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Practice English Speaking&Listening with: The Emerging Role of Pathogen Genomics in Public Health

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>> Good afternoon or good evening or good morning,

depending on when and from where you're joining us.

Dr. John Iskander, Scientific Director

of Public Health Grand Rounds, and it's my pleasure

to welcome you to our November 2019 session.

Public Health Grand Rounds continuing education is

available for physicians, nurses, pharmacists,

veterinarians, health educators, and others.

The course code is PHGR10.

That's one of our most frequently asked questions.

PHGR10. Please see our website

or the CDC Continuing Education website for more details.

And here is our continuing education disclosure statement

for this session.

Grand Rounds is available on the web and all

of your favorite social media sites.

Please send questions to GrandRounds@CDC.GOV,

and we'll try to include your question during our Q&A part

of today's session.

Want to know more?

We have a featured video segment on YouTube

at our website called Beyond the Data,

which is posted after the session.

This month's segment features my interview

with Dr. Rachel Rogers from CDC ATSDR.

We've also partnered with the CDC Public Health Library

to feature scientific articles about the session.

The full listing is available at CDC.GOV/ScienceClips.

In addition to our outstanding speakers,

I'd like to acknowledge the important contributions of all

of the individuals listed here.

Thank you all very much.

Here's a preview of upcoming Grand Rounds topics.

Please join us live or on the web at your convenience.

And it's now my pleasure to introduce the Director

of CDC's National Center for Environmental Health

in the Agency for Toxic Substances

and Disease Registry, Dr. Pat Breysse.

[ Applause ]

>> Thank you, John.

So today we're going to talk about per-

and polyfluoroalkyl substances, better known as PFAS.

PFAS, a large group of compounds used in consumer products

and for especially applications like fighting fires,

have been found to be persistent

in the environment and in our bodies.

This is not a new issue to the CDC.

Our flagship public health surveillance system,

the National Health and Nutrition Examination Survey,

first detected PFAS in human blood samples over 20 years ago.

We're still learning about the extent

to which PFAS contamination from drinking water and other sources

across the country is affecting people's health.

Much of the science around the harmful effects

of PFAS exposure is still emerging.

We'll hear about that today.

CDC ATSDR is working closely with communities affected

by PFAS contamination to help them understand the extent

of the contamination, the impact of the exposures.

CDC is a science-based, data-driven organization,

but we also understand that we serve people and communities

where we live, work, pray, and play.

These impacted communities are more than our partners

in research, they represent fellow citizens

who deserve our empathy and our best efforts

to address the knowledge that they can bring to bear

to address their problems.

In this grand round, you'll hear directly from people

who are living in affected states and communities,

and you'll be inspired by their leadership

and the actions they've taken to address public health.

You'll also learn what we know about PFAS, the science,

and what the key gaps in the knowledge are.

So with that, I welcome you all to the PFAS Grand Rounds,

and let's get started.

[ Applause ]

>> Thank you very much, Dr. Breysse.

Our first speaker is Dr. Rachel Rogers.

>> Hello, and thank you for joining us today

for our discussion about PFAS.

We're going to be talking about what PFAS are, what we know

about them, what we need to learn about them,

as well as how the public health community is responding

to increasing concern about exposures to these compounds.

I'm going to be giving a fairly broad introduction

to the subject with more in-depth presentations

to follow.

I'll start with a bit of background to define

and generally describe PFAS.

I'll explain how PFAS have been used in the past,

and how exposures to PFAS have occurred.

I'll summarize some of the findings

of some important early investigations,

and I'll provide some highlights

of the ongoing multi-agency public health response.

PFAS make up a large class of more

than 5000 individual chemicals.

Chemicals in the class are characterized

by a carbon chain that's either partially or fully fluorinated.

So where there would be hydrogen atoms,

instead you have fluorine atoms.

The carbon-fluorine bond is one of the strongest

in organic chemistry, and as a result,

PFAS have many unique properties.

They repel both water and oil,

and they're particularly well-suited for use

as dispersants and surfactants, as well as in certain types

of firefighting foams and some consumer products.

PFAS are also remarkably persistent in the environment

and in people's bodies.

Once PFAS are released into the environment, they don't break

down or degrade, and when people are exposed to them,

they tend to stick around, bound to proteins,

and circulating through the body.

Ingestion is the primary PFAS exposure pathway.

PFAS can be found near areas where they're manufactured

or where products containing PFAS have been used.

In these areas, PFAS are found in the drinking water,

in fish from contaminated surface water bodies,

in soil, and even in dust.

PFAS exposure can also occur through the use

of certain consumer products,

things like stain-resistance treatments for fabric

and carpets, some food packaging materials.

There's also growing evidence that some food products

that are grown or raised in areas

with PFAS contamination may also contain PFAS.

We also know that fetuses and babies can be exposed

through pregnancy and breastfeeding

if the mother was previously exposed.

PFAS development and use in the United States has a long

and important history.

PFAS were first synthesized in the 1930s and 1940s,

and by the 1950s, large-scale production

of PFAS was well underway.

In 1968, a few very early studies reported PFAS detections

in human blood samples.

Manufacturing peaked between 1970 and 2000, and somewhere

in that time frame, preliminary toxicity studies began

to suggest that PFAS may have the potential

to cause adverse health effects in rats and mice.

Samples collected by the CDC's National Health

and Nutrition Examination Survey, also know and NHANES,

in 1999 revealed that more than 98%

of people tested had some PFAS in their blood,

suggesting that exposure to these chemicals was widespread.

One of the initial investigations of PFAS exposure

in the United States was drinking water sampling,

conducted in accordance with the EPA's third unregulated

contaminant monitoring rule, also known as the UCMR3.

This program required that all public water systems serving

more than 10,000 people, as well

as 800 smaller water systems monitor for 30 contaminants,

including six PFAS, between 2013 and 2015.

Of the 4600 systems that were sampled, 65 had detections

of two species, PFOA and PFOS,

that exceeded the EPA's nonregulatory drinking water

health advisory.

However, many systems were not tested.

So this is some of that data.

Of the approximately 51,000 community water systems

in the United States, 4,600 were sampled.

Of those, 129 systems had any detections of PFAS,

and 65 systems had detections above the EPA health advisory,

so that represents about six million people.

But it's important to note here that the public water systems

that were not tested serve about 60 million people,

not to mention the 33- to 38 million people

who get their water from private wells.

So while this initial exposure investigation really opened our

eyes to the extent of the exposure problem,

it was by no means a comprehensive picture.

Another important initial investigation was the

measurement of PFAS collected by NHANES.

Since 1999, NHANES has measured PFAS

in the blood of the US population.

This work has revealed that most people

in the United States have PFAS in their blood,

especially PFOS and PFOA.

This work has also shed light

on exposure trends in the US population.

Since 2002, production and use of PFOS and PFOA

in the United States has declined.

As the use of some PFAS has declined,

some PFAS blood levels have gone down as well.

So this is that data.

You can see that from 1999 to 2014, blood PFOS levels declined

by more than 80%, while blood PFOA levels declined

by more than 60%.

Two other species, PFHXS and PFNA,

show less of a change over time.

This could be due to greater persistence in the body,

and thus a slower response to changes in production and use,

or other factors that we're still trying to understand.

The C8 Health Project was another important

early investigation.

This large epidemiological study gathered information

on over 60,000 people living

in a community near the DuPont Washington Works facility

in West Virginia, a population that was found

to have high levels of PFAS in their drinking water.

So here you can see the facility and the surrounding area.

The facility was positioned right next to the Ohio River,

and the releases of PFAS since the 1950s impacted individuals

across many counties and several different water districts

in the Mid-Ohio River Valley.

Settlement of a lawsuit against DuPont resulted

in improved water filtration and the impacted water districts,

the establishment of the C8 Science Panel which was charged

with assessing the links between PFOA exposure and a number

of different diseases, as well as the C8 Health Project

which provides medical monitoring

for those diseases determined by the panel

to have a probable link with exposure to PFOA.

So the Science Panel was an independent panel

of three scientists that was chosen to assess the links

between POFA exposure and a number of diseases and resulted

in numerous publications that really laid the foundation

for what we now know about the relationship

between PFAS exposure and the potential

for adverse health effects.

The team reported on what were called "probable links"

between exposure and health outcomes.

But it's important to note here

that a probable link is a legally defined term,

not a scientific one.

So these were health conditions for which a connection

to PFOA exposure was determined to be more likely than not.

The panel found probable links between PFOA exposure

and six health outcomes: high cholesterol, ulcerative colitis,

thyroid disease, testicular cancer, kidney cancer,

and pregnancy-induced hypertension.

In addition to these initial investigations,

the federal response to concerns about PFAS exposure really began

to accelerate in 2015 and 2016

when ATSDR released an updated draft toxicological profile

for PFAS, and EPA issued a nonregulatory drinking water

health advisory for PFOA and PFOS

of 70 parts per trillion either individually or combined.

In 2017, ATSDR added four PFAS

to the substance priorities list, and many agencies

across the federal sphere are now working to provide direction

and to answer questions about PFAS exposure,

human health effects, clean up, and public health action.

ATSDR in particular has conducted investigations,

public health assessments, or supported site work conducted

by partners in more than 40 communities across the country,

some of which you can see here on this map.

We also recently received funding

to conduct PFAS exposure assessments

and a multisite health study to better understand the extent

to which people are exposed to PFAS through drinking water,

and what those exposures may mean for human health.

So before I hand it over to Dr. Ducatman,

it is worth noting some of the significant challenges

that PFAS pose for impacted communities as well

as for public health researchers.

There is a lot of concern about PFAS exposure,

but it is still growing as new communities are identified,

and new pathways of exposure as uncovered.

Only a small handful of PFAS have been studied well,

and new species are being developed to replace others

that are being phased out.

We need more research on the health effects

of these compounds, and better analytical methodology to detect

and measure human exposure.

We know that when people are exposed to PFAS,

it's rarely to just one or two species.

Scientists are still studying what the health effects

of exposure to mixtures of PFAS may be.

This is a big gap in our understanding.

We also need better methods

to treat PFAS-contaminated drinking water.

Some existing technologies can remove PFAS from water,

but they are expensive, they are difficult to monitor

and maintain, they may not remove all PFAS,

and they introduce the new problem of how

to responsibly dispose of the concentrated PFAS that collects

on the filtration media.

There is still so much that we don't know about PFAS exposure

and the potential for adverse health effects.

Questions about how best to help people who have been exposed,

and how to prevent future exposures are keeping the

scientific community quite busy.

So now I'll thank you for your attention, and I'll turn it

over to Dr. Ducatman who will expand on some of what we know

about the human health effects of PFAS exposure.

Thank you.

[ Applause ]

>> Thank you, Dr. Rogers.

This talk is about the human health effects, and oh,

I should also thank our wonderful hosts from CDC

for creating this educational opportunity.

This talk is about the human health effects,

and because there are now more than 2000 publications

about them, some information will be on the PowerPoints

for which there will not be time to have any extended discussion

in this abbreviated conference.

The scope of the C8 Health Project was very large.

Dr. Paul Brooks, whose picture you saw earlier, enrolled more

than 60,000 people in medical monitoring

in two states along the banks of the Ohio River.

And we began to learn about PFAS

in some detail from that project.

Dr. Rogers has already mentioned a couple of the outcomes:

elevated cholesterol, pregnancy-induced hypertension.

There were others that were noted but were not denoted

as probable links: liver function abnormalities,

elevated uric acid related to exposure.

And it was very interesting for the cholesterol findings

to find this dose response where a lot of the action is

at the lower end, unfortunately, of the exposure.

There's a couple of different dose response models for that

in pharmacology that might explain that,

but we don't actually know why it's like that

at this point with certainty.

And in some ways, it becomes a mistake to focus

on that one very large first study because since then,

multiple other studies have looked at similar outcomes

and other outcomes in many other populations around the world.

For example, there are now more than 15 studies showing links

to cholesterol, more than five showing links to abnormal,

higher liver functions and uric acid,

and three different populations, to my knowledge,

that pregnancy-induced hypertension or some aspect

of pregnancy-induced blood pressure problems has

been denoted.

In addition, other studies completely have addressed,

including studies from Harvard, the relationship

between exposure to the two most common PFAS

and diminished response to vaccines and other aspects

of immune down regulation which at this point is one

of the most certain outcomes of health exposure.

And also obviously one of general public health concern.

In addition to that, Dr. Rogers has mentioned reproductive

outcomes such as the inevitability

of transplacental transport, and transport by breastfeeding

to newborns so most infants

and young children have higher PFAS concentrations

than their mothers.

And in addition, there are now a number of findings

about decreased duration of breastfeeding in those exposed,

and that's an interesting finding

for which there may be several different types of explanation.

And then there's developing research about other aspects

of health concern such as reproductive

and developmental aspects and congenital defects.

Endocrine disruption is a very difficult area in which

to do research, and there's lots of research going

on about thyroid disruption

and Sterol hormone disruption including androgens

and estrogens relating to these compounds.

Communities are naturally concerned about cancer.

Dr. Rogers has mentioned

that the C8 Science Panel linked these

to several urogenital cancers, to seminoma and renal cell.

There's other concerns about prostate,

liver, and bladder cancer.

And that's not a complete list, of course.

And then other health outcomes

of research interest are mentioned here,

of which really active areas include obesity in those

who are exposed in pregnancy and early childhood,

bone and joint health, and microvascular kidney disease

and immune-mediated outcomes.

What we're the most certain about, lipid abnormalities

and liver function changes, and thyroid hormone changes,

and immune changes, may not be what communities are the most

concerned about: the reproductive hazards

and the cancer questions, which are harder to do research on.

So in response to those difficulties, what should happen

in affected communities?

Obviously, the first rule of public health

in this instance is reduce the exposure,

and when the exposure is from water,

that means that alternate sources or treatment

of water is the recommended outcome for those

who have contaminated water.

Then the second priority is reduce the impact

of past exposures which leads in turn to questions

about medical monitoring, which is defined as case-finding

in order to refer individuals for further evaluation

and needed treatment which can include testing

for biological effects and assessment of exposure,

either by models or for the PFAS because they're easier to find

in blood actual measures.

That is to say the long-acting ones are easier

to find in blood.

The short-acting ones are darned hard.

CDC has provided for more

than two decades really excellent basic guidelines

for when medical monitoring is helpful, and the bottom line

for that is there should be a reasonable evidence of exposure.

There should be evidence that exposure leads

to adverse outcomes, and then following that,

there should be some way of thinking about monitoring

and whether it brings a net benefit,

including earlier detection or some, and/or and other things

such as the ability to intervene.

There are lots of advantages to community level monitoring

as opposed to individual monitoring.

Access to testing is facilitated.

It's less expensive.

There's a summary report that functions

in the community that's not possible

at the individual level.

There obviously are economies of scale and its ability

to do quality improvement and we know

that communities appreciate the activity

from the C8 Health Project which has already been mentioned,

and from other types of medical monitoring projects

that have been done in the past and some

of which are still ongoing.

But an important limitation

of these medical monitoring projects is finding the

resources to do them.

There are enormous difficulties to getting the resources

to doing community-level medical monitoring

so then individuals want to know what can they do for themselves?

Well, my personal physician's perspective is

that the CDC ATSDR criteria that were published more

than 20 years ago also provide reasonable guidance to people

and their clinical providers so long

as the exposure is documented, and any approach taken

between the individual and the clinician is simple,

acceptable in the community, and the provider

and the individual agree that this is about net benefit.

So things that are simple,

that clinicians understand are simple measures

like body mass index, home blood pressure monitoring

for pregnant women which might,

which might augment the normal things that physicians do,

and discussion about fertility and reproductive concerns

which is one of the most frequent phone calls I get.

In terms of laboratory testing: lipid panels,

liver function tests, TSH especially during pregnancy

because there's a lot of evidence

about thyroid hormone being more important in a developing human.

Uric acid and creatinine and urinalysis are all tests

that clinicians understand very well and are not hard to get.

PFAS testing, on the other hand, is darn hard to get,

and the barriers should be stated honestly.

It takes a committed clinician-patient relationship

in order to get PFAS testing done, and it will be expensive

if done on an individual basis.

On the other hand, when we communicate the limitations,

it's very important to be honest and open that we are not saying

that it should not be done, necessarily.

Patients and community members may not agree

that they're better off without testing.

They have lots of scientific reasons to feel that way.

So in summary, some health effects

of PFAS exposure are well documented.

Others are the subject of ongoing investigation,

and unfortunately, our knowledge is based on only a few

of the many possible PFAS contaminants that can be

in water and that will be in water in the future.

Reduction of exposure and reducing the effects

of past exposure are overarching principles

of the public health response, and medical monitoring,

according to established public health guidance is beneficial

to populations in exposed communities

and can reasonably inform choices for individuals

who don't have access to community-level testing.

I'm now going to introduce Steve Silver,

who's from the Michigan Department

of Environmental Protection.

[ Applause ]

>> Alright, thank you Alan, and thank you CDC

for the opportunity to be on this fine panel here today

to give you Michigan's perspective, talk a little

about how we are addressing PFAS contamination.

So you've heard about how pervasive

and how persistent PFAS can be.

This diagram illustrates how PFAS are cycling throughout our

ecosystem because we are not sequestering or destroying them.

Look at the landfill where all of the consumer products

and industrial waste disposed there release PFAS

into the Leachate.

That Leachate goes

to a wastewater treatment plant not designed to treat them,

so they pass through the surface water,

impacting drinking water and fish.

And some of those PFAS can accumulate

in the wastewater treatment sludges

which could be land applied on agricultural lands,

and affect the soils, ground water, surface water runoff,

and maybe even the crops.

And so our challenge is

to really understand what the occurrence

of PFAS are throughout this cycle and how to break it

to protect public health.

So PFAS emerged in Michigan

when we found really high concentrations

in fish tissue near the former Wurtsmith Air Force Base

in Oscoda high enough to warrant a "Don't eat the fish" advisory.

And then we looked in surface water around there and found

over 5000 parts per trillion of PFOS compared

to about 2.5 parts per trillion statewide

in some of our other surveys.

Then a few years later, our Army National Guard told us

that they had found PFAS contamination

at the Camp Grayling training area.

Shortly thereafter while we were investigating some former

disposal areas in North Kent County for a manufacturer

of shoes that used Scotchgard, we found alarmingly high levels

of PFAS in private residential wells.

And so this statewide scope and potential public health threat

of PFAS contamination led to the creation

of Michigan's PFAS Action Response Team of MPART.

And MPART is an advisory body made

up of seven key state departments responsible

for environmental and natural resources protection,

agriculture, public health, military installations,

and fire departments, as well as commercial airports.

It leads the coordination of all of our efforts across the state

to help ensure that we've got an effective

and efficient approach.

It's also responsible to coordinate with local

and federal partners and other stakeholders to ensure

that we're sharing information and leveraging our resources

because no one can do this alone.

And MPART is really the reason Michigan has been so successful

at rapidly addressing PFAS contamination using a

data-driven and science-based approach.

So we have over 70 sites in Michigan

where groundwater contamination exceeds our state cleanup

criteria of 70 parts per trillion PFOA, PFOS.

These are landfills, industrial sites, military installations,

and airports, and we've got a lot of sites

and some people would say Michigan is more contaminated

than any other state in the country.

Not true. We are just looking more rapidly and comprehensively

than anyone else in the country.

We're looking at over 100 more today of thousands

of potential sites,

and we prioritize those investigations based upon

whether or not an impact

to groundwater could migrate offsite

and impact someone's drinking water.

Protecting public health is job one,

and when we do identify a site,

we have a coordinated public health response, including all

of the MPART agencies, and local health and municipal officials

to inform the residents,

possibly investigate private wells, as well as sometimes

in the interim, before we fully understand

of characterize offsite migration,

put them on a presumptive remedy of filters and bottled water.

We have integrated PFAS testing into the surface water survey,

and surveys of fish as well.

And this helps us identify discharges of PFAS

into our surface water so we can eliminate them.

We've also found really high concentrations of PFAS in foams

that are generated on impacted surface water bodies.

In addition, we worked with our wastewater treatment plants,

asked them to look upstream to industrial users.

For example, like chrome platers to identify them

and eliminate those discharges into the headworks

of the wastewater treatment plant before they get passed

through on the surface water.

And the results of some of those surveys actually can also lead

to public health recommendations.

Those results for fish can lead

to "Don't eat the fish" consumption advisories.

The foam over hundreds of thousands of parts per trillion

of PFOS have been found in these foams.

That's led to, at a minimum, stay out of the foam.

Rinse it off if you get it on you.

And some of the surface water results, for example,

up near Oscoda, Wurtsmith Air Force Base, led to testing

of deer and "Don't eat the deer" advisory.

So we're fortunate in Michigan.

We've got some standards

that can lead the investigations and clean-up of PFAS.

Our groundwater clean-up criteria are protective

of drinking water.

That's that 70 parts per trillion PFOA,

PFOS lifetime health advisory.

If that groundwater also vents to surface water,

it has to meet a more stringent standard for PFOS,

12 parts per trillion.

Our surface water quality standard is 12 PFOS

because it accumulates in fish, and we eat the fish.

Now if that surface water also is a drinking water source,

the standard drops to 11, and when it comes to drinking water,

we've been relying upon EPA's lifetime health

advisory recommendations.

It's really all kind of voluntary,

and the state's been leading the way

on the doing all the testing.

But to understand what's in our drinking water, and whether

or not we need standards, we, in 2018,

sampled all of the community water supplies

and larger non-community supplies like schools

and daycares on their own wells.

And this past year, we've gone back to some of them

and sampled some more to get a better understanding

of any seasonal fluctuations, perhaps, that we might be seeing

as well as what might be happening

in surface water supplies

where fluctuations could be more dramatic.

We've also added some non-transient supplies that,

you know, for some of our more vulnerable populations.

Overall, good news.

Ninety-seven percent of the supplies that we tested

in 2018 don't require any follow-up at this time

because of no or very low concentrations

of PFAS found there, and we tested for 14 of them

under the EPA method 537.

We did find two supplies that required an immediate response,

and they had alternate water provided immediately,

and there's continuing follow-up occurring there.

Found three percent of those supplies were about 61

where the levels weren't at that 70 part per trillion threshold,

but they do require ongoing monitoring again

to determine whether or not those levels change as well

as looking in the community to see what's the source of that.

And if they do have to provide alternate water,

what are their options?

Is it hooking up to a neighbor digging a deeper well,

or adding treatment?

So Michigan has found PFAS in our drinking water supply,

and we know from what our scientists are telling us

that 70 parts per trillion is probably not low enough for PFOA

and PFOS and we're probably not focused on enough

of the contaminants out there.

So typically what we do when we want to integrate testing

into our municipal water supplies and have them take

that over, including the clean-up or mitigation of it,

we adopt federal standards,

federal MCL's maximum contaminant levels.

Well EPA's action plan does not call for those

to be adopted any time in the near future.

And so we feel compelled to act now, given what we know

about our state's water supply.

And so our governor in earlier this year asked MPART

to create a Science Advisory Work Group

to provide some health-based values

to help inform a rule-making process

for state drinking water standards.

And they did that.

They completed their work at the end of June, and they came

up with these seven health-based values

for PFAS in drinking water.

Now notice the values vary anywhere from six to 400,000

and it's for seven, not two,

compared to the EPA lifetime health advisory

of 70 for PFOA and PFOS.

These values have been adopted by MPART and passed

onto the Department of Environment Great Lakes

and Energy and are not the basis for the rule-making

which is well underway.

If these do become enforceable MCL's in Michigan,

remember those 62 supplies I talked about?

Probably about two dozen of those will have

to provide some sort of treatment

or alternate water to their consumers.

So again, Michigan has got a comprehensive approach

to providing, to addressing you know PFAS contamination,

and we've been successful because it's been multi-agency,

and working with our stakeholders as well to have

that data-driven, science-based approach.

So thanks for your attention,

and I'll now invite Andrea Amico to come up.

[ Applause ]

>> Hello. Hello, I am here today

to share the community perspective

on PFAS contamination.

My goals today are to tell you

about how PFAS contamination has impacted my community,

how we organize to respond, the nature of community concerns

and needs, and the important role

of community-level engagement and actions

to protect public health.

I know "public health" is a routine phrase to this audience,

but it's important to remember the "public"

in public health includes real communities and real families.

I live in Portsmouth, New Hampshire.

It is home to a large business park called the Pease

International Tradeport.

The Tradeport was developed in 1991, and is currently home

to about 250, many different types of businesses that employs

about 10,000 people a day.

It is a significant economic hub for the seacoast area

of New Hampshire, and it attracts a diverse group

of people to its location each day

at the two large daycare centers, colleges, restaurants,

golf course, medical office buildings, and more.

Prior to the development of the Pease Tradeport in 1991,

this location was a large

and active Air Force base for about 35 years.

The site has a significant history

of environmental contamination.

In 1991, Pease was classified as a superfund site,

and since that time, there has been extensive investigation,

monitoring, and remediation to clean

up the toxic chemicals and pollutants there.

In May of 2014, high levels of PFAS were discovered

in the drinking water wells at the Pease Tradeport,

causing the largest well to be shut down immediately.

The source of the contamination was identified

as aqueous film-forming foam or A-triple F,

in use when Pease was an active Air Force base.

AFFF polluting water supplies is not unique to Pease

as it is the only firefighting foam that met the specifications

for all branches of the DoD in putting

out petroleum-based fires for decades.

Pease was one of the first communities in the nation

to discover our PFAS

in our drinking water, but we're not alone.

Many communities across the nation from coast

to coast have been affected by PFAS in their water.

This map from the environmental working group shows hundreds

of other sites with known PFAS contamination

and the numbers continue to grow.

It's important to note AFFF is not the only source.

The chemical companies

that manufacture PFAS have also released these chemicals

into water supplies surrounding their factories

and their industrial sites for years.

This is clearly a widespread issue

in our nation's drinking water.

Just because communities have only recently discovered PFAS

in their drinking water, the reality is

that the contamination has been there for decades,

and the exposure has been ongoing for a long time.

PFAS at Pease has affected me personally

because my children attended daycare full time

on the Pease Tradeport,

and my husband worked there for nine years.

My family drank water from those contaminated wells.

When I first learned of the contamination,

I had no idea what these chemicals were,

but I was determined

to understand the effects this exposure would have

on my family.

Myself and two other moms pictured here, Alena Davis

and Michelle Dalton, all had children exposed

at the daycare on Pease.

Together we formed a community action group called Testing

for Pease.

We initially were focused on advocating

for a PFAS blood-testing program

to better quantify our community's exposure.

But our advocacy has expanded beyond just blood testing,

and we are now national leaders and advocates

on many areas pertaining to PFAS, like health studies,

more protective standards in drinking water,

medical monitoring, and more.

We have been incredibly successful

in organizing our community and strongly advocating to local,

state, and federal government officials.

The Pease community was offered a PFAS blood-testing program

that started in 2015.

Many of those samples process here by the CDC lab.

The results of our PFAS blood tests showed significantly

elevated PFAS blood levels when compared

to the general population.

We have also been fortunate that the Air Force has taken action

to clean up the contamination in the environment and groundwater,

and have installed filtration on the drinking water wells.

Our ongoing advocacy has led us to work with ATSDR

to develop a PFAS health study at Pease

that recently started this fall,

and our PFAS health study will serve as the model

for seven other PFAS communities across the nation.

However, the action we have seen at Pease is not typical.

Many communities have received very little action

around their PFAS contamination.

Pease was one of the first communities to discover PFAS,

and we organized quickly and effectively.

However, as more communities discover the problem,

and the large scale of this issue becomes more understood,

communities see less action and responsibility taken

for their contamination.

This is not okay.

My work as a PFAS community leader has opened the doors

for many opportunities for me to share my story,

engage with high-level officials to raise awareness,

and to advocate for action for all impacted communities.

Last year, I had a one-on-one meeting

with then-EPA administrator Scott Pruitt

to share the community perspective.

I testified at the first-ever hearing in the Senate

on PFAS last fall in D.C..

Earlier this year, I attended the President's State

of the Union address as Senator Shaheen's guest

to raise awareness of PFAS.

And in September, I gave a TEDx talk on my story,

on my story as a community leader.

Prior to learning of my family's exposure,

I was never an advocate or an environmentalist.

It took this very personal issue

to awaken the community leader inside of me.

And I'm not doing this work alone.

I just want to recognize there actually are some members

from impacted communities here today in the audience.

The photos in my slides are faces of real community members

across the country that have been impacted

by PFAS contamination and have come together to push for action

and answers for their communities.

In June 2017, the National PFAS Contamination Coalition formed.

We are a group of community leaders from across the US

and Guam, representing 13 states and 21 communities.

The Coalition allows us to collaborate together,

share best practices and lessons learned,

and work in a unified way at a national level to bring

about the action and answers we all need.

Our coalition works to testify at government hearings on PFAS,

present at national conferences,

participate in exposure assessments and health studies,

and actively engage with many levels of government, academics,

scientists, non-governmental organizations,

and other sectors all working to address PFAS.

We work tirelessly to be seen, to be heard,

and to make sure our perspective and needs are at the forefront

in addressing this widespread public health issue.

As impacted communities facing a significant environmental

exposure, and with unclear answers on what this means

for our health, we grapple with many challenges and concerns.

PFAS is a large class of over 5000 chemicals

that are ubiquitous in our environment.

They are in our consumer products, our food and wildlife

and in our drinking water, in some places at very high levels.

However, PFAS has been presumed safe until proven toxic

which means communities are allowed to be exposed

to many different PFAS without knowing the full extent

of the consequences on our health.

Based on what we know about some of the 5000 PFAS,

communities feel PFAS should be seen as toxic until proven safe,

and regulated strictly and conservatively

to protect public health.

Currently, there are no enforceable legal standards

for PFAS in drinking water at the national level,

and only health advisories for two PFAS out of 5000.

These are forever chemicals that do not break down,

build up in our blood, and impact multiple tissues

and systems of the human body.

PFAS are passed to babies through the placenta

in breastmilk, and have been shown to impact fertility.

We must act now in the best interests of human health

and stop the exposure with strict regulations as a class.

Another challenge we face is accessing PFAS blood tests,

interpreting these results, and consulting with our physicians

to know what to do next if we've been exposed to PFAS.

Unfortunately, most physicians are not extensively trained

in environmental health and not prepared to counsel patients

on how to get their blood tested,

and how to monitor their health

when they have suffered a significant PFAS exposure.

This creates stress in communities and adds

to the burden we already take on as victims

of this contamination.

We struggle to develop plans with our providers and are left

to wonder how our health will be impacted in the short

and long term from an exposure we did not choose.

It's an incredibly powerless feeling,

and we must change this.

The cost to exposed communities are significant and devastating.

PFAS contamination causes property values

to decrease significantly.

It impacts businesses' ability to attract and retain employees

and customers due to fear of exposure.

And it causes chronic illness that drives up medical bills

and decreases a person's ability to work.

Most exposed communities are also having to pay

for bottled water, home filtration systems,

PFAS blood tests, and the cost of advocating for more help.

Communities did not voluntarily sign

up to drink contaminated water or be left

to face the devastating consequences of this exposure,

but we pay the highest costs.

It is critical that action is put in place

to hold polluters responsible,

and make the responsible parties pay for these significant costs.

There are huge social and emotional impacts

to communities facing PFAS as well.

PFAS contamination causes stress, fear, worry, anxiety,

depression, feelings of guilt, mistrust, and devastation.

It creates a loss of self-worth, happiness, and time with family.

Illness associated with PFAS have resulted

in people losing their jobs and being unable to work,

losing control of their health and their future all due

to something that was not their fault.

And some have paid the ultimate price

and have lost their life due

to illness related to their exposure.

Despite the significant impacts this contamination has

on many areas of our life, impacted communities struggle

to be seen as critical stakeholders.

We face a culture within our local, state,

and federal agencies that the government knows what is best

for us.

We constantly have to advocate for a seat at the table

to continue to raise our concerns and offer our solutions

that work in our best interest.

I can't emphasize enough that the people closest

to the problem will have the solutions.

And our coalition often has to remind those agencies trying

to help us that they should not make decisions

about us without us.

I would like to end by sharing what communities need

as we move forward in addressing PFAS contamination.

First and foremost, we need PFAS to be strictly regulated

to stop the ongoing exposure to communities.

Some ways to do this are to classify PFAS

as a hazardous substance, and to regulate PFAS as a class

and not one compound at a time.

If this is done, it will also put mechanisms and funding

in place to filter and remediate the current contamination,

and we must make polluters pay the financial costs

of this widespread issue.

We also need to improve access to PFAS blood tests

that are more affordable, and we need medical monitoring guidance

on PFAS issued by the federal health agencies

with comprehensive outreach and education

to healthcare providers in impacted communities.

We must provide the knowledge and tools to allow communities

to know what their PFAS blood levels are and to empower them

to make changes to reduce their exposure and work

with their doctors to prevent chronic illness

and devastating health effects.

And we must prioritize taking action now

on the science we have today.

Communities have been exposed for decades.

Some families for multiple generations.

We cannot wait any longer for our government agencies

to take real and meaningful action.

And lastly, communities must be seen as critical stakeholders

and key decision-makers in how we address PFAS in our country.

When communities are valued and given a seat at the table

to develop collaborative and respectful relationships

with stakeholders, so much can be accomplished

to help those impacted by PFAS.

Thank you very much.

[ Applause ]

>> Alright.

Thank you.

I think at this point, we're going to turn

to the online viewing community for questions.

>> Yes, thank you very much.

First, I'd like to remind our online viewers you can send your

questions to GrandRounds@CDC.GOV or you can post them

on Facebook Live, if that's how you're tuning in with us today.

Let me start with a question

from our online viewers, from Brenda.

I'm going to edit for time.

Her concern is that fluoride compounds added

to drinking water combined

with PFAS may be contributing to the toxicity.

So is CDC looking at how these two compounds interact

when they come together?

PFAS and H2SIF6 may be making secondary compounds

and byproducts.

Is anyone here addressing this issue?

>> Sure, I'm happy to start off,

and then anyone who wants to add.

I think we are all aware of the concerns about exposures

to mixtures of chemicals, both mixtures of PFAS,

but also combined exposures to PFAS and other chemicals.

It's certainly something that, it's a concern

that we're aware of, and that we are working towards answers for.

But unfortunately, this is one of the bigger challenges

that we face around PFAS in particular right now.

>> We have questions in the room.

If you'll go to the microphones,

so that our audiences online can hear you.

>> Hi, thanks very much.

I don't know if this is working.

I'm Barbara Marston from the Center for Global Health,

and I had two questions.

One, [inaudible] the question you raised

about the community challenges, one that was running

through my head the whole time all of you were talking,

which is why are things considered to be okay

until they're proven not to be?

And are there any processes

for evaluating similar compounds before they're marketed instead

of after?

And the other one is just if anybody has any information

about what levels are for exposure internationally,

or other places outside the US?

>> I'll just chime in on the whole concept

of these chemicals being okay until proven not okay,

and that's a challenge that, you know, we've been facing

under the federal Toxic Substance Control Act,

and you know it's unfortunate and this might be an opportunity

to view the need to look

at these compounds before they're actually introduced

into the market so that we're not playing catch-up again

in the future.

>> And then I can add in response to your second question

that there is quite a bit of work going on internationally

around exposure to PFAS.

This is not unique to the United States.

So I think we can probably provide some resources

to additional information about what's going

on in the international community.

Maybe as a follow-up.

Yeah, so Steve Redd.

The question I have is for Miss Amico about,

it's a personal question about the events

that surrounded your decision to become a community leader

and really take on this issue.

You talked a lot about the importance of that work,

but I think for so much of what we need to do

to improve public health,

community leadership is essential.

>> Yeah, thank you very much for that.

I think my work as a community leader was not one

that I ever expected or anticipated, but it took,

like I said, something very personal happening to my family

to empower me to first of all educate myself on what PFAS were

because I had no idea.

And then also to start engaging with local, state,

and federal health agencies.

Initially it was more local and state that I was working with.

And initially we advocated for that blood-testing program.

In the beginning I didn't know where all this would take us.

I'm shocked five years later that we have a health study

and we are where we are.

It's pretty amazing.

But I think what I would say to others is that, you know,

it doesn't take a large group of people.

It doesn't take, you know, extensive training or education

in environmental health, you know.

Find that why.

Find that reason that's so important to you,

and work towards making a change, making a difference.

And the other thing I've had to tell myself

in this work is this is not a sprint.

This is a marathon, you know?

This is going to be lifelong work for me,

and that's something I have come to accept and realize

that this isn't something that's ever going away.

So I'm not sure if I answered your question,

or if you were looking for more.

>> Thanks.

>> Okay, thanks.

>> We have a question from Dr. Iskander here.

I'm going to lend him my mic.

>> This has been a very frequent question from many

of our audiences, and that is what if anything should they do

with consumer products they might own,

such as non-stick cookware.

I think you've already given us some information about the fact

that that's maybe not the major source of exposure,

but what sort of guidance would any

of you give about that issue?

>> These, this is Al Ducatman.

These compounds are so useful, they are in way more products

than most people know about.

And they're products that are things we rely on.

And to the degree that we can decide

that we can either substitute or not have that benefit

that we can potentially improve health.

Now that decision is harder to make

at the individual consumer level than it would be to make

at a national policy level,

but since we are delaying many aspects of national policy,

consumers can become educated to find

out all the interesting things that these are in.

If you want to spend another minute or two,

I can give you a fascinating list of things

that you can encounter them in.

Maybe you can email me later, or I can,

I can send you the PowerPoints from a more detailed lecture

because they're in a surprising number

of places including a Norwegian ski wax.

Ski waxers, who help the ski wax team.

I mean it just goes on and on.

But the, the choices we make are consequential when it comes

to useful products, and that's for sure.

And it is the case that the [inaudible] product, the pot,

the coated pot, is not the most important source of exposure,

the Teflon pot tends to remain intact.

There's other sources

where there's much bigger surface areas

and bigger problems.

>> I am Dr. Kyle Horton from Wilmington, North Carolina,

and this is a question for my medical colleague.

For many of us as clinicians in the reality

of clinical practices, that we're time-starved and crunched,

and for those that are tuning in for CME,

this may be the first time they've ever even heard of PFAS.

How would you recommend a clinician who's busy start the

conversation if they're only preliminarily aware

of this class of chemicals, and maybe the extent

of contamination in their community even,

how do you start the conversation?

And what resource would you tell clinicians to go to first

for reliable information?

>> That is such an important question.

I'm not fully prepared, but I will say this,

someone who's a primary care physician

in an affected community needs to write a review article

from a community perspective.

It would be nice to have maybe a partnership

between an epidemiologist and, but it needs to get done,

and I don't think that overall review article exists.

There are review articles about specific organs.

There's a kidney review article for example,

which I would recommend.

But there's no overall review

for clinical outcomes that I've seen.

Needs to happen.

Good websites?

For sure the federal websites, the international websites.

They are great sources of information.

Anybody has a lot of time just the,

the front piece of the ATSDR summary.

Somebody with a lot of time could read the entire document,

but the summary portion can give you some idea about things

that are agreed upon that we know these chemicals can do.

>> And I'll just take this opportunity

to restate what Dr. Ducatman just mentioned

that ATSDR's website is a wealth of information,

and there is a page specifically targets

for a clinician audience, so anyone listening in on the phone

or in the audience, please check that out.

>> We're rapidly running out of time,

but I have a quick question.

Maybe we can get that while Dr. Iskander returns to the podium,

from Nadia on, I believe Facebook.

It could be our Grand Rounds email box.

My question for Dr. Ducatman, can you speak more

about the challenges to conducting clinical research

on the reproductive effects of these chemicals?

What sort of studies can clinicians and scientists do

in affected communities?

>> First I want to say that there are numerous studies,

so it's not that the studies aren't happening,

it's that the event is less common, that is to say birth

and development than for example,

the ability to measure cholesterol in all 66,000

of the people who consented to have their blood taken

from the C8 Health Project.

In which case everybody has that measure, whereas birth

and development is a one-off outcome for each of us,

so the numbers are smaller.

That's to start with, and then secondly, we're measuring things

in two generations, and then there's lots of issues

with consents, so there's lots and lots of challenges.

I've only just scraped the surface there, but that's not

to say that it's not happening.

The data are coming in.

>> Thank you all very much.

Please, let's have another hand for our speakers.

[ Applause ]

So we will post additional resources on our website:

our scientific reading list.

We will post a link to Ms. Amico's excellent TED talk,

so please, that's another place you can look

for additional scientific resources.

Please join us in January

for our next new Public Health Grand Rounds.

Thank you.

[ Applause ]

The Description of The Emerging Role of Pathogen Genomics in Public Health