Neglected Tropical Diseases of the
Skin
Noma
Training for national and district-
level health workers
Introduction
and overview
LEARNING OBJECTIVES
Epidemiology, pathogenesis, clinical
Describe
aspects, diagnosis and treatment of noma
Socioeconomic impact and interventions to
List
address the public health burden of noma
ABOUT THIS COURSE
Module 1 Introduction
Module 2 Epidemiology and pathogenesis
Module 3 Clinical features and diagnosis
Module 4 Treatment
Module 5 Public health and human rights
considerations
Module 1 Introduction
Part 1: Introduction to noma
Part 2: Noma and its relation to Neglected
Tropical Diseases (NTDs)
PART 1
Introduction
to noma
Introduction
• Noma (cancrum oris) is a rapidly
progressing, invasive, and
debilitating orofacial disease.
• It affects the most vulnerable and
marginalized populations
worldwide.
• Throughout history, the disease has
been accompanied by conditions of
extreme food insecurity,
poverty, poor health and oral
hygiene, and deficient sanitary
conditions.
Drawing: Chloé Fournier / Inediz for • With early detection and
Introduction (Cont’d.)
• Noma is reported mainly in children between two and
six years of age:
o living in poverty condition
o with chronic malnutrition and a high prevalence of
comorbidities such as measles, malaria, and HIV
• Mortality rate in untreated patients is very high.
• The diagnosis is exclusively clinical.
• The pathogenesis of the disease is still being
debated.
History
• Noma (also known as 'cancrum oris’) dates back to
antiquity.
• Noma was regularly reported from settings in Europe
and North America, especially during and in the
aftermath of war and famine.
• Improvements in health care and hygiene standards,
alongside general socioeconomic development, led to a
gradual decline in the number of cases in the 19th
century.
• After the Second World War, cases became rare in
Western countries.
•Reference:
Today, noma cases are mainly reported from low-income
Galli A, Brugger C, Fürst T, Monnier N, Winkler MS, Steinmann P. Prevalence, incidence, and reported global
countries, with most cases occurring in West Africa.
distribution of noma: a systematic literature review. Lancet Infect Dis. 2022 Mar 15:S1473-3099(21)00698-8.
The WHO noma programme
• In 1994, WHO launched an international programme to
control noma.
• In 2001, the WHO Regional Office for Africa (AFRO)
established the Regional Noma Control Programme
(RNCP).
• In the 2nd edition of Integrated Disease
Surveillance and Response (2010), noma was
integrated into the priority list of diseases targeted for
eradication and elimination.
• Since 2013, AFRO has provided technical and financial
support to 10 noma priority countries to implement
References:
the national noma control programme as part of the
WHO Regional Office for Africa (2020). A step-step guide to develop national action plans for noma prevention and control in
priority countries.
PART 2
Noma and
its relation to
NTDs
What are the NTDs?
• NTDs are a medically diverse group of conditions that:
o Impair the lives of more than 1 billion people.
o Are mainly prevalent in tropical areas.
o Are strongly associated with poverty.
• NTDs inflict massive suffering, with many causing life-
long disability and death, stigma, mental distress,
and discrimination.
• NTDs are also neglected by medical research.
NTDs
Helminths Protozoa Viruses Bacteria
Taeniasis / Chagas Rabies Buruli ulcer
Cysticercosis disease Dengue and Leprosy
Echinococcosis Leishmaniasis Chikungunya
Trachoma
Dracunculiasis Human African Yaws
Foodborne trypanosomiasi
trematodiases s
Fungi Ectoparasite Non
Lymphatic s communicab
Mycetoma Scabies
filariasis le
Chromoblasto- Tungiasis Diseases
Soil-transmitted
mycosis and Snake bite
helminthiases Cutaneous
other deep envenoming
larva
Schistosomiasis mycoses migrans
Onchocerciasis
Five core strategic interventions for NTDs
Innovative and Water,
intensified sanitation
disease and hygiene
management (WASH)
Preventive Vector Veterinary
chemotherap control public
y health
Skin-NTDs as a part of NTDs
Have skin manifestations, including ulcers, patches,
nodules, wounds and swelling. They include:
•Buruli ulcer •Onchocerciasis
•Cutaneous leishmaniasis (1) •Post-kala-azar dermal
•Leprosy (Hansen’s disease) (2) leishmaniasis
•Lymphatic filariasis •Scabies (5) and other
•Mycetoma (3), ectoparasitoses (including
chromoblastomycosis tungiasis)
(4) and other deep mycoses •Yaws
1 2 3 4 5
Photos: Mourad Mokni
Noma and NTDs / skin-NTDs?
Noma is not included in the WHO list of NTDs:
• It is primarily found in remote regions, affecting young
children living in extreme poverty.
• Causes skin manifestations, including ulcers.
• Survivors are often severely affected by facial
deformities that cause difficulty with eating,
speaking, and appearance, leading to discrimination,
stigmatization, and isolation.
• Noma is primarily reported from poor developing
countries in Africa and Asia, but it can also occur
wherever the risk factors exist.
Noma and NTDs / skin-NTDs? (Cont’d.)
• The risk factors for noma are common to the current
NTDs, which often exist where noma is found.
• Public health interventions result in the prevention,
detection, and early treatment of noma and disease
sequelae.
• There has not been sufficient research on the
epidemiology, diagnosis, treatment and prevention of
noma to guide control and elimination of the disease.
• The funding and implementation of public health
interventions could lead to the disappearance of noma.
Noma can be incorporated into NTDs / skin-
NTD activities?
