Guidance on PFAS Exposure, Testing, and Clinical Follow-Up (2022) / Chapter Skim
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5 PFAS Testing and Concentrations to Inform Clinical Care of Exposed Patients
5 PFAS Testing and Concentrations to Inform Clinical Care of Exposed Patients
Pages 119-141
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From page 119... ...
testing in a patient's biological samples, strategies for interpreting biomonitoring data, and PFAS concentrations that could inform clinical care of exposed patients. OPTIONS AND CONSIDERATIONS TO GUIDE DECISION MAKING FOR PFAS TESTING PFAS Laboratory Methods There are no standard methods for PFAS exposure biomonitoring; some, but not all, laboratories use methods similar to those used by the CDC.
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From page 120... ...
A method comparable to that of the CDC that reports the linear and branched isomers of PFAS will allow comparison of individual results with those in the National Report on Human Exposure to Environmental Chemicals (CDC, 2015, 2021) -- an informative method for individuals who wish to understand whether their exposure is high or low compared with background exposures in the U.S.
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From page 121... ...
. On multiple occasions, this study's town hall participants indicated that they wanted to know not only their serum PFAS levels but also their breast milk levels, as these translate into early-life exposure for their children.
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From page 122... ...
Alternative measures for estimating long-term exposure include exposure reconstruction of drinking water levels. Also, some physiological events may influence biological levels of PFAS.
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From page 123... ...
Harms of PFAS testing include fear induced by blood draw, a small risk of injury or infection at the draw site, difficulties in interpreting results, and psychological stress that may occur when people who are tested learn that they or their family members have high levels of PFAS exposure. On the other hand, biomonitoring for PFAS blood levels may also alleviate fears associated with not knowing one's PFAS levels.
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From page 124... ...
Community members stated that they want access to PFAS testing so that they can understand their personal level of exposure and, as suggested by Ayesha Khan of Nantucket PFAS Action Group, "help those who are exposed to be proactive in reducing exposure and managing risk." An example of the how PFAS testing can help people manage health risks was presented by Sandy Wynn-Stelt, who learned that the drinking water in her home was contaminated with PFAS at a level more than 1,000 times the current U.S. Environmental Protection Agency (EPA)
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From page 125... ...
In many cases, people who request testing are already worried about their exposure, which is why they are requesting the testing, and they may already be at risk of decreased property values associated with contamination. People in exposed communities have been "contaminated without consent" and "poisoned without permission."4 BOX 5-2 Potential Harms and Benefits of PFAS Testing Potential Harms Fear of blood draw Small risk of injury or infection at draw site Difficulties in interpreting results Stress or concern about the health effects from exposure Decreased property values Social isolation Clinical consequences from medical follow-up as a result of exposure Potential Benefits Increased awareness of exposure so that exposure can be reduced Empowerment of communities to respond to contamination Relief from the stress of not knowing one's exposure level Identification of the potential risk for health conditions associated with PFAS exposure to inform subsequent preventive care Help in monitoring whether efforts to reduce exposure are working through the conduct of baseline and follow-up tests.
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From page 126... ...
Potential health effects of PFAS exposure and strategies for reducing exposure. Limitations of PFAS blood testing: PFAS blood testing does not identify the sources of exposure or predict future health outcomes; it only assesses body burden at the time of sample collection.
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From page 127... ...
. Both approaches can be useful to inform clinical care of exposed patients.
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From page 128... ...
This reference range value was based on the 97th percentile of the BLL distribution for children aged 1–5 years, using 2007–2010 National Health and Nutrition Examination Survey (NHANES) data.
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From page 129... ...
Children younger than 12 also are not included in the National Report on Human Exposure to Environmental Chemicals, although there are published estimates of PFAS exposure for children aged 3–11 years for 2013 and 2014 (Ye et al., 2018)
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From page 130... ...
As part of a settlement for a large class action lawsuit against DuPont, the C-8 Science Panel was established to determine potential health effects of PFOA exposure, and a 1year cross-sectional survey (2005–2006) , known as the C-8 Health Project, was conducted among approximately 70,000 residents with contaminated drinking water (Frisbee et al., 2009)
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From page 131... ...
In 2016, the geometric mean PFOA serum level among participants in the Hoosick Falls Biomonitoring Study who used village water was 43.5 ng/mL (N = 1,640) .8 In the aftermath of Hoosick Falls, impacted community members voiced significant concern that the EPA's recommended health advisory level for drinking water at the time (400 ng/L9)
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From page 132... ...
Serum PFAS levels reflect an integration of multiple exposure sources at a single time and are distinct from recommended levels in water for daily consumption. Instead of comparing PFAS serum levels with PFAS drinking water levels, the committee recommends that individuals refer to health-based and reference-based serum levels.
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From page 133... ...
. The HBM Commission also established HBM-II values in 2021, based on epidemiological studies on PFOA or PFOS and adverse health outcomes, including reduced birthweight, developmental effects, reduced fertility, reduced antibody response to vaccination, increased cholesterol concentrations
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From page 134... ...
Although EFSA did not specifically aim to determine acceptable serum PFAS levels, the 6.9 ng/mL serum concentration could be considered a serum level for women of reproductive age below which risk is negligible. PFAS Concentrations That Could Inform Clinical Care: Findings and Recommendations The HBM Commission has identified risk-based levels for two PFAS chemicals -- PFOS and PFOA -- while EFSA has established such values for the sum of PFOA, PFOS, PFHxS, and PFNA.
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From page 135... ...
risk-based value is a maternal serum PFAS concentration derived from an epidemiological study of children's prenatal and postnatal PFAS exposure and decreased antibody response to vaccines; maternal levels below this value are expected to have negligible impact on children's response to vaccines. The National Health and Nutrition Examination Survey (NHANES)
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From page 136... ...
: Recommendation 5-3: Clinicians should use serum or plasma concentrations of the sum of PFAS* to inform clinical care of exposed patients, using the following guidelines for interpretation: Adverse health effects related to PFAS exposure are not expected at less than 2 nanograms per milliliter (ng/mL)
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From page 137... ...
Therefore, the committee makes the following recommendation: Recommendation 5-4: 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. CONCLUSION Determining options and considerations to guide decision making for PFAS testing and PFAS concentrations that could inform clinical care of exposed patients will be beneficial in helping communities identify those who have elevated exposure to those chemicals.
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From page 138... ...
2021. Outcomes from returning individual versus only study-wide biomonitoring results in an environmental exposure study using the Digital Exposure Report-Back Interface (DERBI)
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2021. Preparing for effective, adaptive risk communication about per- and polyfluoroalkyl substances in drinking water.
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From page 140... ...
2022. Current breast milk PFAS levels in the United States and Canada: After all this time, why don't we know more?
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From page 141... ...
2011. Update of the reference and HBM values derived by the German Human Biomonitoring Commission.
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