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Indian Pediatr 2014;51: 903-905 |
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Child Fluorosis in Chhattisgarh, India: A
Community-based Survey
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Gitte Sunil Vilasrao, KM Kamble and Ramanath N Sabat
From Regional Office of Health and Family Welfare and
Regional Leprosy Training and Research Institute, Government of India,
Under Ministry of Health and Family Welfare, Lalpur, Raipur,
Chhattisgarh, India.
Correspondence to: Dr Sunil Vilasrao Gitte, Deputy
Director, Regional Office of Health and Family Welfare and Regional
Leprosy Training and Research Institute, Government of India, Under
Ministry of Health and Family Welfare, Lalpur, Raipur, Chhattisgarh 492
001, India.
Email: [email protected]
Received: April 22, 2014;
Initial review: June 10, 2014;
Accepted: September 12, 2014.
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Objectives: To assess the prevalence and type of fluorosis among
children from randomly selected villages of Chhattisgarh, and its
relationship with fluoride levels in drinking water.
Methods: A community based
door-to-door survey was conducted in the sampled villages of seven
districts of Chhattisgarh state during the year 2013-14. The field
case definitions were used for labelling types of fluorosis. The
fluoride concentration in drinking water was estimated by ion
selective electrode method.
Results: The prevalence of
fluorosis ranged between 12 to 44% in children of surveyed
districts. The fluoride levels in drinking water of selected
villages were in the range of 0.1-9.0 ppm.
Conclusion: Dental and
skeletal fluorosis is endemic among children in the surveyed
districts of Chhattisgarh State, and is related to drinking water
with fluoride content of ³1.5
ppm.
Keywords: Fluorosis, Genu Varum, Kyphosis,
Skeletal deformities.
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Drinking water with fluoride content >1.5 mg/L may cause fluorosis. The
effects range from mild dental fluorosis to crippling skeletal fluorosis
as the level and period of exposure increases [1]. About 62 million
people, including 6 million children are at risk of fluorosis in India
[2]. The present study was undertaken to determine the extent of
fluorosis among children in surveyed villages of Chhattisgarh state,
where groundwater is the major source of drinking water.
Methods
Community-based, cross-sectional, door-to-door survey
was done in seven villages, randomly selected from seven districts of
the Chhattisgarh State, during May 2013 to January 2014. Initially, a
village map, as per hamlets was prepared with the help of key village
members and ASHA (Accredited Social Health Activist) for population
listing and water source mapping. Informal meetings were held between
local leaders and health officials. The purpose and the period of the
survey, technique to be used and its significance were explained to
them. Announcement was made in each village to get cooperation of
villagers with the aim to cover the entire village population. The
survey teams, each consisting of three to four members, headed by a
doctor, conducted door-to-door survey of the whole village to cover the
entire population. All available house members were clinically examined.
The information was filled in the pre-designed form. Field operational
case definitions (Box I) were used for labelling dental
fluorosis and skeletal fluorosis. A follow-up visit was made on the
evening of the day to cover the houses which were found locked and
persons who were found absent on the day of the survey. The listing,
labelling and collection of water samples were done on the final day of
the survey. These water samples were sent to a Public Health Engineering
(PHE) laboratory for estimation of fluoride levels. Water fluoride
levels were tested by ion selective electrode (4 star Orion) using
TISAB-3 ionie solution. After analysis of water samples, a mapping of
the fluoride content in the separate drinking water sources along with
the affected households was taken in each hamlet of the surveyed
village. A de jure approach was followed for school-going
children for enumeration during analysis purpose.
Box I Field Operational Case Definitions of Fluorosis
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A. |
Dental fluorosis: Teeth exhibit clinical signs showing mottled
enamel, chalk white, yellowish brown or brownish black,
horizontal streaks over teeth’s. |
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B. |
Genu
varum: Outword bowed Legs usually around knee in the standing
position. |
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C. |
Genu
valgum: Inward bowing of legs in standing position. |
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D. |
Kyphosis: Forward bending of spine, with fixed, rigid thoracic
cage |
Results
A total of 1414 (90%) houses in 38 hamlets with
population of 7575 (84.5%) were covered in sampled villages of seven
districts of Chhattisgarh State. Socioeconomic status of the village was
heterogeneous and the villagers mainly depended on agriculture and
casual labor. Out of total population covered, 3390 (44.7%) were
children less than 18 years of age; 1764 (52%) were males. Out of total
children, 740 (21.8%) were aged less than 5 years, 1404 (41.4 %) were
between 6-14 years of age and 1248 (36.8%) were 15-18 years of age.
Fluorosis affected 33.6% boys and 29.9% girls (Table I).
Prevalence of dental fluorosis was 21.4%. The prevalence of fluorosis
among children was highest in Kanker (44%) district followed by
Korba (29%) and Surguja (23%) (Table II).
TABLE I Prevalence and Type of Fluorosis Among Children in Surveyed Districts
| Type
of fluorosis |
6-12 y |
13-18 y |
Total No. (%) |
|
Female (No.) |
Male (No.) |
Female (No.) |
Male (No.) |
|
|
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Dental fluorosis |
194 |
191 |
176 |
164 |
725 |
(21.4) |
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Dental fluorosis and Genu valgum |
6 |
8 |
3 |
6 |
23 |
(0.7) |
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Dental Fluorosis and Genu varum |
5 |
6 |
5 |
11 |
27 |
(0.8) |
| Genu
valgum |
9 |
4 |
2 |
6 |
21 |
(0.6) |
| Genu
varum |
7 |
6 |
9 |
17 |
39 |
(1.2) |
| Genu
varum and Kyphosis |
0 |
0 |
0 |
1 |
1 |
(0.0) |
|
Kyphosis |
0 |
0 |
0 |
1 |
1 |
(0.0) |
| Genu
valgum and Kyphosis |
0 |
0 |
0 |
1 |
1 |
(0.0) |
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Total |
221 |
215 |
195 |
207 |
838 |
(24.7) |
TABLE II District-wise Prevalence of Fluorosis and Water Fluoride Levels (Year 2013-14)
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District |
Fluorosis cases |
Water fluoride level (in |
|
No. (%) |
ppm) Mean (SD); Range |
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Ambikapur |
72(18.0) |
3.8 (1.9); 0.4-6.8 |
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Balod |
91(18.1) |
2.5
(2.0); 0.5-2.2 |
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Balrampur |
50(12.1) |
2.0
(1.9); 0.2-4.0 |
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Bastar |
183(24.8) |
3.0
(2.6); 0.1-7.3 |
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Kanker |
227(44.0) |
2.2
(0.1); 0.5-2.8 |
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Korba |
126(29.0) |
2.8
(2.2); 0.1-3.5 |
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Surajpur |
89(22.9) |
3.3
(1.7); 0.2-9.0 |
In the surveyed area, the children were exposed to
fluoride levels ranging between 0.1-9.0 ppm with mean (SD) of 2.2 (2.1)
ppm in drinking water. Water samples of all wells had fluoride level
less than 1.5 ppm (range 0.1-1.2 ppm) while 54% of hand pumps had
fluoride level more than recommended.
Discussion
The overall prevalence of fluorosis among children
was found to be 24.7%, with fluoride level of drinking water ranging
from 0.1 to 9.0 ppm. The relationship between the level of fluoride in
drinking water and the prevalence of fluorosis varied from place to
place.
Other studies, mostly undertaken among school
children, had reported higher prevalence [3-6]. Dental fluorosis in this
population was significantly higher in boys than girls (P>0.05).
These findings are in accordance to the studies undertaken in India as
well as in other countries [7-9]. Prevalence of manifestation of
skeletal fluorosis was lower than other provinces in India [10]. This
might be due to different water sources used at different times, and
difference in water consumption. Possibility of other factors such as
nutritional status of children, climate conditions, individual
susceptibility, biological response, duration of exposure, dissolved
salts in the water might also have played a role [11]. Common
deformities of genu varum (38.1%) genu vulgum (6.3%) were also as
reported by others [3,11].
The prevalence of fluorosis was not found to be
consistently related to water fluoride concentrations in all the
surveyed hamlets. This may be due to the habit of frequently changing
the drinking water source by the children among the hamlets and school.
Of the 199 drinking water sources in the surveyed hamlets that were
analyzed for fluoride, the mean fluoride level was higher than the
desirable limit of 1.5 ppm for safe drinking water.
Household and school water defluoridation along with
improved nutrition is recommended for amelio-ration of fluorosis in
these villages. These villages would be the priority areas where the
fluoride safe water supply schemes should be provided in the future.
Acknowledgement: We are thankful to the
Officers of PHE for providing necessary facilities for testing of water
fluoride level.
Contributors: SVG: Concept, study design, data
acquisition and analysis, and manuscript preparation; KTK and RNA:
manuscript writing and its approval.
Funding: MoHFW; Competing interests: None
stated.
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What This Study Adds?
• A high prevalence of fluorosis was documented among
children in the study area, with consumption of water with more
than recommended fluoride level.
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