Epidemiological survey of fluorosis in a village of

Address for the Correspondence: Dr. Sunil Vilasrao Gitte, Deputy Director, Regional Offi ce of Health and Family Welfare and Regional Leprosy Training and Research Institute, Under Ministry of Health and Family Welfare, Govt of India, Lalpur, Raipur 492 001, Chhattisgarh, India. E-mail: sv.gitte@gov.in Epidemiological survey of fluorosis in a village of Bastar division of Chhattisgarh state, India


INTRODUCTION
Fluorosis is a disease caused by deposition of fl uorides in the hard and soft tissues of the body.It is not merely caused by excess intake of fl uoride, but also related to other attributes and variables which determine the onset of fl uorosis in human population.Many studies have reported the endemicity of fl uorosis in this geographic area where the fl uoride content in drinking water is high. [1]Various states have reported endemic fl uorosis in India. [2]About 62 million people, including 6 million children are at risk in India suffering from dental, skeletal and/or nonskeletal fl uorosis. [3]Fluoride level of >1.5 mg/l in drinking water is considered to be hazardous to health and manifest in the form dental and skeletal fl uorosis. [4]The disease may occur in an individual at sub-clinical, chronic or acute levels of manifestation.Crippling skeletal fl uorosis can occur when fl uoride content of water is very high (>2-3 ppm) or even at very low (lower than 1 ppm even at 0.7 ppm). [5]The severity of fl uorosis depends upon fl uoride content of drinking water, daily intake of water, continuity and duration of exposure, and climatic conditions.Hence, it is necessary to explore the geographical distribution and present contamination level of water and accordingly developing a strategy for safe drinking water source.Endemic areas have been reported in some pockets of Chhattisgarh, a central Indian state. [6]resent study was carried out as part of disease mapping exercise in selected pocket of a tribal district of Chhattisgarh state with an objective to assess the burden of fl uorosis, mapping the deformities and to detect the fl uoride concentration in prime drinking water sources.population.A follow-up visit was made on the evening of the last day to cover the houses which were found locked and individuals who were absent on the day of the survey.All household members were clinically examined during house to house visit.Data were collected using predesigned, pretested proforma.

RESULTS
Dimrapal village is situated on a Bakawand block of Bastar district with population 1975.The survey covered 10 paras, of which, two paras are 1-1.5 km away from the main locality.The female population was more as compared to male (1095:880).During a door to door survey, totally 1674 (85%) population residing in 291 houses was examined.Ten houses were found to be locked and temporarily remained out of the village on survey dates.Among surveyed population 834 (49.8%) were females and 840 (51.2%) males.Children from primary and secondary schools were separately examined with the help of teachers and local volunteers.

DISCUSSION
The overall prevalence of fl uorosis was 23.1%, water fl uoride levels varied from 0.1 to 7.3 ppm.[9] The prevalence of overall dental fl uorosis was 12.6%, which is lower than other provinces in India. [7,10]The prevalence of dental fl uorosis in children was 23.6% and 34.6% in teenagers.Children and teenage group together contribute about 78.6% of total dental fl uorosis cases.The prevalence of dental fl uorosis declined after 45 years of age.10][11] High prevalence in children and teenage group has been attributed to a higher concentration of fl uoride in water.Additional factors such as nutritional status, climate, and individual susceptibility, and biological response, duration of exposure and frequency of fl uoride intake may also have had played their role. [12]Males had reported higher prevalence, analogous to observations made in UP, India [13] and in contrast to fi ndings from Kerala [14] whereas, others found no gender differences. [10]Differences in physical activity, food pattern, water consumption and mobility might have affected the outcome.In the present study, the prevalence of skeletal fl uorosis is more among the farmers (35.1%) followed by nonagricultural labor (16.0%) while least in business, housewife, students, and service group.Some of the studies had reported a maximum incidence and severity of fl uorosis in farmers and hardworking subjects only. [15,16]This could be due to habitually carrying heavy load on the head, and these people are engaged in activities like digging and ploughing with elementary type of plough.All these put stress on the bone, and this also explains the preponderances of skeletal deformities in this group.A person engaged in light manual labor, housewife, and other group showed a lower incidence of bone lesion.Higher prevalence of fl uorosis with increasing age was in concordance with fi ndings by others researcher [12,17] showing cumulative effect of longterm exposure.Common deformities of genu varum (31.7%) genu vulgum (4.1%) were also as reported by others too. [12,18]Prevalence of skeletal fl uorosis was nearly similar in both sexes while combined fl uorosis was higher in male (2.9%) as compare with female (0.6%) in the present study.Other researchers also reported that males are affected more as compared to females. [18,19]The relationship between the levels of fl uoride in drinking water and fl uorosis vary from place to place but in a study conducted in Rajasthan [7] shows even at low level (<1.5 ppm) the prevalence of skeletal fl uorosis ranged from 6.1% to 9.5%.As shown in Table 2, the paras having highest fl uoride levels in the prime drinking water sources also had the highest prevalence.Natkolkapara had the highest prevalence of fl uorosis even though fl uoride content in the prime drinking water was low.The prevalence of fl uorosis was not found to be linked to water fl uoride concentrations in all the paras.This may be explained by the habit of frequently changing the drinking water sources by the study subjects between the paras.It may also be due to the difference in occupation that may affect the amount of drinking water consumption by inhabitants of different paras.Moreover, the possible contribution of other factors related to the host also must be taken into account.Mean fl uoride content in the hand pumps in the surveyed area was 4.50 ppm with parawise variation.

LIMITATIONS OF THE STUDY
The subject showing sign of fl uorosis was not assessed for serum and urine fl uoride level and role of other factors such as diet, biological and duration of exposure could not be explored in the present study.Apart from these, the relationship between fl uoride intoxication and ingestion of fl uoride is dependent upon meteorological factors, e.g., high temperature, consumption of dirty water laden with suspended an impurity which was not ruled out.Fischer's exact test to male and female (for male P = 0.438, female P = 0.500) Field case defi nitions were used for labeling types of fl uorosis.
Kyphosis deformity was seen in old age group and younger females.Out of total fl uorosis cases 50% of cases were dental fl uorosis, 38% were skeletal fl uorosis and remaining was combined fl uorosis.Table1depicts that the overall prevalence of fl uorosis was 23.1% among the surveyed population.Males were affected more as compared to females.Prevalence of dental fl uorosis was found to be more in male (13.6%) as compared to female (11.6%) while skeletal fl uorosis found to be more in female as compared to male.Dental fl uorosis (55%) and skeletal fl uorosis (38%) were the most common type of fl uorosis found among the surveyed inhabitants.Prevalence of dental fl uorosis was more in 13-19 years age group (34.6%) followed by 6-12 years (23.6%) while prevalence was lower in >45 years age groups.Prevalence of skeletal fl uorosis was more common in above 45 years age group among both sexes while lower in the children(6-12).Prevalence of dental fl uorosis was more in the students (29.2%) whereas skeletal fl uorosis was the highest among farmers (35.1%).Table2indicates the highest number of dental fl uorosis cases found in school para (36.1%) followed by Sadakpara (32.8%).Prevalence of genu varum was more in Nadigudaopara (14.2%) followed by Sadakpara as compared to other paras.Kyphosis prevalence was more in Natkolkapara and Uparpara while multiple fl uorosis deformities were observed in all paras but more prevalent in Sadakpara, Natkolkapara, and Uparpara.High prevalence was recorded in all surveyed hamlets, which may be associated with the highest fl uoride level (>7.0 ppm.) in the prime drinking water source.Natkolkapara had the highest prevalence of fl uorosis even at low fl uoride content in prime drinking water source.
The population pyramid of surveyed population had a broad base and tapering apex showing more number of child and younger population.Children below 12 years of age were 464 (27.7%), and teenagers were 280 (16.7%).The village is split into various paras (local name) according to locality and occupant of the village.Village (Hamlets) was heterogeneous in nature as per income status of occupants and engaged as marginal farmers, agriculture, and nonagricultural labor.32% of occupants were engaged in agriculture while 15% were nonagriculture labor and 28.9% were students.About 10.6% population was below 6 years while 2% were unemployed.Detail information about income of individual members could not be assessed.Dental fl uorosis and genu varum were the most common form of fl uorosis in surveyed paras.29 (7.0%) persons were suffering from multiple fl uorosis deformities ranging from mild to crippling stage.Children were affected by dental fl uorosis while adults were affected by skeletal fl uorosis.

Table 2 : Parawise prevalence of fl uorosis and water fl uoride concentration of drinking water sources
InternationalPrevalence of fl uorosis was >30% among primary school children where the fl uorine content of water was >7.0 ppm.A reason could be changing drinking water sources of the population, especially school going children.The association between water level of fl uoride and sex of fl uorosis affected persons was not signifi cant as shown in Table3.The fl uoride content of various prime drinking water sources in surveyed paras was ranging from 0.1 to 7.30 ppm.A village had mainly 26 water sources and almost all inhabitants depend upon tube wells.Fluoride concentration was >1.5 ppm in 34.0%(10/29) of tube wells.Surveyed village had nine established defl uoridation plant and out of those, fi ve plants had fl uoride level above 1.5 ppm.
Journal of Medicine and Public Health | Jul-Sep 2015 | Vol 5 | Issue 3