2011 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 Manager David Maggio Epidemiologist Antoine Perrymon Epidemiologist 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, 2011 Georgia Tuberculosis Report, Atlanta, Georgia, October 2012. 1 Table of Contents TB Surveillance in Georgia...........................................................3 Current Epidemiology of TB in Georgia..........................................4 High-Risk Populations...............................................................5 Drug Resistance.......................................................................6 Indicators of Infectiousness.........................................................6 Initial Diagnosis, Health Provider Data, And Directly Observed Therapy.....................................................7 TB Mortality...........................................................................7 TB Contact Investigations and Latent TB Infection..............................7 TB Program Objectives...............................................................8 Tables: Morbidity Trends and Program Performance Indicators by Health District..................................................................................10 Figures: Descriptive Epidemiology.................................................19 Graphs: Tuberculosis Morbidity Trends by Health District, 1995-2010......27 2 Tuberculosis (TB) Surveillance in Georgia TB is a reportable disease in Georgia. All Georgia physicians, laboratories and other health care providers are required by law to immediately report clinical and laboratory confirmed TB cases under their care to Georgia public health authorities. TB cases may be directly reported to a County Health Department, a District Health Office, or to the state TB Program and TB Epidemiology 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 control 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, 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. 3 Current Epidemiology of Tuberculosis in Georgia Georgia reported 347 new tuberculosis (TB) cases in 2011. This represents a 16% decrease from 411 TB cases reported in 2010 (Figure 1), and a 62% decrease since 1991 when the peak of a resurgent period of tuberculosis occurred in Georgia. The TB case rate in Georgia decreased from 4.2 cases per 100,000 population during 2010 to 3.5 cases per 100,000 in 2011. Georgia had the eleventh-highest TB case rate among the 50 states of the United States in 2011. Geographic Distribution Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area reported the highest number of TB cases in 2011: DeKalb (76 cases), Gwinnett (48), Fulton (45), and Cobb (16) (Table 1, Figure 2). These four counties accounted for 53% of TB cases reported in Georgia in 2011. 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 2011 (10.9 per 100,000), followed by Albany (5.0 per 100,000) and Lawrenceville (4.8 per 100,000). Sex and Age Distribution In 2011, TB in Georgia occurred predominantly among males (225 cases, 65%), compared to females (122, 35%); 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 (34%) (Figure 4). The highest TB case rate by age group was among persons 45-64 years old (4.6 per 100,000) while the lowest was among children 5-14 years old (0.7 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, increased from 2.0 per 100,000 in 2010 to 2.3 per 100,000 in Georgia during 2011. Race/Ethnicity Distribution and TB Disparities TB disproportionately affects racial/ethnic minorities in Georgia. In 2011, nonHispanic blacks, Asians and Hispanics, accounted for 48%, 17% and 20% of TB cases in Georgia respectively, but only represented 30%, 3.3% and 9.1% of Georgia's population respectively (Figure 6). Non-Hispanic whites constituted 15% of TB cases in 2011. The highest TB case rate among race/ethnic groups was among Asians (16.8 per 100,000), followed by Hispanics (7.6 per 100,000), and non-Hispanic blacks (5.3 per 100,000) (Figure 7). The black non-Hispanic TB case rate in 2011 represents an almost 83% decrease 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 about 6 times higher than the white nonHispanic TB case rate (0.9 per 100,000) in Georgia during 2011 (Figure 8). 4 High-Risk Populations Foreign-Born TB cases among persons born outside of the United States accounted for 46% of TB cases in Georgia in 2011 compared to 44% in 2010. Most foreign-born cases reported in 2011 came from Mexico (27%), and India (12%), Guatemala (9%) - countries where TB is an endemic disease (Figures 9-10). Among 159 foreign-born cases, 60 (38%) were diagnosed in the first five years of their arrival in the U.S. In 2011, four Health Districts reported 68% of the total number of foreign-born TB cases in Georgia: DeKalb (42 cases), Lawrenceville (33), Cobb (15) and Fulton (18). Among these Health Districts, foreign-born TB cases accounted for more than half of the TB cases in Lawrenceville (67%), Cobb (75%) and DeKalb (55%). Foreign-born TB cases in the Fulton Health District accounted for 40% 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 310 TB cases in Georgia with known HIV status in 2011, 10% were HIV-positive compared to 11% in 2010 (Figure 11). Among 31 HIV co-infected TB cases in 2011, 65% were non-Hispanic blacks, 74% were male and 55% were 25-44 years old. HIV status was reported in 89% of TB cases in 2011 compared to 92% in 2010. In the high-risk age group of adults 25-44 years of age, the percentage of TB cases for which HIV was reported was 94% in 2010 and 2011. Among 37 TB cases whose HIV status was not reported, HIV testing was not offered to 30 cases (81%), the HIV test result was unknown in one case (3%), and six (16%) refused testing. The highest proportion by age group among the TB cases that were not offered the HIV test, occurred among children 0-14 years old (12 cases, 40%). 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 2011, 32 (9%) TB cases in Georgia were homeless, 31 (9%) were residents of correctional facilities, and 4 (1%) were residents of long-term care facilities. Of the 31 TB cases incarcerated in correctional facilities, 19 (61%) were inmates in state prisons, five (16%) in county jails, four (13%) in the Immigration and Custom Enforcement Detention Center in Stewart County, and three (10%) were in federal prisons. Substance abuse is the most commonly reported behavioral risk factor among patients with TB in the United States. TB patients who abuse substances often 5 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 75 (22%) TB cases in 2011 (Table 3, Figure 12). Pediatric TB TB in children is considered a sentinel public health event because it often indicates recent transmission from an infectious adult case. Additionally, potentially lethal forms of TB such as TB meningitis or disseminated TB can develop in very young children. In 2011, children younger than 15 years old comprised 8% of Georgia TB cases; 16 cases (2.3 per 100,000) were reported in children younger than 5 years old, 10 cases (0.7 per 100,000) were reported in children 5-14 years old. One child had TB meningitis. Latent tuberculosis infection (LTBI) in children younger than five years old is also a reportable disease 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 2011, 50 children younger than five years old were reported to have LTBI in Georgia; 31 were identified by TB screening in pediatric clinics, and 19 from contact investigations. Public health staff identified the source case of the child's infection in 31 (62%) of these children. Drug Resistance Among 247 culture-positive TB cases in Georgia during 2011, 244 (99%) were tested for initial drug susceptibility to the three first-line anti-TB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 228 tested isolates from Georgia cases with no previous history of TB, 23 (10.1%) had primary resistance to INH, one (0.4%) to RIF, and one (0.4%) to EMB (Table 4). One (0.4%) case in 2011 had multidrug-resistant TB case (MDR-TB, i.e. TB resistant to at least INH and RIF). The percentage of cases with primary INH resistance (INH-R) ranged from 6% to 14% in the past five years while an average of two MDR-TB cases per year was reported in Georgia over that same time period (Figure 13). 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 2011, 78% of all Georgia TB cases had pulmonary 6 TB, 71% had sputum cultures that were positive for Mycobacterium tuberculosis, 34% were sputum AFB smear-positive, and 20% 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 2011, 230 (66%) of the 347 TB cases in Georgia were reported initially by a hospital. Twelve hospitals in Georgia reported five or more TB cases in 2011: Grady Memorial Hospital (32 cases), Northside Hospital (13 cases), DeKalb Medical Center (12 cases), Gwinnett Medical Center (11 cases), St. Joseph's Hospital in Atlanta (8 cases), Medical Center of Central Georgia in Macon (8 cases), Children's Healthcare of Atlanta at Scottish Rite (6 cases), Phoebe Putney Memorial Hospital in Albany (6 cases), Atlanta Medical Center (5 cases), Memorial Health University Medical Center in Savannah (5 cases), Piedmont Hospital (5 cases), and Wellstar Kennestone Hospital (5 cases). These twelve hospitals accounted for half of all patients hospitalized for TB in Georgia in 2011. County health departments provided case management for 88% of all Georgia TB cases, correctional facilities treated 7%, 3% of cases were cared for solely by a private physician and only 2% were managed solely as in-patients. 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 311 Georgia TB cases reported in 2010 with available case completion data, 84% received TB treatment entirely by DOT, 14% were treated by a combination of DOT and self-administered therapy, and only 1% 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). 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) or interferon gamma release assay (IGRA), repeat the TST or IGRA 8-10 weeks after the last exposure to the index case if the initial TST or IGRA is negative, and have a chest radiology exam performed if the TST or IGRA is positive. Persons with LTBI have a positive TST or IGRA, but are asymptomatic and have a normal chest radiology exam. They are not contagious but 7 have a 10% chance of developing TB disease later in life if they do not receive treatment for LTBI. Among 5,352 identified contacts of Georgia TB cases reported in 2010 (the most recent year with completed contact investigation data), 4,440 (83%) were completely evaluated for TB disease and LTBI. Of the completely evaluated contacts, 858 (19%) had LTBI and 25 (0.6%) had TB disease. Among the contacts with LTBI, 539 (63%) started LTBI treatment and among 536 infected contacts with treatment outcome information, only 348 (65%) completed LTBI treatment. TB Program Objectives: Objective 1: By 2015, 93% of Georgia TB patients will complete a course of TB treatment within 12 months of starting treatment. Among 340 TB cases reported in Georgia during 2010 who were eligible to complete TB treatment within 12 months and who did not die or move outside of the U.S. during TB treatment, 338 have available data on TB treatment completion. Of the 338 cases with available treatment completion data, 312 (92%) completed treatment within 12 months; 16 (5%) completed treatment after 12 months, 4 (1.2%) were lost to follow-up, three (0.9%) had to stop treatment due to adverse side effects to TB medications, two (0.6%) were uncooperative and refused treatment and one (0.3%) had "Other" cited as the cause for stopping treatment. Among the 16 TB cases that completed TB treatment but extended treatment beyond 12 months, four were non-adherent to treatment plans, four extended TB treatment due to a clinical indication, and no explanation for extended treatment was available for eight other cases. In 2010, Georgia TB cases who were homeless, drug abuser, correctional facility inmates, were HIV infected, or alcoholics, had lower rates of timely treatment completion (within 12 months) than the over-all average for all TB cases in Georgia. 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: By 2015, 100% of TB cases with sputum smears that are positive for acidfast bacillus (AFB) will have contacts identified. In 2010, all 139 Georgia TB patients with positive AFB sputum smears had contacts elicited, meeting the program target of 95%. Objective 3: By 2015, increase the proportion of contacts of acid fast bacilli (AFB) sputum smear positive (SSP) TB cases in Georgia who are evaluated for TB infection or disease to 93% Among 2,776 contacts to AFB sputum smear positive TB cases in 2010, 2,247 (81%) were completely evaluated for TB infection or disease. Among the 529 contacts 8 who were not completely evaluated, 263 had data on reasons why their evaluations were not completed which included 154 (54%) who refused or were uncooperative, 72 (25%) were lost to follow-up, 18 (6%) had "Other" selected as the reason for incomplete evaluation, 17 (6%) moved, and two (0.7%) died. The incomplete evaluations were due to: 324 (61%) contacts without a second tuberculin skin test (TST) result reported after the first TST was negative, 143 (27%) without an initial TST or interferon gamma release assay (IGRA) test, 44 (8%) with a positive TST or IGRA but no chest radiography report, and 18 (3%) without a second IGRA result after the first IGRA was negative. Objective 4: By 2015, among infected contacts of acid fast bacilli (AFB) sputum smear positive (SSP) TB cases in Georgia, at least 70 percent who started therapy for latent TB infection (LTBI) will complete LTBI therapy. Among 2,247 contacts of AFB SSP cases who were completely evaluated for TB infection or disease, 402 (18%) had latent TB infection (LTBI). Among those with LTBI, 290 (72%) started LTBI treatment but only 169 (58%) of 289 contacts with information on LTBI treatment outcomes, completed LTBI treatment (Tables 11-12). 9 Table 1. Number of TB Cases and TB Case Rates* per 100,000 population by County, Georgia, 2010-2011 2010 2011 COUNTY Number of Case Rate Number of Case Rate cases cases Appling <5 -- 0 0 Atkinson <5 -- <5 -- Bacon 0 0 0 0 Baker <5 -- <5 -- Baldwin <5 -- <5 -- Banks <5 -- 0 0 Barrow 0 0 <5 -- Bartow <5 -- 0 0 Ben Hill 0 0 0 0 Berrien <5 -- 0 0 Bibb 7 4.5 7 4.5 Bleckley 0 0 <5 -- Brantley 0 0 <5 -- Brooks 0 0 <5 -- Bryan 0 0 0 0 Bulloch 0 0 <5 -- Burke 0 0 0 0 Butts 0 0 0 0 Calhoun 0 0 <5 -- Camden <5 -- 0 0 Candler 0 0 0 0 Carroll 0 0 0 0 Catoosa 0 0 <5 -- Charlton 0 0 0 0 Chatham 10 3.8 6 2.2 Chattahoochee 0 0 0 0 Chattooga <5 -- <5 -- Cherokee <5 -- <5 -- Clarke <5 -- <5 -- Clay 0 0 0 0 Clayton 8 3.1 9 3.4 Clinch <5 -- <5 -- Cobb 26 3.8 16 2.3 Coffee 0 0 0 0 Colquitt 0 0 <5 -- Columbia excludes ASMP 8 6.4 4 3.1 Augusta State Med Prison (ASMP) 18 na 16 na Cook 0 0 0 0 Coweta <5 -- <5 -- Crawford 0 0 0 0 Crisp <5 -- <5 -- Dade 0 0 0 0 Dawson 0 0 0 0 Decatur <5 -- <5 -- DeKalb 86 12.4 76 10.9 Dodge 0 0 <5 -- Dooly <5 -- 0 0 Dougherty 6 6.3 5 5.3 Douglas <5 -- <5 -- 10 COUNTY Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether 2010 Number of Case Rate cases 0 0 0 0 <5 -- <5 -- 0 0 0 0 <5 -- <5 -- 0 0 0 0 0 0 51 5.5 <5 -- 0 0 <5 -- <5 -- <5 -- 0 0 56 7.0 <5 -- 6 3.3 0 0 0 0 0 0 0 0 0 0 <5 -- 6 4.3 <5 -- 0 0 0 0 0 0 <5 -- 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 0 0 0 0 <5 -- <5 -- 0 0 2011 Number of Case Rate cases 0 0 0 0 <5 -- 0 0 0 0 <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- 45 4.7 0 0 0 0 <5 -- 0 0 <5 -- <5 -- 48 5.8 0 0 8 4.4 <5 -- 0 0 0 0 <5 -- 0 0 <5 -- <5 -- <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 0 0 <5 -- 0 0 0 0 <5 -- 0 0 <5 -- <5 -- 0 0 0 0 0 0 0 0 11 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 Stewart ICE Detention Center (SDC) SDC only Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware 2010 Number of Case Rate cases 0 0 <5 -- 0 0 0 0 0 0 0 0 8 4.2 5 5.0 0 0 0 0 <5 -- <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 6 3.5 <5 -- 0 0 <5 -- 0 0 <5 -- <5 -- 2011 Number of Case Rate cases 0 0 0 0 0 0 0 0 0 0 <5 -- 5 2.6 <5 -- <5 -- 0 0 0 0 <5 -- <5 -- 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 na 4 na <5 -- <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- <5 -- 0 0 0 0 0 0 0 0 0 0 5 7.4 <5 -- <5 -- <5 -- 0 0 0 0 <5 -- 0 0 <5 -- 0 0 <5 -- <5 -- 0 0 <5 -- <5 -- <5 -- 12 COUNTY Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth Georgia Total 2010 Number of Case Rate cases 0 0 0 0 0 0 0 0 0 0 0 0 <5 -- <5 -- 0 0 0 0 <5 -- 411 4.2 2011 Number of Case Rate cases 0 0 0 0 0 0 0 0 0 0 <5 -- <5 -- 0 0 <5 -- 0 0 0 0 347 3.5 Note: 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. Table 2. Number of TB Cases and TB Case Rates* per 100,000 population by Health District, Georgia, 2010- 2011 2010 2011 Health District Number Case rate Number Case rate of Cases of Cases 1.1 Rome 11 1.7 5 0.8 1.2 Dalton 10 2.3 7 1.6 2.0 Gainesville 10 1.6 14 2.2 3.1 Cobb 28 3.4 20 2.4 3.2 Fulton 51 5.5 45 4.7 3.3 Clayton 8 3.1 9 3.4 3.4 Lawrenceville 65 6.6 49 4.8 3.5 DeKalb 86 12.4 76 10.9 4.0 LaGrange 13 1.6 8 1.0 5.1 Dublin 2 1.3 3 1.9 5.2 Macon 17 3.3 16 3.1 6.0 Augusta 19 4.3 8 1.7 Augusta State 18 na 16 na Medical Prison (ASMP) only 7.0 Columbus 12 2.9 9 3.5 ICE Detention only 6 na 4 na 8.1 Valdosta 10 4.0 9 3.5 8.2 Albany 15 4.2 18 5.0 9.1 Coastal 18 3.2 13 2.2 9.2 Waycross 7 1.9 11 3.0 10 Athens 5 1.1 7 1.5 Georgia Total 411 4.2 347 3.5 13 Table 3. Percentage of TB Cases with Risk Factors for TB by Health District Georgia, 2011 HEALTH Foreign- HIV Homeless Inmate Nursing DISTRICT born % Infected % % % Home % 1.1 Rome 40 0 0 0 0 1.2 Dalton 57 0 0 0 0 2.0 Gainesville 26 10 14 14 0 3.1 Cobb 75 11 10 0 0 3.2 Fulton 40 21 17 2 0 3.3 Clayton 67 25 22 0 0 3.4 Lawrenceville 69 6 0 2 0 3.5 DeKalb 55 13 11 3 0 4.0 LaGrange 13 0 29 0 13 5.1 Dublin 0 0 33 33 0 5.2 Macon 25 0 6 13 6 6.0 Augusta 50 0 0 0 0 ASMP only 0 6 6 100 0 7.0 Columbus 25 0 0 0 0 ICE only 32 0 0 100 0 8.1 Valdosta 22 33 0 0 0 8.2 Albany 39 6 6 0 6 9.1 Coastal 23 8 15 8 0 9.2 Waycross 27 0 0 0 0 10 Athens 57 0 29 20 0 Georgia Total 46 10 9 9 0.8 Substance Abuse % 0 14 21 5 31 11 8 14 15 33 19 0 25 33 25 33 22 8 0 14 17 Table 4. Primary Resistance to First-line Anti-TB Medications by Health District Georgia, 2011 TB Drug Isoniazid Rifampin Ethambutol HEALTH DISTRICT No. % No. % No. % 1.1 Rome 1 33 0 0 0 0 1.2 Dalton 0 0 0 0 0 0 2.0 Gainesville 3 21 0 0 0 0 3.1 Cobb 0 0 0 0 0 0 3.2 Fulton 2 6 0 0 0 0 3.3 Clayton 2 25 1 13 0 0 3.4 Lawrenceville 2 6 0 0 1 3 3.5 DeKalb 4 10 0 0 0 0 4.0 LaGrange 2 25 0 0 0 0 5.1 Dublin 1 33 0 0 0 0 5.2 Macon 0 0 0 0 0 0 6.0 Augusta & ASMP 1 6 0 0 0 0 7.0 Columbus & ICE 0 0 0 0 0 0 8.1 Valdosta 0 0 0 0 0 0 8.2 Albany 1 8 0 0 0 0 9.1 Coastal 0 0 0 0 0 0 9.2 Waycross 1 11 0 0 0 0 10 Athens 2 50 0 0 0 0 Georgia Total 23 10 1 0.4 1 0.4 14 Table 5. Completion of TB Treatment (Tx) by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Cases that % No. Cases that % No. Cases Completed Tx/ No. Completed Tx/No. Missing data Cases Started Tx* Cases Started Tx* 1.1 Rome 11/11 100 11/11 100 0 1.2 Dalton 9/9 100 10/10 100 0 2.0 Gainesville 12/13 92 5/5 100 0 3.1 Cobb 19/19 100 24/25 96 0 3.2 Fulton 67/68 98 46/46 100 0 3.3 Clayton 11/11 100 8/8 100 0 3.4 Lawrenceville 46/51 90 56/60 93 0 3.5 DeKalb 47/57 82 77/78 99 0 4.0 LaGrange 11/12 92 7/10 70 1 5.1 Dublin 3/3 100 1/1 100 0 5.2 Macon 10/10 100 15/15 100 0 6.0 Augusta ASMP only 17/18 94 15/15 100 1 8/9 89 17/18 94 0 7.0 Columbus ICE only 16/17 94 10/10 100 0 0/1 0 na na na 8.1 Valdosta 5/5 100 8/8 100 0 8.2 Albany 14/14 100 12/13 92 0 9.1 Coastal 18/19 95 14/14 100 0 9.2 Waycross 5/5 100 5/5 100 0 10 Athens 4/4 100 5/5 100 0 Georgia Total 333/356 94 346/357 97 2 *patients who died or moved outside the U.S. during TB treatment are not included in calculation Table 6. Timely Completion of TB Treatment (Tx) among TB cases eligible for 12-month TB Tx by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Cases Completed Tx in 12 % No. Cases Completed Tx in 12 % months/ No.Started Tx months/ No. Started Tx 1.1 Rome 1.2 Dalton 9/12 75 11/11 100 9/9 100 10/10 100 2.0 Gainesville 3.1 Cobb 3.2 Fulton 12/13 92 17/18 94 59/63 94 4/5 80 23/25 92 41/44 93 3.3 Clayton 3.4 Lawrenceville 3.5 DeKalb 11/11 100 40/52 77 40/55 73 7/8 88 52/55 94 67/71 94 4.0 LaGrange 5.1 Dublin 5.2 Macon 11/12 92 3/3 100 9/9 100 7/10 70 1/1 100 12/14 86 6.0 Augusta ASMP only 13/18 72 8/9 89 10/11 91 15/18 83 7.0 Columbus 8.1 Valdosta 8.2 Albany 15/16 94 5/5 100 14/14 100 10/10 100 8/8 100 11/13 85 9.1 Coastal 9.2 Waycross 10 Athens 17/18 94 13/14 93 5/5 100 5/5 100 3/4 75 5/5 100 Georgia Total 300/347 86 312/338 92 *patients who died or moved outside the U.S. during TB treatment , or who are not eligible for 12 months TB treatment (rifampin resistant TB, meningeal TB, patients < 15 yrs, old with miliary TB), are not included in calculation No. cases Missing data 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 2 15 Table 7. Sputum Smear Positive (SSP) Cases with Contacts Identified by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. SSP Cases with % No. SSP Cases with % Contacts Identified / Contacts Identified / No. SSP Cases No. SSP Cases 1.1 Rome 5/5 100 4/4 100 1.2 Dalton 7/7 100 4/4 100 2.0 Gainesville 5/5 100 7/7 100 3.1 Cobb 6/6 100 9/9 100 3.2 Fulton 37/37 100 27/27 100 3.3 Clayton 3/3 100 4/4 100 3.4 Lawrenceville 18/18 100 17/17 100 3.5 DeKalb 14/14 100 19/19 100 4.0 LaGrange 7/7 100 5/5 100 5.1 Dublin 3/3 100 2/2 100 5.2 Macon 2/2 100 3/3 100 6.0 Augusta 11/11 100 10/10 100 7.0 Columbus 11/11 100 8/8 100 8.1 Valdosta 1/1 100 4/4 100 8.2 Albany 9/9 100 5/5 100 9.1 Coastal 10/10 100 7/7 100 9.2 Waycross 3/3 100 1/1 100 10 Athens 1/1 100 3/3 100 Georgia Total 153/153 100 139/139 100 Table 8. Completely Evaluated Contacts of Sputum Smear Positive Cases by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Contacts that were % No. Contacts that were % Completely Evaluated / Completely Evaluated / No. Contacts Identified No. Contacts Identified 1.1 Rome 47/54 87 51/52 98 1.2 Dalton 85/92 92 32/36 89 2.0 Gainesville 14/21 67 41/50 82 3.1 Cobb 43/50 86 42/51 82 3.2 Fulton 532/638 83 253/350 72 3.3 Clayton 590/658 90 51/55 93 3.4 Lawrenceville 97/175 55 111/128 87 3.5 DeKalb 84/110 76 1055/1328 79 4.0 LaGrange 54/73 74 231/270 86 5.1 Dublin 44/49 90 69/71 97 5.2 Macon 1/7 14 29/40 72 6.0 Augusta 205/262 78 72/84 86 7.0 Columbus 149/198 75 47/67 70 8.1 Valdosta 5/5 100 15/16 94 8.2 Albany 251/380 66 92/113 81 9.1 Coastal 42/61 69 30/36 83 9.2 Waycross 20/20 100 -- -- 10 Athens 5/8 62 26/29 90 Georgia Total 2268/2861 79 2247/2776 81 16 Table 9. Contacts with Latent TB Infection (LTBI) exposed to Sputum Smear Positive Cases by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Contacts with LTBI/ % No. Contacts with LTBI/ % No. Contacts No. Contacts Completely Evaluated Completely Evaluated 1.1 Rome 13/47 28 21/51 41 1.2 Dalton 41/85 48 7/32 22 2.0 Gainesville 7/14 50 12/41 29 3.1 Cobb 18/43 42 27/42 64 3.2 Fulton 83/532 16 41/253 16 3.3 Clayton 40/590 7 6/51 12 3.4 Lawrenceville 60/97 62 42/111 38 3.5 DeKalb 37/84 44 107/1055 10 4.0 LaGrange 13/54 24 15/231 6 5.1 Dublin 13/44 30 11/69 16 5.2 Macon 1/1 100 6/29 21 6.0 Augusta 31/205 15 35/72 49 7.0 Columbus 35/149 24 10/47 21 8.1 Valdosta 1/5 20 9/15 60 8.2 Albany 68/251 27 20/92 22 9.1 Coastal 18/42 43 12/30 40 9.2 Waycross 6/20 30 -- -- 10 Athens 2/5 40 21/26 81 Georgia Total 486/2268 21 402/2247 18 Table 10. Contacts with LTBI exposed to Sputum Smear Positive Cases started on LTBI Treatment by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Infected Contacts % No. Infected Contacts % on LTBI Treatment / No. on LTBI Treatment / No. Infected Contacts Infected Contacts 1.1 Rome 5/13 38 14/21 67 1.2 Dalton 32/41 78 7/7 100 2.0 Gainesville 7/7 100 9/12 75 3.1 Cobb 13/18 72 19/27 70 3.2 Fulton 42/83 51 30/41 73 3.3 Clayton 21/40 52 1/6 17 3.4 Lawrenceville 39/60 65 21/42 50 3.5 DeKalb 26/37 70 80/107 75 4.0 LaGrange 13/13 100 13/15 87 5.1 Dublin 8/13 62 10/11 91 5.2 Macon 0/1 0 5/6 83 6.0 Augusta 10/31 32 29/35 83 7.0 Columbus 20/35 57 7/10 70 8.1 Valdosta 1/1 100 6/9 67 8.2 Albany 49/68 72 12/20 60 9.1 Coastal 9/18 50 8/12 67 9.2 Waycross 5/6 83 -- -- 10 Athens 0/2 0 19/21 90 Georgia Total 300/486 62 290/402 72 17 Table 11. LTBI Treatment Completion of Infected Contacts exposed to Sputum Smear Positive Cases by Health District, Georgia, 2009-2010 2009 2010 HEALTH DISTRICT No. Contacts that % No. No. Contacts that % Completed LTBI Contacts Completed LTBI Treatment with Treatment / Contacts Treated Missing / Contacts Treated Tx data 1.1 Rome 2/5 40 0 6/14 43 1.2 Dalton 24/32 75 0 3/7 43 2.0 Gainesville 4/7 57 0 6/9 67 3.1 Cobb 10/13 77 0 10/19 53 3.2 Fulton 29/40 72 2 19/30 63 3.3 Clayton 6/7 86 14 1/1 100 3.4 Lawrenceville 21/38 55 1 14/21 67 3.5 DeKalb 14/19 74 7 60/80 75 4.0 LaGrange 4/13 31 0 9/13 69 5.1 Dublin 2/8 25 0 4/9 44 5.2 Macon -- -- 0 4/5 80 6.0 Augusta 7/10 70 0 12/29 41 7.0 Columbus 12/20 60 0 4/7 57 8.1 Valdosta -- -- 1 4/6 67 8.2 Albany 36/49 74 0 7/12 58 9.1 Coastal 5/9 56 0 4/8 50 9.2 Waycross 4/5 80 0 -- -- 10 Athens -- -- 0 2/19 10 Georgia Total 180/275 66 25 169/289 58 No. Contacts with Missing Tx data 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 -0 2 Table 12. Reasons Why Infected Contacts of Sputum Smear Positive cases Stopped LTBI Treatment, Georgia, 2009-2010 Reasons for Stopping LTBI Therapy 2009 2010 N= 275 N= 289 No. % No. % Completed Therapy 180 66 169 58 Chose to Stop 39 14 48 17 Lost to Follow-Up 29 10 40 14 Provider Decision 6 2 7 2 Moved 16 6 12 4 Adverse Reactions 4 2 12 4 Active TB Developed 0 0 0 0 Death 1 0.4 1 0.4 18 Figure 1. TB Cases and Case Rates Georgia,1982-2011 Number of Cases Rate/100,000 1000 16 900 14 800 12 700 600 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 Figure 2. Number of TB Cases by Health Districts Georgia, 2011 1-2 2-0 G 1-1 B P P 3-2 3-4 10-0 H 3-1 3-5 Rockdale 3-3 4-0 5-2 Number of TB Cases: Low incidence: 2-10 Medium incidence: 11-20 High incidence: >20 (29-86) 6-0 7-0 8-2 S D 5-1 9-1 9-2 8-1 19 Figure 3. TB Case Rates by Health Districts Georgia, 2011 G 1-1 B P P H 1-2 2-0 3-2 3-4 3-1 3-5 3-3 Rockdale 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 S 5-1 9-1 9-2 8-1 Fig. 4, TB Cases by Age Group and Sex Georgia, 2011 90 80 70 60 50 Number 40 30 20 10 0 <5 5-14 15-24 25-44 45-64 65 Age group (years) Male Female 20 Figure 5. TB Case Rates* by Age Group 2007-2011, Georgia Age Group 2007 2008 2009 2010 2011 < 5 yrs. 5-14 yrs. 3.5 4.5 2.3 2 2.3 0.8 0.6 0.5 0.9 0.7 15-24 yrs. 4.3 3.9 4.1 3.3 2.8 25-44 yrs. 6 6.3 5.1 5 4.4 45-64 yrs. 6 6.6 5.4 5.8 4.6 65+ yrs. 7.4 5.4 5.7 5.5 4.3 *Rates are per 100,000 population Figure 6. TB Cases by Race/Ethnicity Georgia, 2000 and 2011 Asian 10% White 18% Black 61% Asian 17% White 15% Hispanic 11% 2000 Hispanic 20% 2011 Black 48% 21 Figure 7. TB Case Rates* by Race/Ethnicity Georgia, 2007-2011 Race/ Ethnicity 2007 2008 2009 2010 2011 Asian, non-Hispanic 21.5 27.2 29.7 24.1 16.8 Hispanic, All races 12.9 11.8 11.2 8.2 7.6 Black, non-Hispanic 8.3 7.8 6.2 7.1 5.3 White, non-Hispanic 1.2 1.2 1.2 1 0.9 *Rates are per 100,000 population Figure 8. TB Case Rates in non-Hispanic Blacks and Whites, Georgia, 1993-2011 Non-Hispanic Black Non-Hispanic White Case Rate/100,000 35 30.6 30 25 20 15 10 5 3.7 5.3 0 0.9 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Year 22 Figure 9. US-born and Foreign-born TB Cases Georgia,1993-2011 800 700 600 500 400 300 200 100 0 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Year US-born Foreign-born Figure 10. Percent of Foreign-born TB Cases (n=159) by Country of Origin, Georgia, 2011 Others 42% Mexico 27% Vietnam 5% Guatemala 9% India 12% Ethiopia 5% 23 Figure 11. HIV Status of TB Cases Georgia,1993-2011 Unknown Negative Positive Number 900 800 700 600 500 400 300 200 100 0 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Year Figure 12. TB in Other High-Risk Populations Georgia, 2007-2011 120 100 80 Number 60 40 20 0 2007 2008 2009 2010 2011 Year Substance abuse Homeless Correctionals Long-Term Care 24 Number Percent Figure 13. Primary Drug Resistance and MDR-TB Georgia, 2007-2011 45 16 40 14 14 35 30 25 9 20 15 6 10 12 10 10 8 7 6 4 5 2 0 0 2007 2008 2009 2010 2011 Year INH RIF MDR-TB % INH-R Figure 14. TB Treatment Completion within 12 months and Directly Observed Therapy (DOT) Georgia, 1993-2010* Percent 100 92 80 68 84 60 40 35 20 Completion in 12 months Totally DOT 0 DOT became standard of care 1993 1995 1997 1999 2001 2003 2005 2007 2009 Year Case Counted *In 2009, CDC changed the calculation for TB treatment completion within 12 months to exclude TB cases who moved out of the U.S. while on TB treatment. 25 Figure 15. Completion of Latent TB Infection (LTBI) Therapy among all contacts of TB cases, Georgia, 2005-2010 Percent 80 70 66 66 68 60 57 60 65 50 Completed LTBI Therapy 40 Missing data 30 20 10 0 14 1 4 6 8 1 2005 2006 2007 2008 2009 2010 Year 26 Tuberculosis Morbidity Trends by Health District Georgia, 1995-2011 TB Case Numbers and Rates District 1-1 (Rome),1995-2011 60 51 50 40 30 20 33 18 25 22 31 32 32 30 27 30 17 18 12 15 11 10 0 11.6 5 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 2.4 1.7 0.8 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate 27 TB Case Numbers and Rates District 1-2 (Dalton),1995-2011 25 21 21 20 15 14 12 11 10 10 15 11 10 8 17 14 14 10 10 10 7 5 0 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 1.6 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database TB Case Numbers and Rates District 2 (Gainesville),1995-2011 25 20 20 17 15 15 15 15 12 13 10 10 19 15 16 14 12 11 10 10 8 5 0 5.9 4.9 3.7 3.7 3.5 2.6 2.1 2.0 2.5 1.5 3.5 5.7 2.1 2.6 1.8 1.7 2.2 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database 28 TB Case Numbers and Rates District 3-1 (Cobb),1995-2011 50 44 40 32 30 20 18 38 38 36 32 32 30 30 30 31 29 24 25 21 20 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 2.4 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate TB Case Numbers and Rates District 3-2 (Fulton),1995-2011 250 200 192 207 187 177 150 133 150 136 119 122 116 100 87 72 78 72 81 51 45 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 7.8 5.5 4.7 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database 29 TB Case Numbers and Rates District 3-3 (Clayton),1995-2011 30 28 25 23 20 18 18 19 14 15 15 15 14 15 15 14 15 10 5 9 4.5 8.8 6.7 13.4 7.0 9.7 6.5 7.1 5.4 5.2 5.6 7.0 5.5 11 8 9 5.1 4.0 3.1 3.4 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate TB Case Numbers and Rates District 3-4 (Lawrenceville),1995-2011 100 81 80 68 58 57 60 43 42 46 40 24 26 29 20 12 17 34 21 63 65 49 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 6.3 6.6 4.8 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate 30 TB Case Numbers and Rates District 3-5 (DeKalb),1995-2011 120 100 80 92 99 102 104 84 85 78 88 83 72 80 72 78 86 76 61 62 60 40 20 16.7 17.0 15.9 14.316.9 12.9 11.6 13.0 12.310.6 11.6 8.4 9.8 10.5 8.3 121.40.9 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate TB Case Numbers and Rates District 4 (LaGrange),1995-2011 35 30 24 26 29 25 25 27 25 19 21 20 20 20 16 16 16 15 12 12 13 10 8 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 1 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate 31 TB Case Numbers and Rates District 5-1 (Dublin),1995-2011 20 16 15 12 10 5 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 5.6 4.4 2.9 2.8 5.6 5.5 3 2 3 2.1 1.3 1.9 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database TB Case Numbers and Rates District 5-2 (Macon),1995-2011 60 51 50 46 40 30 20 31 22 27 28 23 20 23 28 24 31 15 18 11 16 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 3.1 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate 32 TB Case Numbers and Rates District 6 (Augusta)*,1995-2011 60 52 50 45 38 39 46 40 30 32 30 20 25 20 24 19 17 16 14 21 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 4.7 8 4.3 1.7 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database *Augusta State Medical Prison cases not included TB Case Numbers and Rates District 7 (Columbus)*,1995-2011 50 46 40 33 34 36 34 28 30 30 30 20 10 0 22 21 18 20 21 23 13.2 14 12 9 9.5 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 3.5 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate *ICE Detention Center cases not included 33 TB Case Numbers and Rates District 8-1 (Valdosta),1995-2011 30 24 25 20 15 10 5 0 21 18 10.2 8.7 20 17 11.5 7.9 14 15 9.3 12 7 6 9 13 10 9 5 5 6.2 6.22 0.9 3.0 5.1 2.5 3.8 2.1 5.3 2.0 4.0 3.5 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database TB Case Numbers and Rates District 8-2 (Albany),1995-2011 50 40 38 45 40 36 43 38 29 30 20 17 24 21 23 25 21 25 18 15 18 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 4.9 4.2 5 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database 34 TB Case Numbers and Rates District 9-1 (Coastal),1995-2011 70 58 60 48 50 40 34 33 33 31 30 20 25 19 23 20 17 19 26 23 20 18 13 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 3.6 3.2 2.2 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate TB Case Numbers and Rates District 9-2 (Waycross),1995-2011 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 16 13 8 5 12 7 7.6 3.9 2.7 4.7 3.8 2.3 1.4 1.9 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rates are per 100,000 population Source: GA TB surveillance database Rate 35 TB Case Numbers and Rates District 10 (Athens),1995-2011 25 22 20 16 16 15 13 13 13 14 13 11 12 10 5 0 6.6 9586447 4.6 4.2 5.1 3.8 3.8 3.4 4.1 2.8 2.9 2.2 1.1 1.8 1.3 0.9 0.9 1.5 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Number Rate Rates are per 100,000 population Source: GA TB surveillance database 36 37