Noma: Overview of a Neglected Disease and Human Rights Violation

Abstract

Noma is an orofacial gangrene affecting malnourished children and mainly observed in tropical countries, particularly sub-Saharan Africa. Epidemiological data on noma are scarce, but a current estimate of the global incidence is 30,000-40,000 cases per year, with a mortality rate of approximately 85% and a burden of disease calculated to be a loss of 1-10 million disability-adjusted life years. The etiology of noma is multifactorial with malnutrition as an ever present factor, often in combination with concomitant diseases, such as measles, malaria, and human immunodeficiency virus (HIV), and poor oral hygiene. The pathogenesis is a fast-spreading, noncontagious gangrenous infection occurring in the face, often preceded by acute necrotizing gingivitis, and stomatitis. Rare microbiological studies suggest an opportunistic infection caused by an imbalance in normal intraoral microorganisms. Prevention lies in food security, measles vaccination, prevention of malaria and HIV, including the early detection and treatment of necrotizing gingivitis and stomatitis. Early treatment with antibiotics may prevent gangrene or reduce its extent. Late treatment consists of surgical rehabilitation, which is often complex. However, access to medical care is very limited for noma patients due to the extremely poor conditions in which they live that are frequently located in remote rural areas. The authors support the United Nations Human Rights Council Resolution 19/7 adopted on March 22, 2012 "The right to food," and advocate for the inclusion of noma on the list of neglected tropical diseases to encourage more medical and institutional attention for this often lethal or very mutilating infectious gangrene.

Epidemiological Investigation of Noma in Papua Province in 2017

“…The risk of noma disease mostly occurs in children aged between 2-6 years with a weak immune system, extreme poverty, poor oral hygiene, malnutrition, malaria, kwashiorkor (edema), measles, HIV/AIDS infection, and adult adolescents with weak immune system (Jain & Ranka, 2017;Neville, Damm, Allen, & Chi, 2019;Prado-calleros et al, 2017;Srour, Marck, & Baratti-mayer, 2017;WHO, 2016). The results of research conducted on 159 cases of acute cancrum oris (noma) treated at Sokoto Hospital, Nigeria, showed that 42.20% of noma patients were accompanied by measles and 42.10% were accompanied by malnutrition.…”

“…This lesion can function as a place for the entry of microorganisms that are responsible for the disease process (Jain & Ranka, 2017). Noma is usually preceded by diseases that can decrease the immune system, such as measles, malaria, diarrhea, tuberculosis, or inflammation of the necrotizing ulcerative gums which are considered as risk factors or significant precursors to noma events (Jain & Ranka, 2017;Srour, Marck, & Baratti-mayer., 2017;WHO, 2016). Noma occurs mainly in poor communities who are untouched by health services and have a nomadic lifestyle.…”

“…This study found that Afimabul village never received immunization services, and found suspected measles in toddlers with red eyes and red spots all over the body as well as body temperature or high fever. Measles can be an important risk factor because it is associated with immunosuppression or inhibitors of antibody formation (Srour, Marck, & Baratti-mayer, 2017).…”

“…Oral candidiasis, periodontitis, melanotic hyperpigmentation, gingivitis, and xerostomia are the most common oral lesions in HIV/AIDS patients. These lesions correlate with a decrease in the number of cell differentiation (CD4) (Frimpong, Amponsah, Abebrese, & Kim, 2017) Noma generally occurs in children under the age of six years, as well as in populations with extreme poverty, malnutrition, unsafe drinking water, poor sanitation, poor oral hygiene, high infant mortality, limited access to health services, living in remote areas that are difficult to reach, and delayed intrauterine growth (Jain & Ranka, 2017;Srour, Marck, & Baratti-mayer, 2017;Srour, Marck, & Baratti-mayer, 2015). This study found that noma cases were five-year-old children living in remote and hard-to-reach areas.…”

“…Noma disease is rare in high-income countries and mostly occurs in Africa and developing countries, especially in children under the age of 6 years . Several studies have found that risk factors for noma are poverty, stunted growth due to malnutrition, measles, malaria, low food microbiology, and sociobiological (Srour, Marck, & Baratti-mayer, 2017). Other research also found that noma cases occuring in Northern Nigeria were caused by a lack of maternal care.…”