrenceville (82%), DeKalb (58%), Cobb (57%), Dalton (53%), and Gainesville (50%). In the Lawrenceville Health District, the number of foreign-born cases has tripled over the past 5 years; most are reported from the cities of Lawrenceville and Norcross. In the DeKalb Health District, the majority of foreign-born cases are reported from the cities of Atlanta and Clarkston. Refugees and Immigrants Of 156 refugees and immigrants who arrived in Georgia in 2007 with non-infectious TB diagnosed abroad in accordance with U.S. Department of State procedures, 134 (86%) were re-evaluated by county health departments after their arrival in the U.S. Nine (7%) were diagnosed with active TB and received TB treatment from public health clinics in Georgia. Of these nine individuals, six had a Class B1 (non-infectious, active TB) overseas classification and three had a Class B2 (non-infectious, inactive TB) classification. HIV co-infection All TB patients need to be tested for HIV infection because TB treatment may change when antiretroviral therapy for HIV is given, and active TB accelerates the natural progression of HIV infection. In 2007, 413 (87%) TB cases had documented test results for HIV. Of these cases, 59 (14%) had HIV infection (Figure 11). Thirty-nine (8%) cases were not offered the HIV test, 11 (2%) refused to be tested, five (1%) had the test done but results were unknown, and five (1%) had an unknown HIV status. HIV co-infected TB cases occurred predominantly among non-Hispanic blacks (80%), males (64%), and in adults aged 25-44 years old (54%). Among TB cases in the 25-44 years old age group, the proportion of those with known HIV test results increased from 90% in 2006 to 95% in 2007. Figure 9. US-born and Foreign-born TB Cases Georgia,1993-2007 Number 800 700 600 500 400 300 200 100 0 1993 1995 1997 1999 2001 Year 2003 2005 2007 US-born Foreign-born Figure 10. Percent of Foreign-born TB Cases (n=194) by Country of Origin, Georgia, 2007 Others 43% Vietnam 9% Mexico 28% India 11% Guatem ala 9% Figure 11. HIV Status of TB Cases Georgia,1993-2007 Unknown Negative Positive Number 900 800 700 600 500 400 300 200 100 0 1993 1995 1997 1999 2001 2003 2005 2007 Year 2007 Georgia Tuberculosis Report | 6 Congregate Settings and Substance Abuse Persons residing in crowded congregate settings such as homeless shelters, prisons, and nursing homes are at risk for acquiring TB. In 2007, 35 (7%) cases were homeless, 27 (6%) were residents of correctional facilities, and 12 (2%) were residents of long-term care facilities. Of the cases incarcerated in correctional facilities, 13 were inmates in state prisons, 8 in the new Immigration and Custom Enforcement Detention Center at Stewart County, and 6 in county jails. Substance abuse of either drugs or alcohol was reported in 85 (18%) cases in 2007 (Table 3, Figure 12). Pediatric TB TB in children is considered a sentinel public health event because it often indicates recent transmission from an infectious adult case. Additionally, potentially lethal forms of TB such as TB meningitis or miliary TB can develop in very young children. In 2007, children younger than 15 years old comprised 8% of Georgia TB cases; 26 cases (3.5 per 100,000) were reported in children younger than 5 years old, 11 cases (0.8 per 100,000) were reported in children 5-14 years old. Three children younger than 15 years old had meningeal TB and one had miliary TB. Drug Resistance Of 372 culture-confirmed cases in 2007, 365 (98%) were tested for drug susceptibility to the three first line antiTB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 353 tested isolates from cases with no previous history of TB, 20 (6%) had primary resistance to INH, 3 (0.8%) to RIF, and 3 (0.8%) to EMB (Table 4). Two multidrug-resistant TB (MDR-TB, i.e. TB resistant to at least INH and RIF) cases were reported in 2007. The percentage of cases with primary INH resistance (INH-R) ranged from 5% to 8% in the past 5 years while an average of two MDR-TB cases per year was reported over that same time period (Figure 13). Figure 12. TB in Other High-Risk Populations Georgia, 2003-2007 120 100 18% 80 Number 60 40 20 7% 6% 2% 0 2003 2004 2005 2006 2007 Year Substance abuse Homeless Correctionals Long-Term Care Number Percent Figure 13. Drug Resistance and MDR-TB Georgia, 2003-2007 35 9 30 8 8 25 7 7 7 66 20 5 5 15 4 10 3 2 5 2 3 1 0 21 0 0 2003 2004 2005 2006 2007 Year INH RIF MDR-TB % INH-R 2007 Georgia Tuberculosis Report | 7 Indicators of Infectiousness Persons with pulmonary or laryngeal TB have the potential of infecting others with TB, and infectiousness is higher if their sputum smears are positive for acid-fast bacilli (AFB), sputum cultures are positive for Mycobacterium tuberculosis, or cavitary lesions are present on chest radiography. In 2007, 74% of cases had pulmonary TB, 57% had sputum cultures that were positive for Mycobacterium tuberculosis, 38% had positive sputum AFB smears, and 31% showed radiographic evidence of cavitary lesions. Initial Diagnosis, Health Provider Data, and Directly Observed Therapy In Georgia, majority of TB patients are initially diagnosed in a hospital and are followed up by county health departments after discharge to continue their TB treatment. In 2007, 318 (67%) of TB patients were initially reported to public health authorities by 106 different hospitals in Georgia. The hospitals in Georgia that admitted the most number of TB patients in 2007 were Grady Memorial Hospital (50 patients), a publicly funded hospital in Atlanta, and Gwinnett Medical Center (21 patients), a private hospital in Lawrenceville. County health departments provided case management for 87% of TB patients and only 13% of cases were cared for solely by a private physician. County health department staff provide directly observed therapy (DOT) to TB patients, which entails watching a patient swallow every dose of their TB medications for at least 6 months. In 2007, among 341 patients with case completion data, 82% received TB treatment entirely by DOT, 14% were treated by a combination of DOT and self-administered therapy, and only 4% self-administered their medications for the entire duration of their treatment. TB Mortality Twenty persons died of TB in GA in 2006, the most recent year with available mortality data. The age-adjusted TB mortality rate was 0.2 per 100,000. From 2002 to 2006, an average of 21 people died of TB each year (range = 15-31). TB Contact Investigations and Latent TB Infection Public health authorities routinely conduct a contact investigation among persons exposed to a TB case to identify secondary TB cases and contacts with latent TB infection (LTBI). Index TB cases with positive acid-fast bacillus (AFB) sputum-smear results or pulmonary cavities have the highest priority for investigation. During a contact investigation, public health staff ask recent contacts to a case if they have TB-like symptoms, administer a TB skin test (TST), repeat the TST after 8-10 weeks if the initial TST is negative, and have a chest radiology exam performed if the TST is positive (>= 5 millimeters induration). Persons with LTBI have a positive TST, but are asymptomatic and have a normal chest radiology exam. They are not contagious but have a 10% chance of developing TB disease later in life if they do not receive treatment for LTBI. Among 7,222 identified contacts of TB cases reported in 2006, 5,942 (82%) were completely evaluated for TB disease and LTBI (Table 8). Of these evaluated contacts, 69 (1%) had TB disease and 1,284 (22%) had LTBI (Table 9). Among contacts with LTBI, 929 (72%) were started on LTBI therapy (Table 10). 2007 Georgia Tuberculosis Report | 8 TB Program Objectives Objective 1: 90% of Georgia TB patients will complete a course of TB treatment within 12 months of starting treatment. Among 453 TB patients started on TB treatment in 2006 who were slated to complete treatment in 2007, 92% completed their full course of treatment; however, only 81% of patients eligible for a 12-month treatment course completed treatment in 12 months (Table 5, 6). Though this objective was not achieved, timely treatment completion has improved since 1994, when directly observed therapy became the recommended standard of care for TB treatment in Georgia (Figure 14). Timely treatment completion was much lower than the state average among HIV-infected persons (67%), homeless persons (73%), and persons abusing illegal drugs (76%). Objective 2: 95% of TB cases with sputum smears that are positive for acid-fast bacillus will have contacts identified. Figure 14. Timely TB Treatment Completion and Directly Observed Therapy (DOT) Georgia, 1993-2006 Percent 90 80 70 60 50 40 30 20 10 DOT became standard of care 0 1993 1995 1997 1999 2001 2003 Year Completion in 12 months Totally DOT 2005 Georgia attained this objective in 2006, the most recent year with completed data on contacts to TB cases. Of 185 TB cases with sputum smears that were positive for acid-fast bacillus (an indicator of infectiousness), 176 (95%) had contacts identified by county health departments (Table 7). Of the nine sputum AFB-smear positive cases with no identified contacts, the reasons for why no contacts were identified were: case was uncooperative/refused to be interviewed and had no proxy interviewee (3 cases), case was too ill to be interviewed and had no proxy interviewee (1), contact investigation was not done (1), and data were missing for 4 cases. Objective 3: At least 70 percent of persons with latent TB infection (LTBI) who started therapy for latent TB infection (LTBI) will complete LTBI therapy. Of 921 infected contacts started on LTBI therapy in 2006 who should have completed preventive treatment by 2007, 522 (57%) completed LTBI treatment, 175 (19%) chose to stop therapy on their own, 100 (11%) were lost to follow-up, 61 (7%) stopped taking medications due to a recommendation from their provider, 40 (4%) moved before completing therapy, 13 (1%) had an adverse reaction to the medications, 7 (0.8%) developed active TB, and 3 (0.3%) died before LTBI therapy was completed. The decline in LTBI treatment completion for infected contacts who started therapy in 2006 may in part be explained by incomplete reporting of LTBI treatment outcomes in previous years (which may inflate completion rates if contacts with missing treatment completion data did not complete treatment), as well as by increases in the percentages of infected contacts who were lost to follow-up or who stopped LTBI therapy due to a provider's decision (Tables 10-12, Figure 15) Figure 15. Completion of Latent TB Infection (LTBI) Therapy, Georgia, 2002-2006 Percent 70 60 55 60 63 66 57 50 40 Completed LTBI Therapy 30 Missing data 20 18 14 10 9 0 3 1 2002 2003 2004 2005 2006 Year 2007 Georgia Tuberculosis Report | 9 Table 1. Number of TB Cases and TB Case Rates per 100,000 population by County, Georgia, 2006-2007* 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 2006 Number of Case Rate cases <5 -- <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 0 0 6 3.9 0 0 <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- 0 0 0 0 <5 -- 0 0 21 8.7 0 0 0 0 <5 -- <5 -- 0 0 18 7.0 <5 -- 30 4.4 <5 -- 6 13.4 2007 Number of Case Rate cases <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 0 0 <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 16 6.4 0 0 0 0 <5 -- 5 4.4 0 0 15 5.1 0 0 27 3.9 <5 -- <5 -- <5 -- <5 -- 0 0 <5 -- <5 -- <5 -- 0 0 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 2007 Georgia Tuberculosis Report | 10 COUNTY DeKalb Dooly Dougherty Douglas 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 2006 Number of Case Rate cases 62 8.6 0 0 8 7.4 0 0 0 0 <5 -- <5 -- 0 0 <5 -- <5 -- 0 0 <5 -- 6 6.3 <5 -- 0 0 73 7.5 <5 -- 0 0 <5 -- 0 0 <5 -- 0 0 59 7.8 <5 -- 6 3.5 <5 -- 0 0 0 0 0 0 0 0 5 -- 19 14.9 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 <5 -- 0 0 <5 -- 0 0 <5 -- 2007 Number of Case Rate cases 72 10 <5 -- <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 0 0 <5 -- 7 7.3 <5 -- <5 -- 78 7.9 <5 -- 0 0 <5 -- <5 -- <5 -- 0 0 53 6.8 <5 -- 5 2.8 <5 -- 0 0 0 0 0 0 0 0 <5 -- 5 3.8 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 5 8.3 2007 Georgia Tuberculosis Report | 11 COUNTY Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether 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 2006 Number of Case Rate cases 0 0 0 0 <5 -- 0 0 <5 -- 0 0 <5 -- 0 0 0 0 <5 -- 0 0 6 25.2 <5 -- 0 0 0 0 <5 -- 12 6.4 5 5.5 0 0 0 0 <5 -- <5 -- 0 0 <5 -- 0 0 <5 -- <5 -- <5 -- <5 -- 0 0 0 0 12 5.7 <5 -- 0 0 0 0 0 0 <5 -- <5 -- <5 -- <5 -- 0 0 0 0 <5 -- 0 0 <5 -- <5 -- 2007 Georgia Tuberculosis Report | 12 2007 Number of Case Rate cases 0 0 0 0 <5 -- 0 0 <5 -- 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 <5 -- 0 0 <5 -- <5 -- 11 5.9 <5 -- 0 0 0 0 <5 -- <5 -- 0 0 <5 -- 0 0 <5 -- <5 -- <5 -- <5 -- 0 0 0 0 7 3.6 <5 -- 0 0 <5 -- 0 0 <5 -- <5 -- 0 0 <5 -- 0 0 0 0 <5 -- 0 0 0 0 <5 -- COUNTY Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth GEORGIA 2006 Number of Case Rate cases <5 -- <5 -- 0 0 0 0 0 0 9 14.2 <5 -- 0 0 <5 -- 0 0 0 0 <5 -- <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 <5 -- <5 -- 0 0 0 0 0 0 507 5.4 2007 Number of Case Rate cases 7 15.5 <5 -- <5 -- 0 0 0 0 7 11.0 0 0 0 0 0 0 0 0 <5 -- 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 0 0 0 0 473 5.0 * In counties where one to four cases were reported, "< 5" is used to represent the number of reported cases, and the case rate is not calculated. 2007 Georgia Tuberculosis Report | 13 Table 2. Number of TB Cases and TB Case Rates per 100,000 population by Health District, Georgia, 2006-2007 HEALTH DISTRICT 2006 2007 Number of cases Case rate Number of cases Case rate 1.1 Rome 17 2.8 18 3.0 1.2 Dalton 14 3.4 14 3.3 2.0 Gainesville 12 2.1 15 2.6 3.1 Cobb 30 3.8 30 3.7 3.2 Fulton 73 7.5 78 7.9 3.3 Clayton 19 7 15 5.5 3.4 Lawrenceville 68 7.3 57 6.0 3.5 DeKalb 62 8.6 72 9.8 4.0 LaGrange 27 3.6 20 2.6 5.1 Dublin 16 11.1 9 5.6 5.2 Macon 31 6.2 15 3.0 6.0 Augusta 17 3.9 16 3.6 Augusta State Medical 14 13 Prison (ASMP) 7.0 Columbus 21 5.9 21 6 ICE Detention Center 0 8 8.1 Valdosta 9 3.8 5 2.1 8.2 Albany 25 6.8 20 5.8 9.1 Coastal 31 5.9 26 4.8 9.2 Waycross 16 4.7 13 3.8 10 Athens 5 1.1 8 1.8 GEORGIA 507 5.4 473 5.0 Table 3. Percentage of TB Cases with Risk Factors for TB by Health District Georgia, 2007 HEALTH DISTRICT Foreign- HIV Homeless Inmate Nursing born % Infected % % % Home % Substance Abuse % 1.1 Rome 39 0 11 6 0 17 1.2 Dalton 57 0 0 0 0 14 2.0 Gainesville 53 8 0 0 0 27 3.1 Cobb 57 7 7 3 3 13 3.2 Fulton 30 27 17 0 3 22 3.3 Clayton 33 23 0 7 0 13 3.4 Lawrenceville 81 11 0 2 0 4 3.5 DeKalb 60 12 11 3 3 12 4.0 LaGrange 20 12 5 0 5 45 5.1 Dublin 0 14 0 0 11 22 5.2 Macon 20 21 0 0 0 13 6.0 Augusta & 19 8 0 0 0 12 ASMP 8 17 0 100 0 58 7.0 Columbus & 24 19 10 0 10 19 ICE Detention 100 0 0 100 0 29 8.1 Valdosta 20 0 0 0 0 40 8.2 Albany 5 10 10 0 0 30 9.1 Coastal 19 24 0 8 8 12 9.2 Waycross 23 0 0 0 8 0 10 Athens 38 0 12 0 0 38 GEORGIA 41 14 7 6 2 18 2007 Georgia Tuberculosis Report | 14 Table 4. Primary Resistance to First-line Anti-TB Medications by Health District Georgia, 2007 TB Drug Isoniazid Rifampin Ethambutol HEALTH DISTRICT No. % No. % No. % 1.1 Rome 0 0 0 0 0 0 1.2 Dalton 0 0 0 0 0 0 2.0 Gainesville 2 20 0 0 0 0 3.1 Cobb 4 17 0 0 0 0 3.2 Fulton 4 6 2 3 1 2 3.3 Clayton 0 0 0 0 0 0 3.4 Lawrenceville 3 7 0 0 1 2 3.5 DeKalb 2 4 0 0 0 0 4.0 LaGrange 0 0 0 0 0 0 5.1 Dublin 0 0 1 14 0 0 5.2 Macon 0 0 0 0 0 0 6.0 Augusta & 1 8 0 0 0 0 ASMP 2 22 7.0 Columbus & 1 6 0 0 0 0 ICE Detention 0 0 0 0 1 14 8.1 Valdosta 1 20 0 0 0 0 8.2 Albany 0 0 0 0 0 0 9.1 Coastal 0 0 0 0 0 0 9.2 Waycross 0 0 0 0 0 0 10 Athens 0 0 0 0 0 0 GEORGIA 20 6 3 0.8 3 0.8 Table 5. Completion of Cases' TB Treatment by Health District, Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. Cases that Completed % No. Cases that Completed % Treatment / No. Cases that Treatment / No. Cases that Started Treatment Started Treatment 1.1 Rome 1.2 Dalton 2.0 Gainesville 3.1 Cobb 3.2 Fulton 3.3 Clayton 23/25 92 16/16 100 8/10 80 13/13 100 15/15 100 10/10 100 22/24 92 26/29 90 77/81 95 68/71 96 11/12 92 11/16 69 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 Coastal 9.2 Waycross 10 Athens GEORGIA 43/52 83 52/60 87 65/69 94 50/53 94 10/10 100 21/24 88 7/7 100 12/13 92 20/21 95 22/27 82 14/14 100 11/13 85 8/8 100 15/15 100 26/27 96 17/18 94 5/5 100 8/8 100 19/21 90 22/23 96 15/17 88 15/16 94 8/8 100 15/15 100 7/7 100 4/4 100 403/433 93 417/453 92 2007 Georgia Tuberculosis Report | 15 Table 6. Timely Completion (within 12 months) of Cases' TB Treatment by Health District, Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. Cases that Completed % No. Cases that Completed % Treatment in 12 months / Treatment in 12 months / No. that Started Treatment No. that Started Treatment 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 Coastal 9.2 Waycross 10 Athens GEORGIA 22/25 88 13/15 87 7/10 70 13/13 100 15/15 100 7/9 78 17/24 71 20/25 80 65/81 80 57/71 80 10/12 83 10/16 62 40/52 77 51/60 85 54/69 78 49/53 92 7/10 70 20/24 83 7/7 100 12/13 92 18/21 86 14/26 54 13/14 93 23/28 82 8/8 100 13/15 87 23/27 85 14/18 78 5/5 100 5/8 62 15/21 71 19/23 83 14/17 82 13/16 81 6/8 75 14/15 93 6/7 86 2/4 50 377/460 82 364/448 81 Table 7. Sputum Smear Positive (SSP) Cases with Contacts Identified by Health District, Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. SSP Cases with % No. SSP Cases with % Contacts Identified / Contacts Identified / No. SSP Cases No. SSP Cases 1.1 Rome 18/18 100 5/5 100 1.2 Dalton 5/5 100 8/8 100 2.0 Gainesville 4/4 100 3/3 100 3.1 Cobb 13/13 100 7/8 88 3.2 Fulton 36/36 100 36/36 100 3.3 Clayton 7/8 88 6/6 100 3.4 Lawrenceville 25/25 100 18/21 86 3.5 DeKalb 27/28 96 16/21 76 4.0 LaGrange 10/10 100 9/9 100 5.1 Dublin 4/4 100 4/4 100 5.2 Macon 11/11 100 10/10 100 6.0 Augusta 9/9 100 13/13 100 7.0 Columbus 20/20 100 4/4 100 8.1 Valdosta 3/3 100 6/6 100 8.2 Albany 16/16 100 8/8 100 9.1 Coastal 6/6 100 16/16 100 9.2 Waycross 3/3 100 2/2 100 10 Athens 1/1 100 1/1 100 GEORGIA 218/220 99 176/185 95 2007 Georgia Tuberculosis Report | 16 Table 8. Completely Evaluated Contacts by Health District, Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. Contacts that were % No. Contacts that were % Completely Evaluated / Completely Evaluated / No. Contacts Identified No. Contacts Identified 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 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens GEORGIA 187/227 82 163/182 90 171/191 90 148/163 91 182/197 92 71/82 87 780/824 95 430/492 87 1298/1643 79 1174/1521 77 109/118 92 78/103 76 236/298 79 184/225 82 303/375 81 183/284 64 142/161 88 125/145 86 138/139 99 135/142 95 226/250 90 144/157 92 478/536 89 882/1103 80 374/426 88 158/192 82 20/21 95 372/405 92 1395/3544 39 1375/1640 84 101/108 94 243/289 84 21/24 88 57/70 81 73/86 85 20/27 74 6234/9163 68 5942/7222 82 Table 9. Contacts with Latent TB Infection by Health District, Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. Contacts with LTBI/ % No. Contacts with LTBI/ % No. Contacts No. Contacts Completely Completely Evaluated Evaluated 1.1 Rome 47/187 25 63/163 39 1.2 Dalton 37/171 22 70/148 47 2.0 Gainesville 67/182 37 25/71 35 3.1 Cobb 65/780 8 64/430 15 3.2 Fulton 360/1298 28 211/1174 18 3.3 Clayton 41/109 28 29/78 37 3.4 Lawrenceville 82/236 35 76/184 41 3.5 DeKalb 86/303 28 50/183 27 4.0 LaGrange 35/142 25 43/125 34 5.1 Dublin 23/138 17 36/135 27 5.2 Macon 50/226 22 56/144 39 6.0 Augusta 119/478 25 117/882 13 7.0 Columbus 106/374 28 64/158 40 8.1 Valdosta 8/20 40 13/372 4 8.2 Albany 124/1395 9 239/1375 17 9.1 Coastal 41/101 41 102/243 42 9.2 Waycross 5/21 24 13/57 23 10 Athens 34/73 47 13/20 65 GEORGIA 1330/6234 21 1284/5942 22 2007 Georgia Tuberculosis Report | 17 Table 10. Infected Contacts Started on LTBI Treatment by Health District Georgia, 2005-2006 HEALTH DISTRICT 2005 2006 No. Infected Contacts % No. Infected Contacts % on LTBI Treatment / No. on LTBI Treatment / No. Infected Contacts Infected Contacts 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 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens GEORGIA 32/47 68 57/63 90 26/37 70 61/70 87 54/67 81 15/25 60 49/65 75 34/64 53 249/360 69 138/211 65 30/41 73 24/29 83 48/82 58 57/76 75 49/86 57 41/50 82 26/35 74 36/43 84 19/23 83 33/36 92 36/50 72 47/56 84 47/119 40 57/117 49 55/106 52 50/64 78 8/8 100 8/13 62 74/124 60 170/239 71 36/41 88 95/102 93 0/5 0 4/13 31 23/34 68 2/13 15 861/1330 65 929/1284 72 Table 11. LTBI Treatment Completion of Infected Contacts by Health District Georgia, 2005-2006 HEALTH DISTRICT 2005 No. Contacts that % Completed LTBI Treatment / Contacts Treated Missing data 2006 No. Contacts that % Completed LTBI Treatment / Contacts Treated 1.1 Rome 1.2 Dalton 2.0 Gainesville 3.1 Cobb 3.2 Fulton 3.3 Clayton 18/23 15/26 34/54 25/43 167/229 9/21 78 9 58 0 63 1 58 6 73 15 43 8 21/54 39 32/59 54 10/15 67 13/34 38 59/138 43 10/24 42 3.4 Lawrenceville 3.5 DeKalb 4.0 LaGrange 5.1 Dublin 5.2 Macon 6.0 Augusta 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens GEORGIA 17/29 19/26 11/17 11/15 25/34 19/43 25/40 2/4 13/15 26/34 0/0 13/21 449/674 59 19 73 22 65 9 73 4 74 2 44 4 62 9 50 4 87 11 76 2 -- -- 62 1 67 126 42/57 74 36/40 90 29/36 81 17/33 52 22/47 47 31/56 55 27/50 54 6/8 75 103/169 61 59/95 62 3/4 75 2/2 100 522/921 57 Missing data 3 2 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 8 2007 Georgia Tuberculosis Report | 18 Table 12. Reasons Why Infected Contacts Treated for LTBI Stopped LTBI Therapy Georgia, 2002-2006 Reasons for Stopping LTBI Therapy Completed Therapy Chose to Stop Lost to Follow-Up Provider Decision Moved Adverse Reactions Active TB Developed Death 2002 n=575 % 55 17 8 8 10 2 0 0.5 2003 n=655 % 60 19 13 4 3 1 0.6 0.2 2004 n=720 % 63 19 10 3 3 1 0.4 0.1 2005 n=738 % 66 15 9 4 3 2 0.4 0 2006 n=921 % 57 19 11 7 4 1 0.8 0.3 2007 Georgia Tuberculosis Report | 19 Tuberculosis Morbidity Trends by Health District, Georgia, 1995-2007 TB Case Numbers and Rates District 1-1 (Rome),1995-2007 60 51 50 40 30 20 33 18 25 22 31 32 32 30 27 30 17 18 10 0 11.6 7.4 4 5.2 3.8 6.1 6 5.9 5.4 4.7 5.2 2.8 3 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 1-2 (Dalton),1995-2007 25 21 21 20 15 12 11 14 10 10 15 11 8 10 14 14 10 5 4.5 4 5 3.3 6.6 4.6 3.2 2.2 2.7 5.5 2.5 3.4 3.3 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 2 (Gainesville),1995-2007 25 20 20 17 19 15 15 15 15 15 12 13 12 10 10 10 8 5 0 5.9 4.9 3.7 3.7 3.5 2.6 2.1 2 2.5 1.5 3.5 2.1 2.6 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 3-1 (Cobb),1995-2007 50 44 40 32 32 38 38 36 32 30 30 30 30 24 25 20 18 10 0 3.1 5.1 6.8 4.9 3.6 6.2 5.2 4.8 3.3 4.2 3.9 3.8 3.7 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 3-2 (Fulton),1995-2007 250 200 192 207 187 177 150 133 150 136 119 122 116 100 87 72 78 50 0 28.1 30 26.8 17.8 19.9 22.4 16.5 14.4 15 14.2 9.7 7.5 7.9 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 3-3 (Clayton),1995-2007 30 28 25 23 20 15 10 5 18 14 9 8.8 6.7 4.5 15 13.4 7 18 19 15 15 14 15 15 9.7 6.5 7.1 5.4 5.2 5.6 7 5.5 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population 2007 Georgia Tuberculosis Report | 20 Tuberculosis Morbidity Trends by Health District, Georgia, 1995-2007 TB Case Numbers and Rates District 3-4 (Lawrenceville),1995-2007 80 68 70 60 58 57 50 43 42 46 40 30 20 12 24 17 26 29 34 21 10 0 2.2 4.1 2.8 4 4.4 6.8 2.8 4.3 5.1 5.3 6.5 7.3 6 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 3-5 (DeKalb),1995-2007 120 100 80 92 99 102 104 84 85 78 88 83 72 80 61 72 60 40 20 15.9 16.7 17 14.3 16.9 12.9 11.6 13 12.3 10.6 11.6 8.4 9.8 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 4 (LaGrange),1995-2007 35 30 24 26 29 25 25 27 25 19 21 20 20 20 16 16 16 15 10 5 3.1 4.4 4.9 3.6 3.3 4.9 2.5 2.4 3.6 3.5 2.2 3.6 2.6 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 5-1 (Dublin),1995-2007 18 16 16 14 12 12 10 8 6 4 2 7 5.6 5 4 6 4.7 4 3.1 9.4 8 9 8 11.1 6 5.9 6.6 4 4 5.6 4.4 2.9 2.8 8 5.6 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 5-2 (Macon),1995-2007 60 51 50 46 40 30 31 22 27 28 23 20 23 28 24 31 20 15 10 0 10.6 11.6 7.2 4.8 5.6 5.9 4.8 4.3 4.7 5.6 4.8 6.2 3 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 6 (Augusta),1995-2007 60 52 50 45 46 40 38 39 30 32 30 20 25 20 24 19 17 16 10 0 14.8 14.6 14.5 9.1 12.9 10.1 12.2 4.6 7.4 5.5 5.3 3.9 3.6 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population 2007 Georgia Tuberculosis Report | 21 Tuberculosis Morbidity Trends by Health District, Georgia, 1995-2007 TB Case Numbers and Rates District 7 (Columbus),1995-2007 50 46 40 33 30 20 34 36 34 28 30 30 22 21 18 20 21 10 9.5 13.2 6.3 9.9 8.1 8.5 5.9 10.1 5 9.9 8.4 5.9 6 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 8-1 (Valdosta),1995-2007 30 24 25 21 20 18 15 20 17 14 15 12 10 5 0 10.2 8.7 11.5 7.9 9.3 6.2 6.2 2 7 3 0.9 9 6 5 5.1 2.5 3.8 2.1 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 8-2 (Albany),1995-2007 50 40 38 45 40 36 43 38 30 29 24 21 23 25 21 20 17 10 11.5 13.6 12.3 10.8 12.3 10.8 8.2 4.8 6.4 6.1 6.4 6.8 5.8 0 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 9-1 (Coastal),1995-2007 70 58 60 48 50 40 30 20 34 33 25 33 19 23 20 17 19 31 26 10 0 10.4 12.4 7.2 6.9 5.2 6.8 3.9 4.6 4 3.3 3.7 5.9 4.8 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rates are per 100,000 population Rate TB Case Numbers and Rates District 9-2 (Waycross),1995-2007 60 50 43 50 48 40 30 30 24 34 25 25 20 15 16.6 15.8 16 13 9 16 13 10 10.4 8.2 0 10.6 7.8 4.9 7.6 3.9 2.7 4.7 3.8 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population TB Case Numbers and Rates District 10 (Athens),1995-2007 25 22 20 16 16 15 13 13 13 14 13 11 12 10 9 8 5 0 4.6 4.2 5.1 6.6 3.8 3.8 3.4 4.1 2.8 2.9 5 2.2 1.1 1.8 95 96 97 98 99 00 01 02 03 04 05 06 07 Year Number Rate Rates are per 100,000 population 2007 Georgia Tuberculosis Report | 22 2007 Georgia Tuberculosis Report Georgia Department of Human Resources | Division of Public Health 2007 Georgia Tuberculosis Report | 23