Research questions and scope

The goal of this scoping review is to map and summarize existing literature on telemedicine applied to NTDs to address the review question: “what is the current state of scientific evidence on the use of telemedicine in the clinical care of patients with NTDs worldwide?”

To answer the study question, we adopted the strategy Population (P), Concept (C) and Context (C), the conceptual mnemonic model PCC [11]. The Population was defined as people affected by NTDs; the Concept as telemedicine interventions for remote clinical care; and the Context as all health settings worldwide. We analyze and organize the findings in ways that highlight potential benefits for the diseases identified. We also suggest ways to conduct future studies.

Definitions

The following subsections provide definitions and explanations of the key terms used throughout this paper.

For the review we considered the list of 21 NTDs and disease groups currently defined and prioritized by WHO [12], with the aim of delimiting the scope of this research.

There are many conceptual definitions of telemedicine in literature. In this study we assume a WHO definition [8] which encompasses the following activities: 1. consultations between a remote person and a healthcare professional; 2. remote monitoring of the person’s health or diagnostic data by the provider; 3. transmission of medical data (e.g. images, notes and videos) to the healthcare provider; and 4. case management consultations between healthcare providers.

We report that, due to the characteristics of the regions studied, the team considered all available means of communication, from videoconferences to regular calls by telephone, for example, as acceptable telemedicine resources.

Protocol and registration

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for Scoping Reviews [10] and followed the methodological framework suggested by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA–ScR) [11]. The research protocol was registered on the Open Science Framework plataform (OSF) in March 2024 and can be accessed in: https://doi.org/10.17605/OSF.IO/XAKF5. The team was composed of academic researchers, clinical health professionals, and digital health specialists.

Eligibility criteria

The inclusion criteria were: 1. Telemedicine for individual clinical care; 2. Report at least one NTDs from the WHO list; and 3. Published between January 2000 and March 2024.

No language restrictions were applied. Systematic and scoping reviews, case studies, book chapters, editorials, grey literature and media sources were excluded.

Search strategy

Three databases and interfaces were chosen for their reliability and ease of searching with extensive MeSH terms: MEDLINE/PubMed, Web of Science and Scopus. An advanced search in the three selected databases was performed using Boolean operators to identify articles of interest published before March 26, 2024 (date of last retrieval).

The keywords and their variations were defined by the working group based on literature review and sensitivity pre-test of the terms in retrieving relevant articles. Combining these groups, we generate keywords lists for two categories (Fig 1).

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Fig 1. Search strategy.

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The expression “telehealth” was also used in our primary search strategies, however only studies that carried out activities within the scope of telemedicine mentioned above were selected [8]. The same criteria were applied to studies retrieved by the terms Digital Health and eHealth (electronic health).

Selection process

Titles and abstracts were selected by two independent reviewers for evaluation according to the inclusion criteria using the Rayyan automation tool [13]. In the same way, the selected articles were read in full and classified. The steps were blinded to reduce bias. All disagreements that arose between the reviewers at each stage of the study selection process were resolved by a third reviewer.

Data extraction and analysis

Data extraction was performed independently by the reviewers. An instrument for evidence synthesis was created in Microsoft Excel after a extraction form was pilot tested by the team, to ensure alignment in capture.

Included studies were divided into the following categories: the characteristics of the articles (authors, year, country of the studied population, country income, main NTD/disease, study design, study focus, sample); contextual factors (communication technology used, type and duration of the telemedicine intervention, rural or urban area, telemedicine care providers involved, team responsible for the telemedicine initiative,clinical applicability) and main outcomes/The major findings were analysis using a thematic descriptive approach. The methodological quality of the studies was not thoroughly evaluated and no critical appraisal of individual sources of evidence was carried out.

Eligible records

The survey results and the selection process are full reported in the PRISMA-ScR flow diagram below (Fig 2). A total of 293 relevant articles were eligible for screening after removing duplicates. After screening abstracts and titles, 43 articles were read in full, and 8 articles were selected by eligibility for data extraction, based on the inclusion and exclusion criteria.

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Fig 2. PRISMA–ScR chart.

* Duplicates identified and excluded by automation tool Rayyan (13); ** abstracts selected by researchers individually in blinded sections and combined using the automation tool Rayyan (13).

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1. Summary of studies characteristics.

The analysis of the final selection showed that four studies (N=4) were focused on dermatological diseases [14,15,16,17]: one specifically on leprosy [14] (N=1), one specifically on leishmaniasis [16] (N=1), and two in general dermatological diseases [15,17]. The remaining studies were related to the management of dengue (N=2) [18,19], cysticercosis (N=1) [20] and trachoma (N=1) [21]. The majority of the 21 NTDs were not represented in the results (Table 1)

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Table 1. Characteristics of the studies included in the Scoping review.

https://doi.org/10.1371/journal.pntd.0012431.t001

2. Contexts of telemedicine interventions for NTDs.

Regarding the geographic profile of the populations studied, two researches took place in Brazil and the others were developed in the following countries: Colombia (n=1), French Guyana (n=1), India (n=1), Ivory Coast (n=1), and Paraguai (n=1). Four studies were conducted in countries classified as upper-middle-income economies [22] (Brazil, Colombia, Paraguay), three studies in lower-middle income economies (India, Ivory Coast, Tanzania), and one in a high-income economy country (French Guyana). Four studies were developed at least one of the arms in remote and/or rural areas [2,15–17], three in urban settings [14,18,19] and in one it was not described [20].

The characteristics of the contexts and the telemedicine technologies are presented in Table 2. Five studies had telemedicine providers who were part of the local primary care team (São Paulo, Brazil; Asunción, Paraguay; Tumaco, Colombia; Cayenne, French Guyana; and Sinfra, Ivory Coast), and two of them utilized telemedicine to enable communication between the local team and the hospital [14,15]. One study was carried out only with staff from a tertiary hospital (New Delhi, India); one in a temporary emergency hospital due to a dengue outbreak (São Paulo, Brazil); and one worked in conjunction with a district-level community prevalence research team (Chamwino, Tanzania), which is still the only study where one arm of the clinical assessment was carried out in a different country (United States).

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Table 2. Thematic framework - characterization of the telemedicine interventions and contexts.

https://doi.org/10.1371/journal.pntd.0012431.t002

Only three studies investigated real-time synchronous interventions of consultations between remote patients and healthcare providers, two of which were via ordinary telephone calls [18,20] and only one via videoconference [19]. In all five other articles, telemedicine was carried out with asynchronous transmission of medical data (e.g. images, descriptive clinical notes), involving teleconsultations for case management between healthcare professionals located in different services [14–17,21].

Regarding the telemedicine software used, two studies worked with specific telemedicine platforms for sending clinical data and images [14,15] and one study tested a software for medical videoconferencing [19], while the use of mobile applications for remote care of NTDs occurred in three studies [16,17,21].

3. Main outcomes synthesis of telemedicine in NTDs care.

A summary of the main evidence of telemedicine benefits obtained in the studies selected for this scoping review is presented in Fig 3. Six studies sought to evaluate the applicability of remote telediagnosis of clinical conditions related to NTD [14,15,17,18,20,21], but only three of them compared the effectiveness/accuracy of remote diagnosis via telemedicine with in-person medical care as a gold standard [14,20,21]. Favorable results have been obtained with the use of teleconsultation in the diagnosis of leprosy (74% of diagnostic agreement) [14], trachoma (95% of diagnostic agreement) [21] and complications of neurocysticercosis (telemedicine sensitivity 89%/specificity 97%) [20], demonstrating high diagnostic accuracy in the use of remote resources for these conditions.

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Fig3. Summary of the main telemedicine benefits for NTD of the scoping review.

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One study found a significant increase in dengue fever detection capacity of the primary care service after implementing remote surveillance of suspected symptoms in the community, with a documented increase in the reporting of suspected cases compared to the previous two years (157 more cases) [18]. An increase on diagnostic and treatment capacity of skin NTDs in communities was also observed in two studies [15,17] in which specialist physicians assessed and followed via telemedicine cases of leprosy, Buruli ulcer, yaws, leishmaniasis, scabies, and tungiasis.

Another primary result on the use of telemedicine found in the studies was a significant reduction in the need for medical in-person specialized consultations for the care of mild and moderate dengue fever suspected cases (94,4%/n=252) [19] and some dermatological NTDs [15], avoiding the need for patients to travel to distant health services and enabling the introduction of early treatment.

Clinical monitoring by telephone for tracking crises in patients with treated neurocysticercosis has proven to be a relevant strategy for remote monitoring of complications of this chronic disease, allowing the necessary clinical follow-up without the need for sophisticated technology [20]. Telemedicine also proved useful in improving clinical monitoring of cutaneous leishmaniasis in one of the studies, in which patients monitored remotely via a mobile application had better adherence to clinical follow-up than patients who were only monitored in person at the service [16].

Remote care for neglected tropical diseases

Cutaneous NTDs stood out for their applicability in remote clinical approaches. The main findings in this review around teledermatology corroborate the evidence on the previous consolidation of this specialty in the international telehealth scenario, including NTDs [24,25]. The ease of managing clinical parameters in dermatology through photographs and videos, increasingly accessible on modern devices seems to facilitate. The use of mobile phones for healthcare (mobile health, currently called mHealth) was also shown to be more focused on neglected skin diseases than other NTDs in our study results. It is important to highlight, however, that there are also limitations that make substitutive and exclusive longitudinal follow-up via telemedicine impossible for some diseases. For leprosy and cutaneous leishmaniasis, for example, the mucosal lesions would be difficult to verify through photographs and would require in-person visits to the service.

Dengue is an NTD transmitted by mosquitoes that can quickly evolve into severity and overwhelm emergency services in local outbreaks. The use of telemedicine in dengue outbreaks has emerged as an effective strategy for early diagnosis and medical assessment of low-to-moderate risk cases, expanding case identification and preventing progression to severity. However, the urgency of the global epidemiological scenario of the disease [26] suggests that this resource could be more often used by health systems in order to avoid preventable deaths in areas with limited health service coverage. Digital health consultations combined with point-of-care diagnostic methods, such as rapid tests, is a window of opportunity to expand the differential diagnosis of acute febrile illnesses in the large endemic regions of South America and Southeast Asia and may also be useful in African regions where there is the challenge of differential diagnosis with malaria.

Trachoma is an infectious eye disease and an important cause of blindness in poor, rural and remote areas of the world. In our review we observed that the integration between screening programs and remote diagnosis by telemedicine can be a feasible advance in its elimination plan. One study uses a mHealth application suggesting an advance incorporation of mobile health resources in trachoma care [21]. However, no telehealth actions focused on preventive chemotherapy for trachoma in endemic communities were identified in our review. The development of integrated preventive chemotherapy telemonitoring actions could be beneficial to support community strategies for the control and elimination of other NTDs, such as onchocerciasis, lymphatic filariasis, schistosomiasis and soil-transmitted helminthiasis in isolated communities at risk.

For some long-term NTDs typical of remote rural areas, such as Chagas Disease and Human African Trypanosomiasis, no results were recovered, although it was expected that continuous chronic telemonitoring of these patients could have good applicability, as it would avoid unnecessary trips to distant specialized centers for clinical monitoring of complications. Despite the advancement of the international debate on One Health approaches, the clinical management of some zoonotic NTDs seem to out of sight by the global digital health agenda, with technological advances more concentrated in sectors like vectors surveillance [27,28] or digital microbiology [29].

Telemedicine scenarios

Most interventions took place in South America. We identified a shortage of studies in African countries and the lack of innovative health experiences aimed at this region is a permanent challenge in controlling NTDs. Although the African continent accounts for around 40% of the global NTD burden [30], its broadband internet penetration rate was still around 33% in 2020 [31]. Applications that work offline and do not require constant internet can be part of the solution, but the challenge of providing access to person-centered services of remote healthcare especially in the sub-Saharan region requires complex multisectoral efforts and local engagement. The shortage of skilled health workforce in this region is a critical problem for addressing prevalent diseases, and consultations with specialists located in distant centers may be a good alternative in supporting infectious disease care [32]. Furthermore, investment in public health systems with broad coverage can contribute to decentralized care in communities affected by NTDs but also requires local governance policies committed to this agenda.

NTDs are closely related to the territory’s environmental health conditions, and telemedicine applied at the level of primary health care, as seen in five of the studies [14,15,16,17,18] has the potential to expand digital community strategies for local surveillance and better epidemiological control. Improving the management of clinical communication between different levels of care (e.g. primary care centers and tertiary hospitals) through integrated telemedicine platforms can also bring potential benefits to continuity, comprehensiveness and clinical coordination, considered internationally as important pillars for strengthening health systems centered on primary care [33]. These results are also important to strengthen joint action between general practitioners and focal specialists through telemedicine in the management of patients with NTDs.

The implementation of telemedicine

The length of the telemedicine studies selected ranged from 2 to 18 months. Lack of results on long-term telemedicine implementations limits the understanding of the real barriers to its incorporation into services. As most of the studies identified in this review consisted of proofs of concept or pilot tests, it would be important to investigate which initiatives remained in operation, to assess the factors that may be associated with their success and sustainability in real-world settings over time.

On the way to mitigate global inequities in access to internet and communication/information technologies in health, the implementation of telemedicine on a large scale requires complex efforts from several areas for its incorporation into health services: legal rules; systems interoperability; person-centered clinical telemedicine protocols; specific training for health providers; and promotion of patients’ digital literacy - which can be difficult for populations with low socioeconomic status. Another aspect that should be considered in telemedicine aimed at NTDs is digital security and ethical regulation practices [3,4,31–33]. Concern about ethical care when sending sensitive health data virtually is mandatory in the development of safe telemedicine tools in poor countries, that sometimes have limited legislation to guarantee the data protection of vulnerable populations.

The temporal analysis demonstrated that 50% of the studies (n=4) were published between 2021 and 2023, following the recent international trend of growing interest in digital health technologies [34]. But most of the initiatives presented in the studies occurred asynchronously or via simple phone calls. Thus, the benefits of implementing synchronous teleconsultations with video calls for the diagnosis and treatment of NTDs was therefore a knowledge gap identified by this review. Only one study presented a structured telemedicine platform that offered teleconsultation via videoconference in real time between patients and doctors, but it did not eliminate the need for the patient to travel to the health service, since the medical teleconsultation took place after an in-person assessment by nursing staff [19]. Henceforth, the use of mobile applications for remote care for NTDs emerges as a promising resource [16,17,21].

Limitations

No formal quality assessment of the studies included was performed, as scoping reviews present a map of what evidence has been produced, rather than only searching for the best available evidence to answer a specific question.

Publication bias is another limitation of this work, as we only considered articles published in journals and the search did not cover grey literature. To overcome this problem, we used broader search strategies to map local experiences originating especially in low-income settings. As NTD constitutes a clinically diverse group of diseases, with different durations, stages of evolution and possible complications, in-depth comparative variables for intervention approaches are scarce. However, we highlight the main common characteristics and interventions aspects.

The group of neglected fungal diseases is not specified in the WHO list, described as “mycetoma, chromoblastomycosis and other deep mycoses” [12], making it difficult to include each of these diseases in the search strategy (Fig 1), which may contribute to selection bias. For example, although paracoccidiomycosis and histoplasmosis are relevant problems in the Americas, we did not find consistent evidence to support the nominal inclusion of these pathologies in our review search strategy [35,36].