Mark J. Mendell

Respiratory and Allergic Health Effects of Dampness, Mold, and Dampness-Related Agents: A Review of the Epidemiologic Evidence

Objectives Many studies have shown consistent associations between evident indoor dampness or mold and respiratory or allergic health effects, but causal links remain unclear. Findings on measured microbiologic factors have received little review. We conducted an updated, comprehensive review on these topics. Data sources We reviewed eligible peer-reviewed epidemiologic studies or quantitative meta-analyses, up to late 2009, on dampness, mold, or other microbiologic agents and respiratory or allergic effects. Data extraction We evaluated evidence for causation or association between qualitative/subjective assessments of dampness or mold (considered together) and specific health outcomes. We separately considered evidence for associations between specific quantitative measurements of microbiologic factors and each health outcome. Data synthesis Evidence from epidemiologic studies and meta-analyses showed indoor dampness or mold to be associated consistently with increased asthma development and exacerbation, current and ever diagnosis of asthma, dyspnea, wheeze, cough, respiratory infections, bronchitis, allergic rhinitis, eczema, and upper respiratory tract symptoms. Associations were found in allergic and nonallergic individuals. Evidence strongly suggested causation of asthma exacerbation in children. Suggestive evidence was available for only a few specific measured microbiologic factors and was in part equivocal, suggesting both adverse and protective associations with health. Conclusions Evident dampness or mold had consistent positive associations with multiple allergic and respiratory effects. Measured microbiologic agents in dust had limited suggestive associations, including both positive and negative associations for some agents. Thus, prevention and remediation of indoor dampness and mold are likely to reduce health risks, but current evidence does not support measuring specific indoor microbiologic factors to guide health-protective actions.

Is CO2 an indoor pollutant? Direct effects of low-to-moderate CO2 concentrations on human decision-making performance.

Background: Associations of higher indoor carbon dioxide (CO2) concentrations with impaired work performance, increased health symptoms, and poorer perceived air quality have been attributed to correlation of indoor CO2 with concentrations of other indoor air pollutants that are also influenced by rates of outdoor-air ventilation. Objectives: We assessed direct effects of increased CO2, within the range of indoor concentrations, on decision making. Methods: Twenty-two participants were exposed to CO2 at 600, 1,000, and 2,500 ppm in an office-like chamber, in six groups. Each group was exposed to these conditions in three 2.5-hr sessions, all on 1 day, with exposure order balanced across groups. At 600 ppm, CO2 came from outdoor air and participants’ respiration. Higher concentrations were achieved by injecting ultrapure CO2. Ventilation rate and temperature were constant. Under each condition, participants completed a computer-based test of decision-making performance as well as questionnaires on health symptoms and perceived air quality. Participants and the person administering the decision-making test were blinded to CO2 level. Data were analyzed with analysis of variance models. Results: Relative to 600 ppm, at 1,000 ppm CO2, moderate and statistically significant decrements occurred in six of nine scales of decision-making performance. At 2,500 ppm, large and statistically significant reductions occurred in seven scales of decision-making performance (raw score ratios, 0.06–0.56), but performance on the focused activity scale increased. Conclusions: Direct adverse effects of CO2 on human performance may be economically important and may limit energy-saving reductions in outdoor air ventilation per person in buildings. Confirmation of these findings is needed.

Improving the Health of Workers in Indoor Environments: Priority Research Needs for a National Occupational Research Agenda

Indoor nonindustrial work environments were designated a priority research area through the nationwide stakeholder process that created the National Occupational Research Agenda. A multidisciplinary research team used member consensus and quantitative estimates, with extensive external review, to develop a specific research agenda. The team outlined the following priority research topics: building-influenced communicable respiratory infections, building-related asthma/allergic diseases, and nonspecific building-related symptoms; indoor environmental science; and methods for increasing implementation of healthful building practices. Available data suggest that improving building environments may result in health benefits for more than 15 million of the 89 million US indoor workers, with estimated economic benefits of

Indoor Environmental Exposures and Exacerbation of Asthma: An Update to the 2000 Review by the Institute of Medicine

5 to

Quantitative relationship of sick building syndrome symptoms with ventilation rates

75 billion annually. Research on these topics, requiring new collaborations and resources, offers enormous potential health and economic returns.

Association of residential dampness and mold with respiratory tract infections and bronchitis: a meta-analysis

Background: Previous research has found relationships between specific indoor environmental exposures and exacerbation of asthma. Objectives: In this review we provide an updated summary of knowledge from the scientific literature on indoor exposures and exacerbation of asthma. Methods: Peer-reviewed articles published from 2000 to 2013 on indoor exposures and exacerbation of asthma were identified through PubMed, from reference lists, and from authors’ files. Articles that focused on modifiable indoor exposures in relation to frequency or severity of exacerbation of asthma were selected for review. Research findings were reviewed and summarized with consideration of the strength of the evidence. Results: Sixty-nine eligible articles were included. Major changed conclusions include a causal relationship with exacerbation for indoor dampness or dampness-related agents (in children); associations with exacerbation for dampness or dampness-related agents (in adults), endotoxin, and environmental tobacco smoke (in preschool children); and limited or suggestive evidence for association with exacerbation for indoor culturable Penicillium or total fungi, nitrogen dioxide, rodents (nonoccupational), feather/down pillows (protective relative to synthetic bedding), and (regardless of specific sensitization) dust mite, cockroach, dog, and dampness-related agents. Discussion: This review, incorporating evidence reported since 2000, increases the strength of evidence linking many indoor factors to the exacerbation of asthma. Conclusions should be considered provisional until all available evidence is examined more thoroughly. Conclusion: Multiple indoor exposures, especially dampness-related agents, merit increased attention to prevent exacerbation of asthma, possibly even in nonsensitized individuals. Additional research to establish causality and evaluate interventions is needed for these and other indoor exposures. Citation: Kanchongkittiphon W, Mendell MJ, Gaffin JM, Wang G, Phipatanakul W. 2015. Indoor environmental exposures and exacerbation of asthma: an update to the 2000 review by the Institute of Medicine. Environ Health Perspect 123:6–20; http://dx.doi.org/10.1289/ehp.1307922

Indoor particles and symptoms among office workers: results from a double-blind cross-over study

UNLABELLED Data from published studies were combined and analyzed to develop best-fit equations and curves quantifying the change in sick building syndrome (SBS) symptom prevalence in office workers with ventilation rate. For each study, slopes were calculated, representing the fractional change in SBS symptom prevalence per unit change in ventilation rate per person. Values of ventilation rate, associated with each value of slope, were also calculated. Linear regression equations were fitted to the resulting data points, after weighting by study size. Integration of the slope-ventilation rate equations yielded curves of relative SBS symptom prevalence vs. ventilation rate. Based on these analyses, as the ventilation rate drops from 10 to 5 l/s-person, relative SBS symptom prevalence increases approximately 23% (12% to 32%), and as ventilation rate increases from 10 to 25 l/s-person, relative prevalence decreases approximately 29% (15% to 42%). Variations in SBS symptom types, building features, and outdoor air quality may cause the relationship of SBS symptom prevalence with ventilation rate in specific situations to differ from the average relationship predicted in this paper. PRACTICAL IMPLICATIONS On average, providing more outdoor air ventilation will reduce prevalence rates of sick building syndrome (SBS) symptoms. However, given the costs of energy use, including increased risks of climate change, it is important to balance the benefits and risks of increased ventilation. This paper provides initial estimates of how the incremental health benefits per unit of increased ventilation diminish at higher levels of ventilation.

Risk factors in heating, ventilating, and air‐conditioning systems for occupant symptoms in US office buildings: the US EPA BASE study

BackgroundDampness and mold have been shown in qualitative reviews to be associated with a variety of adverse respiratory health effects, including respiratory tract infections. Several published meta-analyses have provided quantitative summaries for some of these associations, but not for respiratory infections. Demonstrating a causal relationship between dampness-related agents, which are preventable exposures, and respiratory tract infections would suggest important new public health strategies. We report the results of quantitative meta-analyses of published studies that examined the association of dampness or mold in homes with respiratory infections and bronchitis.MethodsFor primary studies meeting eligibility criteria, we transformed reported odds ratios (ORs) and confidence intervals (CIs) to the log scale. Both fixed and random effects models were applied to the log ORs and their variances. Most studies contained multiple estimated ORs. Models accounted for the correlation between multiple results within the studies analyzed. One set of analyses was performed with all eligible studies, and another set restricted to studies that controlled for age, gender, smoking, and socioeconomic status. Subgroups of studies were assessed to explore heterogeneity. Funnel plots were used to assess publication bias.ResultsThe resulting summary estimates of ORs from random effects models based on all studies ranged from 1.38 to 1.50, with 95% CIs excluding the null in all cases. Use of different analysis models and restricting analyses based on control of multiple confounding variables changed findings only slightly. ORs (95% CIs) from random effects models using studies adjusting for major confounding variables were, for bronchitis, 1.45 (1.32-1.59); for respiratory infections, 1.44 (1.31-1.59); for respiratory infections excluding nonspecific upper respiratory infections, 1.50 (1.32-1.70), and for respiratory infections in children or infants, 1.48 (1.33-1.65). Little effect of publication bias was evident. Estimated attributable risk proportions ranged from 8% to 20%.ConclusionsResidential dampness and mold are associated with substantial and statistically significant increases in both respiratory infections and bronchitis. If these associations were confirmed as causal, effective control of dampness and mold in buildings would prevent a substantial proportion of respiratory infections.

Association of Classroom Ventilation with Reduced Illness Absence: A Prospective Study in California Elementary Schools

Background. We studied the effects of removing small airborne particles in an office building without unusual contaminant sources or occupant complaints. Methods. We conducted a double-blind crossover study of enhanced particle filtration in an office building in the Midwest United States in 1993. We replaced standard particle filters, in separate ventilation systems on two floors, with highly efficient filters on alternate floors weekly over 4 weeks. Repeated-measures models were used to analyze data from weekly worker questionnaires and multiple environmental measurements. Results. Bioaerosol concentrations were low. Enhanced filtration reduced concentrations of the smallest airborne particles by 94%. This reduction was not associated with reduced symptoms among the 396 respondents, but three performance-related mental states improved; for example, the confusion scale decreased (−3.7%; 95% confidence limits (CL) = −6.5, −0.9). Most environmental dissatisfaction variables also improved;eg, “stuffy” air, −5.3% (95% CL = −10.3, −0.4). Cooler temperatures within the recommended comfort range were associated with remarkably large improvement in most outcomes; for example, chest tightness decreased −23.4% (95% CL = −38.1, −8.7) for every 1°C decrease. Conclusions. Benefits of enhanced filtration require assessment in buildings with higher particulate contaminant levels in studies controlling for temperature effects. Benefits from lower indoor temperatures need confirmation.

Elevated symptom prevalence associated with ventilation type in office buildings

UNLABELLED Building-related symptoms in office workers worldwide are common, but of uncertain etiology. One cause may be contaminants related to characteristics of heating, ventilating, and air-conditioning (HVAC) systems. We analyzed data from 97 representative air-conditioned US office buildings in the Building Assessment and Survey Evaluation (BASE) study. Using logistic regression models with generalized estimating equations, we estimated odds ratios (OR) and 95% confidence intervals for associations between building-related symptom outcomes and HVAC characteristics. Outdoor air intakes less than 60 m above ground level were associated with significant increases in most symptoms: e.g. for upper respiratory symptoms, OR for intake heights 30 to 60 m, 0 to <30 m, and below ground level were 2.7, 2.0, and 2.1. Humidification systems with poor condition/maintenance were associated with significantly increased upper respiratory symptoms, eye symptoms, fatigue/difficulty concentrating, and skin symptoms, with OR = 1.5, 1.5, 1.7, and 1.6. Less frequent cleaning of cooling coils and drain pans was associated with significantly increased eye symptoms and headache, with OR = 1.7 and 1.6. Symptoms may be due to microbial exposures from poorly maintained ventilation systems and to greater levels of vehicular pollutants at air intakes nearer the ground level. Replication and explanation of these findings is needed. PRACTICAL IMPLICATIONS These findings support current beliefs that moisture-related HVAC components such as cooling coils and humidification systems, when poorly maintained, may be sources of contaminants that cause adverse health effects in occupants, even if we cannot yet identify or measure the causal exposures. While finding substantially elevated risks for poorly maintained humidification systems, relative to no humidification systems, the findings do not identify important (symptom) benefits from well-maintained humidification systems. Findings also provide an initial suggestion, needing corroboration, that outdoor air intakes lower than 18 stories in office buildings may be associated with substantial increases in many symptoms. If this is corroborated and linked to ground-level vehicle emissions, urban ventilation air intakes may need to be located as far above ground level as possible or to incorporate air cleaners that remove gaseous pollutants.