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.