During a topic near and dear to my heart, as well as some of the team I work with at the Navy Marine Corps Public Health Center, recently renamed with even a longer acronym, the Navy and Marine Corps Force Health Protection Command. The acronym just keeps getting longer, and we've gone from NIMTC to NINCOMPOOP, I don't know. And I work with some really smart people, and it's one of the reasons after I retired from the military, I came back to work at the command I left as an 06, as a retired Navy captain in the Navy Marine Corps Public Health Center, simply to work with people, scientists, that have background and experience way beyond the breadth of medicine, toxicology, risk assessment. You know, I've learned about, you know, one in one million non-cancer and cancer risk and EPA and CERCLA and all these things that physicians typically don't get involved with. So it's been a great learning experience for me, and I wanted to share just a little bit of that background. This is some data that the Epi Data Center, we have about 60 epidemiologists at the Navy Marine Corps Public Health Center doing all various types of epi and analysis and research on health, public health issues. And so we've got some really smart people that have helped collect this data. And quite honestly, I normally don't give this talk, so please excuse me, normally our senior toxicologist gives this talk, but we'll be having here the usual disclaimer, you know, these are my views, don't reflect the Department of Navy, Defense, or U.S. government, and that, you know, this work was prepared as part of my job with the Navy, and I have no other financial interests. Our learning objectives for today, why did the Department of Defense begin PFAS testing to firefighters? And we want to make it very clear, this is not part of their annual medical surveillance exam, but in addition, or in addition, or an option to their annual surveillance exam starting in 2020, why specific PFAS chemicals are tested for in DOD firefighters. Number three, what are the first year of testing results show 2020 through 2021? Our fiscal year in the military is October 1 through the end of September, but we've got some calendar year data, and so again, it crosses over calendar years. And how do these testing results compare to the NHANES National Health and Nutrition Examination Survey results, why PFAS blood levels cannot be currently used to determine health outcomes and medical treatment, and what new projects are being worked on to help categorize or characterize PFAS exposures in firefighters. How did this all start? Well, it wasn't driven by occupational medicine experts, that's for sure, in fact, many of us in the occupational medicine community bulked at this new requirement, but Congress said basically, you're going to do it. And we know that politics drive a lot of rules and regulations and law, but this was part of the National Defense Authorization Act, we call it NDAA 2020, where you can read Provision 707, by the way, these are hundreds of pages long, for those of you involved with federal government, and very, very general, broad, vague guidelines saying, you'll test to determine and document potential exposure to per- and polychlorinated alkylated substances known as PFAS, how you do that, what compounds you test for, none of that put into this language and then defining who the firefighter is. The purpose is, on the previous slide, to determine and document potential exposure to PFAS during the annual occupational examination, and how we did that, how the Tri-Services decided to do this was using a CLIA-approved laboratory. That was interesting. There were not a lot of laboratories that were testing for these compounds back in 2020. There's a couple more now that are testing, but this was new territory. We found a lab, NMS Laboratories in New Jersey, that had been doing some of this testing for firefighters in the New York, New Jersey area, DOD elected to contract with them. So again, kind of parameters of sampling and logistics, the results were then uploaded into the firefighters. We call this the MHS record, which is the Military Health Systems electronic record. That also changed a little bit during the course of this first year. We moved to MHS Genesis, a new electronic health record. Yes, Boo, it's right. Dr. Proctor, be careful what you ask for, because the newer version may not be as good as the old. That's all I'll say. Very fortunate that we had a number of people, again epidemiologists at our EDC Epidata Center that were willing and in position to look at this data and analyze it, and then developing some summary statistics, which were reported to Congress. So some of the analysis challenges identified here with the bullets are the firefighter PFAS results comparable to those in the U.S. population, where we have NHANES data on about 2,000 people. But they're a little bit different, and I want to explain some of that. Again, CDC testing for 12 to 16 compounds. We were testing for six, the six you see in the DOD current analysis. And the other thing is the NHANES methodology for testing, and I've learned a lot about lab methodology, testing methodology, SAPS, QAPS, all these things that the lab people and lab chemists get involved with. It's quite technical, actually, and it was interesting to see some of the discussions taking place. The methodology from NMS labs was just a bit different than the CDC methodology, and I'll go into details later how that's changing this next year and subsequent years. These are the six PFAS. You'll note that the PFOA and PFOS were linear compounds, and the CDC is testing for both linear and branched chain. You can see a little example here of the branched chains there that we see with what we call branched chain PFAS. You see they're highly chlorinated linear carbon chains that are very resistant to degradation and destruction. And again, that's why these compounds work so well to fight fires. Again, they don't decompose with heat, which then makes it a problem. We don't really know if DOD firefighters, we don't know their exposure. We don't have a lot of demographic or occupational history on these firefighters and their exposure to what we call PFAS. This is aqueous film fighting foam. We call it AFFF, and that's where much of these PFAS compounds are located and why Congress was so concerned about firefighters and their exposure is this AFFF foam that's used to put out fires. Some of the results, again, we're looking at 22 and 23 results right now, but again, this is just first year, so I'd like to come back and give you some trending data the following years. But you can see from this slide, we have a lot of Air Force as would be expected, a lot of Air Force personnel. What you see here, Air Force, Army, Marine Corps, Navy, Marine Corps is actually part of Navy, but yet separate. Navy provides medical care for Marine Corps. The other you see is the civilians. Listed amongst the services, that's active duty. The other, which is actually more than the total participants from the active duty side are your civilians, and then some people that we just couldn't identify their services. Here's a little bit of a composite slide on compounded statistics and overall what we're seeing, about 7,000 some samples. Your first two compounds, PFBS and PFHPA, a great percentage of those were below the limits of detection. That's because these compounds have a very short half-life of about 27 days, 70 days respectively. This is not unexpected. They would be below the level of detection because they're simply being eliminated. If you're conducting annual exams within just a few months, as an example, these compounds could be a number of half-lives going. Tests not performed here. These were samples that were collected that were not able to be tested. There's a certain percentage of that, or not readable, or bad samples. And again, about 1% non-applicable. And go to my notes here. These were, again, tests that may have been collected but were not performed due to inadequate samples or extraction of results weren't available. And I have to explain here, too, that we weren't able to extract or look at all the results. We have probably about 10,000 firefighters in DOD. And some of these firefighters are at civilian facilities, not near a medical MTF, a military treatment facility. They're getting these labs run through civilian collection centers where our epic data center doesn't have access to the data. So there's always parameters, right? There's always exclusions and things. We just are limited in information we're limited in obtaining. This is a good take-home slide, a good slide to review with you all, showing that for these two first compounds, PFAS compounds, the majority were below the limit of detection. And you can see the other compounds, PFHXS, PFNA, PFOA, PFOS, we have very tight confidence intervals, which indicates to us and our team that this data is accurate. This data is pretty consistent, real, and falls within a very narrow confidence interval. And what's also interesting to note is that even though our percentile levels were fairly low, we had some outliers. There were some people here, like PFHXS, that were 340 nanograms per deciliter. Our thought on this, and again, we don't know without exposure information. We're wondering whether those exposures are coming from not firefighting, but other sources. So we've got food wrappers, pizza boxes, water, drinking water. That's what you'll be hearing and seeing in the media where PFAS levels are high. So we're kind of suspecting, we're not sure without more information from firefighters about their exposures, where this source of PFAS is coming from. So it could be from multiple areas, not just occupational exposure. So some graphs, some go through about six or seven slides here of the PFAS compounds we're looking at. This one's on PFBS. And you can see our limit of detection there is the dotted red line. And most of our firefighters are below the limit of detection. Again, the graph is a little bit deceiving because it looks like there's values below zero. There's not. It's just graphically how our statisticians and epidemiologists were able to make this again. It's very difficult to present this sometimes. And again, you can see here, just a few people. These numbers down in the lower are actual numbers there of these levels. So you see you've got this one firefighter, outlier, a few of these folks. Many other levels. Again, half-life of this compound, very short, 27 days. PFHPA, again, another very short half-life PFAS. And you can see again some outliers here. Majority of them in this range, some outliers here. Question. The question was, is where the outlier from the previous compound is the same outlier here? And yes, that's true. We had our epi team look back. It was the same individual. Yeah. And we have to be, I should say, we have to be kind of very careful. And because we're a public health command and the whole IRB process and confidentiality and so forth, we have to be very careful in terms of looking at individual data. We still have to be very, very careful in looking at individual data. We still, yes, that is true. That's true, Murray, but we still have to be very careful in how we look at that data and contact with that individual. We can't do that. We're not allowed to do that. Yeah. So here's a little breakout for PFHXS. We thought it'd be interesting to break out what you're seeing there in the box here, up in the corner here, kind of blew that up. That was some interesting analysis that the team did, showing that, yes, most of these folks are right at the level of detection for PFHXS, but there are some people that are over the limit of detection numbers there. PFNA, again, very similar kind of look there. And many of the firefighters appear to have PFNA concentrations greater than the level of detection. I believe PFNA half-life is around 2.5 to 4 years. So again, a little bit longer half-life. And I want to comment, we don't know the source, really, where these chemicals come from in terms of, we don't know if it's occupational or personal exposure. This is interesting, PFOA, which was a big compound in the AFFF up until a few years ago. The DOD is trying to work on substitutions for PFOA and PFOS in the AFFF foam. And we see here that we have some firefighters who are above the 95th percentile. Again, we really need to figure out where some of these outliers are coming from here. Here's PFOS, PFOA. these were the major compounds in AFFF. And again, when we looked at the data, you know, firefighters are no longer, and the DOD are no longer allowed to train with this foam. For many years, they trained with this foam and sprayed it everywhere. Yes, question. It wasn't just, it began in the 1980s. Everybody in the Navy, those firefighter trained, we trained with AFFF, and as a, because I was a little guy at the time, I was a nozzle man, and we were actually told to breathe, to get air. We were, when the fire was coming over the top of our heads, we were told to hold the nozzle up to our noses and get some air coming to dissolve air in the water. And so we all went through firefighter training, and on the flight deck, there's not just the firefighters, but everyone else, everyone on the ship is a firefighter. So the Navy exposure is actually a higher, it's not just the firefighters. That's a very good point, and Congress is now interested in that as well, and they're looking at expansion of the testing program. They're kind of looking at these reports, and there's debate going on about whether to expand that, because a lot of veterans have actually brought that to light. Yeah. What are the symptoms and problems with this? Well, we'll get to that. There's, we'll get to that. Okay, Dr. Reston, we'll get to that. Probably should have put that towards the beginning of it. But, you know, liver, yes, hold tight. We'll be getting to that. Okay. But, you know, the PFOA and the PFOS-2, they have quite long half-lives, you know, five to eight years, and maybe longer. So some of these compounds have very, very long half-lives, and I was talking with Dr. Proctor last night, because some of his civilian firefighters have been former military, and he's noting that, you know, some of the firefighters, even though they've not had a lot of exposure recently, seem to have high blood levels, and those could be from their military, past military experience. Yeah. But the 27 days of discovering it? No, no, 27 and about 70 days for the initial compounds. That was for, that was for the PFBS and the PFHPA, respectively. Yes, please ask questions if you have questions, because I know this information is new to a lot of you, and it was to me before I got involved in this area. Is the VA testing the same as those penal compounds that- We'll get into that a little bit later, Paul, but I cannot answer that question right now. I do not know if the VA is testing for those same compounds. Good question. I can take that back and try to get you an answer, because I do know the health benefits folks on the VA side would work with them frequently. Ben, breaking out the PFOS slide a little bit more here, the breakout, again, kind of this spike and then trailing off with numbers, but again, kind of centrally located just over the limits of detection here. And again, I share that firefighters and the DOD appear to have greater concentrations than the LOD, with perhaps a small peak located about the 10 milligrams per deciliter mark. And then we thought it would be interesting to combine all the PFAS. And I'll share with you, they are different compounds. They are all different compounds. And does any of the group here know how many total PFAS compounds are in use? There's an estimate there's greater than 5,000 PFAS in commercial use. And so I'm not so sure whether the substitution compounds are safer than PFOS or PFOA, which everyone seems to be concerned about. In other words, industry, at least I see as an occupational environmental medicine professional, I see industry possibly skirting the laws, not skirting the law, so to speak, but getting around the law because the concern, let's say is on PFOS or PFOA right now, but they're developing, which are C8 compounds, they're developing C6 compounds, which we just have no knowledge of. We don't know about their health effects. We don't know what they do. So it's kind of a way to get around public concern and even possibly law. That's what I see industry, just personal comment, doing a lot of times. This is an interesting, so that's kind of a summary graphic of the six PFAS that we're currently testing for. And I'll go into what the future looks like and some health effects. But this is an interesting slide here. And it's by Harrison Davila back in 2023. And it was occupational exposures to airborne PFAS substances. It was a review in Indiana Medical Journal. And it reviewed PFAS exposures in the occupational setting, which I thought might be interesting for this group. Do you notice here that, do you notice here ski waxes? I know this is small here. I'll go through this just a little bit here. Do you notice that ski waxers have the highest occupational exposure level to PFAS compounds? Does anybody in the group know why? I don't know why, but I can surmise. When they're waxing skis, they usually develop a ski or develop a wax onto the ski. And I've been in ski people, whatever you call that when you do a ski shop. And I mean, you can actually see the fumes come off. You got it. 10 points for that answer. Yeah. PFAS is very, very smooth. It's water resistant. It's putting a lot of fabrics. It's put water resistant materials. And like I said, McDonald's and Wendy's and so forth use these for packaging for years. They're getting away from it because the grease prevents the grease from penetrating through the wrapper, through the box and onto your clothes. But this is, our group thought that was really interesting to see this study. And then you can see in this block, I wanted to kind of section out here. This is firefighter activities. This is maintenance block. And then, you know, residents, you know, other areas, you know, residences and vehicles and so forth. Just, you know, kind of general public areas over here. But. This is an excellent, all of your projections were good, probably. Absolutely. Yeah, absolutely. Yeah, because, you know, there's some firefighters that are even concerned about their turnout here because that has PFAS in it. And so our toxicologists say that dermal exposure is probably not a big root of exposure, but we're just not sure. We're just not sure yet. And, you know, this is an evolving science. It's an evolving area that I'm glad to talk to you about. This is interesting, this Lavoisier study characterizing firefighters' exposure to over 130 volatile compounds. And it was very unique. We've proposed a study using silicon wristbands. That's what this group did. 27 firefighters at a station in Durham, North Carolina. They measured 19 PFAS. And what was interesting is no PFAS or no AFFF, the firefighting foam. You wouldn't think they had much PFAS exposure because they didn't fight any, they didn't fight fires during the period of this study. But what's interesting is, you know, they kind of had some elevations there in PFAS. If you look at the red arrows, they were up. And some of these firefighters were, they were not fighting fires, you know, so on duty, no fire, on duty firefighting. It's a little bit misnomer. I mean, they were practicing fighting fires, meaning putting out fires, but you can see here, they still had elevations in their level of PFAS, even though they were fighting no fire. So where was this source coming from? Yes. Say that the bunker here, they used one house to cover the bunker here. And then they're all over the place in the firefighter. And when you get exposed to the heat, you can see the hot gas, water like it's staining on the fume zone. Yeah. It's almost like, I mean, they're not a vortex, I mean, they're already warm. So yeah, they are. Yeah. Firefighting in fire, the outside layer is resistance layer, and it's usually no mass, something that's a little fireproof, that's no mass or PBI, but that's plain inner layer. Back when it comes to EMS, proper suit doesn't have it. They've all been replaced by cortex. The inner vapor barrier layer is cortex suit. It's everything's firefighting, cortex and fume. When I was doing military, I was doing volunteer firefighting, they would take the no-mix layer, they only do with like a scotch gauze kind of thing. Yeah, you do that, nothing is even worse. But it's cortex. Which is PEFV, which is PFAS. So again, the sources of where these exposures come from, much of it is unknown. I mean, we can survive, but it's unknown. It's never tested. It's never tested. Housekeeping note, I'm going to get this handheld mic. The audience online would love to participate in our conversation, but they're not able to hear you guys. So what I'd like you to do is if I- Yeah, these are good conversations. I'll probably make this all go. Anyway. Yeah, these are good conversations we're having and the folks online are, my apologies. I'm sorry. Can you hear me. I'm going to try to lock on. Yeah, because I've got one and two you've got one one. Yeah. We're doing pretty well for time so if we want to go, go back to some questions and comments we can do that. Yeah. So a phased, our timeline, you see here, a phased approach to track trend and analyze this data. We've got basically the testing going on. That's what started in 2020 and we're continuing to look at the data and hopefully I can come back. I'd love to come back and show you some trending data that we're collecting for last year and this year. We've proposed three years ago. This is, this is, unfortunately, one of the bad things about the DOD is that things just take forever to get done. I know some of the organizations you all work for that happens, but it's a little bit frustrating for those of us in the science end that want to kind of advance the science and find out more about these exposures is that we'd like to be able to collect some simple demographic information. Where do you work? How many firefighters, how many fires have you fought? What was your experience outside the DOD? When did you come into the DOD? Just basic, you know, basic information that would help us characterize these exposures a little bit more and where they're coming. So, again, we think we're close to about a one page questionnaire. We think we're close to getting that approved. We thought that a year ago, but here we are today and I think we're, I think we're close, not going some I think we're close and hopefully fiscal year 2024, we'll be there. Yeah. Zytoxin. The question was, or is, given things of when DOD's been taking a long time. Why is it taking so long? I mean, we set the goal, I was the chief of research, being married and immediately following the first goal. And we had everything selected. We had access to all of the data within months of cessation of hostilities. Everything else on that. So out of all of the 91 we reported, why is it taking so long? Why can't you get access to the data? This is not something we got to go through 14 different levels of approval. It can't be gone through quickly. Yeah. Well, Murray, I, this is Al-Philippi's opinion. Yeah. And I think there was, there's been a lot of debate about, because there's so little known, there's no, and I'll get into that shortly, because we have no dose response curve, because we don't have limits established, occupational limits established. There's so much we don't know. There's resistance. There's resistance. There's a thought that the DOD should not be advancing the science, that it should be the CDC and ATSDR. It should be some other organization, not the DOD. Yeah, yeah. And that we need to let, you know, NIOSH or CDC or ATSDR take the lead. And so there's been, quite honestly, there's been some resistance from some of the services and trying to move forward with this. And I, you know, I showed you the NHANES data is 2000 people. I got data here on 7,000 firefighters. This is, everything you see here is statistically significant, you know, we're seeing in terms of the data and the validity of the data. I, it's just, you know, my personal opinion and, you know, hopefully we can move this questionnaire forward. You know, it's, it's a simple questionnaire. It's a simple questionnaire. You know, I mean, I've seen things change since NHANES. They have. Commander. And I know that I said to everyone, you know, my troops, I said, this is a democratic society, everybody has one vote and then they held up their tracks and said, and it's mine that counts. Right. So, I mean, if you've got somebody with four stars who says, I want this done, then by golly, it will get done. If you don't, well... Yeah, the flag, the flag level support would help as well. That, you know, that, but, you know, again, this is congressionally ordered. So that that's an issue as well too. Yeah, yeah, it's, it's been, it's been difficult. But I hope, I hope within the year we'll have a decent questionnaire and the services will have it approved and we'll be through the mill, getting that out. We're offering testing. This is as some of the new, new things coming forward that we're, that we're putting into place. We're going to, we're going to get baseline levels, which we hadn't done before, which I think is going to really help. You know, what are people coming into the military with what kind of levels. If they're coming in as civil servants, what level are they coming in with from the previous jobs as firefighters, that's going to be helpful. That's some of the new language in our, this instruction you see is our overarching Department of Defense manual for occupational health exams. So that's one of the changes. In terms of the analytical analysis, I mentioned before that we're moving, and I'm very pleased to report we're moving, NMS Labs has been contracted to move forward with a CDC NHANES methodology. So I mentioned before, methodology, testing, the whole lab process, and we're going to be expanding the chemical PFAS analyte list, which I'm very pleased about. Dr. Jim Smith, who I work with, our senior toxicologist, has really pushed that effort forward, and we're expanding to 13 PFAS analytes. I mentioned to you some of the missing data that we think about around 3,000 firefighters data is missing, and we're getting a direct feed. REPI data center worked with our lab core, which has got the DOD lab contract through NMS to get a direct feed of the data, rather than to have to glean that data from the electronic health record where there might be error. It's just another source of potential error and difficulty getting data. We're getting a direct feed now, which is very, very good. And then, as I mentioned, the firefighter questionnaire and being able to look at future years, we'd like to see what's happening with trends. Are levels going down? Are levels going up? In querying the services, we found out that there were only 10 actual fires that were fought per year. There's only about 10 per year that are being fought, and with training going down, again, exposures to actual AFFF and PFAS may be from other sources. So, I'll just get a microphone. Yes, there's one. Okay, so it's an anecdote. We have accidental releases. You're right, Chris. We're trying to get some of that data as well. As well as from Navy and other services, the maintenance people are claiming that, hey, through the testing and servicing of this equipment, we're exposed. So, we're in the process of deciding, should we be including those maintenance and service people as well in this cohort? Here's our list of the, I'm very excited because this is basically the PFBS and the PFHPA, as I mentioned, have these very short half-lives, not really worth testing, and this is a comparison chart. I like this, showing what the CDC and NHANES is testing for our current panel, and then proposed, which has been accepted, and as of this year, 2023, we're testing for the following compounds and have eliminated these compounds with short half-lives. And those in the green are associated with, directly associated with AFFF, current preparations of AFFF, and possibly impacting drinking water, which is another big exposure of PFAS. I thought this was interesting to show. Our questionnaire, a little bit more detail on that. We're trying to characterize exposures a little bit more. The questionnaire, we've got our IT folks working on an electronic questionnaire that can be completed by the firefighter prior to their annual visit and then uploaded electronically through a secure portal. And then we call it the EDC server and then evaluate. And then we also, we're going to be in a situation where the OM provider, if they want to, can have access, just like the pre and post-deployment health survey, some of you may be familiar with. So, to your question, Dr. Grissom, here are some of the health effects associated with PFAS exposure. And we have to make it very clear here, no health effects are known to be caused by PFAS exposure. These are associations. Much of these associations were, you know, was from the Parkersburg, West Virginia, DuPont, C8, the black, if you recall the recent movie, Black Waters, Mark Ruffalo was in that movie. That is about the big Parkersburg, West Virginia, PFAS exposure. So, I recommend you all, you know, kind of, again, it's glamorized a little bit, but the book is very good. And these exposures from which this data came, are magnitudes or higher than what we're seeing in our firefighters, like one to two orders of magnitude higher. So, can we really say that these smaller exposures are leading or causing these health effects? We don't really know. So, we've got some real, we've got some real science to do, you know, increased blood cholesterol levels, changes in liver enzymes, some decreased vaccination response in children. Whether that means anything or not, our toxicologist says unknown. Whether that decrease in vaccine responsiveness actually equates to less disease prevention, you know, increase in preeclampsia, high blood pressure, pregnant women, small changes in birth weights. And the big concern, the big concern for firefighters is increased kidney and testicular cancer. As I mentioned earlier, many PFAS are slowly excreted and not metabolized. I was talking to Keith about this last night, that these behave like fatty compounds in a way, because they look like fatty acid chains. And so, they actually can be recirculated through the enteropathic circulation and reabsorb. They're just not broken, you know, many of them just not broken down very quickly and then reabsorb. So, guidance for you as occupational health providers. PFAS levels cannot determine health outcome or medical treatment. We don't have medical treatment other than, I guess you could say, reducing potential exposure sources. There have been some studies on colosteramine. Our toxicologist was pointing to some studies, very preliminary, that colosteramine may help with PFAS elimination. I'll just share that with you. We cannot determine when, where, how the PFAS exposure occurred, because this stuff is in so many consumer products, fabrics, testiles, stain-resistant chemicals on furniture. So, it's very difficult to differentiate between occupational and non-occupational exposure. I will share with you this recent NASM guidance for PFAS exposure website there. It's worth looking at. It's got some, we believe, some controversial recommendations. And we were a little surprised that NASM, as this big scientific group, would talk about community involvement. It was a little bit surprising to us that these are scientists. Why would they necessarily want to have a lot of community involvement? I guess it was just to take community concerns into consideration. But these guidelines and recommendations on testing and clinical follow-up were primarily for primary care providers and people's concern in PFAS through water exposure. And we do have a number of military bases around the country where PFAS has gone outside the defense line, military fence line into the community. And that's a whole separate issue as well, and how the DOD is addressing that water filtration and so forth. But this is just hot off the press. I want to share with you, you know, footstomp this, some really good take-home information for you to finish up with. This is this ATSDR very recent guidance in January 2024 for clinicians. And the significant changes from 2019 are that this guidance takes into consideration community concerns, the benefits to you as providers taking at least some exposure history, which we're all familiar in doing, and then helps clinicians determine when they might want to do some PFAS testing. I have a question for the group. Are any of your companies, firefighting, you know, communities testing for PFAS? I think PFAS has hit a lot of the quasi-public type of terms. NSK ran three or four arcs about eliminating PFAS for food packaging. And, you know, there's more and more information coming out on things like microplastics. So I'm just wondering if public awareness exists, will A, speed up the process that you expressed frustration about, and B, how that might change the way an agency might choose to or not interact with the public? Because it's becoming an issue that is beyond just the science community, it's getting into the public discourse. I think you're exactly right, Jeffrey. You know, the public and their knowledge and sharing of information is driving some of this. I think for the public to be aware of this thing, including for our physicians, I worked, I was hoping to provide an occupational medicine physician at a large company. Did not see these people, but in 40 years, in fact, I've had one direct renal cancer. While I was at this company, I kept hearing of someone, some of them were even some of the executives. I was amazed at the number of renal cancers I'd heard of. And I can tell you, and I heard this lecture while I was just, they were trying to get the bug to somebody, have them check for this, because there were a number of them were interested in renal and I heard about more in my three times there than I had in 40 years. Wow, interesting. Yeah, very, very interesting. Yeah, and I think that's what's driving, Naomi, some of this some of this newer guidance from ATSDR. Yep, so weaknesses, I've got to point out the weaknesses with the new ATSDR guidance. No occupational, I wish they had these exposure limits or guidelines, that would be nice. No way to differentiate between occupational, non-occupational exposures. I could footstomp that one again. And then this idea, we have no dose response relationships developed yet, you know, for levels. And I think it's going to be difficult too, because all these compounds behave a little bit differently and are metabolized a little bit differently and have different effects. So this is my last slide. I want to give credit to my team and the people that support us, because this work is not done by Al-Philippi. In fact, I'm a minor player in a lot of this work, but do have to get involved in risk communication and communicating to our firefighters and giving talks like this. But the person in charge of this whole PFAS testing program is Dr. Jody Weierman. He's a senior toxicologist and Assistant Secretary of Defense, Health Readiness Policy and Oversight, they call it HARPO. And he's our lead and champions a lot of this and is championing that questionnaire we've talked about earlier. We've got Beth Poitras at our EpiData Center. She's wonderful, just wonderful to work with, and her junior epidemiologist and statistician, Michelle Madden, and then myself in the Environmental Health Directorate, and Dr. James Smith, who I have to credit. He has literally become the DoD national expert on PFAS and also is working with the DoD on trying to find substitution compounds for AFFF and some of the new compounds that are being used. I'll take any questions. This is just, they just decided with firefighters and responders, 90% of the answers that are covered by HARPO is wrong. They don't, they don't even question, no oncologist. So they're covering it. So comp says it's related and we're going to cover it. But as a provider, I used to be interested. As a provider, I had no incentive. No oncologist would take workman's comp. So what they would do is they would use their insured, pretty robust, insurance providers, and until they died. So they would use their personal insurance and not the workers' compensation insurance. Fascinating. Some of the states are starting to say, okay, we're going to cover AFFF. How does that affect? Yeah, I, Liz, honestly, I can't answer that. That's a good question. I can't answer that at this time. The VA, as far as our active duty service members, I think we'll, we'll, we'll start to cover some of these things, you know. However, many of our firefighters in the DoD are civilians. So stand by. I, I wonder how this is going to play out. Very good question. Thank you. Thank you. When is baseline testing supposed to be done? And is there any thought about the confounding factor in some of our duty? It's also in mutual aid. It might go out to a fire off post and then they're also fighting fire with us later on. It might go to the same branch. Baseline testing. Baseline testing, Dr. Proctor, will begin in 2024. But what group? New DoD or new entrants in the military? Who are they testing? Oh, it will be new, new, newly. Who are they testing? Okay. Yeah. Who are, who, who will, who will be tested as, as, at baseline? So anyone, anybody in the active duty military coming in as active duty fire, firefighting responsibilities, and then new, new civilians, new civilians to the job. Okay. And what was the second part of your question? On mutual aid. So, Right. And whether they could have, whether they could have, right, other exposures outside the military. And yet we hope to gain that information through the questionnaire. We hope to, once that's implemented, we hope next year. Thank you. Good questions. Good, good question. We can't,

PFAS

firefighters

Navy

Marine Corps

health risks

testing program

National Defense Authorization Act 2020

exposure assessment

risk assessment