2010 Georgia Tuberculosis Report Georgia Department of Public Health | Division of Public Health Epidemiology Branch | Prevention Services Branch 1 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. 2 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 i ii 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. 1 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). 2 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). 3 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). 4 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). 5 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%. 6 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 7 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. 11 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 12 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 13 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 14 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