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

High burden of noma in the Gambella region of Ethiopia: a 12-year retrospective study on noma cases from the Facing Africa database

BACKGROUND

Noma, an infectious disease, mainly affects impoverished children. This study retrospectively assessed noma's prevalence in Ethiopia using data from the Facing Africa database and the 2022 United Nations Development Programme poverty index report.

METHODS

A thorough review of medical records spanning 2007 to 2019 identified a total of 235 noma cases. A standardized data extraction template was employed to systematically gather pertinent clinical and demographic data for subsequent analysis. Prevalence rates were calculated nationally and regionally for both the general population and children aged ≤10 y.

RESULTS

The analysis revealed estimated national prevalence rates of 0.65 per 100 000 individuals at risk and 1.9 per 100 000 children aged <10 y at risk. The Gambela region exhibited the highest prevalence rate (11.2 per 100 000), whereas the Benshangul Gumuz region had the lowest (0.25 per 100 000). Similar patterns were observed among children aged ≤10 y, with the Gambela and Benshangul Gumuz regions reporting rates of 32.9 and 0.74 per 100 000, respectively.

CONCLUSIONS

The study highlights noma's significant impact on children aged <10 y in Ethiopia, especially in the Gambella region. It offers crucial baseline data to assist public health professionals, policymakers and healthcare providers in formulating evidence-based strategies to combat noma and improve affected individuals' well-being.

Noma in the WHO's list of neglected tropical diseases: A review of its impact on undeveloped and developing tropical regions

Background

Noma is a neglected tropical disease and a global health concern.

Objectives

To elucidate the epidemiology, management, prevention, and public health implications of Noma.

Methods

PubMed, Scopus, and Web of Science, supplemented by Google Scholar and World Health Organization databases, were searched using keywords to gather both published and grey literature from 1970 to 2023 in English.

Results

Approximately 30,000-40,000 cases occur annually, with varying incidences across various African countries, such as Nigeria, Niger, and Chad. Incidence in Nigerian and Ethiopian states range from 0.6 to 3300 and 1.64 to 13.4 per 100,000 population, respectively. Mortality is approximately 8.5% in Niger. Risk factors include malnutrition, immunocompromised status, poor dental hygiene, inadequate sanitation, gingival lesions, low socioeconomic status, chronic and infectious diseases, low birth weight, high parity, diarrhoea, and fever. Diagnosis is primarily made based on clinical signs/symptoms and accordingly staging of disease is done. Stage I, II and II presents with acute necrotizing gingivitis, facial edema with halitosis, and necrotizing stomatitis, respectively. If the patient survives acute stages, the progress to Stage IV and Stage V manifests as trismus, difficulty in deglutition and phonation, and facial disfigurement, with increased severity in last stage. Treatment encompasses antibiotic therapy (amoxicillin, metronidazole, chlorhexidine, ampicillin, gentamicin), surgical interventions, wound management (honey dressing, ketamine), and nutritional support. Prevention strategies include oral hygiene, vaccination, health education, and community-based interventions.

Conclusion

Noma's recent inclusion in WHO list of neglected tropical diseases is a milestone in recognizing the importance of prevention and early intervention to globally enhance health outcomes.

Noma disease among internally displaced persons in Northeast Nigeria: a retrospective descriptive study

Background

Recently recognized by the World Health Organization as a neglected tropical disease, Noma, an acute and destructive gangrenous disease affecting the gums and facial structures within the oral cavity, has a high mortality rate if untreated.

Objectives

To investigate the prevalence and impact of Noma among internally displaced populations in Northeastern Nigeria.

Design

A retrospective study.

Methods

This retrospective study investigates the prevalence and impact of Noma among internally displaced populations in Northeastern Nigeria. Noma is endemic in Northern Nigeria, Africa, and its occurrence has been linked to extreme poverty, malnutrition, poor hygiene, and inadequate healthcare - conditions exacerbated by the ongoing Boko Haram conflict.

Results

The retrospective descriptive cross-sectional analysis of 17 cases reveals a median age of 8 years, with most of the patients being children who suffer significant social stigmas, such as difficulties in speaking, eating, and social integration, including reduced school attendance and marital prospects.

Conclusion

The study highlights the urgent need for comprehensive research into the etiology of Noma and its socio-economic impact. It emphasizes the necessity for early and effective intervention strategies, particularly in conflict-stricken areas with limited healthcare access.

Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria

INTRODUCTION

Noma is a rapidly spreading infection of the oral cavity which mainly affects young children. Without early treatment, it can have a high mortality rate. Simple gingivitis is a warning sign for noma, and acute necrotizing gingivitis is the first stage of noma. The epidemiology of noma is not well understood. We aimed to understand the prevalence of all stages of noma in hospitalised children.

METHODS

We conducted a prospective observational study from 1st June to 24th October 2021, enrolling patients aged 0 to 12 years who were admitted to the Anka General Hospital, Zamfara, northwest Nigeria. Consenting parents/ guardians of participants were interviewed at admission. Participants had anthropometric and oral examinations at admission and discharge.

FINDINGS

Of the 2346 patients, 58 (2.5%) were diagnosed with simple gingivitis and six (n = 0.3%) with acute necrotizing gingivitis upon admission. Of those admitted to the Inpatient Therapeutic Feeding Centre (ITFC), 3.4% (n = 37, CI 2.5-4.7%) were diagnosed with simple gingivitis upon admission compared to 1.7% of those not admitted to the ITFC (n = 21, CI 1.1-2.6%) (p = 0.008). Risk factors identified for having simple gingivitis included being aged over two years (2 to 6 yrs old, odds ratio (OR) 3.4, CI 1.77-6.5; 7 to 12 yrs OR 5.0, CI 1.7-14.6; p = <0.001), being admitted to the ITFC (OR 2.1; CI 1.22-3.62) and having oral health issues in the three months prior to the assessment (OR 18.75; CI 10.65, 33.01). All (n = 4/4) those aged six months to five years acute necrotizing gingivitis had chronic malnutrition.

CONCLUSION

Our study showed a small proportion of children admitted to the Anka General Hospital had simple or acute necrotizing gingivitis. Hospital admission with malnutrition was a risk factor for both simple and acute necrotizing gingivitis. The lack of access to and uptake of oral health care indicates a strong need for oral examinations to be included in routine health services. This provision could improve the oral status of the population and decrease the chance of patients developing noma.

Reconstruction of Noma Sequelae: A Surgical Treatment Algorithm Developed from Lessons from 210 Cases in Ethiopia

Noma is an infectious disease affecting mostly children aged 0-10. Although it has almost completely disappeared from the Western world, it is still prevalent in many developing regions, mainly Africa's Sahel region. The infection behaves like a necrotizing fasciitis of the face, originating from the gums and progressively expanding into the cheek, nose, or eye regions. In an estimated 90% of cases, the disease is lethal as a result of systemic sepsis. For survivors, typical results are extensive defects of the cheek, nose, and periorbital and perioral regions. Due to the defects, extensive scarring is common, which leads to secondary problems such as growth alterations in an infant's skeleton due to inhibition and restraint of growth resulting typically in cicatricial skeletal hypoplasia. Other sequelae include trismus, partially caused by scarring or complete fusion between maxilla/zygomatic arch and mandible. The resulting overall disfiguring facial appearance results in patients being disabled and socially isolated.

Methods

Facing Africa is a UK-based non-governmental organization that treats the secondary problems of Ethiopian noma survivors. Operations are performed in Addis Ababa by a visiting expert team. Postoperatively, patients are seen annually for years after the surgery.

Results

This article discusses basic principles, goals, and a practical surgical algorithm for operating on lip, cheek, and oral defects, based on 210 noma patients who were operated on in Ethiopia over a period of 11 years.

Conclusions

The suggested algorithm has proven to work for the Facing Africa team members and is considered shareware for all surgeons to use and benefit from.

The key players of dysbiosis in Noma disease; A systematic review of etiological studies

Noma is a rapidly progressing periodontal disease with up to 90% mortality in developing countries. Poor, immunocompromised and severely malnourished children (2 to 6 years old) are mostly affected by Noma. Prevention and effective management of Noma is hindered by the lack of sufficient cohesive studies on the microbial etiology of the disease. Research efforts have not provided a comprehensive unified story of the disease. Bridging the gap between existing studies gives an insight on the disease pathogenesis. This current systematic review of etiological studies focuses on the key players of dysbiosis in Noma disease. This review was performed in accordance with the Preferred Reporting Items for Systemic review and Meta-Analyses (PRISMA) statement. Web of Science, MEDLINE via PubMed, Cochrane Library, Scopus, and Science Direct were searched electronically for clinical trials which applied culture dependent or molecular techniques to identify oral microbiota from Noma patients. Trials which involved periodontal diseases except Noma were excluded. After screening 275 articles, 153 full-texts articles were assessed for eligibility of which eight full text articles were selected for data extraction and analysis. The results show that 308 samples from 169 Noma participants (6 months to 15 years old) have been used in clinical trials. There was some variance in the microbiome identified due to the use of 3 different types of samples (crevicular fluid, subgingival plaque, and swabbed pus) and the ambiguity of the stage or advancement of Noma in the studies. Other limitations of the studies included in this review were: the absence of age-matched controls in some studies; the constraints of colony morphology as a tool in distinguishing between virulent fusobacterium genus at the species level; the difficulty in culturing spirochaetes in the laboratory; the choice of primers in DNA amplification; and the selection of probe sets in gene sequencing. This systematic review highlights spirochaetes and P. intermedia as putative trigger organisms in Noma dysbiosis, shows that F. nucleatum promotes biofilms formation in late stages of the disease and suggests that future studies should be longitudinal, with high throughput genome sequencing techniques used with gingival plaque samples from early stages of Noma.

Noma, a neglected disease: prevention is better than cure

PURPOSE OF REVIEW

There is a need for concerted effort to increase Global awareness about noma (cancrum oris). This paper aims to summarize the recent literature on noma and provide suggestions that could be implemented to raise awareness about this neglected disease.

RECENT FINDINGS

Noma has been recognized, diagnosed and reported for centuries. Despite significant progress in scientific methods over time, the published literature on noma has predominantly been of low level clinical and scientific evidence. Recent studies have reported on noma's global distribution and its predisposing risk factors, its treatment, its knowledge and beliefs and has included a number of literature reviews. Noma cases are being reported from an increasingly diverse set of geographical locations.

SUMMARY

Noma has largely been neglected in the research sphere. Noma is a preventable disease and its progression can be halted if patients are recognized and treated in the early stages of disease. Treatment for late stage noma survivors remains complex and time consuming, requiring substantial human and financial resources most commonly not achieving functional and cosmetic anatomy. The ultimate aim is therefore prevention, initiatives should be integrated into existing health programs.

Noma: Experiences of Survivors, Opinion Leaders and Healthcare Professionals in Burkina Faso

The scientific literature on noma (Cancrum Oris) has clearly increased in recent decades, but there seems to have been limited analysis of issues around the psycho-social impacts of this disease. Even when these issues have been addressed, the focus has tended to be on patient experiences, whereas the community dimension of the disease and the role of healthcare professionals and community leaders in mitigating these impacts remain largely unexplored. A study in the form of semi-directed interviews with 20 noma survivors and 10 healthcare professionals and community leaders was conducted between January and March 2021 in Burkina Faso with the aim of describing the experiences of noma survivors, generating knowledge about living with the burden of the disease and understanding the attitudes of community leaders towards the disease. The results reveal that noma is a disease that affects economically vulnerable populations and leads to extreme household poverty. As far as treatment is concerned, patients tend to turn to practitioners of both traditional and modern medicine. Within communities, noma survivors face discrimination and stigma. The study highlighted a lack of information and knowledge about noma. However, surgical operations lead to patient satisfaction and these remain one of the coping strategies used to tackle the stigma and discrimination. The recommendations set out in this article are aimed firstly at stepping up research into the psycho-social impacts of noma, and secondly at considering these impacts in regional programmes and national plans to combat the disease.

Economic and Social Costs of Noma: Design and Application of an Estimation Model to Niger and Burkina Faso

BACKGROUND

While noma affects hundreds of thousands of children every year, taking their lives, disfiguring them and leaving them permanently disabled, the economic and social costs of the disease have not been previously estimated. An understanding of the nature and levels of these costs is much needed to formulate and implement strategies for the prevention and control of this disease, or to mitigate its burden. The objectives of our study were to develop a model for estimating the economic and social costs of noma and to provide estimates by applying this model to the specific contexts of two countries in the "noma belt", namely Burkina Faso and Niger.

METHODS

Three main approaches were used. The estimation of prevalence levels of potential noma cases and of cases that should receive and actually do receive medical care was carried out using a literature review. The documentary approach made it possible to estimate the direct costs of noma by analyzing the database of a non-governmental organization operating in this field and present in both countries. Indirect costs were estimated using the human capital method and the cost component analysis technique.

RESULTS

The direct costs of care and management of noma survivors amount to approximately USD 30 million per year in Burkina Faso, compared to approximately USD 31 million in Niger. They mainly include costs for medical treatment, surgery, hospital stays, physiological care, psychological care, social assistance, schooling, vocational training and care abroad. Indirect costs are estimated at around 20 million in lost production costs in Burkina and around 16 million in Niger. Costs related to premature deaths are estimated at more than USD 3.5 billion in Burkina Faso and USD 3 billion in Niger. Finally, the costs to survivors who are unable to marry are around USD 13.4 million in Burkina and around USD 15 million in Niger. Intangible costs were not calculated.

CONCLUSIONS

The neglect of noma and inaction in terms of prevention and control of the disease have enormous economic and social costs for households, communities and states. Future studies of this kind are necessary and useful to raise awareness and eradicate this disease, which impacts the health and well-being of children and results in lifelong suffering and severe economic and social costs to survivors and their families.

Noma staging: a review

Noma is a bacterial, non-communicable, grossly destructive and disfiguring necrotising oro-facial disease. It is rare, but occurs most commonly in chronically malnourished children with other debilitating illnesses, in remote, poverty-stricken communities, mainly in sub-Saharan Africa, and much more rarely in central Latin America and in parts of Asia. In South Africa and in Zimbabwe, noma is observed, again rarely, in immunosuppressed HIV-seropositive subjects. The World Health Organization (WHO) has classified noma into five sequential stages: stage 1, acute necrotising ulcerative gingivitis; stage 2, oedema; stage 3, gangrene; stage 4, scarring; stage 5, sequela. In the opinion of the authors, this WHO classification requires fundamental re-appraisal. The purpose of this viewpoint article is to highlight the weaknesses of this classification, and to propose a simpler, more logical and practical evidence-based staging of noma, which if used should improve the quality and value of future epidemiological data about noma.

Noma: A Neglected Area for Research

Noma, a debilitating and destructive orofacial gangrene, remains endemic in the poor countries of sub-Saharan Africa and other noma hotbeds across the globe, mainly in countries characterized as underdeveloped economies with significant impoverished populations. Noma mostly affects children and infants. This is in spite of the universally held notion that noma is a preventable disease. Indeed, the current noma status quo has been cast as a human rights shortfall, since this devasting disease overwhelmingly affects children from poor countries. At the recently held Noma Research Day, a renewed call for the World Health Organization (WHO) to recognize and include noma as one of the neglected tropical diseases was accompanied by a recognition that research into all aspects of noma has waned or remained completely lacking-particularly that which addresses the basic science questions of the etiology, pathophysiology/pathobiology, and underlying mechanisms of the disease. Yet, a lack of incremental knowledge on the various aspects of noma continues to hamper our composite understanding of its biology. Without a fundamental understanding of the biology of noma, current preventive measures and treatment modalities will continue to fall short of the goals of prevention and eradication. This opinion piece draws renewed attention to the urgency of listing noma as a neglected tropical disease by the WHO. It also calls for major international research funding agencies, including the WHO and the National Institutes of Health, to renew their resolve to robustly fund structured, collaborative, and coordinated proposals that address questions on the epidemiology, etiology, pathophysiology/pathobiology, and molecular mechanisms of the disease. This is with a view to achieving more effective public health approaches toward prevention and to designing potential therapeutic regimens for early lesions. These steps are key to the ultimate eradication of noma.

More than 100 years of neglect: a bibliometric analysis of global research on noma (cancrum oris)

BACKGROUND

Research plays a significant role in quantifying and addressing the burden of disease, improving healthcare delivery and developing evidence-based policy for neglected tropical diseases (NTDs). Since noma is not a recognised NTD by the World Health Organization (WHO), research activity is hypothesised to be low. This study aims to understand patterns and trends of research conducted on noma, to understand the patterns of citations, highlight networks of collaboration and analyse stakeholders in noma research.

METHODS

The SCOPUS database was selected and searched. Data analysis was conducted using the bibliometrix package for R in RStudio. Areas of interest included the distribution of research output on noma by year and location, the academic impact of publication output, mapping the major academic community and conducting a thematic analysis of high-frequency keywords.

RESULTS

A total of 208 documents were identified. The annual growth rate of publications is 4.3%. The average number of citations per publication was 11.0 (rounded from 10.98) and the average citations per year per publication was 0.57. The USA was the country with the highest percentage 10.6% (n=22) of corresponding authors, followed by Nigeria (6.7% [n=14]), the UK (6.3% [n=13]) and India (5.8% [n=12]). For those papers with multiple authors, there was an average of 3.22 co-authors per document. The collaboration index was 3.3. Upon plotting collaboration networks between authors, only 11 clusters were identified (frequency and intensity of collaboration). Mapping of trending topics showed a focus on skin grafting and transplantation within the literature.

CONCLUSIONS

In order to progress towards eventual elimination of noma it is key that more research should be undertaken and more interest and funding should be dedicated to work on noma. Recognition of noma as an NTD by the WHO would be a first step in moving towards increased awareness.

Is Blood Transfusion Justified During Soft Tissue Surgery in Noma Patients? A One-Year Appraisal at Noma Children Hospital, Sokoto, Nigeria

BACKGROUND

Non-utilization of blood and inappropriate blood transfusion are common in surgical operations. Some surgical procedures are associated with minimal bleeding that does not warrant blood transfusion. No previous study has looked at the pattern of blood loss in noma defect repair to determine the possible need for blood transfusion.

AIM/OBJECTIVES

This study aimed to determine the total amount of blood loss, the number of units of blood transfused, and the correlation between estimated blood loss and total operating time in patients who had surgical correction of noma defects.

MATERIALS AND METHODS

This is a hospital-based cross-sectional study of 35 patients who underwent surgical correction of noma defects. Age, sex, pre- and post-operative haemoglobin (Hb), number of requested blood units, total operating time, and total estimated blood loss were recorded. The methods used for the blood loss estimation were gauze swabs, Abdo-packs, drapes, and suction bottles.

RESULTS

Comparison of the mean pre- and post-operative Hb did not yield any statistically significant difference. The total estimated blood loss in these surgeries was in the range of 65-209 mL, with a mean of 117.20 ± 35.88 mL. No correlation between estimated blood loss and total operating time was noted (P = 0.940). No blood was transfused in any of the subjects.

CONCLUSION

This study observed minimal blood loss in surgical corrections of the soft tissue noma defect. Apart from blood grouping, there may be no need for routine cross-matching of blood pre-operatively for surgical repair of noma defect. However, more studies are needed to buttress this finding.

OUP accepted manuscript

Noma is a debilitating orofacial necrotizing bacterial disease that disproportionately affects impoverished malnourished persons, particularly young children, the vast majority of whom live in tropical and subtropical areas in sub-Saharan Africa. It has a very high mortality rate; causes significant physical and psychological morbidity, stigmatization and social discrimination; could be prevented, controlled and indeed eliminated by common public health interventions; and is overlooked with regard to public health awareness, in-depth scientific research activities and allocation of funding for prevention, treatment and research.

According to the WHO, noma comprises five sequential ‘stages’: (1) necrotizing gingivitis, (2) edema, (3) gangrene, (4) scarring and (5) sequelae. This WHO staging of noma is contentious, leading to diagnostic confusion with misestimation of the number of noma cases reported in epidemiological studies. We therefore suggest a simpler, more practical and scientifically valid two-stage classification comprising only (1) acute noma and (2) arrested noma.

Noma meets all the WHO criteria for classification as a neglected tropical disease (NTD). Most survivors of noma live with gross physical disfigurement and disability, and with impaired psychosocial functioning, so they are very often stigmatized and unjustifiably discriminated against. Owing to the paucity of evidence-based epidemiological data on noma, the relatively low number of people affected worldwide, and its apparently limited geographic distribution, noma does not yet feature on the WHO's list of NTDs, or on any global health agenda, and thus has not become a health priority for global action. We strongly support the inclusion of noma within the WHO list of NTDs. Without doubt this will increase the awareness of noma among healthcare providers and promote the systematic international accumulation and recording of data about noma.

Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021)

Background

Noma (cancrum oris) is an ancient but neglected and poorly understood preventable disease, afflicting the most disenfranchised populations in the world. It is a devastating and often fatal condition that requires urgent and intensive clinical and surgical care, often difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and identify research gaps that need to be addressed to evolve our understanding of how to address this disease.

Methods

We searched 11 databases and collected primary peer reviewed articles on noma in all languages, the final search was conducted on 24^th August 2021. The oldest manuscript identified was from 28^th March 1843 and the most recently published manuscript was from 3^rd June 2021. Search terms included cancrum oris and noma. Data was extracted using a standardised data extraction tool and key areas of interest were identified. The Preferred Reporting Items for Systemic review and Meta-Analyses requirements were followed.

Results

The review included 147 articles, the majority of the studies (n = 94, 64%) were case reports. Most manuscripts (n = 81, 55%) were published in the 2000s, 49 (33%) were from the 1900s and 17 (12%) from the 1800s. The main areas of interest identified were the history and epidemiology of the disease, noma’s clinical progression and aetiology, treatment regimens, mortality rates and the risk factors for the development of noma.

Conclusions

Noma has been reported in the literature for hundreds of years; however important gaps in our understanding of the disease remain. Future research should focus on determining the burden and distribution of disease; the true mortality rate, pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Noma is a devastating and often fatal condition that mainly affects children in severely disenfranchised communities. Noma is preventable and requires urgent basic medical care in the early stages of disease. Once the disease reaches the last stage, sequelae, survivors require expert surgical care, usually difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and to identify research priorities that will evolve our understanding of how to eradicate this disease. Our review showed that noma has been reported in the literature for hundreds of years; however several major gaps in knowledge still exist. There is appreciation among the small community of clinicians and researchers involved in noma care and research that these gaps in knowledge impact on the ability to develop and implement sound evidence-based policies and activities aimed at eradicating noma from communities that continue to be afflicted by this ancient disease. The main focus of future research should be to study the burden and distribution of disease; the true mortality rate, and the pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Update on Noma: systematic review on classification, outcomes and follow-up of patients undergoing reconstructive surgery after Noma disease

INTRODUCTION

Noma is a significant yet neglected disease which affects some of the least developed countries in the world. The long-term benefit and safety of Noma surgical reconstructive missions have recently been under scrutiny due to a perceived lack of measurable outcomes and appropriate follow-up. This study analyses and reports on classifications, outcome measurement tools and follow-up for reconstructive surgery after Noma disease.

METHODS

This systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The three medical databases Medline, EMBASE and Web of Sciences were searched, articles published between 1 January 1983 and 15 April 2020 were included. All primary evidence on reconstructive surgery following Noma disease, reporting data on outcome after surgery, follow-up time and complications were included. Extracted data were aggregated to generate overall and population corrected mean outcomes and complication rates.

RESULTS

Out of 1393 identified records, 31 studies including 1110 Noma patients were analysed. NOITULP and Montandon/WHO were the most commonly used classification systems. Mouth opening (MO) and complication rates were the two most often reported outcomes. Overall mean complication rate was 44%, reported by 24 studies. Postoperative MO was reported by eight publications, of which, five reported long-term outcomes (>12 months). Mean MO improved by 20 mm when compared with mean population weighted preoperative MO (7 mm). At long-term follow-up, MO decreased to 20 mm.

CONCLUSIONS

Studies reporting on neglected diseases in developing countries often lack methodological rigour. Surgeons should be mindful during patient examination by using a classification system that allows to compare preoperative versus postoperative state of disease. Short-term mission surgery is a vital part of healthcare delivery to underdeveloped and poor regions. Future missions should aim at sustainable partnerships with local healthcare providers to ensure postoperative care and long-term patient-oriented follow-up. A shift towards a diagonal treatment delivery approach, whereby local surgeons and healthcare staff are educated and empowered, should be actively promoted.

PROSPERO REGISTRATION NUMBER

CRD42020181931.

Model of care, Noma Children's Hospital, northwest Nigeria

The Nigerian Ministry of Health has been offering care for noma patients for many years at the Noma Children’s Hospital (NCH) in Sokoto, northwest Nigeria, and Médecins Sans Frontières has supported these initiatives since 2014. The comprehensive model of care consists of four main components: acute care, care for noma sequelae, integrated hospital‐based services and community‐based services. The model of care is based on the limited evidence available for prevention and treatment of noma and follows WHO’s protocols for acute patients and best practice guidelines for the surgical treatment of noma survivors. The model is updated continually as new evidence becomes available, including evidence generated through the operational research studies performed at NCH. By describing the model of care, we wish to share the lessons learned with other actors working in the noma and neglected tropical disease sphere in the hope of guiding programme development.

Mycobacterial and Plasmodium ovale-associated destruction of the jaw bones

OBJECTIVES

The project aims were to identify infectious mechanisms responsible for an extreme form of mandibular osteonecrosis and osteomyelitis in West African populations and test the hypothesis that Mycobacterium tuberculosis plays a pivotal role.

MATERIALS AND METHODS

DNA was extracted from mandibular fragments of 9 of 19 patients previously included in a prospective study leading to the mycobacterial hypothesis. Amplified DNAs were used for preparing libraries suitable for next-generation sequencing. For comparison of the whole-genome sequencing data of the 9 patients with DNAs of both microbiota and human tissues, DIAMOND v0.9.26 was used to align sequencing reads to NCBI-nr database and MEGAN 6 for taxonomy binning and identification of Mycobacterium tuberculosis strains.

RESULTS

The data show that mandibular bone fragments of all 9 patients not only contain Homo sapiens and Mycobacterium tuberculosis DNAs; they also contain DNAs of Plasmodium ovale wallikeri, Staphylococcus aureus, Staphylococcus hominis, and Prevotella P3-120/intermedia; as well as large numbers of DNAs from other infectious components.

CONCLUSIONS

The data obtained provide direct evidence to support the conclusion that combinations of Mycobacterium tuberculosis, Plasmodium ovale wallikeri, and other oral bacteria are involved in this particular type of mandibular destruction in West African individuals of many ages.

First Case of Cancrum Oris (Noma) in an HIV-Positive Patient in Bulgaria

We present a case of a necrotising disease of the orofacial tissues, the so-called noma, in a female patient with AIDS in a stage of severe immune deficiency. To our knowledge, this is the first time a case like that has been reported in Bulgaria. The patient received an antibiotic course of treatment with a triple combination to good effect on the inflammatory process, and began also HAART. Within 3 weeks, the patient’s general condition improved. However, despite the treatment, a demarcation line was formed, and a defect on the lower lip occurred. Noma is a manifestation of severe immune deficiency with lasting adverse consequences for the patient: severe deformation of the maxilo-facial region and functional impairment (i.e. difficulties eating and speaking, and salivary leak).

The prevalence of noma in northwest Nigeria

Background

Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.

Methods

Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0–5 and 6–15 years). Factors associated with noma were estimated using logistic regression.

Results

A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0–5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0–5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3–5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6–15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.

Conclusions

Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list.

Noma-knowledge and practice competence among primary healthcare workers: a cross-sectional study in Burkina Faso

BACKGROUND

Noma is a quickly progressing, neglected opportunistic infection. It starts in the mouth as an oral lesion but can relatively quickly develop into extensive facial destruction and lead to death if not treated in time. This study aims to shed light on primary healthcare workers' practice competences in working with and knowledge of noma.

METHODS

A structured questionnaire using questions and case scenarios was filled out by 76 healthcare workers in Burkina Faso. Half of the nurses included in this study participated in a 2-day noma training. Data were analysed descriptively and Fisher's exact test was used to study differences between occupational groups using Stata.

RESULTS

Most healthcare workers reported having examined the mouth of children with diseases predisposing to noma. The total practice competence was poor, with almost 70% having suboptimal or very low competences. However, competences varied between different stages of noma disease. Knowledge scores varied between occupational groups. The majority of nurses and odontostomatology specialist nurses had optimal or good knowledge of noma. Significant differences in knowledge and practice competence were found between nurses who attended a 2-day training course on noma and those who did not.

CONCLUSIONS

Health care workers in this study had quite poor practice competences in managing noma. The knowledge scores of these health workers were moderate. It is important for healthcare workers to be able to identify noma patients at an early stage, as at this point the disease can still be completely reversed.

Noma (cancrum oris): An unresolved global challenge

Noma (canrum oris) is a mutilating necrotizing disease of uncertain etiology, but it is accepted that it is caused primarily by a polybacterial infection with secondary ischemia. The consequent necrotizing fasciitis, myonecrosis, and osteonecrosis results in destruction of facial structures with severe functional impairment and disfigurement. It most frequently affects children, particularly in sub‐Saharan Africa, who are malnourished or debilitated by systemic conditions including but not limited to malaria, measles, and tuberculosis; and less frequently debilitated HIV‐seropositive subjects. In the vast majority of cases, in susceptible subjects, noma is preceded by necrotizing stomatitis. However, it has been reported, albeit rarely, that noma can arise without any preceding oral lesions being observed. Noma is not recurrent and is not transmissible.

Sociodemographic Characteristics of Traditional Healers and Their Knowledge of Noma: A Descriptive Survey in Three Regions of Mali

Background: Noma can be a lethal disease and causes disfigurement in young children in low-resource countries, particularly in Africa. In these settings, 80% of the population mainly consult traditional healers for healthcare problems. Our study aimed to describe the sociodemographic characteristics of traditional healers and to assess their knowledge of noma. Methods: We conducted a survey among traditional healers in three Malian regions from May 2015 to January 2016 and collected data on sociodemographic characteristics, professional activity, knowledge, and experience of noma and collaboration with modern medicine. Results: Among 770 traditional healers invited to participate, 732 responded (95%) (mean age, 54.5 years). Most were illiterate (66.3%), which was associated with older age (p < 0.001). Although they treated all types of disease, only 10.5% had some knowledge of noma, with regional differences (p < 0.001). Conclusion: Noma is poorly known among traditional healers, especially in remote areas. Our findings suggest a lack of interest among young people for traditional medicine, implying an imminent decrease of healers, and thus the need for national health systems to strengthen and promote access to modern health care. Training programmes to improve the early diagnosis referral of noma patients should include all types of primary health workers.

Pattern of noma (cancrum oris) and its risk factors in Northwestern Nigeria: A hospital-based retrospective study

Background:

Noma (cancrum oris) remains the scourge of children and the “face of poverty” in Sub-Saharan Africa. Recent data on the burden of noma and its risk factors are needed for evaluating and redesigning interventions for its prevention and control.

Objectives:

This study aimed to determine the pattern of noma and its risk factors in Northwestern Nigeria.

Materials and Methods:

It was a retrospective study that looked into cases of noma (cancrum oris) admitted into the Noma Children Hospital, Sokoto, Nigeria, between January 1999 and December 2011. Information on patients’ bio-data, the site and severity of lesions, and presence of trismus and its severity were extracted from the patients’ case files and analyzed using descriptive statistics.

Results:

One hundred and fifty-nine (8.3%) of the 1923 patients admitted to the hospital from January 1999 to December 2011 were diagnosed with fresh noma. The mean age of the patients was 3.0 ± 1.4 years, and majority of them, 139 (87.4%) were aged 1–5 years. The soft-tissue lesions essentially involved multiple sites but most commonly the outer and inner cheeks (84.3%). The most common risk factors identified were measles (47.2%) and protein-energy malnutrition (42.1%). There were rises and falls in the prevalence of noma in the period studied.

Conclusion:

This study showed a high burden of noma in Northwestern Nigeria, mostly among children aged 1–5 years, and with soft-tissue lesions involving multiple sites. Measles and malnutrition were the major risk factors identified, and the disease trend showed a wave-like pattern. There is an urgent need to eliminate the disease in Nigeria through prevention and control of infectious diseases and malnutrition.

Noma in a boy with septic shock: a case report

Background

Noma is a rare disease, which is characterized by rapid progression and a high rate of mortality; however, relatively few cases of noma infection accompanied by septic shock in children have been described. Further, most health care professionals have no knowledge of this disease or of its clinical significance.

Case presentation

Herein, we present a case report of a six-year-old male patient who was diagnosed with noma infection at a Chinese pediatric medical intensive care unit (PMICU), at which time, it was discovered that he had septic shock. Following treatment by continuous renal replacement therapy (CRRT) for septic shock arising from noma, the patient was in generally good condition, and the local wound was seen to be essentially healed five weeks post-admission.

Conclusion

Noma is an opportunistic infectious disease condition. Treatment of the acute phase of noma predominantly focuses on controlling the infection and improving systemic conditions. In addition, CRRT could be considered as a treatment option for cases that present with noma accompanied by septic shock.

Management of noma: practice competence and knowledge among healthcare workers in a rural district of Zambia

Background: Noma is an infectious but opportunistic disease that often results in severe facial disfigurements and mortality if untreated. As noma progresses quickly, early detection and treatment are important to prevent its development.

Objectives: The objective of this study was to investigate primary healthcare workers’ knowledge and management of noma in a rural part of Zambia.

Methods: A cross-sectional self-completed survey was conducted among 35 healthcare workers from two district hospitals and 15 rural health centres in Serenje District, Zambia. Participants’ practice competences and knowledge were grouped into ‘optimal’, ‘medium’, ‘suboptimal’ and ‘very low’.

Results: Most of the healthcare workers stated that they perform mouth examination of a child below five years of age who is suffering from measles, malnutrition or HIV. A majority diagnosed gingivitis correctly and 40% had a medium level of practice competence of the same noma stage. All participants had a suboptimal or very low level on overall practice competence regarding management of noma and two-thirds had a very low level of reported knowledge.

Conclusion: General knowledge on noma and competences of diagnosing and treating noma patients was low among healthcare workers. Lack of knowledge could present a barrier for correctly managing noma at an early stage. Improving knowledge among healthcare workers is one way to prevent the development of the disease. In order to prevent noma from the start, actions need to be focussed on improving (oral) hygiene and health education as well. Telemedicine could also be considered as it can help healthcare workers in handling noma patients through enabling communication and exchange of information with specialist.

Risk factors for diagnosed noma in northwest Nigeria: A case-control study, 2017

Background

Noma (cancrum oris), a neglected tropical disease, rapidly disintegrates the hard and soft tissue of the face and leads to severe disfiguration and high mortality. The disease is poorly understood. We aimed to estimate risk factors for diagnosed noma to better guide existing prevention and treatment strategies using a case-control study design.

Methods

Cases were patients admitted between May 2015 and June 2016, who were under 15 years of age at reported onset of the disease. Controls were individuals matched to cases by village, age and sex. Caretakers answered the questionnaires. Risk factors for diagnosed noma were estimated by calculating unadjusted and adjusted odds ratios (ORs) and respective 95% confidence intervals (CI) using conditional logistic regression.

Findings

We included 74 cases and 222 controls (both median age 5 (IQR 3, 15)). Five cases (6.5%) and 36 (16.2%) controls had a vaccination card (p = 0.03). Vaccination coverage for polio and measles was below 7% in both groups. The two main reported water sources were a bore hole in the village (cases n = 27, 35.1%; controls n = 63, 28.4%; p = 0.08), and a well in the compound (cases n = 24, 31.2%; controls n = 102, 45.9%; p = 0.08). The adjusted analysis identified potential risk and protective factors for diagnosed noma which need further exploration. These include the potential risk factor of the child being fed pap every day (OR 9.8; CI 1.5, 62.7); and potential protective factors including the mother being the primary caretaker (OR 0.08; CI 0.01, 0.5); the caretaker being married (OR 0.006; CI 0.0006, 0.5) and colostrum being given to the baby (OR 0.4; CI 0.09, 2.09).

Interpretation

This study suggests that social conditions and infant feeding practices are potentially associated with being a diagnosed noma case in northwest Nigeria; these findings warrant further investigation into these factors.

Noma or cancrum oris is an orofacial gangrene that rapidly disintegrates the hard and soft tissue of the face. Little is known about noma as most cases live in underserved, difficult to reach locations. There is a dearth of literature on the risk factors for the development of noma. Médecins Sans Frontières (MSF) in collaboration with the Nigerian Ministry of Health runs projects at the Noma Children’s Hospital in Sokoto. A case control study was conducted in northwest Nigeria to explore exposures associated with diagnosed noma using unadjusted and adjusted conditional logistic regression models. Potential risk and protective factors for diagnosed noma were identified and these findings need further exploration. The study identified that feeding pap to the child every day was a potential risk factor for diagnosed noma (possibly a proxy for poor variety in the diet). The following potential protective factors for diagnosed noma were identified: the mother being the primary caretaker, the caretaker being married, and colostrum being given to the baby. Noma is a neglected disease, and current risk factors suggest that intervention efforts could be more effective by focussing on access to health care, the benefits of breastfeeding and a varied diet. However, more research is needed in order to better understand the pathogenesis of this disease in order to improve prevention, early detection and treatment.

Acute necrotising gingivitis in young children from villages with and without noma in Niger and its association with sociodemographic factors, nutritional status and oral hygiene practices: results of a population-based survey

Background

Previous studies have suggested that acute necrotising gingivitis precedes noma disease and that noma clusters in some villages in certain regions of low- and middle-income countries. We sought to assess the prevalence of gingivitis with bleeding in young children from villages with or without a history of noma and to analyse epidemiological differences related to sociodemographic characteristics, nutritional status and oral hygiene practices.

Methods

We conducted a cross-sectional study in 440 children aged between 2 and 6 years from four villages in the Zinder region of southeast Niger in Africa. In two villages, cases of noma have repeatedly been detected; in the other two, noma has never been identified. We randomly selected 110 participants from each village.

Results

The prevalence of acute necrotising gingivitis was significantly higher in the noma villages compared with the non-noma villages (6.8% vs 0.9%; p=0.001). We found differences between the four villages regarding socioeconomic factors, stunting, undernourishment and oral hygiene practices. The type of oral hygiene procedures influenced the amount of dental plaque and gingival inflammation. Children using sand, coal or other abrasive products instead of a toothbrush had a significantly increased likelihood to be diagnosed with acute necrotising gingivitis (p=0.041).

Conclusions

Our data suggest that efforts to prevent noma should focus on populations with a high prevalence of acute necrotising gingivitis and include nutritional support and attempts to introduce safe and efficient oral hygiene practices to improve gingival health.

Noma: Overview of a Neglected Disease and Human Rights Violation

Noma is an orofacial gangrene affecting malnourished children and mainly observed in tropical countries, particularly sub-Saharan Africa. Epidemiological data on noma are scarce, but a current estimate of the global incidence is 30,000-40,000 cases per year, with a mortality rate of approximately 85% and a burden of disease calculated to be a loss of 1-10 million disability-adjusted life years. The etiology of noma is multifactorial with malnutrition as an ever present factor, often in combination with concomitant diseases, such as measles, malaria, and human immunodeficiency virus (HIV), and poor oral hygiene. The pathogenesis is a fast-spreading, noncontagious gangrenous infection occurring in the face, often preceded by acute necrotizing gingivitis, and stomatitis. Rare microbiological studies suggest an opportunistic infection caused by an imbalance in normal intraoral microorganisms. Prevention lies in food security, measles vaccination, prevention of malaria and HIV, including the early detection and treatment of necrotizing gingivitis and stomatitis. Early treatment with antibiotics may prevent gangrene or reduce its extent. Late treatment consists of surgical rehabilitation, which is often complex. However, access to medical care is very limited for noma patients due to the extremely poor conditions in which they live that are frequently located in remote rural areas. The authors support the United Nations Human Rights Council Resolution 19/7 adopted on March 22, 2012 "The right to food," and advocate for the inclusion of noma on the list of neglected tropical diseases to encourage more medical and institutional attention for this often lethal or very mutilating infectious gangrene.

Facial bone reconstruction with prefabricated vascularized calvarium flaps in children and young adults: Advantages and long-term results

INTRODUCTION

Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps.

METHODS

Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect.

RESULTS

Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child.

CONCLUSIONS

Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children.

Bony fusion of the maxilla and mandible as a sequelae of noma: A rare case report

Noma is a gangrenous disease of the orofacial region that leads to severe facial tissue destruction and is a significant cause of death among children. With the advent of modern antibiotics and improved nutrition, children with noma may survive into adulthood, but must face the challenge of undergoing repair of the sequelae of noma. This report describes a case of bony fusion of the maxilla and mandible in a 28-year-old female patient, which was a sequelae of a childhood case of noma.

[Noma]

Noma is a necrotizing ulcerative stomatitis known since Antiquity. It occurs mostly in poor countries, the Sahel countries being the most affected. Each year, several hundred thousand cases are reported. Noma affects especially malnourished children who are less than 6 years old and rarely adults with acquired immunodeficiency (HIV, cancer). Ulcerative lesion is occurring rapidly due to the production of endotoxins by bacteria from oral commensal, telluric and animal origin. Necrotic debridement leads to huge defects: loss of soft tissue (skin, nerves, vessels, eye), bone (maxilla, mandible) and teeth. Death occurs rapidly in a few weeks in 80 % of the cases. In case of survival, the consequences are functional, aesthetic, psychological and social. The goal of the treatment in the acute phase is the patient's survival and the fight against limited mouth opening. The management of the phase of sequela is an anaesthetic, surgical and physiotherapy challenge. Its purpose is the social reintegration of the patient.

A Review on Noma: A Recent Update

Noma is a gangrenous infection primarily affecting under developed countries. The aim of this paper was to review all recent articles on noma from January 2003 to August 2014 and briefly update the latest information related to the topic. A literature search was done on PUBMED using the keywords “noma / cancrum oris”. Noma is commonly seen in malnourished children. There has been an increased incidence of noma in HIV patients. Apart from these, noma has also been reported in association with cyclic neutropenia, herpetic stomatitis, leukemia, Down's syndrome and Burkett's disease. Treatment of acute noma includes transfusion of blood and intravenous fluids, administration of antibiotics, putting the patient on a high protein diet and debridement of necrotic areas. Surgical phase is usually initiated 6 to 18 months after a period of quiescence. Although, the mortality rate associated with noma has reduced significantly with the advent of modern generation antibiotics, the functional, cosmetic and psychological challenges associated with the destruction of soft or hard tissues still remains a huge challenge. Adequate steps must be implemented by the government or medical professionals to prevent the disease and provide an early intervention.

Noma affected children from Niger have distinct oral microbial communities based on high-throughput sequencing of 16S rRNA gene fragments

We aim to understand the microbial ecology of noma (cancrum oris), a devastating ancient illness which causes severe facial disfigurement in>140,000 malnourished children every year. The cause of noma is still elusive. A chaotic mix of microbial infection, oral hygiene and weakened immune system likely contribute to the development of oral lesions. These lesions are a plausible entry point for unidentified microorganisms that trigger gangrenous facial infections. To catalog bacteria present in noma lesions and identify candidate noma-triggering organisms, we performed a cross-sectional sequencing study of 16S rRNA gene amplicons from sixty samples of gingival fluid from twelve healthy children, twelve children suffering from noma (lesion and healthy sites), and twelve children suffering from Acute Necrotizing Gingivitis (ANG) (lesion and healthy sites). Relative to healthy individuals, samples taken from lesions in diseased mouths were enriched with Spirochaetes and depleted for Proteobacteria. Samples taken from healthy sites of diseased mouths had proportions of Spirochaetes and Proteobacteria that were similar to healthy control individuals. Samples from noma mouths did not have a higher abundance of Fusobacterium, casting doubt on its role as a causative agent of noma. Microbial communities sampled from noma and ANG lesions were dominated by the same Prevotella intermedia OTU, which was much less abundant in healthy sites sampled from the same mouths. Multivariate analysis confirmed that bacterial communities in healthy and lesion sites were significantly different. Several OTUs in the Orders Erysipelotrichales, Clostridiales, Bacteroidales, and Spirochaetales were identified as indicators of noma, suggesting that one or more microbes within these Orders is associated with the development of noma lesions. Future studies should include longitudinal sampling of viral and microbial components of this community, before and early in noma lesion development.

Noma is a traumatic disease characterized by oral-facial lesions that often lead to severe disfigurement and ultimately shame and isolation from the community. Because the causes of noma are likely to be numerous, and reaching those who suffer from this illness is challenging, the etiology of noma remains ill-defined. Although it is known that oral hygiene and nutrition influence the development of noma, evidence suggests that one or more microbes play a crucial role in development of noma lesions. Previous studies have examined the DNA of microbes in lesions to determine which species are present and how their abundances differ between healthy mouth sites and noma lesions. These studies used techniques that were state-of-the-art at the time, though we know they likely only scratched the surface of the resident microbial diversity. Here we extend these studies by digging deeper to characterize a larger diversity of microbial species in noma and control samples, with the goal of better identifying which microbes are uniquely present or have altered abundances in noma lesions.

Noma and cervicofacial necrotizing fasciitis: clinicopathological differentiation and an illustrative case report of noma

Noma predominantly affects malnourished young children. The pathogenesis of noma is complex and multifactorial, involving interaction between local polybacterial infection on the one hand, and malnutrition, immunosuppression, or systemic bacterial or viral infections on the other hand. Noma is considered to be an opportunistic disease, but the immediate cause is uncertain. Immunosuppression associated with a high HIV load may be an important risk factor in South Africa. Cervicofacial necrotizing fasciitis, on the other hand, occurs mainly in adults. It is frequently a consequence of an odontogenic infection and is characterized by an irregular pattern of rapidly spreading necrosis of fascia, muscle, and skin. We present an unusual case of noma in a 32-year-old malnourished HIV-seropositive female with AIDS in whom, within a period of 3 days, the initial intraoral necrotizing process spread rapidly and caused circular full thickness perforating destruction of the lower lip. Prompt diagnosis and treatment brought about control of the active disease and limited the extension of the established noma and of progression of the disease at other affected oral sites.

Microarray analysis of microbiota of gingival lesions in noma patients

Noma (cancrum oris) is a gangrenous disease of unknown etiology affecting the maxillo-facial region of young children in extremely limited resource countries. In an attempt to better understand the microbiological events occurring during this disease, we used phylogenetic and low-density microarrays targeting the 16S rRNA gene to characterize the gingival flora of acute noma and acute necrotizing gingivitis (ANG) lesions, and compared them to healthy control subjects of the same geographical and social background. Our observations raise doubts about Fusobacterium necrophorum, a previously suspected causative agent of noma, as this species was not associated with noma lesions. Various oral pathogens were more abundant in noma lesions, notably Atopobium spp., Prevotella intermedia, Peptostreptococcus spp., Streptococcus pyogenes and Streptococcus anginosus. On the other hand, pathogens associated with periodontal diseases such as Aggregatibacter actinomycetemcomitans, Capnocytophaga spp., Porphyromonas spp. and Fusobacteriales were more abundant in healthy controls. Importantly, the overall loss of bacterial diversity observed in noma samples as well as its homology to that of ANG microbiota supports the hypothesis that ANG might be the immediate step preceding noma.