54. Building-Related Disease

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    BUILDING-RELATEDDISEASES

    Michael Hodgson, M.D., M.P.H.U.S. Department of Veterans Affairs

    Occupational Health Program

    Veterans Health Administration

    Washington, DC

    Building-related diseases (BRD) may be classified, among other ways, by mechanisms ofdisease, as is traditional in medical texts; by presenting symptoms, as is useful in the diag-nosis and treatment of patients; or by source and etiologic agent, which are usefulapproaches in engineering and regulatory strategies. Some redundancy will occur in allthree classification systems. This chapter will present diseases according to the first cate-gorization (see Table 54.1).

    Users of this text should remember the distinction between the sick-building syndrome(SBS) and what is often called building-related illness (BRI). The latter represent clearlyrecognized clinical conditions with operational criteria (i.e., medical conditions for whichwide agreement exists on how to make a diagnosis). Even for these, though, there may be

    disagreement on individual diagnoses, on best treatment strategies (as even national con-sensus guidelines may fail to address adequately specific occupational or environmentalhealth aspects of treatment strategies such as removal from work or the importance of expo-sure control), and on the true cause. On the other hand, the SBS remains a term withoutoperational criteria. Although the epidemiology of building-related complaints has beendescribed since the mid-1980s (Finnegan 1984, Kreiss and Hodgson 1984, Mendell 1993)and dose-response relationships have been recognized for over 10 years (Hodgson et al.1991), few studies have examined the mechanism of symptoms in an epidemiologic con-text. Such attempts for eye and nasal symptoms will be described later. Nevertheless,

    Jaakola (1998) suggests that the term SBScurrently represents a construct for discussionpurposes only. As the mechanisms for the various symptoms, from odor and irritationthrough headaches and allergies, are clarified, researchers will characterize the nature andseverity of the underlying conditions and support the use of diagnostic tests in the clinicaldiagnosis of individuals. Individual components of what is now labeled SBS may becomebuilding-related illnesses.

    CHAPTER 54

    54.1

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    54.2 ASSESSING IAQ

    TABLE 54.1 Disease Categories

    Disease Symptoms Mechanisms Diagnostic Criteria

    Rhinitis, sinusitis Stuffy or runny nose; Allergy (IgE) Eosinophilic granulocytes inpostnasal drip; nasal secretions

    sinus congestion; Specific changes on nasalnosebleeds provocation symptoms

    Irritation None described

    Allergic fungal Stuffy nose, postnasal Allergy (IgE), other? CT-scan evidence of

    sinusitis drip, headache inflammation,eosinophilic mucous,fungal hyphae visible onstaining

    Asthma (airways Coughing, wheezing, Allergy (IgE, IgG) Airways hyper-reactivity (moredisease) shortness of breath, than 15 percent change in FEV1)

    chest tightness Reversibility of obstructionwith bronchodilators

    Pharmacologic See above, history of exposureirritant during onset of asthma

    Hypersensitivity Cough, shortness of Type IV allergy (cell- Granulomas on biopsy,pneumonitis breath, muscle aches, mediated immunity) reversible restrictive changes,feverishness (DLCO, TLC, CXR), CT

    scan, thin-section CT scan

    Organic dust toxic Cough, shortness of Endotoxin response DLCO, TLC, spirometry,syndrome (inhala- breath, muscle aches. (macrophage white blood celltion fevers) feverishness receptor based effect) count elevations

    Contact dermatitis Dry, itching, scaling, Type IV skin allergy Inspection, skin biopsy,(allergic) red skin patch testing

    Irritant contact Dry itching or Irritation Inspection, skin biopsydermatitis weeping skin

    Contact urticaria Red, irritated skin, Type I allergy Inspection, RAST or skin pricetesting hives

    Conjunctivitis Eye irritation, dryness, Type I allergy Inspection, RAST or skin prick(allergic) tearing testing, tear-film break-up

    time, conjunctival staining

    Conjunctivitis Eye irritation, dryness, Irritation Inspection, tear film break-up

    (irritant) tearing time

    CNS toxicity Headaches, Carbon monoxide Elevated carboxyhemoglobincognitive impairment (COhgb)

    VOCs Abnormal neuropsychologicaltests

    Heat, noise Calculated heat indices outsiderange; noise levels abovecomfort range

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    BUILDING-RELATED DISEASES 54.3

    TABLE 54.1 Disease Categories

    Diagnostic tests Linkage strategies Causes

    Nasal secretions; eosinophiles IgE-based: RAST or skin Sensitizers in the workplaceCT scan for chronic inflammatory prick tests; nasal challenge (allergens) including molds,

    changes symptom patterns carbonless copy paper, photo-Acoustic rhinometry active processes (toners), andRhinomanometry (anterior and secondary exposures, e.g., cat

    posterior dander brought to work onclothing; pesticides (OPs,pyrethrin)

    None described Symptom patterns Irritant exposures, including clean-ing agents, volatile organic com-pounds, dust, molds and bacteria,low relative humidity

    Surgical tissue for eosinophilic Recurrences at work, same Bioaerosols at work

    staining in mucous, fungal bodies organisms in workplace

    Physical examination Temporal relationship of lung As allergic rhinitis irritant expo-Spirometry with bronchodilators function decrements at sures, including cleaning agents,Methacholine challenge work (PEFR, spirometry) volatile organic compounds,Substance specific challenge Immunologic tests (skin dust, molds and bacteria, low

    prick tests, RAST tests) relative humiditySee above As aboveAs above Clinical history

    Granulomas, restrictive changes in Physiologic linkage (acute Molds and thermotolerant bacterialung function in a convincing disease: reversible patterns) related to moistureclinical setting Immunologic linkage: IgG

    exposure only; lymphocytetransformation to specificantigens

    Bronchial lavage, DLCO, TLC, Temporal pattern and Gram negative bacteria, molds,spirometry, white blood cell exposure documentation polymers in thermal degradationcount elevations related to work

    Inspection, skin biopsy, patch testing Patch testing, temporal pattern Formaldehyde, molds, laser toners,Behenic acid (photoactive

    process)Clinical history, lactic acid Temporal pattern Office products, VOC based

    application (stinger test)

    Clinical history, RAST test Temporal pattern; RAST or Office productsskin prick test

    Punctate conjunctivitis, shortened Clinical impression Molds, sensitizerstear film break-up time, RAST orskin prick testing, cobblestoningon physical examination

    Inspection, tear film break-up time Clinical impression Irritants (VOCs, dust, low relative

    humidity), failure to blink atVDUs

    Neuropsychological tests, COhgb 3% in nonsmokers, Fossil fuel sources: HomeCOhgb levels 8% in smokers attached garages, backdrafting

    appliances, barbecues; commer-cial/public buildingsentrainedexhaust, indoor CO sources

    Abnormal neuropsychological tests Abnormal neuropsychological Imbalance between local VOCtests source and exhaust ventilation

    None Clinical impression Inadequate control strategies

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    54.1 GENERAL APPROACHES

    Diseases related to indoor environments are treated no differently than are conditionspotentially related to other environmental and occupational exposures (see Table 54.2). Thebasic approach includes the following steps:

    G Document disease

    G

    Document exposureG Define linkage (or exclusion) criteria

    G Develop a management plan

    For reasons described below, this approach has not been as successful in indoor environ-ments as elsewhere, and the scientific basis for this approach is often still missing.

    Document Disease

    Physicians and other health care providers make a diagnosis of a condition based primarilyon symptoms. Over 75 percent of conditions encountered in primary care need no furtherdocumentation (Peterson 1992). In fact, for many there is little objective evidence on anindividual basis. In the setting of lawsuits and workers compensation proceedings, physi-cians are often asked to provide evidence. It is therefore important to seek objective signson physical examination and measurements of abnormal organ function in laboratory test-ing, which can often be found. Even then, a few patients with symptoms will have evidenceof some physiologic or immunologic process without meeting a set of diagnostic criteriafor any specific condition.

    At times, even in symptomatic patients, tests are negative. That all tests may have falsenegative results is a fundamental truth, defined in the relationships of sensitivity, speci-ficity, and predictive value. As a test identifies a greater proportion of individuals correctlyas having a specific outcome, it also identifies more individuals without those characteris-tics. As tests are more precise, and identify fewer false positive results, more individualswith the condition are missed. In the absence of economic conflicts, physicians feel verycomfortable ignoring unexpected and unlikely results. In the setting of workers compensa-tion proceedings and litigation, where eco