1. Training ProgrammeonFluorosis Control Programme Presented ByDibyendu Dutta ConsultantFluorosis Control ProgrammeBANKURAMob. No- 8900336639

2. Fluorosis Control Programme : ImportanceImportance of this Programme in this Districti)Fluorosis is a crippled disease. It makes immobilized the patientday by day. Where as no exact mortality is found but its makes thepeople crippled and some cases painful. With out mobility people can not earn and life going unhealthy , stopped.ii) Fluorosis is a chronic disease. Its affect the people slowly and makespreliminary symptoms -> dental fluorosis -> skeletal fluorosis -> spinalcompression ->Crippled disorder. As it is due to make by slowly ingestionof fluoride(more then 1.5 PPM) in drinking water , its severity is verymuch higher.iii) Affected people :Bankura : 90,702.Affected Village: 205Affected Habitaion: 1005Affected Tube well: 778Fluoride range: up to 12.69 ppm water. 3. Fluorosis Control Programme : Status of WestBengal 4. Fluorosis Control Programme : Status ofBankura Persons suffers from Fluorosis in India : 6 Million (Dr. Raja Reddy , NIN ,Hyderabad) Persons suffers from Fluorosis in West Bengal: 2.20 Lakh Persons Suffers from Fluorosis in Bankura: 90,742 Current Status of Fluorosis In Bankura District 5. GIS Mapping of fluorosis endemic Block 6. Fluorosis Control Programme : Magnitudeof the problem West Bengal are worst affected from fluorosis. In BankuraDistrict Fluorosis Unit had already been find that : Water fluoride level various from: 1.00 PPM 12.69 PPM(Machatora,Simlapal) Patient Blood-fluoride level: Sujit Gulimajhi 22/M(Jamda,Simlapal)0.89 ppm Jenu Valgaum. Severe DentalFluorosis. Joint Pain and Back Pain. Highest Urine fluoride level: Bulu Bedia ,Kamladanga11.25 PPM . In all these States, the drinking water has high fluoride content but the informationabout the various food items and industrial emission having high fluoride level is not available.Permissible limit for fluoride, as per BIS, is 1 ppm indrinking water. 7. Fluorosis Control Programme : Magnitudeof the problem 8. Dental fluorosis at Bankura District 9. Skeletal Fluorosis at Bankura District 10. Fluorosis Control Programme :Surveillance Methodology andPromotion of the FluorosisControl Programme 11. Assessment of the ProblemUnder the National Programme for Prevention and Controlof Fluorosis, the district laboratory is established/strengthened for confirmation of fluorosis cases, thedistrict cell under district nodal officer is created, staffedwith consultant and field investigators and funds areprovided for mobility support for undertaking communitybased surveillance. The surveillance would also provide thedatabase for impact assessment of the programme. Thecase definitions, sampling procedure and surveymethodology are as under:(Dr. Pasha,National Consultant) 12. A : Case Definition Suspect Case: Dental Fluorosis: Any case with a history of residing in an endemic area along with one or both of the followings: Chalky white teeth yellow brown/dark brown bands 13. A : Case DefinitionSkeletal FluorosisAny case with a history of residing in an endemic area along with one or more of the following: Severe pain and stiffness in neck and back bone.(Patient has to turn the whole body towards that sideto see) Severe pain and stiffness in joints. Severe pain and rigidity in the hip region ( pelvicgirdle) Knock knee/ Bow leg Inability to squat Ugly gait and posture 14. A : Case DefinitionNon skeletal FluorosisAny case with a history of residing in anendemic area along with one or more ofthe followings Gastro - intestinal problems: Consistent abdominal pain, intermittent diarrhea/Constipation, blood in stool Neurological manifestations: Nervousness & depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinate frequently (Polydipsia and polyuria) Muscular manifestations: Muscle weakness & stiffness, pain in the muscle and loss of muscle power. 15. A : Case Definition Confirmed Case: Any suspect case with one or more of the followings: Any suspect case with high level of fluoride in urine(>1ppm). Any suspect case with interossius membranecalcification in the fore arm confirmed by X-ray. 16. B - Sampling procedureThe information on fluorosis endemic areas along withfluoride level in the drinking water sources is to beobtained from Public Health Engineering Department(PHED) of respective endemic states. Fluoride level in all the drinking water sources is to beestimated by PHED. Based on the level of fluoride content, the villages will bestratified in the following 3 strata as under: StrataFluoride Level I 1 - 3 ppmII3.1 5 ppm III> 5 ppm 17. Sampling procedure For prevalence of fluorosis cases, 10% villages of eachstrata will be selected randomly. If number of villagesis up to 20, then all the villages will be surveyed. Ifnumber of villages is more than 20, then 10% ofvillages from each strata (at least 20 villages in total)will be surveyed. All the children in the age group of 6 to 11 years fromthe primary school (3rd to 5th standard) in theselected villages of the district will be surveyed forprevalence of dental fluorosis. Survey for skeletal and non-skeletal fluorosis caseswould also be carried out in 20 households ofrandomly selected villages of the district where dentalfluorosis is prevalent in school children. 18. C - Survey Methodology Details of survey for dental fluorosis in school childrenwill be collected on predesigned proforma and for skeletaland non-skeletal fluorosis cases in villages would beconducted by trained investigators. The information on demographic profile, dietary intake,drinking water source and clinical manifestations offluorosis in the suspected member (s) of the family will becollected in the predesigned format. Urine samples from fluorosis suspected cases will becollected for confirmation. The suspected cases would be confirmed for interossiusmembrane calcification in the fore arm by X-ray andfluoride level in urine (>1ppm). 19. Survey MethodologyAnalysis of urine sampleSample Collection: 15 ml of spot urine sample of the suspected cases will be collected in 25ml of plastic screw capped bottles. Put 1 - 2 drops of toluene on urine samples to make a complete layer as preservative. Each sample should be properly labeled with number and relevant details. 20. Survey Methodology Transportation of samples: Urine samples should be sent to district laboratory within a weeks time. Samples can be kept at room temperature at district laboratory if not being analyzed immediately. *Report should be sent to State Nodal officer on the predesigned Performa with a copy to Adviser (Nutrition), DGHS, New Delhi(Dr. Pasha,National Consultant) 21. Guidelines for TrainingTraining in a programme is a key step for its successfulimplementation.A pool of trainers will be generated at state/ district levelto provide training of different category of health careproviders at different level.1. Training of Trainers2. Medical Officer3. Laboratory Technicians4. Paramedical5. Training of Health Workers, ASHA and AWWs6. Policy makers &7. Advocacy PRIs & VHSC& Teachers 22. Guidelines for ComprehensiveManagement of Fluorosis Cases Guidelines for Comprehensive Management of Flurosis Cases are:Early Detection &Prompt Intervention 23. Comprehensive ManagementEarly Detection:- It includes physical and radiological examination. During physicalexamination the cases are to be identified as suspected cases andconfirmed cases. The symptoms of the suspected cases are asfollows:- Dental changes chalky white tooth with mottled appearance Pain & stiffness of peripheral joints Deformities of lower limb The confirmation of the cases shall be undertaken by followingmethods: Physical examination Radiological examination X-ray of forearm (AP view) X-ray of most affected part (AP & lateral views) Laboratory tests Urine analysis for fluoride level Blood analysis for fluoride level Analysis of drinking water for fluoride level 24. Comprehensive Management Prompt InterventionThe Prompt Intervention is to be planned in thefollowing manner: Health education Preventive measures Treatment Rehabilitation 25. Media Plan for Prevention and Control ofFluorosisThe IEC Plan covering awareness generation and to bringbehavioural communication changes at the community level inaffected districts are very important in order to prevent andcontrol fluorosis in the community. For this there is a need: to educate community about adverse health effects of drinking waterwith high level of fluoride, to educate the community about the safe drinking water sources intheir habitation and rain water harvesting measures to be adopted. to educate about the benefits of Nutritional interventions. The district level media team would be entrusted with the job ofadvocating with the various functionaries of the district includingcommunity level workers namely, ASHA, AWW, school teachers,Panchayats, etc. 26. IEC Plan for Preventionand Control of Fluorosis 27. Dos and Donts in relation to Nutritionintervention in fluorosis Dos Donts Calcium rich foodBlack teaMilk, Milk products Black/Rock salt Green leafy vegetableTobacco SupariFluoridated tooth paste Vitamin C rich food Citrus fruits Green leafy vegetablesIron rich food Green leafy vegetablesGuava, Banana, Brinjal 28. Programme Stacture and its Overview (NPPCF, Bnakura)The Adviser (Nutrition)The District ConsultantMH&FW.New Delhi.India(NPPCF.Bankura) The National Consultant(NPPCF)The District Lab Tech(NPPCF)The DHSSH&FW. W.B.Field WorkersThe Add. DHS(PH&CD)(NPPCF)SH&FW. Swasthya Bhaban. Kol-91. W.B.The Dy.DHS(PH&CD)and The ADHS(MPHWS) & SPO (NPPCF)Swasthya Bhaban. Kol-91. W.B. The CMOHand District Programme Officer. (NPPCF)The Dy. CMOH-IIand District Nodal Officer(NPPCF) 29. Performance and duties done by District Fluorosis ControlUnit.Bankura. Successful implementation of this National Programme Monitoring the programme by consulting all its The District Consultant Stake-Holders/Concern Persons under direct control of District Programme officers/District Nodal Officers. Management and safe operating of Lab. Instrument.The District Lab Tech Make ready report , Testing of Collected sample and as necessary he should also visit the endemic village for blood collection under supervision of his consultant and direct control od district officers. Field Survey , sample collection and make ready report. Make data-entry of patient line listing (As per state Field Investigators needed) This National Programme will be successful if all district programme holders wants. 30. Promotion of the Programme1. Involvement should be made of Block level2. BPHN/PHN supervise the screening of fluorosis cases and collection of sample made by ANM staffs and ASHA at grass-root level.3. Sample should be sent to District Lab. for testing.4. Block Data Entry Operator should Collect the data / report and make compile report to sent at District.5. District should compile the report from blocks and sent to state authority. And also arrange screening camp + Sample collection + Drug Distribution + IEC Camp etc.6. District fluorosis unit also maintain the overall programme under direct control of District Programme Officer and District Nodal Officer7. District Programme Officer and District Nodal Officer supervise the all programme. 31. THANK YOU 32. Table of Content:PART-A1. Current Status of Fluorosis in World View2. Current Status of fluorosis in India3. Current Status of Fluorosis in West Bengal4. Current Status of Fluorosis in Bankura. 4.1 Data Sheet of fluorosis endemicity 4.2 GIS Mapping of fluorosis endemic Block5. Availability of fluoride-free water scheme by Districtadministration6. Programme Overview (NPPCF, Bnakura)7.Performance and duties done by District Fluorosis ControlUnit.Bankura. 33. 1. Current Status of Fluorosis in World ViewFluorosis is public health problem in 25 countries around the world.(DARKAREAS) 34. 2. Current Status of fluorosis in India Jammu & Kashmir 7 No of affectedHimachal PradeshArunachalDistrict 204 (21PunjabDelhi PradeshStates /UT)82 Haryana31 63Rajastha Sikkimn Uttar Pradesh 22 Assam Nagaland people affected, 62 Bihar 9100.0 Gujarat 15 ManipurTripura Mizoram million ( 6 millionMadhya Pradesh children) 9536 West BengalOrissa 22 Maharashtra 3156 70-100 % Districts affected Causative factor, Andhra Pradesh 40-70 % Districts affected excess consumption Karnataka 70 67 10-40 % Districts affected of fluoride through 1.0ppm) and diet. 28Kerala Andaman21 Nicobar Source:A Treatise on Fluorosis by Dr. A.K. Susheela 35. . Current Status of Fluorosis in West Bengal 36. 4.0 Current Status of Fluorosis in Bankura. 37. endemicity Persons suffers from Fluorosis in India : 6 Million (Dr. Raja Reddy , NIN , Hyderabad) Persons suffers from Fluorosis in West Bengal: 2.20 Lakh Persons Suffers from Fluorosis in Bankura: 90,742 Current Status of Fluorosis In Bankura DistrictAffected Pop. Affected Pop.Affected Vill.Tot. BlocksTot. Villagein BankuraHabitation Habitation(Approx) (Approx) Affected. Tot. Pop.Tot. Pop.Affected Affected BlockPop. Pop. Tot.2231,92,695 1520,21,341 90,7423832 31,92,695271 90,742 77781005 90,742 38. 4.2 GIS Mapping of fluorosis endemic Block 39. Bnakura) The Adviser (Nutrition) The District Consultant MH&FW.New Delhi.India (NPPCF.Bankura)I The National Consultant(NPPCF) The District LabTech(NPPCF)The DHSSH&FW. W.B.Field Workers The Add.(NPPCF) DHS(PH&CD) SH&FW. SwasthyaBhaban. Kol-91. W.B. TheADHS(MPHWS)& SPO (NPPCF)Swasthy a Bhaban. Kol-91. W.B.The CMOHand DistrictProgrammeOfficer. (NPPCF)The Dy. CMOH- II and District NodalOfficer(NPPCF) 40. 7.Performance and duties done by District Fluorosis ControlUnit.Bankura. Successful implementation of this National Programme Monitoring the programme by consulting all its The District Consultant Stake-Holders/Concern Persons under direct control of District Programme officers/District Nodal Officers. Management and safe operating of Lab. Instrument.The District Lab Tech Make ready report , Testing of Collected sample and as necessary he should also visit the endemic village for blood collection under supervision of his consultant and direct control od district officers. Field Survey , sample collection and make ready report. Make data-entry of patient line listing (As per state Field Investigators needed) This National Programme will be successful if all district programme holders wants. 41. Table of Content:PART - B1. Fluorosis and fluoride1.1 Fluoride1.2 Pathophysiology of Fluorosis2.Dental fluorosis3.Skeletal Fluorosis4.Non-Skeletal Manifestation5.Laboratory Support6.Prevention and Control Measure7.Roll of PHED & DH&FWS. Bankura5.Current Research on fluorosis 42. Fluorosis and fluoride 1.1 Fluoride 43. 1.2 Pathophysiology of Fluorosis 44. Ingestion of fluoride causes decrease in ionised calcium.This hypocalcemia leads to changes in internal milieu of the body to maintain thecalcium levels and leads to secondary hyperparathyroidism. The increased parathyroid hormone causes increased activity of Osteoclasts in boneby activating membrane bound 35 Cyclic AMP. This increased osteoclastic activity causes, increases in citric acid and lactic acidrelease from ruffled border of osteoclasts. This causes increase in hydrogen ionconcentration, and hence lysis of lysosomes.Release of lysosomal enzymes viz. acid protease, collagenase, hyaluronic acid inbone and other tissues of the body which catalyzes the reactions favoring thedepolymerization of the glycoprotein of bone and of cartilage. This causes breakdown ofhydroxyproline, which is responsible for stabilization of collagen triple helix. As the protein polymer desegregates and dissolves, the mineral-binding capacity isalso reduced and calcium is liberated, which helps in maintaining the serum calcium level.As a result the solubility of hydroxyappetite crystals also increases, causing its breakdownalong with reduced laying down of collagen by reducing Hydroxylation of proline andlysine. This event simultaneously led to the elevation of the serum mucoprotein orpolysaccharide levels. The net result of degradation of ground substance in, bones andother calcified tissues like teeth leads to symptoms of Fluorosis like, delayed eruption ofteeth, dental Fluorosis, clinical Fluorosis, premature aging etc 45. Dental fluorosisNormal:The enamel surface is smooth, glossyand usually a pale creamy white incolor.Mild: The white opacity of theenamel of the teeth is moreextensive, but covers less than50% of the tooth surface . 46. Moderate:The enamel surface of the teethshows marked wear and tear with brown stainand is frequently a disfiguring feature .Severe: The enamel surface is badlyaffected and hypoplasia is so marked thatthe general form of the tooth may beaffected. There are pitted/worn out areasand widespread brownish discolorationwith the teeth often having a corrodedappearance. 47. Types of skeletal fluorosis - IGenu valgum (KNOCK KNEES)Legs are bowed inwards in the standingposition. The bowing usually occurs ator around the knee, and when standingwith knees together, the feet are farapart.Genu VarumLegs are bowed outwards in thestanding position. The bowingusually occurs at or around theknee. When standing with the feettogether, the knees remains farapart. 48. Types of skeletal fluorosis - IIKyphosis: Forward bending of spine.Fixed and rigid thoracic cage as well asspinal cord compression occur Anterioposterior bowing of tibia 49. Types of skeletal fluorosis - IIIParaplegia: Spinal cordcompression due toosteosclerosis withparaplegia as a resultof endemic skeletalfluorosis 50. NON SKELETAL MANIFESTATIONS Tingling sensation in fingers and toes Excessive thirst Polydypsia and polyurea Nervousness & Depression 51. Laboratory Support 52. Table of Content:PART - C1. Diagramatic view of Programme holder. NPPCF2.Work Structure of National Programme for Prevention andControl of Fluorosis 2.1 District level planning of programme outlet. 2.2 Duties of Block Medical Officer of Health at District(BMOH) 2.3 Duties of Block Public Health Nurse(BPHN) 2.4 Duties of Supervisor at Gram Panchyaet Level. 2.5 Importance of ASHA at next phase of theprogramme.