5

Understanding Health Effects of Incineration

To understand the possible health effects attributable to waste-incineration emissions, information is needed on contributions made by incineration to human exposures to potentially harmful pollutants and the responses that might result from such exposures. As discussed in this chapter, various tools have been used in attempts to evaluate effects of incineration. Of these tools, all of which contribute to our understanding, risk assessment methods have provided the most-detailed information for regulatory decisionmakers. Although past regulatory risk assessments have suggested that the risks posed by emissions from a well-run incinerator to the local community are generally very small, the same may not be true for some older or poorly run facilities. Some of the available assessments, however, may now be considered inadequate for a complete characterization of risk, for example, due to their failure to account for changes in emissions during process upsets, or because of gaps in and limitations of the data or techniques of risk assessment available at the time. There are limitations in the data and techniques of risk assessment, for example, in considering the effect of potential synergisms between chemicals within the complex mixtures to which humans are exposed, or the possible effects of small increments of exposure on unusually susceptible people. In addition, there are important questions not typically addressed by the usual risk assessment for single facilities such as the collective effect of pollutants emitted from multiple units; regional-scale effects of persistent pollutants; and the effects on workers in the facilities themselves.

This chapter examines the tools used to evaluate the potential for health effects from incineration facilities, and discusses some of the results obtained with those tools. The two primary tools are environmental epidemiology and



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WASTE INCINERATION & PUBLIC HEALTH 5 Understanding Health Effects of Incineration To understand the possible health effects attributable to waste-incineration emissions, information is needed on contributions made by incineration to human exposures to potentially harmful pollutants and the responses that might result from such exposures. As discussed in this chapter, various tools have been used in attempts to evaluate effects of incineration. Of these tools, all of which contribute to our understanding, risk assessment methods have provided the most-detailed information for regulatory decisionmakers. Although past regulatory risk assessments have suggested that the risks posed by emissions from a well-run incinerator to the local community are generally very small, the same may not be true for some older or poorly run facilities. Some of the available assessments, however, may now be considered inadequate for a complete characterization of risk, for example, due to their failure to account for changes in emissions during process upsets, or because of gaps in and limitations of the data or techniques of risk assessment available at the time. There are limitations in the data and techniques of risk assessment, for example, in considering the effect of potential synergisms between chemicals within the complex mixtures to which humans are exposed, or the possible effects of small increments of exposure on unusually susceptible people. In addition, there are important questions not typically addressed by the usual risk assessment for single facilities such as the collective effect of pollutants emitted from multiple units; regional-scale effects of persistent pollutants; and the effects on workers in the facilities themselves. This chapter examines the tools used to evaluate the potential for health effects from incineration facilities, and discusses some of the results obtained with those tools. The two primary tools are environmental epidemiology and

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WASTE INCINERATION & PUBLIC HEALTH risk assessment, both of which have been the subject of National Research Council reports (e.g., NRC 1991a, 1994, respectively). In addition, environmental monitoring studies provide immediately useful estimates of ambient concentrations, while biomarker studies hold some promise for future application. The first section of the chapter discusses these tools, and their strengths and limitations relative to one another. There have been few epidemiologic studies in populations characterized as exposed to contaminants emitted by incineration facilities. Thus, there is a lack of evidence of any obvious health effects related specifically to incinerator exposure. That is, there have been few anecdotal reports that indicated any particular concern for incinerators (as opposed to air pollution in general, for example) or that generated testable hypotheses. Moreover, as discussed later in this chapter, it would be difficult to establish causality given the small populations available for study, the possible influence of factors such as variations in the susceptibility of individuals and emissions from other pollution sources, and the fact that effects might occur only infrequently or take many years to appear. The second section of the chapter summarizes what data are available, and discusses what conclusions can be drawn from those data. The main information on potential health effects that might arise in populations potentially exposed to substances emitted by incineration facilities comes from risk assessments of individual chemicals emitted by incinerators, combined with monitoring of emissions from incinerators. Such assessments typically indicate that, of the many agents present in incinerator emissions and known to be toxic at high exposures, only a few are likely to contribute the majority of any health risks and such health risks are typically estimated to be very small. This chapter examines the toxic effects of such agents. It also illustrates ways to compare the expected ranges of environmental concentrations attributable to incineration with concentrations known to be toxic, and in the context of total exposures. The toxic agents were selected for discussion on the basis of the current state of knowledge of the nature of emissions from incinerators and the results of various risk assessments. They are particulate matter (PM), carbon monoxide (CO), acidic gases (i.e., NOx, SO2, HCl) and acidic particles, certain metals (cadmium, lead, mercury, chromium, arsenic, and beryllium), dioxins and furans, polychlorinated biphenyls (PCBs), and polyaromatic hydrocarbons (PAHs). The emissions of most of those substances were considered in Chapter 3 and Chapter 4. Particulate matter, CO, lead, and acidic gases and acidic particles have been under regulatory scrutiny for the longest period. Typically, there are well-defined statutory limits on their emission rates or allowable ambient concentrations or increments in ambient concentrations under federal or state statutes. In many risk assessments, such materials have been evaluated solely by comparisons with such statutorily defined limits, limits that have been designed to reduce certain risks from these pollutants below acceptable values. Although there are occupa-

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WASTE INCINERATION & PUBLIC HEALTH tional-exposure limits for most of the other metals and organic compounds listed above, there are no well-defined ambient or emission standards under federal or some state regulations; however, in risk assessments, those materials are typically found to contribute to the majority of the estimated risk, either in contribution to lifetime cancer risks or in contribution to potential noncancer effects. Historically, risk assessments have identified the dioxins and furans as the principal contributors to estimated risks posed by most incinerators with arsenic often next. However, estimates of relative contributions of pollutants to total risk depend on incinerator emission characteristics, populations potentially exposed, potential routes of exposure, and, to some extent, the amount of information that has been collected. In addition, this chapter discusses “at-risk” populations (populations that might be at increased risk due, at least in part, to pollutants emitted from incinerators). The chapter ends with the main conclusions on understanding health effects of waste incineration reached by the committee and presentation of research needs. TOOLS FOR EVALUATING HEALTH EFFECTS Whenever searching for small or subtle health effects of exposures to environmental contaminants, it is best to use a variety of approaches and to critically compare their results. The primary tools that have been used include epidemiologic studies and risk assessments. These are separately discussed in detail below, although it should be realized that there can be a good deal of overlap between the approaches. Environmental monitoring, biomarkers of exposure or effect, and life-cycle assessment are other commonly used tools that produce data which often confirm, support, or enhance the findings obtained during the conduct of epidemiologic or risk-assessment investigations. Exposure assessment plays an important role in may of those approaches. Such approaches are used to evaluate multiple environmental media (air, surface water, soil, groundwater, sediments, and any other media that might be distinguished), multiple exposure pathways, many scenarios for exposure, multiple routes (inhalation, ingestion, and dermal), multiple chemicals, multiple population groups, and many health end points. However, the approaches currently used to assess the effects of waste incineration are typically site-specific and facility-specific and so fail to address two important questions regarding a facility or site: To what extent does an incineration facility alter the environmental concentrations of substances of concern or alter the existing magnitudes of human exposure to those substances? What are the overall local and regional contributions of waste incineration to human exposures?

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WASTE INCINERATION & PUBLIC HEALTH Epidemiologic Studies Epidemiologic studies are conducted to test hypotheses about the occurrence (usually prevalence or incidence) of a health outcome, to measure the strengths or sizes of relationships between such outcomes and quantifiable factors (e.g., the magnitude of exposures) or qualifiable factors (e.g., exposure status), or to generate testable hypotheses about such relationships. The methodology, strengths, and weaknesses of environmental epidemiologic studies have been discussed in previous NRC reports (NRC 1991c, 1997). As discussed there, the principal strengths of epidemiologic studies are: The people studied include those likely to have been exposed to the material of interest. For incinerator emissions, there is no extrapolation necessary from single chemicals to the complex mixtures to which humans are actually exposed. Humans themselves are studied in actual exposure conditions—there is no extrapolation from different animal species or different conditions. Individual and group variability in both exposure and sensitivity are necessarily taken into account. The principal challenges to be addressed by epidemiologic studies in establishing causality include: Identifying suitably exposed populations of sufficient size. Identifying effect modifiers and/or potentially confounding factors. Identifying biases (including reporting biases) in data collection (e.g., Neutra et al. (1991) present an interesting case study of this problem). Measuring exposures. Measuring effects that are small, might occur only infrequently, or take many years to appear. Risk Assessments Risk assessment is the use of procedures to estimate the probability that harm will arise from some action such as the operation of a facility. The procedures used to perform risk assessments vary widely, from a snap judgment to the use of complex analytic models. However, risk assessments of incineration or incineration facilities have become more structured and formalized, following the four-step paradigm described in previous NRC reports (NRC 1983, 1994). In the case of a particular incinerator, the first step, hazard identification, might begin with enumeration of the chemicals present in emissions and suspected of posing health hazards (and this alone might be an expensive proposition in unusual specific cases). The emissions have to be quantified, the potential health

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WASTE INCINERATION & PUBLIC HEALTH effects identified, and the conditions under which a chemical might cause those effects defined. The attempt to obtain emission-rate estimates might take the form of direct measurements, which are limited by the sensitivity of the measuring methods, the variability over time of emission rates, the cost of such measurements, and the inaccuracies affecting all such field work. Alternatively, similar measurements from other, comparable facilities might be used as bases to estimate emissions. The result is generally a list of chemicals with their expected average emission rates and sometimes a measure of the variability of the emission rates with time—for example, how short-term emission rates might differ from the long-term average. In many cases, there may be a list of the emission rates that are identified as maximums by the owner or operator of the facility. After developing a list of chemicals identified as potentially of concern, a dose-response assessment is used to evaluate quantitatively the relation between exposures and toxic responses. Ideally, this assessment would consider all the particular conditions of exposure, including the complete mix of other potential contaminants from incineration, and exposures to the same and different chemicals from other sources. In practice, dose-response assessments are limited, by the regulatory milieu of most risk assessments, to the use of cancer potency-slope estimates or unit risks1 (for the evaluation of cancer risks) and reference doses2 (for the evaluation of noncancer risks) published in the Integrated Risk Information System (IRIS)3 or other regulatory documents by the Environmental Protection Agency (EPA) or the Agency for Toxic Substances and Disease Registry (ATSDR). Most of the effort of individual risk assessments has gone into the evaluation of exposure, which is the third step in the risk-assessment paradigm. As discussed in Chapter 4, exposure assessment involves an estimation or measure- 1   Cancer potency-slope estimates or unit risks. The human cancer potency-slope is the incremental increase in lifetime cancer risk per incremental unit of lifetime average dose (generally by ingestion, occasionally by other routes of exposure). The estimates of cancer potency-slope is obtained by assuming that the dose-response curve may be linear at low doses, and extrapolating to low dose from higher experimental doses. In many cases, there is an additional extrapolation from laboratory animals to humans. The unit risk is the incremental increase in lifetime cancer risk per incremental unit of air concentration of an airborne carcinogen. It is estimated using methods similar to those used for cancer potency-slope, but with slightly different assumptions adopted for inter-species extrapolation. 2   The reference dose is a long-term average dose rate that is expected to result in no noncancer health effects in humans. It is obtained from experimental results in humans or animals by a relatively well-defined procedure that incorporates safety factors to account for all the defined extrapolations performed. 3   IRIS. EPA's (1992b) Integrated Risk Information System (IRIS) is a database of human health effects that might result from exposure to various substances found in the environment. IRIS is accessible via the Internet at http://www.epa.gov//iris.

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WASTE INCINERATION & PUBLIC HEALTH ment of the concentration of specific substances in each environmental medium, and the time individuals or populations spend in contact with the substances. The network of exposure pathways becomes more and more complex as more-remote regions are incorporated. Food contaminated near an incineration facility might be consumed by people close to the facility or far away from it. Thus, local deposition on food might result in some exposure of populations at great distances, due to transport of food to markets. However, distant populations are likely to be more exposed through long-range transport of pollutants and low-level, widespread deposition on food crops at locations remote from a source incineration facility. To be most useful, exposure assessments need careful definition of the scenarios to which the assessments apply. Within such scenarios, the distribution of individuals or populations exposed need to be accounted for, and other variabilities and uncertainties incorporated (EPA 1992c). In order to dovetail with the dose-response assessments, care must be taken in the exposure assessment so that doses can be evaluated in the correct way. Potential doses can be expressed as the average rates at which material crosses the epithelial layer of an exposed individual (by inhalation or ingestion) or enters the outer layer of skin (e.g., through dermal contact) per unit of body weight per day (EPA 1992d; DTSC 1992a,b). However, such measures do not necessarily correspond to the does-response measures (e.g., carcinogenic potency-slope, unit risk, and reference doses), which typically relate response to exposures rather than doses. In the absence of such exact correspondence, exposure-dose relationships may become crucial. The final step of the risk-assessment paradigm, risk characterization, involves integrating the results of exposure assessment, dose-response assessment, and hazard assessment in such a way as to “develop a qualitative or quantitative estimate of the likelihood that any of the hazards associated with the agent of concern will be realized in exposed people” (NRC 1994). Risk-assessment results are generally expressed as lifetime cancer risks (calculated by taking the sum —over the pollutants of interest—of the products of lifetime average exposure to each pollutant and its potency slope) or as summary hazard indices (the sum over various chemicals of the ratio of estimated dose of each chemical to its reference dose). In the case of lead, projected blood-lead concentrations are used. A complete risk characterization should also contain a full discussion of the uncertainties associated with the estimates of risk. Risk assessment of waste incineration facilities can involve the following aspects: Measurement or estimation of emission rates from specific facilities. Modeling designed for tracking the flow of substances of concern through the environment. A large body of information on toxicity of many emitted substances, in particular of dose-response information.

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WASTE INCINERATION & PUBLIC HEALTH Characterization of the expected effect of new incinerators, or of what might happen in the future with any incinerator. Such risk assessments are congruent with most regulatory schemes—the principal inputs to risk assessments are also characteristics of incinerators that are usually regulated, for example, emission rates. The lack of complete data leads to uncertainties involved and the problem of communicating such uncertainties. Those uncertainties arise from the following: The lack of complete emission data, especially for nonstandard operating conditions. The problem of dose-response assessment at low doses, and in particular of low-dose, cross-species, inter-route, and temporal dose-pattern extrapolation. The lack of toxicity data on most products of incomplete combustion. The lack of physical and chemical information on relevant characteristics of substances of concern. The use of unverified models of transport of substances in the environment, due to incomplete knowledge as to how such transport occurs. The variability of all aspects of the assessment, due to variations in physical conditions (e.g., topography, temperatures, rainfall, soil types, and meteorological conditions), characteristics of people (e.g., eating habits, residence times, age, and susceptibility), and so on, leading to wide ranges of exposures and risks for different people. The possibility of errors and omissions in the assessment (e.g., omission of an important pathway of exposure). Because of the variability and uncertainty, most risk assessments have not been designed to quantify actual health risks; rather they have been designed solely for regulatory purposes to yield upper-bound estimates of health risks that may be compared to regulatory criteria. Other Tools Environmental monitoring and biological markers of exposure or effect are two tools often used in conjunction with epidemiologic or risk assessment investigations. These tools aid in identifying or confirming pollutants that may give rise to adverse health effects. Life-cycle assessment (LCA) has been used to evaluate the resource consumption and environmental burdens associated with a product, process, package, or activity throughout its lifetime over large geographic regions. LCA can be used in conjunction with risk assessments to assess effects over a broad scale—from the time of introduction of a chemical into the environment to its destruction.

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WASTE INCINERATION & PUBLIC HEALTH Environmental Monitoring Studies In principle, it is desirable to measure concentrations of certain pollutants directly from the incinerator in the surrounding environment. Such monitoring is most commonly of the ambient air, but soil, water, sediments, vegetation, and foods have at times been monitored for some of the emitted pollutants. Environmental monitoring is principally useful because it directly measures the concentrations of certain materials from a particular incinerator, in some cases in the media of immediate interest (e.g., dioxins in vegetation and cows' milk). No health effects are measured. For use in evaluating health effects, however, environmental monitoring suffers from several disadvantages, because: There is usually a problem in distinguishing the contribution of the incinerator to environmental concentrations. Monitoring measurements are limited both in space and in time while concentrations are often highly variable in both time and space. For these reasons, environmental monitoring is usually most useful in confirming, calibrating, or disproving the modeling efforts used in risk-assessment methodology. Biologic Markers (Biomarkers) of Exposure or Effect There is now considerable interest in the use of biologic markers of exposures or effects in epidemiologic studies of the health risks posed by some occupational and environmental exposures (NRC 1989a,b, 1992a,b, 1995). Some of these studies are relevant to likely exposures to substances emitted from incinerators—for example, measurements of specific congeners of PCDDs and PCDFs in blood and adipose tissues of exposed workers (Schecter et al. 1994), analyses of chlorophenol and pyrene metabolites in blood and urine of incinerator workers (Angerer et al. 1992), analysis of selected DNA adducts in blood samples of incinerator workers and measurement of various indexes of metal exposure in workers (Malkin et al. 1992). Such studies are likely to be generally useful for evaluating exposures to specific materials that might be present in incinerator emissions or evaluating the presence of effects that might be associated with incinerator emissions. However, no biomarker of exposure or effect associated uniquely with incinerator emissions has been identified, nor is any such biomarker likely to be identified, inasmuch as incineration emissions as a class do not (so far as is now known) have components that are peculiar to them nor that cause unique effects. Thus, although the use of biomarkers might add substantially to the accuracy of measurement of exposures and effects in epidemiology, it is not likely to

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WASTE INCINERATION & PUBLIC HEALTH reduce substantially other major sources of uncertainty that are entailed in the application of epidemiology to incinerator emissions. RESULTS OF EPIDEMIOLOGIC STUDIES OF INCINERATOR-EXPOSED POPULATIONS This section discusses the findings from epidemiologic studies of incinerator-exposed populations, including the few studies of human populations in the vicinity of incinerators and the more-detailed health studies of workers in these facilities. In general, information is rather sparse on the relationship between human exposure to pollutants released to the environment by incinerators and the occurrence of health effects. Studies of Local Populations In one of the earliest epidemiologic studies of populations in the vicinity of waste incinerators, Zmirou et al. (1984) obtained data on the use of medications for respiratory illnesses over a 2-year period among residents of a French village at distances of 0.2, 1, and 2 km from a refuse incinerator. Medication use was determined by examining prescription forms filed by the residents after each purchase. The purchase of respiratory medications (bronchodilators, expectorants, antitussants, and so on) decreased as the distance of the residences from the incinerator increased, and the relationship was statistically significant. However, the prevalence of other possible confounding risk factors for respiratory illness, such as socioeconomic and geographical situation, were not accounted for in this study, and no causal associations can be inferred. After reports of illness and neurologic symptoms in workers employed at the Caldwell Systems, Inc. hazardous-waste incinerator in western North Carolina and health complaints of nearby residents, the Agency for Toxic Substances and Disease Registry (ATSDR) performed a cross-sectional study in the surrounding community for the prevalence of self-reported respiratory, musculo-skeletal, neurologic, irritative, and other symptoms (ATSDR 1993a). A higher prevalence of self-reported respiratory symptoms, but not of respiratory or other diseases, was found in the target population than in a nearby comparison population. Prevalence data were adjusted for age, sex, and cigarette smoking. Members of the population close to the incinerator were almost nine times more likely to report recurrent wheezing or cough, and they were almost twice as likely as those living further from the site to report respiratory symptoms (after adjustment for smoking, asthma, and environmental concern). Other symptoms—including chest pain, poor coordination, dizziness, and irritative symptoms—were also statistically significantly greater in the population close to the incinerator. However, the investigators noted that neither the prevalence of physician-diagnosed diseases (as reported by subjects) nor hospital admissions

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WASTE INCINERATION & PUBLIC HEALTH for these diseases differed between the target and comparison populations, and they pointed out that the retrospective nature of the study (the incinerator operated from 1977 to 1988, and the cross-sectional study was conducted in 1991) limited interpretation of the findings. One of the major concerns was recall bias associated, in part, with the greater than 2-year gap between the shutdown of the incinerator and the conduct of the symptom survey. Another factor was the large amount of adverse publicity that the incinerator received before shutdown. Although the investigators attempted to control for recall bias by stratifying their results according to the respondents' expression of environmental concern, they concluded that they were only partially successful, inasmuch as the higher rate of self-reported symptoms from the population close to the incinerator was not associated with any difference in physician-diagnosed disease rates or in hospital-admission rates between the two communities. The investigators also acknowledged that they had no direct measures of community exposure to incinerator-emitted pollutants, which had ceased more than two years before the study, and thus could not estimate differences in exposures among individuals within the population close to the incinerator. Thus, this study is of limited utility in evaluating the effect of incinerator exposures, but emphasizes the necessity of controlling for various types of bias. Wang et al. (1992) tested the lung function of 86 primary-school children living in Taiwan near a wire-reclamation incinerator and compared the results with those in 92 schoolchildren in a school in a “nonpolluted city.” All children had been inhabitants of their districts since birth and had similar socioeconomic backgrounds. Air pollution in the incinerator district was considerably greater than that in the comparison city. SO2 concentrations were 18.1 and 2.1 parts per billion (ppb), respectively, and NO2 concentrations were 12.6 and 2.1 ppb. Questionnaire responses yielded no differences in the prevalence of respiratory symptoms among children in the two areas. However, the prevalence of children with abnormal forced expiratory volume in 1 second (FEV1) was statistically significantly greater in the incinerator community (17.5% vs. 3.2% with abnormal test results). Two groups of children with no reported respiratory symptoms were tested later for bronchial hyperactivity—26 children in the target population and 26 children in the comparison population. A positive methacholine-challenge test was found in 9 of the former and only 1 in the latter group. The authors concluded that “the high level of air-pollution” in the population close to the incinerator was associated with a detrimental effect on lung function in primary-school children; however, they did not obtain data that would allow them to ascribe the measured air pollution to emissions from the incinerator, nor did they characterize other sources of air pollution in the target population. Thus, this study appears to demonstrate that higher concentrations of air pollutants alter pulmonary function in children, but does not directly allow any inference about the contribution of incinerators as opposed to other pollutant sources to either environmental concentrations or health effects in particular.

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WASTE INCINERATION & PUBLIC HEALTH Gray et al. (1994) studied the prevalence of asthma in children living in two regions of Sydney, Australia, where incinerators burned sewage sludge and in one comparison community within the same metropolitan area. They measured respiratory illness in the previous year by questionnaire, airway hyperactivity by histamine-inhalation tests, and atopy by skin tests in 713 children 8-12 years old in the two regions and in 626 children of the same age in a comparison community without an incinerator. All children attending public and parochial schools within a 5-km radius of each of the study communities were selected for the study. Measurements of SOx, NOx, H2S, O3, and particulate matter during the study period showed no differences among the three regions. The prevalence of current asthma, atopy, symptom frequency, or asthma of any category of severity was not statistically different between incinerator and comparison regions. Results of tests of baseline lung function and of airway hyperactivity also did not differ among the three groups of children. The authors pointed out that their study was not designed to measure short-term acute effects of pollutant exposures. They also noted that the prevalence of asthma symptoms and atopy in this population of Sydney children, including those from the incinerator and comparison communities, was comparable with that in four other populations of children studied in Australia, and they concluded that emissions from high-temperature sewage-sludge incinerators appeared to have no adverse effect on the prevalence or severity of childhood asthma. Shy et al. (1995) reported on the first year of a 3-year study of three incinerator communities and three comparison communities in southwestern North Carolina. The study was designed primarily to assess the acute respiratory effects of living in the neighborhood of an incinerator. Of the incinerators, one was a biomedical-waste incinerator, one a municipal-waste incinerator, and the third an industrial furnace fueled by liquid waste. Comparison neighborhoods were pair-matched to the incinerator communities on density and quality of housing and were upwind of and at least 3 km from the incinerators. In each neighborhood, 400-500 households were surveyed by telephone for sociodemographic characteristics, including prevalence of such respiratory risk factors as smokers in the home, and the prevalence of acute and chronic respiratory symptoms. No differences in respiratory-symptom prevalence were found between the subjects living near to either biomedical-waste incinerator or municipal-waste incinerator and their comparison communities. Several chronic respiratory symptoms were reported to have a higher prevalence in the liquid-waste combustor community than in its comparison group, but this difference did not persist when the symptom prevalence in the liquid-waste combustor community was compared with the pooled prevalence of symptoms in the three comparison communities. Concentrations of particulate matter, including PM10 and PM2.5, and of acidic gases, including SO2 and HCl, were monitored in each of the study areas and did not differ measurably between target and comparison communities, either on a daily-average or monthly-average basis. Results of baseline lung-function

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WASTE INCINERATION & PUBLIC HEALTH FIGURE 5-1 Comparison of range and mean PM10 concentrations in cities in which PM-death associations have been reported, range of mean PM10 in U.S. cities in 1993, and range of increment from incineration. Table 4-9, Table 4-10 through Table 4-11 (see Chapter 4) and the health-effect information presented in Table 5-1. On the basis of these tables, it is seen that the highest PM effect of the uncontrolled incinerators, and especially cement kilns incinerating waste (potentially reaching 30 µg/m3 total PM, or about 20 µg/m3 PM10), might be projected to produce increases in health effects on the worst days in the highesteffect locations (potentially about a 2% increase in daily mortality and a 4% increase in respiratory hospital admissions on the maximum day in the case of the pre-MACT cement kiln). However, after MACT controls are applied to these plants, such projected air-pollution effects should be reduced by almost a factor of 10. As a result, the local effects of individual post-MACT plants (though still non-zero) would be so small that such projections would represent much less than a 1% increase in risk of acute morbidity or death, even at the most affected receptor on the worst-case day, and it is highly unlikely that such potential effects could be detected by even the most carefully designed epidemiologic study. Dioxins The committee has a substantial degree of concern for the potential health effects from exposures of plant workers to highly potent pollutants such as dioxin. There is uncertainty as to whether there is any adequate margin of safety between typical background exposures to dioxins and those with measurable responses that might be related to health. Implementation of MACT controls are unlikely to alter the committee 's degree of concern, because MACT is not designed to reduce worker exposures.

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WASTE INCINERATION & PUBLIC HEALTH On a wider scale, it appears that a portion of dioxins in the environment has been produced by waste incineration and that a portion of the current input into the environment is produced by incineration, but how much is not known. There is substantial evidence that the average concentrations in the biosphere are now decreasing despite past increases in incineration, and it is not clear what effect MACT will have on these average concentrations. The wide dissemination of dioxins throughout the environment including the food supply, results in widespread exposures. Exposure indicators (such as blood and fat concentrations) arising from such exposures are close to the levels that, in some experimental systems, give rise to measurable biologic responses that might be related to adverse health outcomes. Thus, the committee has a substantial degree of concern for the incremental contribution to dioxins emissions from all incinerators on a regional level and beyond. Because the major route of exposure to dioxin is the food chain, the exposure of the local population is not expected to be affected much more by a local incinerator than by one located in another state. The local population shares the widespread increase in dioxin exposure from each incinerator, but experiences minimal additional risk. However, there may be specific individuals who have higher exposures because of their location and activity patterns. The mechanism of dioxin toxicity is known to be complex. Several acute toxic effects are mediated almost solely (at least in the mouse) by the arylhydrocarbon receptor (Fernandez-Salguero et al. 1996), but there are other mechanisms. Studies attempting to elucidate precise mechanisms of action continue, and such studies show detectable effects of dioxin-like materials at concentrations similar to those encountered in the environment although it is unclear to what extent such effects might affect health. Figure 5-2 summarizes some of the dioxin TEQs exposures that are associated with overt toxic effects. Four scales of exposure are shown because no single exposure or dose measure is known to correlate with all toxic effects, and various measures have been used in human and animal studies. The four scales are ambient air concentration, long-term average intake, adipose-tissue concentration, and serum concentration. The scales have been aligned roughly so that the background concentrations —those found in typical U.S. populations—are level (horizontal dotted line), and the range of variation of these typical concentrations is indicated (a question mark indicates little information on the range of variation). On the ambient-air scale are marked the estimated maximal concentrations (worst-case locations) around the worst-case hazardous-waste incinerator and cement kiln, as discussed and depicted in Chapter 4, Table 4-8, Table 4-9, Table 4-10 through Table 4-11. The average-intake scale indicates average human intakes and the intakes associated with overt toxic effects in animals, and the long-term average intakes found to cause cancer in more than about 10% of laboratory animals. Adipose-tissue concentrations that correspond in laboratory animals to no overt effects and the tissue concentration roughly corresponding to the concen-

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WASTE INCINERATION & PUBLIC HEALTH FIGURE 5-2 Dioxin TEQs associated with overt toxic effects and concentrations found in the environment. The typical range of background concentrations is shown by the double ended arrows about the “Background level” starred line, with “?” indicating uncertainty about the range. For the concentration scale on the left, the arrows show the ranges of increments in concentration potentially (as the worst-case location) associated with the labeled incineration sources and conditions. For the three scales on the right, arrows show approximate concentrations associated with the labeled end-points, in animals (to the right of each scale) and humans (to the left of each scale).

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WASTE INCINERATION & PUBLIC HEALTH trations causing cancer in more than 10% of animals are shown. The ratios between concentrations required to cause cancer in animals and typical background concentrations in humans are different for average intake and for adipose-tissue concentrations, possibly because of differences in the pharmacokinetics of dioxin in animals and humans. Finally, to indicate the effects of relatively short-term exposure, the serum concentrations in people who have exhibited dioxin-associated chloracne (one effect definitely associated in humans with dioxin exposure) are shown for both very-short-term exposure (e.g., Seveso children) and chronic occupational exposure. Other Products of Incomplete Combustion Products of incomplete combustion (PICs) have been defined as organic compounds not originally detected in the waste stream entering the incinerator, but found in incinerator stack-gas emissions (Travis and Cook 1989). PICs can arise as new organic compounds formed during the incineration process itself, might have been present in the original waste stream (but at concentrations below the cut-off level used in analyzing the waste feed), or might have been brought into the incineration system from noncombustion sources (e.g., auxiliary fuel feed, or ambient air introduced into the system). It is hypothesized that most PICs are formed from recombination of molecular fragments outside the combustion zone (Trenholm et al. 1984). Because they are widespread, persistent, and potent, the major PICs of concern are dioxins and furans, which are discussed separately in this section. Other PICs of potential health concern are PCBs and PAHs. Incinerators are not major emission sources of these on a local or regional scale. Furthermore, in comparison with dioxins and furans, other PICs emitted by incinerators are estimated to have relatively little effect on health, or little is known about their toxicity at the relatively low concentrations emitted. Lead Lead at low concentrations can have adverse health effects especially infants and children. Therefore, at the local population level, the committee has substantial concerns regarding contributions to total lead exposure by incinerators operating prior to implementation of MACT controls. Incinerators operated under MACT are expected to emit only a negligible amount of lead locally, so the potential health effects in local populations from lead after the implementation of MACT are seen as minimal. Due to its toxic potential, exposures of incinerator workers to lead is of substantial concern to the committee. Implementation of MACT controls are unlikely to alter the committee 's level of concern because MACT is not designed to reduce worker exposures.

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WASTE INCINERATION & PUBLIC HEALTH Figure 5-3 shows reported effects of lead at various concentrations in the blood. Effects that have been clearly established and are well accepted by the scientific community are indicated by solid lines, effects with less certainty are indicated by dashed lines, and more controversial effects are indicated by dotted lines. For example, frank anemia occurs at blood concentrations of 80 µg/dL or above; reduced hemoglobin synthesis occurs in adults at 50 µg/dL and above, although this effect might occur in children at lower concentrations; loss of hearing acuity occurs above 30 µg/dL, but hearing loss has been measured down to 10 µg/dL; and while the effect of lead on diastolic blood pressure is clear above 50 µg/dL, some studies indicate effects on systolic blood pressure above 30 µg/dL, and effects below 10 µg/dL are seen in some studies. Several effects have no apparent threshold (for example, the effects on children's cognitive function, on blood pressure, and on heme synthesis), and other effects might not demonstrably affect health. The bottom of Figure 5-3 presents the most recent information on the distribution of blood lead concentrations in the United States, from NHANES III, phase I, 1988-1991 (JAMA 1994). There has been a remarkable reduction in blood lead concentrations in the United States over the last 15 years. There has been a 78% drop in the average, from 12.8 to 2.8 µg/dL, primarily it is believed, because of the removal of lead from gasoline. But a distribution of blood lead exists in the population, and the data indicate that a small portion of the population has blood lead over 10 µg/dL, as do 9% of children aged 1-5; and 0.2% of the population (over 0.5 million people) have blood lead over 30 µg/dL. Any added lead in the environment might make those people more likely to experience the adverse effects of lead. The lead emissions of incinerators are highly variable (see Chapter 4, Table 4-8 and Table 4-10, and this is reflected in the facts that the mean value of lead emissions from hazardous-waste incinerators is 100 times the median value and that the estimated range of air concentrations due to emissions varies by more than 8 orders of magnitude (from 2.0 × 10-8 to 7 µg/m3). Although maximal lead air concentrations due to emissions is 7 µg/m3, which exceeds the ambient-air standards of the EPA, over 95% of the incinerators were estimated to produce ambient concentration increments everywhere less than 0.5 µg/m3; similarly, maximal lead air concentrations due to emissions from cement kilns was 7 µg/m3, but 95% would be less than 1.2 µg/m3. Translating airborne lead to blood lead is complex but has been well studied: for young children and accounting for both the direct route (inhalation) and the indirect route (ingestion of soil, dust, and food contaminated by airborne lead) of exposure, each microgram of airborne lead per cubic meter could increase blood lead by about 4 µg/dL (EPA 1989; CalEPA 1996). Although the average hazardous-waste incinerator and the average cement kiln would contribute less than 1 µg/dL to the blood lead burden of children around the facilities, there is the potential for the worst-case emitters to add about 20 µg/dL to the lead burden of nearby children. Thus, while the effect of

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WASTE INCINERATION & PUBLIC HEALTH FIGURE 5-3 Blood lead concentrations: background, increment from incineration, and concentrations that have health effects. - -- - - - - - - - - - - - - - - - indicates decreasing controversy and uncertainty (from left to right). Arrows are used to indicate the blood lead level at which an effect is known to occur or the range in which an effect is known to occur.

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WASTE INCINERATION & PUBLIC HEALTH FIGURE 5-4 Mercury concentrations: Background (gas-phase and particle-bound concentrations), increment from incineration, and concentrations at which adverse effects occur for the most-sensitive end points of toxicity. the average incinerator would be minimal, that of the highest-polluting facilities would be of some concern, and the maximally polluting facilities could add substantially to the lead burden in the local population and raise young children's blood lead to the point where multiple adverse health effects have been reported. Mercury Because low concentrations of mercury can have toxic effects, exposure of workers to mercury is of substantial concern to the committee. MACT controls are unlikely to alter the committee's degree of concern, because MACT is not designed to reduce worker exposures. The degree of concern about exposures of the population to mercury is expected to be reduced somewhat under MACT, but, in general, no change is expected regarding the regional level due to the environmental persistence of mercury. Figure 5-4 compares mercury concentrations that are associated with nervous system impairment and behavioral abnormalities with concentrations found in the environment. Other human health effects associated with exposure to inorganic and organic forms of mercury, as displayed in Table 5-4, were not plotted here, because little human exposure information related to these health effects is available or exposures are uncertain or unknown. However, available data indicate that the major health effect of concern for mercury compounds is nervous system impairment. Other organ-system toxicity produced by mercury is reported to occur only after much-higher exposures. As shown in Figure 5-4,

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WASTE INCINERATION & PUBLIC HEALTH the potential effect of the average incinerator is expected to be minimal; however, a maximally polluting facility could add substantially to the mercury burden in the community. The implementation of MACT technology is expected to reduce exposures to mercury at the local level. Air concentration estimates related to incineration (Pre-MACT and Post-MACT) are based on Table 4-8, Table 4-9, Table 4-10 through Table 4-11 in Chapter 4. Acidic Gases and Acidic Aerosols Incinerators directly release both acidic aerosols and gases, as well as acidic aerosol precursors that can be transformed into acid particles in the atmosphere. The acidic gases and vapors released from incinerators are generally of less concern than acids released or formed as aerosols (such as H2SO4). Thus, water-soluble acidic gases and vapors (such as SO2, HCl, and HNO3), are of low concern because, at ambient concentrations, these are efficiently “scrubbed out” in the trachea before reaching the lung. Particularly strong acidic aerosols, such as those containing H2SO4, however, more readily reach into the deepest recesses of the lung and are of greater health concern at ambient concentrations. Acids released from incinerators therefore warrant a varied degree of concern depending on the form of the acid (particulate or gaseous) and the extent of emission (pre or post compliance with MACT). Acidic gases are of minimal health concern to the local population and of negligible concern at the regional level but represent a moderate concern to workers, given that exposures have the potential to become high. Compliance with MACT regulations further diminishes the concern regarding acidic gases at the local and regional levels, but not in the worker environment. Acidic aerosols are associated with a somewhat higher degree of concern because of their particulate form and because MACT regulations are not directly aimed at reducing them. However, the acidity concern is reduced after MACT implementation because some MACT controls (such as SO2 limitations) can be expected indirectly to lower strongly acidic aerosols resulting from such plants. Carbon Monoxide Because only about 1% of all CO emissions are attributable to incineration (EPA 1998b,c), the incremental exposure to CO from incinerators is not considered to represent an important increment at either the local or regional level. Although it is possible for workers to be exposed to high levels of CO from incomplete combustion, no data are available to indicate that this has occurred.

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WASTE INCINERATION & PUBLIC HEALTH CONCLUSIONS AND RESEARCH NEEDS Conclusions Estimates of large increments in ambient concentrations of various pollutants attributable to existing incinerators, particularly heavy metals and dioxins and furans, led to legitimate concerns about potential health effects. Pollutants produced and emitted by incinerators that currently appear to have the potential to cause the largest health effects are particulate matter, lead, mercury, and dioxins and furans. On the basis of available data, a well-designed and properly operated incineration facility emits relatively small amounts of those pollutants, contributes little to ambient concentrations, and so is not expected to pose a substantial health risk. However, such assessments of risk under normal operating conditions may inadequately characterize the risks or lack of risks because of gaps in and limitations of existing data or techniques used to assess risk, the collective effects of multiple facilities not considered in plant-by-plant risk assessments, potential synergisms in the combined effects of the chemicals to which people are exposed, the possible effect of small increments in exposure on unusually susceptible people, and the potential effects of short-term emission increases due to off-normal operations. Reductions in emissions will certainly reduce public health risks from direct and indirect exposure to those emissions. Whether there is a minimal emission rate below which there is no further reduction in health risk has not been established, and the indirect effects of emission reductions (for example, health risks associated with efforts to reduce emissions, as through substitution of other processes or materials, the use of more energy or materials for control equipment, and the manufacture of control equipment) have not yet been evaluated. Epidemiologic studies assessing whether adverse effects actually occurred at individual incinerators have been few and were mostly unable to detect any effects. That result is not surprising, given the small populations available to study; the presence of effect modifiers and potentially confounding factors (such as other exposures and risks in the same communities); the long periods that might be necessary for health effects to be manifested; and the low concentrations (and small increments in background concentrations) of the pollutants of concern. Although such results could mean that adverse health effects are not present, they could also mean that the effects may not be detectable using feasible methods and available data sources. The potential health effects of particulate matter emitted by incinerators may not have received appropriate attention in traditional risk assess-

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WASTE INCINERATION & PUBLIC HEALTH ments. In particular, in well-characterized situations (with well-measured emissions) where the contribution of particulate matter to the total ambient particle load is small (around 1%), the acute health effect of emitted particulate matter might be as large as or larger than that of other incinerator-related pollutants. Some past studies have shown the overall urban background of particulate matter already appear to be causing excess mortality and morbidity in the U.S. population, and the particulatematter increment from all incinerators adds to the existing burden. The committee's evaluation was performed based only on emissions under normal operating conditions. Data are not available for levels during off-normal conditions, or the frequency of such conditions. Such information is needed to address whether emissions resulting from off-normal conditions are a concern with respect to possible health effects. There is a need to focus health research on the greatest potential for exposure. Based on studies of municipal solid-waste incinerators, workers at these facilities are at much higher risk for adverse health effects from exposure to this technology than local residents. There is evidence that incinerator workers have been exposed to high concentrations of dioxins and toxic metals—particularly lead, cadmium, and mercury —in the past. The committee's evaluation of waste incineration and public health has been substantially impaired by the lack of an adequate compilation of the associated ambient concentrations resulting from incinerator emissions. The evaluation was also impaired by the inadequate understanding of the overall contribution of incinerators to pollutants in the total environment, and large variabilities and uncertainties associated with risk-assessment predictions, which, in some cases, limit the ability to define risks posed by incinerators. EPA is proceeding to regulate emissions from incinerators by requiring that incinerators reduce emissions to values achieved by the best controlled 12% of the current incinerators, a standard known as maximal achievable control technology, or MACT. Those regulations will affect emissions of the most-important pollutants unevenly; even under MACT, concerns over the widespread effects of persistent pollutants, such as dioxins, lead, and mercury will not be adequately addressed. Other potential effects can be shown to be negligibly small for some facilities on which well-measured emission data are available. However, for some individual facilities with well-measured emissions, health risks are not negligible. Collective potential effects of incinerators on a regional scale and beyond are unknown. New or modified facilities that meet the proposed MACT requirements are expected to have substantially lower emissions than previous facilities.

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WASTE INCINERATION & PUBLIC HEALTH The reduction in emissions will lower the potential exposures and risk to populations surrounding incinerators in the environment in general. Based on a consideration of normal operating conditions, implementation of MACT standards is expected to substantially reduce the overall health risks from local impacts of particulate matter, lead, and mercury associated with incineration. It is unlikely whether implementation of MACT will substantially reduce the risks at the regional level posed by the persistent environmental pollutants dioxin, lead, and mercury. MACT was not designed to protect workers, and MACT regulations are unlikely to reduce worker exposures. Recommendations To increase the power of epidemiologic studies to assess the health effects of incinerators, future multi-site studies should be designed to evaluate combined data from all facilities in a local area as well as multiple localities that contain similar incinerators and incinerator workers, rather than examining health issues site by site. In addition to using other exposure assessment techniques, worker exposures should be evaluated comprehensively through biological monitoring, particularly in combination with efforts to reduce exposures of workers during maintenance operations. Assessments of health risks that are attributable to waste incineration should pay special attention to the risks that might be posed by particulate matter, lead, mercury, and the dioxin and furans, due to their toxicity and environmental prevalence. Health risks attributable to emissions resulting form incinerator upset conditions need to be evaluated. Data are needed on the levels of emissions during process upsets as well as the frequency, severity, and causes of accidents and other off-specification performance to enable adequate risk assessments related to these factors. Such information is needed to address whether or not off-normal emissions are important with respect to possible health effects. Database compilers should strive to accumulate data not only on emissions from individual facilities (as in the Hazardous Waste Combustor database), but also the resulting estimates of ambient concentrations. Facilities that have performed emissions testing have also often performed site-specific air dispersion modeling, so that little extra effort would typically be required. Moreover, the overall contribution of incinerators to pollutants in the total environment would be easier to assess if any known site-specific measurements of background concentrations of incineratorrelated pollutants were also compiled on a plant-by-plant basis.