2012 Georgia tuberculosis report

2012 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 Antoine Perrymon Epidemiologist David Maggio 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, 2012 Georgia Tuberculosis Report, Atlanta, Georgia, October 2013.
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 359 new tuberculosis (TB) cases in 2012. This represents a 3.5% increase from 347 TB cases reported in 2011. TB case numbers have decreased 61% since 1991 when the peak of a resurgent period of tuberculosis occurred in Georgia (Figure 1). The TB case rate in Georgia increased from 3.5 cases per 100,000 population during 2011 to 3.6 cases per 100,000 in 2012, slightly higher than the U.S. TB case rate in 2012 of 3.2 cases per 100,000 (Figure 2). Georgia had the eighth highest TB case rate among the 50 states of the United States in 2012.
Geographic Distribution
Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area reported the highest number of TB cases in 2012: DeKalb (81 cases), Fulton (54), Gwinnett (29), and Cobb (15) (Table 1, Figure 3). These four counties accounted for 50% of TB cases reported in Georgia in 2012.
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 2012 (11.5 per 100,000), followed by Albany (5.6 per 100,000) and Fulton (5.5 per 100,000) (Table 2, Figure 4).
Sex and Age Distribution
In 2012, TB in Georgia occurred predominantly among males (232 cases, 65%), compared to females (127, 35%); while the highest proportion of TB cases by age group occurred among persons 45-64 years old (128 cases, 36%). Among males, the highest proportion of cases occurred in the 45-64 year old age group (91 cases, 39%) while among females, the highest proportion was in the 25-44 year old age group (40 cases, 31%) (Figure 5). The highest TB case rate by age group was among persons 45-64 years old (5.1 per 100,000) while the lowest was among children 5-14 years old (0.9 per 100,000) (Figure 6). 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 2011 to 1.6 per 100,000 in Georgia during 2012.
Race/Ethnicity Distribution and TB Disparities
TB disproportionately affects racial/ethnic minorities in Georgia. In 2012, nonHispanic blacks, Asians and Hispanics, accounted for 52%, 19% and 15% of TB cases in Georgia respectively, but only represented 30.4%, 3.5% and 9.2% of Georgia's population respectively (Figure 7). Non-Hispanic whites constituted 14% of TB cases in 2012. The highest TB case rate among race/ethnic groups was among Asians (19.8 per 100,000), followed by non-Hispanic blacks (6.1 per 100,000), and Hispanics (6.0 per 100,000) (Figure 8). The black non-Hispanic TB case rate in 2012 represents an 80% decrease from the TB case rate in 1993 (30.6 per 100,000) in this population. The black
4

non-Hispanic TB case rate, however, was still about 7 times higher than the white nonHispanic TB case rate (0.9 per 100,000) in Georgia during 2012 (Figure 9).
High-Risk Populations
Foreign-Born
TB cases among persons born outside of the United States accounted for 43% of TB cases in Georgia in 2012 compared to 46% in 2011. Most foreign-born cases reported in 2012 came from Mexico (18%), Ethiopia (12%), and India (10%) - countries where TB is an endemic disease (Figures 10-11). Among 154 foreign-born cases, 60 (39%) were diagnosed in the first five years of their arrival in the U.S.
In 2012, four Health Districts reported 69% of the total number of foreign-born TB cases in Georgia: DeKalb (64 cases), Gwinnett (21), Fulton (12) and Cobb (10). Among these Health Districts, foreign-born TB cases accounted for more than half of the TB cases in DeKalb (79%), Lawrenceville (68%), and Cobb (59%). Foreign-born TB cases in the Fulton Health District accounted for 22% 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 334 TB cases in Georgia with known HIV status in 2012, 12% were HIV-positive compared to 10% in 2011 (Figure 12). Among 39 HIV co-infected TB cases in 2012, 74% were non-Hispanic blacks, 74% were male and 51% were 25-44 years old.
HIV status was reported in 93% of TB cases in 2012 compared to 89% in 2011. 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 2011 and 97% in 2012. Among 25 TB cases whose HIV status was not reported, HIV testing was not offered to eight cases (32%), the HIV test result was unknown in six cases (24%), and eleven (44%) refused testing. The proportion by age group among the TB cases that were not offered the HIV test was highest among children 0-14 years old (4 cases, 50%); HIV testing was not offered in two cases each in the age group of 25-44 years old and those older than 65 years.
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 2012, 37 (10%) TB cases in Georgia were homeless, 19 (5%) were residents of correctional facilities at the time of TB diagnosis, and 6 (2%) were residents of long-term care facilities (Figure 13). Of the 19 TB cases incarcerated in correctional facilities, six (32%) were inmates in state prisons, eight (42%) in county jails, four (13%) in the Immigration and Custom Enforcement Detention Center in Stewart County, and five (26%) were in federal prisons.
5

Substance 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 69 (19%) of TB cases in 2012 (Table 3, Figure 13).
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 2012, children younger than 15 years old comprised 6% of Georgia TB cases; 11 cases (1.6 per 100,000) were reported in children younger than 5 years old, 12 cases (0.9 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 2012, 56 children younger than five years old were reported to have LTBI in Georgia; 34 were identified by TB screening in pediatric clinics, and 22 from contact investigations. Public health staff identified the source case of the child's infection in 33 (59%) of these children.
Drug Resistance
Among 201 culture-positive TB cases in Georgia during 2012, 100% were tested for initial drug susceptibility to the three first-line anti-TB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 238 tested isolates from Georgia cases with no previous history of TB, 24 (10.1%) had primary resistance to INH, three (1.3%) to RIF, and three (1.3%) to EMB (Table 4). One (0.4%) case in 2012 had multidrugresistant 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 7% 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 14).
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 2012, 77% of all Georgia TB cases had pulmonary
6

TB, 56% had sputum cultures that were positive for Mycobacterium tuberculosis, 40% were sputum AFB smear-positive, and 23% 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 2012, 214 (60%) of the 359 TB cases in Georgia were reported initially by a hospital. Eight hospitals in Georgia reported five or more TB cases in 2012: Grady Memorial Hospital (49 cases), Dekalb Medical Center (13 cases), Gwinnett Medical Center (12 cases), Northside Hospital (11 cases), Phoebe Putney Memorial Hospital in Albany (9 cases), Atlanta Medical Center (8 cases), Children's Healthcare of Atlanta at Scottish Rite (5 cases), and Crisp Regional Hospital (5 cases). These eight hospitals accounted for more than half of all patients hospitalized for TB in Georgia in 2012.
County health departments provided case management for 77% of all Georgia TB cases, 13% of cases were treated by health department and private physician, correctional facilities treated 4%, 4% 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 261 Georgia TB cases reported in 2012 with available case completion data, 89% received TB treatment entirely by DOT, 11% were treated by a combination of DOT and self-administered therapy, and less than 1% self-administered their medications for the entire duration of their treatment.
TB Mortality
Ten persons died of TB in Georgia in 201, the most recent year with available mortality statistics. The age-adjusted TB mortality rate in 2011 was 0.1 per 100,000. From 2007 to 2011, an average of 14 people died of TB in Georgia each year.
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 5,143 identified contacts of all Georgia TB cases reported in 2011 (the most recent year with completed contact investigation data), 4,229 (82%) were completely evaluated for TB disease and LTBI. Of the completely evaluated contacts, 919 (22%) had LTBI and 20 (0.5%) had TB disease. Among the 919 contacts with LTBI, 594 (65%) started LTBI treatment and among these contacts who started LTBI treatment, 411 (70%) completed LTBI treatment, 83 (14%) were lost to follow-up, 49 (8%) chose to stop LTBI treatment on their own, 30 (5%) moved, 10 (2%) had adverse side-effects, 5 (1%) stopped due to a provider's decision, and 2 (.3%) developed active TB (Figure 16).
Among 2,815 completely evaluated contacts of acid-fast bacilli (AFB) sputum smear positive cases reported in 2011, 658 (24%) were diagnosed with latent TB infection and 13 (0.5%) were diagnosed with active TB. Of the 658 contacts with LTBI, 425 (66%) were started on LTBI treatment, and of those started on LTBI treatment, 301 (71%) completed treatment (Tables 7-9).
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 289 TB cases reported in 2011 that were eligible to complete TB treatment within 12 months and had data on treatment completion, 281 (97%) completed TB treatment and 260 (90%) completed treatment within 12 months; 6 (2%) were lost to follow-up and 2 (0.7%) had to stop treatment due to adverse reactions to TB medications. Among 21 TB cases that completed TB treatment but extended treatment beyond 12 months, eight cases had data explaining why treatment was extended entered in the surveillance database: four extended TB treatment due to a clinical indication, three had adverse reactions to the TB medications and were non-adherent to TB treatment, and one had an adverse reaction to the TB medications. Of the other cases who extended TB treatment, four had bone/joint TB and their extended TB treatment may have been a health provider decision, three were co-infected with HIV and had other problems that may have affected treatment adherence (homelessness, foreign-birth, TB of the brain), one was in a correctional facility at the time of TB diagnosis and was hard to locate after discharge from the correctional facility, one was foreign-born and had language/cultural barriers to treatment completion, and one had abused illegal drugs which made treatment adherence difficult (Figure 15).
Objective 2: By 2015, achieve 65% sputum culture conversion documented within 60 days of treatment initiation for patients with positive sputum culture results.
Among 161 patients with positive sputum culture results in 2011 who did not move out of the U.S. while on treatment, 142 (88%) had documented sputum culture conversion
8

and 109 (68%) had sputum conversion documented within 60 days of treatment initiation (median = 31 days), exceeding the target for this objective. Overcoming barriers to treatment adherence is constantly emphasized during case reviews to achieve this objective. Objective 3: By 2015, increase the proportion of contacts of acid-fast bacilli (AFB) sputum smear positive TB cases in Georgia who are evaluated for TB infection or disease to 93%. Among 3,519 contacts to AFB sputum smear positive patients in 2011, 2,815 (80%) were completely evaluated, meeting the program target for this objective (Table 7). Among the 704 contacts that were not completely evaluated, 491 had data on reasons for incomplete evaluation. Of these, 227 (46%) contacts refused evaluation or were uncooperative, 144 (29%) were lost to follow-up, 46 (9%) died, 25 (5%) moved, 13 (3%) were still being followed up, and 36 (7%) had "Other" selected as the reason for incomplete evaluation. The most common step missed in obtaining a complete evaluation was not returning for a second tuberculin skin test (TST) when the first TST is negative; among 1,080 contacts with a negative TST on the first round of testing who required a second TST, 340 (31%) did not receive a second TST.
Objective 4: By 2015, among infected contacts of acid-fast bacilli (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 422 infected contacts of SSP TB patients started on LTBI treatment in 2011 with data on treatment completion, 301 (71%) completed treatment, 65 (15%) were lost to follow-up, 25 (6%) chose to stop treatment on their own, 19 (4%) moved, 6 (1%) stopped treatment due to adverse side effects, 4 (0.9%) stopped treatment due to a provider's decision, and 2 (0.5%) developed active TB (Tables 8-9).
9

Table 1. Number of TB Cases and TB Case Rates* per 100,000 population by County, Georgia, 2011-2012

COUNTY
Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia excludes ASMP Augusta State Med Prison (ASMP) Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty

2011

Number of Case Rate

cases

0

0

<5

--

0

0

<5

--

<5

--

0

0

<5

--

0

0

0

0

0

0

7

4.5

<5

--

<5

--

<5

--

0

0

<5

--

0

0

0

0

<5

--

0

0

0

0

0

0

<5

--

0

0

6

2.2

0

0

<5

--

<5

--

<5

--

0

0

9

3.4

<5

--

16

2.3

0

0

<5

--

4

3.1

16

na

0

0

<5

--

0

0

<5

--

0

0

0

0

<5

--

76

10.9

<5

--

0

0

5

5.3

2012

Number of Case Rate

cases

<5

--

<5

--

0

0

0

0

<5

--

0

0

<5

--

0

0

0

0

5

26.3

<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

9

3.3

0

0

<5

--

<5

--

<5

--

<5

--

13

4.9

<5

--

15

2.1

<5

--

<5

--

<5

--

6

na

0

0

<5

--

0

0

<5

--

0

0

0

0

0

0

81

11.5

0

0

5

34.9

9

9.5

10

Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether

<5

--

<5

--

0

0

0

0

0

0

0

0

<5

--

<5

--

0

0

<5

--

0

0

<5

--

<5

--

<5

--

<5

--

0

0

<5

--

<5

--

<5

--

<5

--

<5

--

0

0

<5

--

0

0

45

4.7

54

5.5

0

0

0

0

0

0

0

0

<5

--

<5

--

0

0

<5

--

<5

--

<5

--

<5

--

0

0

48

5.8

29

3.4

0

0

<5

--

8

4.4

<5

--

<5

--

0

0

0

0

<5

--

0

0

0

0

<5

--

0

0

0

0

0

0

<5

--

<5

--

<5

--

<5

--

<5

--

0

0

0

0

<5

--

0

0

<5

--

0

0

0

0

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

--

0

0

<5

--

<5

--

<5

--

0

0

0

0

0

0

<5

--

<5

--

5

4.4

0

0

<5

--

<5

--

<5

--

<5

--

<5

--

0

0

0

0

0

0

0

0

0

0

<5

--

0

0

<5

--

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

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

2012

Number of Case Rate

cases

0

0

0

0

0

0

0

0

0

0

<5

--

6

3.0

<5

--

<5

--

0

0

<5

--

0

0

0

0

<5

--

0

0

0

0

0

0

<5

--

0

0

0

0

0

0

11

5.4

<5

--

0

0

0

0

0

0

<5

--

5

19.3

0

0

0

0

4

na

5

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

--

0

0

<5

--

<5

--

0

0

<5

--

0

0

0

0

0

0

0

0

<5

--

6

8.8

<5

--

0

0

0

0

0

0

0

0

0

0

0

0

<5

--

<5

--

<5

--

<5

--

0

0

<5

--

0

0

12

COUNTY
Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth GEORGIA

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

2012

Number of Case Rate

cases

0

0

0

0

<5

--

<5

--

0

0

<5

--

0

0

0

0

0

0

0

0

<5

--

359

3.6

Note: In counties where one to four TB cases were reported, "< 5" is used to represent the number of reported cases, and the TB 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

2011

2012

Health District

Number Case rate Number Case rate

of Cases

of Cases

1.1 Rome

5

1.1

10

1.6

1.2 Dalton

7

1.6

6

1.3

2.0 Gainesville

14

2.2

9

1.4

3.1 Cobb

20

2.4

17

2.0

3.2 Fulton

45

4.7

54

5.5

3.3 Clayton

9

3.4

13

4.9

3.4 Lawrenceville

49

4.8

31

3.0

3.5 DeKalb

76

10.9

81

11.5

4.0 LaGrange

8

1.0

13

1.6

5.1 Dublin

3

1.9

1

0.7

5.2 Macon

16

3.1

9

1.7

6.0 Augusta

8

5.1

14

3.0

Augusta State

16

na

6

na

Medical Prison

7.0 Columbus

9

3.5

20

5.3

ICE Detention Center

4

na

5

na

8.1 Valdosta

9

3.5

12

4.7

8.2 Albany

18

5.0

20

5.6

9.1 Coastal

13

2.2

18

3.1

9.2 Waycross

11

3.0

10

2.7

10 Athens

7

1.5

10

2.7

Total

347

3.5

359

3.6

13

Table 3. Percentage of TB Cases with Risk Factors for TB by Health District

Georgia, 2012

HEALTH

Foreign-

HIV

Homeless Inmate Nursing

DISTRICT

born % Infected %

%

%

Home %

1.1 Rome

10

0

10

10

0

1.2 Dalton

67

0

0

0

33

2.0 Gainesville

22

0

11

0

0

3.1 Cobb

59

18

24

0

0

3.2 Fulton

22

19

26

6

0

3.3 Clayton

54

8

8

0

0

3.4 Lawrenceville

68

6

0

0

0

3.5 DeKalb

79

15

5

1

0

4.0 LaGrange

8

0

0

8

0

5.1 Dublin

0

0

0

0

0

5.2 Macon

33

0

11

0

0

6.0 Augusta

21

21

29

0

0

ASMP only

0

0

0

100

0

7.0 Columbus

30

15

0

0

10

ICE only

25

0

0

0

0

8.1 Valdosta

0

0

25

0

0

8.2 Albany

15

11

5

0

5

9.1 Coastal

33

6

11

6

6

9.2 Waycross

20

10

10

0

0

10 Athens

30

0

0

10

0

Georgia Total

43

12

10

5

2

Substance Abuse %
30 0 33 24 28 8 3 6 38 100 11 21 50 30 0 17 35 39 0 20 19

Table 4. Primary Resistance to First-line Anti-TB Medications by Health District

Georgia, 2012

TB Drug

Isoniazid

Rifampin

Ethambutol

HEALTH DISTRICT

No.

%

No.

%

No.

%

1.1 Rome

1

17

0

0

0

0

1.2 Dalton

0

0

0

0

0

0

2.0 Gainesville

5

63

0

0

0

0

3.1 Cobb

1

8

1

8

1

8

3.2 Fulton

3

8

0

0

0

0

3.3 Clayton

0

0

0

0

0

0

3.4 Lawrenceville

2

9

0

0

0

0

3.5 DeKalb

3

7

0

0

0

0

4.0 LaGrange

0

0

0

0

0

0

5.1 Dublin

0

0

0

0

0

0

5.2 Macon

2

29

0

0

0

0

6.0 Augusta & ASMP

6

38

0

0

0

0

7.0 Columbus & ICE

0

0

1

7

1

7

8.1 Valdosta

0

0

0

0

0

0

8.2 Albany

0

0

0

0

0

0

9.1 Coastal

0

0

1

10

0

0

9.2 Waycross

1

11

0

0

0

0

10 Athens

0

0

0

0

0

0

Georgia Total

24

10

3

1

3

1

14

Table 5. Completion of TB Treatment (Tx) by Health District, Georgia, 2010-2011

2010

2011

HEALTH DISTRICT

No. Cases that

% No. Cases that

%

Completed Tx/No.

Completed Tx/No.

No. Cases Missing data

Cases Started Tx*

Cases Started Tx*

1.1 Rome

11/11

100

3/3

100

0

1.2 Dalton

10/10

100

5/6

83

0

2.0 Gainesville

5/5

100

10/10

100

0

3.1 Cobb

24/25

96

17/17

100

0

3.2 Fulton

46/46

100

39/39

100

0

3.3 Clayton

8/8

100

5/6

83

1

3.4 Lawrenceville

56/60

93

44/45

98

0

3.5 DeKalb

77/78

99

66/68

97

0

4.0 LaGrange

7/10

70

7/7

100

0

5.1 Dublin

1/1

100

3/3

100

0

5.2 Macon

15/15

100

11/12

92

0

6.0 Augusta

15/16

94

7/7

100

0

ASMP only

17/18

94

16/16

100

0

7.0 Columbus

10/10

100

6/6

100

0

ICE only*

na

na

na

na

na

8.1 Valdosta

8/8

100

9/9

100

0

8.2 Albany

12/13

92

12/12

100

0

9.1 Coastal

11/11

100

10/11

91

1

9.2 Waycross

5/5

100

9/11

82

0

10 Athens

5/5

100

6/6

100

0

Georgia Total

346/359

96

285/293

97

2

Table 6. Timely Completion of TB Treatment (Tx) among TB cases eligible for 12-month TB Tx by Health District, Georgia, 2009-2010

2010

2011

HEALTH DISTRICT

No. Cases Completed Tx in % No. Cases Completed Tx in %

12 months/ No. Started Tx

12 months/ No. Started Tx

1.1 Rome

11/11

100

2/3

67

1.2 Dalton

10/10

100

5/6

83

2.0 Gainesville

4/5

80

9/10

90

3.1 Cobb

23/25

92

17/17

100

3.2 Fulton

41/44

93

37/38

97

3.3 Clayton

7/8

88

5/6

83

3.4 Lawrenceville

52/55

94

38/44

86

3.5 DeKalb

67/71

94

62/67

92

4.0 LaGrange

7/10

70

6/7

86

5.1 Dublin

1/1

100

1/3

33

5.2 Macon

12/14

86

11/11

100

6.0 Augusta ASMP only

10/11

91

15/18

83

7/7

100

13/16

81

7.0 Columbus

10/10

100

6/6

100

8.1 Valdosta

8/8

100

6/9

67

8.2 Albany

11/13

85

11/12

92

9.1 Coastal

13/14

93

10/12

9.2 Waycross

5/5

100

8/10

80

10 Athens

5/5

100

6/6

100

Georgia Total

312/338

92

260/289

90

No. cases Missing data
0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 2

15

Table 7. Completely Evaluated Contacts of Sputum Smear Positive Cases

by Health District, Georgia, 2010-2011

2010

2011

HEALTH DISTRICT No. Contacts that were

% No. Contacts that were

%

Completely Evaluated /

Completely Evaluated /

No. Contacts Identified

No. Contacts Identified

1.1 Rome

51/52

98

32/34

94

1.2 Dalton

32/36

89

35/46

76

2.0 Gainesville

41/50

82

36/48

75

3.1 Cobb

42/51

82

24/30

80

3.2 Fulton

253/350

72

324/348

93

3.3 Clayton

51/55

93

27/29

93

3.4 Lawrenceville

111/128

87

640/959

67

3.5 DeKalb

1055/1328

79

559/641

87

4.0 LaGrange

231/270

86

55/64

86

5.1 Dublin

69/71

97

236/329

72

5.2 Macon

29/40

72

75/88

85

6.0 Augusta

72/84

86

263/287

92

7.0 Columbus

47/67

70

54/55

98

8.1 Valdosta

15/16

94

15/15

100

8.2 Albany

92/113

81

154/170

91

9.1 Coastal

30/36

83

45/51

88

9.2 Waycross

--

--

166/177

94

10 Athens

26/29

90

75/148

51

Georgia Total

2247/2776

81

2815/3519

80

Table 8. Infected Contacts exposed to Sputum Smear Positive Cases started on

LTBI Treatment by Health District, Georgia, 2010-2011

2010

2011

HEALTH DISTRICT No. Infected Contacts

% No. Infected Contacts

%

on LTBI Treatment /

on LTBI Treatment /

No. Infected Contacts

No. Infected Contacts

1.1 Rome

14/21

67

9/13

69

1.2 Dalton

7/7

100

6/8

75

2.0 Gainesville

9/12

75

14/17

82

3.1 Cobb

19/27

70

1/5

20

3.2 Fulton

30/41

73

45/65

69

3.3 Clayton

1/6

17

4/10

40

3.4 Lawrenceville

21/42

50

59/144

41

3.5 DeKalb

80/107

75

117/153

77

4.0 LaGrange

13/15

87

20/22

91

5.1 Dublin

10/11

91

13/21

62

5.2 Macon

5/6

83

17/26

65

6.0 Augusta

29/35

83

4/14

29

7.0 Columbus

7/10

70

23/32

72

8.1 Valdosta

6/9

67

1/1

100

8.2 Albany

12/20

60

37/57

65

9.1 Coastal

8/12

67

9/12

75

9.2 Waycross

--

--

34/42

81

10 Athens

19/21

90

12/16

75

Georgia Total

290/402

72

425/658

66

16

Table 9. LTBI Treatment Completion of Infected Contacts exposed to Sputum

Smear Positive Cases by Health District, Georgia, 2010-2011

2010

2011

HEALTH DISTRICT

No. Contacts that % Completed LTBI

No. Contacts that % Completed LTBI

Treatment

Treatment

/ Contacts Treated

/ Contacts Treated

1.1 Rome

6/14

43

3/9

33

1.2 Dalton

3/7

43

5/6

83

2.0 Gainesville

6/9

67

10/14

71

3.1 Cobb

10/19

53

1/1

100

3.2 Fulton

19/30

63

29/45

64

3.3 Clayton

1/1

100

4/4

100

3.4 Lawrenceville

14/21

67

38/59

64

3.5 DeKalb

60/80

75

100/117

86

4.0 LaGrange

9/13

69

10/20

50

5.1 Dublin

4/9

44

9/13

69

5.2 Macon

4/5

80

13/17

76

6.0 Augusta

12/29

41

1 / 4

25

7.0 Columbus

4/7

57

18/23

78

8.1 Valdosta

4/6

67

1/1

100

8.2 Albany

7/12

58

25/37

68

9.1 Coastal

4/8

50

7/9

78

9.2 Waycross

--

--

18/34

53

10 Athens

2/19

10

9/12

75

Georgia Total

169/289

58

301/425

71

17

Figure 1. TB Cases and Case Rates Georgia,1982-2012

Number of Cases
1000 909
900

800

700

13.8

600

500

400

300

200

100

0

Rate/100,000 16.0 14.0 12.0 10.0 8.0
359 6.0 3.6 4.0
2.0 0.0

2012

2011

2010

2009

2008

2007

2006 2005

2004

2003

2002

2001

2000

1999

1998

1997

1996 1995

1994

1993

1992

1991

1990

1989

1988

1987

1986 1985

1984

1983

1982

Year Case Counted
Number Case Rate

Case Rate

Figure 2 . TB Case Rates

16.0

Georgia and US, 1982-2012

14.0

12.0

10.0

8.0

6.0
3.6
4.0

2.0

3.2

0.0

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

1990

1989

1988

1987

1986

1985

1984

1983

1982

Year

US Case Rate

GA Case Rate

18

19

Number

Figure 5. TB Cases by Age Group and Sex Georgia, 2012

100 90 80 70 60 50 40 30 20 10 0 <5

5 - 14 15 - 24 25 - 44 45 - 64 >65 Age group (years)

Male Female

Figure 6. TB Case Rates* by Age Group 2008-2012, Georgia
Age Group 2008 2009 2010 2011 2012

< 5 yrs.

4.5 2.3 2 2.3 1.6

5-14 yrs. 0.6 0.5 0.9 0.7 0.9

15-24 yrs. 3.9 4.1 3.3 2.8 2.8

25-44 yrs. 6.3 5.1 5 4.4 4.3

45-64 yrs. 6.6 5.4 5.8 4.6 5.1

65+ yrs. 5.4 5.7 5.5 4.3 4.4
*Rates are per 100,000 population

20

Figure 8. TB Case Rates* by Race/Ethnicity Georgia, 2006-2012

Race/ Ethnicity

2008 2009 2010 2011 2012

Asian, non-Hispanic 27.2 29.7 24.1 16.8 19.8

Hispanic, All races 11.8 11.2 8.2

7.6

6.0

Black, non-Hispanic 7.8

6.2

7.1

5.3

6.1

White, non-Hispanic 1.2

1.2

1

0.9

0.9

*Rates are per 100,000 population

21

Figure 9. TB Case Rates in non-Hispanic Blacks and Whites, Georgia, 1993-2012

35 30.6
30

25

20

15

10

6.1

5 3.7 0.9

0

Non-Hispanic Black Non-Hispanic White

Count

Figure 10. US-born and Foreign-born TB Cases Georgia,1993-2012

900

800

700

600

500

US-born

400

Foreign-born

300

205

200

154

100

0

Year

22

Figure 11. Percent of Foreign-born TB Cases (n=154) by Country of Origin, Georgia, 2012

Others 40%

MEXICO 18%
ETHIOPIA 12%

INDIA VIETNAM 10%
8%

PHILIPPINES 4% GUATEMALA 4%

BHUTAN 4%

Number

Figure 12. HIV Status of TB Cases
Georgia,1993-2012
900

800

700

Unknown

600

Negative

500

Positive

400

300

200

100

0

Year

23

24

25

Tuberculosis Morbidity Trends by Health District Georgia, 1995-2012
26

TB Case Numbers and Rates District 1-1 (Rome),1995-2012
60 51
50

40

33

31 32 32 30

30

30

25

27

22

20

18

10

17 18

15

12

11

10

5

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 1-2 (Dalton),1995-2012
25

21

21

20 17

15

14

12 11

10

10

15

11

10

8

14 14 10

10 10 76

5

0

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

27

TB Case Numbers and Rates District 2 (Gainesville),1995-2012
25

20 20

19

17

16

15 10

15 15 15

12

13

10 10

8

15

12

11

14

10

9

5

0

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

TB Case Numbers and Rates

District 3-1 (Cobb),1995-2012

50

45

44

40

35

32

30

25

20 18

38 38 36

32

32 30 30 30 31

29

24

25

21

20

17

15

10

5 0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

28

TB Case Numbers and Rates

District 3-2 (Fulton),1995-2012
250

207

200 192

187

177

150

150

133

136 119 122 116

100

87 72 78 72 81

50

51 45 54

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 3-3 (Clayton),1995-2012

30

28

25

20

18

15

14

10 9

23

18

19

15

15

15 14 15

15 14

13

11

89

5

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

29

TB Case Numbers and Rates

District 3-4 (Lawrenceville),1995-2012

90 81
80

70

68

63 65

60

58

57

50

43

46 42

49

40

34

30

24

26 29

21

31

20 12

17

10

0

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 3-5 (DeKalb),1995-2011

120

100 80

99 102

104

92

84

85

88 83

78

80

72

78 72

86 76 81

61

62

60

40

20

0

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

30

TB Case Numbers and Rates District 4 (LaGrange),1995-2011
35

30

29

26

25

24

27 25 25

20 19

21 20

20

16 16

16

15

12 12 13

13

10

8

5

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 5-1 (Dublin),1995-2011
18
16
16

14
12
12

10

87

6

6

5

4
4

2

9

8

8

6

44

88

3

3

2

1

0

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

31

TB Case Numbers and Rates District 5-2 (Macon),1995-2012
60
51 50 46

40

31

31

30

27 28

28

20

22

23

23

24

20

18 15

16 16

10

11

9

0

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

TB Case Numbers and Rates

District 6 (Augusta)*,1995-2012

60

52

50 45

46

40

38 39

30

32

30

25

24

20

20

19 17 16 14 21 20

14

10

8

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number Rate

Rates are per 100,000 population Source: GA TB surveillance database

*Augusta State Medical Prison cases not included

32

TB Case Numbers and Rates

District 7 (Columbus)*,1995-2012

50

46

45

40 35 33 30 25 20 15 10

34

36

34

30

30

28

22

21 18

20 21

23

20

14

12

9

5

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate *ICE Detention Center cases not included

TB Case Numbers and Rates
District 8-1 (Valdosta),1995-2012
30

25

24

21

20

18

15

10

5

20

17 14 15

12

13

12

9

10 9

7

6

5

5

2

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

33

TB Case Numbers and Rates

District 8-2 (Albany),1995-2012

50

45 45

43

40 38

40 36

38

35

30

29

25 20

17

24

21

23

25

21

25

18

15

18

20

15

10

5

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 9-1 (Coastal),1995-2012
70

60

58

50 48

40

34 33

33

31

30

25

23

26 23

20

19

20 17 19

20 18

18

13

10

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

34

TB Case Numbers and Rates District 9-2 (Waycross),1995-2012

60

50 43

50 48

40 30
30 24

34

25

25

20

16

16

10

13 9

13 8

5

11 10 7

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number Rates are per 100,000 population Source: GA TB surveillance database

Rate

TB Case Numbers and Rates

District 10 (Athens),1995-2012
25 22

20

16 15 13 13 10
5

16

13 14 13

11 12 9

5

8

6

4

4

10 7

0

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

Number
Rates are per 100,000 population Source: GA TB surveillance database

Rate

35

36