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HEALTH INTERACTIVE WITH DR AMINU MAGASHI African Children and Noma Disease
In October last year , Professor Cyril Obiora Enwonwu who is based at University of Baltimore at Maryland , U.S.A sent me a complementary electronic copy of the Paper he presented at the 23rd Convocation lecture of the National Postgraduate College of Nigeria which was held on Thursday , 15th September 2005 , which I suppose it took place in Lagos , Nigeria . The title of his 17 paged paper ‘Human Face of Poverty in Nigeria: The Scourge of Oro-facial Gangrene (Noma)’ made an interesting reading and although I am not reproducing the entire paper in this discourse , however I strongly believe readers of this column will benefit a lot from excerpts of his paper and finally I will draw my conclusion on the way forward in Nigeria and Africa at large . Coincidentally, a colleague of mine in Kano , a young and promising surgeon , Dr Adamu Atiku was recently in Sokoto to learn more about Noma Disease in terms of prevention and management .
According to the Prof , Noma (Cancrum Oris), an oro-facial gangrene is a reflection of pockets of extreme poverty in Nigeria, potentially Africa’s richest country with huge resources of crude oil and numerous minerals, as well as abundant human power. Additionally, NOMA not only typifies the complex interactions between poverty, infections, malnutrition, and immunity, but also underscores the often forgotten fact that Oral Health is closely integrated with General/Systemic Health.
According to the World Health Organization (WHO) International Statistical Classification of Diseases, Code Number A69.0 lists Necrotizing Ulcerative Stomatitis which includes Noma, Cancrum Oris, Fusospirochaetal Gangrene and Stomatitis Gangrenosa. Noma is derived from a Greek word which means pasture, grazing or to devour [2]. Oro-facial noma is a debilitating infectious disease which starts as a localized gingival ulceration and rapidly spreads through the oro-facial tissues, establishing itself with a well-demarcated perimeter surrounding a blackened necrotic centre ( dead cells )
Fresh Noma is seen predominantly in children ages 1-4 years, although late stages of the disease, including “healed Noma”, are not uncommon in adolescents and adults. The WHO designates Noma a health priority, and has initiated a global information campaign on the disease . Noma has not been reported in healthy, adequately nourished Nigerian children. Poverty is the key risk condition for noma in Africa, and in other places . Chronic malnutrition is a major predisposing factor in all countries reporting noma. The global distribution pattern of noma accurately mirrors the worldwide distribution of malnutrition, particularly deficiencies of vitamin A and other micronutrients in children under 5 years of age.
The environment in which noma thrives is also characterized by unsafe drinking water, deplorable sanitary practices, poor oral health, limited or no access to quality healthcare services, close residential proximity to animals, and a high prevalence of diseases such as measles, malaria, pneumonia, tuberculosis, and diarrhea. The prevalence of low birth weight in some of the communities is as high as 20 percent and it is attributable mainly to intrauterine growth retardation rather than to premature birth. Exclusive breastfeeding in the first 3 months of life is extremely rare in Nigerian villages at risk for noma, and the reported prevalence varies from less than 2% to about 12 percent. Supplementary foods given to infants include locally obtained unprocessed cow’s milk, glucose water, herbal tea, and various indigenous cereal and/or cassava-based diets prepared under less than hygienic conditions. The Infant Mortality Rate is as high as 114/1000 Live Births in some communities. Virtually all cases of noma report distinct histories of prior recent debilitating infections, Measles and Malaria being the most frequent. Other antecedent infections include Severe Diarrhea, Primary Herpes Simplex, Tuberculosis, and Chicken Pox. The potential contribution of several viruses (eg HCMV; Epstein-Barr virus type 1, EBV-1, human immunodeficiency virus, HIV), particularly in relation to their role in the causation of necrotizing ulcerative gingivitis (NUG), is well known. NUG is considered an important risk factor for Noma. In the last two decades, there has also been an increase worldwide in the prevalence of HIV/AIDS-associated NUG. There is however no evidence yet that the current apparent upsurge of Noma in some Nigerian communities is attributable to the pandemic of HIV-infection/AIDS in the country. Nonetheless, in both HIV-positive and –negative individuals in Africa, and worldwide, only a relatively small percentage of NUG cases evolve into Noma.
Since Noma is not the primary disease but rather a secondary complication of a debilitating disease and/or nutritional deficiency state, the patients often present with a myriad of features reflecting the pre-existing health conditions. On first encounter, the child with fresh acute Noma usually presents with fluctuating fever , increase in heart beat , increased respiratory rate and loss of appetite . The medical history generally shows recurrent fevers, diarrhea, parasitic (eg Malaria) and viral infections (eg Measles, Herpes, etc) . The oro-facial lesion may occur unilaterally or bilaterally, but most often the former. The early features include soreness of the mouth, pronounced halitosis( bad breath ) , swollen, tender lip/cheek, enlarged lymph nodes of the neck , excessive salivation, a foul-smelling purulent oral discharge, and a bluish-black discoloration of the skin in the affected area. . There are suggestions that infections by the Measles virus and the Human Herpes viruses HIV, may initiate Noma .
The consequences of acute Noma depend largely on the anatomic sites affected, the extent and severity of tissue destruction, and the stage of development of the oro-facial complex prior to the onset. Survivors of the acute phase of Noma suffer the two-fold problems of disfigurement and functional impairment.
Some of the recommendation in the Prof ‘s Paper were :
Lastly to stimulate thoughts among readers, it is interesting to note that Noma Disease has become virtually extinct in developed countries with improvement in standard of living as well as sanitary practices among the people, and paradoxically, before the discovery of penicillin, observations had suggested that the disease is an opportunistic infection. On the contrary, Noma has remained an important health problem of economically disadvantaged children in developing countries, particularly in sub-Saharan Africa. A “Noma belt” stretching across parts of western and central Africa towards Sudan, appears to harbour most of the cases of Noma seen in Africa. The reason for this geographic distribution is not clear. Even in individual African countries such as Nigeria and Senegal, a few specific regions/states account for most of the national cases of Noma.
In conclusion, let me take a look on the way forward which as Prof has rightly said, there is the need to improve poverty and commence creating awareness on the Disease as well as improve our health system and environmental sanitation. All these items are in line with achieving the Millennium Development Goals (MDGs), which astoundingly Africa is not making much progress in addressing the MGDs’ targets and indicators. Coming back to the tasks listed above, it is obvious to the few that are concern about the welfare of children to be more committed and continue to draw the attention of our government, media and international development partners towards addressing Noma and other related problems associated with it as well as other burden of diseases in Africa. To Professor Cyril Obiora Enwonwu and other Africans in Diaspora, I am of the opinion that their role should not be only restricted to presenting papers, conducting researches on African soil and social visits to African States , but to also help the impoverished Africa by forming various groups in U.S.A and U.K and other places to be continuously pressing request and demand through advocacy and sensitization to International Bodies that may assist in addressing the plight of children in Africa and on a lighter note , our Professor and his colleagues in Diaspora can equally provide support and funding towards the same mission .
Dr Magashi is the Executive Director of Community Health and Research Initiative , Kano , Nigeria and can be reached through healthinteractive@hotmail.com
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