Pattern of noma (cancrum oris) and its risk factors in Northwestern Nigeria: A hospital-based retrospective study

Periodontal diseases in Africa

Periodontal diseases, a group of complex conditions marked by an excessive immune response and periodontal tissue destruction, are a global health concern. Since 1990, the incidence of these diseases has doubled, with Western sub-Saharan Africa experiencing the highest burden. Accurate diagnosis and case identification are crucial for understanding the etiology, features of disease, research, treatment and prevention. Modern perspectives on periodontal disease classification are based on commonality among those affected. However, current literature is often plagued by methodological inconsistencies and focused on disease mechanisms in European populations. Health inequalities in low- and middle-income countries (LMICs) are exacerbated by these challenges, with sub-Saharan Africa, and Nigeria specifically, facing unique difficulties such as clinical personnel shortages and limited research infrastructure. This review explored disparities in periodontal disease research, care and outcomes in African populations. We highlighted these disparities and identified the factors contributing to inequities in periodontal health outcomes. We further demonstrated the critical need for inclusive and equitable healthcare and research practices tailored to the unique challenges faced by diverse populations and regions with limited resources. Addressing these disparities is essential for ensuring that advancements in healthcare are accessible to all, thereby improving global oral health and general health.

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.

Prevalence and associated risk factors for noma in Nigerian children: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence, case-fatality rate, and associated risk-factors of Noma in children in Nigeria.

METHODS

Search was conducted in PubMed, Google Scholar, and Cochrane Library databases. Data were extraction using a double-blind approach. Discrepancies were resolved by a third reviewer. Heterogeneity was evaluated using I2 statistics. Random-effects model was used for the meta-analysis and subgroup analysis was conducted. The study quality was evaluated using standard Critical-Appraisal-Checklist.

RESULTS

Of the 1652 articles identified, 12 studies that met the inclusion criteria included 871 cases of Noma. Two studies had high-risk of bias and were excluded in the meta-analysis. Pooled prevalence of Noma was 2.95% (95%CI:2.19-3.71; Z = 7.60; p < 0.00001, I2:100.0). Case fatality was reported in one study. Sex-distribution had a male-to-female ratio of 1.1:1. Malnutrition (88.42%, 95%CI:52.84-124.00; I2:100.0), measles (40.60%; 95% CI:31.56-49.65; I2:100.0) and malaria (30.75%; 95% CI:30.06-31.45; I2:100.0) were the most notable associated risk-factors. Prevalence of Noma was non-significantly lower in southern (1.96%,95%CI:1.49-2.44;6 studies) than in northern (4.43%; 95%CI:-0.98-9.83; 4 studies) Nigeria. One study reported the prevalence of Noma in children younger than 5 years.

CONCLUSIONS

About every 3 in 100 children in Nigeria had Noma and the prevalence was non-significantly higher in northern than southern Nigeria. Malnutrition, measles, and malaria were major associated risk-factors. Case-fatality rate and prevalence based on different age-groups were inconclusive.

Noma in an 18 months Toddler: A Rare Case Report with Review of Literature

Introduction

Noma is a polymicrobial necrotizing infection of the mouth and face which destroys the soft and hard tissues of the oral and paraoral structures. Malnutrition, poverty, lack of basic hygiene, and chronic disease state etc., possess a risk of developing noma. Noma neonatorum is a progressive gangrenous disease affecting the premature infants.

Aim

We present a rare case of noma in an 18 months toddler with a chronic debilitating condition predisposing to the disease progression.

Results

The necrotizing infection of the face developed after six months of multiple episodes of chronic blood-tinged diarrhea. The facial defect was managed with release of fibrosis and reconstruction with a superiorly based nasolabial flap.

Discussion

Noma reflects extreme malnutrition and poverty with a vast range of etiopathological agents. This case emphasizes the need to understand the host risk factors and etiopathologic agent predisposing to this rare opportunistic and dormant but devastating disease, the morbidities associated with it and measures to prevent it.

Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria

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.

Noma: a PubMed-based informetric analysis of a neglected tropical orofacial disease in Nigeria

Noma is an orofacial gangrenous infection commonly affecting malnourished children in the tropical region of the World, particularly the sub-Saharan Africa. Nigeria is a sub-Saharan African country which is among the countries seriously affected by noma. In Nigeria, noma has been classified as a priority disease. However, only very little attention has been focused on noma research in Nigeria, unlike many other priority diseases. This study conducted an informetric analysis of research outputs on noma in Nigeria, using the PubMed database - a world-leading and authoritative database of medical literature. This study revealed that only 26 PubMed-indexed publications on noma (PONs), published between January 1990 and September 2021, were available. A trend analysis of these PONs showed that the average output (outputs from 1999 to 2020 = 23) rate per year (from 1990 to 2020 [31 years]) was 0.74 (23/31). Sokoto (n = 11), Oyo (n = 4) and Kebbi (n = 3) were the top three Nigerian states surveyed on noma in the included PONs. Only 12 publications had international co-authors, of which only few publications had co-authors affiliated with institutions in other African countries: South Africa - 5 publications; and Rwanda - 2 publications. Only two publications were funded. Also, the top five prolific Nigerian authors on noma in Nigeria were affiliated with Noma Children Hospital, Sokoto State, Nigeria. In conclusion, PONs by Nigerian authors is so meagre in quantity. This low output is an issue of medical concern. More research focused on noma in Nigeria is needed through funding and other research capacity-strengthening measures.

Retrospective Characterization of Noma Cases Found Incidentally across Nigeria during Outreach Programs for Cleft Lip from 2011-2020

Reports of cases of noma in Nigeria remain scarce despite its known and devastating effects on victims. This report presents a retrospective cross-sectional study based on data regarding on patients with noma encountered incidentally during Oral Health Advocacy Initiative outreach on orofacial diseases across 34 states and the Federal Capital Territory in Nigeria over 10 years (2011-2020), which was aimed at contributing to an understanding of the epidemiology of noma in Nigeria. The data were collated and analyzed, and are presented in frequency distribution tables and charts. A total of 7,195 patients with noma were encountered. The northeastern region had the greatest number of patients (n = 1,785, 24.8%) whereas the southwestern region had the least (n = 196, 2.7%). When aggregated by state, Ondo State had the least number of patients (n = 31, 0.4%) whereas Kano State had the greatest (n = 623, 8.7%). Patient age ranged from 3 to 70 years, with a slight male preponderance (56.9%). This report highlights the fact that noma is prevalent in Nigeria but remains neglected, with extensive but preventable physical, emotional, and social debilitation and devastation of the victims across all age groups. There is a need for a more robust survey to determine the true burden of the disease. There is also an urgent need for collaboration between governments and nongovernmental organizations to institute appropriate interventions by way of public education and enlightenment, as well as case detection and early treatment to mitigate the devastating consequences of delayed or poorly managed cases.

A retrospective clinical, multi-center cross-sectional study to assess the severity and sequela of Noma/Cancrum oris in Ethiopia

Introduction

Noma is a disfiguring gangrenous disease of the orofacial tissue and predominantly affects malnourished children. The tissue gangrene or necrosis starts in the mouth and eventually spreads intra-orally with the destruction of soft and hard tissues. If not controlled, the natural course of the condition leads to a perforation through the skin of the face, creating a severe cosmetic and functional defect, which often affects the mid-facial structures. Furthermore, the course of the disease is fulminating, and without timely intervention, it is fatal.

Materials and methods

A retrospective clinical cross-sectional study was conducted to assess the sequela and severity of Noma in Ethiopia. Medical records of patients diagnosed with Noma were reviewed. The medical files were obtained from Yekatik 12 Hospital, Facing Africa, and the Harar project,—the three major Noma treatment centers in Ethiopia. The severity of facial tissue damage and the extent of mouth trismus (ankylosis) were examined based on the NOIPTUS score.

Results

A total of 163 medical records were reviewed. Of those, 52% (n = 85) and 48% (n = 78) have reported left-sided and right-sided facial defects, respectively. The facial defects ranged from minor to severe tissue damage. In other words, 42.3% (n = 69), 30.7% (n = 50), 19% (n = 31), and 8% (n = 13) have reported Grade-2 (25–50%), Grade-3 (50–75%), Grade-1 (0–25%), and Grade-4 (75–100%) tissue damages respectively. Cheek, upper lip, lower lip, nose, hard palate, maxilla, oral commissure, zygoma, infra-orbital region, mandible, and chin are oftentimes the major facial anatomic regions affected by the disease in the individuals identified in our review. Complete loss of upper lip, lower lip, and nose were also identified as a sequela of Noma.

Discussion

The mortality rate of Noma is reported to vary between 85% and 90%. The few survivors suffer from disfigurement and functional impairment affecting speech, breathing, mastication, and/or even leading to changes in vision. Often, the aesthetic damage becomes a source of stigma, leading to isolation from society, as well as one’s family. Similarly, our review found a high level of facial tissue damage and psychiatric morbidity.

Noma is orofacial gangrene that rapidly disintegrates the hard and soft tissue of the face. The mortality rate of Noma varies between 85–90%. The remaining 10–15% of Noma survivors permanently suffer from severe facial deformities. Noma is a widely neglected disease affecting poor people globally. Most cases of Noma are reported from the so-called Noma belt, located south of the Sahara and runs across Africa from Senegal to Ethiopia. Though Ethiopia is one of the countries in the Noma-belt region where people, particularly children, are significantly affected by the disease, the attention given to this devastating condition is remained to be very low. Therefore, we believe that assessing the severity and sequela of Noma in Ethiopia is crucially essential to lay bare the burden of the disease and increase the overall understanding of the condition among different stakeholders. We are also convinced that the study’s findings can serve as baseline data for further in-depth scientific investigations and preventive policy development.

Noma, a neglected disease: prevention is better than cure

PURPOSE OF REVIEW

There is a need for concerted effort to increase Global awareness about noma (cancrum oris). This paper aims to summarize the recent literature on noma and provide suggestions that could be implemented to raise awareness about this neglected disease.

RECENT FINDINGS

Noma has been recognized, diagnosed and reported for centuries. Despite significant progress in scientific methods over time, the published literature on noma has predominantly been of low level clinical and scientific evidence. Recent studies have reported on noma's global distribution and its predisposing risk factors, its treatment, its knowledge and beliefs and has included a number of literature reviews. Noma cases are being reported from an increasingly diverse set of geographical locations.

SUMMARY

Noma has largely been neglected in the research sphere. Noma is a preventable disease and its progression can be halted if patients are recognized and treated in the early stages of disease. Treatment for late stage noma survivors remains complex and time consuming, requiring substantial human and financial resources most commonly not achieving functional and cosmetic anatomy. The ultimate aim is therefore prevention, initiatives should be integrated into existing health programs.

Economic and Social Costs of Noma: Design and Application of an Estimation Model to Niger and Burkina Faso

BACKGROUND

While noma affects hundreds of thousands of children every year, taking their lives, disfiguring them and leaving them permanently disabled, the economic and social costs of the disease have not been previously estimated. An understanding of the nature and levels of these costs is much needed to formulate and implement strategies for the prevention and control of this disease, or to mitigate its burden. The objectives of our study were to develop a model for estimating the economic and social costs of noma and to provide estimates by applying this model to the specific contexts of two countries in the "noma belt", namely Burkina Faso and Niger.

METHODS

Three main approaches were used. The estimation of prevalence levels of potential noma cases and of cases that should receive and actually do receive medical care was carried out using a literature review. The documentary approach made it possible to estimate the direct costs of noma by analyzing the database of a non-governmental organization operating in this field and present in both countries. Indirect costs were estimated using the human capital method and the cost component analysis technique.

RESULTS

The direct costs of care and management of noma survivors amount to approximately USD 30 million per year in Burkina Faso, compared to approximately USD 31 million in Niger. They mainly include costs for medical treatment, surgery, hospital stays, physiological care, psychological care, social assistance, schooling, vocational training and care abroad. Indirect costs are estimated at around 20 million in lost production costs in Burkina and around 16 million in Niger. Costs related to premature deaths are estimated at more than USD 3.5 billion in Burkina Faso and USD 3 billion in Niger. Finally, the costs to survivors who are unable to marry are around USD 13.4 million in Burkina and around USD 15 million in Niger. Intangible costs were not calculated.

CONCLUSIONS

The neglect of noma and inaction in terms of prevention and control of the disease have enormous economic and social costs for households, communities and states. Future studies of this kind are necessary and useful to raise awareness and eradicate this disease, which impacts the health and well-being of children and results in lifelong suffering and severe economic and social costs to survivors and their families.

Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021)

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 24^th August 2021. The oldest manuscript identified was from 28^th March 1843 and the most recently published manuscript was from 3^rd 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.

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.

Case report: a rare case of NOMA (cancrum oris) in a Malian woman

Noma or cancrum oris is a multi-bacterial and opportunistic infection that destroys soft tissue, as well as muscle and bone, and can be fatal. We present a rare case of Noma in a 32-year-old Malian woman, from whom we isolated an Escherichia coli extended-spectrum beta-lactamase.

Facing Africa: Describing Noma in Ethiopia

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.

The prevalence of noma in northwest Nigeria

Background

Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.

Methods

Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0–5 and 6–15 years). Factors associated with noma were estimated using logistic regression.

Results

A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0–5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0–5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3–5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6–15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.

Conclusions

Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list.

Estimated incidence and Prevalence of noma in north central Nigeria, 2010-2018: A retrospective study

Background

Noma is a spreading and fulminant disease believed to be native to Sub-Saharan Africa over the last decade and associated with low socioeconomic status of citizens of the region. Within this noma belt, most epidemiological reports regarding the disease have emanated from the north western region of Nigeria. However, our indigenous surgical mission encountered a substantial number of cases of noma and post-noma defects noteworthy of epidemiological representation across north central Nigeria.

Methods

All noma cases encountered within the 8-year study period were included and divided based on clinical signs into acute and sequelae groups. Incidence estimation was based on acute/recently active cases and was calculated using the statistical method proposed by the WHO Oral Health Unit (1994). Period prevalence of noma was calculated considering the population at risk in the zone.

Findings

A total of 78 subjects were included in the study with age ranging from 2–75 years. Twelve subjects (15.4%) presented with acute disease while 66 (84.6%) had various forms of post-noma defects. The estimated incidence of noma in the north central zone was 8.3 per 100000 with a range of 4.1–17.9 per 100000 across various states. Period prevalence of noma which incorporated all cases seen within the study period was 1.6 per 100000 population at risk.

Conclusion

Although noma may be more prevalent in the north western region of Nigeria, substantial number of cases occurs within the north central zone which calls for deliberate public awareness campaign on disease risk factors and prevention, and education of primary health-care providers.

Noma, a devouring disease of the orofacial complex, is commonly associated with poverty and impoverished regions of the world especially Sub-Saharan Africa termed the noma belt region of the world. With more reports advocating for full inclusion of noma in the WHO Neglected Tropical Diseases (NTDs) program, the apparent neglect of the disease in north central Nigeria compared to other sub-regions is worrisome as the disease burden in the sub-region has not been reported till date. In this light, a retrospective, cross-sectional survey was conducted to provide epidemiological representation to the cases encountered within an eight-year period by the Cleft and Facial Deformity Foundation (CFDF), an indigenous surgical mission. The incidence of noma was estimated using methods recommended by WHO while the period prevalence was calculated considering the population living below poverty line in the sub-region. This study extrapolates an incidence of 8.3 cases per 100000 and a period prevalence of 1.6 per 100000 persons at risk. Notable is the finding that most individuals encountered were above thirty years of age and suffered varying degree of facial disfigurement consequent to acute noma disease experienced in their childhood/early adolescence. Therefore, we advocate public awareness on the disease risk factors and prevention within the sub-region as well as training of primary health personnel on disease identification, primary care and nearest referral centres. We also identify the need to bolster the efforts of existing health facilities and indigenous surgical missions in the management and rehabilitation of noma cases and survivors.