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TB Notes Newsletter

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No. 1, 2010


DTBE Image Library Contest Winners!

DTBE Image Library Photo Contest
This year we had many entries for the DTBE Image Library photo contest. There were so many good entries that we decided to choose first-, second-, and third-place winners. The winning photos were chosen based on image quality, composition, and value or appropriateness to the division. All photos submitted for the contest were judged by division staff with photography, TB laboratory, communication, and public health experience.

We are pleased to announce that Dr. Sundari Mase of the Field Services and Evaluation Branch is the first-place winner, and Dr. Wanda Walton of the Communications, Education, and Behavioral Studies Branch wins second and third place in the DTBE Image Library Photo Contest.

Photo Contest 1st Place

Patient-3Image title: TB Patient – 3.

This is a photo of a patient with multidrug-resistant (MDR) TB in Chuuk before treatment. The photo shows an 11-year-old female MDR TB contact who presented with cough, fever, night sweats, and massive right cervical lymphadenopathy.  The patient was placed on an MDR TB treatment regimen and is currently much improved with no further symptoms.

The first-place image was taken by Sundari while she was working in Micronesia as an MDR TB clinical consultant and for the study following up the MDR TB contacts on LTBI treatment. The Federated States of Micronesia (FSM) is an independent country, made up of four states, located in the Western Pacific. It is currently affiliated with the United States by a Compact of Free Association. Chuuk is the largest of the four states with a population of 55,000. During 2007, the TB incidence rate in Chuuk was 127 cases per 100,000, 30-fold higher than the U.S. rate (4.4 per 100,000). The first known MDR TB case in Chuuk was reported in December 2007.  By April 2008, four deaths from MDR TB had been reported. On May 15, 2008, FSM requested CDC assistance in investigating these cases of MDR TB.

The July 2008 investigation found evidence of two simultaneous MDR TB outbreaks, distinguished by genotype, drug-susceptibility patterns, and epidemiology. The first outbreak included three patients with MDR TB disease with Mycobacterium tuberculosis isolates resistant to five drugs. 

Photo Contest 2nd and 3rd Place
The second- and third-place images were taken by Wanda while she was working in Nepal. Approximately 107,000 Nepali-speaking residents of Bhutan have been confined to seven refugee camps in southeastern Nepal since 1990. With almost 2 decades of failed initiatives to return or locally integrate them, the resettlement program in Nepal began in 2008 with the United States agreeing to resettle approximately 60,000 Bhutanese refugees over the next 5 years.

Before entry into the United States, these applicants are required to undergo medical screening for diseases of public health significance, referred to as inadmissible conditions, which includes infectious TB.  In August 2009, Wanda was a member of an evaluation team which traveled to Damak, Nepal. The team included representatives from CDC’s Division of Global Migration and Quarantine and DTBE, in partnership with two consultants external to CDC and a member of Citizenship and Immigration Canada (CIC).  The purpose of this program evaluation was to provide an objective, in-depth, and sensitive assessment of the International Organization for Migration’s operation within Nepal in relation to the application of the new TB Technical Instructions for detection and treatment of TB in this refugee population.

TB patient with childPhoto Contest 2nd Place Image

Image title: TB patient with child.

This is an adult patient with TB waiting to be seen in the DOT clinic in the Bhutanese refugee camp in Damak, Nepal. The child has a black dot on his forehead for protection against evil spirits.





Directly observed therapy for TBPhoto Contest 3rd Place Image

Image title: Directly observed therapy for TB.

This is a photo of an outreach worker providing directly observed TB treatment to a patient in a refugee camp in Nepal.

DTBE staff can search for these images and many others by visiting the DTBE Image Library website. If you do not have access to the Image Library and would like to request or share images, please send an e-mail to .

A special thanks to those who submitted images for our photo contest!

—Reported by Regina Bess
Div of TB Elimination

Usability Study Results of the CDC TB Website Redesign

The TB website redesign was launched on June 1, 2009. To evaluate the new design, in November 2009 the DTBE Web Team conducted a usability study. The purpose of the study was to gather data for comparison with 2007 baseline data that had been gathered from a usability study conducted on the previous website design.

Study Methods
The November 2009 study followed the same methodology as the 2007 study. It was conducted remotely using a software program called Web Effective. Gov Delivery, the CDC e-mail subscription tool, was used to secure potential study participants. An e-mail that contained a link to the study was sent through Gov Delivery to DTBE website update subscribers. The study took on average 46 minutes to complete, and was completed by 165 participants working at their own computer.

During the usability study, participants--

  1. Completed a background questionnaire,
  2. Answered questions regarding their initial impressions of the website,
  3. Performed real-world tasks on the website,
  4. Answered questions about what they liked or disliked on the website, and
  5. Answered demographic questions about themselves.

Study Participants
We had an equal number of participants from each user group (general public, health care providers, and public heath professionals) of the DTBE website, with 75% of study participants being female. Also, participants were predominantly 35–64 years old; 37% worked in state, local or federal government, and most had achieved a bachelors degree or higher (Figure 1).

Figure 1. Education of participants

education of participants in the 2009 study. See link below for data table.
See data table for more detail

education of the participants in 2007 study. See link below for data table
See data table for more detail

In 2009, more participants considered their level of Internet experience as “expert,” an 8% increase from the 2007 study. Participants who had previously visited the DTBE website prior to the study decreased from 86% in 2007 to 70% in 2009. Of the 70% of participants who had previously visited the DTBE website, 83% visited once a month or less. In 2007, 79% visited the DTBE website more than once a month, with the largest proportion (47%) visiting on a weekly basis (Figure 2).

Figure 2. Participants' use of DTBE website

Participants Use of the TB Website in the 2009 study. See link below for data table.
See data table for more detail

Participants Use of the TB Website in 2007 study. See link below for data table
See data table for more detail

Study task scenarios
The study included 20 task scenarios. Each participant completed 10 tasks, 6 of which were specific to his/her user group. Of the 20 task scenarios, 4 were presented to all participants.

Following is an example of a study task presented to all participants:
“Use the CDC DTBE website to find data on TB cases in the United States. What was the number of TB cases in 2008?”

Participant impressions
At the start of the study, 71% of participants had positive feedback on the newly redesigned TB website. This was an increase from 51% in the 2007 study.

Positive and negative feedback was recorded in response to the following question, “What is your initial impression of the DTBE website?” Below are some of the comments received.

Positive comments

  1. “Professional. Love the topics buttons. Don't have to look for the information all over the site; it is right there in front of me.”
  2. “Easy to navigate, catchy, not intimidating, easy to find whatever info you might want – one of the best websites I’ve seen.”
  3. “It's informative. I like the way it's laid out. It's attractive, simple and direct.”

Negative comments

  1. “Lots of information, busy.”
  2. “Needs more order.”
  3. “I knew exactly where to find what I wanted on the old one. Still have difficulty finding things here.”

Figure 3. Participants' initial impression of the DTBE website.

Participants initial impression of the DTBE website. 2009 study responses: Positive 71%, Negative 11% and Neutral 18%. 2007 study responses: Positive 51%, Negative 21% and Neutral 28%.

Only 11% of participants had negative feedback compared to 21% in 2007 and 18% provided neutral feedback compared to 28% in 2007.

Participant performance
Overall, the new website design resulted in an 11% increase in participant performance compared to 2007. While 61% successfully completed task scenarios in 2007, 72% were successful in 2009.

Compared to 2007, participant performance in 2009 improved significantly on a number of key task scenarios. In figures 4 and 5 below, the tall blue columns indicates that most participants were successful in completing the task, whereas a tall yellow column indicates that most participants failed to complete the task. Please refer to appendix A for study task scenarios.

Figure 4. Participants' success completing task scenarios, 2009

Participants’ Success Completing Task Scenarios 2009. See link below for data table.
See data table for more detail

Figure 5. Participants' success completing task scenarios, 2007

Participants’ Success Completing Task Scenarios 2007. See link below for data table
See data table for more detail

In the 2009, study participants successfully completed 16/20 task scenarios compared to 12/20 task scenarios in the 2007 study; refer to figures 4 and 5.

In 2007, more participants were unsuccessful than successful in completing the following eight task scenarios:

  1. How would you take an online course about TB?
  2. What should you do if you think you have been exposed?
  3. A skin test reaction less than 5 mm is positive in what groups?
  4. Order Forging Partnerships publication
  5. Find QuantiFERON®-TB Gold testing locations
  6. Find out how TB disease is spread.
  7. Order Get the Facts booklet
  8. Find out if it is safe to receive a TB test while pregnant.

In 2009, more participants were unsuccessful than successful in completing the following four task scenarios;

  1. Order TB Questions and Answers
  2. Order Get the Facts booklet
  3. What should you do if you think you have been exposed?
  4. Order Forging Partnerships publication

Figure 4 illustrates that 44% of the study participants successfully ordered the booklet entitled Get the Facts in 2009, compared to 13% in the 2007 study. The task scenario related to TB exposure (What to do if you have been exposed to TB) was successfully completed by 45% of the study participants in 2009, compared to 47% in the 2007 study. The task scenarios, “Order the TB Questions and Answers booklet” and “Order the Forging Partnerships publication” decreased in success in the 2009 study.

This study indicates that the redesigned DTBE website has increased user performance compared to the previous TB website by 11%. The DTBE Web Team would like to improve upon this by increasing overall success to higher than 72% in 2010.  This usability study will aid in making improvements to the DTBE website in 2010. Some of the changes that will be implemented in 2010 are incorporating more images to the DTBE website, reviewing the number of clicks users make before finding popular information, and making it easier to order publications within publication web pages. In 2010, DTBE plans to conduct further usability studies. At that time we will reach out to DTBE website users for assistance.

We would like to thank all who took the time to complete this study, and welcome any comments and feedback you would like to share with the DTBE Web Team

—Reported by Sharon McAleer
Div of TB Elimination

Appendix A – Study task scenarios

  1. Latent vs. active TB: What are the differences between latent TB infection and active TB disease? Which option below is correct?
  2. TB cases: Use the CDC TB Website to find data on TB cases in the United States. What was the number of TB cases in 2006?
  3. TB control telephone number: Use the CDC TB Website to find the telephone number for the Georgia State TB Control Office.
  4. Infection control guidelines: CDC publishes TB guidelines on a variety of topics. When were the “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings” published?
  5. TB symptoms: What are the symptoms of TB disease?
  6. Spreading TB: How is TB disease spread?
  7. Get the Facts booklet: You would like a booklet that provides basic information on TB disease. Locate the publication Get the Facts.
  8. TB exposure: What should you do if you think you have been exposed to someone with TB disease?
  9. Order Q&A: You would like to order the publication Questions and Answers About TB. Is the publication available to order online?
  10. TB Testing & Pregnancy: Is it safe to receive a tuberculin skin test while pregnant?
  11. QFT testing locations: You recently heard about a blood test to check for TB infection called QFT or QuantiFERON-TB Gold test (QFT-G). You would like to find laboratories in your area that conduct the QFT-G test. What is the title of the TB webpage that links to QFT-G testing sites?
  12. TB online course: You would like to take an online course about TB for continuing education (CE) credits. What is the name of a CDC web-based course on TB that offers CE credits?
  13. BCG vaccine: BCG, or bacille Calmette-Guérin, is a vaccine for tuberculosis (TB) disease. Is the BCG vaccine recommended for use in the United States?
  14. Order Forging Partnerships publication: You would like to order the publication “Forging Partnerships to Eliminate Tuberculosis.” What publication formats are available to order?
  15. Slides on investigating contacts: Is a slide set on investigating contacts of persons with TB disease available to download?
  16. Skin test results: CDC recommends criteria for classifying positive tuberculin skin test reactions. A tuberculin skin test reaction of > 5 mm of induration is interpreted as positive in what groups?
  17. Two-step testing: CDC recommends two-step tuberculin skin testing (two-step testing) of adults who are going to be retested periodically. Why is two-step testing recommended?
  18. Order publication TB Facts for HCW: You would like to order the publication “TB Facts for Healthcare Workers.” Is the publication available to order online?
  19. Treatment slide set: Is a slide set on the treatment of TB available to download?
  20. TB first-line drugs: What are the four first-line drugs used to treat TB disease?



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