ENDEMIC FLOUROSIS AND LATHYRISM

1. ENDEMIC FLOUROSIS AND LATHYRISM Dr Navya N Assistant Professor Dept of Community Medicine Yenepoya Medical College

2. FLOURINE • Fluorine – most abundant element in nature • only combined form. • essential - normal mineralization of bones and formation of dental enamel. principal sources • Drinking water : The major source • Foods : seafish, cheese and tea • Reqiurements: in drinking water accepted -0.5 to 0.8 mg/L

3. DEFICIENCY/ EXCESS • two-edged sword. • Prolonged ingestion of fluorides through drinking water in excess- dental and skeletal fluorosis Endemic flourosis : water – 3-5mg/L of flourine a) Dental fluorosis – mottling of dental enamel-above 1.5 mg/L intake b) Skeletal fluorosis : lifetime daily intake of 3.0 to 6.0 mg/L or more • inadequate intake - dental caries. INTERVENTIONS : • Changing water source • Chemical method : Nalgonda technique

4. DISEASE DISTRIBUTION • In many parts of world- drinking water- excessive amounts of fluorine (3-5 mg/L)- endemic fluorosis • Important health problem-e.g.. Andhra Pradesh (Nellore, Nalgonda and Prakasam districts), Punjab, Haryana, Karnataka, Kerala and Tamil Nadu

5. TOXIC MANIFESTATIONS (a) Dental Fluorosis : • Excess fluoride- ingested- years of tooth calcification – 1st7 years of life • Characterised- "mottling“- dental enamel-levels above 1.5 mg/L intake • Early sign- dental fluorosis- teeth lose- shiny appearance and chalk-white patches- develop on them. • Later- white patches yellow brown or black. • Severe cases- loss of enamel- teeth - corroded appearance. • Mottling - best seen- incisors of the upper jaw. • Almost entirely confined- permanent teeth and develops only during the period of formation

6. (A) DENTAL FLUOROSIS :

7. TOXIC MANIFESTATIONS (b) Skeletal fluorosis : • Associated - lifetime daily intake of 3.0 to 6.0 mg/L or more. • Heavy fluoride deposition- skeleton. • Concentration - 10 mg/L- exceeded- crippling fluorosis- leads- permanent disability.

8. Skeletal fluorosis :

9. TOXIC MANIFESTATIONS (c) Genu Valgum: • New form- fluorosis characterised- genu valgum and osteoporosis- lower limbs- recent years – some districts- Andhra Pradesh and Tamil Nadu • Syndrome- staple- sorghum (jowar). • Further studies- diets based on sorghum- higher retention of ingested fluoride than- diets based on rice

10. INTERVENTION • Changing the water source : • Find- new source-drinking water- lower fluoride content (0.5 to 0.8 mg/L) • Running surface water- lower quantities of fluorides than ground water(wells)

11. INTERVENTION 2. Chemical treatment : • Water chemically defluoridated- water treatment plant- moderately expensive • National Environmental Engineering Research lnstitute, Nagpur- developed- technique- Nalgonda technique- defluoridation of water. • lnvolves- addition- two chemicals (viz. lime and alum) in sequence flocculation, sedimentation filtration.

12. INTERVENTION 3. Other measures: • Fluoride supplements- NOT - prescribed for children - who drink fluoridated water. • Use- fluoride toothpaste – areas-endemic fluorosis- NOT recommended- children upto 6 years of age

13. LATHYRISM • Lathyrism- paralysing disease- humans and animals. • Humans- neurolathyrism- affects the nervous system • Animals- osteolathyrism (odoratism)- pathological changes- bones- skeletal deformities • Neurolathyrism- crippling disease- nervous system Characterised: • Gradually developing spastic paralysis- lower limbs, • Adults consuming- pulse- Lathyrussativus- large quantities

14. PROBLEM STATEMENT • Prevalent- Madhya Pradesh, Uttar Pradesh, Bihar and Orissa. • Also- reported - Maharashtra, West Bengal, Rajasthan, Assam and Gujarat- pulse is grown. • Recent reports- are no fresh outbreaks of the disease in endemic areas- shifting trends in agronomical practices • Lathyrism - Spain and Algeria- Lathyrus is eaten

15. PULSE • Lathyrussativus- "Khesari dhal“- local names- Teora dhal, Lak dhal, Batra, Gharas, Matra etc. • Seeds- lathyrus- triangular shape and grey colour. • When dehusked pulse- similar- red gram dhal or bengal gram dhal. • Lathyrus- good source of protein, but toxin- affects nerves. • It is eaten mostly- poor agricultural labourer- relatively cheap. • Studies- diets containing over 30% of dhal- taken over 2-6 months- neurolathyrism

16. KESARI DHAL

17. TOXIN • Beta oxalyl amino alanine (BOAA). • Isolated - crystalline form and is water soluble • This property- made use- removing toxin from pulse- soaking it in hot water and rejecting the soak water. • Studies- blood-brain barrier- toxin. • To overcome this barrier- pulse- eaten in large amounts- period of time for 2 months or more. • Several other toxins have also been reported

18. CLINICAL FEATURES • Disease affects- young men between- age of 15 to 45 years and manifests itself in stages : • LATENT STAGE • NO STICK STAGE • ONE STICK STAGE • TWO STICK STAGE • CRAWLER STAGE

19. CLINICAL FEATURES (a) Latent stage : • Individual- apparently healthy, but- subjected to physical stress- ungainly gait. • Neurological examination- characteristic physical signs. • This stage – important- preventive aspect- if the pulse- withdrawn from the diet- complete remission of the disease. (b) No-stick stage : Patient walks- short jerky steps without the aid of a stick. (c) Onestick stage- Patient walks- crossed gait with a tendency to walk on toes. • Muscular stiffness makes it necessary to use a stick to maintain balance.

20. CLINICAL FEATURES (d) Two stick stage : symptoms- more severe. • Excessive bending of knees and crossed legs- patient needs two crutches for support. • The gait is slow and clumsy- patient gets tired easily after walking a short distance. (e) Crawler stage : Erect posture- impossible- knee joints cannot support the weight of the body. • Atrophy of the thigh and leg muscles. • The patient is reduced- crawling by throwing his weight on his hands

21. CLINICAL FEATURES

22. INTERVENTIONS (a) Vitamin C prophylaxis: certain instances- damages- repaired by the daily administration of 500-1000 mg of ascorbic acid for a week or so. (b) Banning the crop : extreme step not feasible- immediate implementation. • The Prevention of Food Adulteration Act in India-banned lathyrus in all forms - whole, split or flour. • But ban- not operative where it is needed- Madhya Pradesh, Bihar, Orissa and Gujarat- pulse is widely grown. • If not possible to avoid consuming khesari dhal- proportion of the dhal -never form more than a quarter of the total amount of cereals and pulses eaten per day. c) Removal of toxin

23. REMOVAL OF TOXIN 1. Steeping Method : • Toxins- water soluble- can be removed by soaking the pulse in hot water. • This method- practised at home. • A large quantity of boiled and the pulse is soaked in hot water for 2 hours • Soaked water is drained off completely. • Pulse washed again- clean water, then drained off and dried- sun. • The pulse is then used for consumption. • Drawback with this method - loss of vitamins and minerals. • Parboiling : An improved method of detoxicating- "parboiling" • Suitable- large scale operation. • Simple soaking in lime water over- night followed by boiling - destroy the toxin.

24. INTERVENTIONS d) Education : public- dangers of consuming- pulse and need for removing toxin before consumption. e) Genetic approach: Certain strains - very low levels of toxin (0.1%). • The selective propagation and cultivation of such strains f) Socio-economic changes: only socio-economic changes or overall development -root out lathyrism.

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