Guidelines for Surveillance of Fluorosis in a Community

Dr Pasa National Consultant

NPPCF INDIA

Magnitude of the ProblemFluoride 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.

Magnitude of the Problem

States & UTs affected with flurosis are Andhra Pradesh, Assam,Bihar,Chhattisgarh,Gujarat,

Haryana,Jharkhand,Karnataka,Kerala,MadhyaPradesh,Maharashtra,Meghalaya,Orissa,Punjab,Rajasthan,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.

State wise magnitude of the problem in IndiaSr.No.

State Total District

s

Endemic

Districts

Contaminated

Habitations+

Fluoride range (ppm)*

1 Andhra Pradesh

23 19 611 0.40 -29.0

2 Assam 27 5 248 1.60 – 23.403 Bihar 38 14 4157 0.20 – 8.12 4 Chhattisgarh 18 5 20 -5 Gujarat 25 14 186 0.50 – 13.006 Haryana 21 8 32 0.23 – 48.007 Jharkhand 24 5 208 0.50 – 14.008 Karnataka 30 24 3098 0.20 - 7.79

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 – 4.2011 Maharashtra 35 24 1428 0.11 – 10.0012 Meghalaya 17 1 1 -13 Orissa 30 14 656 0.60 – 9.2014 Punjab 20 8 7 0.40 – 42.500

15 Rajasthan 33 31 10813 0.10 – 10.0016 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

Latest Data on Fluorosis Affected Districts/Habitations(as per DDWS web sit information)

2009-2010 2010-2011 2011-2012 AffectedDistrict Habitation

253 33363

AffectedDistrict Habitation

237 26180

AffectedDistrict Habitation

194 22471

Assessment of the ProblemThe 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.

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:

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 

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

A : Case DefinitionNon 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.

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 ppmIII > 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 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).

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.

  

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

Guidelines for TrainingTraining 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 Officer3. Laboratory Technicians4. Paramedicals5. Training of Health Workers, ASHA and AWWs6. Policy makers &7. Advocacy PRIs & VHSC& Teachers

Guidelines for Comprehensive Management of Fluorosis

CasesGuidelines for Comprehensive Management of Flurosis Cases are:

  Early Detection & Prompt Intervention

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

 

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.

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.

 

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 TobaccoSupari

  Fluoridated tooth paste Vitamin C rich food

Citrus fruits Green leafy vegetables

Iron rich food Green leafy vegetables

Guava, Banana, Brinjal

 

         

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