Combating noma in Sokoto

Combating noma in Sokoto

Noma is usually well established in a child before parents seek help, so published de- scriptions of its early stages are often incon- sistent and even inaccurate. The general con- sensus is that noma starts on the alveolar margin and spreads outwards, and that the intraoral destruction is more extensive than the disfigurement that is so obvious exter- nally.

Acute necrotizing gingivitis (ANG), a se- vere and relatively painful form of gingivi- tis that is characterized by a necrotizing in- flammation of one or more marginal inter- dental papillae, is considered to be a pre- cursor to noma. There are also suggestions that infections with the measles virus and the human herpesviridae, particularly the human cytomegalovirus and the herpes sim- plex virus, which cause oral ulcerations may play a role in initiating noma. Other factors, of course, are poverty, poor oral hygiene, poor environmental sanitation, and condi- tions such as tuberculosis, malaria, gastro- enteritis, malnutrition and anaemia.

What is puzzling, of course, is that only a small percentage of malnourished children with ANG and/or the relevant viral infec- tions actually progress to noma. Most do not, which suggests that an unknown "factor X"

speeds the progression of ANG to oro-fa- cial noma. Ongoing research in Sokoto State, Nigeria, supported by the Nestle Foundation, indicates that most noma victims live in un- sanitary environments close to filthy live- stock. The studies also suggest that certain microorganisms, particularly Fusobacterium necrophorum and Prevotella intermedia, may be key constituents of "factor X". Both microorganisms produce a wide array of toxins and metabolites capable of causing rapid and extensive tissue destruction. F.

necrophorum enters the child's mouth via contamination with animal faeces as a re- sult of sharing living quarters, water sources and even drinking vessels with animals Sokoto State has a population of 2.8 mil- lion, almost half of them less than 15 years of age. Three-quarters of the people of Sokoto live in poor rural communities where the literacy rate is low. The main occupa- tions are small-scale trading, cattle rearing

and farming on non-arable land. The typi- cal home is a hut of wood, bamboo thatch and mud, and most people live in close prox- imity to their livestock. Goats, rams, poul- try and other domestic animals wander around family compounds and, quite often, in and out of sleeping quarters. Environmen- tal sanitation in and around the huts is often very poor and the disposal of faeces is inad- equate.

Potable water is available only to about 30%

of the people of Sokoto State, chiefly those in the big towns. Rural communities rely almost exclusively on shallow ponds, streams and open wells for their water sup- ply and, during the rains, human and ani- mal waste can be washed into the water sources. The main health problems are ma- laria, tuberculosis, measles, pneumonia, gas- troenteritis and severe malnutrition. Food is usually prepared with less than adequate hygiene, usually in quantities large enough for several meals, and is stored without re- frigeration.

Data show severe protein-energy malnutri- tion and strong evidence of micronutrient deficiencies in village children. For oral health c~e, the communities rely almost exclusively on chewing sticks, though many mothers clean their children's mouths only with their fingers and water. ANG is com- mon, affecting 76 (13%) of 588 poor rural children studied.

Johannes Meixner, senior consultant surgeon at the Sokoto specialist hospital, believes there are some 10,000 cases of noma in and around Sokoto at any one time. In all, 380 acute cases have been treated at the hospi- tal's paediatric surgical unit in the past eight years. In response to an appeal through vil- lage chiefs and primary health care workers in 1996, 86 cases were treated within a six- month period by a Dutch-German medical team and the joint research group of the University of Maryland, USA, and the Ni- gerian Institute of Medical Research.

An important public health measure that will help to contain the current escalation of noma in sub-Saharan Africa is the preven- tion of faecal contamination of water and

food. This should be combined with efforts to reduce children's susceptibility through good nutrition, improved oral hygiene, and timely immunization against measles and other childhood diseases.

In response to the current upsurge of noma in Nigeria and in other African countries, a noma hospital is presently being constructed in Sokoto. The project is supported by A WD Kinderhilfe in Germany, the Sokoto State government and the federal government of Nigeria. The hospital will serve the needs of Nigeria and neighbouring countries not only by repairing the damage noma causes but also by emphasizing prevention and pro- moting research into this destructive disease.

This article is summarized from a report by Cyril 0. Enwonwu, Professor of Biochemis- try at the Schools of Dentistry and Medicine, University of Baltimore, MD, USA, and former director of the Nigerian Institute of Medical Research, Lagos, and by Johannes Meixner, senior consultant surgeon at the Sokoto specialist hospital and local repre- sentative of AWD Kinderhilfe, Hanover, Germany. •

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12

WHAT IS NOMA 7

Noma, a disease of early childhood

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INTERNATIONAL ACT10N PROGRAMME AGAINST NOMA DMSION OF NONCOMMUNICABlE DISEASES

WORW HEALTH ORGANIZATION • GENEVA - SWJTZERLAND