Request to Address the City Council by Sandy Amberg Regarding Water FluoridationJeanne Schneider - "Contact Us" inquiry from City of Dubuque website
From: "Citizen Support Center" <dubuqueia@mycusthelp.com>
To: <jschneid @cityofdubuque.org>
Date: 01/21/2010 7:18 AM
Subject: "Contact Us" inquiry from City of Dubuque website
Contact Us
Name: Sandy Amberg
Phone: 563 -583 -2572
Email: smamberg52001@yahoo.com
City Department: City Council
Page 1 of 1
Message: I would like to request a slot on the agenda for you next city council meeting to discuss the expense, safety, and
sustainability of adding fluoride to the city water. Thank you, Sandy Amberg
file: / /C: \Documents and Settings \jschneid \Local Settings \Temp \XPgrpwise \4B57FFBBD... 01/21/2010
January 20, 2010
Sandy Amberg
80 Croyden Crest
Dubuque, IA 52001
RE: Fluoride /Hydro Fluorosilicic Acid
Dear Ms. Amberg:
I want to thank you for your concerns on the City's water supply having fluoride. Since
receiving your concern I have reviewed many articles and standards regarding the use
of Hydro Fluorosilicic Acid (Fluoride).
As you may or may not know, fluoride is an acid. It is true that a person could develop
health problems if consumed in high concentration amounts.
However, extensive research that has been conducted reveals the correct level of
fluoride (1.0 to 1.2 ppm) in drinking water has greatly improved the dental health of
consumers. Early studies suggesting that fluoride was a possible cancer - causing
chemical to humans proved to be unsubstantiated.
As you mentioned, fluoride is an industrial co- product. When used this co- product is
required per the Iowa Department of Natural Resources (IDNR) Chapter 42, Section
42.4(3) "b ", page 25 of the rule that this product shall be certified to be in compliance
with the National Sanitation Foundation (NSF) /American National Standard Institute
(ANSI)60 for use in a municipal water system for human consumption. The fluoride we
use and other chemicals used in our treatment process comply to this standard and with
the American Water Works Association (AWWA) Standard B703 -00 for use in a
municipal water system.
DISCUSSION:
NSF /ANSI Standard 60: Drinking Water Treatment Chemicals — Health Effects is the
nationally recognized health effects standard for chemicals which are used to treat
drinking water.
The National Sanitation Foundation (NSSF) is a public and safety company, a not for
profit, non - governmental organization. It is the world leader in standards, development,
product certification, education, and risk - management for public health and safety for
the past 65 years. NSF develops national standards, provides learning opportunities
through its center for public health education, and provides third -party conformity
assessment services while representing the interest of all stakeholder groups including
industry, the regulatory community, and the public at large.
NSF has earned the collaborating center designations by the World Health Organization
(WHO) for food and water safety and indoor environments.
The American National Standards Institute (ANSI) serves in its capacity as
administration and coordinator of the United States private sector voluntary
standardization system for more than 90 years. The institute is a private, nonprofit
membership organization supported by a diverse constituency of private and public
sector organizations.
ANSI facilitates the development of American National Standards by accrediting the
procedures of standards for developing organizations. Accreditation by ANSI signifies
that the procedures used by the standards body in conjunction with the development of
American National Standards meet the institute's essential requirement for openness,
balance, consensus and due process.
A 1993 report by the National Research Council of the National Academy of Sciences,
Health Risk of Ingested Fluoride, states "currently allowed fluoride levels in drinking
water do not pose a risk of health problems such as cancer, kidney failure, or bone
disease." The fluoride level in the City of Dubuque water Supply is set to be 1.0 ppm as
per Environmental Protection Agency (EPA) and the Iowa Department of Public Health
(IDPH) Standards.
This level of fluoride is constantly monitored with other treatment processes twenty -four
hours a day, seven days a week by city staff who are certified by the State of Iowa as
Water Treatment Plant Operators. The City has been providing fluoride in its treatment
process for over fifty years.
To date there has been no known incident(s) of illness or other adverse reactions in the
City of Dubuque or State of Iowa related to the ingestion of municipal drinking water,
when treated as per the EPA/IDPH Standards with fluoride. The key to understanding
the use of fluoride is that when properly monitored and used in its recommended
dosage, the benefits are excellent. This is similar to the other chemicals we use, and
even medication or supplements we take regularly for our personal health.
The following medical associations, government agencies and organizations that
support use and /or set standards for community fluoridation are as follows:
• The United States Surgeon General
• Center for Disease Control (CDC)
• The American Dental Association (levels of 0.7 —1.2 ppm)
• The American Medical Association
• The Iowa Department of Natural Resources
• The Iowa Department of Public Health
• Environmental Protection Agency — sets standards 1.0 — 4.0 pp
• American Water Works Association Standard B703 -00 — municipal use
Finally, the Center for Disease Control and Prevention (CDC), recognizes "fluoridation
in drinking water" as one of the top ten Great Public Health Achievements in the United
States during the 20 Century.
I hope this response helps you better understand our City's use of fluoride in its water
treatment process in our efforts to improve quality of life.
I'm available at your convenience to discuss and answer any questions that you may
have with this response.
Sincerely,
Robert M. Green
Water Department Manager
BG:ve
cc: Michael C. Van Milligen, City Manager
Mary Rose Corrigan, Public Health Specialist
Jackie Rodriguez, Water Plant Manager
File
Dubuque
i ty
DUB T E 1 r
I
Masterpiece on the Mississippi 2007
THE CITY OF
January 20, 2010
Sandy Amberg
80 Croyden Crest
Dubuque, IA 52001
RE: Fluoride /Hydro Fluorosilicic Acid
Dear Ms. Amberg:
Eagle Point Water Plant
1902 Hawthorne Street
Dubuque, Iowa 52001 -1416
Office (563) 589 -4291
Fax (563) 589 -4297
TTY (563) 690 -6678
wtrpint@cityofdubuque.org
www.cityofdubuque.org
I want to thank you for your concerns on the City's water supply having fluoride. Since
receiving your concern I have reviewed many articles and standards regarding the use
of Hydro Fluorosilicic Acid (Fluoride).
As you may or may not know, fluoride is an acid. It is true that a person could develop
health problems if consumed in high concentration amounts.
However, extensive research that has been conducted reveals the correct level of
fluoride (1.0 to 1.2 ppm) in drinking water has greatly improved the dental health of
consumers. Early studies suggesting that fluoride was a possible cancer - causing
chemical to humans proved to be unsubstantiated.
As you mentioned, fluoride is an industrial co- product. When used this co- product is
required per the Iowa Department of Natural Resources (IDNR) Chapter 42, Section
42.4(3) "b ", page 25 of the rule that this product shall be certified to be in compliance
with the National Sanitation Foundation (NSF) /American National Standard Institute
(ANSI)60 for use in a municipal water system for human consumption. The fluoride we
use and other chemicals used in our treatment process comply to this standard and with
the American Water Works Association (AWWA) Standard B703 -00 for use in a
municipal water system.
DISCUSSION:
NSF /ANSI Standard 60: Drinking Water Treatment Chemicals — Health Effects is the
nationally recognized health effects standard for chemicals which are used to treat
drinking water.
The National Sanitation Foundation (NSSF) is a public and safety company, a not for
profit, non - governmental organization. It is the world leader in standards, development,
Service
People Integrity Responsibility Innovation Teamwork
product certification, education, and risk - management for public health and safety for
the past 65 years. NSF develops national standards, provides learning opportunities
through its center for public health education, and provides third -party conformity
assessment services while representing the interest of all stakeholder groups including
industry, the regulatory community, and the public at large.
NSF has earned the collaborating center designations by the World Health Organization
(WHO) for food and water safety and indoor environments.
The American National Standards Institute (ANSI) serves in its capacity as
administration and coordinator of the United States private sector voluntary
standardization system for more than 90 years. The institute is a private, nonprofit
membership organization supported by a diverse constituency of private and public
sector organizations.
ANSI facilitates the development of American National Standards by accrediting the
procedures of standards for developing organizations. Accreditation by ANSI signifies
that the procedures used by the standards body in conjunction with the development of
American National Standards meet the institute's essential requirement for openness,
balance, consensus and due process.
A 1993 report by the National Research Council of the National Academy of Sciences,
Health Risk of Ingested Fluoride, states "currently allowed fluoride levels in drinking
water do not pose a risk of health problems such as cancer, kidney failure, or bone
disease." The fluoride level in the City of Dubuque water Supply is set to be 1.0 ppm as
per Environmental Protection Agency (EPA) and the Iowa Department of Public Health
(IDPH) Standards.
This level of fluoride is constantly monitored with other treatment processes twenty -four
hours a day, seven days a week by city staff who are certified by the State of Iowa as
Water Treatment Plant Operators. The City has been providing fluoride in its treatment
process for over fifty years.
To date there has been no known incident(s) of illness or other adverse reactions in the
City of Dubuque or State of Iowa related to the ingestion of municipal drinking water,
when treated as per the EPA/IDPH Standards with fluoride. The key to understanding
the use of fluoride is that when properly monitored and used in its recommended
dosage, the benefits are excellent. This is similar to the other chemicals we use, and
even medication or supplements we take regularly for our personal health.
The following medical associations, government agencies and organizations that
support use and /or set standards for community fluoridation are as follows:
• The United States Surgeon General
• Center for Disease Control (CDC)
• The American Dental Association (levels of 0.7 — 1.2 ppm)
• The American Medical Association
• The Iowa Department of Natural Resources
• The Iowa Department of Public Health
• Environmental Protection Agency — sets standards 1.0 — 4.0 pp
• American Water Works Association Standard B703 -00 — municipal use
Finally, the Center for Disease Control and Prevention (CDC), recognizes "fluoridation
in drinking water" as one of the top ten Great Public Health Achievements in the United
States during the 20 Century.
I hope this response helps you better understand our City's use of fluoride in its water
treatment process in our efforts to improve quality of life.
I'm available at your convenience to discuss and answer any questions that you may
have with this response.
Sincerely,
R ert M. Green
R ert M. Green
Water Department Manager
BG:ve
cc: Michael C. Van Milligen, City Manager✓
Mary Rose Corrigan, Public Health Specialist
Jackie Rodriguez, Water Plant Manager
File
Masterpiece on the Mississippi
TO: Michael C. Van Milligen, City Manager
FROM: Jacqueline Rodriguez, Water Plant Manager
SUBJECT: Fluoridation of Drinking Water
DATE: January 21, 2010
The purpose of this memorandum is to offer my opinion concerning the fluoridation of
Dubuque's drinking water supply. After reading many articles relating to the benefits of
fluoride for the prevention of tooth decay and evaluating numerous arguments from a
variety of sources that either support or oppose these benefits; I will approach this issue
from a sustainable business point of view. It is my opinion that we should not fluoridate
Dubuque's drinking water and the reasons I support this viewpoint are:
1. The EPA and the Iowa DNR neither endorses nor opposes the addition of
fluoride to drinking water. The EPA has set a maximum contaminant level of 4.0
mg /L and a secondary maximum contaminant level of 2.0 mg /L. The decision to
add fluoride is made on a local basis.
2. We treated approximately 2,863,291,000 gallons of water in fiscal year 2009.
We added 92,274 pounds of a 25% solution of Hydrofluosilicic Acid (fluoride) at a
cost of $22,878.85. If the average person in Dubuque consumes a gallon of tap
water a day, 23,725,000 gallons would be consumed annually. This means that
over 99% of the fluoridated water is just being dumped into the environment.
3. Hydrofluosilicic Acid is a hazardous material and is a safety concern. It is subject
to the Department of Transportation Hazardous Material Regulations (49CFR). It
not only poses a threat during transportation but also to the Water Treatment
Operators who must handle this corrosive chemical. (See attached MSDS)
4. Fluoride can be obtained through other sources such as toothpastes,
mouthwash, medication prescribed by doctors and even food. The fluoridation of
drinking water is an inefficient way to try to prevent tooth decay.
This would be an optimal time to eliminate this corrosive chemical and its
discontinuation would save the city over save $22,000 annually in chemical costs. An
additional $75,000 in CIP monies would be saved this fiscal year by not pursuing the
Fluoride Bulk and Day Tank Upgrade project.
Thank you for your consideration of this controversial topic. I am available at your
request to discuss this matter further.
JR
Attachments
Cc: Bob Green
Dubuque
Ali-America City
r
2007
LCI, Ltd. The Fluoride Specialists Page 1 of 6
This Information
is provided for
your protection
by:
LCI LTD
THE rL UGRIC! S►sCIAL CMS
904 -241 -1200
Y
6 NUTS
Responsible
Distribution l
Process
. Elarintalr. • Sera.116-
MATERIAL SAFETY DATA SHEET
This information is provided for your protection by:
LCI,Ltd.
P. 0. Box 49000
Jacksonville Beach, FL 32240 -9000
904 - 241 -1200
24 Hour Emergency Assistance:
Chemtrec: 1- 800 -424 -9300
Fluorosilicic Acid
Section I Product Name and Description
Section II Personal Protection Information
Section III Health Information
Section IV Emergency and First Aid Procedures
Section V Ingredients
Section VI Physical Data
Section VII Reactivity
Section VIII Fire and Explosion Hazards
Section IX Storage and Special Precautions
Section X Transportation Requirements
Section XI Emergency Action - Spill or Leak
For 24 Hour
Em erg en cy
Assistance
CaII:
CLEM
800 - 424 -93C
NFPA Ratings (Scale 0-4)
Health =3; Fire =0; Reactivity =1
http: / /www.lciltd.com /msds /msdshfs.htm 8/15/2008
LCI, Ltd. The Fluoride Specialists Page 2 of 6
Section 1
PRODUCT NAME AND DESCRIPTION
DOT Chemical Name:
Synonyms:
Chemical Family:
CAS Number: 16961 -83 -4
Note: N/A indicates Not Applicable where shown.
Section 11
Fluorosilicic Acid
Hydrofluosilicic Acid,
Fluosilicic Acid,
Hexafluosilicic Acid
Inorganic Acid
PERSONAL PROTECTION INFORMATION
Formula: H
NIOSH Number: V V 8225000
Respiratory Protection: A NIOSH approved cartridge respirator with full -face shield.
Chemical cartridge should provide protection against acid fumes (Hydrogen Fluoride). For
concentrations greater than 20ppm, a NIOSH approved self- contained breathing apparatus
with full -face shield should be used.
Eye and Face Protection: Use tight - fitting chemical splash goggles and a full -face shield, 8
inch minimum. Contact lenses should not be worn.
Hand, Arm and Body Protection: Prevent contact with skin by use of acid -proof clothing,
gloves and shoes. Use a NIOSH approved acid proof suit and boots where liquid or high vapor
concentration is possible.
Other Protective Clothing and Equipment: Eye wash and emergency shower facilities
should be available in handling area.
Engineering Controls: General or local exhaust systems sufficient to maintain vapors below
2.5 mg /m (as F).
Section 111
HEALTH INFORMATION
OSHA Permissible Exposure Limit (PEL): 2.5mg /m F)
http: / /www.lciltd.com /msds /msdshfs.htm 8/15/2008
LCI, Ltd. The Fluoride Specialists Page 3 of 6
ACGIH Threshold Limit Value (TLV): 2.5mg /m F)
Listing in the following:
Department of Transportation Hazardous Material Regulations (49CFR)
Massachusetts Hazardous Substance List
toxic Substances Control Act Inventory of toxic Substances (TSCA)
OSHA Health Hazard Classification: Corrosive
Primary Route(s) of Entry: Eye and skin contact, inhalation
Symptoms of Exposure:
Acute: Liquid or vapors can cause severe irritation and burns which may not be apparent for
hours. Can cause severe irritation to the lungs, nose and throat if swallowed, can cause severe
damage to throat and stomach.
Chronic: Prolonged exposure could result in bone changes, corrosive effect on mucous
membranes including ulceration of nose, throat and bronchial tubes, cough, shock, pulmonary
edema, Fluorosis, coma and death.
Aggravated Medical Condition: Any skin condition and /or pre- existing respiratory disease
including asthma and emphysema.
Toxic Data: LD mg /kg (Oral - Guinea Pig)
Section IV
EMERGENCY AND FIRST AID PROCEDURES
Inhalation: Remove exposed person to an uncontaminated area immediately. If breathing has
stopped, start artificial respiration at once. Oxygen should be provided for an exposed person
having difficulty breathing (but only by an authorized person) until exposed person is able to
breathe easily by themselves. Exposed person should be examined by a physician.
Eye Contact: Flush eyes for at least 15 minutes with large amounts of water. Eyelids should
be held apart during the flushing to insure contact of water with all accessible tissue of the
eyes and lids. Medical attention should be given as soon as possible.
Skin Contact: Exposed person should be removed to an uncontaminated area and subjected
immediately to a drenching shower of water for a minimum of 15 to 20 minutes. Remove all
contaminated clothing while under shower. Medical attention should be given as soon as
possible for all burns, regardless of how minor they seem.
Ingestion: If conscious, give the exposed person large quantities of water immediately to
dilute the acid. Do NOT induce vomiting. Milk may be given for its soothing effect. A physician
should be contacted immediately.
Note to Physician: Beware of late onset of pulmonary edema for up to 48 hours. Treat severe
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LCI, Ltd. The Fluoride Specialists Page 4 of 6
burns similar to Hydrofluoric Acid exposure.
Section V
INGREDIENTS
Composition
H
H
Section VI
PHYSICAL DATA
Boiling Point: 222 °F (105 °C)
Specific Gravity(H =1): 1.234 @ 25%
Percent Volatile by Volume: N/A
Solubility in Water: Complete
Physical State: Fuming Liquid
Bulk Density: 10.29 Ibs /gal @ 25%
Appearance and Odor: Water white to straw
Section VII
REACTIVITY
Stability: Stable.
Hazardous Polymerization: Will not occur.
Conditions and Materials to Avoid: Metal, glass, stoneware, alkali and strong concentrated
acids.
Hazardous Decomposition Products: When heated to decomposition (222 °F) it emits highly
toxic and corrosive fumes of Hydrogen Fluoride, Silicon Tetra - fluoride and Hydrogen Gas.
Section VIII
Percentage
25.0 +/- 2%
75.0 +/- 2%
FIRE AND EXPLOSION HAZARDS
Flash Point and Method Used: N/A
Flammable Limits - % Volume in Air: Lower N/A Upper N/A
Freezing Point: 4 °F(- 15.5 °C)
Vapor Pressure(mm Hg): 24 @ 77° F
Vapor Density (Air =1): N/A
Evaporation Rate: N/A
Molecular Weight: 144.08
pH (1% Solution): 1.2
yellow,burning liquid,with pungent odor
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LCI, Ltd. The Fluoride Specialists Page 5 of 6
Extinguishing Media: Use agent which is appropriate for surrounding fire.
Special Fire Fighting Procedures and Precautions: Wear NIOSH approved self- contained
acid suits.
Auto Ignition Temperature: N/A
Unusual Fire and Explosion Hazards: Reacts with many metals to produce flammable and
explosive hydrogen gas. Keep container cool with water, using fog nozzles, as decomposition
will occur above
222 °F and produce toxic and corrosive fumes of fluoride.
Section IX
STORAGE AND SPECIAL PRECAUTIONS
Handling and Storing Precautions: Store in containers in cool, dry, well ventilated area away
from sources of heat or ignition. Do NOT store in glass or stoneware. Use non - sparking tools.
Keep separate from alkali metals, oxidizing agent, combustible solids and organic peroxides.
Ventilation: Provide adequate general and /or local exhaust to maintain vapors below 2.5
mg /m (as F).
Other Precautions: Do not inhale fumes and prevent skin contact. If pungent, irritating odor
can be detected, workers are being over - exposed. Eye wash and safety shower should be
available in all acid handling areas.
Section X
TRANSPORTATION REQUIREMENTS
DOT Proper Shipping Name: Fluorosilicic Acid Packing Group: 11
DOT Hazard Class: 8 (Corrosive) Subsidiary Hazard Class: N/A
Identification Number: UN 1778 Placarding Requirement: Corrosive
EPA Hazardous Substance: No Reportable Quantity: N/A
RCRA Status of Unused Material if Discarded: Not Listed
Waste Disposal Method: Disposer must comply with federal, state and local disposal or
discharge laws.
Additional Comments: For International transportation, Fluorosilicic Acid is regulated by the
International Maritime Organization (IMO) and the International Air Transport Association
(IATA) for vessel and air movement as a Class 8. Packaging, marking, labelling and shipping
paper descriptions must precisely reflect the regulation for export movement.
Section XI
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LCI, Ltd. The Fluoride Specialists Page 6 of 6
EMERGENCY ACTION - SPILL OR LEAK
Emergency Action: Keep unnecessary people away. Stay upwind, keep out of low areas.
Isolate hazard area and deny entry. We recommend that the user establish a spill prevention,
control and countermeasure plan. This plan should include procedures for proper storage as
well as containment and clean -up of spills and Teaks. The procedures should conform to safe
practices and provide for proper recovery and disposal in accordance with federal, state and
local regulation. Contact Chemtrec at 1- 800 - 424 -9300 for 24 -hour emergency assistance.
Small Spills: Any personnel in area should wear a NIOSH approved air supplied acid suit.
Dike area to contain material. Do not allow solution to enter sewers or surface water.
Neutralize the spill with water and lime (hydrated lime). Take up with sand or non - combustible
absorbent material and place in containers for later disposal. Provide ventilation and be wary
of hydrogen generation upon reaction with some metals. Contact Chemtrec at 1- 800 - 424 -9300
for 24 -hour emergency assistance.
Large Spills: Contact Chemtrec at 1- 800 - 424 -9300 for 24 -hour emergency assistance. Any
personnel in area should wear a NIOSH approved air supplied acid suit. Dike area ahead of
spill to contain material. Do not allow solution to enter sewers or surface water. Neutralize the
spill with water and lime (hydrated lime). Provide ventilation and be wary of hydrogen
generation upon reaction with some metals. Notify the National Response Center, if required.
DISCLAIMER
The information presented herein is based on data considered to be accurate and that reflects the requirements of the OSHA
Hazard Communication Standards in effect as of the date of preparation of this Material Safety Data Sheet. However, no
warranty or representation, express or implied, is made as to the accuracy or completeness of the foregoing data and safety
information. In addition, no responsibility can be assumed by vendor for any damage or injury resulting from abnormal use,
from any failure to adhere to recommended practices, or from any hazards inherent in the nature of the product.
http: / /www.lciltd.com /msds /msdshfs.htm 8/15/2008
Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... Page 1 of 8
Search Health Topics A -Z
Achievements in Public Health, 1900 -1999:
Fluoridation of Drinking Water to Prevent
Dental Caries
Fluoridation of community drinking water is a major factor responsible for the decline in dental
caries (tooth decay) during the second half of the 20th century. The history of water fluoridation
is a classic example of clinical observation leading to epidemiologic investigation and
community -based public health intervention. Although other fluoride- containing products are
available, water fluoridation remains the most equitable and cost - effective method of delivering
fluoride to all members of most communities, regardless of age, educational attainment, or
income level.
Dental Caries
Dental caries is an infectious, communicable, multifactorial disease in which bacteria dissolve
the enamel surface of a tooth (1). Unchecked, the bacteria then may penetrate the underlying
dentin and progress into the soft pulp tissue. Dental caries can result in loss of tooth structure
and discomfort. Untreated caries can lead to incapacitating pain, a bacterial infection that leads
to pulpal necrosis, tooth extraction and loss of dental function, and may progress to an acute
systemic infection. The major etiologic factors for this disease are specific bacteria in dental
plaque (particularly Streptococcus mutans and lactobacilli) on susceptible tooth surfaces and the
availability of fermentable carbohydrates.
At the beginning of the 20th century, extensive dental caries was common in the United States
and in most developed countries (2). No effective measures existed for preventing this disease,
and the most frequent treatment was tooth extraction. Failure to meet the minimum standard of
having six opposing teeth was a leading cause of rejection from military service in both world
wars (3,4). Pioneering oral epidemiologists developed an index to measure the prevalence of
dental caries using the number of decayed, missing, or filled teeth (DMFT) or decayed, missing,
or filled tooth surfaces (DMFS) (5) rather than merely presence of dental caries, in part because
nearly all persons in most age groups in the United States had evidence of the disease.
Application of the DMFT index in epidemiologic surveys throughout the United States in the
1930s and 1940s allowed quantitative distinctions in dental caries experience among
communities - -an innovation that proved critical in identifying a preventive agent and evaluating
its effects.
History of Water Fluoridation
Weekly
October 22, 1999 148(41);933-940
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Soon after establishing his dental practice in Colorado Springs, Colorado, in 1901, Dr. Frederick
S. McKay noted an unusual permanent stain or "mottled enamel" (termed "Colorado brown
stain" by area residents) on the teeth of many of his patients (6). After years of personal field
investigations, McKay concluded that an agent in the public water supply probably was
responsible for mottled enamel. McKay also observed that teeth affected by this condition
seemed less susceptible to dental caries (7).
Dr. F. L. Robertson, a dentist in Bauxite, Arkansas, noted the presence of mottled enamel
among children after a deep well was dug in 1909 to provide a local water supply. A hypothesis
that something in the water was responsible for mottled enamel led local officials to abandon
the well in 1927. In 1930, H. V. Churchill, a chemist with Aluminum Company of America, an
aluminum manufacturing company that had bauxite mines in the town, used a newly available
method of spectrographic analysis that identified high concentrations of fluoride (13.7 parts per
million [ppm]) in the water of the abandoned well (8). Fluoride, the ion of the element fluorine,
almost universally is found in soil and water but generally in very low concentrations (less than
1.0 ppm). On hearing of the new analytic method, McKay sent water samples to Churchill from
areas where mottled enamel was endemic; these samples contained high levels of fluoride (2.0-
12.0 ppm).
The identification of a possible etiologic agent for mottled enamel led to the establishment in
1931 of the Dental Hygiene Unit at the National Institute of Health headed by Dr. H. Trendley
Dean. Dean's primary responsibility was to investigate the association between fluoride and
mottled enamel (see box). Adopting the term "fluorosis" to replace "mottled enamel," Dean
conducted extensive observational epidemiologic surveys and by 1942 had documented the
prevalence of dental fluorosis for much of the United States (9). Dean developed the ordinally
scaled Fluorosis Index to classify this condition. Very mild fluorosis was characterized by
small, opaque "paper white" areas affecting less than or equal to 25% of the tooth surface; in
mild fluorosis, 26 % -50% of the tooth surface was affected. In moderate dental fluorosis, all
enamel surfaces were involved and susceptible to frequent brown staining. Severe fluorosis was
characterized by pitting of the enamel, widespread brown stains, and a "corroded" appearance
(9).
Dean compared the prevalence of fluorosis with data collected by others on dental caries
prevalence among children in 26 states (as measured by DMFT) and noted a strong inverse
relation (10). This cross - sectional relation was confirmed in a study of 21 cities in Colorado,
Illinois, Indiana, and Ohio (11). Caries among children was lower in cities with more fluoride in
their community water supplies; at concentrations greater than 1.0 ppm, this association began
to level off. At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild.
The hypothesis that dental caries could be prevented by adjusting the fluoride level of
community water supplies from negligible levels to 1.0 -1.2 ppm was tested in a prospective
field study conducted in four pairs of cities (intervention and control) starting in 1945: Grand
Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; Evanston and Oak Park,
Illinois; and Brantford and Sarnia, Ontario, Canada. After conducting sequential cross - sectional
surveys in these communities over 13 -15 years, caries was reduced 50 % -70% among children in
the communities with fluoridated water (12). The prevalence of dental fluorosis in the
intervention communities was comparable with what had been observed in cities where drinking
water contained natural fluoride at 1.0 ppm. Epidemiologic investigations of patterns of water
consumption and caries experience across different climates and geographic regions in the
United States led in 1962 to the development of a recommended optimum range of fluoride
concentration of 0.7 -1.2 ppm, with the lower concentration recommended for warmer climates
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(where water consumption was higher) and the higher concentration for colder climates (13).
The effectiveness of community water fluoridation in preventing dental caries prompted rapid
adoption of this public health measure in cities throughout the United States. As a result, dental
caries declined precipitously during the second half of the 20th century. For example, the mean
DMFT among persons aged 12 years in the United States declined 68 %, from 4.0 in 1966 -1970
(14) to 1.3 in 1988 -1994 (CDC, unpublished data, 1999) (Figure 1). The American Dental
Association, the American Medical Association, the World Health Organization, and other
professional and scientific organizations quickly endorsed water fluoridation. Knowledge about
the benefits of water fluoridation led to the development of other modalities for delivery of
fluoride, such as toothpastes, gels, mouth rinses, tablets, and drops. Several countries in Europe
and Latin America have added fluoride to table salt.
Effectiveness of Water Fluoridation
Early studies reported that caries reduction attributable to fluoridation ranged from 50% to 70 %,
but by the mid -1980s the mean DMFS scores in the permanent dentition of children who lived
in communities with fluoridated water were only 18% lower than among those living in
communities without fluoridated water (15). A review of studies on the effectiveness of water
fluoridation conducted in the United States during 1979 -1989 found that caries reduction was
8 % -37% among adolescents (mean: 26.5 %) (16).
Since the early days of community water fluoridation, the prevalence of dental caries has
declined in both communities with and communities without fluoridated water in the United
States. This trend has been attributed largely to the diffusion of fluoridated water to areas
without fluoridated water through bottling and processing of foods and beverages in areas with
fluoridated water and widespread use of fluoride toothpaste (17). Fluoride toothpaste is
efficacious in preventing dental caries, but its effectiveness depends on frequency of use by
persons or their caregivers. In contrast, water fluoridation reaches all residents of communities
and generally is not dependent on individual behavior.
Although early studies focused mostly on children, water fluoridation also is effective in
preventing dental caries among adults. Fluoridation reduces enamel caries in adults by 20 %-
40% (16) and prevents caries on the exposed root surfaces of teeth, a condition that particularly
affects older adults.
Water fluoridation is especially beneficial for communities of low socioeconomic status (18).
These communities have a disproportionate burden of dental caries and have less access than
higher income communities to dental -care services and other sources of fluoride. Water
fluoridation may help reduce such dental health disparities.
Biologic Mechanism
Fluoride's caries- preventive properties initially were attributed to changes in enamel during
tooth development because of the association between fluoride and cosmetic changes in enamel
and a belief that fluoride incorporated into enamel during tooth development would result in a
more acid - resistant mineral. However, laboratory and epidemiologic research suggests that
fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its
actions primarily are topical for both adults and children (1). These mechanisms include 1)
inhibition of demineralization, 2) enhancement of remineralization, and 3) inhibition of bacterial
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activity in dental plaque (1).
Enamel and dentin are composed of mineral crystals (primarily calcium and phosphate)
embedded in an organic protein/lipid matrix. Dental mineral is dissolved readily by acid
produced by cariogenic bacteria when they metabolize fermentable carbohydrates. Fluoride
present in solution at low levels, which becomes concentrated in dental plaque, can substantially
inhibit dissolution of tooth mineral by acid.
Fluoride enhances remineralization by adsorbing to the tooth surface and attracting calcium ions
present in saliva. Fluoride also acts to bring the calcium and phosphate ions together and is
included in the chemical reaction that takes place, producing a crystal surface that is much less
soluble in acid than the original tooth mineral (1).
Fluoride from topical sources such as fluoridated drinking water is taken up by cariogenic
bacteria when they produce acid. Once inside the cells, fluoride interferes with enzyme activity
of the bacteria and the control of intracellular pH. This reduces bacterial acid production, which
directly reduces the dissolution rate of tooth mineral (19).
Population Served by Water Fluoridation
By the end of 1992, 10,567 public water systems serving 135 million persons in 8573 U.S.
communities had instituted water fluoridation (20). Approximately 70% of all U.S. cities with
populations of greater than 100,000 used fluoridated water. In addition, 3784 public water
systems serving 10 million persons in 1924 communities had natural fluoride levels greater than
or equal to 0.7 ppm. In total, 144 million persons in the United States (56% of the population)
were receiving fluoridated water in 1992, including 62% of those served by public water
systems. However, approximately 42,000 public water systems and 153 U.S. cities with
populations greater than or equal to 50,000 have not instituted fluoridation.
Cost Effectiveness and Cost Savings of Fluoridation
Water fluoridation costs range from a mean of 31 cents per person per year in U.S. communities
of greater than 50,000 persons to a mean of $2.12 per person in communities of less than 10,000
(1988 dollars) (21). Compared with other methods of community -based dental caries
prevention, water fluoridation is the most cost effective for most areas of the United States in
terms of cost per saved tooth surface (22).
Water fluoridation reduces direct health -care expenditures through primary prevention of dental
caries and avoidance of restorative care. Per capita cost savings from 1 year of fluoridation may
range from negligible amounts among very small communities with very low incidence of
caries to $53 among large communities with a high incidence of disease (CDC, unpublished
data, 1999). One economic analysis estimated that prevention of dental caries, largely attributed
to fluoridation and fluoride - containing products, saved $39 billion (1990 dollars) in dental -care
expenditures in the United States during 1979 -1989 (23).
Safety of Water Fluoridation
Early investigations into the physiologic effects of fluoride in drinking water predated the first
community field trials. Since 1950, opponents of water fluoridation have claimed it increased
the risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, acquired
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immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other
health conditions (24). The safety and effectiveness of water fluoridation have been re- evaluated
frequently, and no credible evidence supports an association between fluoridation and any of
these conditions (25).
21st Century Challenges
Despite the substantial decline in the prevalence and severity of dental caries in the United
States during the 20th century, this largely preventable disease is still common. National data
indicate that 67% of persons aged 12 -17 years (26) and 94% of persons aged greater than or
equal to 18 years (27) have experienced caries in their permanent teeth.
Among the most striking results of water fluoridation is the change in public attitudes and
expectations regarding dental health. Tooth loss is no longer considered inevitable, and
increasingly adults in the United States are retaining most of their teeth for a lifetime (12). For
example, the percentage of persons aged 45 -54 years who had lost all their permanent teeth
decreased from 20.0% in 1960 -1962 (28) to 9.1% in 1988 -1994 (CDC, unpublished data, 1999).
The oldest post -World War II "baby boomers" will reach age 60 years in the first decade of the
21st century, and more of that birth cohort will have a relatively intact dentition at that age than
any generation in history. Thus, more teeth than ever will be at risk for caries among persons
aged greater than or equal to 60 years. In the next century, water fluoridation will continue to
help prevent caries among these older persons in the United States.
Most persons in the United States support community water fluoridation (29). Although the
proportion of the U.S. population drinking fluoridated water increased fairly quickly from 1945
into the 1970s, the rate of increase has been much lower in recent years. This slowing in the
expansion of fluoridation is attributable to several factors: 1) the public, some scientists, and
policymakers may perceive that dental caries is no longer a public health problem or that
fluoridation is no longer necessary or effective; 2) adoption of water fluoridation can require
political processes that make institution of this public health measure difficult; 3) opponents of
water fluoridation often make unsubstantiated claims about adverse health effects of
fluoridation in attempts to influence public opinion (24); and 4) many of the U.S. public water
systems that are not fluoridated tend to serve small populations, which increases the per capita
cost of fluoridation. These barriers present serious challenges to expanding fluoridation in the
United States in the 21st century. To overcome the challenges facing this preventive measure,
public health professionals at the national, state, and local level will need to enhance their
promotion of fluoridation and commit the necessary resources for equipment, personnel, and
training.
Reported by Div of Oral Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC.
References
1. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride.
Community Dent Oral Epidemiol 1999;27:31 -40.
2. Burt BA. Influences for change in the dental health status of populations: an historical
perspective. J Public Health Dent 1978;38:272 -88.
3. Britten RH, Perrott GSJ. Summary of physical findings on men drafted in world war. Pub
Health Rep 1941;56:41 -62.
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4. Klein H. Dental status and dental needs of young adult males, rejectable, or acceptable for
military service, according to Selective Service dental requirements. Pub Health Rep
1941; 56:1369 -87.
5. Klein H, Palmer CE, Knutson JW. Studies on dental caries. I. Dental status and dental
needs of elementary school children. Pub Health Rep 1938;53:751 -65.
6. McKay FS, Black GV. An investigation of mottled teeth: an endemic developmental
imperfection of the enamel of the teeth, heretofore unknown in the literature of dentistry.
Dental Cosmos 1916;58:477 -84.
7. McKay FS. Relation of mottled enamel to caries. J Am Dent A 1928;15:1429 -37.
8. Churchill HV. Occurrence of fluorides in some waters of the United States. J Ind Eng
Chem 1931;23:996 -8.
9. Dean HT. The investigation of physiological effects by the epidemiological method. In:
Moulton FR, ed. Fluorine and dental health. Washington, DC: American Association for
the Advancement of Science 1942:23 -31.
10. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep
1938;53:1443 -52.
11. Dean HT. On the epidemiology of fluorine and dental caries. In: Gies WJ, ed. Fluorine in
dental public health. New York, New York: New York Institute of Clinical Oral
Pathology, 1945:19 -30.
12. Burt BA, Eklund SA. Dentistry, dental practice, and the community. 5th ed. Philadelphia,
Pennsylvania: WB Saunders, 1999.
13. Public Health Service. Public Health Service drinking water standards -- revised 1962.
Washington, DC: US Department of Health, Education, and Welfare, 1962. PHS
publication no. 956.
14. National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12-
17 years -- United States. Rockville, Maryland: US Department of Health, Education, and
Welfare, Public Health Service, Health Resources Administration, 1974. Vital and health
statistics, vol 11, no. 144. DHEW publication no. (HRA)75 -1626.
15. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of
water fluoridation. J Dent Res 1990;69:723 -7.
16. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279 -89.
17. Horowitz HS. The effectiveness of community water fluoridation in the United States. J
Public Health Dent 1996;56:253 -8.
18. Riley JC, Lennon MA, Ellwood RP. The effect of water fluoridation and social
inequalities on dental caries in 5- year -old children. Int J Epidemiol 1999;28:300 -5.
19. Shellis RP, Duckworth RM. Studies on the cariostatic mechanisms of fluoride. Int Dent J
1994;44(3 suppl 1):263 -73.
20. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human
Services, Public Health Service, CDC, National Center for Prevention Services, Division
of Oral Health, 1993.
21. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluoridation: 44 Florida communities. J
Public Health Dent 1992;52:75 -80.
22. Burt BA, ed. Proceedings for the workshop: cost effectiveness of caries prevention in
dental public health. J Public Health Dent 1989;49(5, special issue):251 -344.
23. Brown LJ, Beazoglou T, Heffley D. Estimated savings in U.S. dental expenditures, 1979-
89. Public Health Rep 1994;109:195 -203.
24. Hodge HC. Evaluation of some objections to water fluoridation. In: Newbrun E, ed.
Fluorides and dental caries. 3rd ed. Springfield, Illinois: Charles C. Thomas, 1986:221-
55.
25. National Research Council. Health effects of ingested fluoride. Washington, DC: National
Academy Press, 1993.
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Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... Page 7 of 8
26. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal
caries in the primary and permanent dentition of children and adolescents 1 -17 years of
age: United States, 1988 -1991. J Dent Res 1996;75:631 -41.
27. Winn DM, Brunelle JA, Selwitz RH, et al. Coronal and root caries in the dentition of
adults in the United States, 1988 -1991. J Dent Res 1996;75:642 -51.
28. National Center for Health Statistics. Decayed, missing, and filled teeth in adults -- United
States, 1960 -1962. Rockville, Maryland: US Department of Health, Education, and
Welfare, Public Health Service, Health Resources Administration, 1973. Vital and health
statistics vol 11, no. 23. DHEW publication no. (HRA)74 -1278.
29. American Dental Association Survey Center. 1998 consumers' opinions regarding
community water fluoridation. Chicago, Illinois: American Dental Association, 1998.
Figure 1
FIGURE 1. Percentage of population residing in areas with fluoridated community
water systems and mean number of decayed, missing (because of caries), or filled
permanent teeth (DMFT) among children aged 12 years -- United States, 1967 -1992
100 5
E 90 -
80- -4
74 -
60- -3 a)
CD 50- -
a
c 40 - "I
C1 30 - -
a)
2 20- - 1
W
10 -
Mean DMFT
Percentage Drinking
Fluoridated Water....-
0 I I I I I I I I I
1967
I I I I
1977
Year
I 1 1 1 I 1 1 I I I I I
19
0
Sources:
1. CDC. Fluoridation census 1992, Atlanta, Georgia: US Department of Health and Human Serv-
ices, Public Health Service, CDC, National Center for Prevention Services, Division of Oral
Health, 1993.
2. National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12-
17 years -- United States. Rockville, Maryland: US Department of Health, Education, and
Welfare, Public Health Service, Health Resources Administration, 1974. Vital and health
statistics, vol 11, no. 144. DHEW publication no. (HRA)75-1626.
3. National Center for Health Statistics. Decayed, missing, and filled teeth among persons 1-
74 years — United States. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, Office of Health Research, Statistics, and Technology, 1981.
Vital and health statistics, vol 11, no. 223. DHHS publication no. (PHSl81 -1673.
4. National Institute of Dental Research. Oral health of United States children: the National Survey
of Dental Caries in U.S. School Children, 1986 -1987. Bethesda, Maryland: US Department
of Health and Human Services, Public Health Service, National Institutes of Health, 1989. NIH
publication no. 89 -2247.
5. CDC, unpublished data, third National Health and Nutrition Examination Survey, 1988 -1994.
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Ten Great Public Health Achievements -- United States, 1900 -1999 Page 1 of 4
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Weekly
April 02, 1999148(12);241 -243
Ten Great Public Health Achievements --
United States, 1900 -1999
During the 20th century, the health and life expectancy of persons residing in the United States
improved dramatically. Since 1900, the average lifespan of persons in the United States has
lengthened by greater than 30 years; 25 years of this gain are attributable to advances in public
health (1). To highlight these advances, MMWR will profile 10 public health achievements (see
box) in a series of reports published through December 1999.
Many notable public health achievements have occurred during the 1900s, and other
accomplishments could have been selected for the list. The choices for topics for this list were
based on the opportunity for prevention and the impact on death, illness, and disability in the
United States and are not ranked by order of importance.
The first report in this series focuses on vaccination, which has resulted in the eradication of
smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus,
diphtheria, Haemophilus influenzae type b, and other infectious diseases in the United States
and other parts of the world.
Ten Great Public Health Achievements -- United States, 1900 -1999
• Vaccination
• Motor - vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
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Ten Great Public Health Achievements -- United States, 1900 -1999 Page 2 of 4
• Recognition of tobacco use as a health hazard
Future reports that will appear in MMWR throughout the remainder of 1999 will focus on nine
other achievements:
• Improvements in motor - vehicle safety have resulted from engineering efforts to make
both vehicles and highways safer and from successful efforts to change personal behavior
(e.g., increased use of safety belts, child safety seats, and motorcycle helmets and
decreased drinking and driving). These efforts have contributed to large reductions in
motor - vehicle- related deaths (2).
• Work - related health problems, such as coal workers' pneumoconiosis (black lung), and
silicosis -- common at the beginning of the century -- have come under better control.
Severe injuries and deaths related to mining, manufacturing, construction, and
transportation also have decreased; since 1980, safer workplaces have resulted in a
reduction of approximately 40% in the rate of fatal occupational injuries (3).
• Control of infectious diseases has resulted from clean water and improved sanitation.
Infections such as typhoid and cholera transmitted by contaminated water, a major cause
of illness and death early in the 20th century, have been reduced dramatically by
improved sanitation. In addition, the discovery of antimicrobial therapy has been critical
to successful public health efforts to control infections such as tuberculosis and sexually
transmitted diseases (STDs).
• Decline in deaths from coronary heart disease and stroke have resulted from risk - factor
modification, such as smoking cessation and blood pressure control coupled with
improved access to early detection and better treatment. Since 1972, death rates for
coronary heart disease have decreased 51% (4).
• Since 1900, safer and healthier foods have resulted from decreases in microbial
contamination and increases in nutritional content. Identifying essential micronutrients
and establishing food - fortification programs have almost eliminated major nutritional
deficiency diseases such as rickets, goiter, and pellagra in the United States.
• Healthier mothers and babies have resulted from better hygiene and nutrition, availability
of antibiotics, greater access to health care, and technologic advances in maternal and
neonatal medicine. Since 1900, infant mortality has decreased 90 %, and maternal
mortality has decreased 99 %.
• Access to family planning and contraceptive services has altered social and economic
roles of women. Family planning has provided health benefits such as smaller family size
and longer interval between the birth of children; increased opportunities for
preconceptional counseling and screening; fewer infant, child, and maternal deaths; and
the use of barrier contraceptives to prevent pregnancy and transmission of human
immunodeficiency virus and other STDs.
• Fluoridation of drinking water began in 1945 and in 1999 reaches an estimated 144
million persons in the United States. Fluoridation safely and inexpensively benefits both
children and adults by effectively preventing tooth decay, regardless of socioeconomic
status or access to care. Fluoridation has played an important role in the reductions in
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Ten Great Public Health Achievements -- United States, 1900 -1999 Page 3 of 4
tooth decay (40 % -70% in children) and of tooth loss in adults (40 % -60 %) (5).
• Recognition of tobacco use as a health hazard and subsequent public health anti - smoking
campaigns have resulted in changes in social norms to prevent initiation of tobacco use,
promote cessation of use, and reduce exposure to environmental tobacco smoke. Since the
1964 Surgeon General's report on the health risks of smoking, the prevalence of smoking
among adults has decreased, and millions of smoking - related deaths have been prevented
(6).
The list of achievements was developed to highlight the contributions of public health and to
describe the impact of these contributions on the health and well being of persons in the United
States. A final report in this series will review the national public health system, including local
and state health departments and academic institutions whose activities on research,
epidemiology, health education, and program implementation have made these achievements
possible.
Reported by: CDC.
References
1. Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care.
Milbank Quarterly 1994;72:225-58.
2. Bolen JR, Sleet DA, Chorba T, et al. Overview of efforts to prevent motor vehicle - related
injury. In: Prevention of motor vehicle - related injuries: a compendium of articles from the
Morbidity and Mortality Weekly Report, 1985 -1996. Atlanta, Georgia: US Department of
Health and Human Services, Centers for Disease Control and Prevention, National Center
for Injury Prevention and Control, 1997.
3. CDC. Fatal occupational injuries -- United States, 1980 -1994. MMWR 1998;47:297 -302.
4. Anonymous. The sixth report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413 -46.
5. Burt BA, Eklund SA. Dentistry, dental practice, and the community. Philadelphia,
Pennsylvania: WB Saunders Company, 1999:204 -20.
6. Public Health Service. For a healthy nation: returns on investment in public health.
Atlanta, Georgia: US Department of Health and Human Services, Public Health Service,
Office of Disease Prevention and Health Promotion and CDC, 1994.
Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML.
This conversion may have resulted in character translation or format errors in the HTML version. Users should not
rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy
for the official text, figures, and tables. An original paper copy of this issue can be obtained from the
Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402 -9371; telephone:
(202) 512 -1800. Contact GPO for current prices.
* *Questions or messages regarding errors in formatting should be addressed to
mmwrq a,cdc.gov.
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