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The Africa Teledermatology Project: Preliminary experience with a sub-Saharan teledermatology and e-learning program

2009; Elsevier BV; Volume: 61; Issue: 1 Linguagem: Inglês

10.1016/j.jaad.2008.12.007

1097-6787

Steven Kaddu, H. Peter Soyer, Gerald Gabler, Carrie Kovarik,

Infectious Diseases and Mycology

To the Editor: Recent advancements in technology and telecommunications have created special opportunities to use teledermatology in resource-poor settings. There are very few teledermatology programs active in sub-Saharan Africa, and most of these are targeted to specific countries or regions.1Schmid-Grendelmeier P. Masenga E.J. Haeffner A. Burg G. Teledermatology as a new tool in sub-saharan Africa: an experience from Tanzania.J Am Acad Dermatol. 2000; 42: 833-835Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 2Schmid-Grendelmeier P. Doe P. Pakenham-Walsh N. Teledermatology in sub-Saharan Africa.Curr Probl Dermatol. 2003; 32: 233-246Crossref PubMed Google Scholar, 3Caumes E. Le Bris V. Couzigou C. Menard A. Janier M. Flahault A. Dermatoses associated with travel to Burkina Faso and diagnosed by means of teledermatology.Br J Dermatol. 2004; 150: 312-316Crossref PubMed Scopus (28) Google Scholar, 4Fraser H.S.F. McGrath S.J.D. Economical solutions are available to support heath care in remote areas.Br Med J. 2000; 321: 465-466Crossref PubMed Scopus (59) Google Scholar, 5O'Mahony D. Banach L. Mahapa D.H. Lancaster E.W. Van der Linde G.D. Williams B.H. et al.Teledermatology in a rural family practice.SA Fam Pract. 2002; 25: 4-8Google Scholar We have recently established a store and forward teledermatology consultation network ("Africa Teledermatology Project") with the aim of linking a broad range of medical institutions in sub-Saharan Africa involved in treatment of skin diseases to more specialized dermatology units in Europe, the United States, and Australia. We present our preliminary experience with this project. The project was initiated through a special collaboration between the Departments of Dermatology at the Medical University of Graz, Austria, and the University of Pennsylvania, Philadelphia, PA, and the Dermatology Group at the University of Queensland, School of Medicine, Brisbane, Australia. Nine district, regional, and national hospitals with limited dermatology facilities located in seven different sub-Saharan African countries were included in the project, namely the Skin Clinic and the Department of Pediatrics, Faculty of Medicine, Makerere University, Kampala, Uganda; the Dermatology Clinic, Mbarara University, Faculty of Medicine Mbarara, Uganda; the Baylor College of Medicine Abbott Fund Children's Clinical Center of Excellence (COE)–Malawi in Lilongwe; the Botswana–Baylor Children's COE in Gaborone; the Princess Marina Hospital in Gaborone, Botswana; the Baylor College of Medicine-Bristol-Myers Squibb Children's Clinical COE–Lesotho, in Maseru; the Baylor College of Medicine Bristol-Myers Squibb Children's Clinical COE–Swaziland in Mbabane; Kapsowar hospital, Kenya; and Kilimanjaro Christian Medical Centre in Moshi, Tanzania. From February 2007 to May 2008, more than 140 consecutive problematic dermatologic cases with 320 clinical images were successfully submitted over the project Web site (http://telederm.org/africa/), which uses software similar to that employed by the telederm.org program.6Soyer H.P. Hofmann-Wellenhof R. Massone C. Gabler G. Dong H. Ozdemir F. et al.telederm.org: freely available online consultations in dermatology.PLoS Med. 2005; 2: e87Crossref PubMed Scopus (39) Google Scholar The majority of these clinical photographs were taken using cameras with a 4 megapixel resolution capability. Notably, a large proportion of these skin conditions (92 patients; 65%) arose on a background of HIV infection. Overall, cutaneous infections and/or infestations accounted for 30% (42 patients) of all submitted cases. A significant number of cases also represented various types of skin tumors (20 cases; 14%; Fig 1), papulosquamous lesions (18 cases; 12%), and a range of drug reactions (15 cases; 10%). The histopathologic evaluation of skin biopsies was necessary to confirm the teledermatologic diagnoses in 28 cases (20%). In eight patients, a diagnosis was not possible, mainly because of insufficient clinical information or poor quality of images. The majority of consults (60%) were closed within 2 days following submission. Assessment of system performance by patients and remote local medical staff was not specifically performed, but verbal communication from referring medical personnel indicated a high level of mutual satisfaction. A number of teleteaching opportunities were also set up on the project Web site, including a comprehensive list of dermatology literature sources, a dermatology curriculum, a list of exemplary cases with comprehensive discussions in the "case of the month," and a "discussion forum." Temporary interruptions in local telecommunications at the African sites have been the main limiting factor. System problems have only occasionally been encountered. Optimum participation of local medical personnel has sometimes been hampered by manpower shortages. There have been a few reports of patients who refused to be photographed or included in the project, likely because of certain cultural/religious attitudes or a lack of trust in data security or capability of this technology to improve their health. Preliminary results from our project confirm the feasibility of a broad-based, sub-Saharan African store and forward teledermatology network using the currently available telecommunication infrastructure in these countries. In this setting, teledermatology can offer prompt expert diagnostic and treatment suggestions that are helpful in improving management of many skin conditions and provide continuing medical education for local medical staff. Based on our findings and those from previous projects,1Schmid-Grendelmeier P. Masenga E.J. Haeffner A. Burg G. Teledermatology as a new tool in sub-saharan Africa: an experience from Tanzania.J Am Acad Dermatol. 2000; 42: 833-835Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 2Schmid-Grendelmeier P. Doe P. Pakenham-Walsh N. Teledermatology in sub-Saharan Africa.Curr Probl Dermatol. 2003; 32: 233-246Crossref PubMed Google Scholar, 3Caumes E. Le Bris V. Couzigou C. Menard A. Janier M. Flahault A. Dermatoses associated with travel to Burkina Faso and diagnosed by means of teledermatology.Br J Dermatol. 2004; 150: 312-316Crossref PubMed Scopus (28) Google Scholar, 5O'Mahony D. Banach L. Mahapa D.H. Lancaster E.W. Van der Linde G.D. Williams B.H. et al.Teledermatology in a rural family practice.SA Fam Pract. 2002; 25: 4-8Google Scholar we recommend that sub-Saharan African countries consider including telemedicine and teledermatology as an explicit part of their national health care system plans. This could serve to emphasize the important role that telemedicine can play in improving future health care delivery in these countries. Potential challenges of teledermatology mainly represent technical and economic factors. The introduction of new technological developments—such as the use of mobile phones with built-in cameras as an alternative to bulky digital cameras and computers—could drastically lower overall implementation costs and improve efficiency in the delivery of these services. We believe that our initial experience and data may be helpful in providing a foundation for establishment of much larger teledermatology projects in this setting. We extend a special thanks to the following colleagues for their valuable contributions: Dr M. Adler, the Baylor College of Medicine Bristol-Myers Squibb Children's Clinical COE–Swaziland; Dr C. Cox, the Baylor College of Medicine Abbott Fund Children's Clinical COE, Malawi; Dr K. Ferrer, the Baylor College of Medicine Bristol-Myers Squibb Children's Clinical COE-Lesotho; Dr C. Forbes, the Botswana-Baylor Children's COE, the Princess Marina Hospital, Gaborone, Botswana; Dr F. Henderson, the Baylor College of Medicine Bristol-Myers Squibb Children's Clinical COE–Swaziland; Dr S. Kambugu, Skin Clinic, Faculty of Medicine (Mulago National Hospital), Makerere University, Kampala, Uganda; Dr A. Kekitiinwa, Baylor College of Medicine Bristol-Myers Squibb Children's Centre of Excellence–Uganda at Mulago Hospital; Mr R. Kimuli, Pediatric Clinic, Faculty of Medicine (Mulago National Hospital), Makerere University, Kampala, Uganda; Dr P. Larson, Kapsowar Hospital, Kenya; Dr J. Lee, the Botswana–Baylor Children's COE and the Princess Marina Hospital, Gaborone, Botswana; Dr R. Lee, the Botswana–Baylor Children's COE and the Princess Marina Hospital, Gaborone, Botswana;, Dr J. Magina, Mbarara University, Faculty of Medicine Mbarara, Uganda; Mr S. Mugoya, Skin Clinic, Faculty of Medicine (Mulago National Hospital), Makerere University, Kampala, Uganda; Dr G. Mulyowa, Dermatology Clinic, Mbarara University, Faculty of Medicine Mbarara, Uganda; Dr T. S. Peniel, Moshi Hospital, Arusha, Tanzania; Dr J. M. Pierce, the Baylor College of Medicine Bristol-Myers Squibb Children's Clinical COE–Lesotho; Dr T. Sebastian, the Baylor College of Medicine Bristol-Myers-Squibb Children's Clinical COE–Swaziland, and Dr E. Tsai, the Botswana–Baylor Children's COE and the Princess Marina Hospital, Gaborone, Botswana.