2014 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, M.P.H. Program Director Antoine Perrymon, M.P.H. Epidemiologist Lauren DiMiceli, DrPH, M.S.P.H. 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. Further information on this report can be obtained by contacting: Antoine Perrymon, MPH Georgia Department of Public Health Tuberculosis Program Division of Health Protection 2 Peachtree St., NW, Atlanta, GA 30303 Phone: (404) 657-2634 E-mail: Antoine.Perrymon@dph.ga.gov Suggested citation: Georgia Department of Public Health, 2014 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 Treatment Completion............................................................7 TB Contact Investigations and Latent TB Infection..............................7 TB Genotyping........................................................................8 TB Outbreak among Homeless Persons............................................8 Tables: Morbidity Trends and Program Performance Indicators by Health District...................................................................................9 Figures: Descriptive Epidemiology.................................................17 Graphs: Tuberculosis Morbidity Trends by Health District, 1995-2014.......26 2 Tuberculosis Surveillance in Georgia Tuberculosis (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. Current Epidemiology of Tuberculosis in Georgia Georgia reported 335 new TB cases in 2014. This represents a 1.1% decrease from 339 TB cases reported in 2013. 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 3.4 cases per 100,000 population during 2013 to 3.3 cases per 100,000 in 2014, slightly higher than the U.S. TB case rate in 2014 of 3.0 cases per 100,000 (Figure 2). Georgia ranked fifth highest in the United States for the number of newly reported TB cases in 2014 and had the seventh highest TB case rate among the 50 reporting states. 3 Geographic Distribution Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area that reported the highest number of TB cases in 2014 accounted for 59% of TB cases in Georgia: Fulton (76 cases), DeKalb (60), Gwinnett (35), and Cobb (25) (Table 1). 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 2014 (8.3 per 100,000), followed by Fulton (7.6 per 100,000) and Columbus (4.8 per 100,000) (Table 2). Sex and Age Distribution In 2014, TB in Georgia occurred predominantly among males (66%), compared to females (34%); while the highest proportion of TB cases by age group occurred among persons 25-44 years old (36%) (Figure 5). The highest TB case rate by age group occurred among persons 65 years old or older (4.5 per 100,000) while the lowest case rate was among children 5-14 years old (0.8 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, increased from 1.5 per 100,000 in 2013 to 2.3 per 100,000 in Georgia during 2014. Race/Ethnicity Distribution and TB Disparities TB disproportionately affects racial/ethnic minorities in Georgia. In 2014, nonHispanic blacks, Asians and Hispanics, accounted for 47%, 22% and 17% of TB cases in Georgia respectively, but only represented 30.7%, 3.7% and 9.3% of Georgia's population respectively (Figure 7). Non-Hispanic whites constituted 14% of TB cases in 2014. The highest TB case rate among race/ethnic groups was among Asians (19.3 per 100,000), followed by Hispanics (6.2 per 100,000) and non-Hispanic blacks (5.1 per 100,000) (Figure 8). The black non-Hispanic TB case rate in 2014 represents an 83% decrease from the TB case rate in 1993 (30.6 per 100,000) in this population. The black non-Hispanic TB case rate, however, was still about six and a half times higher than the white non-Hispanic TB case rate (0.8 per 100,000) in Georgia during 2014 (Figure 9). High-Risk Populations Foreign-Born TB cases among persons born outside of the United States accounted for 45% of TB cases in Georgia in 2014 compared to 51% in 2013. Most foreign-born cases reported in 2014 came from Mexico (19%), Vietnam (16%), and India (10%) - countries where TB is an endemic disease (Figures 10-11). Among 150 foreign-born cases, 43 (29%) were diagnosed in the first five years of their arrival in the U.S. 4 In 2014, four Health Districts reported 67% of the total number of foreign-born TB cases in Georgia: DeKalb (37 cases), East Metro Atlanta (31), Fulton (18) and CobbDouglas (15). Among these Health Districts, foreign-born TB cases accounted for more than half of the TB cases in East Metro Atlanta (82%), DeKalb (62%), and Cobb-Douglas (60%). Foreign-born TB cases in the Fulton Health District accounted for 23% of reported TB cases. 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 2014, 37 (12%) were HIV-positive compared to 13% in 2013 (Figure 12). Among 37 HIV co-infected TB cases in 2014, 76% were non-Hispanic blacks, 78% were male and 54% were 25-44 years old. HIV status was reported in 93% of TB cases in Georgia in 2014 compared to 92% in 2013. In the high-risk age group of adults 25-44 years of age, 98% reporting of HIV was achieved in 2014. Among 24 TB cases whose HIV status was not reported in 2014, HIV testing was not offered to 14 cases, eight refused testing, and the HIV test result was unknown in two cases. Among the 14 TB cases who were not offered the HIV test, most were children 5 years old and younger (6 cases) and adults older than 70 years old (4 cases); two cases were 25-44 years old and two were in the 45-64 year old age group. 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. From 2013-2014, the number of TB cases who were homeless in Georgia increased 140% from 26 to 62 cases due mainly to a TB outbreak among residents of homeless shelters in Atlanta. In 2014, 9 (3%) TB cases were residents of correctional facilities, and 8 (2%) were residents of long-term care facilities. Of the nine TB cases incarcerated in correctional facilities, three (33%) were inmates in state prisons, three (33%) in county jails, and two (22%) were detainees at the Immigration and Custom Enforcement (ICE) Detention Center in Stewart County. 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 54 (16%) of TB cases in 2014 (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 5 children. In 2014, children younger than 15 years old comprised 8% of Georgia TB cases; 15 cases were reported in children younger than 5 years old, 12 cases were reported in children 5-14 years old. Two children in the 5-14 years old age group developed TB meningitis but completed TB treatment and survived. 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 2014, 42 children younger than five years old were reported to have LTBI in Georgia; Public health staff identified the source case of the child's infection in 14 (33%) of these children. Drug Resistance Among 244 culture-positive TB cases in Georgia during 2014, 100% were tested for initial drug susceptibility to the three first-line anti-TB medications: isoniazid (INH), rifampin (RIF), and ethambutol (EMB). Of 232 tested isolates from Georgia cases with no previous history of TB, 50 (22%) had primary resistance to INH, three (1%) to RIF, and one (0.4%) to EMB (Table 4). Three (0.9%) cases in 2014 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 22% 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 especially higher if their sputum smears are positive for acidfast bacilli (AFB) and their lungs have cavitary lesions as seen on chest radiography. In 2014, 83% of all Georgia TB cases had pulmonary TB, of who 45% were sputum AFB smear-positive and 25% 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 2014, 184 (55%) of the 335 TB cases in Georgia were reported initially by a hospital. Six hospitals in Georgia reported five or more TB cases in 2014 in SendSS: Grady Memorial Hospital (39 cases), Emory Midtown (12 cases), Gwinnett Hospital (7 cases), Emory University Hospital (6 cases), and the Medical Center of Central GA and Medical College of Georgia Hospital and Clinic reported 5 cases each. 6 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, 8% of cases were treated by health department and private physician, correctional facilities treated 0.7%, 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 285 Georgia TB cases reported in 2014 with available case completion data, 88% received TB treatment entirely by DOT, 10% were treated by a combination of DOT and self-administered therapy, and 1% self-administered their medications for the entire duration of their treatment. TB Mortality Fourteen persons died of TB in Georgia in 2013, the most recent year with available mortality statistics. The age-adjusted TB mortality rate in 2013 was 0.1 per 100,000. From 2009 to 2013, an average of 15 people died of TB in Georgia each year, with the highest number of deaths from TB reported in 2012 with 20 deaths. TB Treatment Completion TB treatment completion was achieved in 296 (98%) of 302 TB cases reported in 2013 who did not die or leave the United States during TB treatment. Of those who did not complete treatment, four moved to another state and were lost to follow-up and two stopped treatment due to adverse reactions to TB medications. Among 280 TB cases in 2013 that were eligible to complete TB treatment within 12 months, 261 (93%) completed treatment within that time frame (Figure 15). Of the 13 TB cases who took more than 12 months to complete treatment, seven had information in the surveillance database on the reason for their longer treatment duration: four had clinical indications for extending treatment, two were non-adherent and one had adverse reactions to the TB medications causing treatment interruptions. 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 evaluate recent contacts to a case for signs and symptoms suggestive of TB, 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. TB contacts are diagnosed with latent TB infection (LTBI) when they have a positive TST or IGRA but are asymptomatic and have a normal chest radiology exam. LTBI is not contagious but there is a 10% chance of developing TB disease later in life if LTBI is not treated. 7 Among 4,117 identified contacts of all Georgia TB cases reported in 2013 (the most recent year with completed contact investigation data), 3,156 (77%) were completely evaluated for TB. Of the contacts who completed their TB evaluation, 678 (22%) had LTBI and 12 (0.4%) had TB disease. Among the 678 contacts with LTBI, 452 (67%) started LTBI treatment. Among the 452 infected contacts who started LTBI treatment, 338 (75%) completed LTBI treatment (Figure 16), 48 (11%) chose to stop LTBI treatment, 32 (7%) were lost to follow-up, 13 (3%) had adverse side-effects, 6 (1%) stopped treatment due to a provider's decision, 2 (0.4%) moved, 1 (0.2%) developed active TB, and information on the reason for stopping treatment was missing in 12 (4%) contacts. TB Genotyping TB genotype clusters, which are comprised of two or more TB cases with identical genotypes, are routinely analyzed to identify recent TB transmission, to describe risk factors for recent transmission, to identify possible sources of transmission and to determine ways to stop transmission. From 2010-2014, 100 small (2-3 cases), 25 medium (4-9 cases), and two large ( 10 cases) genotype clusters were identified (Figure 17). During this period, over 60% of the clustered TB cases were part of small genotype clusters (Figures 18). A large genotype cluster in 2014 included 27 TB cases and represented a TB outbreak among residents of several homeless shelters in metropolitan Atlanta. Of these 27 cases, 100% were isoniazid-resistant (INH-R), 93% reported a history of homelessness, 41% had HIV infection and 37% reported a history of substance abuse. One other large genotype cluster that occurred in 2012 included 10 TB cases reported in 3 counties; of which 100% were INH-R, 50% had a history of illicit drug abuse, 40% had a history of alcohol abuse and 30% were homeless. TB Outbreak among Homeless Persons The state TB program, Fulton County and CDC are providing resources to control the aforementioned TB outbreak occurring among homeless persons in Atlanta. The Fulton County TB Program is conducting contact tracing, performing weekly screenings to find active cases and identify latent infection, and providing treatment to cases and infected contacts. The state TB program is providing temporary housing for the homeless TB cases through a contract with the American Lung Association and assisting with shelter screening through a contract with Mercy Care. A TB Task Force which includes homeless service providers, state and county TB program representatives and Emory University volunteers, developed guidelines and administrative practices to prevent and control TB in homeless shelters. A memorandum of agreement between Fulton County and shelter administrators was signed to implement the guidelines which include a requirement for TB clearance by a health clinic before admission for overnight stay at a homeless shelter and TB symptom screening of clients admitted to a shelter. 8 Table 1. Number of TB Cases and TB Case Rates* per 100,000 population by County, Georgia, 2013-2014 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 2013 Number of Case Rate cases < 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 na < 5 -- < 5 -- 0 0 < 5 -- 2014 Number of Case Rate cases 0 0 0 0 < 5 -- < 5 -- 0 0 0 0 <5 -- 3 2.9 <5 -- <5 -- 6 3.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0.9 < 5 -- 0 0 8 2.8 0 0 < 5 -- 2 0.9 0 0 0 0 10 3.7 0 0 25 3.4 0 0 < 5 -- 0 0 <5 na 0 0 2 1.5 0 0 < 5 -- 9 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 2013 Number of Case Rate cases 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 2014 Number of Case Rate cases < 5 -- 0 0 0 0 60 8.3 0 0 0 0 5 5.4 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 < 5 -- 0 0 3 1.5 0 0 76 7.6 < 5 -- 0 0 < 5 0 < 5 0 < 5 0 0 0 35 4.0 0 0 9 4.7 < 5 -- < 5 -- 0 0 0 0 0 0 0 0 2 1.3 0 0 < 5 -- < 5 -- 0 0 0 0 0 0 0 0 10 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 2013 Number of Case Rate cases 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 -- 2014 Number of cases Case Rate < 5 -- 0 0 0 0 < 5 -- 0 0 < 5 -- 0 0 < 5 -- 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 8 4.0 2 1.9 0 0 0 0 1 0.7 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 3.5 < 5 -- < 5 -- 0 0 0 0 0 0 11 COUNTY Stephens Stewart (excludes Immigration & Customs Enforcement (ICE) detainees) ICE detainees 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 2013 Number of Case Rate cases 0 0 2014 Number of Case Rate cases < 5 -- 0 0 <5 -- <5 na <5 -- 0 0 < 5 -- 0 0 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 < 5 -- 0 0 < 5 -- < 5 -- < 5 -- 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- < 5 -- 0 0 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- < 5 -- < 5 -- 0 0 0 0 0 0 0 0 0 0 0 0 < 5 -- 0 0 0 0 0 0 0 0 < 5 -- 4 3.9 0 0 0 0 < 5 -- 0 0 0 0 0 0 < 5 -- 0 0 339 3.4 335 3.3 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. 12 Table 2. Number of TB Cases and TB Case Rates* per 100,000 population by Health District, Georgia, 2013-2014 Health District 2013 2014 Number Case rate Number Case rate of Cases of Cases 1.1 Rome 13 2.0 12 1.9 1.2 Dalton 4 0.9 7 1.5 2.0 Gainesville 17 2.6 13 2.0 3.1 Cobb 19 2.2 25 2.9 3.2 Fulton 49 5.0 76 7.6 3.3 Clayton 9 3.4 10 3.7 3.4 Lawrenceville 48 4.6 38 3.6 3.5 DeKalb 79 11.1 60 8.3 4.0 LaGrange 6 0.7 7 0.7 5.1 Dublin 3 2.0 1 0.7 5.2 Macon 13 2.5 11 2.1 6.0 Augusta 20 4.2 7 1.5 (excludes ASMP) 7.0 Columbus 6 1.6 18 4.8 (excludes ICE) 8.1 Valdosta 9 3.5 5 2.0 8.2 Albany 16 4.5 16 4.5 9.1 Coastal 9 1.5 18 3.0 9.2 Waycross 10 2.7 3 0.8 10 Athens 5 1.1 3 0.6 Total 339 3.4 335 3.3 Table 3. Percentage of TB Cases with Risk Factors for TB by Health District Georgia, 2014 HEALTH Foreign- HIV Homeless Inmate Nursing DISTRICT born % Infected % % % Home % 1.1 Rome 50 0 0 0 0 1.2 Dalton 29 14 29 0 0 2.0 Gainesville 31 0 0 0 0 3.1 Cobb 60 0 4 4 0 3.2 Fulton 24 28 57 1 3 3.3 Clayton 40 0 20 0 10 3.4 Lawrenceville 82 5 0 0 3 3.5 DeKalb 62 17 13 3 2 4.0 LaGrange 29 14 14 0 0 5.1 Dublin 0 100 0 0 0 5.2 Macon 27 0 0 0 0 6.0 Augusta 29 0 0 0 0 ASMP only 33 0 0 100 0 7.0 Columbus 44 0 6 0 11 ICE only 100 0 0 100 0 8.1 Valdosta 60 0 40 0 0 8.2 Albany 25 6 0 0 0 9.1 Coastal 28 0 11 0 6 9.2 Waycross 33 0 0 0 0 10 Athens 67 0 0 0 0 Georgia 45 12 19 3 2 Substance Abuse % 0 57 15 12 30 30 0 3 0 0 0 0 0 28 0 20 44 11 0 0 16 13 Table 4. Primary Resistance to First-line Anti-TB Medications by Health District Georgia, 2014 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 0 0 0 0 0 0 3.1 Cobb 2 18 1 9 0 0 3.2 Fulton 29 52 0 0 0 0 3.3 Clayton 1 12 0 0 0 0 3.4 Lawrenceville 4 14 1 3 1 3 3.5 DeKalb 6 17 1 3 0 0 4.0 LaGrange 0 0 0 0 0 0 5.1 Dublin 0 0 0 0 0 0 5.2 Macon 1 17 0 0 0 0 6.0 Augusta & ASMP 4 67 0 0 0 0 7.0 Columbus & ICE 1 6 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 1 6 0 0 0 0 9.2 Waycross 0 0 0 0 0 0 10 Athens 0 0 0 0 0 0 Georgia Total 50 22 3 1 1 0.4 Table 5. Completion of TB Treatment by Health District, Georgia, 2012-2013 HEALTH DISTRICT 2012 2013 No. Cases that Completed % No. Cases that Completed % Tx/No. Cases Started Tx* Tx/No. Cases Started Tx* 1.1 Rome 1.2 Dalton 10/10 100 10/10 100 3/3 100 4/4 100 2.0 Gainesville 8/8 100 13/14 93 3.1 Cobb 13/14 93 17/17 100 3.2 Fulton 48/49 98 44/44 100 3.3 Clayton 10/12 83 9/9 100 3.4 Lawrenceville 24/25 96 40/41 98 3.5 DeKalb 72/72 100 71/72 99 4.0 LaGrange 11/11 100 6/6 100 5.1 Dublin 5.2 Macon 1/1 100 2/2 100 7/8 88 9/11 82 6.0 Augusta 13/13 100 20/20 100 ASMP only 6/6 100 2/2 100 7.0 Columbus 13/14 93 3/4 75 (excludes ICE) 8.1 Valdosta 10/11 91 9/9 100 8.2 Albany 9.1 Coastal 18/18 100 15/15 100 15/15 100 8/8 100 9.2 Waycross 9/10 90 9/9 100 10 Athens 9/9 100 5/5 100 Georgia Total 300/309 97 296/302 98 *Cases who died or who left the U.S. during TB treatment are excluded 14 Table 6. Timely Completion of TB Treatment (Tx) among TB cases eligible for 12-month TB Treatment by Health District, Georgia, 2012-2013 HEALTH DISTRICT 2012 2013 No. Cases Completed Tx in % No. Cases Completed Tx in % 12 months/ No. Started Tx 12 months/ No. Started Tx 1.1 Rome 9/9 100 8/8 100 1.2 Dalton 3/3 100 3/4 75 2.0 Gainesville 7/7 100 11/12 92 3.1 Cobb 10/12 83 13/14 93 3.2 Fulton 44/46 96 42/43 98 3.3 Clayton 8/11 73 8/8 100 3.4 Lawrenceville 20/21 95 37/38 97 3.5 DeKalb 71/72 99 67/69 97 4.0 LaGrange 11/11 100 5/6 67 5.1 Dublin 1/1 100 1/1 100 5.2 Macon 4/6 67 7/10 70 6.0 Augusta ASMP only 13/13 100 5/5 100 14/17 82 2/2 100 7.0 Columbus only 12/13 92 2/4 50 8.1 Valdosta 10/11 91 9/9 100 8.2 Albany 17/17 100 14/14 100 9.1 Coastal 13/13 100 6/7 86 9.2 Waycross 9/10 90 8/8 100 10 Athens 8/9 89 5/5 100 Georgia Total 275/291 94 261/280 93 *Cases who died or who left the U.S. during TB treatment, rifampin-resistant cases, meningeal TB, TB of the bone, joint 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, 2012-2013 2012 2013 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 70/95 74 18/24 75 42/51 82 18/22 81 48/97 50 120/145 83 22/27 85 60/72 83 217/257 84 226/447 51 50/68 73 65/71 92 154/191 81 187/230 81 650/776 84 122/212 58 106/171 62 4/6 67 15/17 88 14/14 100 172/224 77 37/60 62 563/1002 56 164/180 91 71/89 80 11/16 69 39/67 58 24/41 59 106/167 64 12/12 100 65/95 68 38/42 90 26/37 70 25/40 62 74/92 80 11/17 61 2490/3523 71 1162/1662 70 15 Table 8. Infected Contacts exposed to Sputum Smear Positive Cases started on LTBI Treatment by Health District, Georgia, 2012-2013 2012 2013 HEALTH DISTRICT No. Infected Contacts % No. Infected Contacts % on LTBI Treatment / on LTBI Treatment / No. Infected Contacts No. Infected Contacts 1.1 Rome 9/10 90 5/7 71 1.2 Dalton 11/13 85 6/6 100 2.0 Gainesville 13/13 100 53/53 100 3.1 Cobb 1/ 2 50 11/16 69 3.2 Fulton 43/55 78 23/55 42 3.3 Clayton 3/17 18 10/15 67 3.4 Lawrenceville 22/45 49 46/72 64 3.5 DeKalb 79/143 55 37/59 63 4.0 LaGrange 26/39 67 2/2 100 5.1 Dublin 5/8 62 6/7 86 5.2 Macon 1/14 7 2/4 50 6.0 Augusta 135/197 68 9/17 53 7.0 Columbus 15/19 79 3/4 75 8.1 Valdosta 18/23 78 6/9 67 8.2 Albany 16/25 64 4/4 100 9.1 Coastal 21/30 70 6/6 100 9.2 Waycross 4/4 100 4/11 36 10 Athens 23/26 88 7/7 100 Georgia Total 445/683 65 240/354 68 Table 9. LTBI Treatment Completion of Infected Contacts exposed to Sputum Smear Positive Cases by Health District, Georgia, 2012-2013 2012 2013 HEALTH No. Contacts that % No. Contacts that % DISTRICT Completed LTBI Completed LTBI Treatment Treatment / Contacts Treated / Contacts Treated 1.1 Rome 3/9 33 2/5 40 1.2 Dalton 6/11 55 5/6 83 2.0 Gainesville 6/13 46 42/53 79 3.1 Cobb 1/1 100 8/11 72 3.2 Fulton 35/43 93 13/23 56 3.3 Clayton 2/3 67 9/10 90 3.4 Lawrenceville 19/22 86 39/46 85 3.5 DeKalb 56/79 71 27/37 73 4.0 LaGrange 18/26 69 1/2 50 5.1 Dublin 2/5 40 3/6 50 5.2 Macon 1/2 50 1/1 50 6.0 Augusta 66/135 49 5/9 56 7.0 Columbus 10/15 67 3/3 100 8.1 Valdosta 15/18 83 1/6 17 8.2 Albany 14/16 88 4/4 100 9.1 Coastal 19/21 91 5/6 83 9.2 Waycross 4/4 100 3/4 75 10 Athens 10/23 44 2/7 29 Georgia Total 287/445 64 173/240 72 16 17 18 19 20 21 22 23 24 Frequency Figure 17. TB Genotype Clusters in Georgia, 2010-2014 30 25 20 2-3 cases 15 4-9 cases 10 cases 10 5 0 2010 2011 2012 2013 2014 Figure 18. Proportion of Small, Medium, and Large TB Genotype Clusters, Georgia, 2010-2014 100% 90% 80% 70% 60% 10 cases 50% 4-9 cases 40% 2-3 cases 30% 20% 10% 0% 2010 2011 2012 2013 2014 25 Tuberculosis Morbidity Trends by Health District Georgia, 1995-2014 26 TB Case Numbers and Rates District 1-1 (Rome),1995-2014 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 10 13 12 4 5 2 0 0 Number Rate Rates are per 100,000 population Source: GA TB surveillance database 27 28 29 30 31 32 33 34 35 36