Table 4.
Health outcomes associated with incinerators.
| Study Location | Study Design | Main Findings (e.g., Estimated Risk, CI, p-Value) | Ref. |
|---|---|---|---|
| Mortality | |||
| Italy | Cohort study (retrospective) |
Associations between heavy metals concentration and mortality in the highest exposed group using the lowest exposure category as the reference (rate ratio (RR) and 95% CI): - all causes (men): 1.01 (0.86, 1.20) - all causes (women): 1.12 (1.00, 1.27) a - >cardiovascular diseases (men): 0.98 (0.75, 1.29) - cardiovascular diseases (women): 1.32 (1.00, 1.72) - ischemic heart diseases (men): 0.79 (0.51, 1.22) - ischemic heart diseases (women): 1.14 (0.72, 1.82) - respiratory diseases (men): 1.01 (0.42, 2.45) - respiratory diseases (women): 0.53 (0.18, 1.56) - chronic pulmonary diseases (men): 0.53 (0.15, 1.86) - chronic pulmonary diseases (women): 0.27 (0.03, 2.06) Associations between heavy metals concentration and cancer mortality in the highest exposed group using the lowest exposure category as the reference (rate ratio (RR) and 95% CI): - all cancer (men): 0.85 (0.64, 1.12) - all cancer (women): 1.47 (1.09, 1.99) a - stomach (men): 0.85 (0.35, 2.03) - stomach (women): 1.86 (0.73, 4.75) - colon rectum (men): 2.05 (0.92, 4.58) - colon rectum (women): 2.15 (0.86, 5.37) - liver (men): 0.27 (0.03, 2.18) - liver (women): 5.10 (0.94, 27.80) - larynx (men): no cases - larynx (women): no cases - lung (men): 0.91 (0.53, 1.57) - lung (women): 0.96 (0.31, 2.97) - soft tissue sarcoma (men): no cases - soft tissue sarcoma (women): no cases - breast (women): 2.00 (1.00, 3.99) - prostate (men): 1.57 (0.66, 3.74) - bladder (men): 1.48 (0.52, 4.22) - bladder (women): 3.06 (0.64, 14.70) - central nervous system (men): no cases - central nervous system (women): no cases - lymph. system (men): 0.42 (0.15, 1.23) - lymph. system (women): 1.78 (0.74, 4.25) - non-Hodgkin lymphoma (men): 0.52 (0.11, 2.45) - non-Hodgkin lymphoma (women): 2.03 (0.48, 8.67) - myeloma (men): no cases - myeloma (women): 4.28 (0.77, 23.80) - leukaemia (men): 0.67 (0.14, 3.16) - leukaemia (women): 1.31 (0.25, 6.95) |
[44] |
| Cancer | |||
| Italy | Cohort study (retrospective) | Associations between heavy metals concentration and cancer incidence in the highest exposed group using the lowest exposure category as the reference (Rate Ratio (RR) and 95% CI): - all cancer (men): 0.87 (0.72, 1.06) - all cancer (women): 0.90 (0.73, 1.11) - stomach (men): 1.24 (0.64, 2.40) - stomach (women): 1.09 (0.49, 2.44) - colon rectum (men): 1.00 (0.57, 1.75) - colon rectum (women): 1.33 (0.71, 2.48) - liver (men): 0.26 (0.03, 2.01) - liver (women): 0.94 (0.20, 4.53) - larynx (men): 0.15 (0.02, 1.14) - larynx (women): 1.60 (0.15, 17.64) - lung (men): 0.96 (0.61, 1.52) - lung (women): 0.81 (0.27, 2.42) - soft tissue sarcoma (men): 0.84 (0.09, 8.06) - soft tissue sarcoma (women): no cases - breast (women): 0.76 (0.51, 1.13) - prostate (men): 1.27 (0.82, 1.99) - bladder (men): 0.78 (0.43, 1.42) - bladder (women): 2.30 (0.73, 7.24) - central nervous system (men): 1.35 (0.34, 5.39) - central nervous system (women): no cases - lymph. system (men): 0.70 (0.38, 1.28) - lymph. system (women): 1.23 (0.65, 2.33) - non-Hodgkin lymphoma (men): 0.59 (0.23, 1.57) - non-Hodgkin lymphoma (women): 1.06 (0.39, 2.93) - myeloma (men): 0.61 (0.17, 2.13) - myeloma (women): 0.95 (0.26, 3.45) - leukaemia (men): 1.01 (0.36, 2.84) - leukaemia (women): 1.23 (0.33, 4.62) |
[44] |
| France | Case-control study | Odds ratio (OR) of invasive breast cancer by age bands and dioxin exposure categories (comparing very low with high exposure) (95% CI): - women aged 20–59 years: 0.88 (0.43, 1.79) - women aged 60 years and over: 0.31 (0.08, 0.89) |
[48] |
| Adverse birth and neonatal outcomes | |||
| Italy | Cohort study (retrospective) | Associations between modelled exposure levels to PM10 from the incinerators and reproductive outcomes, for the highest versus the lowest quintile exposure (odds ratio (OR), 95% confidence interval and significance): - preterm births: 1.30 (1.08, 1.57) b, p < 0.05 c; 1.44 (1.11, 1.85) d, p < 0.05 c - sex ratio: 0.91 (0.83, 0.99) b; 0.88 (0.78, 0.99) - multiple births: 0.87 (0.57, 1.33) b; 1.12 (0.60, 2.08) d - small for gestational age (SGA): 1.11 (0.96, 1.28) b; 1.06 (0.87, 1.29) d |
[45] |
| Italy | Cohort study (retrospective) | Associations between modelled exposure levels to PM10 from the incinerators and miscarriages, for the highest versus the lowest quintile exposure (adjusted odds ratio (OR), 95% confidence interval and significance p): - spontaneous abortions: 1.29 (0.97, 1.72) e |
[52] |
| Italy | Cohort study (retrospective) | Associations between modelled exposure levels of pollutants from the incinerator and reproductive outcomes, in terms of Relative Risk computed as the ratio between observed and expected incidence, (95% confidence interval): - Spontaneous abortion: - residents from both areas A and B 1.00 (0.65, 1.48) - area A residents (highest exposure): 0.87 (0.22, 2.38) - area B residents (intermediate exposure): 1.03 (0.64, 1.56) - workers from both areas A and B: 1.04 (0.38, 2.30) - area A workers: 0.00 (0.00, 1.46) - area B workers: 1.81 (0.66, 4.02) - Spontaneous abortion: - residents from both areas A and B: 0.64 (0.20, 1.55) - area A residents: 0.00 (0.00, 4.41) - area B residents: 0.72 (0.23, 1.75) - workers from both areas A and B: 2.26 (0.57, 6.14) - area A workers: 2.22 (0.37, 7.34) - area B workers: 2.27 (0.11, 11.21) |
[49] |
| Great Britain (UK) | Cohort study (retrospective) | Associations between modelled exposure levels of pollutants from the incinerator and reproductive outcomes (adjusted OR and 95% CI): - stillbirths f: 0.99 (0.97, 1.00) - stillbirths g: 1.00 (0.99, 1.02) - neonatal mortality (pregnancy exposure) f: 0.99 (0.96, 1.02) - neonatal mortality (pregnancy exposure) g: 1.01 (1.00, 1.03) - post-neonatal mortality (pregnancy exposure) f: 1.02 (0.96, 1.07) - post-neonatal mortality (pregnancy exposure) g: 0.99 (0.97, 1.02) - post-neonatal mortality (birth to death of case exposure) f: 1.01 (0.98, 1.04) - multiple births f: 0.99 (0.99, 1.00) - multiple births g: 1.00 (0.99, 1.00) - sex ratio f: 1.00 (1.00, 1.00) - sex ratio g: 1.00 (1.00, 1.00) - preterm delivery f: 0.99 (0.97, 1.01) - preterm delivery g: 1.00 (0.99, 1.00) - terms small for gestational age (SGA) f: 0.99 (0.98, 1.00) - terms SGA g: 1.00 (0.99, 1.01) |
[24] |
| England and Scotland (UK) | Cohort study (retrospective) |
Adjusted odds ratio (OR) (95% CI): - all congenital anomalies f: 1.00 (0.98, 1.02) - all congenital anomalies g: 1.02 (1.00, 1.04) - all congenital anomalies excluding chromosomal f: 0.99 (0.97, 1.01) - all congenital anomalies excluding chromosomal g: 1.02 (1.00, 1.04) - nervous system f: 0.97 (0.92, 1.02) - nervous system g: 0.97 (0.93, 1.02) - congenital heart defects f: 0.99 (0.93, 1.05) - congenital heart defects g: 1.04 (1.01, 1.08), p < 0.05 h - abdominal wall defects f: 1.00 (0.92, 1.08) - abdominal wall defects g: 1.00 (0.94, 1.07) - oro-facial clefts f: 1.00 (0.94, 1.07) - oro-facial clefts g: 0.99 (0.94, 1.05) - limb defects f: 1.01 (0.94, 1.08) - limb defects g: 1.02 (0.97, 1.08) - digestive system f: 1.00 (0.92, 1.09) - digestive system g: 1.00 (0.95, 1.06) - urinary system f: 1.00 (0.94, 1.07) - urinary system g: 1.02 (0.97, 1.06) - genital system f: 1.03 (0.95, 1.13) - genital system g: 1.07 (1.02, 1.12), p < 0.05 h - neural tube defects (from congenital anomaly sub-groups (CAS)) f: 1.00 (0.92, 1.07) - neural tube defects (from CAS) g: 0.97 (0.91, 1.03) - severe congenital heart defects (from CAS) f: 1.03 (0.97, 1.10) - severe congenital heart defects (from CAS) g: 1.02 (0.97, 1.07) - gastroschisis (from CAS) f: 1.04 (0.94, 1.15) - gastroschisis (from CAS) g: 0.97 (0.89, 1.05) - cleft palate (from CAS) f: 1.02 (0.92, 1.13) - cleft palate (from CAS) g: 0.98 (0.90, 1.06) - cleft lip with or without cleft palate (from CAS) f: 1.00 (0.93, 1.08) - cleft lip with or without cleft palate (from CAS) g: 1.00 (0.94, 1.07) - limb reduction defects (from CAS) f: 1.02 (0.91, 1.14) - limb reduction defects (from CAS) g: 0.98 (0.90, 1.08) - oesophageal atresia (from CAS) f: 1.04 (0.88, 1.22) - oesophageal atresia (from CAS) g: 0.92 (0.80, 1.05) - anomalies of the renal system (from CAS) f: 1.02 (0.95, 1.10) - anomalies of the renal system (from CAS) g: 1.00 (0.93, 1.07) - obstructive defects of renal pelvis (from CAS) f: 0.97 (0.90, 1.04) - obstructive defects of renal pelvis (from CAS) g: 1.03 (0.97, 1.10) - hypospadias (from CAS) f: 1.00 (0.90, 1.12) - hypospadias (from CAS) g: 1.07 (1.01, 1.12), p < 0.05h |
[25] |
| Taiwan | Cohort study (retrospective) | Difference of birth outcomes between higher exposure and control areas in 1997 (adjusted OR and 95% CI): - birth weight: 1.06 (0.71, 1.57) - gestation weeks, in 1997: 1.22 (0.97, 1.52) - gender, in 1997: 0.90 (0.78, 1.05) |
[51] |
| Italy | Case-control study | Prevalence (odds ratio) for congenital anomalies according to maternal exposure to air emissions from the incinerator (95% confidence interval), with low exposure area as reference: All congenital anomalies: - area B (medium exposure) i: 1.55 (0.67, 3.56) - area B j: 1.10 (0.39, 3.06) - area B k: 3.17 (0.65, 15.46) - area C (high exposure) i: 0.67 (0.25, 1.77) - area C j: 0.41 (0.11, 1.61) - area C k: 1.30 (0.29, 5.82) Cardiovascular anomalies: - area B i: 0.94 (0.27, 3.31) - area C i: 0.58 (0.14, 2.45) - area B j: 0.59 (0.14, 2.49) |
[50] |
| France | Case-control study | Risk of urinary tract birth defects, in terms of OR (with 95% CI), for not exposed group versus exposed above the median: - considering atmospheric dioxins: 2.84 (1.32, 6.09) h - considering dioxin deposits: 2.95 (1.47, 5.92) h - considering metals: 0.73 (0.45, 1.19) - considering consumption of local food and dioxin deposits: 1.88 (0.55, 6.35) |
[46] |
| Cardiovascular diseases | |||
| Italy | Cohort study (retrospective) | Associations between heavy metals concentration and hospitalization for specific causes in the highest exposed group using the lowest exposure category as the reference (rate ratio (RR) and 95% CI): - acute myocardic infarction (men): 0.81 (0.51, 1.28) - acute myocardic infarction (women): 1.40 (0.66, 2.98) - chronic heart failure (men): 0.78 (0.46, 1.33) - chronic heart failure (women): 1.48 (0.90, 2.46) |
[44] |
| Respiratory conditions | |||
| Italy | Cohort study (retrospective) | Associations between heavy metals concentration and hospitalization for specific causes in the highest exposed group using the lowest exposure category as the reference (rate ratio (RR) and 95% CI): - chronic obstructive pulmonary disease (men): 1.43 (0.89, 2.31) - chronic obstructive pulmonary disease (women): 0.63 (0.35, 1.14) - acute respiratory diseases (men): 0.89 (0.63, 1.27) - acute respiratory diseases (women): 1.29 (0.94, 1.78) - asthma (men): 1.16 (0.36, 3.71) - asthma (women): 1.01 (0.40, 2.55) |
[44] |
| Human biomonitoringl, m, n | |||
| China | Cross-sectional study |
Blood PCDD/F levels comparing exposed group with control group: - TEQΣPCDD/Fs: 0.40 vs. 0.28 pg TEQ/g wet weight, p < 0.05 o |
[9] |
| China | Cross-sectional study |
PCDD/Fs and PCBs levels in breast milk comparing exposed and control groups: - TEQ (PCDD/Fs + DL-PCBs): 0.28 vs. 0.16 pg TEQ/g wet weight, p < 0.05 p Mean EDI level in infants comparing exposed and control groups: 22.0 vs. 13.0 pg TEQ/kg bw day, p < 0.05 p |
[47] |
| Spain | Cohort study (perspective) | Concentrations of PCDD/Fs, expressed as pg TEQ/g fat in whole blood samples in exposed/non-exposed (Matarò)/non-exposed (Arenys de Mar): - 1995: 13.0/13.1/Not Measured (NM) - 1997: 15.9/16.4/NM - 1999: 17.8/18.1/18.7 - 2002: 15.1/18.2/16.02 - 2005: 11.7/12.3/17.9 - 2008: 14.6/12.6/14.5 - 2012: 12.9/13.3/12.5 |
[53] |
a The authors indicated the level of significance only when p-value was lower than 0.05. b period 2003–2010; c p < 0.05. Test conducted by the authors for trend across categories of exposure to incinerator emissions; d period 2007–2010; e The authors reported a p-value of 0.042, for testing the trend of groups 1 and 5 (the highest versus the lowest quintile). It can be noted a significant trend for increases in spontaneous abortions with greater PM exposure. f Per doubling of PM10; g Proximity to the nearest MWI, calculated as a continuous measure of linear distance (km); h p < 0.05. Estimated in our systematic review on the basis of 95% Confidence Interval; i Entire study period; j Operation period: from December 1 1998 to October 31 2002 and from April 1 2006 to December 31 2006; k Shut-down period: from 1 February 2003 to 31 December 2005; l In terms of dioxins, whose long-term exposure increases the risk of cancer and other negative health outcomes including reproductive, developmental and neurodevelopmental effects [54,55]; m Values expressed in terms of Toxic Equivalence (TEQ) were assessed. Indeed, TEQs are calculated values that allow to compare the toxicity of different combinations of dioxins and dioxin-like compounds; in order to calculate a TEQ, a toxic equivalent factor (TEF) is assigned to each member of the dioxin and dioxin-like compounds category. TEFs have been established through international agreements and currently range from 1 to 0.0001 [56]; n EFSA et al. [57] considered a threshold value in serum of 7.0 pg/g fat. Furthermore, they established a Tolerable Weekly Intake (TWI) of 2 pg TEQ/kg bw per week. WHO [55] indicates a provisional tolerable intake of 70 pg/kg bw per month for PCDDs, PCDFs and coplanar PCBs expressed as TEFs. It has to be noted that although several studies showed a positive association with cancer, there was no clear dose–response relationship between exposure and cancer development [57]; at the same time, WHO [55] noted since dioxins induce tumors and likely other effects via a receptor-mediated mechanism, tolerable intake guidance based on non-cancer end-points observed at lower doses is considered protective for carcinogenicity. o p < 0.05. When data fit the normal distribution, two independent sample t-tests were performed by the authors to compare the mean levels of the two groups. Otherwise, the Mann–Whitney U test was performed. p p < 0.05. If the data fitted the normal distribution, two independent sample t-tests were performed by the authors to compare the mean levels of the two groups. Otherwise, the non-parametric test was performed.