Endemic Skeletal Fluorosis Understanding the disease -

Ways to contain it

D. Raja ReddyHyderabad

Endemic Skeletal Fluorosis

Fluorosis is a disease caused by excessive ingestion of fluoride through water, food or

both.This disease is widely prevalent in our country.

Incidence of skeletal fluorosis

• 275 districts out of 626 in the country are affected by fluorosis.

• 66 million people are living in the endemic areas who are at risk of contacting fluorosis.

• 6 million Indians are known to be crippled because of fluorosis.

• Hence Fluorosis is a major public health problem in India and it is also a problem in 25 other countries around the world

The Incidence of Endemic Skeletal Fluorosis

• 1974: 25-30 million people at risk and half a million are crippled.

• 1999 (UNICEF): 201 districts affected and 60 million at risk. 6 million people crippled.

• 2009(Ministry of health and family welfare): 275 districts are affected and 66 million people are at risk in endemic areas. 6 millions are crippled.

It is important for us to know about the sources of fluorides, their metabolism in human body and the factors governing

the development of fluorosis in endemic areas of our country so that effective

measures can be undertaken to contain this disease.

Fluoride Metabolism

• Fluorine is a halogen which is most electro negative and highly reactive element and hence it does not occur in free form in nature.

• This element combines readily with other elements to form fluorides which are widely distributed in nature.

• Fluorides are the 13th commonest element in the earth’s crust and are present in some amounts in everything we eat and drink.

• Cristiani & Gautier coined the term fluorosis in 1925.

• Fluorosis in humans was first mentioned asan occupational disease by Feil in 1930.

• This was substantiated in 1932 when Moller and Gudjonsson of Netherlands published about Skeletal fluorosis in cryolite miners.

• In 1937 Shortt et al described the cases of endemic skeletal Fluorosis from India which also contained its neurological manifestations.

What are the sources of fluorides

• Waters: Ground & surface waters: 90% of rural areas depend on ground waters and more than 50% of them have high amounts of fluorides more than 1.5 ppm. All cities get water from perennial rivers having optimum amounts of fluorides around 0.3 - 0.4ppm. Hence fluorosis has become a rural problem.

• Beverages: Tea is exceptionally rich in fluorides• Foods: Crops cultivated in endemic areas with

ground waters having high amounts of fluorides leads to cereals and vegetables containing large amounts of fluorides

Fluoride levels in ground waters in different states of India

-----------------------------------------Assam(2)-1.6-23.4;A.P.(17)-0.4-29.0;Bihar(8)-0.2-

14.0;Delhi(4)-0.9-32.46;Gujarat(All except Dhang)-1.5-13.0;Haryana(12)-0.23-48.0;J&K(1)-0.5-4.21;Karnataka(14)-0.2-7.79;Kerala(3)-0.2-

5.40;Maharashtra(10)-0.11-10.0;M.P.(10)-1.5-4.20;Orissa(3)-0.60-9.20;Punjab(13)-0.4-

42.5;Rajasthan(All32)-0.1-10.0;Tamil Nadu(8)-0.1-7.0;U.P.(7)-0.2-25.0;West Bengal(4)-1.1-14.47;

Fluorides

What are the beneficial uses of fluorides.• Fluorides reduce the incidence of dental decay

and caries. These are very cost effective and hence water supplies are fluoridated having less than optimum amounts of fluorides.

• Another advantage of fluorides is that the incidence of senile osteoporosis is much less in areas having optimum amounts of fluorides.

Col. Henry Edward Shortt, FRS, CIE (1887-1987) - Doctor, Soldier, Scientist & Shikari-A remarkable person.

• Endemic skeletal fluorosis: Clinical and radiological study.

• Kala Azar - caused by fleas-medical treatment with Stibamine reduced mortality from 90% death rate to 90% cure rate.

• Discovered the missing links in malarial parasite cycle. Ross discovered the malarial parasite.

Endemic Fluorosis in the Madras Presidency

Shortt, H.E. et al 1937

Kidney efficiency tests• Filteration rate : Below normal limit in six cases out of ten• Blood urea clearance : In all the cases the figures were

below the normal lower limit• Blood urea• CreatinineResult• Kidney function in the majority of the cases is impaired

Abnormal in majority of cases}

Concentration or dose of fluoride Effect (WHO 1970)1 PPM water Dental caries reduction

2 PPM water Dental fluorosis

5 PPM No Osteosclerosis

8 PPM water 10% Osteosclerosis

20-80 mg / day water or food Crippling skeletal fluorosis

50 PPM water or food Thyroid changes

100 PPM water or food Growth retardation

125 PPM water or food Kidney changes

2.5 - 5 gm acute dose Death

Podili, Darsi and Kanigiri Regions (1937 & 1940,1941 studies)

• Incidence of fluorosis is highest because of high atmospheric temperatures in summer reaching upto 115-116 F.

• Farm laborers are more affected.• More severe in individuals whose diet is

deficient in calories and Vitamin C.• People with kidney disease suffer more.

Daver, M.B. Occurrence of fluorosis in endemic forms in Hyderabad State - Indian Med. Gaz. 80, 332-336, 1945.

Siddiqui, A.H. Fluorosis in Nalgonda District, Hyderabad - Deccan - Brit. Med. J. 2,

1408-1413, 1955.

Krishnamachari K.A.V.R., Krishnaswamy K.,- Genu Valgum and osteoporosis in an area of endemic fluorosis - Lancet 2, 877-879, 1973.

Nalgonda Reports (1945,1955,1973)

• Disease severe in laborers than those involved in sedentary occupations.• Nutrition does play a role in the incidence.• Diets of the region are very poor in calcium intake. Averaged about

300 mg in adults.• High levels of fluoride in water supplies attributed to low levels of calcium in

soils and rocks (Netherland study).• Genu valgum appeared in 1970’s which was not present in 1940s

and 1950.• Bore wells, use of fertilizers and pesticides, sale of vegetables and dairy

products. Increase in fluoride intake and further deterioration of nutrition appear to be the main culprits.

Sl.No. Sample Fluoride (ppm)01 Rice 6002 Brinjal 12003 Bean (Bobbarulu) 12004 Cucumber 8005 Little gourd 16006 Chillies (Powder) 6007 Wheat 10009 Turmeric 24010 Millet (Jowar) 3012 Bean (Chikkudu) 18014 Gingerly 4015 Tamarind 6016 Green Gram 8017 Millet (Sajjalu) 60

Amount of Fluoride in daily diet in endemic

villages, which consisted of 450 grams of Rice,

110 grams of pulses, 200 grams of jowar,

200 grams of vegetables, 20 grams of oil

and 1200 ml of water (in milligrams)

Village Fluoride in Milligrams

Naibai (2.0 - 6.2 PPM) 75.76

Yellareddyguda (2.6 - 10.0) 54.66

Yedavalli (4.4 - 7.5) 62.20

 

Note: In brackets are given fluoride levels in water samples of the villages. Fluoride through water was less than 20% to the total daily intake of fluoride.

…Dirishavancha Village

Estimation of Trace Elements in Drinking Water Supplies of Podili, Darsi and Kanigiri Areas of

Andhra Pradesh

Estimation of trace elements in drinking water supplies of three endemic fluorotic villages of Andhra

Pradesh - Vagella, Yellareddyguda and Yadavalli

Methodology

• Fluoride = Ion selective electrode • Nitrate = Ultraviolet spectrometry • T.D.S = Conductivity • Ca & Mg = EDTA titration • 60 trace elements = ICPMS technique

(Inductively coupled plasma mass spectrometry)

Total Dissolved Solids mg/l 500

Total Hardness mg/l as Ca Co3 300

Fluoride mg/l 1.0

Nitrate mg/l 45

Calcium mg/l 75

Magnesium mg/l 30

Cadmium mg/l 0.01

Chromium mg/l 0.05

Drinking Water - Desirable LimitBureau of Indian Standards &

Central Public Engineering Organisation

Fluoride, Nitrate and TDS valuesS.No. Fluoride (ppm)* Nitrate (ppm)** TDS (ppm)***

1 1.52 28 13022 0.95 5 3153 0.75 5 3394 0.3 5 2945 1.61 2 7746 1.05 144 10867 0.81 5 2558 0.64 47 12729 0.36 12 30610 2.75 210 217211 0.44 8 37812 1.06 21 44713 0.62 57 83414 2.4 3 56415 1.42 48 29116 4.4 93 93617 1.56 17 73218 1.64 57 552Mean 1.3489 42.6111 713.8333SD 1.0154 56.1763 500.2407

 *Acceptable level of fluoride in drinking water is 0.5 ppm for a tropical country like India** Acceptable level of Nitrate in drinking water is 50 ppm***Acceptable value of TDS in drinking water 500 ppm

S.No Li V Cr Fe Cu Zn Ga Se Sr Ba

U B Mo Sb

1 3.8 172 2.6 80 12.6 56 3.4 9.2 418 60.6

15 524 38 1.14

2 3 14.726 2.3 109 55.1 181 2.52 2.12 330 41.7

1.44 101 2.8 0.82

3 3 18.01 4.57 122 80.4 180 2.18 4.51 306 36.8

1.45 100 2.1 0.52

4 3 17.5 1 99.5 5 5 2.51 1.99 285 42.4

1.47 102 2 2.53

5 18.9 74.4 14.3 312 226 223 17.8 6.79 1894 471

5.5 326 3.01 0.7

6 30.4 11.4 6.2 704 5.6 388 7.6 4.8 1204 214

3.6 212 2.2 1.06

7 3 14.1 4.3 112 5 5 2.44 2.66 328 40.6

1.44 106 2.5 0.96

8 54.2 7.35 13.2 513 6.15 10.76 6.34 4.89 1070 175

4.57 413 3.23 1.13

9 8.11 20.8 5.32 138 15.3 53.9 2.75 1.82 628 54.7

1.22 103 2 0.6

10 66 19.8 4.86 442 5 6.9 1.92 9.33 1866 37.2

13.2 687 39 0.6

11 3.27 21 1.04 112 5 5.88 3.73 5.46 306 102

1.58 102 2 0.66

12 5.59 12.7 6.66 85.4 77 175 2.66 2.86 698 44.5

2.67 143 2.18 0.73

13 19.8 24.57 14.09 268 5 85 11.79 4.86 1655 317

11.1 254 2 0.9

14 21.23 6.66 2.99 299 5 131 2.27 1.79 397 40.8

6.78 128 8.45 0.61

15 18.5 4.27 6.34 246 5 12.7 0.62 1.69 383 11.4

2.46 72.4 4.11 0.67

16 31.8 14 20.36 80 5 80.2 0.31 8.84 207 5.61

15.54 493 4.56 0.36

17 29.05 16.21 17.85 108 5 38.4 1.04 2.69 88.2 16.96

9.81 366 18 0.73

18 21.83 6.72 9.18 206 5 151 2.4 2.02 410 40.8

7.01 129 8.8 0.82

Min 3 4.27 1 80 5 5 0.31 1.69 88.2 5.61

1.22 72.4 2 0.36

Max 66 172 20.36 704 226 388 17.8 9.33 1894 471

15.54 687 39 2.53

Mean 19.13 26.45 7.62 224.21 29.34 99.37 4.12 4.35 692.95 97.39

5.88 242.3 8.16 0.86

Median 18.7 15.468 5.76 130 5 68.1 2.515 3.685 403.5 42.05

4.085 136 2.905 0.73

SD 18.24 39.36 5.87 175.45 55.157 102.85 4.38 2.65 585.29 123.37

4.98 183.87 11.73 0.466

7 158 155

List of extremely high trace elements

*All the trace element values in ppb.

S.No

YellareddygudaNitrate TDS F Ca Mg

1 106 1350 8.85 60 50

2 29 954 7.25 50 45

3 16 363 1.45 50 15

4 120 1092 4.25 50 30

5 235 1914 3.05 120 50

6 358 2544 3.45 95 85

7 156 1806 3.6 75 70

8 8 960 5.1 35 50

9 128 1944 8.75 60 80

10 15 1206 5.75 45 30

Total 1171.00 14133.00 51.50 640.00 505.00

Min 8.00 363.00 1.45 35.00 15.00

Max 358.00 2544.00 8.85 120.00 85.00

Mean 117.10 1413.30 5.15 64.00 50.50

SD 112.55 635.51 2.49 25.91 22.54

10.008.006.004.002.000.00

F

40

30

20

10

0

Freq

uenc

y

Mean =2.0089Std. Dev. =2.28876

N =94

F

Fluoride Levels in Water Supplies of Endemic Areas of AP

10000.008000.006000.004000.002000.000.00

Sr

40

30

20

10

0

Freq

uenc

y

Mean =1591.2371Std. Dev. =1670.01876

N =94

Sr

Strontium Levels in Water Supplies of Endemic Areas of AP

Hanumantha Puram Villagein Prakasam

F : 0.9 - 1.7 ppm

TDS : 640 - 1500 ppm

NO3 : 50 - 890 ppm

Sr : 2487.73 - 9931.74 ppb

• •

• •

PH: 7.6 - 8.3, F: 0.3 - 1.5 ppm, Nitrates: 10 - 140 ppm, TDS: 380 - 790 ppm, Uranium: 5.20 - 14.39 ppb,

Chromium: 6.35 - 31-98 ppb, Cadmium: 0.01 - <0.01 ppb

PH 8.3, TDS 530, Nit 10, Fluorides 1.5

• 7 out of 18 water samples are good for drinking in Prakasam District

• 4 out of 30 water samples were good for drinking in Nalgonda and Chittoor Districts

National Symposium on Fluorosis

Hyderabad - October, 3-5,1974Proceedings Published in 1977.

Geological survey of India

96 - 99% of fluoride resides in the skeleton. Fluorides have an affinity to calcium

phosphate moiety of bones.

Rest in soft tissues

Neurological Sequelae of Fluorosis

• Mechanical in nature• Radiculopathy due to compression of spinal

nerves.• Myelopathy due to compression of spinal cord.• Radiculo-myelopathy is common.• Associated with evidence of dental fluorosis

and /or restriction of spine movements in endemic area is diagnostic.

• Confirmation by X-rays and urinary and serum fluoride level estimation.

Role of Magnesium

• Magnesium has a peculiar relationship with fluoride. Mg forms 0.05% of body weight and it is essential. Mg helps in elimination of fluoride from the body by competing with Ca.

• Fluorosis incidence is less in villages where the water content of Mg is high.

• Daily requirement of Mg is 350-500 mg.

• Intravenous magnesium oxide and hydroxide injection increases urinary fluoride excretion in fluorotic dogs.

Role of Vitamin C

• Pandit’s studies in endemic areas of fluorosis of Prakasam district proved that incidence of fluorosis was high in individuals whose diet was poor in vitamin C content. Daily requirement of vitamin C is 40 mg.

• How this vitamin affects fluoride metabolism is not known at present.

• Biological effects of fluoride intoxication are related to the total amount of fluoride ingested, whatever the source be it food, water or both. The factors, which govern the development of fluorosis, are:– The prevalence of high levels of fluoride intake.– Continued exposure to fluoride.– Strenuous manual labor.– Poor nutrition especially deficient intake of calcium,

magnesium and vit. C. – Impaired renal function due to disease.– Presence abnormal amounts of trace elements like

Uranium, Strontium that may aggravate fluoride toxicity.

Main sources of Fluoride

• Drinking water

• Staple foods grown in these regions

• Tea & sea foods

Millennium development goals to be achieved by 2015

• Halving poverty and halving the population of people without access to safe drinking water

Defluoridation Plants

• Based on Nalgonda technique-lime and alum method.

• Addition of aluminum salts, lime and bleaching power followed rapid mixing, flocculation, sedimentation, filtration and disinfection.

• None of the 29 plants installed in Nalgonda district are working.

Domestic Defluoridation Units

• Based on filtration of fluoride rich water with PAC granules (Activated Alumina).

• Specific safe water yield depends upon the amount of activated alumina and its depth. Decrease in yield with decrease in AA depth and cycles of use (IIT Kanpur). DDU design is very important.

…Domestic Defluoridation Units

• 850 rupees needed for every 3months of use.

• Aluminum compounds are being incriminated in the causation of Alzheimer’s disease. Raising the PH is the one way to lessen the amount of AL but Defluoridating property diminishes with increase in PH, which is best at 6.5.

Alleviation of Endemic Fluorosis - Action PlanAP Villages (28,123) Towns 210

Check the teeth of school children Brown / Yellow pigmentation

Non-Fluorotic Fluorotic

Low endemicity (only have dental fluorosis)Milk to children to prevent valgus deformities

High Endemicity have• Genu valgum• Skeletal• Crippling

Investigations• Fluoride estimation of all water sources• Trace Element estimation of all water sources• Estimate the contribution of water and food to the total

daily intake of fluoride

Predominantly water borne - supply water containing optimum fluoride levels

Predominantly Food related- in addition supply water for cultivation

Optimum Fluoride Level in Drinking Water Supplies

• Srikantia, S.G., Permissible levels of fluoride in drinking water. Proceedings of the symposium on fluorosis October 1974. Indian Academy of Geoscience, Hyderabad, India 1977. P.407-409.

• ICMR & WHO - 1.5 PPM• The WHO noted that setting a national standard for

fluoride it is particularly important to consider the climatic conditions, water intake and intake of fluoride from other sources such as food

General Name Telugu Calcium Magnesium Vitamin-C

Equivalent Name (in Mg/100gm of the food source)

Ragi Ragulu 344 -- --

Agathi Avisagu 1130 -- 169

Amaranth Thotakura 530-800 4.2 179

Colacasia leaves Chama Aaku 1546 12.8 --

Curry leaves Karvepaku, Curry Pattha 836 -- --

Poppy feed Ghasalu, Khus Khus 1584 9.9 --Jagary Gur / Bellum 1638 -- --Gingelly seeds Nuuvulu / Til 1450 5.2 --Jowar Jonalu -- 171 --Cummin Jeera Jeelakara 1080 475 --Amla Usrikaya -- -- 600Green chilly Hari Mirch -- -- 111

Summary

• Fluorosis is a major public health problem in our country affecting millions of people in 20 odd states and hence the central government should take it up as Fluorosis control or eradication programme.

• ICMR should fix 0.5 PPM of fluoride as a permissible safe upper limit of fluoride in drinking water supplies in our country.

• Every fluoride affected village must be provided with safe drinking water preferably from perennial river nearby and stop wasting money on erecting defluoridation plants.

Thank you