What is ‘noma’, the latest addition to WHO’s list of neglected tropical diseases

The severe gangrenous disease of mouth and face has 90% mortality rate and is associated with extreme poverty, malnutrition

By Nandita Banerji
Published: Monday 18 December 2023
A 6-year-old noma patient from Borno at a hospital in Sokoto, Nigeria, October 2017. Photo: Inediz/C Jeantet and F Caterini / WHO website

The World Health Organization (WHO) on December 15, 2023 added one of the world’s most underrecognised health challenges, noma, to its official list of neglected tropical diseases (NTD). Also known as cancrum oris or gangrenous stomatitis, it is a severe gangrenous disease of the mouth and face with a mortality rate of approximately 90 per cent. It is also associated with extreme poverty, malnutrition and poor access to sanitation and oral hygiene. 

Noma mainly affects children aged 2-6 years old and is found most commonly among those living in poor communities. There is an extreme lack of awareness regarding the disease. There are no reliable numbers of cases — the WHO website lists the ‘latest’ estimates 140,000 cases per year and a prevalence of 770,000 cases. However, the data dates back to 1998

The illness’s ‘hidden’ or neglected nature is most likely due to the fact that it affects the world’s most marginalised children. The name of the disease comes from the Greek word “nomē”, meaning “to devour”, as noma eats away facial tissue and bones if not treated early. 

Noma is associated with a number of risk factors, including poor oral hygiene, malnutrition, weakened immune systems, infections, and extreme poverty. While the disease is not contagious, it prefers to attack when the body’s defences are weak. The disease begins with gum inflammation and is thought to be caused by bacteria found in the mouth.

The NTD is frequently seen in developing countries, especially in sub-Saharan Africa, where it occurs almost exclusively among poor children usually aged 3-10 years, stated a 1995 study on the neglected disease. “It may be that noma results from oral contamination by a heavy load of Bacteroidaceae and a consortium of other microorganisms,” it said. 

Noma primarily affects children who are malnourished, infected with infectious diseases, living in extreme poverty with poor oral health, or who have weakened immune systems, according to the WHO. Because the disease has a high mortality rate, early detection is critical because therapy is most effective in the early stages of the disease. Its spread can be slowed significantly with basic hygiene, antibiotics, and nutritional rehabilitation. 

The NTD often starts as an ulcer on the mucous membrane lining, commonly after a bout of measles or other diseases, stated another 2003 study

“It quickly develops into a massive necrosis, moving from the inside outward, often involving major portions of the face,” the paper noted. “Early treatment with antibiotics, rehydration, correction of electrolytic imbalances, and administering nutritional supplements will halt the disease. The high mortality rate, however, indicates that many children are not given care or brought for care in time.”

The patients who survive face many consequences, like significant facial disfigurement, spasm of the jaw muscles, oral incontinence and speech problems, according to a 2003 study. The disease is also called the ‘face of poverty’, as effective drugs like sulfonamides and penicillin and adequate surgical treatment for the effects remain inaccessible for many due to extreme poverty.

Noma was common in the Western world in previous centuries, according to a 2001 study. When economic progress enabled the poorest families to feed their children adequately, the disease vanished. “Both prevention (improved feeding, measles vaccination) as the treatment of those who contract and survive noma are a challenge for the ‘global village’ of the modern world,” the paper said. 

The disease was also reported in Europe in concentration camps during World War 2, according to the journal of an Auschwitz survivor. 

An important step towards eradicating the disease is the inclusion of noma on the WHO’s list of neglected tropical diseases, according to medical non-governmental organisation Médecins Sans Frontières / Doctors Without Borders. Now that the hurdle has been cleared, more attention and more resources are needed to tackle noma. 

“The recognition of noma as an NTD aims to amplify global awareness, catalyse research, stimulate funding, and boost efforts to control the disease through multisectoral and multi-pronged approaches. Interventions addressing the burden of this devastating disease will contribute to achieving universal health coverage, as they will specifically target pockets of underserved populations,” the WHO said in a press release. 

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