May 2013

Surveyed and Report Prepared by:

Dr Sunil Gitte, MD (PSM), Deputy Director, Public Health Regional Office of Health and Family Welfare and RLTRI, Ministry Of Health and Family Welfare, Govt of India, Raipur, Chhattisgarh state

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CONTENTS Page. No 1

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Fluorosis is an important public health problem in 24 countries of the world . It

is caused by exposure to continuous high levels of fluoride, mostly from drinking

water and to a certain extent from fluoride containing food items . A continuous

level of 1.5 ppm per liter and above in drinking water is considered hazardous

for the health of bone and teeth. But, it has been reported, the disease even at

lower fluoride concentrations .Fluoride in water and eatables is mostly of

geological origin. India lies in a geographical fluoride belt, which extends from

Turkey up to China and Japan through Iraq, Iran and Afghanistan .In Indian the

disease is endemic in about 275 districts of 20 states and UT’s, with 66 million

people, at risk. In the state of Chhattisgarh, Durg , Bastar, Kanker, Surguja,

Surajpur, Balrampur, Balod and Korba districts having endemic pockets.

Clinically disease manifest in dental and skeletal forms. Dental fluorosis is mostly

seen in children when the exposure is between 1 to 4 years of age and mostly

occurs in children below 12 years of age . Skeletal fluorosis clinically manifests in

the form of various deformities viz. Genu varum, Genu vulgum and Kyphosis .The

disease severity depends on many factors viz. age, nutritional status and

response of the individual to exposure .Children and adolescent are found to be

the main victims by some researchers.

Present survey was carried out as a part of disease mapping exercise, at the

behest of the Ministry of Health and Family Welfare, Govt. of India. The aim of the

survey was to assess the burden of clinical (dental and skeletal) fluorosis,

identify types of deformity and to ascertain the fluoride concentration in prime

drinking water sources with the aim of initiating suitable interventions.

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Initially planning was done to collect data as per GOI, MoHFW protocol (strata

wise) but due to summer vacation the schools were remain closed till June 2013,

so the Investigator decided to modify the protocol and planned to cover the all

population of village to avoid bias in the survey.

A list of villages with fluoride level obtained from PHE Kankar from strata I, one

village was randomly selected . A cross sectional survey of the village was

undertaken. Initially a village map, as per Para (Locality) was prepared with the

help of key informants. The informal meetings with Local leaders and AWW and

ASHA .The locality announcement was made regarding the purpose and period

of the survey, technique to be used and its significance, to get better cooperation

and coverage of the village population. The survey team consisting of three

members, headed by a doctor. The Local language converter accompanied by the

team to avoid language problems. House to house survey of whole village was

undertaken by team simultaneously on the first day and second day to cover the

entire population. A follow-up visit was made on evening of the second day to

cover the houses which were found locked and individuals who were found

absent on the first day of the survey. During house to house visits, all available

house members were clinically examined. The information was filled in the pre-

designed proforma. Standard case definitions were used for labelling the cases of

dental Fluorosis, genu valgum, genu varum and kyphosis.

Sources of drinking water of Government as well as private were also identified.

The listing, labelling and collection of samples were done on the second day of

the survey. Samples were collected in bottles, which were vigorously washed

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with detergents and rinsed with water. Water samples were taken from most

commonly used water sources from each para and private individual hand

pumps . These water samples were sent to Public Health Engineering laboratory

at district headquarter (Kanker), for estimation of water fluoride levels within 24

hours. After analysis of water samples a mapping of the fluoride content in the

different drinking water sources along with the affected households was done in

each hamlets of surveyed village. All data were entered and analysis was done in

the SPSS 17 demo version .

FLUOROSIS CASE DEFINITION:

1) Dental Fluorosis: In teeth exhibit the first sign of fluoride toxicity in the form

of “mottled enamel”. Spots and chalk white, yellowish brown and brownish

black, horizontal streaks over teeth’s. Mild, moderate and severe classification of

dental fluorosis in the field was not done.

2) Skeletal Fluorosis

a. Genu valgum b. Genu varum c. Kyphosis:

Clinical features:

a. Genu valgum: -Legs are bowed inwards in the standing position. The bowing

usually occurs at or around the knee, so that a standing with knees together, the

feet are far apart.

b. Genu varum: - Legs are bowed outwards in the standing position. The

bowing usually occurs at or around the knee. Standing with the feet together, the

knees are far apart.

c. Kyphosis: - Forward bending of spine Fixed and rigid thoracic cage as well as

spinal cord compression occurs.

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About District and survey

village : Around 50

percent of the total

population is Kanker

district is tribal. Most of the

culture of Kanker district is

tribal dominant . The

survey village comes under

block Narharpur with a

significant number of tribal

population.

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Surveyed population: The Domarpani village is located in a Narharpur block of

Kanker district with population 1593 (CNA survey 2013). Subcenter, which

covers 4 villages, is headquartered in Domarpani. The village has a limited

approachability with blocks by Pucca road. The village covering mainly 8 paras ,

of which, 3 paras are 0.5 to 1 Km away from main locality. The houses are

scattered in the areas of Ramna para and Rahena para. The 710 were females

and 654 were male.

During survey 287 (90%of the total) houses and 1359 (85% of the total)

population of the village were covered. 15 houses were locked and remaining

temporarily out of the villages on dates of surveys.

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Age Group

Total

SEX 0-5 years

5-12 years

13-19 years

20-45 years

45-65 years

>65 years

Female Count 58 114 110 283 119 26 710

% within sex 8.2% 16.1% 15.5% 39.9% 16.8% 3.7% 100.0%

% within group 53.2% 56.4% 50.5% 52.9% 49.4% 44.1% 52.1%

% of Total 4.3% 8.4% 8.1% 20.7% 8.7% 1.9% 52.1%

Male Count 51 88 108 252 122 33 654

% within sex 7.8% 13.5% 16.5% 38.5% 18.7% 5.0% 100.0%

% within group 46.8% 43.6% 49.5% 47.1% 50.6% 55.9% 47.9%

% of Total 3.7% 6.5% 7.9% 18.5% 8.9% 2.4% 47.9%

Total Count 109 202 218 535 241 59 1364

% of Total 8.0% 14.8% 16.0% 39.2% 17.7% 4.3% 100.0%

Chi Squar test χ2 = 4.18, df =5, P<0.5

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Surveyed population included 710 (52.1) of Females and 645 (48.9%) males.

Number of children below 12 years of age was 311 (22.80%) and adolescent (13

to 19) was 218 (16.0%). Those above 65 years constituted 59 (4.3%).

Socioeconomic profile: The village is divided into paras and Socioeconomic

status of the village is heterogeneous. Occupant of Neeche and Rehna para

were low wage earners (Marginal farmers viz agriculture labour). In other paras

there were small cultivators as well as agricultural labourers. Information about

occupation and income of individual members could not be recorded in detail.

Water source: The village had 21 Government Hand pumps, 25 individual

household hand pumps. All were borehole water source for drinking water and

nearby ponds for other purpose like washing and cattle use. Maximum Individual

bore well pumps were taken by owners during last 3 to 4 years .Out of three only

one Fluoride filter Pump was working properly. All the inhabitants were relying

solely on hand pump. 80-90% of the inhabitants of the village are till consuming

fluoride containing water as a prime source. The majority of villagers were also

changing the sources of drinking water as per their convenience and need.

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Sr No

Type of fluorosis Prevalence Female

(N=710)

Male

(N=654) Total (N=1364)

1 2 3 4 5 6

Dental Fluorosis

Count 164 175 339

Prevalence 23.09 26.75 24.85

Dental Fluorosis and Genu Valgum

Count 7 11 18

Prevalence 0.98 1.68 1.31

Dental Fluorosis and Genu Varum

Count 2 2 4

Prevalence 0.28 0.30 0.29

Genu Valgum

Count 2 1 3

Prevalence 0.28 0.15 0.21

Genu Varum

Count 16 35 51

Prevalence 2.25 5.35 3.7

Kyphosis

Count 2 0 2

Prevalence 0.28 0.00 0.14

Total

Count 193 224 417

Prevalence 27.18 34.25 30.57

The overall prevalence of fluorosis was 30.57 among the surveyed population.

Males are affected more as compare to female. 339 (24.85%) were showing

signs of dental fluorosis while 18 (3.73%) persons were dental fluorosis with

genu valgum. Genu valgum as noted in 51 persons. 2 (0.14%) persons above 60

years had kyphosis. The reason might be due to age factor or long term exposure

or combined. Males are affected more as compare to female.

Above table depicts the pattern of fluorosis among the surveyed population .As

shown dental fluorosis was commonest (81.29%) followed by genu varum

(12.23%) and genu vulgum (0.71%). 12 (5.27%) cases had multiple deformities.

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Deformity

Total

Age

Groups

Dental

Fluorosis

Dental Fluorosis

and Genu

Valgum

Dental Fluorosis

and

Genu Varum

Genu

Valgum

Genu

Varum

Kyphosis

>65 years

(N=59)

Count 1 2 0 0 12 1 16

Prevalence 1.69 3.38 0.00 0.00 20.33 1.69 27.11

0-5 years

(N=109)

Count 2 0 0 0 0 0 2

Prevalence 1.83 0.00 0.00 0.00 0.00 0.00 1.83

13-19 years

(N=218)

Count 128 3 1 0 2 0 134

Prevalence 57.71 1.37 0.45 0.00 0.91 0.00 61.46

20-45 years

(N=535)

Count 90 8 1 1 13 0 113

Prevalence 18.82 1.49 0.18 0.18 2.42 0.00 21.12

45-65 years

(N=241)

Count 24 4 0 2 24 1 55

Prevalence 9.95 1.65 0.00 0.82 9.95 0.41 22.82

5-12 years

(N=202)

Count 94 1 2 0 0 0 97

Prevalence 46.53 0.49 0.99 0.00 0.00 0.00 48.01

Total

(N=1364)

Count 339 18 4 3 51 2 417

Prevalence 24.85 1.31 0.29 0.21 3.73 0.14 30.57

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square 385.628a 30 .000

Likelihood Ratio 367.295 30 .000

As shown, the prevalence of dental fluorosis was more among 13-19 years of

males while in females it was more in above 20-45 years (25.6%) of age. The

prevalence is lower among older age groups.

Maximum numbers of the dental fluorosis cases were affected in the teen age

group followed by 5-12 years. Only 2 children of age 0-5 years shows signs of

dental fluorosis.

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sex * group * deformity Cross tabulation

Sr no Type of fluorosis Sex

Count/ prevalence

0-5 years

5-12 Years

13-19 years

20-45 Years

45-65 years

>65 years Total

1 Dental

Fluorosis

Female Count 1 51 65 36 11 0 164

Prevalence 1.74 47.73 59.09 12.72 9.2 0.00 23.09

Male Count 1 43 63 54 13 1 175

Prevalence 2 48.86 58.33 21.42 10.65 3.03 26.75

2 Dental

Fluorosis and

Genu Valgum

Female Count 1 2 2 0 2 7

Prevalence 0.87 1.8 0.70 0.00 7.69 0.98

Male Count 0 1 6 4 0 11

Prevalence 0.00 0.92 2.38 3.57 0.00 1.68

3 Dental

Fluorosis and

Genu Varum

Female Count 2 0 0 2

Prevalence 1.75 0.00 0.00 0.28

Male Count 0 1 1 2

Prevalence 0.00 0.92 0.39 0.30

4 Genu Valgum Female Count 0 2 2

Prevalence 0.00 1.68 0.28

Male Count 1 0 1

Prevalence 0.39 0.00 0.15

5 Genu Varum Female Count 0 2 11 3 16

Prevalence 0.00 0.70 9.24 11.53 2.25

Male Count 2 11 13 9 35

Prevalence 1.85 4.36 10.65 27.27 5.35

6 Kyphosis Female Count 1 1 2

Prevalence 0.84 3.84 0.28

The prevalence of skeletal fluorosis was more common above 45 years both in

males (38%) and females (20.75 %) and lowest prevalence in the Children’s (5-

12).

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Dental Fluorosis

Dental Fluorosis and Genu Valgum

Dental Fluorosis and Genu Varum

Genu Valgum

Genu Varum

Kyphosis

Total

Bandha para

(N=125)

Count 44 3 1 1 6 0 55

Prevalence 35.20 2.40 0.80 0.80 4.80 0.00 44.00

Kaas para

(N=171)

Count 42 2 0 0 5 0 49

Prevalence 24.56 1.17 0.00 0.00 2.92 0.00 28.65

Neecha para

(141)

Count 50 4 0 0 1 1 56

Prevalence 35.46 2.84 0.00 0.00 0.71 0.71 39.72

Ramna para

(N=22)

Count 5 1 0 0 1 0 7

Prevalence 22.73 4.55 0.00 0.00 4.55 0.00 31.82

Ramnagar para

(N=230)

Count 58 1 2 0 5 1 67

Prevalence 25.22 0.43 0.87 0.00 2.17 0.43 29.13

Rehna para

(N=74)

Count 8 1 0 1 13 0 23

Prevalence 10.81 1.35 0.00 1.35 17.57 0.00 31.08

School para and Bajar

Chwok(N=436)

Count 102 4 0 0 19 0 125

Prevalence 23.39 0.92 0.00 0.00 4.36 0.00 28.67

Tariya para

(N=165)

Count 30 2 1 1 1 0 35

Prevalence 18.18 1.21 0.61 0.61 0.61 0.00 21.21

Total

(N=1364)

Count 339 18 4 3 51 2 417

Prevalence 24.85 1.32 0.29 0.22 3.74 0.15 30.57

The highest number of dental fluorosis cases was found in Neeche para followed

by Bandha para. Genu valgum cases were more in Rehna and school para as

Probably these differences are similarly associated compared to other paras.

with the fluoride concentration in water , duration of exposure and individual

habits of the persons .

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Hamlets Population Fluorosis cases

Prevalence Mean Fluoride level of water

Min-max SD

1.Bandha para 125 ( 9.16 ) 55 (13.18) 44.00 2.36ppm 1.00-2.5 0.29

2.Kaaspara 171 (12.53 ) 49 (11.75 ) 28.65 2.02 ppm 1.61-2.64 0.40

3.Neecha para 141 (10.33 ) 56 (13.42) 39.72 2.51 ppm 2.51-2.51 0.00

4.Ramna para 22 (1.61) 7 (1.67) 31.82 2.30 ppm 2.30-2.30 0.00

5.Ramnagar para 230 (16.86) 67 (16.06) 29.13 2.24 ppm 1.00-2.59 0.41

6.Rehna para 74 (5.42 ) 23 (5.51) 31.08 2.63 ppm 1.68-2.75 0.33

7.School para and Bajar Chwok

436 (31.96) 125 (29.97) 28.67 2.05 ppm 0.5-2.82 0.52

8.Tariya para 165 (12.09 ) 35 (8.39 ) 21.21 2.20 ppm 1.5-2.32 0.228

Total 1364 (100) 417 (100 ) 30.57 2.19 ppm 0.5-2.86 0.448

As shown highest prevalence (44%) was recorded in Bandha Para, which also

had highest fluoride level (5.9-7.8 p.m.) in the prime drinking water source.

Prevalence was also higher in Neeche para (22.2%) and Rehnai para (31.06%)

with even lower fluoride concentration (1.64 and 3.12 ppm). Fluoride level of

prime drinking water sources of 41 surveyed para which ranged from 0.5 ppm to

2.86 ppm. The fluoride content may unevenly distribute in ground water both

vertically and horizontally.

0

0.5

1

1.5

2

2.5

3

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

school para Tariya Para Ramnagar para Bandha Para

Niche Para Khas Para Rehana Para

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The 98% of the surveyed population exposed to water fluoride level above

normal limit but 30.43%affected with fluorosis. Only 2% of population neither

An individual dietary habbits and general exposed nor affected after mapping.

state of health as well as the body's ability to dispose of fluoride all affect how

the exposure to fluoride manifests itself.

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The overall prevalence of the fluorosis in surveyed area was 30.57% of strata I.

The prevalence of dental fluorosis was also greater in the Children and teen age

groups while skeletal fluorosis in adults and elders groups. The gender, age, and

hamlets related differences in the prevalence of fluorosis. The Mean fluoride

content in the handpumps (Govt and Individuals private owners) in the surveyed

area was 2.19 with parawise variation.

Dental and skeletal fluorosis is a public health problem in the surveyed village of

the Kanker District. This requires the synergistic action of health planners, health

administrators, engineers and the water supply authorities. Recently , active step

has been taken by PHE Kanker installed defluoridate plant near three

handpumps to reduce the morbidity associated with fluorosis in this area , still

80-90% of the inhabitants of the village are till consuming fluoride containing

water as a prime source. Out of 3 fluoride filter has been constructed in the

locality but two of these plants clogs up after some time. During survey the 30-

40% study population were aware of the cause of the dental fluorosis while none

were aware of skeletal deformity. So need of IEC activities, group meetings

through PRI members.

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I would like to thank to Dr R N Sabat , Sr Regional Director for guidance and

support for field survey.

I am deeply indebted and grateful to Chief Engineer Shri A.K Verma and Mr Y.K

Dhruw , Sub Eng PHE for coordination and support before and during survey.

Thanks to Mr. K.S Netam, Pump Mechanic and Pursottam Sahu, Asst H.P Inspector

for mapping , coding , labelling and collection of water samples during the survey

and interpreter . The survey could not complete without the cooperation of the PHE

division of Kanker.

I would like to thank to PRI members Local leaders and ASHA for cooperation and

support during the survey. I would like to extend my sincere thanks to all inhabitant of

village for cooperation during the survey. I would like to express my special gratitude

and thanks to Mr I Masih, PMW for data completion of the survey.

- Dr S V Gitte

ROHFW and RLTRI, GOI,

MoHFW, Raipur,C.G

Email-sv.gitte@nic.in

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PHE intervention : Defluoridation Plant installed with hand pump

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