Noma: neglected, forgotten and a human rights issue

Noma, an orofacial gangrene and opportunistic infection, affects primarily malnourished children living in extreme poverty. Neglected, forgotten, unknown by most health workers, noma results in death, disfigurement and disability of some of the world's most vulnerable children. Noma is a biological indicator of multiple human rights violations, including the right to food. International support and national attention in countries with noma are lacking. The end of neglect of noma can lead to the elimination of this horrific childhood diseas

Risk factors for noma disease: a 6-year, prospective, matched case-control study in Niger

Background Noma is a poorly studied disease that leads to severe facial tissue destruction in children in developing countries, but the cause remains unknown. We aimed to identify the epidemiological and microbiological risk factors associated with noma disease. Methods We did a prospective, matched, case-control study in Niger between Aug 1, 2001, and Oct 31, 2006, in children younger than 12 years to assess risk factors for acute noma. All acute noma cases were included and four controls for each case were matched by age and home village. Epidemiological and clinical data were obtained at study inclusion. We undertook matched-paired analyses with conditional logistic regression models. Findings We included 82 cases and 327 controls. Independent risk factors associated with noma were: severe stunting (odds ratio [OR] 4·87, 95% CI 2·35–10·09) or wasting (2·45, 1·25–4·83); a high number of previous pregnancies in the mother (1·16, 1·04–1·31); the presence of respiratory disease, diarrhoea, or fever in the past 3 months (2·70, 1·35–5·40); and the absence of chickens at home (1·90, 0·93–3·88). After inclusion of microbiological data, a reduced proportion of Fusobacterium (4·63, 1·61–13·35), Capnocytophaga (3·69, 1·48–9·17), Neisseria (3·24, 1·10–9·55), and Spirochaeta in the mouth (7·77, 2·12–28·42), and an increased proportion of Prevotella (2·53, 1·07–5·98), were associated with noma. We identifi ed no specifi c single bacterial or viral pathogen in cases. Interpretation Noma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specifi c bacterial commensals is indicative of a modifi cation of the oral microbiota associated with reduced bacterial diversity.Funding Gertrude Hirzel Foundation

Bacterial Diversity in Oral Samples of Children in Niger with Acute Noma, Acute Necrotizing Gingivitis, and Healthy Controls

Noma is a devastating gangrenous disease that leads to severe facial disfigurement, but its cause remains unknown. It is associated with high morbidity and mortality and affects almost exclusively young children living in remote areas of developing countries, particularly in Africa. Several factors have been linked to the disease, including malnutrition, immune dysfunction, lack of oral hygiene, and lesions of the mucosal gingival barrier, particularly the presence of acute necrotizing gingivitis, and a potentially non-identified bacterial factor acting as a trigger for the disease. This study assessed the total bacterial diversity present in 69 oral samples of 55 children in Niger with or without acute noma or acute necrotizing gingivitis using culture-independent molecular methods. Analysis of bacterial composition and frequency showed that diseased and healthy site bacterial communities are composed of similar bacteria, but differ in the prevalence of a limited group of phylotypes. We failed to identify a causative infectious agent for noma or acute necrotizing gingivitis as the most plausible pathogens for both conditions were present also in sizeable numbers in healthy subjects. Most likely, the disease is initiated by a synergistic combination of several bacterial species, and not a single agent

Etude sur l'étiologie du noma : aspects microbiologiques et facteurs de risque

Le noma est une gangrène faciale qui frappe des enfants ayant un mauvais état général. Le but du travail a été de caractériser, sur le plan bactérien, viral et sérologique des enfants atteints de noma et de les comparer avec leur fratrie ainsi qu'un groupe d'enfants mal nourris. Les résultats bactériologiques ont montré une prévalence élevée de plusieurs pathogènes parodontaux (P. gingivalis, P. intermedia, C. rectus, P. micros) chez les enfants noma et leur fratrie alos que ces bactéries étaient rarement présentes chez les enfants mal nourris. Les résultats sérologiques ont mis en évidence des titres élevés d'IgG contre EBV et CMV dans les 3 groupes. Le taux d'IgM était élevé dans les groupes fratrie et mal nourris mais faible dans le groupe noma. La présence simultanée de virus et de bactéries pathogènes pendant la période de sevrage pourrait être un facteur prédisposant dans l'étiologie de la maladie

Why is noma a neglected-neglected tropical disease?

Noma is an orofacial gangrene affecting primarily children living in extreme poverty in remote parts of subtropical and tropical countries. Mortality and disability are high, and survivors often have physical and functional deformities resulting in stigma and isolation. Many healthcare professionals and primary healthcare workers where noma risk factors exist have no knowledge about noma and its implications. Public health measures to improve nutrition, immunizations, sanitation, and access to healthcare and measures to eliminate extreme poverty can lead to the eradication of noma. Research allocation has been insufficient to study the epidemiology, treatment, and prevention of noma. In a recent editorial by Hotez and colleagues in PLOS Neglected Tropical Diseases (NTDs), "What constitutes an NTD?" Noma is not included. The exclusion of noma from NTDs constitutes this preventable childhood disease as a neglected neglected disease. The purpose of this article is the inclusion of noma with the PLOS NTDs. Increased awareness and attention to noma can lead to the eradication of this disease affecting the world's most vulnerable

Bacterial diversity in oral samples of children in niger with acute noma, acute necrotizing gingivitis, and healthy controls.

BackgroundNoma is a gangrenous disease that leads to severe disfigurement of the face with high morbidity and mortality, but its etiology remains unknown. Young children in developing countries are almost exclusively affected. The purpose of the study was to record and compare bacterial diversity in oral samples from children with or without acute noma or acute necrotizing gingivitis from a defined geographical region in Niger by culture-independent molecular methods.Methods and principal findingsGingival samples from 23 healthy children, nine children with acute necrotizing gingivitis, and 23 children with acute noma (both healthy and diseased oral sites) were amplified using "universal" PCR primers for the 16 S rRNA gene and pooled according to category (noma, healthy, or acute necrotizing gingivitis), gender, and site status (diseased or control site). Seven libraries were generated. A total of 1237 partial 16 S rRNA sequences representing 339 bacterial species or phylotypes at a 98-99% identity level were obtained. Analysis of bacterial composition and frequency showed that diseased (noma or acute necrotizing gingivitis) and healthy site bacterial communities are composed of similar bacteria, but differ in the prevalence of a limited group of phylotypes. Large increases in counts of Prevotella intermedia and members of the Peptostreptococcus genus are associated with disease. In contrast, no clear-cut differences were found between noma and non-noma libraries.ConclusionsSimilarities between acute necrotizing gingivitis and noma samples support the hypothesis that the disease could evolve from acute necrotizing gingivitis in certain children for reasons still to be elucidated. This study revealed oral microbiological patterns associated with noma and acute necrotizing gingivitis, but no evidence was found for a specific infection-triggering agent