Title: Clinical Decision-Making for Drug-Resistant Tuberculosis (Acronym DR-TB)
Keywords: Treatment
Microbial resistance
Medical & Clinical sciences
Country: Belgium
Institution: Belgium - Antwerp Institute of Tropical Medicine
Course coordinator: Prof Dr Lutgarde Lynen (ITM Clinical Sciences Department)
Prof Dr Bouke de Jong (ITM Biomedical Sciences Department)
Date start: 2023-02-27
Date end: 2023-05-26
About duration and dates: Application deadline 12 weeks before the first course day; Online course: 8 weeks and Face-to-face: 9 days
Classification: advanced optional
Mode of delivery: Blended-learning
Course location: Institute of Tropical Medicine (ITM), Nationalestraat 155, 2000 Antwerp, Belgium
ECTS credit points: 5 ECTS credits
SIT: Online asynchronous, including 2 webinars for the distance learing component: 10 hours/week, divided as 8 hours/week for each online module and 2 hours/week for the group work= 80 hours SIT.

Face-to-face:7.5h/day = 67.5 contact hours.

Total = 147.5 contact hours
Language: English
Description: After completion of the course, participants should be able to:
● Characterize the problems with DR-TB in their country in terms of occurrence, diagnosis and treatment, using available data.
● Assess harm and benefits of clinical decisions in the field of DR-TB diagnosis and treatment.
● Appraise evidence-based recommendations for DR-TB diagnosis and treatment for case studies presented by participants and faculty.
● Contextualize these evidence-based recommendations to their own setting.
● Formulate recommendations to prevent the emergence of DR during treatment and preserve treatment options in their own context.
Assessment Procedures: Summative assessment of the participants is based on knowledge check (60% of the final grade) and group work assignments (40% of the final grade).

Knowledge check:
At the end of a specific module of the distance learning component a knowledge check (based on MCQs) will be available on Moodle and students will have one week to complete it by one attempt. The passing mark for each knowledge check is 60%.
A second attempt for all knowledge checks will be available during the “second recap week”. The highest score will be considered for the final knowledge check calculation.
Flat average of all knowledge check scores will be calculated as the “overall knowledge check score”, which contributes 60% to the final course grade calculation.

Group Work Assessment:
During the distance learning component of the course students will have to submit three assignments for the group work. Marking of each assignment will be done by the group facilitator (peer-review, alumni) and a faculty member. Flat average will be considered as the final score.

Rubrics for marking of the assignments and the final presentation are available in the Annex.

The group assignment will be marked during the online component of the course (60% of the group work total mark) and during the final in person presentation, in front of the expert panel (40% of the group work total mark). The marking will be done for the group and not the individual.
The group work score (Annex) will contribute 40% to the final course grade calculation.
Note: Active participation during the group work is obligatory and students who do not actively contribute to group assignments will not be eligible for the calculation of the final course grade. A rubric to assess individual participation in group work is used and shared with the students.
The final course grade is calculated from the knowledge checks (contributing 60%) and the group work final score (contributing 40%). The passing final grade is a minimum of 50%.

Resit: A student who fails to reach a final minimum grade of 50% will have an opportunity for one resit:
● For a student who fails to reach >60% of the final knowledge check score a resit exam will be available on Moodle during the week after the face-to-face course.
● A student who fails to reach a total score minimum 50% on the final group assignment will be asked to present a revised final assignment based on their own case study, within two weeks from the end of the course.
Content: Online course curriculum:
- Epidemiology of RR-TB
- RR-TB diagnostic and treatment gaps
- Principles of diagnostic test characteristic
- Performance characteristics of TB diagnostic tests
- Drug resistance testing and clinical decision making
- The therapeutic threshold
- Diagnosis of TB
- Diagnosis of rifampicin resistance
- Sample transport for diagnostic analyses of MTB
- Interpretation of contradicting test results (+ 2 case studies)
- Practical differences between lab tests
- Lab requirements
- Resistance to other first-line drugs
- Resistance to second-line drugs
- Future perspectives (Next Generation Sequencing)
- Treatment monitoring
- Anti-bacteriological characteristics of drugs used in TB treatment
- Approach to TB treatment-basic concepts
- Evolution of the recommendations for the treatment of DR-TB
- Individualised treatment regimen
- DR-TB in pregnancy – learning by case study
- DR-TB and diabetes melitus - learning by case study
- DR-TB and HIV - learning by case study
- Monitoring of adverse events - general
- Management of common adverse events
- Management of peripheral neuropathy
- Optic neuritis
- Psychiatric disorders during TB treatment
- ECG monitoring

Face-to-face course curriculum
- Pre and post-test probability: case discussions and Excel Engine
- Therapeutic threshold and test-treatment threshold
- Nominal group technique
- Molecular diagnostics- from Xpert to sequencing
- Sample collection and transport
- Phenotypic DST- old and new approaches
- Strengths and limitations of drug susceptibility testing
- Treatment monitoring
- Impact of initial resistance on the outcome of standard regimens
- How do anti-TB drugs work
- Evidence-base of WHO TB guidelines - a closer look
- Effect of INH resistance
- Nation-wide management of DR-TB treatment – Example of Niger
- Modified shorter standardized DR-TB regimens
- Short Oral Treatments- what is known?
- Implementation of Short Oral Treatment- Example of Ukraine
- Implementation of Short Oral Treatment- Example of Afghanistan
- DR-TB prophylaxis – current state of knowledge
- DR-TB in children
- Person Centered Care for specific populations (adolescents, conflict settings)

Group work:
Group work will start during the DL and continue during the F2F component of the course. Students will be divided in groups, based on the problem described in their case discussion (submitted during the application for the course). During the DL component students will develop case series to present and summarize clinical challenge of DR-TB management and to propose solutions for it in their specific contexts. During the face to face course, they will present the case series and discuss further options with DR-TB course experts. Group work is facilitated by the course alumni and one of the ITM DR-TB Course faculty members.
Methods: At application, a written description of a topic that shows 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 their own setting) is required. This topic will be further developed in the course group work as a case study/case series. During the distance learning part each week contains an interactive lecture, interactive discussion platform and there are three group work assignments scheduled during this part of the course. Each week corresponds to an average 10 h or student investment time.

Problem-based learning: During both distance learning and face-to-face, 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: The 9 days face-to-face builds further on the content addressed during the online part, and includes group discussions, case presentations, summary of key learning points by students, and interactive lectures (didactic lecturing takes 30% of the contact hours) on interpretation of different diagnostic tests (2 days), treatment of DR-TB (4 days) and implications of treatment, clinical decision-making (2 days), and the presentations of the final group assignment (1 day) including discussions and formative assessment by DR-TB experts.

Social constructivism: Course participants will construct their knowledge through group work and debates with peers and the faculty.
Prerequisites: The course targets clinicians working in the field of DR-TB.

Participants should:

● Have a university degree in medicine or relevant field (equivalent to 240 ECTS);
● Candidates who are non-native English speakers or who have not already successfully completed higher education in English, must be able to prove their language proficiency with a certificate from a recognized institution (required level: TOEFL Internet-based 88, IELTS 6.5 or CEFR C1 or equivalent. (ITM TOEFL Code: 7727).
● Candidates should have access to a computer and internet connection to be able to participate in the DL part of the course.

To participate in the F2F part of the course student needs to meet the following requirements:
● Completion of minimum of 80% of all DL Modules
● Active participation in the group work
● Submission of assignments 1, 2 and 3 of the group work.
Maximum number 25 (no limit for tropEd students), Minimum: 12
Candidates are selected based on the following criteria:
● Active work experience in DR-TB care.
● Profile as shown in the Curriculum Vitae.
● Motivation letter (including a description of the challenges in DR-TB care they are confronted with and the commitment from own home institution in supporting their application).
● A written description of a topic (case study) that shows challenges with diagnosis and/or the treatment of DR-TB.
730 euro (EEA-student) / 1900 euro (non-EEA)
ITM offers a limited number of scholarships with the financial support of different agencies. The Belgian Directorate General for Development is the main sponsor.

www.itg.be > education > scholarships:
Major changes since initial accreditation: Content of the course is updated every year, because the field of DR-TB care is rapidly changing. Every year we incorporate lectures that reflect on the new evidence and recommendations for the clinical and programmatic management of DR-TB care. We have also expanded our curriculum based on the feedback from the course participants, that demanded specific lectures related to management of DR-TB in specific populations and/or contexts.

Assessment procedure changed to allow more emphasis on the group work, rather than marking student activity during the online (distance learning phase). Group work allows students to interact among themselves during the distance learning (online) phase of the course. It allows them to gain in depth knowledge on specific challenges in DR-TB case management and to learn from their peers coming from different settings; all of this supervised and supported by the facilitators and tutors.

Knowledge check component of the assessment (multiple choice questions) remained the same.
Student evaluation: Positive – major highlight:
Teaching methods that include problem (solution)-
based teaching and demonstration through the real clinical and programmatic cases demonstrated by the lecturers were highly appreciated. Focus on debate and discussion, that provokes interaction and critical thinking among the students and between students and the faculty, was enjoyed by the vast majority of the students every year.

Negative – major highlight
Major challenge to follow up online (distance learning) programme is access to good internet connection. Workload during distance learning modules is > 6 hours/week (as previously stated). More group work (interactive) during some of the face-to-face lectures recommended.
Lessons learned: - Important to keep interactive learning.
- Lectures should always be presented through real life clinical or programmatic cases, rather than passive knowledge sharing.
tropEd accreditation:
Accredited in Antwerp GA, October 2017 and re-accredited in EC Telco in May 2023. This accreditation is valid until May 2028.
Remarks: The course faculty consists of internal (ITM) and external TB experts:
● Alberto Piubello, Damien Foundation
● Armand Van Deun, Damien Foundation
● Conor Meehan, Nottingham University
● Emmanuel Andre, University Hospital Leuven
● Gunta Dravniece, PATH, Ukraine
● Howard Takiff, Pasteur Institute
● Jay Achar, Global Health & Infectious Diseases Consultant
● Chinmay Laxmeshwar, Médecins Sans FrontièresFrontières, India
● Khosa Celso, National TB Programme, Mozambique
● Emmanuel Bottieau, ITM, Department of Clinical Sciences
● Bouke de Jong, ITM, Department of Biomedical Sciences
● Elisa Ardizzoni, ITM, Department of Biomedical Sciences
● Leen Rigouts, ITM, Department of Biomedical Sciences
● Jihan Snobre, ITM, Department of Biomedical Sciences
● Ellen Mitchell, ITM, Department of Public Health
● Anita Mesic, ITM, Department of Clinical Sciences and Médecins Sans Frontières
● Lut Lynen, ITM, Department of Clinical Sciences
● Tom Decroo, ITM, Department of Clinical Sciences

Key readings:
● Global Tuberculosis Report 2021: https://www.who.int/publications/i/item/9789240037021
● WHO recommendations for the management of DR-TB, 2022: https://www.who.int/news/item/02-05-2022-who-issues-rapid-communication-on-updated-guidance-for-the-treatment-of-drug-resistant-tuberculosis
● Aquired bedaquiline resistance – systematic review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8963286/
Email Address: bbroucker@itg.be
Date Of Record Creation: 2017-10-22 16:23:24 (W3C-DTF)
Date Of Record Release: 2017-10-22 20:37:38 (W3C-DTF)
Date Record Checked: 2017-10-22 (W3C-DTF)
Date Last Modified: 2023-06-01 09:25:55 (W3C-DTF)