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X. Kapotth, M.A., Ph.D.
Medical Instructor, University of Houston
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I think you may have heard some testimony of the folks before you who claim that the military still believes that these chemicals are necessary to fight fires, although in your testimony you talk about a number of alternatives. Senator Peters, I would first like to thank you for your leadership on these fluorine-free foams. With what we are using right now, the training is very limited, and it is on a very sporadic basis. Amico, I just wanted to thank you again for taking the time out of what I know is a very busy schedule and time away from your family to come here to D. As you mentioned in our meeting earlier, your husband was employed for a company on Pease for almost 9 years, and both of your children have attended daycare on Pease since they were, what, about 12 weeks old It is impacting several communities 36 across the country, and it is causing a lot of stress for people. The fear of the unknown, having these exposures, in some communities having blood testing that shows high levels but not quite knowing what those high levels in the blood mean is creating worry and fear for people. We are extremely grateful for the health study that will be coming down the pike for our community that may will benefit from. But we are also seeing that people are having to absorb the financial costs of the contamination, which is incredibly wrong. Like I said in my testimony, people are having to pay for their own filters or for bottled water. If communities are not being offered blood testing, some are opting to pay for their own blood testing, which is very expensive. I think we are seeing communities face emotional, physical, and financial impacts because of this contamination. It is very confusing for community members, and it is also very alarming-what are these States seeing, what science are they analyzing that they are coming to these different numbers I say that based on information that I have read in some of the New Jersey data that has come out of their Drinking Water Quality Institute and looking at most sensitive populations and also in my discussions with other researchers and academics across the country. No, to me that is a sensitive popu- 37 lation that we need to be more protective of. As we heard earlier in the statements by the government officials, it is a widespread issue. We all have some level of exposure, but we have a large and growing amount of community members that we are discovering have a very high exposure, and we need to take those folks into consideration as well as we move forward with next steps. You and your colleagues Alayna Davis and Michelle Dalton have done incredible work, and you are continuing to do it with community groups like Testing for Pease. It has been, obviously, really important to the safety of all citizens impacted by dangerous contaminants in our drinking water. In your opinion, what can we as elected officials do to help important action groups like yours continue to succeed It is disheartening to hear that meaningful action can take 5 and 10 years when at Pease we are coming up on 5 years of discovering our contamination. We have several of them found in drinking water across the country, and we need to regulate it as a class. We also need to provide biomonitoring and blood testing for impacted community members, and we also need to provide medical monitoring, which is a program that folks can participate in with their physicians to better monitor their health in the setting of the exposure. The health study, there will be a lot of benefits that come from that, but we heard from Dr. We could not prevent this contamination from happening, but what can we do moving forward to protect our health I take it, given that Europe and, I think you said, Australia already have gotten there, that you might think that we do not need more research, we just need to use their example and get going on a transition. We should use it for our own research and moving forward and getting what we need here. Again, I very much appreciate being able to be part of this very important hearing on an issue that, as we heard from the first panel-and you all clearly can confirm-this is an issue that affects tens of millions of people across the country.
With recurrence of lesions after the first year of life, antimicrobial treatment has been continued 1 to 2 weeks beyond resolution of signs and symptoms. No convincing data are available to allow determination of whether inclusion of these latter two medications would be beneficial. However, the high incidence of allergy to sulfonamides (25%) makes their use for prophylaxis a potential problem. If allergic reactions develop, treatment of active eye disease that occurs later may require use of other antimicrobials. A recent study demonstrates prevention of recurrences with intravitreal clindamycin (1. Treatment was given weekly or every 4 weeks for pregnant patients and was associated with resolution of toxoplasmic retinochoroiditis (Lasave, et al, Ophthalmology, 2010). Because transmission occurs frequently when acute infection is acquired in the latter part of the third trimester, we consider it reasonable to provide treatment for the fetus by administering pyrimethamine and sulfadiazine to the recently infected mother. A diagnostic procedure to detect infection in the fetus (see previous on "Prenatal Diagnosis of Fetal Toxoplasma gondii Infection") should be performed before this therapy is instituted because such treatment may obscure the diagnosis at birth. In such instances, decision making concerning treatment for the infant during the first year of life is significantly complicated by the lack of accurate diagnostic information. When choroidal neovascular membranes have developed in the context of toxoplasmic chorioretinitis [410], especially with retinal hemorrhage, treatment with antibody to vascular endothelial growth factor has been curative. Ophthalmologic Outcomes after Prenatal Followed by Postnatal Treatment of Congenital Toxoplasmosis. Ophthalmologic examinations were performed in 18 children born to mothers infected before 25 weeks of gestation. Four children had posterior pole scars in one eye; each of these four had normal visual acuity, and two of these four had peripheral retinal scars. The outcome was favorable for all but one child, in whom visual acuity was decreased and extensive, bilateral macular and peripheral lesions were present. In a similar, recent study in France [915], outcomes again were very favorable and shorter intervals between diagnosis and initiation of treatment were associated with improved visual outcomes. The improved outcomes most likely reflect prenatal treatment of the French children. These French outcomes, including those of the Parisian center, suggest that a delay of > 8 weeks between maternal seroconversion and beginning of treatment is a risk factor for retinochoroiditis detected during the first two years of life in infants with treated congenital toxoplasmosis [915]. Prospective Ophthalmologic Follow-up Evaluation of a Cohort of Congenitally Infected Infants in Lyon, France. In an observational, prospective cohort study performed in Lyon, France by Binquet and her colleagues [766,887], maternal infections were identified through monthly testing of susceptible women. Most mothers became infected during the second trimester (89 [20%]) or third trimester (219 [68%]). Two hundred seventy-two (84%) were treated during pregnancy: 149 (46%) with spiramycin alone, 104 (32%) with spiramycin followed by pyrimethamine plus sulfadiazine, and 19 (6%) with pyrimethamine plus sulfadiazine. Treatment for the infant included a brief course (3 weeks) of pyrimethamine plus sulfadiazine followed by 1 year of treatment with Fansidar. In this cohort of 327 children (median duration of follow-up from birth was 6 years [interquartile range, 3 to 10], range, 6 months to 14 years), they [766] found that during a median follow-up period of 6 years, 79 (24%) had at least one retinochoroidal lesion, but bilateral visual impairment was not noted. Children who were diagnosed prenatally or at birth (rather than by an increase in specific IgG between 1 and 12 months of life), who had nonocular manifestations at the time of diagnosis, and who were premature had the highest likelihood of developing ophthalmologic manifestations. The authors raise the possibility that the ophthalmologist may have observed those children with extraocular signs more closely. It also is possible that as examinations became easier with the increasing age of the children, more lesions that may have been easier to visualize were detected. These same investigators recently reported that in this same cohort during a median follow-up period of 6 years after birth (interquartile range, 3 to 10 years), 238 (76%) of the 327 children (range, 6 months to 14 years) were free of any eye lesions. Sixty (18%) had no sequelae except for retinochoroiditis; 33 (11%) had at least one clinical sign of the infection (brain calcifications in 31, hydrocephalus in 6, microcephalus in 1). Of the six with hydrocephalus, three had moderate psychomotor retardation, and two with calcifications had a single seizure. The investigators also reported that more than one lesion in the retina of the eye was predictive for involvement of the other eye.
But we have not seen an increase in pediatric cancers in the studies that have been conducted to date. That may in part be because the question has not yet been asked, so I think that there is an opportunity to investigate this elevated rate that appears to be especially in a specific region of New Hampshire. When people design, say, whether it is an animal study or a human study, people usually have a hypothesis that they are testing. Most of the animal studies which provide the biological plausibility to say what we might see in an epidemiology study makes sense have focused on adult animals, not developing animals. As you all know, there were two child-care centers that were located on Pease where children drank that water almost from birth. Chairman, I am out of time, but I have a statement here from the Merrimack Citizens for Clean Water1 as well as the Commissioner of our Department of Environmental Services in New Hampshire that I would like to ask be introduced for the record. We have a number of water supplies in Alabama that a bunch of constituents are affected by what appears to be private manufacturers, and the water supplies have been contaminated. Could you walk me through that process and give me some kind of estimate-and I know as you sit here today, it will not be firm. But walk me through that process and give me some idea of the timeline for a potential designation. As you point out, such an action is a public notice and rulemaking action, so there would be a proposed rule, regardless of the statutory mechanism, a proposed rule, public comment, and then consideration, careful consideration and comment to get to a final rule. We are talking about years before we could have that completed in all likelihood, just recognizing that if the process started, even at the end of the year, we would have to go through the proposal and then the final rule to get there. Related to the question of listing as a hazardous substance, I do not know that we have had discussion with manufacturers on that particular issue, although I will note that we did have the manufacturing community present at the National Leadership Summit this past May, and this was a topic of discussion there. There has been quite a bit of work with the manufacturing community on those particular issues. I hate to belabor the point because it is a pretty complicated process that you guys go through. Has there been any specific pushback to say do not designate this as a hazardous substance Are there any steps being taken right now to just kind of raise awareness of the issues so that people are looking at this There is a great deal underway to raise awareness of this issue and also to engage the public and the States and local communities on these challenges, both through the National Leadership Summit and then through the community engagement meetings we have had now in five States around the country. I cannot emphasize how important it has been to meet with local citizens to hear the challenges that they are experiencing as we think about the development of the National Management Plan, which is going to be a comprehensive view of steps that we can take across our statutory authorities in collaboration and support of States and local communities to address these issues. We are hoping to have that completed by the end of the calendar year, and we will continue both through our website presence but also reaching out to communities-and I mentioned to Senator Peters we will be in Michigan next week for another engagement with constituents there. We are going to continue to talk to communities across the country on these issues. Small systems are, without question, a challenge, and technical assistance is a priority for us to small systems, and I think you know that we fund a number of technical assistance activities for small systems. It is good to see you all again, some of you for the first time, others not the first time. Delaware State officials, along with-it was really an ``all hands on deck' situation. You had the fire company, you had the Delaware National Guard, you had the Delaware Division of Health, the Department of Natural Resources, and our congressional delegation, all descended on this little town to try to make sure that they got the help that they needed. They got it in the form of a filtration system which was added to the public water supply system. By the time the contamination is discovered, though, citizens may have been exposed not for just weeks or months but actually for years. I also believe that the companies that made these chemicals need to share some of the responsibility for finding solutions to the contamination that their chemicals created. A company called ``Chemours,' which is an offshoot, if you will, of DuPont, a big chemical company-the chemical part of DuPont is called ``Chemours.
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