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