New Report Calls for Expanded PFAS Testing for People With History of Elevated Exposure, Offers Advice for Clinical Treatment
(July 29, 2022) - Testing for exposure to perfluoroalkyl and polyfluoroalkyl substances, also known as PFAS, should be offered to patients who are likely to have a history of elevated exposure — such as those exposed to PFAS through their work or who live in areas with known PFAS contamination, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report was developed by the Committee on Guidance on PFAS Testing and Health Outcomes, which includes UAlbany’s Erin Bell.
The report finds evidence of association between PFAS exposure and increased risk of decreased antibody response, dyslipidemia (abnormally high cholesterol), decreased infant and fetal growth, and increased risk of kidney cancer. Intended to inform CDC clinical guidance, the report says if testing reveals PFAS levels associated with an increased risk of adverse effects, patients should receive regular screenings and monitoring for these and other health impacts.
Used worldwide for decades, PFAS are a group of thousands of manufactured chemicals with properties that can make products oil- and water-repellent, reduce their friction, and make them resistant to temperature change. They are used in a broad range of consumer products, from nonstick cookware and stain-resistant fabric to firefighting foams. All PFAS have a carbon-fluorine bond that does not break down naturally. While some PFAS can transform over time, the byproducts of that transformation also contain PFAS, which is why they are sometimes called “forever chemicals.”
“Our report highlights the importance of effective collaboration between local communities, states, and federal agencies in order to respond to the many challenges of PFAS exposure,” said Erin Bell, committee member and professor in the Department of Environmental Health Sciences. “Working within a framework that includes justice and autonomy, we need to learn more about specific health impacts, make testing available to patients, and give clinicians more strategies for counseling patients and providing preventive medical care.”
An estimated 2,854 locations in the U.S. — in all 50 states and two territories — have documented some PFAS contamination, but not all of this contamination exceeds the level in health advisories. People are primarily exposed to PFAS through ingestion, such as by drinking contaminated water or eating contaminated food. The report focuses on PFAS that are currently monitored by CDC: MeFOSAA, PFHxS, PFOA, PFDA, PFUnDA, PFOS, and PFNA.
PFAS Testing
In its recommended updates to CDC’s clinical guidance, the report says clinicians should offer PFAS blood testing to patients who are likely to have a history of elevated exposure. This includes patients with occupational exposure, those who have lived in communities with documented contamination, and those who have lived where contamination may have occurred — such as near facilities that use or have used fluorochemicals, commercial airports, military bases, wastewater treatment plants, farms where sewage sludge may have been used, or landfills or incinerators that have received waste containing PFAS.
Testing should be an informed and shared decision between clinicians and patients, and clinicians should discuss the benefits, harms, and limitations with patients. Testing can help people feel empowered in managing their own health, for example, or relieve the stress of not knowing one’s exposure level. Potential drawbacks of testing can include difficulty in interpreting test results, or decreased property values after contamination is identified.
The report recommends CDC, Agency for Toxic Substances and Disease Registry (ATSDR), and public health departments support clinicians by creating educational materials on PFAS exposure, potential health effects, the limitations of testing, and the pros and cons of testing. Laboratories conducting PFAS testing should report the results to state public health authorities to improve PFAS exposure surveillance.
Clinical Follow-up and Care for PFAS Exposure
CDC should update its clinical guidance for PFAS to make it more succinct and aligned with the report’s findings and recommendations, including the following:
- Using serum or plasma concentrations of the sum of the seven PFAS considered by the committee, patients whose tests show a PFAS blood concentration below 2 nanograms per milliliter (ng/mL) are not expected to have adverse health effects.
- Patients with test results between 2 and 20 ng/mL may face the potential for adverse effects, especially in sensitive populations (such as pregnant individuals). Clinicians should encourage reduction of PFAS exposure for these patients. Following the usual standard of care, clinicians should also prioritize screening for dyslipidemia, hypertensive disorders of pregnancy, and breast cancer based on age and other risk factors.
- Patients with test results above 20 ng/mL may face a higher risk of adverse effects. Clinicians should encourage exposure reduction and prioritize screening for dyslipidemia in accordance with guidance for patients with increased risk. In addition to the care recommended for patients who test between 2 and 20 ng/ml, clinicians should also conduct thyroid function testing, and assess for signs of kidney and testicular cancer and of ulcerative colitis at all wellness visits.
- The report recommends clinicians begin with a conversation on how a patient might be exposed to PFAS, and which exposures they are interested in reducing — including questions about occupational exposures. Clinicians should also advise patients with elevated PFAS in their drinking water to filter their water. The report points to a database created by NSF International to help patients locate water filters that can reduce PFAS.
Health Impacts of PFAS Exposure
Research has yet to determine the relationship between exposure to PFAS at a specific level and the health impacts that may occur. However, the report reviews research on the health impacts associated with PFAS across many levels of exposure, and concludes:
- There is sufficient evidence of association between exposure to PFAS and increased risk of decreased antibody response in adults and children, dyslipidemia in adults and children, decreased infant and fetal growth, and kidney cancer in adults.
- There is limited or suggestive evidence of increased risk of breast cancer in adults, liver enzyme alterations in adults and children, pregnancy-induced hypertension, increased risk of testicular cancer in adults, thyroid disease and dysfunction in adults, and increased risk of ulcerative colitis in adults.
- There is inadequate or insufficient evidence of many other health impacts, such as cardiovascular outcomes other than high cholesterol or developmental outcomes other than small reductions in birthweight, among others.
Breastfeeding, Children, and Pregnancy
While PFAS can pass through breast milk from mother to baby, research has consistently shown benefits of breastfeeding even while PFAS exposures have been occurring for many years. PFAS may also be present in water used to reconstitute formula and potentially in packaged formula and baby food. Overall, the report says, it is not yet clear what types and levels of exposure to PFAS are concerning for child health and development.
Federal environmental health agencies should conduct research to evaluate PFAS transfer and concentrations in breast milk and formula to generate data to provide better guidance for clinicians and parents regarding infant feeding, especially in areas of high exposure. Regardless of current gaps in knowledge, clinicians counseling parents of infants on PFAS exposure should discuss steps to lower PFAS exposure through feeding.
The report notes that more information is also needed on how PFAS affects children under 12 and pregnant people. The National Health and Nutrition Examination Survey should begin collecting and sharing more data on children younger than 12 years of age and pregnant people to generate reference populations for those groups.
CDC Clinical Guidance
CDC should use a reader-centered approach in its revised guidance, taking into account that many different audiences will turn to the document as they prepare for discussions with medical professionals. The agency should update the guidance every two years, using the process outlined in the report.