Abstract
Protecting worker and public health involves an understanding of multiple determinants, including exposures to biological, chemical, or physical agents or stressors in combination with other determinants including type of employment, health status, and individual behaviors. This has been illustrated during the COVID-19 pandemic by increased exposure and health risks for essential workers and those with pre-existing conditions, and mask-wearing behavior. Health risk assessment practices for environmental and occupational health typically do not incorporate multiple stressors in combination with personal risk factors. While conceptual developments in cumulative risk assessment to inform a more holistic approach to these real-life conditions have progressed, gaps remain, and practical methods and applications are rare. This scoping review characterizes existing evidence of combined stressor exposures and personal factors and risk to foster methods for occupational cumulative risk assessment. The review found examples from many workplaces, such as manufacturing, offices, and health care; exposures to chemical, physical, and psychosocial stressors combined with modifiable and unmodifiable determinants of health; and outcomes including respiratory function and disease, cancers, cardio-metabolic diseases, and hearing loss, as well as increased fertility, menstrual dysfunction and worsened mental health. To protect workers, workplace exposures and modifiable and unmodifiable characteristics should be considered in risk assessment and management. Data on combination exposures can improve assessments and risk estimates and inform protective exposure limits and management strategies.
Highlights
A three-tiered review approach was developed to identify a sample of relevant scientific literature related to the effects of combined stressors and personal risk factors on a clinical health outcome (Figure 1)
In Tier 2 abstracts were randomly assigned and each abstract was independently screened by two experts using the following inclusion criteria: (1) English language studies only; (2) clinical health outcome identified as an outcome measure; (3) at least one stressor identified in an occupational environment; (4) author(s) reported the presence of associations and/or effect estimates with p-value(s) < 0.05 or similar measures of statistical significance
Studies evaluating genetic risk factors in combination with occupational stressors were excluded from the present analysis but reserved for separate evaluation
Summary
Most human health risk assessment practices today focus on health effects related to a single stressor. It has been argued, that this focus ignores important co-exposures, and does not adequately assess the exposure-related health risks [1,2]. Approaches for cumulative risk assessment (CRA) rooted in a multi-stressor framework are designed to tackle these challenges [4,5]. US EPA defined CRA as “combined risks from aggregate exposures to multiple agents or stressors” [6].
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