Understanding noma: WHO's recognition and the path forward in global health

The World Health Organization's (WHO) designation of noma as a neglected tropical disease (NTD) on 15 December 2023 marks a crucial advancement in global health efforts. This move sheds light on a condition predominantly affecting undernourished children in isolated regions of sub-Saharan Africa. Recognized as the 21st NTD, noma, or cancrum oris, is a serious condition leading to orofacial gangrene. The disease largely impacts young children and those with compromised immune systems, including individuals with human immunodeficiency virus or leukaemia. Determining the exact prevalence of noma is complex, hindered by rapid disease progression, societal stigma and a lack of reporting, especially in impoverished areas. The WHO's acknowledgment is a significant step, emphasizing the need for more in-depth research and resources to address this overlooked disease. It highlights the critical role of multifaceted prevention strategies, including economic empowerment, improved nutrition and enhanced vaccination efforts. This recognition is pivotal in guiding international health initiatives towards better outcomes for some of the most at-risk populations globally.

High burden of noma in the Gambella region of Ethiopia: a 12-year retrospective study on noma cases from the Facing Africa database

BACKGROUND

Noma, an infectious disease, mainly affects impoverished children. This study retrospectively assessed noma's prevalence in Ethiopia using data from the Facing Africa database and the 2022 United Nations Development Programme poverty index report.

METHODS

A thorough review of medical records spanning 2007 to 2019 identified a total of 235 noma cases. A standardized data extraction template was employed to systematically gather pertinent clinical and demographic data for subsequent analysis. Prevalence rates were calculated nationally and regionally for both the general population and children aged ≤10 y.

RESULTS

The analysis revealed estimated national prevalence rates of 0.65 per 100 000 individuals at risk and 1.9 per 100 000 children aged <10 y at risk. The Gambela region exhibited the highest prevalence rate (11.2 per 100 000), whereas the Benshangul Gumuz region had the lowest (0.25 per 100 000). Similar patterns were observed among children aged ≤10 y, with the Gambela and Benshangul Gumuz regions reporting rates of 32.9 and 0.74 per 100 000, respectively.

CONCLUSIONS

The study highlights noma's significant impact on children aged <10 y in Ethiopia, especially in the Gambella region. It offers crucial baseline data to assist public health professionals, policymakers and healthcare providers in formulating evidence-based strategies to combat noma and improve affected individuals' well-being.

Surgical complications and subsequent revision surgeries among noma cases treated in Ethiopia

Introduction

Noma, an overlooked infectious disease, inflicts severe facial tissue damage, posing substantial challenges in patient care. This study delves into surgical complications and subsequent revision surgeries among noma cases treated in Ethiopia.

Materials and Methods

The research employed a cross-sectional retrospective review of medical records treated between 2007 and 2019 retrieved from the Facing Africa database.

Results

The review encompasses 235 noma cases. Twenty-four cases (19 females and 5 males) experienced various complications, predominately major complications leading to subsequent revision surgeries. The identified complications included flap necrosis, abscess formation, tenderness, graft site infection, flap bulking, dental misalignment, corner of the mouth dehiscence, infected bone and plate, flap malpositioning, restricted mouth opening with ankylosis, neuropathic pain, recurrent flap infection, and offensive odor. Revision surgeries included wound cleansing, abscess drainage, skin graft removal, exploratory surgery, wound care, debulking, scar removal, debridement, trismus release, commisuroplasty, and flap repositioning.

Conclusion

These findings illuminate the intricacies of noma surgery in Ethiopia, emphasizing the importance of understanding the nature and frequency of complications for optimizing treatment outcomes. Insights from this study can guide healthcare providers, especially novice surgeons, and policymakers, in refining surgical interventions and enhancing outcomes for noma patients. Improved knowledge in this realm is crucial for advancing patient care and developing targeted interventions.

Level of Evidence

5.

A Web of Science-Based Bibliometric Analysis of Global Noma Publications

The World Health Organization recognizes noma as a global health problem and has suggested prioritizing research into this disease. A bibliographic search of original articles published in the Web of Science database up to 2022 was performed. A bibliometric analysis was carried out with the bibliometrix package in R and VOSviewer. We identified 251 articles published in 130 journals. The first publication was in 1975, the highest number of publications was in 2003, and the average number of citations per document was 12.59. The author with the highest number of publications was Enwonwu CO, and the Noma Children's Hospital had the highest number of articles on this topic. Plastic and Reconstructive Surgery was the journal with the most publications, and the study by Petersen PE was the most cited. The country of corresponding authors that had the most publications and the most significant number of total citations was the United States. "Children" and "Reconstruction" were the most used keywords. In conclusion, there are few publications on noma worldwide, confirming the neglected status of this disease. Urgent actions are needed to increase evidence in regard to the epidemiology of noma and public health interventions to mitigate the ravages of this disease.

Noma: Experiences of Survivors, Opinion Leaders and Healthcare Professionals in Burkina Faso

The scientific literature on noma (Cancrum Oris) has clearly increased in recent decades, but there seems to have been limited analysis of issues around the psycho-social impacts of this disease. Even when these issues have been addressed, the focus has tended to be on patient experiences, whereas the community dimension of the disease and the role of healthcare professionals and community leaders in mitigating these impacts remain largely unexplored. A study in the form of semi-directed interviews with 20 noma survivors and 10 healthcare professionals and community leaders was conducted between January and March 2021 in Burkina Faso with the aim of describing the experiences of noma survivors, generating knowledge about living with the burden of the disease and understanding the attitudes of community leaders towards the disease. The results reveal that noma is a disease that affects economically vulnerable populations and leads to extreme household poverty. As far as treatment is concerned, patients tend to turn to practitioners of both traditional and modern medicine. Within communities, noma survivors face discrimination and stigma. The study highlighted a lack of information and knowledge about noma. However, surgical operations lead to patient satisfaction and these remain one of the coping strategies used to tackle the stigma and discrimination. The recommendations set out in this article are aimed firstly at stepping up research into the psycho-social impacts of noma, and secondly at considering these impacts in regional programmes and national plans to combat the disease.

More than 100 years of neglect: a bibliometric analysis of global research on noma (cancrum oris)

BACKGROUND

Research plays a significant role in quantifying and addressing the burden of disease, improving healthcare delivery and developing evidence-based policy for neglected tropical diseases (NTDs). Since noma is not a recognised NTD by the World Health Organization (WHO), research activity is hypothesised to be low. This study aims to understand patterns and trends of research conducted on noma, to understand the patterns of citations, highlight networks of collaboration and analyse stakeholders in noma research.

METHODS

The SCOPUS database was selected and searched. Data analysis was conducted using the bibliometrix package for R in RStudio. Areas of interest included the distribution of research output on noma by year and location, the academic impact of publication output, mapping the major academic community and conducting a thematic analysis of high-frequency keywords.

RESULTS

A total of 208 documents were identified. The annual growth rate of publications is 4.3%. The average number of citations per publication was 11.0 (rounded from 10.98) and the average citations per year per publication was 0.57. The USA was the country with the highest percentage 10.6% (n=22) of corresponding authors, followed by Nigeria (6.7% [n=14]), the UK (6.3% [n=13]) and India (5.8% [n=12]). For those papers with multiple authors, there was an average of 3.22 co-authors per document. The collaboration index was 3.3. Upon plotting collaboration networks between authors, only 11 clusters were identified (frequency and intensity of collaboration). Mapping of trending topics showed a focus on skin grafting and transplantation within the literature.

CONCLUSIONS

In order to progress towards eventual elimination of noma it is key that more research should be undertaken and more interest and funding should be dedicated to work on noma. Recognition of noma as an NTD by the WHO would be a first step in moving towards increased awareness.

Model of care, Noma Children's Hospital, northwest Nigeria

The Nigerian Ministry of Health has been offering care for noma patients for many years at the Noma Children’s Hospital (NCH) in Sokoto, northwest Nigeria, and Médecins Sans Frontières has supported these initiatives since 2014. The comprehensive model of care consists of four main components: acute care, care for noma sequelae, integrated hospital‐based services and community‐based services. The model of care is based on the limited evidence available for prevention and treatment of noma and follows WHO’s protocols for acute patients and best practice guidelines for the surgical treatment of noma survivors. The model is updated continually as new evidence becomes available, including evidence generated through the operational research studies performed at NCH. By describing the model of care, we wish to share the lessons learned with other actors working in the noma and neglected tropical disease sphere in the hope of guiding programme development.

Outcomes at 18 mo of 37 noma (cancrum oris) cases surgically treated at the Noma Children's Hospital, Sokoto, Nigeria

Background

Noma is a rapidly progressing infection of the oral cavity frequently resulting in severe facial disfigurement. We present a case series of noma patients surgically treated in northwest Nigeria.

Methods

A retrospective analysis of routinely collected data (demographics, diagnosis and surgical procedures undergone) and in-person follow-up assessments (anthropometry, mouth opening and quality of life measurements) were conducted with patients who had surgery >6 mo prior to data collection.

Results

Of the 37 patients included, 21 (56.8%) were male and 22 (62.9%) were aged >6 y. The median number of months between last surgery and follow-up was 18 (IQR 13, 25) mo. At admission, the most severely affected anatomical area was the outer cheek (n = 9; 36.0% of patients had lost between 26% and 50%). The most frequent surgical procedures were the deltopectoral flap (n = 16; 43.2%) and trismus release (n = 12; 32.4%). For the eight trismus-release patients where mouth opening was documented at admission, all had a mouth opening of 0–20 mm at follow-up. All patients reported that the surgery had improved their quality of life.

Conclusions

Following their last surgical intervention, noma patients do experience some improvements in their quality of life, but debilitating long-term sequelae persist.

'I treat it but I don't know what this disease is': a qualitative study on noma (cancrum oris) and traditional healing in northwest Nigeria

Background

Noma, a neglected disease mostly affecting children, with a 90% mortality rate if untreated, is an orofacial gangrene that disintegrates the tissues of the face in <1 wk. Noma can become inactive with early stage antibiotic treatment. Traditional healers, known as mai maganin gargajiya in Hausa, play an important role in the health system and provide care to noma patients.

Methods

We conducted 12 in-depth interviews with caretakers who were looking after noma patients admitted at the Noma Children's Hospital and 15 traditional healers in their home villages in Sokoto state, northwest Nigeria. We explored perceptions of noma, relationship dynamics, healthcare practices and intervention opportunities. Interviews were audiorecorded, transcribed and translated. Manual coding and thematic analysis were utilised.

Results

Traditional healers offered specialised forms of care for specific conditions and referral guidance. They viewed the stages of noma as different conditions with individualised remedies and were willing to refer noma patients. Caretakers trusted traditional healers.

Conclusions

Traditional healers could play a crucial role in the early detection of noma and the health-seeking decision-making process of patients. Intervention programmes should include traditional healers through training and referral partnerships. This collaboration could save lives and reduce the severity of noma complications.

Noma-knowledge and practice competence among primary healthcare workers: a cross-sectional study in Burkina Faso

BACKGROUND

Noma is a quickly progressing, neglected opportunistic infection. It starts in the mouth as an oral lesion but can relatively quickly develop into extensive facial destruction and lead to death if not treated in time. This study aims to shed light on primary healthcare workers' practice competences in working with and knowledge of noma.

METHODS

A structured questionnaire using questions and case scenarios was filled out by 76 healthcare workers in Burkina Faso. Half of the nurses included in this study participated in a 2-day noma training. Data were analysed descriptively and Fisher's exact test was used to study differences between occupational groups using Stata.

RESULTS

Most healthcare workers reported having examined the mouth of children with diseases predisposing to noma. The total practice competence was poor, with almost 70% having suboptimal or very low competences. However, competences varied between different stages of noma disease. Knowledge scores varied between occupational groups. The majority of nurses and odontostomatology specialist nurses had optimal or good knowledge of noma. Significant differences in knowledge and practice competence were found between nurses who attended a 2-day training course on noma and those who did not.

CONCLUSIONS

Health care workers in this study had quite poor practice competences in managing noma. The knowledge scores of these health workers were moderate. It is important for healthcare workers to be able to identify noma patients at an early stage, as at this point the disease can still be completely reversed.

Noma: a reappraisal in Western countries - are HIV-negative immunocompetent adult patients safe?

Noma is an ancient Greek term referring to a gangrenous disease that destroys soft and hard tissues of oral and perioral structures. This disease has been known since ancient times and persisted in Europe until World War 2, while in the present day it is almost exclusively found in sub-Saharan Africa.

Jaw Osteonecrosis Preceded by Dengue Fever - Possible Pathogenetic Mechanism

Introduction:

Osteonecrosis of jaw (ONJ) is a debilitating condition which can lead to compromised dentition. Various causes for ONJ are suggested in the literature such as drugs, trauma, radiation, chemicals, bacterial, and fungal infections. Knowing etiology for particular case of ONJ is important to prevent further progression of this debilitating condition. It is the first case of ONJ reported with dengue virus as a possible etiology.

Case Report:

This article presents a case of 46-year-old male patient with extensive osteonecrosis of maxilla preceded by dengue fever. In the present case, all known causes for osteonecrosis were ruled out. The present article discusses dengue infection as a possible etiologic agent for ONJ.

Conclusion:

In the present case, probable cause for ONJ can be established as a dengue virus necessitating the need for proper preventive methods to avoid further complication of osteonecrosis.

The surgical management of extra-articular ankylosis in noma patients

Extraarticular ankylosis occurs frequently in children suffering from noma sequelae. Over 20years of operating on these patients, we observed high recurrence of mouth opening limitation. We therefore progressively changed our surgical strategy. This retrospective study compares the impact of different parameters (types of surgery, noma type, physiotherapy compliance, age and sex) on immediate and long-term mouth opening. It includes a series of 121 patients with extraarticular ankylosis operated on between 1990 and 2015. Soft tissue reconstruction evolved from local and pedicled flaps to large free flaps. Mouth opening was performed by bone-bridge excision, sometimes associated to contralateral coronoidectomy. Mouth opening technique including bilateral coronoidectomy with free flap reconstruction was the only independent factor for significantly better immediate mouth opening with a mean increase of 8.7mm [95% confidence interval (CI) 4.3-13.1, P<0.001) and this effect was maintained in the 3years of follow-up. Another positive factor related to long-term results was excellent physiotherapy, while noma type 4 was a negative factor. Recurrence remains problematic in the management of noma sequelae. If physiotherapy and long-term follow-up cannot be offered, patients should not be operated on, because if limitation of mouth opening recurs, oral feeding may become impossible when a facial defect has been reconstructed.

An unusual case of noma caused by Klebsiella pnuemoniae and its management

Noma or cancrum oris is an orofacial gangrene causing progressive mutilating destruction of the infected tissues. It mainly affects malnourished children with poor oral hygiene and concurrent debilitating systemic illnesses. It is a polymicrobial infection and borrelia vincentii and fusobacterium are the most important pathogens known. We present a case of a boy aged 2.5 years with noma where klebsiella was grown and was the initial cause of failure of empiric therapy.

Acute necrotising gingivitis in young children from villages with and without noma in Niger and its association with sociodemographic factors, nutritional status and oral hygiene practices: results of a population-based survey

Background

Previous studies have suggested that acute necrotising gingivitis precedes noma disease and that noma clusters in some villages in certain regions of low- and middle-income countries. We sought to assess the prevalence of gingivitis with bleeding in young children from villages with or without a history of noma and to analyse epidemiological differences related to sociodemographic characteristics, nutritional status and oral hygiene practices.

Methods

We conducted a cross-sectional study in 440 children aged between 2 and 6 years from four villages in the Zinder region of southeast Niger in Africa. In two villages, cases of noma have repeatedly been detected; in the other two, noma has never been identified. We randomly selected 110 participants from each village.

Results

The prevalence of acute necrotising gingivitis was significantly higher in the noma villages compared with the non-noma villages (6.8% vs 0.9%; p=0.001). We found differences between the four villages regarding socioeconomic factors, stunting, undernourishment and oral hygiene practices. The type of oral hygiene procedures influenced the amount of dental plaque and gingival inflammation. Children using sand, coal or other abrasive products instead of a toothbrush had a significantly increased likelihood to be diagnosed with acute necrotising gingivitis (p=0.041).

Conclusions

Our data suggest that efforts to prevent noma should focus on populations with a high prevalence of acute necrotising gingivitis and include nutritional support and attempts to introduce safe and efficient oral hygiene practices to improve gingival health.

Noma Neonatorum From Multidrug-Resistant Pseudomonas aeruginosa: An Underestimated Threat?

We present the case of an extremely low birth weight infant with diffuse gingival noma, initially misdiagnosed as thrush. Multidrug-resistant Pseudomonas aeruginosa strain was cultured and treated with systemic and local colistin with complete healing. Noma neonatorum from multidrug-resistant pathogens may appear in neonatal intensive care units. Old antibiotics may help.Noma (cancrum oris) is a devastating gangrenous disease that leads to destruction of facial tissue with significant morbidity and mortality in children and young adults. Noma has virtually disappeared from Europe and North America, but it is still common among children and young adults in India, Africa, and South America. Noma is a polymicrobial opportunistic infection related to malnutrition and immune dysfunction. In the neonate, a similar but distinct condition, known as "noma neonatorum" was described in 1977, in which gangrenous lesions involve the mucocutaneous junctions of oral, nasal, and anal area, and, occasionally, the eyelids and the scrotum. The neonatal disease has been linked to Pseudomonas aeruginosa, prematurity, and low birth weight. There is no established treatment, and mortality is almost inevitable in the few reported cases. In this study, we present the first European case of noma neonatorum from a multidrug-resistant strain of P aeruginosa.

[Noma in a 4 year-old girl: a case report from Chad]

This case report describes a 4-year-old girl in Chad with noma, also called cancrum oris. This acute gangrenous stomatitis has a combined morbidity-mortality rate that can reach 70%. It occurs worldwide but is most common in sub-Saharan Africa in children aged 2 to 16 years. Its pathogenesis is uncertain, but several bacteria including Fusobacterium necrophorum, Prevotella intermedia and Pseudomonas aeruginosa may be responsible for the development of noma, which develops over the oral lesions these bacteria cause. Poverty is its most important risk factor. Due to its rapid course and high lethality, it requires emergency treatment with antibiotics, daily dressing of the lesion, and nutritional rehabilitation. Surgical removal of the remaining necrotic tissue can be followed by reconstructive procedures. Physical and speech therapy should be initiated to prevent functional complications.

Noma (cancrum oris) in the South African context

Noma (cancrum oris) is a destructive necrotising disease affecting orofacial tissues predominantly of malnourished young children. It is characterised by a rapid acute onset which usually starts in the mouth, spreads intra-orally destroying soft tissue and bone and progresses to perforate the facial skin, causing disfigurement. Polybacterial anaerobic infection is critical too, but is not alone sufficient for the initiation of noma. Cofactors, first and foremost malnutrition, but also systemic viral and bacterial infections are crucial to the development of noma. A patient with necrotising stomatitis or noma must be admitted to hospital for antibiotic treatment, fluid and electrolytes as well as nutritional supplementation and general supportive treatment. The epidemiology of noma in the South African population is unknown, and the clinicopathological features are poorly characterised. Although worldwide there is no evidence that HIV infection is a strong risk factor for noma, HIV infection may play a substantial role in the pathogenesis of noma in South Africa.

Noma (cancrum oris): a report of a case in a young AIDS patient with a review of the pathogenesis

Noma (cancrum oris) is a mutilating necrotising disease of the orofacial tissues. It affects predominantly debilitated malnourished children, in whom the necrotic process may cause severe damage to mid-facial structures. Its aetiopathogenesis is uncertain, but its course is fulminating, and without timely intervention the disease may be fatal. Antibiotic treatment during any stage of necrotising stomatitis and of its sequel noma can stop progression of the disease; therefore detection and treatment of early intraoral necrotising lesions whether necrotising gingivitis, necrotising periodontitis or necrotising stomatitis are critical in preventing noma. We present an extreme case of noma in a malnourished HIV-seropositive child. There was an acute necrotic process affecting both the maxilla and the mandible with denudation of bone, spontaneous exfoliation of teeth, necrotising fasciitis and myonecrosis which destroyed the lips and cheeks and extended to the infra-orbital margins. There was severe disfigurement and severe impairment of function. Noma is primarily an anaerobic bacterial infection with secondary ischaemia leading to osteonecrosis and mid-facial destruction.

Gillies fan flap for the reconstruction of an upper lip defect caused by noma: case presentation

The case of a 65-year-old noma patient with a defect involving her upper lip is presented. The defect also included missing teeth numbers eleven, twelve, 21, and 22 and the adjoining alveolus. One-stage lip reconstruction was carried out with Gillies fan flap followed by vestibuloplasty and commissuroplasty. An acrylic partial denture was subsequently fabricated to replace the missing teeth and thereby restore function. Even though the incidence of cancrum oris has reduced worldwide, cases are still being reported in Africa and can leave behind a significant facial defect. Whereas most cases of lip defects reported from the Western world are due to cancer, cancrum oris could be the cause of lip defects in sub-Saharan Africa. Gillies fan flap could be employed for the reconstruction of a relatively large defect of the lip and the disadvantage of microstomia could be minimized for the restoration of articulation, speech, and masticatory functions of the lip.