title: Systematic review of epidemiological studies on health effects associated with management of solid waste.
abstract: BACKGROUND
  Management of solid waste (mainly landfills and incineration) releases a number of toxic substances, most in small quantities and at extremely low levels. Because of the wide range of pollutants, the different pathways of exposure, long-term low-level exposure, and the potential for synergism among the pollutants, concerns remain about potential health effects but there are many uncertainties involved in the assessment. Our aim was to systematically review the available epidemiological literature on the health effects in the vicinity of landfills and incinerators and among workers at waste processing plants to derive usable excess risk estimates for health impact assessment.
  
  
  METHODS
  We examined the published, peer-reviewed literature addressing health effects of waste management between 1983 and 2008. For each paper, we examined the study design and assessed potential biases in the effect estimates. We evaluated the overall evidence and graded the associated uncertainties.
  
  
  RESULTS
  In most cases the overall evidence was inadequate to establish a relationship between a specific waste process and health effects; the evidence from occupational studies was not sufficient to make an overall assessment. For community studies, at least for some processes, there was limited evidence of a causal relationship and a few studies were selected for a quantitative evaluation. In particular, for populations living within two kilometres of landfills there was limited evidence of congenital anomalies and low birth weight with excess risk of 2 percent and 6 percent, respectively. The excess risk tended to be higher when sites dealing with toxic wastes were considered. For populations living within three kilometres of old incinerators, there was limited evidence of an increased risk of cancer, with an estimated excess risk of 3.5 percent. The confidence in the evaluation and in the estimated excess risk tended to be higher for specific cancer forms such as non-Hodgkin's lymphoma and soft tissue sarcoma than for other cancers.
  
  
  CONCLUSIONS
  The studies we have reviewed suffer from many limitations due to poor exposure assessment, ecological level of analysis, and lack of information on relevant confounders. With a moderate level confidence, however, we have derived some effect estimates that could be used for health impact assessment of old landfill and incineration plants. The uncertainties surrounding these numbers should be considered carefully when health effects are estimated. It is clear that future research into the health risks of waste management needs to overcome current limitations.
authors.affiliation: Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy. porta@asplazio.it
authors.forename: Daniela
authors.initials: D
authors.lastname: Porta
authors.forename: Simona
authors.initials: S
authors.lastname: Milani
authors.forename: Antonio I
authors.initials: AI
authors.lastname: Lazzarino
authors.forename: Carlo A
authors.initials: CA
authors.lastname: Perucci
authors.forename: Francesco
authors.initials: F
authors.lastname: Forastiere
mesh_terms: D000393:Air Pollutants / Q000009:adverse effects*; D016000:Cluster Analysis; D006801:Humans; D017745:Incineration; D009369:Neoplasms / Q000209:etiology*; D016273:Occupational Exposure / Q000009:adverse effects; D012037:Refuse Disposal; D012111:Residence Characteristics; D018570:Risk Assessment; D012307:Risk Factors; D014874:Water Pollutants, Chemical / Q000009:adverse effects*
chemical_list: D000393:Air Pollutants; D014874:Water Pollutants, Chemical