The State of Telepathology in Africa in the Age of Digital Pathology Advancements: A Bibliometric Analysis and Literature Review

Telepathology emerges as a vital tool, offering significant promise for enhancing pathology services in Africa, a region historically challenged by healthcare access and resource limitations. This review explores the development, adoption, and impacts of telepathology in Africa through a comprehensive bibliometric analysis and literature review. A methodical search in PubMed for publications up to 2024 revealed 119 pertinent studies, out of which 47 met the inclusion criteria for a focused review on telepathology's role in African healthcare settings. This research has charted a clear trajectory of growing interest in telepathology, as evidenced by the annual increase in related publications and robust international collaboration. It underscores the expanding utility of telepathology in diagnostics, education, and research within Africa, particularly in domains like dermatopathology, neuropathology, and, notably, oncology. The integration of artificial intelligence into telepathology presents new frontiers for enhancing diagnostic accuracy and efficiency. However, the review also identifies persistent challenges such as infrastructural inadequacies, a shortage of skilled professionals, and regulatory hurdles. The study highlights the indispensable role of international partnerships in advancing telepathology in the region. This review proposes a strategic pivot toward "leapfrogging," an approach that allows Africa to skip traditional developmental hurdles by directly adopting cutting-edge technologies and practices.


Introduction And Background
Telepathology, a significant branch of telemedicine, has emerged as a pivotal innovation, enabling the exchange and interpretation of pathological data over distance through telecommunications technology [1].This discipline, which is integral to the expanding domain of digital pathology, facilitates remote diagnostics, thereby dismantling geographical barriers that previously hindered the accessibility and efficiency of pathology services.Defined as the practice of pathology at a distance using telecommunication means, telepathology was conceptualized in the early 1980s, marking a transformative era in medical diagnostics [2].Its evolution traces back to the pioneering application of telecommunication for transmitting static images, progressing towards dynamic telepathology with real-time video feeds, and culminating in the advent of whole slide imaging (WSI) [3].These milestones reflect a trajectory of technological and methodological advancements aimed at enhancing the fidelity and utility of remote pathology consultations.
Telepathology systems are broadly categorized into static, dynamic, and virtual slide systems [4].Static telepathology involves the transmission of pre-captured digital images, suitable for cases where real-time interaction is not critical.Conversely, dynamic telepathology enables live, interactive analysis through video microscopy, necessitating a robust bandwidth for real-time data transmission.Virtual slide systems represent a synthesis of the static and dynamic modalities, leveraging WSI to produce high-resolution, digital facsimiles of entire slides.Each modality addresses distinct operational and diagnostic needs, ranging from primary diagnoses and inter-institutional consultations to educational purposes and quality control measures.
The integration of telepathology into healthcare systems has been catalyzed by significant advancements in digital imaging, artificial intelligence (AI), and telecommunications [5].These technological strides have not only expanded the capabilities and reliability of telepathology services but have also streamlined the diagnostic process, enhancing the speed and accuracy of pathological assessments [6].Furthermore, the incorporation of AI algorithms offers the promise of automated preliminary analyses, potentially revolutionizing diagnostic workflows and accuracy [7].
Despite the clear benefits and transformative potential of telepathology, its adoption and implementation in Africa are confronted with unique challenges.Amidst these advancements, the African continent faces a unique set of challenges in adopting telepathology, notably underscored by a pronounced shortage of pathologists [8].Moreover, the continent's vast, unevenly distributed population, compounded by variable telecommunications infrastructure and differing regulatory contexts, presents a complex matrix of barriers to widespread telepathology deployment [9].However, these challenges coexist with unparalleled opportunities to leapfrog conventional healthcare delivery limitations, offering a pathway to significantly improve access to specialized diagnostic services.
This paper presents a comprehensive overview and bibliometric analysis of the application and development of telepathology in the African healthcare context, with a specific focus on its implication amid digital pathology advancements.

Review Methodology
We conducted a comprehensive search using the PubMed database to seek documents published up to 2024.The search string utilized included keywords related to telepathology and Africa with the list of all African countries: (telepathology OR "remote pathology" OR "digital pathology" OR "whole slide imaging" OR "virtual microscopy") AND (Africa OR Algeria OR Angola ... OR Zambia OR Zimbabwe).
A bibliometric study is a valuable method for determining the overall trend of research activity and elucidating the connections between relevant research institutions [10].Bibliometrics provide a valuable means of assessing the evolution of scientific publications across different countries and periods in various fields and are particularly useful for emerging disciplines including biomedical fields [11].However, to date, no bibliometric analyses have been published to illustrate the trends in telepathology applications in African healthcare settings.This study provides an analysis of the related published data using VOSviewer (Centre for Science and Technology Studies, Leiden, The Netherlands) and Bibliometrix tools [12].This step involved examining publication metrics, co-authorship networks, and keyword occurrences to identify research trends, influential authors, and collaborative networks within the scope of telepathology in Africa.
Records retrieved in the initial search underwent a selection process using the Rayyan tool (Qatar Computing Research Institute, Doha, Qatar) to identify relevant studies to be included in the analysis [13].We included articles in English, French, and German that reported on telepathology healthcare systems in African countries or studies conducted in African countries that involved aspects of telepathology, such as digital pathology.Exclusions were made for general reviews and articles that broadly approached telepathology without a specific focus on African implementations.
Two authors independently screened titles and abstracts against the inclusion criteria.Discrepancies were resolved through discussion or consultation with a third researcher.The process of screening titles and abstracts led to the exclusion of 61 articles, and after a detailed full-text review of the remaining 58, 47 publications were selected based on predefined inclusion criteria (Figure 1).Two team members independently extracted data using Google sheets.Extracted data included the publication year, author(s), title, a summary of the telepathology experience reported, application field, presence of international collaboration, and outcomes, including any noted evolution or future perspectives (Table 1).

Bibliometric Analysis
The bibliometric analysis identified a total of 119 articles across 71 journals.The very first publication dates back to 2001.This research has demonstrated a notable annual growth rate of 6.21%, contributed by 953 authors with an average collaboration of 10.6 co-authors per document.The analysis highlighted a robust level of international collaboration, accounting for 46.22% of the publications.
Source and publication trends : Among these sources, Diagnostic Pathology, the American Journal of Clinical Pathology, the Journal of Telemedicine and Telecare, and the Journal of the American Society of Cytopathology emerged as the predominant journals for disseminating telepathology findings (Figure 2).A significant increase in publications was observed between 2020 and 2023, peaking in 2022 with 18 articles (Figure 3).N.Articles, number of articles; TC per Year, total citations per year Geographic distribution : The geographic analysis of the corresponding authors showed the United States, South Africa, and Egypt as leading countries in telepathology research related to Africa (Figures 5-6).Following these were Italy, Germany, the Netherlands, Switzerland, and Tanzania, showcasing the international collaboration and interest in African telepathology.Specifically within Africa, South Africa and Egypt stood out for their research contributions.Thematic evolution and collaborations: Keyword trends revealed a focus on "telepathology/methods," "algorithms," and "reproducibility of results," with a notable pivot towards "artificial intelligence" in recent years.The transition from early themes of "remote consultation" and "internet" usage in developing countries to advanced topics such as AI since 2022 marks a significant evolution in research focus (Figure 7).The bibliometric network highlighted "Humans" as a central node, connecting closely with "telepathology" and "digital pathology," indicative of these being foundational themes.Emerging links to "artificial intelligence" and "developing countries" signal shifting research priorities (Figure 8).Collaboration patterns, particularly between the United States and South Africa (frequency = 8), as well as Italy and Egypt (frequency = 6), reflect the global collaborative efforts underpinning telepathology advancements in Africa.The collaboration network analysis among telepathology researchers in Africa identified several key contributors based on centrality measures.The top 10 nodes by PageRank are presented in Table 2.The network graph (Figure 9) visually represents these relationships, where node sizes correspond to their centrality measures."Michelow p" emerged as the most influential node with the highest PageRank of 0.039 and a high betweenness centrality of 4.716, indicating a central role in connecting various subgroups within the network."Sayed s" also demonstrated significant influence with a PageRank of 0.028 and an exceptionally high betweenness centrality of 125, underscoring its critical function in bridging different clusters.The analysis revealed dense internal connections within clusters.For example, on the network representation, the cluster led by "sayed s" showed substantial collaboration, with notable interactions involving "acosta haab g" and "gingeriadis a" (Figure 9).Similarly, the cluster centered around "stauch g" exhibited strong internal ties, with an important collaboration within this subgroup.

Overview on telepathology use in Africa
The origins of telepathology in Africa trace back to South Africa in 2001, within a broader national telemedicine program that began in 1999 [14].However, actual projects started in 2008 [15,16].Among the publications, Tanzania was the most frequently mentioned country, followed by South Africa, Egypt, and then Uganda, Rwanda, and Kenya.The technologies employed varied over time, beginning with static images and progressing to dynamic or robotic microscopes equipped with cameras [17,18].By 2011, Egypt had integrated WSI, marking a significant advancement in the region's telepathology capabilities [22].
The review revealed a mix of telepathology applications from primary diagnoses and teleconsultations to educational uses, and more recently, engagements in research and the integration of digital pathology technologies.A common theme across many telepathology initiatives was the involvement in international collaborations, particularly with partners from the United States, Italy, and Germany, aligning with the bibliometric analysis that also ranked these countries as primary collaborators.
Chronologically, consistent updates and reports of telepathology experiences were notable in Tanzania, Egypt, and South Africa.This suggests an ongoing engagement with telepathology from as early as 2010 through to the beginning of 2017, highlighting varied and evolving applications mainly in sub-Saharan African countries.Tanzania's telepathology journey was particularly well-documented, providing insight into the structured development of such initiatives within the country.This period also saw other African nations gradually adopting telepathology, indicating a broadening interest and application of this technology across the continent.

Discussion
The number of publications on telepathology in Africa remains comparatively low compared to other bibliometric studies.For instance, Mea conducted a bibliometric study in 2011 using PubMed and identified a total of 967 reports [61].A more recent study in 2020 by Şenel and Baş identified 1,986 publications on Web of Science [62].The United States and developed countries continue to be at the forefront of telepathology research, while other regions, such as Africa, are still catching up.This trend is evident in our own findings, despite including African countries in our keyword search.This could be attributed to coauthorship, where African institutions are affiliated with the research but the studies may not directly reflect a true African experience.
The journey of telepathology in Africa commenced with foundational projects aimed at integrating telemedicine systems to address acute healthcare service gaps.In South Africa, the inception of a national telemedicine system in 1998 included telepathology among its services, although it faced implementation challenges that extended the project's timeline without specific outcomes reported for telepathology [13].This period marked the initial foray into utilizing technology to bridge healthcare delivery gaps in the continent.Subsequently, advancements were made in Egypt, where telepathology projects since the early 2000s demonstrated tangible benefits in diagnostics and education, achieving notable success in challenging case consultations and educational advancements without explicit metrics of success.Similarly, Tanzania's decade-long engagement with telepathology notably reduced diagnostic times from weeks to days, illustrating the technology's potential to significantly enhance healthcare efficiency and access across Africa [38].
Telepathology has experienced significant technological evolution, beginning with static digital systems and progressing to dynamic and robotic telepathology, alongside the integration of WSI and AI.This evolution is evident in the adoption of Nikon Coolscope for dynamic telepathology in South Africa and the implementation of WSI for educational and diagnostic purposes in Egypt and Tanzania [15,17,18].These advancements have improved the diagnostic accuracy and expanded the scope of telepathology applications.
Subsequent years saw a proliferation of telepathology projects driven by cross-country collaborations, such as the pilot project between Italy and Egypt in 2008, and the dynamic telepathology feasibility study using Nikon Coolscope in South Africa [14,15].These early collaborations underscored the potential of telepathology for diagnostic, educational, and consultative purposes, even though, they highlighted the necessity for robust infrastructure and reliable internet connectivity.The role of international collaboration and education has been pivotal in the expansion of telepathology in Africa.Projects have leveraged expertise from developed countries and utilized platforms like iPath and Vsee for teleconsultations, as evidenced by Völker et al.'s work in Tanzania and Felix Manirakiza's use of Vsee in Rwanda (2023) [38,58].These collaborations have not only facilitated rapid diagnostic processes but also fostered educational exchanges, and building local capacities.
The global impact of telepathology is underscored by its ability to bridge the gap in pathology services, particularly in under-resourced regions.Studies from Zambia, Uganda, and Rwanda highlighted the role of telepathology in enhancing diagnostic capabilities and providing educational support [16,18,27,56,58].The implementation of telepathology in these regions demonstrates a significant improvement in cancer diagnosis, management of infectious diseases, and access to specialized pathology consultations.
The application of telepathology across specific pathologies and specialties, including oncology, infectious diseases, neuropathology and dermatopathology, has shown promising outcomes [19,22,23,25,28,42].The validation of a portable WSI scanner for lymphoma diagnosis in Tanzania and Uganda and the use of telepathology for cervical lesion diagnosis in Tanzania illustrate its diagnostic accuracy and potential to support cancer care [48,55].Additionally, the development of an immunoscore system for colorectal adenocarcinoma in Tunisia and the assessment of deep learning algorithms for breast cancer diagnosis in Morocco, leveraging AI and WSI technologies indicates telepathology's expanding role in personalized medicine [40,51].The establishment of a telepathology system in Benin's Saint Jean de Dieu Hospital significantly improved cancer diagnosis capabilities [45].
Telepathology has also made significant strides in education and research, with initiatives like the online COVID-19 autopsy biorepository showcasing its utility in facilitating research and education despite pandemic-related restrictions [47].The use of telepathology for training and consultation in Nigeria and the generation of synthetic urine cytology images for educational purposes in South Africa reflect its expanding role beyond diagnostics into educational enhancement and research support [50,59].
Despite its benefits, telepathology faces challenges including infrastructure requirements, data security concerns, and the need for user training.The integration of AI, presents opportunities for enhancing diagnostic accuracy but also necessitates careful validation to ensure reliability.
The main limitation of our study was the inability to conduct a citation analysis using PubMed.This limitation arose due to PubMed's interface and database structure, which primarily focuses on indexing articles but does not provide extensive citation linkage data.Another intrinsic limitation stems from the nature and detail level of the papers included in our review.Our inclusion criteria were designed to broadly identify where telepathology is used and its main outcomes, rather than delving into the depths of detailed telepathology experiences.This approach inherently limited our ability to capture and analyze a common primary outcomes.

Conclusions
Telepathology in Africa stands as a testament to innovation within the digital pathology landscape, buoyed by the promise of enhanced healthcare access and improved diagnostic accuracy, as revealed through our comprehensive bibliometric analysis and literature review.However, this burgeoning field navigates a complex terrain marked by infrastructure deficiencies, a dearth of local expertise, and regulatory challenges.The reliance on international collaboration, while instrumental in driving initial advancements, underscores a critical dependency that may impede the journey towards a self-sustaining telepathology ecosystem.This review proposes a strategic pivot towards "leapfrogging" -an approach that allows Africa to skip traditional developmental hurdles by directly adopting cutting-edge technologies and practices.By fostering local capacity building and making strategic investments in technology, Africa can leverage telepathology not just to catch up with, but to leap ahead in the global healthcare landscape, transforming challenges into stepping stones towards an autonomous, innovative, and equitable healthcare future.

FIGURE 1 :
FIGURE 1: Flow diagram of publication selection for telepathology research in Africa from PubMed.

FIGURE 2 :FIGURE 3 :
FIGURE 2: Distribution of top 10 journals publishing telepathology research on Africa from 2001 to 2023.

FIGURE 4 :
FIGURE 4: Evolution of author contributions in African telepathology research over time.

FIGURE 6 :
FIGURE 6: Geographic distribution of telepathology research in Africa.

FIGURE 7 :FIGURE 8 :
FIGURE 7: Evolution of trend topics over time on telepathology research in Africa.

Authors Title Year Country Field of use Technology Collaborator Findings
Digital dynamic pathology systems were deployed in Mthatha, East London, and Port Elizabeth, South Africa, to mitigate pathologist shortages.Connected through LAN or WAN, these systems facilitated 60 review sessions in Cape Town and Pretoria, diagnoses when biopsies were done, the study acknowledged issues like image quality but validated telecytology's feasibility in East Africa.The article reviews telepathology in Botswana, noting the Zeiss Mirax Live system's deployment, 2024 El Jiar et al.Cureus 16(7): e63835.DOI 10.7759/cureus.638354 of 17 Establishing Telepathology in Africa: Lessons from Botswana 2013 Botswana Diagnosis, Education Robotic Unspecified and challenges like processing, connectivity, and power, underscoring the importance of government backing and adaptation to local needs, proving its effectiveness in improving healthcare and education in resource-limited areas.The implementation of virtual microscopy involved digital slide acquisition and training for staff and students, modernizing medical education.It notably enhanced resource accessibility, student engagement, and hinted at digital pathology's diagnostic potential.States The study details establishing a telepathology system to enhance cancer care, from training and setting up internet connections to using online tools for diagnosis.It achieved over 95% diagnostic agreement with traditional methods, proving its efficacy in improving accuracy and capacity in resource-limited settings.experiences.It notes improvements in diagnostics, faster results, and better collaboration, with challenges like costs, power reliability, and the need for dependable information sources.The study details telepathology (TP) setup and 2024 El Jiar et al.Cureus 16(7): e63835.DOI 10.7759/cureus.638355 of 17 training in a hospital lacking a resident pathologist, reporting on 545 cases.Seventy percent of TP diagnoses were confirmed by second opinions, with an 84% overall diagnostic usefulness.Minor deviations occurred in 14% of cases, while 5% were misinterpreted benign/malignant, and 8% were insufficient for TP diagnosis, indicating specific disease subgroups had higher accuracy.cases using static-image teleneuropathology to enhance diagnostic accuracy.It achieved a 71% agreement with on-site glass diagnosis under strict criteria and 88% with less stringent criteria, signifying a notable improvement from the initial 36% by general pathologists to 71% with static 2024 El Jiar et al.Cureus 16(7): e63835.DOI 10.7759/cureus.638356 of 17 telepathology.States The report summarizes the 4th PALOP-AORTIC cancer conference, highlighting efforts to control cancer in Portuguese-speaking African countries.It emphasizes education, telepathology, and collaborative research to tackle the increasing cancer burden in PALOP.Specific outcomes include telepathology in Nigeria due to pathology personnel shortage and setup challenges.While specific outcomes are not detailed, telepathology offers broad benefits including quality assurance, cost reduction, faster pathology reports, and improved capacity for research and teaching.2024 El Jiar et al.Cureus 16(7): e63835.DOI 10.7759/cureus.638357 of 17 learning models on their dataset for image classification.Focus is on categorizing images into normal tissue, benign lesions, in situ carcinoma, and invasive carcinoma.Xception slightly outperforms ResNet50, achieving 88% overall accuracy and 95% sensitivity for carcinoma detection, highlighting deep learning's potential in breast cancer diagnosis.2024 El Jiar et al.Cureus 16(7): e63835.DOI 10.7759/cureus.638358 of 17 In Rwanda, a low-cost telepathology system using Vsee videoconferencing transmitted live histologic images for diagnostic purposes.It achieved substantial agreement with conventional microscopy-based diagnoses, with a Cohen's kappa of 0.77 and 76.6% perfect agreement for 60 cases.