indoor air quality: effects on human health kenneth h. dangman, phd, md, mph, eileen storey, md,...
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INDOOR AIR QUALITY: INDOOR AIR QUALITY: EFFECTS ON HUMAN HEALTHEFFECTS ON HUMAN HEALTH
Kenneth H. Dangman, PhD, MD, MPH, Kenneth H. Dangman, PhD, MD, MPH,
Eileen Storey, MD, MPH, andEileen Storey, MD, MPH, and
Michael J. Hodgson, MD, MPHMichael J. Hodgson, MD, MPH
from thefrom the Division of Occupational Environmental Medicine Division of Occupational Environmental Medicine
University of Connecticut Health CenterUniversity of Connecticut Health Center
June 15, 2005June 15, 2005
Effects of Air Pollution on the Health of Older AdultsEffects of Air Pollution on the Health of Older Adults
Arlington, VAArlington, VA
Changes in building designChanges in building designstarting after the 1930s:starting after the 1930s:
““Tighter” buildings with lower Tighter” buildings with lower heating/cooling costsheating/cooling costs
outdoor air outdoor air indoor air indoor air
(attenuation) (concentration)(attenuation) (concentration)
Point Sources: Synthetic building Point Sources: Synthetic building materials, office machines, people, materials, office machines, people, cigarettes, microbial reservoirs cigarettes, microbial reservoirs
Contaminants: VOCs, ozone, ETS, Contaminants: VOCs, ozone, ETS, CO, radon, bioaerosolsCO, radon, bioaerosols
Are there known health effects Are there known health effects of poor indoor air quality on of poor indoor air quality on older adults? older adults?
Indoor air pollution and Indoor air pollution and Older Adults: Older Adults:
Carbon MonoxideCarbon Monoxide Low level exposures lead to non-specific Low level exposures lead to non-specific symptoms (‘flu, gastroenteritis, fatigue, HA)symptoms (‘flu, gastroenteritis, fatigue, HA)
Elderly susceptible—Housebound, Less Elderly susceptible—Housebound, Less physiological reservephysiological reserve
Exacerbation of CAD/angina, COPD, Exacerbation of CAD/angina, COPD, dementia. Delayed neuropsych impairment dementia. Delayed neuropsych impairment after 2-28 days after 2-28 days behavioral changes, ataxia, behavioral changes, ataxia, memory deficits in 3%. memory deficits in 3%.
Limited correlation of COHb and severity of Limited correlation of COHb and severity of clinical features (nl < 2-5%)clinical features (nl < 2-5%)
Harper & Croft-Baker, Age and Aging, 33: 105, 2004Harper & Croft-Baker, Age and Aging, 33: 105, 2004
Indoor air pollution and Indoor air pollution and Older Adults: Older Adults:
Particulate MatterParticulate Matter PM Sources: Tobacco smoke, PM Sources: Tobacco smoke, Heating/cooking fuels (biomass fuels, Heating/cooking fuels (biomass fuels, wood, kerosene), Outdoor air infiltrationwood, kerosene), Outdoor air infiltrationApparent relationship to respiratory Apparent relationship to respiratory symptoms/disease in adults symptoms/disease in adults (Asthma/wheezing/shortness of breath)(Asthma/wheezing/shortness of breath)
Mishra, Effect of indoor air pollution from biomass combustion on Mishra, Effect of indoor air pollution from biomass combustion on prevalence of asthma in the elderly, EHP 111: 71, 2003; prevalence of asthma in the elderly, EHP 111: 71, 2003;
Simoni et al, Towards Healthy Air in Dwellings in Europe, THADE Simoni et al, Towards Healthy Air in Dwellings in Europe, THADE Project Report, www.efanet.org Project Report, www.efanet.org
Building Related Illness (BRI) Building Related Illness (BRI) in DOEM patientsin DOEM patients
AsthmaAsthma
ILD (HP)ILD (HP)
Rhinitis/Sinusitis/Laryngitis/ Vocal cord Rhinitis/Sinusitis/Laryngitis/ Vocal cord dysfunction syndromes dysfunction syndromes
DermatitisDermatitis
Toxic Syndromes – ClToxic Syndromes – Cl2,, Pb,Pb, CO, etc. CO, etc.
Lung cancer (biomass fuels, ETS) Lung cancer (biomass fuels, ETS)
(Transmitted Infections —TB, Legionella, Flu and (Transmitted Infections —TB, Legionella, Flu and other respiratory viruses) other respiratory viruses)
Sick Building SyndromeSick Building SyndromeItchy, dry eyesItchy, dry eyes
Nasal symptomsNasal symptoms
HeadacheHeadache
Fatigue/sleepinessFatigue/sleepiness
CoughCough
Characterized by rapid Characterized by rapid improvement upon going outsideimprovement upon going outside
Point Sources-1:“Point Sources-1:“Sewage Workers Lung Disease”Sewage Workers Lung Disease” in a government building in DC (1977-87) in a government building in DC (1977-87)
Photograph courtesy of Phil Morey, PhD, CIH Hodgson M et al. Pulmonary disease associated with cafeteria flooding. Arch Environ Health 40: 96, 1985
Point Sources-2: Point Sources-2: (Asthma in a CT hospital building)(Asthma in a CT hospital building)
Clinical EvaluationClinical EvaluationMedical HistoryMedical History——chronology, environmental chronology, environmental
contextcontext
Environmental HistoryEnvironmental History——work, home, elsewhere work, home, elsewhere
Personal HabitsPersonal Habits
Physical ExamPhysical Exam
Laboratory studiesLaboratory studies
Radiologic studiesRadiologic studies
Functional studiesFunctional studies——bracketed spirometrybracketed spirometry
UCHC IH Walkthrough InspectionUCHC IH Walkthrough Inspection
Plexiglas plates over diffusers (18 inPlexiglas plates over diffusers (18 in22);); foam inserts. Installed by Hospital foam inserts. Installed by Hospital Engineering Dept to decrease/balance Engineering Dept to decrease/balance airflow from diffusers, 2-5 yrs priorairflow from diffusers, 2-5 yrs prior
Discolored for several yearsDiscolored for several years
Stained ceiling tiles—minor history of Stained ceiling tiles—minor history of leaks from the 2leaks from the 2ndnd floor plumbing floor plumbing
Office located in a basement, with Office located in a basement, with carpet over concrete floorcarpet over concrete floor
Plexiglass plate:Plexiglass plate:
Wipe Samples: culture results—Wipe Samples: culture results— Cladosporium sp. 200 (CFU per inCladosporium sp. 200 (CFU per in22)) Penicillium sp. 3,300Penicillium sp. 3,300 Bacillus sp. 730,000 Bacillus sp. 730,000 Gram Neg sp. 64,000Gram Neg sp. 64,000
After removal of the Plexiglas, and After removal of the Plexiglas, and general remediation of the workplace, general remediation of the workplace, the patient was able to return to her jobthe patient was able to return to her job
Approach to Environment-BRIApproach to Environment-BRI
AllergensAllergens - - microbes, animals, chemicalsmicrobes, animals, chemicals
IrritantsIrritants - - chemicals, dustchemicals, dust
Point Sources Point Sources - water incursion, - water incursion,
malfunctioning equipment, new materialsmalfunctioning equipment, new materials
Exposure mechanism (Pathways)Exposure mechanism (Pathways)
Dilution ventilationDilution ventilation
What about What about water incursion and water incursion and indoor mold growth?indoor mold growth?
Clinical Effects of Indoor Clinical Effects of Indoor Fungi/MoldFungi/Mold
(Established Mechanisms)(Established Mechanisms)
Infectious DiseaseInfectious Disease
Hypersensitivity Responses and Hypersensitivity Responses and Allergic ReactionsAllergic Reactions
Irritant ResponsesIrritant Responses
Toxic EffectsToxic Effects
Mold-Induced Mold-Induced Allergic/Hypersensitivity ReactionsAllergic/Hypersensitivity Reactions
Upper Respiratory SyndromesUpper Respiratory Syndromes
Rhinitis/SinusitisRhinitis/Sinusitis
AsthmaAsthma
Hypersensitivity PneumonitisHypersensitivity Pneumonitis
Farmer’s Lung Farmer’s Lung ((AspergillusAspergillus species) species)
Summer house HP Summer house HP ((Trichosporon cutaneumTrichosporon cutaneum))
Irritant Agents from MoldsIrritant Agents from MoldsVolatile Organic Compounds (VOC’s)Volatile Organic Compounds (VOC’s)
–alcoholsalcohols
–aldehydesaldehydes
–organic acidsorganic acids
–aromatic compounds aromatic compounds
(e.g., pinene, limonene)(e.g., pinene, limonene)
(1(13)-3)- --D-glucans — irritation and D-glucans — irritation and
immunomodulation (Rylander et al)immunomodulation (Rylander et al)
Mold-Induced Irritant Mold-Induced Irritant EffectsEffects
Burning eyesBurning eyesNasal stuffinessNasal stuffinessSore throatSore throatLaryngitisLaryngitisChest painChest painCoughCoughSkin rashSkin rashHeadache, fatigueHeadache, fatigue
Stachybotrys chartarumStachybotrys chartarum(Moisture Signature Fungi)(Moisture Signature Fungi)
Soil fungus/plant parasiteSoil fungus/plant parasite
ccommonly found indoors on wet ommonly found indoors on wet materials containing cellulose, such materials containing cellulose, such as wallboard, jute backing on rugs, as wallboard, jute backing on rugs, wicker, straw, and paper materialswicker, straw, and paper materials
Thought to be allergenicMay Thought to be allergenicMay produce potent mycotoxinsproduce potent mycotoxins– Trichothecenes (Satratoxins)Trichothecenes (Satratoxins)– HemolysinsHemolysins– Proteolytic enzymes (Proteolytic enzymes (>>6 types)6 types)
? mycotoxicosis? mycotoxicosis
Modified from University of Tulsa website; http//pollen.utulsa.edu/Medical%20Botany/mycotoxins.ppt
Indoor Mold, Bioaerosols and Indoor Mold, Bioaerosols and BRIBRI
Two areas of uncertainty re: indoor molds:Two areas of uncertainty re: indoor molds:– Exposure level in a given “problem” buildingExposure level in a given “problem” building
No established standards for indoor fungi in No established standards for indoor fungi in air or on surfacesair or on surfaces
– Health effects that result from those exposuresHealth effects that result from those exposures
Dose response relationships not knownDose response relationships not known–Are there Are there Sensitive PopulationsSensitive Populations, such as the , such as the
elderly?elderly?–Toxicity resulting from threshold dosages?Toxicity resulting from threshold dosages?–Subspecies of Stachybotrys chartarum?Subspecies of Stachybotrys chartarum?
Indoor Mold, Bioaerosols and Indoor Mold, Bioaerosols and BRIBRI
Current approachCurrent approach
–Vigilant observation of the patientVigilant observation of the patient
–Prudent remediation of the structure Prudent remediation of the structure (water incursion)(water incursion)
In summary:In summary: It is possible that Older Adults are more It is possible that Older Adults are more susceptible to deleterious effects of indoor susceptible to deleterious effects of indoor air pollutants, including bioaerosols, than air pollutants, including bioaerosols, than younger people for a variety of reasons. younger people for a variety of reasons.
To understand the sum total of effects of To understand the sum total of effects of ambient air pollution on the Older Adult, it ambient air pollution on the Older Adult, it will be necessary to include the role of will be necessary to include the role of indoor environments, where it appears the indoor environments, where it appears the majority of elderly people spend most of majority of elderly people spend most of their timetheir time…. ….
Indoor Air Pollution and Indoor Air Pollution and Older Adults—Older Adults—
Remaining questions:Remaining questions:
Which Agents? Which Agents?
Pathophysiological Mechanisms?Pathophysiological Mechanisms?
Lower thresholds for toxic effects? Lower thresholds for toxic effects?
Longer recuperation times? Longer recuperation times?
Future DirectionsFuture Directions
Assess the prevalence of BRI and Assess the prevalence of BRI and SBS in older adults SBS in older adults
Evaluate housing stock where Evaluate housing stock where older adults live older adults live
Evaluate the health impacts of Evaluate the health impacts of allergens and irritants in the indoor allergens and irritants in the indoor environment on older adults. environment on older adults.