“I suspected some contamination of the water of the much-frequented street pump in Broad Street, near the end of Cambridge Street”, said John Snow, about the contaminated water pump of the cholera outbreak of 1854, in London, UK.1 In September, 2015, a Somalian man aged 46 years presented to a refugee clinic within 1 month of resettlement to Canada. From 2009 to 2015, this patient had lived in the Kakuma refugee camp (Rift Valley Province, Kenya), which houses 184, 966 inhabitants.2

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“I suspected some contamination of the water of the much-frequented street pump in Broad Street, near the end of Cambridge Street”, said John Snow, about the contaminated water pump of the cholera outbreak of 1854, in London, UK.1

In September, 2015, a Somalian man aged 46 years presented to a refugee clinic within 1 month of resettlement to Canada. From 2009 to 2015, this patient had lived in the Kakuma refugee camp (Rift Valley Province, Kenya), which houses 184, 966 inhabitants.2, 3 He had chronic, debilitating, diffuse axial bone pain, insidiously worsening over the previous 5 years, beginning with lumbar and hip pain. In the year before presentation, he was no longer able to rise from a chair alone and had an antalgic, shuffling gait with pronounced kyphosis. His sclerae were white and dentition poor. Spinal and hip mobility was severely limited in all directions, and point tenderness was present throughout the lumbar spine, sacro-iliac joints, and chest wall.

Clinical investigation revealed elevated serum alkaline phosphatase with normal serum calcium, albumin, and 25-hydroxyvitamin D. All investigations are summarised in the appendix. Pelvic radiograph, CT scan, and a whole body technetium-labelled bisphosphonate bone scan revealed diffuse osteosclerosis with ligamentous calcifications. Bone densitometry (Hologic Discovery W; Marlborough, MA, USA) showed lumbar spine and femoral neck Z scores of 8·7 and 3·7, respectively.

The extensive osteosclerosis led to measurement of serum and urine fluoride; both were within the normal range for someone drinking municipally fluoridated water (appendix). In October, 2016, a tetracycline-labelled iliac crest open bone biopsy for histomorphometry revealed a combination of osteosclerosis with severe low turnover osteomalacia, suggesting skeletal fluorosis (appendix). Additional bone biopsy specimen sections were ashed for direct bone fluoride content measurement, revealing 6·73 g/kg fluoride ash weight (normal range 0·5–1·2 g/kg), confirming severe skeletal fluorosis.

In July 2016, 15 water wells supplying drinking water for Kakuma’s residents had fluoride concentrations of 1·5–8·4 mg/L.3

WHO drinking water guidelines4 recommend fluoride concentrations of 1·5 mg/L or less. Our patient lived in a camp section exclusively supplied by a single well (borehole 5; figure), 5,6 which consistently contained high fluoride concentrations between 2014 and 2016 (8·4 mg/L in July, 2016).3

Figure thumbnail gr1
FigureMap of Kenya and of the Kakuma refugee camp highlighting borehole 5 and associated water lines, tap stands, and the drinking water-dependent residential areas where the patient had lived.5,6

Clinical diagnosis of fluorosis is challenging and requires multidisciplinary collaboration (appendix). Clinicians in migrant-receiving nations often lack awareness of, and available diagnostic tests for, fluorosis, which probably leads to under-reporting. No treatment exists for fluorosis other than halting exposure, with symptom resolution as fluoride mobilises slowly from bone.8 The patient’s symptoms markedly improved with reduced pain and with improved mobility and daily activity over the subsequent 9 months after diagnosis, nearly 2 years after fluoride exposure cessation.

Here we have presented a single case of severe skeletal fluorosis; however, entire populations, such as Kakuma’s approximately 185,000 residents, who depend on naturally occurring fluoride-contaminated well water, might be affected en masse.2,3,4 Many countries with naturally high water-fluoride concentrations host large refugee populations, including Ethiopia, Iraq, Kenya, South Sudan, Syria, and Turkey.4,7,10 Displaced populations who depend on well water in these areas can be at particular risk, especially children with developing skeletons and lower volumes of distribution. We relayed our clinical information to the Kakuma refugee camp UNHCR Water, Sanitation, and Hygiene officers, who subsequently successfully drilled three new water wells with safe fluoride concentrations (<1·5 mg/L) for the first time.3,4 Boreholes 13, 14, and 15 produced well water with fluoride concentrations of 1·1 mg/L, 0·9 mg/L, and 0·6 mg/L, respectively (personal communication; Paul Bauman, Advisian, Worley Parsons Group).

The prevalence of skeletal fluorosis in Kakuma could be under-reported. As the numbers of forcefully displaced persons rise globally,10 clinicians in refugee host nations should maintain a broad approach to newcomers’ health issues and consider potentially important environmental exposures in addition to infectious pathogens. Ultimately, safe drinking water endures as a fundamental principle of human health.

We declare no competing interests. There was no direct funding source for this study. Academic support for GEF and GAK is provided by the Cumming School of Medicine, O’Brien Institute for Public Health, and the W21C Research and Innovation Centre at the University of Calgary and Alberta Health Services. We thank the health-care providers, staff, and patients at the Mosaic Refugee Health Clinic and the institutional support provided by the O’Brien Institute for Public Health and the W21C Research and Innovation Centre at the University of Calgary Cumming School of Medicine— in particular, Garielle Brown for her efforts, without which this report would not be possible. The patient provided written consent for use and disclosure of all relevant clinical information presented.

We declare no competing interests. There was no direct funding source for this study. Academic support for GEF and GAK is provided by the Cumming School of Medicine, O’Brien Institute for Public Health, and the W21C Research and Innovation Centre at the University of Calgary and Alberta Health Services. We thank the health-care providers, staff, and patients at the Mosaic Refugee Health Clinic and the institutional support provided by the O’Brien Institute for Public Health and the W21C Research and Innovation Centre at the University of Calgary Cumming School of Medicine— in particular, Garielle Brown for her efforts, without which this report would not be possible. The patient provided written consent for use and disclosure of all relevant clinical information presented.

Supplementary Material

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    *Original full-text article online at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32842-3/fulltext