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Your Environment. Your Health.

Perfluorooctanoic acid and low birth weight: Estimates of US attributable burden and economic costs from 2003 through 2014

Environmental Health Economic Analysis Annotated Bibliography


Research article Cost benefit analysis (CBA)
Malits J, Blustein J, Trasande L, Attina TM
Int J Hyg Environ Health
In this cost-benefit analysis, the authors calculated the proportion of PFOA-attributable LBW births and associated costs in the United States from 2003 to 2014, a period during which there were industry-initiated and regulatory activities aimed at reducing exposure. Results showed that serum PFOA levels remained approximately constant from 2003–2004 (median: 3.3 ng/mL) to 2007–2008 (3.5 ng/mL) and declined from 2009–2010 (2.8 ng/mL) to 2013–2014 (1.6 ng/mL). From 2003 to 2014, an estimated total of 118,009 LBW cases were potentially preventable if PFOA exposure were reduced to the base case reference level per year. The total cost of PFOA-attributable LBW for 2003 through 2014 was estimated at $13.7 billion, with $2.97 billion in 2003–2004, $2.4 billion in 2009–2010 and $347 million in 2013–2014. The authors concluded that declines in PFOA levels were of a magnitude expected to meaningfully reduce the estimated incidence of PFOA-attributable LBW and associated costs.
Women of childbearing age (18-44 years), newborns

Health Outcomes

  • Birth outcomes (low birth weight)

Environmental Agents

List of Environmental Agents:

  • Fluorinated compounds (Perfluorooctanoic acid (PFOA))

Source of Environmental Agents: (Not available)

Economic Evaluation / Methods and Source


  • Cost benefit analysis (CBA)

Cost Measured:

  • Hospitalization for medical concerns (direct cost), lost economic productivity as measured in loss of IQ points (indirect cost)

Potential Cost Measures:

  • Additional costs of reduced IQ on an individual's quality of life
  • Costs associated with adult health consequences of reduced birthweight (e.g., cardiovascular disease)
  • Individual's willingness to pay to avoid low birth weight
  • Other costs associated with LBW, such as out-of-pocket expenditures and parental lost work days

Benefits Measures:

  • Avoided hospitalization costs, avoided lost economonic productivity costs, avoided LBW cases

Potential Benefits: (Not available)


  • United States

Models Used: (Not available)

Methods Used:

  • The authors calculated costs associated with the proportion of low birth weight (LBW) births attributable to PFOA exposure in the United States from 2003-2014. The authors – 1) used data from the NHANES 2003-2014 to define serum PFOA levels for women of childbearing age; 2) determined LBW information (e.g., total mean birthweight, number of LBW births) for each year using natality data from the National Vital Statistics System; 3) developed groups defined by percentile of levels of PFOA exposure from the NHANES data; 4) calculated the number of LBW births that occurred during each year for each percentile group; 5) modeled PFOA-attributable changes in birthweight using a counterfactual approach; 6) calculated the number of LBW births that could have been prevented if PFOA exposures were reduced; and 7) estimated the total cost of LBW by adding the LBW-associated costs of hospitalization for medical concerns (direct costs) and lost economic productivity (indirect costs).

Sources Used:

  • Serum PFOA levels for women of childbearing age from the United States National Health and Nutrition Examination Survey (NHANES) 2003-2014 administered by the National Centers for Health Statistics of the Centers for Disease Control and Prevention (CDC) (NHANES, 2017); low birth weight data from the National Vital Statistics System of the National Center for Health Statistics (CDC/NCHS, 2017); PFOA- birth weight exposure-response relationship data from a meta-analysis of nine human cohort studies (Johnson et al., 2014); IQ loss associated with low birth weight relationship data (Kormos et al., 2014); the Medical Care Consumer Price Index and All Items Consumer Price Index (US Department of Labor Bureau of Labor Statistics, 2017); additional sources cited in publication

Economic Evaluation / Methods and Source


  • Malits J, Blustein J, Trasande L, Attina TM. 2018. Perfluorooctanoic acid and low birth weight: Estimates of US attributable burden and economic costs from 2003 through 2014. Int J Hyg Environ Health.
  • Pubmed
  • DOI

NIEHS Funding: (Not available)

Other Funding: (Not available)

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