3.1
This chapter addresses the following term of reference:
(d) the adequacy of health advice and testing of current and former defence and civilian personnel and members of the public exposed in and around Defence bases identified as potentially affected by contamination.
3.2
The chapter includes:
an overview of concerns about the possible health effects of PFAS exposure;
an overview of the current health advice and findings of the Expert Health Panel for PFAS;
a discussion of concerns about the adequacy of the current health advice and suggestions for improvement; and
a discussion about the Government’s voluntary blood testing program for PFAS, and the associated epidemiological study;
the Committee’s conclusions and recommendations.
Concerns about the health effects of PFAS
3.3
Although the evidence has largely been inconsistent, exposure to PFAS has been associated with certain medical conditions in some overseas studies. A 2013 ‘synthesis paper’ published by the Organisation for Economic Development and Co-operation and the United Nations Environment Program summarised the potential adverse effects of PFAS chemicals on humans as follows:
High levels of PFOS and PFOA are toxic for reproduction and development of the fetus (such as reducing birth weight and lowering semen quality) and are potentially carcinogenic in animal tests. In addition, 8:2 fluorotelomer phosphate diesters (8:2 PAPs), 8:2 FTOH, and PFOA show endocrine effects in different in vitro and in vivo tests. Furthermore, a study with 656 children has demonstrated that elevated exposures to PFOA and PFOS are associated with reduced humoral immune response to routine childhood immunizations in children aged five and seven years.
In addition to toxicity studies, a large epidemiological study of 69,000 persons – the C8-science panel – found probable links between elevated PFOA blood levels and the following diseases: high cholesterol (hypercholesteremia), ulcerative colitis, thyroid diseases, testicular cancer, kidney cancer, preeclampsia, and elevated blood pressure during pregnancy.
3.4
In 2016, ‘following evaluation of human epidemiological studies’, the German Human Biomonitoring Commission rated human health effects in the following areas as ‘well proven, relevant, and significantly associated with exposure to PFOA and/or PFOS’:
1
Fertility and pregnancy - Time to wanted pregnancy-Waiting period for pregnancies >1 year -gestosis and gestational diabetes
2
Weight of newborns at birth
4
Immunity after vaccination, immunological development
5
Hormonal development, age at puberty/menarche
3.5
The United States United States Environmental Protection Agency provides the following advice to the public:
There is evidence that exposure to PFAS can lead to adverse human health effects. … Studies indicate that PFOA and PFOS can cause reproductive and developmental, liver and kidney, and immunological effects in laboratory animals. Both chemicals have caused tumors in animal studies. The most consistent findings from human epidemiology studies are increased cholesterol levels among exposed populations, with more limited findings related to:
effects on the immune system,
thyroid hormone disruption (for PFOS).
3.6
As a result of this evidence, many community members in contaminated areas expressed a high degree of anxiety about the possible health effects of their PFAS exposure. Examples of some of the comments received by the Committee are provided in Box 3.1 below.
Box 3.1: Community concerns about PFAS health effects
My wife and I had several miscarriages before resorting to IVF in Adelaide. I have genuine concerns for my health and that of my wife and now 2-year-old daughter. I keep my fingers crossed that my daughter’s tiny little organs have not been exposed to PFAS. This is a fear that I live with every day. Her heart is barely the size of her fist and kidneys smaller than the palm of her hand. It wouldn’t take much PFAS to damage her vital organs, although the information we are working with is limited, the balance of probability is that this has done some damage and may limit her quality of life.
The added stress that this brought to our family life has been at times intolerable, to the extent where all of my children have questioned whether these chemicals will kill them. This is not a concern any child should have to ask their parents about.
There seems to be very little accurate advice regarding the health aspect of this contamination in Oakey. Whilst being advised not to consume food or water from the contaminated zone, no-one seems to be able to say definitively what the chemical already in our body can do.
Let me tell you that does not feel good at all. I worry about this every day.
My bore has extremely high levels of PFAS, as does my blood. The various reports that have come out make reference to the numerous ways that we can ingest PFAS by washing, swimming etc but they never make any reference to the likely effect to people who drink the contaminated bore water. We went straight on to town water in 2014 when we learnt of the problem. With a house full of teenage children, we lived on bore water not knowing about the contamination until we found out in 2014 and I worry about any long-term health effects (for my children especially).
In 2016 we gave birth to our first child and the full concern of the impact of this contamination really hit home. Although there is no conclusive evidence that these chemicals cause adverse health effects, the existing research which I have seen is consistent with our pregnancy and birth – these being developmental (low birth weight, laryngomalacia and skeletal effects) and pregnancy-induced hypertension. Obviously these things can occur in any pregnancy, but statistically we were at low risk, the skeletal hypermobility is unusual, and to have the collection is worrying.
I worry what health affects the contamination will have on my children that lived there in the past, my young grandchildren that come and visit me and of course any health concerns I may have. I suffer from anxiety, depression and stress due to the worry. I have sleepless nights, there are days I cannot face anything and return to bed, there are days where I feel I have had enough and do not want to go on. How can I continue?
Our daughter and son in law felt compelled to move away from the area when she became pregnant due to the risks involved. After hearing about contamination in the blood levels of babies in the area it wasn’t a risk we were prepared to take.
3.7
Concern about the possible long term health effects of PFAS, in conjunction with other factors, was identified as a major contributor to poor mental health experienced by many residents of contaminated areas. This is discussed further in Chapter 4.
Health advice to affected communities
Current Australian advice regarding the health impacts of PFAS
3.8
The Environmental Health Standing Committee of the Australian Health Protection Principal Committee (enHealth) provides the following general advice concerning the health impacts from exposure to PFAS:
There is currently no consistent evidence that exposure to PFAS causes adverse human health effects.
Because these chemicals persist in humans and the environment, enHealth recommends that human exposure to these chemicals is minimised as a precaution.
3.9
Underpinning this guidance, which forms the basis of the Government’s advice to the public, enHealth explains:
Because the human body is slow to rid itself of PFAS, continued exposure to these chemicals can result in accumulation in the body. Due to the potential for accumulation, and while uncertainty around their potential to cause human adverse health effects remains, it is prudent to reduce exposure to PFAS as far as is practicable. This means that action needs to be taken to address the exposure source or possible routes of exposure. Determination of exposure is best achieved through a full human health risk assessment that examines all routes of exposure.
3.10
The Australian Government’s submission summarised the current status of research into the health effects of PFAS exposure as follows:
Some human health studies have found associations between exposure to these chemicals and health effects and others have not. In addition, the studies that found associations were not able to determine with certainty that the health effects were caused by the chemical being studied or other factors, such as smoking. More research is required before definitive statements can be made on causality or risk.
3.11
The Department of Health has established a PFAS Health Information Service, including a 1800 number and email address for general enquiries. The Department has also participated in community consultations in affected areas in order to:
… provide advice to communities and help inform them of the current evidence related to health effects and exposure as well as programs and services, administered by the Department of Health, that are available.
3.12
Site-specific precautionary advice in relation to each investigation area (such as water use and dietary advice) is provided by state and territory local government authorities (see Chapter 2) and through community consultation mechanisms (see Chapter 5).
Expert health panel
3.13
An Expert Health Panel for PFAS was established by the Government in December 2016 to ‘provide independent advice to the Government on potential health impacts of PFAS exposure and to identify priority areas for future research’. The panel was chaired by Professor Nick Buckley of the University of Sydney, and comprised panellists with expertise in the fields of environmental health, toxicology, epidemiology and/or public health.
3.14
According to its report, the Expert Health Panel undertook a ‘comprehensive review of recent literature reviews regarding Australian and international evidence on potential human health effects of PFAS exposure’. It noted:
In order to provide final advice by February 2018, the Panel focussed on identifying and reviewing the latest systematic reviews of human epidemiological studies and (inter)national authority/intergovernmental/governmental reviews and reports on potential human health effects of PFAS exposure. This challenging timeframe was set to balance the need for well-informed expert advice on the possible effects of PFAS on human health, and the need for timely advice for the [National Health and Medical Research Council] and affected communities.
3.15
The Expert Health Panel also conducted a public consultation process in order to ‘inform the Panel of the communities’ concerns regarding PFAS and their health, as well as their view on priorities for future research’.
3.16
The Expert Health Panel’s summary of its findings in relation to the health effects associated with PFAS exposure is contained Box 3.2 below.
Box 3.2
Although the evidence on health effects associated with PFAS exposure is limited, the current reviews of health and scientific research provide fairly consistent reports of associations with several health outcomes, in particular: increased cholesterol, increased uric acid, reduced kidney function, altered markers of immunological response, levels of thyroid and sex hormone levels, later menarche and earlier menopause, and lower birth weight. Differences between those with the highest and lowest exposures are generally small, with the highest groups generally still being within the normal ranges for the whole population. There is mostly limited or no evidence for an association with human disease accompanying these observed differences. There is no current evidence that supports a large impact on an individual’s health. In particular, there is no current evidence that suggests an increase in overall cancer risk. The main concerning signal for life-threatening human disease is an association with an increased risk of two uncommon cancers (testicular and kidney). These associations in one cohort were possibly due to chance and have yet to be confirmed in other studies. However, because the evidence is very weak and inconsistent in many respects, some degree of important health effects for individuals exposed to PFAS cannot be ruled out based on the current evidence.
Source: Expert Health Panel for Per-and Poly-Fluoroalkyl Substances (PFAS), March 2018, p. 3.
3.17
The Expert Health Panel cautioned that the published evidence was mostly based on studies in just seven cohorts, which have generated ‘hundreds of publications’. It considered that there is a ‘high risk that bias or confounding is affecting most of the results reported’. The Panel explained:
There are very large numbers of comparisons being done in many studies, such that the risk of random variation in exposures and outcomes being interpreted as real associations is greatly increased. This is compounded by the fact that there are multiple PFAS, and other environmental or occupational hazards, so that there may be interacting toxic effects, and it is hard to isolate the association with one or two analysed compounds. Many of the biochemical and disease associations may be explainable by confounding or reverse causation. Many studies had limited power to detect important associations.
3.18
The Expert Health Panel provided the following advice to the Government:
Our advice to the Minister in regards to public health is that the evidence does not support any specific biochemical or disease screening, or health interventions, for highly exposed groups (except for research purposes). Decisions to regulate or avoid specific PFAS chemicals should continue to be largely based on evidence of persistence and accumulation; they should not need to also be justified by strong evidence of adverse health effects.
3.19
The Australian Government submitted that the Expert Health Panel’s findings support the existing enHealth advice that there is ‘no consistent evidence’ that exposure to PFAS causes adverse human health effects. It added:
The Panel’s report should reassure communities that they are being provided with up to date and independent advice on the potential health effects of PFAS exposure.
3.20
However, some participants in the inquiry criticised aspects of the Expert Health Panel’s review. For example, the Williamtown and Surrounds Residents Action Group criticised the Panel’s public consultation process and considered that the report ‘did not present as an independent report’, particularly due to the Government’s announcement on the same day as the report’s release that it was not considering property buy backs.
3.21
The Coalition Against PFAS told the Committee that the Expert Health Panel report ‘was unnecessarily rushed and opaque, adopted the wrong methodology, and had little to no scientific value’. The group particularly criticised the level of community consultation, the lack of distinguishing between independent studies and those sponsored by industry, and the exclusion of the ‘C8 Science Panel’ report on a study of blood samples taken from 69 000 people over seven years, which had found ‘probable links’ to a number of health conditions. It concluded that the results reported by the Expert Health Panel were ‘unreliable’.
3.22
The New South Wales Government supported the Expert Health Panel’s finding that further research was required to address the insufficient evidence on possible adverse health outcomes. It recommended:
Given these substances persist in the environment for a long period of time it is important to take actions to minimise exposure. The response to PFAS should continue to emphasise messaging regarding minimising exposure, rather than focus on the lack of evidence of health impacts.
Is Australia’s health advice up to date?
3.23
The Committee noted that many participants in the inquiry considered the current Australian health advice to be not consistent or up to date with research linking PFAS exposure to a range of diseases and the Committee supports the application of the precautionary principle in this case. In particular, many participants pointed out that overseas bodies had appeared to place a greater emphasis than Australia on the potential adverse health effects of exposure to PFAS.
3.24
Dr Geralyn McCarron argued that the current Australian advice was ‘based on denial of health harms’ and was ‘out of step with both the precautionary principle and the body of evidence linking PFAS to impairment of human health’:
The risks to human health, denied by the Australian Government are acknowledged by the US, Germany, Britain, and the International Agency on Research on Cancer (IARC). Acknowledged health risks of exposure in humans include testicular and kidney cancer, immune impairment, thyroid disorders, impaired fertility, pregnancy induced hypertension and preeclampsia, and altered liver function.
3.25
The National Toxics Network submitted that, based on the ‘overwhelming evidence from independent published scientific research and developed countries regulatory assessments’, the Government’s current health advice is ‘both ill-informed and scientifically unsound’.
3.26
Friends of the Earth Brisbane pointed to a recent review by the United States Agency for Toxic Substances and Disease Registry, which it said suggested that ‘the impacts of PFAS may be far greater than previously predicted and at much lower doses than previously calculated’. The Group called for the Government to ‘acknowledge the wide acceptance of potential health impacts and review all guidelines in light of this recent scientific review’.
3.27
The Royal Australasian College of Physicians (RACP)—in a submission led by the Australasian Faculty of Occupational and Environmental Medicine (AFOEM) Policy and Advocacy Committee—also contrasted the Australian advice with advice provided overseas. The RACP recommended that the Government’s current health advice be ‘updated to refer to the identified possible health effects outlined in the findings of the Expert Health Panel and the conclusions of international agencies’.
3.28
Dr Andrew Jeremijenko, a Brisbane-based specialist in occupational and environmental medicine, described the current health advice as ‘inadequate’. He endorsed the previously expressed views of the AFOEM and the Australasian Faculty of Public Health Medicine (AFPHM) that that the existing enHealth advice, as currently worded, was ‘highly problematic’ in that it:
… does not adequately address the entire body of evidence demonstrating the association of PFAS with adverse human health effects; is inconsistent with the guidelines, health advice and classifications as referenced above; and takes the narrow view of evidence for causation alone. This advice is likely to be confusing for the public and could weaken the concurrent approaches in Australia that apply the precautionary principle when advising the public about food and water consumption at sites potentially contaminated with PFAS.
3.29
Dr Jeremijenko elaborated on his comments at a public hearing, where he cited a number of findings from the Expert Health Panel report that noted links, or potential causes and associations between, PFAS exposure and high cholesterol, impaired kidney function, thyroid disease, effects on human reproduction and reproductive hormones, impaired vaccine response, and effects on the immune system.
Communication of health advice
3.30
Dr Jeremijenko considered that the current advice was ‘increasing outrage in the community’ due to its ‘playing down’ of risk. He indicated that ‘focusing on the negative’ amounted to poor risk communication:
Basically, when you’re doing risk communication, you don’t go and tell people, ‘There’s nothing wrong. There’s nothing wrong. There’s nothing wrong’, because it makes them concerned that you’re covering up something. It’s actually much better to say: ‘There may be some health effects. We’re still doing research, but we want you to know that we’re taking the precautionary approach. We want you to be aware that we’re not sure, and we want you to be safe’. That’s the advice that should be coming from the government—not this, ‘There’s no consistent evidence of health effects. Don’t worry’, because that makes the community angrier.
3.31
Dr Jeremijenko suggested:
A clearer and more explicit acknowledgement of uncertainty; a greater reference to health associations; and a clearer statement that cancer effects may yet to be seen would all be useful and make the government appear more in touch with community feeling.
3.32
The New South Wales Government similarly wrote that the advice from the Commonwealth Government that there is no consistent evidence of harm to human health from exposure to PFAS had ‘proved problematic from a risk communication perspective’ and had ‘created considerable concern in impacted communities and a lack of surety for industry’.
3.33
The General Manager of Port Stephens Council told the Committee that, ‘effective and timely guidance and assistance should be prioritised into the future’. He observed that health advice and protection had been ‘seen to be slow and not clearly rolled out or understood by those right across the community’.
3.34
The RACP submission made several suggestions for improving the way health information is communicated to the public, including:
consolidating the relevant advice on PFAS found across sources and websites;
developing a list of frequently asked questions for the varying stakeholders to cover the range of issues presented by PFAS;
giving clear advice to stakeholders that exposures above recommended levels do not necessarily equate to harm or disease; and
a statement outlining that ‘although there is little available evidence that PFAS is associated with the development of specific diseases, the potential long-term effects, including health and environmental effects, are not currently known due to the extremely long elimination half-lifes of PFAS from the body which justify the reduction in use and exposure to these chemicals’.
3.35
The RACP was also concerned that the final Health Based Guidance Values for PFAS (see Chapter 6) were not reflected the current health advice:
The health advice “that there is currently no consistent evidence of health effects” could be interpreted to mean there is no unsafe dose and no health effects even for exposures above the interim values. We suggest that including a statement such as “at levels below the Tolerable Daily Intake (µg/kg/d); Drinking Water Quality Guideline (µg/L) and/or Recreational Water Quality Guideline (µg/L)” would be appropriate when discussing the difference between Australian advice for PFAS (as currently constructed) and international advice.
3.36
Further, the RACP identified that that there was a ‘gap’ in terms of a ‘lack of specific guidance on PFAS aimed a medical practitioners’.
3.37
Nonetheless, the RACP concurred with the Expert Health Panel’s recommendation against any routine population-based health monitoring or screening. Instead, the RACP recommended that the ‘main focus’ be on reducing human exposure to below guideline levels, consistent with the precautionary principle.
Response from the Government
3.38
At its public hearing in Canberra, the Committee followed up some of the concerns raised about the current health advice with the Department of Health. The Department’s Chief Medical Officer, Professor Brendan Murphy, agreed that the current evidence base on the health effects of PFAS was ‘weak and inconsistent’, and justified a precautionary approach. He initially emphasised that the known health associations were ‘relatively low-grade’, and that current evidence was that there is ‘no clinically significant adverse health outcome’ associated with PFAS. However, he agreed that it would take ‘long term studies with large numbers’ to be able to obtain conclusive evidence of the health outcomes associated with PFAS, and that the existing data was ‘certainly insufficient’ to say that clinically significant adverse health outcomes will never be shown.
3.39
Later in the hearing, Professor Murphy, while standing by the position that there are ‘no clinically significant health impacts’, acknowledged the Expert Health Panel’s reporting of certain health effects and associations. He indicated that the Department of Health concurred with the RACP’s submission, and would ask enHealth to review the wording of its current statement ‘to incorporate those known associations’.
Blood testing and epidemiological study
3.40
The National Centre for Epidemiology and Population Health at the Australian National University (ANU) has been commissioned by the Australian Government to undertake an epidemiological study into the potential effects of PFAS contamination on the health of residents surrounding the Williamtown, Oakey and Katherine investigation areas.
3.41
Concurrent with the epidemiological study, the Australian Government is offering one free blood test for PFAS to individuals who live and work, or have previously lived and worked, in the Williamtown, Oakey and Katherine investigation areas. The voluntary blood testing program commenced in November 2016 (initially only in Oakey and Williamtown) and is available until 30 April 2019. In December 2016, a similar blood testing program was also introduced for Australian Defence Force members who have lived in or worked in the Williamtown, Oakey or Katherine investigation areas.
3.42
Where individual consent is provided, blood samples and test results are provided to the ANU to contribute to the epidemiological study.
Epidemiological study
3.43
The ANU epidemiological study aims to examine whether rates of diseases, including cancers, potentially associated with PFAS are higher among people who have lived in the investigations areas compared to the general population.
3.44
The study is being run over three years, and began with a systematic literature review ‘to identify what health effects had been documented in the literature’, published in January 2018. Professor Martyn Kirk, Principal Investigator for the study, summarised the findings of the review as follows:
The results showed that there was consistent evidence of a health effect around cholesterol and limited evidence of a range of other metabolic effects, also including cancers—testicular cancer and kidney cancer—and immunological effects from vaccines, for a few vaccines.
3.45
The research team has since conducted focus groups in Oakey, Williamtown and Katherine. It intends to publish a report on the findings of these focus groups later in 2018.
3.46
This will be followed by a blood serum study, which will use samples from the Government’s voluntary blood testing program. The research team has also obtained funding for additional blood testing to be conducted, both in affected communities and in some comparison unaffected communities. Complementing the blood testing, the research team will conduct a cross-sectional survey in order to understand the risk and exposure factors of each participant, and their self-reported health effects, including mental health.
3.47
Finally, the team will conduct a ‘data linkage’ study using Medicare data to examine sex-specific and age-adjusted rates of disease in all people who have lived in contaminated areas, in comparison to unaffected communities and the general population.
Voluntary blood testing program
3.48
The Government’s voluntary blood testing program includes a pre-counselling session, at which doctors are advised to talk to the person taking the limitations of the test—that is, that the test can detect how much of each PFAS is in the person’s blood, but not where they came from or what it means for the individual’s health. Following the test, a post-counselling session is used for the doctor to provide and explain the results.
3.49
While there is not considered to be any ‘normal’ PFAS range for individuals in Australia or overseas, an individual’s blood result can be compared to historic pooled community levels. Participants in the program are advised that all Australians are expected to have detectable levels of PFAS in their blood, and a broad range of levels would be expected in all communities due to background exposures. Results are benchmarked against the estimated 95th percentile for the Australian population, as set out in the below table.
Table 3.1: Estimated 95th percentile for the Australian population, 2011–2012
|
|
|
|
|
PFOS
|
0–4 years
|
13
|
|
5–15 years
|
18
|
|
16–30 years
|
20
|
|
31–45 years
|
25
|
|
46–60 years
|
29
|
|
61+ years
|
37
|
|
PFOA
|
0–4 years
|
9
|
|
5–15 years
|
8
|
|
16–30 years
|
8
|
|
31–45 years
|
8
|
|
46–60 years
|
8
|
|
61+ years
|
10
|
Source: Department of Health, Voluntary Blood Testing Program for PFAS: Post-Test Consultation Advice for GPs
3.50
Participants who return blood results that are below the 95th percentile are reassured that their result is consistent with background exposure in the general population of that specific age-group. Participants whose results exceed the 95th percentile are advised that this is suggestive of previous exposure to PFAS at levels higher than the general population, and are educated on precautionary strategies to limit exposure, ‘noting no conclusive evidence of adverse health effects’.
3.51
The Coalition Against PFAS queried why Australian blood tests were benchmarked against the 95th percentile of the population, rather than the ‘much lower’ 50th percentile that is used in the United States and Canada.
3.52
In its submission, the Australian Government noted that blood testing had limited value at an individual level, but potentially greater benefit at a community level:
A PFAS blood test will provide an individual with their PFAS blood level at a point in time. It will not provide any information on how or when exposure to PFAS occurred and is of no diagnostic or prognostic value. Frequent blood testing for individuals is of limited value due to the long biological value half-life of PFAS. However, the monitoring of pooled community blood samples over time may help determine the success of exposure reduction measures.
3.53
The Queensland Government, while noting the diagnostic limitations of blood testing, stated that its experience was that blood testing has the potential to reduce community anxiety:
For this reason, the Queensland Government offered free voluntary blood testing to people inside the Svensson Heights investigation area of Bundaberg. All results were well within the acceptable background levels of PFAS in Australia. Because of this testing, the community had a tangible means of reassurance that they were not heavily affected.
3.54
The Victorian Government reported that no testing for PFAS in blood has been undertaken in communities surrounding Defence sites in Victoria. However, a voluntary health surveillance program is being managed by the Country Fire Authority for individuals who worked at or attended its PFAS contaminated training site at Fiskville, Victoria, and neighbouring property owners. The program:
… consists of an initial health check by an independent medical clinic who determine if further monitoring is required as part of the annual health surveillance program. This may include a blood test to determine PFAS levels in the blood stream.
3.55
Victoria’s Metropolitan Fire and Emergency Services Board (MFB) separately advised that it had commenced offered a voluntary blood testing program to its employees in 2016, with over 640 employees being tested. MFB considered that early testing provides an opportunity for early detection, monitoring and intervention, and provides for ‘increased employee physical, mental and emotional health’.
Concerns about low participation
3.56
Nicole Smith, a resident of Katherine, submitted that many people were ‘not aware they are even eligible’ for the blood testing program. She noted that because the tests were advertised as ‘specific to people livening in and around the “Tindal RAAF Base Investigation Area”‘, it was not clear ‘who exactly is eligible for the testing’.
3.57
Dr Peter Spafford, who helps facilitate the voluntary blood testing program through his general practice clinic in Katherine, advised that only 380 of an anticipated 2000 blood tests had been undertaken to date. Dr Spafford partially attributed this to instructions from the Department of Health and the Primary Health Network that the practice should not promote the service ‘in any way, shape or form’ because the government would undertake all the advertising and promotion. He noted that there had been some advertising of the program on local community radio and in the Katherine Times, but that this advertising did not extend to ‘an official “these are the times and this is where you can go”‘.
3.58
Dr Spafford also criticised the quality of advice provided to doctors participating in the program when elevated levels are detected:
As a stakeholder in the health industry being asked to assist with the voluntary blood testing and giving advice on the results, the advice was found to be superficial and dismissive, and gave no information on the substance PFHxS that was found to be the major contaminant. Enquiries to obtain information on this contaminant were made, but little or no effort was made by the Department of Health to provide advice considering the very high levels that were being reported. Any advice received was again dismissive and failed to take into account the severity of the level of contamination compared to population studies done elsewhere in Australia and overseas.
3.59
At the Oakey hearing, Ms Dianne Priddle told the Committee that a local general practitioner had been ‘verballing people out of having the free blood test done’, allegedly due to a belief that the test ‘serves no purpose’. Ms Jennifer Spencer described the process of getting the test as ‘very harrowing’, and suggested that it should be streamlined:
I believe that you should just be able to walk in to Sullivan Nicolaides Pathology with no referral and tell the lady or the operator there—the phlebotomists—that you would like a PFAS blood test. She would then give you a PFAS blood test, it would be sent off and then you’ll be sent the results to your home, not the GP, and you would then have that available for you to read. If you had trouble deciphering it or were was wondering what it was all about, then you could contact a doctor of your choice or this GP.
3.60
EcoNetwork Port Stephens submitted that many families in the Williamtown area were ‘thoroughly disillusioned with the testing regime’. It said the arrangements were ‘slow and bureaucratic’, and relied on individuals ‘proactively seeking’ tests. It also said that the implications of test results were not being well explained.
3.61
Mrs Samantha Kelly considered that the rollout of the program was ‘disorganised’, with blood tests initially undertaken through one company using a different methodology to tests subsequently undertaken by another company. She said that this had resulted in the test results of some people not being able to be used.
3.62
Dr Andrew Jeremijenko expressed concern about people being told not do blood tests, as it ‘takes away from the efficacy of the epidemiological study’. He noted:
We can’t prove these health associations that have been proven overseas if we don’t have the data, so it’s really important that we get these people blood tested and that we know their levels. Then we can follow them up, do the epidemiological studies and get the evidence.
Adequacy of current blood testing program to meet its objectives
3.63
Some participants in the inquiry considered there would be more benefit if free blood tests were provided periodically, rather than on a one-off basis.
3.64
As noted in Chapter 1, in its two 2016 reports on PFAS, the Senate Foreign Affairs, Defence and Trade References Committee recommended that blood tests be made available to residents of Oakey and Williamtown on an annual basis. It also recommended:
… that voluntary blood testing be made available to current and former workers at sites where firefighting foams containing PFOS/PFOA have been used, and current and former residents living in proximity to these sites who may be affected by contamination.
3.65
The Coalition Against PFAS submitted that the ‘obvious and fundamental issue’ with the epidemiological study was that it is ‘too limited in its scope’. It its view, the statistical sample size of the tests in the three communities would be ‘far too small to draw meaningful conclusions’. The group considered that the study should be extended to survey:
… all PFAS affected communities in Australia, including those near civil airports and firefighting bases, and survey all occupationally exposed individuals such as firefighters.
3.66
The Coalition Against PFAS also suggested that data from the Australian study could be combined with that from other international studies in order to increase the sample size further.
3.67
Professor Martyn Kirk, Principal Investigator for the ANU’s PFAS Health Study, estimated that there would about around 3000 people included in the blood testing component of the study, as uptake in some communities had been ‘relatively low’. However, he noted that it was common for researchers to share datasets with investigators across the globe in order to increase the power of their research.
3.68
Professor Kirk also noted that the data-linkage component of the study would have ‘many more people in it’, including anyone who has ever lived in the community.
Other proposed studies
3.69
MFB advised that it had provisionally selected Macquarie University as its academic partner to conduct a study of PFAS contaminates in firefighters’ blood. The study would consider whether regular blood and/or plasma donations reduce PFAS levels in the blood:
This research study is a randomized interventional study to compare a number of intervention groups donating blood and possibly plasma and a control group with no intervention. It is anticipated that the study may identify a possible relationship between the interventions and reduced levels of PFAS after 16 months (baseline +12 months intervention period).
3.70
The United Firefighters Union of Australia, which had negotiated with MFB to commission the Macquarie University study, recommended further research to scientifically identify the incidence of specific illnesses associated with PFAS contamination ‘so that the impact of this exposure is better understood and accepted’. The Union further recommended that all Commonwealth, state and territory career firefighters (and retired firefighters) be offered free voluntary blood testing, with ‘appropriate support and analysis’.
3.71
Separately, in the 2017–18 Budget, the Australian Government committed $12.5 million towards establishing a National Research Program into the Health Effects of PFAS, to be administered by the National Health and Medical Research Council (NHMRC). The program will be informed by the report of the Expert Health Panel. The NHMRC intends to conduct a targeted call for research in late 2018.
Committee comment
3.72
The Committee recognises that there is a high degree of anxiety among members of affected communities in relation to the possible health effects of PFAS exposure. This anxiety is particularly acute amongst residents who have experienced themselves, or whose loved ones have experienced, medical conditions that could possibly be attributed to PFAS exposure.
3.73
The health advice provided by Australian authorities emphasises that there is currently ‘no consistent evidence’ that PFAS exposure causes adverse human health effects. While this statement may be true, overseas jurisdictions appear to have been more ‘upfront’ in communicating the possible health effects of exposure to PFAS. This presents a confusing message to the Australian public and contributes to an impression amongst community members that the Australian Government is downplaying the risks in order to avoid taking responsibility for the contamination. Furthermore, while many uncertainties remain, it is not clear that the current advice takes into account evidence from international studies, including those reviewed by the Expert Health Panel, of potential links to certain medical conditions.
3.74
The Committee notes that there appears to be a broad consensus, including the Department of Health, that the current advice should be updated to acknowledge the known links and associations, while continuing to make clear the many uncertainties. The Committee supports the review of the existing health advice to ensure it is more upfront about the risks of PFAS exposure, while continuing to emphasise the precautionary nature of the advice.
Recommendation 3
3.75
The Committee recommends that the Australian Government review its existing advice in relation to the human health effects of PFAS exposure, including to acknowledge the potential links to certain medical conditions.
3.76
The Committee welcomes the Australian Government’s investment in an epidemiological study to help contribute to our understanding of the human health effects of PFAS exposure. The success of the associated voluntary blood testing program will have an important role to play in ensuring that the research is able to produce meaningful results.
3.77
The Committee was concerned to hear that participation in the blood testing program has been lower than expected to date. Anecdotal evidence suggests that the reasons for this low participation rate include an inability for participating doctors to promote the service, an overly bureaucratic testing process and a lack of appreciation of the value of the test, including amongst some general practitioners. The Committee considers that measures should be taken to improve participation in the program as soon as possible. This may include extending the blood testing program to more communities affected by PFAS contamination.
3.78
The Committee also notes continued calls for blood testing to be made available to residents on a periodic basis, such as annually, rather than a one-off test. The Committee notes that such testing would have little diagnostic value until the human health effects of PFAS exposure are better understood. However, the Committee considers that periodic testing should be considered for its potential role in monitoring the effectiveness of precautionary measures that have been introduced to reduce exposure pathways, in addition to reducing community anxiety.
Recommendation 4
3.79
The Committee recommends that the Australian Government, as soon as possible, undertake measures to improve participation in the voluntary blood testing program for PFAS. This should include measures to:
increase community awareness about the purpose and importance of the tests, and the associated epidemiological study;
simplify the testing process;
extend the program to be available in additional areas; and
ensure Australia’s testing strategy is comparable to international studies.
Further, the Committee recommends that the Government consider the potential value of blood testing to monitor the effectiveness of measures being used to break PFAS exposure pathways in affected communities. This will necessitate longitudinal analysis of those who have been previously tested and additional tests being made available, after an appropriate period, to persons who have previously been tested.