Drug-resistant tuberculosis (DR TB) is an important challenge for clinicians. With the introduction of molecular diagnostic tests, such as the Xpert MTB/RIF assay and Line Probe Assays, the notification of DR TB is increasing and the time to diagnosis can be shortened, allowing earlier treatment initiation. Shorter treatment regimens (STR) of nine months duration are now also recommended by WHO, thus simplifying treatment for patients and National TB Programs alike. Bedaquiline and Delamanid, two new TB drugs, have been approved for use under defined conditions. Clinicians require training in the use of these new diagnostic tools and in making informed choices for treatment initiation and monitoring and in adequate and timely clinical decision making. Moreover, there is a need to contextualize generic guidelines making them applicable to local settings.
This blended course offers interdisciplinary and interactive training on clinical aspects of DR TB diagnosis and care. It consists of an eight-week online training (8 hours/week) followed by nine days face-to-face.
The following subjects will be addressed:
- identification of persons to be evaluated for DR TB
- epidemiology of DR-TB in the participant’s setting
- diagnosis of DR TB using phenotypic and genotypic methods
- dealing with discordant diagnostic test results
- DR TB classification
- activity and therapeutic efficacy of the different TB drugs and regimens
- criteria for choosing the most appropriate treatment regimens, with a special focus on the STR
- clinical-decision making, and the concept of treatment threshold
- design of treatment regimens for patients with adverse drug events and/or resistance to one or more DR-TB drugs
- management of DR TB patients with co-morbidities
- monitoring of treatment effectiveness (including efficacy and tolerance), surveillance of drug-resistance
- DR TB care program implementation, including new drugs and regimens
During the online part the case studies are provided by the course faculty. During the F2F part, case studies are provided by the faculty and the participants.
Online module (includes a break of 2 weeks):
- 8 weeks address the following subjects:
- Epidemiology of DR TB in the participant’s setting (1 week, LO 1)
- Phenotypic and genotypic diagnostic tests for DR TB (2 weeks, LO 1)
- Drugs and regimens for DR TB treatment (2 weeks, LO 1)
- Clinical decision making in DR TB (2 weeks, LO 1 & 2)
- Implementation of new drugs and regimens (1 week, LO 1 & 3)
- Each week contains an interactive lecture, an interactive discussion platform, and an assignment
- Each week corresponds with an average of 8 hours student investment time
- Interpretation of DST results and implications for treatment in the setting of the participants and lab visit (2.5 days; LO 1 & 3)
- Interpretation and discussion of exclusion criteria for the STR
- Challenges with clinical care for complex cases, such as extensively drug-resistant TB, co-morbidities, adverse drug reactions, … (3.5 days; LO 1 & 3)
- Discuss practices concerning treatment delivery options, prevention of drug resistance, monitoring and surveillance of drug resistance (1 day; LO 1 & 3)
- Clinical decision-making: agree on a threshold to diagnose multidrug-resistant TB (1 day; LO 1 & 2)
- Apply guidelines and evidence to case studies presented by participants and faculty (daily during the lectures, plus one full day for the assessment of the personal project; LO 1 & 3)
- Each day includes a wrap up of take home messages of the previous day, case study presentation and debate of questions related to the learning objectives and the presented case study, and short lectures.
- Each day corresponds with an average of 8 hours student investment time
Teaching and learning methods
At application, a brief written description of a topic that highlights challenges with diagnosis and/or the treatment of DR TB (including the clinical problem description, type of patients affected, the importance of the problem, and how clinicians currently deal with this problem in his/her own setting; max length: ½ A4) is required. This topic will be further developed as a case study during the course.
Learning methods include:
- Problem-based learning: During both the online and face to face part, case studies are used. As such, the learning experience fits as much as possible the problems experienced by participants in their programmatic setting. Moreover, face-to-face sessions often start with a case study presentation. Case studies are followed by an interactive debate between participants and experts. At the end of a session, the expert provides a lecture to complement the debate. As such the theory aligns well with the problems identified by participants.
- Flipped learning: During the online part course participants prepare for the face-to-face debates. Most of the theory will be digested at home, which allows students to use the precious class time for interaction with peers and experts. Participants have access to guidelines and other sources of evidence for consultation, and gaps in the evidence base are identified. In addition, challenges and achievements in diagnosing and treating DR TB, as experienced by the participants, will be discussed. The 9 days face-to-face builds further on the content addressed during the online part, and includes group discussions, case presentations, summaries of key learning points by students, and interactive lectures (didactic lecturing accounts for 30% of the contact hours).
- Social constructivism: Course participants will construct their knowledge through debates with peers and experts, and group work
- Alberto Piubello, Damien Foundation and The Union
- Anita Mesic, Médecins Sans Frontières Operational Centre Amsterdam
- Armand Van Deun, Damien Foundation and Institute of Tropical Medicine Antwerp, Department of Biomedical Sciences
- Bouke de Jong, Institute of Tropical Medicine Antwerp, Department of Biomedical Sciences
- Emmanuel Andre, Université catholique de Louvain, Brussels
- Gunta Dravniece, KNCV Tuberculosis Foundation
- Hans Rieder, University of Zurich
- Leen Rigouts, Institute of Tropical Medicine Antwerp, Department of Biomedical Sciences
- Lut Lynen, Institute of Tropical Medicine Antwerp, Department of Clinical Sciences
- Tom Decroo, Institute of Tropical Medicine Antwerp, Department of Clinical Sciences
Summative assessment of the participants is based on participation during the online part (exercises/assignments based on case studies presented by faculty and online discussions) and development of a case study originating from the participant’s own context with a presentation of recommendations at the end of the face-to-face part.
Final score calculation:
The final score is based on five online assignments (1. Critical review of DR-TB cascade in their country, 2. Analysis of DR-TB diagnostic methods available in their country and a proposal for a diagnostic flowchart, 3. Peer review and feedback on the diagnostic flowchart of other participants, 4. Discussion on challenges to access new DR-TB drugs and regimens, 5.Quiz on the building of a conventional and short MDR-TB regimen) during the online part (50%) and a personal project during the F2F part; analysis of a case study with recommendations for DR-TB care contextualized to the setting of the participants (50%). This personal project is presented and defended in front of a jury of DR-TB experts. This final assessment includes 10 minutes presentation and 10 minutes for “questions and answers”.
- As the face-to-face part builds on the online part, participants who fail to participate during the online part in at least 7 out of 8 discussion forums will not be allowed to join the face-to-face part in Antwerp; participants also fail if they don’t submit all 5 online assignments
- Criteria for the score on the presentation of the case study during the face-to-face part will consist of the following:
- introduction (context of the program, patient history, clinical presentation, available lab results) & problem statement;
- formulation of recommendations for diagnostic tests and treatment within the current program;
- balance benefit / harm of clinical decisions;
- formulation of recommendations for implementation of new diagnostic tools / treatment to treat optimally the described case.
Remark: The case study presented as final assessment differs from the first presentation of the case study. The focus of the first presentation (during class hours) is on presenting the context and the clinical challenge in the field of DR TB prevention, diagnosis and/or treatment, while the second presentation focusses on recommendations for clinical DR TB care and the DR TB program, to illustrate the take home messages the student retrieved from participation during the DR TB course.
Resit: A student who does not comply with the entry criteria for the F2F part, cannot do a resit of the online part. A student who fails to reach a total score of 50% on the final case study presentation, can present a revised final assignment through skype.
The course targets clinicians working in the field of DR TB.
- Participants should be holders of a university degree in medicine (min. 4 years) equivalent to 240 ECTS (referred to as a Master degree in the European Union).
- Proficiency in English is required. If your university studies were done in English: you are exempted of a language certificate. If this is not the case: an officially recognised proficiency language certificate is mandatory. Required level for English: TOEFL paper-based 580, computer-based 230, Internet-based 88 or IELTS 6.5 (ITM Toefl Code 7727).
- To participate in the online and the face-to-face course, access to a computer and internet connection is required. We strongly suggest to use Mozilla firefox or Google Chrome in order to access our website (Internet explorer is not 100% compliant).
- Only if you want to apply for a DGD scholarship: at least two years of professional experience is required. (Other requirements for the DGD scholarship: please check http://www.itg.be/E/scholarships).
Candidates will be selected based on the following criteria:
- Active work experience in DR TB care
- Previous attendance in DR TB courses
- Profile as shown in the Curriculum Vitae
- Motivation letter (including a description of the challenges in DR TB care you are confronted with and the commitment from own home institution in supporting your application)
- Two reference letters (including a description of the applicant’s involvement in DR TB care)
- A written description of a topic that shows challenges with diagnosis and/or the treatment of DR TB