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Int J Environ Res Public Health. 2018 Dec 10;15(12). pii: E2797. doi: 10.3390/ijerph15122797.

Methods for Evaluating the Combined Effects of Chemical and Nonchemical Exposures for Cumulative Environmental Health Risk Assessment.

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Maryland Institute for Applied Environmental Health, University of Maryland School of Public Health, 2234 L SPH, 255 Valley Drive, College Park, MD 20742, USA.
Department of Environmental Health, Boston University School of Public Health, 715 Albany St., TW4, Boston, MA 02118, USA.
Department of Environmental Health, Boston University School of Public Health, 715 Albany St., TW4, Boston, MA 02118, USA.
Department of Environmental Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Box EHSC, Rochester, NY 14642, USA.
The Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, 1200 Pressler Street, Suite W-1030, Houston, TX 77030, USA.
Department of Environmental & Occupational Health, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 350, Pittsburgh, PA 15219, USA.
Environmental and Occupational Health Sciences Institute, Rutgers School of Public Health, 170 Frelinghuysen Rd, room 204, Piscataway, NJ 08854, USA.
Institute for Health Policy, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler, Houston, TX 77030, USA.
Dornsife School of Public Health, Drexel University, 3215 Market Street, Nesbitt Hall, Office 616, Philadelphia, PA 19104, USA.


Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary analytical methods to support CRA are available but are ultimately context-dependent. These projects collectively provided advancements for CRA in the areas of community engagement, characterization of exposures to nonchemical stressors, and assessment of health effects associated with joint exposures to chemical and psychosocial stressors.


community health; cumulative risk; environmental justice; methods; psychosocial stressors

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