Environmental Engineering Reference
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management approach. This approach should begin with establishing tolerable levels
of risk to human health of the speciic chemicals followed by appropriate risk manage-
ment strategies. In this connection, a novel concept of IFM has been developed and imple-
mented jointly by the United Nations Children's Fund (UNICEF) and Council of Scientiic
and Industrial Research (CSIR)-National Environmental Engineering Institute (NEERI) to
address the growing problem of luorosis.
The scientiic tool Quantitative Chemical Risk Assessment (QCRA) has been used for
the irst time as a diagnostic parameter before applying an appropriate luorosis mitiga-
tion strategy. The QCRA, with data on health surveys, provides the basis for use-based
separation of water sources. Groundwater consumption can also be reduced by creating
alternative water resources, such as rainwater harvesting or reuse of gray water for sani-
tation/gardening. Development of an improved and simple process for deluoridation of
drinking water at the household level could also be an effective way of deluoridation of
drinking water. The IFM concept has been studied and implemented under a systematic
study in the Dhar and Jhabua districts of Madhya Pradesh, India. Water quality moni-
toring and surveys, along with reported dental/skeletal luorosis symptoms, have been
used for identiication of luoride contamination as the chief problem in the study region.
Initial interventions based on the above study have shown excellent results toward actu-
ally controlling the luorosis in the study area. A dental luorosis survey postintervention
has shown a 47% reduction in dental luorosis, as a result of IFM.
17.2.3.1 IFM Approach
This approach needs to begin with better understanding of health impacts of excessive
luoride intake in relation with the nutritional aspects, and establishing tolerable levels
of risk to human health followed by an integrated strategy involving water management
solutions, new water deluoridation techniques, as well as nutritional supplementation. It
is now established beyond doubt that luoride intake is not the only factor responsible for
luorosis, and malnutrition can play a crucial role in aggravating the problem. As a conse-
quence, nutritional solutions can also be effective in luorosis mitigation. Similarly, there
seems to be considerable scope for improvement in existing deluoridation techniques for
water, as they may not be techno-economically feasible in many rural and less developed
areas.
While water can be a major source of enteric pathogens and hazardous chemicals, it is
by no means the only source. In setting standards, consideration needs to be given to other
sources of exposure, including food. There is limited value in establishing a strict target
concentration for a chemical in drinking water, as it provides only a small proportion
of total exposure (WHO, 2004c). Drinking water may be only a minor contributor to the
overall intake of a particular chemical, and in some circumstances controlling the levels
in drinking water, at considerable expense, may have little impact on overall exposure.
Drinking water risk management strategies should therefore be considered in conjunction
with other potential sources of human exposure.
Fluorosis is caused by intake of high levels of luoride from various exposure routes,
while its impact on human health also depends on various factors, including the nutri-
tional status. Therefore, luorosis mitigation needs a multidimensional approach, starting
with proper identiication of the problem and its causes. Scientiic tools such as the QCRA
are used for assessment of health impacts due to excessive luoride intake in relation with
the nutritional aspects, and inally establishing tolerable levels of risk to human health.
Water quality monitoring and surveys along with reported dental/skeletal luorosis
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