1. University of Texas School of Medicine at San Antonio
Is it the building, the occupant, or both? Using the QEESI© to investigate indoor air concerns.
June 7, 2011
Indoor Air 2011
Tatjana Walker, RD, MPH; Thomas J. Prihoda, PhD; Claudia S. Miller, M.D., M.S.
University of Texas School of Medicine at San Antonio
Good morning. I’m Tatjana Walker. Today I’ll be speaking about how you can use a questionnaire to assist in resolving indoor air concerns. The title of our paper is, 的s it the building, the occupant, or both? Using the QEESI to investigate indoor air concerns.
QEESI stands for: Quick Environmental Exposure and Sensitivity Inventory. It is a validated, published tool for assessing chemical intolerance, and it was developed by my coauthors, also from the UT School of Medicine at San Antonio, Dr. Thomas Prihoda and Dr. Claudia Miller. I’m delighted that Dr. Miller is here with us today and will available for questions after this presentation.

2. Chemical Intolerance
About 5% of people report multiple chemical intolerances
“Do you consider yourself sensitive to everyday chemicals like those in household cleaning supplies, paints, perfumes, soaps, garden sprays, or things like that?” (15%)
We should begin by defining chemical intolerance. We prefer the term chemical intolerance to the other terms in use. Another common term, Multiple Chemical Sensitivity, is particularly problematic in the medical community, because the term sensitivity implies an immunologic sensitization involving IgE. Although a limited number of chemicals are sensitizing, in general the complaints of people with chemical intolerance are not related to allergic sensitization.

3. A New Theory of Disease— Toxicant-Induced Loss of Tolerance or “TILT”
In fact, what Dr. Miller and her colleague Dr. Nicholas Ashford noted, is that chemical intolerances are just one facet of a larger underlying dynamic called TILT or Toxicant Induced Loss of Tolerance.

4. Evidence That We Are Dealing With a New Disease Mechanism
Similar reports from more than a dozen countries—different languages, media
YET they report similar new onset intolerances to structurally unrelated substances (foods, medications, alcoholic beverages, caffeine) and symptoms affecting multiple organ systems in response to these.
This is what Kuhn called a “compelling anomaly”—observations that do not fit known theories of disease
Compelling anomalies drive the search for new explanations, paradigms, theories

5. Common Indoor Conditions Linked to TILT (Stage 1)
Remodeling—new carpets, glues, cleaners, and other VOC emitters
Pesticides
Mold
Insufficient fresh make-up air

6. TOXICANT-INDUCED LOSS OF TOLERANCE ?
Solvents
Glues
Paints
Gasoline
Nail polish/remover
Indoor Air Volatile Organic Compounds (VOCs)
New carpet
Plasticizers
Formaldehyde
Fragrances
Mold VOCs
Drugs/Medical Devices
Vaccines
Anesthetics
Implants
Antibiotics
Chemotherapy
TOXICANT-INDUCED
LOSS OF
TOLERANCE ?
Combustion-related Products
Engine exhaust
Tobacco smoke
Oil well fire smoke
Natural gas
Tar/asphalt
Cleaning Agents
Phenolic disinfectants
Ammonia
Bleach
Pesticides
Organophosphates
Carbamates, pyridostigmine
Pentachlorophenol
Pyrethrins

7. TOXICANT-INDUCED LOSS OF TOLERANCE ?
Neuropsychological
Attention Deficit Hyperactivity
Disorder (ADHD)
depression
bipolar disorder
panic disorder
migraines and other headaches
seizures
autism
Ear, Nose and Throat
sinusitis
polyps
tinnitus
recurrent otitis
Cardiovascular
arrhythmias
hypertension
hypotension
Raynaud's phenomenon
Miscellaneous Syndromes
Chronic Fatigue Syndrome
implant syndromes
''Gulf War Syndrome“
Post/other disaster
syndromes
Respiratory
asthma
Reactive Airways Dysfunction
Syndrome (RADS)
toluene dlisocyanate
(TDI) hypersensitivity
TOXICANT-INDUCED
LOSS OF
TOLERANCE ?
Skin
eczema
hives
other rashes,
eruptions
Gastrointestinal
irritable bowel
reflux
Connective Tissue/Musculoskeletal
fibromyalgia
carpal tunnel syndrome
temporomandibular joint
dysfunction (TMJ) syndrome
arthritis
lupus and other auto-immune diseases

8. Identifying Toxicant-Induced Loss of Tolerance (TILT)?

9. The QEESI Validated, published questionnaire and screening tool
50 questions, self-administered
12-15 minutes to administer
Research, clinical, building investigations
Helps occupants understand their symptoms and intolerances

10. Available for download at:

14. QEESI Symptom Star Pre- and Post-Exposure
Before exposure event Since exposure event

15. QEESI Symptom Stars for 4 People in Sick Buildings
Courtesy of Carl E. Grimes

18. How Can You Use This Information Without “Practicing Medicine”?
Provide link to QEESI for occupants to self-administer
Invite affected occupants to take the results to their doctors
Some occupants will share the results with you, but don’t ask them to
In either case, those affected will self-identify and will begin to understand that they may be especially susceptible
These are the people who need accommodation
Look for physicians you can work with—QEESI will help them understand too

19. Tatjana Walker, RD, MPH
University of Texas School of Medicine at San Antonio
The QEESI is Available for Download at: