Noma, a neglected disease: A viewpoint article

Noma, also known as cancrum oris, is a gangrenous infection that causes rapid, widespread orofacial destruction [1]. The reported mortality rate for untreated patients is 90% within weeks after the onset of first symptoms [1]. Treatment in the early acute stages with antibiotics, wound debridement, and nutritional support greatly reduces mortality and morbidity [1]. The cause of noma is unknown, and noma is not contagious [2]. Those who survive the acute stages of noma face a lifetime of functional challenges such as difficulty eating and speaking [1]. Survivors and their families frequently suffer stigmatization [3]. Extensive reconstructive surgery is often utilized in an attempt to improve function and aesthetics for patients with sequelae [4]. Noma most frequently affects children between 2 and 5 years of age who live in low-income settings in Africa and Asia [1]. The World Health Organization (WHO) estimates that 140,000 new cases of noma occur annually [1]. The main risk factors for noma include chronic malnutrition, a lack of access to healthcare (specifically immunizations), and comorbidities such as measles and human immunodeficiency virus (HIV) [1]. WHO classifies noma into stages: Stage 0: simple gingivitis, Stage 1: acute necrotizing gingivitis, Stage 2: oedema, Stage 3: gangrene, Stage 4: scarring, and Stage 5: sequelae [1]. The disease was once frequently reported in Europe and North America, although as living conditions improved in these settings, noma has been eradicated (besides a few sporadic cases in immunocompromised individuals) [2].

Noma cases are frequently reported in Nigeria [2]. For the past 2 decades, the Nigerian Ministry of Health has run a specialized program at the Noma Children’s Hospital in Sokoto State in the northwest of the country, supported by Médecins Sans Frontières (MSF) since 2014. Activities include providing care for patients with acute noma (antibiotics, oral hygiene, treatment for underlying morbidities, wound debridement, and wound dressing), continuous care for patients with noma sequelae (surgical interventions and postoperative care), integrated hospital-based services (nutrition, mental health, physiotherapy, lab services, water and sanitation, and vaccinations), and community-based services (follow-up, active case finding, awareness raising, health promotion, and education).

This viewpoint article offers a summary of what is known about noma and suggestions for why noma is still neglected, despite the severe ramifications of the infection and the centuries of clinical reporting of the disease in the scientific literature. We explore the disability-adjusted life years (DALYs) for noma in northwest Nigeria and how these compare to diseases listed on WHO’s list of neglected tropical diseases (NTDs). We demonstrate the importance of recognizing noma as a neglected disease and offer ideas for the integration of noma into existing health structures. These suggestions could lead to the effective control of noma in a globally integrated manner.