Education/Training
Program
Goal of The Program
The goal of the training program on treatment and management of MDR-TB incorporates Stop-TB strategy with emphasis on DOTS and MDR-TB treatment and management strategies in TB control. The goal of the training for TB Program managers, physician, nurses working with MDR-TB, social workers and laboratory staff from other countries is to train specialists who after this training course will be able to carry out high quality medical practice (care) in the field,- management of MDR-TB in their representative countries and will be able to train others in MDR-TB management based on experience gained during the training course in Latvia. This will result in a decline in MDR-TB spread in these countries if they successfully implement their own programs. Successful implementation of MDR-TB management will result in considerable financial savings to those countries which implement it since failure to do so will result in even further spread of costly and difficult –to-treat strains of MDR-TB.
Objective
To offer a TB specialist, managers, nurses the chance to acquire necessary theoretical knowledge and practical skills on tuberculosis and MDR-TB Epidemiology, diagnostics, clinics, treatment, case management and program management, data collection and analysis.
General characteristics
The training program on management of TB and MDR-TB encompasses the development of doctors’ professionalism (professional competence) in the field and basic skills needed for carrying out DOTS and DOTS plus programs.
The quality of the educational process and developing of competence of the teaching staff is ensured by the training of teaching doctors in form of courses, seminars, workshops in accordance to study programs.
Organization of the training program
Actual Services Provided by WHO CC up to now
• Communication with participants or donor agencies
• Estimation of needed funds and provision for the training course
• Preparation of curriculum
• Learning material preparation- translation into Russian, English, proofreading, printing, copying (each participant have received learning materials).
• Course implementation- the curriculum was implemented using active teaching methods- lectures, pair/group work and practical work.
Theoretical workshops -video conferences (exchange of experience)
The tuberculosis and multi-drug resistant tuberculosis training program is offered and implemented by teaching doctors of the WHO CC of State Agency of Tuberculosis and Lung diseases of Latvia.
Teaching process
- Teaching will be placed into working days.
- The lengths of the studies will be 9 hours per day (1 study hour-45 minutes).
- Group consists of 3-10 participants.
The group is divided into subgroups when the practical lessons will take place
Operation of the teaching process:
- Registration of the participants
- Accommodation
- Delivery of printed materials and curricula
- Studies
- Transportation
Methods used for evaluation of the training course and participants knowledge, skills and attitude before and after training course:
- Group/pair discussions
- Self-evaluation
- Home tasks
- Multi-choice test
- Questionnaires
- Feedback
Annotation of the of Training Program MDR TB treatment
and management
1. Epidemiology of TB and MDR-TB
- Basics of TB epidemiology
- WHO/IUATLD survey on drug resistance
- Global TB and MDR-TB epidemiology
- MDR/TB and HIV co-infection
- MDR-TB impact on TB control
- Epidemiology XDR TB
2. Program for TB and MDR – TB control
- WHO working group on MDR TB and Green Light Committee (GLC)
- Application to GLC for MDR TB management in resources limited settings
- Experience from pilot projects on MDR-TB management
2.1. Management of MDR – TB framework approach
- Sustained government commitment
- Diagnosis of MDR – TB through culture and DST
- Appropriate treatment strategy utilizing second line anti - TB drugs
- Uninterrupted supply of quality assured drugs
- A recording and reporting system designed for MDR – TB
2.3. International standards of TB care
2.4. Six components of STOP-TB strategy
3. Mycobacteriology
- Role of laboratory services in MDR – TB management
- Specimen’s management and laboratory methods
- Laboratory processing
- Smear microscopy
- Culture of M. tuberculosis
- Identification
- Drugs susceptibility testing (DST)
- WHO recommendation for DST to second line antituberculosis drugs
- Limitations of DST
- Standard and genetic methods for DST
- Rapid diagnostic methods
- Principles for quality assurance for DST
- Drug resistance surveillance
4. Development of drug resistance
- History of TB chemotherapy and drug resistance
- Definitions of drug resistance
- Molecular mechanism of drug resistance
- Development of drug resistance due treatment irregularity
- Factors contributing drug resistance
- The DOTS as a cornerstone to prevent MDR - TB
5. MDR-TB case finding strategies and case definitions
- Risk groups for DR and MDR – TB
- Case finding strategies
• Strategies for programs with no access to DST
• Strategies for programs with access to DST
- General consideration for use of DST
• Use of rapid diagnostic methods
• Use of second line DST
- MDR-TB case definition
- Initial clinical evaluation before MDR-TB treatment is started
6. Treatment of MDR
6.1 Drugs for treatment of MDR - TB
- Classification of anti- tuberculosis drugs
- Pharmacology of I line drugs
- Pharmacology of II line drugs
- Drug dosages and administration
- Adverse effects of I line drugs
- Adverse effects of II line drugs
- Drug interactions
6.2 Management of Tuberculosis drugs adverse effects
- Anaphylaxis and other allergic reactions
- Gastrointestinal disturbances
- Hepatitis
- Electrolytes disturbances
- Nephrotoxicity
- Ototoxicity
- Pheripheral neurophaty
- Hedache
- Psichosis
- Seizures
- Depression
- Hypothireosis
- Musculo-sceletal problems
- Ancillary medications for treatment adverse effects
6.3 Treatment strategies for MDR – TB
- Basic principles for MDR-TB treatment
- Drug selection for MDR-TB treatment
- Standardized treatment regimen (STR)
- Empiric treatment regimen (ETR)
- Individualized treatment regimen (ITR)
- Assessment of DST results to designe treatment regimen
- Duration of injectable agent use
- Duration of treatment
7. MDR – TB treatment monitoring and outcome evaluation
- MDR – TB documentation
- Clinical response
- Bacteriological investigations
• Intervals of testing
• Definitions of conversion
- Radiology
- Other laboratory examinations
- Reassessment of therapy after 4-6 months of treatment
- Clinical assessment of failure of MDR-TB
- Clinical assessment of cure of MDR-TB
- Follow up monitoring after completion of therapy
8. Special situation
- MDR-TB and pregnancy
• Methods of contraception
• Treatment regimen
• Breastfeeding
- MDR-TB and diabetes
- MDR-TB and gastric disorders
- MDR-TB and renal insufficiency
- MDR – TB and liver disorders
- Management of psychiatric patients and seizure for MDR – TB patients
- Substance dependency
9. MDR-TB in children
- Diagnostic of respiratory tract TB in children
- Principles of MDR-TB management in children
- Ambulatory management of TB in children
- Role of contact investigation
10. MDR – TB and HIV
- Clinical presentation and diagnosis of HIV related MDR – TB patients
- MDR – TB treatment for HIV – positive patients
- MDR-TB patient detection among HIV infected
• Establishing treatment regimen for HIV infected
• Timing of MDR-TB treatment
• Side effects
• Efficacy of treatment
- Antiretroviral treatment
• Goals of antiretroviral treatment
• Timing of initiation of ART in adult MDR – TB patients
• Patients monitoring
• Management of drug adverse effects
- Concomitant MDR – TB in children with HIV infection
- Prophylaxis of opportunistic infection
- Immune reconstitution syndrome
11. Extra pulmonary MDR-TB treatment
- TB bones and joints
- TB pleurisies, empiema
- Other sites and organs
12. Adjuvant therapies for MDR-TB treatment
- Nutrition
- Physical activities;
- Physiotherapy;
- Physiotherapy for treatment drug side effects
- Role of surgery in MDR – TB treatment
• Indications for surgery
• Timing for surgery
• Treatment after surgery
• Experience from different countries
- Management of MDR – TB treatment failures
- Palliative/supportive care
- Complications of TB, MDR-TB
13. Case management of TB and MDR-TB
- Teamwork
- The role of nurse
- Case management planning
- Directly observed treatment
- Patient adherence to treatment
- Patient education
- Confidentiality in TB and MDR-TB control
- Legal and ethical in MDR-TB control
- Psychosocial aspects in MDR-TB control
- Social support for TB patients, incentives and enablers
- Psychosocial support
- Communications skills - relationship: patient–health care worker
14. MDR – TB contacts
- Evaluating the risk of MDR – TB in contacts
- Infectiousness of the source case
- Closeness and of MDR – TB exposure
- Management of adult and pediatric contacts of MDR – TB patients
- Management of HIV – positive contacts of MDR – TB patients
- Chemo prophylaxis of MDR-TB
15. MDR-TB reporting, recording, cohort analysis, system of recording and reporting
- Case registration and treatment outcome definitions
- MDR treatment and registration cohort
- Interim and final outcomes
- Recording and reporting system
- Information, recorded in MDR-TB registry
16. Infection control
- TB and MDR-TB transmission in congregate settings
- Measures for reducing TB, MDR – TB transmission in health care settings
- Hierarchy of infection control measures
- Administrative measures/Infection control plan
- Engineering measures – ventilations, HEPA filters
• Measurements and ventilation systems
• Ultraviolet germicidal irradiation
- Personal respiratory protection
• Respirators, surgical masks
• Personal respirator program
- Special areas and procedures
- Sputum collection and cough inducing procedures of infection control
- Patients flow in the TB facility
Practical training is provided individually or in small groups.
Teaching doctor (trainer, educator) is able to ensure a high quality learning process for acquirements of practical skills, secure practical training for trainees.
Materials
MDR-TB treatment manual
These drug cards provide information of therapy for MDR-TB icluding doasages, daily and intermitent regimen, standartized and individual treatment regimens, side effects and dragogramms.
These can be used in their current form or modified and updated for pocal programms.
• Treatment of MDR-TB
• Treatment for MDR-TB/HIV
• Tretament for TB/MDR-TB in children
Gudelines for initiating DOTS, DOTS plus
Handbook provides information how to establish sucessful DOT, follow-up during the course of treatment, supervision of every-day work, quality assurance
Training methods
- Lectures
- Seminars
- Workshops
- Individual/ pair/ group work
- Practice
- Group training with tutor
- Group/ pair training
- Flexible training (with periodical tutoring)
- Video conferencing (lectures and consultations)
- Project work
- Video conferencing (lectures and consultations)
- Project work
- Workshop
Training aids
- Printed (books, manuals, guides)
- Overhead
- Laptop
- Whiteboard
- Flipchart
- Platforms
• PC or compatible
• Microsoft
• Other
- Storage materials
• Floppy/diskette
• CD-ROM
- Software
• Database
• Multimedia
• Other (specify)
- Communication media
• Internet
• Telephone switched network
• Other
- Application
• Data transfer
• Videoconferencing
Methods of evaluation
Methods used for evaluation of the training course and participants knowledge, skills and attitude before and after training course:
- Group/pair discussions
- Self-evaluation
- Home tasks
- Multi-choice test
- Questionnaires
- Feedback
Duration
Course duration depends on Terms of Reference of trainees.
The center offers the folowing opportunities for education and training
International Training: provides intensive clinical and didactic expierence in the diagnosis, managment and treatment of tuberculosis for pulmonary, pediatric, health care providers and social workers
The training: 2;3;4 weeks training includes learning, clinical practices, diagnostic techniques, research methodologies, case managment, surveillance and data managment and DOTS, DOTS plus ( mycobacteriology)
Consultation: a multi disciplinary team consisting of physician, nurse, programmanager, data manager, epidemiologist is available for consultation, as well as for developing and presenting at a co-sponsored training seminar in your community
Tuberculosis Intensive
7-day course for medical providers covering epidemiology, diagnosis, managment and treatment of MDR-TB; laboratory tesiting and infection control. (physicians, physician assistants, nurses who are involved in the care of patients of tuberculosis)
Pediatric tuberculosis
½ day course covering all aspects of pediatric tuberculosis including diagnosis, treatment, case managment, contact tracing, vacination, preventative therapy of children living with susceptible and resistant tuberculosis (physicians, nurses, case managers, school nurses)
Tuberculosis Case Management for nurses
1-day course for nurses providing an overview of public health nursing competence, role of the case manager in tuberculosis, drug managment, confidentiality,
Legal interventions for Tuberculosis Control
½ day course covering patients rights, confidentiality, infection control and legal aspects of TB control
Adjuvant treatment
½ -day course covering, surgery, nutrition and rehabilitation etc.
Social suport
½ day –course covering patient’s rights, benefits, supports
Medical managment of TB in people with HIV
½ day course for medical providers covering screening and anergy testing, risk factors and preventative theraphy, managment of combination therapy and legal issues of confidentiality
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