Download as pdf or txt
Download as pdf or txt
You are on page 1of 28

Review

Municipal Solid Waste Management and Adverse Health


Outcomes: A Systematic Review
Giovanni Vinti 1, Valerie Bauza 2, Thomas Clasen 2, Kate Medlicott 3, Terry Tudor 4, Christian Zurbrügg 5
and Mentore Vaccari 1,*

1 Department of Civil, Environmental, Architectural Engineering and Mathematics, University of Brescia,


25123 Brescia, Italy; [email protected]
2 Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University,

Atlanta, GA 30322, USA; [email protected] (V.B.); [email protected] (T.C.)


3 Department of Public Health, Environment and Social Determinants of Health, World Health Organization,

1202 Geneva, Switzerland; [email protected]


4 SusConnect Ltd., Weedon Bec, Northamptonshire NN7 4PS, UK; [email protected]

5 Department of Sanitation, Water and Solid Waste for Development (Sandec), Eawag: Swiss Federal Institute

of Aquatic Science and Technology, Überlandstrasse 133, 8600 Dübendorf, Switzerland;


[email protected]
* Correspondence: [email protected]; Tel.: +39-030-371-1300

Abstract: Municipal solid waste (MSW) can pose a threat to public health if it is not safely managed.
Despite prior research, uncertainties remain and refurbished evidence is needed along with new
approaches. We conducted a systematic review of recently published literature to update and ex-
Citation: Vinti, G.; Bauza, V.; Clasen, pand the epidemiological evidence on the association between MSW management practices and
T.; Medlicott, K.; Tudor, T.; resident populations’ health risks. Studies published from January 2005 to January 2020 were
Zurbrügg, C.; Vaccari, M. Municipal searched and reviewed following PRISMA guidelines. Eligible MSW treatment or disposal sites
Solid Waste Management and were defined as landfills, dumpsites, incinerators, waste open burning, transfer stations, recycling
Adverse Health Outcomes: A sites, composting plants, and anaerobic digesters. Occupational risks were not assessed. Health ef-
Systematic Review. Int. J. Environ.
fects investigated included mortality, adverse birth and neonatal outcomes, cancer, respiratory con-
Res. Public Health 2021, 18, 4331.
ditions, gastroenteritis, vector-borne diseases, mental health conditions, and cardiovascular dis-
https://doi.org/
eases. Studies reporting on human biomonitoring for exposure were eligible as well. Twenty-nine
10.3390/ijerph18084331
studies were identified that met the inclusion criteria of our protocol, assessing health effects only
Academic Editor: Paul B.
associated with proximity to landfills, incinerators, and dumpsites/open burning sites. There was
Tchounwou some evidence of an increased risk of adverse birth and neonatal outcomes for residents near each
type of MSW site. There was also some evidence of an increased risk of mortality, respiratory dis-
Received: 5 March 2021 eases, and negative mental health effects associated with residing near landfills. Additionally, there
Accepted: 16 April 2021 was some evidence of increased risk of mortality associated with residing near incinerators. How-
Published: 19 April 2021 ever, in many cases, the evidence was inadequate to establish a strong relationship between a spe-
cific exposure and outcomes, and the studies rarely assessed new generation technologies. Evidence
Publisher’s Note: MDPI stays neu- gaps remain, and recommendations for future research are discussed.
tral with regard to jurisdictional
claims in published maps and institu-
Keywords: MSW; public health; epidemiology; PRISMA guidelines
tional affiliations.

1. Introduction
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland. Municipal solid waste (MSW) poses a threat to public health and the environment if it
This article is an open access article is not safely managed from separation, collection, transfer, treatment, and disposal or recy-
distributed under the terms and cling and reuse. The World Health Organization (WHO) has highlighted the risks associated
conditions of the Creative Commons with the inadequate disposal of solid waste with respect to soil, water, and air pollution and
Attribution (CC BY) license the associated health effects for populations surrounding the involved areas [1].
(http://creativecommons.org/licenses Globally, MSW generation is expected to increase to 3.40 billion tonnes by 2050 [2].
/by/4.0/). In general, waste management practices tend to improve going from low-income to high-

Int. J. Environ. Res. Public Health 2021, 18, 4331. https://doi.org/10.3390/ijerph18084331 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 4331 2 of 28

income countries [3,4]. As a consequence, the related health risks tend to be greater in low-
income countries, where the most dangerous practices, such as open dumping and un-
controlled burning of solid waste, are still common [5]. Using published data, Vaccari et
al. [6] compared characteristics of leachate from more than 100 landfills and dumpsites in
Asia, Africa, and Latin America, and found statistically significant concentrations of pol-
lutants in dumpsites.
Waste treatment and disposal includes recycling, composting, anaerobic digestion,
incineration, landfilling, open dumping, and dumping in marine areas [2]. The impact of
solid waste on health may vary depending on numerous factors such as the nature of
waste management practices, characteristics, and habits of the exposed population, dura-
tion of exposure, prevention, and mitigation interventions (if any) [5,7,8]).
An investigation of the relationship between solid waste and human health begins
with hazard identification and exposure assessment [1]. Figure 1 schematically represents
the linkages between waste management practices, the respective hazards associated with
these practices, the possible environmental pathways of transmission by which the most
vulnerable or exposed population segments can absorb contaminants, and possible ad-
verse health outcomes. Different waste management practices result in the release of dif-
ferent specific substances, including different environmental matrices that can be in-
volved in transport and exposure. For example, air is the first environmental transport
pathway for burning waste. By-products such as dioxins can be generated, and the inges-
tion of contaminated dairy products can represent an indirect source of exposure [9].
Other practices, such as waste disposal in landfills or dumpsites, can also affect ground-
water through the leaking of leachate [10]; the consequent exposure would be represented
by the ingestion of water contaminated with toxic or carcinogenic compounds [11].
Various reviews have explored the health effects related to solid waste management.
Cointreau [12] published a detailed report on solid waste and health risks for population
and workers, noting that the situation in low-income countries is usually worse. Coin-
treau’s work is probably the most exhaustive of the last 15 years. Porta et al. [13] examined
epidemiological studies on health effects associated with management of solid waste, ex-
cept for dumpsites and open burning areas. Mattiello et al. [14] analyzed the health effects
focusing on people living nearby landfills and incinerators. Ashworth et al. [15] gathered
data focusing on waste incineration and adverse birth outcomes. Ncube et al. [16] consid-
ered epidemiological studies related to municipal solid waste management, assembling
the results based on the health risk (e.g., cancer, birth weight, congenital malformations,
respiratory diseases), but this made difficult a comparison among MSW practices. None
of these reviews analyzed studies published later than 2014. A further systematic review,
recently published [17], focused on waste incinerators’ health impact, considering studies
until 2017. In many cases, the authors suggested that MSW management practices can
pose some adverse health effects for the population residing nearby, although the current
evidence often lacked statistical power, highlighting the need for further investigations.
At the same time, with a moderate level of confidence, some authors derived effects from
old landfills and incinerators, such as an increased risk of congenital malformation within
2 km for landfills and cancer within 3 km for incinerators [13]; other authors [14] found
an increased risk of congenital anomalies mainly nearby special waste landfills, and re-
garding incinerators some authors found some limited risks of cancer and birth defects,
highlighting changes in technology are producing more reassuring results [14]. Still, the
previous reviews rarely analyzed the changing operational standards associated with the
evolving legislation. Although their approach can represent a prudent strategy, it limited
the interpretation of some data. Only Mattiello et al. [14] conducted this type of analysis.
Int. J. Environ. Res. Public Health 2021, 18, 4331 3 of 28

Figure 1. Schematic representation of the linkages between solid waste management practices and
possible adverse health outcomes.

Focusing on composting facilities, two systematic reviews analyzed health outcomes,


but only considered bioaerosols exposure [18,19]. In both studies, the authors concluded
that there is insufficient evidence to provide a quantitative comment on the risk to nearby
residents, although there is sufficient evidence to support a precautionary approach, and
further research is needed.
In most of the reviews mentioned above, vector-borne diseases (such as malaria)
were not included. Only Ncube et al. [16] cited one study about malaria [20] and Cointreau
[12] mentioned a couple of old studies related to vector-borne diseases. Although one re-
cent review [21] focused on the link between solid waste and vector-borne diseases, the
methodology and results did not follow a systematic procedure, and appeared excessively
approximate.
Additionally, the PRISMA methodology, characterizing a recently recommended
systematic review approach [22,23], was rarely implemented. Only in the works of Pear-
son et al. [18], [19] and Tait et al. [17] was it applied, i.e., in studies that only involved a
specific solid waste management practice.
Therefore, despite such prior reviews, uncertainties remain. In many cases, how fu-
ture research should be developed was not addressed enough. Additionally, the influence
of national legislation, characterizing operational standards and technological level, was
rarely investigated. Furthermore, WHO [1] noted that the health effects of waste manage-
ment and disposal activities are only partly understood. In some cases, it is challenging to
apply estimates and evidence from studies related to high levels of emissions from the
past to new-generation incineration plants. It has to be highlighted that solid waste legis-
lation influences the technological level and emission limits associated with solid waste
management plants, such as landfills and incinerators. Indeed, in many European coun-
tries, modern technology has been reducing noxious emissions, and measurable health
impacts have, in many cases, become smaller. For example, even the review of Tait et al.
[17], in which the authors focused on incinerators’ publications until 2017, should be re-
newed, based on more recent and robust studies (e.g., [24,25]). At the same time, it has to
Int. J. Environ. Res. Public Health 2021, 18, 4331 4 of 28

be considered that the so-called emerging contaminants (ECs) are not commonly moni-
tored in the environment, but they have the potential to enter the environment and cause
known or suspected adverse health effects [26]. In addition, many new chemicals are con-
stantly approved for commercial use; for example, over 40,000 chemicals are actively be-
ing manufactured, processed, and imported in the United States, but the health effects of
few of them have been monitored in the population [27,28]. Such substances can easily
reach the solid waste phase, leading to underestimated adverse health outcomes. Besides,
countries with weak environmental legislations can be affected by additional risks. For
instance, some persistent organic pollutants (POPs) are still in production and use in coun-
tries that have not ratified the Stockholm Convention, such as in Southern Asia [29]. Con-
sequently, updated evidence is needed for the policy debate.
Thus, we have undertaken the present systematic review in order to update and ex-
pand on previous reviews, based on the PRISMA statement [23]. Specifically, the objective
was to assess and summarize the evidence on the association between municipal solid
waste (MSW) management practices and health risks to populations residing nearby. Data
were gathered and analyzed in a different way compared with the studies aforemen-
tioned. After summarizing the results, the findings are discussed in detail in the Discus-
sion section, considering the influence of national legislation and the technological level
in the case of landfills and incinerators. It represents the main novelty of the topic. Fur-
thermore, the update of the recent scientific literature related to MSW and health out-
comes using the PRISMA statement was provided, also taking into consideration that
some categories, such as dumpsites and vector-borne diseases, were not adequately ana-
lyzed in previous reviews. Such a comprehensive approach represented an added value
to the manuscript. Finally, we also discussed how further research should be conducted.

2. Methods
The methods used in this review were developed based on the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [22,23]. The
PRISMA is a procedure that originated in 2009, consisting of a 27-item checklist and a
PRISMA flow diagram [23] that helps authors develop the systematic review in a well-
structured way to address recent advances in the science of systematic reviews. The com-
plete procedure is available in the protocol registered on PROSPERO [30], an international
database of prospectively registered systematic reviews.

2.1. Definitions
Some of the technical terms used in this review are defined below.
 Municipal solid waste (MSW): any material from residential, commercial, and insti-
tutional activities which is discarded. It is important to note that industrial, medical,
hazardous, electronic, and construction and demolition wastes belong to other cate-
gories [2].
 Engineered landfill: site characterized by the registration and placement/compaction
of waste. Such landfills typically use daily cover material, surface and ground water
monitoring, infrastructure, and a waterproof liner at the bottom [6].
 Sanitary landfill: site characterized by the registration and placement/compaction of
waste. Best practices include a waterproof liner at the bottom, leachate and gas col-
lection systems, daily cover, a final top cover and closure, infrastructure as well as a
post-closure plan [6].
 Dumpsites: open and unregulated areas or holes in the ground with no environmen-
tal protection and disposal controls [6]. Due to lack of controls, dumpsites may re-
ceive different waste streams including MSW, sewage sludge, hazardous waste, elec-
tronic waste, healthcare waste [31].
 Transfer stations: facilities in which waste is transferred from smaller vehicles used for
waste collection into bigger vehicles for hauling to a disposal or treatment site [32].
Int. J. Environ. Res. Public Health 2021, 18, 4331 5 of 28

 Incinerators: a specialized engineered system where waste is burned. Through com-


bustion waste is converted into ash, flue gas, and heat. The flue gases are treated to
reduce impact of air pollution on environment and health. Energy from an incinera-
tor can be recovered [32].
 Open burning of waste: burning of solid waste in open areas without air pollution
controls [32].
Dumpsites and open burning were categorised together since burning waste in
dumpsites is a common practice, especially in low- and middle-income countries [5,12],
making it impossible to split it into two separate categories. As the definition of dumpsites
suggests, it was not always possible to assure a clear distinction between MSW and other
categories of waste. As a consequence, dumpsites were excluded in cases where the sites
did not receive MSW but only other categories of solid waste. Furthermore, in many cases
it was not possible to find a clear distinction between sanitary and engineered landfills
among the publications, as a consequence the two categories were combined. However,
as will be discussed later, such definitions of landfills and incinerators need to be contex-
tualised. Indeed, the fast-evolving technologies and more restrictive legislation [1] can in-
fluence the emission limits and the related health outcomes.

2.2. Study Eligibility


As detailed more fully in the review protocol, studies were eligible for inclusion in
the review if they met specified criteria for population, exposure, and health effects. The
eligible population and exposures were persons, both children and adults, living, study-
ing, or spending time near MSW treatment or disposal sites, such as landfills, dumpsites,
incinerators, areas in which open burning of waste is conducted, transfer stations, recy-
cling sites, composting plants, and anaerobic digesters. Eligible comparators were resi-
dents who were not exposed, residents with a lower level of exposure and residents lo-
cated at different distances from MSW treatment or disposal sites. Occupational risks and
therefore waste workers (regular or informal) were not assessed, because they were re-
lated to a further category, subjected to different exposures also in terms of time. Health
effects included mortality, adverse birth and neonatal outcomes, respiratory conditions,
cancer, gastroenteritis, vector-borne diseases, mental and social health conditions, and
cardiovascular diseases. Studies reporting on human biomonitoring for exposure were
also eligible. The inclusion of transfer stations and vector-borne diseases [33] as an out-
come was a modification from the pre-specified protocol submitted to PROSPERO. How-
ever, no changes were made to the search strategy as a result of this addition.
Randomized controlled trials (RCTs) and the following non-randomized controlled
studies (NRS) were included: quasi-RCTs, non-RCTs, controlled before-and-after studies,
interrupted-time-series studies, historically controlled studies, case-control studies, co-
hort studies, and cross-sectional studies that include a comparison group. Studies were
excluded if they reported qualitative data only.
To be eligible for inclusion, studies had to be peer reviewed and published in English.

2.3. Search Strategy; Screening and Data Extraction; Narrative Review


The search for eligible studies was conducted using relevant search engines (i.e., Sco-
pus, ScienceDirect, Google Scholar) with a combination of keywords based on possible
MSW exposure and health effects. Further details regarding the electronic search strategy,
including the keywords and string, are available in the protocol. Studies published from
January 2005 to January 2020 were examined.
Following an initial screening of paper titles and abstracts, the full paper was exam-
ined for eligibility by a single reviewer. Thereafter, data were extracted from eligible stud-
ies and compiled solely from the paper.
Due to substantial differences between the studies included in terms of settings, pop-
ulations, study designs, contexts, MSW management practices, exposure assessment, case
Int. J. Environ. Res. Public Health 2021, 18, 4331 6 of 28

definitions, outcome definitions and outcome assessment, it was determined that a pooled
analysis using meta-analysis or meta-regression was not appropriate. Accordingly, this
review adopted a narrative approach.

2.4. Risk of Bias; Quantity and Strength of Evidence


One reviewer assessed the risk of bias associated with experimental studies, based on
the Liverpool Quality Assessment Tool (LQAT), an adaptation of the Newcastle-Ottawa
Scale [34]. Observational studies were automatically scored as having a very serious risk of
bias due to the many potential sources of bias inherent in the study design.
Finally, the strength of evidence was summarized to develop the different health out-
comes as a function of the categories of exposure analyzed (e.g., landfills, dumpsites). The
following values were given: (0) no studies; (−) studies, but no evidence of increased risk;
(+) studies, providing some evidence of increased risk; (++) studies, with stronger evidence
of increased risk. The findings are discussed in detail in the discussion section taking also
into consideration the technological level of the units in the case of landfills and incinerators.

3. Results
3.1. Study Selection
A total of 253 studies, including 33 reviews and reports, were initially identified. Af-
ter adjusting for duplicates, 236 remained. Of these, 37 studies were discarded after re-
viewing the abstracts (if any) because it appeared these papers clearly did not meet the
criteria. The full text of the remaining 199 publications was examined in more detail. A
total of 170 studies did not meet the inclusion criteria previously described. Twenty-nine
studies met the inclusion criteria and are included in this review. The PRISMA flow chart
describing the process for determining study eligibly appears in Figure 2 below. All stud-
ies screened are available in Supplementary Materials.

Figure 2. PRISMA flow diagram summarizing the study selection.


Int. J. Environ. Res. Public Health 2021, 18, 4331 7 of 28

3.2. MSW Transfer and Treatment Sites


Although the review sought to summarize studies investigating health effects asso-
ciated with MSW transfer and treatment sites, we did not identify any eligible studies.
Specifically, no studies were found that met the review’s inclusion criteria for health ef-
fects associated with proximity to transfer stations, recycling centers, composting plants,
and anaerobic digesters.

3.3. MSW Disposal Sites


Tables 1–6 summarize the results. In particular, in terms of the methodology used in
each paper, the results concerning MSW disposal sites are summarized in Table 1 (land-
fills), Table 3 (incinerators) and Table 5 (dumpsites and open burning). The studies are
listed in alphabetical order by author. In terms of health outcomes, the results are sum-
marized in Table 2 (landfills), Table 4 (incinerators), and Table 6 (dumpsites and open
burning). In Tables 2, 4, and 6, the results are gathered based on the eight categories of
health outcomes previously mentioned (i.e., mortality, adverse birth and neonatal out-
comes, respiratory conditions, gastroenteritis, vector-borne diseases, mental and social
health conditions, cardiovascular diseases, human biomonitoring). Consequently—in Ta-
bles 2, 4, and 6—the same research can be cited multiple times if different outcomes were
assessed within the same study. Additionally, when an adverse health effect resulted in p
< 0.05, it was bolded within the table. However, the publications rarely mentioned tech-
nological elements and emission limits characterizing landfills and incinerators in the case
study. Therefore, we carried out an additional investigation to address this aspect.

3.3.1. Landfills
We identified nine studies relating to landfills (Table 1). These were mainly con-
ducted in Europe (5) and North America (2). Only one was from Asia (China) and one
from Africa (South Africa). Five papers were retrospective cohort studies and four were
cross-sectional studies.
The overall evidence of health risks associated with residing near a landfill is mixed
(Table 2). Considering results with a significance of p < 0.05, there is some evidence in-
creased risk of mortality for lung cancer [35], births with congenital anomalies [36], and
negative respiratory conditions in people aged ≤ 14 years, considering both all respiratory
diseases and only acute respiratory infections [35], association between increase of PM2.5
concentration and reduction of forced vital capacity in children aged 6–12 years [37], mu-
cosal irritation and upper respiratory symptoms [38], and other mild symptoms [39,40].
There was also some evidence of worsening mental and social health conditions, such as
alteration of daily activities or negative mood states [38]. Other studies, however, found
no evidence of mortality or adverse health effects. Indeed, Mataloni et al. [35] did not find
evidence of increased mortality for other specific cancers (i.e., colorectal, kidney, liver,
pancreas, larynx, bladder, stomach, brain, and lymphatic tissue) as well as for cardiovas-
cular, digestive, ischemic heart, respiratory, and urinary system diseases. For congenital
anomalies, no evidence of increased cases was found by Elliott et al. [41]. Jarup et al. [42]
found no evidence of increased risk of birth with Down’s Syndrome. No evidence of in-
creased specific cardiovascular diseases (cardiac, ischemic, and cerebrovascular) was
found by Mataloni et al. [35]. Neither evidence of increased risk of asthma [35,39] nor
gastrointestinal symptoms [38] was found.
Int. J. Environ. Res. Public Health 2021, 18, 4331 8 of 28

Table 1. Landfills—methodology characterizing each research


Study
Study Design Study Participants Study Period Exposure Source Outcomes Investigated Ref.
Location
8804 landfills, The risk of congenital anomalies in
10,064,382 live births, 52,532
England Cohort study Births between 1983 including 607 which relation to an index of geographic
stillbirths and 12,373 [41]
(UK) (retrospective) and 1998 handled special density of landfill sites (within 2 km
terminations
(hazardous) waste from landfills)
Assessment of PM2.5 concentration
23 children aged 6–12 years Study conducted
in indoor environments of the
Cross-sectional residing within 2 km from between November The Bisasar Road MSW
South Africa subjects involved in the study and [37]
study the landfill site for at least 5 2013 and January landfill
its association with lung function
years 2014
patterns
North 23 participants among Relationships between H2S, odour,
Cross-sectional Between January and
Carolina people living within 0.75 A MSW landfill and health outcomes in a [38]
study November 2009
(USA) miles to a landfill community living close to a landfill
6289 landfill sites
The risk of giving birth to a child
England processing special
Cohort study 4,584,541 births in England Births between 1989 with Down syndrome associated
and Wales (hazardous), non- [42]
(retrospective) and Wales and 1998 with residence near landfill sites
(UK) special and unknown
(within 2 km)
waste
2477 live births with
Risk of congenital anomalies
congenital anomalies in
combined and congenital anomalies
Cohort study Denmark in three different Births between 1997
Denmark 48 landfills of the cardiovascular and nervous [43]
(retrospective) zones of distance from and 2001
systems with maternal residence in
landfills (0–2 km; 2–4 km; 4–
function of distance from landfills
6 km)
Health survey through 170
households within a 3.2-km The Bridgeton Landfill
Conducted from Respiratory symptoms and diseases
Missouri Cross-sectional radius from a landfill and in St. Louis County, in
February to March were assessed, though household [39]
(USA) study 173 households more distant which MSW is
2016 interviews
(comparison group) from the disposed of
landfill
9 MSW landfills
Residents between operating in the Lazio The association between landfill
1996 and 2008, region, in which the H2S exposure and mortality (both
Cohort study 242,409 people living within followed for exposure to landfills natural and cause-specific) and
Italy [35]
(retrospective) 5 km from landfills mortality and was assessed using H2S hospital admissions for
hospitalizations until as a tracer in air cardiorespiratory diseases was
2012 (calculated with a evaluated
model)
The increased risk of births with at
542,682 births in Wales least one congenital malformation
24 landfill sites for
Cohort study between 1983 and 1997. in population living within 2 km
Wales (UK) See previous column commercial, industrial, [36]
(retrospective) 97,292 births in Wales from landfill sites, comparing it
and household waste
between 1998 and 2000 with population living at least 4 km
away
Association between air pollutants
951 children from primary
and respiratory health in exposed
school studying and residing
area, considering lysozyme and
near a landfill. 4 schools
Cross-sectional secretory immunoglobulin A
China within 5 km of the landfill Not specified A MSW landfill [40]
study (which are typically considered as
(exposed area). 1 school
the first line of defence from air
(non-exposed area) more
pollutants and higher levels show
distant (5.8 km away)
good related health conditions)
Int. J. Environ. Res. Public Health 2021, 18, 4331 9 of 28

Table 2. Health outcomes associated with landfills

Study
Study Design Main Findings (e.g., Estimated Risk, CI, p-Value) Ref.
Location
Mortality
Associations between H2S (>75° quartile) and cause-specific mortality (hazard
ratio (HR) and 95% Confidence Interval):
- natural cases: 0.98 (0.91, 1.05)
- all cancers: 1.03 (0.91, 1.16)
- specific cancers:
- stomach: 0.88 (0.54, 1.42)
- colorectal: 0.91 (0.64, 1.28)
- liver: 0.76 (0.48, 1.2)
- pancreas: 0.73 (0.41, 1.32)
- larynx: 0.26 (0.07, 0.95)
Cohort study
Italy - lung: 1.34 (1.06, 1.71), p < 0.05 a [35]
(retrospective)
- bladder: 0.94 (0.5, 1.80)
- kidney: 0.86 (0.41, 1.83)
- brain: 1.76 (0.81, 3.81)
- lymphatic and hematopoietic
- tissue: 1.12 (0.74, 1.17)
- cardiovascular diseases: 0.91 (0.81, 1.02)
- ischemic heart diseases 0.78 (0.64, 0.95)
- respiratory diseases: 1.30 (0.99, 1.70)
- digestive diseases: 0.97 (0.69, 1.35)
- urinary system diseases: 1.42 (0.84, 2.40)
Adverse birth and neonatal outcomes
Rates of congenital anomalies in the category with the highest exposure index (the
fourth), for non-special or unknown waste sites (adjusted odds ratio (OR) and
95% Credible Interval):
- all congenital anomalies (hypospadias and epispadias, cardiovascular defects,
England Cohort study
neural tube defects, abdominal wall defects): 1.02 (0.98, 1.07) [41]
(UK) (retrospective)
- hypospadias and epispadias: 0.97 (0.89, 1.06)
- neural tube defects: 1.04 (0.93, 1.18)
- cardiovascular defects: 0.94 (0.82, 1.07)
- abdominal wall defects: 1.11 (0.94, 1.32)
Risk rate b, comparing the closest zones with the others. When RR < 1.000 the risk
is lower, compared to the closest zone:
Cohort study - combined congenital anomalies: 1.000 (closest zone), 0.991 (middle zone),
Denmark [43]
(retrospective) 1.013 (farthest zone)
- congenital anomalies in the cardiovascular system: 1.000 (closest zone), 0.926
(middle zone), 0.854 (farthest zone)
Relative risk (RR) c (95% Credible Interval) of Down’s syndrome near landfill sites:
England and Cohort study - considering both operating and closed sites (non-special waste): 1.000 (0.909,
[42]
Wales (UK) (retrospective) 1.095)
- considering only operating sites (non-special waste): 1.011 (0.901, 1.126)
Cohort study Ratio between risk of congenital anomalies (in live births) after and before
Wales (UK) [36]
(retrospective) opening of sites (95% Confidence Interval): 1.39 (1.21, 1.72), p < 0.05 a
Cardiovascular diseases
Cohort study Associations between H2S (>75° quartile) and cardiorespiratory morbidity (HR
Italy [35]
(retrospective) and 95% Confidence Interval):
Int. J. Environ. Res. Public Health 2021, 18, 4331 10 of 28

- (all) cardiovascular diseases: 1.02 (0.97, 1.07)


- cardiac disease: 1.04 (0.97, 1.11)
- ischemic heart diseases: 0.99 (0.88, 1.10)
- cerebrovascular diseases: 0.98 (0.88, 1.10)
Respiratory conditions
Associations between H2S (>75° quartile) and cardiorespiratory morbidity (HR
and 95% Confidence Interval):
- (all) respiratory diseases: 1.05 (0.99, 1.11)
- acute respiratory infections: 1.07 (0.97, 1.18)
Cohort study
Italy - COPD (chronic obstructive pulmonary disease): 1.06 (0.90, 1.25) [35]
(retrospective)
- asthma: 1.09 (0.90, 1.33)
- (all) respiratory diseases (age ≤ 14 years): 1.11 (1.01, 1.22), p < 0.05 a
- Acute respiratory infections (age ≤ 14 years): 1.20 (1.04, 1.38), p < 0.05 a
- asthma (age ≤ 14 years): 1.13 (0.91, 1.41)
Regression models expressing the association between a 24-h average indoor
PM2.5 exposure and lung function outcomes, in terms of slope coefficient (95% CI):
- PM2.5 concentration level and forced expiratory volume in 1s (FEV1): −0.60
Cross-sectional
South Africa (−1.23, 0.01) [37]
study
- PM2.5 concentration level and forced vital capacity (FVC): −2.12 (−3.39, −0.85),
p< 0.05 d
- PM2.5 concentration level and FEV1/FVC: −1.42 (−4.85, 2.01)
Differences in the prevalence of diseases, between the two groups, in terms of
significance:
- p > 0.05 e: ever told asthma; asthma attack in last 12 months; ever told have
chronic obstructive pulmonary disease (COPD); nasal allergies in last 12
Missouri Cross-sectional
months; wheezing, cough, eye irritation, fatigue (tiredness), headaches, [39]
(USA) study
nausea, trouble sleeping in the last 12 months
- p < 0.05 e: other respiratory conditions (the most commonly reported
included pneumonia, sleep-related disorders, and bronchitis)
- p < 0.01 e: attack of shortness of breath in the last 12 months
Students in non-exposure areas had significantly (p < 0.05 f) higher levels of
Cross-sectional
China lysozyme, secretory immunoglobulin A (SIgA), and better lung capacity than [40]
study
students in exposed areas
North Symptoms associated to odour (odds ratio (OR) and 95% confidence interval (CI)):
Cross-sectional
Carolina - mucosal irritation 3.7 (2.0, 7.1), p < 0.05 a [38]
study
(USA) - upper respiratory symptoms 3.9 (2.2, 7.0), p < 0.05 a
Gastroenteritis
North
Cross-sectional Symptoms associated to odour (odds ratio (OR) and 95% confidence interval (CI)):
Carolina [38]
study - gastrointestinal symptoms 1.0 (0.4, 2.6)
(USA)
Mental and social health conditions
Symptoms associated to odour (odds ratio (OR) and 95% confidence interval (CI)):
North
Cross-sectional - alteration of daily activities: 9.0 (3.5, 23.5), p < 0.05 a
Carolina [38]
study - negative mood states: 5.2 (2.8, 9.6), p < 0.05 a
(USA)
- positive mood states: 0.6 (0.2, 1.5)
ap < 0.05. Estimated in our systematic review on the basis of 95% Confidence Interval; b The sum of anomalies divided by
the total proximal sum of births; c People living beyond the 2-km zone of all known landfill sites represented the reference
population; d p< 0.05. Value from regression models. e p-value for test of equality; f Multiple linear regression models were
conducted by the authors to determine the associations between health end points and air pollutants.
Int. J. Environ. Res. Public Health 2021, 18, 4331 11 of 28

3.3.2. Incinerators
Table 2 summarizes the evidence related to incinerators. A total of 13 studies were
identified, 10 of which were conducted in Europe and three in Asia. Seven papers were
retrospective cohort studies, one was a prospective cohort study, three were case-control
studies and two were cross-sectional studies.
Considering results with a significance of p < 0.05, like landfills, the evidence of in-
creased health risks from residing near an incinerator is mixed. A study reported in-
creased risk of mortality in women for various health outcomes, including cancer [44].
There is also evidence of adverse birth and neonatal outcomes—i.e., preterm births [45],
congenital heart defects, genital system defects and hypospadias [25], urinary tract birth
defects [46]. Furthermore, human biomonitoring studies suggest higher levels of dioxins
found in residents near incinerators [9,47]. Other studies, however, found no evidence of
adverse health effects. In particular, Viel et al. [48] found no evidence of increased invasive
breast cancer in women aged 20–59 years, even founding a significant reduction in inva-
sive breast cancer in women aged 60 years and over. Ranzi et al. [44] found no evidence
of increased cancer diseases both in men and women. Several studies reported no evi-
dence of many adverse birth outcomes [24,25,45,46,49–51]. Ranzi et al. [44] found neither
evidence of increased risk of cardiovascular diseases nor respiratory issues. There was
also no evidence of increased mortality in men for various health outcomes, including
cancer.

Table 3. Health outcomes associated with landfills

Study
Study Design Study Participants Study Period Exposure Source Outcomes Investigated Ref.
Location
8 MSW Assessment of the effects of air
21,517 births in women
Residents incinerators emissions from MSW incinerators
Cohort study (aged 15–49 years) residing
Italy between 2003 operating in the (simulated with a dispersion [45]
(retrospective) within 4 km from an
and 2010 Emilia Romagna model) on reproductive outcomes
incinerator a
region
11,875 pregnancies with 7 MSW
Assessment of the effects of air
1375 miscarriages from Residents incinerators
Cohort study emissions from MSW incinerators
Italy women (aged 15–24 years) between 2002 operating in the [52]
(retrospective) (simulated with a dispersion
residing within 4 km from and 2006 Emilia Romagna
model) on spontaneous abortions
a MSW incinerator region
Comparison of 304 infants
Association between the risk of
with urinary tract birth 21 MSW
urinary tract birth defects and
Case-control defects with a control Between 2001 incinerators active
France living near MSW incinerators, [46]
study group of 226 infants and 2004 in the Rhone-Alps
using a model to predict the
randomly selected in the region
exposure to dioxins
same region
1,025,064 births and 18,694 22 MSW Associations between modelled
Great infant deaths in Great Births and incinerators ground-level particulate matter
Cohort study
Britain Britain. Incinerators deaths between (operating from incinerators emission within [24]
(retrospective)
(UK) emissions within 10 km 2003 and 2010 between 2003 and 10 km and selected
were considered 2010) reproductive/birth outcomes
6697 neonates assessed one
The relationships between
year before the MSW
The MSW exposure to elevated PCDD/Fs
Cohort study incinerator started, and Neonates in
Taiwan incinerator of concentration generated by a [51]
(retrospective) 6282 neonates assessed five 1991 and in 1997
Taipei MSW incinerator (using a model),
years later incinerator
and various birth outcomes
opening
104 exposed subjects The MSW
7 different To monitor PCDD/Fs and PCBs
Cohort study (living < 1 km from the incinerator of
Spain campaigns were levels in blood samples in the [53]
(perspective) MSW incinerator) and 97 Matarò (activated
performed different exposed groups
non-exposed subjects in 1995)
Int. J. Environ. Res. Public Health 2021, 18, 4331 12 of 28

(living > 3 km from the between 1995


incinerator) were and 2012
randomly selected.
From 1999 one additional
group (100 unexposed
subjects, in Arenys de Mar,
about 11 km from the
incinerator) was selected
219,486 births, stillbirths,
and terminations of
10 MWIs in
pregnancy for foetal Birth and Associations between modelled
England England and
anomaly, in which adverse birth ground-level particulate matter
and Cohort study Scotland
5154 were cases of outcomes from incinerators emission within [25]
Scotland (retrospective) (operating
congenital anomalies. between 2003 10 km and selected
(UK) between 2003 and
Incinerators emissions and 2010 reproductive/birth outcomes
2010)
within 10 km were
considered
An MSW Health outcomes among people
31,347 residents within a Residents
Cohort study incinerator and a living close to incinerators (using
Italy 3.5 km radius of two between 1990 [44]
(retrospective) hospital waste a dispersion model for exposure
incinerators and 2003
incinerator in Forlì assessment)
Between 1996
434 incident cases of The association between dioxins
and 2002 (cancer
invasive breast cancer The MSW emitted from a MSW incinerator
Case-control diagnosis in the
France diagnosed (case group) incinerator in (air exposure using a model) and [48]
study case group).
compared with 2170 Besançon invasive breast cancer risk among
1999 (control
controls randomly selected women residing in the area
group) b
Rates of spontaneous abortion
Residents or and prevalence of birth defects
Women residing or The MSW
Cohort study workers among women living or working
Italy working near a MSW incinerator of [49]
(retrospective) between 2003 near a MSW incinerator,
incinerator of Modena Modena
and 2006 modelling incinerator emissions
exposure
Women (aged 16–44 years) The relationship between
residing near a MSW Birth defects The MSW exposure to the emissions from an
Case-control
Italy incinerators, assessing 228 between 1998 incinerator of MSW incinerator and risk of birth [50]
study
cases of congenital and 2006 Reggio Emilia defects, modelling incinerator
anomalies emissions exposure
82 children living near a
Samples A MSW
Cross-sectional MSW incinerator in China To monitor PCDD/F levels in
China collected in incinerator in the [9]
study and 49 from a control area, blood in different exposed groups
October 2013 Zhejiang Province
both in Zhejiang Province
14 mothers living near a
Samples
MSW incinerator (exposure A MSW To monitor PCDD/Fs and PCBs in
Cross-sectional collected in
China area) and 18 mothers from incinerator in the the breast milk of mothers in [47]
study September and
a control area, both in Zhejiang Province different exposed groups
October 2013
Zhejiang Province
a The estimated annual average exposure to PM10 from incinerators in the study areas was 0.96 ng/m3 in 2003, decreasing

to 0.26 ng/m3 in 2010 because of the improvements of the plant during the study period; b Some weaknesses in the study:
controls were residents in 1999, whereas cases were diagnosed between 1996 and 2002, introducing a time lag in the sam-
pling for some matched sets.
Int. J. Environ. Res. Public Health 2021, 18, 4331 13 of 28

Table 4. Health outcomes associated with incinerators

Study
Study Design Main Findings (e.g., Estimated Risk, CI, p-Value) Ref.
Location
Mortality
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)
Cohort study
Italy - liver (men): 0.27 (0.03, 2.18) [44]
(retrospective)
- 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)
Cancer
Int. J. Environ. Res. Public Health 2021, 18, 4331 14 of 28

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)
Cohort study
Italy - soft tissue sarcoma (men): 0.84 (0.09, 8.06) [44]
(retrospective)
- 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)
Odds ratio (OR) of invasive breast cancer by age bands and dioxin exposure categories
(comparing very low with high exposure) (95% CI):
France Case-control study [48]
- women aged 20–59 years: 0.88 (0.43, 1.79)
- women aged 60 years and over: 0.31 (0.08, 0.89)
Adverse birth and neonatal outcomes
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):
Cohort study
Italy - preterm births: 1.30 (1.08, 1.57) b, p < 0.05 c; 1.44 (1.11, 1.85) d, p < 0.05 c [45]
(retrospective)
- sex ratio: 0.91 (0.83, 0.99) b; 0.88 (0.78, 0.99) d
- 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
Associations between modelled exposure levels to PM10 from the incinerators and
Cohort study miscarriages, for the highest versus the lowest quintile exposure (adjusted odds ratio
Italy [52]
(retrospective) (OR), 95% confidence interval and significance p):
- spontaneous abortions: 1.29 (0.97, 1.72) e
Associations between modelled exposure levels of pollutants from the incinerator and
Cohort study reproductive outcomes, in terms of Relative Risk computed as the ratio between
Italy [49]
(retrospective) observed and expected incidence, (95% confidence interval):
- Spontaneous abortion:
Int. J. Environ. Res. Public Health 2021, 18, 4331 15 of 28

- 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)
- Birth defects:
- 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)
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)
Great Britain Cohort study
- post-neonatal mortality (birth to death of case exposure) f: 1.01 (0.98, 1.04) [24]
(UK) (retrospective)
- 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)
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
England and Cohort study - abdominal wall defects f: 1.00 (0.92, 1.08)
[25]
Scotland (UK) (retrospective) - 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)
Int. J. Environ. Res. Public Health 2021, 18, 4331 16 of 28

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
Difference of birth outcomes between higher exposure and control areas in 1997
(adjusted OR and 95% CI):
Cohort study
Taiwan - birth weight: 1.06 (0.71, 1.57) [51]
(retrospective)
- gestation weeks, in 1997: 1.22 (0.97, 1.52)
- gender, in 1997: 0.90 (0.78, 1.05)
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)
Italy Case-control study [50]
- 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
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
France Case-control study [46]
- 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)
Cardiovascular diseases
Associations between heavy metals concentration and hospitalization for specific causes
Cohort study
Italy in the highest exposed group using the lowest exposure category as the reference (rate [44]
(retrospective)
ratio (RR) and 95% CI):
Int. J. Environ. Res. Public Health 2021, 18, 4331 17 of 28

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)
-
Respiratory conditions
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)
Cohort study
Italy - chronic obstructive pulmonary disease (women): 0.63 (0.35, 1.14) [44]
(retrospective)
- 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)
Human biomonitoring l, m, n
Cross-sectional Blood PCDD/F levels comparing exposed group with control group:
China [9]
study - TEQΣPCDD/Fs: 0.40 vs. 0.28 pg TEQ/g wet weight, p < 0.05 o
PCDD/Fs and PCBs levels in breast milk comparing exposed and control groups:
Cross-sectional - TEQ (PCDD/Fs + DL-PCBs): 0.28 vs. 0.16 pg TEQ/g wet weight, p < 0.05 p
China [47]
study Mean EDI level in infants comparing exposed and control groups:
22.0 vs. 13.0 pg TEQ/kg bw day, p < 0.05 p
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
Cohort study
Spain - 1999: 17.8/18.1/18.7 [53]
(perspective)
- 2002: 15.1/18.2/16.0
- 2005: 11.7/12.3/17.9
- 2008: 14.6/12.6/14.5
- 2012: 12.9/13.3/12.5
aThe 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 expo-
sure 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.
Int. J. Environ. Res. Public Health 2021, 18, 4331 18 of 28

3.3.3. Dumpsites and Open Burning


Table 3 summarizes the effects of residing near dumpsites and open burning. This
includes a total of seven studies, one of which was carried on in Latin America, two in
North America and four in Africa. Three were retrospective cohort studies, and four were
cross-sectional studies.
Once again, the evidence of adverse health effects from the exposure is mixed. Con-
sidering results with a significance of p < 0.05, there is some evidence suggesting that re-
siding near dumpsites is associated with increased risk of adverse birth or neonatal out-
comes in terms of low birth weight [58]. However, most studies found no evidence of
adverse health effects, including mortality [59], and congenital malformations [60]. In
terms of gastroenteritis, all studies were from Africa and cross-sectional [20,61–63], but
the results were mixed and not statistically significant. Malaria was the only vector-borne
disease that studies were identified for. The same four studies that reported on gastroen-
teritis also reported on malaria, and the evidence suggested that there may be an increased
risk of malaria for nearby residents, although none of the results were statistically signif-
icant.

Table 5. Dumpsites and open burning—methodology characterizing each research

Study
Study Design Study Participants Study Period Exposure Source Outcomes Investigated Ref.
Location
78 residents in an area
To determine the health
very close to a dumpsite The authors did
effects of a dumpsite on the
Cross-sectional and 39 people closer (<200 not specify the A dumpsite in Manzini
Swaziland surrounding human [20]
study m) and 39 further away period of the city
settlement through self-
(>200 m) from the questionnaires
administered questionnaires
dumpsite
100 household residents
To determine the health
within 250 m radius of a Data collected
effects of a dumpsite on the
Cross-sectional dumpsite and 100 from 23 October
Nigeria A dumpsite in Lagos surrounding human [61]
study household residents 2015 to 5
population through self-
between 250–500 metres November 2015
administered questionnaires
from the same dumpsite
The 15 solid waste
To evaluate the association
landfill sites within the
between living close to a
People living within 2 km municipality of São Paulo
Cohort study Between 1998 and controlled dumpsite and
Brazil from the 15 landfills in the (all, except one, were [59]
(retrospective) 2002. occurrences of deaths for
municipality of São Paulo controlled dumpsite with
cancer or congenital
no waterproof layer at
malformations
the bottom)
To evaluate adverse birth
10,073 infants born in 197 outcomes (low and very low
villages close to dumpsites Infants born birth weight, preterm birth,
Cohort study
Alaska (ranked in high, between 1997 and 197 dumpsites and intrauterine growth [58]
(retrospective)
intermediate, and low 2001 restriction (IUGR)) in
hazard) infants born close to
dumpsites
To evaluate the rates of
10,360 infants born in 197 adverse pregnancy
Infants born
Cohort study villages close to dumpsites outcomes as foetal death,
Alaska between 1997 and 197 dumpsites [60]
(retrospective) (ranked in higher and neonatal death, congenital
2001
lower hazard) anomalies, close to
dumpsites
To determine the health
Sierra Cross-sectional 398 residents nearby (<50 The authors did
A dumpsites in Freetown effects of a dumpsite on the [62]
Leone study m) and 233 residents not specify the
surrounding human
Int. J. Environ. Res. Public Health 2021, 18, 4331 19 of 28

further away (>50 m) a period of the population through self-


dumpsite questionnaires administered questionnaires
150 residents in a
community nearby To determine the health
The authors did
dumpsites, comparing effects of dumpsites on the
Cross-sectional not specify the A dumpsite in the
Ghana three distances between surrounding human [63]
study period of the Ashanti Region
people and disposal sites: population through self-
questionnaires
(a) less than 5 min, (b) 5– administered questionnaires
10 min, (c) 11–15 min a
a The authors did not write how many of the people interviewed lived in zone (a), (b), (c).

Table 6. Health outcomes associated with dumpsites and open burning

Study
Study Design Main Findings Ref.
Location
Mortality
Standardized mortality ratios (SMRs) for areas of 2 km around the solid waste landfill sites (95% CI):
- bladder cancer: 0.98 (0.79, 1.21)
- liver cancer: 1.00 (0.86, 1.16)
Cohort study
Brazil - leukaemia in adults: 0.92 (0.77, 1.10) [59]
(retrospective)
- leukaemia in children: 0.84 (0.54, 1.31)
Standardized mortality ratios (SMRs) for areas of 2 km around the solid waste landfill sites (95% CI):
- congenital malformation: 0.86 (0.72, 1.03)
Adverse birth and neonatal outcomes
Adjusted odds ratios (95% CI) describing the relations between low and high hazard exposure categories
and incidence of low and very low birth weight, preterm birth, and intrauterine growth retardation:
- low birth weight: 2.06 (1.28, 3.32), p < 0.05 a
Cohort study
Alaska - low birth weight adjusted for gestation: 2.20 (1.26, 3.85), p < 0.05 a [58]
(retrospective)
- very low birth weight: 1.17 (0.37, 3.67)
- preterm birth: 1.24 (0.89, 1.74)
- intrauterine growth retardation: 3.98 (1.93, 8.21), p < 0.05 a
Adjusted rate ratios (95% CI) describing the relationships between lower and higher hazard exposure
categories and incidence of foetal and neonatal death and congenital anomalies:
- all deaths: 0.65 (0.34, 1.27)
- foetal deaths: 0.75 (0.28, 1.99)
- neonatal deaths: 0.55 (0.22, 1.38)
- all congenital anomalies (CA), (listed separately in the categories below): 1.37 (0.92, 2.04)
Cohort study
Alaska - central nervous system CA: 2.36 (0.37, 14.71) [60]
(retrospective)
- circulatory/respiratory CA: 1.42 (0.39, 5.42)
- gastrointestinal CA: 0.58 (0.14, 2.40)
- urogenital CA: 2.71 (0.67, 10.95)
- musculoskeletal/integumental CA: 1.61 (0.79, 3.29)
- others CA: 1.38 (0.77, 2.39)
- multiple CA: 1.33 (0.34, 5.20)
Gastroenteritis
Diseases which affected residents:
- diarrhoea: 16% of closer residents vs. 5% of further away residents
Cross-sectional
Swaziland Reasons for hospitalization among the interviewed: [20]
study
- diarrhoea: 16% of closer residents vs. 26% of further away residents
- cholera: 12% of closer residents vs. 0% of further away residents
Diseases which affected residents b:
Cross-sectional - cholera and diarrhoea: 10 closer households vs. 5 further away households reported 1–2
Nigeria [61]
study cases; 0 closer households vs. 0 further away households reported 3–4 cases; 0 closer
households vs. 0 further away households reported at least 5 cases
Diseases which affected residents c:
Sierra Cross-sectional
- diarrhoea: about 10% of closer residents vs. about 12% of further away residents [62]
Leone study
- cholera: about 11% of closer residents vs. about 15% of further away residents
Int. J. Environ. Res. Public Health 2021, 18, 4331 20 of 28

Diseases which affected residents d:


Cross-sectional
Ghana - cholera: (a) 67%; (b) 33%; (c) 0% (out of a total of 6 people affected) [63]
study
- typhoid fever: (a) 75%; (b) 25%; (c) 0% (out of a total of 12 people affected)
Vector-borne diseases
Diseases which affected residents:
Cross-sectional - malaria: 36% of closer residents vs. 13% of further away residents
Swaziland [20]
study Reasons for hospitalization among the interviewed:
- malaria: 44% of closer residents vs. 18% of further away residents
Diseases which affected residents b:
Cross-sectional - malaria: 20 closer households vs. 24 further away households reported 1–2 cases; 4 closer
Nigeria [61]
study households vs. 8 further away households reported 3–4 cases; 0 closer households vs. 1
further away households reported at least 5 cases
Sierra Cross-sectional Diseases which affected residents c:
[62]
Leone study - malaria: 40% of closer residents vs. 35% of further away residents
Cross-sectional Diseases which affected residents d:
Ghana [63]
study - malaria: (a) 73%; (b) 25%; (c) 2% (out of a total of 103 people affected)
a p < 0.05. The authors indicated the p-value when it was lower than 0.05; b The authors categorized counts of reported

cases into groups for each health outcome and then used a chi-square test to test for differences. No significant differences
were found; c The % is an approximate value taken from a figure in the article; d Comparing three temporal distances
between people and disposal sites: (a) less than 5 min, (b) 5–10 min, (c) 11–15 min.

3.4. Study Quality


All studies that met the established inclusion criteria for this review were observa-
tional studies, and thus were automatically scored as having a very serious risk of bias
due to the many potential sources of inherent bias with these study designs. In particular,
many included studies suffered from deficiencies such as lack of control for potential con-
founders, small sample size, unclear case definitions, reliance on self-reported data,
and/or the inclusion of several different health outcomes which could increase the type I
error rate.

3.5. Summary of Results


Table 7 summarizes the quantity and strength of the evidence related to MSW sites
and health outcomes by type of MSW exposure and outcome. In general, there is a paucity
of evidence, with no studies for certain exposures and outcomes. This is particularly true
in the case of mental health and social health conditions and in biomonitoring, and for
most health outcomes associated with dumpsites and open burning. Only mortality and
adverse birth outcomes have at least one study for each type of exposure.
In addition to the dearth of evidence, the results are mixed. There was evidence to
suggest an increased risk of adverse birth and neonatal outcomes for all types of MSW
sites, whereas for other outcomes there was either a lack of evidence for one or more MSW
site type or varied evidence of health effects for different kinds of MSW sites. There was
also some evidence of health outcomes for landfills and incinerators compared to
dumpsites or open burning sites. However, legislation that could characterize landfills
and incinerators in each country should be taken into account. This aspect is addressed in
the Discussion section below.
Int. J. Environ. Res. Public Health 2021, 18, 4331 21 of 28

Table 7. Evidence to develop health outcomes among residents living nearby landfills, incinerators, and dumpsites/open
burning
Adverse Birth Mental
Mortalit Cardiovascular Respiratory Vector-Borne Human
Heading Cancer and Neonatal Gastroenteritis Health
y Diseases Conditions Diseases Biomonitoring a
Outcomes Conditions
Landfills b + (1) 0 + (4) − (1) + (5) − (1) 0 + (1) 0
Incinerators b + (1) − (2) + (8) − (1) − (1) 0 0 0 + (3)
Dumpsites and
− (1) 0 + (2) 0 0 − (4) − (4) 0 0
Open Burningb
aHuman biomonitoring studies measured dioxins, whose long-term exposure increases the risk of cancer and other neg-
ative health outcomes including reproductive, developmental, and neurodevelopmental effects [54,55]; b Strength of evi-
dence: 0: no studies; (−): No evidence of increased risk; (+): Some evidence of increased risk; (++): Strong evidence of in-
creased risk. The number in parentheses beside each symbol represents the total number of studies that assessed each
health outcome (which are reported in detail in Tables 2,4,6). Although the evidence for some outcomes was mixed, this
number includes all the available studies, including both studies finding evidence and studies finding no evidence of an
increased risk for each outcome.

4. Discussion
We conducted a systematic review of literature published within the past 15 years (Jan-
uary 2005 to January 2020) to assess and summarize the epidemiological evidence on the
association between MSW treatment or disposal sites and health risks to resident popula-
tions. The 29 studies that met the inclusion criteria investigated the health effects associated
with living nearby landfills (9 studies), incinerators (13 studies), and dumpsites or open
burning sites (7 studies). Health outcomes included a large range of conditions, including
mortality, cancer, adverse birth and neonatal conditions, cardiovascular diseases, respira-
tory conditions, gastroenteritis, vector-borne diseases, and mental health conditions. Three
studies reported on biomarkers of disease rather than actual health conditions.
Overall, the results were mixed or limited. The most consistent evidence was on the
adverse birth and neonatal outcomes, with studies identifying increased risks associated
with living near all three types of MSW disposal sites. There was some evidence of in-
creased risk of mortality associated with living near landfills or incinerators. We found no
evidence suggesting an increased risk of cancer, cardiovascular diseases, gastroenteritis,
or vector-borne diseases. There were no studies on these outcomes in respect of landfills
or dumpsites and cancer, dumpsites/burning and cardiovascular diseases, or incinerators
and gastroenteritis, and landfills or incinerators and vector-borne diseases. Mental health
conditions were investigated only in the case of landfills, where there was evidence of
adverse effects. Similarly, human biomonitoring was explored only in the case of inciner-
ators where there was evidence of an increased level of PCDD/F in children’s blood and
mother’s breast milk in studies in China [9,47] but not in Spain [53]. As outlined, the pub-
lications rarely mentioned technological elements and emission limits regarding solid
waste management for the case studies. Therefore, we carried out additional investiga-
tions to fill this gap.
With respect to proximity to landfills, there was evidence of an increased risk of con-
genital anomalies in a retrospective cohort study by Palmer et al. [36]; while in another
cohort study Elliot et al. [41] did not find evidence of increased risk. However, Palmer et
al. [36] and Elliot et al. [41] studied landfills that were operational between the early 1980s
and the late 1990s in the UK. Landfills in the UK were regulated by the Control of Pollu-
tion Act [64], replaced by the Waste Management Licensing Regulations in 1994 [65], and,
the UK only fulfilled the European Landfill Directive [66] to improve standards and re-
duce adverse effects on the environment in 2002. As a consequence, the two studies were
related to the impact of old landfills, i.e., from the previous generation used in the UK.
There appears to also be an increased risk in mortality for lung cancer and respiratory
diseases, as well as increased morbidity related to respiratory diseases, mainly among
youths and children [35,37,38]. In particular, Mataloni et al. [35] considered the association
to landfill H2S exposure (used as a tracer in the air). When they repeated the analysis using
Int. J. Environ. Res. Public Health 2021, 18, 4331 22 of 28

the distance from landfill instead of H2S concentration, there were no significant associa-
tions between mortality outcomes and living 0–2 km from a landfill compared to 3–5 km.
Models that consider the pathways of contaminants instead of only focusing on the dis-
tance are likely more accurate. However, Mataloni et al. [35] considered the health effects
of landfills in Italy between 1996 and 2008, and the European Landfill Directive [66] was
implemented in 2003 [67] in Italy, and by 2009 the landfills that were already operational
had to be adapted to the new legislation. All landfills included in Mataloni et al. [35] were
activated before the new Italian legislation. Consequently, it can be assumed that the find-
ings refer to the effect of the old generation landfills in the country. Furthermore, the study
of Gumede and Savage [37] was carried out in South Africa, in which the operational
standards related to landfills are less restrictive than the most recent European directives
[68]. In addition, Heaney et al. [37] found an increased risk of alteration of daily activities
and negative mood states, but the cross-sectional study included only 23 participants.
However, the research of Heaney et al. [38] was carried out in North Carolina (USA) in
2009, but the Federal Regulation concerning MSW landfills was revised in 2011, address-
ing some major aspects including operating practices and composite liners requirements
[69]. Therefore, even in this case, the adverse health outcomes related to new generation
landfills in the USA could be lower. In the studies included in this systematic review, there
was no other evidence of increased risks related to other kind of diseases. In addition, it
must be noted that none of the studies on landfills explicitly focused on potential leachate
pollution and related human health risks. Indeed, even modern landfills with good qual-
ity geomembranes can sometimes leak leachate due to thermal expansion of the material,
folds generated during installation or initial defect density, causing potential risk for wa-
ter bodies and its consumers; as a consequence, the risks related to landfills are not only
due to air emissions [70].
Likewise, there is mixed and limited evidence on the health effects associated with
living near incinerators. It is also important to consider the type of incinerators and emis-
sions control technologies being implemented when assessing health effects. MSW incin-
erators operating in Europe before the Waste Incineration Directive [71] can be considered
from the old generation of incinerators. After the implementation of the directive, that
existing plants needed to comply with by the end of December 2005, the corresponding
incinerators can be assumed to be from the new generation. Further improvements were
made in 2018 when the new Best Available Techniques (BATs) for waste treatment was
adopted by the European Commission [72], and the MSW incinerators that were already
operational have four years to comply with the new standards. Thus, the last category can
be assumed as the newest generation, for which no epidemiological studies exist. Regard-
ing the research included in Table 4, two retrospective cohort studies [24,45] assessing
European incinerators between 2003 and 2010 obtained different results for preterm
births. Compared to Ghosh et al. [24], Candela et al. [45] used a smaller buffer zone around
each incinerator, namely 4 km instead of 10 km. According to Ghosh et al. [24] this differ-
ence in approach may have led to fewer outcomes with a lower estimated exposure in-
cluded. Additionally, in Candela et al. [45], which was carried out in Italy, the estimated
annual average exposure to PM10 from incinerators in the study areas was 0.96 ng/m3 in
2003, decreasing to 0.26 ng/m3 in 2010 because of the improvements of the incineration
plant during the study period. However, the annual average exposure to PM10 estimated
in Ghosh et al. [24] was in the same order of magnitude. In terms of birth with congenital
anomalies of the genital system, Parkes et al. [25] found an association with distance from
incinerators but not PM10. Ghosh et al. [24] and Parkes et al. [25] assessed an intermediate
period between old and new generation plants; indeed, for the existing plants the new
directive became operational in the end of December 2005. Therefore, although the epide-
miological studies mentioned above are among the widest and most recent, their findings
can be assumed to be a transition period, between old and new generation plants. Up-
dated research is necessary, only focusing on emissions from new and newest generation
plants. In a retrospective cohort study involving residents in Forly (Italy), Ranzi et al. [44]
Int. J. Environ. Res. Public Health 2021, 18, 4331 23 of 28

found a general higher rate of mortality in women and also a higher rate of mortality
considering all types of cancer in women. However, the authors analyzed a cohort of peo-
ple until 2003. As a consequence, the results are only related to old generation plants.
Furthermore, Cordier et al. [46] found an increased risk of urinary track birth defects
(UTBD) in infants exposed to MSW incineration dioxins (both atmospheric and deposits).
In addition, the findings of Cordier et al. [46] suggested that consumption of local food
modified the risk, increasing it in exposed areas. However, the authors analyzed the out-
puts between 2001 and 2004; therefore, the incinerators belonged to the old generation
sites [73]. Noteworthy, Parkes et al. [25] found no evidence of increased risk of UTBD, and
their study analyzed more recent incinerators. Regarding biomonitoring studies, Xu et al.
[9,47] found higher levels of dioxins in residents near incinerators in China. In contrast,
the values from a study conducted in Spain [53] were uncertain, varying over the years
and often being greater in unexposed groups. However, it is important to highlight in the
studies of Xu et al. [9,47] that the samples were collected in China in 2013, i.e., before the
approval of more restrictive legislation for MSW incinerators emissions in 2014 [74]. The
new Chinese legislation has standards comparable to those of the European Union [74].
Consequently, updated studies are necessary.
As highlighted in the studies discussed above, the definitions of landfills and incin-
erators need to be contextualized based on the evolving technologies and national/inter-
national legislation [1]. For example, European incinerators’ current emission limits are
more restrictive than a couple of decades ago. Therefore, many health outcomes related
to such new generation plants appear to be lower than in the past. However, the results
from such old generation plants can continue to be suitable in areas where less restrictive
limits continue to be applied, such as in some developing countries [75].
Many results are also consistent with the systematic review of Ncube et al. [16], in
which the authors found landfills and incinerators presented adverse health endpoints
even if epidemiological evidence in reviewed articles were often inadequate. However, as
discussed above, although the operational standards have changed over time, they were
not considered by Ncube et al. [16].
As many dumpsites also practice open burning, it was not possible to assess the ef-
fects of these separately. An increased risk of adverse birth outcomes was found for low
birth weight and intrauterine growth retardation. However, the main related study [58]
did not expressly specify if the dumpsites were all for MSW. The lack of studies on
dumpsites and open burning is especially noteworthy given the widespread prevalence
of these methods for disposing of MSW [5].
In addition, four studies assessed the association between vector-borne diseases and
dumpsites [20,61–63]. Although these were cross-sectional studies with small sample
sizes, making the evidence too weak to link to an increased risk, they analyzed important
health outcomes rarely taken into account. Besides, an increased risk of malaria in people
residing closer to dumpsites was noted by some authors [20,62,63], offering some sugges-
tive evidence of this adverse health effect. Still, more robust studies are needed.
Overall, many of the studies that were identified and included in this review were of
low quality, therefore the potential for causal inference from the studies is limited. While
randomized controlled trials of these conditions are probably not possible, there may be
opportunities for future studies to use natural experiments or time series analyses. All of
the included studies followed observational study designs and presented significant po-
tential for bias and confounding. For example, important measures of exposure such as
length of time, activity, technological characteristics, and distance to the hazard, were not
always controlled. Case definitions were not always clear, and the methods for case ascer-
tainment in some cases was reported rather than clinically confirmed. In addition, given
the range of types of studies and the exposures and outcomes measured, the use of a nar-
rative, as opposed for example, to a meta-analysis or meta-regression was effective in
searching, screening, and extracting the necessary data for the review.
Int. J. Environ. Res. Public Health 2021, 18, 4331 24 of 28

This review focused on health effects associated with residing near MSW sites and
our findings are limited to only nearby resident populations. A limitation of this work is
that it does not consider the health of the larger community in relation to solid waste man-
agement or the differential health effects associated with varying levels of MSW manage-
ment. For example, even if there are some negative health risks for nearby residents of
MSW sites, appropriate solid waste management could overall be helpful for the health
of populations at large. Living near unmanaged solid waste could also lead to greater
negative health impacts than living near a managed solid waste site and this review did
not perform a comparative analysis for different types of solid waste management situa-
tions (such as no waste management, poorly managed MSW sites, well management MSW
sites, and reduced waste generation).
In future, in addition to epidemiological studies, consideration should be given to
conducting biomonitoring research. Indeed, focusing on the burning of solid waste (both
in incinerators and through uncontrolled open burning) most general population expo-
sure to dioxin (PCDD/F) is through ingestion of contaminated foods of animal origin [55],
with approximately 80–90% of the total exposure via fats in fish, meat, and dairy products
[76]. Generally, levels of dioxins in air are very low, except close to sources such as ineffi-
cient incinerators or open burning. Releases into the air ends up contaminating soil and
aquatic sediments and can lead to bioaccumulation and bioconcentration through food
chains [55]. Furthermore, dioxins decompose very slowly in the environment, remaining
there for very long periods [76]. Thus, the biomonitoring of the presence of dioxins as well
as other persistent pollutants in farm animals and their derivatives nearby incinerators
would be useful. Some works have already been carried out and can be taken as references
for future research. For example, Cordier et al. [46] analyzed the association between local
food consumption, dioxin deposits generated by MSW incinerators and risk of urinary
tract birth defects. More recently, Xu et al. [9] studied the concentration of dioxins on eggs
close to an MSW incinerator in China.
In addition, the biomonitoring studies should be extended to other waste practices.
The work of Scaramozzino et al. [77] can be considered as well. The authors conducted
the first proposal for a standardized protocol for farm animal biomonitoring that can be
useful for both environmental and human risk assessments.
Furthermore, technical aspects influenced by national legislation should be investi-
gated further. This would allow for easier comparisons between evolving technologies for
which environmental and health impacts tend to decrease.

5. Conclusions
In conducting this systematic review, 29 studies were identified that met the inclu-
sion criteria of our protocol, assessing health effects only associated with proximity to
landfills, incinerators, and dumpsites/open burning sites. Compared to most previous re-
views, national legislation’s influence—characterizing operational standards and techno-
logical level—was investigated. There was some evidence of an increased risk of adverse
birth and neonatal outcomes for residents near landfills, incinerators, and dumpsites/open
burning sites. There was also some evidence of an increased risk of mortality, respiratory
diseases, and negative mental health effects associated with residing near landfills. Addi-
tionally, there was some evidence of increased risk of mortality associated with living near
incinerators. However, in many cases, the evidence was inadequate to establish a strong
relationship between a specific exposure and outcomes. Additionally, most landfills and
incinerators investigated referred to the old generation of technologies, although studies
on new generations’ plants are starting to be published. Therefore, future research should
focus on new generation landfills and incinerators, to have a more specific analysis of
these upgraded MSW practices. Additionally, the health effects related to the open burn-
ing of waste need further investigation, and the association between dumpsites in devel-
oping countries and vector-borne diseases require more robust epidemiological studies.
Int. J. Environ. Res. Public Health 2021, 18, 4331 25 of 28

However, none of the 29 studies that we identified investigated the health effects
associated with MSW transfer and treatment, such as transfer stations, recycling centers,
composting plants, and anaerobic digesters. This appears to be a major gap in the litera-
ture since transfer and treatment facilities are widespread and could pose health risks in-
cluding exposure to toxins, particulate or infectious agents via direct contact, and aerosol-
ization or other pathways. Since these health risks are potentially different from those
associated with MSW disposal sites, future research must address this gap to assess rela-
tive risks associated with various management and disposal options.

Supplementary Materials: The following are available online at www.mdpi.com/1660-


4601/18/8/4331/s1: List of the studies screened (excluding duplicates)—in alphabetic order.
Author Contributions: Conceptualization, G.V., V.B., T.C., K.M., T.T., C.Z., and M.V.; Methodol-
ogy, G.V., V.B., T.C., and M.V.; Papers identification, screening and eligibility, G.V.; Data extraction,
G.V.; Risk of bias assessment, V.B.; Data analysis, G.V. and V.B.; Writing—first version, G.V., V.B.,
and T.C.; Writing—revised version, G.V., V.B., and T.T.; Supervision, T.C., K.M., T.T., C.Z., and M.V.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: V.B. and T.C. were funded in part by a grant to Emory University from the
World Health Organization. V.B. was supported by a grant from the National Institute of Environ-
mental Health Sciences, USA (T32ES012870 to VB). The authors alone are responsible for the views
expressed in this article and they do not necessarily represent the views, decisions or policies of the
institutions with which they are affiliated.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. WHO (World Health Organization). Waste and Human Health: Evidence and Needs; WHO Meeting Report; World Health Organ-
ization: Bonn, Germany, 5–6 November 2015.
2. Kaza, S.; Yao, L.C.; Bhada-Tata, P.; Van Woerden, F. What a Waste 2.0: A Global Snapshot of Solid Waste Management to 2050; Urban.
Development; World Bank: Washington, DC, USA, 2018.
3. Perteghella, A.; Gilioli, G.; Tudor, T.; Vaccari, M. Utilizing an integrated assessment scheme for sustainable waste management
in low and middle-income countries: Case studies from Bosnia-Herzegovina and Mozambique. Waste Manag. 2018, 113, 176–
185, doi:10.1016/j.wasman.2020.05.051.
4. Wilson, D.C.; Rodic, L.; Modak, P.; Soos, R.; Carpintero Rogero, A.; Velis, C.; Iyer, M.; Simonett, O. Global Waste Management
Outlook; Report; UNEP: Nairobi, Kenya, 2015.
5. Ferronato, N.; Torretta, V. Waste mismanagement in developing countries: a review of global issues. Int. J. Environ. Res. Public
Health 2019, 16, 1060, doi:10.3390/ijerph16061060.
6. Vaccari, M.; Tudor, T.; Vinti, G. Characteristics of leachate from landfills and dumpsites in Asia, Africa and Latin America: An
overview. Waste Manag. 2019, 95, 416–431, doi:10.1016/j.wasman.2019.06.032.
7. Di Bella, V.; Vaccari, M. Constraints for solid waste management in Somaliland. Proceedings of institution of civil engineers.
Waste Resour. Manag. 2014, 167, 62–71, doi:10.1680/warm.12.00023.
8. Ziraba, A.K.; Haregu, T.N.; Mberu, B. A review and framework for understanding the potential impact of poor solid waste
management on health in developing countries. Arch. Public Health 2016, 74, 55, doi:10.1186/s13690-016-0166-4.
9. Xu, P.; Chen, Z.; Wu, L.; Chen, Y.; Xu, D.; Shen, H.; Han, J.; Wang, X.; Lou, X. Health risk of childhood exposure to PCDD/Fs
emitted from a municipal waste incinerator in Zhejiang, China. Sci. Total Environ. 2019, 689, 937–944, doi:10.1016/j.sci-
totenv.2019.06.425.
10. Vaccari, M.; Vinti, G.; Tudor, T. An analysis of the risk posed by leachate from dumpsites in developing countries. Environments
2018, 5, 99, doi:10.3390/environments5090099.
11. Negi, P.; Mor, S.; Ravindra, K. Impact of landfill leachate on the groundwater quality in three cities of North India and health
risk assessment. Environ. Dev. Sustain. 2020, 22, 1455–1474, doi.10.1007/s10668-018-0257-1.
12. Cointreau, S. Occupational and Environmental Health Issues of Solid Waste Management: Special Emphasis on Middle and Lower-Income
Countries; World Bank: Washington, DC, USA, 2006.
13. Porta, D.; Milani, S.; Lazzarino, A.I.; Perucci, C.A.; Forastiere, F. Systematic review of epidemiological studies on health effects
associated with management of solid waste. Environ. Health 2009, 8, 60, doi:10.1186/1476-069X-8-60.
14. Mattiello, A.; Chiodini, P.; Bianco, E.; Forgione, N.; Flammia, I.; Gallo, C.; Pizzuti, R.; Panico, S. Health effects associated with
the disposal of solid waste in landfills and incinerators in populations living in surrounding areas: A systematic review. Int. J.
Public Health 2013, 58, 725–735, doi:10.1007/s00038-013-0496-8.
Int. J. Environ. Res. Public Health 2021, 18, 4331 26 of 28

15. Ashworth, D.C.; Elliott, P.; Toledano, M.B. Waste incineration and adverse birth and neonatal outcomes: A systematic review.
Environ. Int. 2014, 69, 120–132, doi:10.1016/j.envint.2014.04.003.
16. Ncube, F.; Ncube, E.J.; Voyi, K. A systematic critical review of epidemiological studies on public health concerns of municipal
solid waste handling. Perspect Public Health 2017, 137, 102–108, doi:10.1177/1757913916639077.
17. Tait, P.W.; Brew, J.; Che, A.; Costanzo, A.; Danyluk, A.; Davis, M.; Khalaf, A.; McMahon, K.; Watson, A.; Rowcliff, K.; Bowles,
D. The health impacts of waste incineration: A systematic review. Aust. N. Zeal. J. Public Health 2020, 44, 40–48.
18. Pearson, C.; Littlewood, E.; Douglas, P.; Robertson, S.; Gant, T.W.; Hansell, A.L. Exposures and health outcomes in relation to
bioaerosol emissions from composting facilities: A systematic review of occupational and community studies. J. Toxicol. Environ.
Health B Crit. Rev. 2015, 18, 43–69, doi:10.1080/10937404.2015.1009961.
19. Robertson, S.; Douglas, P.; Jarvis, D.; Marczylo, E. Bioaerosol exposure from composting facilities and health outcomes in work-
ers and in the community: A systematic review update. Int. J. Hyg. Environ. Health 2019, 222, 364–386,
doi:10.1016/j.ijheh.2019.02.006.
20. Abul, S. Environmental and health impact of solid waste disposal at Mangwaneni dumpsite in Manzini: Swaziland. J. Sustain.
Dev. Afr. 2010, 12, 7.
21. Krystosik, A.; Njoroge, G.; Odhiambo, L.; Forsyth, J.E.; Mutuku, F.; LaBeaud, A.D. Solid wastes provide breeding sites, burrows,
and food for biological disease vectors, and urban zoonotic reservoirs: A call to action for solutions-based research. Front. Public
Health 2020, 7, 405, doi.10.3389/fpubh.2019.00405.
22. Liberati, A.; Altman, D.G.; Tetzlaff, J.; Mulrow, C.; Gøtzsche, P.C.; Ioannidis, J.; Clarke, M.; Devereaux, P.J.; Kleijnen, J.; Moher,
D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions:
Explanation and elaboration. PLoS Med. 2009, 6, e1000100, doi:10.1371/journal.pmed.1000100.
23. Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G. The PRISMA group. preferred reporting items for systematic reviews and
meta-analyses: The PRISMA statement. PLoS Med. 2009, 6, e1000097.
24. Ghosh, R.E.; Freni-Sterrantino, A.; Douglas, P.; Parkes, B.; Fecht, D.; de Hoogh, K.; Fuller, G.; Gulliver, J.; Font, A.; Smith, R.B.;
et al. Fetal growth, stillbirth, infant mortality and other birth outcomes near UK municipal waste incinerators; retrospective
population based cohort and case-control study. Environ. Int. 2019, 122, 151–158, doi:10.1016/j.envint.2018.10.060.
25. Parkes, B.; Hansell, A.L.; Ghosh, R.E.; Douglas, P.; Fecht, D.; Wellesley, D.; Kurinczuk, J.J.; ì Rankin, J.; de Hoogh, K.; Fuller,
G.W.; et al. Risk of congenital anomalies near municipal waste incinerators in England and Scotland: Retrospective population-
based cohort study. Environ. Int. 2020, 134, 104845, doi:10.1016/j.envint.2019.05.039.
26. Rosenfeld, P.E.; Feng, L.G.H. Risks of Hazardous Wastes; Hardcover; Elsevier: Amsterdam, The Netherlands, 2011; ISBN:
9781437778427.
27. Pellizzari, E.D.; Woodruff, T.J.; Boyles, R.R.; Kannan, K.; Beamer, P.I.; Buckley, J.P.; Wang, A.; Zhu, Y.; Bennett, D.H. Identifying
and prioritizing chemicals with uncertain burden of exposure: Opportunities for biomonitoring and health-related research.
Environ. Health Perspect. 2019, 127, 126001.
28. Seltenrich, N. Beyond the light under the lamppost: New chemical candidates for biomonitoring in young children. Environ.
Health Perspect. 2020, 128, 84005, doi.10.1289/EHP6902.
29. La Merrill, M.A.; Johnson, C.L.; Smith, M.T.; Kandula, N.R.; Macherone, A.; Pennell, K.D.; Kanaya, A.M. Exposure to persistent
organic pollutants (POPs) and their relationship to hepatic fat and insulin insensitivity among asian indian immigrants in the
united states. Environ. Sci. Technol. 2019, 53, 13906–13918, doi.10.1021/acs.est.9b03373.
30. Vinti, G.; Bauza, V.; Clasen, T.; Tudor, T.; Vaccari, M.; Zurbrügg, C. Municipal Solid Waste Management and Adverse Health
Outcomes of Nearby Residents: A Systematic Review. PROSPERO 2020 CRD42020176495. Available online:
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020176495.(accessed on 10 December 2020)
31. Mavropoulos, A.; Newman, D. Wasted Health. The Tragic Case of Dumpsites; International Solid Waste Association: Vienna, Aus-
tria, 2015; Available online: https://www.iswa.org/fileadmin/galler-
ies/Task_Forces/THE_TRAGIC_CASE_OF_DUMPSITES.pdf (accessed on 26 March 2020).
32. Chandrappa, R.; Das, D.B. Solid Waste Management. Principles and Practice; Springer: Berlin/Heidelberg, Germany, 2012; ISBN
978-3-642-28680-3.
33. WHO (World Health Organization). Vector-Borne Diseases; Available online: https://www.who.int/news-room/fact-sheets/de-
tail/vector-borne-diseases (accessed on 16 June 2020)
34. Wells, G.A.; Shea, B.; O’Connell, D.; Peterson, J.; Welch, V.; Losos, M.; Tugwell, P. The Newcastle-Ottawa Scale (NOS) for Assessing
the Quality of Nonrandomised Studies in Meta-Analyses; University of Ottawa: Ottawa, Canada, 2019. Available online:
http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed on 20 January 2020).
35. Mataloni, F.; Badaloni, C.; Golini, M.N.; Bolignano, A.; Bucci, S.; Sozzi, R.; Forastiere, F.; Davoli, M.; Ancona, C. Morbidity and
mortality of people who live close to municipal waste landfills: A multisite cohort study. Int. J. Epidemiol. 2016, 45, 806–815,
doi:10.1093/ije/dyw052.
36. Palmer, S.R.; Dunstan, F.D.; Fielder, H.; Fone, D.L.; Higgs, G.; Senior, M.L. Risk of congenital anomalies after the opening of
landfill sites. Environ. Health Perspect. 2005, 113, 1362–1365, doi:10.1289/ehp.7487.
37. Gumede, P.R.; Savage, M.J. Respiratory health effects associated with indoor particulate matter (PM2.5) in children residing
near a landfill site in Durban, South Africa. Air Qual. Atmos. Health 2017, 10, 853–860, doi:10.1007/s11869-017-0475-y.
Int. J. Environ. Res. Public Health 2021, 18, 4331 27 of 28

38. Heaney, C.D.; Wing, S.; Campbell, R.L.; Caldwell, D.; Hopkins, B.; Richardson, D.; Yeatts, K. Relation between malodor, ambient
hydrogen sulfide, and health in a community bordering a landfill. Environ. Res. 2011, 111, 847–852, doi:10.1016/j.en-
vres.2011.05.021.
39. Kret, J.; Dalidowitz Dame, L.; Tutlam, N.; DeClue, R.W.; Schmidt, S.; Donaldson, K.; Lewis, R.; Rigdon, S.E.; Davis, S.; Zelicoff,
A.; et al. A respiratory health survey of a subsurface smoldering landfill. Environ. Res. 2018, 166 427–436, doi:10.1016/j.en-
vres.2018.05.025.
40. Yu, Y.; Yu, Z.; Sun, P.; Lin, B.; Li, L.; Wang, Z.; Ma, R.; Xiang, M.; Li, H.; Guo, S. Effects of ambient air pollution from municipal
solid waste landfill on children's non-specific immunity and respiratory health. Environ. Pollut 2018, 236, 382–390,
doi:10.1016/j.envpol.2017.12.094.
41. Elliott, P.; Richardson, S.; Abellan, J.J.; Thomson, A.; de Hoogh, C.; Jarup, L.; Briggs, D.J. Geographic density of landfill sites and
risk of congenital anomalies in England. Occup. Environ. Med. 2009, 66, 81–89, doi:10.1136/oem.2007.038497.
42. Jarup, L.; Morris, S.; Richardson, S.; Briggs, D.; Cobley, N.; de Hoogh, C.; Gorog, K.; Elliott, P. Down syndrome in births near
landfill sites. Prenat Diagn 2007, 27, 1191–1196, doi:10.1002/pd.1873.
43. Kloppenborg, S.C.H. Brandt, U.K.; Gulis, G.; Ejstrud, B. Risk of congenital anomalies in the vicinity of waste landfills in Den-
mark; An epidemiological study using GIS. Cent. Eur. J. Public Health 2005, 13, 137–143.
44. Ranzi, A.; Fano, V.; Erspamer, L.; Lauriola, P.; Perucci, C.A.; Forastiere, F. Mortality and morbidity among people living close
to incinerators: A cohort study based on dispersion modeling for exposure assessment. Environ. Health 2011, 10, 22,
doi:10.1186/1476-069X-10-22.
45. Candela, S.; Ranzi, A.; Bonvicini, L.; Baldacchini, F.; Marzaroli, P.; Evangelista, A.; Luberto, F.; Carretta, E.; Angelini, P.;
Sterrantino, A.F.; et al. Air pollution from incinerators and reproductive outcomes: A multisite study. Epidemiology 2013, 24,
863–870, doi:10.1097/EDE.0b013e3182a712f1.
46. Cordier, S.; Lehébel, A.; Amar, E.; Anzivino-Viricel, L.; Hours, M.; Monfort, C.; Chevrier, C.; Chiron, M.; Robert-Gnansia, E.
Maternal residence near municipal waste incinerators and the risk of urinary tract birth defects. Occup. Environ. Med. 2010, 67,
493–499, doi:10.1136/oem.2009.052456.
47. Xu, P.; Wu, L.; Chen, Y.; Xu, D.; Wang, X.; Shen, H.; Han, J.; Fu, Q.; Chen, Z.; Lou, X. High intake of persistent organic pollutants
generated by a municipal waste incinerator by breastfed infants. Environ. Pollut 2019, 250, 662–668,
doi:10.1016/j.envpol.2019.04.069.
48. Viel, J.F.; Clément, M.C.; Hägi, M.; Grandjean, S.; Challier, B.; Danzon, A. Dioxin emissions from a municipal solid waste
incinerator and risk of invasive breast cancer: A population-based case-control study with GIS-derived exposure. Int. J. Health
Geogr. 2008, 7, 4, doi:10.1186/1476-072X-7-4.
49. Vinceti, M.; Malagoli, C.; Teggi, S.; Fabbi, S.; Goldoni, C.; De Girolamo, G.; Ferrari, P.; Astolfi, G.; Rivieri, F.; Bergomi, M.
Adverse pregnancy outcomes in a population exposed to the emissions of a municipal waste incinerator. Sci. Total Environ. 2008,
407, 116–121, doi:10.1016/j.scitotenv.2008.08.027.
50. Vinceti, M.; Malagoli, C.; Fabbi, S.; Teggi, S.; Rodolfi, R.; Garavelli, L.; Astolfi, G.; Rivieri, F. Risk of congenital anomalies around
a municipal solid waste incinerator: A GIS-based case-control study. Int. J. Health Geogr. 2009, 8, 8, doi:10.1186/1476-072X-8-8.
51. Lin, C.M.; Li, C.Y.; Mao, I.F. Birth outcomes of infants born in areas with elevated ambient exposure to incinerator generated
PCDD/Fs. Environ. Int. 2006, 32, 624–629, doi:10.1016/j.envint.2006.02.003.
52. Candela, S.; Bonvicini, L.; Ranzi, A.; Baldacchini, F.; Broccoli, S.; Cordioli, M.; Carretta, E.; Luberto, F.; Angelini, P.; Evangelista,
A.; et al. Exposure to emissions from municipal solid waste incinerators and miscarriages: A multisite study of the MONITER
Project. Environ. Int. 2015, 78, 51–60, doi:10.1016/j.envint.2014.12.008.
53. Parera, J.; Serra-Prat, M.; Palomera, E.; Mattioli, L.; Abalos, M.; Rivera, J.; Abad, E. Biological monitoring of PCDD/Fs and PCBs
in the City of Mataró. A population-based cohort study (1995–2012). Sci. Total Environ. 2013, 461–462, 612–617,
doi:10.1016/j.scitotenv.2013.04.094.
54. IARC (International Agency for Research on Cancer). IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, No.
100F. 2,3,7,8-TETRACHLORODIBENZO-para-DIOXIN, 2,3,4,7,8-PENTACHLORODIBENZOFURAN, AND 3,3′,4,4′,5-
PENTACHLOROBIPHENYL; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans: Lyon, France, 2012.
Available online: https://www.ncbi.nlm.nih.gov/books/NBK304398/ (accessed on 26 March 2020).
55. WHO (World Health Organization). Preventing Disease through Healthy Environments: Exposure to Dioxins and Dioxin-Like
Substances: A Major Public Health Concern World Health Organization: Geneva, Switzerland, 2019. Available online:
https://apps.who.int/iris/bitstream/handle/10665/329485/WHO-CED-PHE-EPE-19.4.4-eng.pdf?ua=1 (accessed on 26 March
2020).
56. US EPA (United States Environmental Protection Agency). Toxics Release Inventory (TRI) Program. Dioxin and Dioxin-Like
Compounds Toxic Equivalency Information; United States Environmental Protection Agency: Washington, DC, USA, 2016.
Available online: https://www.epa.gov/toxics-release-inventory-tri-program/dioxin-and-dioxin-compounds-toxic-
equivalency-information (Accessed on 7 April 2020).
57. EFSA (European Food Safety Authority); Knutsen, H.K.; Alexander, J.; Barregård, L.; Bignami, M.; Bruschweiler, B.; Ceccatelli,
S.; Cottrill, B.; Dinovi, M.; Edler, L.; et al. Risk for animal and human health related to the presence of dioxins and dioxin-like
PCBs in food and feed. EFSA J. 2018, 16, 05333.
58. Gilbreath, S.; Kass, P.H. Adverse birth outcomes associated with open dumpsites in Alaska Native Villages. Am. J. Epidemiol
2006, 164, 518–528, doi:10.1093/aje/kwj241.
Int. J. Environ. Res. Public Health 2021, 18, 4331 28 of 28

59. Gouveia, N.; do Prado, R.R. Health risks in areas close to urban solid waste landfill sites. Rev. Saude Publica 2010, 44, 859–866,
doi:10.1590/s0034-89102010005000029.
60. Gilbreath, S.; Kass, P.H. Fetal and neonatal deaths and congenital anomalies associated with open dumpsites in Alaska Native
villages. Int. J. Circumpolar Health 2006, 65, 133–147, doi:10.3402/ijch.v65i2.18088.
61. Babs-Shomoye, F.; Kabir, R. Health effects of solid waste disposal at a dumpsite on the surrounding human settlements. J. Public
Health Dev. Ctries. 2016, 2, 268–275.
62. Sankoh, F.P.; Yan, X.; Tran, Q. Environmental and health impact of solid waste disposal in developing cities: A case study of
granville brook dumpsite, freetown, sierra leone. J. Environ. Prot. 2013, 4, 665–670.
63. Suleman, Y.; Darko, E.T.; Agyemang-Duah, W. Solid waste disposal and community health implications in Ghana: Evidence
from sawaba, asokore mampong municipal assembly. J. Civil. Environ. Eng. 2015, 5, 1000202.
64. UK. Control of Pollution Act (COPA); The Stationery Office Books: London, UK, 1974; ISBN 0105440744.
65. UK. Waste Management Licensing Regulations 1994 (S.I. No. 1056 of 1994). Available online:
https://www.legislation.gov.uk/uksi/1994/1056/made (accessed on 5 March 2021).
66. EC (European Commission). Council Directive 1999/31/EC of 26 April 1999 on the Landfill of Waste. Available onlinw:
https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A31999L0031 (accessed on 5 March 2021).
67. D. Lgs. 36/2003. Supplemento Ordinario N. 40 alla Gazzetta Ufficiale 12 Marzo 2003 N. 59. Implementation of the European
Directive 1999/31/CE in Italy. Available online: https://www.minambiente.it/sites/default/files/dlgs_13_01_03_36.pdf (accessed
on 26 December 2020).
68. Godfrey, L.; Oelofse, S. Historical review of waste management and recycling in South Africa. Resources 2017, 6, 57.
doi.10.3390/resources6040057.
69. US EPA (United States Environmental Protection Agency). Municipal Solid Waste Landfills. Website. Available online:
https://www.epa.gov/landfills/municipal-solid-waste-landfills#regs (accessed on 11 February 2021).
70. Paladino, O.; Massabò, M. Health risk assessment as an approach to manage an old landfill and to propose integrated solid
waste treatment: A case study in Italy. Waste Manag. 2017, 68, 344–354, doi:10.1016/j.wasman.2017.07.021.
71. EC (European Commission). Directive 2000/76/EC of the European Parliament and of the Council of 4 December 2000 on the Incineration
of Waste.
72. EC (European Commission). Best Available Techniques (BAT) Reference Document for Waste Treatment; Publications Office of the
European Union: 2018; ISBN 978-92-79-94038-5. Available online: https://eippcb.jrc.ec.europa.eu/sites/default/files/2019-
11/JRC113018_WT_Bref.pdf (accessed on 10 February 2021).
73. Autret, E.; Berthier, F.; Luszezanec, A.; Nicolas, F. Incineration of municipal and assimilated wastes in France: Assessment of
latest energy and material recovery performances. J. Hazard. Mater. 2007, 139, 569–574.
74. Lu, J.W.; Zhang, S.; Hai, J.; Lei, M. Status and perspectives of municipal solid waste incineration in China: A comparison with
developed regions. Waste Manag. 2017, 69, 170–186, doi:10.1016/j.wasman.2017.04.014.
75. Nixon, J.D.; Dey, P.K.; Ghosh, S.K. Energy recovery from waste in India: An evidence-based analysis. Sustain. Energy Technol.
Assess. 2017, 21, 23–32.
76. FAO (Food and Agriculture Organization), WHO (World Health Organization). Joint FAO/WHO Food Standards Programme.
Codex Committee on Contaminants in Foods. 12th Session, Utrecht, 12–16 March 2018. Proposed draft revision of the Code of
Practice for the Prevention and Reduction of Dioxins and Dioxin-like PCBs in Food and Feed. 2018. Available online:
http://www.fao.org/fao-who-codexalimentarius/sh-
proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FMeetings%252FCX-735-
12%252FWD%252Fcf12_08e.pdf (accessed on 26 March 2020).
77. Scaramozzino, P.; Battisti, S.; Desiato, R.; Tamba, M.; Fedrizzi, G.; Ubaldi, A.; Neri, B.; Abete, M.C.; Ru, G. Application of a risk-
based standardized animal biomonitoring approach to contaminated sites. Environ. Monit. Assess. 2019, 191, 526,
doi:10.1007/s10661-019-7653-3.

You might also like