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Figure 1.
Acute Noma
Acute Noma

A young child presents with acute noma in the setting of severe malnutrition.

Figure 2.
Healed Noma
Healed Noma

The same child who survived acute noma is left with orofacial defects after healing by secondary intention. She now presents for surgical reconstruction.

1.
Enwonwu  CO, Falkler  WA  Jr, Phillips  RS.  Noma (cancrum oris).  Lancet. 2006;368(9530):147-156.PubMedGoogle ScholarCrossref
2.
Marck  KW.  A history of noma, the “face of poverty”.  Plast Reconstr Surg. 2003;111(5):1702-1707.PubMedGoogle ScholarCrossref
3.
Bourgeois  DM, Diallo  B, Frieh  C, Leclercq  MH.  Epidemiology of the incidence of oro-facial noma: a study of cases in Dakar, Senegal, 1981-1993.  Am J Trop Med Hyg. 1999;61(6):909-913.PubMedGoogle ScholarCrossref
4.
Tempest  MN.  Cancrum oris.  Br J Surg. 1966;53(11):949-969.PubMedGoogle ScholarCrossref
5.
Stewart  MJ.  Observations on the histopathology of cancrum oris.  J Pathol. 1912;16:221-225.Google ScholarCrossref
6.
Bourgeois  DM, Leclercq  MH.  The World Health Organization initiative on noma.  Oral Dis. 1999;5(2):172-174.PubMedGoogle ScholarCrossref
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Research Letter
AAFPRS Research Award Winner
April 12, 2018

Evaluation of the Noma Disease Burden Within the Noma Belt

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
  • 2Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
  • 3Department of Otolaryngology, University Teaching Hospital Kigali, University of Rwanda College of Medicine & Health Sciences, Kigali, Rwanda
  • 4Department of Oral and Maxillofacial Surgery, Katharinen Hospital, Stuttgart, Germany
  • 5Children’s Noma Hospital, Sokoto State, Nigeria
  • 6Department of Anaesthesia and Critical Care, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
  • 7Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 8Department of Otorhinolaryngology, Ochsner Health System, New Orleans, Louisiana
JAMA Facial Plast Surg. Published online April 12, 2018. doi:10.1001/jamafacial.2018.0133

Noma is a relatively unknown but devastating opportunistic infection of the face that occurs in the setting of extreme poverty. Noma cases are concentrated within the “noma belt,” a region that extends from Senegal to Ethiopia where malnutrition is endemic.1 Acute noma begins in the gingiva as a necrotizing lesion, progressing rapidly through the hard and soft tissues of the face (Figure 1).2 Untreated noma carries a 90% mortality rate.3,4 Survivors are left with complex facial deformities in a low-resource setting (Figure 2).5

The noma disease burden is poorly understood as epidemiologic information remains sparse and unreliable.1 In 1998 the World Health Organization estimated the incidence to be 140 000 cases per year.6 However, because no more than 10% of patients seek care during the acute stage,1 this percentage may greatly underestimate the disease burden. Furthermore, nations in which hunger is endemic often do not have the infrastructure to keep meaningful mortality statistics. Thus, the severity of the noma disease burden is difficult to identify. We hypothesize that a significant delay in care between acute noma and definitive surgery exists and that this metric can serve as a proxy measure of disease burden severity when other metrics are not available.

Methods

A Doctors Without Borders intervention at Sokoto Children’s Noma Hospital, northern Nigeria, provided facial reconstructive surgery for a referred sample of 18 patients with noma in August 2017. Patients were queried as to the age of onset for acute disease and their current age in years. The delay in treatment between age of onset and age of surgical treatment was determined. Descriptive statistics were obtained using Stata, version 15 (StataCorp). All patients gave informed written and oral consent for data collection. Ethics review board approval by Doctors Without Borders was granted.

Results

A total of 260.5 untreated noma disease-years existed within this cohort of 18 patients. A mean (SD) of 14.5 (13) (range, 2.0-40.5) years existed between the onset of acute noma and definitive surgery in this cohort.

Discussion

Noma disease occurs in the setting of chronic malnutrition and poverty. Delay in care serves as an alternative metric to evaluate noma disease burden when few other data exist. Delay in care reflects disease incidence, prevalence, and the ability of existing surgical care systems to offer treatment; however, this metric is unable to substratify these data.

In northern Nigeria, which lies within the noma belt, we identified a delay of 14.5 years between the onset of acute noma disease and surgical treatment in a recent cohort of patients with noma. This prolonged delay is consistent with the known burden of disease. Further methods of evaluating the noma disease burden should be explored to better understand and eventually treat the disease.

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Article Information

Accepted for Publication: January 23, 2018.

Corresponding Author: David A. Shaye, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (david_shaye@meei.harvard.edu).

Published Online: April 12, 2018. doi:10.1001/jamafacial.2018.0133

Author Contributions: Dr Shaye had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Shaye, Vo, Adetunji, Magee, Winters.

Acquisition, analysis, or interpretation of data: Shaye, Vo, Adetunji, Rabbels, Winters.

Drafting of the manuscript: Shaye, Adetunji, Winters.

Critical revision of the manuscript for important intellectual content: Shaye, Vo, Magee, Rabbels, Winters.

Statistical analysis: Shaye, Adetunji.

Administrative, technical, or material support: Shaye, Vo, Adetunji, Magee, Winters.

Study supervision: Shaye, Vo, Rabbels.

Conflict of Interest Disclosures: None reported.

References
1.
Enwonwu  CO, Falkler  WA  Jr, Phillips  RS.  Noma (cancrum oris).  Lancet. 2006;368(9530):147-156.PubMedGoogle ScholarCrossref
2.
Marck  KW.  A history of noma, the “face of poverty”.  Plast Reconstr Surg. 2003;111(5):1702-1707.PubMedGoogle ScholarCrossref
3.
Bourgeois  DM, Diallo  B, Frieh  C, Leclercq  MH.  Epidemiology of the incidence of oro-facial noma: a study of cases in Dakar, Senegal, 1981-1993.  Am J Trop Med Hyg. 1999;61(6):909-913.PubMedGoogle ScholarCrossref
4.
Tempest  MN.  Cancrum oris.  Br J Surg. 1966;53(11):949-969.PubMedGoogle ScholarCrossref
5.
Stewart  MJ.  Observations on the histopathology of cancrum oris.  J Pathol. 1912;16:221-225.Google ScholarCrossref
6.
Bourgeois  DM, Leclercq  MH.  The World Health Organization initiative on noma.  Oral Dis. 1999;5(2):172-174.PubMedGoogle ScholarCrossref
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