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Farley E, Karinja MN, Lawal AM, Olaleye M, Muhammad S, Umar M, Gaya FK, Mbaeri SC, Sherlock M, Kabila DW, Peters M, Samuel J, Maloba G, Usman R, van der Kam S, Ritmeijer K, Ariti C, Amirtharajah M, Lenglet A, Falq G. Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria. PLoS Negl Trop Dis 2023; 17:e0011508. [PMID: 37889919 PMCID: PMC10645368 DOI: 10.1371/journal.pntd.0011508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/14/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Noma is a rapidly spreading infection of the oral cavity which mainly affects young children. Without early treatment, it can have a high mortality rate. Simple gingivitis is a warning sign for noma, and acute necrotizing gingivitis is the first stage of noma. The epidemiology of noma is not well understood. We aimed to understand the prevalence of all stages of noma in hospitalised children. METHODS We conducted a prospective observational study from 1st June to 24th October 2021, enrolling patients aged 0 to 12 years who were admitted to the Anka General Hospital, Zamfara, northwest Nigeria. Consenting parents/ guardians of participants were interviewed at admission. Participants had anthropometric and oral examinations at admission and discharge. FINDINGS Of the 2346 patients, 58 (2.5%) were diagnosed with simple gingivitis and six (n = 0.3%) with acute necrotizing gingivitis upon admission. Of those admitted to the Inpatient Therapeutic Feeding Centre (ITFC), 3.4% (n = 37, CI 2.5-4.7%) were diagnosed with simple gingivitis upon admission compared to 1.7% of those not admitted to the ITFC (n = 21, CI 1.1-2.6%) (p = 0.008). Risk factors identified for having simple gingivitis included being aged over two years (2 to 6 yrs old, odds ratio (OR) 3.4, CI 1.77-6.5; 7 to 12 yrs OR 5.0, CI 1.7-14.6; p = <0.001), being admitted to the ITFC (OR 2.1; CI 1.22-3.62) and having oral health issues in the three months prior to the assessment (OR 18.75; CI 10.65, 33.01). All (n = 4/4) those aged six months to five years acute necrotizing gingivitis had chronic malnutrition. CONCLUSION Our study showed a small proportion of children admitted to the Anka General Hospital had simple or acute necrotizing gingivitis. Hospital admission with malnutrition was a risk factor for both simple and acute necrotizing gingivitis. The lack of access to and uptake of oral health care indicates a strong need for oral examinations to be included in routine health services. This provision could improve the oral status of the population and decrease the chance of patients developing noma.
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Affiliation(s)
- Elise Farley
- Médecins Sans Frontières, Noma Children’s Hospital, Sokoto, Nigeria
| | | | | | - Michael Olaleye
- Médecins Sans Frontières, Noma Children’s Hospital, Sokoto, Nigeria
| | - Sadiya Muhammad
- Médecins Sans Frontières, Nigeria Mission, Zamfara and Abuja, Nigeria
| | - Maryam Umar
- Médecins Sans Frontières, Nigeria Mission, Zamfara and Abuja, Nigeria
| | | | | | | | | | - Miriam Peters
- Médecins Sans Frontières, Nigeria Mission, Zamfara and Abuja, Nigeria
| | - Joseph Samuel
- Médecins Sans Frontières, Noma Children’s Hospital, Sokoto, Nigeria
| | - Guy Maloba
- Médecins Sans Frontières, Nigeria Mission, Zamfara and Abuja, Nigeria
| | - Rabi Usman
- Zamfara Ministry of Health, Zamfara, Nigeria
| | | | | | - Cono Ariti
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bala M, Omotayo SA, Braimah RO, Taiwo AO, Jaafar R, Abubakar AB, Abubakar MK, Saleh AA. Knowledge, Attitude, and Practices of Primary Health-Care Workers toward NOMA Disease in Sokoto. DENTISTRY AND MEDICAL RESEARCH 2022. [DOI: 10.4103/dmr.dmr_33_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Farley E, Mehta U, Srour ML, Lenglet A. Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021). PLoS Negl Trop Dis 2021; 15:e0009844. [PMID: 34905547 PMCID: PMC8670680 DOI: 10.1371/journal.pntd.0009844] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Noma (cancrum oris) is an ancient but neglected and poorly understood preventable disease, afflicting the most disenfranchised populations in the world. It is a devastating and often fatal condition that requires urgent and intensive clinical and surgical care, often difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and identify research gaps that need to be addressed to evolve our understanding of how to address this disease. Methods We searched 11 databases and collected primary peer reviewed articles on noma in all languages, the final search was conducted on 24th August 2021. The oldest manuscript identified was from 28th March 1843 and the most recently published manuscript was from 3rd June 2021. Search terms included cancrum oris and noma. Data was extracted using a standardised data extraction tool and key areas of interest were identified. The Preferred Reporting Items for Systemic review and Meta-Analyses requirements were followed. Results The review included 147 articles, the majority of the studies (n = 94, 64%) were case reports. Most manuscripts (n = 81, 55%) were published in the 2000s, 49 (33%) were from the 1900s and 17 (12%) from the 1800s. The main areas of interest identified were the history and epidemiology of the disease, noma’s clinical progression and aetiology, treatment regimens, mortality rates and the risk factors for the development of noma. Conclusions Noma has been reported in the literature for hundreds of years; however important gaps in our understanding of the disease remain. Future research should focus on determining the burden and distribution of disease; the true mortality rate, pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment. Noma is a devastating and often fatal condition that mainly affects children in severely disenfranchised communities. Noma is preventable and requires urgent basic medical care in the early stages of disease. Once the disease reaches the last stage, sequelae, survivors require expert surgical care, usually difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and to identify research priorities that will evolve our understanding of how to eradicate this disease. Our review showed that noma has been reported in the literature for hundreds of years; however several major gaps in knowledge still exist. There is appreciation among the small community of clinicians and researchers involved in noma care and research that these gaps in knowledge impact on the ability to develop and implement sound evidence-based policies and activities aimed at eradicating noma from communities that continue to be afflicted by this ancient disease. The main focus of future research should be to study the burden and distribution of disease; the true mortality rate, and the pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.
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Affiliation(s)
- Elise Farley
- Noma Children’s Hospital, Médecins Sans Frontières, Sokoto, Nigeria
- Nudibrink Research Consultancy, Cape Town, South Africa
- * E-mail:
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, Western Cape, South Africa
| | | | - Annick Lenglet
- Médecins Sans Frontières, Amsterdam, The Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
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Isah S, Amirtharajah M, Farley E, Semiyu Adetunji A, Samuel J, Oluyide B, Bil K, Shoaib M, Abubakar N, de Jong A, Pereboom M, Lenglet A, Sherlock M. Model of care, Noma Children's Hospital, northwest Nigeria. Trop Med Int Health 2021; 26:1088-1097. [PMID: 34080264 PMCID: PMC9292046 DOI: 10.1111/tmi.13630] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | | | - Elise Farley
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | - Joseph Samuel
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | - Karla Bil
- Médecins Sans Frontières, Amsterdam, Netherlands
| | | | - Nura Abubakar
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | | | - Annick Lenglet
- Médecins Sans Frontières, Amsterdam, Netherlands.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Rickart AJ, Rodgers W, Mizen K, Merrick G, Wilson P, Nishikawa H, Dunaway DJ. Facing Africa: Describing Noma in Ethiopia. Am J Trop Med Hyg 2020; 103:613-618. [PMID: 32372746 DOI: 10.4269/ajtmh.20-0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Noma affects the most marginalized communities in the world, beginning as oral ulceration and rapidly progressing to orofacial gangrene. With a mortality rate estimated to be as high as 90% and with very few able to access treatment in its active phase, very little is understood about the disease. This retrospective review of patients treated by Facing Africa for deformity and functional impairment secondary to noma between May 2015 and 2019 highlights some of the difficulties encountered by those afflicted. Eighty new patients with historical noma defects were identified and were seen over the course of nine surgical missions, with notes providing valuable geographical, socioeconomic, and psychosocial information. The mean self-reported age of onset was 5 years and 8 months, with a median time of 18 years from onset to accessing treatment. Before intervention, 65% covered their face in public, 59% reported difficulty eating, 81% were unhappy with their appearance, and 71% experienced bullying. We aimed at emphasizing the significant burden, both psychologically and physically of noma, demonstrating the disparity between recent decades of progress in the well-being of Ethiopians in general and the access to health care and mental health support for some of those most in need.
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Affiliation(s)
- Alexander J Rickart
- Department of Oral and Maxillofacial Surgery, Great Ormond Street NHS Foundation Trust, London, United Kingdom
| | - Will Rodgers
- Department of Oral and Maxillofacial Surgery, Barts Health NHS Trust, London, United Kingdom
| | - Kelvin Mizen
- Department of Oral and Maxillofacial Surgery, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Graham Merrick
- Department of Oral and Maxillofacial Surgery, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | - Paul Wilson
- Department of Plastic Surgery, North Bristol NHS Trust, Bristol, United Kingdom
| | - Hiroshi Nishikawa
- Department of Plastic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - David J Dunaway
- Department of Plastic Surgery, Great Ormond Street NHS Foundation Trust, London, United Kingdom
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Brattström-Stolt L, Funk T, Sié A, Ndiaye C, Alfvén T. Noma-knowledge and practice competence among primary healthcare workers: a cross-sectional study in Burkina Faso. Int Health 2019; 11:290-296. [PMID: 30561632 DOI: 10.1093/inthealth/ihy088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/30/2018] [Accepted: 10/24/2018] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
| | - Tjede Funk
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Charlotte Ndiaye
- Regional Advisor for Oral Health, World Health Organization Regional Office for Africa, Harare, Zimbabwe
| | - Tobias Alfvén
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
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Adeniyi SA, Awosan KJ. Pattern of noma (cancrum oris) and its risk factors in Northwestern Nigeria: A hospital-based retrospective study. Ann Afr Med 2019; 18:17-22. [PMID: 30729928 PMCID: PMC6380110 DOI: 10.4103/aam.aam_5_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Noma (cancrum oris) remains the scourge of children and the “face of poverty” in Sub-Saharan Africa. Recent data on the burden of noma and its risk factors are needed for evaluating and redesigning interventions for its prevention and control. Objectives: This study aimed to determine the pattern of noma and its risk factors in Northwestern Nigeria. Materials and Methods: It was a retrospective study that looked into cases of noma (cancrum oris) admitted into the Noma Children Hospital, Sokoto, Nigeria, between January 1999 and December 2011. Information on patients’ bio-data, the site and severity of lesions, and presence of trismus and its severity were extracted from the patients’ case files and analyzed using descriptive statistics. Results: One hundred and fifty-nine (8.3%) of the 1923 patients admitted to the hospital from January 1999 to December 2011 were diagnosed with fresh noma. The mean age of the patients was 3.0 ± 1.4 years, and majority of them, 139 (87.4%) were aged 1–5 years. The soft-tissue lesions essentially involved multiple sites but most commonly the outer and inner cheeks (84.3%). The most common risk factors identified were measles (47.2%) and protein-energy malnutrition (42.1%). There were rises and falls in the prevalence of noma in the period studied. Conclusion: This study showed a high burden of noma in Northwestern Nigeria, mostly among children aged 1–5 years, and with soft-tissue lesions involving multiple sites. Measles and malnutrition were the major risk factors identified, and the disease trend showed a wave-like pattern. There is an urgent need to eliminate the disease in Nigeria through prevention and control of infectious diseases and malnutrition.
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Srour ML, Marck K, Baratti-Mayer D. Noma: Overview of a Neglected Disease and Human Rights Violation. Am J Trop Med Hyg 2017; 96:268-274. [PMID: 28093536 DOI: 10.4269/ajtmh.16-0718] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/30/2016] [Indexed: 11/07/2022] Open
Abstract
Noma is an orofacial gangrene affecting malnourished children and mainly observed in tropical countries, particularly sub-Saharan Africa. Epidemiological data on noma are scarce, but a current estimate of the global incidence is 30,000-40,000 cases per year, with a mortality rate of approximately 85% and a burden of disease calculated to be a loss of 1-10 million disability-adjusted life years. The etiology of noma is multifactorial with malnutrition as an ever present factor, often in combination with concomitant diseases, such as measles, malaria, and human immunodeficiency virus (HIV), and poor oral hygiene. The pathogenesis is a fast-spreading, noncontagious gangrenous infection occurring in the face, often preceded by acute necrotizing gingivitis, and stomatitis. Rare microbiological studies suggest an opportunistic infection caused by an imbalance in normal intraoral microorganisms. Prevention lies in food security, measles vaccination, prevention of malaria and HIV, including the early detection and treatment of necrotizing gingivitis and stomatitis. Early treatment with antibiotics may prevent gangrene or reduce its extent. Late treatment consists of surgical rehabilitation, which is often complex. However, access to medical care is very limited for noma patients due to the extremely poor conditions in which they live that are frequently located in remote rural areas. The authors support the United Nations Human Rights Council Resolution 19/7 adopted on March 22, 2012 "The right to food," and advocate for the inclusion of noma on the list of neglected tropical diseases to encourage more medical and institutional attention for this often lethal or very mutilating infectious gangrene.
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Affiliation(s)
| | - Klaas Marck
- Department of Plastic Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Denise Baratti-Mayer
- Geneva Study Group on Noma (GESNOMA), Service of Plastic and Reconstructive Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Zwetyenga N, See LA, Szwebel J, Beuste M, Aragou M, Oeuvrard C, Martin D, Emparanza A. [Noma]. ACTA ACUST UNITED AC 2015; 116:261-79. [PMID: 26235765 DOI: 10.1016/j.revsto.2015.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/23/2015] [Indexed: 11/30/2022]
Abstract
Noma is a necrotizing ulcerative stomatitis known since Antiquity. It occurs mostly in poor countries, the Sahel countries being the most affected. Each year, several hundred thousand cases are reported. Noma affects especially malnourished children who are less than 6 years old and rarely adults with acquired immunodeficiency (HIV, cancer). Ulcerative lesion is occurring rapidly due to the production of endotoxins by bacteria from oral commensal, telluric and animal origin. Necrotic debridement leads to huge defects: loss of soft tissue (skin, nerves, vessels, eye), bone (maxilla, mandible) and teeth. Death occurs rapidly in a few weeks in 80 % of the cases. In case of survival, the consequences are functional, aesthetic, psychological and social. The goal of the treatment in the acute phase is the patient's survival and the fight against limited mouth opening. The management of the phase of sequela is an anaesthetic, surgical and physiotherapy challenge. Its purpose is the social reintegration of the patient.
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Affiliation(s)
- N Zwetyenga
- Service de stomatologie, chirurgie maxillo-faciale, chirurgie plastique esthétique et reconstructrice, chirurgie de la main, centre hospitalier universitaire de Dijon, boulevard Delattre-de-Tassigny, 21000 Dijon, France; Laboratoire EA 4268 4IS, université de Franche-Comte, place Saint-Jacques, 35000 Besançon, France.
| | - L-A See
- Service de stomatologie, chirurgie maxillo-faciale, chirurgie plastique esthétique et reconstructrice, chirurgie de la main, centre hospitalier universitaire de Dijon, boulevard Delattre-de-Tassigny, 21000 Dijon, France
| | - J Szwebel
- Service de chirurgie plastique, hôpital Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris, France
| | - M Beuste
- CHRU, 80054 Amiens cedex 1, France
| | - M Aragou
- Département d'anesthésie, hôpital Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris, France
| | - C Oeuvrard
- Département d'anesthésie, centre hospitalier universitaire de Dijon, boulevard de Lattre-de-Tassigny, 21000 Dijon, France
| | | | - A Emparanza
- Calle Federico García Lorca, 7, 20014, San Sebastian, Espagne
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Ashok N, Tarakji B, Darwish S, Rodrigues JC, Altamimi MA. A Review on Noma: A Recent Update. Glob J Health Sci 2015; 8:53-9. [PMID: 26573028 PMCID: PMC4873589 DOI: 10.5539/gjhs.v8n4p53] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/09/2015] [Indexed: 11/16/2022] Open
Abstract
Noma is a gangrenous infection primarily affecting under developed countries. The aim of this paper was to review all recent articles on noma from January 2003 to August 2014 and briefly update the latest information related to the topic. A literature search was done on PUBMED using the keywords “noma / cancrum oris”. Noma is commonly seen in malnourished children. There has been an increased incidence of noma in HIV patients. Apart from these, noma has also been reported in association with cyclic neutropenia, herpetic stomatitis, leukemia, Down's syndrome and Burkett's disease. Treatment of acute noma includes transfusion of blood and intravenous fluids, administration of antibiotics, putting the patient on a high protein diet and debridement of necrotic areas. Surgical phase is usually initiated 6 to 18 months after a period of quiescence. Although, the mortality rate associated with noma has reduced significantly with the advent of modern generation antibiotics, the functional, cosmetic and psychological challenges associated with the destruction of soft or hard tissues still remains a huge challenge. Adequate steps must be implemented by the government or medical professionals to prevent the disease and provide an early intervention.
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Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, François P, Pittet-Cuenod B, Huyghe A, Bornand JE, Gervaix A, Montandon D, Schrenzel J, Mombelli A, Pittet D. Risk factors for noma disease: a 6-year, prospective, matched case-control study in Niger. LANCET GLOBAL HEALTH 2013; 1:e87-e96. [PMID: 25104163 DOI: 10.1016/s2214-109x(13)70015-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Noma is a poorly studied disease that leads to severe facial tissue destruction in children in developing countries, but the cause remains unknown. We aimed to identify the epidemiological and microbiological risk factors associated with noma disease. METHODS We did a prospective, matched, case-control study in Niger between Aug 1, 2001, and Oct 31, 2006, in children younger than 12 years to assess risk factors for acute noma. All acute noma cases were included and four controls for each case were matched by age and home village. Epidemiological and clinical data were obtained at study inclusion. We undertook matched-paired analyses with conditional logistic regression models. FINDINGS We included 82 cases and 327 controls. Independent risk factors associated with noma were: severe stunting (odds ratio [OR] 4·87, 95% CI 2·35-10·09) or wasting (2·45, 1·25-4·83); a high number of previous pregnancies in the mother (1·16, 1·04-1·31); the presence of respiratory disease, diarrhoea, or fever in the past 3 months (2·70, 1·35-5·40); and the absence of chickens at home (1·90, 0·93-3·88). After inclusion of microbiological data, a reduced proportion of Fusobacterium (4·63, 1·61-13·35), Capnocytophaga (3·69, 1·48-9·17), Neisseria (3·24, 1·10-9·55), and Spirochaeta in the mouth (7·77, 2·12-28·42), and an increased proportion of Prevotella (2·53, 1·07-5·98), were associated with noma. We identified no specific single bacterial or viral pathogen in cases. INTERPRETATION Noma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity. FUNDING Gertrude Hirzel Foundation.
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Affiliation(s)
- Denise Baratti-Mayer
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Angèle Gayet-Ageron
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Clinical Epidemiology, Department of Community Health and Medicine, University of Geneva Hospitals, Geneva, Switzerland; Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland
| | - Stéphane Hugonnet
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland; Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Patrice François
- Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland
| | - Brigitte Pittet-Cuenod
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Antoine Huyghe
- Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva, Sciences III, Department of Plant Biology, Microbiology Unit, Geneva, Switzerland
| | - Jacques-Etienne Bornand
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Central Laboratory of Virology, University of Geneva Hospitals, Geneva, Switzerland
| | - Alain Gervaix
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Department of Paediatrics, University of Geneva Hospitals, Geneva, Switzerland
| | - Denys Montandon
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Jacques Schrenzel
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland
| | - Andrea Mombelli
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Department of Periodontology and Oral Pathophysiology, School of Dental Medicine, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Didier Pittet
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland.
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Lee JI, Kim KS, Oh BC, Kim NA, Kim IH, Park CG, Kim SJ. Acute necrotic stomatitis (noma) associated with methicillin-resistant Staphylococcus aureus infection in a newly acquired rhesus macaque (Macaca mulatta). J Med Primatol 2011; 40:188-93. [PMID: 21332756 DOI: 10.1111/j.1600-0684.2011.00470.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A newly acquired rhesus macaque was suffering from rapid destruction of the left cheek caused by necrotizing stomatitis. METHODS To restore reconstructive surgery and intensive care with antibiotics, wound protection, wound healing agents, and debridement were applied. RESULTS Staphylococcus aureus and Enterococcus faecalis were isolated from the culture of the lesion, and the antibiotic susceptibility test revealed methicillin-resistant Staphylococcus aureus infection. Vancomycin and ampicillin-sulbactam effectively treated the bacterial infections, and reconstructive surgery was performed once the infection was cleared. Topical application of recombinant human epidermal growth factor (rhEGF) was useful to treat exposed wound of the noma lesion. CONCLUSIONS Simian noma associated with methicillin-resistant Staphylococcus aureus (MRSA) had not previously been reported in non-human primates. Although noma associated with MRSA is hard to cure because of its rapid and destructive progress, the aggressive therapy used in this study led to the successful resolution of an acute necrotic stomatitis lesion in a rhesus macaque.
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Affiliation(s)
- J-I Lee
- Xenotransplantation Research Center, Seoul National University Hospital, Seoul, South Korea
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Affiliation(s)
- Joseph E. Tonna
- Stanford/Kaiser Emergency Medicine Residency, Stanford University, Stanford, California, United States of America
| | - Matthew R. Lewin
- Institute for Exploration and Travel Health, California Academy of Sciences, San Francisco, California, United States of America
- * E-mail:
| | - Brett Mensh
- Institute for Exploration and Travel Health, California Academy of Sciences, San Francisco, California, United States of America
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Ogbureke KU, Ogbureke EI. NOMA: A Preventable "Scourge" of African Children. Open Dent J 2010; 4:201-6. [PMID: 21243072 PMCID: PMC3020568 DOI: 10.2174/1874210601004010201] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 07/10/2010] [Accepted: 07/19/2010] [Indexed: 11/22/2022] Open
Abstract
Noma is a serious orofacial gangrene originating intraorally in the gingival-oral mucosa complex before spreading extraorally to produce a visibly destructive ulcer. Although cases of noma are now rarely reported in the developed countries, it is still prevalent among children in third world countries, notably in sub-Sahara Africa, where poverty, ignorance, malnutrition, and preventable childhood infections are still common. This review summarizes historical, epidemiological, management, and research updates on noma with suggestions for its prevention and ultimate global eradication. The global annual incidence remains high at about 140,000 cases, with a mortality rate exceeding 90% for untreated diseases. Where the patients survive, noma defects result in unsightly facial disfigurement, intense scarring, trismus, oral incompetence, and social alienation. Although the etiology has long been held to be infectious, a definitive causal role between microorganisms cited, and noma has been difficult to establish. The management of noma with active disease requires antibiotics followed by reconstructive surgery. Current research efforts are focused towards a comprehensive understanding of the epidemiology, and further elucidation of the microbiology and pathogenesis of noma.Although a formidable public health challenge, noma can be prevented with a potential for subsequent global eradication. To achieve both desirable goals, detection of early disease is crucial because these early lesions respond to conventional antibiotic treatments when instituted side by side with nutritional rehabilitation, and obviates the necessity for extensive surgical reconstruction often indicated in late stage disease. The eradication of noma in the developed world in the mid 20(th) century bears out the notion of a similar outcome following effective preventive strategies in Africa. A fundamental and necessary step towards attaining this goal is for the international community to adopt a perception of noma as an urgent global public health challenge. Research effort toward deciphering the microbiology, molecular events, and pathogenesis of noma also should intensify.
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Affiliation(s)
- Kalu U.E Ogbureke
- Department of Oral Biology, School of Dentistry, Medical College of Georgia, Augusta Georgia, U.S.A
- Department of Oral Health and Diagnostic Sciences, School of Dentistry, Medical College of Georgia, Augusta Georgia, U.S.A
| | - Ezinne I Ogbureke
- Department of Oral Health and Diagnostic Sciences, School of Dentistry, Medical College of Georgia, Augusta Georgia, U.S.A
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RUSSELL STEFANIEL, PSOTER WALTERJ, JEAN-CHARLES GERMAIN, PROPHTE SAMUEL, GEBRIAN BETTE. Protein-energy malnutrition during early childhood and periodontal disease in the permanent dentition of Haitian adolescents aged 12-19 years: a retrospective cohort study. Int J Paediatr Dent 2010; 20:222-9. [PMID: 20409204 PMCID: PMC2866123 DOI: 10.1111/j.1365-263x.2010.01031.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this retrospective cohort study was to examine whether exposure to early childhood protein-energy malnutrition (ECPEM) is related to worsened periodontal status in the permanent dentition during adolescence. DESIGN A trained clinician/researcher examined the periodontal status of 96 persons aged 12-19 living in rural Haiti using WHO diagnostic criteria (Community Periodontal Index, WHO 1997). Malnutrition data of the study participants had been collected during the years 1988-1993 by a nongovernmental organization. We compared those who had been malnourished in early childhood, based on z-scores for anthropomorphic data collected during the first 5 years of life, with those who had not been malnourished, regarding mean Community Periodontal Index (CPI) score, controlling for age, sex, socioeconomic status, and smoking. RESULTS Overall, 57.3% of the participants demonstrated a CPI score of 3 or greater in at least one sextant. ECPEM was independently and positively related to mean CPI score, when controlling for sex and smoking. CONCLUSIONS More than half of these young Haitians demonstrated CPI scores of 3 or greater, and ECPEM was related to poorer periodontal status, as measured by CPI, in the permanent dentition.
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Affiliation(s)
- STEFANIE L. RUSSELL
- Department of Epidemiology & Health Promotion, New York University College of Dentistry, New York, NY, USA
| | - WALTER J. PSOTER
- Department of Epidemiology & Health Promotion, New York University College of Dentistry, New York, NY, USA, School of Dentistry, University of Puerto Rico, San Juan, PR, USA
| | - GERMAIN JEAN-CHARLES
- Oral Diagnostic Sciences, School of Dental Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - SAMUEL PROPHTE
- Department of Periodontology and Department of Preventive Dentistry, l’Université d’Etat d’Haiti, Faculté d’Odontologie, Port-au-Prince, Haiti
| | - BETTE GEBRIAN
- Haitian Health Foundation, Norwich, CT, USA, School of Nursing, University of Connecticut, Storrs, CT, USA
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Chidzonga MM, Mahomva L. Recurrent noma (cancrum oris) in human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS): report of a case. J Oral Maxillofac Surg 2008; 66:1726-30. [PMID: 18634964 DOI: 10.1016/j.joms.2007.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 08/22/2007] [Indexed: 10/21/2022]
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Chidzonga MM, Mahomva L. Noma (cancrum oris) in human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS): clinical experience in Zimbabwe. J Oral Maxillofac Surg 2008; 66:475-85. [PMID: 18280380 DOI: 10.1016/j.joms.2007.09.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 06/12/2007] [Accepted: 09/05/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE This retrospective study describes the clinical features and management of noma (cancrum oris) in patients with HIV and AIDS. PATIENTS AND METHODS Records of 48 consecutive patients with noma (cancrum oris) seen between July 2002 and November 2006 were reviewed for age, gender, clinical features, and management. Other reports on noma in HIV and AIDS in Zimbabwe were also reviewed. RESULTS There were 48 patients included; 35.4% (n = 17) were males, of which 64.7% (n = 11) were children (16 years and younger) and 35.3% (n = 6) were adults; 64.6% (n = 31) were females, out of which 87.1% (n = 27) were children and 12.9% (n = 4) were adults. The average age was 14.2 years (range, 3 to 30 years) for males and 9.2 years (range, 1 to 36 years) for females. The average age for the entire group was 11 years (range, 1 to 36 years). All patients were HIV-positive by the ELISA method. Only 13 patients had CD4 cell and CD8 cell count obtained, ranging from 10 to 594 cells/microL with a CD4/CD8 ratio ranging from 0.02 to 0.45. Only 5 patients had microbiologic investigations conducted, isolating Staphylococcus aureus, Klebsiella species, group D Streptococcus, and group B hemolytic Streptococcus. Isolated cheek defect (37.5%) was most common, followed by the type I and type IV defect (25% each). Administration of antibiotics, nutritional support, wound debridement, and sequestrectomy were conducted before definitive reconstructive surgery. Facial reconstruction was performed using distant and local advancement flaps. No bony reconstruction was performed. Satisfactory results were achieved with minimal infection and flap breakdown. Follow-up was difficult; patients were lost to follow-up within 6 to 12 months after surgery. CONCLUSION Noma cases are on the increase in line with the current HIV and AIDS epidemic. Female children appear to be more commonly affected than their male counterparts. Reconstructive surgery is possible in patients with low CD4/CD8 ratios because of HIV infection.
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Abstract
PURPOSE OF REVIEW Nutritional deficiency, a global problem, remains uncommon in developed nations. Associated morbidity and mortality make it imperative that clinicians remain familiar with the clinical signs and symptoms of nutritional deficiencies to facilitate diagnosis. This article will review the cutaneous findings and recent literature regarding B12, niacin, zinc, vitamin A, kwashiorkor, biotin and selenium deficiencies, along with the clinical entities of noma and phrynoderma. RECENT FINDINGS Much of our understanding of the clinical manifestations of nutritional deficiencies comes from old literature; however, recent case reports and series have highlighted several patient populations that may be at risk from acquired deficiencies, including patients with anorexia nervosa, cystic fibrosis, patients receiving long-term tube-feeding and those with perceived or real food allergy. There can be significant clinical overlap between various micronutrient, protein and vitamin deficiencies. Additionally, providers should consider the possibility of multiple deficiencies coexisting in individual patients. SUMMARY Reports of nutritional deficiency continue to surface in developed nations and pediatricians need to have a basic understanding of their clinical manifestations. The skin is commonly affected and can be the presenting sign of illness. A higher clinical suspicion needs to be maintained in certain populations.
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Affiliation(s)
- Michelle L Heath
- Department of Medicine, Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, WA 98105, USA
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Abstract
Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inflammation to grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of acute noma is at ages 1-4 years, coinciding with the period of linear growth retardation in deprived children. Noma is a scourge in communities with poor environmental sanitation. It results from complex interactions between malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3-6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases.
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Affiliation(s)
- Cyril O Enwonwu
- Department of Biomedical Sciences, School of Dentistry, University of Maryland, Baltimore, MD 21201, USA.
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