Fluoridation Committee 2016-17ANNUAL REPORT

Version: FINALMAY 2018

Table of Content

s1. Introduction.....................................................................................................12. The Fluoridation Committee............................................................................23. Achievements 2016-17....................................................................................34. Fluoridation Plant Status and Performance.....................................................3

4.1. Regulatory Framework..............................................................................34.2. Fluoridation Overview...............................................................................44.3. Fluoride Compliance..................................................................................9

5. Oral Health Data............................................................................................115.1. Mean Oral Health Data............................................................................11

6. Future Activities............................................................................................16List of Tables and FiguresTable 1: Population receiving a reticulated drinking water supply that is fluoridated.............................................................................................................4Table 2: Characteristics of fluoridated supplies and performance summary for operational compliance.........................................................................................6Table 3: Compliance assessment of fluoridation stations 2016-17 based on daily operational data from the treatment plant............................................................9Table 4: Fluoridation stations not meeting the requirement of having 90 per cent of all operational fluoride samples and/or an average fluoride concentration within the 0.8-1.2 mg/L range.............................................................................10Table 5: Mean dmft and DMFT for children by LGA..............................................13Figure 1: Geographic location of WTPs..................................................................8Figure 2: Mean dmft of 6 year olds examined by OHST 2017 by LGA..................14Figure 3: Mean DMFT of 12 year olds examined by OHST 2017 by LGA..............15

1. IntroductionThis Report has been prepared in accordance with Section 17(2) of the Fluoridation Act 1968 (the Act) and provided to the Minister for Health. It contains such matters as specified in Sections 8(1) (da) and (db) of the Act and a copy will be provided to the Office of the Tasmanian Economic Regulator as required by Section 17(3) of the Act.Water fluoridation is the adjustment of fluoride in drinking water to a concentration that helps prevent dental decay. The National Health and Medical Research Council (NHMRC) recently affirmed that water fluoridation remains the most socially equitable method of achieving community-wide exposure to the health benefits of fluoride. Adjusting fluoride concentrations to the NHMRC-recommended levels in public water supplies is proven a safe and effective measure to help prevent dental health problems. During 2017, the NHMRC reviewed their 2007 Efficacy Statement, following an extensive review of recent relevant published research, and a revised statement was released in late 2017 that reaffirmed their position (www.nhmrc.gov.au/health-topics/health-effects-water-fluoridation).Water fluoridation is endorsed by more than 150 science and health organisations worldwide, and fluoridation programs have the strong support of the NHMRC, the World Dental Federation, the International Association for Dental Research, the World Health Organization and Kidney Health Australia (www.kideny.org.au/cms-uploads/docs/2018-review-of-fluoride-position-statement-final.pdf).The National Oral Health Plan 2015-2024 stated that for each dollar invested in water fluoridation the savings in dental treatment costs ranged from $12 to $801. Comparable financial data are not available for Tasmania; however, in Victoria it is estimated that in 25 years after it was introduced, fluoridation saved the community nearly $1 billion in avoided dental costs and preserved productivity and leisure time2. Given the improvements in oral health and reductions in associated health costs, Australian governments have stated their intentions to extend their fluoridation programs under the National Oral Health Plan 2015-2024.

1 Department of Health, South Australia (2015). Australia’s National Oral Health Plan 2015-2024. Prepared by the National Advisory Committee on Oral Health.

2 Department of Human Services, Victoria (2007). Information about water fluoridation: fluoridation strengthens teeth throughout life.

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In Tasmania, 98 per cent of the population receiving a reticulated water supply receives fluoridated drinking water. All public water supply systems servicing communities above 1 000 in population within Tasmania are fluoridated in accordance with the National Oral Health Plan 2015-2024. Tasmania, the Northern Territory and the Australian Capital Territory are the only jurisdictions in Australia to achieve this goal. Several communities within Tasmania under 1000 people also enjoy the benefits of fluoridated water. Fluoridation of Tasmanian public drinking water supply systems commenced in 1953, in Beaconsfield, making Tasmania the first jurisdiction to do so. Under the Fluoridation Act 1968, the Minister for Health directs the Water Corporation (based on recommendations from the Fluoridation Committee) to fluoridate specific public water supplies in a prescribed manner. Included in this Ministerial Direction is the need to monitor the level of fluoride in drinking water daily . The Fluoridation Committee’s Annual Report 2016-17 is the eighth reporting period in which the performance of the State’s fluoridation systems has been publicly reported. Water fluoridation is the responsibility of TasWater as the regulated entity managing and controlling drinking water provision across Tasmania. The role of the Department of Health and Human Services (DHHS) is as the regulatory body. The Fluoridation Committee provide strategic oversight and advise the Minister for Health on matters relating to fluoridation. 2. Fluoridation CommitteeThe Fluoridation Committee consists of five members, each appointed by the Minister for Health. The principal functions of the Fluoridation Committee are to act as an expert advisory committee to interested parties including the Minister, on matters relating to fluoridation of drinking water and to provide strategic oversight of fluoridation works in Tasmania and report on the performance and outcomes of the fluoridation plants throughout the state.For 2016-17 the Fluoridation Committee members were: Mr Paul Hunt, State Manager of Environmental Health Services, Department

of Health and Human Services (Chair). Mr Bill (Kai Chye) Ho, Manager Water and Sewerage, Department of

Industry, New South Wales. Dr Chris Handbury, Clinical Director, Oral Health Services Tasmania,

Tasmanian Health Service. Dr John O’Reilly, Section Head – Inorganic Chemistry (Metals), Analytical

Services Tasmania, Department of Primary Industries, Parks, Water and Environment.

Dr Mark Veitch, Director of Public Health, Department of Health and Human Services.

Mr Cameron Dalgleish, State Water Officer, DHHS also attends the meetings in an administrative capacity.Meetings of the Fluoridation Committee were held: 21 July 2016 17 November 2016 29 March 2017

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3. Achievements 2016-17The following are the key achievements in the implementation of water fluoridation during 2016-17: Ongoing implementation of the Fluoridation Committee’s Strategic Plan. Fluoridation of the Scamander and Bicheno water supplies. Achieving fluoridation of all water supplies servicing popultaions over 1 000. Monitoring improvements in fluoridation performance across the State. Verification monitoring of fluoridated supplies conducted by DHHS. Review of oral health data and hospital admissions.4. Fluoridation Plant Status and Performance4.1.Regulatory FrameworkDHHS previously issued the Tasmanian Code of Practice for the Fluoridation of Public Water Supplies 2007-2010, which set a standard for fluoridation operation and service delivery. An ongoing review of the Code of Practice has sought to rationalise the requirements for prescriptive operation of fluoridation stations and to incorporate elements of the 2017 NHMRC Statement. This resulted in the issuing of the Tasmanian Code of Practice for the Fluoridation of Public Water Supplies 2017-2021 in its draft form. Although it is not required by legislation, the Code of Practice is consistent with the requirements of the Fluoridation Act 1968 and Fluoridation (Interim) Regulations 2009. The aim of the Code of Practice is to ensure that the addition of fluoride to public water supplies in Tasmania is carried out safely, effectively and consistently and managed in accordance with best practice management. Ministerial Directions issued to the regulated entity to fluoridate a water supply, based on recommendations of the Fluoridation Committee, thereby establishes the requirement for the regulated entity to comply with the Code of Practice.

The current regulatory framework sets an operating target fluoride concentration of 1mg/L in treated water and a target range of 0.8-1.2mg/L. The NHMRC has for some years recommended a target range of 0.6-1.1mg/L; but has acknowledged that for Tasmania’s cooler climate the operating range within the Fluoridation (Interim) Regulations 2009 is appropriate. The Regulations are currently being reviewed with the intent to bring the optimum range within Tasmania’s drinking water to between 0.8 and 1.1 mg/L. Natural fluoride concentrations in water depend on the type of soil and rock through which the source water drains, and typically range from <0.1 to 0.5 mg/L. In fluoridated supplies, the Tasmanian target fluoride concentration is 1 mg/L. This value also takes into account the Australian Drinking Water Guidelines (ADWG) health based guideline value (maximum), which is 1.5 mg/L. Fluoride has been shown to prevent dental caries. The NHMRC has extensively reviewed the health aspects of fluoride and its prevention of dental disease. Many health authorities around the world recommend fluoridation of public water supplies as an important public health measure. DHHS supports the advice made by the NHMRC in their 2017 Fluoridation Statement.

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Concentrations of fluoride above 1.5 mg/L may disturb tooth mineralisation in children up to about six to eight years, leading to dental fluorosis – a mottling of the teeth which is usually minor but sometimes more conspicuous. Skeletal fluorosis generally only occurs after prolonged exposure (several years) to much higher levels of fluoride (> 3 mg/L), particularly in combination with high water consumption. Although skeletal fluorosis may contribute to brittle bones, it is reversible if the exposure is removed, allowing the fluoride level in bones to gradually decline. The ADWG health based guideline value has been set to protect children from the risk of dental fluorosis, and provides a considerable safety margin to prevent skeletal fluorisis.4.2.Fluoridation OverviewEighty-seven public drinking water supplies provide reticulated water to approximately 98 per cent of the Tasmanian population. The 38 operating fluoridation plants in Tasmania during the 2016-17 reporting period serviced 50 of the 87 water supplies. Fluoridated water is provided to 98 per cent of the Tasmanians that receive a reticulated water supply, or about 92 per cent of the Tasmanian population.

Tasmania

No. of supplies fluoridated 50

Population receiving fluoridated water 475 756

Population receiving a water supply 486 061

Percentage of population receiving a water supply that is fluoridated

97.6

Table 1: Population receiving a reticulated drinking water supply that is fluoridated

The operating fluoridation plants and a summary of their performance can be seen in Table 2, with compliance data generated only when the fluoridation plant is operational.

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Water Supply System

Pop3 Fluoride StationFluoridating

Agent

Mean concentration (mg/L)4

Within 0.8-1.2 mg/L range5

Bicheno 1 052 Bicheno WTP Sodium Fluoride 0.71 35%

3 DHHS (2018). Annual Report: Drinking Water Quality of Public Water Supplies in Tasmania – 1 July 2016 to 30 June 2017 (available at http://www.dhhs.tas.gov.au/publichealth/water/drinking/guidelines) 4 Compliance is measured as being between the operating range of 0.8-1.2mg/L for all daily samples taken when the fluoridation plant is operational5 Percentage of daily samples recorded that fall within the operating target range when the fluoridation plant is operational

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Water Supply System

Pop Fluoride StationFluoridating

Agent

Mean concentration (mg/L)

Within 0.8-1.2 mg/L range

Bridport 1 538 Bridport WTP Fluorosilicic Acid 0.95 95%

Cam River 9 492 Cam River WTP Fluorosilicic Acid 0.81 77%

Campbell Town/Ross 1 683 Campbell Town

WTPSodium Fluoride 0.99 90%

Deep Creek 5 090 Deep Creek WTP Fluorosilicic Acid 0.91 100%

Deloraine 2 820 Deloraine WTP Fluorosilicic Acid 0.88 93%

Distillery Creek 38 615 Distillery Creek

WTPFluorosilicic

Acid 0.55 52%

Dover 1 312 Dover WTP Sodium Fluoride 1.01 91%

Forth River 38 132 Forth WTP Fluorosilicic Acid 0.92 88%

Gawler River 12 730 Gawler WTP Fluorosilicic Acid 0.64 37%

Greater Hobart

225 319

Bryn Estyn WTP, Fern Tree, Merton, National Park

Fluorosilicic Acid and Sodium Fluoride

0.93 90%

Huon Valley 8 421 Huon Valley WTP Sodium Fluoride 0.98 100%

Lake Barrington 2 607 Barrington WTP Sodium

Fluoride 0.97 95%

Leven River 4 816 Whitehills WTP Fluorosilicic Acid 0.46 19%

Longford 9 924 Longford WTP Fluorosilicic 0.93 98%

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Water Supply System

Pop Fluoride StationFluoridating

Agent

Mean concentration (mg/L)

Within 0.8-1.2 mg/L range

Acid

Manuka River 962 Strahan WTP Sodium Fluoride 0.95 96%

North Esk 36 590 Chimney Saddle WTP

Fluorosilicic Acid 0.86 83%

Oatlands 962 Oatlands WTP Sodium Fluoride 1.08 94%

Orford 784 Orford WTP Sodium Fluoride 0.99 94%

Pet River 18 822 Burnie WTP Fluorosilicic Acid 0.96 99%

Queenstown 2 576 Queenstown WTP Sodium Fluoride 1.00 98%

Rocky Creek 1 171 Rocky Creek Sodium Fluoride 0.92 81%

Rosebery

Rosebery

881

881

Howard Street Sodium Fluoride 0.82 84%

Stirling Valley Sodium Fluoride 0.84 90%

Scamander 1 052 Scamander WTP Sodium Fluoride 0.73 57%

Scottsdale 2 988 Scottsdale WTP Fluorosilicic Acid 0.91 95%

South Esk 13 059 Mt Leslie WTP Fluorosilicic Acid 0.99 96%

St Helens 3 038 St Helens WTP Fluorosilicic Acid 0.13 6%

St Marys 792 St Marys WTP Sodium 0.95 89%

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Water Supply System

Pop Fluoride StationFluoridating

Agent

Mean concentration (mg/L)

Within 0.8-1.2 mg/L range

Fluoride

Swansea 1 030 Swansea WTP Sodium Fluoride 0.98 97%

Triabunna 988 Triabunna WTP Sodium Fluoride 1.00 96%

Waratah 224 Waratah WTP Sodium Fluoride 0.95 96%

West Tamar 23 941 Reatta Road WTP Fluorosilicic Acid 0.77 74%

Westbury 2 478 Westbury WTP Sodium Fluoride 0.93 96%

Zeehan 1 200 Zeehan WTP Sodium Fluoride 0.93 97%

Table 2: Characteristics of fluoridated supplies and performance summary for operational compliance

Nineteen plants use sodium fluoride (NaF), which is a white material available as an odourless powder or in a crystalline form. Fluoridation is accomplished by dissolving the sodium fluoride in water. Nineteen plants use Fluorosilicic acid (H2SiF6), commonly known as FSA. FSA has advantages with regard to dosing accuracy and economics and is in use in most of the large water treatment plants around the state. The use of automated dosing systems to add FSA to water significantly reduces occupational health and safety issues.FSA is an extremely corrosive and volatile liquid with a pH level of 1.2 that can lower the pH of drinking water if the water does not have sufficient buffering capacity to neutralise the effect of this acidic fluoridating agent. This issue is monitored daily by TasWater.Most fluoridation systems service one water supply. One exception to this is that of the Greater Hobart supply area, where there are four fluoridation stations (Bryn Estyn, Merton, Fern Tree and National Park) that service the nine water supplies within Greater Hobart. The operation of the Greater Hobart water supply means that fluoridated water from any of the four stations can be provided to customers within Greater Hobart.

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At times the Greater Hobart water supply is a combination of fluoridated waters, ie there is a mix of supplies. The Greater Hobart water supply is therefore considered as one fluoridated system where all individual data are averaged across Greater Hobart. Another exception is the Rosebery water supply, which is serviced by two fluoridation stations, one at the Howard Street WTP and one at the Stirling Valley WTP. As each of these WTP operates independently, they are considered as two fluoridation stations. At times only one will be operational, supplying the whole of the Rosebery water supply. When they are both operational, they service different areas of the Rosebery reticulation area and there is no mixing of these systems.Additionally, the examination of TasWater’s compliance against fluoridation criterion is based on 35 fluoridated systems rather than the 38 fluoridation stations. Figure 1shows the location of all of the Water Treatment Plants (WTP) operated by TasWater across Tasmania. Only those included in Table 2 are fluoridated.

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Figure 1: Geographic location of WTPs

4.3.Fluoride ComplianceThe Tasmanian Fluoridation Code of Practice (2017-2021) and the Fluoridation (Interim) Regulations 2009 specify that compliance of fluoridation stations is measured against the requirement to have greater than 90 per cent of all fluoride samples fall within the fluoride concentration range of 0.8-1.2mg/L.

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An operational fluoride sample is taken each day at the dosing station when it is producing treated drinking water. The sample location is downstream from the dosing point and designed to be representative of the fluoride concentrations produced by the WTP. Further operational samples are taken from two locations within each reticulation network each week, with one of those sample sets being sent to an externally accredited laboratory for fluoride analysis. It is only the samples taken from within the reticulation networks that are assessed for compliance as this is indicative of what the consumers are being exposed to. Based on this requirement, 22 of the 35 assessable fluoridation systems were compliant. A summary of this is seen in Table 3 with specific details on the non-compliant systems in Table 4. Another measure of operational performance is the non-regulatory metric that examines the average fluoride concentration taken over all water samples. This gives an indication of the population’s exposure to fluoride through the public drinking water supplies. The regulatory measure discussed above focuses on the reliability of the fluoridation station whereas the non-regulatory measure focuses on public fluoride exposure. For 2016-17, 28 of the 35 assessable fluoridation stations were compliant with this metric. There were seven non-compliant fluoridation stations. A summary of these data are in Table 3, with detailed reporting only on non-compliant stations in Table 4.

Metric Compliant Non-compliant

90% of all [F] samples fall within the 0.8-1.2 mg/L range

22 13

Average [F] of all samples fall within the 0.8-1.2 mg/L range

28 7

Table 3: Compliance assessment of fluoridation stations 2016-17 based on daily operational data from the treatment plant

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Fluoridation Station % of all [F] samples falling within the 0.8-1.2 mg/L

range

Average fluoride concentration (mg/L)

Bicheno 57% 0.73

Cam River 77%

Distillery Creek 52% 0.55

Forth River 88%

Gawler 37% 0.64

Leven River 19% 0.46

North Esk 83%

Rocky Creek 81%

Rosebery – Howard Street 84%

St Helens 6% 0.13

St Marys 89%

Scamander 35% 0.71

West Tamar 74% 0.77

Table 4: Fluoridation stations not meeting the requirement of having 90 per cent of all operational fluoride samples and/or an average fluoride concentration within the 0.8-1.2 mg/L range

Monitoring of fluoride concentrations only occurs when a system is producing treated water. There are instances when the fluoridation plant needs to be taken offline so that necessary repairs, maintenance and replacement can occur to ensure that the system is working effectively. It is generally only when fluoride concentrations start to decrease that it becomes evident that there are problems with the operation of a system. Common faults are the failure of dosing pumps, line blockages and leaking storage tanks. Upon resumption of fluoridation, the initial concentrations are set below the target range to ensure that the equipment is working. After establishing this, the concentration of fluoride is gradually increased to within the target range. This approach means that non-compliant data is generated during times of reinstating the optimal concentration.

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5. Oral Health DataOral health is measured by dmft (decayed, missing and filled deciduous teeth) and DMFT (decayed, missing and filled permanent teeth) in Tasmanian children examined in Oral Health Services Tasmania (OHST) clinics over a calendar year. Their Report for 20176 (covering the 2017 calendar year) is used as the basis for the statistics presented in this Report. Their Report is based on Local Government Areas (LGA), of which there are 29 in Tasmania. Data for King Island and Flinders Island has not been included owing to their small sample sizes, which becomes an unreliable metric for assessing population oral health. 5.1.Mean Oral Health DataTable 5 shows the mean dmft (six years) and mean DMFT (12 years) for children examined by Oral Health Services Tasmania. It does not include statistics generated from private dental practices.Compared to the OHST 2016 Report, an improvement has been seen in the percentage of children with no dental decay. All LGAs showed improvement in oral health; with the exceptions being Kentish and the Tasman. None of the Tasman LGA receives reticulated water and therefore does not have access to fluoridated water. Large portions of the Kentish LGA do not have a reticulated supply and therefore cannot access fluoridated water. The National Child Oral Health Study (2012-14)7, published in 2016, shows that Tasmania and South Australia have the lowest dmft rates in Australia. In Tasmania, the average dmft was 2.25, compared to the National average of 3.10. The average DMFT rate in Tasmania of 0.77 was slightly higher than the national published average of 0.71. The 2017 NHMRC Information Statement8 and the York Review9 found on average when children in the same community were surveyed before and after fluoridation introduction, the average was 14.3 per cent improvement in the population of children without dental decay.

6 OHST DMFT Report (Issue 7) – THO South, Oral Health Services Tasmania. 16 February 2018.7 Do LG and Spencer AJ (eds) (2016). Oral Health of Australian Children: the National Child Oral Health Study 2012-14. Adelaide: University of Adelaide Press.8 www.nhmrc.gov.au/health-topics/health-effects-water-fluoridation9 BMJ 2000 (321): 855-89 (https://doi.org/10.1136/bmj.321.7265.855)

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LGA Mean dmft 6 years – deciduous teeth

Mean DMFT 12 years – permanent teeth

Break O’Day 2.69 1.20

Brighton 2.75 0.55

Burnie 2.15 0.59

Central Coast 1.61 0.90

Central Highlands 2.14 1.29

Circular Head 3.17 1.29

Clarence 1.33 0.83

Derwent Valley 1.85 0.93

Devonport 1.98 0.68

Dorset 2.50 1.18

Flinders Island NA NA

George Town 2.68 0.44

Glamorgan Spring Bay

3.36 0.80

Glenorchy 2.20 0.66

Hobart 1.03 0.37

Huon Valley 1.49 0.51

Kentish 3.34 1.09

King Island NA NA

Kingborough 1.80 0.73

Latrobe 2.19 0.88

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LGA Mean dmft 6 years – deciduous teeth

Mean DMFT 12 years – permanent teeth

Launceston 2.06 0.82

Meander Valley 2.34 0.51

Northern Midlands 1.61 0.53

Sorell 2.68 0.48

Southern Midlands 2.43 1.42

Tasman 3.00 0.31

Waratah/Wynyard 1.93 0.76

West Coast 2.86 1.00

West Tamar 1.51 0.48

Table 5: Mean dmft and DMFT for children by LGA

Figure 2 and Figure 3 show the data from Table 5 graphically from Tasmania by LGA. Note the scale used in these Figures differs; so comparison needs to be made with caution.

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Figure 2: Mean dmft of 6 year olds examined by OHST 2017 by LGA

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Figure 3: Mean DMFT of 12 year olds examined by OHST 2017 by LGA

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6. Future Activities Fluoridation of the Ringarooma Valley Scheme servicing Ringarooma,

Branxholm, Derby, Legerwood and Winnaleah (completed August 2017). Ongoing verification monitoring. Finalisation of Fluoridation Regulations and implementation of Code of

Practice for the Fluoridation of Public Water Supplies. Verification of compliance with Code of Practice and legislative requirement

through third party audits. Fact Sheet and summary brochure published and available on the DHHS

website. Establish a new regulatory compliance assessment framework for the

revised operating range of 0.8-1.1mg//L based on reticulation network monitoring data only.

Track the implementation of the Fluoridation Committee’s Strategic Plan 2018.

Maintain a presence at the National level interfacing with the NHMRC on fluoridation matters.

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