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ENDEMIC FLUOROSIS & National Programme for prvention & control of

flurosis (राष्ट्रीय फ्लोरोसि�� प्रति�बंध व ति�यंत्रण काय�क्रम)

Presented by : DR Sachin Shekde (Taluka health officer dharur)

Guided by : DR Sangle sir ( DHO BEED) DR Wadgave sir ( DRCHO BEED)

DEPARTMENT OF PUBLIC HEALTH BEED

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INTRODUCTION• Fluorine is the 13th most abundant naturally occurring

element in the Earth’s crust. • It is the lightest member of the halogens. • It is the most electronegative and reactive of all the

elements and as a result, elemental fluorine does not occur in nature but found as a fluoride mineral complexes.

• Fluorine is more reactive than chlorine> bromine> iodine.

• Fluorine is essential for mineralization of bones & formation of dental enamels

• 96% of fluoride of body found in bones & teeth.

• Normally small amount of fluoride is required (0.5 to 0.8 mg/lit) in drinking water.

• Fluorine is often called as two-edged sword.

• Prolonged ingestion of fluoride through drinking water in excess of the daily requirement is associated with dental and skeletal Fluorosis.

• Similarly, inadequate intake of fluoride in drinking water is associated with dental caries.

• World Health Organization (WHO) has set the upper limit of fluoride concentration in drinking water at 1.5 mg/l .

• The Bureau of Indian Standards, has therefore, laid down Indian standards as 1 mg/l as maximum permissible limit of fluoride with further remarks as “lesser the better” .

Permissible limit of fluoride in drinking waterName of organisation Desirable limit (mg/L)

Bureau of Indian Standards (BIS) 1.0

Indian Council of Medical Research (ICMR) 1.0

The Committee on Public Health Engineering Manual and Code of

Practice, Government of India 1.0

World Health Organization (International Standards for

Drinking Water) 1.5

What is Fluorosis ?• Fluorosis, a public health problem is caused by

excess intake of fluoride through drinking water/food products/industrial emission over a long period resulting permanent and irreversible damages.

• The duration for the clinical manifestation to appear varies depending on various factors like age, nutritional status, quantity of fluoride ingested, efficiency of kidney to excrete fluoride.

WORLDWIDE DISTRIBUTION

• Worldwide in distribution.• Endemic in 22 countries. • Asia and in Asia,India and China are worst

affected.• Mexico in North and Argentina in Latin

America.• East and North Africa are also endemic.

• Fluorosis is an important public health problem in

24 countries, including India, which lies in the

geographical fluoride belt that extends from Turkey

to China and Japan through Iraq, Iran and

Afghanistan .

• Of the 85 million tons of fluoride deposits on the

earth’s crust, 12 million are found in India . Hence

it is natural that fluoride contamination is

widespread, intensive and alarming in India.

UNICEF Map of Fluorosis

FLUOROSIS IN INDIA

• Endemic fluorosis is prevalent in India since 1937 .

• It has been estimated that the total population

consuming drinking water containing elevated levels of fluoride is over 66 million .

• Endemic fluorosis resulting from high fluoride concentration in groundwater is a public health problem in India .

• The available data suggest that 15 States in India are endemic for fluorosis (fluoride level in drinking water >1.5 (mg/l) .

• about 62 million people in India suffer from dental, skeletal and non-skeletal fluorosis.

• Out of these; 6 million are children below

the age of 14 years .

Fluoride Levels in Indian States• Andhra Pradesh: 0.4 - 29.0 mg/L• Assam : 1.6 - 23.4 mg/L• Bihar: 0.2 - 8.32 mg/L• Chhattisgarh: information awaited• Delhi: 0.2 - 32.0 mg/L• Gujarat: 1.5 - 18.0 mg/L• Haryana: 0.2 - 48.32 mg/L• Jammu & Kashmir: 0.5 -4.21 mg/L• Jharkhand: 0.5 - 14.32 mg/L• Karnataka: 0.2 - 7.79 mg/L

Fluoride Levels in Indian States

• Kerala: 0.2 - 5.40 mg/L• Madhya Pradesh: 1.5 - 4.20 mg/L• Maharashtra: 0.11 - 10.00 mg/L• Orissa: 0.6 - 9.2 mg/L• Punjab: 0.4 - 42.0 mg/L• Rajasthan: 0.10 - 10.0 mg/L• Tamil Nadu: 0.1 - 7.0 mg/L• Uttaranchal: information awaited• Uttar Pradesh: 0.2 - 25.0 mg/L• West Bengal : 1.1 - 14.47 mg/L

Bhandara Chanderpur Buldhana Jalgaon Nagpur Akola Amravati Nanded Solapur Yavatmal

BEEDJALNALATURWASHIM

Maharashtra : The districts endemic for Fluorosis are:

Sources of Fluoride• Contaminated ground

water is the main source.

• Contaminated drinking & cooking water, agricultural & food products, drugs and industrial emissions & pollutants

• Primarily it is Fluoride which is present in

drinking water .• when F in water is more than 1.5 mg per litre,

it is toxic to health . • calcium in the diet reduces the absorption of F .

• Hard water rich in Calcium reduces the F toxicity .• Fresh Fruits and Vit.C reduces the effect of F .

AGENT FACTORS

• In School going children seen as dental

fluorosis.

• In third and fourth decade of life seen as

Skeletal Fluorosis.

• Males suffer more than females.

Host Factors

• High Annual Mean Temperature.

• Low Rainfall.

• Low humidity.

• F rich Natural subsoil rocks.

• Vegetables from high F belts.

• Fluoridated tooth paste particularly when

used by children.

• Tropical climate.

Environmental Factors

Types of Fluorosis

Dental Skeletal Non Skeletal

DENTAL FLUOROSIS• The teeth loose their shiny appearance and

chalk-white patches develop on them.This is the early sign of dental fluorosis.

• Later the white patches become yellow and sometimes brown or black.

• In severe cases, loss of enamel gives the teeth a corroded appearance. Mottling is best seen on the incisors of the upper jaw.

Classification/Degrees of Dental Fluorosis

Normal: Transluscent, smooth enamel with a glossy appearance.

Questionable: Seen in endemic areas, borderline between normal and very mild

Very mild: Small opaque, paper-white areas scattered irregularly over the labial and buccal surface of teeth.

Mild: Entire tooth surface involved, minute pitting often present on labial and buccal surfaces, brown surface, brown stains .

Moderate: Entire tooth surface involved, marked pitting with intense brown stain.

Severe: Widespread, deep brown or black areas, corrosion type of mottled enamel.

SKELETAL FLUOROSIS

• Associated with lifetime daily intake of 3.0 to 6.0 mg/l or more.

• It affects young as well as old.

• The symptoms include severe pain and stiffness in

the backbone, joints and/or rigidity in hip bones.

A VICTIM OF SKELETAL FLUOROSIS WITH STIFFNESS OF NECK AND SPINE

Skeletal Fluorosis

How to test pain in major joints (possibly Skeletal Fluorosis)

• COIN TEST: The subject is asked to lift a coin from the floor without bending the knee. A fluorotic subject would not be able to lift the coin without flexing the large joints of lower extremity.

• CHIN TEST: The subject is asked to touch the anterior wall of the chest with the chin. If there is pain or stiffness in the neck, it indicates the presence of fluorosis.

• STRETCH TEST: The individual is made to stretch the arm sideways fold at elbow and touch the back of the head. When there is pain and stiffness, it would not be possible to reach to the occiput indicating presence of Fluorosis.

Non Skeletal fluorosis

Neurological Manifestations

1. Nervousness & Depression

2. Tingling sensation in fingers and toes

3. Excessive thirst and tendency to urinate

Frequently ( Polydypsia and polyurea )

2. Muscular manifestations • Muscle Weakness & stiffness

• Pain in the muscle and loss of muscle power

3.Gastro-intestinal problems: • Consistent abdominal pain,

• intermittent diarrhea/Constipation,

• bloated feeling,

• nausea,

• loss of appetite.

Mitigation of Fluorosis • Closing contaminated water source• Arranging alternative safe water source• Flocculation, sedimentation, coagulation (with lime &

alum), filtration of drinking water before use• Health education, dietary counseling & nutrition• Dietary supplementation of calcium, vitamin C, D3 &

iron

Mitigation of Fluorosis

• Enhanced surveillance, early detection, proper treatment & rehabilitation.

• Rain & surface water harvesting for agriculture & household.

• Supply of pipeline river water from water treatment plant

Do’s & Don’ts in relation to Nutrition intervention in Fluorosis

Do’sCalcium rich food

MilkMilk Products

Green leafy vegetablesVitamin C rich food

Citrus fruitsIron rich food

Green leafy vegetablesBanana, Guava, Brinjal

Don’ts

Black Tea

Black/Rock salt

Tobacco

Supari

Fluoridated Tooth Paste

Fluoride Containing Items to be avoided

Treatment of Fluorosis

• Medical treatment: No specific treatment; supplementation with vitamin C & D, antioxidants, calcium & correction of malnutrition

• Treatment of deformities: Orthoses, surgical shoes, physiotherapy, reconstructive surgery .

Medical Management of Fluorosis

Early Detection

Physical Examinatio

n

Dental Changes, Pain & Stiffness

in Joints, Skeletal Deformities

Laboratory Tests

Urine & Water

analysis

Radiological Exam

X Ray Forearm / most

affected part

Prompt Intervention

Health Education Safe Drinking Water

Referral Services (Village to Dist

Linkages)

Medical Managemen

tImprove Quality of

LifeCa, Vit C,

Anti oxidents

T/t Malnutriti

onPhysiother

apy, Corrective

Plaster, Orthoses

NPPCF Programme Framework & Phasing

Year Districts Selected

2009-10 Chandrapur

Nanded

2010-11 Latur

Yavatmal Washim

2011-12 Beed2012-13 No New district & No funds2013-14

2014-15 NPPCF intended to include Nagpur,

Jalgaon, Jalna, Bhandara, Hingoli&Parbhani

GOAL OF NPPCF• Goal of National Programme for

Prevention and Control of Fluorosis (NPPCF):

To prevent and control fluorosis cases in the country.

Objectives of NPPCF• To collect & use baseline survey data of

fluorosis.

• Comprehensive management of fluorosis in

endemic areas.

• Capacity building for prevention, diagnosis &

management of fluorosis cases.

Strategies of NPPCF

• Capacity Building o Training of field level health personneloManpower Support

• Surveillance of Fluorosis in the community including schools.

o Resurvey after 3 months of intervention activities• Establishment of Diagnostic facilities in District

Hospitals & Medical Colleges

Activities under NPPCF at Community (Village Level Activities)

• Provisional community diagnosis by consultant with the help of Field investigator.

• Verification of Community Diagnosis by PHC Doctors.• Training about General Symptoms and preventive

management of MOs PHCs and Mukhya Sevika of ICDS.• Line listing of sources reduction activity, Reconstructive

Surgery Cases, Rehabilitative Intervention Activities,local action & referral.

• Appropriate IEC.• Inter-sectoral Co-operation.• Measures for prevention and health promotion.

Community Health Centre / FRU Level Activities

• Training for Clinical Examination and Management.

• Training of Block staff & ICDS staff.• Preliminary Diagnostic Parameters

Assessment.• Monitoring of Village / PHC Level Activities.• Referral.

District Level Activities

• Training of MO for Management of Cases.• Training of Dist staff, ICDS & Educational Personnel.• Fully Equipped Lab.• Diagnostic support for all kinds of Fluorosis.• Monitoring.• Basic medical, surgical & rehabilitative activities for

diagnosed cases by dist level specialist.• Referral of difficult cases to near by Medical College.

GUIDELINES FOR SURVEILLANCE OF

FLUROSIS IN A COMMUNITY

Guidelines for Surveillance

• Permissible limit of fluoride in drinking water: One mg. / liter or one ppm in drinking water as per Bureau of Indian Standard (BIS)

• The magnitude of Fluorosis problem in endemic area need to assessed based on appropriate surveillance-case definitions, adequate & proper sampling & survey methodology.

• District Laboratory established/strengthened for confirmation of Fluorosis cases.

• District Nodal Officer & Staff with Consultant & Field Investigators are to be created.

• Funds are provided for mobility support for undertaking community based surveillance.

CASE DEFINATION

1) Suspected Cases of Dental Fluorosis

Any case with a history of residing in an endemic area along with one/both of the followings-

• Chalky white teeth• Transverse yellow brown or dark brown bands

or spots on the enamel surface (Discoloration away from the gums & bilaterally symmetrical)

2) Suspected Cases of Skeletal Fluorosis

Any case with a history of residing in an endemic area along with one/more of the followings-

• Severe pain & stiffness in the neck & back bone (lumber region), shoulder, knee & hip region.

• Increased girth , thickening & density of bone by x - ray• Knock knee / Bow leg (In children, adolescents)• Inability to squat (Advanced stage)• Ugly gait & posture ( Advanced stage)

3) Suspected cases of Non – skeletal Fluorosis

Any case with a history of residing in an endemic area along with one/more of the followings-

• Gastro –intestinal problems: Consistent abdominal pain, intermittent diarrhoea /constipation, bloated feeling,nausea, loss of appetite

• Neurological manifestations: Nervousness & depression, tingling sensation in fingers & toes, polydypsia, polyurea

• Muscular manifestations: Muscle weakness & stiffness, pain in the muscle, loss of muscle power,unable to walk or work

Confirmation of Fluorosis

Any suspect case with one or both of the followings ;

• Any suspect case with high level of fluoride in urine (>1mg/L)

• Any suspect case with interosseius membrane calcification in the forearm confirmed by X-ray

Sampling ProcedureFluoride level is to be obtained from PHED. Fluoride level in all drinking water sources is to be estimated by

PHED. Villages will be stratified in the 3 strata.

Strata Fluoride Level I 1-3 ppm II 3.1-5 ppm III > 5 ppm

10% villages of each strata will be selected randomly (if villages in each stratum >20).

6 to 11 yrs.(Std 1-5) children will be surveyed for prevalence of dental Fluorosis.

Survey for Skeletal & Non Skeletal carried out in 20 household randomly selected villages where dental flurosis is prevalent in school children .

Survey Methodology

• SCHOOL SURVEY – This survey is for Dental Fluorosis (DF) & visible Bone deformities. (BD)

• COMMUNITY SURVEY - Survey for skeletal & non skeletal fluorosis cases would also be carried out in at least 20 households of each of the randomly selected villages of the district where DF is prevalent in school children.

Sample Collection

Transportation of Samples

Name of District No. of watersources tested

Fluoride contaminat

ed water sources

%

Nagpur 6822 812 11.90Chandrapur 10264 924 9.00

Nanded 5756 499 8.67Yaotmal 7107 471 6.63Hingoli 2699 139 5.15Beed 4282 116 2.71Jalna 2220 37 1.67

Washim 2104 23 1.09Jalgaon 2335 13 0.56

Bhandara 5899 25 0.42Latur 3591 8 0.22

Parbhani 2273 5 0.22

CHEMICAL CAMPAIGN – 1 Sept 2014 to 31 May 2015(State – 1,64,936/4049/2.45%)

Selection of Villages For Survey I SN District Strata I Strata II Strata III Total Villages to

be surveyed

Total Villages

Villages selected by survey

Total Villages

Villages selected by survey

Total Villages

Villages selected by survey

1 Chandrapur 353 35 18 2 6 6 377 43

2 Nanded 684 68 24 3 11 11 719 82

3 Latur 3 3 2 2 2 2 7 7*

4 Yavatmal 652 65 27 3 11 11 690 79

5 Washim 16 16 0 0 0 0 16 16*

6 Beed 92 9 21 8 3 3 116 20

Selection of Villages For Survey II SN District Strata I Strata II Strata III Total Villages to

be surveyed

Total Villages

Villages selected by survey

Total Villages

Villages selected by survey

Total Villages

Villages selected by survey

1 Jalgaon 11 11 0 0 0 0 11 11*

2 Nagpur 950 95 45 5 6 6 1001 106

3 Jalna 178 18 3 3 0 0 181 21

4 Bhandara 17 17 0 0 0 0 17 17*

5 Hingoli 122 12 45 5 26 3 193 20

6 Parbhani 5 5 0 0 0 0 5 5*

Expected Outcome

Monitoring

• Monthly • Quarterly & • Six monthly reports ( 15 April & 15 Oct)

In following format …

टी ओ टी

जि�ल्हा नोडल अधि�कारी

वैदयकीय अधि�कारी (प्रा आ कें द्र)

तालुका वैद्यकीय अधि�कारी

निनवासी वै अ (शालेय तपासणी)

वैदयकीय अधि�कारी (रुग्णालये)

शालेय आरोग्य तपासणी मोनिहमेतील वैदयकीय अधि�कारी

दंतरोग तज्ञ, नि,जि�शिशयन, अस्थि/रोगतज्ञ

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