Unpacking The New PFAS Clinical Guidance, Part 1: PFAS Blood Testing, Screening, & Monitoring
Last week, the National Academies of Sciences, Engineering and Medicine (NASEM) released first ever clinical guidance on PFAS exposures. This report reviewed the best available scientific research on PFAS and their associated health risks, then drafted recommendations for health professionals on how best to provide testing, screening and patient care related to PFAS exposures.
NASEM is a prestigious nonprofit recognized nationally for their work on shaping and informing federal and state public policies. In 2021, NASEM formed a committee to oversee the development and drafting of this report. Emily Donovan, co-founder of Clean Cape Fear, was invited to present our community’s contamination story to the committee during their Eastern Town Hall. Clean Cape Fear also created a small working group to draft a letter of recommendations to the committee which was unanimously signed by all 41 Community Liaisons who participated in the public feedback process.
Clean Cape Fear also partnered with Dr. Kyle Horton with On Your Side Action—a Wilmington, NC based health equity action group. Dr. Kyle drafted recommendations to the committee on behalf of concerned health professionals. We believe clinical perspectives are a critical component because this report was developed for clinicians–if the committee drafting the report does not understand the real world environment today’s clinicians maneuver then there will be a disconnect between the guidance provided and clinician’s ability to adopt them practically.
Ultimately, this new PFAS clinical guidance is a good first step at acknowledging our global PFAS public health crisis. It's important to remember the report is not enforceable, it is up to state/federal agencies and health care providers to independently adopt the recommendations outlined in the report. Additionally, recommendations provided are likely not covered under most insurance carriers–at this time. You may be required to pay out of pocket for any of the tests and screenings recommended if you and your clinician elect to have them done.
One limitation of this report for our region is the narrow scope of the PFAS under review. The report focused on 7 PFAS monitored by the CDC: MeFOSAA, PFHxS, PFOA, PFDA, PFUnDA, PFOS, and PFNA. Our region was overexposed to high levels of hundreds of different PFAS for decades. Unfortunately, we are still fighting to close the data gaps on many of those exposures.
In 2019, Clean Cape Fear organized a coalition of NC environmental and justice groups to help gain access to this missing data. We are currently suing the EPA to issue critical test orders regarding 54 Chemours specific PFAS we were exposed to via our air, soil, water and food supply. These test orders would provide comprehensive human health, epidemiological, and toxicity studies for our region.
In the meantime, we believe this NASEM report is still an important first step for our community because many of us were likely exposed to some of the 7 PFAS selected for review. This report allows us to begin the process of caring for the elevated disease burdens our region is experiencing.
Last year, EPA data revealed North Carolinians with PFAS contaminated tap water were more likely to have two or more chronic diseases than residents in the rest of the state. Two months ago, new research showed possible associations between PFAS blood contamination and deaths in the United States related to heart disease and cancer–killing Americans every year at the similar rate of COVID-19. Wilmington and Fayetteville residents have PFAS contamination in their blood at two to three times above the national average.
Below are some of the recommendations outlined in the NASEM report:
Blood Testing
The report recommends health professionals test patient’s blood for PFAS if they have a history of PFAS exposures.
“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 also recommends public health departments provide clinicians with reliable information on PFAS exposures, testing, pros/cons, etc. We recommend clinicians utilize this fact sheet created by PFAS-REACH, a partnership between leading PFAS scientists and public health and community advocates. PFAS-REACH also provides a useful reference guide on blood laboratories for individuals.
Blood Testing Results
If patients have between 2 ng/ml - 20 ng/ml of total PFAS in their blood, the report recommends clinicians begin screening for the following:
“dyslipidemia, hypertensive disorders of pregnancy, and breast cancer based on age and other risk factors.”
If patients have 20 ng/ml or higher of total PFAS in their blood, the report recommends:
“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.”
Health Impacts & Screening Recommendations
The report concluded the following health effects were of concern regarding exposures to the PFAS defined in their scope of work:
“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.
NOTE: Clean Cape Fear believes there is sufficient evidence to suggest abnormal liver function and Non-Alcoholic Fatty Liver Disease may be associated with certain PFAS exposures. We consulted experts who expressed grave concerns that the report minimizes the scientific body of evidence correlating PFAS exposures with liver dysfunction. We believe individuals concerned about elevated levels of PFAS in their blood should work with their clinicians to discuss screening liver enzymes.
Explore this interactive guide regarding the report.