Sandra K. White

Hydrophilic Fungi and Ergosterol Associated with Respiratory Illness in a Water-Damaged Building

Background Damp building–related respiratory illnesses are an important public health issue. Objective We compared three respiratory case groups defined by questionnaire responses [200 respiratory cases, 123 of the respiratory cases who met the epidemiologic asthma definition, and 49 of the epidemiologic asthma cases who had current physician-diagnosed asthma with post-occupancy onset] to a comparison group of 152 asymptomatic employees in an office building with a history of water damage. Methods We analyzed dust samples collected from floors and chairs of 323 cases and comparisons for culturable fungi, ergosterol, endotoxin, and cat and dog allergens. We examined associations of total fungi, hydrophilic fungi (requiring water activity ≥ 0.9), and ergosterol with the health outcomes using logistic regression models. Results In models adjusted for demographics, respiratory illnesses showed significant linear exposure–response relationships to total culturable fungi [interquartile range odds ratios (IQR-OR) = 1.37–1.72], hydrophilic fungi (IQR-OR = 1.45–2.19), and ergosterol (IQR-OR = 1.54–1.60) in floor and chair dusts. Of three outcomes analyzed, current asthma with postoccupancy physician diagnosis was most strongly associated with exposure to hydrophilic fungi in models adjusted for ergosterol, endotoxin, and demographics (IQR-OR = 2.09 for floor and 1.79 for chair dusts). Ergosterol levels in floor dust were significantly associated with epidemiologic asthma independent of culturable fungi (IQR-OR = 1.54–1.55). Conclusions Our findings extend the 2004 conclusions of the Institute of Medicine [Human health effects associated with damp indoor environments. In: Damp Indoor Spaces and Health. Washington DC:National Academies Press, 183–269] by showing that mold levels in dust were associated with new-onset asthma in this damp indoor environment. Hydrophilic fungi and ergosterol as measures of fungal biomass may have promise as markers of risk of building-related respiratory diseases in damp indoor environments.

Respiratory morbidity in office workers in a water-damaged building

We conducted a study on building-related respiratory disease and associated social impact in an office building with water incursions in the northeastern United States. An initial questionnaire had 67% participation (888/1,327). Compared with the U.S. adult population, prevalence ratios were 2.2–2.5 for wheezing, lifetime asthma, and current asthma, 3.3 for adult-onset asthma, and 3.4 for symptoms improving away from work (p < 0.05). Two-thirds (66/103) of the adult-onset asthma arose after occupancy, with an incidence rate of 1.9/1,000 person-years before building occupancy and 14.5/1,000 person-years after building occupancy. We conducted a second survey on 140 respiratory cases, 63 subjects with fewer symptoms, and 44 comparison subjects. Health-related quality of life decreased with increasing severity of respiratory symptoms and in those with work-related symptoms. Symptom status was not associated with job satisfaction or how often jobs required hard work. Respiratory health problems accounted for one-third of sick leave, and respiratory cases with work-related symptoms had more respiratory sick days than those without work-related symptoms (9.4 vs. 2.4 days/year; p < 0.01). Abnormal lung function and/or breathing medication use was found in 67% of respiratory cases, in 38% of participants with fewer symptoms, and in 11% of the comparison group (p < 0.01), with similar results in never-smokers. Postoccupancy-onset asthma was associated with less atopy than preoccupancy-onset asthma. Occupancy of the water-damaged building was associated with onset and exacerbation of respiratory conditions, confirmed by objective medical tests. The morbidity and lost work time burdened both employees and employers.

Identification of Mold and Dampness-Associated Respiratory Morbidity in 2 Schools: Comparison of Questionnaire Survey Responses to National Data

BACKGROUND Dampness and mold problems are frequently encountered in schools. Approximately one third of US public schools require extensive repairs or need at least 1 building replaced. This study illustrates how national data can be used to identify building-related health risks in school employees and students. METHODS School employees (n = 309) in 2 elementary schools (schools A and B) with dampness and mold problems completed standardized questionnaires. Responses were compared with participant responses from the 3rd National Health and Nutrition Examination Survey and were indirectly standardized for gender, age, smoking status, and (for school B) race. Uncontrolled comparisons were made to responses from a study of office workers, as well as between responses from school employees in different sections of the school buildings designated by decade of construction. RESULTS Employees from both schools had excess work-related throat and lower respiratory symptoms, as well as eye, nasal, sinus, and wheezing symptoms. School B employees also had excess physician-diagnosed asthma and work-related fatigue, headache, and skin irritation. Employees in sections of the school buildings that were categorized as having greater dampness and mold contamination had more frequent upper and lower respiratory symptoms than employees working in other building sections. CONCLUSIONS This noncostly type of analysis of indoor air quality complaints can be used to motivate and prioritize building remediation in public schools where funds for building remediation are usually limited.

Respiratory inflammatory responses among occupants of a water-damaged office building.

UNLABELLED The National Institute for Occupational Safety and Health (NIOSH) received a request for evaluation of a water-damaged office building which housed approximately 1300 employees. Workers reported respiratory conditions that they perceived to be building related. We hypothesized that these symptoms were associated with airways inflammation. To test this hypothesis, we assessed airways inflammation in employees using exhaled breath condensate (EBC) and the fraction of exhaled nitric oxide (FENO). In September 2001, a health questionnaire was offered to all employees. Based on this questionnaire, NIOSH invited 356 symptomatic and asymptomatic employees to participate in a medical survey. In June 2002, these employees were offered questionnaire, spirometry, methacholine challenge test, allergen skin prick testing, EBC and FENO. FENO or EBC were completed by 239 participants. As smoking is highly related to the measurements that we used in this study, we included only the 207 current non-smokers in the analyses. EBC interleukin-8 (IL-8) levels, but not nitrite, were significantly higher among workers with respiratory symptoms and in the physician-diagnosed asthmatic group. Of the analyses assessed, EBC IL-8 showed the most significant relationship with a number of symptoms and physician-diagnosed asthma. PRACTICAL IMPLICATIONS Implementation of exhaled breath condensate and exhaled nitric oxide in indoor air quality problems.

Lack of respiratory improvement following remediation of a water‐damaged office building

BACKGROUND Damp buildings are commonly remediated without removing employees or ongoing medical surveillance. METHODS We examined paired pulmonary function and questionnaire data from 2002 and 2005 for 97 employees in a water-damaged building during ongoing but incomplete remediation. RESULTS We observed no overall improvement in respiratory health, as reflected in symptom scores, overall medication use, spirometry abnormalities, or sick leave. Four employees went from borderline bronchial hyperresponsiveness to bronchial hyperresponsiveness; six developed abnormal spirometry; three more reported post-occupancy current asthma, and four hypersensitivity pneumonitis. The number of participants without lower respiratory symptoms decreased from 27 in 2002 to 20 in 2005. Respiratory cases relocated in the building had a decrease in medication use and sick leave in 2005. CONCLUSIONS During dampness remediation, relocation may be health protective and prevent incident building-related respiratory cases. Without relocation of entire workforces, medical surveillance is advisable for secondary prevention of existing building-related disease.

What are the effects of having an illness or injury whilst deployed on post deployment mental health? A population based record linkage study of UK army personnel who have served in Iraq or Afghanistan.

BackgroundThe negative impact of sustaining an injury on a military deployment on subsequent mental health is well-documented, however, the relationship between having an illness on a military operation and subsequent mental health is unknown.MethodsPopulation based study, linking routinely collected data of attendances at emergency departments in military hospitals in Iraq and Afghanistan [Operational Emergency Department Attendance Register (OpEDAR)], with data on 3896 UK Army personnel who participated in a military health study between 2007 and 2009 and deployed to Iraq or Afghanistan between 2003 to 2009.ResultsIn total, 13.8% (531/3896) of participants had an event recorded on OpEDAR during deployment; 2.3% (89/3884) were medically evacuated. As expected, those medically evacuated for an injury were at increased risk of post deployment probable PTSD (odds ratio 4.27, 95% confidence interval 1.80-10.12). Less expected was that being medically evacuated for an illness was also associated with a similarly increased risk of probable PTSD (4.39, 1.60-12.07) and common mental disorders (2.79, 1.41-5.51). There was no association between having an OpEDAR event and alcohol misuse. Having an injury caused by hostile action was associated with increased risk of probable PTSD compared to those with a non-hostile injury (3.88, 1.15 to 13.06).ConclusionsPersonnel sustaining illnesses on deployment are just as, if not more, at risk of having subsequent mental health problems as personnel who have sustained an injury. Monitoring of mental health problems should consider those with illnesses as well as physical injuries.

Markers of upper airway inflammation associated with microbial exposure and symptoms in occupants of a water‐damaged building

BACKGROUND Water damage in buildings has been associated with reports of upper airway inflammation among occupants. METHODS This survey included a questionnaire, allergen skin testing, nasal nitric oxide, and nasal lavage on 153 participants. We conducted exposure assessments of 297 workstations and analyzed collected dust for fungi, endotoxin, and (1 → 3)-β-D-glucan to create floor-specific averages. RESULTS Males had higher levels of nasal inflammatory markers, and females reported more symptoms. ECP, IL-8, and MPO were significantly associated with nasal symptoms, flu-like achiness, or chills. Fungi and glucan were positively associated with blowing out thick mucus. Endotoxin was significantly associated with ECP in overall models, and with ECP, IL-8, MPO, and neutrophils among non-atopic females. CONCLUSIONS In this study, we documented an association between endotoxin and nasal inflammatory markers among office workers. The results of our study suggest that a non-allergic response may contribute to symptoms occurring among occupants in this water-damaged building.

Work-related peak flow and asthma symptoms in a damp building.

BACKGROUND Working in damp conditions is associated with asthma, but few studies have used objective testing to document work-related patterns. AIMS To describe the relationship of peak flow measurements to work-related asthma (WRA) symptoms and WRA among occupants in a damp office building. METHODS At the beginning of the study, all workers were offered a questionnaire and methacholine challenge testing. Participants were then instructed to perform serial spirometry using handheld spirometers five times per day over a 3 week period. Peak flow data were analysed using OASYS-2 software. We calculated the area between the curves (ABC score) using hours from waking. We considered a score >5.6 L/min/h to be indicative of a work-related pattern. RESULTS All 24 employees participated in the questionnaire. Seven participants (29%) reported physician-diagnosed asthma with onset after starting work in the building. Almost two-thirds (63%) of participants reported at least one lower respiratory symptom (LRS) occurring one or more times per week in the last 4 weeks. Twenty-two (92%) consented to participate in serial spirometry. Fourteen participants had adequate quality of serial spirometry, five of whom had ABC scores >5.6, ranging from 5.9-23.0. Of these five, two had airways responsiveness, three had current post-hire onset physician-diagnosed asthma and four reported work-related LRS. CONCLUSIONS We found evidence of work-related changes in serial peak flows among some occupants of an office building with a history of dampness. Serial peak flows may be a useful measure to determine WRA in office settings.

Changes in respiratory and non-respiratory symptoms in occupants of a large office building over a period of moisture damage remediation attempts

There is limited information on the natural history of building occupants’ health in relation to attempts to remediate moisture damage. We examined changes in respiratory and non-respiratory symptoms in 1,175 office building occupants over seven years with multiple remediation attempts. During each of four surveys, we categorized participants using a severity score: 0 = asymptomatic; 1 = mild, symptomatic in the last 12 months, but not frequently in the last 4 weeks; 2 = severe, symptomatic at least once weekly in the last 4 weeks. Building-related symptoms were defined as improving away from the building. We used random intercept models adjusted for demographics, smoking, building tenure, and microbial exposures to estimate temporal changes in the odds of building-related symptoms or severity scores independent of the effect of microbial exposures. Trend analyses of combined mild/severe symptoms showed no changes in the odds of respiratory symptoms but significant improvement in non-respiratory symptoms over time. Separate analyses showed increases in the odds of severe respiratory symptoms (odds ratio/year = 1.15‒1.16, p-values<0.05) and severity scores (0.02/year, p-values<0.05) for wheezing and shortness of breath on exertion, due to worsening of participants in the mild symptom group. For non-respiratory symptoms, we found no changes in the odds of severe symptoms but improvement in severity scores (-0.04‒-0.01/year, p-values<0.05) and the odds for mild fever and chills, excessive fatigue, headache, and throat symptoms (0.65–0.79/year, p-values<0.05). Our study suggests that after the onset of respiratory and severe non-respiratory symptoms associated with dampness/mold, remediation efforts might not be effective in improving occupants’ health.

Burden of respiratory abnormalities in microwave popcorn and flavouring manufacturing workers

Objectives Diacetyl, a butter flavour compound used in food and flavouring production, is a respiratory toxin. We characterised the burden of respiratory abnormalities in workers at popcorn and flavouring manufacturing facilities that used diacetyl as evaluated through US National Institute for Occupational Safety and Health (NIOSH) health hazard evaluations. Methods We performed analyses describing the number and percentage of current and former workers from popcorn and flavouring manufacturing facilities where NIOSH administered a respiratory health questionnaire and spirometry testing who met case definitions of suspected flavouring-related lung disease. Case definitions were pathologist reported: lung biopsy pathology report stating supportive of/consistent with constrictive bronchiolitis or bronchiolitis obliterans; probable: obstructive/mixed spirometric pattern with forced expiratory volume in 1 s (FEV1) <60% predicted; possible: obstructive/mixed spirometric pattern with FEV1 ≥60% or any spirometric restriction; symptoms only: normal spirometry plus exertional dyspnoea or usual cough. Results During 2000–2012, NIOSH collected questionnaire and spirometry data on 1407 workers (87.0% current, 13.0% former) at nine facilities in eight states. After applying case definitions, 4 (0.3%) were classified as pathologist reported, 48 (3.4%) as probable, 234 (16.6%) as possible and 404 (28.7%) as symptoms only. The remaining 717 (51.0%) workers had normal spirometry without exertional dyspnoea or usual cough. Seven of 11 workers with biopsies did not meet the pathologist-reported case definition, although four met probable and three met possible. Conclusions This approach demonstrates the substantial burden of respiratory abnormalities in these workers. A similar approach could quantify the burden of respiratory abnormalities in other industries that use diacetyl.