Necrotizing Fasciitis: A Six-Year Experience

Edin Tunovic, BSc MED,* Justin Gawaziuk, MSc,* Tom Bzura, BSc MED,*
John Embil, MD,* Ali Esmail, MD,* Sarvesh Logsetty, MD*

Necrotizing fasciitis (NF) is a life-threatening infectious disease whose incidence has been
on the rise. Commonly a consequence of group A beta-hemolytic Streptococcus infection, it
results in high levels of morbidity and mortality. Diagnosis is difficult and treatment in-
volves emergent surgical intervention and antibiotic therapy. The aim of this study is to ex-
amine the incidence of NF in Manitoba with the goal of observing whether there is a geo-
graphic variation in incidence and outcomes based on Regional Health Authorities (RHAs).
This is a 6-year retrospective chart review of all NF patients who presented to the Health
Sciences Center from 2004 to 2009. A total of 130 patients satisfied the inclusion criteria.
The mean age was 47 16 years. The most common comorbidities were diabetes (33.8%)
and hypertension (33.1%). The overall mortality was 13.1% with advanced age being an in-
dependent risk factor (P < .05). Lower extremity was the most common location of infec-
tion (44.6%) and the most common causative organism was group A beta-hemolytic Strepto-
coccus (63.9%). The type of infection (mono- vs. polymicrobial) was not found to affect
length of stay, amputation rate, or mortality. There was no statistical difference in rate of
amputations, length of stay, or mortality based on RHA. Incidence within the province,
however, varied significantly based on RHA and ethnicity (P < .05). We determined that
regardless of origin before admission, all our patients have equivalent prognosis. Burn-
twood RHA was found to have substantially higher incidence than the rest of the province,
and higher incidence was established among the Aboriginal population. (J Burn Care Res
2012;33:93100)

Necrotizing fasciitis (NF), commonly known as
flesh-eating disease, causes significant tissue dam-
age, can lead to amputation, and is potentially life
threatening. The disease was originally described in
France in 1783.1 Throughout the 19th and 20th cen-
turies, it was commonly chronicled in military hospi-
tals with occasional outbreaks noted in the general
public.1 While a number of bacteria may cause NF,
the most common organism is group A beta-hemolytic
Streptococcus (GABS). Canadian studies report an an-
nual incidence of GABS infection of 1.5 cases per
100,000 individuals, wherein 6% of these infections
progress to NF.2 Actual numbers of NF infections
From the *University of Manitoba, Sections of General and
Plastic Surgery, Department of Surgery, and Section of
Infectious Diseases, Department of Medicine, Winnipeg,
Manitoba, Canada.
Presented at the 43rd annual meeting of the American Burn
Association, Chicago, Illinois, March 29 to April 1, 2011.
Address correspondence to Sarvesh Logsetty, MD, Department of
Surgery and Childrens Health, University of Manitoba, GC
401A-820 Sherbrook Street, Winnipeg, MB R3A 1R9.
Copyright 2012 by the American Burn Association.
1559-047X/2012
DOI: 10.1097/BCR.0b013e318239d571
may vary as this does not take into account other
infective organisms. In Canada, as of 2001, there
were 90 to 200 estimated cases of NF per year which
was fatal in about 20 to 30% of cases.1
Due to the magnitude of the consequences of the
disease, it is considered a mandatorily reportable dis-
ease under the Public Health Act in Manitoba.1 Re-
cently the Chief Medical Examiner of Manitoba
stated that there seems to be an increasing incidence
of NF in this province.3 Manitoba has a population
base of approximately 1.15 million but has recently
reported more than 20 cases a year, almost one third
of the total reported for Canada despite having less
than 4% of the population.4 The incidence is dispro-
portionately high within the context of the relatively
small population of Manitoba compared with the rest
of Canada. This trend is disturbing considering the
seriousness of the disease process and its impact on
health care resources.
The rationale for our project is centered on the
observation of the increased incidence of NF in Man-
itoba and motivated by the fact that this is a serious
disease that carries substantial morbidity and mortal-
ity. In recent studies, mortality rates have been re-

93

94 Tunovic et al
ported to range from 4 to 33%.511 To examine this
trend, we performed a 6-year (2004 2009) retro-
spective chart review of all NF patients admitted to
the Health Sciences Center (HSC) in Winnipeg,
Manitoba, Canada. This is one of only two centers
with plastic surgery coverage in the province and re-
ceives the majority of NF patients for the province.
The disease is grouped into two etiological types
based on the causative organisms. Type I is a polymi-
crobial infection and can involve Gram-positive,
Gram-negative, and aerobic as well as anaerobic or-
ganisms in addition to fungi in rare cases. Type II is a
monomicrobial infection typically by group A Strep-
tococcus either with or without the association of
Staphylococcus aureus.12,13 The invasive process is
aided by the production of various exotoxins and en-
dotoxins, which accelerate the infection by significantly
contributing to progressive tissue necrosis.12,13 Throm-
bosis of local vessels, ischemia, liquefaction necrosis, and
an exaggerated immune response are the hallmarks of
NF.5,1214 This process can extend from the superficial
plane to the deep fascial planes.14 The infection can
spread as fast as 2.5 cm (1 inch) per hour leading to
further necrosis, sepsis, toxic shock, and eventual death
if it is not controlled.12,13
Antibiotic therapy has an important role to play in
the treatment of NF. A challenge to selecting the
correct antibiotic is the growing number of resistant
bacteria in the community. The current standard of
care is to use broad-spectrum antibiotics early and to
narrow the antibiotic choice once the bacterial sensi-
tivities are known. One theoretical problem with early
antibiotic treatment in NF is that it may mask the
underlying condition thus delaying diagnosis.9
The approach to treatment of patients with NF is
emergent surgical debridement and appropriate anti-
biotics. Studies have shown that a delay in surgical
treatment is associated with increased mortality rates.
Golger et al demonstrated that patients who under-
went surgery within 24 hours had a better outcome
when compared with the patients who were operated
on at 36 hours (27 percent versus 55 percent mor-
tality rate), and many authors have recommended
early, often wide, surgical debridement as an initial
treatment in all patients with NF.57 Multiple surgical
debridements/interventions are often required for
preventing disease progression and effective treat-
ment of the infectious process. Surgery often requires
amputation of portions and even entire limbs.5,8,9
Given the large transport distances involved with pa-
tient care in Manitoba, we hypothesized that there is
a potential difference in outcomes based on health
care region and distance to tertiary surgical care.
The disease burden and accompanying comorbidi-
Journal of Burn Care & Research
January/February 2012
ties can result in significant long-term sequelae. Re-
cent evidence by Light et al15 demonstrates that pa-
tients who survive an episode of NF, despite being
treated appropriately for it, are at a risk of premature
death when compared with age- and gender-matched
controls. Given the burden of illness, it is important
that we gain insight into the Manitoba experience
with NF so that we can understand our patient pop-
ulation and take the appropriate steps to minimize the
impact of the disease on our patient population as
well as health care system.
Literature Review
The literature review was conducted using searches
on PubMed/Medline. Terms used were NF, NF
literature review(s), NF chart review studies, NF and
diabetes, NF comorbidities, NF treatment, and NF in
Canada. Searches were initially conducted for general
reviews on the subject. Case studies were excluded
from the review.
Several recent large-scale studies were used as spe-
cific reference material for information regarding co-
morbidities, morbidity, and mortality, as well as other
patient outcomes. Eight representative studies were
examined with publication years ranging from 2003
to 20106 8,10 12,15,16 (Table 1). The number of pa-
tients ranged from 12 to 345. The majority of studies
had less than 10 patients a year. As such the studies
were not consistent in reporting factors of interest. A
study may report microbiology, surgical intervention,
or on outcomes, but no study reported on all factors.
Comorbidities and risk factors seen with NF are
varied, but there has been some consensus in recent
large group studies. Diabetes mellitus (DM) is the
most commonly associated comorbidity in the NF
patient population. Additional conditions often re-
ported include immunocompromised status, varicella
zoster in children, peripheral vascular disease, alco-
holism, congestive heart failure, chronic obstructive
pulmonary disease, end-stage renal disease, tubercu-
losis, and malignancy.511,18 It is clear that DM is
becoming the most commonly associated comorbid-
ity around the world.5,6,9
A New Zealand study, by Tiu et al, was unique
because it examined the referral population based on
ethnicity, finding that Maori and Pacific Islanders
accounted for 64% of total admissions despite making
up only 31% of the referral population. This partic-
ular ethnic group is found to be of lower socioeco-
nomic status and to have a high incidence of DM,
which was found to be an independent risk factor for
mortality in their study.7
All NF cases in the Manitoba are typically trans-
ferred to one of two hospitals with the majority of
Journal of Burn Care & Research
Volume 33, Number 1 Tunovic et al 95

Table 1. Major studies used for literature review

Author(s) Golger et al Light et al Wong et al Tiu et al Rieger et al Khanna et al Redman et al Ryssel et al

Journal Plast Reconstr J Burn Care Res J Bone Joint ANZ J Surg Ann Plastic Surg Int J Low Extrem South Med J Arch Orthop
Surg (2010) Surg Am (2005) (2007) Wounds (2003) Trauma
(2007) (2003) (2009) Surg
(2010)
Demographics
No. patients 99 345 (226 used for 89 48 16 (13 NF and 3 118 12 34
retrospective necrotizing
chart review) myositis)
Mortality (%) 20 25 21.3 29 25.4 (NF) 15 33 4
Male/female (%) 54/46 57/43 59.6/40.4 56/44 66/44 66.1/42.9 33.3/66.7 52.9/47.1
Avg. age 44.6 23.9 49 (avg.) 56 (avg.) 51 (median: 47.1 (avg.) 45 16 (mean: 58 (mean: 56.7 10.6
(avg.) 1980) 1295) 2690) (avg.)
Comorbidities (%)
Diabetes 30 56 70.8 39.6 24 39 16.7 56
Immunocompromised 17 0.85 8.3
Renal failure 4 12 4.2 1.7 33.3 16
Malignancy 5 5 2.2 3.4
CV disease 6 38 6.2 25 68*
IV drug use 3 31.3
Ethanol abuse 24 16.7
Smoking 33
Location of infection
Upper extremities 27 10.1 62 7.7 0 25 100
Lower extremities 28 69.7 69.2 100 75
Genitalia/perineum 21 0 1518 0 0 0 N/A
Trunk 18 20.2 20 15.4 0 0 0
Head and neck 5 0 5 7.7 0 0 N/A
Microbiology
Type I (%) 54 53.9 31 31.3 12.2 98 47
Type II (%) 46 46.1 69 62.5 87.8 2 53
Surgery
No. procedures Avg. 2.7 4 (median: 5.2 (avg.: 2.3 (mean: 15) 3.4 (mean: 3.3 (avg)
debridements 113) 215) 010)
Days in hospital 40.6 31 (median: 46.6 (avg.: 34.3 21 (avg.: 1 64 5.5
1300) 2133) (mean: 648) 94)
Amputations (%) 22.5 10.42 0 20.3 0 23.5

* HTN (40) and coronary disorders (28).

Only for NF patients in study.
CV, cardiovascular; HTN, hypertension; NF, necrotizing fasciitis.

cases being treated at the Health Sciences Centre.
This 6-year retrospective study aims to examine the
increasing incidence of NF and achieve a further un-
derstanding into the causative factors and details of
this phenomenon. It is unique because it is the first to
examine this phenomenon in Manitoba while analyz-
ing geographic variation in NF characteristics. Al-
though our study is focused on Manitoba, we believe
that there is a significant potential for universal appli-
cation of our results for patient treatment, manage-
ment, and education.
METHODS
Our study is a 6-year retrospective chart review
ranging from 2004 to 2009 inclusive. We have in-
cluded all cases of NF admitted to the Health Sci-
ences Center in Winnipeg, Manitoba, Canada. The
project proposal was approved by the Faculty Eth-
ics Committee for the use of human subjects in
research and the Health Research Ethics Board at
University of Manitoba.
After Health Research Ethics Board approval, pa-
tients were identified by Health Information Services
at Health Sciences Centre with a search based on
ICD-10-CA codes as well as patient discharges as
noted on HSC patient ward admission logs. The
ICD-10-CA codes used to find patients were NF
(M72.6), Fourniers Gangrene (male/female:
N49.3/N76.8), and myositis (M60). For each indi-
vidual patient (2004 2009), the chart was reviewed
and confirmed as a true NF case based on macro-
scopic surgical confirmation at the time of surgical
debridement. To ensure that no cases were missed,
we also included those patients with sepsis and sus-
pected NF who succumbed before surgical confir-
 Journal of Burn Care & Research
96 Tunovic et al January/February 2012

mation. Laboratory and microbiology data were

collected from the HSC computer records. Surgical
information was collected as per explanation in the
surgical notes with flaps, grafts, and amputations
being the most pertinent information collected.
Amputations were considered to be any bony de-
bridement with the exception of the digits where
amputation was considered to be removal of pha-
lange(s) or more. Obesity was defined as a BMI
greater than 35 kg/m2.
Regional health authority was assigned based on the
patients residence postal code. Patient information was
entered into a database created using FileMaker Pro 11
software (Apple, Cupertino, CA), and statistical analysis
was completed using SPSS version 19 software (IBM,
Chicago, IL). Descriptive statistics were obtained for all Figure 1. Age distribution of patients with necrotizing
variables. Students t-test or Wilcoxon rank-sum test fasciitis.
were used for continuous variables, and 2 or Fishers
exact tests were used to compare proportions between
the various groups. Regression analysis was performed affected, the mean is 6.3 6.2% (range: 0.15
to determine determinants of death, amputation, and 35.0%). Mean white blood cell count was 16.7 9.4.
length of stay. A P value .05 was accepted as statisti- The most common comorbidities identified in the
cally significant. patient population were DM (33.8%), hypertension
(HTN) (33.1%), smoking (24.6%), obesity (13.1%),
and substance (drugs or ethanol) abuse (23.1%).
RESULTS Obesity was identified as a body mass index (BMI)
greater than 35 kg/m2.
A total of 130 patients were identified (Table 2). Of Lower extremity was the most common location of
these patients, 75 were male and 55 were female. The infection (44.6% of cases) followed by upper extrem-
mean age was 47.0 15.9 years (range: 0.8 79.3 ity (23.1%), genitalia (20.8%), trunk (13.1%), and
years) and follow a normal distribution (Figure 1). head/neck (7.7%).
During this period, we identified that only two chil- Microbiological data (Table 3) could only be ac-
dren were admitted to our provincial childrens hos- quired for 114 of 130 patients. Data for 16 patients
pital with NF. Patients had an average TBSA of 723 were omitted due to lack of electronic records. For
745 cm2 (range: 53925 cm2). Expressed as % TBSA 8.5% (N 11), there was no organism isolated de-
spite cultures being obtained. Analysis showed that
43.1% of all patients were diagnosed with a type II
Table 2. General patient characteristics (N 130)

Age (yr) 47.0 15.9 Table 3. Microbiological data

Sex (n)
Type of Infection No. Patients % of all Patients
Male 75
Female 55 Type I 5 3.8
Body area involved (%) (N 108) TII: Strep 39 30.0
Head and neck 7.7 TII: non-GABS Strep 6 4.6
Upper extremity 23.1 TII: Non-Strep 11 8.5
Trunk 13.1 Missing 16 12.3
Genitalia 20.8 No growth 11 8.5
Lower extremity 44.6 Unknown 42* 32.3
TBSA (cm2) 723.4 745.3 Total 130 100
Length of stay 33.3 38.7
No. procedures 2.4 1.2 Type I is polymicrobial infection. Type II is monomicrobial and is
WBC (N 97) 16.7 9.2 subdivided into Streptococcal (GABS, Group C, or Strep. spp.) and
non-Streptococcal categories.
Data are shown as mean SD. * Patients whose cultures grew contaminants but no pathogens.
WBC, white blood cell. GABS, group A beta-hemolytic Streptococcus.
Journal of Burn Care & Research
Volume 33, Number 1
Table 4. Microbiological data based on presence or
absence of Streptococcal spp. infection
Type of Infection No. Patients % of all Infections
Type I 5 8.2
TII: Strep 39 63.9
TII: non-GABS Strep 6 9.8
TII: Non-Strep 11 18.9
Total 61 100
GABS, group A beta-hemolytic Streptococcus.
infection. In patients with a discernable infection, the
most common causative organism was Streptococcus
in 91.8% (Table 4). This is in contrast to an article by
Anaya et al., in which the most common species iso-
lated was Staphylococcus aureus.17 The type of infec-
tion was found not to affect length of stay, amputa-
tion rate, or mortality. We found that 7.8% of our
total patients were methicillin-resistant Staphylococcus
aureus positive on admission swabs.
The average patient received 2.4 1.2 (range:
0 7) procedures. A total of six patients (4.6%) re-
ceived amputations as a definitive treatment. It was
found that amputation rate did not depend on re-
gional health authority (RHA), age, gender, ethnic-
ity, body part affected, source of admission (internal
vs. external admission), number of comorbidities, or
number of procedures.
The overall mortality rate was 13.1% (17/130 pa-
tients). The only factor significantly associated with
rate of mortality was advanced patient age (P .05).
Examination of geographic origin revealed that
there was no statistical difference in rate of amputa-
tions, length of stay, and mortality based on RHA.
Patients identified were all from RHAs with the ex-
ception of Churchill and Brandon. There were a total
of 17 patients who were from outside of Manitoba.
Annual incidence increased from 12 cases in 2004
to a high of 32 cases in 2007 and 2008. It has then
decreased to 16 cases/year in 2009 (Figure 2). Inci-
dence within the province (Table 5) was highest in
the Burntwood RHA (Figure 3), with an incidence of
9.68 per 100,000 individuals which is 5.2 times the
provincial average.
Information on ethnicity (Table 6) shows a higher
incidence of NF in Manitoba in the Aboriginal pop-
ulation with an incidence of 29.8 per 100,000 indi-
viduals compared with an incidence of 8 per 100,000
individuals in the province. The difference between
First Nations patients and non-First Nations patients
varied across the province. Winnipeg and Central
RHA showed a higher incidence of NF in the Aborig-
inal population than the general population. Burn-
Tunovic et al 97
Figure 2. Annual incidence of necrotizing fasciitis at
Health Sciences Center.
twood showed the highest incidence per capita in the
Aboriginal population and also the highest incidence
per capita in the non-Aboriginal population.
DISCUSSION
We identified a total 130 NF patients over 6 years,
making our study one of the largest NF patient pop-
ulations examined at a single center in such short
time. Our patient demographics and comorbidities
were similar to other studies. The mean age of 47.0
15.9 years was in the middle of the distribution when
compared with other studies (Table 1).
The two most common comorbidities identified
were DM (33.8%) and HTN (33.1%). Other major
comorbidities identified were smoking, obesity, sub-
stance abuse, and renal disease. Of those, DM, HTN,
malignancy, and renal disease were consistently noted
in the charts. Recording of the other comorbidities
varied and hence they may be underrepresented. We
believe that obesity, in particular, was significantly
underrepresented, as recorded information regarding
patient weight and height was highly variable from
chart to chart. This made BMI calculations difficult to
obtain for a large number of patients. We were able to
obtain it only for 18 patients.
As found in other studies, the most common site of
infection was the extremities (67.7%), with the lower
extremities being the most common at 44.6%.
We had bacteriologic information in 72 patients. As
expected, the most common bacterial species was Strep-
tococcus with GABS representing 73.7% of all infections
(Table 4). We still recommend initial broad-spectrum
antibiotics, not specifically targeted at Streptococcus, as
there is a significant proportion of infections with other
bacteria, and the risk of not treating these infections is
 Journal of Burn Care & Research
98 Tunovic et al January/February 2012

Table 5. Rates of comorbidities in Manitoba health care regions for patients with NF

Health Region or Province of Origin DM HTN Smoking Obesity Substance Abuse Renal Disease

Assiniboine 1 1
Burntwood 9 13 5 5 5 4
Central 3 1 2 1 2
Interlake 3 2 1 2 1 1
Nor-Man 1 1 1 2 1
North Eastman 2 3 4 1 1
Parkland
South Eastman
Winnipeg 19 18 16 5 17 1
Nunavut 1
Ontario 7 4 2 2
Total Manitoba 37 38 30 15 28 7
% Total patients affected 33.8 33.1 24.6 13.1 23.1 6.2

NF, necrotizing fasciitis; DM, diabetes mellitus; HTN, hypertension.

devastating. Hence, the current protocol of starting
with broad-spectrum antibiotics and narrowing once
the organism is isolated is still appropriate. Although
7.8% of our patients were swab positive for methicillin-
resistant Staphylococcus on admission, in only three of
these cases was methicillin-resistant Staphylococcus au-
reus deemed to be a causative organism as evidenced by
positive wound culture or absence of other pathological
bacteria in the wound.
We found that amputation rate showed no associ-
ation based on health region, age, gender, ethnicity,
body part affected, number of comorbidities, or num-
ber of procedures. This indicates that rate of ampu-
tation may be not be related to individual character-
istics or distance to tertiary care.
Mortality rates of NF patients treated at the HSC
were 13.1% (17/130 patients). This is lower than
most NF populations studied, the majority of which
(6/8; Table 1) had a mortality rate 20%.
Examining whether there is geographic variation to
NF incidence and outcomes in Manitoba, we found
some interesting results. With regard to prognosis,
we found that there was no statistical difference in
rate of amputations, length of stay, and mortality
based on RHA. This means that regardless of distance
travelled before admission at our institution, all our
patients have equivalent prognosis once they are
transferred to our facility. There were, however, sig-
nificant differences noted when it comes to regional-
ity of NF incidence.
Analysis revealed that 65.4% of our population
were from only two RHAs. 47.7% of our patient
population was from Winnipeg and 17.7% was from
the Burntwood RHA. This result is startling con-
sidering that Burntwood has 4% of the total pro-
vincial population.19 Normalizing for population
we found that the highest incidence was in Burn-
twood at 6.3 times the annual incidence of the rest
of the province (Figure 3).
Searching for explanations for this high localized
incidence, we reviewed comorbidities and presence
of risk factors between the regions. A recent study
revealed that Burntwood RHA has the highest
prevalence of DM in Manitoba.20 Considering the
relationship between NF and DM as a comorbidity,
this could be a link between Burntwood and a high
incidence of NF.

Table 6. Incidence of NF in Manitoba according

to ethnicity

Aboriginal Unknown

Total cases 30 83
Population (2006) 100,640 1,032,875
Incidence/100,000 29.8 8.0
Figure 3. Incidence of per 100,000 individuals in Mani-
toba Regional Health Authorities. NF, necrotizing fasciitis.
Journal of Burn Care & Research
Volume 33, Number 1
A second interesting finding was the differences in
incidence of NF with regard to ethnicity. We found
that the incidence of NF in the province is higher
among our Aboriginal population when compared
with the general population (Table 6). Aboriginals
comprise 7% of the general Manitoba population
(Government of Manitoba data), in contrast aborig-
inals comprise 36.1% of the NF population, which is
more than five times higher than the Aboriginal pop-
ulation in the province, which is 7% of the total (MB
health stats). When normalized per capita, we saw a
significantly higher incidence (29.8) among the Ab-
original population than the general population (8.0
per 100,000 individuals).
A contributing factor could be the higher incidence
of DM among aboriginals compared with the rest of
the population. Aboriginal males have been previ-
ously reported to have three times the DM incidence
compared with males in the general population while
Aboriginal females have four times the incidence of
DM as females in the general population.19
In terms of incidence based on ethnicity per RHA, we
found that Burntwood had similar incidence in terms of
Aboriginal and non-Aboriginal individuals, while Cen-
tral RHA and Winnipeg have substantially higher inci-
dence among the Aboriginal populations. This maybe
related to the higher prevalence of DM in Burntwood
RHA. There were no differences in outcomes (rate of
amputations, length of stay, and mortality) based on
ethnicity, as mentioned earlier, but the difference in in-
cidence warrants further examination.
Limitations
An important point to note is that Aboriginal inci-
dence of NF may vary from what we reported. For the
purposes of this study, ethnicity was identified by self-
reporting in the medical records. It was found that
this is underreported in hospital charts, and as such a
proportion of the group coded as non-Aboriginal
may in fact be of First Nations origin leading to an
underestimate of the true incidence of NF in the Ab-
original population.
Our ability to comment on the effects associated
with specific organisms is limited in that microbiolog-
ical data were not available for a significant number of
patients. For 16 patients, we were not able to access
the laboratory results while others had inconclusive
culture results despite being cultured. This may be
due to aggressive and early antibiotic therapy before
culture or improper culturing techniques.
Although all plastic surgery in the province is done
at one of two centers, primary debridement may be
undertaken at referring hospitals before transfer. We
may have missed patients who underwent debride-
Tunovic et al 99
ment at local hospitals and did not require grafting.
Also, we do not have information on patients who
passed away at other centers. In addition, while the
Health Sciences Centre is the primary referral hospital
for NF for the province of Manitoba, there is a second
regional center. St. Boniface Hospital is estimated to
receive between 5 and 10 additional cases of NF a
year, predominantly from within the city of Winni-
peg. Incorporation of the St. Boniface Hospital data
and obtaining the medical examiners data for deaths
throughout the province remain our priority to as-
semble a more complete database.
Future Goals
Examining the differences in comorbidities within in-
dividual RHAs for possible insight into predisposing
factors remains to be determined. In addition, we are
discussing this subject matter with First Nations
groups and RHAs at increased risk, especially Burn-
twood, for ways to improve detection and provide
earlier treatment is a major focus moving forward. In
addition, future studies will identify whether socio-
economic, demographic, or medical comorbidities
explain the increased risk in the Aboriginal popula-
tion. As a consequence of this study, we have ap-
proached both the Regional Health Authority and
the provincial Aboriginal health care leaders to de-
velop more information on local factors that may ex-
plain the increased incidence in these groups. In ad-
dition, we have embarked on an education campaign
in the Regional Health Authorities at risk to help
primary care givers understand the risks of NF.
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