A Ramjatan - WISA Paper 11 February 2000 1

Presented at the WISA 2000 Biennial Conference, Sun City, South Africa, 28 May 1 June 2000

The Potential Impacts of Water Fluoridation:
A Case Study of the Umgeni Water Operational Area,
KwaZulu-Natal.



A Ramjatan, F Ahmed, K Hodgson, D Simpson & N Quinn
Water Quality Department, Umgeni Water, P O Box 9, Pietermaritzburg, 3200
Telephone (0331) 3411335, Fax (0331) 3411349, E-mail asha.ramjatan@umgeni.co.za





ABSTRACT

In anticipation of water fluoridation becoming mandatory in South Africa, water utilities like Umgeni
Water, a bulk water supply authority in the KwaZulu-Natal (KZN) province of South Africa, are faced
with having to deal with the potential impacts of water fluoridation. An investigation was undertaken to
assess the impact of fluoridation on the receiving rivers and the downstream environment. This paper
discusses the fate of fluoride discharged to the environment and its impact on water users with
specific reference to reuse for potable supply.

The baseline fluoride concentrations in rivers were examined and it was found that the median fluoride
concentrations varied between 0.05 mg/l and 1.79 mg/l. Examination of baseline data for
impoundments, Water Works raw and final waters, and borehole water indicated that the fluoride
concentrations were less than 0.5 mg/l for fifty percent of the time. This implies that the raw water at
the Water Works would require to be fluoridated to meet the proposed fluoride standard of 0.7 mg/l.
Hot spots were identified as sites with fluoride concentrations in excess of 1 mg/l, since long term
consumption of water with high fluoride concentrations can lead to dental and skeletal fluorosis. Five
river sites, one point source, one effluent site and sixteen borehole sites were found, on occasions, to
exceed a fluoride concentration of 1 mg/l. The fluoride source of the Mshazi, KwaNyuswa and
KwaNgcolosi inflows to Inanda dam appeared to be related to the catchment geology. The Mshwati,
MgoShongweni and the point source (storm water discharge from AECI) indicated fluoride sources
associated with industrial activities. For borehole water, the fluoride concentrations at the hot spots
ranged from 1 to 8mg/l, indicating varying health impacts with long term consumption, from slight
mottling of dental enamel to severe tooth damage and crippling skeletal fluorosis. The high fluoride
concentrations in these boreholes and rivers indicated the need for defluoridation in order to reduce
the concentrations to safer levels for long term consumption.

In order to raise the fluoride concentration at eleven Water Works to the proposed standard
(0.7 mg/l), the concentration requirement ranged between 0.32 and 0.65 mg F/l and translated into a
dosage from 0.77 to 1.55 kg of sodium fluoride per megalitre of treated water.
A Ramjatan - WISA Paper 11 February 2000 2

The amount of fluoride removed from the influent at the Darvill Wastewater Works was 22.4 percent.
However, the loss of fluoride from the influent implies that fluoride is taken up by the sludge, indicating
a need to assess the cumulative impacts of fluoride arising from sludge disposal on the environment.

A study of the predicted discharge of fluoridated water from the Darvill Wastewater Works, indicated
that the average monthly fluoride concentration would increase from 0.117 to 0.764 mg/l, still
complying with the fluoride standard for effluent discharge (1 mg F/l). However, according to Foulkes
and Anderson (1994), artificial fluoride concentrations as low as 0.1 mg/l have been shown to be
lethal to the water flea, Daphnia magna. Thus an increase in the average monthly effluent
concentration from 0.117 to 0.764 mg/l could significantly impact Daphnia populations, and cause
fluoride induced reduction of food supply for fish and other aquatic life. The average monthly fluoride
load discharged from Darvill Wastewater Works would increase from 0.23 tons to 1.48 tons, an
additional load of 1.25 tons per month on the aquatic environment of the Msunduzi river. The average
monthly fluoride load to Inanda dam main basin is predicted to increase from 4.31 to 5.56 tons
resulting in the fluoride concentration of the water abstracted from Inanda dam for treatment at the
Wiggins Water Works increasing from 0.155 mg/l to 0.200 mg/l.

It is known that water fluoridation can have detrimental health effects on sensitive groups including,
children below three years old, malnourished individuals with zinc deficiency and individuals that are
infected with HIV (Water Research Commission, 1998). Thus a significant percentage of the
population in KZN could be adversely affected by water fluoridation. It was therefore recommended
that health impact assessments be undertaken should water fluoridation become mandatory.



INTRODUCTION

As the largest catchment based water utility in South Africa, Umgeni Water (UW) provides drinking
water to an area of 24 000 km
2
in the province of KwaZulu-Natal (KZN). Umgeni Water is primarily a
bulk water supplier that provides approximately 331 million cubic metres of water per year for domestic
and industrial use. Wastewater is also treated to set standards to safeguard water sources against
pollution. Since Umgeni Water is dependent on the sustainable management of the water supply, the
organisation is committed to working with its customers and the public at large to manage water
resources on a catchment basis.

KwaZulu-Natals population was 8.7 million people in 1995 with a growth rate of 2.8% per annum. Of
concern is the fact that at least 57% of the households live in poverty with poor sanitation and
hygiene. Health care facilities are inadequate and poorly distributed in relation to need, with 318
trained environmental health professionals in KZN compared to an estimated need of 579 (Allan et al,
1998). Tooth decay is one of the most common health problems in South Africa and leads to
substantial loss of working and schooling days as a result of pain and suffering. Dental caries affect
90 to 93% of the South African population and oral health in the disadvantaged community is in a sad
state of affairs (Muller et al, 1998).

In the interest of improving human health, many water authorities in the USA, Canada and other
countries fluoridate water. However, the issue of fluoridating potable water to control the incidence of
dental caries is a highly controversial one, and there is much debate about whether or not the
A Ramjatan - WISA Paper 11 February 2000 3
consumption of fluoridated water does in fact reduce the incidence of dental caries. According to
Muller et al, 1998, Since the South African Department of Health tabled legislation to make
fluoridation of public water supplies mandatory, the issue of whether fluoride is beneficial or harmful
has, once again, become controversial in South Africa.

In June 1998, the Minister of Health published draft regulations for the fluoridation of public water
supplies proposing a maximum concentration of 0.7 mg/l. Water utilities such as Umgeni Water would
be required to implement the legislation and face their consumers on this controversial issue of
fluoridation.

Compared to the proposed fluoride concentration for potable water, the natural concentration of
fluoride in surface water is generally much lower. This is supported by a report which gives, the
concentration of fluoride in unpolluted surface water, as typically 0.1 - 0.3 mg/l, (Water Research
Commission, 1998). Unlike surface water, the concentration of fluoride in borehole waters is usually
much higher as a result of leaching from fluoride containing minerals into the ground water and can
range between 3 mg/l and 12 mg/l (DWAF, 1996). Depending on the fluoride concentration of the
water source, surface or borehole water, water utilities may be required to fluoridate or defluoridate
the water to adjust the fluoride concentrations to the proposed standard.

It is reported that water fluoridation at different optimal levels, varying from 0.6 mg/l in subtropical
regions to 1.1 mg/l in temperate climates, provides significant benefits for both deciduous and
permanent teeth (NHMRC, 1999). This report also indicated that while the evidence for a protective
effect on dental health is strongest in childhood, it can also be demonstrated in adults. However, on
the negative side the South African Water Quality Guideline for Domestic Use (DWAF, 1996),
indicates that fluoride concentrations of 1 mg/l to 5 mg/l can cause slight mottling of dental enamel in
sensitive individuals; the threshold for marked dental mottling with associated tooth damage due to
softening of dental enamel was reported as 1.5 mg/l. This indicates a relatively narrow range of
fluoride concentrations in water that is beneficial to human health. Reasons for not fluoridating the
water supply are based on the fact that an excess of fluoride is poisonous (Muller et al, 1998) and
hence, the optimal control of the fluoride concentration by water utilities is critical. In addition, since
fluoride has no taste, colour, or smell and cannot be detected aesthetically even at high
concentrations, the detection of fluoride by water utilities using adequate monitoring and analytical
techniques is also critical.

While monitoring of surface water and borehole water has been carried out in the Umgeni Water
Operational Area for many years, the baseline concentration of fluoride has not been closely studied.
In addition, the location of high concentrations of fluoride, sources, potential impacts and cumulative
effects of water fluoridation have not been examined in any detail.

This paper aims to highlight the fluoride concentrations in surface and ground waters within the
Umgeni Water Operational Area and assess the potential impacts of fluoridation of potable water.

The main objectives are to :
Establish the baseline fluoride concentrations in surface and ground water;
Identify hot spots, sites where the concentration of fluoride is greater than 1 mg/l;
Identify possible sources of high fluoride concentrations;
A Ramjatan - WISA Paper 11 February 2000 4
Calculate the additional fluoride dosage at water treatment works that will be required to
meet the proposed standard of 0.7 mg/l;
Establish whether there is any loss of fluoride during wastewater treatment;
Predict future fluoride concentrations in surface water that will receive return flows and
evaluate potential concentrations against environmental and potable criteria;
Determine the number of people in sensitive groups that could be detrimentally affected by
water fluoridation.



THE STUDY AREA

The study area, the Umgeni Water Operational Area, lies within the province of KwaZulu-Natal along
the eastern shores of the Republic of South Africa. The Umgeni Water Operational Area extends from
the Tugela river in the north to the Mtwalume river in the south, the Mooi river in the west and the
Indian Ocean in the east, occupying an area of approximately 24 000 square kilometres. Umgeni
Water operates 13 water treatment works of which Durban Heights, Wiggins and Midmar are the
largest. To monitor the quality of its resources Umgeni Water regularly monitors various
bacteriological, algal and chemical water quality variables including fluoride. Figure 1 illustrates the
sites monitored for fluoride in the Umgeni Water Operational area.



MATERIALS AND METHODS

Fluoride data for surface water were obtained from Umgeni Water for rivers, dams, water works raw
and final waters, and wastewater influents and effluents for the period January 1996 to September
1999. The sampling frequency was quarterly for rivers, monthly for water works raw and final waters
and weekly for wastewater effluents. The results for borehole data were based on one off sampling
undertaken by Umgeni Water and the Natal KwaZulu Hydrogeological Mapping Project as a joint
investigation (1994 to 1996). The topographical data used in this study was the South African 1 : 50
000 (third edition, 1981) published by the chief director of Surveys and Mapping .

To establish baseline fluoride concentrations of surface and ground water, the data was tabulated,
summary statistics calculated and time series graphs prepared. The summary statistics was then
used to identify hot spots, sites where the concentration of fluoride was greater than 1 mg/l. This
was done by tabulating the sites which had a maximum concentration in excess of 1 mg/l. Possible
sources of high fluoride concentrations were identified (e.g. geological, anthropogenic activities such
as industries and other urban activities) by relating the problem sites hot spots to landuse, geology
and soils data and from discussions with Umgeni Water personnel dealing with catchment
management.
The impact of water fluoridation on Umgeni Water was investigated by calculating the additional
fluoride dosage at the Umgeni Water water treatment works that will be required to meet the proposed
standard of 0.7 mg/l. The calculation was based on a report by Haarhoff (1998) which indicated that
the amount of chemical required to dose 1 mg fluoride per litre was 2.329 to 2.458 kg sodium fluoride
A Ramjatan - WISA Paper 11 February 2000 5
per mega litre of water, approximately 1.684 kg sodium fluosilicate per mega litre of water or
approximately 4.21 to 5.497 litres of fluosilicic acid per mega litre of water.
A Ramjatan - WISA Paper 11 February 2000 6
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Figure 1. The Umgeni Water Operational Area showing the surface water sample sites monitored for fluoride and concentration ranges.
A Ramjatan - WISA Paper 11 February 2000 7
To establish whether there was any loss of fluoride during the wastewater treatment process, influent
and effluent fluoride concentrations were compared and the percentage fluoride loss calculated.
Future fluoride levels in surface water that will receive return flows were calculated and evaluated
against environmental and potable criteria. The impact of the Darvill Wastewater Works return-flows
on the Inanda impoundment was determined, and subsequently used to predict the fluoride
concentration in the Inanda impoundment, which is the raw water source for the Wiggins Water Works.
This process involved calculating the current average monthly fluoride load of the Darvill effluent,
predicting the load from Darvill after fluoridation and then predicting the impact of this load on the
Inanda impoundment.
The number of people in sensitive groups that could be affected by water fluoridation was estimated
by using the 1996 census data as well as literature data.



RESULTS AND DISCUSSION

Baseline Fluoride Concentrations Of Surface And Ground Water In The Umgeni
Water Operational Area.

The baseline fluoride concentrations of surface and ground water in the Umgeni Water Operational
Area were examined and are summarised in Table 1.
Analysis of the fluoride concentrations for impoundments, Water Works raw and final waters,
Wastewater Works influents and effluents and boreholes, showed that the concentrations were less
than 0.5 mg/l fifty percent of the time. Water Works raw waters showed fluoride concentrations
that are less than 0.6 mg/l ninety five percent of the time. This implies that potable water will need
to be fluoridated to meet the proposed standard of 0.7 mg/l.
The fluoride concentrations in rivers vary, with some river sites exhibiting median fluoride
concentrations as low as 0.05 mg/l, while other river sites have concentrations as high as
1.79 mg/l.
High fluoride concentrations, in excess of 1mg/l, were also recorded at some boreholes. This
implies that water abstracted for domestic use from these sites would require defluoridation to
reduce the fluoride concentrations to safe levels.

Table 1. Summary Statistics of baseline fluoride data.
Summary Statistics - Fluoride Concentrations (mg/l)
Sample Type No. of
Sites
Average Median 75
th

Percentile
95
th

Percentile
Maximum
Rivers 119 0.040 - 1.922 0.050 - 1.792 0.050 - 2.092 0.054 - 4.203 0.061 - 5.000
Impoundments 11 0.046 - 0.230 0.050 - 0.251 0.050 - 0.281 0.056 - 0.338 0.059 - 0.367
WW Raws 11 0.042 - 0.446 0.050 - 0.453 0.050 - 0.510 0.050 - 0.580 0.050 - 0.721
WW Finals 11 0.053 - 0.379 0.050 - 0.406 0.050 - 0.476 0.091 - 0.573 0.113 - 0.649
WWW Influents 3 0.084 - 0.319 0.050 - 0.272 0.112 - 0.406 0.159 - 0.756 0.202 - 1.010
WWW Effluents 3 0.081 - 0.344 0.050 - 0.344 0.110 - 0.401 0.138 - 0.573 0.171 - 0.677
Boreholes 286 0.301 0.038 0.142 1.213 9.878
Point Source 3 0.143 - 0.843 0.152 - 0.842 0.171 - 0.980 0.193 - 1.427 0.199 - 1.654
A Ramjatan - WISA Paper 11 February 2000 8
Note : WW denotes Water Works and WWW denotes Wastewater Works
Hot Spots - Surface Water Sites With Fluoride Concentrations In Excess Of 1 mg/l
And Possible Fluoride Sources.

Sites that exhibit fluoride concentrations in excess of 1 mg/l were identified and are listed in Table 2.
These sites were identified because fluoride concentrations in excess of 1 mg/l are considered to be
unsafe for human consumption as long term exposure to high fluoride concentrations could lead to
dental and skeletal fluorosis. The possible sources of high fluoride concentration at the hot spots
were investigated by using various techniques including landuse, geology, soils and topographical
maps as well as through consultation with Water Quality Scientists and are discussed below.

Table 2. Hot spots for rivers, point source and wastewater works (fluoride
concentrations greater than 1 mg/l).
Summary Statistics (Fluoride in mg/l)
Sample Sites - Rivers N Average Median 75
th

Percentile
95
th
Percentile Maximum
Mshazi above Mgeni Confluence 15 0.691 0.794 0.902 1.085 1.200
Kwanyuswa adjacent to Mshazi 14 0.655 0.722 0.799 0.932 1.100
KwaNgcolosi inflow (minor) to Inanda
Dam
12 0.753 0.908 1.043 1.171 1.220
Mshwati 14 0.663 0.510 1.158 1.308 1.360
Mgoshongweni Stream 7 1.923 1.792 2.092 4.203 5.000
Sample Sites - Pollution Points
AECI storm water 31 0.843 0.842 0.980 1.427 1.654
Sample Sites - WWW Influents
Hammarsdale Influent 68 0.319 0.272 0.406 0.755 1.010

The Mshwati stream is a tributary of the Msunduzi river and is situated in the Valley of a Thousand
Hills area. It was found that the Mshwati stream has fluoride concentrations in excess of 1 mg/l for
at least 25 percent of the time. The Mshwati catchment is home to some industries such as
Feralloys (a smelting plant), an aluminium recovery plant and a fertilizer production plant that are
possible sources of fluoride. Smelting and aluminium recovery plants normally use fluxing agents
such as sodium fluoride in their production processes and according to Gehr (1998), the aluminium
industry has been known for decades to be the origin of most of the fluoride emissions into the
environment. In addition to this, Benefield et al, (1982) states that large quantities of fluorides are
released when fertilizer is manufactured from phosphate rock containing fluorapatite. The high
fluoride concentrations in the Mshwati stream are therefore attributed to the industrial activities in
this catchment.
The Mshazi, Kwanyuswa and KwaNgcolosi streams are all minor inflows to Inanda Dam, situated
within the Valley of a Thousands Hills. It was found that the KwaNgcolosi stream has a fluoride
concentration in excess of 1 mg/l at least 25 percent of the time, while the Mshazi and Kwanyuswa
streams exceeded this concentration about 5percent of the time. For these sites, the fluoride
source was found to be mainly geology (Terry, 2000). Landuse in this area is primarily semi -rural
to transitional settlements and the source of the high fluoride concentrations can be attributed to
the impact of the weathering of igneous rocks such as granites that are intrusive in the area.
The MgoShongweni stream is a tributary of the Mlazi river, downstream of the Shongweni dam
(Figure 2) and exhibits fluoride concentrations in excess of 1 mg/l at least 75 percent of the time.
In terms of domestic use, this water will need to be defluoridated to reduce the fluoride
concentrations to safer levels and reduce cumulative effects. For livestock watering, long term
exposure of 2 to 4 mg F/l (present at least 25 percent of the time) could have adverse chronic
A Ramjatan - WISA Paper 11 February 2000 9
affects associated with dental fluorosis in monogastrics (DWAF, 1996). It was found that the
MgoShongweni stream
A Ramjatan - WISA Paper 11 February 2000 10
Enviroserve Hazardous
Waste Disposal Site
Mgoshongweni
Stream
0 1 2 Kilometers
N

Figure 2 . Topographical map showing the MgoShongweni river in relation to the Waste Disposal Site.
A Ramjatan - WISA Paper 11 February 2000 11

drains the Enviroserve Hazardous Waste Disposal Site (class H:h which include hazards but not
highly hazardous substances), which is the likely source of fluoride. The waste disposal site
contains many types of industrial waste including fluoride wastes such as electroplating, metal
processing and refining wastes and is not leak proof.
The AECI storm water discharge has high fluoride concentrations at least 20 percent of the time.
The concentrations exceed 1.4 mg/l (average fluoride concentration of sea water is 1.4 mg/l),
about 5 percent of the time and thus there is a potential local impact in the sea. The high fluoride
concentration at the storm water site at AECI most likely arises from chemical activities such as the
use of fluxing agents by industries in the AECI area.
Although the Hammarsdale influent had high fluoride concentrations for about 5 percent of the
time, the effluent fluoride concentrations complied with the 1 mg/l standard for effluent discharge.
The high fluoride concentrations in the influent arise from the effluent discharged from industries in
the Hammarsdale industrial area as the fluoride concentration of the potable water in the area is
low (approximately 0.055 mg F/l).

Since the natural concentration of fluoride in unpolluted surface water is typically 0.1 - 0.3 mg/l, it is
clear that the sites listed above indicate varying levels of pollution. Hence, users of this water for
consumption could develop symptoms of long term exposure to high fluoride concentrations. In order
to control environmental impacts and minimise health risks, steps can be taken to defluoridate the
water, and industries advised to minimise activities that give rise to fluoridated waste products.



Hot Spots Borehole Sites With Fluoride Concentrations In Excess Of 1 mg/l And
Potential Health Effects.

The fluoride concentrations of borehole waters are generally much higher than unpolluted surface
water. Fluoride concentrations were measured at a number of boreholes and the results are
depicted spatially in Figure 3. Borehole sites with particularly high fluoride concentrations, that is in
excess of 1 mg/l, are given in Table 3.
In terms of domestic use, long term exposure to the fluoride concentrations between
1 and 1.5 mg/l, at boreholes JD26, C29, H19, CB7, 112/1, 69/5, Thembeni 108 and E&C Charcoal
could lead to slight mottling of the dental enamel in sensitive individuals.
Long term consumption of water from borehole 77/1 could lead to marked dental mottling and tooth
damage. The threshold for marked dental mottling with associated tooth damage due to softening
of enamel is 1.5 mg/l (DWAF, 1996).
Continuous consumption of water from borehole JD27 with fluoride concentrations between
3.5 to 4 mg/l (the threshold for chronic effects of fluoride exposure) could lead to severe tooth
damage especially to infants temporary and permanent teeth, softening of enamel and dentine
could also occur.
Long term consumption of water from the Clansthal Caravan Park Borehole could lead to severe
tooth damage with skeletal fluorosis. However, it is not likely that there would be permanent
campers at this site and therefore the risk to health would be lessened. It is not likely that there
would be long term effects to the high fluoride concentration for occasional campers. However,
campers should be warned of the high fluoride concentrations as it could impact on people that are
sensitive to fluoride. These include individuals with HIV infection, suboptimal dietary calcium, liver
or kidney disease, a high daily water intake and individuals on renal dialysis (WRC, 1998). Long
A Ramjatan - WISA Paper 11 February 2000 12
term consumption of water from Thembeni 105, Keats Drift borehole 1 and 2 could lead to severe
tooth damage and crippling skeletal fluorosis.

Detailed health impact studies in the above areas should be undertaken to assess the effects of long
term exposure to high fluoride concentrations and advice should be given to consumers on
defluoridation techniques.

An attempt was made to identify the borehole water fluoride sources. While it is expected that the
source of fluoride would be the underlying geology, there were no obvious relationships between the
concentrations and the geological data.


Table 3. Hot spots for boreholes (fluoride concentrations greater than 1 mg/l) and
potential health effects.

Borehole
Description
Fluoride
mg/l
Effects (cumulative) of Fluoride
for Domestic Use
Effects of Fluoride for Livestock Health
Thembeni 105 8.314 Severe tooth damage and crippling
skeletal fluorosis
Adverse chronic effects and crippling to
monogastrics; adverse chronic effects to
ruminants
Keats Drifts
Borehole 2
6.365 Severe tooth damage and
pronounced skeletal fluorosis
Adverse chronic effects and crippling to
monogastrics; adverse chronic effects to
ruminants
Keats Drifts
Borehole 1
7.596 Severe tooth damage and
pronounced skeletal fluorosis
Adverse chronic effects and crippling to
monogastrics; adverse chronic effects to
ruminants
Clansthal caravan
Park C0
4.390 Severe tooth damage with skeletal
fluorosis
Adverse chronic effects and crippling to
monogastrics; adverse chronic effects may
occur in ruminants
Borehole JD27 3.983 Severe tooth damage (chronic
effects)
Adverse chronic effects to monogastrics
Borehole H13 2.764 Marked dental mottling and tooth
damage
Adverse chronic effects to monogastrics
Borehole H10 2.146 Marked dental mottling and tooth
damage
Adverse chronic effects to monogastrics
Borehole 77/1 1.528 Marked dental mottling and tooth
damage
No adverse effects to ruminants and
monogastrics
E&C Charcoal 1.319 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole JD26 1.235 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole C29 1.453 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole H19 1.450 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole CB7 1.148 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole 112/1 1.277 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Borehole 69/5 1.473 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics
Thembeni 108 1.061 Slight mottling of dental enamel No adverse effects to ruminants and
monogastrics

A Ramjatan - WISA Paper 11 February 2000 13
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Mvoti River
MtwalumeRiver
Mzi nto River
Mzimayi Ri ver
Mkomazi Ri ver
Lovu River
Mgeni Ri ver
Mdloti Riv er
M
sund
uz
i R
i v
er
Mlazi Ri ver
Mooi Ri ver Town
Greytown
Stanger
Howi ck
Pietermaritzburg
Richmond
Durban
Durban Metro
Pietermaritzburg TLC
Rivers
<
Towns
Catchment Boundary
Dams
% Wastewater Works
& Water Works
Effects of fluori de for Domestic Use
# < 1 mg/l : No adverse health effects
#S
1 - 1.5 mg/l :Slight mottling of dental enamel
#S 1.5 - 3.5 mg/l : Marked dental mottling and tooth damage
#S
3.5 - 4.0 mg/l : Severe tooth damage (chroni c effects)
#S 4.0 - 6.0 mg/l : Severe tooth damage with sketetal fl uorosis
#S 6.0 - 8.0 mg/l : Severe tooth damage and pronounced skeletal fluorosi s
#S > 8.0 mg/l : Severe tooth damage and cri ppling skeletal fluorosis
0 10 20 Kilometers
29
29
30
30
31
31
-30
-30
-29
-29

A Ramjatan - WISA Paper 11 February 2000 14
Figure 3 . Location of boreholes, fluoride concentrations and potential health effects.
A Ramjatan - WISA Paper 11 February 2000 15
The Implication Of Water Fluoridation For Umgeni Water.

If water fluoridation becomes mandatory in South Africa, Umgeni Water would be required to fluoridate
water at its various water treatment works. The amount of fluoridating agent required to increase the
fluoride concentrations to the proposed standard of 0.7 mg/l will depend on the incoming raw water
fluoride concentration to the Water Works. The current fluoride concentrations of the final water were
used to estimate the additional fluoride dosage that will be required to meet the proposed fluoride
concentration and the masses required are shown in Table 4.

Table 4. Additional fluoride dosage requirement.
Water Works Mean baseline F
-

concentration (mg/l)
Mean additional F
-

required (mg/l)
Mean Dosage Requirement per Ml
NaF
(kg/Ml)
Sodiumfluorosilicat
e (kg/Ml)
Fluosilicic
acid (l/Ml)
Mtwalume 0.198 0.502 1.201 0.845 2.436
Ogungini 0.164 0.536 1.283 0.902 2.601
Imfume 0.379 0.321 0.768 0.540 1.557
Ixopo 0.160 0.540 1.293 0.910 2.622
Umzinto 0.245 0.455 1.090 0.767 2.210
Amanzimtoti 0.051 0.649 1.553 1.093 3.149
Hazelmere 0.136 0.564 1.349 0.949 2.735
Wiggins 0.137 0.563 1.347 0.948 2.731
Durban
Heights
0.057 0.650 1.555 1.094 3.153
DV Harris 0.055 0.645 1.545 1.087 3.132
Midmar 0.053 0.647 1.548 1.089 3.139

The expected raw water fluoride concentrations entering the Water Works range from 0.057 to
0.379 mg/l, which translates in fluoride doses of sodium fluoride to 1.555 to 0.768 kg/Ml, respectively.
These calculations are based on mean results and in reality the incoming fluoride concentrations will
fluctuate. The fluoride dosage required to meet the proposed standard will incur many costs to
Umgeni Water including purchase and installation of fluoridating equipment, training of operators,
fluoridating chemicals, monitoring of fluoride concentrations and environmental impact assessments.

In addition, the environmental impacts associated with the operation of a water fluoridation programme
were investigated by Hunt (1998) for Umgeni Water. Hunt highlighted the possible environmental
impacts associated with the fluoridation process using the Life Cycle Assessment (LCA) technique, a
technique used to address the possible impacts associated with the manufacture and consumption of
products. This included environmental aspects and potential impacts throughout a products life from
the extracting, processing, and transport of raw materials through production by industry, consumption
by the consumer and ultimate disposal. A management strategy to setup, operate and maintain a
water fluoridation programme to comply with the proposed South African National legislation was also
recommended.



Comparison Of Influent And Effluent Fluoride Concentrations At Wastewater Works

Wastewater Works operated by Umgeni Water do not have any defluoridation mechanisms in their
processes. It was decided to compare the fluoride concentrations of the influents and effluents at
A Ramjatan - WISA Paper 11 February 2000 16
Darvill, Hammarsdale and the Mpophomeni Wastewater Works to establish statistically whether there
was any removal of fluoride during the treatment process. Since the data were found not to be
normally distributed, the nonparametric Wilcoxon Matched Pairs Test was used to compare the
fluoride data for influents and effluents.
The influent and effluent results for Mpophomeni were found not to be significantly different at the
95 percent confidence limit, indicating no removal of fluoride during the treatment process.
For the Darvill Wastewater Works, the influent and effluent fluoride concentrations were found to
be significantly different with the fluoride concentrations lower in the effluent (Figure 4), indicating
removal of fluoride during the treatment process. This loss of fluoride was found to be 22.4
percent and is most likely removed during the activated sludge process (Borain, 2000), resulting in
a loss of fluoride from the influent and a gain in fluoride concentration in the sludge. This implies
that the fluoride concentrations of the sludge need to be monitored to assess the impact of fluoride
arising from sludge disposal on the environment.

Darvill WWW
0
100
200
300
400
500
F
l
u
o
r
i
d
e

(

g
/
l
)
Influent New Effluent

Figure 4. Time series graph of fluoride data for Darvill influent and
effluent.

The influent and effluent results for Hammarsdale were found to be significantly different, but with
the fluoride concentrations of the effluent generally higher than those of the influent. A possible
reason for this is that the influent and effluent data were not actual pairs and a process time of
approximately three days needs to be considered when conducting a comparison.

From the above assessment these wastewater treatment processes do not appear to remove fluoride,
and where there is some evidence of fluoride removal, the fluoride is likely to be transferred to the
sludge. The effect of possible higher concentrations of fluoride in sludge disposed to land or by other
means needs to be investigated.



Calculation Of Future Fluoride Levels In Surface Water That Will Receive Return
Flows.
As a case study, the impact of the Darvill Wastewater Works return-flow, to the Msunduzi river which
drains to the Inanda impoundment was calculated. This was used to predict the concentration of
fluoride that will pertain in the raw water that is abstracted for treatment at the Wiggins Water Works
(Figure 5).

A Ramjatan - WISA Paper 11 February 2000 17
The current average fluoride load per month at the Msunduzi river upstream of Edendale is 0.34 tons
and the load downstream of Pietermaritzburg City is 0.70 tons (at Motocross). The load from the
Citys Wastewater Works, Darvill (0.23 tons), contributes towards the difference. After fluoridation of
potable water, the fluoride concentration of the Darvill effluent is expected to increase from 0.117 to
0.764 mg/l, which will comply with the fluoride standard of 1 mg/l for effluent discharge. However,
according to Foulkes and Anderson (1994), artificial fluoride concentrations as low as 0.1 mg/l have
been shown to be lethal to the water flea, Daphnia magna. Thus an increase in the average monthly
effluent concentration from 0.117 to 0.764 mg/l could significantly impact Daphnia populations, and
cause fluoride-induced reduction of food supply for fish and other aquatic life. It is recommended that
toxicity testing is conducted to assess the impact of increased fluoride concentrations on Daphnia
populations.
The reason for the Darvill effluent discharge being raised above 0.7 mg/l is that the Citys activity
(industrial and use of fluoridated dental care products) raises the present influent concentration at
Darvill WWW by 0.064 mg/l. The average monthly fluoride load discharged from Darvill Wastewater
Works will increase from 0.23 tons to 1.48 tons, an additional load of 1.25 tons per month on the
aquatic environment of the Msunduzi river. The average monthly fluoride load to Inanda dam main
basin is predicted to increase from 4.31 to 5.56 tons, resulting in the fluoride concentration of the
water abstracted from Inanda dam for treatment at the Wiggins Water Works increasing from
0.155 mg/l to 0.200 mg/l.
According to legislation (Republic of South Africa Government Gazette No. 6208, Department of
Health), a water provider will be required to carry out an environmental impact assessment of the
catchment receiving return flows resulting from fluoridated water. The full impact of this fluoride load
on the environment can then be estimated.
A Ramjatan - WISA Paper 11 February 2000 18

Figure 5. Schematic diagram of the potential impact of Darvill effluent after fluoridation of
water.
Estimate Of The Number Of People In Sensitive Groups That Could Be Affected By
Water Fluoridation.
According to the Water Research Commission (1998), the groups of people listed in Table 5 are
sensitive to fluoride. An estimate of the numbers in some sensitive groups in KwaZulu-Natal are also
presented where available.

Table 5. An Estimate of Groups of People Sensitive to Fluoride.
Sensitive Group Estimate for KwaZulu-Natal
Children up to the age of three
years
The South African census data for 1996, indicates that there are 110 755 children up to
four years old in KZN. If it is assumed that three quarter of this number of children are
below three years old, then at least 83 066 babies in KZN will be sensitive to fluoridated
water.
Individuals with HIV infection Of the 8.4 million people living in KwaZulu-Natal it is estimated that one out of every five
people are infected with HIV and that 3 300 people get infected each month (Staden,
1999). This implies that one fifth of the KZN population could be sensitive to fluoridated
water as a result of this disease.

Individuals with malnutrition,
particularly those with zinc
deficiency
According to the Preliminary State of the Environment Report (Allan et al ., 1998), 57% of
the households in KwaZulu-Natal live in poverty. If it is assumed that many of these
individuals are malnourished it would imply that about 57% of the population in KZN could
be sensitive to fluoride. It would therefore be necessary to undertake health impact
A Ramjatan - WISA Paper 11 February 2000 19
assessments to establish the impacts of water fluoridation on people that belong to these
sensitive groups.
Individuals with suboptimal dietary
calcium
No data available.
Individuals with liver or kidney
disease
No data available.
Individuals with a high daily water
Intake
No data available.
Individuals on renal dialysis No data available.


Discussion on optimum fluoride concentrations for potable water.

Epidemiological work done in the Free State Goldfields during 1991 and 1992 revealed that for the
Highveld of South Africa, taking into account the average daily maximum air temperature, the altitude
above sea level, the nutritional status of the children and availability of other forms of fluoridating the
mouth, 0.55 mg/l is the optimum concentration of fluoride (Plessis, 1998). The safe maximum
concentration was considered to be 0.7 mg/l and at a concentration of 0.9 mg/l objectionable dental
fluorosis would definitely occur. This paper also indicated that these values would be valid for the
Johannesburg, Soweto and Vereeniging areas and that the Natal coastal areas, especially Durban
and the North coast, would have to start with lower fluoride concentrations in potable water and slowly
build up as evidence of safety is gathered. A possible reason for this is that Durban and the North
coast have a higher annual average maximum temperature than Johannesburg. Muller et al (1998)
suggested that the fluoridation level be determined by the use of a sliding scale guideline of 0.4 to
0.7 mg/l, and suggested that Cape Town may decide on a higher fluoride level than Durban because
Cape Town has a lower annual average maximum temperature than Durban.

From the above it is evident that the optimum suggested fluoride concentration of 0.55 mg/l for
Johannesburg should not be applied to the Natal coastal areas but that a lower concentration is
recommended for the latter. If, for normal individuals, a lower optimum fluoride concentration (of less
than 0.55 mg/l) is appropriate, then it is likely that the people in the sensitive groups could react to
lower fluoride concentrations than suggested by the Water Research Commission report (1998). It is
therefore recommended that the fluoride concentration at which the groups of people listed above
become sensitive, is recalculated by taking account of all the conditions in KwaZulu-Natal. This could
be done as part of health impact assessments. It is also suggested that a sliding scale fluoride
guideline of 0.4 to 0.7 mg/l would be better than the uniform standard of 0.7 mg/l proposed by the
legislation of South Africa.



CONCLUSIONS AND RECOMMENDATIONS

This research has shown that the fluoride concentrations in dams, Water Works raw and final waters,
wastewater influent and effluents studied, were less than 0.5 mg/l fifty percent of the time. Some
rivers (Mshazi, KwaNyuswa, KwaNgcolosi, Mshwati and the Mgoshongweni) exhibited high fluoride
concentrations ranging from 0.05 to 5mg/l. Since the current fluoride concentrations in the raw
A Ramjatan - WISA Paper 11 February 2000 20
waters at the Water Works are low, fluoride will need to be added to meet the proposed standard of
0.7 mg/l.

Hot Spots, where the fluoride concentration exceeds 1 mg/l, are present within the study area, for
both surface and borehole water. High fluoride concentrations in the Mshazi, KwaNyuswa and the
KwaNgcolosi streams (inflows to the Inanda dam) are associated with the catchment geology. The
Mshwati and the Mgoshongweni exhibit high fluoride concentrations as a result of industrial activities in
their respective catchments. It is recommended that :
the wastes from the respective industries be monitored and the industries be advised to
reduce the fluoride concentration in these wastes (and impact on the environment) to
meet the standards (for example the DWAF General Standards for effluents) set by the
Department of Water Affairs and Forestry.
where chronic fluoride levels were recorded, consumers be advised of defluoridation
techniques to reduce the fluoride concentration to safer levels.
detailed environmental and health impact assessments be undertaken in areas where
waters high in fluoride concentrations are being consumed.

The raw water fluoride concentrations entering the Water Works ranged from 0.057 to 0.379 mg/l
which requires doses of sodium fluoride ranging from 1.555 to 0.768 kg/Ml, respectively. The
additional fluoride dosage required to meet the proposed standard will incur many costs to Umgeni
Water and its consumers including, purchase and installation of fluoridating equipment, training of
operators, fluoridating chemicals, monitoring of fluoride concentrations and environmental impact
assessments and ultimately the water tariff.

There was no evidence of fluoride removal at the Mpophomeni Wastewater Works. The amount of
fluoride removed from the influent at the Darvill Wastewater Works was 22.4 percent. However, the
loss of fluoride from the influent implies a gain in fluoride concentration of the sludge. It is therefore
recommended the sludge at Darvill be monitored for fluoride and the impacts (including
cumulative effects) of this fluoride on the environment be assessed, should water
fluoridation become mandatory.

If water fluoridation becomes mandatory in South Africa, the Darvill Wastewater Works will receive
fluoridated return flows, and discharge an increased fluoride concentration to the Msunduzi river. This
will result in the concentration of fluoride discharged from Darvill Wastewater works being increased
from 0.117 to 0.764 mg/l, which will still comply with the fluoride standard of 1 mg/l for effluents.
However, an increase in the average monthly effluent concentration from 0.117 to 0.764 mg/l could
significantly impact Daphnia populations, and cause fluoride-induced reduction of food supply for fish
and other aquatic life. In addition, the average monthly fluoride load discharged from Darvill
Wastewater Works will increase from 0.23 tons to 1.48 tons, an additional load of 1.25 tons per month
on the aquatic environment of the Msunduzi river. It is therefore recommended that, if water
fluoridation becomes mandatory, a detailed environmental impact assessment be done by
Umgeni Water on the catchments receiving fluoridated return flows.

Since the optimum suggested fluoride concentration of 0.55 mg/l for Johannesburg may not be
applicable to the Natal coastal areas due to higher mean annual temperatures, a lower concentration
is recommended. This implies that if, for normal individuals, a lower optimum fluoride concentration
(of less than 0.55 mg/l) is appropriate, then it is likely that people in the sensitive groups could react
to lower fluoride concentrations than suggested by the Water Research Commission (1998). It is
A Ramjatan - WISA Paper 11 February 2000 21
therefore recommended that the maximum fluoride concentration for sensitive groups is
recalculated by taking account all the conditions in KwaZulu-Natal. It is suggested that a
sliding scale fluoride guideline of 0.4 to 0.7 mg/l would be better than the uniform standard
of 0.7 mg/l proposed by the legislation of South Africa. It is also recommended that health
impact assessments be undertaken should water fluoridation become mandatory in South
Africa.



REFERENCES

Allan, S. Archer, D. Thompson, G. & Plaistowe, M. 1998. Preliminary State of the Environment Report for KwaZulu-
Natal. Conditions and Trends. Facts and Figures. Problems and Possible Solutions.
Benefield, L D. Judkins, J F (JR), Weand, B L. 1982. Process Chemistry for Water and Wastewater Treatment.
Published by Prentice-Hall, New Jersey.
Borain, G. 2000. Regional Scientist for the Operations Division at Umgeni Water. Personal communication.
Department of Water Affairs and Forestry, 1996a. South African Water Quality Guidelines (second edition). Volume 1:
Domestic Use.
Department of Water Affairs and Forestry, 1996b. South African Water Quality Guidelines (second edition). Volume 1:
Livestock Watering.
Foulkes RG. & Anderson AC. 1994. Impact of Artificial Fluoridation on Salmon species in the NorthWest USA and
British Columbia, Canada. Fluoride Vol. 27. No. 4 pp 220 - 226
Gehr, R & Choueiri, N. 1998. Fluoride in Drinking Water. Fluoride Chemistry and Measurement. Published by the
Rand Afrikaans University, Water Research Group as a short course.
Haarhoff, J. 1998. Fluoride Addition to Water. Published by the Rand Afrikaans University, Water
Research Group as a short course.
Hunt, R P. 1998. The Environmental Impacts Associated with the Operation of a Water Fluoridation Programme.
Muller, WJ. Heath, RGM. & Villet, MH. 1998. Finding the Optimum : Fluoridation of Potable Water in South Africa.
Water SA. Vol. 24. No 1. pp 21- 27.
National Health and Medical Research Council, 1999. Review of Fluoridation and Fluoride Intake from Discretionary
Fluoride Supplements. Melbourne, Australia
Plessis JB. 1998. Medical Perspectives on Fluoridation. Published by the Rand Afrikaans University, Water Research
Group as a short course.
Republic of South Africa Government Gazette, No 6208, Department of Health, Health Professions Act, 1974 (Act No.
56 of 19974).
Staden R, 1999. AIDS Awareness Programme.
Surveyor General. 1981. Topographical Map Series (1: 50 000). Mowbray, Cape Town, South Africa.
Terry S, 2000. Pollution Prevention Scientist at Umgeni Water. Personal communication.
Water Research Commission. 1998. Quality of Domestic Water Supplies (second edition). Published by the
Department of Water Affairs and Forestry, Department of Health and the Water Research Commission,
A Ramjatan - WISA Paper 11 February 2000 22
South Africa.




ACKNOWLEDGEMENTS

This paper is presented with the permission of the Chief Executive Officer of Umgeni Water.