2015 Georgia tuberculosis report

2015 GEORGIA TUBERCULOSIS
REPORT

2015 Georgia Tuberculosis Report
Georgia Department of Public Health.....................Brenda Fitzgerald, M.D. Commissioner
Division of Health Protection.....................................J. Patrick 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, 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: 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, 2015 Georgia Tuberculosis Report, Atlanta, Georgia, November 2016
2015 GEORGIA TUBERCULOSIS REPORT 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.........................................................7 Initial Diagnosis, Health Provider Data, And Directly Observed Therapy....................................................7 TB Mortality...........................................................................7 TB Treatment Outcomes..............................................................8 TB Contact Investigations and Latent TB Infection...............................8 TB Genotype Clusters.................................................................8 Tables: Morbidity Trends and Program Performance Indicators by Health District..................................................................................11 Figures: Descriptive Epidemiology.................................................20 Graphs: Tuberculosis Morbidity Trends by Health District, 1995-2015...... 29
2015 GEORGIA TUBERCULOSIS REPORT 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, screening persons 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.
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 TB infection rates. The data are used 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 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.
TB Case Definition for Public Health Surveillance
Clinical case definition A case that meets all of the following criteria:
A positive tuberculin skin test or positive interferon gamma release assay for M. tuberculosis
Signs and symptoms compatible with TB (abnormal chest imaging study or clinical evidence of current disease)
Treatment with two or more anti-TB medications A completed diagnostic evaluation Laboratory criteria for diagnosis Isolation of M. tuberculosis complex on a culture from a clinical specimen, or Demonstration of M. tuberculosis complex from a clinical specimen by nucleic
acid amplification test Confirmed case: A case that meets the clinical case definition or is laboratory confirmed
2015 GEORGIA TUBERCULOSIS REPORT 3

Current Epidemiology of Tuberculosis in Georgia
Georgia reported 321 new tuberculosis (TB) cases in 2015. This represents a 4% decrease from 334 TB cases reported in 2014. TB case numbers have decreased 65% since 1991 when the peak of a resurgent period of tuberculosis occurred in Georgia (Figure 1). The TB case rate in Georgia decreased from 3.3 cases per 100,000 population during 2014 to 3.1 cases per 100,000 in 2015, slightly higher than the U.S. TB case rate in 2015 of 3.0 cases per 100,000 (Figure 2). Georgia had the fifth highest number of new TB cases and ranked eighth highest for TB case rates among the 50 reporting states in the United States in 2015.
Geographic Distribution
Among the 159 counties in Georgia, four counties in the metropolitan Atlanta area and their corresponding Health Districts reported the highest number of TB cases in 2015: Fulton (63), DeKalb (58 cases), Gwinnett (29), and Cobb (26) (Table 1, Figure 1). These four counties accounted for 55% of TB cases reported in Georgia in 2015.
Among Georgia's 18 Health Districts, which has oversight responsibility for public health in the state's 159 counties, DeKalb Health District had the highest TB case rate in 2015 (7.9 per 100,000), followed by Fulton (6.2 per 100,000) and Columbus (4.5 per 100,000) (Table 2, Figure 2).
Sex and Age Distribution
In 2015, TB in Georgia occurred predominantly among males (201 cases, 63%), compared to females (120, 37%). The highest proportion of TB cases by age group occurred among persons 45-64 years old (122 cases, 38%), which is a change from 2014 when the highest proportion of TB cases occurred among 25-44 year olds (120 cases, 36%). Among the 45-64 age group, (87 cases, 71%) were male and (35 cases, 29%) were female (Figure 5). This age group also had the highest TB case rate (4.7 per 100,000) while the lowest was among children 5-14 years old (0.2 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 2.3 per 100,000 in 2014 to 2.1 per 100,000 in Georgia during 2015.
Race/Ethnicity Distribution and TB Disparities
TB disproportionately affects racial/ethnic minorities in Georgia. In 2015, non-Hispanic blacks, Asians and Hispanics, accounted for 48%, 25% and 13% of TB cases in Georgia respectively, but only represented 32%, 4% and 10% of Georgia's population respectively (Figure 7). The highest TB case rate among race/ethnic groups was among Asians (20.2 per 100,000), followed by non-Hispanic blacks (5.0 per 100,000) and Hispanics (4.1 per 100,000) (Figure 8). The Hispanic case rate decreased 34% from 6.2 per 100,000 in 2014, which is the largest decrease in over five years. The black nonHispanic TB case rate in 2015 represents an 84% decrease from the TB case rate in 1993
2015 GEORGIA TUBERCULOSIS REPORT 4

(30.6 per 100,000) in this population. The black non-Hispanic TB case rate, however, was still about six times higher than the white non-Hispanic TB case rate (0.8 per 100,000) in Georgia during 2015 (Figure 9).
High-Risk Populations
Foreign-Born
TB cases among persons born outside of the United States accounted for 46% of TB cases in Georgia in 2015. Most foreign-born cases reported in 2015 came from India (15%), Mexico (14%), and Vietnam (11%) - countries where TB is an endemic disease (Figures 10-11). Among 149 foreign-born cases, 62 (42%) were diagnosed in the first five years of their arrival in the U.S. This represents a 44% increase from 43 foreign-born cases being diagnosed within first five years in 2014.
In 2015, four counties reported 64% of the total number of foreign-born TB cases in Georgia: DeKalb (40 cases), Gwinnett (22), Fulton (19) and Cobb (14). Among these counties, foreign-born TB cases accounted for more than half of the TB cases in Gwinnett (76%), DeKalb (69%), and Cobb (54%). Foreign-born TB cases in Fulton County accounted for 30% 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. HIV status was reported in 93% of TB cases in 2014 and 2015. Among 298 TB cases in Georgia with known HIV status in 2015, 9% were HIVpositive compared to 12% in 2014 (Figure 12). Among 27 HIV co-infected TB cases in 2015, 85% were non-Hispanic blacks, 70% were male and 59% were 45-64 years old.
In the high-risk age group of adults 25-44 years of age, the percentage of TB cases for which HIV was reported was 98% in 2014 and 2015. In 2015, HIV testing was not offered to 10 TB cases (3%), 8 (2%) refused HIV testing, and the HIV test result was unknown in five cases (2%), Half of the TB cases that were not offered the HIV test were children younger than 5 years old, the other half not offered the test were adults 45 years old and older.
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 2015, 27 (8%) TB cases in Georgia were homeless, 8 (2%) were residents of correctional facilities, and 4 (1%) were residents of long-term care facilities. Of the eight TB cases incarcerated in correctional facilities, five (62%) were inmates in county jails and three (38%) were inmates in state prisons. No TB cases were reported from the Immigration and Customs Enforcement (ICE) detention
2015 GEORGIA TUBERCULOSIS REPORT 5

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 (17%) TB cases in 2015 (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 2015, children younger than 15 years old comprised 6% of Georgia TB cases; 15 TB cases (2.1 per 100,000) were reported in children younger than 5 years old, 3 cases (0.2 per 100,000) were reported in children 5-14 years old. Two children younger than 5 years old had TB meningitis, two other children in this same age group developed disseminated TB; all four 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 2015, 47 children younger than five years old were reported to have LTBI in Georgia; 16 of who were identified by contact investigations. Public health staff identified the source case of the child's infection in 33 (39%) of these children.
Drug Resistance
Among 235 culture-positive TB cases in Georgia during 2015, 100% were tested for initial drug susceptibility however two patients of private physicians had incomplete test results: one case was only tested for isoniazid and rifampin and one other case only had a molecular drug resistance test performed for rifampin. Both cases were culture negative by the time they were referred to public health for case management and therefore the state public health laboratory had no isolate to perform a complete drug susceptibility test. Of 226 tested isolates from Georgia cases with no previous history of TB, 30 (13%) had primary resistance to isoniazid (INH), three (1%) to rifampin (RIF), and none to ethambutol (EMB) (Table 4). No cases of multidrug-resistant TB (MDR-TB, i.e. TB resistant to at least INH and RIF) were reported in 2015 compared to three (0.9%) MDRTB cases in 2014. The percentage of cases with primary INH resistance (INH-R) ranged from 8% to 22% in the past five years while an average of less than two MDR-TB cases per year was reported in Georgia over that same time period (Figure 14).
2015 GEORGIA TUBERCULOSIS REPORT 6

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 2015, 81% of all Georgia TB cases had pulmonary TB, 50% had sputum cultures that were positive for Mycobacterium tuberculosis, 36% were sputum AFB smear-positive, and 20% showed cavitary lesions on chest radiography.
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 2015, 186 (58%) of the 321 TB cases in Georgia were reported initially by a hospital. Seven hospitals in Georgia reported five or more TB cases in 2015: Grady Memorial Hospital (42 cases), Children's Healthcare of Atlanta (6 cases), Emory Midtown Hospital (6 cases), Gwinnett Hospital (5 cases), Emory University Hospital, Medical Center of Central GA, and Phoebe Putney Memorial Hospital reported 5 cases each.
Among TB cases with available data on type of outpatient healthcare provider, county health departments provided sole case management for 85% of all Georgia TB cases, 11% were co-managed by a county health department and private physician, 3% were treated solely by a private physician, correctional facilities treated 0.7%, and 0.3% 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 275 Georgia TB cases reported in 2015 with available case completion data, 90% received TB treatment entirely by DOT, 8% were treated by a combination of DOT and self-administered therapy, and 2% selfadministered their medications for the entire duration of their treatment.
TB Mortality
According to Georgia Vital Records data, six persons died of TB in Georgia in 2015, where the age-adjusted TB mortality rate in 2015 was 0.1 per 100,000. From 2011 to 2015, an average of 12 people died of TB in Georgia each year. Within these years, the highest number of deaths from TB was reported in 2012 with 20 deaths.
TB Treatment Outcomes
Among 292 TB cases in Georgia who started treatment for TB in 2014, (the most recent year with completed treatment outcome data), 284 (97%) completed treatment, 4 (1%) were lost to follow-up, 2(1%) are still undergoing treatment in 2016, 1(0.3%) stopped treatment due to an adverse treatment reaction, and 1(0.3%)
2015 GEORGIA TUBERCULOSIS REPORT 7

non-infectious extrapulmonary case was uncooperative and refused to complete TB treatment.
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 have a 10% chance of developing TB disease later in life if they do not receive treatment for LTBI.
Among 2,907 identified contacts of sputum smear positive TB cases reported in Georgia in 2014 (the most recent year with completed contact investigation data), 2,378 (82%) were completely evaluated for TB disease and LTBI. Among the completely evaluated contacts, 420 (18%) had LTBI and 20 (0.5%) had TB disease. Among the 420 contacts with LTBI, 319 (76%) started LTBI treatment and among these contacts who started LTBI treatment, 218 (68%) completed LTBI treatment, 37 (12%) chose to stop LTBI treatment on their own, 27 (8%) were lost to follow-up, 17 (5%) stopped treatment due to their health provider's decision, 12 (4%) stopped treatment due to adverse side-effects to the TB medications, 6 (2%) moved out-of-state and 2 (0.6%) developed active TB.
Surveillance Summary of TB Genotype Clusters
TB Genotyping
TB genotyping is a laboratory method that determines the genetic relatedness of TB strains among different patients with culture-positive TB disease. Identical genotypes among persons with TB disease suggest recent person-to-person transmission. The state TB program routinely analyzes TB genotype clusters, which are comprised of two or more TB cases with identical genotypes, to identify recent TB transmission, to describe risk factors for transmission, to identify possible sources of transmission, and to determine ways to stop transmission.
From 2011-2015, 94 small (2-3 cases), 20 medium (4-9 cases), and 11 large ( 10 cases) genotype clusters were identified in Georgia (Figure 17). Some genotype clusters such as the cluster associated with a TB outbreak among homeless persons persisted throughout this 5-year time period and an upsurge of TB cases associated with this outbreak strain occurred in 2014 and 2015. Table 10 summarizes the distribution of fourteen medium and
2015 GEORGIA TUBERCULOSIS REPORT 8

five large TB genotyped clusters across several counties in Georgia from 2013-2015. These clusters were predominantly reported from Fulton County (42%), DeKalb (37%), Gwinnett (16%), and Glynn (16%) counties.
TB Outbreak among Homeless Persons
From 2014-2015, a TB outbreak comprised of 42 TB cases with the genotype G05625 was reported among persons who had either stayed or volunteered at homeless shelters in Fulton (n=37), DeKalb (n=3), Chatham (n=1) and Paulding (n=1) counties (Figure 18). All the cases were resistant to a first-line anti-tuberculosis medication, isoniazid (INH). Of the 42 cases, all were male, 93% were US-born and 84% were African-American. TB cases in this cluster had a high prevalence of homelessness (83%), substance abuse (36%), HIV infection (26%), and 19% had sputum smear positive and cavitary pulmonary disease. The first TB case in the United States with the genotype G05625 was reported in Fulton County, Georgia in March 2008 when the TB outbreak started and since then, 13 other states in the U.S. have reported 38 TB cases with this genotype.
The Fulton County Health Department, the Georgia TB program, and CDC are providing resources to control this INH-resistant TB outbreak. The Fulton County TB Program is conducting contact tracing, performing TB screenings at the county TB clinic and in homeless shelters, 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 federally qualified health center. 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 homeless 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 before admittance to a shelter.
Statewide Cluster Investigation Involving Two Separate Populations
From 2013-2015, a TB outbreak consisting of 13 TB cases with the genotype G10763 which was also characterized by INH resistance was reported from Hart (n=5), Richmond (n=5), Gwinnett (n=1), Houston (n=1) and Newton (n=1) counties. Among the 13 TB cases, all were US-born, 92% were African-American between the ages of 40 and 60, 92% reported INH resistance, 69% were male, 31% reported a history of substance abuse and 31% reported a history of excessive alcohol use. One case developed resistance to both INH and rifampin (multidrug-resistant TB). The county and state TB programs initiated a cluster investigation to identify epidemiologic links among the cases and conducted extensive TB screening of persons exposed to the cases in this cluster. The investigation suggested that two separate modes of transmission were occurring in this cluster. In Hart County, all five cases were African-American and the majority (80%) were males; 80% reported substance abuse, 80% reported excessive alcohol use and cases
2015 GEORGIA TUBERCULOSIS REPORT 9

were either relatives or close friends of the cases who were relatives. In Richmond County, the cases were identified from a school contact investigation with no apparent epidemiologic linkage to the Hart County cases. Whole genome sequencing (WGS), a laboratory method that provides greater resolution than routine genotyping testing methods and improves the ability to distinguish genetic variations between culturepositive specimens, was performed for all cases with this genotype. WGS confirmed that the TB cases from Hart County and Richmond County differed in their genetic makeup, thus providing evidence that the cases from these two counties and cases with the genotype G10763 in other counties were not epidemiologically linked. CDC, state, and local personnel discussed the WGS results and determined that a thorough contact investigation had been conducted and no additional follow up was needed.
Statewide Cluster Investigation Involving Correctional Facilities and an Apartment Complex
Another large statewide genotype cluster comprised of 12 TB cases (G12352) was identified from 2013-2015. Of the cases in this cluster, 7 (58%) were reported from Hall County, two in Clarke County, and one case each was reported from Jackson, Columbia, and Stephens counties. The majority of the cases were US-born (92%) and AfricanAmerican (75%). Half of the cases were sputum smear positive with cavitary pulmonary disease and 25% reported a history of substance abuse. The state TB program conducted a cluster investigation which involved searching publicly available online databases for records of incarceration at Hall County jail and other correctional facilities throughout Georgia. WGS was performed for 11 TB cases in the cluster and helped confirm the epidemiologic links of several TB cases associated with incarceration in correctional facilities and an association among TB cases who were residents of an apartment complex with cases in their social networks. CDC, state, and local health department personnel held meetings to discuss this cluster and agreed that thorough contact investigation activities had been conducted and that no further follow up was needed.
2015 GEORGIA TUBERCULOSIS REPORT 10

Table 1. Number of TB Cases and TB Case Rates* per 100,000 population by County, Georgia, 2014-2015

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 Augusta State Med Prison (ASMP) Cook Coweta Crawford Crisp

2014
Number of Case Rate cases

0

0

0

0

< 5

--

< 5

--

0

0

0

0

<5

--

< 5

--

<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

< 5

--

< 5

--

0

0

8

2.8

0

0

< 5

--

< 5

--

0

0

0

0

10

3.7

0

0

25

3.4

0

0

< 5

--

0

0

<5

na

0

0

< 5

--

0

0

< 5

--

2015
Number of Case Rate cases

< 5

--

< 5

--

0

0

< 5

--

0

0

< 5

--

< 5

--

< 5

--

0

0

0

0

< 5

--

0

0

0

0

0

0

0

0

0

0

< 5

--

< 5

--

0

0

< 5

--

0

0

< 5

--

< 5

--

< 5

--

<5

--

0

0

0

0

< 5

--

< 5

--

0

0

8

2.9

0

0

26

3.5

< 5

--

0

0

<5

--

<5

na

< 5

--

< 5

--

0

0

< 5

--

2015 GEORGIA TUBERCULOSIS REPORT 11

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

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

< 5

--

0

0

77

7.7

< 5

--

0

0

< 5

--

< 5

--

< 5

--

0

0

35

4.0

0

0

9

4.7

< 5

--

< 5

--

0

0

0

0

0

0

0

0

< 5

--

0

0

< 5

--

< 5

--

0

0

0

0

0

0

0

0

2015

Number of Case Rate cases

0

0

0

0

0

0

58

7.9

0

0

0

0

< 5

--

0

0

0

0

0

0

< 5

--

0

0

< 5

--

0

0

0

0

0

0

< 5

--

7

3.3

0

0

63

6.2

0

0

0

0

< 5

--

0

0

< 5

--

< 5

--

29

3.1

< 5

--

6

3.1

0

0

0

0

0

0

< 5

--

0

0

< 5

--

6

4.0

0

0

0

0

0

0

< 5

--

0

0

0

0

0

0

2015 GEORGIA TUBERCULOSIS REPORT 12

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

2014

Number of Case Rate cases

< 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

< 5

--

0

0

0

0

< 5

--

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

2015

Number of cases

Case Rate

0

0

< 5

--

0

0

< 5

--

< 5

--

< 5

--

0

0

0

0

< 5

--

0

0

< 5

--

0

0

0

0

0

0

< 5

--

< 5

--

0

0

< 5

--

0

0

0

0

0

0

0

0

11

5.5

< 5

--

0

0

0

0

< 5

--

0

0

0

0

0

0

0

0

0

0

< 5

--

< 5

--

< 5

--

< 5

--

0

0

7

3.5

5

5.6

0

0

< 5

--

< 5

--

< 5

--

2015 GEORGIA TUBERCULOSIS REPORT 13

COUNTY Stephens

2014

Number of Case Rate cases

< 5

--

2015

Number of Case Rate cases

0

0

Stewart ICE Detention Center 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

<5

--

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

0

0

0

0

0

0

0

0

0

0

< 5

--

0

0

0

0

< 5

--

0

0

0

0

0

0

0

0

< 5

--

< 5

--

0

0

0

0

0

0

0

0

0

0

0

0

0

0

< 5

--

0

0

< 5

--

0

0

0

0

< 5

--

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

< 5

--

< 5

--

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

334

3.3

321

3.1

Note: In counties where one to four cases were reported and the county population is less than 100,000, "< 5" is used to represent the number of reported cases, and the case rate is not calculated.

2015 GEORGIA TUBERCULOSIS REPORT 14

Table 2. Number of TB Cases and TB Case Rates* per 100,000 population by Health District, Georgia, 2014- 2015

2014

2015

Health District

Number Case rate Number Case rate

of Cases

of Cases

1.1 Rome

12

1.9

8

1.2

1.2 Dalton

7

1.5

4

1.2

2.0 Gainesville

13

2.0

20

3.0

3.1 Cobb

25

2.9

26

2.9

3.2 Fulton

77

7.7

63

6.2

3.3 Clayton

10

3.7

8

2.9

3.4 Lawrenceville

38

3.6

35

3.2

3.5 DeKalb

60

8.3

58

7.9

4.0 LaGrange

6

0.7

15

1.8

5.1 Dublin

1

0.7

2

1.3

5.2 Macon

11

2.1

11

2.1

6.0 Augusta

6

1.3

12

2.5

ASMP

3

na

2

na

7.0 Columbus

18

4.8

17

4.5

ICE Detention Center

2

na

0

na

8.1 Valdosta

5

2.0

2

0.8

8.2 Albany

16

4.5

10

2.8

9.1 Coastal

18

3.0

12

2.0

9.2 Waycross

3

0.8

10

2.7

10 Athens Total

3

0.6

6

1.2

334

3.3

321

3.1

Table 3. Percentage of TB Cases with Risk Factors for TB by Health District, Georgia, 2015

HEALTH DISTRICT

Foreign-

HIV*

Homeless Inmate Nursing Substance

born % Infected %

%

%

Home % Abuse %

1.1 Rome

13

0

0

0

0

25

1.2 Dalton

75

0

0

0

0

0

2.0 Gainesville

60

0

0

0

0

30

3.1 Cobb

54

11

0

0

0

8

3.2 Fulton

30

19

30

6

0

27

3.3 Clayton

75

14

0

0

0

0

3.4 Lawrenceville

66

3

0

0

3

11

3.5 DeKalb

69

4

9

2

0

7

4.0 LaGrange

20

13

13

7

0

20

5.1 Dublin

50

0

0

0

0

0

5.2 Macon

36

27

0

0

0

9

6.0 Augusta

50

17

0

0

0

25

ASMP

50

0

0

100

0

50

7.0 Columbus

18

7

0

0

12

35

ICE Detention Ctr

0

0

0

0

0

0

8.1 Valdosta

0

0

0

0

0

0

8.2 Albany

10

0

10

0

10

30

9.1 Coastal

50

9

0

0

0

8

9.2 Waycross

30

0

0

0

0

10

10 Athens Georgia

50

0

46

9

0

0

0

0

8

2

1

17

*Percentage of HIV infection among TB cases with known HIV status

2015 GEORGIA TUBERCULOSIS REPORT 15

Table 4. Primary Resistance to Anti-TB Medications by Health District, Georgia, 2015*

TB Drug

Isoniazid

Rifampin

Ethambutol

HEALTH DISTRICT

No.

%

No.

%

No.

%

1.1 Rome

1

14

0

0

0

0

1.2 Dalton

0

0

0

0

0

0

2.0 Gainesville

4

22

0

0

0

0

3.1 Cobb

0

0

2

12

0

0

3.2 Fulton

14

28

0

0

0

0

3.3 Clayton

0

0

0

0

0

0

3.4 Lawrenceville

2

8

1

3

0

0

3.5 DeKalb

3

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

2

22

0

0

0

0

6.0 Augusta

3

43

0

0

0

0

ASMP

0

0

0

0

0

0

7.0 Columbus

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

0

0

0

0

9.2 Waycross

0

0

0

0

0

0

10 Athens Georgia Total

1

25

0

0

0

0

30

13

3

1

0

0

* Drug resistance among culture positive TB cases with no previous history of TB treatment

Table 5. Completion of TB Treatment by Health District, Georgia, 2013-2014

2013

2014

HEALTH DISTRICT

No. Cases that Completed % No. Cases that Completed

%

Tx/No. Cases Started Tx*

Tx/No. Cases Started Tx*

1.1 Rome

10/10

100

11/11

100

1.2 Dalton

4/4

100

6/6

100

2.0 Gainesville

13/14

93

12/12

100

3.1 Cobb

17/17

93

18/19

95

3.2 Fulton

44/44

100

65/66

98

3.3 Clayton

9/9

100

9/9

100

3.4 Lawrenceville

40/41

98

33/34

97

3.5 DeKalb

71/72

99

53/55

96

4.0 LaGrange

6/6

100

5/6

83

5.1 Dublin

2/2

100

2/2

100

5.2 Macon

10/11

91

9/11

91

6.0 Augusta ASMP

20/20

100

6/6

100

2/2

100

3/3

100

7.0 Columbus

3/4

75

12/14

86

8.1 Valdosta

9/9

100

4/4

100

8.2 Albany

15/15

100

11/11

100

9.1 Coastal

8/8

100

17/17

100

9.2 Waycross

9/9

100

3/3

100

10 Athens

5/5

100

2/2

100

Georgia Total

298/302

99

284/292

97

*Cases who died or who left the U.S. while on TB treatment are excluded

2015 GEORGIA TUBERCULOSIS REPORT 16

Table 6. Completion of TB Treatment (Tx) within 12 months among TB cases eligible for

12-month TB Treatment by Health District, Georgia, 2013-2014

2013

2014

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

8/8

100

11/11

100

1.2 Dalton

3/4

75

6/6

100

2.0 Gainesville

11/12

92

10/12

83

3.1 Cobb

13/14

93

14/16

88

3.2 Fulton

42/43

98

58/64

91

3.3 Clayton

8/8

100

9/9

100

3.4 Lawrenceville

37/38

97

30/32

94

3.5 DeKalb

67/69

97

50/52

96

4.0 LaGrange

4/6

67

3/5

60

5.1 Dublin

1/2

50

2/2

100

5.2 Macon

8/10

80

9/11

91

6.0 Augusta ASMP

14/17

82

2/2

100

5/6

83

3/3

100

7.0 Columbus

3/4

75

12/14

86

8.1 Valdosta

9/9

100

4/4

100

8.2 Albany

14/14

100

11/11

100

9.1 Coastal

6/7

86

17/17

100

9.2 Waycross

8/8

100

3/3

100

10 Athens

5/5

100

2/2

100

Georgia Total

262/280

94

260/281

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, 2013-2014

2013

2014

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

18/24

75

24/27

89

18/22

81

51/54

94

120/145

83

141/164

86

60/72

83

58/77

75

226/447

51

890/964

92

65/71

92

27/29

93

187/230

81

79/92

86

122/212

58

347/414

84

4/6

67

12/14

86

14/14

100

1/1

100

37/60

62

20/133

15

164/180

91

393/544

72

11/16

69

77/87

88

24/41

59

6/10

60

12/12

100

194/233

83

38/42

90

48/54

89

25/40

62

0/0

na

11/17

61

10/10

100

1162/1662

70

2387/2907

82

2015 GEORGIA TUBERCULOSIS REPORT 17

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

LTBI Treatment by Health District, Georgia, 2013-2014

2013

2014

HEALTH DISTRICT

No. Infected Contacts on LTBI Treatment / No. Infected Contacts

% No. Infected Contacts

%

on LTBI Treatment /

No. Infected Contacts

1.1 Rome

5/7

71

2/3

67

1.2 Dalton

6/6

100

16/16

100

2.0 Gainesville

53/53

100

30/42

71

3.1 Cobb

11/16

69

19/24

79

3.2 Fulton

23/55

42

63/90

70

3.3 Clayton

10/15

67

6/7

86

3.4 Lawrenceville

46/72

64

14/18

78

3.5 DeKalb

37/59

63

53/77

69

4.0 LaGrange

2/2

100

5/7

71

5.1 Dublin

6/7

86

0/1

0

5.2 Macon

2/4

50

6/8

75

6.0 Augusta

9/17

53

21/33

64

7.0 Columbus

3/4

75

39/45

87

8.1 Valdosta

6/9

67

2/2

100

8.2 Albany

4/4

100

14/16

88

9.1 Coastal

6/6

100

29/31

94

9.2 Waycross

4/11

36

0/0

na

10 Athens

7/7

100

0/0

na

Georgia Total

240/354

68

319/420

76

Table 9. LTBI Treatment Completion of Infected Contacts exposed to Sputum Smear Positive Cases by Health District, Georgia, 2013-2014

HEALTH DISTRICT

2013
No. Contacts that % Completed LTBI Treatment / Contacts Treated

2014
No. Contacts that % Completed LTBI Treatment / Contacts Treated

1.1 Rome

2/5

40

2/2

100

1.2 Dalton

5/6

83

13/16

81

2.0 Gainesville

42/53

79

21/30

70

3.1 Cobb

8/11

72

10/19

53

3.2 Fulton

13/23

56

36/63

57

3.3 Clayton

9/10

90

3/6

50

3.4 Lawrenceville

39/46

85

12/14

86

3.5 DeKalb

27/37

73

44/53

83

4.0 LaGrange

1/2

50

5/5

100

5.1 Dublin

3/6

50

0/0

na

5.2 Macon

1/1

50

4/6

67

6.0 Augusta

5/9

56

8/21

38

7.0 Columbus

3/3

100

23/39

59

8.1 Valdosta

1/6

17

2/2

100

8.2 Albany

4/4

100

11/14

79

9.1 Coastal

5/6

83

24/29

83

9.2 Waycross

3/4

75

0/0

na

10 Athens

2/7

29

0/0

na

Georgia Total

173/240

72

218/319

68

2015 GEORGIA TUBERCULOSIS REPORT 18

Table 10. Number of TB Cases in Medium and Large TB Genotype Clusters by County, Georgia, 2013-2015

Medium Genotype Clusters

(4 9 TB cases per cluster)

Genotype Name

Counties

G10063

Muscogee (n=7)

G05614 G15727

Fulton (n=5) Cobb (n=1) DeKalb (n=1) Spalding (n=1)
Fulton (n=5) Bibb (n=1)

G00518

DeKalb (n=4) Gwinnett (n=2)

G07486

Liberty (n=4) Cobb (n=1)

G10773 G10753 G15752 G07343 G00628
G16216 G00010
G13198 G14729

DeKalb (n=3) Fulton (n=1) Muscogee (n=1) Whitfield (n=3) Catoosa (n=1) Fulton (n=2) Appling (n=1) Walker (n=1) Gwinnett (n=2) DeKalb (n=1) Crisp (n=1) DeKalb (n=2) Fulton (n=1) Clayton (n=1) Macon (n=1) Houston (n=2) Laurens (n=2) Fulton (n=1) Cobb (n=1) Clayton (n=1) Effingham (n=1) McIntosh (n=2) Lowndes (n=1) Glynn (n=1) Rockdale (n=1) Glynn (n=1) Grady (n=1) Forsyth (n=1)

Large Genotype Clusters

( 10 TB cases per cluster)

Genotype Name

Counties

G05625

Fulton (n=33)

DeKalb (n=4)

Chatham (n=1)

Paulding (n=1)

G10763

Richmond (n=5)

Hart (n=5)

Houston (n=1)

Newton (n=1)

G00013

Gwinnett (n=1) Fulton (n=8)

DeKalb (n=2)

Clayton (n=1)

Glynn (n=1)

G12352

Dawson (n=1) Hall (n=7)

Clarke (n=2)

Jackson (n=1)

Stephens (n=1)

G10265

Columbia (n=1) Dougherty (n=5)

Troup (n=3)

Upson (n=2)

Mitchel (n=1)

Lee (n=1)

2015 GEORGIA TUBERCULOSIS REPORT 19

2015 GEORGIA TUBERCULOSIS REPORT 20

2015 GEORGIA TUBERCULOSIS REPORT 21

2015 GEORGIA TUBERCULOSIS REPORT 22

2015 GEORGIA TUBERCULOSIS REPORT 23

2015 GEORGIA TUBERCULOSIS REPORT 24

2015 GEORGIA TUBERCULOSIS REPORT 25

2015 GEORGIA TUBERCULOSIS REPORT 26

2015 GEORGIA TUBERCULOSIS REPORT 27

Figure 17. Proportion of Small, Medium, and Large TB Genotype Clusters, Georgia, 2011-2015

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

2011

2012

2013

2014

2015

10 cases 4-9 cases 2-3 cases

2015 GEORGIA TUBERCULOSIS REPORT 28

Tuberculosis Morbidity Trends by Health District Georgia, 1995-2015
2015 GEORGIA TUBERCULOSIS REPORT 29

TB Case Numbers and Rates

District 1-1 (Rome),1995-2015

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 8

4

5

2

0

0

Number

Rate

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

2015 GEORGIA TUBERCULOSIS REPORT 30

2015 GEORGIA TUBERCULOSIS REPORT 31

2015 GEORGIA TUBERCULOSIS REPORT 32

2015 GEORGIA TUBERCULOSIS REPORT 33

2015 GEORGIA TUBERCULOSIS REPORT 34

2015 GEORGIA TUBERCULOSIS REPORT 35

2015 GEORGIA TUBERCULOSIS REPORT 36

2015 GEORGIA TUBERCULOSIS REPORT 37

2015 GEORGIA TUBERCULOSIS REPORT 38

2015 GEORGIA TUBERCULOSIS REPORT 39