Noma, the forgotten disease that remains invisible

A research team from the Barcelona Institute for Global Health (ISGlobal), a centre supported by the “la Caixa” Foundation, has documented for the first time the presence of noma in Mozambique. The study, published in BMJ Global Health, shows that this devastating but preventable and treatable disease continues to affect communities living in extreme poverty, while going unnoticed by health systems. The work concludes that the situation is not unique to Mozambique: wherever there is poverty, there might be noma.

Noma, also known as cancrum oris, is an oral infection that rapidly destroys facial tissues and can be fatal within weeks if left untreated. It primarily affects children living in extreme poverty, under conditions of malnutrition, poor oral hygiene, and following infections such as measles or malaria. Although the disease can be prevented and treated with antibiotics and nutritional support in its early stages, if left untreated, the mortality rate reaches 90%. Survivors are left with lifelong physical, functional and social sequelae that carry a heavy stigma.

In 2023, the WHO officially recognised noma as a Neglected Tropical Disease—an important step to foster research and action at the global level. Yet it remains invisible in many countries.

First evidence in Mozambique

The ISGlobal team, in collaboration with the Oral Health Programme of Zambezia Province, in Mozambique, and the University of Navarra, has provided the first empirical evidence that noma exists in the country, despite never having been documented in the scientific literature before.

Over five weeks of fieldwork in Zambezia Province, the team implemented an active case-finding strategy inspired by the smallpox eradication campaign: showing posters with images of noma sequelae to health professionals and groups of people in markets and health centres, and asking whether they knew anyone affected by the disease. They identified 21 survivors, some with sequelae dating back to the 1970s. In addition, during this short period, two acute cases were treated at the referral hospital.

Based on the detected cases, the team estimated an incidence of 13.7 cases per 100,000 children under nine years of age, a figure similar to estimates in Ethiopia and Nigeria. However, referral surgeons treat only a few acute cases each year, since fewer than two out of every ten children with noma ever reach a hospital with specialists. This means that for every case treated, many more remain invisible. Considering also that untreated noma carries a mortality rate of around 90%, the researchers estimate that at least 200 cases occur annually among children under nine in Zambezia alone. In other words, the official figures represent just the tip of the iceberg.

A disease that reflects inequities

Noma is not contagious, but its occurrence is closely linked to the social determinants of health: poverty, malnutrition, lack of vaccination, recurrent infections, and limited access to quality health services. Testimonies collected in Mozambique also show that many communities interpret the disease as witchcraft or punishment, further stigmatising patients and delaying care.

“The absence of records does not mean the disease does not exist—it means that efforts are not being made to identify it,” explains Marta Ribes, ISGlobal researcher and first author of the study. “Our work shows that, as in Mozambique, noma is probably present in many other places where poverty puts children at risk of developing the disease, and of subsequently being left without diagnosis or treatment, which means their cases are never documented. Moreover, this study validates a simple, low-cost method to detect cases in these settings, generating the first evidence needed to demand public health policies to fight the disease.”

Beyond Mozambique

Although this study focuses on a single country, its conclusions are extrapolable: where there is poverty, there is noma. The lack of diagnoses and information reflects the neglect of vulnerable communities—made invisible even in global health statistics.

“This study shows that with simple tools, invisible diseases can be uncovered by health systems. But above all, it reminds us that noma is an extreme expression of inequity: a preventable disease that only persists because it affects the poorest of the poor,” says Carlos Chaccour, co-author and ISGlobal researcher at the time of the study, now at the University of Navarra’s Centre for International Development.

The authors stress the need to raise awareness among health professionals, develop national surveillance plans and ensure resources for early detection and treatment. With timely antibiotics and nutritional support, noma is both preventable and curable.

Reference

Ribes M, Atumane A, Padama F, et al. Wherever there is poverty: active and passive case finding to address neglect of noma in Mozambique. BMJ Glob Health. 2025;0:e020859. doi:10.1136/bmjgh-2025-020859