Impact Assessment and Project Appraisal

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Methods for quantitative health impact

assessment of an airport and waste incinerator:
two case studies

Caroline Phillips , Mark McCarthy & Roger Barrowcliffe

To cite this article: Caroline Phillips , Mark McCarthy & Roger Barrowcliffe (2010) Methods for
quantitative health impact assessment of an airport and waste incinerator: two case studies, Impact
Assessment and Project Appraisal, 28:1, 69-75, DOI: 10.3152/146155110X488808

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 Impact Assessment and Project Appraisal, 28(1), March 2010, pages 69–75
DOI: 10.3152/146155110X488808; http://www.ingentaconnect.com/content/beech/iapa

Methods for quantitative health impact

assessment of an airport and waste incinerator:
two case studies

Caroline Phillips, Mark McCarthy and Roger Barrowcliffe

Findings from epidemiological studies can be used to make quantitative predictions of health impacts
of new developments in a land-use planning context. In UK practice, exposures that may impact on
health are described in environmental statements, but the health outcomes are rarely assessed
explicitly. Methods for quantitative health impact assessments (HIA) are demonstrated in two case
studies: proposals to extend an airport in south-east England and to build a waste incinerator in
London. Four dimensions were assessed: particulate matter and gases, airborne carcinogens, transport
accidents and noise. Calculations demonstrate that the health of the exposed populations would be
affected by both developments, but that the added burden of disease would be very low in comparison
with that in the existing population levels. Epidemiology provides a relevant method for extending
environmental impact assessment. Quantitative assessment will allow decision-making authorities to
make more informed decisions on proposed developments in the context of land-use planning.

Keywords: health, disease, epidemiology, airport, incinerator, quantitative, assessment, risk

E NVIRONMENTAL IMPACT ASSESS-

MENT (EIA) is required by law in European
Union countries (European Community,
2003) for developments that have potential envi-
ronmental effects. In the UK, the Environmental
Statement, created as a result of the EIA process,
sets out in detail the proposed development and ex-
pected environmental effects. The Environmental
Statement is a public document and a copy is held
by the public authority (city, province, region or
Mark McCarthy and Caroline Phillips are at UCL Department of
Epidemiology & Public Health, University College London,
Gower Street, London WC1E 6BT, UK; Email: m.mccarthy@
ucl.ac.uk. Roger Barrowcliffe and Caroline Phillips are at Envi-
ronmental Resources Management, 2nd Floor, Exchequer Court,
33 St Mary Axe, London EC3A 8AA, UK.
CP was supported financially through the Knowledge Trans-
fer Partnership programme of the UK Department of Trade and
Industry. MM was employed by UCL. RB was employed by
ERM.
nation). EIA has traditionally focused on the physi-
cal and ecological effects on the environment and
has developed a strong quantitative approach to as-
sess such impacts. Until recently there has been less
interest in the health impacts of environmental
change as the result of a project or policy.
Health impact assessment (HIA) is a more recent
development (Kemm et al, 2004; Mindell et al,
2008). Unlike EIA, most countries have no statutory
requirement for a HIA to be undertaken. HIA is a
process that can confirm or offer alterations or alter-
natives to plans and policies from a health perspec-
tive. A definition of HIA proposed by WHO (World
Health Organization, 1999) the ‘Gothenburg Con-
sensus’, stated that ‘HIA is the combination of pro-
cedures, methods and tools by which a policy,
program or project may be judged as to its potential
effects on the health of the population, and the dis-
tribution of those effects within the population’. An
overview of concepts, theory, techniques and appli-
cations in HIA (Kemm et al, 2004) includes a brief
presentation on integrated quantitative methods

Impact Assessment and Project Appraisal March 2010 1461-5517/10/010069-07 US$12.00 © IAIA 2010 69
Quantitative health impact assessment of an airport and waste incinerator
Both quantitative and qualitative
methods therefore have a role to play
when identifying health outcomes
associated with exposures, not least
because not all such outcomes can be
quantified
(McCarthy and Utley, 2004), and quantitative ap-
proaches are now being developed in European stud-
ies including HEIMTSA (2009) and INTARESE
(2009). Both quantitative and qualitative methods
therefore have a role to play when identifying health
outcomes associated with exposures, not least be-
cause not all such outcomes can be quantified.
Environmental factors may affect acute health
states such as communicable diseases and accidents,
chronic diseases such as cancer and heart disease,
and subjective perceptions including mental health
and wellbeing. Health impact assessments have been
considered in commercial developments including
transport, regeneration and waste, and in the extrac-
tive industries such as the mining, oil and gas sectors
(Quigley and Taylor, 2003). An HIA aims to deliver
Baseline data collection
Community
profile
Stakeholder
engagement
Reporting
Conclusions and recommendations,
including monitoring and evaluation
Figure 1. Diagram of health impact assessment process
70
evidence-based recommendations, to reduce nega-
tive health effects and to maximise health benefits,
in order to assist in the decision making process. A
summary of an HIA process is shown in Figure 1.
This process will vary depending on the scale and
aims of the HIA, but in general the various compo-
nents will be undertaken in all HIAs.
There is increasing demand for quantitative esti-
mates of health effects to complement the findings
of qualitative analysis and stakeholder engagement,
and to match the quantitative estimates of environ-
mental impact assessment. Estimates of health ef-
fects and knowledge of baseline levels of disease
may also play a useful role in any future monitoring
and evaluation of the health effects of the develop-
ment, if it is constructed. In this paper, we present
two case studies of HIA where quantitative estimates
of effect have been calculated, and provide the
methodologies used to perform the calculations.
Methods
Quantified dose–response data relating environ-
mental change with health outcomes exist for the ef-
fects of airborne particles, airborne carcinogens,
road traffic accidents and noise. Changes in these
exposures are calculated routinely in the EIA pro-
cess: the exposure calculations can be used as the
basis of quantification in HIA.
Scoping
report
Review of Project profile
available evidence
Identification,
consideration and
appraisal of impacts
HIA
final
report
Impact Assessment and Project Appraisal March 2010
 Quantitative health impact assessment of an airport and waste incinerator

Particulates and gases synthesis of available evidence. Years of life lost as

Sufficient evidence exists of a causal link between
particulate matter and long-term health effects
(Committee on the Medical Effects of Air Pollut-
ants, 2009). Associations between NO2 and poor
health have also been observed (Katsouyanni et al,
2001), although there is insufficient evidence to de-
termine causality and NO2 may in fact be a marker
for other pollutants. The European Commission
study Clean Air For Europe (2005) and the UK
Committee on the Medical Effects of Air Pollutants
(2006) proposed concentration response functions,
based on numerous studies, including evidence from
hospital admissions (Atkinson et al, 2001) and com-
parative national studies (Kunzli et al, 2000).
To predict the health effect (ΔE) of air pollutants
three pieces of information are required: baseline
rates of disease, ideally at a local level (E), dispersion
modelling data, showing concentration changes (ΔC)
and population (P) distribution data, showing the
number of people exposed to a particular concentra-
tion (C). The dose–response coefficient (β), derived
from the studies referenced above is applied to quan-
tify acute health effects. This is encapsulated by the
following linear equation ΔE = β × ΔC × P × E.
Dispersion modelling data is a normal output of
EIA. The health outcomes that can be calculated
from various exposures, to particles and gases, and
the risks applied which relate to dose–response coef-
ficients (β) described above are shown in Table 1.
Following numerous studies around the world, nu-
merical values for dose–response coefficients are
now well established. The values used in this paper
are taken from comprehensive reviews of the litera-
ture by such bodies as COMEAP and represent a
a result of PM2.5 is based on a simplification of the
life tables approach and uses the following calcula-
tion: annual death rate × population size × %increase
in death rate per μg/m3 PM2.5 × change in PM2.5.
Airborne carcinogens
These are chemicals that are released during incin-
eration and similar activities. These airborne car-
cinogens are persistent in the environment and can
interact with humans, causing chronic and cumula-
tive effects. Airborne carcinogens are analysed sepa-
rately from other air pollutants, as a consequence of
the different ways in which they interact with the
body. The most frequently considered carcinogens
are dioxins and some metals, which are released in
small amounts when substances are burnt. EIA,
when necessary, calculates the level of exposure
for a hypothetically maximally exposed individual
(HMEI). The HMEI represents a worst case scenario
in which a person spends their entire lifetime at the
epicentre of the emissions. The all-cancer risk for
the HMEI is calculated within the Environmental
Statement, drawing on the different carcinogens es-
timated to be in the emissions and the sum of their
individual risks (US Environmental Protection
Agency, 2009). As a general rule, the carcinogens
released in this process follow a similar dispersion
pattern to other air pollutants.
To calculate the effect of changes in exposure to
airborne carcinogens the following information is
required: age-specific cancer incidence and death
rates, ideally at a local level, HMEI exposure level,
and air pollutant dispersion modelling data, showing
concentration changes and population data.

Table 1. Health outcomes and associated risk

Exposure Health outcome Risk (%) Source

1
PM10 Chronic bronchitis 0.7 CAFE
Hospital admissions: cardiovascular 0.06 CAFE
Hospital admissions: respiratory 0.114 CAFE
GP consultations asthma (April–Sept, 15–64 years age) 0.25 CAFE
Lower respiratory symptoms*: children 0.0004 CAFE
Lower respiratory symptoms*: adults 0.0017 CAFE
2
Mortality 0.043 Kunzli
PM2.5 Restricted activity days 0.0475 CAFE
Years of life lost 0.6 CAFE
3
NO2 Non-traumatic deaths 0.034 APHEA
4
Hospital admissions: cardiovascular 0.13 COMEAP
Hospital admissions: respiratory 0.03 COMEAP
-7 5
Transport accidents Additional deaths 1.29117x10 /trip TSGB
-6
Additional KSI 1.7754 x10 /trip TSGB
6
Noise Annoyance - RIVM
7
Reading ability - RANCH

Notes: *Lower respiratory symptoms include wheeze, shortness of breath, phlegm production.
1. Clean Air For Europe (2005)
2. Kunzli et al (2000)
3. Atkinson et al (2001)
4. Committee on the Medical Effects of Air Pollutants (2006)
5. UK Department for Transport (2006)
6. van Kempen et al (2005)
7. Stansfeld et al (2005)

Impact Assessment and Project Appraisal March 2010 71

Quantitative health impact assessment of an airport and waste incinerator
Transport accidents
The major health effect associated with transporta-
tion is human injury as a result of the impact of a
vehicle’s momentum. The mode of transport sub-
stantially affects the risk of collision injuries: for ex-
ample the number of injuries associated with railway
travel is substantially lower than for cars (Depart-
ment for Transport, 2006).
It is possible to calculate the injury rate per trip
based on national statistics by dividing the number
of trips per annum by the number of people killed or
seriously injured (KSI), recorded by police statistics.
Additional trips associated with the development can
be estimated to create an increase in accidents pro
rata. A more complex calculation, based on accident
rate per kilometre by road type can also be calcu-
lated. This combines traffic flow for individual roads
(according to road type); known accident rates for
each road type can then be applied to the distance
travelled on each road link. The first methodology
can be applied to all modes of transport whereas the
second version is limited to road transport.
Noise
New developments may be associated with an in-
crease in noise either during the operation or in the
construction phases of the development. The impacts
of noise on the health of the population include an-
noyance, sleep disturbance and impacts on educa-
tional development (for aircraft noise) (van Kempen
et al, 2005; Expert Group on the Effects of Envi-
ronmental Noise on Health, 2009). Dose–response
curves exist for all noise as well as for source-
specific noise exposures (e.g. traffic, rail). Confi-
dence intervals associated with the dose–response
curves allow for sensitivity analysis to be performed.
Annoyance can be predicted based on dose–
response curves, which show the percentage of peo-
ple that are annoyed at a given noise level in deci-
bels (dB). The number of people annoyed in the
development scenario can be compared with the
number of people annoyed at baseline. Limitations
apply to this methodology as annoyance from noise
is subjective and habituation may occur to pre-
existing sources of noise. Community noise annoy-
ance curves for airports in the UK are based on the
results of an air noise survey undertaken in the
1980s (Civil Aviation Authority, 1985).
As well as annoyance, exposure to aircraft noise
during school hours is associated with delay, by up
to 2 months, in the reading ability of children aged
9–10 for every 5 dB increase in exposure. (Stansfeld
et al, 2005). If the development is related to frequency
of aircraft movements, then it is possible to predict the
change in reading delay which will occur by compar-
ing the reading delay time pre- and post-development,
in much the same way as for annoyance.
WHO guidelines conclude that sleep disturbance
can be an important effect of environmental noise.
72
Exposure may cause primary effects during sleep
and secondary effects after the exposure, including
tiredness and lack of concentration the next day.
Drawing on a review of evidence (Michaud et al,
2007), the likelihood of the average person being
awakened by an aircraft noise event in the range of
90–100 dBA SEL (Sound Exposure Level, 80–95
dBA Lmax) is about 1 in 75. Outdoor noise events be-
low 90 dBA SEL are unlikely to cause an increase in
the normal rate of sleep disturbance.
Case studies
Expansion of Stansted Airport – second runway
Stansted Airport is one of four international airports
serving London and south-east England. It has been
identified by the Government for expansion to meet
predicted increases in air travel (Department for
Transport, 2003).
A second runway has been proposed which will
result in an increase in the number of aircraft move-
ments and an additional 3.5 million road trips per
annum. The additional runway would increase ca-
pacity up to 68 million passengers per annum
(mppa) by 2030 from 25 mppa currently. The air-
field is set to the east of Bishop’s Stortford, and the
surrounding area also has a number of villages. The
most significant quantifiable changes would result
from increased air pollution, noise and road traffic
accidents.
An HIA was undertaken using the methodology
summarised in Figure 1. As part of the appraisal
component of the HIA quantification of the health
effects of noise (annoyance, sleep disturbance and
reading delay), air quality and road traffic accidents
were calculated using the methodologies outlined
above. For each type of exposure the number of
people affected varied due to nature of the exposures
(e.g. noise was related to the flight path and traffic
was influenced by the road network pattern). Quanti-
fication of the health effects associated with em-
ployment and unemployment were also considered
(not shown in this analysis).
Energy from waste incinerator
The construction of a new energy from waste power
station burning on average 585,000 tonnes of waste
per annum over a 30-year period generating electric-
ity was proposed in London, sited by the Thames to
facilitate delivery of waste using the river. It was an-
ticipated that 85% of the waste would be delivered
by barge, with the remaining waste being delivered
by road. Residue from the process would also be
removed by barge and road. This would result in an
additional 55,328 road trips per annum.
The health determinants considered were airborne
particles, airborne carcinogens and road traffic acci-
dents (based on the simple per trip methodology).
Impact Assessment and Project Appraisal March 2010
 Quantitative health impact assessment of an airport and waste incinerator

The health effects on the population within a 20
kilometre radius were calculated for air pollution,
based on the dispersion mapping available: a large
population exposed to even low level exposures may
result in adverse health effects. As this is an urban
area the exposed population was therefore over 5
million people.
Quantification
The change in effect for each health outcome was
estimated with the linear equation, using each dose-
response coefficient, expected baseline prevalence
rates (from national data sets), and populations ex-
posed to different concentration levels summed
(drawn from the Environmental Statement). Table 2
shows the health effect baseline rates, populations at
risk and calculated changes in effect for each case
study.
For the energy from waste incinerator, quantifica-
tion has shown that the health effects associated with
air quality will be marginal. The effect on morbidity
is slight and for mortality, determined by exposure
to PM2.5, the loss of life expectancy is very small –
in comparison with the loss currently experienced
through exposure to air pollution and other lifestyle
factors that influence life expectancy, when the size
of the exposed population is considered. Cancer in-
cidence and death rates are also small in relation to
the rate in the population, as are the number of road
traffic accidents reflecting the small number of trips
associated with the development.
For the quantification of the development of a
second runway at Stansted Airport, air quality
changes will result in very small health effects that
will have no discernible consequences for the health
of the communities around Stansted Airport over
and above existing levels or those proposed under
stage one of the development. Road traffic accidents
are among some of the most acute health effects
seen, including an additional death per annum, but
set against the background context the increase is
relatively small and most likely to be on major
roads, not in the surrounding communities. Air noise
will result in an increase in the number of people
annoyed over time as a result of the greater fre-
quency of overhead flights. Night-time awakenings
will be at their greatest in 2015 but will reduce to 20

Table 2. Predicted added health effects per annum

Health effect Baseline rate per Energy for waste incinerator Airport expansion
1,000 population,
England

Population at risk Change in effect Population at risk Change in effect

Chronic bronchitis GP prevalence 8 5,691,255 0.592 54,802 0.32 (0.13–0.51)

Hospital admissions: 14 5,691,255 0.088 54,802 0.048
cardiovascular (0.019–0.077)
Hospital admissions: respiratory 7.8 5,691,255 0.094 54,802 0.051 (0.02- 0.082)
GP consultations asthma 64.3 5,691,255 1.085 54,802 0.59
(April–Sept, 15–64 years age) (0.23–0.94)
Lower respiratory symptoms: 325 5,691,255 0.013 54,802 0.0074
children (0.002–0.012)
Lower respiratory symptoms: 204.4 5,691,255 0.036 54,802 0.02
adults (0.0078–0.032)
Deaths brought forward 7.69 5,691,255 0.0349 - NC
Restricted activity days 31,000 5,691,255 91.91 54,802 57
(17–98)
† †
Years of life lost 8 months average 5,691,255 332.5 54,888 18.87
due to PM2.5 (6.29–34.60)
Non-traumatic deaths brought 7.69 - NC 55,421 0.12
forward NO2 (0.06–0.19)
Cardiovascular hospital 14 - NC 55,421 0.82
admissions NO2 (0.39–1.25)
Respiratory hospital admissions 7.8 - NC 55,421 0.13 (0.06–0.19)
NO2
Cancer incidence 333 5,691,255 0.11 - NC
Cancer deaths 250 5,691,255 0.06 - NC
Additional trips RTA All 280,840* - 0.599 15.2 million trips NC
Additional trips RTA KSI 34,351* - 0.0781 15.2 million trips 12
Distance RTA KSI 34,351* - NC 7 (1 fatal)
Highly annoyed due to noise 2% per dB over 45 - NC 14,951 710
dB
Reading ability delay (months) - - NC 90 1–2
30 <2 months
Awakenings (SEL90dB) - NC 1,100 17

Notes: * Total number of accidents from UK Department for Transport statistics

NC – Not calculated for this HIA
KSI – Killed or seriously injured
RTA – Road traffic accidents
† This is the total number of years of life lost in the exposed population (not per annum)

Impact Assessment and Project Appraisal March 2010 73

Quantitative health impact assessment of an airport and waste incinerator
awakenings by 2030 as a result of the introduction of
quieter aircraft. Reading delay varies as a result of
spatial changes in the noise contour ‘footprint’, but
overall any negative effect remains small, as do the
positive effects for schools who experience a de-
crease in noise. The additional employment oppor-
tunities associated with the second runway should
have a beneficial effect in terms of a reduction in
premature mortality for a small number of people,
and an improvement in mental health and long-term
limiting illness for a minority of the additional peo-
ple employed, assuming that such people were pre-
viously unemployed.
The magnitude of the health effects presented
here are influenced by three factors: how common
the outcome is in the population already, the size of
the change in exposure and the number of people
that are affected by the exposure. The number of
people exposed is controlled by the decisions in
modelling in the EIA. An artefact of the process is
that the larger the area covered the greater the health
effects seen will be. A limitation in the use of the
quantitative HIA is that the input data depend on the
initial environmental impact assessment. If these
data are incorrect or limited in scope, then these
limitations and errors will also limit the HIA calcu-
lations.
The incidences of some of the effects are esti-
mated on the basis of national or district rates as op-
posed to rates in the exposed population. The results
are therefore indicative only, to provide a sense of
scale of the outcomes, rather than a definitive quan-
titative estimate. Other uncertainties associated with
estimating the health effect relate to the transferabil-
ity of the studies on which the coefficients are based
and the fact that the coefficients are derived from
large diverse populations. If the population that is
likely to be impacted by the development is special
in any way then consideration should be given to
this before applying the calculations.
Discussion
The case studies show two contrasting health impact
assessments. Exposure data can be drawn from envi-
ronmental statements, but need to be related to de-
fined human populations, with appropriate time-
scales of exposure. Dose-response data are available
for some, but not all, environmental factors, and it is
not possible at present to sum the many effects into a
single health index, as was considered in the simpler
ARMADA model (McCarthy et al, 2002). The im-
pacts are also only predictions: the actual effects
would be randomly distributed in the population and
at levels too low for epidemiological detection.
What levels of health effect are acceptable in im-
pact assessment? For cancer, environmental risks of
one in a million over a lifetime have traditionally
been proposed as ‘acceptable’, while a risk of one in
ten thousand is moving towards ‘unacceptable’.
Risks under personal control or volition are more
74
Quantitative estimates of the
additional health burden from a
development complements the
qualitative aspects of an HIA,
including public perceptions, and
contributes to the level of knowledge
available to the decision-makers in the
planning process, linking HIA with
other impact assessments
acceptable to an individual than risks without
choice, and people are less likely to pay personally
for risks to be removed than to expect the commu-
nity to pay to reduce risk (Bennett and Calman,
1999). However, public and individual perceptions
are mediated by social influences (Pidgeon et al,
2003), and these may change through discussion and
debate.
Quantitative estimates of the additional health
burden from a development complements the quali-
tative aspects of an HIA, including public percep-
tions, and contributes to the level of knowledge
available to the decision-makers in the planning
process, linking HIA with other impact assessments
(British Medical Association, 1998). Health impacts
occur in the population around the development,
rather than the users of a development, and it is
therefore their interests that are of concern in the
planning process. Communities and other stake-
holders may be wary that a scientific approach might
be used to justify and push through unpopular pro-
posals, especially where debate exists within the sci-
entific community over the most appropriate
methods and inferences.
However, quantitative health impact findings can
be put in context of other risks in daily life, for ex-
ample personal behaviours such as smoking, driving
or sports, that are also public health risks (Bennett,
1997).
Future work
At present, health impact assessments in the com-
mercial sector are undertaken individually for a spe-
cific development or policy, without a broader
context. But if health impact assessment compari-
sons can estimate the health effects of different sites
for an incinerator, airport or any other development,
then there is an opportunity for them to play a
greater role in the decision-making process. As quan-
tified health impact assessment develops (O’Connell
and Hurley, 2009), modelling (McCarthy et al, 2002)
and health scenarios can be developed, allowing
Impact Assessment and Project Appraisal March 2010
 Quantitative health impact assessment of an airport and waste incinerator
health considerations to be matched against cost by
developers at an early stage. On the other hand, by
no means all potential health effects are yet quantifi-
able, and balancing and consideration of both quan-
titative and qualitative evidence will still need to be
undertaken.
Quantification is a logical development for health
impact assessment in presenting scientifically based
relationships between environment and health. The
information available for quantitative health impact
assessment depends partly on comparability; for ex-
ample, some chemicals may be teratogenic rather
than carcinogenic, creating disability which is less
readily measured than mortality). Quantified meas-
ures will improve as a result of further epidemiol-
ogical studies and meta-analysis, for example the
UK Committee on the Medical Effects of Air Pollut-
ants (2009) revised their estimates of mortality from
long-term exposure, and with the work of inter-
national studies such as HEIMTSA (2009) and
INTARESE (2009). Better epidemiological informa-
tion is needed to use as population attributable risks
for other dimensions of concern to health impact as-
sessment: for example acute toxic incidents, com-
munity severance, employment, income, need for
welfare services and social equity and capital. The
challenge for quantitative health impact assessment
is both to improve existing quantitative estimates
and to develop epidemiological measures in new
fields.
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