By ANI FREEDMAN, InDepthNH.org
PFAS blood testing could be a way for people exposed to these chemicals to be proactive in their health, but barriers such as cost, accessibility, and an information deficit in the medical community make the process more challenging, medical experts and policymakers say.
Dr. Megan Romano, Associate Professor of Epidemiology at the Dartmouth Geisel School of Medicine, said in a phone interview that while it still isn’t possible to predict disease risk from blood testing, the tests can allow New Hampshire residents impacted by PFAS pollution to better understand their health risks. Romano specializes in the influence of exposure to environmental endocrine disrupting chemicals, such as PFAS, on pregnant and breastfeeding women, and works to help people understand how to approach medical care and PFAS health risks.
While someone may not be experiencing symptoms, blood testing can help answer the unknowns of how PFAS exposure is impacting them and just how much exposure they have, Romano said.
“Regardless of whether or not you personally may have very high PFAS exposures, that experience of living in a PFAS-contaminated community is going to affect your health due to the stress of living with that uncertainty and what we do and don’t understand about how that might affect your health,” Romano said.
PFAS, also known as forever chemicals, are being found in groundwater and soil samples in New Hampshire, according to the Department of Environmental Services, but they are also found in the blood of people exposed to these chemicals.
PFAS, or per- and polyfluoroalkyl substances, are described by the EPA as long-lasting chemicals that break down slowly over time—giving them the “forever chemicals” nickname—and bioaccumulate in the body as people are repeatedly exposed over time, increasing risk for various health impacts.
“It helps them make decisions with their medical providers,” Romano said. “Often that leads to people being more proactive about the standard preventative screenings, like monitoring their cholesterol and blood pressure.”
Romano cited a study from 2020 in the journal of Environmental Toxicology and Chemistry that outlines the level of risk for certain health outcomes from PFAS exposure, which indicated that the health effects with “high certainty” and the greatest evidence of being linked to PFAS are: thyroid disease, increased cholesterol levels, liver damage, kidney cancer, testicular cancer, delayed mammary gland development in pregnant women, and reduced response to vaccines and lower birth weight for newborns. The health effects with “lower certainty” are: obesity, early puberty onset, and low sperm count and mobility from prenatal exposure, and increased miscarriage risk, breast cancer, inflammatory bowel disease, and pregnancy induced hypertension.
Romano said another crucial outcome of a blood test is offering people peace of mind. “The stress of living in a community that has had environmental contamination is very real, and the health effects of living with that stress are very real,” Romano said.
One of the most impacted communities is Merrimack in southern New Hampshire, the site of the manufacturing facility, Saint-Gobain, which recently announced the plant’s closure after high levels of drinking water contamination was discovered in 2016.
State Representative and Merrimack resident Wendy Thomas said the pollution caused by Saint-Gobain has become an issue of social injustice, especially when it comes to addressing health impacts. “The cost falls onto the victims,” she said.
After Thomas was diagnosed with breast cancer in May of last year, she got a blood test for 40 different PFAS chemicals in her blood, just from a single finger prick. The results showed 12 PFAS chemicals that were above the toxic limit.
“I was shocked about the amount,” Thomas said. She said it sent her into a panic, especially without the help of a medical professional to guide her through her results.
According to the CDC, a PFAS blood test will indicate how many levels of each PFAS chemical are in your blood. Current research of PFAS chemicals from the EPA indicates that there are thousands in existence, but the amount of PFAS chemicals measured will depend on which lab that conducts the test. The CDC says that the test cannot indicate specific health problems, provide information for treatment, or predict or rule out specific health problems that are associated with PFAS.
Larger population blood testing for PFAS has been conducted by the National Health and Nutrition Examination Survey since 1999-2000 to 2018-2018. Levels of the four main regulated PFAS chemicals, PFOA, PFOS, PFHxS, and PFNA, have steadily decreased in the U.S. population since testing began. PFOS blood levels decreased by over 85% and PFOA blood levels decreased by over 70% as the production of these chemicals has decreased. The Agency for Toxic Substances and Disease Registry (ATDSR) at the CDC states that PFAS exposure can come from various sources, including contaminated drinking water, consuming fish caught in contaminated water, swallowing contaminated soil or dust, eating food grown or raised near places that used or made PFAS, eating food packaged in materials containing PFAS, or using some consumer products that contain PFAS, such as stain resistant carpeting or water repellent clothing.
In 2020, Governor Sununu signed into law HB 1264, which mandated insurance coverage for PFAS and PFC blood tests, with certain exceptions. Representative David Meuse, D-Portsmouth, co-sponsored HB 1264. He said that while the bill required insurance coverage, “the law doesn’t differentiate between diagnostic and preventive care.”
Preventive care usually involves routine healthcare meant to keep someone healthy, with check-ups and health evaluation while you are symptom-free, while diagnostic care includes treatment while you are experiencing symptoms to receive a potential diagnosis, according to UnitedHealthcare. Since the law does not differentiate between these types of care, as Meuse pointed out, an insurer may interpret it to mean that preventive care isn’t included in the mandate, thus a PFAS blood test for someone not experiencing symptoms might not be covered.
The exact phrasing of HB 1264 states: “Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for perfluoroalkyls (PFAS) and perfluorinated compound (PFC) blood testing.”
Mindi Messmer, environmental scientist and former state Representative, said the tests could cost as much as $300 to $600 out-of-pocket for uninsured or those whose insurance does not cover the tests. Messmer pointed out that New Hampshire is one of the few states that has a law requiring these blood tests to be covered by insurance.
According to the New Hampshire Insurance Department, PFAS blood testing is covered by any “major medical insurance” obtained within the state. Any “non-major medical insurance” is not required to cover the tests, leaving it up to individuals to contact their insurance provider to know if the tests will be covered. The department’s policy states that via HB 1264, any residents who obtain insurance policies or work in another state are not protected by New Hampshire insurance laws. The department’s policy encourages individuals to contact their insurance carrier with specific concerns.
Messmer isn’t happy that in some cases, responsibility to pay for the tests is placed on individuals impacted by PFAS pollution. “There’s no requirement for Saint-Gobain to pay for testing,” Messmer said over the phone, referring to the company responsible for high levels of drinking water pollution from the Merrimack facility, which recently announced the plant’s closure.
Representative and Merrimack local Nancy Murphy plans to introduce legislation to address that. One of the bills she has introduced this session aims to allocate funding for the blood tests of any Merrimack resident. Murphy said in an interview that through her bill, she is asking Saint-Gobain to set aside money to cover blood tests for residents of southern New Hampshire who qualify as having been impacted by the company’s pollution. The bill will not be voted on until early next year, but Murphy hopes it will help hold Saint-Gobain accountable if it is passed.
Thomas’ test wasn’t covered by insurance. But after corresponding with the activist organization Environmental Working Group, she was able to convince them to cover the cost of the test for her, which totaled $400.
After she received her results, Thomas brought the information to a surgeon she initially chose for her breast cancer surgery. She said the doctor told her, “I don’t need to know about PFAS. I’m just a surgeon.” Thomas immediately switched doctors.
“At this point, I’m not going to put up with any doctor who chooses to remain ignorant of such an incredible health crisis in southern New Hampshire,” Thomas said.
Thomas is concerned that doctors aren’t educated enough on caring for patients with health impacts from PFAS exposure. Romano hopes that will change.
In 2022, the National Academies of Sciences, Engineering, and Medicines (NASEM) released Guidance on PFAS Testing and Health Outcomes, which determined the level of association of certain health outcomes with PFAS exposure. The NASEM guidance provides insight for preventative care based on the cumulative levels of PFAS in the blood. For blood tests showing PFAS levels between 2 to 20 ng/mL, NASEM recommends screening for cholesterol levels, screening for hypertensive disorders during pregnancy, and breast cancer screening; for levels above 20 ng/mL, NASEM recommends cholesterol screening, thyroid function testing, and signs and symptoms of kidney cancer, ulcerative colitis, and testicular cancer. For levels below 2 ng/mL, the general preventive standard of care is recommended.
The guidance is still under review by the ATDSR at the CDC, but Romano said this could potentially help doctors understand patients who were exposed to PFAS and what health impacts they may be experiencing.
It is important to remember that per the CDC guidance, these blood tests are not clear indicators of these health outcomes; however, Romano believes this knowledge can equip doctors and patients with the foresight to screen for possible health risks.
The New Hampshire Department of Health and Human Services partnered with the Dartmouth Geisel School of Medicine to release the Guidance for New Hampshire Clinicians in June. Romano said environmental exposure doesn’t get covered much in medical training; but this resource could help equip doctors with the necessary knowledge of what PFAS are and how to order blood tests for their patients.
The guidance advises doctors that these tests “could indicate they may be at an increased risk for certain health effects; therefore, if a person has high PFAS levels, providers should address health concerns and discuss how a person can reduce their exposure.”
Thomas felt empowered by her blood test results to take control of her health, despite the initial shock.
“Knowing that I have these chemicals in my blood, I’m going to be on top of colon screening, breast cancer screening, for my kids, too,” she said. “There’s not much you can do if it’s in your blood other than to be aware of what you should be looking for.”
The knowledge of what’s in your blood can be daunting, Thomas acknowledged, but she thinks that awareness is crucial for others like her who have been chronically exposed to PFAS chemicals.
“Waiting until it’s too late is going to be so harmful to yourself, to your family, and to your wallet,” she said. “Those are very good reasons to stay on top of screening.”
“I want people to be informed, to screen, but I don’t want them to be paranoid or fearful,” Thomas added. “If you catch things early, they can be corrected.”
Thomas is grateful she chose to get her blood tested. For her, it offered an explanation for some of the things she felt weren’t right with her body.
“It allows me to be more proactive in my health,” Thomas said. “Now that I know those chemicals are in my body, I’m on the lookout for more PFAS-related cancers.”
Romano encouraged patients to bring the fact sheet to the doctor with them if they have concerns about their PFAS exposure or are looking to get a blood test.