Fluoride occurrence in the lower East African Rift System, Southern Malawi

Poor oral health and the risk of esophageal squamous cell carcinoma in Malawi

Esophageal squamous cell carcinoma (ESCC) is the second most common cancer in Malawi. Risk factors for this cancer in Malawi are poorly understood. Poor oral health has previously been linked to increased ESCC risk in other high-incidence regions, including parts of Eastern and Southern Africa. We assessed the relationship between oral health and ESCC risk in a sex, age and location frequency-matched case-control study based at two hospitals in Lilongwe, Malawi from 2017 to 2020. Trained interviewers used a structured questionnaire and direct observation to collect data on demographics; behaviors; oral hygiene habits; the sum of decayed, missing or filled teeth (DMFT score); oral mucosa status; lip depigmentation and dental fluorosis via a visual scale. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI), adjusted for known and suspected ESCC risk factors. During the study period, 300 cases and 300 controls were enrolled. Subjects in the highest tertile of DMFT score (≥7) had an increased risk of ESCC with an adjusted OR of 1.96 (95% CI: 1.16-3.36) compared to those with a DMFT score of 0. Severe dental fluorosis was associated with a statistically nonsignificant increased risk of ESCC (adjusted OR = 2.24, 95% CI: 0.97-5.49) compared to individuals with no fluorosis. Associations with oral mucosa status, lip depigmentation and toothbrushing method and frequency were mostly null or uncertain. Poor oral health, indicated by a higher DMFT score, was associated with increased ESCC risk in Malawi. Dental fluorosis is another possible risk factor in this population, but further evaluation is necessary to clarify any effects of fluorosis on ESCC risk.

Fluoride exposure and prevalence of osteochondroma in drinking water Endemic fluorosis areas of Heilongjiang Province, China: a cross-sectional study

To investigate the relationship between fluoride exposure and Osteochondroma (OC) prevalence, a cross-sectional study was conducted in drinking water endemic fluorosis areas of Heilongjiang Province, China. Our study first reported that the prevalence of OC was 2.3% in drinking water endemic fluorosis areas of Heilongjiang Province, China, and no difference in gender. Logistic regression analysis found that compared to 1st quartile participants, the prevalence of OC was 73% lower in the 2nd quartile participants of WF (Water fluoride), and 3.4 times higher among the 2nd quartile UF (Urinary fluoride) participants. Our study suggests that 0.259-0.420 mg/L of WF may be considered an appropriate level for reducing OC prevalence, while UF (≥0.750 mg/L) could slightly increase the prevalence of OC. In summary, the link between fluoride and OC prevalence is complicated and needs to be further investigated in a cohort population.

State-of-the-art of research progress on adsorptive removal of fluoride-contaminated water using biochar-based materials: Practical feasibility through reusability and column transport studies

Fluoride (F^-) is one of the essential elements found in soil and water released from geogenic sources and several anthropogenic activities. Fluoride causes fluorosis, dental and skeletal growth problems, teeth mottling, and neurological damage due to prolonged consumption, affecting millions worldwide. Adsorption is an extensively implemented technique in water and wastewater treatment for fluoride, with significant potential due to efficiency, cost-effectiveness, ease of operation, and reusability. This review highlights the current state of knowledge for fluoride adsorption using biochar-based materials and the limitations of biochar for fluoride-contaminated groundwater and industrial wastewater treatment. Biochar materials have shown significant adsorption capacities for fluoride under the influence of low pH, biochar dose, initial concentration, temperature, and co-existing ions. Modified biochar possesses various functional groups (-OH, -CC, -C-O, -CONH, -C-OH, X-OH), in which enhanced hydroxyl (-OH) groups onto the surface plays a significant role in fluoride adsorption via electrostatic attraction and ion exchange. Regeneration and reusability of biochar sorbents need to be performed to a greater extent to improve removal efficiency and reusability in field conditions. Furthermore, the present investigation identifies the limitations of biochar materials in treating fluoride-contaminated drinking groundwater and industrial effluents. The fluoride removal using biochar-based materials at an industrial scale for understanding the practical feasibility is yet to be documented. This review work recommend the feasibility of biochar-based materials in column studies for fluoride remediation in the future.

The effect of mining development in karst areas on water acidification and fluorine enrichment in surface watersheds

High fluoride water is a crucial driving factor for endemic fluorosis. As an important research content of hydrogeochemistry, the enrichment of fluorine in alkaline water has received a fair amount of scholarly attention, but the understanding of the migration and enrichment of fluorine in acid mine drainage (AMD) in karst area remains very limited. An analysis of 13 consecutive periods of hydrochemical samples (312 samples in total) revealed that the weathering of carbonates and sulfide-rich coal measures induced a pH as low as 2.29 in the Chetian River in Jinsha, Southwest China. The highest content of fluorine in AMD was 23.8 mg/L, and the average content in the basin was 1.4 mg/L. In terms of the seasonal variation in the whole basin, the fluorine content were higher in the rainy season than in the dry season. The mineral saturation index shows that the dissolution of fluorapatite and fluorite is an important source of fluorine. The chloro-alkaline indices displayed a strong ion exchange process in the basin, promoting the release of fluorine in silicate minerals. In comparison, the contribution of external inputs, such as atmospheric deposition, was less. Additionally, evaporation was shown to have a limited influence on fluorine enrichment. Meanwhile, pH was an essential factor driving the dynamic transformation of the mode of occurrence of fluorine in water. In the upstream alkaline water, the main occurrence form of fluorine was free F^-, while the F/Al ratio for most of the acidic samples was ≤ 1.0, indicating the main occurrence form of fluorine was likely AlF²⁺. The conclusion of this study provides a new understanding for deepening the geochemical characteristics of fluorine in karst surface water.

Neuro-medical manifestations of fluorosis in populations living in the Main Ethiopian Rift Valley

Prolonged exposure to higher concentrations of fluoride (> 1.5 mg/L) is associated with dental and skeletal fluorosis. The effects of fluoride on dental and skeletal system have been studied extensively; however, the neurological consequences of fluoride in population-based studies are limited. The study aims to assess the epidemiology of neurological and other manifestations of fluorosis among rural populations living in the Main Ethiopian Rift valley. In this cross-sectional study, we enrolled 316 individuals from 23 rural communities in the Main Ethiopian Rift valley. Fluoride concentration was measured in drinking water samples collected from 23 community wells. Association between fluoride concentrations and clinical features of fluorosis was assessed using student t test, chi square, multivariable regression using adjusted odds ratio (OR). The mean fluoride concentration in the drinking water was 6.8 ± 4.3 mg/L (range: 0.3-15.5 mg/L). At least one clinical sign of skeletal fluorosis was observed in 54.4% (n = 175) of the study participants. Headache and joint pain reported by 67.1% and 56.3% of the participants as the most common neurological manifestation, and skeletal fluorosis symptom, respectively. The mean fluoride level was higher for those individuals who reported paresthesia compared to those with no-paresthesia. Loss of appetite, constipation, and fatigue were reported by 48.0%, 45.6%, and 56.6% of the participants, respectively. Signs of crippling fluorosis were observed in small proportion (1.6%) of the participants. Individuals who reported headache are most likely exposed to higher fluoride concentrations in drinking water compared to those reported no-headache (p < 0.001). The study demonstrates high prevalence of neuro-medical manifestations of fluorosis in population living in the Main Ethiopian Rift valley. Fluoride concentration in drinking water and joint pain were independent predictors of fluorosis.

Acute health risks to community hand-pumped groundwater supplies following Cyclone Idai flooding

This longitudinal flood-relief study assessed the impact of the March 2019 Cyclone Idai flood event on E. coli contamination of hand-pumped boreholes in Mulanje District, Malawi. It established the microbiological water-quality safety of 279 community supplies over three phases, each comprising water-quality survey, rehabilitation and treatment verification monitoring. Phase 1 contamination three months after Idai was moderate, but likely underestimated. Increased contamination in Phase 2 at 9 months and even greater in Phase 3, a year after Idai was surprising and concerning, with 40% of supplies then registering E. coli contamination and 20% of supplies deemed 'unsafe'. Without donor support for follow-up interventions, this would have been missed by a typical single-phase flood-relief activity. Contamination rebound at boreholes successfully treated months earlier signifies a systemic problem from persistent sources intensified by groundwater levels likely at a decade high. Problem extent in normal, or drier years is unknown due to absence of routine monitoring of water point E. coli in Malawi. Statistical analysis was not conclusive, but was indicative of damaged borehole infrastructure and increased near-borehole pit-latrine numbers being influential. Spatial analysis including groundwater flow-field definition (an overlooked sector opportunity) revealed 'hit-and-miss' contamination of safe and unsafe boreholes in proximity. Hydrogeological control was shown by increased contamination near flood-affected area and in more recent recharge groundwater otherwise of good quality. Pit latrines are presented as credible e-coli sources in a conceptual model accounting for heterogeneous borehole contamination, wet season influence and rebound behavior. Critical to establish are groundwater level - flow direction, hand-pump plume draw, multiple footprint latrine sources - 'skinny' plumes, borehole short-circuiting and fast natural pathway (e.g. fracture flow) and other source influences. Concerted WASH (Water, Sanitation and Hygiene) sector investment in research and policy driving national water point based E. coli monitoring programs are advocated.

Comparison of Water Defluoridation Using Different Techniques

Fluoride pollution in subsurface water is a significant problem for different nations across the world because of the intake of excessive fluoride caused by the drinking of the contaminated subsurface. Water pollution by flouride can be attributed to the natural and human-made agents. Increased levels of fluoride in drinking water may result in the irretrievable demineralization of bone and tooth tissues, a situation called fluorosis, and other disorders. There has long been a need for fluoride removal from drinking water to make it safe for human use. Among the various fluoride removal methods, adsorption is the method most popularly used due to its cheap cost, ease of utilization, and being a scalable and simple physical technique. According to the findings of this study, the highest concentration of fluoride (0.1–15.0 mg/L) was found in Sweden and the lowest (0.03–1.14 mg/L) in Italy. We collected the values of adsorption capacities and fluoride removal efficiencies of various types of adsorbents from valuable released data accessible in the literature and exhibited tables. There is still a need to find the actual possibility of using biosorbents and adsorbents on a commercial scale and to define the reusability of adsorbents to decrease price and the waste generated from the adsorption method. This article reviews the currently available methods and approaches to fluoride removal of water.

Delivering urgent oral healthcare in Sub-Saharan Africa: supporting sustainable local development

Oral disease continues to be a public health burden, affecting almost half of the global population, and disproportionately affecting the most vulnerable communities.¹ Development organisations use different approaches to tackle this through short-term volunteering programmes in low- and middle-income countries, to address oral health needs in a variety of ways. There is evidence that volunteering requires a high level of cultural competence to avoid negatively impacting on local healthcare systems.^2-4The oral health care needs of communities in Sub-Saharan Africa (SSA) differ markedly from those in the developed world, posing challenges for volunteering organisations to provide effective programmes in circumstances where there is a lack of resources, equipment and infrastructure.

Long-term exposure to the fluoride blocks the development of chondrocytes in the ducks: The molecular mechanism of fluoride regulating autophagy and apoptosis

Long-term exposure to excessive fluoride causes chronic damage in the body tissues and could lead to skeletal and dental fluorosis. Cartilage damage caused by excessive fluoride intake has gained wide attention, but how fluoride accumulation blocks the development of chondrocytes is still unclear. Here, we report a negative correlation between the length and growth plate width after NaF treatments via apoptosis and autophagy, with shrinkage of cells, nuclear retraction, dissolution of chondrocytes. Whereas, fluoride exposure had no significant effect on the number and distribution of the osteoclasts which were well aligned. More importantly, fluoride exposure induced apoptosis of tibial bone through CytC/Bcl-2/P53 pathways via targeting Caspase3, Caspase9, Bak1, and Bax expressions. Meanwhile, the Beclin1, mTOR, Pakin, Pink, and p62 were elevated in NaF treatment group, which indicated that long-term excessive fluoride triggered the autophagy in the tibial bone and produced the chondrocyte injury. Altogether, fluoride exposure induced the chondrocyte injury by regulating the autophagy and apoptosis in the tibial bone of ducks, which demonstrates that fluoride exposure is a risk factor for cartilage development. These findings revealed the essential role of CytC/Bcl-2/P53 pathways in long-term exposure to fluoride pollution and block the development of chondrocytes in ducks, and CytC/Bcl-2/P53 can be targeted to prevent fluoride induced chondrocyte injury.

Removal of Fluorides from Aqueous Solutions Using Exhausted Coffee Grounds and Iron Sludge

Many countries are confronted with a striking problem of morbidity of fluorosis that appears because of an increased concentration of fluorides in drinking water. The objective of this study is to explore opportunities for removal of fluoride from aqueous solutions using cheap and easily accessible adsorbents, such as exhaustive coffee grounds and iron sludge and to establish the efficiency of fluoride removal. Twelve doses (1, 2, 3, 4, 5, 6, 10, 20, 30, 40, 50 and 60 g/L) of adsorbents were used and five durations of the sorption process (30, 60, 90, 120 and 150 min). The results showed that the most optimum dose of iron sludge for 3 mg/L of fluoride removal was 30 g/L and the contact time was 30 min, the efficiency of fluoride removal achieved 62.92%; the most optimum dose of exhausted coffee grounds was 60 g/L with the most optimum contact time of 60 min; at a dose of 50 g/L with contact time of 90 min, the efficiency of fluoride removal achieved 56.67%. Findings demonstrate that adsorbents have potential applicability in fluoride removal up to the permissible norms.

‘Hidden Hot Springs’ as a Source of Groundwater Fluoride and Severe Dental Fluorosis in Malawi

Hidden hot springs likely impact rural water supplies in Malawi’s Rift Valley with excess dissolved fluoride leading to localised endemic severe dental fluorosis. Predicting their occurrence is a challenge; Malawi’s groundwater data archive is sporadic and incomplete which prevents the application of standard modelling techniques. A creative alternative method to predict hidden hot spring locations was developed using a synthesis of proxy indicators (geological, geochemical, dental) and is shown to be at least 75% effective. An exciting collaboration between geoscientists and dentists allowed corroboration of severe dental fluorosis with hydrogeological vulnerability. Thirteen hidden hot springs were identified based on synthesised proxy indicators. A vulnerability prediction map for the region was developed and is the first of its kind in Malawi. It allows improved groundwater fluoride prediction in Malawi’s rift basin which hosts the majority of hot springs. Moreover, it allows dentists to recognise geological control over community oral health. Collaborative efforts have proven mutually beneficial, allowing both disciplines to conduct targeted research to improve community wellbeing and health and inform policy development in their respective areas. This work contributes globally in developing nations where incomplete groundwater data and vulnerability to groundwater contamination from hydrothermal fluoride exist in tandem.

Predicting Groundwater Vulnerability to Geogenic Fluoride Risk: A Screening Method for Malawi and an Opportunity for National Policy Redefinition

Fluoride concentrations in Malawi’s groundwater are primarily controlled by geogenic sources that are highly variable and may cause a heterogeneous fluoride occurrence and local-to-regional variations in fluorosis health risks posed. Our aim was to address the challenge of developing a national solution to predicting groundwater vulnerability to geogenic fluoride risk in the country of Malawi where incidences of fluorosis are reported and typical developing world problems of limited data and resources abound. Previously there have only been sporadic, local-scale studies linking fluoride occurrence with health risks in Malawi with no attempts to tackle the issue nationally. We hence develop a screening method for predicting groundwater vulnerability to geogenic fluoride in the form of detailed risk maps developed from statistical relationships shown between groundwater fluoride occurrence and known geogenic fluoride sources. The approach provides for dynamic update and informed acquisition of new data and hence on-going improving capacity to manage fluoride risks in Malawi. Our screening method provides a technical basis for redefining national fluoride policy to ensure commensurate management of health risks posed. Specifically, the approach provides a pathway for stepped progression from the current 6 mg/L Malawian standard for fluoride in drinking water to adoption of the World Health Organisation 1.5 mg/L guideline standard.

Paleo-Geohydrology of Lake Chilwa, Malawi is the Source of Localised Groundwater Salinity and Rural Water Supply Challenges

Meeting long-term rural community water supply needs requires diligent geohydrological conceptualisation. Study of Malawi’s Lake Chilwa Basin, including sampling of 330 water points in Phalombe District, enabled assessment of groundwater quality influence upon supply. The control of larger Lake Chilwa paleo-environments on current Basin groundwater quality is demonstrated. Lacustrine sediment deposition forming high-level deposits under open lake conditions and terrace deposits under open and closed lake conditions significantly control the groundwater major-ion quality and salinity now observed. Paleo-lake extent marks the transition between low-TDS (total dissolved solids) groundwater suitable for water supply at higher elevations and high-TDS brackish groundwater in areas overlain by lacustrine deposits closer to the current lake level. Low-TDS groundwater is limited to mid-to-low reach influent leakage of rivers incising terraces. Permeable fluvial deposits within the deeper paleo-river channel may possibly provide low-TDS water. The conceptual model, whereby paleo-lake controls groundwater salinity, provides science-based evidence to address policy to manage the significant water point functionality concerns quantified at the district and river basin scales. Targeting of the low-TDS groundwater alongside improved use of upland low-TDS stream/river sources with fewer, but larger capacity, and better maintained gravity-fed supply schemes are recommended. This study hence shows the value of paleo-geohydrology interpretation of the lake–groundwater system conceptualisation to inform Sustainable Development Goal 6 (SDG 6.5.1)—integrated water resources management policy for rural water supply.

Identifying Groundwater Fluoride Source in a Weathered Basement Aquifer in Central Malawi: Human Health and Policy Implications

Consumption of groundwater containing fluoride exceeding World Health Organization (WHO) 1.5 mg/L standard leaves people vulnerable to fluorosis: a vulnerability not well characterised in Malawi. To evaluate geogenic fluoride source and concentration, groundwater fluoride and geology was documented in central Malawi where groundwater supplies are mainly sourced from the weathered basement aquifer. Lithological composition was shown as the main control on fluoride occurrence. Augen gneiss of granitic composition posed the greatest geological fluoride risk. The weathered basement aquifer profile was the main factor controlling fluoride distributions. These results and fluoride-lithology statistical analysis allowed the development of a graded map of geological fluoride risk. A direct link to human health risk (dental fluorosis) from geological fluoride was quantified to support science-led policy change for fluoride in rural drinking water in Malawi. Hazard quotient (HQ) values were calculated and assigned to specific water points, depending on user age group; in this case, 74% of children under six were shown to be vulnerable to dental fluorosis. Results are contrary to current standard for fluoride in Malawi groundwater of 6 mg/L, highlighting the need for policy change. Detailed policy recommendations are presented based on the results of this study.

A review on the potential sources and health implications of fluoride in groundwater of Sub-Saharan Africa

Groundwater is a major source of drinking water for millions of people around the world. Over 400 million people in Africa depend solely on it as their main source of water supply. Fluoride is a common contaminant in groundwater. In low concentration (0.5-1.0 mg/L), fluoride is needed by humans for healthy development of bones and teeth, however, a concentration >1.5 mg/L has been linked with several fluorosis and non-fluorosis diseases. Dental and skeletal fluorosis are the major fluorosis diseases commonly reported with the consumption of fluoride-rich water. Although fluoride intake through other pathways such as the drinking of tea and eating of vegetables have been reported, the drinking of fluoride-rich water remains the major pathway of fluoride into humans. Cases of high fluoride levels in groundwater have been reported in almost all the sub-Saharan Africa region but it is more prevalent in East African countries, Sudan and South Africa. Although fluoride is present in surface water mostly in the East African Rift Valley across different countries in East Africa, its significant or high levels are usually associated with groundwater. Geogenic sources such as fluorite, apatite, biotite, amphibole, micas, topaz, cryolite, muscovite and fluorspar have been identified as the major sources of fluoride in groundwater. High fluoride levels have been reported across sub Saharan Africa, with generally higher levels in East Africa resulting from the volcanic activities in the rift system. Dental fluorosis has been reported in many sub-Saharan African countries including South Africa, Tanzania, Uganda, Ethiopia, Kenya, Sudan, Niger, Nigeria, Benin, Ghana and Malawi. Geothermal temperature has been regarded as one of the driving forces for high fluoride levels recorded in groundwater from deep aquifers and geothermal springs. The most affected people with the consumption of fluoride-rich water are the poor with low socioeconomic status who live in rural areas. Some of the proposed alternative sources include rainwater and fog water harvesting and blending of water from various sources. Low-cost and sustainable deflouridation technique remains one of the best ways to treat fluoride contaminated water either at communal level or at the point-of-use.

Seasonally Variant Stable Isotope Baseline Characterisation of Malawi’s Shire River Basin to Support Integrated Water Resources Management

Integrated Water Resources Management (IWRM) is vital to the future of Malawi and motivates this study’s provision of the first stable isotope baseline characterization of the Shire River Basin (SRB). The SRB drains much of Southern Malawi and receives the sole outflow of Lake Malawi whose catchment extends over much of Central and Northern Malawi (and Tanzania and Mozambique). Stable isotope (283) and hydrochemical (150) samples were collected in 2017–2018 and analysed at Malawi’s recently commissioned National Isotopes Laboratory. Distinct surface water dry-season isotope enrichment and wet-season depletion are shown with minor retention of enriched signatures ascribed to Lake Malawi influences. Isotopic signatures corroborate that wet-season river flows mostly arise from local precipitation, with dry-season flows supported by increased groundwater contributions. Groundwater signatures follow a local meteoric water line of limited spread suggesting recharge by local precipitation predominantly during the peak months of the wet-season. Relatively few dry-season groundwater samples displayed evaporative enrichment, although isotopic seasonality was more pronounced in the lowlands compared to uplands ascribed to amplified climatic effects. These signatures serve as isotopic diagnostic tools that valuably informed a basin conceptual model build and, going forward, may inform key identified Malawian IWRM concerns. The isotopic baseline establishes a benchmark against which future influences from land use, climate change and water mixing often inherent to IWRM schemes may be forensically assessed. It thereby enables both source-water protection and achievement of Sustainable Development Goal 6.