Syllabus: Science

• Noma, also known as cancrum oris, is a severe gangrenous disease that primarily affects children between the ages of 2 to 6 years.
• In December 2023, the World Health Organization (WHO) officially classified it as a neglected tropical disease (NTD) due to its high fatality rate and lack of global attention.
• While noma is most prevalent in sub-Saharan Africa, cases have also been reported in parts of Asia and the Americas.
• The disease progresses rapidly, leading to severe facial disfigurement, lifelong disabilities, and profound social stigma.

Pathogenesis and Risk Factors

• Noma is caused by a non-specific polymicrobial infection, involving a combination of bacteria and fungi. It typically develops in malnourished children living in extreme poverty, particularly in areas with poor sanitation and inadequate healthcare access. The major risk factors include:
• Severe malnutrition, especially during vulnerable periods such as weaning.
• Poor oral hygiene, which allows bacteria to thrive.
• Underlying infections, including measles, malaria, and HIV, that weaken the immune system.
• Environmental factors, such as overcrowding, poor living conditions, and lack of clean water.
• Due to these conditions, children with compromised immunity are particularly susceptible to noma.

Clinical Stages of Noma

The WHO categorizes noma into five progressive clinical stages:

• Stage 0 – Simple gingivitis: Early gum inflammation without visible ulcers.
• Stage 1 – Acute necrotising gingivitis: Rapid bacterial infection causing gum tissue destruction.
• Stage 2 – Oedema: Swelling of the face and mouth, leading to increased tissue damage.
• Stage 3 – Gangrene: Severe tissue necrosis with facial disintegration.
• Stage 4 – Scarring: Healing process begins but results in severe disfigurement.
• Stage 5 – Sequelae: Long-term complications, including difficulty in eating, speaking, and social exclusion.

The disease typically begins with a minor oral ulcer but can escalate rapidly, causing irreversible damage within days if untreated.

Treatment and Management

• Early diagnosis and intervention are crucial for saving lives. Treatment strategies include:
• Antibiotic therapy (e.g., penicillin and metronidazole) to combat bacterial infection.
• Nutritional support to address severe malnutrition.
• Oral hygiene improvement through antiseptic mouth rinses.
• Reconstructive surgery for survivors with facial disfigurements.
• Despite treatment, mortality rates remain alarmingly high, with only 15% of affected children surviving the acute phase. Survivors require extensive surgical reconstruction and long-term rehabilitation to regain basic functions like eating and speaking.

Global Response and Challenges

Estimating the true burden of noma is difficult due to:

• High case fatality rates before medical intervention.
• Weak healthcare infrastructure in affected regions.
• Social stigma, which discourages families from seeking medical help.
• WHO’s last recorded estimate (1998) suggested 140,000 cases per year, but the actual prevalence remains unknown. In 2012, the United Nations Human Rights Council recognized the neglect of noma as a potential violation of children’s rights, highlighting the need for global action.

Efforts to combat noma focus on:

• Food security and malnutrition prevention.
• Vaccination programs against measles and other infections.
• Early detection and community education on oral hygiene and sanitation.
• Future Strategies for Eradication
• The WHO aims to integrate noma into existing healthcare frameworks, ensuring:
• Stronger health systems for early detection and treatment.
• Training programs for healthcare workers in affected regions.
• Community awareness campaigns to reduce stigma and promote hygiene.

Noma remains a critical public health challenge, particularly in poverty-stricken regions. Addressing it requires global advocacy, increased funding, and policy-level interventions. Only through sustained efforts can this preventable yet deadly disease be effectively managed and ultimately eliminated.