Health-based risk targets for fluorosis in tribal children of rural Madhya Pradesh, India

Conventional approaches to fluorosis mitigation and control are based on reduction of excess fluoride consumption from water. Country specific standard limits of 1 mg/l or 1.5mg/l are established and monitored by water departments based on recommendations outlined in the World Health Organization (WHO) Guidelines for Drinking Water Quality (GDWQ). With the advent of the third edition of the WHO GDWQ there is a fundamental departure from standard setting, based on doseresponse affect, towards risk assessment and risk management. The water quality framework, outlined in the guidelines, consists of an iterative cycle, comprising: an assessment of risk, health targets linked to the wider public health context; risk management (with these components being informed by aspects of environmental exposure and acceptable risk) The guidelines advocate for the use of Water Safety Plans, as risk management tool, to help achieve Health Based Risk Targets. This paper presents the application of a Quantitative Chemical Risk Assessment (QCRA) method for determining health based risk targets for fluorosis control. The paper presents evidence from Madhya Pradesh, India. The findings indicate firstly that to control fluorosis total daily consumption from all exposure routes (water and food) must be considered, secondly that the most exposed population group to fluorosis are children due to lack of alternative early nutrients (e.g. exclusive breastfeeding) and, thirdly, that quantifying chemical risk is essential for appropriate risk management strategies to reduce fluorosis in children.