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Water Fluoridation Policy Issuance

Public Health Service
Indian Health Service
Rockville, Maryland 20857

Refer to: OPH/DCPS


Effective Date:  05/21/1999


  1. PURPOSE.  To establish a national policy for the Indian Health Service (IHS) involvement in the fluoridation of Indian owned and operated water supplies.

  2. BACKGROUND.  At present, an estimated 400,000 American Indians and Alaskan Natives (AI/AN) are provided water from systems with water fluoridation equipment.  The dental health benefits of consuming optimally fluoridated water are well documented, and water fluoridation is an extremely cost-effective public health measure.

    The previous IHS Circular 94-1, "Water Fluoridation Policy Issuance," was issued in April 1994.  That policy specified the roles and responsibilities at all levels of the IHS with regard to providing support services for tribal fluoridation activities.  Area fluoridation teams and specific technical assistance functions and surveillance activities, in a multi-disciplinary effort from environmental health and dental programs, were required.

    Since the issuance of IHS Circular No. 94-1, there have been two significant developments:

    1. The IHS has been restructured, with significant resources and responsibilities transferred to local tribal and Federal programs.  Through the provisions of P.L. 93-638, The Indian Self-Determination and Education Assistance Act, as amended; tribes have greater ability to take full responsibility, through a negotiation process, for services that would otherwise be provided by the Federal Government.  This law has resulted in all tribes having a greater role in the establishment of Area-specific policies and procedures through a collective consultation process.

      Furthermore, as sovereign nations, tribes may elect to work directly with the IHS, the Centers for Disease Control and Prevention, State programs, or other entities in the administration of their fluoridation program.

    2. In September 1995, the Centers for Disease Control and Prevention issued the document, "Engineering and Administrative Recommendations for Water Fluoridation" (EARWF), which provides detailed criteria for the safe implementation of a community water fluoridation program.

      Because of these new developments, it is no longer appropriate to have a comprehensive policy that requires all Areas to follow the same detailed set of nationally mandated requirements.  The national policy is hereby amended to promote fluoridation and the ability of each Area, in consultation with the tribes in that Area, to implement Area-specific and tribal-specific fluoridation activities for Indian owned and operated water systems.  The key to successful fluoridation is the capability and commitment of each tribe that assumes this responsibility.  The IHS's goal is to support tribes in this endeavor.

  3. POLICY STATEMENT.  The IHS strongly endorses community water flouridation.  The IHS shall promote the dental disease prevention benefits of fluoridation and encourage tribes to safely and effectively fluoridate their water supplies.

    The fluoridation of community water supplies is among the safest and most effective public health measures available.  Evidence of a safe and effective fluoridation program includes the following:

    1. The community has demonstrated support for fluoridation, and there is a demonstrated commitment for long-term operational and financial support of fluoridation activities.

      (Note, the IHS does not participate in the administration, operation, or monitoring of tribal water systems.)

    2. The community has adopted, and complies with, the Centers for Disease Control and Prevention's EARWF.  These recommendations outline standards for construction, administration, oversight, reporting, training, and inspection that are essential for a safe and effective fluoridation program.  (The IHS considers this a goal and not a prerequisite for technical assistance.)

  4. IHS FUNCTIONAL RESPONSIBILITY.  This policy shall be promoted in a multi-disciplinary effort by the IHS Dental Program and the IHS Environmental Health and Engineering Program consistent with Area-specific policies and initiatives, and tribal-specific agreements.
    1. The IHS will provide fluoridation equipment, installation, a l year supply of chemicals, and training and technical assistance to water plant operators for new and renovated water systems in accordance with current project priority methodologies.  The funding source for initial fluoridation systems is provided through authority described in P.L. 86-121, "Indian Sanitation Facilities Act."  However, before IHS funding is made available to a tribe for fluoridation equipment or chemicals, the tribe must: (1) provide documentation of local governmental support for fluoridation and evidence of resources committed for continued operation of the tribal fluoridation program, and (2) develop and implement operating criteria for water fluoridation activities.
    2. The IHS Dental Program will maintain a fluoridation reporting system to document the effectiveness of fluoridation efforts.
    3. The IHS Dental and Environmental Health and Engineering staff will promote the benefits of fluoride to tribes and, when requested, will provide consultative support in the implementation of EARWF requirements.
    4. Each IHS Area will notify tribes of any available fluoridation conferences or training courses provided by the IHS or other entities and encourage tribal attendance.
    5. A tribal government and the IHS may jointly agree that the compelling public health need requires more extensive IHS participation in fluoridation activities than would be provided with ongoing IHS program functions.  Examples of such participation might include, but are not limited to, activities such as special fluoridation educational projects, cooperative surveillance activities, emergency response coordination, or special training.  Under special circumstances, the Areas could consider developing cooperative agreements with the tribes for those activities consistent with any appropriate Area policies.

  5. SUPERSEDED:  This Circular supersedes the IHS Circular No 94-1 entitled "Water fluoridation Policy Issuance," dated April 5, 1994, in its entirety.

  6. EFFECTIVE DATE:  This policy is effective upon date of signature by the Director, IHS.

/Michael H. Trujillo, M.D./
Michael H. Trujillo, M.D., M.P.H., M.S.
Assistant Surgeon General
Director, Indian Health Service

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