Teledermatology Use in Remote Areas of French Guiana: Experience From a Long-Running System

Does the Diagnostic Accuracy and Rates of Face-to-Face Visits Occurring Shortly after an Asynchronized Teledermatology Consultation Justify Its Implementation? An 18-Month Cohort Study

INTRODUCTION

In 2019, Maccabi Health Services (MHS) rolled out the store-and-forward "Dermadetect" teledermatology consultation (TC) application. Study goal was to analyze MHS records of TCs (August 2019-February 2021) for the rate and reasons for face-to-face consultations (FTFC) occurring shortly after a TC with emphasis on FTFCs resulting in a different diagnosis for the same indication.

METHODS

The records of FTFCs held up shortly after TCs were reviewed and classified into cases marked as unsuited for teledermatology, cases in which the indication differed, and cases with the same indication, which were analyzed for concordance of diagnoses.

RESULTS

Dermadetect was used by 12,815 MHS beneficiaries. In 30% of cases, following FTFC occurred within the subsequent 5 months, and 901 of them occurred in the subsequent 2 weeks and were analyzed. Thirty percent were not suited for teledermatology, 15% were held for a different indication, and 55% occurred for the same indication. The diagnosis concordance between the TC and recurrent FTFC for the same indication was 97.4%, with full concordance at 68.1% and partial concordance at 29.3%. Overall, 13 patients (1.4%) of the 901 patients using the application only once had a subsequent FTFC within 2 weeks and received a different diagnosis than the one given in the TC.

CONCLUSIONS

When considering the implementation of store-and-forward TC's, a 30% rate of following FTFC's during the next 5 months should be considered when planning the reimbursement model. Diagnosis discordance may be disregarded due to its low rates.

Teledermatology to Improve Access to and Quality of Skin Care in Eastern Indonesia

Skin diseases are a major public health concern in Indonesia, although access to specialized care in remote areas is limited. We initiated a low-cost teledermatology service in Sumba, a remote island in eastern Indonesia. Eighteen healthcare workers (HCWs) at five primary healthcare centers received training to manage common skin diseases and submit clinical cases beyond their expertise to an online platform. Submitted cases were reviewed by at least one dermatologist. Diagnostic agreement between HCWs and dermatologists was calculated. The HCWs participated in a satisfaction survey 2 years after project initiation. Since October 2020, of 10,384 patients presenting with skin complaints in a 24-month period, 307 (3%) were submitted for a teledermatology consultation. The most frequent skin diseases were infections and infestations (n = 162, 52.8%) and eczematous (85, 27.7%) and inflammatory (17, 5.5%) conditions. Fifty-three patients (17.3%) were diagnosed with a neglected tropical skin disease, including leprosy and scabies. Dermatologist advice was provided within a median of 50 minutes (interquartile range, 18-255 minutes), with 91.9% of consultations occurring within 24 hours. The diagnostic agreement level between HCWs and dermatologists significantly improved over time, from 46.9% in the first 6-month period (κ = 0.45; 95% CI, 0.37-0.54) to 77.2% in the last 6-month period (κ = 0.76; 95% CI, 0.67-0.86; global P < 0.001). The HCWs reported that the teledermatology service was extremely/very useful in supporting daily practice (100%) and improved their knowledge of skin diseases tremendously/a lot (92%). Teledermatology can improve accessibility and quality of skin services in medically underserved areas, providing opportunities for scalability and knowledge transfer to frontline HCWs.

Emerging computational technologies in human leishmaniasis: where are we?

Human leishmaniasis is a neglected tropical disease (NTD) with high morbidity and is endemic in low- to middle-income countries. Its diagnosis, treatment and epidemiological control methods are outdated and obsolete, which has become a challenge for health practitioners in controlling the disease. Computational methods have proven to be beneficial and have become popular in many fields of medicine, especially in affluent countries. However, they have not been widely used for NTDs. To date, few computational technologies have been employed for leishmaniasis. Although new technologies in leishmaniasis are theorized, they have only been minimally applied and have not been updated, even in other infections. Research and development on NTDs suffers from the inherent difficulties of the demographic regions the diseases afflict. In this narrative review we described the e-tools available in managing leishmaniasis, ranging from drug discovery to treatment.

Teledermatology in Rural, Underserved, and Isolated Environments: A Review

Purpose of Review

Recent Findings

Summary

Quantifying Population Burden and Effectiveness of Decentralized Surveillance Strategies for Skin-Presenting Neglected Tropical Diseases, Liberia

We evaluated programmatic approaches for skin neglected tropical disease (NTD) surveillance and completed a robust estimation of the burden of skin NTDs endemic to West Africa (Buruli ulcer, leprosy, lymphatic filariasis morbidity, and yaws). In Maryland, Liberia, exhaustive case finding by community health workers of 56,285 persons across 92 clusters identified 3,241 suspected cases. A total of 236 skin NTDs (34.0 [95% CI 29.1–38.9]/10,000 persons) were confirmed by midlevel healthcare workers trained using a tailored program. Cases showed a focal and spatially heterogeneous distribution. This community health worker‒led approach showed a higher skin NTD burden than prevailing surveillance mechanisms, but also showed high (95.1%) and equitable population coverage. Specialized training and task-shifting of diagnoses to midlevel health workers led to reliable identification of skin NTDs, but reliability of individual diagnoses varied. This multifaceted evaluation of skin NTD surveillance strategies quantifies benefits and limitations of key approaches promoted by the 2030 NTD roadmap of the World Health Organization.

Spectrum of skin diseases in Maroon villages of the Maroni area, French Guiana

BACKGROUND

Due to their genetic characteristics and their high exposure to infectious diseases, Maroons are likely to suffer from a specific spectrum of skin diseases. However, skin disorders have never been explored in this population. We aimed to describe all skin diseases in Maroon villages of the Maroni region in French Guiana.

METHODS

This retrospective study concerned all patients who consulted in the remote health centers of Apatou, Grand-Santi, Papaichton, and Maripasoula between October 5, 2017, and June 30, 2020. We included all patients registered with a skin disorder (International Classification of Diseases) in the medical database. We excluded patients whose diagnosis was invalidated after cross-checking by a dermatologist.

RESULTS

A total of 4741 patients presented at least one skin disease, for 6058 different disorders. Nonsexually transmitted infections represented 71.6% of all diagnoses, followed by inflammatory diseases (9.8%) and bites/envenomations (4.6%). The three most frequent conditions were scabies, abscesses, and impetigo. Besides scabies, neglected tropical diseases (NTDs) were still prevalent as we reported 13 cases of leprosy and 63 cutaneous leishmaniasis. Atopic dermatitis (AD) represented only 2.5% of our diagnoses.

CONCLUSIONS

With the exception of AD, which was less frequent among Maroons, these results are similar to those previously reported in Amerindians. Therefore, a common exposure to rainforest pathogens seems to induce a common spectrum of skin diseases dominated by infections. The high prevalence of NTDs requires specific public health actions.

Teledermatology in the Control of Skin Neglected Tropical Diseases: A Systematic Review

Introduction

Neglected tropical diseases (NTDs) include a group of about 20 illnesses that have garnered relatively little attention, despite their ability to inflict significant suffering and disability. Skin neglected tropical diseases (sNTDs) are a subset of NTDs that present with cutaneous manifestations and are well known for their ability to generate stigma and promote poverty. Teledermatology (TD) represents a potential method to control sNTDs.

Objective

We sought to analyze the potential for TD to ease the burden of sNTDs.

Methods

We performed a systematic literature search using the Texas Medical Center Library One Search, which scans 167 databases, including Embase, PubMed, and Scopus. We included all original investigations published after 2011 that assessed the impact of TD intervention in the control of one or more sNTDs. We excluded studies not written in English and studies that did not perform any outcome analyses.

Results

Twenty studies met our search criteria, and 18 expressed positive attitudes towards TD. Overall, we found that TD may be a sustainable, cost-effective strategy for expanding access to care for individuals afflicted with sNTDs. However, poor image quality, lack of access to further diagnostic tests, and ethical, legal, and cultural issues pose as barriers to TD utilization.

Conclusion

TD may be helpful in achieving control of sNTDs but has its limitations. An integrated approach, which employs TD in conjunction with other strategies, represents a realistic path for alleviating sNTDs.

International Teledermatology Review

Purpose of Review

The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Improving technology and the recent COVID-19 pandemic have hastened its use internationally.

Recent Findings

Some barriers to the use of teledermatology have fallen considerably in the last year.

Summary

Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and variable use within countries. Many barriers remain to increasing the use of teledermatology.

Referral Activity in Three Store-and-Forward Networks during the COVID-19 Coronavirus Pandemic

We surveyed three well-established store-and-forward telemedicine networks to identify any changes during the first half of 2020, which might have been due to the effect of the COVID-19 coronavirus pandemic on their telemedicine operations. The three networks all used the Collegium Telemedicus system. Various quantitative performance indicators, which included the numbers of referrals and the case-mix, were compared with their values in previous years. Two of the three networks surveyed (A and B) provided telemedicine services for any type of medical or surgical case, while the third (network C) handled only pediatric radiology cases. All networks operated in Africa, but networks A and C also provided services in other resource-constrained regions. Two of the networks (networks B and C) used local staff to submit referrals, while network A relied mainly on its expatriate staff. During the first half of 2020, the numbers of referrals received on network B increased substantially, while in contrast, the numbers of referrals on network A declined. All three networks had relatively stable referral rates during 2018 and 2019. All three networks delivered a service that was rated highly by the referrers. One network operated at relatively high efficiency compared to the other two, although it is not known if this is sustainable. The networks which were more reliant on local referrers saw little reduction—or even an increase—in submitted cases, while the network that had the most dependence on international staff saw a big fall in submitted cases. This was probably due to the effect of international travel restrictions on the deployment of its staff. We conclude that organizations wanting to build or expand their telemedicine services should consider deliberately empowering local providers as their referrers.

A systematic review of handheld tools in lieu of colposcopy for cervical neoplasia and female genital schistosomiasis

Background

Visualization of the lesions in the lower genital tract is the mainstay for diagnosis of the four lesions found in female genital schistosomiasis (FGS), but colposcopes are generally not available in low‐resource settings.

Objective

We sought to review handheld devices that could potentially be used for FGS diagnosis.

Search strategy

We searched Medline and Embase 2015–2019 for handheld devices used in cervical cancer screening and FGS diagnosis.

Selection criteria

We excluded studies that did not compare the device to standard‐of‐care colposcopes or histopathology.

Main results and conclusion

In 11 studies, four handheld colposcopes, two smartphones, and one compact digital camera were evaluated. Two handheld colposcopes were found to be potentially adequate for FGS diagnosis, namely Gynocular and Mobile ODT. The smartphones and digital camera did not have sufficient magnification to diagnose grainy sandy patches, one of the FGS lesion types. Customized software should be made to support the diagnosis of both FGS and cervical neoplasia. Real‐time postgraduate training and quality control should be considered in future studies of handheld colposcopes. For patients from schistosomiasis endemic areas, we recommend that handheld devices are used for FGS. Studies are needed to determine which of the two devices is most adequate for FGS diagnosis in schistosomiasis endemic areas.

Handheld colposcopy for schistosomiasis endemic areas should be adequate for both cervical cancer and genital schistosomiasis diagnoses.

Spatio-Temporal Dynamics of Plasmodium falciparum and Plasmodium vivax in French Guiana: 2005-2019

Aims: This study examines the dynamics of malaria as influenced by meteorological factors in French Guiana from 2005 to 2019. It explores spatial hotspots of malaria transmission and aims to determine the factors associated with variation of hotspots with time. Methods: Data for individual malaria cases came from the surveillance system of the Delocalized Centers for Prevention and Care (CDPS) (n = 17) from 2005–2019. Meteorological data was acquired from the NASA Goddard Earth Sciences Data and Information Services Center (GES DISC) database. The Box–Jenkins autoregressive integrated moving average (ARIMA) model tested stationarity of the time series, and the impact of meteorological indices (issued from principal component analysis—PCA) on malaria incidence was determined with a general additive model. Hotspot characterization was performed using spatial scan statistics. Results: The current sample includes 7050 eligible Plasmodium vivax (n = 4111) and Plasmodium falciparum (n = 2939) cases from health centers across French Guiana. The first and second PCA-derived meteorological components (maximum/minimum temperature/minimum humidity and maximum humidity, respectively) were significantly negatively correlated with total malaria incidence with a lag of one week and 10 days, respectively. Overall malaria incidence decreased across the time series until 2017 when incidence began to trend upwards. Hotspot characterization revealed a few health centers that exhibited spatial stability across the entire time series: Saint Georges de l’Oyapock and Antecume Pata for P. falciparum, and Saint Georges de l’Oyapock, Antecume Pata, Régina and Camopi for P. vivax. Conclusions: This study highlighted changing malaria incidence in French Guiana and the influences of meteorological factors on transmission. Many health centers showed spatial stability in transmission, albeit not temporal. Knowledge of the areas of high transmission as well as how and why transmission has changed over time can inform strategies to reduce the transmission of malaria in French Guiana. Hotspots should be further investigated to understand other influences on local transmission, which will help to facilitate elimination.

Validation of Swab Sampling and SYBR Green-Based Real-Time PCR for the Diagnosis of Cutaneous Leishmaniasis in French Guiana

Recent studies have highlighted the interest in noninvasive sampling procedures coupled with real-time PCR methods for the detection of Leishmania species in South America. In French Guiana, the sampling method still relied on skin biopsies. Noninvasive protocols should be tested on a large annual cohort to improve routine laboratory diagnosis of cutaneous leishmaniasis. Therefore, we evaluated the performance of a new Leishmania detection and species identification protocol involving cotton swabs and SYBR green-based real-time PCR of the Hsp70 gene, coupled with Sanger sequencing. Between May 2017 and May 2018, 145 patients with ulcerated lesions compatible with cutaneous leishmaniasis were included in the study at the Cayenne Hospital and its remote health centers. Each patient underwent scrapings for a smear, skin biopsies for parasite culture and PCR-restriction fragment length polymorphism (RFLP) (RNA polymerase II), and sampling with a cotton swab for SYBR green-based PCR. The most accurate diagnostic test was the SYBR green-based PCR on swab samples, showing 98% sensitivity. The mean PCR cycle threshold (C_T ) was 24.4 (minimum C_T , 17; maximum C_T , 36) and was <35 in 97.6% of samples. All samples positive by SYBR green-based real-time PCR were successfully identified at the species level by DNA sequencing. This new method should be considered for routine diagnosis of cutaneous leishmaniasis in South America and especially for remote areas, since noninvasive collection tools are easier to use and require fewer precautions for transportation.