Training Programme onFluorosis Control Programme Presented By Dibyendu Dutta Consultant Fluorosis Control Programme BANKURA Mob. No- 8900336639
Fluorosis Control Programme : ImportanceImportance of this Programme in this Districti) Fluorosis is a crippled disease. It makes immobilized the patient day by day. Where as no exact mortality is found but its makes the people crippled and some cases painful. With out mobility people can not earn and life going unhealthy , stopped.ii) Fluorosis is a chronic disease. Its affect the people slowly and makespreliminary symptoms -> dental fluorosis -> skeletal fluorosis -> spinalcompression ->Crippled disorder. As it is due to make by slowly ingestionof fluoride(more then 1.5 PPM) in drinking water , its severity is verymuch higher.iii) Affected people : Bankura : 90,702. Affected Village: 205 Affected Habitaion: 1005 Affected Tube well: 778 Fluoride range: up to 12.69 ppm water.
Fluorosis Control Programme : Status of WestBengal
Fluorosis Control Programme : Status ofBankura 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
Fluorosis Control Programme : Magnitudeof the problem West Bengal are worst affected from fluorosis. In Bankura District Fluorosis Unit had already been find that : Water –fluoride level various from: 1.00 PPM – 12.69 PPM (Machatora,Simlapal) Patient Blood-fluoride level: Sujit Gulimajhi 22/M (Jamda,Simlapal)0.89 ppm Jenu Valgaum. Severe Dental Fluorosis. Joint Pain and Back Pain. Highest Urine fluoride level: Bulu Bedia ,Kamladanga 11.25 PPM . In all these States, the drinking water has high fluoride content but the informationabout the various food items and industrial emission having high fluoride level is not available. Permissible limit for fluoride, as per BIS, is 1 ppm in drinking water.
Fluorosis Control Programme : Magnitudeof the problem
Fluorosis Control Programme :Surveillance Methodology andPromotion of the FluorosisControl Programme
Assessment of the Problem Under the National Programme for Prevention and Control of Fluorosis, the district laboratory is established/ strengthened for confirmation of fluorosis cases, the district cell under district nodal officer is created, staffed with consultant and field investigators and funds are provided for mobility support for undertaking community based surveillance. The surveillance would also provide the database for impact assessment of the programme. The case definitions, sampling procedure and survey methodology are as under:(Dr. Pasha,National Consultant)
A : Case Definition Suspect Case: Dental Fluorosis: Any case with a history of residing in an endemic area along with one or both of the followings: Chalky white teeth yellow brown/dark brown bands
A : Case DefinitionSkeletal FluorosisAny case with a history of residing in an endemic area along with one or more of the following: Severe pain and stiffness in neck and back bone. (Patient has to turn the whole body towards that side to see) Severe pain and stiffness in joints. Severe pain and rigidity in the hip region ( pelvic girdle) Knock knee/ Bow leg Inability to squat Ugly gait and posture
A : Case DefinitionNon skeletal FluorosisAny case with a history of residing in anendemic area along with one or more ofthe followings Gastro - intestinal problems: Consistent abdominal pain, intermittent diarrhea/Constipation, blood in stool Neurological manifestations: Nervousness & depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinate frequently (Polydipsia and polyuria) Muscular manifestations: Muscle weakness & stiffness, pain in the muscle and loss of muscle power.
A : Case Definition Confirmed Case: Any suspect case with one or more of the followings: Any suspect case with high level of fluoride in urine (>1ppm). Any suspect case with interossius membrane calcification in the fore arm confirmed by X-ray.
B - Sampling procedure The information on fluorosis endemic areas along with fluoride level in the drinking water sources is to be obtained from Public Health Engineering Department (PHED) of respective endemic states. Fluoride level in all the drinking water sources is to be estimated by PHED. Based on the level of fluoride content, the villages will be stratified in the following 3 strata as under: Strata Fluoride Level I 1 - 3 ppm II 3.1 – 5 ppm III > 5 ppm
Sampling procedure For prevalence of fluorosis cases, 10% villages of each strata will be selected randomly. If number of villages is up to 20, then all the villages will be surveyed. If number of villages is more than 20, then 10% of villages from each strata (at least 20 villages in total) will be surveyed. All the children in the age group of 6 to 11 years from the primary school (3rd to 5th standard) in the selected villages of the district will be surveyed for prevalence of dental fluorosis. Survey for skeletal and non-skeletal fluorosis cases would also be carried out in 20 households of randomly selected villages of the district where dental fluorosis is prevalent in school children.
C - Survey Methodology Details of survey for dental fluorosis in school children will be collected on predesigned proforma and for skeletal and non-skeletal fluorosis cases in villages would be conducted by trained investigators. The information on demographic profile, dietary intake, drinking water source and clinical manifestations of fluorosis in the suspected member (s) of the family will be collected in the predesigned format. Urine samples from fluorosis suspected cases will be collected for confirmation. The suspected cases would be confirmed for interossius membrane calcification in the fore arm by X-ray and fluoride level in urine (>1ppm).
Survey MethodologyAnalysis of urine sample Sample Collection: 15 ml of spot urine sample of the suspected cases will be collected in 25ml of plastic screw capped bottles. Put 1 - 2 drops of toluene on urine samples to make a complete layer as preservative. Each sample should be properly labeled with number and relevant details.
Survey Methodology Transportation of samples: Urine samples should be sent to district laboratory within a weeks time. Samples can be kept at room temperature at district laboratory if not being analyzed immediately. *Report should be sent to State Nodal officer on the predesigned Performa with a copy to Adviser (Nutrition), DGHS, New Delhi (Dr. Pasha,National Consultant)
Guidelines for TrainingTraining in a programme is a key step for its successfulimplementation.A pool of trainers will be generated at state/ district levelto provide training of different category of health careproviders at different level.1. Training of Trainers2. Medical Officer3. Laboratory Technicians4. Paramedical5. Training of Health Workers, ASHA and AWWs6. Policy makers &7. Advocacy PRIs & VHSC& Teachers
Guidelines for Comprehensive Management of Fluorosis Cases Guidelines for Comprehensive Management of Flurosis Cases are: Early Detection & Prompt Intervention
Comprehensive ManagementEarly Detection:- It includes physical and radiological examination. During physical examination the cases are to be identified as suspected cases and confirmed cases. The symptoms of the suspected cases are as follows:- Dental changes – chalky white tooth with mottled appearance Pain & stiffness of peripheral joints Deformities of lower limb The confirmation of the cases shall be undertaken by following methods: Physical examination Radiological examination X-ray of forearm (AP view) X-ray of most affected part (AP & lateral views) Laboratory tests Urine analysis for fluoride level Blood analysis for fluoride level Analysis of drinking water for fluoride level
Comprehensive Management Prompt Intervention The Prompt Intervention is to be planned in the following manner: Health education Preventive measures Treatment Rehabilitation
Media Plan for Prevention and Control of Fluorosis The IEC Plan covering awareness generation and to bring behavioural communication changes at the community level in affected districts are very important in order to prevent and control fluorosis in the community. For this there is a need: to educate community about adverse health effects of drinking water with high level of fluoride, to educate the community about the safe drinking water sources in their habitation and rain water harvesting measures to be adopted. to educate about the benefits of Nutritional interventions. The district level media team would be entrusted with the job of advocating with the various functionaries of the district including community level workers namely, ASHA, AWW, school teachers, Panchayats, etc.
IEC Plan for Preventionand Control of Fluorosis
Do’s and Don’ts in relation to Nutritionintervention in fluorosis Do’s Don’ts Calcium rich food Black tea Milk, Milk products Black/Rock salt Green leafy vegetable Tobacco Supari Fluoridated tooth paste Vitamin C rich food Citrus fruits Green leafy vegetables Iron rich food Green leafy vegetables Guava, Banana, Brinjal
Programme Stacture and its Overview (NPPCF, Bnakura) The Adviser (Nutrition) The District Consultant MH&FW.New Delhi.India (NPPCF.Bankura) The National Consultant(NPPCF) The District Lab Tech (NPPCF) The DHS SH&FW. W.B. Field Workers The Add. DHS(PH&CD) (NPPCF) SH&FW. Swasthya Bhaban. Kol-91. W.B. The Dy.DHS(PH&CD) and The ADHS(MPHWS) & SPO (NPPCF)Swasthya Bhaban. Kol-91. W.B. The CMOH and District Programme Officer. (NPPCF) The Dy. CMOH-II and District Nodal Officer(NPPCF)
Performance and duties done by District Fluorosis ControlUnit.Bankura. • Successful implementation of this National Programme • Monitoring the programme by consulting all its The District Consultant Stake-Holders/Concern Persons under direct control of District Programme officers/District Nodal Officers. • Management and safe operating of Lab. Instrument. The District Lab Tech • Make ready report , Testing of Collected sample and as necessary he should also visit the endemic village for blood collection under supervision of his consultant and direct control od district officers. • Field Survey , sample collection and make ready report. • Make data-entry of patient line listing (As per state Field Investigators needed) • This National Programme will be successful if all district programme holders wants.
Promotion of the Programme1. Involvement should be made of Block level2. BPHN/PHN supervise the screening of fluorosis cases and collection of sample made by ANM staffs and ASHA at grass-root level.3. Sample should be sent to District Lab. for testing.4. Block Data Entry Operator should Collect the data / report and make compile report to sent at District.5. District should compile the report from blocks and sent to state authority. And also arrange screening camp + Sample collection + Drug Distribution + IEC Camp etc.6. District fluorosis unit also maintain the overall programme under direct control of District Programme Officer and District Nodal Officer7. District Programme Officer and District Nodal Officer supervise the all programme.
Table of Content: PART-A1. Current Status of Fluorosis in World View2. Current Status of fluorosis in India3. Current Status of Fluorosis in West Bengal4. Current Status of Fluorosis in Bankura. 4.1 Data Sheet of fluorosis endemicity 4.2 GIS Mapping of fluorosis endemic Block5. Availability of fluoride-free water scheme by Districtadministration6. Programme Overview (NPPCF, Bnakura)7.Performance and duties done by District Fluorosis ControlUnit.Bankura.
1. Current Status of Fluorosis in World ViewFluorosis is public health problem in 25 countries around the world.(DARKAREAS)
2. Current Status of fluorosis in India Jammu & Kashmir 7 No of affected Himachal Pradesh Arunachal District 204 (21 Punjab Delhi Pradesh States /UT) 82 Haryana 31 63 Rajastha Sikkim n Uttar Pradesh 22 Assam Nagaland people affected, 62 Bihar 9 100.0 Gujarat 15 Manipur Tripura Mizoram million ( 6 million Madhya Pradesh children) 95 36 West Bengal Orissa 22 Maharashtra 31 56 70-100 % Districts affected Causative factor, Andhra Pradesh 40-70 % Districts affected excess consumption Karnataka 70 67 10-40 % Districts affected of fluoride through <10% Districts affected drinking water Tamil Nadu Endemicity not known (>1.0ppm) and diet. 28 Kerala Andaman 21 Nicobar Source:A Treatise on Fluorosis by Dr. A.K. Susheela
endemicity 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 (Approx) (Approx) Affected. 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
Bnakura) The Adviser (Nutrition) The District Consultant MH&FW.New Delhi.India (NPPCF.Bankura) I The National Consultant(NPPCF) The District Lab Tech (NPPCF) The DHS SH&FW. W.B. Field Workers The Add. (NPPCF) DHS(PH&CD) SH&FW. Swasthya Bhaban. Kol-91. W.B. The ADHS(MPHWS) & SPO (NPPCF)Swasthy a Bhaban. Kol-91. W.B. The CMOH and District Programme Officer. (NPPCF) The Dy. CMOH- II and District Nodal Officer(NPPCF)
7.Performance and duties done by District Fluorosis ControlUnit.Bankura. • Successful implementation of this National Programme • Monitoring the programme by consulting all its The District Consultant Stake-Holders/Concern Persons under direct control of District Programme officers/District Nodal Officers. • Management and safe operating of Lab. Instrument. The District Lab Tech • Make ready report , Testing of Collected sample and as necessary he should also visit the endemic village for blood collection under supervision of his consultant and direct control od district officers. • Field Survey , sample collection and make ready report. • Make data-entry of patient line listing (As per state Field Investigators needed) • This National Programme will be successful if all district programme holders wants.
Table of Content: PART - B1. Fluorosis and fluoride 1.1 Fluoride 1.2 Pathophysiology of Fluorosis2. Dental fluorosis3. Skeletal Fluorosis4. Non-Skeletal Manifestation5. Laboratory Support6. Prevention and Control Measure7. Roll of PHED & DH&FWS. Bankura5. Current Research on fluorosis
Ingestion of fluoride causes decrease in ionised calcium. This hypocalcemia leads to changes in internal milieu of the body to maintain the calcium levels and leads to secondary hyperparathyroidism. The increased parathyroid hormone causes increased activity of Osteoclasts in bone by activating membrane bound 35 Cyclic AMP. This increased osteoclastic activity causes, increases in citric acid and lactic acid release from ruffled border of osteoclasts. This causes increase in hydrogen ion concentration, and hence lysis of lysosomes. Release of lysosomal enzymes viz. acid protease, collagenase, hyaluronic acid in bone and other tissues of the body which catalyzes the reactions favoring the depolymerization of the glycoprotein of bone and of cartilage. This causes breakdown of hydroxyproline, which is responsible for stabilization of collagen triple helix. As the protein polymer desegregates and dissolves, the mineral-binding capacity is also reduced and calcium is liberated, which helps in maintaining the serum calcium level. As a result the solubility of hydroxyappetite crystals also increases, causing its breakdown along with reduced laying down of collagen by reducing Hydroxylation of proline and lysine. This event simultaneously led to the elevation of the serum mucoprotein or polysaccharide levels. The net result of degradation of ground substance in, bones and other calcified tissues like teeth leads to symptoms of Fluorosis like, delayed eruption of teeth, dental Fluorosis, clinical Fluorosis, premature aging etc
Dental fluorosisNormal:The enamel surface is smooth, glossyand usually a pale creamy white incolor.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.
Types of skeletal fluorosis - IGenu valgum (KNOCK KNEES)Legs are bowed inwards in the standingposition. The bowing usually occurs ator around the knee, and when standingwith knees together, the feet are farapart.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 - IIKyphosis: – Forward bending of spine.Fixed and rigid thoracic cage as well asspinal cord compression occur Anterioposterior bowing of tibia
Types of skeletal fluorosis - IIIParaplegia: Spinal cordcompression due toosteosclerosis withparaplegia as a resultof endemic skeletalfluorosis
NON SKELETAL MANIFESTATIONS Tingling sensation in fingers and toes Excessive thirst Polydypsia and polyurea Nervousness & Depression
Table of Content: PART - C1. Diagramatic view of Programme holder. NPPCF2.Work Structure of National Programme for Prevention andControl of Fluorosis 2.1 District level planning of programme outlet. 2.2 Duties of Block Medical Officer of Health at District(BMOH) 2.3 Duties of Block Public Health Nurse(BPHN) 2.4 Duties of Supervisor at Gram Panchyaet Level. 2.5 Importance of ASHA at next phase of theprogramme.