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
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PHE intervention : Defluoridation Plant installed with hand pump
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