endemic flurosis

1. ENDEMIC FLUOROSIS &
National Programme for
prvention & control of flurosis
(राष्ट्रीय फ्लोरोसिि प्रतिबंध व तियंत्रण
काययक्रम)
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 1

2. 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.
2

3. • 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.

4. • 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.

5. • 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” .

6. Permissible limit of fluoride in drinking
water
Name 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

7. 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.

8. 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.

9. • 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.

10. UNICEF Map of Fluorosis

11. 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 .

12. • 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 .

13. 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

14. 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

15. Bhandara
Chanderpur
Buldhana
Jalgaon
Nagpur
Akola
Amravati
Nanded
Solapur
Yavatmal
BEED
JALNA
LATUR
WASHIM
Maharashtra : The districts
endemic for Fluorosis are:

16. Sources of Fluoride
• Contaminated ground
water is the main
source.
• Contaminated
drinking & cooking
water, agricultural &
food products, drugs
and industrial
emissions & pollutants

17. • 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

18. • 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

19. • 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

20. Types of Fluorosis
Dental Skeletal
Non
Skeletal

21. 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.

22. Classification/Degrees of Dental
Fluorosis
Normal: Transluscent, smooth enamel with
a glossy appearance.

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

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

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

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

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

29. 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.

30. A VICTIM OF SKELETAL FLUOROSIS
WITH STIFFNESS OF NECK AND SPINE

31. Skeletal Fluorosis

32. 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.

34. 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 )

35. 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.

36. 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

37. 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

38. Do’s & Don’ts in relation to Nutrition
intervention in Fluorosis
Do’s
Calcium rich food
Milk
Milk Products
Green leafy vegetables
Vitamin C rich food
Citrus fruits
Iron rich food
Green leafy vegetables
Banana, Guava, Brinjal
Don’ts
Black Tea
Black/Rock salt
Tobacco
Supari
Fluoridated Tooth Paste

39. Fluoride Containing Items to be
avoided

40. 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 .

41. Medical
Management of
Fluorosis
Early Detection
Physical Examination
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 Management
Improve Quality of
Life
Ca, Vit C, Anti
oxidents
T/t Malnutrition
Physiotherapy,
Corrective Plaster,
Orthoses

42. NPPCF Programme Framework & Phasing
Year Districts Selected
2009-10
 Chandrapur
 Nanded
2010-11
 Latur
 Yavatmal
 Washim
2011-12  Beed
2012-13
No New district & No funds
2013-14
2014-15
NPPCF intended to include Nagpur,
Jalgaon, Jalna, Bhandara,
Hingoli&Parbhani

43. GOAL OF NPPCF
• Goal of National Programme for
Prevention and Control of Fluorosis
(NPPCF):
To prevent and control fluorosis cases
in the country.

44. 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.

45. Strategies of NPPCF
• Capacity Building
oTraining of field level health personnel
oManpower 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

46. 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.

47. 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.

48. 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.

49. GUIDELINES FOR
SURVEILLANCE OF
FLUROSIS IN A
COMMUNITY

50. 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.

51. 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)

52. 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)

53. 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

54. 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

55. Sampling Procedure
Fluoride 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 .

56. 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.

57. Sample Collection

58. Transportation of Samples

59. Name of
District
No. of watersources tested
Fluoride
contaminat
ed water
sources
%
Nagpur 6822 812 11.90
Chandrapur 10264 924 9.00
Nanded 5756 499 8.67
Yaotmal 7107 471 6.63
Hingoli 2699 139 5.15
Beed 4282 116 2.71
Jalna 2220 37 1.67
Washim 2104 23 1.09
Jalgaon 2335 13 0.56
Bhandara 5899 25 0.42
Latur 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%)

60. 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

61. 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*

68. Expected Outcome

69. Monitoring
• Monthly
• Quarterly &
• Six monthly reports ( 15 April & 15 Oct)
In following format …

72. टी ओ टी
जिल्हा नोडल अधिकारी
वैदयकीय अधिकारी (प्रा आ कें द्र)
आरोग्य
सेवक,
आरोग्य
सेववका,
आरोग्य
सहायक,
पययवेक्षक इ
आशा
तालुका वैद्यकीय अधिकारी
एकाजमिक बाल
ववकास काययक्रि
अंतर्यत अंर्णवाडी
सेववका आणण
अंर्णवाडी
पययवेक्षक, आशा
सिन्वयक
शालेय शशक्षण
ववभार्ातील
र्टस्तरीय
अधिकारी,
िुख्याध्यापक इ.
ननवासी वै अ (शालेय तपासणी)
वैदयकीय अधिकारी
(रुग्णालये)
शालेय आरोग्य तपासणी
िोहहिेतील वैदयकीय
अधिकारी
दंतरोर् तज्ञ,
फिजिशशयन,
अजस्िरोर्तज्ञ

73. THANK YOU
Please Save water and Use it Appropriately for
us and our next generations

74. The woods are lovely, dark & deep
But I have promises to keep…
And miles to go before I sleep…!
--- Robert Frost.