Science of the Total Environment 530–531 (2015) 120–128

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Science of the Total Environment

journal homepage: www.elsevier.com/locate/scitotenv

Review

Assessing burden of disease as disability adjusted life years in life

cycle assessment
Yumi Kobayashi a, Greg M. Peters a,b, Nicholas J. Ashbolt a,c, Sean Shiels d, Stuart J. Khan a,⁎
a
School of Civil & Environmental Engineering, University of New South Wales, Sydney, NSW 2052, Australia
b
Department of Chemistry and Chemical Engineering, Chalmers University of Technology, SE-412 96 Gothenburg, Sweden
c
School of Public Health, University of Alberta, Edmonton T6G 2G7, Alberta, Canada
d
Knowledge, Technology & Innovation, Environment Protection Authority Victoria, 200 Victoria Street, Carlton, VIC 3053, Australia

H I G H L I G H T S

• Assumptions used in DALY derivation in LCA may be relevant only to specific regions.
• QRA can potentially compensate disregarded human BoD impacts in LCA.
• Environmental impact assessment would be more holistic by combining LCA and QRA.
• Use of DALYs appears beneficial for combined use of LCA and QRA.

a r t i c l e i n f o a b s t r a c t

Article history: Disability adjusted life years (DALYs) have been used to quantify endpoint indicators of the human burden of
Received 22 October 2014 disease in life cycle assessment (LCA). The purpose of this paper was to examine the current use of DALYs in
Received in revised form 28 April 2015 LCA, and also to consider whether DALYs as used in LCA have the potential to be compatible with DALYs as
Accepted 4 May 2015
used in quantitative risk assessment (QRA) to facilitate direct comparison of the results of the two approaches.
Available online 29 May 2015
A literature review of current usage of DALYs in LCA was undertaken. Two prominent methods were identified:
Editor: Simon Pollard ReCiPe 2008 and LIME2. The methods and assumptions used in their calculations were then critically reviewed.
The assumptions used for the derivation of characterization factors in DALYs were found to be considerably
Keywords: different between LCA methods. In many cases, transparency of these calculations and assumptions is lacking.
Climate change Furthermore, global average DALY values are often used in these calculations, but may not be applicable for
Human toxicity impact categories where the local factors play a significant role.
Ozone depletion The concept of DALYs seems beneficial since it enables direct comparison and aggregation of different health im-
Respiratory effects pacts. However, given the different assumptions used in each LCA method, it is important that LCA practitioners
Human health impacts
are aware of the differences and select the appropriate method for the focus of their study. When applying DALYs
ReCiPe 2008
as a common metric between LCA and QRA, understanding the background information on how DALYs were de-
LIME2
rived is crucial to ensure the consistency of DALYs used in LCA and QRA for resulting DALYs to be comparable and
to minimize any double counting of effects.
© 2015 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.1. Climate change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.2. Ozone depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Abbreviations: BoD, burden of disease; CF, characterization factor; DALE, disability adjusted life expectancy; DALY, disability adjusted life year; GBD, the global burden of disease; HeaLY,
healthy life year; IARC, International Agency for Research on Cancer; LCA, life cycle assessment; LCIA, life cycle impact assessment; QALY, quality adjusted life years; QRA, quantitative risk
assessment; ReCiPe, ReCiPe 2008; SHS, sick house syndrome; TD50, tumorigenic dose rate of 50; YLD, years lost due to disability; YLL, years of life lost.
⁎ Corresponding author at: School of Civil & Environmental Engineering, University of New South Wales, 2052 NSW, Australia.
E-mail address: s.khan@unsw.edu.au (S.J. Khan).

http://dx.doi.org/10.1016/j.scitotenv.2015.05.017
0048-9697/© 2015 Elsevier B.V. All rights reserved.
 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128 121

3.3. Human toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

3.4. Respiratory effects (particulate matter and ozone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
3.5. Ionizing radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
3.6. Indoor air pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
3.7. Noise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
3.8. Cultural perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
4.1. Differences between LCA methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
4.2. Missing human BoD impact categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
4.3. Interrelationship between impact categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
4.4. Local specific considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
4.5. Value choices — use of assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

1. Introduction
Life cycle assessment (LCA) is an environmental management tool
commonly applied to support environmental decision making. It evalu-
ates potential environmental impacts, including damage to human
health, throughout the life cycle of a product, process or service, being
framed around a ‘functional unit’ (Curran, 2006). A strength of LCA is
that many types of environmental impacts can be assessed (Olsen
et al., 2001). Because of this broad perspective, it helps to detect burden
shifting across space, time as well as across impact categories. As de-
fined by ISO14040 (ISO, 2006) formal LCA is composed of four phases,
usually termed goal and scope definition, inventory analysis, impact as-
sessment, and interpretation. Various methods have been developed to
convert the outcomes of the inventory analysis to impact category indi-
cators in the life cycle impact assessment (LCIA) phase.
LCIA can be applied at what is known as “midpoint” and/or “end-
point” levels. At the midpoint level, emissions are typically expressed in
a mass equivalent of a reference substance in each impact category. At
the endpoint level, the impacts are expressed at the level of areas of pro-
tection such as human health. The number of categories to be consid-
ered is significantly reduced at the endpoint level, which can be
advantageous for the interpretation phase. The disadvantage of end-
point assessments, however, is that additional sources of uncertainty
and variability are compounded in the translation of midpoint measures
to endpoint outcomes (EC-JRC, 2011).
Human health as an endpoint impact category is important for LCA
since a number of midpoint indicators including toxicity and contribu-
tions to climate change and ozone depletion potentially cause impacts
to human health. Within the risk assessment literature, there are a num-
ber of mortality/morbidity metrics used internationally that address
human burden of diseases (BoD). These include years of life lost (YLL),
quality adjusted life years (QALYs), disability adjusted life expectancy
(DALE), healthy life years (HeaLY) and disability adjusted life years
(DALYs) (Bleichrodt and Pinto, 2012; Hofstetter and Hammitt, 2001;
Prüss-Üstün et al., 2003). Of the two metrics used most widely, QALYs
measure an integration of health quality over time, while DALYs
measure years with morbidity and those lost due to premature death
(Hofstetter and Hammitt, 2002; Weidema, 2006).
Among these BoD metrics, DALYs are particularly encompassing
since, in addition to the number of deaths, they account for years of
life lost due to premature death, severity and duration of morbidity,
and the number of individuals affected (Murray and Acharya, 1997).
Social preferences, for example different values of life years at different
stages of life, can also be incorporated when preferred (Murray and
Acharya, 1997). As such, DALYs have become one of the most common
metrics for BoD in a wide variety of applications (Knol and Staatsen,
2005) and have now been adopted to a limited extent as an endpoint in-
dicator for LCA methods (Goedkoop et al., 2013; Goedkoop and
Spriensma, 2001a; Itsubo and Inaba, 2010). QALYs have advantages
similar to those of DALYs and have also been considered as an LCA end-
point indicator (Weidema, 2006), but appear not to have been adopted
in existing LCA methods.
The concept of DALYs was developed to measure the BoD and injury
of humans (WHO, 2001). A DALY measures the gap between a particular
health status and an ideal health status and it is expressed as the sum of
years of life lost (YLL) and years lost due to disability (YLD) (WHO,
2015). Disabilities are weighted according to severity which ranges
from zero for complete health to up to a maximum of one for a
completely debilitating disability, and various degrees of illnesses
are rated in between (Fèvre et al., 2008; Mathers et al., 2001). YLL
is a function of the number of deaths and the standard life expectan-
cy at the age of premature death in years. YLD is determined by the
number of cases, duration of the disability and the disability weighting.
In cases where the value of lost life years is considered to be differ-
ent depending on a person's age, or years of present healthy life are
considered to be worth more than equivalent years in the future, the
concepts of age-weighting and future discounting, respectively, can
be applied (Mathers et al., 2001). Age-weighting is typically ex-
pressed by a continuous function ranging from zero at birth, peaking
at around 1.5 in early middle age and falling below 0.8 at retirement
age (Prüss-Üstün et al., 2003). With future discounting, the value of
life year in the future is reduced at a fixed annual percentage (Prüss-
Üstün et al., 2003).
DALYs have increasingly been applied in LCA methods to quantify
BoD impacts. However, the assumptions used to arrive at the DALY
value derivations differ between LCA methods. DALYs have more com-
monly been used in quantitative risk assessment (QRA) (enHealth,
2012; Prüss-Üstün et al., 2003; WHO, 2011). QRA is another tool often
used for environmental decision making. Both LCA and QRA have been
developed to evaluate environmental impacts, and their similarities
and commonalities have been discussed (De Haes et al., 2006;
McKone et al., 2006; Owens, 1997; Sleeswijk et al., 2003), however,
their approaches are distinct. A principal difference is that LCA has a
broader view and is superior in assessing impacts at larger, national
or global scales while QRA has a relatively narrow view but is capa-
ble of taking specific local conditions into account. Due to their dif-
ferences in strengths and weaknesses, it has been recognized that
the combined use of LCA and QRA would be beneficial to achieve a
more holistic environmental impact evaluation (Barberio et al., 2014;
De Haes et al., 2006; Kobayashi et al., 2015; Potting et al., 1999;
Sonnemann et al., 2004; Wegener Sleeswijk, 2003).
Here we examine the current use of DALYs in LCA, and also consider
whether DALYs as used in LCA have the potential to be compatible with
DALYs that specifically addressed the local impacts as in QRA, to facili-
tate direct comparison of the results. The remainder of this paper re-
views the existing literature on the use of DALYs within LCA methods
122 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128
and examines the possibility and advantages of the use of DALYs as a
common metric between LCA and QRA.
2. Method
Online database searches using Scopus and Web of Science were
conducted. Firstly, keywords with Boolean operators [(LCA OR “life
cycle assessment”) AND (DALY* OR “disability adjusted life year*”)]
were used to identify LCA methods that included DALYs. Several end-
point oriented LCIA methods which incorporate the use of DALYs for
BoD were identified. ReCiPe 2008 (ReCiPe) is one of such methods. It
was developed by the Dutch National Institute for Public Health and En-
vironmental Hygiene, Radboud University Nijmegen, CML and PRé Con-
sultants to harmonize the widely accepted midpoint method (the CML
method) and endpoint method (Eco-indicator 99) (Goedkoop et al.,
2013). LIME2 is another method that uses DALYs as an endpoint indica-
tor. It was developed by the Japanese National Institute of Advanced In-
dustrial Science and Technology to reflect the Japanese environmental
background (Itsubo and Inaba, 2010).
Value choices made to derive endpoint characterization factors (CFs)
(expressed in DALYs per unit amount of substance emissions for BoD)
significantly affect the final results of LCA studies. Cultural theory has
been used to handle value choices in some LCA methods. Publications
discussing the concepts of cultural theory in LCA were then more selec-
tively identified by the inclusion of additional keywords and Boolean
operators [(LCA OR “life cycle assessment”) AND (“cultural theor*” OR
“cultural perspective*”)] to examine the current use of cultural theory
in LCA methods.
Subsequently, manuals and reports of LCA methods, online datasets,
and other supportive information for the identified LCA methods apply-
ing DALYs were further searched by using the online search engine.
Existing peer reviewed literature, published books as well as federal
and international organization technical reports and databases which
were referenced in the manuals and reports of methods were also
reviewed to comprehend the more detailed methods and their back-
ground data.
3. Results
The current uses of DALYs as an endpoint indicator in each impact
category of ReCiPe and LIME2 are analyzed in the following sections.
3.1. Climate change
Various BoD effects are expected to occur due to climate change.
However, only a limited subset of these effects has been included in
LCA because of a paucity of data (De Schryver et al., 2009; Itsubo and
Table 1
BoD effects included in ReCiPe and LIME2 caused by climate change.
Health effects ReCiPea
Diarrhea ✓ where the type of cancer developing is unknown. It is unclear how
Malaria ✓ ✓
Dengue fever
Malnutrition ✓ ✓
Heat stress
Heat stress overall
Cardiovascular disorders ✓
Disaster damage
Flooding ✓ ✓
Landslide
Tidal waves
Typhoons
✓: included.
a
Goedkoop et al. (2013).
b
Itsubo and Inaba (2010).
Inaba, 2010). Different types of BoD were analyzed in ReCiPe and
LIME2 as summarized in Table 1. The BoD effects considered in LIME2
were selected according to the likelihood of occurrence, degree of the
damage and the data availability (Itsubo and Inaba, 2012). While ReCiPe
adapted the BoD effects considered in a WHO report (McMichael et al.,
2003).
ReCiPe generally adapted the DALYs provided in the global burden of
disease (GBD) (Murray and Lopez, 1996a). Since effects caused by nat-
ural disasters are not related to specific diseases, DALYs were estimated
based on the annual incidence of death provided by the Centre for Re-
search on the Epidemiology of Disasters database, EM-DAT (CRED,
2014). The number of deaths in a region was multiplied by half the av-
erage life expectancy of the region assuming that these deaths were
spread evenly over all ages of the population (Goedkoop et al., 2009).
In this impact category, ReCiPe used total number of DALYs instead of
DALYs per incidence as used in LIME2.
The derivations of DALYs per case in LIME2 were largely based on
the DALYs reported by WHO (WHO, 2000), which are more recent
than those used in the ReCiPe method. As future discounting was ap-
plied to the DALYs in the WHO report, Itsubo and Inaba (2012) convert-
ed them to non-discounted DALYs by referencing DALYs in the GBD. For
damage due to heat stress, DALYs per death of 2.0 was selected since
two or more DALYs per death could be inferred from a study by
Honda et al. (1998) while Goedkoop and Spriensma (2001b) adopted
a value of 0.75 (Itsubo and Inaba, 2012).
3.2. Ozone depletion
The anthropogenic emission of ozone depleting substances has been
identified as a major cause of global stratospheric ozone depletion
(WMO, 2010). The ozone depleting substances considered in ReCiPe
and LIME2 are identical (Goedkoop et al., 2013; Itsubo and Inaba, 2010).
Cataracts and three types of skin cancers (basal cell carcinoma, squa-
mous cell carcinoma and melanoma) were considered as BoD due to
ozone depletion in ReCiPe and LIME2. Itsubo and Inaba (2012) report
that the DALY values in LIME2 were calculated with reference to the sec-
ond edition of the Eco-indicator 99 Methodology Report which was
based on the GBD study (Goedkoop and Spriensma, 2000). ReCiPe
used the DALY values calculated by the Assessment Model for Ultravio-
let Radiation and Risks (Van Dijk et al., 2008).
3.3. Human toxicity
ReCiPe and LIME2 included carcinogenic and non-carcinogenic sub-
stances in their analysis. In ReCiPe, the world average DALYs and num-
ber of cases for 1990 provided by the GBD and Murray and Lopez
(1996b) were used for each type of illness. LIME2 used Japanese local
data when available and the data for similar conditions as Japan from
the GBD Murray and Lopez (1996b) and other sources.
When substances cause multiple types of cancers, a value corre-
sponding to the cancer-type with the highest DALYs was used in ReCiPe
LIME2b while DALYs for overall cancer incidence were used for substances
DALYs were selected for each carcinogenic substance in LIME2. For
✓
non-cancer disease, although Itsubo and Inaba (2010) mentioned that
heavy metal and non-heavy metal substances were distinguished for
DALY value derivations, few details were documented. Within ReCiPe,
✓
an average DALY value was used for all substances for non-cancer
diseases.
3.4. Respiratory effects (particulate matter and ozone)
✓
✓
✓ The DALY values used in LIME2 were taken from Hofstetter (1998).
Hofstetter used the data based on the GBD for disability weights
where available. For others, the disability weight and the duration of ill-
nesses were estimated by using various assumptions (Hofstetter, 1998).
 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128 123

Table 2 3.7. Noise

YLL in LIME2 and ReCiPe.

Pollutant Disease LIME2a ReCiPeb Noise was also uniquely included in LIME2. Itsubo and Inaba (2010)
YLL YLL
modified the method developed by Müller-Wenk (2004) to reflect local
Japanese factors. The noise energy levels of cars and trucks and their
(years) (years)
impacts to BoD during the day and night were separately considered.
PM10 Chronic mortality 6.6 10 The endpoint effects considered were sleep disturbance at night and
Acute mortality 0.75 0.25
communication disturbance during the day. As mortality is unlikely to
Ozone Acute mortality 0.75 0.25
occur, only YLD was taken into account for DALY derivations. Müller-
a
Hofstetter (1998). Wenk (2002) derived disability weights for sleep and communication
b
van Zelm et al. (2008).
disturbances through surveys with medical experts in Switzerland.
Itsubo and Inaba (2010) applied the F-distribution at 5% to those values
The calculations of YLL by Hofstetter (1998) were based on the mortality to exclude outliers.
statistics of respiratory diseases reported by WHO (1995). For chronic
mortality, Hofstetter appeared to decide that the resulting YLLs were 3.8. Cultural perspective
too large and used 50% of the calculated value.
In ReCiPe, YLL, durations and severities of diseases were taken from Three of the cultural perspectives, egalitarian, hierarchist, and
works by Künzli et al. (2001) and Knol and Staatsen (2005). Knol and individualist, are often applied in LCA. There are two other perspectives,
Staatsen adopted severity values primarily from RIVM (2004). Assump- fatalism and autonomy, however, they are thought not to apply to LCA
tions used in their derivations were not always clear. The selected YLL for decision-making, and hence are generally disregarded (Hofstetter,
values are shown in Table 2. Due to the inconsistent evidence for a rela- 1998). According to De Schryver et al. (2012) egalitarians tend to
tionship between chronic mortality and ozone, only acute mortality was view nature as fragile, and apply precautionary principles. Hierarchists
included for ozone in ReCiPe (van Zelm et al., 2008). tend to believe that the environmental impacts can be avoided if prop-
erly managed, and they make choices depending upon the level of sci-
3.5. Ionizing radiation entific consensus. Individualists have optimistic views on human
adaptation to environmental impacts, and consider present effects
The ionizing radiation impact category was included in ReCiPe but more important than future effects. ReCiPe applies cultural theory in
not in LIME2. In ReCiPe, the approach was based on the study done by its analysis. The choices made for each cultural perspective within ReC-
Frischknecht et al. (2000). The standard life expectancy for the iPe are shown in Table 3. The values selected in LIME2 are also present-
Japanese female population and the number of cases of death for each ed in the table for a comparison. While LIME2 did not apply cultural
age-class, sex and cancer site in established market economies reported
in the GBD were used to derive the average number of YLL for fatal can- Table 3
cers. Frischknecht et al. (2000) assumed that the cancer incidents in- Value choices for different cultural perspectives.
duced by radiation followed the same age pattern as those induced by
ReCiPea LIME2b
other causes. Disability weights were taken from the GBD and the dura-
Egalitarian Hierarchist Individualist
tions of diseases and age-onset were from Murray and Lopez (1996b).
YLD, YLL and DALY values for fatal cancer cases were calculated and CC Time horizon 500 100 20 100
the same YLD values were applied for non-fatal cases due to the lack (years)
Adaptation No Mean Full adaptation –
of information (Frischknecht et al., 2000). The justification for this as- adaptation adaptation
sumption was stated to be that the duration of illness before the death Cardiovascular ✓c ✓ – ✓
may be shorter, but the severity is higher (Frischknecht et al., 2000). Malnutrition ✓c ✓ – ✓
For hereditary effects, DALYs per case were derived by assuming 50% Natural ✓c ✓d ✓e ✓
disasters
of the cases cause the immediate death and the remainders live with
OD Time horizon Infinite Infinite Infinite Infinite
an average disability weight of 0.4 taken from the GBD. (years)
Cataract ✓ ✓ – ✓
3.6. Indoor air pollution HT Time horizon Infinite Infinite 100 –f
Substance Chemicals Chemicals Chemicals with TD50 IARC 1, 2
included with TD50 with TD50 classified as IARC 1, and
LIME2 considered indoor air pollution as an impact category for a 2A, 2B others
limited range of chemical hazards while ReCiPe does not. Although var- Exposure All All Organics: all Allg
ious types of substance emissions and corresponding health effects routes Metals: air and
were expected, only limited effects of limited substances were included water
RE Pollutants CO ✓ ✓ ✓ –f
due to the limited data availability (Itsubo and Inaba, 2010).
SO2 ✓ ✓ ✓ ✓
In the case of sick house syndrome (SHS), only YLD was considered NO2 ✓ ✓ ✓ ✓
in the DALY calculations as it is unlikely to cause mortality. The disability Nitrates ✓ ✓ ✓ ✓
weights of health effects similar to symptoms of SHS were used by med- IR Time horizon 100,000 100,000 100 IR not
ical experts to estimate the average disability weight for SHS (Itsubo (years) included
DALY Age weighting – – – –
and Inaba, 2010). The resulting disability weight for SHS was 0.096 for
mucosa symptoms and 0.220 for psychiatric symptoms. The average ✓: included.
CC: climate change, OD: ozone depletion, HT: human toxicity, RE: respiratory effects,
of two year duration was assumed for DALYs per incident case.
IR: ionizing radiation, TD50: tumorigenic dose rate of 50, IARC: International Agency for
DALY values for nasopharyngeal cancer have been derived in the Research on Cancer.
human toxicity impact category and the same value was adopted. a
Goedkoop et al. (2013).
b
Only YLD was considered for manifestation of toxicity caused by toluene Itsubo and Inaba (2010).
c
for the same reason as SHS. The disability weight of 0.08 was taken from High risk.
d
Medium risk.
Nakanishi and Kishimoto (2005) and the duration was assumed to be e
Low risk.
two years. For respiratory effects, DALYs per incidence case reported f
Indefinite.
by Hofstetter (1998) were adapted. g
Air, water and soil.
124 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128
theory, the choices made in LIME2 for most of the items tend to fit be-
tween hierarchists and egalitarians of ReCiPe, though which cultural
perspective it is closest to cannot be easily determined as the signifi-
cance of each item's contribution to the total impact is unclear.
For climate change, ReCiPe considered different levels of socioeco-
nomic adaptation to the impacts depending upon cultural perspectives.
For instance, hierarchists assumed that an increase in the risks of diar-
rhea was negligible in regions with national Gross Domestic Product
per capita of more than $6000 per year. The individualist perspective
was that climate change would not cause the higher risk of heat stroke
nor malnutrition, and only low risk of natural disasters was expected
due to technological and economic growth. Egalitarians did not accept
any adaptation, hence, high risks for cardiovascular diseases, natural di-
sasters and malnutrition were expected.
The same DALY values regardless of cultural perspective were used
for BoD caused by ozone depletion in ReCiPe. Individualists were differ-
entiated from others by excluding cataracts since their relationship to
UV exposure is less certain.
For human toxicity, the carcinogenic substances included in the
analysis varied depending upon methods and the cultural perspectives.
In ReCiPe, all chemicals for which a tumorigenic dose rate (TD50) has
been reported, which indicates the detection of tumors in half an animal
test population over their lifespan, were included for egalitarians and
hierarchists. Only substances with reported TD50 and which are classi-
fied as 1, 2A and 2B by the International Agency for Research on Cancer
(IARC) were included for individualists.
For LIME2, substances considered as carcinogenic were those:
1) identified as carcinogens by one of the following organizations:
IARC, United States Environmental Protection Agency, European
Union, National Toxicology Program, American Conference of Govern-
mental Industrial Hygienists and Japan Society for Occupational Health;
2) categorized in IARC 2A or 2B; or 3) identified as probable carcinogens
by two of the other organizations mentioned above.
In terms of exposure routes, only drinking water and air were con-
sidered for metals by individualists in ReCiPe, while other perspectives
also included food ingestion. All of these routes were included in
LIME2. For overall calculations, a long term scenario was used for egali-
tarians and hierarchists and a short term scenario was used for individ-
ualists in ReCiPe.
No differentiation has been made between cultural perspectives in
respiratory effects in ReCiPe.
For ionizing radiation, the only difference was the time horizon con-
sidered for substances' fates. It was chosen to be 100,000 years for egal-
itarians and hierarchists and 100 years for individualists in ReCiPe.
4. Discussion
4.1. Differences between LCA methods
The endpoint CF for human health should be equivalent regardless of
a chosen LCA method for global impacts such as climate change and
stratospheric ozone depletion. However, there are considerable differ-
ence between the methods in the case of climate change (ReCiPe —
1.40E − 6 DALYs/kg CO2-eq. for hierarchist perspective; LIME2 —
1.3E−7 DALYs/kg CO2-eq.) (Goedkoop et al., 2013; Itsubo and Inaba,
2010). For ozone depletion, the resulting CFs (DALYs/kg CFC-11-eq.) dif-
fer by about 30%. These differences are caused by not only DALY value
variations but also differences in other components such as substance
fate models. The uncertainty involved in the CF derivations could be re-
duced in the future as understanding of environmental mechanisms
and data availability advances.
For impact categories affecting only smaller regions including
human toxicity and respiratory effects, differences in CFs between ReC-
iPe and LIME2 are expected. That is because ReCiPe is generally based on
European-scale factors such as population density and weather models,
and LIME2 uses those of Japan. In addition, because of the different types
of BoD taken into account and different data referred for DALY values
for each BoD in the two methods, the average DALYs for overall cancer
derived in the two methods differed by 23% and those of non-cancer
disease differed by 76% (Huijbregts et al., 2005; Itsubo and Inaba,
2012). The data used to calculate DALYs in these methods are currently
not always the specific local values due to the limited data availability.
As more local specific data become available, the degree of difference
between the LCA methods will possibly change.
4.2. Missing human BoD impact categories
LCA is a relatively holistic environmental management tool com-
pared to other tools such as QRA as it can assess many different types
of environmental impacts. However, there still are several BoD impact
categories disregarded in current LCA methods. Its comprehensiveness
will be enhanced by including those missing BoD impacts. For instance,
indoor air pollution and noise which would cause impacts on human
health were not considered in ReCiPe. Skaar and Jørgensen (2012)
point out that disregarding indoor emissions may lead to underestima-
tion of the importance of the use phase of LCA, and may cause environ-
mental impacts to shift onto workers' or consumers' health (Hellweg
et al., 2009).
Some effects to human health due to eutrophication and acidifica-
tion are also expected, however, BoD impacts are not considered in ReC-
iPe and LIME2. Excess growth of algae and cyanobacteria caused by
eutrophication potentially disturb human health via toxin exposures
(ingestion, dermal and inhalation) (Falconer, 1999). Diseases such as
paralytic shellfish poisoning are known to result from consuming shell-
fish in which dinoflagellate toxins have accumulated (Brett, 2003). The
population change in zooplankton, fish and shellfish caused by eutro-
phication (WHO Regional Office for Europe and European Commission,
2002) and reduction in plant growth rate due to soil acidification
(Hayashi et al., 2004) could increase human malnutrition. Also,
cyanobacterial blooms resulting from eutrophication may lead to
cyanotoxins that are not removed by traditional drinking water treat-
ment processes and impact the food chain (Falconer et al., 1999;
Falconer, 1999). Acidification may also cause nitrate pollution of
groundwater (Itsubo and Inaba, 2012), and accelerate global warming
due to declines in forest cover.
In the category of water depletion, freshwater use will lead to water
deprivation for primarily three functions which fulfill essential human
needs depending on local conditions: domestic use (hygiene and inges-
tion), agriculture, and aquaculture/fisheries. Accordingly, its contribu-
tion to BoD can be significant in increasing parts of the world (Ercin
et al., 2013; Padowski and Jawitz, 2012). Several methods have been
developed in this category (Boulay et al., 2011; Frischknecht et al.,
2006; Hoekstra, 2012; Motoshita et al., 2011; Pfister et al., 2009;
Ridoutt and Pfister, 2010). Consequently this area of knowledge is ex-
pected to continue rapid development.
4.3. Interrelationship between impact categories
Since environmental impacts often share cause–effect relationships,
to avoid double counting and to account for the influence of factors in
other impact categories, it is vital to consider interrelations between im-
pact categories for more precise assessment. However, such interrela-
tions are not formally considered in current LCA methods.
For example, it is known that there are strong relationships between
climate change and ozone depletion. The increased concentration of
greenhouse gases will affect the atmospheric circulation patterns (the
Brewer–Dobson circulation) leading to reduced ozone concentrations
in tropical regions and increases elsewhere (Bais et al., 2015).
At ground level, climate change may increase or decrease the inten-
sity of UV radiation by altering, for example, precipitation and cloud
cover. The change in atmospheric temperature and humidity may influ-
ence human behavior such as clothing choice and the frequency of
 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128
outdoor activities which affect human UV exposure (Thomas et al.,
2012). In addition, it is reported that the risks of some types of skin can-
cer increase with temperature (Norval et al., 2011). In developing re-
gions, cataract development could be enhanced by dehydration which
may potentially be a consequence of climate change while reduction
in ice and/or snow cover may lower the risk of cataracts in other areas
(Thomas et al., 2012).
While higher temperatures may increase the risk of gastroenteritis,
an inverse relationship between UV radiation intensity and gastroenter-
itis incidence has been reported, possibly due to the inactivation of
pathogens by UV radiation (Thomas et al., 2012). However, it was also
observed that UV radiation hinders the effectiveness of some bacteria
used as biopesticides to control mosquito larvae, and thus may increase
risks of vector-borne diseases (Thomas et al., 2012). The intensity of
these interactions varies among regions and it could be significant for
lower altitude regions where impacts of these diseases are already high.
The formation and transportation of air pollutants linked to respira-
tory effects may be influenced by some factors of climate change such as
temperature (Thomas et al., 2012). Tropospheric ozone concentrations
can also be influenced by UV radiation. A rise in UV radiation intensity
is expected to decrease tropospheric ozone in a clean environment,
while increased UV in regions with NOx rich atmospheres will lead to
increased tropospheric ozone concentrations (Tang et al., 2011).
The degree of effects due to these interrelationships often depends
upon regional or local conditions, thus highlighting the need to consider
local contexts for assumed values in an LCA.
4.4. Local specific considerations
Current LCIA methods are generally challenged by the need to take
localized impacts into account. For example, in contrast to QRA, only ge-
neric exposure scenarios with no local specific conditions are consid-
ered in their analysis (Goedkoop et al., 2013; Itsubo and Inaba, 2010).
QRA considers diverse locally specific scenarios for sources, pathways
and exposures so that more realistic assessment is achievable. The im-
portance of regional variation in exposure pathways has been recog-
nized and development of spatially differentiated toxicity model has
been attempted (Humbert et al., 2009; Pennington et al., 2005;
Wegener Sleeswijk and Heijungs, 2010), however such applications in
current LCA remain limited.
The inclusion of a finite number of specific chemicals and their ef-
fects may be considered as a possible disadvantage of current LCA. Not
all the possible effects are included, mainly due to limited data availabil-
ity. For human toxicity, as an example, while acute exposure to some
substances may cause serious consequences (Jarup, 2003; WHO, 1985,
1993), only chronic exposures are taken into account in ReCiPe and
LIME2. For climate change, the BoD effects included in current LCA
methods are very limited and some of them, i.e. diarrhea, malaria and
schistosomiasis, are mostly relevant to developing regions (Hunter,
2003). For developed regions, effects due to respiratory environmental
pathogens such as Legionella spp. and non-tuberculous mycobacteria
via water/aerosol exposures may be much more significant than the
fecal pathogens that cause diarrhea (Ashbolt, 2015; Collier et al.,
2012), however, these pathogens were not considered.
Furthermore, as intensity and frequency of water related events
such as storms and floods increase in some regions as a consequence
of climate change induced by human activities, human exposures to
vector-borne, food-borne, water-borne, water-based and sewage-
borne pathogens are likely to increase (Cann et al., 2013; Schijven
et al., 2013). The alteration of climate factors may also change reproduc-
tion and transmission pattern of pathogens which would contribute to a
rise in pathogen infections (Charron et al., 2004; Gage et al., 2008).
While the burden of pathogen related infections can be quantified
in DALYs as commonly being done in quantitative microbial risk as-
sessment (QMRA) (Machdar et al., 2013; Xiao et al., 2012), it is mostly
disregarded in LCA methods.
125
4.5. Value choices — use of assumptions
To overcome some of the shortcomings of current LCAs discussed in
previous sections, combined use of LCA and more locally specific envi-
ronmental impact assessment tool such as QRA seems effective. The
use of DALYs as a common metric for that matter appears beneficial
since it facilitates direct comparison of the results of the two tools. How-
ever, to do so, assumptions involved in DALY derivation in LCA and QRA
need to be consistent.
World and regional average DALYs are often used in current LCAs
while in QRA, local data are used for the analysis where data is available.
The DALY values used in LCA methods are fixed regardless of the region
of interest in a study. In contrast, within QRA, there is flexibility to use
more regional or locally specific DALY values when preferred. When av-
erage rather than local values are used, this should be considered when
interpreting LCA outcomes. Broad average values may be applicable for
impacts with global and regional effects, however, for those that are
more specific to local regions, DALY variables should reflect this speci-
ficity. As an example, the DALY value for a type of illness may vary de-
pending on local accessibility of medical treatment, such as ozone
depletion associated cataracts where sufficient treatment is readily
available in developed countries, but the consequences in developing
regions may be severe (Goedkoop et al., 2013). The assumption of life
expectancy of 80–82.5 years which is commonly used may also cause
inaccuracies in regions with shorter life expectancies (Havelaar and
Melse, 2003).
Probabilities of developing health outcomes as a consequence of ex-
posure to risk factors may also vary between regions. Locally dependent
factors such as human behavior including clothing selection, time spent
outside and use of sunscreens, as well as occupation may affect the UV
radiation exposure and consequently change the risk of skin cancer
and cataract development (Norval et al., 2011). However, only ReCiPe
accounted for these factors. Differences in dose due to behavior across
the population can be as much as one-tenth to ten times the mean
value, according to Thomas et al. (2012).
Similar to regional differences, appropriate DALY values may differ
for different times, as the medical treatments and availability are ad-
vancing with time. Inclusion of temporal information may influence
the results especially for substances for which impacts may be greatly
delayed from the time of exposure. Skin cancers and cataracts caused
by ozone depletion may fall into this category as it could require 30 to
50 years of UV-dose accumulation before diagnosis (Goedkoop et al.,
2013). However, temporal consideration such as future discounting is
disregarded for DALYs in LCA. Moreover, while DALY values have been
continuously updated (Mathers and Loncar, 2006), ReCiPe generally re-
ferred to GDB published in 1996 which was based on 1990 data for
DALY values. DALY values used in QRA may be taken from more recent
literature.
Because of the delay in the appearance of effects, a rise in prevalence
of skin cancers and cataracts occur at age groups of 40 and older
(Goedkoop et al., 2013). In these cases, the consideration of regional de-
mographic information becomes important. Goedkoop and Spriensma
(2001a) mention that disregarding the population demographics may
lead to an underestimation of impacts. Further, Goedkoop et al.
(2013) identified that the reason why the characterization factors for
ozone depletion are much higher in ReCiPe than in LIME2 may be relat-
ed to the inclusion of demographic information. Similarly, in the case of
heat stress caused by climate change, the inclusion of demographic in-
formation and the other regional factors may alter the significance, as
elderly individuals are more vulnerable to heat and larger numbers of
heat-exposed occupations are in lower income countries (Matzarakis
et al., 2011; Thomas et al., 2012; Vandentorren et al., 2006).
Further considerations arise from impacts due to natural disasters.
It was assumed in ReCiPe that such impacts were spread over the pop-
ulation equally regardless of age (Goedkoop et al., 2009). However,
there is evidence to suggest that natural disasters can significantly affect
126 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128
different age groups to various degrees. For example, a study on Hurri-
cane Katrina on the US Gulf Coast in 2005 showed that the mean age for
loss of life was 69 with about half being 75 and older and less than 10%
being younger than 45 (Brunkard et al., 2008).
Crucially, another significant issue is that decisions affecting the pa-
rameters often vary due to value-based assumptions. While the cultural
theory of risk has potential to aid in consistent value-based assumptions
and has been applied in some LCA methods, its implementation in LCA is
still limited and not always consistent (De Schryver et al., 2011). Since
the value choices are generally made by experts and not by the general
public (Goedkoop and Spriensma, 2001a), the method has been criti-
cized for its limited representation of the world and for its lack of empir-
ical validation (De Schryver et al., 2011; Van Asselt and Rotmans, 1996).
ReCiPe and LIME2 do not use age-weighting for any of the perspec-
tives. Without the age-weighting, YLL values become relatively high for
health impacts that potentially affect young children. From the DALY
values with and without age-weighting provided by Hofstetter (1998) it
can be seen that the influence of age-weighting on the resulting DALY
value for each cancer type can be considerable, up to 35%, except for
skin cancers which usually develop at an older age. Hence, it is crucial
to ensure the consistent use of age-weighting when comparing or aggre-
gating DALYs estimated with different approaches such as LCA and QRA.
The variations in cultural perspective adopted may result in signifi-
cant differences in endpoint CFs (De Schryver et al., 2011); for instance,
the impact of greenhouse gases on BoD varied by 5 orders of magnitude
for substances with longer residence time, mainly due to the difference
in the time horizon selected (De Schryver et al., 2009). By comparing
their climate change CFs with those of other models (Eco indicator 99
and EPS), De Schryver et al. (2009) indicated that value choices have a
greater influence than calculation model choices.
5. Conclusion
Through this paper, the current uses of DALYs in ReCiPe and LIME2
have been reviewed and differing assumptions were identified. While
some of the differences are due to the lack of knowledge and/or data,
others are due to regional differences where LCA methods were focused
in their development. LCA practitioners should select LCA methods with
these differences in mind. Applying methods incomparable to the re-
gions of interest in a study may lead to inadequate results.
Many of the potential BoD impacts disregarded in the LCA methods
reviewed here seem possible to be compensated for by applying QRA.
Despite uncertainty and variability, endpoint analysis of LCA is useful
especially in this regard. DALYs as a common metric between LCA and
QRA appear to be a good starting point as they facilitate direct compar-
isons. To take such approach meaningfully, assumptions used to derive
DALYs in LCA and QRA need to be consistent. Particularly, the following
should be considered:
• DALY values estimated for different geographical locations;
• DALY values estimated in different times (recent data or older data);
and
• Application of social preferences (age-weighting and future
discounting).
Determining to what extent LCA results would differ when the fol-
lowing items are considered can be a beneficial next step:
• Disregarded substances and BoD effects;
• Missing BoD impact categories;
• Interrelationships between the impact categories.
Also, to what extent QRA can be used to supplement the current
shortcomings of LCA to enhance the comprehensiveness of BoD impact
assessment is another meaningful step.
Acknowledgments
This work was funded by the Australian Research Council (ARC)
Linkage Projects Program (Grant No. LP 110200594) and the Swedish
Research Council for Environment, Agricultural Sciences and Spatial
Planning (FORMAS) under grant agreement no. 2012–1122. Industry
contributions to this grant are provided by EPA Victoria. The opinions
expressed in this paper are those of the authors, and do not necessarily
reflect the official positions and policies of the EPA Victoria.
References
Ashbolt, N., 2015. Microbial contamination of drinking water and human health from
community water systems. Curr. Environ. Health Rep. 2 (1), 95–106.
Bais, A.F., McKenzie, R.L., Bernhard, G., Aucamp, P.J., Ilyas, M., Madronich, S., Tourpali, K.,
2015. Ozone depletion and climate change: impacts on UV radiation. Photochem.
Photobiol. Sci. 14 (1), 19–52.
Barberio, G., Scalbi, S., Buttol, P., Masoni, P., Righi, S., 2014. Combining life cycle assess-
ment and qualitative risk assessment: the case study of alumina nanofluid produc-
tion. Sci. Total Environ. 496, 122–131.
Bleichrodt, H., Pinto, J., 2012. The Elgar Companion to Health Economics. In: Jones, A.M.
(Ed.), Edward Elgar, Cheltenham, UK.
Boulay, A.M., Bulle, C., Bayart, J.B., Deschênes, L., Margni, M., 2011. Regional characteriza-
tion of freshwater use in LCA: modeling direct impacts on human health. Environ. Sci.
Technol. 45 (20), 8948–8957.
Brett, M.M., 2003. Food poisoning associated with biotoxins in fish and shellfish. Curr.
Opin. Infect. Dis. 16 (5), 461–465.
Brunkard, J., Namulanda, G., Ratard, R., 2008. Hurricane Katrina deaths, Louisiana, 2005.
Disaster Med. Public Health Prep. 2 (4), 215–223.
Cann, K.F., Thomas, D.R., Salmon, R.L., Wyn-Jones, A.P., Kay, D., 2013. Extreme water-
related weather events and waterborne disease. Epidemiol. Infect. 141 (4), 671–686.
Charron, D.F., Thomas, M.K., Waltner-Toews, D., Aramini, J.J., Edge, T., Kent, R.A., Maarouf,
A.R., Wilson, J., 2004. Vulnerability of waterborne diseases to climate change in
Canada: a review. J. Toxicol. Environ. Health A 67 (20–22), 1667–1677.
Collier, S.A., Stockman, L.J., Hicks, L.A., Garrison, L.E., Zhou, F.J., Beach, M.J., 2012. Direct
healthcare costs of selected diseases primarily or partially transmitted by water.
Epidemiol. Infect. 140 (11), 2003–2013.
CRED, 2014. EM-DAT. The International Disaster Database, Centre for Research on the
Epidemiology of Disasters. School of Public Health, Université Catholique de Louvain,
Brussels, Belgium.
Curran, M.A., 2006. Life cycle assessment: principles and practice. In: National Risk
Management Research Laboratory Office of Research and Development (Ed.), U.S. En-
vironmental Protection Agency, Cincinnati, OH.
De Haes, H.A.U., Sleeswijk, A.W., Heijungs, R., 2006. Similarities, differences and syner-
gisms between HERA and LCA — an analysis at three levels. Hum. Ecol. Risk. Assess.
12 (3), 431–449.
De Schryver, A.M., Brakkee, K.W., Goedkoop, M.J., Huijbregts, M.A.J., 2009. Characteriza-
tion factors for global warming in life cycle assessment based on damages to humans
and ecosystems. Environ. Sci. Technol. 43 (6), 1689–1695.
De Schryver, A.M., Van Zelm, R., Humbert, S., Pfister, S., McKone, T.E., Huijbregts, M.A.J.,
2011. Value choices in life cycle impact assessment of stressors causing human health
damage. J. Ind. Ecol. 15 (5), 796–815.
De Schryver, A.M., Humbert, S., Huijbregts, M.A.J., 2012. The influence of value choices in
life cycle impact assessment of stressors causing human health damage. Int. J. Life
Cycle Assess. 1–9.
EC-JRC, 2011. ILCD Handbook: Recommendations for Life Cycle Impact Assessment in the
European Context. EC-JRC, Luxemburg.
enHealth, 2012. Environmental Health Risk Assessment: Guidelines for Assessing Human
Health Risks From Environmental Hazards. In: The Department of Health (Ed.), Com-
monwealth of Australia, Canberra.
Ercin, A.E., Mekonnen, M.M., Hoekstra, A.Y., 2013. Sustainability of national consumption
from a water resources perspective: the case study for France. Ecol. Econ. 88,
133–147.
Falconer, I.R., 1999. An overview of problems caused by toxic blue-green algae
(cyanobacteria) in drinking and recreational water. Environ. Toxicol. 14 (1),
5–12.
Falconer, I., Bartram, J., Chorus, I., Kuiper-Goodman, T., Utilen, H., Burch, M., Codd, G.,
1999. Toxic cyanobacteria in water: a guide to their public health consequences,
monitoring and management. In: Chorus, I., Bartram, J. (Eds.), WHO, Geneva.
Fèvre, E.M., Odiit, M., Coleman, P.G., Woolhouse, M.E.J., Welburn, S.C., 2008. Estimating
the burden of rhodesiense sleeping sickness during an outbreak in Serere, eastern
Uganda. BMC Public Health 8.
Frischknecht, R., Braunschweig, A., Hofstetter, P., Suter, P., 2000. Human health damages
due to ionising radiation in life cycle impact assessment. Environ. Impact Assess.
Rev. 20 (2), 159–189.
Frischknecht, R., Steiner, R., Braunschweig, A., Egli, N., Hildesheimer, G., 2006. Swiss Eco-
logical Scarcity Method: The New Version 2006. ESU-services Ltd, Berne, Switzerland.
Gage, K.L., Burkot, T.R., Eisen, R.J., Hayes, E.B., 2008. Climate and vectorborne diseases. Am.
J. Prev. Med. 35 (5), 436–450.
Goedkoop, M., Spriensma, R., 2000. The Eco-indicator 99—A Damage Oriented
Method for Life Cycle Impact Assessment. PRé Consultants, Amersfoort, The
Netherlands.
 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128
Goedkoop, M., Spriensma, R., 2001a. The Eco-indicator 99. A Damage Oriented Method for
Life Cycle Impact Assessment. PRe Consultants, Amersfoort, Netherlands.
Goedkoop, M., Spriensma, R., 2001b. The Eco-indicator 99—A Damage Oriented Method
for Life Cycle Impact Assessment. Publikatiereeks produktenbeleidMinisterie van
Volkshiusvesting, Ruimtelijke Ordening en Milieubeheer, Den Haag, NL.
Goedkoop, M., Heijungs, R., Huijbregts, M., De Schryver, A., Struijs, J., van Zelm, R., 2009. ReC-
iPe 2008: A life cycle impact assessment method which comprises harmonised category
indicators at the midpoint and the endpoint level. Report I: Characterisation —
Supporting Information.
Goedkoop, M., Heijungs, R., Huijbregts, M., De Schryver, A., Struijs, J., van Zelm, R., 2013.
ReCiPe 2008: A Life Cycle Impact Assessment Method Which Comprises Harmonised
Category Indicators at the Midpoint and the Endpoint Level. 1st ed. Ministry of Housing,
Spatial Planning and Environment (VROM), Netherlands (version 1.08).
Havelaar, A.H., Melse, J.M., 2003. Quantifying public health risk in the WHO Guidelines for
Drinking-Water Quality: a burden of disease approach. RIVM Report; No. 734301022/
2003. National Institute for Public Health and the Environment (RIVM), Bilthoven,
The Netherlands.
Hayashi, K., Okazaki, M., Itsubo, N., Inaba, A., 2004. Development of damage function of
acidification for terrestrial ecosystems based on the effect of aluminum toxicity on
net primary production. Int. J. Life Cycle Assess. 9 (1), 13–22.
Hellweg, S., Demou, E., Bruzzi, R., Meijer, A., Rosenbaum, R.K., Huijbregts, M.A.J., McKone,
T.E., 2009. Integrating human indoor air pollutant exposure within life cycle impact
assessment. Environ. Sci. Technol. 43 (6), 1670–1679.
Hoekstra, A.Y., 2012. Water Accounting: International Approaches to Policy and Decision-
making. Edward Elgar Publishing Limited, UK, pp. 58–75.
Hofstetter, P., 1998. Perspectives in Life Cycle Impact Assessment: A Structured Approach
to Combine Models of the Technosphere, Ecosphere and Valuesphere. Kluwer Aca-
demic Publishers, Boston.
Hofstetter, P., Hammitt, J.K., 2001. Human Health Metrics for Environmental Decision US
EPA Office of Research and Development Support Tools: lessons from health econom-
ics and decision analysis and development. In: National Risk Management Research
Laboratory Office of Research (Ed.), U.S. Environmental Protection Agency, Cincinnati.
Hofstetter, P., Hammitt, J.K., 2002. Selecting human health metrics for environmental
decision-support tools. Risk Anal. 22 (5), 965–983.
Honda, Y., Ono, M., Sasaki, A., Uchiyama, I., 1998. Shift of the short-term temperature
mortality relationship by a climate factor — some evidence necessary to take account
of in estimating the health effect of global warming. J. Risk Res. 1 (3), 209–220.
Huijbregts, M.A.J., Rombouts, L.J., Ragas, A.M., van de Meent, D., 2005. Human-
toxicological effect and damage factors of carcinogenic and noncarcinogenic
chemicals for life cycle impact assessment. Integr. Environ. Assess. Manag. 1 (3),
181–244.
Humbert, S., Manneh, R., Shaked, S., Wannaz, C., Horvath, A., Deschênes, L., Jolliet, O.,
Margni, M., 2009. Assessing regional intake fractions in North America. Sci. Total En-
viron. 407 (17), 4812–4820.
Hunter, P.R., 2003. Climate change and waterborne and vector-borne disease. J. Appl.
Microbiol. 94, 37S–46S.
ISO (2006) ISO 14040 International Standard. In: International Standard. In: Environmen-
tal Management — Life Cycle Assessment — Principles and Framework. International
Organisation for Standardization, Geneva, Switzerland.
Itsubo, N., Inaba, A., 2010. LIME2 — Life-cycle Impact Assessment Method Based on End-
point Modeling. Nippon Publicity, Tokyo, Japan.
Itsubo, N., Inaba, A., 2012. LIME2. Life-cycle impact assessment method based on endpoint
modeling. In: Life-Cycle Assessment Society of Japan (Ed.), (Japan).
Jarup, L., 2003. Hazards of heavy metal contamination. Br. Med. Bull. 68, 167–182.
Knol, A.B., Staatsen, B.A.M., 2005. Trends in the Environmental Burden of Disease in The
Netherlands, 1980–2020. RIVM, Bilthoven, The Netherlands.
Kobayashi, Y., Peters, G.M., Ashbolt, N.J., Heimersson, S., Svanström, M., Khan, S.J., 2015. Glob-
al and local health burden trade-off through the hybridisation of quantitative microbial
risk assessment and life cycle assessment to aid water management. Water Res. 79,
26–38.
Künzli, N., Medina, S., Kaiser, R., Quéne, P., Horak Jr., F., Studnicka, M., 2001. Assessment of
deaths attributable to air pollution: should we use risk estimates based on time series
or on cohort studies? Am. J. Epidemiol. 153 (11), 1050–1055.
Machdar, E., van der Steen, N.P., Raschid-Sally, L., Lens, P.N.L., 2013. Application of quan-
titative microbial risk assessment to analyze the public health risk from poor drinking
water quality in a low income area in Accra, Ghana. Sci. Total Environ. 449, 134–142.
Mathers, C.D., Loncar, D., 2006. Projections of global mortality and burden of disease from
2002 to 2030. PLoS Med. 3 (11), 2011–2030.
Mathers, C.D., Vos, T., Lopez, A.D., Salomon, J.A., Ezzati, M., 2001. National burden of dis-
eases studies: a practical guide. In: WHO Global Program on Evidence for Health
Policy (Ed.), Edition 2.0 World Health Organization, Geneva.
Matzarakis, A., Muthers, S., Koch, E., 2011. Human biometeorological evaluation of heat-
related mortality in Vienna. Theor. Appl. Climatol. 105 (1–2), 1–10.
McKone, T.E., Kyle, A.D., Jolliet, O., Olsen, S.I., Hauschild, M., 2006. Dose–response model-
ing for life cycle impact assessment: findings of the Portland Review Workshop. Int.
J. Life Cycle Assess. 11 (2), 137–140.
McMichael, A.J., Campbell-Lendrum, D.H., Corvalan, C.F., Ebi, K.L., Githeko, A., Scheraga,
J.D., Woodward, A., 2003. Climate Change and Human Health. Risk and Responses.
World Health Organization, Geneva.
Motoshita, M., Itsubo, N., Inaba, A., 2011. Development of impact factors on damage
to health by infectious diseases caused by domestic water scarcity. Int. J. Life
Cycle Assess. 16 (1), 65–73.
Müller-Wenk, R., 2002. Attribution to Road Traffic of the Impact of Noise on Health. Swiss
Agency for the Environment, Forest and Landscape, Bern.
Müller-Wenk, R., 2004. A method to include in LCA road traffic noise and its health effects.
Int. J. Life Cycle Assess. 9 (2), 76–85.
127
Murray, C.J.L., Acharya, A.K., 1997. Understanding DALYs. J. Health Econ. 16 (6),
703–730.
Murray, C.J.L., Lopez, A.D., 1996a. The Global Burden of Disease — A Comprehensive As-
sessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in
1990 and Projected to 2020. Harvard School of Public Health, Boston, USA.
Murray, C.J.L., Lopez, A.D., 1996b. Global health statistics: a compendium of incidence,
prevalence and mortality estimates for over 200 conditions. Global Burden of Disease
and Injury Series. Harvard University, Cambridge (MA), USA.
Nakanishi, J., Kishimoto, M., 2005. Risk Assessment Document Series — Toluene. Maruzen,
Tokyo, Japan.
Norval, M., Lucas, R.M., Cullen, A.P., De Gruijl, F.R., Longstreth, J., Takizawa, Y., Van Der
Leun, J.C., 2011. The human health effects of ozone depletion and interactions with
climate change. Photochem. Photobiol. Sci. 10 (2), 199–225.
Olsen, S.I., Christensen, F.M., Hauschild, M., Pedersen, F., Larsen, H.F., Tørsløv, J., 2001. Life
cycle impact assessment and risk assessment of chemicals — a methodological com-
parison. Environ. Impact Assess. Rev. 21 (4), 385–404.
Owens, J.W., 1997. Life-cycle assessment in relation to risk assessment: an evolving per-
spective. Risk Anal. 17 (3), 359–365.
Padowski, J.C., Jawitz, J.W., 2012. Water availability and vulnerability of 225 large cities in
the United States. Water Resour. Res. 48.
Pennington, D.W., Margni, M., Ammann, C., Jolliet, O., 2005. Multimedia fate and human
intake modeling: spatial versus nonspatial insights for chemical emissions in West-
ern Europe. Environ. Sci. Technol. 39 (4), 1119–1128.
Pfister, S., Koehler, A., Hellweg, S., 2009. Assessing the environmental impacts of freshwa-
ter consumption in LCA. Environ. Sci. Technol. 43 (11), 4098–4104.
Potting, J., Hauschild, M., Wenzel, H., 1999. ‘Less is better’ and ‘only above threshold’: two
incompatible paradigms for human toxicity in life cycle assessment? Int. J. Life Cycle
Assess. 4 (1), 16–24.
Prüss-Üstün, A., Mathers, C., Corvalán, C., Woodward, A., 2003. Environmental Bur-
den of Disease Series, No.1 — Introduction and Methods: Assessing the Environ-
mental Burden of Disease at National and Local Levels. World Health Organization,
Geneva.
Ridoutt, B.G., Pfister, S., 2010. A revised approach to water footprinting to make transpar-
ent the impacts of consumption and production on global freshwater scarcity. Glob.
Environ. Chang. 20 (1), 113–120.
RIVM, 2004. Nationaal Kompas Volksgezondheid. [Online], RIVM, Bilthoven (Available:
http://www.nationaalkompas.nl [Accessed September 21st 2014]).
Schijven, J., Bouwknegt, M., de Roda Husman, A.M., Rutjes, S., Sudre, B., Suk, J.E.,
Semenza, J.C., 2013. A decision support tool to compare waterborne and
foodborne infection and/or illness risks associated with climate change. Risk
Anal. 33 (12), 2154–2167.
Skaar, C., Jørgensen, R.B., 2012. Integrating human health impact from indoor emissions
into an LCA: a case study evaluating the significance of the use stage. Int. J. Life
Cycle Assess. 1–11.
Sleeswijk, A.W., Heijungs, R., Erler, S.T., 2003. Risk assessment and life-cycle assessment:
fundamentally different yet reconcilable. Greener Manag. Int. 41, 77–87.
Sonnemann, G., Castells, F., Schuhmacher, M., 2004. Integrated Life-cycle and Risk Assess-
ment for Industrial Processes. Lewis Publishers, Boca Raton, Fla.
Tang, X., Wilson, S.R., Solomon, K.R., Shao, M., Madronich, S., 2011. Changes in air quality
and tropospheric composition due to depletion of stratospheric ozone and interac-
tions with climate. Photochem. Photobiol. Sci. 10 (2), 280–291.
Thomas, P., Swaminathan, A., Lucas, R.M., 2012. Climate change and health with an em-
phasis on interactions with ultraviolet radiation: a review. Glob. Chang. Biol. 18 (8),
2392–2405.
Van Asselt, M.B.A., Rotmans, J., 1996. Uncertainty in perspective. Glob. Environ. Chang. 6
(2), 121–157.
Van Dijk, A., Den Outer, P., Slaper, H., 2008. Climate and ozone change effects on ultravi-
olet radiation and risks (COEUR) using and validating earth observations. RIVM Re-
port 61000 (2001).
van Zelm, R., Huijbregts, M.A.J., den Hollander, H.A., van Jaarsveld, H.A., Sauter, F.J., Struijs,
J., van Wijnen, H.J., van de Meent, D., 2008. European characterization factors for
human health damage of PM10 and ozone in life cycle impact assessment. Atmos. En-
viron. 42 (3), 441–453.
Vandentorren, S., Bretin, P., Zeghnoun, A., Mandereau-Bruno, L., Croisier, A., Cochet, C.,
Riberon, J., Siberan, I., Declercq, B., Ledrans, M., 2006. August 2003 heat wave in
France: risk factors for death of elderly people living at home. Eur. J. Pub. Health 16
(6), 583–591.
Wegener Sleeswijk, A., 2003. General prevention and risk minimization in LCA: a com-
bined approach. Environ. Sci. Pollut. Res. 10 (1), 69–77.
Wegener Sleeswijk, A., Heijungs, R., 2010. GLOBOX: a spatially differentiated global fate,
intake and effect model for toxicity assessment in LCA. Sci. Total Environ. 408 (14),
2817–2832.
Weidema, B.P., 2006. The integration of economic and social aspects in life cycle impact
assessment. Int. J. Life Cycle Assess. 11 (SPEC. ISS. 1), 89–96.
WHO, 1985. International Programme on Chemical Safety: environmental health criteria
52 toluene. [Online] Geneva. Available, http://www.inchem.org/documents/ehc/ehc/
ehc52.htm (Accessed August 1st 2014).
WHO, 1993. International Programme on Chemical Safety: environmental health criteria
150 benzene. [Online] Geneva. Available:, http://www.inchem.org/documents/ehc/
ehc/ehc150.htm (Accessed August 1st 2014).
WHO, 1995. World Health Statistics Annual, 1994. World Health Organization, Geneva.
WHO, 2000. The World Health Report 2000: Health Systems: Improving Performance.
World Health Organization, Geneva.
WHO, 2001. National Burden of Disease Studies — A Practical Guide. Edition 2.0. World
Health Organization Global, Geneva.
WHO, 2011. Guidelines for Drinking-water Quality. World Health Organization, Geneva.
128 Y. Kobayashi et al. / Science of the Total Environment 530–531 (2015) 120–128

WHO, 2015. Health statistics and information systems. [Online], World Health Organiza-
tion (Available: http://www.who.int/healthinfo/global_burden_disease/metrics_
daly/en/ [Accessed April 13th 2015]).
WHO Regional Office for Europe and European Commission, 2002. Eutrophication
and Health. Office for Official Publications of the European Communities,
Luxembourg.
WMO, 2010. Scientific assessment of ozone depletion: 2010. Global Ozone Research and
Monitoring Project.
Xiao, S., An, W., Chen, Z., Zhang, D., Yu, J., Yang, M., 2012. The burden of drinking water-
associated cryptosporidiosis in China: the large contribution of the immunodeficient
population identified by quantitative microbial risk assessment. Water Res. 46 (13),
4272–4280.