Why They Matter
You may already be familiar with the infamous term “PFAS” – an acronym used to represent per- and polyfluorinated substances. They seem to be a “hot topic” in the world of ‘green’ and ‘clean’ living, gaining unwanted attention, particularly for their popularity in nonstick pans and cookware. PFAS are often referred to as “forever chemicals” and for good reason: PFAS represent a chemical class of thousands of compounds that are environmentally persistent and can travel long distances by water and air. They accumulate in the bodies of animals and humans and are associated with multiple adverse health effects.
The big problem? PFAS are virtually everywhere due to their prevalence in various types of consumer goods. Our current understanding of PFAS is mostly dependent on only four out of the thousands of PFAS in the marketplace. Regulatory actions have resulted in the phase out of widely used and researched PFAS chemicals known to be toxic, but other PFAS compounds with similar properties take their place. Here, we talk about the hazards of PFAS and what steps you can take at the consumer level to limit your exposures to this sneaky class of chemicals.
What Are They?
Per- and polyfluorinated substances (PFAS) are a diverse array of compounds used in a wide range of consumer goods for water, stain, and grease resistance. PFAS have been in production since the 1940s,[1] and there are currently thousands of PFASs in the global marketplace.[2] PFAS can be categorized into two descriptive categories: “long-chain” or “short-chain”. By definition, according to the Organization for Economic Co-operation and Development (OECD), “long-chain” PFAS are “perfluoroalkyl carboxylic acids with eight carbons (i.e., with 7 or more perfluorinated carbons) and perfluoroalkane sulfonates with six carbons and greater (i.e., with 6 or more perfluorinated carbons)”.[3][4] Generally, any perfluoroalkyl chain with 7 or more carbon atoms is considered long-chain.[5] Any precursors of the aforementioned substances are also considered to be long-chain.[6] Scientific understanding of PFAS and their effects on humans and the environment are primarily based on studies in four specific types: perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA). [7] There is limited research on the effects of most other PFAS chemicals. To sufficiently evaluate their human and environmental impacts (rather than take on the feat of evaluating thousands of compounds on an individual basis), some scientists push the need for methods of grouping together similar PFAS compounds for analysis. [8] [9]
One of the most studied of these compounds, PFOA (also called C8), is a long-chain perfluoroalkyl substance that served as one of the primary components of Teflon. It has largely been phased out of use due to its adverse effects on humans and the environment. Yet, it has been replaced by PFAS with similar properties, such as polytetrafluorethylene (PTFE). PFOA can still be found in older consumer products in which it was used before phase-out.[10]
Where They're Found
PFAS can be found in numerous products including textiles, paints, personal care products, carpet, adhesives, cookware, to-go containers, linings of food packaging, computers, cell phones, automobiles, mattresses, shoes, clothing, microwave popcorn bag linings, papers used at delis and bakeries, and much more.
The Health Concern
Our scientific understanding of PFAS is limited to four out of more than 10,000 [11] individual substances that constitute this chemical class. As a result, PFAS’s adverse impacts on human health, as a whole, are mostly considered to be “correlations rather than direct causation, and the risks of specific exposure levels are unknown for most PFAS”. [12] Many PFAS are persistent in the environment,[13][14] bioaccumulate (stay in the body for long periods of time) in humans and animals, [15] and elicit a range of toxic effects[16] like adverse effects on sexual function and fertility, [17] endocrine disrupting capabilities, [18] cancer, [19][20] developmental and reproductive toxicity, [21] [22] and more. The behavior and toxicity of PFAS in humans, animals, and the environment can change depending on the length of its carbon chain (i.e., long-chain vs. short-chain).[23]
Pre- and postnatal exposures to perfluorinated compounds were assessed in a cohort of children between the years 1997 and 2000 to understand the associations between PFAS exposure and antibody concentrations following immunizations (against diphtheria and tetanus). This assessment was used “as a proxy for the immune system’s ability to respond to disease in general”[24] and exhibited an association between PFAS exposure and weakened immune response. [25] PFAS exposure may also elicit a range of adverse effects associated with the liver, as long-chain PFAS tend to accumulate there.[26]
A 2007 study from the CDC found PFOA in the blood of 99.7% of Americans.[27] After a class-action lawsuit that revealed PFOA’s links to cancer and other diseases, DuPont (PFOA’s major producer) made a deal with the EPA[28] to phase out its use beginning in 2006 — however, this doesn’t mean that PFOA has disappeared from consumer products purchased prior to its phase out. Additionally, PFOA has a long half-life in humans, is persistent in the environment, and can be produced from the degradation of other PFAS chemicals;[29] not to mention, PFOA has been replaced with other PFAS with similar properties. [30] In total, eight major PFAS manufacturers participated in the phase out of PFOA, its longer-chain homologues, and their precursors beginning in 2006 – with the goal of full elimination by 2015.[31]
Following the elimination of bioaccumulative and toxic long-chain PFAS, manufacturers insisted that short-chain PFAS were not a health concern and used short-chain PFAS as substitutes. [32] Several studies indicate long-chain PFAS to be more bioaccumulative than their short-chain alternatives.[33] Yet, hexafluoropropylene oxide dimer acid (HFPO-DA, or GenX) and perfluorobutane sulfonic acid (PFBS) are listed by European Union regulation as Substances of Very High Concern. [34][35] DuPont introduced GenX as a replacement for PFOA in 2009, and PFBS is a short-chain degradation product.[36][37] There are studies linking GenX to developmental toxicity[38][39] and adverse effects on the liver.[40][41]
Aside from manufacturing, use, and disposal, PFAS may be released to the environment as impurities in other substances or through the degradation of compounds known to be precursors of PFAS by way of biotic (e.g., by living organisms) and/or abiotic (e.g., by non-living, physical processes) factors.[42] Some PFASs can partially degrade, but all chemicals of this class transform into highly persistent perfluoroalkyl(poly)ether acids (PFAAs).[43] Owing to their persistence and solubility in water, PFAS and/or their degradation products can travel long distances in the natural environment.[44][45] PFAS compounds have been found even in remote locations, like the Arctic,[46] and in various aquatic species. [47]
Scientists are still trying to understand the mechanisms behind the health impacts of PFAS and the toxicological implications of PFAS compounds in combination.[48] Research obstacles, like PFAS impacting humans and experimental animals differently, pose a challenge. The half-life of PFAS (the amount of time it takes a chemical’s concentration to reduce by half), for instance, can drastically change depending on the body system and its associated protein structures. PFOA can take years to clear from a human body and only days to clear from a mouse. [49][50] Computer models investigating the associations between PFAS bioaccumulation and a liver protein suggest nine PFAS compounds remain in the bodies of humans, rats, rainbow trout, and chicken for similar lengths of time. Contrastingly, some compounds exhibit higher retention times in humans when compared to two species of fish. [51]
While there are data gaps on the various types of PFAS chemicals, the science available to us on select compounds is convincing enough to limit subsequent exposures to these “forever chemicals” in ways that are possible – and to limit the environmental burden. Despite the widespread concern, there is little regulatory action to keep them out of our consumer products; not to mention, new PFAS chemicals continue to be approved for use. [52]
MADE SAFE requires all companies and their associated manufacturers to disclose any finishes or substances added to products for functionality. From textiles to personal care, PFAS chemicals are subject to the MADE SAFE 360° Ecosystem Approach Screening and are not allowed as added ingredients in certified products. Plus, the phase out of longer chain PFAS has resulted in the replacement of compounds with little to no safety data.[53] To prevent regrettable substitutions, at MADE SAFE, we exercise the precautionary principle – which states that substances are “guilty until proven innocent” and are not permitted as added ingredients in certified products until there is substantial data to support safety.
How to Avoid Them
- Opt for stainless steel, cast iron, or glass cookware. Avoid nonstick cookware, even if it’s labeled as “healthy”, “green”, or “nontoxic”, as these are unregulated terms. While we highly recommend avoiding all nonstick pans, if you must continue using them: turn down the heat below 400 degrees, ventilate your kitchen well during use, cease using them immediately if they become scratched or the coating is flaking or peeling, and use softer utensils like wood or silicone to avoid scratching the surface.
- Cook at home when possible. To-go packaging from restaurants and grocery stores can be lined with PFAS. If opting for takeout, heat up food on a glass plate instead of within the to-go packaging, even if it’s labeled as microwave-safe. Or, use the stove top.
- Avoid any consumer products (particularly textiles) labeled “nonstick”, “easy care”, “no iron”, “waterproof”, “stain resistant”, and other similar terms, as they can be coated with PFAS.
- Use waterproof products only when completely necessary. Opt for boots and outdoor wear that aren’t coated, when possible.
- Avoid microwaveable popcorn and make stove top popcorn at home. Microwaveable popcorn bags can be coated with PFAS.
- Choose dental floss that uses natural coatings like vegetable wax or beeswax, or go with completely uncoated floss. Some conventional dental floss can be coated with PFAS, which is not necessarily disclosed to the consumer. Choose dental flosses that explicitly disclose the composition of the coating.
- Look for household water filters or filtration systems that are proven effective at removing PFAS compounds from tap water.
- Shop MADE SAFE Certified products.
For more information, check out the MADE SAFE fact sheet: All About PFAS.
References
[1] Wang, Z., DeWitt, J. C., Higgins, C. P., & Cousins, I. T. (2017). A never-ending story of per- and polyfluoroalkyl substances (PFASs)? Environmental Science & Technology, 51(5), 2508-2518. https://doi.org/10.1021/acs.est.6b04806
[2] Cousins, I.T., DeWitt, J.C., Glüge, J., Goldenman, G., Herzke, D., Lohmann, R., Miller, M., Ng, C.A., Scheringer, M., Vierke, L., Wang, Z. (2020). Strategies for grouping per- and polyfluoroalkyl substances (PFAS) to protect human and environmental health. Environmental Science Processes & Impacts. 22:1444. https://doi.org/10.1039/d0em00147c
[3] [OECD] Organisation for Economic Co-operation and Development. (2011). OECD portal on perfluorinated chemicals. Retrieved from http://www.oecd.org/site/0,3407,en_21571361_44787844_1_1_1_1_1,00.html
[4] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[5] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[6] [OECD] Organisation for Economic Co-operation and Development. (2011). OECD portal on perfluorinated chemicals. Retrieved from http://www.oecd.org/site/0,3407,en_21571361_44787844_1_1_1_1_1,00.html
[7] Cousins, I.T., DeWitt, J.C., Glüge, J., Goldenman, G., Herzke, D., Lohmann, R., Miller, M., Ng, C.A., Scheringer, M., Vierke, L., Wang, Z. (2020). Strategies for grouping per- and polyfluoroalkyl substances (PFAS) to protect human and environmental health. Environmental Science Processes & Impacts. 22:1444. https://doi.org/10.1039/d0em00147c
[8] Cousins, I.T., DeWitt, J.C., Glüge, J., Goldenman, G., Herzke, D., Lohmann, R., Miller, M., Ng, C.A., Scheringer, M., Vierke, L., Wang, Z. (2020). Strategies for grouping per- and polyfluoroalkyl substances (PFAS) to protect human and environmental health. Environmental Science Processes & Impacts. 22:1444. https://doi.org/10.1039/d0em00147c
[9] Wang, Z., DeWitt, J. C., Higgins, C. P., & Cousins, I. T. (2017). A never-ending story of per- and polyfluoroalkyl substances (PFASs)? Environmental Science & Technology, 51(5), 2508-2518. https://doi.org/10.1021/acs.est.6b04806
[10] Lerner, S. (2016, Mar 3,). A chemical shell game: how DuPont concealed the dangers of the new Teflon Toxin. The Teflon toxin part 8. The Intercept. Retrieved from https://theintercept.com/2016/03/03/how-dupont-concealed-the-dangers-of-the-new-teflon-toxin/
[11] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[12] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[13] Chemsec - The International Chemical Secretariat. (2017). Search the SIN (substitute it now) list: PFOA. Accessed May 22, 2023. Retrieved from http://sinlist.chemsec.org/
[14] The Stockholm Convention on Persistent Organic Pollutants. (2008). All POPs listed in the Stockholm convention. Retrieved from http://chm.pops.int/TheConvention/ThePOPs/AllPOPs/tabid/2509/Default.aspx
[15] The Stockholm Convention on Persistent Organic Pollutants. (2008). All POPs listed in the Stockholm convention. Retrieved from http://chm.pops.int/TheConvention/ThePOPs/AllPOPs/tabid/2509/Default.aspx
[16] The Stockholm Convention on Persistent Organic Pollutants. (2008). All POPs listed in the Stockholm convention. Retrieved from http://chm.pops.int/TheConvention/ThePOPs/AllPOPs/tabid/2509/Default.aspx
[17] Chemsec - The International Chemical Secretariat. (2017). Search the SIN (substitute it now) list: PFOA. Accessed May 22, 2023. Retrieved from http://sinlist.chemsec.org/
[18] The Endocrine Disruptor Exchange, (TEDX). (2017). Search the TEDX list: PFOA. Accessed May 22, 2023. Retrieved from http://endocrinedisruption.org/interactive-tools/tedx-list-of-potential-endocrine-disruptors/search-the-tedx-list
[19] Regulation (EC) no 1272/2008 of the European Parliament and of the Council of 16 December 2008 on classification, labelling and packaging of substances and mixtures, amending and repealing directives 67/548/EEC and 1999/45/EC, and amending regulation (EC) no 1907/2006, (2008). Retrieved from http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:02008R1272-20170101
[20] Office of Environmental Health Hazard Assessment, (OEHHA). (2012). Chemicals Considered or Listed Under Proposition 65: Perfluorooctanoic Acid (PFOA). California Environmental Protection Agency. Accessed May 22, 2023. Retrieved from https://oehha.ca.gov/proposition-65/chemicals/perfluorooctanoic-acid-pfoa-and-its-salts
[21] Office of Environmental Health Hazard Assessment, (OEHHA). (2012). Chemicals Considered or Listed Under Proposition 65: Perfluorooctanoic Acid (PFOA). California Environmental Protection Agency. Accessed May 22, 2023. Retrieved from https://oehha.ca.gov/proposition-65/chemicals/perfluorooctanoic-acid-pfoa-and-its-salts
[22] National Institute of Technology and Evaluation, Japan. (2013). Accessed May 22, 2023. GHS classification results. Retrieved from http://www.safe.nite.go.jp/english/ghs/all_fy_e.html
[23] [OECD] Organisation for Economic Co-operation and Development. (2011). OECD portal on perfluorinated chemicals. Retrieved from http://www.oecd.org/site/0,3407,en_21571361_44787844_1_1_1_1_1,00.html
[24] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[25] Grandjean, P., Andersen, E.W., Budtz-Jorgensen, E., Nielsen, F., Molbak, K., Weihe, P., Heilmann, C. (2012). Serum vaccine antibody concentrations in children exposed to perfluorinated compounds. JAMA. 307(4): 391-397. https://doi.org/10.1001/jama.2011.2034
[26] Fenton, S.E., Ducatman, A., Boobis, A., DeWitt, J.C., Lau, C., Ng, C., Smith, J.S., Roberts, S.M. (2021). Per- and polyfluoroalkyl substance toxicity and human health review: Current state of knowledge and strategies for informing future research. Environ Toxicol Chem. 40(3): 606-630. https://doi.org/10.1002/etc.4890
[27] Calafat, A.M., Wong, L., Kuklenyik, Z., Reidy, J.A., Needham, L.L. (2007). Polyfluoroalkyl chemicals in the U.S. population: Data from the national health and nutrition examination survey (NHANES) 2003-2004 and comparisons with NHANES 1999-2000. Environmental Health Perspectives. 115(11):1596-1602. https://doi.org/10.1289/ehp.10598
[28] Lerner, S. (2015, Aug 20). How Dupont slipped past the EPA. The Intercept. Retrieved from https://theintercept.com/2015/08/20/teflon-toxin-dupont-slipped-past-epa/
[29] Blake, B.E., Cope, H.A., Hall, S.M., Keys, R.D., Mahler, B.W., McCord, J., Scott, B., Stapleton, H.M., Strynar, M.J., Elmore, S.A., Fenton, S.E. (2020). Evaluation of maternal, embryo, and placental effects in CD-1 mice following gestational exposure to perfluorooctanoic acid (PFOA) or hexafluoropropylene oxide dimer acid (HFPO-DA or GenX). Environ Health Perspect. 128:27006. https://doi.org/10.1289/EHP6233
[30] Wang, Z., DeWitt, J. C., Higgins, C. P., & Cousins, I. T. (2017). A never-ending story of per- and polyfluoroalkyl substances (PFASs)? Environmental Science & Technology, 51(5), 2508-2518. https://doi.org/10.1021/acs.est.6b04806
[31] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[32] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[33] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[34] European Chemicals Agency (ECHA). Candidate list of substances of very high concern for authorisation. Accessed May 10, 2023. Retrieved from https://echa.europa.eu/candidate-list-table
[35] Cousins, I.T., DeWitt, J.C., Glüge, J., Goldenman, G., Herzke, D., Lohmann, R., Miller, M., Ng, C.A., Scheringer, M., Vierke, L., Wang, Z. (2020). Strategies for grouping per- and polyfluoroalkyl substances (PFAS) to protect human and environmental health. Environmental Science Processes & Impacts. 22:1444. https://doi.org/10.1039/d0em00147c
[36] European Chemicals Agency (ECHA). Candidate list of substances of very high concern for authorisation. Accessed May 10, 2023. Retrieved from https://echa.europa.eu/candidate-list-table
[37] Cousins, I.T., DeWitt, J.C., Glüge, J., Goldenman, G., Herzke, D., Lohmann, R., Miller, M., Ng, C.A., Scheringer, M., Vierke, L., Wang, Z. (2020). Strategies for grouping per- and polyfluoroalkyl substances (PFAS) to protect human and environmental health. Environmental Science Processes & Impacts. 22:1444. https://doi.org/10.1039/d0em00147c
[38] Blake, B.E., Cope, H.A., Hall, S.M., Keys, R.D., Mahler, B.W., McCord, J., Scott, B., Stapleton, H.M., Strynar, M.J., Elmore, S.A., Fenton, S.E. (2020). Evaluation of maternal, embryo, and placental effects in CD-1 mice following gestational exposure to perfluorooctanoic acid (PFOA) or hexafluoropropylene oxide dimer acid (HFPO-DA or GenX). Environ Health Perspect. 128:27006. https://doi.org/10.1289/EHP6233
[39] Conley, J.M., Lambright, C.S., Evans, N., Strynar, M.J., McCord, J., McIntyre, B.S., Travlos, G.S., Cardon, M.C., Medlock-Kakaley, E., Hartig, P.C., Wilson, V.S., Gray, L.E. Jr. (2019). Adverse maternal, fetal, and postnatal effects of hexafluoropropylene oxide dimer acid (GenX) from oral gestational exposure in Sprague-Dawley rats. Environ Health Perspect. 127:37008. https://doi.org/10.1289/EHP4372
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[41] Guillette, T.C., McCord, J., Guillette, M., Polera, M.E., Rachels, K.T., Morgeson, C., Kotlarz, N., Knappe, D.R.U., Reading, B.J., Strynar, M., Belcher, S.M. (2020). Elevated levels of per- and polyfluoroalkyl substances in Cape Fear River striped bass (Morone saxatilis) are associated with biomarkers of altered immune and liver function. Environ Int. 136:105358. https://doi.org/10.1016/j.envint.2019.105358
[42] Buck, R.C., Franklin, J., Berger, U., Conder, J.M., Cousins, I.T., de Voogt, P., Jensen, A.A., Kannan, K., Mabury, S.A., van Leeuwen, S.PJ. (2011). Perfluoroalkyl and polyfluoroalkyl substances in the environment: Terminology, classification, and origins. Integrated Environmental Assessment and Management. 7(4): 513-541. https://doi.org/10.1002/ieam.258
[43] Wang, Z., DeWitt, J. C., Higgins, C. P., & Cousins, I. T. (2017). A never-ending story of per- and polyfluoroalkyl substances (PFASs)? Environmental Science & Technology. 51(5): 2508-2518. https://doi.org/10.1021/acs.est.6b04806
[44] McCarthy, C., Kappleman, W., DiGuiseppi, W. (2017). Ecological considerations of per- and polyfluoroalkyl substances (PFAS). Curr Pollution Rep. 3: 289-301. https://doi.org/10.1007/s40726-017-0070-8
[45] Wang, Z., DeWitt, J. C., Higgins, C. P., & Cousins, I. T. (2017). A never-ending story of per- and polyfluoroalkyl substances (PFASs)? Environmental Science & Technology. 51(5), 2508-2518. https://doi.org/10.1021/acs.est.6b04806
[46] Butt, C.M., Mabury, S.A., Kwan, M., Wang, X., Muir, D. (2008). Spatial trends of perfluoroalkyl compounds in ringed seals (Phoca hispida) from the Canadian arctic. Environ Toxicol Chem. 27(3):542–53. https://doi.org/10.1897/07-428.1
[47] McCarthy, C., Kappleman, W., DiGuiseppi, W. (2017). Ecological considerations of per- and polyfluoroalkyl substances (PFAS). Curr Pollution Rep. 3: 289-301. https://doi.org/10.1007/s40726-017-0070-8
[48] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[49] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[50] Fenton, S.E., Ducatman, A., Boobis, A., DeWitt, J.C., Lau, C., Ng, C., Smith, J.S., Roberts, S.M. (2021). Per- and polyfluoroalkyl substance toxicity and human health review: Current state of knowledge and strategies for informing future research. Environ Toxicol Chem. 40(3): 606-630. https://doi.org/10.1002/etc.4890
[51] Cheng, W., Doering, J.A., LaLone, C., Ng, C. (2021). Integrative computational approaches to inform relative bioaccumulation potential of per and polyfluoroalkyl substances (PFAS) across species. Toxicol. Sci. https://doi.org/10.1093/toxsci/kfab004
[52] Beans, C. (2021). News feature: How “forever chemicals” might impair the immune system. PNAS. 118(15): e2105018118. https://doi.org/10.1073/pnas.2105018118
[53] Fenton, S.E., Ducatman, A., Boobis, A., DeWitt, J.C., Lau, C., Ng, C., Smith, J.S., Roberts, S.M. (2021). Per- and polyfluoroalkyl substance toxicity and human health review: Current state of knowledge and strategies for informing future research. Environ Toxicol Chem. 40(3): 606-630. https://doi.org/10.1002/etc.4890
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