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Liddie JM, Bind MA, Karra M, Sunderland EM. County-level associations between drinking water PFAS contamination and COVID-19 mortality in the United States. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2024:10.1038/s41370-024-00723-5. [PMID: 39369072 DOI: 10.1038/s41370-024-00723-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 09/23/2024] [Accepted: 09/25/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Epidemiologic and animal studies both support relationships between exposures to per- and polyfluoroalkyl substances (PFAS) and harmful effects on the immune system. Accordingly, PFAS have been identified as potential environmental risk factors for adverse COVID-19 outcomes. OBJECTIVE Here, we examine associations between PFAS contamination of U.S. community water systems (CWS) and county-level COVID-19 mortality records. Our analyses leverage two datasets: one at the subnational scale (5371 CWS serving 621 counties) and one at the national scale (4798 CWS serving 1677 counties). The subnational monitoring dataset was obtained from statewide drinking monitoring of PFAS (2016-2020) and the national monitoring dataset was obtained from a survey of unregulated contaminants (2013-2015). METHODS We conducted parallel analyses using multilevel quasi-Poisson regressions to estimate cumulative incidence ratios for the association between county-level measures of PFAS drinking water contamination and COVID-19 mortality prior to vaccination onset (Jan-Dec 2020). In the primary analyses, these regressions were adjusted for several county-level sociodemographic factors, days after the first reported case in the county, and total hospital beds. RESULTS In the subnational analysis, detection of at least one PFAS over 5 ng/L was associated with 12% higher [95% CI: 4%, 19%] COVID-19 mortality. In the national analysis, detection of at least one PFAS above the reporting limits (20-90 ng/L) was associated with 13% higher [95% CI: 8%, 19%] COVID-19 mortality. IMPACT STATEMENT Our findings provide evidence for an association between area-level drinking water PFAS contamination and higher COVID-19 mortality in the United States. These findings reinforce the importance of ongoing state and federal monitoring efforts supporting the U.S. Environmental Protection Agency's 2024 drinking water regulations for PFAS. More broadly, this example suggests that drinking water quality could play a role in infectious disease severity. Future research would benefit from study designs that combine area-level exposure measures with individual-level outcome data.
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Affiliation(s)
- Jahred M Liddie
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Marie-Abèle Bind
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mahesh Karra
- Frederick S. Pardee School of Global Studies, Boston University, Boston, MA, USA
| | - Elsie M Sunderland
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
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Timmermann A, Johansen IS, Tolstrup M, Heilmann C, Budtz-Jørgensen E, Tolstrup JS, Nielsen F, Grandjean P. Antibody response to SARS-CoV-2 mRNA vaccination in Danish adults exposed to perfluoroalkyl substances (PFASs): The ENFORCE study. ENVIRONMENTAL RESEARCH 2024; 263:120039. [PMID: 39326653 DOI: 10.1016/j.envres.2024.120039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 09/08/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
INTRODUCTION Per- and polyfluoroalkyl substances (PFASs) have immunotoxic effects in children while studies in adults, including recent studies on the SARS-CoV-2 vaccine response have been less consistent. In a cohort of 50-69-year-olds repeatedly vaccinated against COVID-19 in Denmark from early 2021, we aimed to assess the association between serum-PFAS concentrations and SARS-CoV-2 antibody responses. METHODS We assessed serum-PFAS concentrations among 371 middle-aged adults from the National Cohort Study of Effectiveness and Safety of SARS-CoV-2 vaccines (ENFORCE) who had received their first vaccination against COVID-19. Following the second dose and the booster (third) Pfizer-BioNTech mRNA vaccination, we measured the specific spike IgG antibody response. Associations between serum-PFAS concentrations at inclusion and spike IgG antibody concentrations after vaccination were assessed using median regression, and analyses were adjusted for age, sex, presence of diabetes, number of vaccines received, and time since vaccination. We further examined the associations between serum-PFAS concentrations at inclusion and changes in spike IgG antibody concentration between the second dose and booster (third) vaccination. RESULTS Serum-PFAS concentrations were not associated with spike IgG antibody concentrations after the SARS-CoV-2 vaccinations, but the increase in response after the booster (third) vaccination compared to after the second vaccination was consistently lower at higher serum-PFAS concentrations. Each doubling in the concentration of seven serum-PFASs was associated with a 802 BAU/mL lower median increase in spike IgG antibody response after the booster (third) vaccination (95% CI: -1812; 208) adjusted for confounders. DISCUSSION As many adults were probably not immunological naïve prior to vaccination, our results were likely affected by individual variability in immune response to the vaccination. Despite this uncertainty, the diminished increase in SARS-CoV-2 spike antibody response after the booster (third) vaccination at higher PFAS exposure may potentially reflect an immunotoxic impact of the PFASs.
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Affiliation(s)
- Amalie Timmermann
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Isik S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Research Unit of Infectious Diseases, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Martin Tolstrup
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Carsten Heilmann
- Department of Pediatrics and Adolescent Medicine, Pediatric Hematopoietic Stem Cell Transplantation and Immunodeficiency, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | | | - Janne S Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Flemming Nielsen
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark.
| | - Philippe Grandjean
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark; Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, RI, United States.
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Tursi AR, Lindeman B, Kristoffersen AB, Hjertholm H, Bronder E, Andreassen M, Husøy T, Dirven H, Andorf S, Nygaard UC. Immune cell profiles associated with human exposure to perfluorinated compounds (PFAS) suggest changes in natural killer, T helper, and T cytotoxic cell subpopulations. ENVIRONMENTAL RESEARCH 2024; 256:119221. [PMID: 38795951 DOI: 10.1016/j.envres.2024.119221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 05/28/2024]
Abstract
Per- and polyfluoroalkyl substances (PFAS) constitutes a group of highly persistent man-made substances. Recent evidence indicates that PFAS negatively impact the immune system. However, it remains unclear how different PFAS are associated with alterations in circulating leukocyte subpopulations. More detailed knowledge of such potential associations can provide better understanding into mechanisms of PFAS immunotoxicity in humans. In this exploratory study, associations of serum levels of common PFAS (perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS)) and immune cell profiles of peripheral blood mononuclear cells, both with and without immunostimulation, were investigated. High-dimensional single cell analysis by mass cytometry was done on blood leukocytes from fifty participants in the Norwegian human biomonitoring EuroMix study. Different PFAS were associated with changes in various subpopulations of natural killer (NK), T helper (Th), and cytotoxic T (Tc) cells. Broadly, PFAS concentrations were related to increased frequencies of NK cells and activated subpopulations of NK cells. Additionally, increased levels of activated T helper memory cell subpopulations point to Th2/Th17 and Treg-like skewed profiles. Finally, PFAS concentrations were associated with decreased frequencies of T cytotoxic cell subpopulations with CXCR3+ effector memory (EM) phenotypes. Several of these observations point to biologically plausible mechanisms that may contribute to explaining the epidemiological reports of immunosuppression by PFAS. Our results suggest that PFAS exposures even at relatively low levels are associated with changes in immune cell subpopulations, a finding which should be explored more thoroughly in a larger cohort. Additionally, causal relationships should be confirmed in experimental studies. Overall, this study demonstrates the strength of profiling by mass cytometry in revealing detailed changes in immune cells at a single cell level.
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Affiliation(s)
- Amanda R Tursi
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | | | | - Trine Husøy
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Sandra Andorf
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Beyerlein A, Heinze S, Quartucci C, Katz K. No increased rates of COVID-19 breakthrough infections in Altötting, a Bavarian district with a history of environmental PFOA contamination-results from a retrospective observational study. Infection 2024; 52:1639-1642. [PMID: 38480642 PMCID: PMC11289349 DOI: 10.1007/s15010-024-02230-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/07/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Andreas Beyerlein
- Bavarian Health and Food Safety Authority, Oberschleißheim, Germany.
- Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit, Lazarettstraße 67, 80636, München, Germany.
| | - Stefanie Heinze
- Bavarian Health and Food Safety Authority, Oberschleißheim, Germany
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Caroline Quartucci
- Bavarian Health and Food Safety Authority, Oberschleißheim, Germany
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Katz
- Bavarian Health and Food Safety Authority, Oberschleißheim, Germany
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Pierpont TM, Elmore J, Redko A, Anannya O, Imbiakha B, O'Hare K, Villanueva A, Anronikov S, Bondah N, Chang S, Sahler J, August A. Effects of Perfluorohexane Sulfonate Exposure on Immune Cell Populations in Naive Mice. Immunohorizons 2024; 8:538-549. [PMID: 39109956 PMCID: PMC11374752 DOI: 10.4049/immunohorizons.2300049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/10/2024] [Indexed: 09/08/2024] Open
Abstract
Perfluorohexane sulfonate (PFHxS) is a member of the per- and polyfluoroalkyls (PFAS) superfamily of molecules, characterized by their fluorinated carbon chains and use in a wide range of industrial applications. PFHxS and perfluorooctane sulfonate are able to accumulate in the environment and in humans with the approximated serum elimination half-life in the range of several years. More recently, some PFAS compounds have also been suggested as potential immunosuppressants. In this study, we analyze immune cell numbers in mice following 28-d repeated oral exposure to potassium PFHxS at 12, 120, 1,200, and 12,000 ng/kg/d, with resulting serum levels ranging up to ∼1,600 ng/ml, approximating ranges found in the general population and at higher levels in PFAS workers. The immunosuppressant cyclophosphamide was analyzed as a positive control. B cells, T cells, and granulocytes from the bone marrow, liver, spleen, lymph nodes, and thymus were evaluated. We found that at these exposures, there was no effect of PFHxS on major T or B cell populations, macrophages, dendritic cells, basophils, mast cells, eosinophils, neutrophils, or circulating Ab isotypes. By contrast, mice exposed to cyclophosphamide exhibited depletion of several granulocyte and T and B cell populations in the thymus, bone marrow, and spleen, as well as reductions in IgG1, IgG2b, IgG2c, IgG3, IgE, and IgM. These data indicate that exposures of up to 12,000 ng/kg of PFHxS for 28 d do not affect immune cell numbers in naive mice, which provides valuable information for assessing the risks and health influences of exposures to this compound.
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Affiliation(s)
| | - Jessica Elmore
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Amie Redko
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Orchi Anannya
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Brian Imbiakha
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Katelyn O'Hare
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Alanis Villanueva
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Sasha Anronikov
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Narda Bondah
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | | | - Julie Sahler
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
| | - Avery August
- Department of Microbiology & Immunology, Cornell University, Ithaca, NY
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Porter AK, Kleinschmidt SE, Andres KL, Reusch CN, Krisko RM, Taiwo OA, Olsen GW, Longnecker MP. Occurrence of COVID-19 and serum per- and polyfluoroalkyl substances: A case-control study among workers with a wide range of exposures. GLOBAL EPIDEMIOLOGY 2024; 7:100137. [PMID: 38293561 PMCID: PMC10826147 DOI: 10.1016/j.gloepi.2024.100137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/01/2024] Open
Abstract
Per- and polyfluoroalkyl substances (PFAS) are a broad class of synthetic chemicals; some are present in most humans in developed countries. Some studies suggest that certain PFAS may have immunotoxic effects in humans, which could put individuals with high levels of exposure at increased risk for infectious diseases such as COVID-19. We conducted a case-control study to examine the association between COVID-19 diagnosis and PFAS serum concentrations among employees and retirees from two 3 M facilities, one of which historically generated perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), and perfluorohexane sulfonic acid (PFHxS). Participants completed enrollment and follow-up study visits in the Spring of 2021. Participants were categorized as cases if they reported a COVID-19 diagnosis or became sick with at least one symptom of COVID-19 when someone else in their household was diagnosed, otherwise they were categorized as a control. COVID-19 diagnosis was modeled in relation to concentration of serum PFAS measured at enrollment after adjusting for covariates. The analytic sample comprised 573 individuals, 111 cases (19.4%) and 462 controls (80.6%). In adjusted models, the odds ratio of COVID-19 was 0.94 per interquartile range (14.3 ng/mL) increase in PFOS (95% confidence interval 0.85, 1.04). Results for PFOA, PFHxS, and perfluorononanoic acid (PFNA) were similar. Other PFAS present at lower concentrations were examined as categorical variables (above the limit of quantification [LOQ], yes vs. no [referent category]), and also showed no positive associations. In our study, which used individual-level data and included people with high occupational exposure, the serum concentrations of all PFAS examined were not associated with an increased odds ratio for COVID-19. At this point, the epidemiologic data supporting no association of COVID-19 occurrence with PFAS exposure are stronger than those suggesting a positive association.
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Affiliation(s)
- Anna K. Porter
- Ramboll U.S. Consulting, 3214 Charles B. Root Wynd, Suite 130, Raleigh, NC 27612, United States of America
| | - Sarah E. Kleinschmidt
- 3M Company, Corporate Occupational Medicine, St. Paul, MN 55144, United States of America
| | - Kara L. Andres
- 3M Company, Corporate Occupational Medicine, St. Paul, MN 55144, United States of America
| | - Courtney N. Reusch
- 3M Company, Corporate Occupational Medicine, St. Paul, MN 55144, United States of America
| | - Ryan M. Krisko
- 3M Company, Environment, Health, Safety and Product Stewardship, St. Paul, MN 55144, United States of America
| | - Oyebode A. Taiwo
- 3M Company, Corporate Occupational Medicine, St. Paul, MN 55144, United States of America
| | - Geary W. Olsen
- 3M Company, Corporate Occupational Medicine, St. Paul, MN 55144, United States of America
| | - Matthew P. Longnecker
- Ramboll U.S. Consulting, 3214 Charles B. Root Wynd, Suite 130, Raleigh, NC 27612, United States of America
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7
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Iannone A, Carriera F, Passarella S, Fratianni A, Avino P. There's Something in What We Eat: An Overview on the Extraction Techniques and Chromatographic Analysis for PFAS Identification in Agri-Food Products. Foods 2024; 13:1085. [PMID: 38611389 PMCID: PMC11011820 DOI: 10.3390/foods13071085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
Per- and polyfluorinated alkyl substances (PFASs) are a group of anthropogenic chemicals used in a range of industrial processes and consumer products. Recently, their ubiquitous presence in the environment as well as their toxicological effects in humans have gained relevant attention. Although the occurrence of PFASs is widely investigated in scientific community, the standardization of analytical method for all matrices still remains an important issue. In this review, we discussed extraction and detection methods in depth to evaluate the best procedures of PFAS identification in terms of analytical parameters (e.g., limits of detection (LODs), limits of quantification (LOQs), recoveries). Extraction approaches based on liquid-liquid extraction (LLE), alkaline digestion, and solid phase extraction (SPE), followed by liquid chromatography-mass spectrometry (LC-MS) and gas chromatography-mass spectrometry (GC-MS) analysis are the main analytical methods applied in the literature. The results showed detectable recoveries of PFOA and PFOS in meat, milk, vegetables, eggs products (90.6-101.2% and of 89.2-98.4%), and fish (96-108%). Furthermore, the low LOD and LOQ values obtained for meat (0.00592-0.01907 ng g-1; 0.050 ng g-1), milk (0.003-0.009 ng g-1; 0.010-0.027 ng g-1), fruit (0.002-0.009 ng g-1; 0.006-0.024 ng g-1), and fish (0.00369-0.017.33 ng g-1; 0.05 ng g-1) also confirmed the effectiveness of the recent quick, easy, cheap, effective, rugged, and safe method (QuEChERS) for simple, speedy, and sensitive ultra-trace PFAS analysis.
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Affiliation(s)
- Alessia Iannone
- Department of Agriculture, Environmental and Food Sciences, University of Molise, Via De Sanctis, IT-86100 Campobasso, Italy; (A.I.); (F.C.); (S.P.); (A.F.)
| | - Fabiana Carriera
- Department of Agriculture, Environmental and Food Sciences, University of Molise, Via De Sanctis, IT-86100 Campobasso, Italy; (A.I.); (F.C.); (S.P.); (A.F.)
| | - Sergio Passarella
- Department of Agriculture, Environmental and Food Sciences, University of Molise, Via De Sanctis, IT-86100 Campobasso, Italy; (A.I.); (F.C.); (S.P.); (A.F.)
| | - Alessandra Fratianni
- Department of Agriculture, Environmental and Food Sciences, University of Molise, Via De Sanctis, IT-86100 Campobasso, Italy; (A.I.); (F.C.); (S.P.); (A.F.)
| | - Pasquale Avino
- Department of Agriculture, Environmental and Food Sciences, University of Molise, Via De Sanctis, IT-86100 Campobasso, Italy; (A.I.); (F.C.); (S.P.); (A.F.)
- Institute of Atmospheric Pollution Research, Division of Rome, c/o Ministry of Environment and Energy Security, Via Cristoforo Colombo 44, IT-00147 Rome, Italy
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8
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Zhou T, Li X, Liu H, Dong S, Zhang Z, Wang Z, Li J, Nghiem LD, Khan SJ, Wang Q. Occurrence, fate, and remediation for per-and polyfluoroalkyl substances (PFAS) in sewage sludge: A comprehensive review. JOURNAL OF HAZARDOUS MATERIALS 2024; 466:133637. [PMID: 38306831 DOI: 10.1016/j.jhazmat.2024.133637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
Addressing per-and polyfluoroalkyl substances (PFAS) contamination is an urgent environmental concern. While most research has focused on PFAS contamination in water matrices, comparatively little attention has been given to sludge, a significant by-product of wastewater treatment. This critical review presents the latest information on emission sources, global distribution, international regulations, analytical methods, and remediation technologies for PFAS in sludge and biosolids from wastewater treatment plants. PFAS concentrations in sludge matrices are typically in hundreds of ng/g dry weight (dw) in developed countries but are rarely reported in developing and least-developed countries due to the limited analytical capability. In comparison to water samples, efficient extraction and cleaning procedures are crucial for PFAS detection in sludge samples. While regulations on PFAS have mainly focused on soil due to biosolids reuse, only two countries have set limits on PFAS in sludge or biosolids with a maximum of 100 ng/g dw for major PFAS. Biological technologies using microbes and enzymes present in sludge are considered as having high potential for PFAS remediation, as they are eco-friendly, low-cost, and promising. By contrast, physical/chemical methods are either energy-intensive or linked to further challenges with PFAS contamination and disposal. The findings of this review deepen our comprehension of PFAS in sludge and have guided future research recommendations.
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Affiliation(s)
- Ting Zhou
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Xuan Li
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia.
| | - Huan Liu
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Shiman Dong
- Department of Life Sciences and Systems Biology, University of Torino, Via Accademia Albertina 13, Turin 10123, Italy
| | - Zehao Zhang
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Zhenyao Wang
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Jibin Li
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Long D Nghiem
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Stuart J Khan
- School of Civil Engineering, University of Sydney, NSW 2006, Australia
| | - Qilin Wang
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia.
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Hollister J, Caban-Martinez AJ, Ellingson KD, Beitel S, Fowlkes AL, Lutrick K, Tyner HL, Naleway AL, Yoon SK, Gaglani M, Hunt D, Meece J, Mayo Lamberte J, Schaefer Solle N, Rose S, Dunnigan K, Khan SM, Kuntz JL, Fisher JM, Coleman A, Britton A, Thiese MS, Hegmann KT, Pavuk M, Ramadan FA, Fuller S, Nematollahi A, Sprissler R, Burgess JL. Serum per- and polyfluoroalkyl substance concentrations and longitudinal change in post-infection and post-vaccination SARS-CoV-2 antibodies. ENVIRONMENTAL RESEARCH 2023; 239:117297. [PMID: 37816422 PMCID: PMC10842580 DOI: 10.1016/j.envres.2023.117297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/17/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
Per- and polyfluoroalkyl substances (PFAS) are ubiquitous throughout the United States. Previous studies have shown PFAS exposure to be associated with a reduced immune response. However, the relationship between serum PFAS and antibody levels following SARS-CoV-2 infection or COVID-19 vaccination has not been examined. We examined differences in peak immune response and the longitudinal decline of antibodies following SARS-CoV-2 infection and COVID-19 vaccination by serum PFAS levels in a cohort of essential workers in the United States. We measured serum antibodies using an in-house semi-quantitative enzyme-linked immunosorbent assay (ELISA). Two cohorts contributed blood samples following SARS-CoV-2 infection or COVID-19 vaccination. We used linear mixed regression models, adjusting for age, race/ethnicity, gender, presence of chronic conditions, location, and occupation, to estimate differences in immune response with respect to serum PFAS levels. Our study populations included 153 unvaccinated participants that contributed 316 blood draws over a 14-month period following infection, and 860 participants and 2451 blood draws over a 12-month period following vaccination. Higher perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA) concentrations were associated with a lower peak antibody response after infection (p = 0.009, 0.031, 0.015). Higher PFOS, perfluorooctanoic acid (PFOA), PFHxS, and PFNA concentrations were associated with slower declines in antibodies over time after infection (p = 0.003, 0.014, 0.026, 0.025). PFOA, PFOS, PFHxS, and PFNA serum concentrations prior to vaccination were not associated with differences in peak antibody response after vaccination or with differences in decline of antibodies over time after vaccination. These results suggest that elevated PFAS may impede potential immune response to SARS-CoV-2 infection by blunting peak antibody levels following infection; the same finding was not observed for immune response to vaccination.
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Affiliation(s)
- James Hollister
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.
| | - Alberto J Caban-Martinez
- Department of Public Health Sciences and Physical Medicine and Rehabilitation, University of Miami, Miller School of Medicine, USA
| | - Katherine D Ellingson
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Shawn Beitel
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | | | - Karen Lutrick
- College of Medicine - Tucson, University of Arizona, Tucson, AZ, USA
| | | | - Allison L Naleway
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Sarang K Yoon
- University of Utah Health, Rocky Mountain Center for Occupational and Environmental Health, USA
| | - Manjusha Gaglani
- Baylor Scott and White Health, Temple, TX, USA; Texas A&M University College of Medicine, Temple, TX, USA
| | | | | | | | - Natasha Schaefer Solle
- Department of Public Health Sciences and Physical Medicine and Rehabilitation, University of Miami, Miller School of Medicine, USA
| | | | | | - Sana M Khan
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | | | - Alissa Coleman
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | | | - Matthew S Thiese
- Rocky Mountain Center for Occupational and Environmental Health, University of Utah, Salt Lake City, UT, USA
| | - Kurt T Hegmann
- Rocky Mountain Center for Occupational and Environmental Health, University of Utah, Salt Lake City, UT, USA
| | - Marian Pavuk
- Agency for Toxic Substances and Disease Registry, CDC, Atlanta, GA, USA
| | - Ferris A Ramadan
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, USA
| | | | - Amy Nematollahi
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Ryan Sprissler
- University of Arizona Genetics Core, Office for Research, Innovation and Impact, University of Arizona, Tucson, AZ, USA
| | - Jefferey L Burgess
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
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Burgoon LD, Clewell HJ, Cox T, Dekant W, Dell LD, Deyo JA, Dourson ML, Gadagbui BK, Goodrum P, Green LC, Vijayavel K, Kline TR, House-Knight T, Luster MI, Manning T, Nathanail P, Pagone F, Richardson K, Severo-Peixe T, Sharma A, Smith JS, Verma N, Wright J. Range of the perfluorooctanoate (PFOA) safe dose for human health: An international collaboration. Regul Toxicol Pharmacol 2023; 145:105502. [PMID: 38832926 DOI: 10.1016/j.yrtph.2023.105502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/16/2023] [Accepted: 09/28/2023] [Indexed: 06/06/2024]
Abstract
Many government agencies and expert groups have estimated a dose-rate of perfluorooctanoate (PFOA) that would protect human health. Most of these evaluations are based on the same studies (whether of humans, laboratory animals, or both), and all note various uncertainties in our existing knowledge. Nonetheless, the values of these various, estimated, safe-doses vary widely, with some being more than 100,000 fold different. This sort of discrepancy invites scrutiny and explanation. Otherwise what is the lay public to make of this disparity? The Steering Committee of the Alliance for Risk Assessment (2022) called for scientists interested in attempting to understand and narrow these disparities. An advisory committee of nine scientists from four countries was selected from nominations received, and a subsequent invitation to scientists internationally led to the formation of three technical teams (for a total of 24 scientists from 8 countries). The teams reviewed relevant information and independently developed ranges for estimated PFOA safe doses. All three teams determined that the available epidemiologic information could not form a reliable basis for a PFOA safe dose-assessment in the absence of mechanistic data that are relevant for humans at serum concentrations seen in the general population. Based instead on dose-response data from five studies of PFOA-exposed laboratory animals, we estimated that PFOA dose-rates 10-70 ng/kg-day are protective of human health.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Anurag Sharma
- Nitte University Centre for Science Education and Research, India
| | | | - Nitin Verma
- Chitkara University School of Pharmacy, Chitkara University Himachal Pradesh, India
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11
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Pumarega J, Gasull M, Koponen J, Campi L, Rantakokko P, Henríquez-Hernández LA, Aguilar R, Donat-Vargas C, Zumbado M, Villar-García J, Rius C, Santiago-Díaz P, Vidal M, Jimenez A, Iglesias M, Dobaño C, Moncunill G, Porta M. Prepandemic personal concentrations of per- and polyfluoroalkyl substances (PFAS) and other pollutants: Specific and combined effects on the incidence of COVID-19 disease and SARS-CoV-2 infection. ENVIRONMENTAL RESEARCH 2023; 237:116965. [PMID: 37652221 DOI: 10.1016/j.envres.2023.116965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE To investigate the specific and combined effects of personal concentrations of some per- and polyfluoroalkyl substances (PFAS), other persistent organic pollutants (POPs), and chemical elements -measured in individuals' blood several years before the pandemic- on the development of SARS-CoV-2 infection and COVID-19 disease in the general population. METHODS We conducted a prospective cohort study in 240 individuals from the general population of Barcelona. PFAS, other POPs, and chemical elements were measured in plasma, serum, and whole blood samples, respectively, collected in 2016-2017. PFAS were analyzed by liquid chromatography-triple quadrupole mass spectrometry. SARS-CoV-2 infection was detected by rRT-PCR in nasopharyngeal swabs and/or antibody serology in blood samples collected in 2020-2021. RESULTS No individual PFAS nor their mixtures were significantly associated with SARS-CoV-2 seropositivity or COVID-19 disease. Previously identified mixtures of POPs and elements (Porta et al., 2023) remained significantly associated with seropositivity and COVID-19 when adjusted for PFAS (all OR > 4 or p < 0.05). Nine chemicals comprised mixtures associated with COVID-19: thallium, ruthenium, lead, benzo[b]fluoranthene, DDD, other DDT-related compounds, manganese, tantalum, and aluminium. And nine chemicals comprised the mixtures more consistently associated with SARS-CoV-2 seropositivity: thallium, ruthenium, lead, benzo[b]fluoranthene, DDD, gold, and (protectively) selenium, indium, and iron. CONCLUSIONS The PFAS studied were not associated with SARS-CoV-2 seropositivity or COVID-19. The results confirm the associations between personal blood concentrations of some POPs and chemical elements and the risk of COVID-19 and SARS-CoV-2 infection in what remains the only prospective and population-based cohort study on the topic. Mixtures of POPs and chemical elements may contribute to explain the heterogeneity in the risks of SARS-CoV-2 infection and COVID-19 in the general population.
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Affiliation(s)
- José Pumarega
- School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Hospital del Mar Research Institute, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
| | - Magda Gasull
- Hospital del Mar Research Institute, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Jani Koponen
- Finnish Institute for Health and Welfare (THL), Kuopio, Finland
| | - Laura Campi
- Hospital del Mar Research Institute, Barcelona, Spain
| | - Panu Rantakokko
- Finnish Institute for Health and Welfare (THL), Kuopio, Finland
| | - Luis A Henríquez-Hernández
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Canary Islands, Spain; CIBER de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - Ruth Aguilar
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Carolina Donat-Vargas
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; ISGlobal, Campus Mar, Barcelona, Spain; Cardiovascular and Nutritonal Epidemiology Unit, Institut of Enviornmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Manuel Zumbado
- Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Canary Islands, Spain; CIBER de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | | | - Cristina Rius
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Catalonia, Spain; Agència de Salut Pública de Barcelona, Barcelona, Spain
| | | | - Marta Vidal
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Alfons Jimenez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Mar Iglesias
- Hospital del Mar Research Institute, Barcelona, Spain
| | - Carlota Dobaño
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Gemma Moncunill
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Miquel Porta
- School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Hospital del Mar Research Institute, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Catalonia, Spain.
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12
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Bailey JM, Wang L, McDonald JM, Gray JS, Petrie JG, Martin ET, Savitz DA, Karrer TA, Fisher KA, Geiger MJ, Wasilevich EA. Immune response to COVID-19 vaccination in a population with a history of elevated exposure to per- and polyfluoroalkyl substances (PFAS) through drinking water. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2023; 33:725-736. [PMID: 37337047 PMCID: PMC10541329 DOI: 10.1038/s41370-023-00564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Exposure to per- and polyfluoroalkyl substances (PFAS) has been linked to lower vaccine-induced antibody concentrations in children, while data from adults remains limited and equivocal. Characteristics of PFAS exposure and age at vaccination may modify such effects. OBJECTIVE We used the mass administration of novel COVID-19 vaccines to test the hypothesis that prior exposure to environmentally-relevant concentrations of PFAS affect antibody response to vaccines in adolescents and adults. METHODS Between April and June 2021, 226 participants aged 12-90 years with a history of exposure to PFAS in drinking water and who received an mRNA COVID-19 vaccine participated in our prospective cohort study. SARS-CoV-2 anti-spike and anti-nucleocapsid antibodies (IgG) were quantified before the first and second vaccine doses and again at two follow-ups in the following months (up to 103 days post dose 1). Serum PFAS concentrations (n = 39 individual PFAS) were measured once for each participant during baseline, before their first vaccination. The association between PFAS exposure and immune response to vaccination was investigated using linear regression and generalized estimating equation (GEE) models with adjustment for covariates that affect antibody response. PFAS mixture effects were assessed using weighted quantile sum and Bayesian kernel machine regression methods. RESULTS The geometric mean (standard deviation) of perfluorooctane sulfonate and perfluorooctanoic acid serum concentrations in this population was 10.49 (3.22) and 3.90 (4.90) µg/L, respectively. PFAS concentrations were not associated with peak anti-spike antibody response, the initial increase in anti-spike antibody response following vaccination, or the waning over time of the anti-spike antibody response. Neither individual PFAS concentrations nor their evaluation as a mixture was associated with antibody response to mRNA vaccination against COVID-19. IMPACT STATEMENT Given the importance of understanding vaccine response among populations exposed to environmental contaminants and the current gaps in understanding this relationship outside of early life/childhood vaccinations, our manuscript contributes meaningful data from an adolescent and adult population receiving a novel vaccination.
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Affiliation(s)
- Jordan M Bailey
- Division of Environmental Health, Michigan Department of Health and Human Services, Lansing, MI, USA.
| | - Ling Wang
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Jennifer M McDonald
- Division of Environmental Health, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Jennifer S Gray
- Division of Environmental Health, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Joshua G Petrie
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Emily T Martin
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - David A Savitz
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Timothy A Karrer
- Division of Chemistry and Toxicology, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Keri A Fisher
- Division of Chemistry and Toxicology, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Matthew J Geiger
- Division of Chemistry and Toxicology, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Elizabeth A Wasilevich
- Division of Environmental Health, Michigan Department of Health and Human Services, Lansing, MI, USA
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13
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Andersson AG, Lundgren A, Xu Y, Nielsen C, Lindh CH, Pineda D, Cederlund J, Pataridou E, Søgaard Tøttenborg S, Ugelvig Petersen K, Fletcher T, Lagging M, Bemark M, Jakobsson K, Li Y. High Exposure to Perfluoroalkyl Substances and Antibody Responses to SARS-CoV-2 mRNA Vaccine-an Observational Study in Adults from Ronneby, Sweden. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:87007. [PMID: 37578904 PMCID: PMC10424820 DOI: 10.1289/ehp11847] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 05/01/2023] [Accepted: 07/03/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Per- and polyfluoroalkyl substances (PFAS) are widely used, environmentally ubiquitous, and stable chemicals that have been associated with lower vaccine-induced antibody responses in children; however, data on adults are limited. The drinking water from one of the two waterworks in Ronneby, Sweden, was heavily contaminated for decades with PFAS from firefighting foams, primarily perfluorohexane sulfonic acid and perfluorooctanesulfonic acid (PFOS). Vaccination against SARS-CoV-2 offered a unique opportunity to investigate antibody responses to primary vaccination in adults who had been exposed to PFAS. OBJECTIVES Our objective was to evaluate associations between PFAS, across a wide range of exposure levels, and antibody responses in adults 5 wk and 6 months after a two-dose vaccination regime against SARS-CoV-2. METHODS Adults age 20-60 y from Ronneby (n = 309 , median PFOS serum level 47 ng / mL , fifth to 95th percentile 4 - 213 ng / mL ) and a group with background exposure (n = 47 , median PFOS serum level 4 ng / mL ) received two doses of the Spikevax (Moderna) mRNA vaccine. The levels of seven PFAS were measured in serum before vaccination. Serum immunoglobulin G antibodies against the SARS-CoV-2 spike antigen (S-Abs) were measured before vaccination and at 5 wk (n = 350 ) and 6 months (n = 329 ) after the second vaccine dose. Linear regression analyses were fitted against current, historical, and prenatal exposure to PFAS, adjusting for sex, age, and smoking, excluding individuals with previous SARS-CoV-2-infection. RESULTS PFAS exposure, regardless of how it was estimated, was not negatively associated with antibody levels 5 wk [current PFOS: - 0.5 % S-Abs/PFOS interquartile range (IQR); 95% confidence interval (CI): - 8 , 7] or 6 months (current PFOS: 3% S-Abs/PFOS IQR; 95% CI: - 6 , 12) after COVID-19 vaccination. DISCUSSION Following a strict study protocol, rigorous study design, and few dropouts, we found no indication that PFAS exposure negatively affected antibody responses to COVID-19 mRNA vaccination for up to 6 months after vaccination. https://doi.org/10.1289/EHP11847.
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Affiliation(s)
- Axel G Andersson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Lundgren
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yiyi Xu
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christel Nielsen
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian H Lindh
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Daniela Pineda
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | | | | | - Sandra Søgaard Tøttenborg
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kajsa Ugelvig Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Tony Fletcher
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Martin Lagging
- Department of Infectious Diseases, Institute of Biomedicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Bemark
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Jakobsson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ying Li
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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14
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Starling AP. Invited Perspective: Per- and Polyfluoroalkyl Substances and Impaired Antibody Response to Vaccination-Who Is Affected? ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:81304. [PMID: 37578903 PMCID: PMC10424815 DOI: 10.1289/ehp12971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/19/2023] [Accepted: 07/03/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Anne P. Starling
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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