Exposure to the toxic “forever chemicals” known as PFAS has been linked to decreased infant and fetal growth, high cholesterol, an increased risk of kidney cancer, and a weakened immune system.
So, tests that measure PFAS levels in blood should be offered to anyone likely to have a history of exposure, and those with elevated levels should receive regular health monitoring — that’s according to a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM).
The report is one of the first comprehensive summaries of the link between PFAS and specific health risks, and the first to provide clinical guidelines for how physicians should test and treat patients who have been exposed to the toxic chemicals.
The report is a “bold step forward” for public health, said Dr. Robert Laumbach, a professor of environmental occupational health at the Rutgers School of Public Health, who studies the impacts of PFAS.
“There has been a lot of demand from community members who are affected, understandably so, for action, for clear guidelines or recommendations,” he said.
For decades, PFAS (per- and polyfluoroalkyl substances) have tainted the water, air, and soil — in the Delaware Valley region and across the country. These “forever” chemicals (because they can last in the environment for decades) have been widely used in consumer products, such as nonstick cookware, flame-retardant fabrics, and some food packaging, as well as in firefighting foam used at current and decommissioned military bases.
‘Testing will justify increased medical attention’
Due to its widespread use, it’s likely that most people have PFAS in their bodies. However, people exposed to PFAS at work or by drinking contaminated water can have higher than average levels.
It’s estimated that 2,854 locations in the U.S. and two territories have documented PFAS contamination, according to the NASEM report. However, not all exceed health advisory levels.
Currently, there are no federal maximum contaminant levels (MCLs) for PFAS in public drinking water. The Environmental Protection Agency previously set a federal health advisory level of 70 parts per trillion for two PFAS compounds, PFOA and PFOS. In June, the agency reduced that to almost zero parts per trillion, after announcing the compounds are more dangerous than once thought. But unlike MCLs, the advisory is non-enforceable. The EPA said it plans to propose national regulations, however.
Some states, like New Jersey, have implemented enforceable MCLs for specific compounds, while Pennsylvania and Delaware have proposed implementing their own MCLs.
The new report recommends that clinicians offer PFAS blood testing to patients with occupational exposure, patients who have lived in communities with known contamination, and those who have lived near areas where contamination took place. Those areas include: 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.
Currently, participating in a study is the only opportunity for people to get their blood tested for PFAS.
In the U.S., there is no official standard that determines what levels of PFAS in the body are unsafe. However, the authors of the report used various studies evaluating PFAS levels and potential health impacts to establish general guidance that could inform clinical care.
The report says patients with a PFAS blood concentration between 2 and 20 ng/mL may face adverse effects, especially high-risk individuals, like pregnant people, and certain health screenings should be offered.
And patients with test results above 20 ng/mL may face a higher risk of adverse effects. Clinicians should conduct thyroid function testing, and assess for signs of kidney and testicular cancer and of ulcerative colitis at all wellness visits, the researchers advise.
“It’s really, ‘What adverse health effects could I experience as a consequence of those concentrations?’” said Dr. Laura Labay, a forensic toxicologist at Jefferson University. “And if somebody is really elevated, or if they have ongoing exposure to PFAS, I believe that that testing for some people at least will justify increased medical attention.”
She said that testing could also help parents decide whether to breastfeed their child. The report recommends that federal environmental health agencies should conduct research to evaluate PFAS transfer and concentrations in breast milk to provide better guidance for clinicians and parents regarding infant feeding, especially in areas of high exposure.
Clinicians also should advise patients on how to reduce their exposure to PFAS, the researchers recommend. Though PFAS can remain in the body for several years, the levels can be reduced over time.
Laumbach and his team at Rutgers have been studying residents of Paulsboro, N.J., whose drinking water was contaminated with PFAS. They’ve found that some PFAS reduce about 15% every year or so, meaning it has a half life of about four years.
Dr. Mary Regina Boland, a biomedical informatics researcher who studies environmental health risks at the University of Pennsylvania’s Perelman School of Medicine, said if the patients getting tested discovered the source of their exposure, they could lower their health risks.
“I see this as being useful in that if you find that your blood levels are high, then maybe you can filter your water and then your blood levels will go down. And then a lot of the risk for these diseases will then go away — not completely, but to some extent,” she said.
Boland added that some people may relocate to a new residence before their neighborhood is discovered to be contaminated with PFAS. Therefore, it’s a good idea for anyone to consider getting tested.
‘The more you know’
Al Fidance and his wife found out they had elevated levels of PFAS after participating in a CDC study of residents near the New Castle Air National Guard Base in Delaware. The agency’s report found that some PFAS in residents’ blood were as much as 9.8 times higher than national levels.
Fidance said he has high blood pressure and cholesterol, but he doesn’t know if it’s related to his exposure. He said he would welcome the opportunity to receive medical care based on his test results.
“The more you know, the more you know,” Fidance said. “And then if there’s steps that can be taken either through diet or medicines or something like that to help reduce the effects of it, that would be great.”
Jill Florin, of Dresher, Pa., is awaiting the results of a PFAS blood test she took as part of a study in Montgomery and Bucks counties. She believes the recommendations would be beneficial for people exposed to PFAS, as long as the guidance is measurable. Otherwise, she said, it could lead to unnecessary stress and anxiety for the patient.
Florin also has concerns about whether insurance companies would cover the testing and screenings.
“I don’t know if we have insurance companies on board with that yet, so who’s paying?”
Labay said she agrees that if someone exposed to PFAS wants to receive related medical care, it should not be out-of-pocket.
“I don’t think the person who’s been exposed should have to pay directly. And so hopefully, if the CDC provides guidance that this is relevant, that these substances have been linked to very serious conditions, it does move the needle,” she said.
The report acknowledges that there are cons to testing too, such as decreased property values or difficulty interpreting the results, and that patients should be made aware of that. The authors say testing and screening should be a patients’ decision alone.
The report also states that health agencies must provide education about PFAS to clinicians in order to carry out the recommendations.
“It takes an informed clinician or practitioner to provide the information to patients in a way that they can make an informed decision that’s reasonable for them,” Laumbach said. “And then if they did get tested, what they should do with the results.”