Noma in Mozambique. Epidemiological efforts to uncover a neglected disease

[eng] INTRODUCTION: Noma, or cancrum oris, is a rapidly progressing necrotising orofacial infection that primarily affects children living in poverty, although it can also occur in immunocompromised adults. Noma begins as a necrotising gingivitis which, if left untreated, rapidly evolves into necrosis of the soft and hard tissues of the face. Despite being preventable and easily treatable with first-line antibiotics, nutritional support and wound debridement, the lack of awareness among healthcare workers and the impoverished circumstances of patients often result in delayed treatment, with a mortality rate of approximately 90%. The 10% surviving are left with facial disfigurement,, often leading to functional and psychosocial sequelae that are rarely manegeable in the settings where noma occurs. Noma is classified as a Neglected Tropical Disease. Indeed, since its disappearance from Europe and North America—where it was common until the 18th century—the disease has largely ceased to be studied or researched. To date, its causal agent has not been definitively established. It is known that noma is not transmissible, and that affected individuals present with dysbiosis of the oral microbiome. It is therefore considered an aggravated stage of necrotising gingivitis and stomatitis, which progress to noma in the context of malnutrition, poor oral hygiene, and immune suppression. The incidence and prevalence of noma remain unknown, as does its geographical distribution. In recent decades, cases have been reported mainly in Africa, but also in Asia and Latin America. Prior to this project, no primary data existed regarding the presence of noma in Mozambique. HYPOTHESES: The principal hypothesis of this thesis is that noma is endemic in Mozambique, despite the lack of official reports. The secondary hypothesis is that healthcare workers in Zambezia Province have a limited level of knowledge about the disease. OBJECTIVES: The primary objective of this study was to gather, for the first time, empirical evidence of the continued presence of noma in Zambezia Province, Mozambique. As a secondary objective—acknowledging the critical role of early diagnosis and treatment in preventing mortality and sequelae—the study aimed to assess the knowledge, attitudes and practices regarding noma among healthcare workers in primary, secondary and referral health centres.