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urinary published paper Dhar fluoride (1)
1. 1 23
Environmental Monitoring and
Assessment
An International Journal Devoted to
Progress in the Use of Monitoring Data
in Assessing Environmental Risks to
Man and the Environment
ISSN 0167-6369
Environ Monit Assess
DOI 10.1007/s10661-012-2713-y
Urinary fluoride as a monitoring tool for
assessing successful intervention in the
provision of safe drinking water supply
in five fluoride-affected villages in Dhar
district, Madhya Pradesh, India
R. Srikanth, Anil Gautam, Suresh
Chandra Jaiswal & Pavitra Singh
2. 1 23
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3. Urinary fluoride as a monitoring tool for assessing successful
intervention in the provision of safe drinking water supply in five
fluoride-affected villages in Dhar district, Madhya Pradesh, India
R. Srikanth & Anil Gautam &
Suresh Chandra Jaiswal & Pavitra Singh
Received: 7 August 2011 /Accepted: 28 May 2012
# Springer Science+Business Media B.V. 2012
Abstract Endemic fluorosis was detected in 31
villages in the Dhar district of Madhya Pradesh,
Central India. Out of the 109 drinking water sources that
were analyzed, about 67 % were found to contain high
concentration of fluoride above the permissible level of
1.0 mg/l. Dental fluorosis among the primary school
children in the age between 8 and 15 served as primary
indicator for fluoride intoxication among the children.
Urinary fluoride levels among the adults were found to
be correlated with drinking water fluoride in 10 villages
affected by fluoride. Intervention in the form of alternate
safe water supply in five villages showed significant
reduction in the urinary fluoride concentration when
compared to the control village. Urinary fluoride serves
as an excellent marker for assessing the effectiveness of
intervention program in the fluoride-affected villages.
Keywords Dental fluorosis . Groundwater.
Urinary fluoride . Alternate safe sources . Dhar.
Madhya Pradesh . India
Introduction
Elevated levels of fluoride in drinking water, i.e.,
above the guideline value of 1.0 mg/l (WHO 2003)
have been detected in numerous countries around the
world (Bailey et al. 2006; Srikanth et al. 2002). Fluoride
in drinking water is a causative factor for both dental and
skeletal fluorosis in overwhelming cases (Fewtrell et al.
2006).
About 62 million people in India suffer from dental,
skeletal, and/or non-skeletal fluorosis (Susheela and
Majumdar 1992). About 20 states in India are affected
by this crippling disease (Srikanth et al. 2008). Of
these, six million are children below the age of 15
(Kodali et al. 1994). Rural population who are mainly
dependent on the groundwater for drinking and
domestic water needs are worstly affected (Srikanth
2009). More than 85 % of the rural population in the
country uses groundwater for drinking and domestic
purposes (Handa 1984). High concentration of fluoride
in groundwater above the permissible limit poses the
health problem; however, dental fluorosis is also
detected at lower fluoride concentration level in villages
in India (Srikanth et al. 1994). The major source of
fluoride in the groundwater is geogenic, that is, from
fluoride-bearing rocks, it gets weathered and/or leached
Environ Monit Assess
DOI 10.1007/s10661-012-2713-y
R. Srikanth (*)
DFID Project, Bihar Health Society,
Sheikhpura,
Patna, Bihar, India
e-mail: rsrikanth60@gmail.com
A. Gautam :P. Singh
People Science Institute,
252, Vasant Vihar,
Dehradun, India
S. C. Jaiswal
WaterAid India,
Arera Colony,
Bhopal, India
Author's personal copy
4. out and contaminates the water (Rakesh Kumar et al.
2005). In India, about 20 states have been identified
with the problem of excess fluoride in groundwater
(CPCB 1999).
Madhya Pradesh is one of the largest states in
Central India. Among the districts in Madhya Pradesh,
Dhar is one of the districts severally affected by fluoride
in groundwater. No baseline data exist on the extent of
dental fluorosis occurrence in this district. Therefore, the
present study was designed to address the following
objectives:
& To identify target villages affected by fluoride
based on groundwater fluoride concentration
levels and the prevalence of dental fluorosis
among the school children
& To assess the level of urinary fluoride in adults in
10 endemic villages affected by fluoride
& To study the effectiveness of the intervention
through the provision of safety to the community
in five affected villages by assessing the urinary
fluoride level after a span of 6 months
Materials and method
Geographical location
Dhar district lies in the southern part of Madhya Pradesh.
The district extends over three physiographic divisions.
They are the Malwa in the north, the Vindhyachal range
in central zone, and the Narmada valley along the
southern boundary (Fig. 1). The majority of the
population in Dhar district is tribal with poor
socioeconomic status and is subjected to various
degrees of malnutrition. Groundwater serves as a
major source of drinking water in these villages
and the traditional open wells that were fluoride-free are
abandoned in favor of hand pumps because of the
government program on increasing the access to
water to the rural communities from deeper aquifers
resulting in fluoride ingestion.
Analysis of groundwater
A temporary mobile field laboratory was established at
the Dhar district of MP. Samples were collected from
the field in polyethylene bottles, which was vigorously
washed with detergents and rinsed with distilled water
prior to sample collection. The samples were analyzed
within 24 h of the collection in the field laboratory.
Battery-operated fluoride ion meter (model 290A+
Orion, USA) was used to measure the fluoride
concentrations. Standard methods of water analysis
prescribed by the American Public Health Association
(APHA) were followed in the analysis of all the
parameters.
All the drinking water sources and individuals were
selected for monitoring. The samples were also
collected from a control village which had fluoride levels
within the permissible levels of 1 ppm.
Urine sample collection and analysis
Pre-labeled 500-ml plastic-capped disposable bottles
(prewashed and dried containing 0.2 g of EDTA) were
distributed to the selected persons in the village in the
previous evening. EDTA (0.2 g) was added to check
and minimize the interference from complexation of
fluoride by cations such as calcium. The individuals
were asked to collect their first urine samples in the
morning. The individuals were also explained the
importance of the program and were motivated to
cooperate in this study. An informed consent was
obtained from the participants.
Information on the drinking water sources and dietary
practice was collected and other related data were
obtained through an open-ended questionnaire. A
sample from all the drinking water sources of the
villages was collected as per the guidelines mentioned in
the APHA.
The urine samples obtained were stored in an ice
box and taken to the field laboratory, where they were
analyzed for the fluoride concentration on the same
day using the battery-operated fluoride ion meter
(model 290A+ Orion, USA). The urine samples were
analyzed following the NIOSH manual method 8308
(NIOSH Manual of Analytical Methods 1994).
Health survey
For conducting the health survey, necessary questionnaire
was developed to correlate with the drinking water
source, fluoride level along with the socioeconomic
conditions. A dental survey format was utilized for
conducting survey among students in the primary
schools aged between 8 and 16 years in the fluoride-
affected villages.
Environ Monit Assess
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5. Results and discussion
Fluoride in drinking water source
Out of the 109 water sources that were monitored in
the 31 villages, the fluoride concentration was found
to be in the range of 0.18–11.6 mg/l (Table 1). Table 1
gives the number of safe and unsafe sources along
with the total sources.
The sources include 83 hand pumps, 17 open dug
wells, 3 deep tube wells, and 6 ponds. The results
revealed that 67 % of the hand pumps and 100 % of
the tube well sources were unsafe; the fluoride
concentration was found to be above the permissible
limit of 1.0 mg/l.
The water samples of the wells and ponds had
fluoride concentration within safe limits (Table 2).
Over 28 % of the hand pump sources were found to
have fluoride concentration above 5 mg/l. It should be
noted that hand pumps and deep tube wells constitute
the major source of water for consumption among the
communities and therefore constituted the major
health risk in exposing the communities to fluoride.
Dental fluorosis among children in 15 villages in Dhar
district
Results from the dental survey conducted among
1,300 children in the age group of 6–16 years in 31
schools are summarized in Table 3. It was observed
that out of the 1,300 children, over 436 (33.5 %) were
affected by mild fluorosis, 105 (8 %) by moderate
fluorosis, and 10 (0.8 %) by severe fluorosis. From
the study, it was seen that higher incidence of dental
fluorosis in terms of percentage is seen in villages that
had fewer number of safe drinking water sources than
those villages that had relatively larger number of safe
water sources (Table 1). Less number of safe sources
offers little choice among the communities to access
safe water. The village, namely Kalapani, which
showed more than 85 % cases of dental fluorosis had
less than two safe sources out of total four sources.
Fig. 1 Location map of the district
Environ Monit Assess
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7. Similar situation was found in villages like Kalikarai,
Tarapur, etc. where significant percentages of dental
fluorosis were detected had few safe sources available
in these villages (Tables 1 and 2).
A comparative analysis of drinking water fluoride and
urinary fluoride is presented in Table 4. Urinary fluoride
concentration is well-established as a way to estimate
fluoride exposure among general population throughout
the world for different purposes (Cooper and Wickham
1991; Kolsenik and Pakhomov 1997; Wang et al. 1997).
Results show consistently high concentration of
fluoride in subjects exposed to high levels of drinking
water fluoride when compared with the control
village, Kakadada, where fluoride concentration in
drinking water was low and was in the range of
0.27–0.32 mg/l and corresponding urinary concentration
was also found to be low (0.5 mg/l) when compared to
nine other affected villages (Table 4).
Kalikirai village showed highest mean concentration
of fluoride in drinking water (7.59 mg/l) and corre-
spondingly high concentrations in urinary excretion
among the subjects were recorded (Table 4). This study
clearly shows that drinking water fluoride has a direct
impact on urinary fluoride excretion in community
exposed to high fluoride concentration in water.
Effectiveness of intervention
Several studies have monitored urinary excretion of
fluoride during fluoridation programs of salt (Marthler
Table 2 Fluoride concentration in various sources
Sample no. Type of the
water source
Total number of tested
sources
No. of water sources
(fluoride concentration<1.0 mg/l)
No. of water sources
(fluoride concentration>1.0 mg/l)
Fluoride-affected sources (%)
1 Hand pump 83 27 56 67
2 Well 17 17 – 0
3 Tube well 03 – 03 100
4 Pond 06 06 – 0
Table 3 Status of dental fluorosis in 15 villages of Dhar district
Sample
no.
Name of the school Total no. of
students surveyed
Dental
fluorosis (%)
Sample
no.
Name of the school Total no. of
students surveyed
Dental
fluorosis (%)
1 Gov. Pri. School, Badpipali 73 42.4 16 Gov. Pri. School, Abdulpura 28 61.2
2 Gov. Pri. School, Sitapath 33 39.4 17 Gov. Middle School, Umaria 74 17.5
3 Gov. Middle School, Paldiya 70 37.1 18 Middle School Bholiyapura 165 55.1
4 Satyam Vidhya Niketan,
Paldiya (Pvt.)
42 23.8 19 Primary School Surandi 19 47.2
5 Gov. Pri. School, Matlabpura 27 14.8 20 Primary School, Nirgudiya Pura 37 24.3
6 Gov. Middle School, Bahadra 63 42.9 21 Pvt. Middle Devi Nihalde 42 38.0
7 Gov. Pri. School, Bahadra 35 71.4 22 Middle School Bagwania 27 46.3
8 Gov. Girls Adiwashi Ashram,
Bahadra
46 34.8 23 Village children of Lohgarpura 22 27.2
9 Gov. Pri. School, Kalapani 20 85.0 24 Village children of Kali Karai 24 75
10 Gov. High School, Tarapur 75 43.9 25 Village children of Lalmatia 14 64.2
11 Gov. Girls Ashram, Tarapur 46 32.6 26 Middle School, Devi Nehalde
(Chiktiyawad)
30 23.3
12 Adiwashi Balak-Kanya
Ashram, Tarapur
69 39.1 27 Gov. Primary. School, Bholiya Pura 36 30.4
13 Gov. Pri. School Brahman puri 9 55.5 28 Gov. Primary School, Ahmadpura 24 37.4
14 Gov. Pri. School Chitari
(Choti)
16 37.5 29 Gov. Primary School, Kacchuwania 16 12.5
15 Gov. Pri. School,
Jamunwalapura (Bahadra)
11 54.3 30 Gov. Middle School, Kacchuwania 78 41.0
Total 1,300 42.3 31 Gov. Primary. School, Karondiya 29 58.5
Govt. government, Pri. primary
Environ Monit Assess
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8. et al. 2000), milk (Ketley and Lenon 2001), water, and
toothpaste (Forte et al. 2008), but few have conducted
a study of baseline urinary concentration of community
exposed to fluoride and followed it up with additional
data on urinary fluoride after sucessful intervention
through provision of safe water in the affected
communities.
In the present study, the urinary fluoride concentration
was monitored among those subjects whose urine
samples were already monitored earlier as baseline.
Four intervention villages (Bahadra, Ahmadpura,
Matlabpura, and Kalikirai) along with one control
village (Anuppura) were assessed on the impact of
the safe water. The safe water provision was made
through mini water supply schemes from alternative
safe sources that had fluoride well below permissable
level of 1.0 mg/l. Urinary fluoride was analyzed after a
span of 5 to 6 months after the communities were
introduced to safe water supply.
Mean paired urinary fluoride values are presented
in Table 5. Study revealed a significant decrease in
fluoride concentration in the urine samples among the
communities exposed to safe water. The decrease in
urinary fluoride varied from 13.8 to 43.38 % in
comparison with the control village of Annupura
which showed elevated concentraion of urinary
fluoride during the same period where no interven-
tion took place.
From this study, it is also clear that in Kallikirai
village that had maximum fluoride levels in drinking
water as well as in the urine in the subjects show slow
trend in reverting to normal levels when compared to
other vilages benifiting from safe water. This may be
due to continued exposure to the contaminated water
sources inspite of intervention.
Table 4 Fluoride concentrations in water and urine samples in 10 villages of Dhar district
Sample no. Name of village Total subject Fluoride in water (mg/l) Fluoride in urine (mg/l)
Range Mean Range Mean
1 Kalikirai 30 3.11–13.4 7.59 2.6–37.9 8.87
2 Ahmadpura 50 0.36–5.29 1.52 0.86–15.9 4.67
3 Kakadada 40 0.27–0.32 0.29 0.07–2.21 0.95
4 Bahadara 50 1.25-4.02 2.29 1.84–20.0 6.12
5 Matalabpura 22 0.18–3.62 2.2 0.51–4.81 2.54
6 Anuppura 41 1.4–2.74 2.02 1.31–18.2 5.66
7 Sitapath 73 0.47–6.79 2.73 0.62–11.9 3.33
8 Badpipli 40 0.40–11.3 4.46 0.68–15.1 7.12
9 Talavpura 46 0.67–2.81 1.64 0.63–9.25 2.77
10 Kalapani 40 0.56–10.8 3.65 0.97–18.0 4.85
Table 5 Paired mean and standard deviation before and after
intervention
Village Pair Mean n (total no. of
people)
Standard
deviation
Standard error
of mean
Kalikirai 01 7.6348 21 5.65186 1.23334
02 6.5714 21 3.46456 0.75603
Ahmadpura 01 4.2050 46 3.08866 0.45540
02 2.7572 46 2.26791 0.33438
Bahadra 01 6.5933 36 4.70948 0.78491
02 3.7294 36 2.43234 0.40539
Matlabpura 01 2.4531 16 1.22679 0.30670
02 1.8875 16 1.27279 0.31820
Anuppura 01 4.8812 26 2.43632 0.47780
02 5.8492 26 4.56809 0.89588
Table 6 Paired correlations
Village Pair n (total no. of people) Correlation
(col. 3)
Significance
Kalikirai 01 and 02 21 −0.196 0.395
Ahmadpura 01 and 02 46 0.312 0.035
Bahadra 01 and 02 36 0.562 0.000
Matlabpura 01 and 02 16 −0.248 0.354
Anuppura 01 and 02 26 0.316 0.115
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9. From the study, it can be concluded that high concen-
tration of fluoride in drinking water leads to increased
dental deformities among primary school childrens and
also urinary fluoride is a good indicator of community
exposure to fluoride. It also establishes the fact that
urinary fluoride tests serve as effective monitoring and
evaluation tool for assessing the outcome of sucessful
mitigation strategy in areas affected with severe fluorosis.
Statistical analysis
The tool used here is paired t test. This was used to
compare means on the same or related subject over
time. In this case, our interest was to find out if safe
water provision to affected community (intervention)
is really effective in bringing down the fluoride con-
centration in urine.
From the results, it is clear that the p value is less than
0.05 in two villages, i.e., Ahmedpura and Bahadara,
showing effectiveness of intervention as compared to
villages like Matlabpura and Kalikirai and the control
village of Annupura. The study calls for strengthening
the IEC strategy in building up community awareness in
two villages (Matlabpura and Kalikirai) were the results
were not statistically significant (Tables 6 and 7).
Conclusions
From the study, following conclusions can me made:
& High concentration of fluoride in drinking water leads
to increased dental deformities. The degree of dental
sources is related to the availability of safe sources.
& Urinary fluoride is a good tool for studying
community exposure to fluoride.
& It also establishes the fact that urinary fluoride tests
serve as effective monitoring and evaluation tool for
assessing the outcome of sucessful mitigation
strategy in areas affected with severe fluorosis.
& Blanket testing of all drinking water sources helps
in identifying safe and unsafe sources and helps in
developing small water supply schemes for protecting
the community in the endemic zones.
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Table 7 Paired t test for comparing data before and after intervention
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