2013 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 Acknowledgments: We thank the County Health Department staff, District Health Office TB coordinators, and state TB epidemiology and surveillance staff that collected, reported and analyzed the data used in this annual 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: RoseMarie.Sales@dph.ga.gov Suggested citation: Georgia Department of Public Health, 2013 Georgia Tuberculosis Report, Atlanta, Georgia, October 2014. 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.................................................18 Graphs: Tuberculosis Morbidity Trends by Health District, 1995-2010......26 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 339 new tuberculosis (TB) cases in 2013. This represents a 5.6% decrease from 359 TB cases reported in 2012. TB case numbers have decreased 63% since 1991 when the peak of a resurgent period of tuberculosis occurred in Georgia (Figure 1). The TB case rate in Georgia decreased from 3.6 cases per 100,000 population during 2012 to 3.4 cases per 100,000 in 2013, slightly higher than the U.S. TB case rate in 2013 of 3.0 cases per 100,000 (Figure 2). In 2013, Georgia had the fourth highest number of TB cases and the seventh highest TB case rate among the 50 states of the U.S. Geographic Distribution Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area reported the highest number of TB cases in 2013: DeKalb (79 cases), Fulton (49), Gwinnett (48), and Cobb (19) (Table 1). These four counties accounted for 58% of TB cases reported in Georgia in 2013. 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 2013 (11.1 per 100,000), followed by Fulton (5.0 per 100,000) and Gwinnett (4.6 per 100,000). Sex and Age Distribution In 2013, TB in Georgia occurred predominantly among males (227 cases, 67%), compared to females (112, 33%); while the highest proportion of TB cases by age group occurred among persons 25-44 years old (123 cases, 36%) (Figure 5). The highest TB case rate by age group was among persons 25-44 and 45-64 years old (4.5 per 100,000) while the lowest was among children 5-14 years old (1.2 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 1.6 per 100,000 in 2012 to 1.5 per 100,000 in Georgia during 2013. Race/Ethnicity Distribution and TB Disparities TB disproportionately affects racial/ethnic minorities in Georgia. In 2013, nonHispanic blacks, Asians and Hispanics, accounted for 51%, 21% and 17% of TB cases in Georgia respectively, but only represented 30.5%, 3.6% and 9.2% of Georgia's population respectively (Figure 7). Non-Hispanic whites constituted 11% of TB cases in 2013. The highest TB case rate among race/ethnic groups was among Asians (19.5 per 100,000), followed by Hispanics (6.2 per 100,000) and non-Hispanic blacks (5.5 per 100,000) (Figure 8). The black non-Hispanic TB case rate in 2013 represents an 82% 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 8 times higher than the white nonHispanic TB case rate (0.7 per 100,000) in Georgia during 2013 (Figure 9). 4 High-Risk Populations Foreign-Born For the first time since 1993, when expanded TB surveillance in the U.S. started, TB cases among persons born outside of the United States accounted for the majority of TB cases in Georgia - 51% in 2013 compared to 5% in 1993. Most foreign-born TB cases reported in 2013 came from Mexico (18%), India (14%), and Ethiopia (10%) countries where TB is an endemic disease (Figures 10-11). Among 173 foreign-born cases, 65 (38%) were diagnosed in the first five years of their arrival in the U.S. In 2013, four Health Districts reported 72% of the total number of foreign-born TB cases in Georgia: DeKalb (57 cases), Gwinnett (41), Fulton (14) and Cobb (13). Among these Health Districts, foreign-born TB cases accounted for more than half of the TB cases in Gwinnett (85%), DeKalb (72%), and Cobb (68%). 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 311 TB cases in Georgia with known HIV status in 2013, 13% were HIV-positive compared to 12% in 2012 (Figure 12). Among 39 HIV co-infected TB cases in 2013, 85% were non-Hispanic blacks, 74% were male and 54% were 25-44 years old. HIV status was reported in 92% of TB cases in 2013 compared to 93% in 2012. In the high-risk age group of adults 25-44 years of age, the percentage of TB cases for which HIV was reported was 97% in 2012 and 2013. Among 28 TB cases whose HIV status was not reported, HIV testing was not offered to 15 cases (54%), nine (32%) refused testing, and the HIV test result was unknown in four cases (14%). The highest number and proportion of TB cases by age group that were not offered the HIV test were among children 0-14 years old (9 cases, 60%). 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 2013, 26 (8%) TB cases in Georgia were homeless, 10 (3%) were residents of correctional facilities, and 2 (1%) were residents of long-term care facilities. Of the 10 TB cases incarcerated in correctional facilities, four (40%) were inmates in state prisons, four (40%) in county jails, and two (20%) were in the Immigration and Custom Enforcement Detention Center in Stewart County. 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 48 (14%) of TB cases in 2013 (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 2013, children younger than 15 years old comprised 8% of Georgia TB cases; 10 cases (1.5 per 100,000) were reported in children younger than 5 years old, 17 cases (1.2 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 2013, 45 children younger than five years old were reported to have LTBI in Georgia; 27 were identified by TB screening in pediatric clinics, and 18 from contact investigations. Public health staff identified the source case of the child's infection in 24 (53%) of these children. Drug Resistance Among 236 culture-positive TB cases in Georgia during 2013, 100% were tested for initial drug susceptibility to the three first-line anti-TB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 224 tested isolates from Georgia cases with no previous history of TB, 19 (8.5%) had primary resistance to INH, five (2.2%) to RIF, and none (0%) to EMB (Table 4). Two (0.9%) cases in 2013 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 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 2013, 78% of all Georgia TB cases had pulmonary 6 TB, 55% had sputum cultures that were positive for Mycobacterium tuberculosis, 34% were sputum AFB smear-positive, and 19% 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 2013, 194 (57%) of the 339 TB cases in Georgia were reported initially by a hospital. Ten hospitals in Georgia reported five or more TB cases in 2013: Grady Memorial Hospital (35 cases), DeKalb Medical Center (12 cases), Northside Hospital (11 cases), Gwinnett Medical Center (10 cases), Phoebe Putney Memorial Hospital (8 cases), Medical Center of Central Georgia (6 cases), and Atlanta Medical Center, Children's Healthcare of Atlanta at Scottish Rite, Northside Hospital, and Wellstar Kennestone Hospital reported (5 cases) each. These ten hospitals accounted for more than half of all patients hospitalized for TB in Georgia in 2013. Among TB cases with available data on type of outpatient healthcare provider, county health departments provided case management for 85% of all Georgia TB cases, 10% of cases were treated by health department and private physician, correctional facilities treated 1%, 3% of cases were cared for solely by a private physician and only 1% 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 289 Georgia TB cases reported in 2013 with available case completion data, 88% received TB treatment entirely by DOT, 8% were treated by a combination of DOT and self-administered therapy, and 3% self-administered their medications for the entire duration of their treatment. TB Mortality Twenty persons died of TB in Georgia in 2012, the most recent year with available mortality statistics. The age-adjusted TB mortality rate in 2012 was 0.2 per 100,000. 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 7 asymptomatic and have a normal chest radiology exam. They are not contagious but have a 10% chance of developing TB disease later in life if they do not receive treatment for LTBI. Among 5,173 identified contacts of all Georgia TB cases reported in 2012 (the most recent year with completed contact investigation data), 3,814 (73%) were completely evaluated for TB disease and LTBI. Of the completely evaluated contacts, 908 (24%) had LTBI and 29 (0.8%) had TB disease. Among the 908 contacts with LTBI, 574 (71%) started LTBI treatment and among these contacts who started LTBI treatment, 369 (64%) completed LTBI treatment, 76 (13%) chose to stop LTBI treatment on their own, 49 (8%) were lost to follow-up, 34 (6%) had adverse side-effects, 14 (2%) stopped due to a provider's decision, 10 (2%) moved, 3 (0.5%) developed active TB, and 19 (3%) had missing data for the reason for stopping 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 291 TB cases reported in 2012 that were eligible to complete TB treatment within 12 months, 275 (94.5%) completed treatment within 12 months; 7 (2.4%) completed treatment after 12 months, 4 (1.4%) were lost to follow-up, 3 (1%) had "Other" cited as the reason for not completing treatment, 1 (0.3%) refused treatment, and 1 (0.3%) had an adverse reaction to TB medications (Table 6, Figure 15). Objective 2: By 2015, 100% of TB cases with sputum smears that are positive for acidfast bacillus (AFB) will have contacts identified. In 2012, all TB patients with positive AFB sputum smears had contacts elicited. 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 3,523 contacts to AFB sputum smear positive (SSP) patients in 2012, 2,490 (71%) were completely evaluated (Table 7). Among 835 contacts that were not completely evaluated and had available data on reason for an incomplete evaluation, 649 (78%) refused evaluation or were uncooperative, 139 (17%) were lost to follow-up, 27 (3%) moved, 11 (1%) were still being follow-up, 10 (1%) had "Other" selected as the reason for incomplete evaluation, and 1 (.1%) died. 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. 8 Among 445 infected contacts of SSP TB patients started on LTBI treatment in 2012 with data on treatment completion, 287 (66%) completed treatment, 60 (14%) chose to stop treatment on their own, 37 (8%) were lost to follow-up, 29 (7%) stopped treatment due to adverse side effects, 11 (2%) stopped treatment due to a provider's decision, 8 (2%) moved, 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, 2012-2013 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 Augusta State Med Prison (ASMP) - ASMP only Cook Coweta Crawford Crisp 2012 Number of TB Case TB Cases Rate <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 -- 2013 Number of TB Case TB Cases Rate < 5 -- < 5 -- 0 0 0 0 < 5 -- 0 0 < 5 -- < 5 -- 0 0 < 5 -- 10 6.5 < 5 -- 0 0 0 0 0 0 < 5 -- < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- < 5 -- 0 0 0 0 < 5 -- 0 0 9 3.4 < 5 -- 17 2.4 0 0 0 0 <5 -- <5 -- 6 na <5 na 0 0 < 5 -- <5 -- < 5 -- 0 0 0 0 <5 -- < 5 -- 10 COUNTY Dade Dawson Decatur DeKalb Dodge Dooly Dougherty 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 2012 Number of TB Case TB Cases Rate 0 0 0 0 0 0 81 11.5 0 0 5 34.9 9 9.5 <5 -- 0 0 0 0 <5 -- <5 -- <5 -- <5 -- 0 0 <5 -- <5 -- 0 0 0 0 54 5.5 0 0 0 0 <5 -- <5 -- <5 -- 0 0 29 3.4 <5 -- <5 -- 0 0 <5 -- 0 0 0 0 0 0 <5 -- <5 -- 0 0 <5 -- <5 -- 0 0 0 0 0 0 0 0 2013 Number of TB Case TB Cases Rate 0 0 < 5 -- < 5 -- 79 11.1 < 5 -- 0 0 6 6.5 < 5 -- 0 0 0 0 < 5 -- 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- < 5 -- 0 0 49 5.0 < 5 -- 0 0 < 5 -- 0 0 0 0 0 0 45 5.2 < 5 -- 7 3.7 0 0 < 5 -- 0 0 < 5 -- 0 0 < 5 -- < 5 -- 0 0 < 5 -- 0 0 0 0 0 0 0 0 0 0 11 COUNTY Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether 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 2012 Number of TB Case TB Cases Rate 0 0 0 0 0 0 <5 -- <5 -- <5 -- 0 0 <5 -- 5 4.4 <5 -- <5 -- <5 -- 0 0 0 0 <5 -- <5 -- 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 -- 2013 Number of TB Case TB Cases Rate 0 0 0 0 0 0 < 5 -- < 5 -- < 5 -- 0 0 0 0 6 5.3 < 5 -- < 5 -- 0 0 0 0 0 0 0 0 0 0 0 0 6 26.0 0 0 0 0 0 0 < 5 -- < 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 0 0 10 5.0 < 5 -- 0 0 0 0 0 0 < 5 -- 12 COUNTY 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 Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth GEORGIA 2012 Number of TB Case TB Cases Rate 5 19.3 2013 Number of TB Case TB Cases Rate 0 0 0 0 0 0 5 na <5 na <5 -- 0 0 0 0 0 0 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 <5 -- 0 0 0 0 < 5 -- <5 -- < 5 -- <5 -- < 5 -- 0 0 < 5 -- 0 0 0 0 6 8.8 < 5 -- 0 0 0 0 0 0 0 0 0 0 < 5 -- <5 -- 0 0 <5 -- < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 < 5 -- 0 0 0 0 <5 -- 0 0 <5 -- 0 0 0 0 0 0 <5 -- 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 0 0 <5 -- < 5 -- 359 3.6 339 3.4 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. 13 Table 2. Number of TB Cases and TB Case Rates* per 100,000 population by Health District, Georgia, 2012-2013 Health District 2012 2013 Number of TB Cases TB Case Rate Number of TB Cases 1.1 Rome 10 1.6 13 1.2 Dalton 6 1.3 4 2.0 Gainesville 9 1.4 17 3.1 Cobb 17 2.0 19 3.2 Fulton 54 5.5 49 3.3 Clayton 13 4.9 9 3.4 Lawrenceville 31 3.0 48 3.5 DeKalb 81 11.5 79 4.0 LaGrange 13 1.6 6 5.1 Dublin 1 0.7 3 5.2 Macon 9 1.7 13 6.0 Augusta (excludes ASMP) 14 3.0 20 ASMP only 6 na 2 7.0 Columbus excludes SDC 20 5.3 6 SDC only 5 na 2 8.1 Valdosta 12 4.7 9 8.2 Albany 20 5.6 16 9.1 Coastal 18 3.1 9 9.2 Waycross 10 2.7 10 10 Athens 10 2.7 5 Total 359 3.6 339 TB Case Rate 2.0 0.9 2.6 2.2 5.0 3.4 4.6 11.1 0.7 2.0 2.5 4.2 na 1.6 na 3.5 4.5 1.5 2.7 1.1 3.4 Table 3. Percentage of TB Cases with Risk Factors for TB by Health District Georgia, 2013 HEALTH Foreign- HIV Homeless Inmate Nursing DISTRICT born % Infected % % % Home % 1.1 Rome 8 10 8 0 8 1.2 Dalton 75 0 0 0 0 2.0 Gainesville 59 0 0 0 6 3.1 Cobb 68 16 0 0 0 3.2 Fulton 29 16 27 4 0 3.3 Clayton 56 0 0 0 0 3.4 Lawrenceville 85 7 2 0 0 3.5 DeKalb 72 17 3 3 0 4.0 LaGrange 17 25 0 0 0 5.1 Dublin 33 0 0 0 0 5.2 Macon 46 10 15 0 0 6.0 Augusta 27 5 15 0 0 ASMP only 0 50 0 100 0 7.0 Columbus 33 25 0 0 0 SDC only 100 0 0 100 0 8.1 Valdosta 11 0 0 0 0 8.2 Albany 19 38 6 13 0 9.1 Coastal 33 0 11 0 0 9.2 Waycross 40 0 10 0 0 10 Athens 20 0 20 0 0 Georgia 51 12 8 3 1 Substance Abuse % 0 25 6 5 20 11 11 6 0 0 8 10 100 33 0 22 50 20 20 40 14 14 Table 4. Primary Resistance to First-line Anti-TB Medications by Health District Georgia, 2013 TB Drug Isoniazid Rifampin Ethambutol HEALTH DISTRICT No. % No. % No. % 1.1 Rome 0 0 0 0 0 0 1.2 Dalton 1 25 0 0 0 0 2.0 Gainesville 2 13 0 0 0 0 3.1 Cobb 3 18 0 0 0 0 3.2 Fulton 3 9 0 0 0 0 3.3 Clayton 0 0 0 0 0 0 3.4 Lawrenceville 4 13 1 3 0 0 3.5 DeKalb 4 9 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 0 0 0 0 0 0 6.0 Augusta & ASMP 3 30 2 20 0 0 7.0 Columbus & SDC 0 0 0 0 0 0 8.1 Valdosta 0 0 0 0 0 0 8.2 Albany 0 0 0 0 0 0 9.1 Coastal 0 0 1 14 0 0 9.2 Waycross 0 0 1 14 0 0 10 Athens 0 0 0 0 0 0 Georgia Total 19 8 5 2 0 0 Table 5. Completion of TB Treatment (Tx) by Health District, Georgia, 2011-2012 HEALTH DISTRICT 2011 2012 No. Cases that Completed % No. Cases that Completed % Tx/No. Cases Started Tx* Tx/No. Cases Started Tx* 1.1 Rome 3/3 100 10/10 100 1.2 Dalton 5/6 83 3/3 100 2.0 Gainesville 10/10 100 8/8 100 3.1 Cobb 3.2 Fulton 17/17 100 13/14 93 39/39 100 48/49 98 3.3 Clayton 5/6 83 10/12 83 3.4 Lawrenceville 44/45 98 24/25 96 3.5 DeKalb 66/68 97 72/72 100 4.0 LaGrange 5.1 Dublin 7/7 100 11/11 100 3/3 100 1/1 100 5.2 Macon 11/12 92 7/8 88 6.0 Augusta 7/7 100 13/13 100 ASMP only 16/16 100 6/6 100 7.0 Columbus 6/6 100 13/14 93 SDC only* na na na na 8.1 Valdosta 8.2 Albany 9/9 100 10/11 91 12/12 100 18/18 100 9.1 Coastal 10/11 91 15/15 100 9.2 Waycross 9/11 82 9/10 90 10 Athens 6/6 100 9/9 100 Georgia Total 285/293 97 300/309 97 *Cases who died or who left the U.S. during TB treatment are excluded 15 Table 6. Timely Completion of TB Treatment (Tx) among TB cases eligible for 12-month TB Tx by Health District, Georgia, 2011-2012 HEALTH DISTRICT 2011 2012 No. Cases Completed Tx in % No. Cases Completed Tx in % 12 months/ No. Started Tx 12 months/ No. Started Tx 1.1 Rome 2/3 67 9/9 100 1.2 Dalton 5/6 83 3/3 100 2.0 Gainesville 9/10 90 7/7 100 3.1 Cobb 17/17 100 10/12 83 3.2 Fulton 37/38 97 44/46 96 3.3 Clayton 5/6 83 8/11 73 3.4 Lawrenceville 38/44 86 20/21 95 3.5 DeKalb 62/67 92 71/72 99 4.0 LaGrange 6/7 86 11/11 100 5.1 Dublin 1/3 33 1/1 100 5.2 Macon 11/11 100 4/6 67 6.0 Augusta ASMP only 7/7 100 13/16 81 13/13 100 5/5 100 7.0 Columbus only 8.1 Valdosta 6/6 100 6/9 67 12/13 92 10/11 91 8.2 Albany 11/12 92 17/17 100 9.1 Coastal 10/12 13/13 100 9.2 Waycross 8/10 80 9/10 90 10 Athens 6/6 100 8/9 89 Georgia Total 260/289 90 275/291 94 *Cases who died or who left the U.S. during TB treatment, rifampin-resistant cases, meningeal TB, TB of the bone or central nervous system, and children < 15 with miliary TB are excluded Table 7. Completely Evaluated Contacts of Sputum Smear Positive Cases by Health District, Georgia, 2011-2012 2011 2012 HEALTH DISTRICT No. Contacts Evaluated/ % No. Contacts Evaluated/ % No. Contacts Identified No. Contacts Identified 1.1 Rome 1.2 Dalton 2.0 Gainesville 3.1 Cobb 3.2 Fulton 3.3 Clayton 3.4 Lawrenceville 3.5 DeKalb 4.0 LaGrange 5.1 Dublin 5.2 Macon 6.0 Augusta 7.0 Columbus 8.1 Valdosta 8.2 Albany 9.1 Coastal 9.2 Waycross 10 Athens Georgia Total 32/34 94 70/95 74 35/46 76 42/51 82 36/48 75 48/97 50 24/30 80 22/27 85 324/348 93 217/257 84 27/29 93 50/68 73 640/959 67 154/191 81 559/641 87 650/776 84 55/64 86 106/171 62 236/329 72 15/17 88 75/88 85 172/224 77 263/287 92 563/1002 56 54/55 98 71/89 80 15/15 100 39/67 58 154/170 91 106/167 64 45/51 88 65/95 68 166/177 94 26/37 70 75/148 51 74/92 80 2815/3519 80 2490/3523 71 16 Table 8. Infected Contacts exposed to Sputum Smear Positive Cases started on LTBI Treatment by Health District, Georgia, 2011-2012 2011 2012 HEALTH DISTRICT No. Infected Contacts % No. Infected Contacts % on LTBI Treatment / on LTBI Treatment / No. Infected Contacts No. Infected Contacts 1.1 Rome 9/13 69 9/10 90 1.2 Dalton 6/8 75 11/13 85 2.0 Gainesville 14/17 82 13/13 100 3.1 Cobb 1/5 20 1/ 2 50 3.2 Fulton 45/65 69 43/55 78 3.3 Clayton 4/10 40 3/17 18 3.4 Lawrenceville 59/144 41 22/45 49 3.5 DeKalb 117/153 77 79/143 55 4.0 LaGrange 20/22 91 26/39 67 5.1 Dublin 13/21 62 5/8 62 5.2 Macon 17/26 65 1/14 7 6.0 Augusta 4/14 29 135/197 68 7.0 Columbus 23/32 72 15/19 79 8.1 Valdosta 1/1 100 18/23 78 8.2 Albany 37/57 65 16/25 64 9.1 Coastal 9/12 75 21/30 70 9.2 Waycross 34/42 81 4/4 100 10 Athens 12/16 75 23/26 88 Georgia Total 425/658 66 445/683 65 Table 9. LTBI Treatment Completion of Infected Contacts exposed to Sputum Smear Positive Cases by Health District, Georgia, 2011-2012 2011 2012 HEALTH No. Contacts that % No. Contacts that % DISTRICT Completed LTBI Completed LTBI Treatment Treatment / Contacts Treated / Contacts Treated 1.1 Rome 3/9 33 3/9 33 1.2 Dalton 5/6 83 6/11 55 2.0 Gainesville 10/14 71 6/13 46 3.1 Cobb 1/1 100 1/1 100 3.2 Fulton 29/45 64 35/43 93 3.3 Clayton 4/4 100 2/3 67 3.4 Lawrenceville 38/59 64 19/22 86 3.5 DeKalb 100/117 86 56/79 71 4.0 LaGrange 10/20 50 18/26 69 5.1 Dublin 9/13 69 2/5 40 5.2 Macon 13/17 76 1/2 50 6.0 Augusta 1 / 4 25 66/135 49 7.0 Columbus 18/23 78 10/15 67 8.1 Valdosta 1/1 100 15/18 83 8.2 Albany 25/37 68 14/16 88 9.1 Coastal 7/9 78 19/21 91 9.2 Waycross 18/34 53 4/4 100 10 Athens 9/12 75 10/23 44 Georgia Total 301/425 71 287/445 64 17 18 19 20 21 22 23 24 25 Tuberculosis Morbidity Trends by Health District Georgia, 1995-2013 TB Case Numbers and Rates District 1-1 (Rome),1995-2013 60 14 51 50 12 10 40 33 31 32 32 30 30 8 30 25 27 22 6 20 18 10 17 18 15 12 11 13 4 10 5 2 0 0 2013 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 26 27 28 29 30 31 32 33 34 35