Implications of chemical mixtures in public health practice.

The Agency for Toxic Substances and Disease Registry (ATSDR) is a federal public health agency that investigates and strives to prevent human health problems produced by exposure to toxic chemicals and their mixtures in the environment. Most human exposures involving toxic chemicals or mixtures are thought to originate from environmental and occupational sources; however, concurrent exposures are also likely from other sources, such as prescription and nonprescription drugs, indoor air pollutants, alcohol, and tobacco smoke. Thus, in evaluating the potential hazard following exposure to environmental mixtures, ATSDR not only considers the inherent joint toxicity of the mixture but also the influence of environmental, demographic, occupational, and lifestyle factors. To foster these goals, ATSDR has pursued a Mixtures Research and Assessment Program that consists of three component efforts: trend analysis, joint toxicity assessment, and experimental testing. Through trend analysis, ATSDR sets priorities for environmental mixtures of concern for which joint toxicity assessments are conducted as needed. If data are not available to conduct appropriate assessments, a research agenda is pursued through established extramural mechanisms. Ultimately, the data generated are used to support ATSDR's work at sites involving exposure to chemical mixtures. This pragmatic approach allows testable hypotheses or research needs to be identified and resolved and enhances our understanding of the mechanisms of joint toxicity. Several collaborative and cooperative efforts with national and international organizations such as the Toxicology and Nutrition Office, the Netherlands, and the Department of Energy are being pursued as part of these activities. ATSDR also develops guidance manuals to consistently and accurately apply current methodologies for the joint toxicity assessment of chemicals. Further, expert panels often are assembled to resolve outstanding scientific issues or obtain expert advice on pertinent issues. Recently, the need for studies on chemical mixtures has been proposed as one of the six priority areas the agency identified in its agenda for public health environmental research. This has been reinforced through the agency's close work with communities whose leaders have spoken passionately about their concern for information on exposures to chemical mixtures. The five other priority research areas the agency identified are exposure, susceptible populations, communities and tribal involvement, evaluation/surveillance of health effects, and health promotion/prevention.