Public Health Hazards by Fluoride & its Management Thanks to Dr. Passa Former NPPCF National Consultant India

1. Guidelines for Surveillance of
Fluorosis in a Community
Dr Pasa
National Consultant
NPPCF INDIA

2. Magnitude of the Problem
 Fluoride endemicity has been reported in
about 248districts of 19 states and UT’s of
the country. The population at risk with
fluorosis is about 66 million and 25 million
are suffering in the country. It affects all
ages.

3. Magnitude of the
Problem
States & UTs affected with flurosis are Andhra
Pradesh, Assam,Bihar,Chhattisgarh,Gujarat,
Haryana,Jharkhand,Karnataka,Kerala,MadhyaPr
adesh,Maharashtra,Meghalaya,Orissa,Punjab,R
ajasthan,UttarPradesh, Uttrakhand, Tamil Nadu
and West Bengal are affected from fluorosis.
In all these States, the drinking water has high
fluoride content but the information about 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.

4. State wise magnitude of the problem in India
Sr.
No
.
State Total
Districts
Endemic
Districts
Contaminated
Habitations+
Fluoride range
(ppm)*
1 Andhra
Pradesh
23 19 611 0.40 -29.0
2 Assam 27 5 248 1.60 – 23.40
3 Bihar 38 14 4157 0.20 – 8.12
4 Chhattisgarh 18 5 20 -
5 Gujarat 25 14 186 0.50 – 13.00
6 Haryana 21 8 32 0.23 – 48.00
7 Jharkhand 24 5 208 0.50 – 14.00
8 Karnataka 30 24 3098 0.20 - 7.79

5. State wise magnitude of the problem in India
Sr.
NO.
State Total
districts
Endemic
districts
Contaminated
Habitations+
Fluoride range (ppm)*
9 Kerala 14 7 109 0.20 – 5.400
10 Madhya Pradesh 50 22 3006 1.50 – 4.20
11 Maharashtra 35 24 1428 0.11 – 10.00
12 Meghalaya 17 1 1 -
13 Orissa 30 14 656 0.60 – 9.20
14 Punjab 20 8 7 0.40 – 42.500
15 Rajasthan 33 31 10813 0.10 – 10.00
16 Tamil Nadu 32 5 20 0.10 – 7.00
17 Uttarakhand 13 2 2 -
18 Uttar Pradesh 70 42 2401 0.20 – 25.00
19 West Bengal 19 8 538 0.10 – 14.47
+ As per DDWS statistics out of 1,47,386, water contaminated habitations in 19 endemic
States, 27,541 habitations are endemic for fluorosis. Report Printed On 18- June-2010
02:46:35
* Data from State of Art Reoprt,UNICEF, 1999

6. Latest Data on Fluorosis Affected
Districts/Habitations(as per DDWS web sit
information)
2009-2010 2010-2011 2011-2012
Affected
District Habitation
253 33363
Affected
District Habitation
237 26180
Affected
District Habitation
194
22471

7. Assessment of the Problem
 The magnitude of Fluorosis problem in
an endemic area need to be assessed
based on appropriate surveillance
tools including case definitions,
adequate and proper sampling, and
survey methodology for taking
preventive measures, health
promotion activities, deformity
correction and rehabilitation of cases.

8. 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:

9. 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
 Transverse yellow brown/dark brown bands

10. A : Case Definition
 Skeletal Fluorosis
Any 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)
 Increased girth, thickening and density of bone by X-
ray
 Knock knee/ Bow leg
 Inability to squat
 Ugly gait and posture

11. A : Case Definition
Non skeletal Fluorosis
Any case with a history of residing in
an endemic area along with one or
more of the followings
 Gastro - intestinal problems: Consistent abdominal pain,
intermittent diarrohea/Constipation, blood in stool
 Neurological manifestations: Nervousness & depression,
tingling sensation in fingers and toes, excessive thirst and
tendency to urinate frequently (Polydypsia and plyurea)
 Muscular manifestations: Muscle weakness & stiffness, pain in
the muscle and loss of muscle powe.

12. 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.

13. 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

14. 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.

15. C - Survey Methodology
 Details of survey for dental fluorosis in school children
will be collected on predesinged 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).

16. Survey
Methodology
Analysis 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 (AR grade) on urine
samples to make a complete layer as preservative.
 Each sample should be properly labeled with
number and relevant details.

17. 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

18. Guidelines for Training
Training in a programme is a key step for its successful
implementation.
A pool of trainers will be generated at state/ district level
to provide training of different category of health care
providers at different level.
1. Training of Trainers
2. Medical Officer
3. Laboratory Technicians
4. Paramedicals
5. Training of Health Workers, ASHA and AWWs
6. Policy makers &
7. Advocacy PRIs & VHSC& Teachers

19. Guidelines for Comprehensive
Management of Fluorosis Cases
Guidelines for Comprehensive Management
of Flurosis Cases are:
 Early Detection &
 Prompt Intervention

20. Comprehensive Management
 Early 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

21. Comprehensive Management
Prompt Intervention
The Prompt Intervention is to be planned in the
following manner:
◦ Health education
◦ Preventive measures
◦ Treatment
◦ Rehabilitation

22. 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.

23. Media Plan for Preventionand
Control of Fluorosis
Slogan for Prevention and Control of
Fluorosis
 Peele dant haddi jam yeh hay pani mey fluoride
ka kam.
 Doodh, dahi, hari sabzi khao fluorosis se mukti
pao.
 Peeney ke pani mey fluoride hay jahan
fluorosis hay vahan.
 Peeney ke pani ki janch karo, apenko fluorosis
se bachao.

24. Do’s and Don’ts in relation to
Nutrition intervention 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

26. THANK U