2010
Georgia Tuberculosis Report
Georgia Department of Public Health | Division of Public Health Epidemiology Branch | Prevention Services Branch
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2010 Georgia Tuberculosis Report
Georgia Department of Public Health...................Brenda Fitzgerald, M.D.
Commissioner
Division of Health Protection..................................Pat O'Neal, M.D.
Director
Epidemiology Branch.......................................Cherie Drenzek, D.V.M., M.S.
State Epidemiologist
Tuberculosis Program.......................................Dr. Rose-Marie F. Sales
Program Director and
Epidemiology Section Chief
Acknowledgments
We thank the County Health Department staff, District Health Office TB coordinators, and state TB surveillance staff that collected and reported the data 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:
Dr. Rose-Marie F. Sales Georgia Department of Public Health Tuberculosis Program Division of Health Protection 2 Peachtree St., NW, Atlanta, GA 30303 Phone: (404) 657-2634 E-mail: rfsales@dhr.state.ga.us
Suggested citation: Georgia Department of Public Health, 2010 Georgia Tuberculosis Report, Atlanta, Georgia, July 2012.
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Table of Contents
TB Surveillance in Georgia...............................................................13 Current Epidemiology of TB in Georgia..............................................14 High-Risk Populations....................................................................35 Drug Resistance............................................................................46 Indicators of Infectiousness.............................................................56 Initial Diagnosis, Health Provider Data, And Directly Observed Therapy........................................................75 TB Mortality..................................................................................57 TB Contact Investigations and Latent TB Infection................................67 TB Program Objectives...................................................................68 Tables: Morbidity Trends and Program Performance Indicators by Health District .....................................................................................................79 Figures: Descriptive Epidemiology..................................................................2129 Graphs: Tuberculosis Morbidity Trends by Health District, 1995-2010...................2287
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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 Section of the Georgia Department of Public Health (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 DPH, or by calling, mailing or faxing a report to public health authorities. Hospital infection preventionists 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 web site 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 (CDC) and become part of the national TB surveillance database.
Current Epidemiology of Tuberculosis in Georgia
In 2010, Georgia reported 411 new tuberculosis (TB) cases in 2010., representing This represents a slight a 1% decrease from 415 412 TB cases reported in 2009 (Figure 1), but a 55% decrease since 1992 when the peak of a resurgent period of tuberculosis occurred in Georgia. The TB case rate in Georgia was 4.2 cases per 100,000 population during 2009 and 2010. Georgia had the eleventh highest TB case rate among the 50 states of the United States in 2010.
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Geographic Distribution
Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area reported the highest number of TB cases in 2010: DeKalb (86 cases), Gwinnett (56), Fulton (51), and Cobb (26) (Table 1, Figure 2). These four counties accounted for 53% of TB cases reported in Georgia in 2010.
Among Georgia's 18 Health Districts, which have oversight responsibility for public health in the state's 159 counties, DeKalb Health District had the highest TB case rate in 2010 (12.4 per 100,000), followed by Lawrenceville (6.6 per 100,000) and Fulton (5.5 per 100,000).
Sex and Age Distribution
In 2010, TB in Georgia occurred predominantly among males (270 cases, 66%) compared to females (141, 34%), while the highest proportion of TB cases by age group occurred among persons 45-64 years old (143 cases, 35%). Among males, the highest proportion of cases occurred in the 45-64 year old age group (37%) while among females, the highest proportion was in the 25-44 year old age group (39%) (Figure 4). The highest TB case rate by age group was among persons 45-64 years old (5.8 per 100,000) while the lowest was among children 5-14 years old (0.9 per 100,000) (Figure 5). The TB case rate for children younger than 5 years of age, an age group at high risk for developing deadly forms of TB, decreased from 2.3 per 100,000 in 2009 to 2.0 per 100,000 in Georgia during 2010.
Race/Ethnicity Distribution and TB Disparities
TB disproportionately affects racial/ethnic minorities in Georgia. In 2010, non-Hispanic blacks, Asians, and Hispanics, accounted for 51%, 18% and 17% of TB cases in Georgia, respectively, but only represented 33%, 3.5% and 8.8% of Georgia's population, respectively (Figure 6). Non-Hispanic whites constituted 13% of TB cases in 2010. The highest TB case rate among race/ethnic groups was among Asians (24.1 per 100,000), followed by Hispanics (8.2 per 100,000), and non-Hispanic blacks (7.1 per 100,000) (Figure 7). The black nonHispanic TB case rate in 2010 represents an almost 80% drop from the TB case rate in 1993 (30.6 per 100,000) in this population. The black non-Hispanic TB case rate, however, was still seven times higher than the white non-Hispanic TB case rate (1.0 per 100,000) in Georgia during 2010 (Figure 8).
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High-Risk Populations
Foreign-Born
TB cases among persons born outside of the United States accounted for 44% of TB cases in Georgia in 2010 compared to 42% in 2009. Most foreign-born cases reported in 2010 came from Mexico (20%), Vietnam (14%), and India (9%) - countries where TB is an endemic disease (Figures 9-10). Among 183 foreign-born cases, 92 (50%) were diagnosed in the first five years of their arrival in the U.S.
In 2010, four Health Districts reported 72% of the total number of foreign-born TB cases in Georgia: DeKalb (52 cases), Lawrenceville (46), Cobb (20) and Fulton (14). Among these Health Districts, foreign-born TB cases accounted for more than half of the TB cases in Lawrenceville (71%), Cobb (69%) and DeKalb (60%). Foreign-born TB cases in the Fulton Health District accounted for 27% of reported TB cases in Fulton.
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 often accelerates the natural progression of HIV infection. Among 380 TB cases in Georgia with known HIV status in 2010, 10% were HIV positive compared to 15% in 2009 (Figure 11). Among 43 HIV co-infected TB cases in 2010, 86% were non-Hispanic blacks, 72% were male and 51% were 25-44 years old.
HIV status was reported in 92% of TB cases in 2010 compared to 91% in 2009. In the highrisk age group of adults 25-44 years of age, the percentage of TB cases for which HIV status was reported slightly decreased from 96% in 2009 to 94% in 2010. Among 31 cases whose HIV status was not reported, HIV testing was not offered to 19 cases (61%), HIV test results were unknown in seven cases (23%), and five (16%) refused testing. Of the 19 TB cases that were not offered the HIV test, the majority was either elderly or very young: six (32%) were 65 years old or older, while four (21%) were younger than five years old.
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 2010, 26 (6%) TB cases in Georgia were homeless, 38 (9%) were residents of correctional facilities, and 3 (0.7%) were residents of long-term care facilities. Of the 38 TB cases incarcerated inSubstance abuse is the most commonly reported behavioral risk factor among patients with TB in the United States. TB patients who abuse substances often experience treatment failure and remain infectious longer because treatment failure presumably extends periods of infectiousness. In Georgia, abuse of either illicit drugs or alcohol was reported in 72 (18%) TB cases in 2010 (Table 3, Figure 12).
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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 disseminated TB can develop in very young children. In 2010, children younger than 15 years old comprised 7% of Georgia TB cases; 14 cases (2.0 per 100,000) were reported in children younger than 5 years old, and 13 cases (0.9 per 100,000) were reported in children 5-14 years old. Two children had TB meningitis.
Latent tuberculosis infection (LTBI) in children younger than five years old is also a reportable disease condition in Georgia. When LTBI in a child less than five years of age is reported, public health personnel will initiate contact investigations to identify the source of the infection, recommend treatment for latent TB infection, follow up with the child to ensure completion of treatment and monitor for development of active TB disease. Early identification of TB infection and treatment in children can prevent progression to active disease and identify a previously undiagnosed and untreated case of active TB.
In 2010, 51 children younger than five years old were reported to have LTBI in Georgia; 38 were identified by TB screening in pediatric clinics and 13 from contact investigations. Public health staff identified the source case of the child's infection in 26 (51%) of these children.
Drug Resistance
Among 303 culturepositive TB cases in Georgia during 2010, 298 (98%) were tested for initial drug susceptibility to the three first-line anti-TB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 279 tested isolates from Georgia cases with no previous history of TB, 20 (7.2%) had primary resistance to INH, 10 (3.6%) to RIF, and 2 (0.8%) to EMB (Table 4). Three (1%) multidrug-resistant TB (MDR-TB, i.e. TB resistant to at least INH and RIF) cases were reported in 2010 among cases tested for drug susceptibility. The percentage of cases with primary INH resistance (INH-R) ranged from 6% to 14% in the past 5 years while an average of two MDR-TB cases per year was reported in Georgia over that same time period (Figure 13).
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Indicators of Infectiousness
Persons with pulmonary or laryngeal TB have the potential to infect 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 2010, 78% of all Georgia TB cases had pulmonary TB, 54% had sputum cultures that were positive for Mycobacterium tuberculosis, 34% were sputum AFB smearpositive, and 22% showed cavitary lesions on chest radiography.
Initial Diagnosis, Health Provider Data, and Directly Observed Therapy
In Georgia, the majority of TB patients are initially diagnosed in a hospital and patients are followed up by county health departments after discharge to continue their TB treatment. In 2010, 241 (59%) of the 411 TB cases in Georgia were reported initially by a hospital. Eight hospitals in the metropolitan Atlanta area reported five or more TB cases in 2010: Grady Memorial Hospital (41 cases), DeKalb Medical Center (11 cases), Northside Hospital (11 cases), Emory University Hospital (9 cases), Gwinnett Medical Center (8 cases), Wellstar Cobb Hospital (8 cases), Atlanta Medical Center (5 cases) and Wellstar Kennestone Hospital (5 cases). Four hospitals outside of the metropolitan Atlanta area reported five or more cases in 2010: Northeast Georgia Medical Center in Gainesville (7 cases), Memorial Health University Medical Center in Savannah (7 cases), Phoebe Putney Memorial Hospital in Albany (6 cases), and Medical Center of Central Georgia in Macon (5 cases). These twelve hospitals accounted for 51% of the patients hospitalized for TB in Georgia in 2010. County health departments provided case management for 90% of all Georgia TB cases, correctional facilities treated 7%, and only 3% of cases were cared for solely by a private physician. County health department staff provides directly observed therapy (DOT) to TB patients, which entails watching a patient swallow every dose of their TB medications for at least 6 months. Among 389 Georgia TB cases reported in 2009 with available case completion data, 76% received TB treatment entirely by DOT, 21% were treated by a combination of DOT and self-administered therapy, and only 3% self-administered their medications for the entire duration of their treatment.
TB Mortality
Eighteen persons died of TB in Georgia in 2010. The age-adjusted TB mortality rate in 2010 was 0.2 per 100,000. From 2005 to 2010, an average of 17 people died of TB in Georgia each year (range = 14-31).
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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 4,449 identified contacts of Georgia TB cases reported in 2009, (the most recent year with completed contact investigation data), 3,701 (83%) were completely evaluated for TB disease and LTBI. Of these evaluated contacts, 50 (1.4%) had TB disease and 803 (22%) had LTBI.
TB Program Objectives
Objective 1: 90% of Georgia TB patients will complete a course of TB treatment within 12 months of starting treatment.
Among 347 TB cases reported in Georgia during 2009 who were eligible to complete TB treatment within 12 months, 320 (92%) completed treatment and 301 (87%) completed treatment within 12 months; 17 (5%) were lost to follow-up, eight (2%) moved out of Georgia and were subsequently lost to follow-up, one (0.3%) was uncooperative and refused treatment, and one (0.3%) had to stop treatment due to adverse side effects to anti-TB medications (Tables 5, 6).
In 2009, Georgia TB cases with HIV, who were foreign-born, or who were correctional facility inmates, had lower rates of timely treatment completion than the over-all average for all TB cases. Interventions need to focus on these populations to improve timely treatment completion. 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).
Objective 2: 95% of TB cases with sputum smears that are positive for acid-fast bacillus (AFB) will have contacts identified.
In 2009, all 153 Georgia TB cases with positive AFB sputum smears had contacts elicited, exceeding the program target of 95%.
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Objective 3: Among infected contacts of AFB sputum smear-positive TB cases in Georgia, at least 70 percent who started therapy for latent TB infection (LTBI) will complete LTBI therapy.
Among 486 infected contacts of 153 AFB sputum smear-positive TB cases in 2009, 300 (62%) were started on LTBI treatment; of 275 infected contacts started on LTBI treatment with treatment completion data available, 180 (66%) completed treatment, 39 (14%) chose to stop treatment on their own, 29 (10%) were lost to follow-up, 16 (6%) moved, six (2%) stopped treatment due to a provider's decision, four (1.5%) stopped treatment due to adverse side effects, and one (0.4%) died (Tables 11, 12).
Table 1. Number of TB Cases and TB Case Rates per 100,000 population by County,
Georgia, 2009- 2010
COUNTY
2009
2010
Number of cases
Case Rate
Number of cases
Case Rate
Appling
<5
--
<5
--
Atkinson
<5
--
<5
--
Bacon
0
0
0
0
Baker
0
0
<5
--
Baldwin
0
0
<5
--
Banks
0
0
<5
--
Barrow
<5
--
0
0
Bartow
<5
--
<5
--
Ben Hill
0
0
0
0
Berrien
0
0
<5
--
Bibb
5
3.2
7
4.5
Bleckley
0
0
0
0
Brantley
0
0
0
0
Brooks
0
0
0
0
Bryan
0
0
0
0
Bulloch
<5
--
0
0
Burke
0
0
0
0
Butts
<5
--
0
0
Calhoun
0
0
0
0
Camden
<5
--
<5
--
Candler
0
0
0
0
Carroll
<5
--
0
0
Catoosa
<5
--
0
0
Charlton
0
0
0
0
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Table 1. Number of TB Cases and TB Case Rates per 100,000 population by County,
Georgia, 2009- 2010
Chatham
11
4.3
10
3.8
Chattahoochee
0
0
0
0
Chattooga
0
0
<5
--
Cherokee
<5
--
<5
--
Clarke
<5
--
<5
--
Clay
0
0
0
0
Clayton
11
4.0
8
3.1
Clinch
0
0
<5
--
Cobb
18
2.5
26
3.8
Coffee
0
0
0
0
Colquitt
<5
--
0
0
Columbia
5
4.4
7
5.6
Augusta State
9
Med. Prison
(ASMP)
n/a
18
n/a
Cook
0
0
0
0
Coweta
0
0
<5
--
Crawford
0
0
0
0
Crisp
<5
--
<5
--
Dade
0
0
0
0
Dawson
0
0
0
0
Decatur
<5
--
<5
--
DeKalb
63
8.4
86
12.4
Dodge
<5
--
0
0
Dooly
<5
--
<5
--
Dougherty
5
5.2
6
6.3
Douglas
<5
--
<5
--
COUNTY
2009
2010
Number of cases
Case Rate
Number of cases
Case Rate
Early
0
0
0
0
Echols
0
0
0
0
Effingham
0
0
<5
--
Elbert
<5
--
<5
--
Emanuel
0
0
0
0
Evans
0
0
0
0
Fannin
<5
--
<5
--
Fayette
<5
--
<5
--
8
Floyd
<5
--
0
0
Forsyth
<5
--
0
0
Franklin
0
0
0
0
Fulton
82
7.9
51
5.5
Gilmer
<5
--
<5
--
Glascock
<5
--
0
0
Glynn
0
0
<5
--
Gordon
0
0
<5
--
Grady
5
19.9
<5
--
Greene
<5
--
0
0
Gwinnett
54
6.7
56
7.0
Habersham
0
0
<5
--
Hall
8
4.3
6
3.3
Hancock
0
0
0
0
Haralson
0
0
0
0
Harris
0
0
0
0
Hart
0
0
0
0
Heard
0
0
0
0
Henry
0
0
<5
--
Houston
5
3.8
6
4.3
Irwin
0
0
<5
--
Jackson
0
0
0
0
Jasper
<5
--
0
0
Jeff Davis
0
0
0
0
Jefferson
0
0
<5
--
Jenkins
0
0
0
0
Johnson
0
0
<5
--
Jones
0
0
0
0
Lamar
0
0
0
0
Lanier
0
0
0
0
Laurens
0
0
0
0
Lee
0
0
0
0
Liberty
6
9.6
0
0
Lincoln
0
0
0
0
Long
<5
--
0
0
Lowndes
<5
--
<5
--
Lumpkin
<5
--
0
0
Macon
<5
--
0
0
Madison
0
0
0
0
Marion
0
0
0
0
9
McDuffie McIntosh Meriwether 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 (excludes Immigration and Customs Enforcement (ICE) cases) ICE Detention Center Sumter Talbot
0 0 0
2009 Number of cases
<5 <5 0 0 0 <5 13 <5 0 0 <5 0 0 0 0 <5 0 0 0 0 0 10 <5 0 <5 0 <5 0 0
5
<5 0
0 0 0
Case Rate --0 0 0 -6.8 -0 0 -0 0 0 0 -0 0 0 0 0 5.0 -0 -0 -0 0
n/a
-0
10
<5 <5 0
2010 Number of cases
0 <5 0 0 0 0 8 5 0 0 <5 <5 0 0 0 0 0 0 <5 0 0 8 <5 0 <5 0 <5 <5 0
--0
Case Rate 0 -0 0 0 0 4.2 5.0 0 0 --0 0 0 0 0 0 -0 0 4.0 -0 -0 --0
6
n/a
<5
--
0
0
Taliaferro Tattnall Taylor Telfair Terrell Thomas
Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton
Ware COUNTY
Warren Washington
Wayne Webster Wheeler
White Whitfield Wilcox Wilkes Wilkinson
Worth Georgia Total
0 0 0 <5 0 <5 <5 0 0 0 6 <5 0 0 0 5 0 <5
2009 Number of cases
0 0 0 0 <5 0 <5 0 0 0 0 412
0 0 0 -0 --0 0 0 9.3 -0 0 0 7.7 0 --
Case Rate 0 0 0 0 -0 -0 0 0 0 4.2
0 0 0 0 <5 <5 <5 <5 0 0 5 <5 0 <5 <5 <5 0 <5
2010 Number of cases
0 0 0 0 0 0 <5 <5 0 0 <5 411
0 0 0 0 ----0 0 7.5 -0 ---0 --
Case Rate 0 0 0 0 0 0 --0 0 -4.2
* 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.
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Table 2. Number of TB Cases and TB Case Rates per 100,000 population by Health District,
Georgia, 2009-2010
2009
2010
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 ICE Detention Ctr.
8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens Georgia Total
Number of Cases 16 10 14 21 82 11 59 63 12 3 11 20 9 23 5 5 17 21 5 5 412
Case rate 2.6 2.3 5.0 2.5 7.9 4.0 5.9 8.4 1.5 2.1 2.1 4.5 na 6.4 na 2.0 4.6 3.8 1.4 1.1 4.2
Number of Cases 11 10 10 29 51 8 65 86 13 2 16 20 18 12 6 10 15 18 7 4 411
Case rate 1.7 2.3 1.7 3.5 5.5 3.1 6.6 12.4 1.6 1.3 3.1 4.3 na 2.9 na 4.0 4.2 3.2 1.9 0.9 4.2
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Table 3. Percentage of TB Cases with Risk Factors for TB by Health District, Georgia, 2010
HEALTH Foreign-born HIV Infected % Homeless %
DISTRICT
%
Inmate %
Nursing Home %
Substance Abuse %
1.1 Rome
18
0
0
0
0
9
1.2 Dalton
60
0
0
0
0
20
2.0 Gaines-
40
0
0
30
0
0
ville
3.1 Cobb
71
4
7
0
0
4
3.2 Fulton
28
29
20
4
0
33
3.3 Clayton
38
12
0
0
0
12
3.4 Law-
71
2
2
2
3
6
renceville
3.5 DeKalb
60
16
7
1
0
9
4.0 La-
23
18
0
0
0
8
Grange
5.1 Dublin
50
50
0
0
0
0
5.2 Macon
12
12
0
0
6
12
6.0 Augusta
26
17
5
0
0
10
ASMP
2
11
17
100
0
61
7.0 Colum-
25
0
0
0
0
42
bus
ICE Deten-
32
16
18
100
0
34
tion
8.1 Valdosta
20
0
0
0
0
30
8.2 Albany
7
0
7
0
0
40
9.1 Coastal
33
12
6
33
0
22
9.2 Way-
43
0
cross
0
14
0
29
10 Athens
50
0
0
0
0
0
Georgia
45
11
6
9
1
17
Total
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TB Drug 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 & ICE 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens Georgia Total
Table 4. Primary Resistance to First-line Anti-TB Medications by Health District, Georgia, 2010
Isoniazid
Rifampin
No.
%
No.
%
0
0
0
0
0
20
0
0
2
11
0
0
4
21
1
5
4
10
1
2
1
17
0
0
3
9
1
3
2
4
1
2
1
8
0
0
0
0
0
0
1
8
2
15
3
7
4
14
0
0
0
0
0
0
0
0
1
9
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20
7
10
4
Ethambutol
No.
%
0
0
0
0
0
0
1
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0.4
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Table 5. Completion of TB Treatment by Health District, Georgia, 2008-2009
HEALTH DIS- No. Cases Completed Tx in % No. Cases Completed Tx
%
TRICT
12 months / No. Started Tx
in 12 months / No. Started
Tx
1.1 Rome
9/9
100
11/12
92
1.2 Dalton
15/16
94
10/10
100
2.0 Gainesville
9/10
90
12/12
100
3.1 Cobb
22/22
100
20/21
95
3.2 Fulton
64/66
97
68/70
97
3.3 Clayton
10/11
91
11/11
100
3.4 Lawrenceville
61/69
88
47/57
82
3.5 DeKalb
66/68
97
47/60
78
4.0 LaGrange
7/8
88
11/12
92
5.1 Dublin
7/7
100
3/3
100
5.2 Macon
16/16
100
10/10
52
6.0 Augusta
11/12
92
16/17
94
ASMP
11/11
100
9/10
90
7.0 Columbus
12/12
100
15/16
94
ICE Detention
0/5
0
4/5
80
8.1 Valdosta
13/13
100
5/5
100
8.2 Albany
19/22
86
15/16
94
9.1 Coastal
19/21
90
18/18
100
9.2 Waycross
4/6
67
5/5
100
10 Athens
6/6
100
4/4
100
Georgia Total
981/410
93
337/374
90
*Denominator does not include TB patients who died while on TB treatment
15
Table 6. Timely Completion of TB Treatment (Tx) by Health District, Georgia, 2008-2009
2008
2009
HEALTH DIS- No. Cases that Com-
%
No. Cases that Completed Tx/
%
TRICT
pleted Treatment (Tx) /
No. Cases Started on Tx
No. Cases Started on
Treatment
1.1 Rome
7/9
78
9/12
75
1.2 Dalton
14/16
88
2.0 Gainesville
7/10
70
3.1 Cobb
10/22
45
3.2 Fulton
60/64
94
10/10
100
12/12
100
18/20
90
60/65
92
3.3 Clayton
10/11
91
11/11
100
3.4 Lawrenceville
54/69
78
41/56
73
3.5 DeKalb
60/68
88
4.0 LaGrange
7/8
88
5.1 Dublin
7/7
100
5.2 Macon
14/16
88
6.0 Augusta
11/12
92
ASMP
11/11
73
40/58 11/12
3/3 9/9 123/17 98/109
69 92 100 100 123/17 98/109
7.0 Columbus
10/12
100
14/15
93
ICE Detention
0/5
0
0
0/5
8.1 Valdosta
13/13
100
5/5
100
8.2 Albany
19/22
86
15/16
94
9.1 Coastal
18/21
86
17/17
100
9.2 Waycross
4/6
67
5/5
100
10 Athens
6/6
100
3/4
75
Georgia Total
349/410
85
304/362
84
16
Table 7. Sputum Smear Positive (SSP) Cases with Contacts
Identified by Health District, Georgia, 2008-2009
2008
2009
HEALTH DISTRICT No. SSP Cases
%
No. SSP Cases
%
with Contacts
with Contacts
Identified /
Identified /
1.1 Rome
4/4
100
5/5
100
1.2 Dalton
1/1
100
7/7
100
2.0 Gainesville
1/1
100
5/5
100
3.1 Cobb
3/3
100
6/6
100
3.2 Fulton
25/25
100
37/37
100
3.3 Clayton
3/3
100
3/3
100
3.4 Lawrenceville
10/10
100
18/18
100
3.5 DeKalb
22/22
100
14/14
100
4.0 LaGrange
0/0
--
7/7
100
5.1 Dublin
0/0
--
3/3
100
5.2 Macon
7/7
100
2/2
100
6.0 Augusta
6/6
100
11/11
100
7.0 Columbus
3/3
100
11/11
100
8.1 Valdosta
0/0
--
1/1
100
8.2 Albany
10/10
100
9/9
100
9.1 Coastal
10/10
100
10/10
100
9.2 Waycross
2/2
100
3/3
100
10 Athens
4/4
100
1/1
100
Georgia Total
110/110
100
153/153
100
17
Table 8. Completely Evaluated Contacts of SSP Cases by Health District, Georgia, 2008-2009
2008
2009
HEALTH DIS- No. Contacts that
%
No. Contacts that
%
TRICT
were Completely
were Completely
Evaluated / No.
Evaluated / No.
Contacts Identified
Contacts Identified
1.1 Rome
28/28
100
47/54
87
1.2 Dalton
7/7
100
85/92
92
2.0 Gainesville
9/9
100
14/21
67
3.1 Cobb
20/21
95
43/50
86
3.2 Fulton
371/427
87
532/638
83
3.3 Clayton
5/6
83
590/658
90
3.4 Lawrenceville
53/54
98
97/175
55
3.5 DeKalb
321/359
89
84/110
76
4.0 LaGrange
0/0
--
54/73
74
5.1 Dublin
0/0
--
44/49
90
5.2 Macon
59/65
91
1/7
14
6.0 Augusta
167/179
93
205/262
78
7.0 Columbus
6/6
100
149/198
75
8.1 Valdosta
0/0
--
5/5
100
8.2 Albany
284/338
84
251/380
66
9.1 Coastal
48/49
98
42/61
69
9.2 Waycross
6/6
100
20/20
100
10 Athens
21/21
100
5/8
62
Georgia Total
1405/1575
89
2268/2861
79
18
Table 9. Contacts with Latent TB Infection (LTBI) exposed to Sputum Smear
Positive (SSP) Cases by Health District, Georgia, 2008-2009
HEALTH DISTRICT
2008
2009
No. Contacts with
%
No. Contacts with
%
LTBI/ No. Con-
LTBI/ No. Con-
tacts Completely
tacts Completely
Evaluated
Evaluated
1.1 Rome
6/28
21
13/47
28
1.2 Dalton
5/7
71
41/85
48
2.0 Gainesville
1/9
11
7/14
50
3.1 Cobb
4/20
20
18/43
42
3.2 Fulton
163/371
44
83/532
16
3.3 Clayton
2/5
40
40/590
7
3.4 Lawrenceville
17/53
32
60/97
62
3.5 DeKalb
40/320
12
37/84
44
4.0 LaGrange
--
--
13/54
24
5.1 Dublin
--
--
13/44
30
5.2 Macon
11/59
19
1/1
100
6.0 Augusta
48/167
29
31/205
15
7.0 Columbus
1/6
17
35/149
24
8.1 Valdosta
--
--
1/5
20
8.2 Albany
77/284
27
68/251
27
9.1 Coastal
18/48
38
18/42
43
9.2 Waycross
4/6
67
6/20
30
10 Athens
2/21
10
2/5
40
Georgia Total
399/1404
28
486/2268
21
19
Table 10. Contacts with LTBI exposed to SSP Cases started on LTBI Treatment
by Health District, Georgia, 2008-2009
HEALTH DISTRICT
2008
2009
No. Infected Con-
%
tacts on LTBI Treat-
ment / No. Infected
Contacts
No. Infected
%
Contacts on LTBI
Treatment / No.
Infected Contacts
1.1 Rome
5/6
83
5/13
38
1.2 Dalton
4/5
80
32/41
78
2.0 Gainesville
1/1
100
7/7
100
3.1 Cobb
3/4
75
13/18
72
3.2 Fulton
106/163
65
42/83
51
3.3 Clayton
2/2
100
21/40
52
3.4 Lawrenceville
9/17
53
39/60
65
3.5 DeKalb
28/40
70
26/37
70
4.0 LaGrange
--
--
13/13
100
5.1 Dublin
--
--
8/13
62
5.2 Macon
8/11
73
0/1
0
6.0 Augusta
23/48
48
10/31
32
7.0 Columbus
1/1
100
20/35
57
8.1 Valdosta
--
--
1/1
100
8.2 Albany
48/77
62
49/68
72
9.1 Coastal
13/18
72
9/18
50
9.2 Waycross
0/4
0
5/6
83
10 Athens
2/2
100
0/2
0
Georgia Total
253/399
63
300/486
62
20
Table 11 LTBI Treatment Completion by Infected Contacts exposed to SSP Cases
by Health District, Georgia, 2008-2009
HEALTH DISTRICT
2008
2009
No. Contacts
% No. Contacts No. Contacts %
that Completed
with Missing that Com-
LTBI Treatment
Tx data pleted LTBI
/Contacts
Treatment
Treated
/ Contacts
Treated
No. Contacts with Missing Tx data
1.1 Rome
4/5
80
0
2/5
40
0
1.2 Dalton
3/4
75
0
24/32
75
0
2.0 Gaines-
1/1
100
0
4/7
57
0
ville
3.1 Cobb
1/3
33
0
10/13
77
0
3.2 Fulton
80/104
77
2
29/40
72
2
3.3 Clayton
1/2
50
0
6/7
86
14
3.4 Law-
3/9
33
0
21/38
55
1
renceville
3.5 DeKalb
16/28
57
0
14/19
74
7
4.0 La-
--
--
0
4/13
31
0
Grange
5.1 Dublin
--
--
0
2/8
25
0
5.2 Macon
3/8
38
0
--
--
0
6.0 Augusta
5/21
24
2
7/10
70
0
7.0 Colum-
0/1
0
0
12/20
60
0
bus
8.1 Valdosta
--
--
0
--
--
1
8.2 Albany
29/42
69
6
36/49
74
0
9.1 Coastal
12/13
92
0
5/9
56
0
9.2 Way-
--
--
0
4/5
80
0
cross
10 Athens
1/2
50
0
--
--
0
Georgia
159/243
67
10
180/275
66
25
Total
21
Table 12. Reasons Why Infected Contacts of SSP cases Stopped LTBI Treatment, Georgia, 2008-2009
Reasons for Stopping LTBI Therapy
2008 N=243
2009 N= 275
No.
%
No.
%
Completed Therapy
159
65
180
66
Chose to Stop
29
12
39
14
Lost to Follow-Up
29
12
29
10
Provider Decision
7
3
6
2
Moved
10
4
16
6
Adverse Reactions
6
2
4
2
Active TB Developed
1
0.4
0
0
Death
2
0.8
1
0.4
Figure 1. TB Cases and Case Rates Georgia,1982-2010
Number of Cases
Rate/100,000
1000
16
900
14
800 700
12
600
10
500
8
400
6
300 200
4
100
2
0
0
1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Year Case Counted
Number Case Rate
22
Figure 2. Number of TB Cases by Health Districts, Georgia, 2010
Har al s on
1-2
2-0
Gor don
1-1 Bar t ow
Pol k Paul di ng
3-2 3-4
3-1
3-5
3-3
R oc k da le
10-0
4-0 5-2
Number of TB Cases: Low incidence: 2-10 cases Medium incidence: 11-20 cases High incidence: >20 (29-86) cases
6-0
7-0
8-2
Semi nol e Decat ur
5-1 9-1
9-2 8-1
Figure 3. TB Case Rates by Health Districts, Georgia, 2010
1-2
Gor don
2-0
1-1 Bar t ow
Pol k Paul di ng
Har al s on
3-1
3-2 3-4
3-5
3-3
R oc k da le
10-0
4-0 5-2
Case rates/100,000 population:
<= 3.5 (2000 national target) 3.6 to 4.2 > 4.2 (2010 state average)
6-0
7-0
8-2
Semi nol e
5-1
9-1
9-2 8-1
23
Figure 4. TB Cases by Age Group and Sex, Georgia, 2010
120 100
80 Number 60
40 20
0 < 5
5-14 15-24 25-44 45-64 >= 65 Age Group (years)
Male Female
Figure 5. TB Case Rates* by Age Group, 2006-2010, Georgia
Age Group 2006
< 5 yrs. 4.1 5-14 yrs. 0.8 15-24 yrs. 5.1 25-44 yrs. 6.9 45-64 yrs. 6.6 65+ yrs. 6.1
2007
3.5 0.8 4.3 6.0 6.0 7.4
2008
4.5 0.6 3.9 6.3 6.6 5.4
2009
2.3 0.5 4.1 5.1 5.4 5.7
2010
2.0 0.9 3.3 5.0 5.8 5.5
*Rates are per 100,000 population
24
Figure 6. TB Cases by Race/Ethnicity, Georgia, 2000 and 2010
Asian 10% White 18%
Hispanic 11%
2000
Asian 18%
Black 61%
White 13%
Black 52%
Hispanic 17%
2010
Figure 7. TB Case Rates* by Race/Ethnicity Georgia, 2006-2010
Race/ Ethnicity
Asian, non-Hispanic Hispanic, All races Black, non-Hispanic White, non-Hispanic
2006 2007 2008 2009 2010 26.4 21.5 27.2 29.7 24.1 16.5 12.9 11.8 11.2 8.2 9.0 8.3 7.8 6.2 7.1 1.3 1.2 1.2 1.2 1.0
*Rates are per 100,000 population
25
Figure 8. TB Case Rates in non-Hispanic Blacks and Whites, Georgia, 1993-2010
Non-Hispanic Black Non-Hispanic White
Case Rate/100,000
35 30.6 30
25
20
15
10
7.1
5 3.7
1.0
0
1993 1995 1997 1999 2001 2003 2005 2007 2009
Year
Figure 9. US-born and Foreign-born TB Cases, Georgia,1993-2010
Number 800 700 600 500 400 300 200 100
0 1993 1995 1997 1999 2001 2003 2005 2007 2009
Year US-born Foreign-born
26
Figure 10. Percent of Foreign-born TB Cases (n=183) by Country of Origin, Georgia, 2010
Others 45%
Mexico 20%
Vietnam 14%
Guatemala 6%
India 9%
Ethiopia 6%
Figure 11. HIV Status of TB Cases, Georgia,1993-2010
Unknown Negative Positive
Number
900 800 700 600 500 400 300 200 100
0
1993 1995 1997 1999 2001 2003 2005 2007 2009
Year
27
Figure 12. TB in Other High-Risk Populations, Georgia, 2006-2010
120
100
80
16%
Number 60 40
6% 9%
20
1%
0 2006 2007 2008 2009 2010
Year
Substance abuse Homeless Correctionals Long-Term Care
Number Percent
Figure 13. Drug Resistance and MDR-TB Georgia, 2006-2010
45
16
40
14
14
35
12
30
25
9
20
7
15
6
10 78
6
10
4
5
2
0
0
2006 2007 2008 2009 2010
Year
INH RIF MDR-TB % INH-R
28
Figure 14. Timely TB Treatment Completion and Directly Observed Therapy (DOT) Georgia, 1993-2009
Percent
100
80 68
84 76
60
Completion in 12 months
40
Totally DOT
20
0 DOT became standard of care
1993 1995 1997 1999 2001 2003 2005 2007 2009
Year Case Counted
Figure 15. Completion of Latent TB Infection (LTBI) Therapy among all contacts of TB cases,
Georgia, 2005-2009
Percent
80
70 66
66
68
60
57
60
50
Completed LTBI Therapy
40
Missing data
30
20
10 0
14 1
4
6
8
2005 2006 2007 2008 2009
Year
29
Tuberculosis Morbidity Trends by Health District Georgia, 1995-2010
TB Case Numbers and Rates District 1-1 (Rome),1995-2010
60 51 50
40 30 20
33 18 25 22 31 32 32 30 27 30 17 18 12 16 11
10 0
11.6 7.4 4.0 5.2 3.8 6.1 6.0 5.9 5.4 4.7 5.2 2.8 3.0 1.9 2.6 1.7
Year
Number Rate
Rates are per 100,000 population Source: GA TB surveillance database
TB Case Numbers and Rates
District 1-2 (Dalton),1995-2010
25
21
21
20 15 12 11 14 10 10
15 11 8 10
17 14 14
10
10 10
5
4.5 4.0 5.0 3.3 6.6 4.6 3.2 2.2 2.7 5.5 2.5 3.4 3.3 4.0 2.3 2.3
0
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
30
TB Case Numbers and Rates District 2 (Gainesville),1995-2010
25 20 15 10
20 17 15 15 15 12 10 10 13
8
19 12 15 11 14 10
5 0
5.9
4.9
3.7
3.7
3.5
2.6
2.1
2.0
2.5
1.5
3.5
2.1
2.6
1.8
5.0 1.7
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Number Rate
Rates are per 100,000 population Source: GA TB surveillance database
TB Case Numbers and Rates District 3-1 (Cobb),1995-2010
50
44
40
32
30 20 18
32 24 38 38 36 25 32 30 30 30 31 21 29
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 3.8 2.5 3.5
2211122222222211009990000000009900999100000000995287609876431095
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
31
TB Case Numbers and Rates District 3-2 (Fulton),1995-2010
250 200 150
192 207 187
177
133 150
136 119 122 116
100
87 72 78 72 82 51
50 0
28.1 30.0 26.8 17.8 19.9 22.4 16.5 14.4 15.0 14.2 9.7 7.5 7.9 7.1 7.9 5.5
2222221112222211000000999000009910000099900000990765218759843096
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 3-3 (Clayton),1995-2010
30
28
25 20 15 10
5
18 14
9
8.8 6.7
4.5
23
15
13.4
7.0
18
19
15
15 14 15
15 14
11
9.7
8
6.5 7.1 5.4 5.2 5.6 7.0 5.5 5.1 4.0 3.1
0
2222222222211111000000000009999901000000000999996098754321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
32
TB Case Numbers and Rates District 3-4 (Lawrenceville),1995-2010
100
81
80
68
58
60 40 20
12 24 17 26 29 43 21 34 42 46
57
59 65
0
2.2 4.1 2.8 4.0 4.4 6.8 2.8 4.3 5.1 5.3 6.5 7.3 6.0 8.3 5.9 6.6
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 3-5 (DeKalb),1995-2010
120 100
80
92
99 102 104
84
85
78
88
83
72
80
61
72
78
63
86
60
40
20 0
151.96.7 17.0 14.316.9 12.9 11.6 13.0 12.310.6 11.6 8.4 9.8 10.5 8.412.4
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
33
TB Case Numbers and Rates District 4 (LaGrange),1995-2010
35 30 25 20 15
19 24 26 21 20 29 16 16 25 25 16 27 20 12 12 13
10
5 0
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 1.5 1.5 1.6
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates
District 5-1 (Dublin),1995-2010
20
16
15
12
10 5 0
7 5.6 5 4.0 6 4.7 4 3.1
9.4 8
6
9
8
88
11.1
5.9
6.6 4 4
4.4
5.6
2.9 2.8
5.6 5.5 3 2 2.1 1.3
2122222222221111090000000000999909100000000099996809875432109765
34
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 5-2 (Macon),1995-2010
60 50
46 51
40 30 20
31 22 27 28 23 20 23 28 24 31 15 18 11 16
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 3.0 3.5 2.1 3.1
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 6 (Augusta),1995-2010
60
52
50 40 30
45
46
38 39
25
30
20
32
20
24 19 17 16 14 20 20
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
3.1
4.5 4.3
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
35
TB Case Numbers and Rates District 7 (Columbus),1995-2010
50
46
40 33 30 20
34 28 30
36
34 30
22
21
18
20 21
23
14
12
10 0
9.5
13.2 6.3
9.9
8.1
8.5
5.9
10.1 5.0
9.9
8.4
5.9
6.0
3.9
6.4 2.9
2222222222211111000000000009999910000000000999990719865432098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 8-1 (Valdosta),1995-2010
30 25 20 15 10
5 0
24
21 18
10.2 8.7
20
17
11.5 7.9
14 15
9.3
6.2 6.22
0.9
7
12
3.0 5.1
6
9
2.5
3.8
5
13
5.3 2.1
5
10
2.0 4.0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Number Rate
Rates are per 100,000 population Source: GA TB surveillance database
36
TB Case Numbers and Rates
District 8-2 (Albany),1995-2010
50 40
38 45 40 36 43 38
30 20
29 17 24 21 23 25 21 25 17 15
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 6.8 4.6 4.2
0
2122222222111122090000000099990009100000009999002709876530986541
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates District 9-1 (Coastal),1995-2010
70 60 50
58 48
40 30 20
34 33 25 33 19 23 20 17 19 31 26 23 21 18
10 0
10.4 12.4 7.2 6.9 5.2 6.8 3.9 4.6 4.0 3.3 3.7 5.9 4.8 4.3 3.8 3.2
2222211122222211000009990000009900000999100000999621087508754396
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
37
TB Case Numbers and Rates District 9-2 (Waycross),1995-2010
60 50 43
50 48
40
30
30
24
34
25
25
20 10
0
15.0 10.4 8.2
16
16.6 15.8 10.6 7.8 4.9
13 9
7.6 3.9
16 13
2.7 4.7 3.8
8
5
2.3
1.4
7
1.9
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
TB Case Numbers and Rates
District 10 (Athens),1995-2010
25
22
20 15 10
5 0
16 13 13
4.6 4.2 5.1
13 14 13 16 11 12 9
6.6
5
8
6
5
4
3.8 3.8 3.4 4.1 2.8 2.9 2.2 1.1 1.8 1.3 1.1 0.9
2222222222211111000000000009999910000000000999990987654321098765
Year
Number
Rates are per 100,000 population Source: GA TB surveillance database
Rate
38