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1 Title A review of the effect of high fluoride content of water on health and environment and the strategy adopted for its prevention and control, with special reference to India Author(s) Dharmshaktu, Neha Citation Issued Date 2013 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 A Review of the Effect of High Fluoride Content of Water on Health and Environment and the Strategy Adopted for its Prevention and Control, with Special Reference to India submitted by DHARMSHAKTU Neha, B.E. M.Sc. Dissertation A dissertation submitted in partial fulfilment of the requirements for the Degree of Master of Science in Environmental Management at The University of Hong Kong June 2013

3 Disclosure Statement This dissertation is submitted in partial fulfilment of the requirements for the Master of Science Degree in Environmental Management from The University of Hong Kong. This dissertation represents the author's own work conducted for the purposes of this program. All significant data or analysis used in this dissertation which draws extensively on others sources - including work the author has carried-out for purposes other than for this program - has clearly been identified as such. Signed: DHARMSHAKTU Neha Printed Name: i

4 Abstract of dissertation entitled A Review of the Effect of High Fluoride Content of Water on Health and Environment and the Strategy Adopted for its Prevention and Control, with Special Reference to India submitted by DHARMSHAKTU, Neha for the degree of Master of Science in Environmental Management at the University of Hong Kong in June 2013 This study aimed to (1) review the reported levels of fluoride in drinking waters, food stuffs and other environmental media around the world, and the current magnitude of prevalence of fluorosis observed in human being and animals, with special reference to India and (2) critically evaluate the strategy adopted for prevention and control of the fluorosis problem in India by conducting questionnaire surveys with professionals from 11 endemic districts, and high school students of two schools located at an endemic area with high fluorosis incidences. Through a comprehensive literature review, it was able to identify 18 endemic states in India with high fluoride levels in their drinking waters while having various degrees of fluorosis problems. These states were further classified into three categories, namely high (>10 mg/l fluoride in drinking waters), moderate (5-9.9 mg/l) and low (1-4.9 mg/l) endemic regions. There were five, nine and four states falling into the high, moderate and low endemic categories, respectively. High fluoride concentrations were observed in the soil near industrial sites, foodstuffs and beverages, ii

5 and tea leaves. Also, adverse effects of fluoride on terrestrial and aquatic plants, terrestrial vertebrates and invertebrates, and aquatic vertebrates and invertebrates, were observed and demonstrated in laboratory conditions. The questionnaire survey with Indian professionals in 11 fluoride endemic districts found that although all districts had received funds for combating fluorosis problems, there had been delays in executing the associated health promotion, monitoring and treatment programmes in some districts and the utilisation of the fund for the programmes was quite slow. Staff appointment, staff training, medical treatment provision, education and awareness activities, referral hospital facility provision, vehicle facility, monthly reporting, clinical survey and water and urine samples testing, timely monitoring and supervision, and involvement of various medical staff, were found to be inadequate in most districts. In the questionnaire survey conducted at the two high schools, one of the schools (school A) was supplied with alternate source of filtered water (i.e., with normal fluoride concentration) and the second school (school B) was one, which had non-defluoridated ground water supply for drinking (i.e., with high fluoride concentration). This survey found that the awareness about signs of fluorosis, field visit of health worker, cause and preventability of fluorosis, and perception of spread of fluorosis, was comparatively better amongst students of school A than that of school B. Both the schools students had positive attitude towards cooperation, prevention and control efforts being made for fluorosis. iii

6 DEDICATED TO MY FAMILY AND FRIENDS iv

7 Acknowledgements It has been my immense pleasure and honour to be supervised by Dr. Kenneth Mei Yee Leung, Associate Professor of School of Biological Sciences, the University of Hong Kong. His vast knowledge and foresight have guided me at each step of this study. I am grateful and indebted in every possible way and shall always cherish this association with him. I am greatly indebted to my teachers from the School of Biological Sciences, Kadoorie Institute, Faculty of Engineering and Faculty of Law, the University of Hong Kong, for their patient teaching, guidance, valuable suggestions and healthy criticism, which helped me to present this work in a more scientific and methodical manner. My special thanks to all the central and state government officers of India s National Programme on the Prevention and Control of Fluorosis (NPPCF), the teachers of the high school students of the endemic districts in India, and the high school students themselves, for their cooperation. I would like to express thanks to my parents, my brother and my sister for their unconditional support and prayers, and for showing me the joy of intellectual pursuit ever since I was a child, all of who have helped me come so far. Thanks for being there for me. v

8 Last but not the least; I thank all my friends at the University of Hong Kong. Acknowledgements will remain incomplete without thanking the almighty for his kind benevolence and blessings. DHARMSHAKTU Neha vi

9 Table of Contents Topics Disclosure Statement Abstract Dedication Acknowledgements Table of Contents List of Tables List of Figures List of Abbreviations Page i ii iv v vii xiii xvi xviii Chapter 1: General Introduction Study Background Study Objectives Outline of the Dissertation 5 Chapter 2: Guidelines for Fluoride Concentrations in Drinking Water and 7 the Current Status of Fluorosis Around the Globe 2.1. Standards for Fluoride Concentrations in Drinking Water Global Magnitude and Distribution of the Problem of 10 Fluorosis Global Scenario - Present Status of Affairs Observations on Country-Wise Fluorosis Scenario 16 vii

10 due to Excessive Fluoride Levels in the Drinking Waters Chapter 3: Current Status of Fluorosis in India The Indian Background Fluorosis in India The Present Status of Affairs Fluorosis Management in India Objectives of the National Fluorosis Programme Framework of the National Fluorosis Programme Activities Undertaken in the National Fluorosis 25 Programme Chapter 4: Study Objectives and Methodology Study Objectives Methodology 26 Chapter 5: Levels of Fluoride in Different Environmental Media and Food 29 and Beverages 5.1. Methodology for Data Mining Introduction to Fluorosis and Fluoride Properties Causes for Fluoride in Environment Natural Causes Anthropogenic Causes Methods for Fluoride Detection and Removal Fluoride Concentration in Different Environmental Media 32 and Products Fluoride Concentration in Soil Media 33 viii

11 Observations Fluoride in Food and Beverages Fluoride in Drinking Water Fluoride Levels in the Air Fluoride Levels in Ambient Air and Outdoor 39 Air Near the Industrial Sources Fluoride in Infant Foodstuffs Fluoride in Surface Water Fluoride Concentrations in Indoor Air 46 Chapter 6: Effects of Fluoride on Human and Environment Methodology for Data Mining Short Term and Medium Term Effects of Fluoride on 49 Animals in the Laboratory and Field Observations on Short Term and Medium Term 56 Effects of Fluoride on Animals in the Laboratory and Field 6.3. Effect of Fluoride on Plants in the Laboratory and Field Observations on Effect of Fluoride on Terrestrial 61 and Aquatic Plants in the Laboratory and Field 6.4. Neoplastic and Non-neoplastic (Long-Term) Effects of 62 Fluoride on Test Animals and Humans Observations on Neoplastic (Cancerous) and Non- 65 Neoplastic (Non-Cancerous) (Long Term) Effects of Fluoride on Test Animals and Humans ix

12 6.5. Genotoxic, Reproductive and Developmental Effects of 66 Fluoride in Test Animals and Humans Observations on Genotoxic, Reproductive and 70 Developmental Effects of Fluoride in Test Animals and Humans 6.6. Effects of Fluoride in Humans from Accidental Acute 71 Exposure and Fluoride Therapy Observations on Effect of Fluoride in Humans After 72 Accidental Acute Exposure and Fluoride Therapy 6.7. Effect of Fluoride on Human Systems Observations on Effect of Fluoride on Various 77 Human Systems Chapter 7: Critical Review of the Strategy Adopted for the Prevention and 79 Control of Fluorosis in India 7.1. Introduction District Nodal Officer s Questionnaire Study Observations on Availability of Logistic Support in 80 the Endemic Districts Covered Under the National Fluorosis Programme Observations on Availability of Other Logistic 81 Support Provided in the Endemic Districts Covered Under the National Fluorosis Programme Observations on Involvement of General Health 81 x

13 Care Staff in the Endemic Districts Covered Under the National Fluorosis Programme Observations on Training Status of the Staff of 81 National Fluorosis Programme in Comparison to the Target Given in the National Guidelines Observations on Status of Clinical Fluorosis Survey 82 Done in the Endemic Districts Observations on Urine Samples Examined in 83 Suspected Cases Observations on Coordination, Monitoring and 83 Supervision of Programme in the Endemic District Observations on Activities Undertaken by the 84 District Rural Water Supply and Sanitation Department (RWSD) Observations on Three Most Important Constraints 84 and Suggestions Offered by the District Nodal Officers Summary of Findings of the District Nodal 85 Officer s Questionnaire Study 7.3. Knowledge, Attitude and Perception Study Findings from the Knowledge, Attitude and 86 Perception Study Chapter 8: Conclusions Summary of the Study 129 xi

14 8.2. Main Findings Findings from Review of Literature Findings from Survey of 11 Endemic Districts Findings from the Knowledge, Attitude and 132 Perception Study 8.3. Recommendations Limitations and Future Research 136 References 138 Annexure Annexure Annexure xii

15 List of Tables Table Table 2.1. Various Standards for the Fluoride Concentrations (mg/l) in Page 7 Drinking Water Set in Different Countries and by WHO Guidelines Table 6.1. Short Term and Medium Term Effects of Fluoride on Animals 49 in the Laboratory and Field Table 6.2. Effect of Fluoride on Terrestrial and Aquatic Plants in the 58 Laboratory and Field Table 6.3. Neoplastic (Cancerous) and Non-Neoplastic (Non-Cancerous) 62 (Long Term) Effects of Fluoride on Test Animals and Humans Table 6.4. Genotoxic, Reproductive and Developmental Effects of Fluoride 66 in Test Animals and Humans Table 6.5. Effect of Fluoride in Humans After Accidental Acute Exposure 71 and Fluoride Therapy Table 6.6. Effect of Fluoride on Various Human Systems 73 Table 7.1. Availability of Logistic Support for National Fluorosis 90 Programme in the Endemic Districts Covered Under the Programme Table 7.2. Availability of Other Logistic Support Provided in the Endemic 92 Districts Covered Under the Programme Table 7.3. Involvement of General Health Care Staff in the Endemic 94 Districts Covered Under the National Fluorosis Programme Table 7.4. Training Status of the Staff of National Fluorosis Programme in 96 xiii

16 Comparison to the Target Given in the National Guidelines Table 7.5. Status of Clinical Fluorosis Survey Done in the Districts 100 Table 7.6. Extent of Fluoride Level in Water in the Villages/Human 104 Habitations Surveyed Table 7.7. Result of Urine Samples Examined in Suspected Cases 106 Table 7.8. Coordination, Monitoring and Supervision of Programme in the 108 District Table Three Most Important Constraints and Suggestions Offered by 113 the District Nodal Officers Table Total Number of High School Students Present on Day of the 118 Interview and Response Received Table Comparison of Knowledge of Fluorosis between the High 119 School Students of the Two Schools Table Comparison of Knowledge of Cause and Prevention of 120 Fluorosis between the High School Students of the Two Schools Table Comparison of Testing of Drinking Water for Fluoride Content 122 between the High School Students of the Two Schools Table Comparison of Knowledge about Information, Education and 123 Communication (IEC) Activities between the High School Students of the Two Schools Table Comparison of Perception about the Symptoms of Fluorosis 125 between the High School Students of the Two Schools Table Comparison of Attitude Towards Fluorosis between the High 127 xiv

17 School Students of the Two Schools xv

18 List of Figures Figure Page Figure 2.1. Countries with Artificially Fluoridated Water Supplies 11 Figure 2.2. Global Fluoride Map Showing Fluorosis Endemic Areas 12 Figure 2.3(a). Country-Wise Fluorosis Status Associated with Excessive 13 Fluoride Levels in Drinking Waters Figure 2.3(b). Country-Wise Fluorosis Status Associated with Excessive 14 Fluoride Levels in Drinking Waters Figure 2.3(c). Country-Wise Fluorosis Status Associated with Excessive 15 Fluoride Levels in Drinking Waters Figure 3.1(a). Endemic Districts of India with High Fluoride 20 Concentrations in Groundwater Figure 3.1(b). Endemic Districts of India with High Fluoride 21 Concentrations in Groundwater Figure 5.1. Total and Water-soluble Fluoride Concentrations (mg/kg) in the 34 Soils Collected from Various Studies in Different Parts of the World Figure 5.2. Fluoride Concentrations (mg/kg) in Different Types of 36 Foodstuffs and Beverages Figure 5.3. Fluoride Concentrations (mg/l) in Fresh Water or Ground 38 Water from Different Parts of the World Figure 5.4. Fluoride Concentrations (μg/m3) in Ambient Air Samples 40 Collected in Different Countries xvi

19 Figure 5.5. Fluoride Concentrations (μg/m3) in the Outdoor Air Samples 41 Taken in Areas Near Industrial Sources in Various Countries Figure 5.6. Fluoride Concentrations (μg/l) in Infant Foodstuffs Stuffs 43 Figure 5.7. Natural Fluoride Concentrations (mg/l) in Ambient Surface 45 Unpolluted Water Figure 5.8. Fluoride Concentrations in Indoor Air Samples (mg/l) 47 Collected in the Netherlands and China xvii

20 List of Abbreviations AWW AIIHPH AIIMS ARWSP ATSDR ANM BFS CAS CHC m 3 DEO DNA DDWS DGHS DWI ESD Et al. GPD Aangan Waadi Worker All India Institute of Hygiene and Public Health All India Institute of Medical Sciences Accelerated Rural Water Supply Programme Agency for Toxic Substances and Disease Registry Auxiliary Nurse Midwifery British Fluoridation Society Chemical Abstracts Service Community Health Centre Cubic metre Data Entry Operator Deoxyribonucleic Acid Department of Drinking Water Supply Directorate General of Health Services Drinking Water Inspectorate Engineering Services Division Et alia Gallons Per Day > Greater than IEC Greater than or Equal to Information, Education and Communication xviii

21 IQ IAHS IWA IWTC Kg km LT Intelligence Quotient International Association of Hydrological Sciences International Water Association International Water Technology Conference Kilogram Kilometre Laboratory Technician < Less than L LLC l.f. LIVSFS MAC MCL MCLG μg Litre Limited Liability Company Linnaeus filius Livsmedelsverkets föreskrifter (National Food Agency s Regulation) Maximum Acceptable Concentration Maximum Contaminant Level Maximum Contaminant Level Goal Microgram µm Micro molar mg mm MHFW MHLW MHSSE MPW Milligram Milli molar Ministry of Health and Family Welfare Ministry of Health, Labour and Welfare Ministry of Health, Social Services and Equality Multi Purpose Health Workers xix

22 NICD NIN NPPCF NRC NTP NIS NGO N-E NEIA No. ppm National Institute of Communicable Diseases National Institute of Nutrition National Programme on Prevention and Control of Fluorosis National Research Council National Toxicology Programme Nigerian Industrial Standards Non-Governmental Organisation North East Northern Environmental Ireland Agency Number Part Per Million % Percentage PHC RGNDWM Rs. RWSD SMCL SC Suppl. UK TCVN TV UNICEF Primary Health Centre Rajiv Gandhi National Drinking Water Mission Rupees Rural Water Supply and Sanitation Department Secondary Maximum Contaminant Level Sub Centre Supplement United Kingdom Tiêu chuẩn Việt Nam Television United Nations Children s Emergency Fund xx

23 USEPA USA WEDC WES WHO Water SA United States Environmental Protection Agency United States of America Water, Engineering and Development Centre Water, Environment and Sanitation World Health Organization Water South Africa xxi

24 CHAPTER 1. General Introduction This chapter summarised the concentrations of fluoride in various environmental compartments by collecting relevant data from literature. Results are useful to determine the normal and abnormal levels of fluoride in these environmental media Study Background Currently in India, there are 230 districts in 18 states and union territories, which have been confirmed to be endemic for fluorosis (Susheela, 2002). Within these endemic districts, 66 million people have been identified to be at risk, while 25 million people are affected from the condition of dental fluorosis. Majority of the affected people (i.e., 6 million) are children who are less than 18 years of age (Susheela, 2002). In all of these states, the drinking water has a high fluoride concentration but the information about the various food items and industrial emissions having a high fluoride level is not available (MHFW, 2009). World Health Organisation (WHO) guidelines (2002) suggested that in moderately hot climate, the most favourable fluoride concentration in drinking water should remain less than 1 mg/l (1 ppm or part per million), since during warmer climate people tend to perspire frequently and thus drinking more water. In chilly climates, people do perspire as frequently and drink comparatively lesser water. Thus, in the chillier climate, the favourable fluoride concentration could reach up to 1.2 mg/l. Taking into account both of these cases, the 1

25 guideline value (permissible upper limit) in drinking water was set at 1.5 mg/l, by WHO (2002). Looking at national (Indian) level of fluoride contamination, the extent ranges from 1.0 to 48 mg/l (Susheela, 2002). India lowered its permissible limit to 1 ppm from 1.5 ppm in 1998 for defining contamination level in drinking water. In addition, there are significant environmental contaminations with fluoride, which are associated with unprotected mines, industrial emission, coal burning, and the use of fertilizers and pesticides (Quian, et al., 1999). Although throughout the early twentieth century fluoride was used for preventing dental cavities, now many researchers consider this more of a presumption than a fact, because of conflicting evidence from studies in India and several other countries over the last 10 to 15 years (Susheela, 2002). Nevertheless, there is universal agreement that excessive fluoride intake can lead to dental fluorosis (Susheela, 2002). For instance, severe, chronic and cumulative over-exposure of fluoride can cause incurable crippling skeletal fluorosis (Quian, et al., 1999). It has been proven that fluoride may be important for animals and humans, but the same cannot be said for humans, since there is no data available which can demonstrate its nutritional importance in humans (WHO, 2006). Fluoride concentrations as low as 1mg/kg of body weight have been found to produce signs of acute fluoride intoxication (Janssen et al., 1988 cited by WHO, 2006). Also, great deal of research studies in different countries have been carried out which have demonstrated adverse effects from long-term ingestion of fluoride through drinking water (WHO, 2006). These adverse effects were found to mainly affect the human skeletal and dental system, during the age of 22 to 26 months, which is the period when the secondary 2

26 upper central incisor teeth become mineralised (WHO, 2006). But it was also found that in low concentrations, fluoride in drinking water could provide protection against dental caries, especially in children (WHO, 2006). These positive and protective effects of fluoride have been found to increase with fluoride concentration up to about 2 mg/l in drinking water (WHO, 2006). But, as mentioned before, fluoride in drinking water at concentrations of mg/l can have negative effect on tooth enamel and give rise to mild dental fluorosis (prevalence: 12 33%; Dean, 1942). According to Cao (1992) and USEPA (1985a), because people perspire very frequently and drink more water in hot climates, dental fluorosis can occur at lower fluoride concentrations in drinking water. But, in areas where people are exposed to air, water, foodstuff or beverages, which contain high concentrations of fluoride, dental fluorosis will develop at fluoride concentrations <1.5 mg/l in drinking water (Cao, 1992). Another form of fluorosis called skeletal fluorosis (affecting bone structure and skeletal tissues) may be observed at fluoride concentrations between 3-6 mg/l in drinking water (Susheela, 2002). And the extreme form of skeletal fluorosis may occur at fluoride concentrations >10mg/L in drinking water (WHO, 2002). According to the USEPA (1985b), fluoride concentrations of 4 mg/l in drinking water may prove to be protective against extreme skeletal fluorosis. WHO (2006) states that fluoride concentrations >1.5 mg/l in drinking water may cause dental fluorosis with increasing risk at higher concentrations and may even lead to skeletal fluorosis. They also believe that there is yet no significant information, which can prove that their guidelines value set at 1.5 mg/l in drinking water needs to be revised. Their guidelines value for waters, which are artificially fluoridated, is between 3

27 mg/l (WHO, 2006). While setting guideline values for fluoride at local or international level, it is very important to consider intake from other possible routes (e.g., from air and food) and when the total intake values are found to be >6 mg/day, it is suggested to set the guideline value to <1.5 mg/l (WHO, 2006). While the endemicity of the problem of 230 districts in India has been identified more then a decade ago but so far only 91 districts have been released funds from the health department of central government to the states/union territories under National Programme for Prevention and Control of Fluorosis (NPPCF) of the Ministry of Health and Family Welfare (MHFW). The progress of providing filtered water supply by the Public Health Engineering Department, Ministry of Drinking Water and Sanitation is slow in India. Monitoring of fluoride levels in drinking water is conducted by the Public Health Engineering Department and the Ministry of Drinking Water and Sanitation, which fixes its own targets for providing safe drinking water. It is the MHFW, which decides endemicity of the district based on the water testing report of Ministry of Drinking Water and Sanitation. Government of India has realized the importance of the problem and created a system to prevent and control problem of fluorosis (MHFW, 2009) but the scaling up of the programme seems to be slow, perhaps the reason being that some of local implementing agencies do not view fluorosis as a major public health problem (MHFW, 2009). The present study has reviewed the literature to address the issue of effect of fluoride on human health and the environment (i.e., animals and plants) and also the industries responsible for the increase in fluoride emission. The study will give suggestions to the government and findings may be helpful in attracting the attention of 4

28 policy makers and will thereby be helpful to the affected people and better improve the environment from effect of fluoride Study Objectives The first objective of this study was to review the globally reported high fluoride levels in the various environmental media and the magnitude of prevalence of fluorosis observed in human being, terrestrial and aquatic plants and animals, with special reference to India. Second, a critical review was carried out to evaluate the effectiveness of various strategies adopted for the prevention and control of fluorosis in India Outline of the Dissertation This dissertation consists of eight chapters. The outline and content of each chapter are detailed below: Chapter 1: This chapter describes background of the study and introduces the global problem of fluorosis on an international and national (Indian) level. It also specifies the goals and objectives of this study. Finally, an outline of this dissertation is described to comprehend the rationale and development of this study. Chapter 2: This chapter compares International guidelines for protective fluoride levels 5

29 in drinking water. It further examines the global magnitude and distribution of the problem of fluorosis due to excessive fluoride levels in the drinking waters. Chapter 3: This chapter reviews the Indian magnitude and distribution of the problem of fluorosis due to excessive fluoride levels in drinking waters. It also evaluates the current state of fluorosis management in India. Chapter 4: This chapter illustrates the methodology of conducting the present study with regard to achieve the study aim. Chapter 5: This chapter reviews the relevant literature on the levels of fluoride in the different environmental media and foods and beverages in different countries over the past. Chapter 6: This chapter describes the effects of fluoride on human and the environment on the basis of review of past studies carried out worldwide. Chapter 7: This chapter describes the collection and analysis of primary data questionnaire surveys to professionals and general public as well as high school students at the endemic site. Chapter 8: This chapter concludes with the evaluation of the effectiveness of various strategies adopted for the prevention and control of fluorosis in India along with implications and recommendations. 6

30 CHAPTER 2. Guidelines for Fluoride Concentrations in Drinking Water and the Current Status of Fluorosis Around the Globe In this chapter, attempts have been made to summarize the available drinking water standards for fluoride concentrations in different parts of the world, and review the current situation of fluorosis around the globe Standards for Fluoride Concentrations in Drinking Water Various national and international standards for the level of fluoride in drinking water are tabulated in Table 2.1. Table 2.1. Various Standards for the Fluoride Concentrations (mg/l) in Drinking Water Set in Different Countries and by WHO Guidelines Type of Description Guideline References Standards value (mg/l) Indian Desired limit 1 Srimurali & standards Permissible limit in the 1.5 Karthikeyan, 2008 absence of other source WHO Guideline value 1.5 WHO, 2006 guidelines USEPA Maximum-contaminant-level 4 NRC,

31 standards goal (MCLG) Primary maximum 4 Contaminant Level (MCL) Secondary maximum 2 Canadian guidelines contaminant level (SMCL) Maximum acceptable concentration (MAC) 1.5 Ministry of Health of Government of Canada, 2010 Nigerian standards Maximum permissible limit 1.5 Standards Organization of Nigeria, 2007 Hong Kong Desired limit 0.5 Water Supplies Department of Government of Hong Kong Special Administrative Region, 2012 South Korea Maximum permissible limit 1.5 Ministry of Environment of Republic of Korea, 2013 Japan Standard value 0.8 MHLW, Singapore Maximum prescribed quantity 0.7 National Environmental Agency of Singapore, 8

32 2008 Malaysia Maximum permissible limit 1.5 ESD, 2004 Ireland Maximum permissible limit 1.5 NEIA, 2012 UK Maximum permissible limit 1.5 DWI, 2010 Vietnam Maximum permissible limit 1 Ministry of Public Health of Government of Vietnam, 1995 Spain Maximum permissible limit 1.5 MHSSE, 2003 Sweden Maximum permissible limit 1.5 NFA, 2011 Switzerland Maximum permissible limit 1.5 Bucheli, et al., 2010 Australia Maximum impurity concentration 1.5 National Resource Management Ministerial Council of Commonwealth of Australia, 2011 New Zealand Maximum acceptable value 1.5 Ministry of Health of Government of New Zealand, In 1984, WHO established the internationally recommended guideline value for the level of fluoride in drinking water (WHO, 2002) after an extensive review of all available literature on the effects of fluoride on humans. The problem of dental and skeletal fluorosis has been observed at fluoride concentrations in drinking water, 9

33 between 1.5 mg/l and 10 mg/l. The recommended guideline value of 1.5 mg/l is not fixed for every nation or region, and should be adapted according to the local conditions and factors such as the climate, diet and volume of water consumed (WHO, 2002) because these local conditions might be significantly different for different nations. However, due to lack of significant amount of data, it is still unclear (WHO, 2002) as to how many of such local conditions can be applied quantitatively. So, the best general recommendation for different regions/locations would be to establish and maintain a monitoring system for keeping the level of fluoride in check in the local drinking water supplies and to also regularly monitor the signs of excessive fluoride exposure in the local population (WHO, 2002) Global Magnitude and Distribution of the Problem of Fluorosis Global Scenario - Present Status of Affairs According to the British Fluoridation Society (2012), there are currently 25 countries, which artificially fluoridate their water and supply to an estimated population of 377,655,000. In addition, there are 28 more countries, which have naturally fluoridated water being supplied to more than 280 million people (BFS, 2012). The 25 countries, which artificially fluoridate their water supplies along with the estimated population coverage are shown in Figure

34 Figure 2.1. Countries with Artificially Fluoridated Water Supplies (BFS, 2012) It is estimated that around 200 million people from around 34 countries (Ayoob & Gupta, 2006; Choubisa et al., 1997; Hitchon, 1995; Karthikeyan et al., 1996;; Kloos & Tekle-Haimanot, 1999; Nyaora et al. 2002; Ponikvar, 2008) (Figure 2.2) are currently affected by the different types of fluorosis, as a result of the presence of excessive amounts of fluoride in the drinking waters (Figures 2.3(a), (b) and (c)). 11

35 Figure 2.2. Global Fluoride Map Showing Fluorosis Endemic Areas (WHO, 2006) 12

36 Country/Observations References India (Range throughout country) Susheela, 2003 (High fluoride levels found in Rajasthan) 69.7 WHO, 2006 (High fluoride levels found in Rajasthan) Upto 44 Agarwal et al., 1999 (High fluoride levels found in Haryana) 48 WHO, 2006 (High fluoride levels found in New Delhi) 32 Susheela & Bhatnagar, 1999 (High fluoride levels found in Assam) 23 WHO, 2006 (Occurrence of dental fluorosis observed) (Occurrence of skeletal fluorosis observed) Ayoob & Gupta, 2006 Ayoob & Gupta, 2006 Occurrence of crippling fluorosis observed) China 2.8 Ayoob & Gupta, 2006 (Maximum fluoride levels found in Kuitan, Zhuiger) Tanzania Upto 21.5 Wang et al., 1997; WHO, 2006 (Range throughout country, with Arusha, Kilimanjaro, Mwanza, Mara, Shinyanga & Singda) Mjengera & Mkongo, 2003 Republic of South Africa (Fluoride range throughout the country in Northwest province and Western Bushveld area) Coetzee et al., 2003; Grobler & Dreyer, 1988 (Pilansberg and Western Bushveld area) Upto 30 Grobler et al., 2001 (Dental fluorosis in 47% children from Sanddrif area) (Dental fluorosis in 50% children from Kuboes area) Mothusi, 1998 Mothusi, 1998 (Dental fluorosis in 95% children from Leeu-Gamka area) (Kenyan study where:) 3 Mothusi, 1998 (60% of 1000 ground water samples exceeded this level) 1 Nair et al., 1984 (20% of 1000 ground water samples exceeded this level) 5 Nair et al., 1984 (12% of 1000 ground water samples exceeded this level) 8 Nair et al., 1984 (Highest values observed in Elmentaita lakes) 1640 Nair & Manji, 1982 (Highest values observed in Nukuru lakes) 2800 Nair & Manji, 1982 (Skeletal fluorosis observed at this level) Ghana 18 Kau et al., 1997 (Dental fluorosis observed in 62% of the total school Apambire et al., 1997 children population of the Bongo) Sudan (High fluoride levels found in 60.4% of the population and 91% of the children population in two villages of Sudan) USA (Range of fluoride levels found in in Illinois) (Range of fluoride levels found in in Texas) (Range of fluoride levels in Yellowstone National Park) (Range of fluoride levels found in Western United States) (Range of fluoride levels in Southern California Lakeland) Mexico (Range of fluoride levels found in urban areas) (Range of fluoride levels found in rural areas) Ethiopia (Highest number of dental fluorosis cases were observed in the Ethiopian Rift Valley with skeletal fluorosis in Wonji-Shoa sugar estates of the Valley) Figure 2.3(a). Country-wise Fluorosis Status associated with Excessive Fluoride Levels in Drinking Waters Smith et al., 1953 Ibrahim et al., 1995 Cohen & Conrad, 1998 Driscoll et al., 1983 Neuhold & Sigler, 1960 Reardon & Wang, 2000 Segreto et al., 1984 Dfaz-Barriga et al., 1997 Dfaz-Barriga et al., 1997 Haimanot et al., 1987 Kloos & Tekle-Haimanot, 1993 Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration 13

37 Country/Observations Canada (Fluoride level observed in the regions of Alberta) 4.3 Health Canada, 1994 (Fluoride level observed in the regions of Saskatchewan) (Fluoride level observed in the regions of Quebec) (Range of fluoride levels found in Rigolet, Labrador region) Poland (High fluoride level was observed) Finland (High fluoride level was observed) Czech Republic (High fluoride level was observed) Brazil (Range of fluoride levels found in Paraiba state) (Range of fluoride levels found in Ceara state) Indonesia (Well waters of Asembagus coastal plain, Java, Indonesia) Israel (High fluoride level was observed in Negev desert region) Turkey (Denizli-Saraykoy and the Caldiran Plains) Senegal (In 30-60% of the children in region of Guinguinéo) (In 30-60% of the children in region of Darou Rahmane Fall) Uganda (Range of fluoride levels found in Rift Valley) Argentina (Fluoride levels in South-East Sub-Humid Pampa regions) Norway (Dental fluorosis observed in Hordaland, Norway) Germany (High fluoride level was observed in Muenster, Germany) Spain (Highest fluoride levels observed in Tenerife, Spain) Niger (Skeletal fluorosis observed in young boys in Tibiri, Niger) Nigeria (26.1% of entire population in Langtang town of Nigeria) Pakistan (Fluorosis observed in the areas nearby and within Naranji) Saudi Arabia (Highest fluoride levels reported in Mecca) (Highest fluoride levels reported in Hail ) Eritrea (The highest fluoride levels in Keren) 50 References 2.8 Health Canada, Health Canada, Ismail & Messer, 1996 >3 >3 >3 Czarnowski et al., 1996 WHO, 2002, 2006 WHO, 2002, Cortes et al., Cortes et al., 1996 Heikens et al., 2005 Upto 3 Milgalter et al., 1974 Upto 13.7 Azbar & Türkman, Brouwer et al., Brouwer et al., Rwenyonyi et al., Paoloni et al., Upto Bardsen et al., 1999 Queste et al., 2001 Hardisson et al., WHO, Wongdem et al., Shah & Danishwar, Al-Khateeb et al., 1991 Akpata et al., 1997 Srikanth et al., 2002 Figure 2.3(b). Country-wise Fluorosis Status associated with Excessive Fluoride Levels in Drinking Waters Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration 14

38 Country/Observations Sri Lanka (Maximum fluoride levels observed Upto 10 Dissanayake, 1996 in the North Central Province) Thailand (Fluorosis observed in Thailand) (Level in 1% of all natural water sources ) Japan (Dental fluorosis prevalent in 15.4% of population) Korea (25% of the wells in Southeastern >10 WHO, 2006 >2 WHO, 2006 Upto 1.4 Tsutsui et al., 2000 >5 Kim & Jeong, References Korea containing maximum fluoride levels) Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration Figure 2.3(c). Country-wise Fluorosis Status associated with Excessive Fluoride Levels in Drinking Waters 15

39 Observations on Country-wise Fluorosis Scenario due to Excessive Fluoride Levels in Drinking Waters i. The highest level of fluoride in the drinking water has been found in Kenya (i.e., 1640 mg/l and 2800 mg/l in Elementaita & Nakuru Lake), followed by in Ethiopia with 177 mg/l and in India with 69.7 mg/l (Haimanot et al., 1987; Kloos & Tekle-Haimanot, 1993; Nair & Manji, 1982; WHO, 2006). ii. Countries such as Ghana, Sudan, Uganda, Nigeria and Japan having drinking water fluoride levels between 1 to 3 mg/l showed prevalence of dental fluorosis (Apambire et al., 1997; Ibrahim et al., 1995; Rwenyonyi et al., 2000; Smith et al., 1953; Tsutsui et al., 2000; Wongdem et al., 2000). iii. Countries like India, Tanzania, Kenya, Ethiopia, Norway, Senegal and Niger having drinking water fluoride levels above 3 mg/l showed prevalence of severe dental fluorosis and/or skeletal fluorosis (Ayoob & Gupta, 2006; Bardsen et al., 1987; Brouwer et al., 1988; Haimanot et al., 1987; Kloos & Tekle-Haimanot, 1993; Mijengera & Mkongo, 2003; Nair & Manji, 1982; Nair et al., 1984; WHO, 2006). Hence, from the programme management point of view, water fluoride level above 3 mg/l may be taken as a risk factor for severe dental fluorosis and skeletal fluorosis and the water fluoride level 1 to 3 mg/l be taken as risk factor for dental fluorosis in endemic countries. iv. Specific categorization of other countries mentioned in Figures 2.4(a), (b) and (c), cannot be assigned as a broad category of fluorosis prevalence is used. 16

40 CHAPTER 3. Current Status of Fluorosis in India 3.1. The Indian Background Today India is the seventh biggest, and the second most heavily populated country in the world with a landmass of 3.29 million square km (slightly larger than a third of the United States) with more than 1.04 billion people, serving as a home for a- sixth of humanity (Planning Commission, 1996, 2002). Total population of India will exceed 1330 million in 2020 and water consumption is expected to move up by 20 40% (Planning Commision, 2002). India possesses 16% of the world s population but with just 4% of its water resources (Planning Commission, 1996). Though the surface water in India is scarce and groundwater is deep and difficult to reach (UNICEF, 2002), almost 90% of the drinking water needs are met from groundwater only. Even in urban areas, only 70% of people have access to basic sanitation services (Planning Commission, 2003) and 63% have tapped water within premises (Srinivas & Narender, 2003). In reality, about 50% of the total villages of India are facing drinking water scarcity (Planning Commission, 1996). Thus, the provision of reliable and potable water supply is still a challenge for most of the cities and towns in India, constituting a serious public health risk (Srinivas & Narender, 2003). The technological advances made in irrigation and drinking water sector developed almost simultaneously in India. While the technology has allowed drinking water to be pumped from the ground through bore wells and hand pumps, it also provided irrigation sector the means for unfettered pumping of ground water through 17

41 millions of irrigation bore wells (nearly 3.7 million in 2004), leading to imbalance in natural ecological system resulting in scarcity and pollution of ground water (Daw, 2004; UNICEF, 1999). This unregulated ground water tapping intensified the failure of drinking water sources and mainly paved the way for geogenic pollutants like fluoride contaminating the ground water (Daw, 2004). In addition, geological processes, weathering of fluoride bearing minerals in soil under different hydro-geological settings also contributed to higher groundwater fluoride levels in endemic areas (Daw, 2004). Thus the scarcity of groundwater and presence of excess fluoride can be treated as the two most crucial, critical and core issues in the Indian system of sustainable drinking water supply (Daw, 2004) Fluorosis in India The Present Status of Affairs In India, a high concentration of fluoride was first detected in drinking water at Nellore district of Andhra Pradesh in 1937 (Ayoob & Gupta, 2006). In early 1930 s fluorosis was reported only in four states of India, in 1986 it was 13, in 1992 it was 15, in 2002 it was 17 and now it is 18, indicating that endemic fluorosis has been emerging as one of the most alarming public health problem of the country. Among the affected states, Rajasthan, Andhra Pradesh and Gujarat are the three most endemic states (Planning Commission, 2002; Susheela, 2003). Districts known to be endemic for fluoride in various states of India and the ranges of fluoride concentrations being detected in their drinking groundwater are shown in Figures 3.1(b) and (b). The fluoride concentration in the groundwater is found to be more than 10 mg/l in the five states of 18

42 India including Andhra Pradesh, Haryana, Rajasthan, Maharashtra and Madhya Pradesh. It ranged from 5 to 9.9 mg/l in nine states of India namely Assam, Delhi, Gujarat, Karnataka, Kerala, Orissa, Punjab, Tamil Nadu and West Bengal. In the remaining four states of Chattisgarh, Bihar, Jammu and Kashmir, and Uttar Pradesh, the fluoride concentration ranges from 1.02 to 4.9 mg/l. Overall, there are 18 states in India having high fluoride concentrations in the groundwater. 19

43 State/City Assam (Goalpara, Kamrup, Nagaon, Anglong, Karbi) Susheela, 1999 (Guwahati) Andhra Pradesh (Adilabad, Anantpur, Chittoor, Guntur, Hyderabad, Medak Karimnagar, Khammam, Krishna, Kurnool, Mahbubnagar) (Nalgonda) (Kurmapalli) (Vamsadhara ) (Visakhapatnam ) (Wailapall ) Bihar (Aurangabad, Banka, Buxar, Jamui, Kaimur [Bhabua] Munger, Nawada, Rohtas, Supaul) Chhattisgarh (Bastar, Bilaspur, Dantewada, Janjgir-Champa, Jashpur, Kanker, Korba, Koriya, Mahasamund, Raipur, Rajnandgaon, Surguja) Delhi (East Delhi, North West Delhi, South Delhi, South West, Delhi, West Delhi, Kanjhwala, Najafgarh, Alipur) Gujarat (Ahmedabad, Amreli, Anand, Banaskantha, Bharuch Bhavnagar, Dohad, Junagadh, Kachchh) (Mehsana) (Mehsana) (Narmada, Panchmahals, Patan, Rajkot, Sabarkantha, Surat, Surendranagar, Vadodara) Haryana (Bhiwani) (Faridabad, Gurgaon, Hissar, Jhajjar, Jind, Kaithal, Sirsa Kurushetra, Mahendragarh, Panipat, Rewari, Rohtak, Sonepat) Jammu and Kashmir (Doda, Rajauri, Udhampur) Karnataka (Bagalkot, Bangalore, Belgaun) (Bellary) (Bidar, Bijapur,Chamarajanagar, Chikmagalur, Chitradurga, (Dharwad, Gadag, Gulburga, Haveri, Kolar, Koppal, Mandya, Davangere, Mysore, Raichur, Tumkur) Kerala (Palakkad) (Palghat) (Allepy, Vamanapuram, Alappuzha) Upto Upto References Das et al., 2003 Susheela, 1999 Rao et al., 1993 Mondal et al., 2009 Rao, 1997 Rao, 2009 Reddy et al., 2010 Susheela, 1999 Susheela, 1999 Susheela, 1999 Susheela, 1999 Salve et al., 2008 Dhiman & Keshari, 2006 Susheela, 1999 Garg et al., 2009 Das et al., 2003 Susheela, 1999 Susheela, 1999 Wodeyar & Sreenivasan, 1996 Susheela, 1999 Susheela, 1999 Shaji et al., 2007 Susheela, 1999 Figure 3.1(a). Endemic Districts of India with High Fluoride Concentrations (mg/l) in Groundwater Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration 20

44 State/City Maharashtra (Amravati, Chandrapur, Dhule, Gadchiroli, Gondia, Jalna, Nagpur, Nanded) (Yavatmal) Madhya Pradesh (Bhind, Chhatarpur, Chhindwara, Datia, Dewas, Dhar, Guna, Gwalior, Harda, Jabalpur, Jhabua, Khargaon, Mandsaur, Rajgarh, Satna, Seoni, Shajapur, Sheopur, Sidhi) Orissa (Angul, Balasore, Bargarh, Bhadrak, Bandh, Cuttack, Deogarh, Dhenkanal, Jajpur, Keonjhar, Sonapur) Punjab (Amritsar, Bhatinda, Faridkot, Fatehgarh Sahib, Firozepur, Gurdaspur, Mansa, Moga, Muktsar, Patiala, Sangrur) Rajasthan (Ajmer, Alwar, Banaswara, Barmer, Bharatpur, Bhilwara, Bikaner, Bundi, Chittaurgarh, Churu, Dausa, Dhaulpur, Dungarpur, Ganganagar) (Hanumangarh) (Jaipur, Jaisalmer, Jalor, Jhunjhunun, Jodhpur, Karauli, Kota, Nagaur, Pali, Rajsamand, Sirohi, Sikar, Sawai Madhopur, Tonk, Udaipur) Tamilnadu (Coimbatore, Dharmapuri, Dindigul) (Erode) (Karur, Krishnagiri, Namakkal, Perambalur, Puddukotai, Ramanathapuram, Salem Sivaganga, Theni, Thiruvannamalai, Tiruchirapally, Vellore, Virudhunagar) Uttar Pradesh (Agra, Aligarh, Etah, Firozabad, Jaunpur, Kannauj, Mahamaya Nagar, Mainpuri, Mathura, Mau) (Kanpur) West Bengal (Bankura, Bardhaman, Birbhum, Dakshindinajpur, Malda, Nadia, Purulia, Uttardinajpur) (Hooghly) References Susheela, Madhnure et al., 2007 Susheela, Susheela, 1999 Susheela, Susheela, Suthar et al., Susheela, Susheela, Karthikeyan et al., Susheela, 1999 Susheela, 1999 Sankararamakrishnan et al., Susheela, 1999 Kundu & Mandal, Figure 3.1(b). Endemic Districts of India with High Fluoride Concentrations(mg/L) in Groundwater Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration 21

45 3.3. Fluorosis Management in India Until 2008, there was no national programme for management of fluorosis in India. In 2008, in response to the urgency of the problem of fluorosis, the NPPCF was initiated during India s 11th Five Year Plan ( ) by the Planning Commission of India (MHFW, 2009). This national initiative has been handled by the joint collaboration of different governmental and non-governmental organisations like the MHFW, the Ministry of Drinking Water and Sanitation, the Rajiv Gandhi National Drinking Water Mission (RGNDWM) and UNICEF. Presently, data regarding prevalence of fluorosis in India is based on studies conducted by different groups over a period of time (MHFW, 2009). So far, the Department of Drinking Water Supply (DDWS), Government of India has collected baseline data of households of 196 districts in 19 States/union territories (MHFW, 2009). For the provision of safe drinking water, government of India supplements the efforts of state government and union territories by providing funds under the Accelerated Rural Water Supply Programme (ARWSP) (MHFW, 2009). It was when the chairman of National Human Rights Commission and the Prime Minister s Office reviewed the fluorosis situation in the country that a national programme for fluorosis control was recommended. The modality of the National Programme on Fluorosis falls under the supervision of the MHFW. A few number of government institutions like All India Institute of Medical Sciences (AIIMS), National Institute of Communicable Diseases (NICD), National Institute of Nutrition (NIN), and All India Institute of Hygiene and Public Health (AIIHPH) in India have the infrastructure for fluorosis diagnosis as and when requested for, mostly by State 22

46 Governments/NGO s (Non-Governmental Organisations)/research groups (MHFW, 2009). However, despite these efforts, inadequate information is available with practicing doctors regarding fluorosis. Thus, there is an urgent need to address these issues. A coordinated effort on part of different ministries is required to tackle this problem Objectives of the National Fluorosis Programme One of the objectives of the NPPCF includes collection, assessment and use of the baseline survey data on fluorosis made available by the DDWS (MHFW, 2009). Another objective is the comprehensive management of fluorosis in certain selected areas (100 endemic districts) (MHFW, 2009). Last but not the least the programme is also designed to foster capacity building for the prevention, diagnosis and management of fluorosis cases in India (MHFW, 2009) Framework of the National Fluorosis Programme The national programme is currently being implemented in 100 out of 196 endemic districts in 19 States/union territories in a phase-wise manner as a part of the Planning Commission s 11th Five Year Plan (MHFW, 2009). There are four phases in this programme (MHFW, 2009), including: i. Phase-I: This phase was carried out during the period 2008 to In the first year, baseline data was collected from the DDWS after which the programme was implemented in five districts (listed under) selected from each of the zones of the country based on prevalence data as collected from DDWS. These 23

47 districts were given community diagnosis, early detection and rapid management, capacity building by way of strengthening the laboratories, training of medical and laboratory manpower, surgery and Information, Education and Communication (IEC) materials. These five districts were: a. Southern zone (one district - Nellore, Andhra Pradesh); b. Western zone (one district Jamnagar, Gujarat); c. Northern zone (one district Nagaur, Rajasthan); d. Eastern zone (one district Nayagarh, Orissa) and e. Central zone (one district Ujjain, Madhya Pradesh). ii. Phase-II ( ): This phase was carried out during the period 2009 to The activities of the Phase-I were continued in this Phase along with the addition of 15 new districts. The activities carried out in these 15 districts were the same those in Phase-I. iii. Phase-III: This phase was carried out during the period 2010 to The activities of the Phase-II were continued with the addition of 40 more districts. iv. Phase-IV: This phase was carried out during the period 2011 to In the 4th year of the programme, coverage was given to 40 additional districts. At the beginning of this phase, the programme was evaluated by an independent organization after which necessary mid-term corrections/suggestions were incorporated into the programme of all the covered districts till date and those proposed to be covered in the 12th Five Year Plan of the Planning Commission ( ). Thus, in this manner, 100 districts out of total 196 endemic districts were covered in the 11th Five Year Plan. 24

48 Activities Undertaken in the National Fluorosis Programme According to MHFW (2009), the following activities have been undertaken in the National Fluorosis Programme (NPPCF): i. Community diagnosis of fluorosis according to village/block/cluster. ii. Village/block/district-wise facility mapping from prevention, health promotion, diagnostic facilities, reconstructive surgery and medical rehabilitation. iii. Gap analysis in facilities and organization of physical and financial support for bridging these gaps, according to the strategies listed above. iv. The diagnosis of individual cases and providing its management; and public health intervention on the basis of community diagnosis. v. Behavioural change by way of IEC materials. 25

49 CHAPTER 4. Study Objectives and Methodology 4.1. Study Objectives The aim of this study was to assess the extent of the problem of fluorosis and the priorities being given by the government of India. To achieve this, there were two objectives. The first objective of this study was to review the globally reported high fluoride levels in the various environmental media and the magnitude of prevalence of fluorosis observed in human being, terrestrial and aquatic plants and animals, with special reference to India. Second, a critical review was carried out to evaluate the effectiveness of various strategies adopted for the prevention and control of fluorosis in India. The hypothesis for the study was that fluorosis is not a high public health and environmental problem needing immediate attention of the Government of India. In order to address the objectives of the study and test the hypothesis, a methodology framework was prepared which is detailed below Methodology i. The Nutrition Division of Directorate of General Health Services, Ministry of Health and Family Welfare, Government of India defines a confirmed case or patient of fluorosis as one which has any of the clinical signs or symptoms of dental/skeletal/non-skeletal fluorosis alongwith fluoride concentrations >1 mg/l in the urine (Susheela, 2003). For this study, all signs and symptoms defined by 26

50 the Government of India under each category of suspected dental/skeletal/nonskeletal fluorosis was adopted. ii. The DGHS, MHFW, Government of India defines an endemic district for fluorosis as one which has the presence of any clinical sign of dental/skeletal fluorosis as well as presence of fluoride content of above 2.5 mg/l in drinking water from 25 or more than 25 habitations. For this study, this definition was adopted for the confirmation of an endemic district in India. iii. Categorization of a district as mild, moderate or high endemic was done on the basis of the definition adopted by the Nutrition Division, Directorate General Of Health Services (DGHS), Government of India: a. Mild Endemic District: Fluoride concentration in drinking water of the district is between 1 to 3 mg/l along with presence of signs of nonskeletal fluorosis in district population. b. Moderate Endemic District: Fluoride concentration in drinking water of the district is between 3.1 to 5 mg/l along with presence of signs of dental fluorosis in less then 20% of the district population. c. High Endemic District: Fluoride concentration in drinking water of the district is more 5mg/L along with presence of signs of dental fluorosis in more than 20% of the district population, or the presence of any case of skeletal fluorosis. iv. To assess the global extent of the problem of fluorosis, a review was done of the globally reported high fluoride levels in the various environmental media. The magnitude of prevalence of fluorosis observed in human being, terrestrial and 27

51 aquatic plants and animals, was further reviewed with special reference to India. The approach used for this included searching various databases and reading relevant scientific literature and government reports. v. To evaluate the effectiveness of the various strategies adopted for the prevention and control of fluorosis in India, two questionnaire surveys was carried out. First, information was collected from at least 10% of the total 91 district nodal officers of the NPPCF. Second, a knowledge, perception and behaviour survey was done through distant questionnaire method. This was carried out in an endemic area of an Indian district, where the NPPCF has been implemented for at least last three years. In the endemic district, information was collected from the high school students of two schools. One school was being supplied with alternate source of filtered water supply having normal fluoride concentration. And, the second school had non-defluoridated/pre-existing ground water supply for drinking, containing higher fluoride concentration. Both schools were located in the same endemic district. 28

52 CHAPTER 5. Levels of Fluoride in Different Environmental Media and Foods and Beverages This chapter summarised the concentrations of fluoride in various environmental compartments by collecting relevant data from literature. Results are useful to determine the normal and abnormal levels of fluoride in these environmental media Methodology for Data Mining The approach used for this literature review included searching various databases and reading relevant scientific literature and government reports. The search of the available data and literature was primarily conducted through searching the following databases: a. Thomson Reuters Web of Knowledge database ( o?product=wos&search_mode=generalsearch&sid=t1fenchjnni3fk2hkad&p referencessaved=), b. Elsevier s Scopus or SciVerse Scopus database ( and c. University Microfilms International s ProQuest LLC database ( 29

53 The above three listed databases were searched by using the key word of fluorosis. All the articles that were listed as a result of the search were investigated for relevance and the retrieved information was tabulated. In addition to this step, a further search in these articles reference lists and citation lists was made to include any additional connections in the review. Finally, a search of Google and Google scholar using the key words fluorosis, fluorosis in India and global fluorosis was made Introduction to Fluorosis and Fluoride Properties According to the Merriam-Webster s collegiate dictionary (2003): Fluorosis is an abnormal condition (as mottling of the teeth) caused by fluorine or its compounds. Thus, we see that it is fluorine, the thirteenth most abundant element, which is the main cause of the global problem of fluorosis (Cao et al., 1992; Weinstein & Davison, 2003). Being electronegative and reactive, fluorine has a natural tendency of combining with every other element (except for inert gases) (Dean, 1942; Gillespie et al., 1989) to produce compounds like hydrogen fluoride and sodium fluoride in water. In case of humans, fluoride is deposited in the form of calcium fluorite crystals, after combining with the calcium found in the bones and teeth (Susheela, 2003). Fluoride may also get discharged from the human body by way of sweat, urine and stool, but the extent of discharge will depend on various factors like the age, nutritional status, climatic conditions and so on (Susheela, 2003). 30

54 5.3. Causes for Fluoride in Environment Fluoride can be found in the different environmental media like air, water, soil and food, due to both natural and anthropogenic causes. Both of these are explained in details in the following sections Natural Causes The fluoride found naturally in the environment is due to the weathering of fluoride rich rocks, volcanic ash, and marine aerosols (ATSDR, 1993; Symonds et al., 1988). Fluoride rich rocks include igneous, sedimentary and metamorphic rocks. Igneous rocks like granite and volcanic rocks, sedimentary rocks like limestone, and metamorphic rocks like quartzite, contain a fluoride concentration between 100 to >1000 mg/l, 200 to 1000 mg/l, and 100 to > 5000 mg/l, respectively (Frencken, 1992) Anthropogenic Causes Fluoride may also be released into the environment (air, water and soil) through the discharge of wastewater, fumes or solid waste from industrial processes like phosphate fertilizer, glass, brick and steel production, to name a few. Other than these, possible sources may include pesticides, drinking water fluoridation and coal burning (Health Canada, 1994; Sloof et al., 1989; USEPA, 1999). 31

55 5.4. Methods for Fluoride Detection and Removal There are various methods for fluoride determination in the urine, serum, plasma, organs, bone, teeth, foodstuffs, air, water and soil, and these include the potentiometry method, spectrophotometry method, gas chromatography method, ion chromatography method, capillary electrophoresis method, atomic absorption method and photon activation method (ATSDR, 1993). Out of all of these, the potentiometry is the most commonly used method in both developing and developed countries (ATSDR, 1993). For the removal of fluoride from the groundwater, there are nine most commonly used methods around the globe with varying frequency in developed and developing countries. These are the Activated Alumina method, Ion Exchange method, Reverse Osmosis method, Electro-dialysis method, Nalgonda technique, Contact Precipitation method, Bone Charcoal method and the Calcined Clay method (Feenstra et al., 2007). Out of these, the most commonly used method (e.g. in India) is the Nalgonda technique. In addition to these, new technologies have been developed in Netherlands, Denmark and India, in recent years, like the Crystalactor technology, Memstill technology, Water Pyramid Solution technology, Solar Dew Collector System technology, Brushite and Calcite Boiling method and the use of new absorbents (Feenstra et al., 2007) Fluoride Concentrations in Different Environmental Media and Products The intake of fluoride can be originated from various sources like the air, water, foodstuffs, beverages and consumer products. The fluoride concentrations found in the 32

56 different products and environmental media, in different countries and studies, have been given below, in form of figures (that is, Figures 5.1 to 5.8). The observations made from each of these figures have been further discussed in the following sections Fluoride Concentration in Soil Media The total and water-soluble fluoride concentrations found in some soils of various countries by research studies has been depicted in Figure 5.1. In Figure 5.1, the total fluoride concentration (coloured rectangles) and the water-soluble fluoride concentration (grey coloured rectangles) (in mg/kg) have been given for different soils found in the different countries like Canada (Blue), USA (orange), Greece (purple), Netherlands (pink) and China (orange). These fluoride levels have been given for different sites, at varying distances from the industrial facilities like aluminium smelter, phosphorous plant and petrochemical waste site. 33

57 Country/Soil details Canada (3 reference soil sample) (23 reference soil sample) (Forest soil sample) (Various forest soil sample) (0.7km N-E of Phosphorous plant) (18.7km N-E of Phosphorous plant) USA (55 soil sample) (201 soil sample) (Forest soil sample) (7 soil sample from Aluminium plant) (Reference site) (Petro-chemical waste site) Greece (0-4km from Aluminium plant) (5-15km from Aluminium plant) (8-15km from Aluminium plant) Austria (0.5km from Aluminium smelter) (1km from Aluminium smelter) (4km from Aluminium smelter) (15km from Aluminium smelter) Netherland China < Figure 5.1. Total and Water-soluble Fluoride Concentrations (mg/kg) in the Soils Collected from Various Studies in Different Parts of the World References Schuppli, 1985 Schuppli, 1985 Sidhu, 1982 Sidhu, 1979 Sidhu, 1979 Sidhu, 1979 Gilpin & Johnson, 1980 Omueti & Jones, 1977 Polomski et al., 1982 McClenahen, 1976 Schroder et al., 1999 Schroder et al., 1999 Tsiros et al., 1998 Tsiros et al., 1998 Tsiros et al., 1998 Tscherko & Kandeler, 1997 Tscherko & Kandeler, 1997 Tscherko & Kandeler, 1997 Tscherko & Kandeler, 1997 Sloof et al., 1989 Fung et al., 1999 Colored bars - Total fluoride concentration in mg/kg Grey bars - Water-soluble fluoride concentration in mg/kg All values are mean or range of fluoride concentration 34

58 Observations Amongst all the countries, the total fluoride concentration is the highest in soils collected at the petrochemical waste site in the United States (Figure 5.1; Schroder et al., 1999). In Canada and Greece, the highest total fluoride values were found within 0.7 km of the Phosphorous plant and 4 km of the Aluminium plant, respectively (Sidhu, 1979; Tsiros et al., 1998). In Austria, only water-soluble fluoride levels were studied, which were found to be highest within 4 km of the aluminium smelter (Tscherko & Kandeler, 1997). In Netherlands and China, 72 and 19 samples of agricultural soil were studied, respectively (Fung et al., 1999; Sloof et al., 1989) Fluoride in Food and Beverages Fluoride concentrations in different types of foods and beverages found in various countries are summarized in Figure 5.2. In Figure 5.2, the fluoride concentration (coloured rectangles) (in mg/kg except for liquids, which is in mg/l) has been given for each type of foodstuffs and beverages found in the different countries like Canada (Blue), Hungary (green), Germany (purple), USA (orange), China (light orange) and Hong Kong (red). Amongst all the different kinds of foodstuffs and beverages, the highest fluoride content was found in the tea leaves of Hong Kong, China and Hungary (Chen et al., 1996; Schamschula et al., 1988; Wei et al., 1989). 35

59 Country/Foodstuffs and Beverages Canada (Dairy products) (Cooked and raw meat and poultry) (Fish) (Baked goods and cereals) (Raw, cooked and canned vegetables) (Fruit and fruit juices) (Fat and oil) (Sugar containing products) (Beer, wine, coffee and soft drink) (Tea) Hungary (Dairy products) (Cooked and raw meat and poultry) (Soup ) (Baked goods and cereals) (Raw, cooked and canned vegetables) (Fruit and fruit juices) (Sugar containing products) (Coffee and soft drinks) (Tea) Germany (Soft drinks) Bergmann, 1995 (Milk and milk products) (Canned meat and sausage) Bergmann, 1995 Bergmann, 1995 (Bread and grains) Bergmann, 1995 (Vegetables) Bergmann, 1995 (Fruits) (Fruit juices) (Herbals and childern s tea) (Black tea) USA (Fish) (Fruit juice and juice flavoured beverage) (Soft drinks) China (Rice) (Vegetables) (Tea) Hong Kong (Tea) References Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Dabeka & McKenzie, 1995 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Schamschula et al., 1988 Bergmann, 1995 Bergmann, 1995 Bergmann, 1995 Bergmann, 1995 Whitford, 1996 Kiritsy et al., 1996 Heilman et al., 1999 Chen et al., 1996 Chen et al., 1996 Chen et al., 1996 Wei et al., 1989 Colored bars - Total fluoride concentration in mg/kg All values are mean or range of fluoride concentration Figure 5.2. Fluoride Concentrations (mg/kg) in Different Types of Foodstuffs and Beverages 36

60 Fluoride in Drinking Water The fluoride concentrations found in the fresh water or ground water of some developed countries by various research studies are summarized in Figure 5.3. In Figure 2.3, fluoride concentrations (coloured rectangles) (in mg/l) have been given for different types of fresh water or ground water found in different countries like Canada (dark blue), Czech Republic (green), Finland (light orange), Germany (purple), Netherland (pink), Poland (light blue) and USA (dark orange). Amongst the given developed countries, the highest fluoride concentration was found in water samples from Finland (Figure 5.3; Korkka-Niemi et al., 1993; Lahermo & Backman, 2000; Lahermo et al., 1990). 37

61 Country/Survey details Canada (Non-fluridated samples-67 communities, 5 provinces) (Fluridated samples-320 communities, 8 provinces) Czech Republic (>4000 drinking water samples-36 districts) Finland (5900 ground water samples) (1421 well water samples) (7229 shallow well water samples) (571 drilled well water samples) Germany (Various drinking water facilities) Netherland (Drinking water samples-12 provinces) Poland (Drinking water samples-94 localities) USA (Public drinking water serving 62% US population) (Public drinking water serving 14% US population) (52 bottled water varieties-houston, Texas, USA) (Bottled water varieties-cleveland, Ohio, USA) (>24 domestic & imported bottled water varieties) < < < < < < < References Health Canada, 1994 Health Canada, 1994 NIPH, 1996 Lahermo et al., 1990 Korkka-Niemi et al., 1993 Lahermo & Backman, 2000 Lahermo & Backman, 2000 Bergmann, 1995 Sloof et al., 1989 Czarnowski et al., 1996 USEPA, 1985; USDHHS, 1991 USEPA, 1985; USDHHS, 1991 Tate & Chan, 1994 Lalumandier & Ayers, 2000 Nowak & Nowak, 1989; Stannard et al., 1990 Figure 5.3. Fluoride Concentrations (mg/l) in Fresh Water or Ground Water from Different Parts of the World Colored bars - Total fluoride concentration in mg/l All values are mean or range of fluoride concentration 38

62 Fluoride Levels in the Air Fluoride Levels in Ambient Air and Outdoor Air Near the Industrial Sources Fluoride concentrations found in the ambient air and in the outdoor air near the industrial sources of some countries by various research studies are summarised and tabulated as shown in Figures 5.4 and 5.5. In Figures 5.4 and 5.5, fluoride concentrations (coloured rectangles) (in μg/m 3 ) have been given for the different locations in different countries like Canada (dark blue), USA (dark orange), UK/Norway (green), Netherland (pink), South Africa (purple), and China (light orange). In Figure 5.5, the grey coloured rectangles represent the distance (in km) of the different sites from industrial sources. Fluoride concentrations in the ambient air ranged from μg/m 3 in Arctic region, Canada to 0.17 μg/m 3 in the UK (Figure 5.4; Barrie & Hoff, 1985; Bennett & Barratt, 1980). In Figure 5.5, it is observed that the fluoride content in the outdoor air (near industrial sources) has been reported to be the highest in China (Liu, 1995), out of all the countries indicated. 39

63 Country Canada (3 Arctic location, Canada) (Toronto, Ontario, Canada) USA (147 non-industrial urban locations) (29 rural locations) UK (1 non-industrial urban location) Netherland (4 non-industrial urban locations) < 0.05 < 0.05 < References Barrie & Hoff, 1985 Health Canada, 1994 Thompson et al., 1971 Thompson et al., 1971 Bennett & Barratt, 1980 Sloof et al., 1989 Colored bars - Total fluoride concentration in µg/m3 All values are mean or range of fluoride concentration Figure 5.4. Fluoride Concentrations (µg/m3) in Ambient Air Samples Collected in Different Countries 40

64 Country/Site location Canada (Cornwall Island, Ontario) (Cornwall Island, Ontario) (Brampton, Ontario) (Trail, British Columbia) (Quebec) South Africa (Highveld) Norway Netherland (Groningen) (Zeeland) China < < References Health Canada, 1989 Health Canada, 1989 Health Canada, 1994 Health Canada, 1994 Health Canada, 1994 Scheifinger & Held, 1997 Søyseth et al., 1996 Sloof et al., 1989 Sloof et al., 1989 Liu, 1995 Colored bars - Total fluoride concentration in µg/m3 Grey bars - Distance of site from industrial source in km All values are mean or range of fluoride concentration Figure 5.5. Fluoride Concentrations (µg/m3) in the Outdoor Air Samples taken in Areas near Industrial Sources in Various Countries 41

65 Fluoride in Infant Foodstuffs Fluoride concentrations found in the various types of infant foodstuffs in different countries are summarized in Figure 5.6. In Figure 5.6, the fluoride concentration (grey rectangles) (in mg/l) has been given for the different types of infant foodstuffs. The results showed that there were wide variations in the fluoride concentrations in infant foodstuffs ranging from 5 μg/l in human milk to 5000 μg/l in poultry containing products. 42

66 0 Type of Infant food/reference Human milk Ekstrand et al.,1984; Esala et al., 1982; Spak et al.,1983 Ready to feed Johnson & Bawden, 1987; McKnight-Hanes et al., 1988 Concentrated liquid Johnson & Bawden, 1987; McKnight-Hanes et al., 1988 (Milk based) (Isolated soybean based) Powdered Johnson & Bawden, 1987; McKnight-Hanes et al., 1988 (Milk based) (Isolated soybean based) Products except dry cereal Dabeka et al., 1982; Singer & Ophaug, 1979 Fruit Juices Dabeka et al., 1982; Singer & Ophaug, (Produced with non-fluoridated water) (Produced with fluoridated water) Dry cereal Dabeka et al., 1982; Singer & Ophaug, 1979 (Produced with non-fluoridated water) (Produced with fluoridated water) Wet pack cereal fruit products Dabeka et al., 1982; Singer & Ophaug, 1979 Poultry containing products Dabeka et al., 1982; Singer & Ophaug, Grey bars - Fluoride concentration in µg/l All values are mean or range of fluoride concentration Figure 5.6. Fluoride Concentrations (µg/l) in Infant Foodstuffs Stuffs 43

67 5.6. Fluoride in Surface Water Fluoride concentrations found in the natural ambient surface unpolluted water of some countries are summarized in Figure 5.7. In Figure 5.7, the fluoride concentration (grey coloured rectangles) (in mg/l) has been given for the ambient surface unpolluted water found in different countries by different research studies. Amongst the given countries, the highest fluoride concentration was found in Kenya and the United States (Figure 5.7; Nair et al., 1984; Neuhold & Sigler, 1960). 44

68 Country/Reference Canada Health Canada, 1994 USA Overton et al., 1986 Camargo et al., 1992 Neuhold & Sigler, 1960 Neuhold & Sigler, 1960 Sigler & Neuhold, upto 13 Belgium Van Craenenbroeck & Marivoet, 1987 France Martin & Salvadori, 1983 Norway Skjelkvåle, 1994 Spain Camargo, 1996 UK Fuge & Andrews, 1988 Neal, 1989 Nigeria Nriagu, 1986 India Zingde & Mandalia Datta et al., 2000 China Cao et al., 2000 Kenya Nair et al., < < upto 2800 Grey bars - Fluoride concentration in mg/l All values are mean or range of fluoride concentration Figure 5.7. Natural Fluoride Concentrations (mg/l) in Ambient Surface Unpolluted Water 45

69 5.7. Fluoride Concentrations in Indoor Air Fluoride concentrations found in the indoor air samples from the Netherlands and China are summarized in Figure 5.8. The data available for fluoride concentrations in indoor air samples are very limited. Fluoride concentrations in the indoor air ranged from <2 mg/l in Netherlands to 155 mg/l in certain parts of China (Sloof et al., 1989; Zhang & Cao, 1996). Comparatively, the level is higher in China than in the Netherlands. 46

70 Country/Refences Netherland Sloof et al., 1989 China Gu et al., 1990 Liu, 1995 Zhang & Cao, < Grey bars - Fluoride concentration in mg/l All values are mean or range of fluoride concentration Figure 5.8. Fluoride Concentrations in Indoor Air Samples (mg/l) collected in the Netherlands and China 47

71 CHAPTER 6. Effects of Fluoride on Human and Plants and Animals This chapter summarised the effects of fluoride in human and plants and animals by collecting relevant data from literature. Results are useful to determine the effects of fluoride at different levels of fluoride in the test subjects Methodology for Data Mining The approach used for this literature review included searching various databases and reading relevant scientific literature and government reports. The search of the available data and literature was primarily conducted through searching the following databases: a. Thomson Reuters Web of Knowledge database ( input.do?product=wos&search_mode=generalsearch&sid=t1fenchjnni 3Fk2hkAD&preferencesSaved=), b. Elsevier s Scopus or SciVerse Scopus database ( and c. University Microfilms International s ProQuest LLC database ( The above three listed databases were searched by using the key word of fluorosis, fluoride toxicity and effect of fluoride. All the articles that were listed as 48

72 a result of the search were investigated for relevance and the retrieved information was tabulated. In addition to this step, a further search in these articles reference lists and citation lists was made to include any additional connections in the review. Finally, a search of Google and Google scholar using the key words fluorosis, effect of fluoride and fluoride toxicity was made Short and Medium Term Effects of Fluoride on Animals in the Laboratory and Field The short and medium term effects of fluoride on the terrestrial and aquatic animals found in different countries and studies are tabulated in Table 6.1. Table 6.1. Short Term and Medium Term Effects of Fluoride on Animals in the Laboratory and Field Country Test animals Fluoride concentration 1. Terrestrial Vertebrates in the Laboratory Conditions A. Short Term Exposure Effects References USA Male and female mg/l Reduced survival in NTP, 1990 F344/N rats (Rattus both male and female norvegicus) rats (after 14 days) USA Male and female mg/l Reduced survival only NTP, 1990 B6C3F1 mice (Mus in male mice (after 14 musclus) days) Canada Female Wistar rats mg/l Inhibition of cancellous Harrison et al., 49

73 (Rattus norvegicus) bone mineralization 1984 (after 5 weeks) USA Male Holtzman rats 85.5 mg/l Inhibition of endosteal Turner et al., (Rattus norvegicus) bone formation and 1989 reduction in cancellous bone volume (after 21 days) Turkey Male albino rats (Rattus norvegicus) USA Male Sprague- Dawley rats (Rattus norvegicus) France Male C57BL/6 14 mg/kg Delayed fracture healing and reduction in collagen synthesis (after 30 days) 17.5 mg/kg Increase in dermatan sulfate and chondroitin- 6-sulfate in the tibia (after 1-2 months) 0.8 mg/kg Increase in bone matrix Uslu, 1983 Prince & Navia, 1983 Marie & Mott, mice (Mus formation (after musclus) weeks) China Male Wistar rats 100 mg/l Ultra-structural changes Pang et al., 1996 (Rattus norvegicus) in skeletal muscles (after 8 weeks) India Male Swiss mice 5.2 mg/kg Reduced red blood cell Pillai et al., 1988 (Mus musclus) and lymphocyte counts and increased number of eosinophils monocytes, and basophils (after 35 days) 50

74 B. Medium Term Exposure USA Adult rats (Rattus mg/l Decreased femoral Turner et al., norvegicus) bone bending strength 1992 (after 16 weeks) Denmark Female Wistar rats 100 or 150 mg/l Reduced vertebral bone Søgaard et al., (Rattus norvegicus) quality (after 90 days) 1995 USA Male and female >22.7 and 45.4 Altered bone NTP, 1990 B6C3F1 mice (Mus musclus) mg/l remodelling (after 6 months) USA F344/N rats (Rattus 45.4 mg/l Hyperplasia of fore- NTP, 1990 norvegicus) stomach (nonglandular) (after 6 months) 136 mg/l Lymphocytic infiltration, hyperplasia and necrosis of glandular stomach (after 6 months) India Rabbits 22.7 mg/kg Reduced maturation Sharma, 1982 and metabolism of collagen (after 136 days) 2. Terrestrial Invertebrates in the Laboratory Conditions Short Term and Medium Term Exposure China Silkworms 30 mg/kg Threshold level for Wang & Bian, (Bombyx mori) mortality mg/kg 30% mortality observed mg/kg 70% mortality observed 51

75 mg/kg 95% mortality observed >80 mg/kg Inhibition of cocoon production USA Flour beetles 4524 mg/kg Egg production and Johansson & (Tribolium confusum) survival were adversely affected (after 27 days) mg/kg Significant stimulation of egg production (after 1 7 days) Johansson, Terrestrial Vertebrates in the Field UK Field voles (Microtus agrestis) and Bank voles (Clethrionomys glareolus) 549 mg/kg Severe dental lesions in voles near chemical plant 187 mg/kg Severe dental lesions in voles near near aluminium smelter 80 mg/kg Less severe dental lesions in voles near mine tailings Boulton et al., 1994 UK Field voles up to 15,000 mg/kg Between m of Walton, 1987 (Microtus agrestis) aluminium smelter, Wood (Apodemus sylvaticus) Moles europaea) mice (Talpa severe dental damage was seen and significantly increased tooth wear was seen between 4 and 15 km of 52

76 smelter USA Cotton rats (Sigmodon hispidus) 1515 mg/kg Dental fluorosis observed in 80% of the rats at petrochemical site Schroder et al., Terrestrial Invertebrates in the Field USA Honeybees (Apis mellifera) mg/kg No significant effect of fluoride on bees or honey development or bees survival observed Mayer et al., 1988 USA Cabbage looper (Trichoplusia ni) mg/kg No significant effect Hughes et al, 1985 UK Lepidoptera (Pieris brassicae) Up to 500 mg/kg No significant effect Port et al., Aquatic Invertebrates in the Laboratory Conditions Short Term and Medium Term Exposure Sweden Water flea (Daphnia magna) 205 mg/l Immobilisation (after 24 hours) 98 mg/l Immobilisation (after 48 hours) >8.9 mg/l Reduced survival time >3.7 mg/l Partial growth inhibition (after 7 days) Dave,

77 and inhibition of parthenogenetic reproduction 4.4 mg/l Safe concentration South Prawn (Penaeus 1118 mg/l 50% population death McClurg, 1984 Africa indicus) (after 96 hours) USA Mysid shrimp (Mysidopsis bahia) 10.5 mg/l 50% population death (after 96 hours) LeBlanc, 1984 Spain Caddisfly 120 mg/l 50% population death Camargo, 1991 (Chimarra (after 48 hours) marginata) 79.7 mg/l 50% population death Camargo, 1991 (after 72 hours) 44.9 mg/l 50% population death (after 96 hours) Camargo Tarazona, 1990 & 6. Aquatic Vertebrates in the Laboratory Conditions Short Term and Medium Term Exposure USA Rainbow trout (Oncorhynchus mykiss) 200 mg/l 50% population death (after 96 hours) Smith et al., 1985 Fathead minnow 315 mg/l 50% population death (Pimephales (after 96 hours) promelas) Threespine stickleback 340 mg/l 50% population death (after 96 hours) (Gasterosteus aculeatus) Bluegill (Lepomis >240 mg/l 50% population death LeBlanc, 1984 macrochirus) (after 96 hours) 7. Aquatic Invertebrates in the Field 54

78 USA Water flea (Daphnia magna) >26 mg/l Reproduction impairment (after 3 weeks) Fieser et al., 1986 South Brown mussel 7.2 mg/l 30% mortality observed Hemens & Africa (Perna perna) (after 5 days) Warwick, 1972 Spain Caddisfly species (Hydropsyche pellucidula) 0.39 mg/l Safe concentration (after 8760 hours) Camargo & La Point, 1995 Caddisfly species 1.18 mg/l (Hydropsyche lobata) Caddisfly (Chimarra marginata) species 1.79 mg/l 8. Aquatic Vertebrates in the Field India Adult leopard frogs 1.9 mg/l Hatching delayed by 6 Pillai & Mane, (Rana pipiens) hours 1984 >3.2 mg/l Hatching delayed by 1 2 hours USA Freshwater catla (Catla catla) 5-50 mg/l Reduced total red and white cell numbers mg/l Reduced survival time Kaplan et al.,

79 Observations on Table on Short Term and Medium Term Effects of Fluoride on Animals in the Laboratory and Field From short-term studies on terrestrial vertebrates in the laboratory (Section 1A, Table 6.1) it was found that fluoride concentrations as small as 0.8 mg/kg (in mice) can increase the bone matrix formation, while fluoride concentration of mg/l (in mice and rats) can reduce the survival of both male and female mice/rats (Marie & Mott, 1986; NTP, 1990). Medium term studies done on terrestrial vertebrates (Section 1B, Table 6.1) in the laboratory found that fluoride level of 22.7 mg/kg reduces the maturation and metabolism of collagen, while that ranging from mg/l can effectively cause altered bone remodelling and hyperplasia of glandular and nonglandular stomachs in mice and rats (Sharma, 1982; NTP, 1990). Short term and medium term studies on terrestrial invertebrates (Section 2, Table 6.1) done in the laboratory in China and USA, found that the threshold level of mortality in silkworms was 30 mg/kg, beyond which increasing level of mortality was observed along with inhibition of cocoon development (Wang & Bian, 1988). In the case of flour beetles, conflicting evidence was found which showed that while fluoride concentration of mg/kg could significantly stimulate of egg development (after 1 7 days), fluoride concentration of 4524 mg/kg could negatively affect the egg development and survival (after 27 days) (Johansson & Johansson, 1972). The effect of fluorides on terrestrial vertebrates (Section 3, Table 6.1) in the field near industrial sites was found in research studies in UK and USA. In field voles, bank voles, wood mice and moles found near an aluminium smelter, fluoride levels ranging 56

80 between 80-15,000 mg/kg caused severe dental damage and tooth wear, within m and 4-15 km of the smelter, respectively (Boulton et al., 1994; Walton, 1987) In a study done in the USA, dental fluorosis was observed in 80% of the cotton rats found near a petrochemical site (Schroder et al., 1999). In the studies done on terrestrial invertebrates in the field near industrial sites like aluminium plant (Section 4, Table 6.1), no significant effect was noticed in honeybees, cabbage loopers and lepidopterans at fluoride levels ranging between mg/kg (Hughes et al, 1985; Mayer et al., 1988; Port et al., 1998). Studies done on aquatic invertebrates in the laboratory in different countries (Section 5, Table 6.1) found that in water flea, tolerance was observed at fluoride concentration of 4.4 mg/l, while between >3.7 and 205 mg/l, partial growth and reproduction inhibition followed by reduced survival time and then immobilisation was caused with increasing fluoride levels (Dave, 1984). In prawns, shrimps and caddisfly species, 50% population death (after 96 hours) was observed at fluoride levels of 1118 mg/l, 10.5 mg/l and 44.9 mg/l, respectively (Camargo & Tarazona, 1990; LeBlanc, 1984; McClurg, 1984). In the studies done on aquatic vertebrates in the laboratory (Section 6, Table 6.1), 50% population death (after 96 hours) was observed at fluoride levels of 200 mg/l, 315 mg/l, 340 mg/l and >240 mg/l in rainbow trouts, fathead minnows, threespine sticklebacsk and bluegills, respectively (LeBlanc, 1984; Smith et al., 1985). Studies done on aquatic invertebrates in the field in USA, South Africa and Spain (Section 7, Table 6.1) found that fluoride levels of >26 mg/l and 7.2 mg/l can cause reproduction impairment in water fleas and 30% mortality in brown mussels, 57

81 respectively (Fieser et al., 1986; Hemens & Warwick, 1972). In caddisfly species, tolerance was observed to fluoride levels of 0.39 mg/l, 1.18 mg/l and 1.79 mg/l (Camargo & La Point, 1995). In monitoring studies done on aquatic vertebrates in the field in India and USA (Section 8, Table 6.1), hatching was delayed by 1-6 hours in adult leopard frogs at fluoride levels ranging from 1.9->3.2 mg/l (Pillai & Mane, 1984). In freshwater catla, the total number of red blood and white blood cells was reduced between fluoride levels of 5-50 mg/l while between mg/l the mortality of catla increased with increasing fluoride concentrations (Kaplan et al., 1964) Effect of Fluoride on Plants in the Laboratory and Field The effect of fluoride on the terrestrial and aquatic plants found in different countries and studies is tabulated in Table 6.2. Table 6.2 Effect of Fluoride on Terrestrial and Aquatic Plants in the Laboratory and Field Country Test Plant Fluoride concentration 1A. Effect of Fluoride on Terrestrial Plants in the Field Effects References Canada Vegetation 281 mg/kg Severe damage (near phosphorous Thompson et al., 1979 plant) Canada Vegetation 44 mg/kg Light damage (near phosphorous Thompson et al.,

82 plant) Canada Balsam fir (Abies 11.4 µg/m 3 (1.4 km Impaired seed Sidhu & balsamea), black from phosphorous production by Staniforth, 1986 spruce (Picea plant) 76.4%, 87.4% and mariana) and larch 0.08 µg/m 3 ( %, in balsam (Larix laricina) km from fir, black spruce phosphorous plant) 0.9 µg/m 3 (10.3 km from phosphorous plant) and respectively larch, UK Lichen (Xanthoria >90 mg/kg Visible damage Davies, 1982 parietina) UK Epiphytic lichens mg/kg Severe damaged Gilbert, 1985 (Ramalina farinacea) 1B. Effect of Fluoride on Terrestrial Plants in the Laboratory Conditions Netherlands Tulip (Tulipa sp.) µg/m 3 Leaf tip necrosis Wolting, 1978 (after exposure for 6 hours per day for 3 days) USA Gladiolus (Gladiolus 0.17 µg/m 3 Leaf tip necrosis Hitchcock et al., sp.) (after 90 days) 1962 Wheat plants 0.9 µg/m 3 Significant MacLean & (Triticum aestivum) reduction in the mean dry mass (after 4 days) Schneider,

83 USA Bean plants (no species stated) 0.58 µg/m 3 No effect Pack, 1971 >2.1 µg/m 3 Severe stunting and distortion of some the primary leaves 2A. Effect of Fluoride on Aquatic Plants in the Field Greece Seagrasses mg/kg No significant Malea, 1995 (Posidoniaceae, effect on Zosteraceae, chlorophyll and Hydrocharitaceae or protein contents Cymodoceaceae) India Macrophyte 20 mg/l Decreased Sinha et al., 2000 (Hydrilla chlorophyll and verticillata) protein contents (after 7 days) 2B. Effect of Fluoride on Aquatic Plants in the Laboratory Conditions USA Common duckweed >60 mg/l Reduction in Wang, 1986 (Lemna minor) growth in 50% of the samples India Duckweed 20 mg/l No significant Shirke & (Spirodela effect on Chandra, 1991 polyrrhiza) chlorophyll and protein contents (after 7 days) 60

84 Observations on Effect of Fluoride on Terrestrial and Aquatic Plants in the Laboratory and Field The effect of fluoride on terrestrial plants in the field (Section 1A, Table 6.2) has been observed in monitoring studies carried out in UK and Canada. Vegetation found near a phosphorous plant in Canada showed increasing damage at fluoride levels ranging from mg/kg (Thompson et al., 1979). In the balsam fir, black spruce and larch found near another phosphorous plant in Canada, increasing inhibition of seed development was observed at increasing levels of fluoride from µg/m 3 (Sidhu & Staniforth, 1986). In the lichens and epiphytic lichens found in UK visible damage was observed at very high levels of fluoride of >90 mg/kg and mg/kg, respectively (Davies, 1982; Gilbert, 1985). In the studies done on terrestrial plants in the laboratory (Section 1B, Table 6.2), leaf tip necrosis was observed in tulips and gladiolus at fluoride levels of and 0.17 µg/m 3, respectively (Hitchcock et al., 1962; Wolting, 1978). Significant dry mass reduction and sever stunting of primary leaves was found in the wheat plants (0.9 µg/m 3 fluoride) and bean plants (>2.1 µg/m 3 fluoride) found in the USA (MacLean & Schneider, 1981; Pack, 1971). During the monitoring studies carried out on aquatic plants in the field (Section 2A, Table 6.2), in Greece and India contradicting evidence was found, with no significant effects on the chlorophyll and protein contents of seagrasses ( mg/kg fluoride) and decreased levels in the chlorophyll and protein contents of macrophytes (20 mg/l) (Malea, 1995; Sinha et al., 2000). During the studies on aquatic plants (duckweed) in the laboratory (Section 2B, Table 6.2), significant effects on growth was observed at fluoride levels >60 mg/l (Lemna minor), 61

85 but none was found at 20 mg/l (Spirodela polyrrhiza) (Shirke & Chandra, 1991; Wang, 1986) Neoplastic and Non-neoplastic (Long-Term) Effects of Fluoride on Test Animals and Humans The neoplastic and non-neoplastic effects of fluoride on test animals and humans found in different countries and studies are tabulated in Table 6.3. Table 6.3. Neoplastic (Cancerous) and Non-Neoplastic (Non-Cancerous) (Long Term) Effects of Fluoride on Test Animals and Humans 1. Neoplastic (Cancerous) Effects in Test Animals Long Term Studies Country Test Animal Fluoride Concentration Effects References USA Male F344/N rats 11, 45 and 79 mg/l Osteosarcomas NTP, 1990 (Rattus increased with norvegicus) increase in fluoride USA Female F344/N levels (after 2 years exposure) 11, 45 and 79 mg/l Osteosarcomas NTP, 1990 rats (Rattus increased with norvegicus) increase in fluoride levels (after 2 years exposure) USA Male and female 4, 10 and 25 mg/l Osteosarcomas Maurer et al., 62

86 albino (CD-1) increased with 1993 mice musclus) (Mus increase in fluoride levels (after 95 and 97 weeks exposure for male and female mice, respectively). The study was confounded by presence of retrovirus, thus making it invalid 2. Non-Neoplastic Effects in Test Animals Long Term Studies India Albino rabbits (Oryctolagus cuniculus) 4.5 mg/kg Adverse effect on the normal erythrocyte membrane function (after 6-24 months) Jain & Susheela, 1987 India Albino rabbits 4.5 mg/kg Alterations in the Sharma & (Oryctolagus glycosaminoglycan Susheela, 1988a cuniculus) of cancellous bone (after 6-24 months) India Albino rabbits (Oryctolagus cuniculus) 4.5 mg/kg Toxic effects on the hematological profile of adult rabbits and adverse effects on their offspring (after 6-24 months) Susheela & Jain, 1983 India Albino rabbits 4.5 mg/kg Alterations in the Sharma & 63

87 (Oryctolagus glycosaminoglycan Susheela, 1988b cuniculus) of cancellous bone (after 6-24 months) India Albino rabbits 4.5 mg/kg Calcification of aorta Susheela & (Oryctolagus (after 6-24 months) Kharb, 1990 cuniculus) India Albino rabbits (Oryctolagus cuniculus) 4.5 mg/kg Significant morphological alterations in the duodenum (after 6-24 months) Susheela & Das, 1988 India Albino rabbits 4.5 mg/kg Glomerular Bhatnagar & (Oryctolagus hypercellularity (after Susheela, 1998 cuniculus) 6-24 months) China Male and female 22.7 and 36.3 mg/l Bone mineralization Qiu et al., 1987 rats (Rattus (based on norvegicus) microscopic analysis) USA Male Sprague- was inhibited (after 250 days) 50 mg mg/l Femoral bone Turner et al., 1995 Dawley (Rattus norvegicus) rats strength was reduced (18 months) 3. Carcinogenic Effects in Humans Long Term Studies USA Humans ( mg/l, Increased incidence Gelberg et al., male and female mg/l, of osteosarcoma with

88 osteoporotic mg/l increasing exposure patients aged 24 and levels in some but not years and less) mg/l all subjects. USA Humans (167 male and female osteoporotic patients) Significant protective trend was observed in males >0.7 mg/l No significant increased risk of osteosarcoma Moss et al., Observations on Neoplastic (Cancerous) and Non-Neoplastic (Non- Cancerous) (Long Term) Effects of Fluoride on Test Animals and Humans Long-term studies have been done on the neoplastic (cancerous) effects of fluoride on test animals (Section 1, Table 6.3), in the USA (NTP, 1990; Maurer et al., 1993). These found that the incidence of osteosarcoma increased with increasing fluoride levels in mice and rats. However, one of these studies (Maurer et al., 1993) was confounded with the presence of retrovirus. Thus, looking at the collective data of these studies and other similar studies, it may be concluded that there is inadequate experimental data available to prove that fluoride is found to be carcinogenic to animals. But, it was also found that there is clear evidence of occurrence of nonneoplastic effects like - alterations in the glycosaminoglycan of cancellous bone, haematological toxic effects, bone mineralisation inhibition and reduced bone strength in rats, from experimental studies carried out in India, China and USA (Section 2, Table 6.3) (Bhatnagar & Susheela, 1998; Jain & Susheela, 1987; Sharma & Susheela, 1988a; 65

89 Sharma & Susheela, 1988b; Susheela & Jain, 1983; Susheela & Kharb, 1990; Qiu et al., 1987; Turner et al., 1995). Limited and inconsistent data available on the carcinogenicity of fluoride in humans (Section 3, Table 6.3) based on human ecological studies carried out in the USA has lead to the conclusion that fluoride is not carcinogenic to humans (Gelberg et al., 1995; Moss et al., 1995) Genotoxic, Reproductive and Developmental Effects of Fluoride in Test Animals and Humans The Genotoxic, reproductive and developmental effects of fluoride in test animals and humans found in different countries studies are tabulated in Table 6.4. Table 6.4. Genotoxic, Reproductive and Developmental Effects of Fluoride in Test Animals and Humans Country Test Fluoride Effects References subjects/cells concentration 1. In-Vitro Genotoxicity A. Mice and Rats UK L5178Y mice 500 µg/l Division of cultured Cole et al., 1986 (Mus cultured musclus) mammalian cells lymphoma cells Jordan Sprague-Dawley Up to 2 mg/l No increased sister Khalil & rats (Rattus chromatic exchange Da dara, 1994 norvegicus) frequency (after 12 to 36 66

90 cultured marrow cells bone hours), but chromosomal aberration increased with dose USA L5178Y mice µg/ml Increased mutagenesis Caspary et al., (Mus cultured musclus) 1987 lymphoma cells USA Adult male Fischer F ,700 µg/ml No genotoxic effects observed Tong et al., 1988 rats (Rattus norvegicus) liver epithelial cells B. Hamsters and Great Apes Japan Apes (Pan troglodytes, Pongo mg/l Increased chromosomal aberrations observed only in ape cells like pygmy Kishi & Ishida, 1993 pygmaeus), Old and common chimpanzee World (Macaca monkeys cells with none in hamster cells fascicularis), New World monkeys (callithricid), Prosimians (Galago crassicaudatus, Lemur catta), Chinese hamster 67

91 (Cricetulus griseus) C. Humans Japan Cultured human µg/ml DNA (Deoxyribonucleic Tsutsui et al., (Homo sapiens) Acid) damage was 1984 diploid observed fibroblasts Japan Cultured human 0.45 to 4.5 mg/l No damage observed Tsutsui et al., (Homo diploid sapiens) 1995 fibroblasts Japan Cultured human (Homo sapiens) cell lines 1-6 mm Increased chromosomal aberrations Kishi & Ishida, 1993 USA Cultured human >50 mg/l Increased chromosomal Aardema & (Homo sapiens) aberrations Tsutsui, 1995 diploid fibroblasts Japan Cultured human µm Increased chromosomal Tsutsui et al., (Homo sapiens) aberrations in human oral 1991 oral keratinocytes keratinocytes 2. In-Vivo Toxicity in Test Animals and Humans USA Mice (Mus mg/l Increased chromosomal Mohammed & musclus) bone aberrations in bone Chandler, 1982 marrow cell marrow cell chromosomes chromosomes and and spermatocytes spermatocytes China Human (Homo 4-5 mg/l The micronucleus rate and Wu & Wu,

92 sapiens) sister chromatic exchange peripheral blood lymphocytes frequency significantly high was Russia Mice (Mus 1 mg/m 3 The chromosomal Voroshilin, et musclus) and rats aberration frequency was al., 1975 (Rattus significantly high in bone norvegicus) bone marrow of rats but no marrow cells effect was observed in mice Japan Mice (Mus 30 or 80 mg/kg Micronuclei were not Hayashi et al., musclus) bone induced 1988 marrow Germany Mice (Mus 144 mg/kg Micronuclei were not Gocke et al., musclus) bone induced 1981 marrow USA (Diabetic and Up to 50 mg/l No increased sister Dunipace et al., non-diabetic) chromatic exchange 1996 Zucker male rats (Rattus frequency (after 6 months) norvegicus) 3. Effect of Fluoride on Reproduction and Development in Test Animals Jordan Male mice (Mus 100, 200 and 300 Significant reduction in Elbetieha et al. musclus) mg/l fertility rate (after weeks) India Male mice (Mus 4.5 mg/kg Significant reduction in Chinoy & musclus) fertility rate and sperm Sharma, 1998 numbers (after 30 days) India Female mice 10 mg/kg Decreased protein in liver, Chinoy et al. 69

93 (Mus musclus) muscle, and small 1994 India Female mice (Mus musclus) intestine with significant glycogen accumulation in gastrocnemius muscle and liver 5 mg/kg Impaired production of gluthathione and impaired function of the protective enzymes within the ovaries with decreased calcium concentration Chinoy & Patel Observations on Genotoxic, Reproductive and Developmental Effects of Fluoride in Test Animals and Humans In the in-vitro genotoxicity tests done on mice, rat, ape, and hamster cells, increased sister chromatic exchange frequency and chromosomal aberration was seen after short and long term exposure to increasing fluoride levels, in some but not all studies (Caspary et al., 1987; Cole et al., 1986; Khalil & Da dara, 1994; Kishi & Ishida, 1993; Tong et al., 1988). Similarly, for the tests done on cultured humans cells, increased chromosomal aberrations was found only at fluoride levels >50mg/L and that too after a short and long term application (Aardema & Tsutsui, 1995; Tsutsui et al., 1984). Thus, it may be concluded that the genotoxic effects of fluoride depends on a number of factors including the dose, time of application of fluoride relative to the time within the cell cycle and the type of cells used for the experiments. In the various in-vivo genotoxicity tests done on mice and rat bone marrow and 70

94 cultured human lymphocytes, contradictory evidence has been found with both positive and negative results of increased/decreased chromosomal aberration, micronucleus rate and sister chromatic exchange (Dunipace et al., 1996; Hayashi et al., 1988; Mohammed & Chandler, 1982; Wu & Wu, 1995). This has lead to the conclusion that fluoride has very low probability of genotoxic risk in humans Effects of Fluoride in Humans from Accidental Acute Exposure and Fluoride Therapy The effect of fluoride in humans after accidental acute exposure and fluoride therapy found in different countries studies is tabulated in Table 6.5. Table 6.5. Effect of Fluoride in Humans after Accidental Acute Exposure and Fluoride Therapy Country Study subjects Fluoride concentration Effects References USA Men and mg/kg Acute fluoride poisoning Whitford, 1996 women followed by death (after 24 to 32 hours) USA Men and 150 mg/l Acute fluoride poisoning Gessner et al., women followed by death ( people poisoned and 1 dead) USA Men and mg/l Acute fluoride toxicity of Hoffman et al. women the gastric epithelium (

95 people) USA Men and 250 mg/l Acute fluoride toxicity of Vogt et al women the gastric epithelium (22 people) Canada Men and women mg/kg Hip fractures observed (7 people) Bayley et al., 1990 France Women 26.4 mg/kg Early increase in the bone mineral density and high Delmas et al., 1990 incidence of lower extremity pain syndrome (81 women) USA Women 75 mg/kg Increased cancellous bone Riggs et al., 1990 South Africa Men and women USA Men and women mineral density with skeletal fragility and decreased cortical bone mineral density (66 women) 0.99 mg/kg Temporary weakening of the bone and increased incidence of stress fractures (18 patients) 25 mg/kg No development of micro-fractures or hip fractures (48 patients) Schnitzler et al., 1990 Pak et al., Observations on Effect of Fluoride in Humans after Accidental Acute Exposure and Fluoride Therapy 72

96 Based on monitoring studies carried out in the USA, adverse health effects to acute accidental exposure to 75 mg/l of fluoride has been observed in 34 patients while a dose of 150 mg/l of fluoride has proved to be lethal to one patient (Riggs et al., 1990; Gessner et al., 1994). The adverse health effects of acute exposure to fluoride include cardiac arrest, respiratory effects, tissue damage and death (WHO, 2006). In the male and female osteoporotic patients being subjected to fluoride therapy, temporary weakening of the bone and increased incidence of stress fractures has been observed at 0.99 mg/kg of fluoride, while hip fractures and increased bone density have been observed at mg/kg and 75 mg/kg of fluoride respectively (Bayley et al., 1990; Riggs et al., 1990; Schnitzler et al., 1990) Effect of Fluoride on Human Systems The effect of fluoride on the various human body systems found in different countries and studies is tabulated in Table 6.6. Table 6.6. Effect of Fluoride on Various Human Systems Country Study subjects Fluoride concentra tion 1. Reproductive System Effect References USA Men and women 3 mg/l Reduced total fertility rates in Freni, 1994 population mean (combined result showed negative association between 73

97 fertility rate and fluoride concentration) (people in 30 regions of 9 states of the USA) India Pregnant women Passive diffusion of fluoride from the Malhotra et μg/ml mother to foetus (25 women) al., 1993 India Men Skeletal fluorosis with significantly Susheela & mg/l lower testosterone serum concentration (30 men) Jethanandani, Respiratory System China Men and women mg/m 3 Skeletal fluorosis, chronic bronchitis, diffused interstitial fibrosis and pulmonary emphysema (45 people) Liu, 1996 Canada Children 600 μg/m 3 Abnormalities in airways (11-17 years) Ernst et al., Neuro-Behavioural System China Children mg/l USA Children mg/l Significantly low average intelligence quotient (IQ) (8-13 years old children) Reduced reaction times and visuospatial perceptiveness (6-8 years old children) Xiang et al., 2003 Calderon et al., Genetic System China Children 0.2 and 5 mg/l Lower average sister chromatic exchanges per cell in people from higher fluoride concentration regions Li et al.,

98 (8-13 years old 907 children) USA Men and women 0.2, 1, and 4 mg/l Slightly higher average sister chromatic exchanges per cell in residents exposed to fluoride concentration of 4 mg/l (68 people) Jackson et al., 1997 Netherlands Women mg/day No observed cytogenetic effects (after 1-4 years) (7 non-smoking women) Van Asten et al., Hepatic and Renal System USA Elderly 23 mg/l No hepatic or renal effects observed Jackson et postmenopausal (after 4.2 years) (25 women) al., 1994 osteoporotic women Finland Men and women 1.5 mg/l Increased incidence of kidney stones (residents of two cities in southern Finland) Juuti Heinonen, 1980 & India Men and women mg/l Increased incidence of kidney stones, which may have also have been due to malnutrition (18,706 people) Singh et al., Human Skeletal System China Men and women 4.32 mg/l Increased risk of bone fractures (531 people) (not less than 50 years old) Li et al., 2001 USA Women 4 mg/l Increased risk of bone fractures (20- Sowers et al., 75

99 80 years old) (230 women) 1991 USA Children mg/l Increased risk of bone fractures (in 60 years)) children (6-12 years) and adults (13- Alarcón- Herrera et al, 2001 USA Men and women Increased secondary Dure-Smith mg/kg hyperparathyroidism and et al., 1996 osteomalacia (16 people) USA 54-year-old Skeletal fluorosis (after seven years Felsenfeld & woman mg/l exposure) Roberts, 1991 South Africa Children 8-12 mg/l Skeletal fluorosis (6-16 years old children) (260 children) Pettifor et al., 1989 India Children Human Dental Development mg/l Metabolic fluoride related bone diseases (calcium deficiency further increased the effect) (90% of 45,725 children) Teotia et al., 1998 USA Children >2 mg/l Increased dental fluorosis prevalence (8-10 and years old) Selwitz et al. 1995, 1998 Ethiopia Children mg/l Increased dental fluorosis prevalence (10-14 years old) Haimanot et al USA Children >4mg/L Severe dental fluorosis prevalence (after 5 years) (8-10 years and Heifetz et al years old children) USA Men and women 3.5 mg/l Severe dental fluorosis prevalence Eklund et al., (27-64 years) (76% of 192 adults years old) 76

100 1987 UK Men and women <0.1 mg/l Increased dental decay Edmunds & Smedley, Observations on Effect of Fluoride on Various Human Systems Reduced male and female fertility rate has been observed at fluoride levels 3 mg/l and low testosterone concentrations in males have been found at as low as 1.5 mg/l of fluoride, in some studies done in USA and India (Freni, 1994; Susheela & Jethanandani, 1996). However, such studies are few and also have several limitations in their design and power, thus making them inadequate to prove that fluoride exposure may cause significant reproductive effects in humans. Abnormalities in the airways of children have been observed at fluoride levels of 600 μg/m 3 in Canada, while chronic bronchitis and pulmonary emphysema was documented in men and women in China at fluoride levels from mg/m 3 (Ernst et al., 1986; Liu, 1996). Significantly low IQ levels, reduced reaction and visuospatial perceptiveness found in children in China and Mexico, shows that fluoride does have significant neurobehavioural effects in children and more research needs to be done in this area for further evaluation (Calderon et al., 2000; Xiang et al., 2003). There has been inconsistency in the data available on the positive genotoxic effects of fluoride in humans, which has lead to the conclusion that fluoride has very low probability of genotoxic risk in humans (NRC, 2006). Increased incidence of kidney stones has been seen in humans at very low fluoride levels of 1.5 mg/l in Finland while no hepatic or 77

101 renal effects were observed in elderly female patients at a high fluoride level of 23 mg/l (Juuti & Heinonen, 1980; Jackson et al., 1994). In another study carried out in India, there was increased incidence of kidney stones at mg/l fluoride levels but this may also have been due to malnutrition of the subjects (Singh et al., 2001). Thus, there is a lack of consistent data available on the significance of effects of fluoride on the hepatic and renal systems in humans, which warrants the need for more research. Skeletal fluorosis has been observed in children in India at fluoride level of 1.5 mg/l and increased risk of bone fractures has been documented at fluoride levels 4.32 mg/l in China (Li et al., 2001; Teotia et al., 1998). Studies with similar findings of adverse skeletal effects have been carried out in USA and South Africa (Felsenfeld & Roberts, 1991; Pettifor et al., 1989). It may thus be concluded that there is a clear risk of fluoride at levels of 4.32 causing adverse effects to the skeletal system in humans. Based on studies carried out in UK, it has been proven that fluoride levels as low as 0.1 mg/l has been known to cause dental decay while increased prevalence of dental fluorosis in children has been found at fluoride levels >2 mg/l in the USA, with the severity of dental fluorosis increasing with increasing fluoride levels (Edmunds & Smedley, 1996; Selwitz et al. 1995, 1998). 78

102 CHAPTER 7. Critical Review of the Strategy Adopted for the Prevention and Control of Fluorosis in India 7.1. Introduction The strategy adopted for the prevention and control of fluorosis in India and its effectiveness have been critically assessed in this study by two ways. One is by collecting information on written questionnaires from at least 10% of the total 91 district nodal officers of India s NPPCF, all of whom were selected randomly after listing them state-wise. The second method was by conducting a knowledge, perception and behaviour study through distant questionnaire method in an endemic area of an Indian district, where there has been implementation of the NPPCF for at least three years. The study was carried out through interviews with the high school students of two schools of that endemic area. One of the schools was taken from a habitation/village, which had defluoridated/alternate source of filtered water supply having normal fluoride content. While the second school was one, which had non-defluoridated/pre-existing ground water supply for drinking containing higher fluoride, situated in the same high endemic district. Both of these questionnaire studies have been explained in detail in the following sections. 79

103 7.2. District Nodal Officer s Questionnaire Study The NPPCF has so far covered 100 Indian districts of the total of 230 districts identified as endemic for fluorosis from 19 states and union territories. These 100 districts have been mentioned in detail in chapter three of this dissertation. For the purpose of conducting the district nodal officer s questionnaire study, the 91 nodal officers (covered under NPPCF) were first listed state-wise in alphabetical order, after which 10% of them were selected randomly. All the pre-designed questionnaires (Annexure 1) were sent by electronic mail, after taking due permission (no objection letter) (Annexure 2) from the national programme officer of the NPPCF. A total of 11 questionnaire replies were received, which were then tabulated and analysed in detail. The tabulated data and the findings of the same have been given in the following sections Observations on Availability of Logistic Support for NPPCF in the Endemic Districts Covered Under the Programme All information has been tabulated in Table 7.1. Funds have been provided to 10 out of 11 districts, national guidelines for programme implementation have been provided to all the 11 districts, IEC material for creating awareness has been supplied in nine districts, and laboratory equipment has not been purchased by two districts out of 11. Provision of aids and appliances for disabled people is being provided in four districts and medical treatment facilities are being provided in eighth out of the 11 districts. 80

104 Observations on Availability of Other Logistic Support Provided in the Endemic Districts Covered Under the Programme All information has been tabulated in Table 7.2. Out of the total 11 districts, laboratory was established in nine, upgraded operation facility was provided in three districts and vehicle hiring and field-work was done in five districts. There was linkage with referral hospitals done in five districts, however, it is not mentioned whether the funds earmarked for rehabilitation is being used or not Observations on the Involvement of General Health Care Staff in the Endemic Districts Covered Under the NPPCF All information has been tabulated in Table 7.3. No district consultant was appointed in three districts out of 11. In four districts, field investigators have not been appointed. Data entry operator was engaged by only one district and no lab technician was appointed in three districts. Involvement of the general health care staffs of District Hospitals/CHCs (Community Health Centres)/PHCs (Primary Health Centres)/SCs is adequate in only two districts Observations on Training Status of the Staff of NPPCF in Comparison to the Target Given in the National Guidelines All information has been tabulated in Table 7.4. The training of targeted number of medical officers was done in two districts (Nalgonda and Chandrapur), training of upto 50% of targeted number of medical officers was done in other four districts (Ujjain, Bellary, Nayagarh and Nellore) and no training was started in the remaining five 81

105 districts (Latur, Nagaon, Mysore, Karim Nagar and Prakasam). Training of targeted number of laboratory technicians was completed in two districts (Mysore and Nalgonda) and in one more district (Ujjain) only one laboratory technician was trained. Training of laboratory technicians was not started in the remaining eighth districts. Paramedical training (ANM (Auxiliary Nurse Midwives/Health Supervisors/MPW (Multi-Purpose health Workers)) of the targeted number of staff was done in seven districts (Nalgonda, Chandrapur, Nellore, Bellary, Mysore, Nagaon and Ujjain); in one additional district (Nayagarh) it was done only in one block of the district and in the remaining three districts (Prakasam, Latur and Karim Nagar) it has not yet been started. The targeted number of ASHAs (female volunteers) and AWWs (Angan Wadi Workers) has been trained in seven districts (Nalgonda, Chandrapur, Nellore, Bellary, Mysore, Nagaon and Ujjain); in one additional district (Nayagarh) only one block of the district has been covered by training and in the remaining three districts (Prakasam, Karim Nagar and Latur) training has not yet started. Training of the targeted number of punchayat members was done in three districts (Nalgonda, Bellary and Nagaon) and was also done in one more district (Nayagarh) but only one district block was covered. In the remaining seven districts (Chandrapur, Nellore, Prakasam, Karim Nagar, Mysore, Latur, Ujjain) punchayat leader training has not yet started Observations on Status of Clinical Fluorosis Survey Done in the Districts All information has been tabulated in Table 7.5. Both community and school surveys have been conducted in four districts (Nellore, Nalgonda, Prakasam and Karim 82

106 Nagar) while school survey alone done in additional four districts (Ujjain, Nagaon, Bellary and Mysore). And no survey was done in the remaining three districts (Chandrapur, Nayagarh and Latur). Occurrence of dental fluorosis in school children ranged from 17.4% (Nellore) to 77% (Karim Nagar), and in the community people of villages it ranged from 12.7% (Nellore) to 16.8% (Karim Nagar). Skeletal fluorosis in the form of joint pain in the community people ranged from 0.76% (Nellore) to 42% (Nalgonda) and in the school Children it rangesd from 0% (Nellore) to 9.2% (Mysore) Observations on Urine Samples Examined in Suspected Cases All information has been tabulated in Table 7.7. Urine sample was examined in nine district laboratories (Nellore, Nalgonda, Prakasam, Bellary, Mysore, Nagaon and Ujjain). The number of clinically suspected cases confirmed by urine examination was above 90% in 4 districts (Nellore, Prakasam and Bellary), between 79 and 90% (range) in one district (Nalgonda), and about 71% in one district (Ujjain). But it was only 53% in Mysore district and 45% in Naogaon district. The low confirmation in these two districts may be because of low laboratory technician training status or due to other laboratory reasons Observations on Coordination, Monitoring and Supervision of Programme in the District All information has been tabulated in Table 7.8. Although coordination with other departments has been done in 10 districts out of 11 districts, it was not adequate in some districts. In five districts the nodal officers had not visited the field in the last 83

107 three months. In eighth districts people were aware about the risk of fluorosis from the ground water. In eighth districts the villages, which have yet not been tested for fluoride were listed properly. In seven districts, proper monitoring was done by the senior officers, while in five districts there was none. None of the districts has data on the services provided to the patients at the referral hospitals and only three districts has mentioned that the monthly reports are being sent to the state nodal officers Observations on Activities Undertaken by the District Rural Water Supply and Sanitation Department (RWSD) All information has been tabulated in Table 7.9. Total eighth districts provided alternative supply of water but it is not of adequate quantity and thus the districts have to partly depend on high-fluoridated water supplies Observations on Three Most Important Constraints and Suggestions Offered by the District Nodal Officers All information has been tabulated in Table The three most important limitations identified are: a. provision of three field investigators for six months per district is too less, b. provision of vehicles for hiring is not provided, and c. There is a no periodic/repeat training of Medical Officers/ASHAs/ANMs/AWWs/MPWs, local public and community leaders. The three most important suggestions provided by the nodal officers are: a. vacant staff should be filled immediately, b. equipment needs to be purchased for testing of water samples and urine samples of patients, and c. funds need to be provided. 84

108 Summary of Findings of the District Nodal Officer s Questionnaire Study It was found that all the 11 districts, from which the questionnaires were collected, had been carrying out the NPPCF for at least the past three years. All the districts had received funds, however, there had been delays in the same in five of the districts. The utilisation of this fund was quite slow in four of the districts, but the implementation of the activities identified under the NPPCF like distribution of IEC material, training of targeted number of staff (doctors, laboratory technicians, paramedicals, ASHAs, AWWs and punchayat members) and the provision of medical treatment was found to be adequate in eighth of the 11 districts. Activities in certain areas like provision of proper referral facility established (six districts), aids and appliances for disabled persons (four districts), vehicle/hiring facility (five districts), population and school survey done (four districts), adequate monitoring (five districts) and supervision (four districts) were found to be quite lacking in timely implementation. There seems to be satisfactory coordination with other government departments (nine districts) but an inadequate level of involvement of DH/CHC/PHC/SC (District Hospital/Sub-Centre) staff (eighth districts). The reason for the inadequate level of population and school surveys done by the districts is due to lack of provision of adequate number of trained staff like field investigators that is only three investigators for six months for each district, which is insufficient for carrying out the field surveys. While alternative safe drinking water supply is being supplied in seven of the districts, defluoridation of groundwater is being done in only two of the districts. Also, monthly reports were being sent by only five of the 11 districts. The range for the 85

109 prevalence of (joint) skeletal fluorosis was found to be between 0.70 and % in the 11 districts. Information on villages identified as having two or more categories of fluorosis was available only in four districts with no data on categorisation/classification of fluorosis being available in the remaining seven Knowledge, Attitude and Perception Study A comparison study of the knowledge, attitude and perception (KAP) of high school children (9th and 10th standards) was done between one school having ground water non-filtered supply in one of the endemic districts with the KAP of high school children of another school in the same endemic district having filtered water supply. This was done by collecting information on pre-designed questionnaire (Annexure 3) through the health staff and school teachers. A total of 185 questionnaires were collected from the high school children (9th and 10th standards) in the two schools. The tabulated data and the findings of the same have been given in the following sections Findings from the Knowledge, Attitude and Perception Study Response received from a total of 194 students from the school with filtered river water supply (school A) and from a total of 189 students from the school with unfiltered ground water supply (school B) (Table 7.12). The awareness about the signs of fluorosis was 89.5% to 94.7% in school A and the field visit of the health worker was also higher (63%) amongst students of school A when compared with those from school B (Table 7.13). Awareness about the cause (94.7%) and preventability (71.6% to 75.8%) 86

110 of fluorosis was higher amongst students from school A (Table 7.13). The knowledge about the cause of fluorosis was marginally better (94.7%) in school A (Table 7.13). Most of the students in both schools did not know if the fluoride content of their school s water supply had been tested for fluoride as only 1.05 % of school A s students and 23.3% of school B s student had knowledge about this (Table 7.14), although this knowledge was slightly better (23.3%) in School B (Table 7.14). Poster, newspaper and TV were the three most common source of information, in the order of response, in both the schools (Table 7.15). A greater number of students from School B said that patients of fluorosis could spread the disease to others, which was likely due to wrong perception. However, the experience of having symptoms of fluorosis amongst the family members was more or less the same in both schools (Table 7.16). Surprisingly, more students from School B said that they liked to drink the groundwater, which might be either due to the taste of the water or lack of alternate source of water supply in the school. The number of people with the symptoms of fluorosis, who visited the doctor, when they developed the symptoms, was similar between the two schools. The attitude of students from both schools was positive or favourable as a very high number of students said that they were willing to cooperate and help the government/health workers coming to their village to improve their water supply (Table 7.17). A good number (95% in School A and 82.8% in School B) of students from both schools said that they would spread the correct informative messages to local people, about fluorosis and its prevention (Table 7.17). Very few of students from both schools had negative attitude (no interest) towards the prevention and control efforts being made 87

111 for fluorosis, as only 4 to 6 % of them said that they would not waste their time in cooperating and helping the visiting government/health staff (Table 7.17). The statistical difference between the students of school A and school B, with regards to their knowledge and awareness of early signs of dental and skeletal fluorosis, cause and spread of fluorosis, fluorosis prevention and remediation, government monitoring of drinking water, was found to be highly significant (p-value= ; A was better than B). The statistical difference between the students of school A and school B, on their awareness of fluorosis from radio messages or TV messages was also found to be highly significant (p-value= ; A was better than B). The statistical difference between the students of school A and school B, regarding their knowledge of the advantages of drinking defluoridated or filtered water with permissible fluoride levels (p-value=0.0509; A was better than B), affirmation of assistance to the government for any future improvement plans of water supply (pvalue= ; A was better than B), affirmation of assistance to government for any future information requirement (p-value= ; A was better than B, and awareness of family members visit doctor for fluorosis related health problem (p-value= ; A was better than B), was found to be just significant. The statistical difference between the students of school A and school B, regarding their knowledge of health worker s visit to locality in the last three months (pvalue=0.582), and knowledge of NPPCF s IEC activities from TV (p-value=0.5782), radio (p-value=1.0), newspaper (p-value=0.2338), poster pamphlet or health worker (pvalue=0.6596), mix or more than two of these media methods (p-value= ), and 88

112 other means or from community volunteers (p-value=0.884), was found to be not significant. The statistical difference between the students of school A and school B, with regards to their knowledge of signs of fluorosis from local posters, hoardings or wall writings (p-value=0.8204) (not significant), positive attitude towards drinking water available at their schools (p-value=0.729), awareness of family members experience with symptoms of different types of fluorosis (p-value=0.4324), affirmation towards providing help for educating community members about fluorosis (p-value=0.6795), and negative attitude towards educating community members about fluorosis (pvalue=0.6795), was found to be not significant. 89

113 Table 7.1. Availability of Logistic Support for National Fluorosis Programme in the Endemic Districts Covered Under the Programme District, State Year of National IEC Training Equipment Provision for aids Provision for receiving guidelines material material for and appliances for medical treatment funds provided provided provided laboratory disabled persons facilities Nalgonda, 2009 Yes Yes Yes Yes No Yes Andhra Pradesh Chandrapur, Maharashtra Not yet provided Yes Yes Yes Yes No No Nellore, 2008 Yes Yes Yes Yes Yes Yes Andhra Pradesh Prakasam, 2010 Yes Yes Yes Yes Yes Yes Andhra Pradesh Karim Nagar, 2010 Yes Yes Yes Yes No Yes Andhra Pradesh Nayagarh, 2009 Yes No No Yes Yes Yes Orissa 90

114 Bellary, 2010 Yes Yes Yes Yes No No Karnataka Mysore, 2011 Yes Yes Yes No Yes Yes Karnataka Latur, 2005 Yes No No No No No Maharashtra Nagaon, 2011 Yes Yes Yes Yes No Yes Assam Ujjain, 2009 Yes Yes Yes Yes No Yes Madhya Pradesh 91

115 Table 7.2. Availability of Other Logistic Support Provided in the Endemic Districts Covered Under the Programme District, State Established special Established Vehicle/hiring Referral hospital system set up laboratory for testing upgraded facility provided of water/urine blood operation theatre samples Nalgonda, Andhra Pradesh Chandrapur, Yes Yes Yes Yes, at Gandhi and Osmania Hospital, Yes No Yes No Hyderabad Maharashtra Nellore, Andhra Pradesh Yes No No Yes, at Sri Venkateswara Ramnarain Ruia (SVRR) Government General Hospital, Andhra Pradesh Prakasam, Andhra Pradesh Karim Nagar, Andhra Pradesh Yes No No Yes, at Gandhi and Osmania Hospital, Hyderabad Yes No No Yes, at Gandhi and Osmania Hospital, Hyderabad Nayagarh, No No No No 92

116 Orissa Bellary, Karnataka Mysore, Yes Yes Yes Yes, at Vijayanagara Institute of Yes No No No Medical Sciences, Bellary Karnataka Latur, No No No No Maharashtra Nagaon, Yes No Yes No Assam Ujjain, Yes Yes Yes No Madhya Pradesh 93

117 Table 7.3. Involvement of General Health Care Staff in the Endemic Districts Covered Under the National Fluorosis Programme District, State Amount of funds Separate staff provided on contract (Number engaged/number Level of involvement of received in sanctioned) DH/CHC/PHC/SC staff Indian currency Consultant Field DEO (Data LT (Laboratory (Adequate/Inadequate/Not yet (Rs) investigator entry technician) started) operator) Nellore, Rs Lakhs 1/1 0/3 0/1 1/1 Inadequate Andhra Pradesh Nalgonda, Rs Lakhs 1/1 3/3 0/1 1/1 Inadequate Andhra Pradesh Chandrapur, Nil 0/1 0/3 0/1 0/1 Inadequate Maharashtra Prakasam, Rs Lakhs 1/1 3/3 0/1 1/1 Inadequate Andhra Pradesh Karim Nagar, Rs Lakhs 1/1 3/3 0/1 1/1 Inadequate Andhra Pradesh Nayagarh, Nil 1/1 0/3 0/1 1/1 Inadequate Orissa 94

118 Bellary, Nil 1/1 3/3 0/1 1/1 Inadequate Karnataka Mysore, Nil 1/1 3/3 0/1 1/1 Adequate Karnataka Latur, Rs Lakhs 0/1 0/3 0/1 0/1 Not yet started Maharashtra Nagaon, Nil 1/1 3/3 0/1 1/1 Adequate Assam Ujjain, Nil 0/1 3/3 1/1 0/1 Inadequate Madhya Pradesh 95

119 Table 7.4. Training Status of the Staff of National Fluorosis Programme in Comparison to the Target Given in the National Guidelines District with Targeted category of staff number to be trained/targeted duration target and Doctors Laboratory Paramedicals ASHAs/AWWs Punchayat members actually trained technicians Nalgonda, Andhra Pradesh a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained >100/one day > 20/five days >30/half day > 30/half day >35/2 hours Chandrapur, Maharashtra a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 150/one day 0/five days 606/one day 193/one day 0/2 hours Nellore, Andhra Pradesh a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 86/one day 0/five days 192/half day 20/half day 0/2 hours Prakasam, 96

120 Andhra Pradesh a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 0/one day 0/one day 0/half day 0/half day 0/2 hours Karim Nagar, Andhra Pradesh a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 0/one day 0/five days 0/half day 0/half day 0/2 hours Nayagarh, Orissa a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 41/one day 0/five days (Trained only for (Trained only for (Trained only for Nayagarh block Nayagarh block Nayagarh block out out of eight out of eight of eight blocks of blocks of district. blocks of district. district. Need funds Need funds for Need funds for for rest.) rest.) rest.) Bellary, 97

121 Karnataka 100/one day 20/five days 30/half day 30/half day 35/2 hours a. Target 42/one day 0/five days 946/half day 946/half day 90/2 hours b. Actual trained (Including (Including ASHAs/AWWs) paramedicals) Mysore, Karnataka a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 0/one day 20/five days 30/half day 92/half day 0/2 hours Latur, Maharashtra a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 0/one day 0/five days 0/half day 0/half day 0/2 hours Nagaon, Assam a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 0/one day 0/five days 33/half day 36/half day 32/2 hours (9/2/2012) (26/6/2012) 31/half day 32/half day 98

122 (13/2/2012) 28/half day (27/2/2012) (30/6/2012) 23/half day (26/7/2012) Ujjain, Madhya Pradesh a. Target 100/one day 20/five days 30/half day 30/half day 35/2 hours b. Actual trained 60/one day 1/five days 160/three days 996/half day 0/2 hours 99

123 Table 7.5. Status of Clinical Fluorosis Survey Done in the Districts District, State Villages Persons Number of cases of fluorosis found surveyed examined Dental Non-skeletal fluorosis Joint pain Restricted Deformity fluorosis (Gastro intestinal and movement and and crippled neurological symptoms) stiffness of joints Nellore, 71 villages people 850 people (10.7%) 61 people (0.7%) (Included in 61 cases (Included in 61 Andhra surveyed people (12.7%) (Including stiffness in joint pain cases in joint Pradesh of joint and column) pain column) crippling deformity) 74 schools children Nil Nil Nil Nil surveyed children (17.4%) Nalgonda, people Nil 3706 people 872 people 9 people Andhra villages people (66.5%) (42%) (9.9%) (0.1%) Pradesh surveyed (Some had both dental fluorosis and skeletal fluorosis) 46 schools Nil Nil Nil Nil 100

124 surveyed children children (65.9%) Chandrapur, Nil Nil Nil Nil Nil Nil Nil Maharashtra Prakasam, people 3962 people (22.9%) 51 people (0.3%) (Included in 51 cases 9 people Andhra villages people (37.4%) (Including stiffness in joint pain Pradesh surveyed of joint) column) Nil Nil Nil Nil schools children children surveyed (39.7%) Karim Nagar, Nil people 1144 people (35.4%) 272 people (8.4%) (Included in 272 (Included in 272 Andhra people (68.2%) (Including stiffness cases in joint pain cases in joint Pradesh of joint and column) pain column) crippling deformity) 101

125 Nil 2093 children 1626 children (77.7%) Nil Nil Nil Nil Nayagarh, Orissa 39 schools surveyed Nil Nil Nil Nil Nil Nil Bellary, Nil 6238 (73.1%) Nil (0.3%) children (Included in the 0.3% Nil Karnataka children children (Including stiffness cases in joint pain of joint) column) Mysore, 5 taluks Nil 413 children (9.2%) (Included in 413 Nil Karnataka children children (Including stiffness cases in joint pain (23.8%) of joint) column) Latur, Nil Nil Nil Nil Nil Nil Nil Maharashtra Nagaon, Nil children Nil 6 children (0.6%) (Included in 6 cases Nil Assam children (42.8%) (Including stiffness in joint pain of joint) column) Ujjain, Nil Nil 17 children (0.14%) (Included in 17 cases Nil Madhya children children (Including stiffness in joint pain 102

126 Pradesh (41.1%) of joint) column) Note: Most of the cases of joint fluorosis also had dental fluorosis. Detailed break up of these cases, which was of more than two types, is not reflected 103

127 Table 7.6. Extent of Fluoride Level in Water in the Villages/Human Habitations Surveyed District, State Total villages Number of water Level of Fluoride level in the tested water sources or habitations sources 1 or below to 3.1 to 5ppm 5.1 ppm or above tested/number of ppm 3ppm samples Nellore, Nil 71/ 216 Nil 40 Nil Nil Andhra Pradesh Nalgonda, /1174 Nil Andhra Pradesh Chandrapur, Nil Nil Nil Nil Nil Nil Maharashtra Prakasam, /787 Nil Andhra Pradesh Karim Nagar, Nil 90/650 Nil Nil Nil Nil Andhra Pradesh Nayagarh, Nil 24/9043 Nil 202 Nil Nil Orissa Bellary, Nil 1128/Nil Nil 495 Nil Nil 104

128 Karnataka Mysore, Nil 257/Nil Nil 104 Nil Nil Karnataka Latur, Nil Nil/7343 Nil 21 Nil Nil Maharashtra Nagaon, Nil Nil Nil Assam Ujjain, Nil 102/110 Nil Madhya Pradesh 105

129 Table 7.7. Result of Urine Samples Examined in Suspected Cases District, State Suspected cases identified for urine examination (normal level in urine 0.1 to 1.0 ppm) Dental fluorosis Number of cases in which more then 1 ppm fluoride found in a particular category Dental fluorosis Nellore, Andhra Pradesh Nalgonda, Andhra Pradesh 599 samples tested for all types of clinical fluorosis 552 samples found positive for all types of clinical fluorosis (92%) 1681 samples tested for all types of clinical fluorosis 1336 samples found positive for all types of clinical fluorosis (79.5 %) 946 samples tested in camps for all types of clinical 876 found positive (92.6%) fluorosis 1628 school children tested for dental fluorosis 1293 found positive ( 79.4%) Chandrapur, Maharashtra Nil Nil Prakasam, Andhra Pradesh 1422 samples tested for all types of clinical fluorosis 1283 samples found positive for all types of clinical fluorosis (90.2%) Karim Nagar, Andhra Pradesh Nil Nil Nayagarh, Nil Nil 106

130 Orissa Bellary, Karnataka Mysore, Karnataka 2275 samples tested for all types of clinical fluorosis 2142 samples found positive for all types of clinical fluorosis (94.2%) 122 samples tested for all types of clinical fluorosis 70 samples found positive for all types of clinical fluorosis (53.4%) Latur, Maharashtra Nil Nil Nagaon, Assam Ujjain, Madhya Pradesh 161 samples tested for all types of clinical fluorosis 72 samples found positive for all types of clinical fluorosis (44.7%) samples tested for all types of clinical fluorosis 7868 samples found positive for all types of clinical fluorosis (70.9%) 107

131 Table 7.8. Coordination, Monitoring and Supervision of Programme in the District District, Coordination Nodal officer Asked people Has listed Visited by Advice given Have data of Send State done with visited health about source villages senior officer by fluorosis monthly other centre in last of drinking where water of state visiting patients who report departments three months water and is not yet government officer were provided risk of tested for in the last service at fluorosis fluoride three months referral hospital Nalgonda, Yes Yes (2 times) Yes Yes Yes Yes No Yes Andhra Pradesh Nellore, Yes Yes (4 times Yes Yes Yes Yes No Yes Andhra for 6 PHCs Pradesh and 2 times for 7 PHCs) Chandrapu Yes No No No No No No No r, Maharasht 108

132 ra Prakasam, Yes No Yes Yes Yes Yes No Yes Andhra Pradesh Karim Yes No Yes Yes Yes Yes No No Nagar, Andhra Pradesh Nayagarh, No Yes (6 times) Yes No No No No No Orissa Bellary, Yes Yes (9 times) Yes Yes Yes Yes No No Karnataka Mysore, Yes No No Yes Yes Yes No No Karnataka Latur, No No No No No No No No Maharasht ra Nagaon, Yes Yes (6 times) Yes Yes No No No No 109

133 Assam Ujjain, Yes Yes (18 times) Yes Yes Yes Yes No No Madhya Pradesh 110

134 Table 7.9. Activities Undertaken by the District Rural Water Supply and Sanitation Department (RWSD) District, Rain Providing test kits to Educating people on Providing alternative safe Defluoridation State water village panchayats for drinking safe water with water for drinking of ground harvesting testing fluoride level in permissible limits of fluoride water the water Nalgonda, No No No Yes No Andhra Pradesh Nellore, No No No Yes No Andhra Pradesh Chandrapu No No No Yes Yes r, Maharasht ra Prakasam, No No Yes No No Andhra Pradesh 111

135 Karim No No No No No Nagar, Andhra Pradesh Nayagarh, No No No Yes No Orissa Bellary, No No No Yes No Karnataka Mysore, No No No Yes No Karnataka Latur, No No No Yes No Maharasht ra Nagaon, No No No Yes No Assam Ujjain, No No No Yes No Madhya Pradesh 112

136 Table Three Most Important Constraints and Suggestions Offered by the District Nodal Officers District, Three most important constrains in order Three most important suggestions in order State One Two Three One Two Three Nellore, Nil Nil Nil More personnel in the Training should be given to Doctors also need Andhra district may be given as lab technicians, ASHAs, training Pradesh three field investigators AWAs and PHC staff for sixe months each is not sufficient to complete surveys Nalgonda, Field No Training not Need more field Need transportation facility to Single round of Andhra investigators vehicles/hirin given investigators cover the remaining schools orientation has been Pradesh (three) in six g facilities regularly to as three field and communities done, which needs months is too was given field staff investigators for six to be repeated less months each is not alongwith provision sufficient to complete of computer surveys systems, and so on Chandrap There is no ion- There is no Nil Need urgent appointment Need urgent supply of ion- Nil ur, metre for laboratory of laboratory technician metre for analysis of water 113

137 Maharash analysis of technician and urine samples tra water and urine samples Prakasam Field No Periodical For mobility of the team, Nil Nil, Andhra investigators vehicles/hirin reorientation transportation needs to Pradesh (three) in six g facilities of the PHC be provided by the months is too was given staff is not district medical and less done health officer with necessary fuel Karim Nagar, Andhra Pradesh Field investigators (three) in six months is too less Nil Nil Nil Nil Nil Mysore, Field No Nil Continuation of field Nil Nil Karnatak investigators vehicles/hirin staff will effectively help a (three) in six g facilities in field work months is too was given 114

138 less Nayagarh During phase Post of field ASHAs are Field investigators need Separate dealing assistant or Supply of specific, Orissa I to Phase IV investigator unwilling to to be posted for survey some special allowances to the medicines and its of NPPCF only had been perform work in remaining seven present dealing assistant may guidelines to be 22 villages and abolished survey work blocks of the district be provided to help with provided 22 schools had after six on fluorosis where the survey work proper documentation and been surveyed months and and are has not been conducted coordination of the in only one there after no requesting till date programme block out of the field for some eight blocks in investigator incentive like the district has been other health posted for related conducting programmes survey work Bellary, Urine sampling Nil Nil Sufficient funds need to A vehicle is required vehicle ASHA workers are Karnatak collection and be provided to carryout for visiting villages or crucial for health a labelling, water all the programmes of provisions need to be made in education activities. sampling and the NPPCF the guidelines for hiring the Provision is to be 115

139 community vehicles in emergency cases made in the survey is very difficult to do guidelines paying for them without any honorarium support of field staff Mysore, There is a No Nil Continuation of field Nil Nil Karnatak shortage of field vehicles/hirin staff will effectively help a staff g facilities in field work was given Latur, There is a There is a no Nil Posting of investigators There is a no training of Nil Maharash shortage of training of and specialists is needed medical officers, local public tra investigators medical and community leaders is and specialists officers, local needed public and community leaders Nagaon, Most of the With mostly Nil Services of three field Nil Nil 116

140 Assam fluoride affected labour on investigators may be villages of the daily wages it extended to the Phase-II district are is often phase of the NPPCF as inaccessible difficult to they can help the health reach the care providers to reach villages the affected person(s). during village They may thus help a lot survey in comprehensive management of cases Ujjain, Allotment of There is no There is no Yearly orientation and Diagnostics camps need to Hike is required at Madhya funds was mobility provision of refresher training needs provided at each level like 20% remuneration Pradesh delayed by support for supportive to be provided for PHCs/CHCs/civil hospitals for the programme about one and a field visits and clerical Medical staff half years staff Officers/ASHAs/ANMs/ AWWs/MPWs 117

141 Table Total Number of High School Students Present on Day of the Interview and Response Received Total number of high school School A School B p-value students Total number of students present in class Total number of students who (n=) 95 (96%) (n=) 90 (91%) (not significant) responded 118

142 Table Comparison of Knowledge of Fluorosis between the High School Students of the Two Schools Variable School A School B p-value Total number of students who have 90 (94.7%) 57 (63.3%) (highly significant) seen patients with transverse band of n=95 n=90 yellow or dark brown coloured teeth Total number of students who have 85 (89.5%) 59 (65.5%) (highly significant) seen patients complaining of stiffness n=95 n=90 of neck joint and/spine with bow leg or knock-knee Total number of students who knew 57 (63.3%) 19 (21.1%) (not significant) about health worker s visit in their n=95 n=90 locality in the last 3 months and query about above signs 119

143 Table Comparison of Knowledge of Cause and Prevention of Fluorosis between the High School Students of the Two Schools Variable School A School B p-value Total number of students who knew 90 (94.7%) 83 (92.2%) (highly significant) that excess of fluoride in drinking water n=95 n=90 can cause fluorosis Total number of students who knew 72 (75.8%) 21 (23.3%) (highly significant) that the early signs/symptoms of n=95 n=90 fluorosis can be reversed by drinking water which has the accepted level of fluoride Total number of students who knew 68 (71.6%) 28 (31.1%) (highly significant) that the deformity of teeth and skeleton, n=95 n=90 which is related to excess fluoride intake, can be prevented by stopping the drinking of water with high fluoride content 120

144 Total number of students who knew the 45 (47.4%) 29 (32.2%) (just significant) advantages of defluoridation (removal n=95 n=90 of excess fluoride in water)/filtered drinking water that has permissible limit of fluoride content 121

145 Table Comparison of Testing of Drinking Water for Fluoride Content between the High School Students of the Two Schools Variable School A School B p-value Total number of students who knew that the 1 (1.05%) 21 (23.3%) fluoride level/content of their drinking water n=95 n=90 (highly significant) source had been tested by the government Total number of students who knew that the 4 (4.2%) Not applicable for school NA excess of fluoride content present in the n=95 drinking water of school water supply has been removed by defluoridation/alternate source of safe water Total number of students who knew that their drinking water has excessive fluoride content, is not defluoridated, and are still drinking the same water Not applicable for school 41 (45.5%) n=90 NA 122

146 Table Comparison of Knowledge About IEC Activities between the High School Students of the Two Schools Variable School having filtered river water School having ground water p-value supply supply Common sources of information were: 24 (25.3%) 27 (30%) TV n=95 n=90 (not significant) Radio 4 (4.2%) n=95 Newspaper 26 (27.3%) n=95 Poster pamphlet/ health worker 41 (43.1%) n=95 4 (4.4%) n=90 17 (18.9%) n=90 35 (38.9%) n= (not significant) (not significant) (not significant) Mix or more than two of the 17 (17.9%) 0 (0%) above n=95 n=90 (significant) Other/ community volunteer 10 (10.5%) n=95 1 (1.1%) n= (not significant) Total 112 (17 Mix * ) (Out of 95) 84 Out of 90 (students who did not respond, had gone out of class for other 123

147 activities - 6) Total number of students who 23 (24.21%) 20 (22.2%) have seen in their area, posters, n=95 n=90 (not significant) hoardings or wall writings showing the signs/symptoms of dental and skeletal fluorosis Total number of students who had 64 (71.1%) 63 (70%) heard radio message/tv message n=95 n=90 (highly significant) on dental or skeletal fluorosis * Already included due to mixed response 124

148 Table Comparison of Perception About the Symptoms of Fluorosis between the High School Students of the Two Schools Variable School A School B p-value Total number of students who said 4 (4%) 22 (22.2%) that patients having skeletal n=95 n=90 (highly significant) deformity due to fluorosis, spread this disease to others Total number of students who said 9 (9.1%) 40 (40.4%) (not significant) they like the water that is available n=95 n=90 for drinking at their school Total number of students who said 43 (43.43%) 44 (44.4%) (not significant) he/she and/or family member(s), n=95 n=90 have experienced frequent abdominal pains, intermittent diarrhoea/constipation, tingling in fingers and toes, chronic joint pain or stiffness of neck transverse Total number of students who said 41 (41.41%) 45 (45.45%) (just significant) he/she and/or family member(s) n=95 n=90 125

149 have visited doctor for above health problem 126

150 Table Comparison of Attitude Towards Fluorosis between the High School Students of the Two Schools Variable School A School B p-value Total number of students who 95 (95.96%) 84 (84.85%) (just significant) said that they would assist the n=95 n=90 government staff in their village if the government, in future, planned to improve the water supply, after testing the quality of the water Total number of students who 94 (98.5%) 82 (97.6%) (just significant) said they would cooperate with n= 95 n=90 the government staff to provide all the information required by them Total number of students who 91 (95.78%) 86 (95.5%) (not significant) said they would help in n=95 n=90 educating community members about the problem 127

151 arising due to excess fluoride intake from the water Total number of students who 4 (4.2%) 6 (6.7%) (not significant) said they prefer not to waste n=95 n=90 time in any such work mentioned above 128

152 CHAPTER 8. Conclusion 8.1. Summary of the Study This study focused on the review of the globally reported high fluoride levels in the various environmental media and foodstuffs, and the magnitude of prevalence of fluoride contamination observed in human being, terrestrial and aquatic plants and animals as well as fluorosis problems in people, with special reference to India. It also critically assessed the strategy adopted for prevention and control of the fluorosis problem in India by two steps. First, a questionnaire study (on pre-designed questionnaire) was conducted with at least 10% of the total of 91 district nodal officers of India s NPPCF. Second, a knowledge, attitude and perception study was conducted in an Indian endemic district, where there had been implementation of the NPPCF for at least three years. This study was carried out through interviews with the high school students of the two schools located within the same endemic area. One of the schools was taken from a habitation/village, which had alternate source of filtered water supply having normal fluoride content. In contrast, the second school had non-defluoridated/pre-existing ground water supply for drinking purpose and its water contained a high fluoride concentration. The major findings, limitations of the study and recommendations are highlighted and discussed in the following sections Main Findings Findings from Review of Literature 129

153 Based on literature review of the nationally (Indian) reported fluoride levels in drinking water of different endemic states, it was found that fluoride concentrations between 1 to 3 mg/l could result in dental fluorosis and fluoride concentrations above 3 mg/l could result in severe dental fluorosis and skeletal fluorosis. The 18 endemic states of India can be grouped into three main categories of high, moderate and low endemic of fluorosis. Five of these states fall under high endemic (>10 mg/l of fluoride in drinking water) category, nine states under moderate endemic (5-9.9 mg/l) category and remaining four states under low endemic (1-4.9 mg/l) category. It was observed that fluoride concentrations in the soil increased with decreasing distance of petrochemical waste dumping sites and phosphorous and aluminium plants, particularly within distances of 4 km. Amongst all foodstuffs and beverages, tea leave were found to contain the highest fluoride concentrations. Adverse effects of fluoride on terrestrial and aquatic plants, terrestrial vertebrates and invertebrates, and aquatic vertebrates and invertebrates, have been observed in the field and demonstrated in laboratory conditions Findings from Survey of 11 Endemic Districts It was found that the Government of India s NPPCF had been implemented in all the 11 districts, for at least three years. All the 11 districts had received funds for carrying out the NPPCF, however, there had been delays in the delivery of the programme in five of the districts. Also, the utilisation of this fund was quite slow in four of the districts. No district consultants had been appointed in three districts, field investigators were appointed in seven districts and laboratory technicians were appointed in eight districts. Training of the targeted number of staff (doctors, laboratory technicians, paramedicals, ASHAs, AWWs and punchayat members) and 130

154 the provision of medical treatment were found to be adequate in eighth of the 11 districts. Some IEC materials had been distributed in eight districts. Activities in areas like establishment of proper referral facility provision, provision of aids and appliances for disabled persons, vehicle or hiring facility, population and school survey, were conducted in six, four, five and four districts, respectively. Monitoring of the programme was adequate in five districts and supervision was found to be lacking in timely implementation in four districts. There seems to be satisfactory coordination with other government departments (nine districts) but an inadequate level of involvement of DH/CHC/PHC/SC staff (nine districts). No clinical survey for fluorosis was carried out in three districts and urine samples were examined for fluoride in nine districts. The percentage of clinically suspected cases confirmed by urine examination was found to be in the range of 45-90% of the suspected cases. The reason for the inadequate level of population and school surveys done by the districts was due to lack of provision of adequate number of trained staff like field investigators; for example, there were only three investigators for six months in each district, and such limited manpower resources were insufficient for carrying out the field surveys with good quality. While an alternative safe drinking water supply was provided in seven of the districts, defluoridation of groundwater had been applied in only two of the districts, at which the fluoride contaminated water supply had been replaced by filtered river water supply. Also, monthly progress reports on the NPPCF were prepared and submitted by only five of the 11 districts. The range for the prevalence of (joint) skeletal fluorosis was found to be between 0.70 and % in the 11 districts. 131

155 Findings from the Knowledge, Attitude and Perception Study Responses were received from a total of 194 students from the school with filtered river water supply (school A) and from a total of 189 students from the school with ground water supply (school B) containing high fluoride. The students awareness about the signs of fluorosis ranged from 89.5% to 94.7% in school A and the field visit of the health worker was also higher (63%) amongst students of school A when compared with those from school B. The students awareness about the cause (94.7%) and preventability (71.6% to 75.8%) of fluorosis was higher amongst students from school A. The knowledge about the cause of fluorosis was marginally better (94.7%) in school A than in school B. Most of the students in both schools did not know if their school s water supply had been tested for fluoride content. Only 1.05 % of school A s students and 23.3% of school B s students had knowledge about this, although this knowledge was slightly better (23.3%) in school B. Poster, Newspaper and TV were the three most common sources of information, in the order of responses from students, in both schools. A greater number of students from school B said that patients of fluorosis could spread the disease to others; this was likely due to wrong perception. However, the experience of having symptoms of fluorosis amongst the family members was more or less the same amongst students in both schools. Surprisingly, more students from school B said that they liked to drink the groundwater, which might be either due to the taste of the water or lack of an alternate source of water supply in the school and in their home. The number of people with symptoms of fluorosis, who visited the doctor, when they developed the symptoms, was similar between the two schools. The attitude of students from both schools was positive or favourable as a very high number of students said that they were willing to cooperate and help the 132

156 government/health workers coming to their village to improve their water supply. A good number (95% in school A and 82.8% in school B) of students from both schools said that they would spread the correct informative messages to local people, about fluorosis and its prevention. Very few of students from both schools had negative attitude (no interest) towards the prevention and control efforts being made for fluorosis, as only 4 to 6 % of them said that they would not waste their time in cooperating and helping the visiting government/health staff. The statistical difference between the students of school A and school B, with regards to their knowledge and awareness of early signs of dental and skeletal fluorosis, cause and spread of fluorosis, fluorosis prevention and remediation, government monitoring of drinking water, was found to be highly significant (pvalue= ; A was better than B). The statistical difference between the students of school A and school B, on their awareness of fluorosis from radio messages or TV messages was also found to be highly significant (p-value= ; A was better than B). The statistical difference between the students of school A and school B, regarding their knowledge of the advantages of drinking defluoridated or filtered water with permissible fluoride levels (p-value=0.0509; A was better than B), affirmation of assistance to the government for any future improvement plans of water supply (p-value= ; A was better than B), affirmation of assistance to government for any future information requirement (p-value= ; A was better than B, and awareness of family members visit doctor for fluorosis related health problem (p-value= ; A was better than B), was found to be just significant. The statistical difference between the students of school A and school B, regarding their knowledge of health worker s visit to locality in the last three months 133

157 (p-value=0.582), and knowledge of NPPCF s IEC activities from TV (pvalue=0.5782), radio (p-value=1.0), newspaper (p-value=0.2338), poster pamphlet or health worker (p-value=0.6596), mix or more than two of these media methods (pvalue= ), and other means or from community volunteers (p-value=0.884), was found to be not significant. The statistical difference between the students of school A and school B, with regards to their knowledge of signs of fluorosis from local posters, hoardings or wall writings (p-value=0.8204) (not significant), positive attitude towards drinking water available at their schools (p-value=0.729), awareness of family members experience with symptoms of different types of fluorosis (p-value=0.4324), affirmation towards providing help to educating community members about fluorosis (p-value=0.6795), and negative attitude towards educating community members about fluorosis (pvalue=0.6795), was found to be not significant Recommendations i. An high priority needs to be given for providing alternate safe drinking water supply and the implementation of NPPCF, in the 18 endemic districts in the order of their importance (i.e., high endemic, moderate endemic and low endemic). The high endemic districts should be given the top priority for implementation of the programme so that not only can the people with higher prevalence of fluorosis be provided early relief, spread of fluorosis among other people can be also be avoided by early detection and prevention of the disease. 134

158 ii. Another strategy would be providing alternative safe drinking water to the general population or providing defluoridation plants. However, the provision of alternative supply of water will depend on the local situation of the district, like availability of river or some other natural water body nearby or rain water harvesting possibility, since water treatment and distribution can be quite expensive in certain areas. In case of existing alternate safe water being supplied to some of the Indian endemic districts, there is a need to increase the daily drinking water supply to more than an hour per day. Also, defluoridation plants are expensive and their regular maintenance can further add to the cost. Progress in the current implementation of this strategy is slow in India and there is a need for conducting projects with a time-bound mission mode. iii. Another recommendation would be the completion of surveys in the district in time-bound manner and the provision of adequate medical treatment facilities with upgraded operation theatres and specialist doctors at referral hospitals. But for proper medical treatment, adequate supply of medicines and adequate number of trained staff are required along with other logistic support. For this, there must be increased linkages of the districts with referral hospitals and better involvement of the general health care staff. iv. People need to be educated on drinking safe water with permissible limits of fluoride and possibility of rain water harvesting for those who can afford it. v. Another strategy would be to plan and build all future townships and habitations, in the endemic districts, at a safe distance from fluoride releasing industries like petrochemical refineries, phosphorous and aluminium plants, coal and cement industries, and the like. Based on the knowledge, aptitude 135

159 and perception study conducted amongst the high school students at the endemic district, it is noticed that untreated or unfiltered ground water is still being supplied to schools through hand pumps. There is thus an urgent requirement to stop this practise and close down all such water supply stations with hand pumps. vi. There is need for proper and uniform monthly reports, for monitoring of the NPPCF, which should preferably be checked by an independent department of the government of India, at frequent intervals for reporting to policy makers. vii. District consultants and all other required staff should be appointed on priority in all the remaining endemic districts. District consultants should be given training for conducting the survey and fluorosis management, through identified training institutions which have faculties from the areas of dental health, orthopaedics, public health, IEC, nutrition, disability care and rehabilitation. viii. Robust advocacy and effective IEC activities need to be implemented in all of the endemic districts Limitations and Future Research This study critically assessed the effectiveness of the strategies adopted by the Government of India s NPPCF. The two questionnaire studies with the district nodal officers and the high school students investigated the availability of logistic support, involvement of general health care staff, training status of staff, status of clinical fluorosis survey, fluoride levels in the local water supplies, status of urine samples examination, coordination, monitoring and supervision of the programme, status of 136

160 alternative safe drinking water supplies provision, defluoridation status, education and awareness status and rain water harvesting promotion. However, I was able to conduct survey only in 11 districts and there is a need to conduct such studies in all the remaining endemic districts in the field, so as to find out the operational difficulties of the NPPCF and come up with best solutions. There is not much conclusive data available in certain areas like fluoride emitting industries, and adverse effects of fluoride on terrestrial and aquatic plants and animals and humans in India. There is an urgent need to carry out additional research on this from both experimental and clinical scientists. In the endemic areas of India, where drinking water is not easily available, there is more dependence on ground water for which defluoridation is required, which is quite expensive. Therefore research and development should be conducted for coming up with cheaper alternatives for defluoridation treatment of the ground water. 137

161 References Aardema, M.J., & Tsutsui, T. (1995). Sodium fluoride-induced chromosome aberrations in different cell cycle stages. Mutation Research, 331(1), doi: / (95)00053-l Agarwal, C., Gupta, K., & Gupta, B. (1999). Development of new low cost defluoridation technology. Water Science and Technology, 40(2), doi: /s (99) ATSDR. (1993). Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine. Atlanta, Georgia: ATSDR. Akpata, E., Fakiha, Z., & Khan, N. (1997). Dental fluorosis in year-old rural children exposed to fluorides from well drinking water in the Hail region of Saudi Arabia. Community Dentistry and Oral Epidemiology, 25(4), doi: /j tb00947.x Al-Khateeb, T., Al-Marasaf, A., & O'Mullane, D. (1991). Caries prevalence and treatment need amongst children in an Arabian community. Community Dentistry and Oral Epidemiology, 19(5), doi: /j tb00167.x 138

162 Alarcón-Herrera, M.T., Martín-Domínguez, I.R., Trejo-Vázquez, R., & Rodriguez- Dozal, S. (2001). Well water fluoride, dental fluorosis, and bone fractures in the Guadiana Valley of Mexico. Fluoride, 34(2), Apambire, W., Boyle, D., & Michel, F. (1997). Geochemistry, genesis, and health implications of fluoriferous ground waters in the upper regions of Ghana. Environmental Geology, 33(1), doi: /s Ayoob, S., & Gupta, A. K. (2006). Fluoride in drinking water: A review on the status and stress effects. Critical Reviews in Environmental Science and Technology, 36(6), doi: / Azbar, N., & Türkman, A. (2000). Defluoridation in drinking water. Water Science and Technology, 42(1-2), Bardsen, A., Mock, K., & Bjorvatn, K. (1999). Dental fluorosis among persons exposed to high- and low-fluoride drinking water in western Norway. Community Dentistry and Oral Epidemiology, 27(4), doi: /j tb02019.x Barrie, L.A., & Hoff, R.M. (1985). Five years of air chemistry observations in the Canadian arctic. Atmospheric Environment, 19(12), doi: / (85)

163 Bayley, T.A., Harrison, J.E., Murray, T.M., Josse, R.G., Sturtridge, W., Pritzker, K.P., Strauss, A., Vieth, R., & Goodwin, S. (1990). Fluoride-induced fractures: Relation to osteogenic effect. Journal of Bone Mineral and Research, 5(Suppl. 1), S217-S222. doi: /jbmr Bennett, A., & Barratt, R. (1980.) Some observations on atmospheric fluoride concentrations in Stoke-on-Trent. Journal of Royal Society of Health, 100(3), doi: / Bergmann, R. (1995). Fluorid in der Ernährung des Menschen: Biologische Bedeutung für den wachsenden Organismus. Berlin, Germany: Virchow- Klinikum der Humboldt-Universität. Bhatnagar, M., & Susheela, A.K. (1998). Chronic fluoride toxicity: An ultrastructural study of the glomerulus of the rabbit kidney. Environmental Science and Technology, 6(1), Boulton, I.C., Cooke, J.A., & Johnson, M.S. (1994). Fluoride accumulation and toxicity in wild small mammals. Environmental Pollution, 85(2), doi:0.1016/ (94) Brouwer, I., Dirks, O., De-Bruin, A., & Hautvast, J. (1988). Unsuitability of World Health Organization guidelines for fluoride concentrations in drinking water in Senegal. The Lancet, 1(8579), doi: /s (88)

164 Bucheli, M., Kunz, Y., & Schaffner, M. (2010). Reporting for Switzerland under the protocol on water and health. Bern, Switzerland: Federal Office for the Environment. Calderon, J., Machado, B., Navarro, M., Carrizales, L., Ortiz, M.D., & Diaz-Barriga, F. (2000). Influence of fluoride exposure on reaction time and visuospatial organization in children. Epidemiology, 11(4), S153. Camargo, J.A. (1991). Ecotoxicological study of the influence of an industrial effluent on a net-spinning caddisfly assemblage in a regulated river. Water, Air and Soil Pollution, 60(3-4), doi: /bf Camargo, J.A. (1996). Comparing levels of pollutants in regulated rivers with safe concentrations of pollutants for fishes: A case study. Chemosphere, 33(1), doi: / (96) Camargo, J.A., & La Point, T.W. (1995). Fluoride toxicity to aquatic life: A proposal of safe concentrations for five species of palearctic freshwater invertebrates. Archives of Environmental Contamination and Toxicology, 29(2), doi: /bf Camargo, J.A., & Tarazona, J.V. (1990). Acute toxicity to freshwater benthic macroinvertebrates of fluoride ion (F ) in soft water. Bulletin of Environmental Contamination and Toxicology, 45(6), doi: /bf

165 Camargo, J.A., Ward, J.V., & Martin, K.L. (1992). The relative sensitivity of competing hydropsychid species to fluoride toxicity in the Cache la Poudre river, Colorado. Archives of Environmental Contamination and Toxicology, 22(1), doi: /bf Cao, J., Zhao, Y., Liu, J., Xirao, R., & Danzeng, S. (2000). Environmental fluoride content in Tibet. Environmental Research, 83(3), doi: /enrs Cao, S. (1992). Study on preventive and control measures on coal-combustion type endemic fluorosis in the Three Gorges area in China. Chinese Journal of Endemic Disease, 2, Caspary, W., Myhr, B., Bowers, L., McGregor, D., Riach, C., & Brown, A. (1987). Mutagenic activity of fluorides in mouse lymphoma cells. Mutational Research, 187(3), doi: / (87)90084-x Chen, Y.X., Lin, M.Q., He, Z.L., Chen, C., Min, D., Liu, Y.Q., & Yu, M.H. (1996). Relationship between total fluoride intake and dental fluorosis in areas polluted by airborne fluoride. Fluoride, 29(1), Chinoy, N. J., & Patel, D. (1998). Influence of fluoride on biological free radicals in ovary of mice and its reversal. Environmental Science and Technology, 6(3),

166 Chinoy, N.J., & Sharma. A. (1998). Amelioration of fluoride toxicity by vitamins E and D in reproductive functions of male mice. Fluoride, 31(4), Chinoy, N.J., Walimbe, A.S., Vyas, H.A., & Mangla. P. (1994). Transient and reversible fluoride toxicity in some soft tissues of female mice. Fluoride, 27(4), Choubisa, S., Choubisa, D., Joshi, S., & Choubisa, L. (1997). Fluorosis in some tribal villages of Dungapur district of Rajasthan, India. Fluoride, 30(4), Coetzee, P., Coetzee, L., Puka, R., & Mubenga, S. (2003). Characterisation of selected South African clays for defluoridation of natural waters. Water SA, 29(3), Cohen, D., & Conrad, M. (1998). 65,000 GPD fluoride removal membrane system in Lakeland, California, USA. Desalination, 117(1-3), doi: /s (98) Cole, J., Muriel, W., & Bridges, B. (1986). The mutagenicity of sodium fluoride to L5178Y [wild-type and TK+/- (3.7.2C)] mouse lymphoma cells. Mutagenesis, 1(2), doi: /mutage/

167 Cortes, D., Ellwood, R., O'Mullane, D., & Bastos, J. (1996). Drinking water fluoride levels, dental fluorosis and caries experience in Brazil. Journal of Public Health Dentistry, 56(4), doi: /j tb02441.x Czarnowski, W., Wrzenioska, K., & Krechniak, J. (1996). Fluoride in drinking water and human urine in northern and central Poland. Science of the Total Environment, 191(1-2), doi: / (96)05259-x Czarnowski, W., Wrzesniowska, K., & Krechniak, J. (1996). Fluoride in drinking water and human urine in northern and central Poland. Science of the Total Environment, 191(1-2), doi: / (96)05259-x Dabeka, R.W., & McKenzie, A.D. (1995). Survey of lead, cadmium, fluoride, nickel, and cobalt in food composites and estimation of dietary intakes of these elements by Canadians in Journal of the Association of Official Analytical Chemists International, 78(4), Dabeka, R.W., McKenzie, A.D., Conacher, H.B.S., & Kirkpatrick, B.S. (1982). Determination of fluoride in Canadian infant foods and calculation of fluoride intake by infants. Canadian Journal of Public Health, 73, Das, B., Talukdar, J., Sarma, S., Gohain, B., Dutt, R.K., Das, H.B, & Das, S.C. (2003). Fluoride and other inorganic constituents in groundwater of Guwahati, Assam, India. Current Science, 85(5),

168 Datta, D.K., Gupta, L.P., & Subramanian, V. (2000). Dissolved fluoride in the Lower Ganges Brahmaputra Meghna River system in the Bengal Basin, Bangladesh. Environmental Geology, 39(10), doi: /s Dave, G. (1984). Effects of fluoride on growth, reproduction and survival in Daphnia magna. Comparative Biochemistry and Physiology, 78C(2), doi: / (84) Davies, F.B.M. (1982). Accumulation of fluoride by Xanthoria parietina growing in the vicinity of the Bedfordshire brickfields. Environmental Pollution, 29(3), doi: / (82) Daw, R.K. (2004). People-centred Approaches to Water and Environmental Sanitation. In 30th WEDC International Conference, Vientiane, Lao PDR. Experiences with Domestic Defluoridation in India. New Delhi, India: WES, UNICEF. Dean, H.T. (1942). Epidemiological studies in the United States. In F.R. Moulton (Ed.), Fluorine and Dental Health (Publication No. 19). Washington: American Association for the Advancement of Science. Delmas, P.D., Dupuis, J., Duboeuf, F., Chapuy, M.C., & Meunier, P.J. (1990). Treatment of vertebral osteoporosis with disodium monofluorophosphate: Comparison with sodium fluoride. Journal of Bone and Mineral Research, 5(Suppl. 1, S doi: /jbmr

169 Dfaz-Barriga, F., Navarro-Quezada, A., Grijalva, M., Loyola-Rodriguez, J., & Ortz, M. (1997). Endemic fluorosis in Mexico. Fluoride, 30(4), Dhiman, S., & Keshari, A. (2006). Hydro-geochemical evaluation of high fluoride groundwaters: A case study from Mehsana district, Gujarat, India. Hydrological Sciences Journal, 51(6), doi: /hysj Dissanayake, C. (1996). Water quality and dental health in the dry zone of Sri Lanka. Environmental Geochemistry and Health, 113, doi: /GSL.SP Driscoll, W., Horowitz, H., Meyers, R., Heifetz, S., Kingman, A., & Zimmerman, E. (1983). Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations. The Journal of American Dental Association, 107(1), Dunipace, A.J., Wilson, C.A., Wilson, M.E., Zhang, W., Kafrawy, A.H., Brizendine, E.J., Miller, L.L., Katz, B.P., Warrick, J.M., & Stookey, G.K. (1996). Absence of detrimental effects of fluoride exposure in diabetic rats. Archives of Oral Biology, 41(2), doi: / (95) Dure-Smith, B.A., Farley, S.M., Linkhart, S.G., Farley, J.R., & Baylink, D.J. (1996). Calcium deficiency in fluoride-treated osteoporotic patients despite calcium 146

170 supplementation. The Journal of Clinical Endocrinology and Metabolism, 81(1), doi: /jc DWI. (2010). Drinking Water Standards. London, UK: DWI. Edmunds, W.M., & Smedley, P.L. (1996). Groundwater geochemistry and health: An overview. In J.D. Appleton, R. Fuge & G.J.H. McCall (Eds.), Environmental Geochemistry and Health (pp ). Oxford: Geological Society Special Publication. Eklund, S.A., Burt, B.A., Ismail, A.I., & Calderone, J.J. (1987). High-fluoride drinking water, fluorosis, and dental caries in adults. Journal of the American Dental Association, 114(3), Ekstrand, J., Hardell, L.I., & Spak, C.J. (1984). Fluoride balance studies on infants in a 1-ppm water fluoride. Caries Research, 18(1), doi: / Elbetieha, A., Darmani, H., & Al-Hiyasat, A.S. (2000). Fertility effects of sodium fluoride in male mice. Fluoride, 33(3), Ernst, P., Thomas, D., & Becklake, M. (1986). Respiratory survey of North American Indian children living in proximity to an aluminum smelter. American Review of Respiratory Disease, 133(2),

171 Esala, S., Vuori, E., & Helle, A. (1982). Effect of maternal fluorine intake on breast milk fluorine content. British Journal of Nutrition, 48(2), doi: /bjn ESD. (2004). National Standard for Drinking Water Quality. Putra Jaya, Malaysia: ESD, Ministry of Health. Feenstra, L., Vasak, L., & Griffioen, J. (2007). Fluoride in Groundwater: Overview and Evaluation of Removal Methods (Report No. SP ). Utrecht: International Groundwater Resources Assessment Centre. Felsenfeld, A., & Roberts, M. (1991). A report of fluorosis in the United States secondary to drinking well water. Journal of the American Medical Association, 265(4), doi: /jama Fieser, A.H., Sykora, J.L., Kostalos, M.S., Wu, Y.C., & Weyel, D.W. (1986). Effect of fluorides on survival and reproduction of Daphnia magna. Journal of the Water Pollution Control Federation, 58(1), Fluorosis. (n.d.). In Merriam-Webster s Online Dictionary. Retrieved on February 24, 2013, from Frencken, J.E.F.M. (Ed.) (1992). Endemic Fluorosis in Developing Countries, Causes, Effects and Possible Solutions (Publication No ). Leiden: NIPG-TNO. 148

172 Freni, S.C. (1994). Exposure to high fluoride concentrations in drinking water is associated with decreased birth rates. Journal of Toxicology and Environmental Health, 42(1), doi: / Fuge, R., & Andrews, M.J. (1988). Fluorine in the UK environment. Environmental Geochemistry and Health, 10(3-4), doi: /bf Fung, K.F., Zhang, Z.Q., Wong, J.W.C., & Wong, M.H. (1999). Fluoride contents in tea and soil from tea plantations and the release of fluoride into tea liquor during infusion. Environmental Pollution, 104(2), doi: /s (98) Garg, V., Suthar, S., Singh, S., Sheoran, A., Garima, M., & Jain, S. (2009). Drinking water quality in villages of south-western Haryana, India: Assessing human health risks associated with hydrochemistry. Environmental Geology, 58(6), doi: /s y Gelberg, K.H., Fitzgerald, E.F., Hwang, S.A., & Dubrow. R. (1995). Fluoride exposure and childhood osteosarcoma: A case-control study. American Journal of Public Health, 85(12), Gessner, B., Beller, M., Middaugh, J., & Whitford, G. (1994). Acute fluoride poisoning from a public water system. The New England Journal of Medicine, 330(2), doi: /nejm

173 Gilbert, O.L. (1985). Environmental effects of airborne fluorides from aluminium smelting at Invergordon, Scotland Environmental Pollution, 39(4), doi: / (85) Gillespie, R.J., Humphries, D.A., Baird, N.C., & Robinson, E.A. (1989). Chemistry (2nd ed.). Boston, Massachusetts: Allyn and Bacon. Gilpin, L., & Johnson, A. (1980). Fluorine in agricultural soils of south-eastern Pennsylvania. Soil Science Society of American Journal, 44(2), doi: /sssaj x Gocke, E., King, M.T., Eckhardt, K., & Wild, D. (1981). Mutagenicity of cosmetics ingredients licensed by the European Communities. Mutation Research, 90, doi: / (81) Grobler, S., & Dreyer, A. (1988). Variations in the fluoride levels of drinking water in South Africa, implications for fluoride supplementation. South African Medical Journal, 73(4), Grobler, S., Dreyer, A., & Blignaut, R. (2001). Drinking water in South Africa: Implications for fluoride supplementation. Journal of the Dental Association of South Africa, 56(11), Gu, S., Rongli, J., & Shouren, C. (1990). The physical and chemical characteristics of particles in indoor air where high fluoride coal burning takes place. Biomedical and Environmental Sciences, 3(4),

174 Haimanot, R., Fekadu, A., & Bushra, B. (1987). Endemic fluorosis in the Ethiopian Rift Valley. Tropical and Geographical Medicine, 39(3), Haimanot, R.T., Fekadu, A., & Bushra, B. (1987). Endemic fluorosis in the Ethiopian Rift Valley. Tropical and Geographical Medicine, 39(3), Hardisson, A., Rodriguez, M., Burgos, A., Flores, L., Gutierrez, R., & Varela, H. (2001). Fluoride levels in publically supplied and bottled drinking waters in the island of Tenerife, Spain. Bulletin of Environmental Contamination and Toxicology, 67(2), doi: /s Harrison, J., Hitchman, A., Hassany, S., Hitchman, A., & Tam, C. (1984). The effect of diet on fluoride toxicity in growing rats. Canadian Journal of Physiology and Pharmacology, 62(3), doi: /y Hayashi, M., Kishi, M., Sofuni, T., & Ishidate, M.J. (1988). Micronucleus test in mice on 39 food additives and eight miscellaneous chemicals. Food and Chemical Toxicology, 26(6), doi: / (88) Health Canada. (1989). Ambient Air Levels of Fluoride at Cornwall Island, Ontario, April 14, 1988 October 12, 1988: Final Report. Ottawa, Ontario: Health Canada. 151

175 Health Canada. (1994). Inorganic Fluorides. Ottawa, Ontario: Canada Communication Group-Publishing. Heifetz, S.B., Driscoll, W.S., Horowitz, H.S., & Kingman, A. (1988). Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water-fluoride concentrations: A 5-year follow-up survey. Journal of the American Dental Association, 116(4), Heikens, A., Sumart, S., van Bergen, M., Widianarko, B., Fokkert, L., van Leeuwen, K., & Seinen, W. (2005). The impact of the hyperacid Ijen Crater Lake: Risks of excess fluoride to human health. Science of the Total Environment, 346(1-3), doi: /j.scitotenv Heilman, J.R., Kiritsy, M.C., Levy, S.M., & Wefel, J.S. (1999). Assessing fluoride levels of carbonated soft drinks. Journal of American Dental Association, 130(11), Hemens, J., & Warwick, R.J. (1972). The effects of fluoride on estuarine organisms. Water Research, 6(11), doi: / (72) Hitchcock, A.E., Zimmerman, P.W., & Coe, R.R. (1962). Results of ten years work ( ) on the effects of fluorides on gladiolus. Contributions from Boyce Thompson Institution, 21(5),

176 Hitchon, B. (1995). Fluorine in formation water, Alberta basin, Canada. Applied Geochemistry, 10(3), doi: / (95) Hoffman, R., Mann, J., Calderone, J., Trumbull, J., & Burkhart, M. (1980). Acute fluoride poisoning in a New Mexico elementary school. Paediatrics, 65(5), Hughes, P.R., Weinstein, L.H., Johnson, L.M., & Braun, A.R. (1985). Fluoride transfer in the environment: Accumulation and effects on cabbage looper Trichoplusia ni of fluoride from water soluble salts and HF-fumigated leaves. Environmental Pollution, A37(2), doi: / (85) Ibrahim, Y., Affan, A., & Bjorvatn, K. (1995). Prevalence of dental fluorosis in Sudanese children from two villages with respectively 0.25 mg/l and 2.56 mg/l fluoride in the drinking water. International Journal of Paediatric Dentistry, 5(4), Ismail, A., & Messer, J. (1996). The risk of fluorosis in students exposed to a higher than optimal concentration of fluoride in well water. Journal of Public Health Dentistry, 56(1), doi: /j tb02390.x Jackson, R., Kelly, S., Noblitt, T., Zhang, W., & Dunipace, A. (1994). The effect of fluoride therapy on blood chemistry parameters in osteoporotic females. Journal of Bone and Mineral Metabolism, 27(1),

177 Jackson, R.D., Kelly, S.A., Noblitt, T.W., Zhang, W., Wilson, M.E., Dunipace, A.J., Li, Y., Katz, B.P., Brizendine, E.J., & Stookey, G.K. (1997). Lack of effect of long-term fluoride ingestion on blood chemistry and frequency of sister chromatid exchange in human lymphocytes. Environmental and Molecular Mutagenesis, 29(3), doi: /(sici) (1997)29:3<265::aid-em6>3.0.co;2-b Jain, S., & Susheela, S. (1987). Effect of sodium fluoride on erythrocyte membrane function - with reference to metal ion transport in rabbits. Chemosphere, 16(5), doi: / (87) Johansson, T.S.K., & Johansson, M.P. (1972). Sublethal doses of sodium fluoride affecting fecundity of confused flour beetles. Journal of Economic Entomology, 65(2), Johnson, J., & Bawden, J.W. (1987). The fluoride content of infant formulas available in Paediatric Dentistry, 9(1), Juuti, M., & Heinonen, O.P. (1980). Incidence of urolithiasis and composition of household water in southern Finland. Scandinavian Journal of Urology and Nephrology, 14(2), doi: / Kaplan, H.M., Yee, N., & Glaczenski, S.S. (1964). Toxicity of fluoride for frogs. Laboratory Animal Care, 14(3),

178 Karthikeyan, G., Anitha, P., & Apparao, B. (1996). Contribution of fluoride in water and food to the prevalence of fluorosis in areas of Tamil Nadu in south India. Fluoride, 29(3), Karthikeyan, K., Nanthakumar, K., Velmurugan, P., Tamilarasi, S., & Lakshmanaperumalsamy, P. (2010). Prevalence of certain inorganic constituents in groundwater samples of Erode district, Tamil Nadu, India, with special emphasis on fluoride, fluorosis and its remedial measures. Environmental Monitoring and Assessment, 160(1-4), doi: /s Kau, P., Smith, D., & Binning, P. (1997). Fluoride detention by kaolin clay. Journal of Contaminant Hydrology, 28(3), Khalil, A.M., & Da dara, A.A. (1994). The genotoxic and cytotoxic activities of inorganic fluoride in cultured rat bone marrow cells. Archives of Environmental Contamination and Toxicology, 26(1), doi: /bf Kim, K., & Jeong, Y. (2005). Factors influencing natural occurrence of fluoride-rich groundwaters: A case study in the south-eastern part of the Korean peninsula. Chemosphere, 58(10), doi: /j.chemosphere

179 Kiritsy, M.C., Levy, S.M., Warren, J.J., Guha-chowdhury, M., Heilman, J.R., & Marshall, T. (1996). Assessing fluoride concentrations of juices and juiceflavoured drinks. Journal of American Dental Association, 127(7), Kishi, K., & Ishida, T. (1993). Clastogenic activity of sodium fluoride in great ape cells. Mutation Research, 301(3), doi: / (93) Kloos, H., & Tekle-Haimanot, R. (1993). The Ecology of Health and Disease in Ethiopia. Boulder, Colorado: Westview Press. Kloos, H., & Tekle-Haimanot, R. (1999). Distribution of fluoride and fluorosis in Ethiopia and prospects for control. Tropical Medicine and International Health, 4(5), doi: /j x Korkka-Niemi, K., Sipilä, A., Hatva, T., Hiisvirta, L., Lahti, K., & Alfthan, G. (1993). Nation-wide Rural Well Water Survey (The Quality of Household Water and Factors Influencing It). Helsinki: National Board of Waters and the Environment. Kundu, M., & Mandal, B. (2009). Assessment of potential hazards of fluoride contamination in drinking groundwater of an intensively cultivated district in West Bengal, India. Environmental Monitoring and Assessment, 152(1-4), doi: /s

180 Lahermo, P., & Backman, B. (2000). The Occurrence and Geochemistry of Fluorides with Special Reference to Natural Waters in Finland (Report of Investigation 149). Espoo: Geological Survey of Finland. Lahermo, P., Ilmasti, M., Juntunen, R., & Taka, M. (1990). The Geochemical Atlas of Finland (Part 1: The Hydrogeochemical Mapping of Finnish Groundwater). Espoo, Finland: Geological Survey of Finland. Lalumandier, J.A., & Ayers, L.W. (2000). Fluoride and bacterial content of bottled water vs tap water. Archives of Family Medicine, 9(3), doi: /archfami LeBlanc, G.A. (1984). Interspecies relationships in acute toxicity of chemicals to aquatic organisms. Environmental Toxicology and Chemistry, 3(1), doi: /etc Li, Y., Liang, C., Slemenda, C.W., Ji, R., Sun, S., Cao, J., Emsley, C., Ma, F., Wu, Y., Ying, P., Zhang, Y., Gao, S., Zhang, W., Katz, B., Niu, S., Cao, S., & Johnston, C. (2001). Effect of long-term exposure to fluoride in drinking water on risks of bone fractures. Journal of Bone and Mineral Research, 16(5), Li, Y., Liang, C.K., Katz, B.P., Brizendine, E.J., & Stookey, G.K. (1995). Long-term exposure to fluoride in drinking water and sister chromatid exchange 157

181 frequency in human blood lymphocytes. Journal of Dental Research, 74(8), doi: / Liu, B.K. (1996). Lung X-ray changes in skeletal fluorosis caused by coal combustion. Fluoride, 29(1), Liu, Y. (1995). Human Exposure Assessment of Fluoride (An International Study within the WHO/UNEP Human Exposure Assessment Location (HEAL) Programme). Beijing, China: Institute of Environmental Health Monitoring, Chinese Academy of Preventive Medicine. MacLean, D.C., & Schneider, R.E. (1981). Effects of gaseous hydrogen fluoride on the yield of field-grown wheat. Environmental Pollution, 24(1), doi: / (81) Madhnure, P., Sirsikar, D., Tiwari, N., Ranjan, B., & Malpe, D. (2007). Occurrence of fluoride in the groundwaters of Pandharkawada area, Yavatmal district, Maharashtra, India. Current Science, 92(5), Malea, P. (1995). Fluoride content in three seagrasses of the Antikyra Gulf (Greece) in the vicinity of an aluminum factory. Science of the Total Environment, 166(1-3), doi: / (95)04513-z Malhotra, A., Tewari, A., Chawla, H.S., Gauba, K., & Dhall, K. (1993). Placental transfer of fluoride in pregnant women consuming optimum fluoride in 158

182 drinking water. Journal of Indian Society of Pedodontics and Preventive Dentistry, 11(1), 1-3. Marie, P., & Mott, M. (1986). Short-term effects of fluoride and strontium on bone formation and resorption in the mouse. Metabolism, 35(6), doi: / (86) Martin, J.M., & Salvadori, F. (1983). Fluoride pollution in French rivers and estuaries. Estuarine Coastal and Shelf Science, 17(3), doi: / (83) Maurer, J., Cheng, M., Boysen, B., Squire, R., Strandberg, J., Weisbrode, J., & Anderson, R. (1993). Confounded carcinogenicity study of sodium fluoride in CD-1 mice. Regular Toxicology and Pharmacology, 18(2), doi: /rtph Mayer, D.F., Lunden, J.D., & Weinstein, L.H. (1988). Evaluation of fluoride levels and effects on honey bees (Apis mellifera L.) (Hymenoptera, Apidae). Fluoride, 21(3), McClenahen, J. (1976). Distribution of soil fluorides near an airborne fluoride source. Journal of Environmental Quality, 5(4), doi: /jeq x 159

183 McClurg, T.P. (1984). Effects of fluoride, cadmium and mercury on the estuarine prawn Penaeus indicus. Water SA, 10(1), McKnight-Hanes, M., Leverett, D., Adair, S., & Shields, C. (1988). Fluoride content of infant formulas: Soy-based formulas as a potential factor in dental fluorosis. Paediatric Dentistry, 10(3), MHFW. (2009). National Programme for Prevention and Control of Fluorosis. New Delhi, India: Nutrition Division, DGHS, MHFW. MHLW. (2010). Drinking Water Quality Standards in Japan. Retrieved on June 10, 2013, from MHSSE. (2003). Royal Decree 140/ Health Criteria Quality of Drinking Water. Retrieved on June 10, 2013, from Milgalter, N., Zadik, D., & Kelman, A. (1974). Fluorosis and dental caries in Yotvata area. Israel Journal of Dental Sciences, 23, Ministry of Environment of Republic of Korea. (2009). Drinking Water Quality Standards. Retrieved on June 10, 2013, from: up_pol_drinking 160

184 Mjengera, H., & Mkongo, G. (2003). Appropriate deflouridation technology for use in flourotic areas in Tanzania. Physics and Chemistry of the Earth, 28(20-27), doi: /j.pce Ministry of Health of Government of Canada. (2010). Guidelines for Canadian Drinking Water Quality: Guideline Technical Document - Fluoride. Ottawa, Ontario: Ministry of Health of Government of Canada. Ministry of Health of Government of New Zealand. (2008). Drinking-Water Standards for New Zealand 2005 (Rev. ed.). Wellington, New Zealand: Ministry of Health of Government of New Zealand. Mohammed, A., & Chandler, M. (1982). Cytological effects of sodium fluoride on mice. Fluoride, 15(3), Mondal, N., Prasad, R., Saxena, V., Singh, Y., & Singh, V. (2009). Appraisal of highly fluoride zones in groundwater of Kurmapalli watershed, Nalgonda district, Andhra Pradesh, India. Environmental Earth Sciences, 59(1), doi:0.1007/s x Ministry of Public Health of Government of Vietnam. (1995). Water Quality - Quality Standard of Surface Water (TCVN Surface Water Quality Standard of Vietnam). Hanoi, Vietnam: Ministry of Public Health of Government of Vietnam. 161

185 Moss, M.E., Kanarek, M.S., Anderson, H.A., Hanrahan, L.P., & Remington, P.L. (1995). Osteosarcoma, seasonality, and environmental factors in Wisconsin, Archives of Environmental Health, 50(3), Mothusi, B. (1998). Psychological Effects of Dental Fluorosis. South Africa: Department of Health, North West Province. Nair, K., & Manji, F. (1982). Endemic fluorosis in deciduous dentition - A study of 1276 children in typically high fluoride area (Kiambu) in Kenya. Tropical Dental Journal, 5(4), Nair, K., Manji, F., & Gitonga, J. (1984). The occurrence and distribution of fluoride in ground waters in Kenya. In Harare Symposium. Challenges in African Hydrology and Water Resources (pp ). Harare, Zimbabwe: IAHS publications. Nair, K.R., Manji, F., & Gitonga, J.N. (1984). The occurrence and distribution of fluoride in groundwaters in Kenya. East African Medical Journal, 61(7), National Institute of Public Health. (1996). System of Monitoring the Environmental Impact on Population Health of the Czech Republic (Summary Report 1995). Prague: National Institute of Public Health. 162

186 National Environmental Agency of Singapore. (2008). Environmental Public Health (Quality of Piped Drinking Water) Regulations. Retrieved on June 6, 2013, from e=0;query=type%3aact,sl%20%28quality%20of%20piped%20drinking%20 water%29%20status%3a%22published%22;rec=3;resurl=http%3a%2f%2fs tatutes.agc.gov.sg%2faol%2fsearch%2fsummary%2fresults Neal, C. (1989). Fluorine variations in Welsh streams and soil waters. Science of the Total Environment, 80(2-3), doi: / (89) NEIA. (2012). Compliance with Drinking Water Quality Standards in Northern Ireland, Belfast, Ireland: NIEA. Neuhold, J., & Sigler, W. (1960). Effects of sodium fluoride on carp and rainbow trout. Transactions of the American Fisheries Society, 89(4), doi: / (1960)89[358:eosfoc]2.0.co;2 Neuhold, J.M., & Sigler, W.F. (1960). Effects of sodium fluoride on carp and rainbow trout. Transactions of the American Fisheries Society, 89(4), doi: / (1960)89[358:eosfoc]2.0.co;2 NFA. (2011). Regulations Amending the Food Administration Regulations of Drinking Water (LIVSFS 2011:3). Retrieved on June 9, 2013, from 163

187 Nowak, A., & Nowak, M. (1989). Fluoride concentration of bottled and processed waters. Iowa Dental Journal, 75(4), 28. NRC. (2006). Fluoride in Drinking Water: A Scientific Review of EPA s Standards. Washington, District Columbia: The National Academies Press. Nriagu, J.O. (1986). Chemistry of the river Niger 1. Major ions. Science of the Total Environment, 58(1-2), doi: / (86) National Resource Management Ministerial Council of Commonwealth of Australia. (2011). Australian Drinking Water Guidelines Paper 6 National Water Quality Management Strategy. Canberra, Australia: National Health and Medical Research Council of Commonwealth of Australia. NTP. (1990). Toxicology and Carcinogenesis Studies of Sodium Fluoride (CAS No ) in F344/N Rats and B6C3F1 (Drinking Water Studies) (Technical Report 393). Bethesda, Maryland: National Institutes of Health, USDHHS. Nyaora, M., Tole, M., & Davies, T. (2002). The contribution of drinking water towards dental fluorosis: A case study of Nyoro division, Nakuro district, Kenya. Environmental Geochemistry and Health, 24(2),

188 Omueti, J., & Jones, R. (1977). Regional distribution of fluorine in Illinois soils. Soil Science Society of American Journal, 41(4), doi: /sssaj x Overton, W.S., Kanciruk, P., Hook, L.A., Eilers, J.M., Landers, D.H., Brakke, D.F., Blick, D.J., Linthurst, R.A., de Haan, M.D., & Omernik, J.M. (1986). Characteristics of Lakes in Eastern United States (Vol. II). Washington, District of Columbia: USEPA. Pack, M.R. (1971). Effects of hydrogen fluoride on bean reproduction. Journal of the Air Pollution Control Association, 21(3), doi: / Pak, C.Y.C., Sakhaee, K., Piziak, V., Peterson, R.D., Breslau, N.A., Boyd, P., Poindexter, J.R., Herzog, J., Heard-Sakhaee, A., Haynes, S., Adams-Huet, B., & Reisch, J.S. (1994). Slow-release sodium fluoride in the management of postmenopausal osteoporosis. A randomized controlled trial. Annals of Internal Medicine, 120(8), Pang, Y.X., Guo, Y.Q., Fu, K.W., Sun, Y.F., & Tang, R.Q. (1996). The effects of fluoride, alone and in combination with selenium, on the morphology and histochemistry of skeletal muscle. Fluoride, 29(2),

189 Paoloni, J., Florentino, C., & Sequeira, M. (2003). Fluoride contamination of aquifers in the southeast sub-humid pampa, Argentina. Environmental Toxicology, 18(5), doi: /tox Pettifor, J.M., Schnitzler, C.M., Ross, F.P., & Moodley, G.P. (1989). Endemic skeletal fluorosis in children: Hypocalcemia and the presence of renal resistance to parathyroid hormone. Bone and Mineral, 7(3), doi: / (89) Pillai, K., Mathai, A., & Deshmuhk, P. (1988). Effect of subacute dosage of fluoride on male mice. Toxicology Letters, 44(1-2), doi: / (88) Pillai, K.S., & Mane, U.H. (1984). The effect of fluoride on fertilized eggs of a freshwater fish, Catla catla (Hamilton). Toxicology Letters, 22(2), doi: / (84) Planning Commission of Government of India. (1996). Mid-Term Appraisal ( ). New Delhi, India: Planning Commission. Planning Commission of Government of India. (2002). India Assessment, Water Supply and Sanitation (A WHO-UNICEF Sponsored Study Report). New Delhi, India: Planning Commission. 166

190 Planning Commission of Government of India. (2003). Report of the Committee on India Vision New Delhi, India: Planning Commission. Polomski, J., Fluhler, H., & Blaser, P. (1982). Accumulation of airborne fluoride in soils. Journal of Environmental Quality, 11(3), doi: /jeq x Ponikvar, M. (2008). Exposure of Humans to Fluorine and Its Assessment. In A. Tressaud (Ed.), Fluorine and Health (pp ). Boston, Massachusetts: Elsevier Science. Port, G.R., Davies, M.T., & Davison, A.W. (1998). Fluoride loading of a lepidopteran larva (Pieris brassicae) fed on treated diets. Environmental Pollution, 99(2), doi: /s (97) Prince, C., & Navia, J. (1983). Glycosaminoglycan alterations in rat bone due to growth and fluorosis. Journal of Nutrition, 113(8), Qiu, M., Zhu, X., Li, S., Sun, G., Ni, A., Song, W.Z., & Zhang, J. (1987). Bone dynamic changes in experimental fluorosis of rats. Chinese Medical Journal, 100(11), Queste, A., Lacombe, M., Hellmeier, W., Hillermann, F., Bortulussi, B., Kaup, M., Ott, K., & Mathys, W. (2001). High concentrations of fluoride and boron in drinking water wells in the Muenster region - Results of a preliminary 167

191 investigation. International Journal of Hygiene and Environmental Health, 203(3), doi: /s (04) Quian, J.S. (1999). Fluoride in Water: An Overview. New York: WES, UNICEF. Rao, N., Rao, K., & Schuiling, R. (1993). Fluorine distribution in waters of Nalgonda district, Andhra Pradesh, India. Environmental Geology, 21(1-2), doi: /bf Rao, N.S. (1997). The occurrence and behaviour of fluoride in the groundwater of the lower Vamsadhara river basin, India. Hydrological Sciences, 42(6), doi: / Rao, N.S. (2009). Fluoride in goundwater, Varaha river basin, Visakhapatnam district, Andhra Pradesh, India. Environmental Monitoring and Assessment, 152(1-4), doi: /s Reardon, J., & Wang, Y. (2000). A limestone reactor for fluoride removal from wastewaters. Environmental Science and Technology, 34(15), doi: /es990542k Reddy, D., Nagabhushanam, P., Sukhija, B., Reddy, A., & Smedley, P. (2010). Fluoride dynamics in the granitic aquifer of the Wailapally watershed, Nalgonda district, India. Chemical Geology, 269(3-4), doi: /j.chemgeo

192 Riggs, B., Hodgson, S., O Fallon, W., Chao, E., Wahner, H., Muhs, J., Cedel, S., & Melton, L. (1990). Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. The New England Journal of Medicine, 322(12), doi: /nejm Rwenyonyi, C., Birkeland, J., Haugejorden, O., & Bjorvatn, K. (2000). Age as a determinant of severity of dental fluorosis in children residing in areas with 0.5 and 2.5 mg fluoride per litre in drinking water. Clinical Oral Investigations, 4(3), doi: /pl Salve, P., Maurya, A., Kumbhare, P., Ramteke, D., & Wate, S. (2008). Assessment of groundwater quality with respect to fluoride. Bulletin of Environmental Contamination and Toxicology, 81(3), doi: /s x Sankararamakrishnan, N., Sharma, A., & Iyengar, L. (2008). Contamination of nitrate and fluoride in groundwater along the Ganges alluvial plain of Kanpur district, Uttar Pradesh, India. Environmental Monitoring and Assessment, 146(1-3), doi: /s Schamschula, R., Duppenthaler, J., Sugar, E., Toth, K., & Barmes, D. (1988). Fluoride intake and utilization by Hungarian children: Associations and interrelationships. Acta Physioogical Hungarica, 72(2),

193 Scheifinger, H., & Held, G. (1997). Aerosol behaviour on the South African Highveld. Atmospheric Environment, 31(21), doi: /s (97) Schnitzler, C.M., Wing, J.R., Mesquita, J.M., Gear, A.K., Robson, H.J., & Smyth, A.E. (1990). Risk factors for the development of stress fractures during fluoride therapy for osteoporosis. Journal of Bone and Mineral Research, 5(Suppl 1), S195-S200. doi: /jbmr Schroder, J.L., Basta, N.T., Rafferty, D.P., Lochmiller, R.L., Kim, S., Qualls, W., & McBee, K. (1999). Soil and vegetation fluoride exposure pathways to cotton rats on A petrochemical contaminated landfarm. Environmental Toxicology and Chemistry, 18(9), doi: /etc Schuppli, P. (1985). Total Fluorine in CSSC reference soil samples. Canadian Journal of Soil Science, 65(3), doi: /cjss Segreto, V., Collins, E., Camann, D., & Smith, C. (1984). A current study of mottled enamel in Texas. The Journal of American Dental Association, 108(1), Selwitz, R.H., Nowjack-Raymer, R.E., Kingman, A., & Driscoll, W.S. (1995). Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations: A 10-year follow-up survey. Journal of Public Health Dentistry, 55(2), doi: /j tb02337.x 170

194 Shah, M., & Danishwar, S. (2003). Potential fluoride contamination in the drinking water of Naranji area, northwest frontier province, Pakistan. Environmental Geochemistry and Health, 25(4), doi: /b:egah e7 Shaji, E., Viju, B., & Thambi, D. (2007). High fluoride in groundwater of Palghat district, Kerala. Current Science, 92(2), Sharma, K., & Susheela, A. (1988a). Effect of fluoride on molecular weight, charge density and age related changes in the sulphated isomers of glycosaminoglycans of the rabbit cancellous bone. International Journal of Tissue Reaction, 10(5), Sharma, K., & Susheela, A. (1988b). Fluoride ingestion in excess and its effect on the disaccharide profile of glycosaminoglycans of cancellous bone of the rabbit. Medical Science Research, 16(7), Sharma, Y. (1982). Effect of sodium fluoride on collagen cross-link precursors. Toxicology Letters, 10(1), doi: / (82) Shirke, P.A., & Chandra, P. (1991). Fluoride uptake by duckweed Spirodela polyrrhiza. Fluoride, 24(3),

195 Sidhu, S. (1979). Fluoride levels in air, vegetation and soil in the vicinity of a phosphorous plant. Journal of the Air Pollution Control Association, 29(10), doi: / Sidhu, S. (1982). Fluoride deposition through precipitation and leaf litter in a boreal forest in the vicinity of a phosphorous plant. Science of the Total Environment, 23, doi: /s (08) Sidhu, S.S., & Staniforth, R.J. (1986). Effects of atmospheric fluorides on foliage, and cone and seed production in balsam fir, larch spruce, and larch. Canadian Journal of Botany, 64(5), doi: /b Sigler, W.F., & Neuhold, J.M. (1972). Fluoride intoxication in fish: A review. Journal of Wildlife Diseases, 8(3), Singer, L., & Ophaug, R. (1979). Total fluoride intake of infants. Paediatrics, 63(3), Singh, P.P., Barjatiya, M.K., Dhing, S., Bhatnagar, R., Kothari, S., & Dhar, V. (2001). Evidence suggesting that high intake of fluoride provokes nephrolithiasis in tribal populations. Urological Research, 29(4), doi: /s

196 Sinha, S., Saxena, R., & Singh, S. (2000). Fluoride removal from water by Hydrilla verticillata (l.f.) Royle and its toxic effects. Bulletin of Environmental Contamination and Toxicology, 65(5), doi: /s Skjelkvåle, B.L. (1994). Factors influencing fluoride concentrations in Norwegian lakes. Water, Air and Soil Pollution, 77(1-2), doi: /bf Sloof, W., Eerens, H., Janus, J., & Ros, J. (1989). Integrated Criteria Document: Fluorides (Report No ). Bilthoven: National Institute of Public Health and Environmental Protection. Smith, D., Harris, H., & Kirk, R. (1953). Fluorosis in the Butana, Sudan. The American Journal of Tropical Medicine and Hygiene, 56(3), Smith, L.R., Holsen, T.M., Ibay, N.C., Block, R.M., & De Leon, A.B. (1985). Studies on the acute toxicity of fluoride ion to stickleback, fathead minnow, and rainbow trout. Chemosphere, 14(9), doi: / (85) Society, B.B. (2012). One in a Million: The Facts about Water Fluoridation (3rd Ed.). Oldham, UK: BFS. Standards Organization of Nigeria. (2007). Nigerian Standard for Drinking Water Quality (NIS 554: 2007). Lagos, Nigeria: Standards Organization of Nigeria. 173

197 Sowers, M.F.R., Clark, M.K., Jannausch, M.L., & Wallace, R.B. (1991). A prospective study of bone mineral content and fracture in communities with differential fluoride exposure. American Journal of Epidemiology, 133(7), Spak, C.J., Hardell, L.I., & de Chateau, P. (1983). Fluoride in human milk. Acta Paediatrica Scandinavica, 72(5), doi: /j tb09796.x Srikanth, R., Viswanatham, K., Kahsai, F., Fisahatsion, A., & Asmellash, M. (2002). Fluoride in groundwater in selected villages in Eritrea (North East Africa). Environmental Monitoring and Assessment, 75(2), doi: /a: Srimurali, M., & Karthikeyan, J. (2008). Activated alumina: Defluoridation of water and household application - A study. In Twelfth International Water Technology Conference (pp. 1-13). Alexandria, Egypt: IWTC12. Srinivas, C., & Narender, A. (2003). Indian Water Sector: Need for Change Management (Change Management Times March 2003 Issue). Bedford, UK: Silsoe College, Cranfield University. 174

198 Stannard, J., Rovero, J., Tsamtsouris, A., & Gavris, V. (1990). Fluoride content of some bottled waters and recommendations for fluoride supplementation. Journal of Pedodontics, 14(2), Susheela, A. (1999). Fluorosis management programme in India. Current Science, 77(10), Susheela, A. (2002). Fluorosis in developing countries: Remedial measures and approaches. Proceedings of the Indian National Science Academy, B68(5), Susheela, A. (2003). A Treatise on Fluorosis (2nd Ed.). New Delhi, India: Fluorosis Research and Rural Development Foundation. Susheela, A., & Bhatnagar, M. (1999). Structural aberrations in fluorosed human teeth: Biochemical and scanning electron microscopic studies. Current Science, 77(12), Susheela, A., & Das, T. (1988). Chronic fluoride toxicity: A scanning electron microscopic study of duodenal mucosa. Clinical Toxicology, 26(7), doi: / Susheela, A., & Jain, S. (1983). Fluoride-induced haematological changes in rabbits. Bulletin of Environmental Contamination and Toxicology, 30(1), doi: /bf

199 Susheela, A., & Kharb, P. (1990). Aortic calcification in chronic fluoride poisoning: Biochemical and electron-microscopic evidence. Experimental and Molecular Pathology, 53(1), doi: / (90) Susheela, A.K., & Jethanandani, P. (1996). Circulating testosterone levels in skeletal fluorosis patients. Journal of Clinical Toxicology, 34(2), doi: / Suthar, S., Garg, V., Jangir, S., Kaur, S., Goswami, N., & Singh, S. (2008). Fluoride contamination in drinking water in rural habitations of northern Rajasthan, India. Environmental Monitoring and Assessment, 145(1-3), 1-6. doi: /s x Symonds, R., Rose, W., & Reed, M. (1988). Contribution of Cl- and F-bearing gases to the atmosphere by volcanoes. Nature, 334, doi: /334415a0 Søgaard, C.H., Mosekilde, L., Schwartz, W., Leidig, G., Minne, H.W., & Ziegler, R. (1995). Effects of fluoride on rat vertebral body biomechanical competence and bone mass. Bone, 16(1), doi: / (95)80028-o Søyseth, V., Kongerud, J., & Boe, J. (1996). Allergen sensitization and exposure to irritants in infancy. Allergy, 51(10), doi: /j tb02116.x 176

200 Tate, W.H., & Chan, J.T. (1994). Fluoride concentrations in bottled and filtered waters. General Dentistry, 42(4), Teotia, M., Teotia, S.P., & Singh. K.P. (1998). Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India: Year Indian Journal of Paediatrics, 65(3), doi: /bf Thompson, L.K., Sidhu, S.S., & Roberts, B.A. (1979). Fluoride accumulations in soil and vegetation in the vicinity of a phosphorus plant. Environmental Pollution, 18(3), doi: / (79) Thompson, R., McMullen, T., & Morgan, G. (1971). Fluoride concentrations in the ambient air. Journal of the Air Pollution Control Association, 21(8), doi: / Tong, C., McQueen, C., Ved Brat, S., & Williams, G. (1988). The lack of genotoxicity of sodium fluoride in a battery of cellular tests. Cell Biology and Toxicology, 4(2), doi: /bf Tscherko, D., & Kandeler, E. (1997). Ecotoxicological effects of fluorine deposits on microbial biomass and enzyme activity in grassland. European Journal of Soil Science, 48(2), doi: /j tb00553.x 177

201 Tsiros, J.X., Haidouti, C, & Chronopoulou, A. (1998). Airborne fluoride contamination of soils and olive trees near an aluminium plant. Measurements and simulations. Journal of Environmental Science and Health, A33(7), doi: / Tsutsui, A., Yagi, M., & Horowitz, A. (2000). The prevalence of dental caries and fluorosis in Japanese communities with up to 1.4 ppm of naturally occurring fluoride. Journal of Public Health Dentistry, 60(3), Tsutsui, T., Kawamoto, Y., Suzuki, N., Gladen, B., & Barrett, J. (1991). Cytotoxicity and chromosome aberrations in normal human oral keratinocytes induced by chemical carcinogens: comparison of inter-individual variations. Toxicology In Vitro, 5(4), doi: / (91) Tsutsui, T., Suzuki, N., Ohmori, M., & Maizumi, H. (1984). Cytotoxicity, chromosome aberrations and unscheduled DNA synthesis in cultured human diploid fibroblasts induced by sodium fluoride. Mutational Research, 139(4), doi: / (84) Tsutsui, T., Tanaka, Y., Matsudo, Y., Uehama, A., Someya, T., Hamaguchi, F., Yamamoto, H., & Takahashi, M. (1995). No increases in chromosome aberrations in human diploid fibroblasts following exposure to low concentrations of sodium fluoride for long times. Mutational Research, 335(1), doi: / (95)

202 Turner, C., Akhter, M., & Heaney, R. (1992). The effects of fluoridated water on bone strength. Journal of Orthopaedic Research, 10(4), doi: /jor Turner, C.H., Hasegawa, K., Zhang, W., Wilson, M., Li, Y., & Dunipace, A.J. (1995). Fluoride reduces bone strength in older rats. Journal Dental Research, 74(8), doi: / Turner, R., Francis, R., Brown, D., Garand, J., Hannon, K., & Bell, N. (1989). The effects of fluoride on bone and implant histomorphometry in growing rats. Journal of Bone and Mineral Research, 4(4), doi: /jbmr UNICEF. (1999). A Water Handbook: Water, Environment and Sanitation Technical Guidelines (Series No. 2). New York: WES, UNICEF. UNICEF. (2002). Learning from Experience: Water and Environmental Sanitation in India. New York: UNICEF. USDHHS. (1991). Review of Fluoride: Benefits and Risks (Report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs). Washington, District of Columbia: USDHHS. USEPA. (1985). Drinking Water Criteria Document on Fluoride. Washington, District of Columbia: USEPA. 179

203 USEPA. (1999). Chemical Specific Toxic Release Inventory Release and Waste Management Data Washington, District of Columbia: USEPA. Uslu, B. (1983). Effect of fluoride on collagen synthesis in the rat. Research in Experimental Medicine, 182(1), doi: /bf Van Asten, P., Darroudi, F., Natarajan, A.T., Terpstra, I.J., & Duursma, S.A. (1998). Cytogenetic effects on lymphocytes in osteoporotic patients on long-term fluoride therapy. Pharmacy World and Science, 20(5), doi: /a: Van Craenenbroeck, W., & Marivoet, J. (1987). A comparison of simple methods for estimating the mass flow of fluoride discharged into rivers. Water Science and Technology, 19(5-6), Vogt, R.L., Witherell, L., LaRue, D., & Klaucke, D.N. (1982). Acute fluoride poisoning associated with an on-site fluoridator in a Vermont elementary school. American Journal of Public Health, 72(10), Voroshilin, S.I., Plotko, E.G., Nikiforova, Y.A. (1975). Mutagenic effect of hydrogen fluoride on animals. Tsitol Genet, 9(1),

204 Walton, K.C. (1987). Tooth damage in field voles, wood mice and moles in areas polluted by fluoride from an aluminium reduction plant. Science of the Total Environment, 65, doi: / (87) Wang, G., Huang, Y., Xiao, B., Qian, X., Yao, H., Hu, Y., et al. (1997). Toxicity from water containing arsenic and fluoride in Xinjiang. Fluoride, 30(2), Wang, J.X., & Bian, Y.M. (1988). Fluoride effects on the mulberry silkworm system. Environmental Pollution, 52(1), doi: / (88) Wang, W. (1986). Toxicity tests of aquatic pollutants by using common duckweed. Environmental Pollution, B11(1), doi: / x(86) Wei, S.H.Y., Hattab, F.N., & Mellberg, J.R. (1989). Concentration of fluoride and other selected elements in teas. Nutrition, 5(4), Weinstein, L.H., & Davison, A. (2003). Fluorides in the Environment. Oxfordshire, UK: CABI Publishing. Whitford, G. (1996). The Metabolism and Toxicity of Fluoride (2nd Ed.). Basel, Switzerland: Karger Publications. WHO. (1994). Fluorides and Oral Health (Technical Report Series No. 846). Geneva, Switzerland: WHO. 181

205 WHO. (2002). Fluorides (Environmental Health Criteria, 227). Geneva, Switzerland: WHO. WHO. (2006). Fluoride in Drinking Water. J. Fawell, K. Bailey, J. Chilton, E. Dahi, L. Fewtrell and Y. Magara (Eds.). London, UK: IWA Publishing. Wodeyar, B., & Sreenivasan, G. (1996). Occurrence of fluoride in the groundwaters and its impact in Peddavankahalla basin, Bellary district, Karnataka - A preliminary study. Current Science, Wolting, H.G. (1978). Gevoeligheid van kastulphen voor chronische inwerking van fluorhoudende luchtverontreiniging. Bloembollenculture, 31, Wongdem, J., Aderinokun, G., Sridhar, M., & Selkur, S. (2000). Prevalence and distribution pattern of enamel fluorosis in Langtang town, Nigeria. African Journal of Medicine and Medical Sciences, 29(3-4), Water Supplies Department of Government of Hong Kong Special Administrative Region. (2012). Drinking Water Quality for the Period of October September Retrieved on January 10, 2013, from toring_data/index.html Wu, D.Q., & Wu, Y. (1995). Micronucleus and sister chromatid exchange frequency in endemic fluorosis. Fluoride, 28(3),

206 Xiang, Q., Liang, Y., Chen, L., Wang, C., Chen, B., Chen, X., & Zhou, M. (2003). Effect of fluoride in drinking water on children s intelligence. Fluoride, 36(2), Zhang, Y., & Cao, S.R. (1996). Coal burning induced endemic fluorosis in China. Fluoride, 29(4), Zingde, M.D., & Mandalia, A.V. (1988). Study of fluoride in polluted and unpolluted estuarine environments. Estuarine, Coastal and Shelf Science, 27(6), doi: / (88)

207 Annexure 1 184

208 185

209 186

210 187

211 188

212 189

213 190

214 191

215 192

216 193

217 194

218 195

219 196

220 197

221 198

222 199

223 Annexure 2 200

224 Annexure 3 201