Article: Patrick Leander Scheid

Use Of Telemedicine For The Diagnosis Of Parasites And Viruses In A Deployed Setting

Infectious diseases are among the most common causes of morbidity in military deployment situations. Their diagnosis requires
special equipment and expertise, which are both normally provided by laboratories within the mission area. In order to further
enhance the diagnostic process by means of distant expert support, a telemicrobiology module with special devices, camera and
software has been designed and deployed within the medical service of the German armed forces as a modification to the
standard telemedicine workstation. The telemicrobiology equipment, which was both developed and evaluated at Koblenz, has
been installed in the mission laboratories and has proved useful in routine practice. Teleparasitology is the most frequently used
application under the conditions encountered during missions abroad. Televirology is useful to contribute to the establishment
of scientific network capabilities. The most predominant and important benefit of having this capability available is the ability
to immediately access expertise from the mission area without the exportation of the expert.

Introduction

In military deployments abroad, infectious diseases are among the most common diseases and are frequently responsible for days of lost duty time for  deployed personnel. During deployments abroad, military personnel may be exposed to pathogens specific to the country of deployment (i.e. endemic), but non-existent or less frequent in their home country. Any individual predisposition to infections may be increased by stress, heavy physical workload and life in confined camps. Moreover, these same conditions facilitate the airborne transmission of pathogens (mainly viruses). The hazards caused by infectious pathogens must be countered by means of fast, accurate diagnosis.  Local microbiological laboratories (within the mission area) are normally used to provide the expertise. In order to support the laboratory personnel at a distance (via Telemedicine), the Medical Service of the Bundeswehr developed a “telemicrobiology” module, which now consists of three pillars: “telebacteriology”, “televirology” and “teleparasitology”. This report will provide a closer look at the latter two subdisciplines. The Telebacteriology system has previously been described in detail. The lead microbiology laboratory for support of operations and the telemicrobiology center of expertise are located in the Koblenz Central Institute of the Bundeswehr Medical Service. Telemicrobiology workstations have been implemented in all Bundeswehr deployment areas and on board medically upgraded naval ships. The ability to accurately diagnose parasites is of special significance in the use of this telemedicine system.

Material and Methods

The telemedicine workstation  used for telemedicine operational support in microbiological diagnosis (including parasite diagnosis) was developed in Koblenz as Module 4 “Telemicrobiology” in 2002/2003 and has subsequently been validated in several steps. A standard transmitted light microscope and a plate microscope are used as recording platforms for a digital camera with 1360x1024 pixels for taking detailed photographs of digital images. Moreover, the special image processing, transmission and archiving software DISKUS (Hilgers, Königswinter) is used. This software was developed especially for this type of image transmission or storage and has been successfully adapted to user requirements. The transmission of data such as the adjusted lens magnification along with the photos enables automatic measuring operations at the receiving end, e.g. measuring amoeba cysts or worm eggs. Once the static photomicrographs have been transmitted, a video conference is established between the transmitting facility and the expert workstation to enable discussions of the current cases on the basis of laboratory numbers (without patient-related data) by the transmitter (e.g.medical laboratory staff) and the expert, e.g. the parasitologist.

Results

Outcome of the Validation of the Telemicrobiology Workstation 

PhotoCysts of Giardia lamblia; light microscopy as an example of the quality of the microscopical photos The display quality of essential morphological parasite characteristics was initially assessed on the basis of microscopic and macroscopic images of parasites in blood and stool (malaria parasites, leishmania, helminth stages, protozoa) and/or evaluated with regard to sensitivity and specificity in several double-blind trials. The validation revealed that the specificity of the diagnostic process had been improved significantly since more species could be diagnosed and less time was required. Yet, when transmitting static images in bacteriology and parasitology, the expertise of the transmitting user is of decisive importance because he cannot transmit what he does not notice. The evaluation results clearly showed that implementing telemedicine processes in microbiology/parasitology helps to significantly improve the sensitivity, specificity and overall accuracy of the diagnostic results.

Training Requirements for Medical Laboratory Assistants Employed in Laboratories Within the Mission Area 

The training conducted in a standardized way by a particular group of advisors in Koblenz is extremely important since the expert workstation depends on the informative value of the image transmitted by the transmitting end in the country of deployment to be able to provide a successful diagnosis and/or way of proceeding. The transmitting user will not be able to take images of things he does not detect and he will, therefore, not transmit the relevant images. In our view, this potentially limiting factor can only be addressed through extensive training of personnel to be deployed. The training and instruction of the medical laboratory staff designated for duty in microbiological laboratories in the mission area including the “telemicrobiology” telemedical training module is conducted in Koblenz. A transmitting workstation including identical microscopes is available for training and instruction purposes in Koblenz at all times. The medical laboratory staff is being prepared for the tasks to be accomplished during deployments abroad and is familiarized with the effective operation of the telemicrobiology workstation by conducting a (currently) three-week course and four weeks of practical training in the individual laboratories in Koblenz. Teleparasitology assumes great importance in this training program. The above procedure also ensures that the experts of the Central Institute of the Bundeswehr Medical Service (ZInstSanBw) in Koblenz personally know all members of the medical laboratory staff deployed in the microbiological field laboratories. These “human factors” should not be neglected in spite of all technological possibilities available. Of course, the medical laboratory staff also participates in round robin tests on deployment, again drawing on telemicrobiology support during their mission. 

Examples of Possibilities Offered by Telemedicine: Teleteaching and E-Learning

In addition to its primary functions, the workstation is applied as an innovative means of training in medical qualification (including quality management and quality development). It can be used to provide information sheets, diagnostic instructions and photomicrographs for purposes of basic, advanced and follow-on training on-site in the mission area and on demand. For example, a medical parasitology database is available. It includes a large number of microscope images showing parasites including different stainings, several fact sheets etc. This information may also be provided through the expert workstation to the personnel in the laboratories within the mission area.

Individual Aspects Concerning Televirology 

In general terms, the incorporation of international civilian expert workstations for purposes of consultation as well as the integration into international communication networks of infectious disease centers and microbiology experts are of interest for all diagnostic and research facilities providing surveillance services. In order to obtain an expansion of virology/ cell culture-related competence in the Bundeswehr with regard to diagnostics and surveillance, the obvious solution was to use a telemicrobiology workstation to allow consultation with a skilled virologist. 

In practice, a collaboration of laboratories between the ZInstSanBw in Koblenz and the Department of Medical Microbiology of the Cardiff University School of Medicine in Wales was formally established in 2005 and 2006 under an initially bilateral Microbiology telemedicine network. The technical laboratory cooperation focused on the establishment of WHO-acknowledged laboratory techniques to diagnose virus outbreaks by means of the Koblenz cell culture laboratory, particularly with a view to influenza surveillance and diagnostics.

Individual Aspects Concerning Teleparasitology 

The diagnosis of parasites is largely based on the direct detection of pathogens using a light microscope. This non-selective method enables experts especially to diagnose their stages, e.g. worm eggs and cysts, on the basis of morphological characteristics. Parasitology as “imaging diagnostics“is, therefore, well-suited for transmission via telemedicine systems. However, expertise in the special field of medical parasitology is still the decisive factor for a target-oriented diagnosis. Teleparasitology enables the expert (parasitologist) to provide his expertise to the laboratories within the mission area, provided that the diagnostically relevant stages have been detected and digitally photographed in the best possible way. In the recent past, valuable support has been provided with regard to the diagnosis of parasites endemic to the mission area, such as leishmania or intestinal helminths and protozoa.

Discussion

What is the Secret of Success of Telemicrobiology/Teleparasitology?

PhotoTelemicrobiology workstation in a microbiology field laboratory in a deployed setting. It became obvious early in the validation process that fruitful utilization of telemicrobiology is possible only within a fine-tuned and largely standardized overall diagnostic system. Moreover, telemicrobiology only serves as a vehicle for results to be interpreted visually. Subsequently, not only has diagnosis been standardized and refined and/or adapted, but training and implementation (on-site setup including briefing of the medical laboratory staff) have also been largely standardized. The standardization of all possible parameters in conjunction with the “human factors” mentioned above accounted for the system’s success. It is thus ensured that the clinician within the mission area is provided with e.g. parasitology expertise otherwise not available on site. We, therefore, have succeeded in applying the telemedicine motto “Exporting expertise instead of exporting experts“ to pathogen diagnosis, and this capability is currently used in all Bundeswehr deployments where laboratory facilities are installed. 

Lessons Learnt from Routine Operation of Telemicrobiology

The telemicrobiology module established on the basis of operational validation has proven effective in practice. It has been confirmed without any doubt that the specificity of the diagnostic process has been improved by the application of telemedical and/or telemetric procedures within medical parasite diagnosis and that therapeutically relevant information is very quickly available. Expertise can be provided (almost) irrespective of space and time. It is, therefore, no longer necessary to wait for a diagnosis from Germany after the shipping of samples. Quality control and surveillance measures (confirmation and authorization of the findings by the lead institute) or control of diagnostic procedures and, in some cases, teleteaching and e‑learning are achieved automatically by way of daily teleconferences. As opposed to several telemedicine applications used in other subject fields, medical microbiology comprises not only advice to those responsible on site (“secondary opinion”) but also the functions controlling diagnosis and the responsible release of medical findings (“primary opinion”). This system of “primary opinions” has been applied successfully since 2003 with convincing outcomes, minimized manpower demand and an excellent economic impact. Moreover, televirology applications have demonstrated impressively that the currently-configured telemedicine module is well-suited for network building.

Final Remarks

From its very beginning, the Koblenz telemicrobiology system has contributed towards providing high-quality, standardized and very quick diagnostics to mission support. The most predominant and important factor is the immediate increase of expertise in the mission area without having to export the expert. The system has become an indispensable part of routine practice today. It is a “success model that is fit for the future”. It has placed the Bundeswehr at the forefront of the global military environment and allowed the Bundeswehr to take the leading role in the field of telemicrobiology within NATO. Similar capabilities should be considered and deployed by other military forces which carry out deployed missions. 



Acknowlegements: We thank Lars Peters, BSprA and Dr. David Lam M.D., M.P.H. (U.S. Army Retired) for their assistance in translating this article scientifically correctly


References: ref@mci-forum.com


Texts to the pictures:


Fig. 1 Telemicrobiology workstation in a microbiology field laboratory in a deployed setting


Fig. 2 Overview of the Televirology Network activated in 2005/2006 and used particularly within the scope of influenza surveillance


Fig. 3 Cysts of Giardia lamblia; light microscopy as an example of the quality of the microscopical photos



Authors address:

Lieutenant Colonel Patrick L. Scheid, PHD

Medical Parasitology and Cell culture Laboratory

Central Institute of the Bundeswehr Medical Service

Laboratory Department I (Medicine); Diagnostics

Andernacher Street 100

56070 Koblenz

Germany


Telephone:                   +49-261-896-7270

Video-Conference:      +49-261-896-7281

Fax:                              +49-261-896-720


SHORT CV

Name: Lieutenant Colonel Dr. Patrick Leander Scheid, PHD

Nationality: German

Date and place of birth: 25. June 1967, born in St. Wendel (Saarland, Germany)

Major subject at university: Lecturer of Medical and Ecological Parasitology; University Koblenz-Landau; 56070 Koblenz

Current occupation: Head of the Parasitology and cellculture laboratories at the Central Institute of the Bundeswehr Medical Service; Laboratory Department I (Medicine); Diagnostics; Medical Microbiology; Andernacher Street 100; 56070 Koblenz

Relevant additional qualifications: Project Officer “Telemicrobiology”

Date: 11/22/2018

Source: Medical Corps International Forum (3/2013)