The international programme.

Bulgaria

Twenty years ago Bulgaria became the first country in the world to implement a community based milk fluoridation scheme. Since then the programme has gradually expanded, becoming established in six principal cities; Plovdiv, Varna, Veliko Turnovo, Burgas, Shoumen and Stara Zagora. More recently the small town of Sevlievo, in the Gabrovo province, was incorporated. However, sadly, the programme has recently suffered severe disruption. This has been due primarily to a major campaign by a group fundamentally opposed to fluoridation although difficulties encountered with the supply of fluoridated milk, caused by major changes within the dairy industry, have also had an adverse impact.

The National Steering Group, formed to co-ordinate the further development of the programme, reviewed the challenges faced and identified a series of measures designed to reinforce the position of the schemes, and of the programme as a whole. These actions, combined with the determined efforts of the local Associations, have improved the outlook. Although the overall 'rebuilding' process is far from complete, the signs are encouraging with collaborative agreements for the extension of the schemes now under consideration.

None of this has affected the comprehensive evaluation study that has been conducted under the direction of the WHO. Caries increment and prevalence were measured over five years in two cohorts of 3-year-old children. Using a multi-stage cluster sampling methodology, the sample of children was taken across the six main sites participating in the programme. The control group was selected from two well matched principal cities outside the programme, Sliven and Pleven. The work on this study will be completed during the current year.

Chile

The progress achieved in the milk fluoridation programme in Chile has been impressive. It now reaches 3,600 rural schools in 9 regions of the country, with the total number of participating children increasing to 235,000.

Water fluoridation plays a vital role in the prevention of dental disease in Chile, but is only available to people living in urban or semi-urban areas. The milk supplied to children in rural areas under the School Food Assistance Program, operated by the Junta Nacional de Auxilio Escolar y Becas (JUNAEB), therefore provides an excellent vehicle for the delivery of fluoride.

Milk fluoridation was first introduced to this country in 1994, with a pilot project implemented in the rural community of Codegua, in the VIth region. The positive results from the evaluation of this scheme led to development of a programme in the 1Xth region and the subsequent expansion of milk fluoridation in Chile. Interestingly, this is the only country which uses fluoridated powdered milk products. Another variation is in the fluoridating agent; disodium monofluorophosphate is used as opposed to sodium fluoride in the other locations.
From the outset, the Instituto de Nutricion y Tecnologia de los Alimenos(INTA), Santiago, has been instrumental in the development of milk fluoridation in Chile. It continues to play an important role with a commitment to further research in this field and through the ongoing technical support provided to JUNAEB.

China

A pilot project was conducted in the Haidian district of Beijing between 1994 and 1999. This involved the distribution of fluoridated milk to kindergarten children aged 3 - 6 years. The evaluation of the scheme, completed in 1999, showed positive results and generated considerable interest in the potential for the use of fluoridated milk in China.

The Foundation has since worked closely with the University of Hong Kong, in consultation with the National Committee for Oral Health, to develop stronger links with potential collaborators in China. Annual one month training courses were run at the University to provide selected young dentists, from each of the country's six regions, with training in the principles of dental public health. The initiative, which included seven dentists from mainland China, began in 2003 was completed in 2007. It is hoped that it will provide a network of dentists, from the various regions, with the necessary skills to assist in establishing the potential for milk fluoridation in China.

Republic of Macedonia

As part of a national strategy for prevention of oral diseases in children aged 0-14 years the Ministry of Health in the Republic of Macedonia, introduced a milk fluoridation programme in October 2009. It has been established through the kindergarten system, and is currently reaching approximately 7800 children aged 3 to 5 years. Importantly the government has engaged some 200 or so public health dentists and nurses to deliver the national strategy and these dental teams, have been supporting the implementation of milk fluoridation. The Ministry of Health is keen to see the programme extended to schoolchildren and will be exploring the feasibility of this over the coming 12 months.

Peru

The Foundation was pleased to collaborate with the University of Trujillo and the University of Wales to develop a milk fluoridation scheme in Trujillo. Unfortunately the scheme which was introduced in 1999 was discontinued in 2004, as an increase in the community's exposure to fluoride was detected through the routine monitoring procedures. Further investigations revealed that fluoridated salt, commonly used in many other parts of Peru, had become available in local shops and markets. Whilst the studies indicated that the children involved in the scheme were not exposed to significantly higher levels of fluoride than those in neighbouring districts, the continuation of milk fluoridation could not be justified given the increase in the background levels in the community as a whole.

During its operation the scheme provided an interesting variation to others in that it was established under a national nutrition programme, the Programa del Vaso de Leche. Funded by the Peruvian government and administered by the local municipalities, milk directed towards children from poorer families is distributed through local community centres, known as "Mothers Clubs". They serve many functions, but with a universal theme of self-help, particularly in the interests and health of children. The use of this programme enabled fluoridated milk to reach children from weaning up to 14 years of age, and to be consumed on a daily basis. This was in contrast to other projects where participation is limited to the age groups attending kindergartens or schools, with consumption restricted to the number of days children are in attendance.

Russian Federation

The programme in the Russian Federation was introduced in 1994, with schemes being implemented in the cities of Voronezh, Maikop and Smolensk. This was developed through the kindergarten system, providing fluoridated fresh pasteurized milk to children aged 3 - 6/7 years.

A scheme implemented in the Republic of Tatarstan is now reaching over 23,000 kindergarten children aged 3-6 years. The supply of fluoridated milk is currently restricted to the city of Niznekamsk and the neighbouring community of Zelenodolsk although official approval has been granted to introduce a scheme in Naberezhnye Chelni which could potentially include 25,000 pre-school children.

Plans are also underway to consult the Chief Dental Officers, in seven districts of the principal city, Kazan, and a further ten districts within the region, on the need and potential for milk fluoridation. In parallel to this, it is hoped that permission can be obtained to produce fluoridated UHT milk to facilitate the development of the scheme.

Thailand

The milk fluoridation programme in Thailand, developed under the direction of the Department of Health (DOH), has expanded rapidly since its launch in 2000 and currently involves over 450,000 children at four sites.

The DOH has worked closely with the Bangkok Metropolitan Administration (BMA) to establish the scheme in the capital city and under an integrated health programme, the provision of fluoridated milk has been extended to all schools, reaching over 300,000 children. The scheme in Bangkok has benefited from considerable support from the Royal Chitralada Projects, a unique agricultural and research development initiative established by King Bhumibol Adulyadej in the grounds of his Chitralada Palace. The production of fluoridated milk was established here, and the staff have continued to play an essential role in the development of the scheme, and indeed, the wider programme in Thailand.

Three further schemes are in operation: in Chumphon, where there are more than 15,000 children involved, in Surat Thani 6,000, and in Khon Kaen over 100,000. The introduction of fluoridated UHT milk, produced in Khon Kaen by the Dairy Farming Promotion Organization of Thailand (DPO), has played a major role not only in expansion locally, but also in the schemes in Bangkok and Chumpon.

A National Network Group was been established in 2009, by the Department of Health, with the primary aim of improving communication and collaboration amongst those responsible for the delivery of the respective schemes. This forum has proved most valuable in further strengthening and developing the programme.

United Kingdom

Milk was first used as a vehicle for fluoride in the UK in 1993, in St Helens, Merseyside. The successful implementation of this demonstration scheme generated considerable interest and led to the development of the UK programme which currently involves over 33,000 children aged 3 - 11 from several local authority districts. The use of established school milk systems has been a key factor in the success of the programme. Another has been the reconfiguration of existing resources within the health authorities to manage the schemes.

A strong focus on communications has also proved to be an important aspect of the programme. The formation of the National Milk Fluoridation Network Group has provided the opportunity for those working at all levels within the programme to share experiences and support one another in the development of their respective schemes. This has been complemented by the establishment of a smaller group, dedicated to the needs of project workers, concentrating on the practical aspects of schemes faced by those working at an operational level.