Noma: the mask of poverty

Author(s) Angèle Gayet-Ageron1, Denise Baratti-Mayer2, Patrice François3, Brigitte Pittet-Cuenod 4, Alain Gervaix 5, Jacques Schrenzel6, Andrea Mombelli7, Didier Pittet8
Affiliation(s) 1Division of Clinical Epidemiology, University hospitals of Geneva, Geneva, Switzerland, 2Division of Plastic and Reconstructive Surgery, University hospitals of Geneva, Geneva, Switzerland, 3Genomic Research Laboratory and Clinical Microbiology Laboratory, University hospitals of Geneva, Geneva, Switzerland, 4Division of Plastic and Reconstructive Surgery, University hospitals of Geneva, Geneva, Switzerland, 5Department of Paediatrics, University hospitals of Geneva, Geneva, Switzerland, 6Department des laboratoires, University hospitals of Geneva, Geneva, Switzerland, 7Department of Periodontology and Oral Pathophysiology, School of Dental Medicine, University of Geneva Faculty of Medicine, Geneva, Switzerland, 8Direction médicale, University hospitals of Geneva, Geneva, Switzerland
Country - ies of focus Niger
Relevant to the conference tracks Infectious Diseases
Summary To the best of our knowledge, this study is the first to assess both epidemiological risk factors and microbiology with a case-control design. From a practical perspective, our data confirm the importance of pre-existing malnutrition and the role of poverty in children with noma. Our results showed no involvement of specific bacteria in the cause of the disease. Overall, these data suggest new areas of research and draw attention to potential new primary preventive strategies to be developed for the disease.
Background Noma is a poorly investigated disease affecting young children living in the most deprived regions of the world, particularly sub-Saharan Africa. The lesion originates in the mouth and extends rapidly to the face, often leading to death or severe disfigurement in a high proportion of children. Malnutrition and debilitating diseases, such as malaria or measles, have been recognized as possible risk factors, thus leading to the hypothesis that the aetiology could be bacterial. However, this hypothesis has never been assessed in a case-control study.
Objectives We aimed to identify the epidemiological and microbiological risk factors associated with noma disease.
Methodology We conducted a prospective, matched, case-control study in Niger to identify the epidemiological and microbiological risk factors for noma. All acute cases of noma in children less than 12 years were included and 4 controls were matched by age and village of residence for each child. Epidemiological data and biological samples were collected for both cases and controls. Conditional logistic regression models were used.
Results We included 82 cases and 327 controls between August 2001 and October 2006. Noma was independently associated with severe malnutrition, the presence of respiratory disease, diarrhoea or fever in the past three months, and social indicators of precarity. The microbiological analysis showed differences in the proportion of some oral bacteria (Fusobacterium, Capnocytophaga, Neisseria and Spirochaeta) between cases and controls, but no specific agent was clearly associated with noma.
Conclusion Noma is associated with severe malnutrition and oral bacterial imbalance. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity.

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