|
 
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| ORIGINAL RESEARCH REPORT |
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| Year : 2023 | Volume
: 20
| Issue : 1 | Page : 35-39 |
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Telemedicine system for the diagnosis and management of invasive fungal infections in Nigeria
Solomon Nwaneri1, Rita Oladele2
1 Department of Biomedical Engineering, Faculty of Engineering, University of Lagos, Lagos, Nigeria
2 Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| Date of Submission | 25-Nov-2022 |
| Date of Acceptance | 24-Feb-2023 |
| Date of Web Publication | 29-Mar-2023 |
Correspondence Address:
Dr. Solomon Nwaneri
Department of Biomedical Engineering, Faculty of Engineering, University of Lagos, P.M.B. 12003, Lagos
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcls.jcls_86_22
Background: Invasive fungal infections are not usually suspected by clinicians in our setting resulting in avoidable deaths, morbidity, and irrational/misuse of antibiotics. Unfortunately, there are few specialists of Medical Mycology in Nigeria working in very few centers where fungal infections can effectively be managed. This article describes a telemedicine system designed to provide an electronic consultation platform for the diagnosis and management of invasive fungal infections in Nigeria. Methods: The telemedicine center was designed and implemented using state-of-the-art technologies comprising hardware and software components. The center includes a high-resolution 60-inch liquid-crystal display smart television, an Intel Core i3 Desktop Computer, webcam system, a broadband Internet connection, and a backup electricity supply. The system currently uses the Zoom platform to establish virtual connections with collaborators as well as patients. Results: Since its inception, the center has managed 34 serious patients whose managing clinicians have called in for consultation. The establishment of the center has led to increased collaboration with other specialists in clinical mycology across Africa and Europe. Patient outcome has also been impacted positively because of consultation provided on diagnosis and antifungal therapy. The center has further accelerated the exchange of knowledge and ideas between health-care practitioners in Africa on the management of invasive fungal infections. Conclusions: Therefore, telemedicine center has been immensely beneficial for the management of patients suffering from invasive fungal infections in Nigeria.
Keywords: Invasive fungal infections, teleconferencing, telemedicine
How to cite this article:
Nwaneri S, Oladele R. Telemedicine system for the diagnosis and management of invasive fungal infections in Nigeria. J Clin Sci 2023;20:35-9 |
| Introduction | |  |
Telemedicine is a technology-driven system designed to deliver health-care services and share medical knowledge at a long distance using telecommunication technologies.[1] The adoption of telemedicine has led to increased access to specialized medical care with considerable improvement in health outcomes globally.[2] Telemedicine leads to a reduction in physical contact between patients and physicians and is capable of decreasing hospital congestion.[3],[4] Hospital congestion is a very common feature of public hospitals in many developing countries which could be remarkably addressed with the increased adoption of telemedicine. Decongestion of hospitals is possible because patients with no urgent need for urgent physical intervention can receive medical consultations remotely. Therefore, essential components such as terminal devices, telecommunication equipment, communication networks, remote diagnosis, and content-based image retrieval are needed for telemedicine implementation.[5]
Despite the existence of telemedicine for over two decades, it has witnessed phenomenal growth after the onset of coronavirus disease (COVID-19) pandemic.[6],[7] Since then, various medical organizations have continued to seek better ways of reaching out to their patients, thus, breaking geographical barriers by the innovative use of telemedicine. In countries with low doctor:patient ratio, telemedicine has been suggested as a means to extend medical services to patients unable to receive adequate medical attention.[8]
Given the increasing global health-care challenges, the demand for specialized medical services has far exceeded the available medical experts. This is particularly worrisome in low-and middle-income countries with a high burden of diseases caused by various pathogens. Nigeria and many other countries in sub-Saharan Africa have a high incidence of fungal infections with an acute shortage of qualified mycologists to provide diagnosis and treatment of invasive fungal infections.[9] Nigeria, Africa's most populous nation with a population of over 200 million, is experiencing a dire challenge in meeting the specialty care access needs for its people, with extremely limited capacity to deliver subspecialty health care. Over 11.8% of the Nigerian population are estimated to suffer from a serious fungal infection each year with substantial mortality.[10] A recent report highlighted a serious knowledge gap among Nigerian resident doctors with only 2 (0.002%) out of the 1046 respondents having a good level of awareness of invasive fungal infections.[11] Almost all the data on invasive fungal infections published in Nigeria have been from the Department of Medical Microbiology and Parasitology, College of Medicine University of Lagos (CMUL). Clinical mycology as a subspecialty is grossly lacking in Nigeria.[11],[12]
Telemedicine which is known to play a vital role in health-care delivery can be used to bridge this gap by providing access to several persons in remote locations where the services of mycologists are not easily available. The aim of this article is to describe the establishment of a telemedicine program, which provided consultation and training services for clinicians on the diagnosis and management of IFIs. This helped improve the health outcome of patients at risk of life-threatening IFIs in Nigeria.
| Methods | | |
The center is domiciled in the Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria. The Department of Medical Microbiology and Parasitology is host to a WHO malaria reference laboratory; it also has a virology laboratory (where the first case of Ebola in Nigeria was diagnosed and is currently used for diagnosis of COVID-19 infections). The department is also a WHO infection prevention and control learning hub. The invasive fungal infections telemedicine center was inaugurated by the Provost of CMUL, on Thursday, October 21, 2021, at the Department of Medical Microbiology and Parasitology, CMUL.[13],[14],[15],[16]
System architecture
The center was built with state-of-the-art technologies designed to provide both remote monitoring and store-and-forward telemedicine services for the diagnosis and treatment of invasive fungal infections. The center consists of hardware and software components. The hardware includes a 60-inch liquid-crystal display (LCD) smart television (TV), a modern desktop computer, a set of webcam camera system, a 4G LTE Internet modem, a 1.5 KVA uninterruptible power supply (UPS), and a 10 KVA backup generator. The LCD smart TV provides a clear, high-definition real-time visual display of images of patients or physicians at remote locations. It can also show clear images of tumors and other visual symptoms associated with invasive fungal infections being investigated at remote locations for better diagnosis. The webcam cameras capture the image of the physician at the telemedicine center to enable patients and physicians at the remote location to clearly see them. The system configuration of the computer is Intel (R) Core (TM) i3-5005U CPU at 2.00 GHz, 16 GB RAM, and 256 GB SSD hard disk. The computer contained the operating system (Windows 2010) and several software applications which provided the functions of videoconferencing, image processing, security, and word processing. The UPS ensured adequate backup for the telemedicine system before the generator is powered on. Electricity supply in Nigeria remains unstable, and a reliable backup electricity supply was, therefore, provided.
The telemedicine system provided both real-time and store-and-forward telemedicine services with full teleconferencing facilities. Internet access was achieved using a high-speed 4G LTE modem. The cameras helped to provide clear real-time video of the doctor at the center to the remote patient or other physicians in various locations. This was also necessary for the transmission of real-time high-quality video of patients' diagnoses to other highly qualified specialists for further consultation and to seek their second opinion on sensitive cases. The block diagram in [Figure 1] shows the architecture of the telemedicine system.
A teaching microscope was also installed for training purposes with support from IMMY diagnostics. [Figure 2] shows the flowchart for the treatment procedure at the telemedicine center.
Algorithm of operations at the telemedicine center
We propose an algorithm to determine the right medical mycology expert to consult to minimize patient waiting time and also get the best expert medical support.
- Patient or managing physician calls our center for consultation for one of his patients
- The center administrator routes the call to the relevant specialist
- Zoom meeting is scheduled between the mycologist, specialist, and managing physician
- During the Zoom meeting, if the matter is resolved, the case is closed:
- Sometimes, physicians can call again to report progress or challenges with therapy
- If the case is not resolved, it is escalated to other specialists from the European Confederation of Medical Mycology (ECMM)
- End.
| Results | | |
This project was able to reach 550 health-care professionals (namely, clinical microbiologists, pediatricians, physicians, surgeons, infectious diseases physicians, pathologists, ENT surgeons, intensivists, laboratory scientists, etc.) using social media, professional organizations, and e-mails. A total of 32 cases of invasive fungal infections were diagnosed and management advice was provided. [Table 1] shows the distribution of infections diagnosed and managed.
Patient groups managed included immunocompromised patients, long-term stay intensive care unit patients, suspected cases of mucormycosis, facial masses (nonmalignant), patients not responding to long-term antibiotics use, neonates, and patients with nontuberculosis respiratory infections.
| Discussion | | |
The Nigerian health-care sector is presently grossly underdeveloped and does not meet local needs.[17] Much of the health-care infrastructure is confined to major cities with people living in urban areas getting four times as much access to health care as those living in rural areas.[18] According to a 2015 body mass index report, there were an estimated 3534 hospitals in 2014, of which 950 were in the public sector. These include 54 federal tertiary hospitals. The private sector is the dominant provider of care in many areas, accounting for the greater part of secondary care facilities. The number of registered medical doctors in Nigeria has risen to 74,543 with only 42,000 available to manage the 200 million people in Nigeria. The rest have emigrated to “greener pastures.”[19] Nigeria's health infrastructure remains low and insufficient to cater for its growing population. Invasive fungal infections are not usually suspected by clinicians in our setting, resulting in avoidable deaths, morbidity, and irrational/misuse of antibiotics. Furthermore, there are not many specialists of Medical Mycology in Nigeria; and as a result, there are few centers where fungal diseases would be effectively managed. As a result, the telemedicine center has been highly impactful in comanaging of patients with consultations coming from other African countries such as Ghana, Cameroun, and Mali. Some of the diagnoses made included invasive candidiasis, cryptococcal meningitis, mucormycosis, chronic granulomatous fungal rhinosinusitis, histoplasmosis, invasive aspergillosis, chronic pulmonary aspergillosis, subacute invasive aspergillosis, pneumocystis pneumonia, chronic fungal skin infections, etc. [Table 1]. This has further raised awareness on these disease entities. Some biopsy slides were reviewed by a pathologist in South Africa to help in making the diagnosis. Patient outcome has also been impacted positively because of consultation provided on antifungal therapy.
The ECMM offered to partner with the center by providing free specialist consultations of cases we cannot handle. Since opening, there have been 48 serious patients whose managing clinicians have called in for consultation and have been attended to, by various specialists in clinical mycology including from Europe.
Furthermore, there has been access to other clinical mycologists from other parts of the world in providing consultation for patients. The center has also been able to positively impact the exchange of knowledge and ideas between health-care practitioners through teleconferencing. Like other telemedicine systems,[20],[21],[22],[23],[24],[25] knowledge sharing achieved through this platform has significantly improved the quality of invasive fungal infection diagnosis.
Barriers/challenges
A number of barriers to this project were identified. There was no software application designed for this project. As a result of this, consultation relied on Zoom meetings due to the prohibitive cost of commercial telemedicine software. Furthermore, there were instances where the Internet connection was erratic, and this had a negative effect on the consultation sessions after appointments have been booked. Even with the best network provider in the area, the network sometimes is erratic. Furthermore, more patients can be reached if people were more aware of the importance of making proper diagnosis of fungal infections. Funds were transferred in local currency which markedly reduced the amount available to procure items, especially from outside the country. Thus, a teaching microscope could not be procured due to insufficient funds. However, a couple of months ago, IMMY diagnostics supported the project with a teaching microscope. For the sustainability of the project, it is imperative that a dedicated administrative staff and an app be developed and shared widely to increase the reach of the program.
| Conclusions | | |
The establishment of the invasive fungal infections telemedicine center has significantly helped in improving the management of invasive fungal infections. In places where access to specialists is a challenge, videoconference may provide access to appropriate specialists for their infections. The center would continue to receive and manage patients, thereby reducing the burden of fungal infections in Nigeria. We are currently working on the development of telemedicine software to enhance the quality of services delivered at the center.
Acknowledgment
The study was supported by Pfizer Limited. The content is solely the responsibility of the authors and does not necessarily represent the official views of Pfizer Limited.
Financial support and sponsorship
The project was funded by Pfizer Limited.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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