>> 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
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
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
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.
[ 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
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
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
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
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
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 ]
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
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
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.
>> 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.
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.
[ Applause ]