Guidance

Epidemiological evidence review in the UK and EU, following implementation of the Waste Incineration Directive

Updated 9 June 2025

The full title of this report is:

Health impacts of waste incineration: a systematic review of epidemiological evidence in the UK and EU, following implementation of the Waste Incineration Directive.

Executive Summary

This report provides a systematic review of the available evidence regarding the potential health impacts of air pollutants emitted by municipal waste incinerators (MWI) on nearby communities. It builds on the Health Protection Agency’s (HPA) (a predecessor to the UK Health Security Agency) position statement from 2009 and supports UK Health Security Agency’s (UKHSA) current opinion statement, which is that modern, well run and regulated municipal waste incinerators are not a significant risk to public health.

The evidence considered was focused on MWI in the UK and European Union (EU), reporting epidemiological health outcomes from exposure to MWI emissions, from the incineration process.

Twelve eligible studies were identified investigating a range of physical health outcomes:

• cancer
• pregnancy and adverse birth outcomes
• mortality
• morbidity
• hospital admission

These studies have been assessed for the overall evidence of association and important findings are summarised in this report.

The papers identified for inclusion were epidemiological studies with measured physical human health outcomes and an exposure period post implementation of the Waste Incineration Directive (WID, 2000), in countries in the European Union in 2000, which included the UK. The implementation of the Waste Incineration Directive (WID) came into operation in late 2003 for new build MWI and 2005 for existing MWI. (European Union, 2000; Defra, 2015). This criterion ensured that the studies considered in this review were applicable to UK MWI and considered health effects from the emissions from the incineration process only.

The studies included have a variety of limitations which affect their applicability to modern MWI: a long latency period for cancer was not considered in the studies; and there is a lack of adjustment for confounders, for example, co-exposures to other pollutants. However, the majority of the studies identified found no association for exposure and health outcomes.

Levels of airborne emissions from individual MWI are significantly lower now than in the past due to implementation of stricter legislative controls and improved technologies (WID, 2000).  Additionally, these incinerators only make a small contribution to local concentrations of air pollutants when compared to other sources of air pollution.

This systematic review shows that currently there is no clear evidence of association between human health exposure to emissions from modern, well-regulated MWI and morbidity, cancers, or adverse birth outcomes in the UK.

Introduction 

The Environment Agency (EA) consult UK Health Security Agency (UKHSA) on Environmental Permit applications to operate municipal waste incinerators (MWI) in England under the Environmental Permitting Regime (Defra, 2015). In Scotland and Wales, this responsibility lies with the Scottish Environment Protection Agency and Natural Resources Wales respectively who will consult their respective public health agency.

The UKHSA regularly receives enquiries about the evidence base around MWI sites, particularly when planning and Environmental Permit applications are made to build and operate such facilities.

Purpose

The purpose of this systematic review is to collate the available scientific evidence on the potential health effects of air pollutants emitted from the incineration process on the communities that live near MWI. The results of which have been used to inform the UKHSA’s current opinion. The evidence considered was focused on MWI from the UK and European Union (EU), reporting epidemiological health outcomes from exposure to MWI emissions from the incineration process. It builds on the Health Protection Agency’s (HPA) (a predecessor to the UKHSA) position statement from 2009 and supports UKHSA current opinion statement.

Municipal Waste Incinerators and Regulations

Municipal waste (MW) consists of a complex mixture of waste materials discarded within districts managed by a local government, to include households, businesses, commercial sites, and institutions (Gueboudji and others, 2024). Residual waste is what is left of municipal waste from unrecyclable materials unable to be reused or prevented (Defra, 2014). Residual waste may comprise materials as defined in the Waste Framework Directive (2000/76/EC), which may include organic waste composed of food and garden waste, or inert materials such as paper, plastics, glass, and metals (European Commission, 2023).

The combustion treatment of residual waste can generate energy either in the form of electricity or heat. Industrial plants may vary in thermal treatment technology for waste-to-energy recovery. Additional outcomes for waste treatment processes are to reduce mass and volume of MW and reduce waste landfilling (Environment Agency, 2009). See Annex 1 for further details of the incineration process.

Defra lead on waste management policy and the legislation relating to MWI, and the EA regulate MWI under the Environmental Permitting Regulations: The Environmental Permitting (England and Wales) Regulations 2016, which set the emission limits for MWI in England and Wales and aim to achieve a high level of protection for the environment, including human health.

The operators of MWI are required to monitor emissions to ensure that they comply, as a minimum, with the emission limits in the IED (2010/75/EU), which sets strict emission limits for pollutants. The Directive has been implemented in England and Wales by the Environmental Permitting Regulations (EPRs) 2016, as amended. The Directive has been implemented in Scotland by the Pollution Prevention and Control (Scotland) Regulations 2012. The IED is a recast of the 7 existing Directives including the Waste Incineration Directive (2000/76/EC). The implementation of the Waste Incineration Directive (WID) came into operation in late 2003 for new build MWI and 2005 for existing MWI, with the objective to limit and minimise the release of pollutants from new and existing incineration of waste as far as practicable. (European Union, 2000; Defra, 2015). This report will refer to modern MWI that operate under post-WID regulations and focus on emissions to air. See Annex 2 for further details on the relevant legislation in place for MWI in the UK.

Material and methods 

Authors carried a literature search out using databases Medline, Embase, Scopus, Green file and Grey literature combining terms associated with incineration, and terms associated with health impacts up to 2023.

The authors obtained a total of 2,258 papers from the search, published up to 2023. Duplicates were removed, then screened by title and abstract, resulting in 256 papers. The authors screened the full text of these remaining papers resulting in 12 papers for qualitative analysis (Figure 1).

The results were screened by title and abstract independently by 2 reviewers, and any disagreements were discussed with a third reviewer to come to a decision based on the exclusion criteria. The full text of the papers identified were screened by 2 reviewers and those suggested for inclusion were subsequently checked by another reviewer to reach a consensus. Eligibility criteria such as population, outcomes and study design were considered in the review. 

The papers identified for inclusion were epidemiological studies with measured physical human health outcomes and an exposure period post implementation of the WID in countries in the European Union in 2000, that is, including the UK. This criterion ensured that the studies considered in this review were applicable to UK MWI and considered health effects from the emissions from the incineration process only.

Figure 1:  Diagram for the identification of peer-reviewed papers included in the review.

Data extraction 

We created a standardised data extraction form to capture all relevant information from each full text paper. Data extraction was undertaken by 2 reviewers independently. Any disagreement was resolved with the help of a third reviewer.

Results 

Health Effects 

This review included 12 papers which considered a variety of health outcomes. These could be broadly categorised as:

• pregnancy and adverse birth outcomes including infant mortality (Vinceti and others, 2018; Parkes and others, 2020; Candela and others, 2013; Vinceti and others, 2008; Vinceti and others, 2009, Freni-Sterrantino and others, 2019; Ghosh and others, 2019)
• cancer studies (Mariné Barjoan and others, 2020; Romanelli and others, 2019; Ancona and others, 2015; Garcia-Perez and others, 2013)
• non cancer mortality and morbidity studies (Romanelli and others, 2019; Gandini and others, 2022 and Ancona and others, 2015).

Pregnancy and adverse birth outcomes including infant mortality

A series of 3 studies (Vinceti and others, 2008; 2009; 2018) investigated pregnancy and birth outcomes around a MWI in Modena, Italy. The overall results did not reveal any significant association between exposure to emissions from MWI and birth outcomes in children born to women exposed to these emissions.

The 2008 study analysed rates of spontaneous abortion and congenital anomalies in the group of women residing or working near the MWI during 2003 to 2006 (compared to the non-exposed group). 

The study was unable to detect an excess risk of miscarriage in women residing close to the MWI. The overall study found no substantial evidence that maternal exposure to dioxins from MWIs increased risk of miscarriage and birth defects in the offspring. A similar finding was obtained in the case-control study by the same group of authors (Vinceti and others, 2009) which examined the extent to which the risk of congenital anomalies varied with maternal exposure to emissions from MWI using Geographical Information System (GIS) data.

The authors mapped cases of congenital anomalies and miscarriages for a slightly longer period (for example, during 1998 to 2006). In a more recent study, (Vinceti and others, 2018) the authors modelled the dioxin emissions to provide a measure of exposure and investigated miscarriages or spontaneous abortion in women, and congenital anomalies in children. The study considered the period 2003 to 2013 and assessed the databases of the Modena Municipal General Registry Offices to identify and select 16 to 49 year old women residing in the high and intermediate exposure areas. Like the previous 2 studies, the results of this study were unable to show an association between exposure to MWI emissions and miscarriage in women or occurrence of birth defects in the children. Although the authors acknowledged a few limitations of the study such as small numbers, the overall result of the study does not appear to be different from null findings on risk of miscarriages in women and exposure to emissions from the MWI.

Three papers were identified from a UK-based study on:

• congenital anomalies
• fetal growth
• pre-term birth
• multiple births (rates of twin births)
• sex ratio
• infant mortality

It includes a before and after analysis of MWI opening (Parkes and others, 2020; Ghosh and others, 2019 and Freni-Sterrantino and others, 2019). The retrospective population-based cohort study on congenital anomalies in relation to MWI by Parkes and others, (2020) conducted a national investigation of congenital anomalies in babies born to mothers living within 10km of an MWI in England and Scotland.

The authors included 10 eligible MWI in England or Scotland operating between April 1 2003, to the end of December 2010 and for which data on congenital anomalies were available in the surrounding areas. For exposure assessment, the authors used both a distance-based approach as well as dispersion modelling data to estimate daily mean ground-level PM10 concentrations from MWI emissions.

Although the authors found small increased risks (2 to 7%) for congenital anomalies, for example, congenital heart defects and genital anomalies specifically hypospadias, using proximity for the exposure assessment, this might reflect residual confounding effects. The results using dispersion modelling for the exposure assessment showed no significant associations between modelled PM10 emissions and the congenital anomalies after fully adjusting for confounders.

The linked retrospective population-based cohort and case-control study (Ghosh and others, 2019) looked at:

• fetal growth
• pre-term birth
• multiple births
• sex ratio and infant mortality

All between 2003 and 2010 and included all MWI nationally. The authors included infant mortality cases living within 10km of an operating MWI. The daily estimated concentrations of ground-level PM10 from the MWI emissions was used as a proxy for general MWI emissions. The overall results suggest that no associations for stillbirths per doubling of PM10 from MWI in the adjusted models. There was no excess risk in relation to the other pregnancy and birth outcomes investigated in this study. The authors also applied additional adjustment for tobacco sales and birth registration (a proxy of socio-economic status) and were unable to see any change.

In the third linked study, Freni-Sterrantino and others (2019) used an alternative approach to evaluate whether opening a MWI related to infant mortality and sex ratios in the surrounding areas. The authors included all 8 new MWI coming into operation in England and Wales between 2003 and 2010 and considered the exposed areas for each incinerator to be within a 10 km radius.

For each MWI, the study period considered 5 years before and after the opening date. Data on infant mortality and sex ratio were obtained from the Office for National Statistics. The overall results indicated no significant increase in infant mortality (rates decreased from 4.8 to 3.9 (per 1000) in the MWI areas, 5.0 to 4.6 (per 1,000) in the comparator areas). For sex ratio, there was no difference between before and after MWI opening. 

An ecological study investigating health outcomes between 2003 and 2010, showed no effect of exposure to emissions on rates of twin or multiple births from MWI based on modelled emission data (Candela and others, 2013). The study around 8 MWIs in Italy reported no change in the number of infants which were small for gestational age (SGA), but significant trends in pre-term (less than 37 weeks) and very pre-term (less than 32 weeks) births were detected. The highest versus lowest exposure pre-term birth odds ratio (OR)=1.30, 95% confidence interval (CI)=1.08 to 1.57, very pre-term birth OR=2.19, 95% CI=1.24 to 3.85.

The study period involved both pre- and post-WID regulations and as the authors stated that the PM10 decreased (0.96 ng/m³ to 0.26 ng/m³) over this time, the potential impacts on pre-term births could be attributed to a persisting pre-WID effect.   

Cancer studies

In a retrospective cohort Italian study by Romanelli and others (2019), tumour of the lymphohematopoietic system was studied in a population exposed to emissions from a MWI in Pisa, Italy, during the period of 2001 to 2014. The authors used modelled nitrogen oxides (NOx) dispersion data as a surrogate for air pollution, due to the high correlation of NOx with other pollutants, for example, emissions from industrial plants and traffic. In males, mortality results showed higher incidence of death due to tumour of the lymphohematopoietic system as expressed in Hazard Ratio trend (HRt) (p=0.01) and morbidity analysis showed a HRt for lymphohematopoietic system tumours of p=0.04.

In a French study, the authors studied cancer incidence in the proximity of a MWI in Nice from 2005 to 2014 (Mariné Barjoan and others, 2020). The results revealed higher incidence for acute myeloid leukaemia, myelodysplastic syndromes and myeloma (in women) and soft tissue sarcomas, myeloma and lung cancers (in men). The study also reported that during 2010 to 2014, no excess cancer incidences among women were found but higher incidence of myeloma and lung cancer were common in men which could be attributed to some extent by implementation of strict regulation to European standards with time. The incidence of cancer among men between 2010 and 2014 could be attributed by either a very long latency period (20 years) (Cesana and others, 2002; Mouhieddine and others, 2019) or due to improved diagnostic procedures over previous years (Mateos and Landgren, 2016). Additionally, one of the potential known risk factors for lung cancer is tobacco smoking, which was not considered in this study. The authors noted that other risk factors, for example, vicinity to a major road, population density and social characteristics, could also have contributed to these results. 

An increased risk of laryngeal cancer mortality in women expressed as hazard ratio or HR=1.92, (95% CI=1.16 to 3.19) was reported in an Italian cohort study (Ancona and others, 2015) investigating collected data on natural and cause-specific mortality and hospital admissions, along with different cancer types during the period 2001 to 2010. The authors used PM10 as a marker of incinerator emissions. In addition, this study reported significant findings for pancreatic cancer mortality (men: HR=1.40, 95% CI=1.03 to 1.90, women: HR=1.47, 95% CI=1.12 to 1.93), and pancreatic cancer hospital admissions for men (HR=1.35, 95% CI=1.01 to 1.81). This study also considered a nearby landfill site and petrochemical plant, noting that the marker contaminants from these are highly correlated with PM10. However, because of the overlap in emitted pollutants, this approach did not allow for specific health outcomes to be attributed to a single source of exposure.   

A single study (Garcia-Pérez and others, 2013) looked at the association between living near a MWI and overall cancer mortality. In this study of multiple cancer sites in a town situated near incinerators and hazardous waste treatment plants investigating mortality due to cancer for the period 1997 to 2006 reported a significantly increased risk of overall cancer mortality within 5 km of an incinerator (RR=1.09, 95% CI=1.01 to 1.18).  The author also reported an increased risk of lung cancer mortality (RR=1.17, 95% CI=1.01 to 1.34 for the whole population, RR=1.19, 95% CI=1.01 to 1.38 for men, RR=0.94, 95% CI=0.75 to 1.16 in women); stomach cancer mortality (RR=1.38, 95% CI=1.09 to 1.72) in women; and gallbladder cancer mortality (RR=1.43, 95% CI=1.04 to 1.92) and pleural cancer mortality (RR=1.98, 95% CI=1.09 to 3.29) in men.  This was an ecological study and due to its design, it was not possible for the analysis to account for a number of potential confounders. 

Non-cancer Mortality and Morbidity studies

The study by Romanelli and others (2019) described above also reported hospital discharge and non-cancer mortality as health outcomes of living in proximity to an incinerator. Mortality results for males showed higher incidence of death due to natural causes (HRt p less than 0.05) and cardiovascular diseases (HRt p less than 0.01). In the case of females only, increased trends for acute respiratory diseases (HRt p=0.04) were found. The authors discussed a number of limitations which could have impacted the result, for example, lack of adjustment for background exposures, not considering individual risk factors like:

• occupation
• tobacco smoke
• other lifestyle habits
• a positive correlation with deprivation index

Given the other potential sources of exposure in the area and the potential for effects arising from exposures before the implementation of the WID, there are limitations of the findings of the study to modern MWI. 

An Italian cohort study of emergency department (ED) cases and hospital admission for circulatory and respiratory system disease was carried out by Gandini and others (2022). The authors looked at adverse health effects, for example, hospital admissions as a result of single and repeated peaks in emissions of a MWI in Turin. An exposed group and control group of all ages with similar socio-economic and environmental exposure characteristics were studied for pre and post start up period of the incinerator. The study also looked at an approach to compare the standardised rates of ED access and hospital admissions over time, covering prior and post incinerator start-up without using information on daily emissions. The association between exposure to emissions and ED cases for cardiorespiratory causes was not statistically significant and there were no statistically significant differences in circulatory and respiratory disease ED access or first hospital admission between the pre and post incinerator start-up periods.

Another longitudinal study by Ancona and others (2015) looked at mortality and morbidity in a population in Rome exposed to multiple sources of air pollution which includes a landfill (H₂S), an incinerator (PM10) and a refinery plant (SO₂). The study did not find any association with exposure to emissions from a MWI when corrected with estimated annual average exposure levels. Cardiovascular and respiratory diseases are associated with exposure to particulate matter and air pollution, and the PM10 (used as a proxy to emissions from incinerators) emission was recorded as low, with a mean annual concentration below 0.17 ng/m³ (Ancona and others, 2015).  

Discussion 

In this systematic review, the studies included have investigated health effects in populations residing near MWI situated in the UK and EU, as these operate under requirements of the WID and IED. The review focused on time periods post the implementation of the WID.  

The papers included in this review reveal variations in terms of study designs, number of participants, range of health outcomes and exposure assessment. The number of incinerators included in the studies varies from a single plant to 22 and the study designs vary from cohort, descriptive ecologic study, cross sectional, and interrupted time series studies.  

One study which included a distance-based approach showed a correlation between distance from an incinerator and an increased risk of congenital anomalies (Parkes and others, 2020). It should be noted, as mentioned by the authors, this does not realistically reflect potential exposures to emissions which is more accurately predicted using air dispersion modelling.

The health outcomes assessed include pregnancy and adverse birth outcomes including infant mortality, cancer outcomes and non cancer mortality and morbidity. Most of the studies used residents who lived further away from an incinerator as a control group compared to residents who lived closer as the exposure group. In addition, in almost all studies, exposure has been evaluated at the place of residence, thus ignoring variations arising from individuals who spent a substantial time away from home (for example, at work, commuting, leisure activities, travel). The exposure assessment regarding emissions from the incinerators range in design and complexity, from exposure modelling using PM as a proxy (Parkes and others, 2020; Ghosh and others, 2019; Freni-Sterrantino and others, 2019) or dioxins (Vinceti and others, 2018;) or NOx (Romanelli and others, 2019; Gandini and others, 2022). Several studies used atmospheric dispersion models incorporating information on individual incinerator characteristics, emission concentrations, local meteorological conditions, and topography which contribute to observed concentrations and spatial patterns of incinerator emissions.

The majority of the studies identified reported no association between exposure to the emissions from incinerators and adverse health outcomes. While 5 (Candela and others., 2013; Marine Barjoan and others, 2020; Romanelli and others, 2019; Ancona and others, 2015; and Garcia-Pérez and others, 2013) did find an association, these studies failed to adjust for potential confounders and therefore could contain possible exposure misclassifications. Also, to evaluate outcomes most studies relied solely on available databases (for example, hospital records, disease registry, mortality records) without accounting for potential confounders and lack of data at individual level. Moreover, a long latency period between exposure and diagnosis of the chronic disease may lead to misclassification of exposure as people investigated may have migrated into or out of the exposed area during the latency period (Knox, 2000).  

In terms of cancer outcomes, some significant association with exposure was found in 4 out of the 7 studies. These 4 studies looked at multiple cancer outcomes for example, higher mortality in males due to tumor of lymphohematopoietic system (Romanelli and others, 2014), higher incidence for acute myeloid leukaemia, myelodysplastic syndromes and myeloma (in women) and soft tissue sarcomas, myeloma and lung cancers (in men) (Marine Barjoan and others, 2020); increased risk of laryngeal cancer mortality in women (Ancona and others, 2015); and overall cancer mortalities (Garcia-Pérez and others, 2013).

In addition, the exposure periods considered for these studies overlapped with pre-WID exposure (that is, 1990 to 2014). The different exposure periods considered by these studies were: 2001 to 2014 for Romanelli and others; 2010 to 2014 for Marine Barjoan and others, 2001 to 2010 for Ancona and others, and 1990 to 2006 for Garcia- Pérez and others.  

Taking into account the heterogeneity of cancer outcomes reported, the different exposure times including pre-WID time periods, and the long latency period associated with some cancer outcomes (up to 2 to 35 years depending on the cancer type) the results cannot be extrapolated to modern post-WID MWI, which emit lower concentrations of pollutants compared to pre-WID MWI. 

Seven studies are available investigating impacts of incinerator emissions on pregnancy and adverse birth outcomes including infant mortality. Three studies led by Vinceti and others, modelled dioxin emissions to provide a measure of exposure during 2003 to 2013 (Vinceti and others, 2018), 2003 to 2006 (Vinceti and others, 2008) and 1998 to 2006 (Vinceti and others, 2009). Four studies measured exposure based on modelled PM10 data for the period of 2003 to 2010 (Parkes and others, 2020, Ghosh and others, 2019, Freni-Sterrantino and others, 2019 and Candela and others, 2013). Six out of seven studies found no association between maternal exposures and adverse pregnancy and birth outcomes. The study by Candela and others, 2013, found significant association of preterm birth and maternal exposure. However, this study did not find any association with other birth outcomes, for example, sex ratio, multiple births or SGA in children and maternal exposure to incinerator emissions. The study relied on delivery certificate database and municipal General Registry Offices for pregnancy and birth outcome results and maternal information, but did not obtain information on potential confounders, for example, occupational exposures or daily activities. Moreover, the authors acknowledged that preterm birth is a syndrome initiated by multiple mechanisms including social stress and race, infection and inflammation and genetics, endocrine disruption etc. The Ghosh and others (2019) study did not identify an association with pre-term birth when considering UK incinerators.

In terms of non cancer mortality and morbidity outcomes, 2 out of 3 studies (Gandini and others, 2022 and Ancona and others, 2015) did not find association with exposure to emissions from MWI. A single study by Romanelli and others (2019) reported mortality results for males living near a MWI with a higher incidence of death due to natural causes and cardiovascular diseases. This study also found higher trends for acute respiratory diseases in females. While a number of limitations with the study were described by the authors and given the other potential sources of emissions from incinerators and effects arising from exposures before the implementation of the WID, it is not applicable to modern MWI.

In addition to the epidemiological evidence presented in this review, a study by Douglas and others (2017) found that overall emissions from UK modern incinerators are low and make only a small contribution to local air quality.

Conclusion 

This systematic review shows that currently there is no clear evidence for associations between exposure to emissions from modern, well-regulated MWI and morbidity, cancers, or adverse birth outcomes, and these incinerators only make a small contribution to local concentrations of air pollutants when compared to other sources of air pollution.

This review supports the current UKHSA opinion statement, which is that modern, well run and regulated municipal waste incinerators are not a significant risk to public health.  

Overall, while it is not possible to rule out adverse health effects from MWI completely, any potential effect on people living close by is likely to be very small.

Acknowledgements 

UKHSA would like to thank all those members of the Environmental Hazards and Emergencies Department and Toxicology Department involved with the literature review and contributions to this report.

References 

1. Ancona C, Badaloni C, Mataloni F, Bolignano A, Bucci S, Cesaroni G, Sozzi R, Davoli M, Forastiere F. ‘Mortality and morbidity in a population exposed to multiple sources of air pollution: A retrospective cohort study using air dispersion models’. Environmental Research 137:467-74, 2015. 
2. Candela S., Ranzi A., Bonvicini L., Baldacchini F., Marzaroli P., Evangelista A., Luberto F., Carretta E., Angelini P., Freni Sterrantino AF., Broccoli S., Cordioli M., Ancona C., Forastiere. ‘Air Pollution from Incinerators and Reproductive Outcomes-A Multisite Study’. Epidemiology 24, 6, 863-870, 2013.
3. Cesana C, Klersy C, Barbarano L, Nosari AM, Crugnola M, Pungolino E, Gargantini L, Granata S, Valentini M, Morra E. ‘Prognostic factors for malignant transformation in monoclonal gammopathy of undetermined significance and smoldering multiple myeloma’. Journal of Clinical Oncology 20, 1,625 to 1,634, 2002. 
4. Department for Business, Energy and Industrial Strategy. ‘Advanced Gasification Technologies Review and Benchmarking: summary report’. Advanced Gasification Technologies Review and Benchmarking: summary report. 2021.
5. Defra. ‘Environmental permitting guidance: waste incineration. Environmental permitting guidance: waste incineration. 2015. 
6. Defra. ‘Energy from waste. A guide to the debate’. Energy from waste: a guide to the debate. 2014. 
7. Defra. ‘Incineration of Municipal Solid Waste’. Incineration of Municipal Solid Waste. 2013.
8. Defra. ‘The Waste Incineration Directive, For the Environmental Permitting (England and Wales) Regulations 2010’. Environmental permitting guidance: The Waste Incineration Directive. 2010. 
9. Directorate-General for Environment. ‘Waste Framework Directive’. European Commission. Waste Framework Directive. 2023. 
10. Dong J, Tang Y, Nzihou A, Chi Y, Weiss-Hortala E, Ni M, Zhou Z. ‘Comparison of waste-to-energy technologies of gasification and incineration using life cycle assessment: Case studies in Finland, France and China. Journal of Cleaner Production, 203:287-300, 2018.  
11. Douglas P., freni-Sterrantino A., Sanchez M L., Ashworth D.C., Ghosh., R.E., Fetch D., Font. A., Blangiardo M., Gulliver J., Toledano M B., Elliott., de Hoogh K., Fuller G W., Hansell A L. ‘Estimating particulate exposure from modern municipal waste incinerators in Great Britain’. Environmental Science & Technology 51: 7511-7519, 2017.
12. European Union. ‘Directive 2000/31/EC of the European Parliament and of the Council of 4 December 2000 on the incineration of waste. EUR-Lex, Access to European Union Law. OJ L 332, 28.12.2000, p. 91-111. 2000. 
13. Environment Agency. ‘How to comply with your environmental permit. Additional guidance for: The Incineration of Waste (EPR 5.01)’. Defra. How to comply with your environmental permit. 2009. 
14. Environment Agency. ‘Waste management data for England 2017’. Waste management data for England 2017. 2017. 
15. European Commission. ‘Waste Framework Directive’. Waste Framework Directive - European Commission. 2023. 
16. Freni-Sterrantino A, Ghosh RE, Fecht D, Toledano MB, Elliott P, Hansell AL, Blangiardo M. ‘Bayesian spatial modelling for quasi-experimental designs: An interrupted time series study of the opening of Municipal Waste Incinerators in relation to infant mortality and sex ratio’. Environment International, 128:109-115, 2019. 
17. Gandini M, Farina E, Cemaria M, Lorusso B, Croseto L., Rowinski M, Ivaldi C, Cadum E, Bena A. ‘Short-term effects on emergency room access or hospital admissions for cardio-respiratory diseases: methodology and results after three years of functioning of a waste-to-energy incinerator in Turin (Italy)’. International Journal of Environmental Health Research, 32 (5) 1164-1174, 2022. 
18. García-Pérez J, Fernández-Navarro P, Castelló A, López-Cima MF, Ramis R, Boldo E, López-Abente G. ‘Cancer mortality in towns in the vicinity of incinerators and installations for the recovery or disposal of hazardous waste’. Environment International, 51:31-44, 2013. 
19. Ghosh RE, Freni-Sterrantino A, Douglas B, Parkes D, Fecht K de, Fuller G, Gulliver J, Font A, Smith RB, Blangiardo M, Elliot P, Toledano MB, Hansell AL. ‘Fetal growth, stillbirth, infant mortality and other birth outcomes near UK municipal waste incinerators; retrospective population based cohort and case-control study’. Environment International, 122, 122-151, 2019. 
20. Knox E. ’Childhood cancers, birthplaces, incinerators and landfill sites’. International Journal of Epidemiology, 29(3), 391-397, 2000. 
21. Mariné Barjoan E, Doulet N, Chaarana A, Festraëts J, Viot A, Ambrosetti D, Lasalle JL, Mounier N, Bailly L, Pradier C. ‘Cancer incidence in the vicinity of a waste incineration plant in the Nice area between 2005 and 2014’. Environmental Research, 188, 109681, 2020. 
22. Mateos MV, Landgren O. ‘MGUS and smoldering multiple myeloma: diagnosis and epidemiology’. Cancer Treatment Research 169, 3–12. 2016. 
23. Mouhieddine T H, Weeks LD, Ghobrial IM. ‘Monoclonal gammopathy of undetermined Significance’. Blood 133, 2484–2494, 2019. 
24. Parkes B, Hansell AL, Douglas P, Fecht D, Wellesley D, Kurinczuk J J, Rankin J, Hoogh Kd, Fuller GW, Elliott P, Toledano MB. ‘Risk of congenital anomalies near municipal waste incinerators in England and Scotland: Retrospective population-based cohort study’. Environment International, 134, 104845, 2020. 
25. Romanelli AM, Bianchi F, Curzio O, Minichilli F. ‘Mortality and Morbidity in a Population Exposed to Emission from a Municipal Waste Incinerator. A Retrospective Cohort Study’. International Journal of Environmental Research and Public Health. 10,16(16):2863, 2019. 
26. Shah H H, Amin M, Iqbal A, Nadeem I, Kalin M, Soomar A m, Galal A M. ‘A review on gasification and pyrolysis of waste plastics. Frontiers in Chemistry. 10: 960894, 2022. 
27. UK Legislation. ‘Directive 2010/75/EU of the European Parliament and of the Council’. European Union Directive, 75, Annex VI Part 3. Directive 2010/75/EU of the European Parliament and of the Council of 24 November 2010 on industrial emissions (integrated pollution prevention and control) ,2010. 
28. UK Legislation. ‘Directive 2008/98/EC of the European Parliament and of the Council, Article 5’. European Union Directive, 98, Chapter I, Article 5. Directive 2008/98/EC of the European Parliament and of the Council of 19 November 2008 on waste and repealing certain Directives ,2008. 
29. Vinceti M, Carlotta M, Teggi S, Fabbi S, Goldoni C, Girolamo G, D., Ferrari P, Astolfi G, Rivieri F, Bergomi M. Adverse pregnancy outcomes in a population exposed to the emissions of a municipal waste incinerator.” Science of the Total Environment 2008 Vol. 407 Issue 1 Pages 116-121, 2008.
30. 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.” International Journal of Health Geographics 2009 Vol. 8 Issue 1.
31. Vinceti M, Malagoli C, Werler MM, Filippini T, Girolamo GD, Ghermandi G, Fabbi S, Astoflfi G, Teggi S. ‘Adverse pregnancy outcomes in women with changing patterns of exposure to the emissions of a municipal waste incinerator’. Environmental Research. 164, 444-451, 2018. 

Annex 1: The Incineration process

The incineration process involves the combustion of raw or residual MW, with temperatures in excess of 850°C requiring enough oxygen to fully oxidise the waste (Defra, 2013). There are other waste management processes or installations where the evidence presented in this report is not necessarily applicable. For instance, pyrolysis is a thermal conversion process where waste materials are decomposed in the absence of oxygen and under elevated temperatures (varying between 150 to 700°C) to generate by-products comprising of combustible gas, oil, wax, or solid char (Shah and others, 2022).

Similarly, gasification involves thermal processing under low oxygen levels to convert biodegradable waste into gas fuel, where its components vary in the ratio of carbon monoxide (CO), hydrogen (H₂), carbon dioxide (CO₂) and methane (CH₄) (Dong and others, 2018). These thermal conversion technologies are not as common in the UK, as many have never been successfully commissioned, did not perform in line with initial expectations, or were only operated for a limited period (Defra, 2021).

Annex 2: Legislation

The emission limit values set by the WID are to control the critical loads and levels of harmful pollutants, including:

• acidic gases, such as nitrogen oxides (NOx)
• ammonia (NH₃)
• sulphur dioxide (SO₂)
• chlorinated gases (HF, HCl, HBr)
• carbon monoxide (CO)
• particulate matter (PM2.5 being particles with a diameter of 2.5 microns or less in diameter and PM10 being particles with a diameter of 10 microns)
• heavy metals, such as lead, zinc and chromium
• hydrocarbons, to include polycyclic aromatic compounds
• persistent organic pollutants, namely dioxins and furans (UK Legislation, 2010)

Since by-products from incinerated waste can present different environmental impacts, Article 5(1) of the Waste Framework Directive mandates to classify and manage by-products correctly to avoid pollutant by-products that may impact public health or negatively alter the environment (UK Legislation, 2008).  

MWI operators must also meet the requirements of Commission Implementing Decision (EU) 2019/2010 of 12 November 2019 establishing the best available techniques (BAT) conclusions for waste incineration (the 2019 Waste Incineration BAT Conclusions). The BAT Conclusions introduced even lower emissions limits for most pollutants which applied to new plants from 3 December 2019 and to existing plants from 3 December 2023.

In the UK, Part A1 installations consisting of incinerator plants that thermally treat hazardous and non-hazardous waste as fuel generally apply under Chapter IV of the Industrial Emissions Directive (IED or post-WID), though only a small number of installations apply to combust hazardous waste (Environment Agency, 2017). The requirements set under Chapter IV, specify to comply Emission Limit Values (ELVs) with stringency for a range of pollutants emitted to environmental pathways, to include emissions to air (Department for Environment Food and Rural Affairs, 2010). As such, Part A1 waste incinerators must obtain an Environmental Permit issued by the Environmental Agency under the Environmental Permitting (England and Wales) Regulations 2016 (as amended) and abide by Best Available Techniques (BAT) to minimise pollutant practices. Therefore, the regulation of MWI is mandatory under UK legislation to operate combustion activities with minimal risk to public health.