A/HRC/19/73 40. First, malnutrition is considered to be the major predisposing factor for noma.89 Experts describe malnutrition as “mandatory” for noma to appear.90 The absence of noma cases in well-nourished African children associated with the occurrence of the illness in Nazi concentration camps where malnourishment was rampant strongly supports other evidence that malnutrition plays a significant role in the development of this disease. 91 In the words of Dr. Enwonwu et al, “the global distribution pattern of the disease reflects the worldwide distribution of malnutrition”. 92 41. Recent research is inquiring into the relevance of prenatal malnutrition for the contraction of noma by children. In several countries where noma has been documented, malnutrition is said to commence in utero as a consequence of the poor nutrition of the mother, which then results in intrauterine growth retardation and a baby with a low birthweight.93 In early postnatal life, and often extending through adolescence into adulthood, babies with a low birthweight suffer of chronic malnutrition and have a diminished resistance to infections. 94 These in turn are key contributing elements to the development of noma. Therefore, in the context of preventing noma, tackling malnutrition of babies, as well as mothers, is imperative. 42. Second, poor oral hygiene is necessary for noma to develop. Experts consider that noma is less likely to occur in malnourished children provided that oral care is undertaken regularly and thoroughly. 95 Preventive oral examinations and providing education to parents on good practices in respect to oral hygiene are key interventions to preventing noma in malnourished children. 43. Third, the weakening of the immune system due to malnutrition and infections, such as measles, malaria, tuberculosis and HIV, can contribute to the development of noma in children.96 44. Fourth, research has shown that a high bacterial load of normal micro-organisms from the mouth breaks the resistance of a failing immune system. 97 The present expert consensus is that acute necrotizing gingivitis is a precursor of noma.98 Previously Fusobacterium necrophorum and Prevotella intermedia were thought to be key players in this process in which components of the normal oral flora become pathogenic,99 but recent investigations conducted with more advanced technologies could not identify a specific bacteriological agent for noma.100 89 90 91 92 93 94 95 96 97 98 99 100 Ibid. Barmes, “The need for action”, p. 1111. Enwonwul, “Noma (cancrum oris)”, p. 151. Ibid. C.O. Enwonwu, “Ruminations on the causation of noma”, Stomatolgie, vol. 104, No. 1, 2007 pp. 43– 44. Ibid. Submission by MSF, November 2011. Bos, Surgical Treatment, p. 13. Fieger, “An estimation”, p. 402. Baratti-Mayer, “Noma: an „infectious‟ disease”, p. 421; P. Moynihan, P.E. Petersen, “Diet, Nutrition and the Prevention of Dental Diseases”, Public Health Nutrition, vol. 7, No. 1A, February 2004, p. 203. Neville, Oral and Maxillofacial Pathology, p. 201; see also Srour, “Noma in Laos”, p. 539. Paster, “Prevalent Bacterial Species”, pp. 2187–2191; I. Bolivar et al., “Bacterial diversity in oral samples of children in Niger with acute Noma, acute necrotizing gingivitis, and healthy controls”, submitted to the Journal of Clinical Microbiology. 15