NATIONAL PROGRAMMEFOR PREVENTION AND CONTROL OF FLUOROSIS Dr. Jagannath Dinda The Chief Medical Officer of Health . Bankura Govt. of West Bengal Mob No-
FLUOROSIS: INTRODUCTION A N E W P U B L I C H E A LT H PROBLEM FLUOROSIS IN IMMAGE Fluorosis is a slow, progressive and crippling malady affecting most of the organs in the body where flouride in drinking water is > 1.0ppm. More than 90% of rural drinking water supply programmes are based on ground water available, which is being overexploited for agriculture, causing a high influx of fluoride into water. Endemic fluorosis has been steadily increasing ever since the disease was discovered in India during the 1930s . In West Bengal Birbhum , Bankura, Purulia are grossly effected.
Fluorosis : An endemic burdenWorld Wide Magnitude of the problem 25 countries around the world.(DARK AREAS) A crippling Disease 1. Slow –Progressive Cripple 2. Affect all aged person. 3. Health Complain-Overlapping many disease 4. Impact depends on a. Age b. Hormonal Status c. Nutritional Status d. Efficiency of Kidney 3
Problem in India No of affected District 204 (21 States /UT) Jammu & Kashmir 7 Himachal Pradesh people affected, 62 Arunachal Punjab Delhi Pradesh million ( 6 million 82 Haryana 31 children) 63 Rajastha Sikkim Uttar Pradesh Assam Nagaland n 22 Bihar 9 Manipur Causative factor, 100.0 Gujarat 15 Tripura Mizoram excess consumption Madhya Pradesh 95 36 West Bengal of fluoride through Orissa 22 Maharashtra 56 drinking water 31 70-100 % Districts affected (>1.0ppm) and diet. Andhra Pradesh 40-70 % Districts affected Karnataka 67 70 10-40 % Districts affected BIS- Burro of Indian <10% Districts affected Standard Tamil Nadu Endemicity not known BIS= Permissible Limit of Kerala 28 Andaman Fluoride: 1.5 mg/L or PPM 21 Nicobar Source:A Treatise on Fluorosis by Dr. A.K. Susheela
Fluorosis : An endemic burden inWest Bengal Scenario in W.B: 45 Blocks in District Total People affected: 2.20 Lakhs In West Bengal Malda, Birbhum, Bankura, Purulia and South 24 Paraganas,Malda are affected. Of them Purulia, Bankura, Birbhum & Daxin Dinajpur are worst affected.
PREAMBLE Persons suffers from Fluorosis in India : 6 Million (Dr. Raja Reddy , NIN , Hyderabad) Persons suffers from Fluorosis in West Bengal: 2.20 Lakh Persons Suffers from Fluorosis in Bankura: 90,742 Current Status of Fluorosis In Bankura District Affected Pop. Affected Pop. Affected Vill.Tot. Blocks Tot. Village in Bankura Habitation Habitation Affected. (Approx) (Approx) Tot. Pop. Tot. Pop. Affected Affected Block Pop. Pop. Tot. 22 31,92,695 15 20,21,341 90,742 3832 31,92,695 271 90,742 7778 1005 90,742
PREVALANCE IN BANKURAMost affected groups are:Age Group between 4-11 and > 40 aged people.Dental Fluorosis Present in Age group 4-11Dental and Skeletal Fluorosis Present in agegroup >40In children mainly Dental Fluorosis arepresent
Clinical symptomsInitial symptoms : Headache, constipation, vague body pains, backache, joint rigidity & general weakness.These were followed by multiple joint pains, mostly in the feet, knees, and back.Difficulty in walkingLimitation of joint movement. Inability to close the fistSpinal stiffness and kyphosis developed in a few patients.Flexion of spineNeurological complication
Types of Fluorosis Dental Skeletal Non skeletal
Dental fluorosisNormal:The enamel surface is smooth,glossy and usually a pale creamywhite in color.Mild: The white opacity of theenamel of the teeth is moreextensive, but covers less than50% of the tooth surface .
Moderate:The enamel surface of the teethshows marked wear and tear with brown stainand is frequently a disfiguring feature .Severe: The enamel surface is badlyaffected and hypoplasia is so marked thatthe general form of the tooth may beaffected. There are pitted/worn out areasand widespread brownish discolorationwith the teeth often having a corrodedappearance.
COIN TEST: The subject isasked to lift a coin from the floorwithout bending the knee. Afluorotic subject would not beable to lift the coin without flexingthe large joints of lower extremity CHIN TEST: The subject is asked to touch the chin with the chest. A fluorotic subject would not be able to do so, if there is pain or stiffness in the neck.
STRETCH TEST: The individual is made to stretch the arms sideways, fold the arm and try to touch the back of the head. If there is pain or stiffness in the shoulder joint and backbone, the exercise will be difficult, suggesting possibility of fluorosis Confirmation with X-rayOssified Interosseous Membrane
Types of skeletal fluorosis - I Genu valgum, Genu varum, Anterioposterior bowing of tibia (Saber tibia), Scoliosis, Paraplegia are severe forms of skeletal fluorosis
RECENT NIN STUDY CONDUCTED IN BIHAR CHILDREN OF 2-3 YEAR WERE AFFECTED WITH SEVER FORMS OF CRIPPLING BONE DEFORMITIESChildren affected from fluorosis
Types of skeletal fluorosis - IIGenu valgum (KNOCK KNEES) Legs are bowed inwards in thestanding position. The bowing usuallyoccurs at or around the knee, andwhen standing with knees together,the feet are far apart.Genu VarumLegs are bowed outwards in thestanding position. The bowingusually occurs at or around theknee. When standing with the feettogether, the knees remains farapart.
Types of skeletal fluorosis - IIIKyphosis: – Forward bending of spine.Fixed and rigid thoracic cage as well asspinal cord compression occur Anterioposterior bowing of tibia
Types of skeletal fluorosis - IVParaplegia: Spinalcord compression dueto osteosclerosis withparaplegia as a resultof endemic skeletalfluorosis
NON SKELETAL MANIFESTATIONS Tingling sensation in fingers and toes Excessive thirst Polydypsia and polyurea Nervousness & Depression
INTERVENTION1.Safe Water Supply bellow<1.5 mg/L2. Domestic Filter3. Small defluoridation Plant4. Nutrition and Proper Diet5. Supplementary Medicine vit- C vit- D Ca Antioxident6. Clinical Interventiona. Screeningb.Diagnostic Testc.Identificationd.Surgery and Medication
INTERVENTIONProper Nutrition and Diet1. Green Vegetable should be taken large amount in a day.2. Carrot and Tomato are the main source of antioxidant .3. Milk and Small –fish are the rich source of Calcium.Avoid Fluoride containt food, Cosmetics and tooth-pest.
ROLE OF P.H.E.D1.Surface Water Utilization for Drinking2.Aluminum Sulfate Filter Distribution3.Long Term Water Plant , based on Surface Water4.Rain water HarvestingMore Over Distribution of Pure Fluoridefree water supply
ROLE OF DISTRICT HEALTH AND FAMILYWELLFARE SAMITY(DH&FWS)Survey1. At least 20 House Hold survey for identification of Dental as well as skeletal fluorosis2. School Survey for identification of Dental Fluorosis among school children.Screening and Symptomatic IdentificationDiagnostic Test1. Water- Fluoride 2. Urine-fluoride 3. Blood-fluoride* Medical Intervention by Surgery and Medication*Behavioral changes through IEC*Most of all Make People Awareness to come at nearest BPHC and PHC for primary Screening and Supplementary Medication*Possible referral services will be made to the Medical College and Hospital .
CO-OPERATION BETWEENHEALTH AND P.H.E.D*Identification and Treatment of Fluorosis Affected People*Provide them Pure fluoride free Water*Treatment of malnutrition*Surgery*Good Health promotion and Pure water*Sort and Long Term Measurement of water supply