2010 Georgia tuberculosis report

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