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TB Notes Newsletter

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No. 2, 2010


TB ETN Member Highlights

In this issue we highlight Sheanne Allen, Ashley Ewing, Caroline Carman, and Gail Denkins, who have been selected as the new 2010 TB ETN Steering Committee members.

Sheanne Allen, BS, CHES, is a TB Education Promotion Consultant for the Washington State TB Program. Her job responsibilities are planning, organizing, and coordinating the surveillance activities of the Washington State TB Program. In this position, she assists in compiling, analyzing, and reviewing cohort, genotyping, and ARPE (Aggregate Reports for TB Program Evaluation) surveillance data. She provides liaison with TB program and statewide partners; provides TB program consultation to local health jurisdictions (LHJs), health agencies, and related organizations regarding surveillance activities; plans, develops, and monitors consolidated contracts with LHJs; prepares and monitors federal grant applications; and plans, organizes, and coordinates statewide TB training and education initiatives. She joined TB ETN to enhance her TB training and education knowledge, and to build a network base for future TB projects and initiatives.

Caroline Carman, MSW, LISW AP/CP is a licensed independent social worker who is the South Carolina Social Work Consultant for Tuberculosis. She received her BA in sociology and masters degree in social work (MSW) from the University of South Carolina. Caroline's job responsibilities are to address psychosocial needs of patients, provide education and material about TB for patients and the community, serve as the legal liaison for the division, serve as the TB Training Focal Point, facilitate the development of the Human Resource Development Plan, and assist in implementing the Plan.  As a member of TB ETN, Caroline was an active member of the former Cultural Competency Workgroup and looks forward to her work on the TB ETN Steering Committee.

Gail Denkins, RN, BS, is a TB Nurse Consultant with the Michigan Department of Community Health.  Gail is currently the TB Program Evaluation focal point. Her responsibilities include writing the program evaluation plan and overseeing its progress.  In addition, she will be implementing a cohort review process for the state.  Prior to this assignment, she was the TB Education focal point for 6 years. Gail is proud of the Michigan TB Nurse Network and the 2009 TB Nursing Certification Project for Michigan (please see Gail’s recent TB Notes article on the nursing certification project).  She would like to see TB ETN assist and guide new members with integrating education and program evaluation as shared goals in TB programs.

Ashley Ewing, BS, serves as an Education and Training Coordinator with the North Carolina TB Control Program. Her job responsibilities include planning, organizing, and implementing TB health education programs for public health personnel, private providers, and other health care providers as requested; assessing health education plans and modifying as required to meet program goals and objectives; serving as liaison to local health department nurses for education and training opportunities; conducting program planning and evaluation; and developing a working relationship with the CDC Division of Tuberculosis Elimination (DTBE). Ashley joined TB ETN because she thought it would be a great way to learn about TB from the perspective of a health educator versus that of a health care provider. She also joined to learn about methods for developing effective educational tools for both providers and patients.

If you’d like to join Sheanne, Caroline, Gail, and Ashley as a TB ETN member and take advantage of all TB ETN has to offer, please send an e-mail requesting a registration form to You can also send a request by fax to 404-639-8960 or by mail to TB ETN, CEBSB, Division of Tuberculosis Elimination, CDC, 1600 Clifton Rd., N.E., MS E10, Atlanta, Georgia 30333 or, if you would like additional information about the TB Education and Training Network.

—Reported by Regina Bess
Div of TB Elimination

Program Highlight: Innovative Strategies Lead to Success in TB Control in a Crack Cocaine–Using Community

A TB team working in a traditionally low-incidence area successfully applied a systematic approach to developing strategies used to treat latent TB infection (LTBI) in a crack cocaine–using community. 

Vancouver Island Health Authority TB team, March 2008
Vancouver Island Health Authority TB team, March 2008

When a TB outbreak occurred in the Alberni Valley on the west coast of Vancouver Island in British Columbia, the newly formed TB team was challenged to develop effective management strategies. Social networking analysis identified the crack cocaine–using community as a key focus in transmission. In the course of the outbreak, 74% of the active TB cases were in persons associated with this community. Providing treatment of LTBI within this community was identified as a priority for outbreak management. However, reaching and involving this community in treatment was proving to be a significant challenge: By the end of the first year of the outbreak, only one person associated with the crack cocaine–using community had been placed on treatment for LTBI.

Crack Cocaine as a Risk Factor
A literature review identified an emerging body of evidence associating crack cocaine use with active TB disease. Several conditions attached to use of crack cocaine increase the risk of transmission of this disease. These include “prolonged sharing of closed and confined airspace, intensive coughing, and other acute pulmonary complications of crack cocaine inhalation” (Story, 2008). Other social factors that influence outcomes in this group include inadequate access to health centers, noncompliance once access is obtained, and an environment of pervasive drug use and homelessness (Leonhardt, 1994). Finally, prolonged cocaine use and associated malnutrition can lead to immunosuppression as well as respiratory damage, which may predispose users to infectivity. (Story, 2008)

Needs Assessment
A needs assessment was informally crafted to identify barriers to treatment of LTBI. It focused on TB clients, physicians and other caregivers, the local TB team, and documentation. Data collection methods included self-report, informal interviews, written communications, and chart reviews. The needs assessment identified gaps in knowledge, communication breakdowns, logistical problems, and challenges related to homelessness and addiction behaviors.

Objectives & Activities
A multipronged strategy was developed to address the identified needs. Objectives and activities are summarized in the following table.


1. Caregivers will understand the importance of LTBI treatment within the crack cocaine community

In-services for physicians, nurses, and outreach workers

Distribution of a quarterly physician newsletter with TB updates

Development of local protocols

Daily team meetings to plan and review work

Identification of better communication lines with Provincial TB Control to ensure that they are fully aware of individual client risk factors

2. Persons in the crack cocaine– using community will understand the importance of treatment for LTBI

Letters delivered to crack houses

Peers used to transmit messages around
TB screening and treatment

Media used to convey messages around treatment of LTBI

Identification and utilization of more effective educational tools

3. Clients will understand that flexible treatment plans and incentives are available

Clients allowed to choose treatment options that best suit their needs

Clients allowed to choose incentive options that best assist them during the treatment period

Information sheets distributed at key locations used by the target group

Business cards distributed with basic messages, contact numbers, and locations

4.  The wider community will be aware of the risks of TB disease for crack cocaine users

Community workshop

Educational sessions for every agency working with the target group

Media messaging

5. Trust will be established between physicians, TB team, and clients

TB nurses expanded their scope of practice to support clients with issues not directly related to TB

Physician hired to serve clients without a family physician

Incentives integrated into the program

Template developed for physician communication to request LTBI treatment and outline management plans

Monthly updates sent to physicians

Neighborhood “yard parties” set up for screening and relationship-building

Workers providing direct observed therapy expanded their role to include assisting with finding housing and connecting clients to other service agencies, including addictions counselors

Team expanded to include a First Nations Cultural coordinator who accessed programming for cultural safety

Three levels of evaluation were applied: process, outcome, and impact. The process evaluation showed successful implementation with appropriate mid-stream adaptations based on ongoing team evaluation of the effectiveness of the strategies. Positive community engagement occurred on multiple levels. Outcome evaluation underlined the success of the strategies in that after December of 2008 there were no new cases of TB from within the crack cocaine using community. The impact was reflected in observed behaviour changes as both the target community and the health care providers engaged in the treatment of LTBI within the crack cocaine using community. By February 2010, a total of 87 individuals from within this community had been placed on treatment for LTBI. This represented 56% of the infected population.

Graph showing the treatment of LTBI as compared to New infections and new cases, 2006 to 2009. 2006: New + TST = 38; Disease Treatment = 9; LTBI Treatment = 1; 2007: New + TST = 54; Disease Treatment = 16; LTBI Treatment = 35; 2008: New + TST = 52; Disease Treatment = 8; LTBI Treatment = 32; 2009: New + TST = 12; Disease Treatment = 0; LTBI Treatment = 19; Cumulative: New + TST = 156; Disease Treatment = 33; LTBI Treatment = 87.

Lessons Learned
The team gleaned a number of lessons from their experience:

  • Working successfully with populations with addictions requires unconventional approaches, innovation, and flexibility.
  • Partnerships with primary care providers and other service agencies are necessary and can be highly effective.
  • An education plan needs to be multifaceted, community-based, and adaptable.
  • Educational programming is successful when it addresses identified needs.
  • TB management can be powerfully influenced by effective educational programming.

This project was implemented in partnership with Nuu chah nulth Community Health Nursing.

—Submitted by Janice Jespersen
Clinical Coordinator, Port Alberni TB Program
Vancouver Island Health Authority


  1. Leonhardt KK, Gentile F, Gilbert BP, and Aiken M. A cluster of tuberculosis among crack house contacts in San Mateo County, California. American Journal of Public Health 1994 Nov; 84 (11): 1834-6.
  2. Story A, Bothamley G, and Hayward A. Crack cocaine and infectious tuberculosis. Emerging Infectious Diseases 2008 Sept; 14(9): 1466-9.


TB ETN’s Ask the Experts

I am developing an ongoing TB update and training for our local hospital providers: physicians, nurses, and medical assistants.  Our providers range in age from 18 to 69.  I know if I do something on the web I might lose the older ones, and if I provide lectures on a regular basis, I could lose the younger ones.  Can you help me?

This is a very interesting dilemma for many people.  In your case, not only are you dealing with different generations, but also with different levels of knowledge and education. This is quite a challenge!

So that everybody is on the same page, let us start by defining some terms.  Numerous books and articles have characterized different generations into cohorts born during several time periods, with the members of each cohort sharing key societal experiences (e.g., historic events and economic circumstances) when they were all about the same age. Each of these generational groups also generally share common beliefs and behaviors throughout their lifetimes. A recent study by The Sloan Center on Aging and Work at Boston College (Research Highlight March 2009; divided study subjects into the following generational cohorts:

  • Generation Y, or Millennials, or Generation Next, or Generation Net: born after 1980 (age 29 or under in 2010)
  • Younger Generation Xers: born 1972 to 1980 (age 30-38 in 2010)
  • Older Generation Xers: born 1965-1971 (age 39-45 in 2010)
  • Younger Boomers: born 1955-1964 (age 46-55 in 2010)
  • Older Boomers: born 1946 to 1954 (age 56-64 in 2010)
  • Traditionalists, or Matures, or Silents: born before 1946 (65 or older in 2010)

Using these groupings, they made many different comparisons and came up with some interesting differences and similarities about experiences in the workplace. Unfortunately, they did not address the topic of learning styles or training preferences.

Faculty in the Effective Teaching and Learning Department of Michigan’s Baker College have addressed the topic of “Teaching Across Generations” by developing a list of approaches that will generally work with a multi-generational group in a training session (  A few suggestions pertinent to your question include the following:

  • Ask Boomers and Xers to share professional experiences pertinent to the topic
  • Tap into the technological savvy and interest of Xers and Millennials
  • Change activities often – the attention span of a typical adult is only 15-20 minutes
  • Require participation in some form during the session
  • Through practice, find the right mix of guidance and structure for all participants
  • Encourage discussion
  • Provide feedback and encouragement; recognize excellent performers individually

Very little research has been done specifically about how best to teach multi-generational groups, but many authors have a variety of opinions.  An excellent literature review asking the question, “Do generational differences matter in instructional design?” was recently published on-line by Professor Thomas C. Reeves of the University of Georgia ( Some suggestions from this review, although not always based on research, include:

  • Begin with an orientation about what will be covered
  • Assess what learners know at the beginning of the class
  • Continually reinvent your training as you teach the same materials again and again
  • Communicate where to turn for answers
  • Don’t just train the what, train the why
  • Keep training fun, interactive, and engaging
  • Make sure the setting is comfortable
  • Pay attention to the learning styles of the different generations represented
  • Be sure the training has real substance

Although there is a plethora of books and articles about generational differences, most of the information is based on surveys of college students and “knowledge workers.”  Race, ethnicity, culture, and socioeconomic status are variables that are often ignored.  Thus, the results of studies that have been done may not be generalizeable to the wider population of people employed in today’s workplaces. It is also very important not to apply generalizations about groups to individuals, which is why assessing your audience each time you teach is key.

Finally, students always respond positively to an engaged, energetic, and interested instructor. Regardless of the methods you choose to reach your learners, if you are passionate about the subject matter and genuine in wanting the participants to learn what you have to teach them, you will be successful. 

—Submitted by Marguerite Jackson, PhD, RN, FAAN
Formerly Director of Education, Development & Research, U.C. San Diego Medical Center
and Director, Administrative Unit, National Tuberculosis Curriculum Consortium,
UCSD School of Medicine, San Diego, California


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