Environmental and health risks related to waste incineration

Abstract

The article presents a mini review of the published research focused on understanding environmental and human health impacts nearby waste incineration plants. We found no studies indicating that modern-technology waste incineration plants, which comply with the legislation on emissions, are a cancer risk factor or have adverse effects on reproduction or development. There are several factors in favor of this affirmation: (a) the emission levels of the plants currently built in the developed countries are several orders of magnitude lower than those of the plants in whose environments epidemiological studies have been carried out and which have found some kind of negative association in terms of health; (b) risk assessment studies indicate that most of the exposure is produced through the diet and not by a direct route; and (c) monitoring dioxin level studies in the population resident in the environment of incineration plants did not reveal increases of these levels when compared with a population living in reference areas. A necessary condition for the development of a waste incineration plant is to generate the conditions to prevent any impact that activates or potentially carries damage or risks to the environment and, in particular, to health. This makes it imperative to use a preventive strategy through the implementation of a previous environmental impact assessment and the establishment of emissions standards and an emissions monitoring program in order to ensure the prevention of environmental damage.

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https://doi.org/10.1177/0734242X19859700
Waste Management & Research
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Introduction
As long as society sustains a linear economy of extraction of
resources, production, consumption and disposal, an increasing
amount of waste will be generated every day.
The generation of waste and the collection, processing, trans-
port and disposal of it—the process of “waste management”
(WM)—is important for both the health of the public and aes-
thetic and environmental reasons. Since waste is anything dis-
carded by an individual, household or organization, waste results
a complex mixture of different substances, only some of which
are intrinsically hazardous to health.
WM is now tightly regulated in most countries. Solid urban
waste incineration (WI) started at the end of the 19th century.
After the crisis of the 1930s, WI declined due to the impoverish-
ment of its energy content, and it was not until 1960s–70s that it
became a common tool for WM, as technology evolved. The sig-
nificant reduction of emissions to nearby communities has
reduced concerns that the resulting products may have potential
impact on the environment and human health.
Today, WI is a technology widely used in developed countries.
Thus, in 2015 there were 507 WI plants in 25 European countries.
A significant value of WI lies in the development of the technology
of thermovaluation or Waste to Energy, widely used in Japan with
210 plants, Germany with 121 plants, France with 126 plants, the
rest of Europe and Russia with 276 plants, China with 225 plants,
the rest of Asia with 62 plants and the USA with 99 plants, giving
value to 240 million tonnes of annual non-recyclable waste to pro-
duce electricity (CEWEP, 2015; Comisión Europea y Ministerio
de Medio Ambiente y Medio Rural y Marino de España, 2011;
Eurocities, 2017; Eurostat, 2015; ISWA, 2013; Perona, 2016).
However, certain sectors from civil society express some con-
cerns on the impact of WI on the environment and the population
living near WI plants.
In 1996 the World Health Organization (WHO) published the doc-
ument “Waste incineration” in which incineration was defined as “an
hygienic methodology to reduce the volume and weight of the waste
as well as its pollutant potential” and “Is one of a number of waste
disposal strategies which can be used to ensure that wastes are handled
in an environmentally suitable manner” (Haukohl et al., 1996).
Thereafter, a WHO exposure assessment expert group sug-
gested that priority pollutants should be defined on the basis of
Environmental and health risks
related to waste incineration
Ernesto de Titto1 and Atilio Savino2
Abstract
The article presents a mini review of the published research focused on understanding environmental and human health impacts
nearby waste incineration plants. We found no studies indicating that modern-technology waste incineration plants, which comply
with the legislation on emissions, are a cancer risk factor or have adverse effects on reproduction or development. There are several
factors in favor of this affirmation: (a) the emission levels of the plants currently built in the developed countries are several orders
of magnitude lower than those of the plants in whose environments epidemiological studies have been carried out and which have
found some kind of negative association in terms of health; (b) risk assessment studies indicate that most of the exposure is produced
through the diet and not by a direct route; and (c) monitoring dioxin level studies in the population resident in the environment of
incineration plants did not reveal increases of these levels when compared with a population living in reference areas. A necessary
condition for the development of a waste incineration plant is to generate the conditions to prevent any impact that activates or
potentially carries damage or risks to the environment and, in particular, to health. This makes it imperative to use a preventive
strategy through the implementation of a previous environmental impact assessment and the establishment of emissions standards and
an emissions monitoring program in order to ensure the prevention of environmental damage.
Keywords
Waste management, waste incineration, health effects, environmental exposure
Received 8th February 2019, accepted 3rd June 2019 by Associate Editor Mario Grosso.
1Universidad ISALUD, Argentina
2Asociación para el Estudio de los Residuos Sólidos, Argentina
Corresponding author:
Atilio Savino, Asociación para el Estudio de los Residuos Sólidos,
Venezuela 931, Ciudad Autónoma de Buenos Aires, C1095AAS,
Argentina.
Email: asavino@ars.org.ar
859700WMR0010.1177/0734242X19859700Waste Management & Researchde Titto and Savino
review-article2019
Mini-review Article

2 Waste Management & Research 00(0)
toxicity, environmental persistence and mobility, bioaccumula-
tion and other hazards such as explosivity (WHO, 2000).
The incineration process may result in three potential sources
of exposure to the environment: (a) atmospheric emissions, (b)
ashes and slags, and (c) through cooling water. Accepting that the
ashes and cooling water are properly managed and arranged,
atmospheric emissions are the only source of danger as people’s
route of exposure. The concern related to these emissions is
focused on some well-known contaminants: particulates, dioxins
and furans and other carcinogens such as polycyclic aromatic
hydrocarbons (PAHs), whose health effects are quite well known.
The aim of the present study is to review the health risks
linked to municipal solid waste incineration practices within and
across different countries and identify key issues. Although
incineration plant technology has evolved significantly over
time, reports associated with “old fashioned” plants were not
excluded since they present evidence that must be taken into
account in less developed countries at the time of evaluating and
taking decisions to incorporate incineration plants into their
waste management programs. So, we believe the present work
may help to gain a clearer picture of the situation on the ground
and identify areas of improvement.
Methods
The scientific literature was scrutinized through computerized lit-
erature searches using the Google Scholar search engine and the
PubMed Library. The keywords to search the database included
municipal solid waste incineration, environmental exposure, envi-
ronmental disease and health risks as well as various combinations.
Literatures selected must meet the following overall criteria: (a)
the objective of the study is focused on the consequences of incin-
eration of municipal solid waste; (b) the article must be written in
English or Spanish; and (c) the article is published in a peer-
reviewed journal or published by government departments, non-
governmental organizations such as ISWA and multilateral
agencies such as WHO. In addition, articles were traced through
references listed in previous reviews. The papers included in this
review include those published between 1999 and mid-2018. It is
interesting to note that although the category “any language” was
always employed, the search yielded almost twice the number of
references when the search was formulated in English than in
Spanish. Our initial search yielded a total of 12,100 research arti-
cles. In successive iterations, articles focused on subjects such as
history and technology, articles mentioning health risks only in
passing as well as general articles or those focusing on limited cat-
egories of waste were also excluded. Remaining articles were ana-
lyzed individually to assess if they focused on our primary interest.
Hence the article selection followed an iterative process in which
non-relevant articles were excluded from subsequent searches.
Health risks
Briefly, let us remember that exposure to particles—both in the
short and long term—is detrimental to health. Long-term exposure
increases the risk of death, especially from cardiovascular disease
and lung cancer. Short exposure impacts have cardio-respiratory
effects including increased heart attack mortality and respiratory
disease. Threshold values have not been identified in either of the
two situations so it is accepted that any increase in the concentration
of particles has an effect on health. So the critical step is not to say
that an effect is possible but to estimate the weight of that effect.
The pathological mechanisms are also not known in detail, although
various processes involved have been identified and studied. It is
interesting to note that particle size appears to be more relevant than
its composition, but this is still a matter of discussion (World Health
Organization, 2006).
It is important to remember that in order to reduce particu-
late emissions some years ago equipment was designed to
retain particles known as PM10 (expressed in µg/m3), essen-
tially selecting all particles with an aerodynamic diameter
equal to or less than 10 microns; that is, those capable of pass-
ing through the upper airways (nostrils, mouth, pharynx and
larynx) and being deposited in the lungs. Therefore, PM10
includes PM2, 5 particles which represents the fraction of the
aerosol with high probability of depositing in the pulmonary
zone of gaseous exchange and nanoparticles (less than 0.1
micron or 100 nm, PM0, 1). In addition, while it is correct to say
that nanoparticles are probably the largest contributor to the
number of particles in the air, their contribution to the local
mass of particles is low and hardly reflected in the PM10 or
PM2, 5 registered. Nor is it accurately known how it is reflected
in its impact on health.
We also consider it advisable to summarize some concepts
related to carcinogens, a denomination that includes any sub-
stance that causes cancer.
For the purposes of risk assessment, carcinogens can be
divided into two groups according to their mechanism of action.
The first group is that of genotoxic carcinogens, those that
induce cancer by a mechanism involving the substance, or a
metabolite of it, which reacts directly with the genetic material
of the cells (DNA) producing a mutation. This process is called
mutagenicity and is assumed to have no threshold: any exposure
is associated with increased risk. Examples are aflatoxins, ben-
zene and polycyclic aromatic compounds. The second group is
non-genotoxic carcinogens, which induce cancer by non-muta-
genicity-based mechanisms. In these cases different mechanisms
are involved and it is accepted that the effects have a threshold
based on the precursor toxicological effect. Examples are estro-
gens and dioxins.
Incineration impact on environmental
and human health
In 1998, 2000 and 2007, the World Health Organization (WHO)
convened expert meetings on WM. In the first two, it focused its
attention on the impacts of management problems and the impact
of landfills, without specifically including incineration-related
aspects. In the third, under the understanding that WM becomes

de Titto and Savino 3
more complex over time and that in some communities there was
concern about the possible health and welfare effects of exposure
to waste and management products, the scientific information
available on WM and its relationship with community health was
reviewed. In addition, the situation of key European countries
was analyzed within the scope of exploring how to give better
support to the authorities responsible for WM (World Health
Organization, 2007).
With regards to incineration facilities it was concluded that:
Incinerators have been operating in many European countries
since the 1960s and their technology has evolved over time, in
general with a reduction of emissions to nearby communities.
As to the possible health effects of incinerators, reasons for
concern are inhalation of airborne pollutants resulting from
combustion and from incomplete combustion, consumption of
contaminated foods and water, or contact with contaminated
soil. Information on the presence of hazardous agents in the
vicinity of an incinerator is not easily translated into useful
exposure measures. Compared to landfills, fewer
epidemiological studies are available. While some positive
studies exist, the evidence is, overall, not conclusive to establish
the occurrence and magnitude of risks. As in landfill studies,
increases in relative risk are difficult to detect because they are
generally caused by long-term low-level exposures. Studies
pointing to an increase in soft tissue sarcomas (STS) and non
Hodgkin’s lymphomas (NHL) support a possible etiologic role
of 2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3,7,8 T4CDD). The
evidence is inadequate to draw conclusions that can be used to
determine optimal policy choices on incineration: relatively few
good quality studies exist and they refer mostly to old generation
incineration plants—an important distinction, as stack emissions
from modern plants are much reduced compared to old
generation plants.
The workshop also allowed the identification of some factors
of confusion that may affect the results of an epidemiological
study and agreed on the variables that should be taken into
account to evaluate the potential impact of an incineration plant,
which we now mention to facilitate the re-evaluation of some
previously presented works.
A confusing factor is the difficulty in translating the presence
of hazardous substances into exposure information, except for
those substances that can be biomonitored. It has often become
necessary to estimate the exposure by factors such as the dis-
tance from the possible exposed to the source, which requires
adjustments for example by the height of the column, the shape
of the atmospheric dispersion plumes or the local wind rose at
the time of the emission, factors that have not always been
considered.
Another factor of confusion, sometimes critical, is the location
of the plant and its vicinity to other probable sources of emissions
or its establishment in neighborhoods with a shortage of basic
services that make its population more vulnerable. The biggest
challenge for these studies is how to eliminate the effects of con-
founding factors on the environment–health relationship, such as
age, ethnicity, gender, socioeconomic conditions and access to
health care, lifestyles, food quality and time of exposure.
In this scenario it should be noted that the emission condi-
tions established by the European Union from the year 2000
define a before and after for the plants that motivated most of the
known bibliography. Nevertheless, it is convenient to review
some studies.
Epidemiological studies
Hu and Shy (2001) reviewed the bibliography for the period
1985–1999 by studying 11 publications evaluating the impact of
incineration plants on the health of neighboring communities (in
Australia, Scotland, USA, Finland, UK, Italy and Sweden) and 11
publications focused on plant workers. The various studies
reported a wide variety of outcomes including associations with
decreased proportion of male births, increased number of twins,
increased number of cases of various types of cancer and blood
levels of organic compounds and metals, while other studies
showed the absence of changes in respiratory symptoms and lung
function in some types of cancer. The authors concluded that the
most striking feature of that review was that “the findings for can-
cer and reproductive outcomes were inconsistent”; that is, similar
plants in comparable locations do not have comparable impacts,
and emphasized the need to deepen epidemiological studies.
Rushton (2003) reviewed six studies carried out in the
United Kingdom. Four of them reported cases of excess cancer
(digestive system, liver, kidneys, pancreas and non-Hodgkin’s
lymphoma and for skin, stomach and respiratory system in
occupational studies) and the possible association with low
birthweight. The author concluded that:
there is little evidence for an association with reproductive or
developmental effects with proximity to incinerators. Studies of
cancer incidence and mortality in populations around landfill
sites or incinerators have been equivocal, with varying results for
different cancer sites. Many of these studies lack good individual
exposure information and data on potential confounders, such as
socio-economic status. The inherent latency of diseases and
migration of populations are often ignored.
Franchini et al. (2004) reviewed a total of 45 articles pub-
lished between 1987 and 2003. Of these, 32 referred to the health
of neighboring populations to incineration plants, 11 to occupa-
tional exposure and 2 included both situations. It was again
stressed that in the vast majority of work the conditions of expo-
sure were poorly described due to lack of information on emis-
sions, the nature of the incinerated material and the migration
routes of emissions, and they referred to first generation incin-
erators characterized by limited abatement technology and low
combustion temperatures resulting in higher emissions. So it
was difficult to compare the studies and consistency in the
results would not be expected. Positive results were found for
some specific types of cancer and inconsistent results for others,
and inconclusive results for other non-tumor pathologies. Some
conditions were also identified in occupational studies but not
conclusive evidence, even with biomonitoring. The authors con-
clude that:

4 Waste Management & Research 00(0)
effect of biases and confounding factors must be considered in the
explanation of findings. Methodological problems and insufficient
exposure information generate difficulties on study results. Research
needs include a better definition of exposure in qualitative and
quantitative terms in particular by developing the use of biomarkers
and by implementing environmental measurements.
A new review carried out by Defra in the United Kingdom
(Enviros, 2004) “found no conclusive evidence of association
between incinerators and cancer and reduced evidence of respira-
tory problems, stresses that in most cases emissions of incinera-
tors make a minor contribution to local air pollution levels.”
Cordier et al. (2004) studied the impact of the emission of the
incinerators on the rate of congenital anomalies in the French
region of Rhône-Alpes. This region has held a population register
of these types of anomalies (register of the center-east of France)
since 1978. Among the 2879 communities that exist in the region,
they selected for the study the 2872 that have fewer than 50,000
inhabitants. Throughout the region, 70 incinerators were identi-
fied, which over the period of study (1988–1997) had been in
operation for at least one year. They considered 194 communities
to be exposed and 2678 not exposed. The study showed that the
overall rate of malformations was not greater in the exposed
areas than in the non-exposed (RR: 1.04; 95% CI: 0.97–1.11). An
excess of risk was observed for some groups of anomalies: facial
clefts and renal dysplasia. Although the associations found are
biologically plausible, the same authors conclude that they must
be very cautious in assessing them for the limitations presented
by the study, mainly related to the way of estimating exposure,
which makes it impossible to discard other explanations for the
associations found. On the other hand, they point out that if there
was any relation between the observed effects and the exposure
to incinerators it should be attributed to the persistence of the pol-
lution generated by old technology incinerators.
Other adverse effects studied include the prevalence of acute
and chronic respiratory diseases, frequency of symptoms, hyper-
sensitivity of the airways, atopy and indicators of respiratory
function. Shy et al. (1995) from the University of North Carolina
and USEPA studied simultaneously air quality and respiratory
function and symptoms in three neighboring populations to
incineration plants in the USA Residents were studied in an
ellipse of 2 km × 5 km defining the major axis by the prevailing
wind direction in each locality, and compared with three other
locations without plants. Direct air quality measurements and
estimates based on mass balances for a recipient model showed
no impact on regularly monitored air pollutants. A baseline sur-
vey was also conducted (n = 6963, residents in 2592 households)
that also did not reveal consistent differences between communi-
ties in the prevalence of both acute and chronic respiratory symp-
toms. A similar study was developed in Taiwan (Hu et al., 2001)
in three areas neighboring incinerators and three control areas
and studying 1018 individuals. The results found no significant
differences between the populations exposed and those not
exposed in terms of prevalence of respiratory illnesses or symp-
toms, adjusted by the use of gas stoves, the time of residence and
the history of smokers.
Elliott et al. (1996) conducted a study in the UK which, after
identifying what types of tumors could show increased incidence
among residents in the environment of 20 incinerators, sought a
confirmation of the findings obtained with the rest of the 52 oper-
ational WI in the country at that time. The analysis of the results
showed that although in the first instance there was an increase in
the expected cases of all combined cancers, stomach cancer,
colorectal, lung and liver cancer, this effect was already observ-
able in the period prior to the operation of such incinerators and
before the minimum latency period considered for cancer in its
entirety and for stomach, lung and colorectal cancer had elapsed,
indicating that the observed effects were not attributable to incin-
erator emissions. The only type of cancer that showed a signifi-
cant increase in the areas near the incinerators that was not
randomly attributed was liver cancer. The authors point out that
this effect is likely to result from the effect of socioeconomic
variables associated with the urban environments closest to
incinerators, as well as to the effect of poor classification of liver
tumors. In a later study Elliot et al. (2000) showed an overestima-
tion of the primary liver cancers in the total of the tumors for that
location. Although this did not eliminate the increased risk found,
it was significantly reduced. This result does not exclude the fact
that the small increase observed was due to the confusion gener-
ated by socioeconomic factors. The findings of Elliott’s studies
refer in any case to “old” incineration plants, which were
launched before 1976 and which are far from the characteristics
of the current facilities that have to comply with EU legislation in
emissions terms.
Porta et al. (2009) examined the published, peer-reviewed lit-
erature addressing health effects of waste management between
1983 and 2008, including 21 epidemiologic studies conducted on
residents of communities with solid waste incinerators. They
evaluated the overall evidence and graded the associated uncer-
tainties. In most cases the evidence was inadequate to establish a
relationship between a specific waste process and health effects;
while the evidence from occupational studies was not sufficient
to make an overall assessment. For community studies, at least
for some processes, there was limited evidence of a causal rela-
tionship. For populations living within 3 km of old incinerators,
there was limited evidence of an increased risk of cancer, with an
estimated excess risk of 3.5%. The confidence in the evaluation
and in the estimated excess risk tended to be higher for specific
cancer forms such as non-Hodgkin’s lymphoma and soft tissue
sarcoma than for other cancers. According to the authors, the
reviewed studies suffer from many limitations due to poor expo-
sure assessment, ecological level of analysis and lack of informa-
tion on relevant confounders.
Federico et al. (2010), from the Universitá degli Studi di
Módena e Reggio Emilia (Italia), evaluated the incidence of can-
cer in residents of the city of Modena, neighbors within a radius
of 5 km of the local WI plant. They reviewed the 16,443 new
cases reported between 1991 and 2005. The space-time grouping
identified three clusters but their formats could not be statisti-
cally associated with exposure to the plant, nor was any excess
risk found in the area adjacent to it.

de Titto and Savino 5
A deep review was presented by Mattiello et al. in 2013.
Thirty-one papers on the health effects in the communities living
in the proximity of incinerators were evaluated (2 cohort studies,
9 case–control studies, 17 ecological studies, 3 cross-sectional
studies). The authors concluded that the evidence appears weak
and conflicting in 15 studies, mostly ecological or case–control
and only one based on a retrospective cohort, which analyzed the
relationship between incinerator activity and cancer. Inconsistent
results came from the evaluation of 10 studies (eight ecological,
one case–control and one retrospective cohort study) analyzing
birth defects and reproductive disorders.
Finally, it should be noted that at the beginning of the century
a study was carried out in Japan to compare mortality rates, for
all causes and five groups of major diseases, of 590 municipali-
ties with WI plants with those of municipalities without WI
plants (Fukuda et al., 2003). As indicators of exposure to dioxins,
the concentrations of dioxin emissions from the incinerators were
used, the amount of dioxins per population, the accumulated
amount of dioxins and the amount of dioxins accumulated per
unit of area. The results showed no significant differences for any
of the causes of death analyzed when they were adjusted by the
socioeconomic characteristics of the cities.
Risk assessment studies
In addition to the epidemiological studies identified, risk assess-
ment studies have also been carried out. In these studies, different
scenarios were established from available information on WI
emissions, measurements of contaminants in environmental sam-
ples (air, soil, vegetables), eating habits, dioxin content of food
and place of residence, among other factors. In each of the sce-
narios the doses of the different pollutants to which the popula-
tion may be exposed and the different types of risk associated
with this estimated exposure to WI plants were estimated in the
USA (Hallenbeck et al., 1993; Nessel et al., 1991), Belgium
(Nouwen et al., 2001), Spain (Schuhmacher et al., 2001) and
France (Boudet et al., 1999), among others. The synthesis of the
results indicates that, in general terms, neither direct exposure to
emissions from the incineration plant nor indirect exposure due
to food poses a significant additional risk of cancer for residents
in the vicinity of the WI plant. In addition, the possible contribu-
tion of modern plant emissions to the levels of soil, flora and food
contaminants generated in the plant environment does not appear
to be significant, and given that the majority pattern of food con-
sumption in urban areas has very varied provenance and only a
small part comes from the same area, it is reasonable to consider
that direct dioxin emissions from modern plants do not pose a
significant risk.
Yoshida et al. (2000) assessed the health risk of dioxins in
several population groups in Japan: general population, residents
in the environment of a WI, high fish consumers and children and
fetuses of all these groups, looking for adverse health effects such
as cancer, reproductive dysfunctions, endometriosis and neuro-
behavioral effects. Although the estimated risks for cancer and
reproductive dysfunction were not excessively high for the three
defined adult groups, some doubts were raised about the risk of
endometriosis, even when the evidence of causality in humans
for this type of effect is very weak. In addition, the results sug-
gested that children and fetuses of women living in the environ-
ment of an incinerator or major fish consumers may be exposed
to a considerable risk of neuro-behavioral effects. These results
have been taken with reservations because the data of the levels
of contamination by dioxins (air, soil and vegetables) used in this
study for the estimation of the daily intake in the population resi-
dent in the environment of the incinerators were, in general, far
superior to those used in the risk assessments discussed above.
Biomarkers studies
As has been seen, in the studies of risk assessment the exposure
to the various pollutants emitted by the WI plants is estimated
from data obtained in the air, water, soils or other means, taking
into account the different routes of exposure possible for each
pollutant and making assumptions about the exchange of pollut-
ants between the different environmental compartments. This
external exposure may be considered only as a gross estimate of
the dose of internal exposure to chemical components. In the
studies with biomarkers, the concentration of the different com-
pounds is measured in different organic compartments, which
allows measurement of the internal exposure to which tissues and
cells are subjected. In addition, some of these studies have had a
longitudinal character, with follow-up over time for the same
group of people with a before and after in relation to the start of
the WI plant activity, which allows assessment of the impact that
this activity has on internal exposure.
It is interesting to review the work done in Mataró (Barcelona,
Spain), where the evolution of dioxin levels with time has been
studied since the start-up of the municipal incinerator in
1995(these results can be considered as baseline levels) and was
repeated in 1997, 1999 and 2002. The four evaluations com-
pared the levels of dioxins in blood samples of the general popu-
lation living in the vicinity of the plant (< 1.5 km) with the
population that lives approximately 4 km from it. In 1999 and
2002 a third sampling was undertaken, incorporating a sample of
a similar population located 20 km from the incinerator. The par-
ticipants in the study were randomly selected from the municipal
censuses. No significant differences were observed in dioxin
levels among residents near and far from the incineration plant
in any of the four evaluations performed. However, the studies
showed a tendency to increase the levels of dioxins expressed in
toxic equivalency (TEQ) from approximately 13 pg/g of lipid in
1995 to approximately 20 pg/g of lipid in 1999, consisting of all
age groups and both sexes. In 2002, a decrease was observed in
the presumably most exposed people (with a residence 0.5–1 km
from the WI plant) and in the resident controls at 20 km, while
in the control group of Mataró an increase was observed. The
results suggested that changes in the level of dioxins observed
could not be attributed to the WI plant, but should be related to
dioxin levels in food (González et al. 1998, 2000, 2001; Unitat
de Recerca, 2004).

6 Waste Management & Research 00(0)
In Germany, Deml et al. (1996) compared the concentrations
of dioxins/furans measured in samples of blood and breast milk
of people living in the environment of a WI, for more than 15
years, with concentrations found in the general population not
exposed to known sources of dioxins. Both the blood and milk
levels found were in the range of the background levels of the
German population.
In Belgium, Fierens et al. (2003) studied the concentration of
dioxins and polychlorinated biphenyls (PCBs) in blood of 84
subjects who had lived for an average of 18 years in the environ-
ment (within a radius of 2 km) of two old WI, which began to
work in 1978 and 1980, one located in a rural area (51 subjects)
and the other in an industrial area (33 subjects). These subjects
were compared with 63 controls living in an uncontaminated
rural area. Exposed people and controls regularly consumed
locally produced foods. The people resident in the industrial
environment did not have higher levels than the controls.
However, residents in the WI environment located in the rural
area showed in serum higher levels of dioxins than the controls.
The difference in impact between the two WIs was attributed to
the residents’ dietary habits. According to the authors, the only
determinants of the level of dioxins in the residents in the WI
environment were the consumption of animal fat and age. The
authors suggested that a significant increase in the level of diox-
ins is likely to occur only when dioxin emissions exceed 5 ng
TEQ/m3.
In 2008, the National Institute for Public Health Surveillance
in France, in collaboration with the French Food Safety Agency,
announced the results of a national study on dioxin and PCBs
levels carried out in 2005 (Fréry et al., 2008). Its main objective
was to investigate whether the populations neighboring WI plants
had different levels from those that lived far from them and to see
to what extent the consumption of locally produced food contrib-
uted to that exposure. In a multicenter study more than 1000
adults (30–65 years old, average 52 years old, 54.7% women)
residing in eight different locations were studied. The results
showed that dioxin levels were similar to those reported in other
European countries, with no significant differences between resi-
dent and non-resident populations in the area of impact of the WI.
The only differences found were in the consumers of local animal
products (including dairy and eggs) among residents in areas near
old incinerators identified as polluters in the past. However, an
increased risk of non-Hodgkin’s lymphoma (NHL) was found
among neighbors of a French municipal solid WI with previous
high levels of dioxin emissions (Besançon, France) by using
serum concentrations of pesticides, dioxins, furans and PCBs to
assess exposure on 34 newly diagnosed NHL cases (2003–2005)
and 34 controls. Authors were not able to present environmental
levels of contaminants nor make it clear which source and route
of exposure led to the pathogenesis of NHL in the study area
(Viel et al., 2011).
Epidemiological studies were also carried out for two years
after the operation of an incineration plant built in Bilbao, Spain,
in 2005. Its results revealed that the blood and urinary levels of
heavy metals (lead, chromium and mercury) in adults living in
the environment were indistinguishable from those of more
remote populations. Interestingly, cadmium levels were high but
were not modified during the study period suggesting that the
source of contamination was not the incineration plant (Begona
Zubero et al., 2010).
Reis et al. (2007a) of the University of Lisbon carried out
biomonitoring of the body load of dioxins, assessed by blood
levels, of the general population living in the vicinity of a WI
near Lisbon, which had operated since 1999, and on the island of
Madeira, Portugal, operating since 2002. They concluded that
the populations’ exposure to the dioxins could not be related to
the emissions from these facilities, which supports the effective-
ness of the control of the sources of dioxin in both incinerators.
The follow-up of a small group of people from Lisbon suggested
the temporal effectiveness of the installation control there. As
for the comparison between the levels of polychlorodibenzodi-
oxins and polychlorodibenzofurans (PCDD/Fs) of the communi-
ties of Lisbon and Madeira, the individuals from Lisbon showed
higher levels of PCDD/F, which can be better explained by the
most highly contaminated areas of Lisbon than by eventual dif-
ferences in dietary habits of the studied groups. The comparison
between Lisbon and Madeira in relation to the pattern of conge-
ners for PCDD/Fs showed a very similar profile. In the same
study, stable and indistinguishable levels of total dioxin load
controls were found in samples taken during 4 years of breast
milk from mothers living in the vicinity of plants, and the already
reported tendency for dioxin levels to increase with age (Reis
et al., 2007b).
Other emissions
Bearing in mind that in the case of European plants these ante-
cedents are limited by the normative changes of 2000 already
stated we must revise some more recent antecedents.
For particles, mainly formed by ash, which can lead to heavy
metals, acid gases, dioxins and furans, it is important to note that
the usual methods of control of emissions in WI prevent the emis-
sion into the atmosphere of “breathable” particles (> 2.5 µm), but
are limited for ultrafine particles (< 0.1 µm).
Heavy metals can be left in the residual ashes or evaporated,
in which case they can be condensed when the gases are cooled,
forming aerosols or adsorbed on the fly ash. It must be expected
that ashes from WI deposited in landfills can contaminate the
subsoil and groundwater with compounds that have leached from
the waste; this has been documented. To avoid this, leaching
should be reduced by stabilizing the fly ash with cement before
depositing in safety fillers.
As previously mentioned, lead, cadmium, mercury, chro-
mium, arsenic and beryllium are metals associated with WI
emissions. All of them, in one or more forms, and by more than
one pathway and route of exposure have been identified as
responsible for a wide range of carcinogenic and non-carcino-
genic effects on human health. However, in general, the epide-
miological evidence of greater risk for environmental exposure
levels in the WI environment is scarce or equivocal and it is

de Titto and Savino 7
therefore extremely difficult to assess the impact, if any, of the
small exposure that incinerators could cause (Begona-Zubero
et al., 2010; Lee et al., 2012; Ranzi et al., 2013; Reis et al.,
2007a). In a study conducted in Shenzhen, south China, multiple
exposure routes of heavy metals including Pb, Cr, Cd and Mn
were assessed by investigating the metals in foods (such as veg-
etables, crops, meats and fruits), drinking water, ambient air and
soil collected surrounding a WI facility. Vegetable ingestion
played the most important role in the total average daily dose of
Pb and Cr, and cereals were the key exposure routes for Mn and
Cd (Li et al., 2017).
The emission of carcinogenic heavy metals that are part of
the waste is preventable. In Germany, for example, it became
compulsory in the mid-1990s to install filters (17th Ordinance
on the Implementation of the Federal Immission Control Act—
“17th BimSchV”), with significant results. Before 1990 toxic
emissions were equivalent to 188 tonnes of arsenic. If we include
in the calculation the emissions avoided when replacing fossil
fuels by WI for the production of energy, in addition to that
retained in the filters, we would be avoiding emitting another 3 t
of arsenic per annum. The obligation to install filters for particu-
late matter had the same impact. The 25,000 t of particulates
estimated to be released annually before 1990 fell by 2001 to
less than 3000 t while another 5000 t were avoided from conven-
tional fossil fuel-fired power plants, and in the emission of met-
als as mercury and lead.
The remaining critical group is that of organic compounds:
polycyclic aromatic hydrocarbons (PAHs), dioxins and furans,
products of incomplete combustion, which occur when the oper-
ating conditions are not adequate—low temperature, low oxygen
level, insufficient time—or by plant overload, and can be detected
by controlling the composition of the combustion gas.
Among them, particular importance is given to “dioxins and
furans,” due to their carcinogenic characteristics, and whose
processes of formation and destruction have received great
attention. Dioxins were first detected in municipal solid waste
incinerator (MSWI) emissions in the 1970s in the Netherlands
(Olie et al., 1977).
The polychlorodibenzodioxins (PCDD) and polychlorodiben-
zofurans (PCDF), especially 2,3,7,8-tetrachlorodibenzo-p-dioxin
(TCDD), have generated enormous interest and concern in the
population, mainly as a result of the accident that took place in
1976 in a chemical plant in Seveso (Italy). A large area around
the plant was contaminated, initiating a whole series of investiga-
tions aimed at identifying the degree of environmental pollution
and the health effects for residents according to their different
levels of exposure.
The social impact of the term “dioxin” is fully justified by the
high toxicity found in studies with experimental animals and the
physicochemical characteristics of these substances, including
their high chemical stability and liposolubility as well as their
high resistance to metabolic degradation, which confers to this
group of substances a great capacity for persistence and bioaccu-
mulation. TCDD is classified as carcinogenic by the International
Agency for Research in Cancer (IARC). Toxicological studies
reveal a wide range of adverse effects: cancer, reproductive toxic-
ity, immunosuppression, hepatotoxicity, neurological dysfunc-
tion, and dermatotoxicity.
However, epidemiological studies carried out with popula-
tions that have been accidentally exposed have not allowed con-
firmation of such a range of effects. Thus, although the discussion
between different groups of researchers continues, and not all
groups agree on the adverse effects that can be attributed to diox-
ins, it can be considered that there are different degrees of evi-
dence in relation to different adverse effects. The effects for
which a sufficient degree of association is established are: soft
tissue sarcoma, non-Hodgkin’s lymphoma and chloracne. Those
for which the degree of evidence is considered to be limited or
suggestive are: respiratory cancers, prostate cancer, multiple
myeloma, spine bifida and acquired porphyries. Other adverse
effects have been associated with weaker evidence. The cohorts
that have been studied in more depth are those from the Seveso
accident (1976) those from the Yusho (1968) and Yu-Cheng
(1979) diseases in Taiwan, who were exposed through oil con-
taminated with a commercial mix of PCBs and dioxins, and the
population of the Great Lakes environment in the U.S., exposed
through ingestion of contaminated fish. Other cohorts, such as
the American military personnel in contact with phenoxyacetic
pesticides in Vietnam (1962–1970), and those affected by the
transformer fire in Binghamton, New York (1981), have also
served as an important source of information (Ansorena Miner,
2008, 2009; Ibarluzea and Basterretxea, 2004).
Evidence that inevitable dispersion of PCDD/Fs in the work-
ing environments during recycling and disposal of fly ash from
MSWIs may pose health threats for onsite workers was recently
demonstrated in southern Taiwan. Through assessing health risk
with a Monte Carlo simulation, both the 95 percentile carcino-
genic and non-carcinogenic risks for onsite workers exceeded the
threshold limit (Hsieh et al., 2018).
The situation of the general population not exposed to occupa-
tional or accidental episodes cannot be considered similar to that
described above. It is considered that the general population is
exposed to dioxins mainly through the diet (> 90%). Exposure by
air, air pollution and by dermal route is considered to be less than
10% (Reis et al., 2007a).
The gas purification systems currently used have minimized
the possibility of releasing dioxins. According to the German
Ministry of Environment, between 1990 and 2000 the emissions
of the WI plants in Germany were reduced almost 1000 times and
presently represent less than 1% of the emissions derived from
human activity (Federal Ministry, 2005). In fact, the emissions of
the WI plants are the source of dioxins that have been more dras-
tically reduced: while in 1990 they were responsible for one-third
of the total dioxins emitted, in 2000 they only accounted for 1%
of emissions. Besides, it has been estimated that home chimneys
discharge to the environment 20 times more dioxins than WI
plants, an estimate supported by the seasonality of emissions that
are five times higher in winter than in summer. Similar results
were presented by the UK Ministry of Environment in 2004
(Enviros, 2004).

8 Waste Management & Research 00(0)
Studies carried out in the USA, France and Spain point in
the same direction. In 2006 the Environmental Protection
Agency of the United States of America (USEPA) published
the inventory of sources and the environmental emissions of
dioxins in the years 1987, 1995 and 2000, concluding that
there was a 90% reduction in the emission of dioxins by WI in
that period. Thus, the incinerators went from first to fourth
place in the ranking of sources, with the burning of waste out-
doors in first place (USEPA, 2006). All French MSWIs are
operated well below the EU and French standard of 0.1 ng
TEQ Nm3 (toxic equivalent nanograms per standard cubic
meter) and their total dioxin/furan emissions decreased from
435 g TEQ in 1997 to only 1.2 g in 2008 (Nzihou et al., 2012).
Several studies by AEVERSU (Spanish Association of
Energetic Valorization of Urban Waste) carried out in the
environment of several incinerators such as those of Reus,
Mataró and Tarragona (all in Catalonia) or Zabalgarbi (in
Bilbao) concluded that WI plants have no impact on their
environment or on the health of people (AEVERSU, 2015;
Rovira et al., 2015), and the Department of the Basque
Government affirmed that “there is no scientific evidence that
modern incineration and with limited emission levels suppose
an additional risk significant for the health of the population.”
However, experience recommends the idea of continuous
emissions monitoring (Universitat Rovira i Virgili, 2016).
A poorly studied aspect is the analysis of the environmental
concentrations of volatile organic compounds (VOCs) and bio-
aerosols (fungi and bacteria) in the vicinity of a WI plant. A study
carried out in Spain (Vilavert et al., 2009) found that these con-
centrations are very low, for example in comparison with the val-
ues inside and outside a composting plant or mechanical-biological
treatment (MBT) plant and are at the lower level of the range
found in the ambient air of various urban and industrial areas.
Moreover, no correlation was found between these concentra-
tions and the distance to the WI plant, although higher values
were found in the prevailing direction of the wind and major—
although statistically not significant—VOC values in the imme-
diate environment of the incinerator, which the authors attribute
to the greater accumulation of waste and the greater intensity of
vehicular traffic in that area.
Almost 20 years ago Greenpeace evaluated WI in Austria to
conclude that “The Austrian incineration plants have a high envi-
ronmental standard as far as air and water emissions are con-
cerned. Compared to other sources (industry, traffic, etc.) air and
water emissions are relatively low” (Schuster, 1999).
More recently, the Health Protection Agency (2009) “reviewed
the research carried out to examine possible relationships
between the emissions of municipal WI plants and the health
effects” to conclude:
That while it is not possible to rule out with complete certainty
possible adverse effects of modern and well-regulated plants of
incineration on health, any potential harm to the health of those
who live in their vicinity is likely to be very small, if it were
detectable.
Moreover, Defra stated that “since any possible effect on
health is probably very low or undetectable, it is not recom-
mended to conduct public health studies in the environment of
modern and well-managed incineration plants.”
Some sectors of civil society have argued that living near as
well as working in WI is associated with a wide range of health
effects, including cancer (in adults and children), adverse impacts
on the respiratory system, heart disease, effects on the immune
system, increased allergies and congenital malformations.
Holding this position, however, in most cases health effects that
have been associated with the presence of incinerators have not
been related to a particular contaminant (Allsopp et al., 2001;
Carrasco-Gallegos, 2017).
Prevention more than precaution
In view of the possible consequences of poor management of the
WI facilities and the difficulties enunciated to make any potential
environmental damage evident, it is imperative to use a preven-
tive strategy. It is noteworthy here that we speak of prevention
and not of precaution understanding that in the case of “preven-
tion,” the danger of the thing or activity is already known and the
only thing that is ignored is if the damage will occur in a specific
case, while, in the case of “precaution,” uncertainty rests on the
very danger of the thing, because scientific knowledge is still
insufficient to give a final answer about it. Thus, in the present
case, we understand that “the first and most suitable is the pre-
vention of damage to the environment, to avoid its completion”.
Especially given that it is a “non-monetized” good, that is, not
translatable in compensation and difficult to return to the previ-
ous undamaged state.
Let us complement this conception by remembering that the
precautionary principle applies when an activity is potentially
threatening to the environment or human health even if the cause-
effect relationships are not scientifically established, considering
that definitive demonstrations are often not easy – because the
conditions that science requires to establish causality are very
demanding – and the delay in establishing precautionary criteria
would allow the accumulation of damage.
None of these conditions is present in the proposal to operate
a WI plant: the dangers associated with poor operation are known
as well as the means to avoid them.
We understand that the implementation of a comprehensive
environmental impact assessment, the establishment of a rigorous
emissions standard, as the European Union has, and a rigorous
emissions monitoring program that includes alarm signals, with
public “on line” publication, appear as inescapable tools to ensure
the prevention of the occurrence of environmental damage.
Adherence to this line of action would satisfy the obligation to
carry out anticipatory activities required to prevent eventual
damages, and to demonstrate the safety of the proposed process
or activity, which are the full responsibility of the proposed
development. They would also give the installation and operation
process an open, informed and democratic character.

de Titto and Savino 9
This direction, in the same sense, was already laid out in a
number of international agreements: at the Stockholm Conference
of 1972, which included it in recommendation No. 70 of the Plan
of Action; in the Nairobi Declaration of 1982 which agreed that
“Prevention of damage to the environment is preferable to the
burdensome and extensive repair of damage already done” and in
the Rio Declaration on Environment and Development of 1992,
which contemplates externalities and applications of this preven-
tive emphasis both in Principle 15 and in dealing with environ-
mental impact assessment in Principle 17.
Within the wide range of measures to prevent environmental
damage, the environmental impact assessment (EIA) is notable
for its importance. EIA is present in the vast majority of national
legal systems and unanimously recommended by international
sources.
It should be recalled that the first country that incorporated the
EIA in its regulations was the United States of America, through
the National Environmental Policy Act (known as NEPA or U.S.
NEPA), in 1969. Since then it has been consecrated in many
national laws, including but not limited to: Germany (1971);
Canada (1973); New Zealand (1974); Colombia (1974); Thailand
(1975); Philippines, France, Venezuela and Ireland (1976);
Australia (1979); Kuwait (1980); South Korea and Brazil (1981);
Mexico, Indonesia and South Africa (1982); Pakistan (1983); the
countries of Europe, following the pronouncement of the European
Community through Directive 85/337/EEC of 27 June 1985 on
“Assessment of the incidences of certain public and private pro-
jects on the environment”; and India and Guatemala (1986).
The implementation of preventive measures does not obey
only to the fulfillment of the legal norms in force on the particular
but also to a logical and unquestionable ethical reason.
Conclusions
Waste incineration has been a common practice in many coun-
tries since the 1960s and its technology has evolved over time,
minimizing its emissions to neighboring communities. Data from
Germany, the U.SA. and the UK reveal that the installation of
suitable filters reduced the emission of heavy metals by 90% and
dioxins by more than 99%.
For more than 50 years many studies have been carried out to
establish the occurrence and magnitude of the risks that WI oper-
ation can mean for the health of the environment and of the peo-
ple who live in the environment of the WI plants.
The vast majority of the works published until the first years
of the 21st century referred to first generation incinerators char-
acterized by limited technology of abatement and low combus-
tion temperatures resulting in higher emissions.
The review of these works shows a general difficulty in circum-
venting the factors of confusion of the results. First, the difficulty
in translating the presence of hazardous substances into exposure
information, which has been often resolved by estimating the
exposure by factors such as the distance from the possible exposed
population to the source, without considering adjustments such as
by column height, feather shape or local wind rose at the time of
emission. Second, the vicinity of the plant to other probable sources
of emissions. Third, the lack of tools to quantify the effects of other
factors of confusion on the environment–health relationship, such
as age, ethnicity, gender, socioeconomic conditions, access to
health care, livelihoods, quality of feeding and exposure time.
The results presented by various epidemiological studies con-
ducted in different countries (Australia, Scotland, USA, Finland,
France, UK, Italy, Japan, Sweden) are inconsistent. They report a
wide variety of outcomes (some report increased number of
twins, increased number of cases of various types of cancer,
increased blood levels of organic compounds and metals; other
studies show no change in prevalence of acute and chronic res-
piratory diseases, in the frequency of symptoms, in hypersensi-
tivity of the respiratory tract, in atopy, in indicators of respiratory
function, in the number of congenital anomalies, in various types
of cancers) but none of them is presented systematically.
Environmental epidemiology of WI suffers from limitations
conducive to inadequate or contrasting results:
1. Because most disease are “rare” in populations, a large num-
ber of individuals have to be observed for a long time period
to identify a potential determinant, and studies carried out in
small communities for a limited number of years lack statisti-
cal power.
2. Specific attention is often given to communities where
exposure is “visibly” higher compared with others, thereby
emphasizing the effect.
3. Exposure is mostly not based on individual measurements or
accurate modeling of differences in population groups.
4. Potential concomitant causes of harm to health should be
measured and controlled for in the analyses as confounders
such as the socioeconomic conditions.
5. There is a widespread lack of information on individual risk
factors competitive for many diseases, such as smoking, die-
tary habits, alcohol use and occupation (Mattiello et al., 2013).
Risk assessment studies, which estimate the doses of the dif-
ferent pollutants to which the population may be exposed and the
different types of risk associated with this estimated exposure in
WI plants in Belgium, Spain, USA and France, show that neither
direct exposure to plant emissions nor indirect food exposure
poses a significant additional risk of cancer to residents in the
vicinity of the WI plant, or for the natural resources of the instal-
lation environment.
In order to reduce the uncertainty many research groups have
adopted studies using biomarkers that measure the concentration
of the different compounds in different organic compartments,
which allows identification of the internal exposure to which tis-
sues and cells are subjected. In addition, some of these studies have
had a longitudinal character, with follow-up over time of the same
group of people with a before and after the start of the WI plant
activity, which allows assessment of the impact that this activity
has on the internal exposure. Studies conducted in Germany,

10 Waste Management & Research 00(0)
Belgium, Spain, France and Portugal found no difference in dioxin
levels among residents—in some locations for 15 or more years—
in neighboring areas to incineration plants and the general popula-
tion. The same results were found when the breast milk of mothers
living in the vicinity of the plants was studied. Incinerator emis-
sions make a minor contribution to local air pollution levels.
New assessments of the hypothetical sanitary impact of a WI
plant will only come from epidemiological studies that include
exposure routes and biomarkers and compare WI-related expo-
sure with other sources of pollution.
The community perception of the risk associated with WI
plants has a dual character that integrates individual and socio-
cultural factors, which in their interaction build the notion of risk
of each individual. This notion is strongly tainted by its media
visibility, beyond the specific probabilities that it will become an
event, driven by “social cascades,” informative – when the indi-
vidual perception of risk is constituted through the perception of
third parties, without independent sources of information that
verify their veracity – and reputation – when the belief is based
on social approval. As a result, the individual perception of risk
and the likelihood of that risk being concrete for any individual
do not have to agree.
A necessary condition for the development of a WI plant is
to generate the conditions to prevent any impact that activates
or potentially carries damage or risks to the environment and, in
particular, to human health. Attentive to this, it is imperative to
use a preventive strategy. The implementation of a comprehen-
sive EIA, the establishment of an emissions standard and a rig-
orous emissions monitoring program appear as inescapable
tools to ensure the prevention of the occurrence of environmen-
tal damage.
In summary, there is no known scientific evidence that WI
plants designed and operated in order to comply with the emis-
sion standards in force in developed countries have a significa-
tive impact on the environment and the health of people living
in their environment. Therefore, the establishment and compli-
ance of emission standards should be sufficient to ensure their
safety for the environment. The realization of a previous socio-
environmental impact assessment and a participatory follow-up
process of their operation are sufficient guarantees for the
authorities and the community that the operation of the WI
plant is a virtuous step in the management of waste with the
added value of contributing to the reduction of greenhouse gas
emissions.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Atilio Savino https://orcid.org/0000-0003-0998-3149
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