Five-year-old Fatima was brought to the clinic by her parents. She was tired and weak with her head properly covered in clothes. When unwrapped, there was a massive darkened area on the left side of her face involving her cheek, nose and the lower eyelid with a horrible odour pervading the whole clinic. Fatima has a history of gum swelling and fever. When she came in, her family said she had not eaten anything tangible in three days. She was grossly malnourished and could no longer see out of her left eye. Her family came to the clinic from a long distance.
Fatima’s story is common to children who are affected by that debilitating condition called Cancrum Oris, commonly known as Noma. It is a condition in children between two and six years old, where flesh-eating bacteria eat up the tissues of the face. It happens because of the buildup of bacteria in the mouth known as plaque, usually made worse as a result of factors such as poverty, malnutrition and childhood diseases.
The bacteria in plaque are allowed to grow and the infection spreads when children have little access to dental care, present late to the hospital, have low immunity due to malnutrition, come from poor families, or when they share the same source of drinking water with animals, which further exposes them to more bacteria. When left untreated, Noma kills between 70–90% of those affected by the disease. Those who survive are left with varying degrees of facial defects which permanently affect their smile, facial appearance, speech, and other related functions depending on the part of the face affected. It is estimated that about 140,000 cases are recorded annually in Sub-Saharan Africa, which has earned the region the name “Noma Belt”. This “belt” is a stretch of countries, from Senegal to Ethiopia. While Nigeria does not have an official figure, most cases of Noma are found in Northern Nigeria due to the higher prevalence of risk factors in the region.
Plaque buildup around the teeth leads to irritation of the gums. If left untreated, the inflammation persists, aided by a suppression of the immune system in a child who is already malnourished. This leads to a “dead gum”, which is the decay of the soft tissue around the teeth. Within a week, the part of the face in direct contact with the dead gum itself dies. This could be the cheek, lips or nose, and in extreme cases, the lower eyelid. There is swelling of the affected portion of the face, followed by darkening and shedding of the dead cells on the skin. Generally, the patient looks ill, is irritable, refuses to eat, has a very unpleasant odor in the mouth and the bacteria spreads throughout the body, which leads to death.
Nutrition and income level are the foremost determinants of health that affect the development of Noma. Malnutrition is the lack of protein and vitamins needed for vital biochemical processes of the body as well as the defense system. Close to half of all children younger than 5 years in Northeast and Northwest geopolitical zones were estimated to be stunted in their growth for their age in 2013 compared to 22% of children in the rest of Nigeria.
Poverty affects living standards, feeding, source of drinking water as well as medical services the family can afford. There is usually a prior history of some of these childhood diseases, like malaria and measles, shortly before the appearance of the jaw swelling and subsequent deadening of the gum and oral tissues.
There are organisations that offer free surgical repair for Noma patients in Nigeria. However, prevention should be prioritized for the following reasons.
First, the mortality is very high. With 70–90% mortality, it means 7–9 out of 10 affected children will die.
Second, the cost of treatment is high and comes in different forms. Parents of patients pay huge amounts directly for drugs and surgery while in the hospital and also pay indirectly because they are unable to go to work where they could have earned more money.
Third, survivors are often stigmatised because of the defect in the face which affects their aesthetics, with no way to conceal it. This prevents them from going to school and socialising during the developmental stage. Furthermore, there is less human resources and hospital facilities to cater for the number of people that require facial reconstruction. Specifically, there is just one hospital in Nigeria that does this, the Noma Children Hospital in Sokoto, operated in conjunction with Medecins Sans Frontieres (MSF). Tackling this menace will require a multipronged approach, the first of which is the adequate inclusion of oral health into all related health programs and facilities.
While Lancet profiled the state of oral health across the world in 2019 and documented that about 3.5 billion of people worldwide are suffering from one form of oral disease or another, they identified the various dimensions in which oral health was excluded from most health programs. The absence of dental services in most PHCs and general hospitals across Nigeria supports this claim. Also, private dental practices are located only in the urban centres and are expensive, leaving poor people in rural settings undeserved. This shows the exclusion and inequality associated with oral diseases and the poor people respectively. This ugly trend must be quickly reversed.
Fourth, the common risk factor strategy presents a great way to approach Noma. These risk factors are common with other childhood diseases which have already received attention from policy makers and international bodies. For example, vaccines have been used to prevent and treat a number of childhood diseases and some of them are administered through the mouth. As such, immunisation officers can be trained to identify early changes in the mouth and refer for appropriate management. As an added advantage, these immunisation officers go to remote places where Noma cases are frequently seen to vaccinate children and are already familiar with the terrain. This principle also applies to nutritional programs involving Ready To Use Therapeutic Food (RUTF) which are administered through the mouth. They can also be trained to identify early changes.
Fifth, include Noma in the list of Neglected Tropical Diseases (NTDs). Sadly, this was omitted in the NTD strategic action plan that was released at the World Health Assembly in May 2020. The resources required to eradicate the conditions classified as NTDs are huge and enormous. Characterizing Noma as an NTD will bring it into the mainstream and attract needed attention from policy makers, health planners and financiers, and as such will expose it to the political determinants of health that will drive the needed change.
Lastly, awareness campaigns by individuals, organisations and governments will help in tackling this menace. Populations at-risk should be adequately informed of this disease, mode of prevention, early signs and its effects so as to reduce the incidence of the disease. Noma relates directly to sustainable development goals (SDGs) 1,2,3,4,5,6 and 17. This means deliberate and creative efforts must be taken to incorporate Noma in the set targets, as Noma still poses a significant disease burden in sub Saharan Africa both in terms of morbidity and mortality.
Fatima’s family managed to raise funds needed for her hospital bills and she was resuscitated. Her family was also informed about the free facial reconstruction surgery at the hospital in Sokoto. Adequate attention must be given to Noma in particular and oral health in general, to prevent more children from suffering from this debilitating disease.
What strategies should be implemented to encourage better oral hygiene in underserved communities? Let us know in the comment section below or on social media, @nighealthwatch on Twitter or @nigeriahealthwatch on Facebook and Instagram.
Ifeoluwa Adetula holds a bachelor’s degree in Dental Surgery from OAU and has practiced dentistry in different parts of Nigeria in the past seven years. He is doing his postgraduate studies in Public Health Dentistry with a focus on health systems. He leads the ZeroNoma Initiative, a volunteer-based NGO which seeks to prevent Noma, and has had trainings in Global Health.