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Barnowska EJ, Fastenau A, Penna S, Bonkass AK, Stuetzle S, Janssen R. Diagnosing skin neglected tropical diseases with the aid of digital health tools: A scoping review. PLOS DIGITAL HEALTH 2024; 3:e0000629. [PMID: 39374195 PMCID: PMC11458012 DOI: 10.1371/journal.pdig.0000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 09/03/2024] [Indexed: 10/09/2024]
Abstract
Delays in diagnosis and detection of skin neglected tropical diseases (NTDs) pose obstacles to prompt treatment, which is crucial in preventing disability. Recent developments in digital health have given rise to approaches that could increase access to diagnosis in resource-poor areas affected by skin NTDs. This scoping review provides an overview of current digital health approaches that aim to aid in the diagnosis of skin NTDs and provides an insight into the diverse functionalities of current digital health tools, their feasibility, usability, and the current gaps in research around these digital health approaches. This scoping review included a comprehensive literature search on PubMed, EMBASE and SCOPUS, following the PRISMA guidelines. Eleven studies were included in the review and were analysed using a descriptive thematic approach. Most digital tools were found to be mobile-phone based, such as mobile Health (mHealth) apps, store-and-forward tele-dermatology, and Short Messaging Service (SMS) text-messaging. Other digital approaches were based on computer software, such as tele-dermatopathology, computer-based telemedicine, and real-time tele-dermatology. Digital health tools commonly facilitated provider-provider interactions, which helped support diagnoses of skin NTDs at the community level. Articles which focused on end-user user experience reported that users appreciated the usefulness and convenience of these digital tools. However, the results emphasized the existing lack of data regarding the diagnostic precision of these tools, and highlighted various hurdles to their effective implementation, including insufficient infrastructure, data security issues and low adherence to the routine use of digital health tools. Digital health tools can help ascertain diagnosis of skin NTDs through remote review or consultations with patients, and support health providers in the diagnostic process. However, further research is required to address the data security issues associated with digital health tools. Developers should consider adapting digital health tools to diverse socio-cultural and technical environments, where skin NTDs are endemic. Researchers are encouraged to assess the diagnostic accuracy of digital health tools and conduct further qualitative studies to inform end-user experience. Overall, future studies should consider expanding the geographical and disease scope of research on digital health tools which aid the diagnosis of skin NTDs.
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Affiliation(s)
- Ewelina Julia Barnowska
- Department of Health, Ethics & Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Anil Fastenau
- Department of Health, Ethics & Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- German Leprosy and Tuberculosis Relief Association (DAHW), Wuerzburg, Germany
- Marie Adelaide Leprosy Center, Karachi, Pakistan
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Srilekha Penna
- German Leprosy and Tuberculosis Relief Association (DAHW), Wuerzburg, Germany
| | - Ann-Kristin Bonkass
- Department of Health, Ethics & Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sophie Stuetzle
- Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Marie Adelaide Leprosy Center, Karachi, Pakistan
| | - Ricky Janssen
- Department of Health, Ethics & Society, Care and Public Health Research Institute (CAPHRI)/MHeNs School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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El Jiar M, Eliahiai I, Chaib S, Elmorabit K, Mouatakid M, Kharmoum J, Chraibi M. The State of Telepathology in Africa in the Age of Digital Pathology Advancements: A Bibliometric Analysis and Literature Review. Cureus 2024; 16:e63835. [PMID: 39099907 PMCID: PMC11297393 DOI: 10.7759/cureus.63835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/06/2024] Open
Abstract
Telepathology emerges as a vital tool, offering significant promise for enhancing pathology services in Africa, a region historically challenged by healthcare access and resource limitations. This review explores the development, adoption, and impacts of telepathology in Africa through a comprehensive bibliometric analysis and literature review. A methodical search in PubMed for publications up to 2024 revealed 119 pertinent studies, out of which 47 met the inclusion criteria for a focused review on telepathology's role in African healthcare settings. This research has charted a clear trajectory of growing interest in telepathology, as evidenced by the annual increase in related publications and robust international collaboration. It underscores the expanding utility of telepathology in diagnostics, education, and research within Africa, particularly in domains like dermatopathology, neuropathology, and, notably, oncology. The integration of artificial intelligence into telepathology presents new frontiers for enhancing diagnostic accuracy and efficiency. However, the review also identifies persistent challenges such as infrastructural inadequacies, a shortage of skilled professionals, and regulatory hurdles. The study highlights the indispensable role of international partnerships in advancing telepathology in the region. This review proposes a strategic pivot toward "leapfrogging," an approach that allows Africa to skip traditional developmental hurdles by directly adopting cutting-edge technologies and practices.
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Affiliation(s)
- Mohammed El Jiar
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Imane Eliahiai
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Sanae Chaib
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Khalid Elmorabit
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Mohamed Mouatakid
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Jinane Kharmoum
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
| | - Mariame Chraibi
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, MAR
- Department of Pathology, University Hospital Mohammed VI of Tangier, Tangier, MAR
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Razzano D, Puranam K, Tomoka T, Fedoriw Y. The role of telepathology in improving cancer diagnostic and research capacity in sub-Saharan Africa. Front Med (Lausanne) 2022; 9:978245. [PMID: 36325383 PMCID: PMC9618672 DOI: 10.3389/fmed.2022.978245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Non-communicable disease (NCD), including cancer, disproportionately affect Low- and Middle-Income Countries (LMICs). This inequity is in part due to limitations of pathology services, both human and infrastructural. While significant improvements have been made to address these gaps, creative approaches that are mindful of regional priorities, cultural differences, and unique local challenges are needed. In this perspective, we will describe the implementation of telepathology services in sub-Saharan Africa (SSA) that serve as cornerstones for direct patient care, multi-disciplinary care coordination, research programs, and building human capacity through training. Models and challenges of system implementation, sustainability, and pathologist engagement will be discussed. Using disease and site-specific examples, we will suggest metrics for quality control and improvement initiatives that are critical for providing high-quality cancer registry data and necessary for future implementation of therapeutic and interventional clinical trials.
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Affiliation(s)
- Dana Razzano
- Department of Pathology, Stanford University, Stanford, CA, United States
| | - Kaushik Puranam
- School of Medicine, Georgetown University, Washington, DC, United States
| | - Tamiwe Tomoka
- Department of Pathology, UNC Project Malawi Cancer Program, Lilongwe, Malawi
| | - Yuri Fedoriw
- Department of Pathology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- *Correspondence: Yuri Fedoriw
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Kabukye JK, Kakungulu E, Keizer ND, Cornet R. Digital health in oncology in Africa: A scoping review and cross-sectional survey. Int J Med Inform 2021; 158:104659. [PMID: 34929545 DOI: 10.1016/j.ijmedinf.2021.104659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied. AIMS To describe the current landscape of digital health interventions in oncology in Africa. METHODS We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer. RESULTS The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows. CONCLUSION Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.
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Affiliation(s)
- Johnblack K Kabukye
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands; Uganda Cancer Institute, Upper Mulago Hill Road, P.O. Box 3935, Kampala, Uganda.
| | - Edward Kakungulu
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
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Erzer JN, Jaeger VK, Tikly M, Walker UA. Systemic sclerosis in sub-Saharan Africa: a systematic review. Pan Afr Med J 2020; 37:176. [PMID: 33447331 PMCID: PMC7778190 DOI: 10.11604/pamj.2020.37.176.22557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/04/2020] [Indexed: 11/18/2022] Open
Abstract
Systematic studies on connective tissue disorders are scarce in sub-Saharan Africa. Our aim was to analyse the published clinical data on systemic sclerosis (SSc) in sub-Saharan Africa. A systematic review was carried out in accordance with the PRISMA guidelines. We screened the Embase, PubMed and African Health Sciences databases for literature published until March 2018. Searches produced 1210 publications. After abstract and full-text screenings, 91 publications were analysed, and epidemiological information and clinical features extracted. Publications were mostly publications case reports (36%), cross-sectional studies (26%) and case series (23%) and came predominantly from South Africa (45%), Nigeria (15%) and Senegal (14%). A total of 1884 patients were reported, 66% of patients came from South Africa. The patients were between 4 and 77 years old; 83% of patients were female. Overall, 72% had diffuse SSc. Raynaud´s phenomenon was reported in 78% and skin ulcerations in 42% of patients. Focal skin hypopigmentation was common and telangiectasia not frequent. Interstitial lung involvement was reported in 50%, pulmonary hypertension in 30%, heart involvement in 28% of patients. Oesophageal reflux was observed in 70% and dysphagia in 37% of patients. Antinuclear antibodies were positive in 65% of patients. Anti-centromere autoantibodies (9.2%) and RNA polymerase 3 antibodies (7.1%) were rare and anti-fibrillarin most frequent (16.5%). SSc presentations in sub-Saharan Africa differ from those reported in Europe and America by a frequent diffuse skin involvement, focal skin hypopigmentation and a high prevalence of anti-fibrillarin autoantibodies.
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Affiliation(s)
| | - Veronika Katharina Jaeger
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland.,Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Mohammed Tikly
- Division of Rheumatology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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“Teledermatopathology: A Review”. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ren Y, Lv Q, Yue W, Liu B, Zou Z. The programmed cell death protein-1/programmed cell death ligand 1 expression, CD3+ T cell infiltration, NY-ESO-1 expression, and microsatellite instability phenotype in primary cutaneous melanoma and mucosal melanoma and their clinical significance and prognostic value: a study of 89 consecutive cases. Melanoma Res 2020; 30:85-101. [PMID: 31095042 DOI: 10.1097/cmr.0000000000000620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We evaluated the expression of programmed cell death protein-1 (PD-1), programmed cell death ligand 1 (PD-L1), and NY-ESO-1 antigen; the infiltration of CD3+ T cells; and the microsatellite instability (MSI) phenotype, as well as the relationship of each factor to survival in malignant melanoma patients. Malignant melanoma samples from 89 patients were stained by immunohistochemistry to evaluate PD-1, PD-L1, CD3+ tumor-infiltrating lymphocytes (TILs), NY-ESO-1, and MSI. PD-1 and PD-L1 were expressed in 19.1 and 32.6% of the 89 samples, respectively. There was a significant correlation between PD-1 and PD-L1 expression (r = 0.207, P = 0.046). High infiltration of CD3+ T cells was observed in 41.6% of the samples, and increased cell infiltration was associated with increased PD-1 expression (P = 0.001). NY-ESO-1 antigen was detected in 13.5% of all samples, and the expression of NY-ESO-1 was positively correlated with the expression of PD-1 (P < 0.001). In our research, MSI was detected in 18 samples (20.2%). Survival analysis showed that a high infiltration of CD3+ T cells was related to longer progression-free survival (PFS) [24.0 months, 95% confidence interval (CI): 7.4-40.6 vs. 11.0 months, 95% CI: 7.1-12.9, P = 0.031], similarly, the median overall survival (OS) of the CD3+ T cell high-infiltration patients was also longer (53.0 vs. 38.0 months), but with no statistical significance (P = 0.200). The results for the immune markers mentioned above provide a theoretical basis for the prognosis and immunotherapy selection of malignant melanoma patients.
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Affiliation(s)
- Yu Ren
- Department of the Comprehensive Cancer Center, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School
| | - Qing Lv
- Yi Xing Tumor Hospital, Yixing, China
| | - Wuheng Yue
- Department of the Comprehensive Cancer Center, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School
- The Comprehensive Cancer Center, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing
| | - Baorui Liu
- Department of the Comprehensive Cancer Center, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School
| | - Zhengyun Zou
- Department of the Comprehensive Cancer Center, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School
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Montgomery ND, Tomoka T, Krysiak R, Powers E, Mulenga M, Kampani C, Chimzimu F, Owino MK, Dhungel BM, Gopal S, Fedoriw Y. Practical Successes in Telepathology Experiences in Africa. Clin Lab Med 2018; 38:141-150. [PMID: 29412878 PMCID: PMC5996143 DOI: 10.1016/j.cll.2017.10.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Across much of Africa, there is a critical shortage of pathology services necessary for clinical care. Even in settings where specialty-level clinical care, such as medical oncology, is available, access to anatomic pathology services has often lagged behind. Pathology laboratories in the region are challenging to establish and maintain. This article describes the successful implementation of telepathology services in Malawi and reviews other successful programs developed to support diagnostic pathology in resource-limited settings.
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Affiliation(s)
- Nathan D Montgomery
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, CB 7525, Chapel Hill, NC 27599-7525, USA
| | - Tamiwe Tomoka
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Robert Krysiak
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Eric Powers
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, CB 7525, Chapel Hill, NC 27599-7525, USA
| | - Maurice Mulenga
- Kamuzu Central Hospital, Tidziwe Centre, PO Box 149, Lilongwe, Malawi
| | - Coxcilly Kampani
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Fred Chimzimu
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Michael K Owino
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | | | - Satish Gopal
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi; Lineberger Comprehensive Cancer Center, CB 7295, Chapel Hill, NC 27599-7295, USA
| | - Yuri Fedoriw
- Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, CB 7525, Chapel Hill, NC 27599-7525, USA; Lineberger Comprehensive Cancer Center, CB 7295, Chapel Hill, NC 27599-7295, USA.
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Utility of international store-and-forward teledermatopathology among a cohort of mostly female patients at a tertiary referral center in Afghanistan. Int J Womens Dermatol 2017; 4:83-86. [PMID: 29872681 PMCID: PMC5986254 DOI: 10.1016/j.ijwd.2017.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 11/24/2022] Open
Abstract
Background The variety and complexity of dermatologic diseases in Afghanistan and the associated diagnostic resource constraints have not been previously studied. Moreover, the utility of store-and-forward teledermatopathology in this resource-limited setting has not been investigated. Methods A retrospective analysis was conducted of 150 store-and-forward teledermatopathology cases that were composed of a clinical history, clinical images, and histologic images that were sent from an academic teaching hospital in Kabul to a dermatology-trained dermatopathologist at Emory University in the United States between November 2013 and June 2017. For each case, the histologic impression of the Emory dermatopathologist was compared with that of the Kabul-based general pathologist and the clinical differential diagnosis and histologic impression of the Kabul-based dermatologist. Results Eighty-one of the cases that were analyzed were from female patients. The diagnosis after telepathology consultation differed from the first entity in the clinical differential diagnosis in 34.7% of cases. The telepathology consultation refined the Afghan general pathologist’s histologic impression 45.5% of the time and the Kabul-based dermatologist’s histologic impression 24.3% of the time. A clinically significant difference in care was made in 19.3% of cases for which an analysis could take place between the histologic impressions of the Emory dermatopathologist and U.S.-trained dermatologist. The most common resource constraints that limited a definitive diagnosis were the inability to perform infectious stains and cultures to identify specific pathogens (19.3% of cases) and immunofluorescence studies to confirm autoimmune bullous disease (6.7% of cases). Conclusions These results highlight the important diagnostic role that teledermatopathology can serve in resource-limited settings such as in Afghanistan.
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Chang A, Kiprono S, Maurer T. Providing dermatological care in resource-limited settings: barriers and potential solutions. Br J Dermatol 2017; 177:247-248. [DOI: 10.1111/bjd.15372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- A.Y. Chang
- Department of Dermatology; University of California; San Francisco; School of Medicine and University of California Global Health Institute; San Francisco CA U.S.A
- Academic Model Providing Access to Healthcare; Eldoret Kenya
| | - S.K. Kiprono
- Academic Model Providing Access to Healthcare; Eldoret Kenya
- Department of Medicine; Moi University School of Medicine; Eldoret Kenya
| | - T.A. Maurer
- Department of Dermatology; University of California; San Francisco; School of Medicine and University of California Global Health Institute; San Francisco CA U.S.A
- Academic Model Providing Access to Healthcare; Eldoret Kenya
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