1. INDOOR AIR QUALITY: EFFECTS ON HUMAN HEALTH Kenneth H. Dangman, PhD, MD, MPH, Eileen Storey, MD, MPH, and Michael J. Hodgson, MD, MPH from the Division of Occupational Environmental Medicine University of Connecticut Health Center June 15, 2005 Effects of Air Pollution on the Health of Older Adults Arlington, VA

2. Changes in building design starting after the 1930s: “Tighter” buildings with lower heating/cooling costs outdoor air  indoor air outdoor air  indoor air (attenuation) (concentration) (attenuation) (concentration) Point Sources: Synthetic building materials, office machines, people, cigarettes, microbial reservoirs  Point Sources: Synthetic building materials, office machines, people, cigarettes, microbial reservoirs  Contaminants: VOCs, ozone, ETS, CO, radon, bioaerosols

3. Are there known health effects of poor indoor air quality on older adults?

4. Indoor air pollution and Older Adults: Carbon Monoxide Low level exposures lead to non-specific symptoms (‘flu, gastroenteritis, fatigue, HA) Elderly susceptible—Housebound, Less physiological reserve Exacerbation of CAD/angina, COPD, dementia. Delayed neuropsych impairment after 2-28 days  behavioral changes, ataxia, memory deficits in 3%. Limited correlation of COHb and severity of clinical features (nl < 2-5%) Harper & Croft-Baker, Age and Aging, 33: 105, 2004 Harper & Croft-Baker, Age and Aging, 33: 105, 2004

5. Indoor air pollution and Older Adults: Particulate Matter PM Sources: Tobacco smoke, Heating/cooking fuels (biomass fuels, wood, kerosene), Outdoor air infiltration Apparent relationship to respiratory symptoms/disease in adults (Asthma/wheezing/shortness of breath) Mishra, Effect of indoor air pollution from biomass combustion on prevalence of asthma in the elderly, EHP 111: 71, 2003; Mishra, Effect of indoor air pollution from biomass combustion on prevalence of asthma in the elderly, EHP 111: 71, 2003; Simoni et al, Towards Healthy Air in Dwellings in Europe, THADE Project Report, www.efanet.org Simoni et al, Towards Healthy Air in Dwellings in Europe, THADE Project Report, www.efanet.org

6. Building Related Illness (BRI) in DOEM patients Asthma ILD (HP) Rhinitis/Sinusitis/Laryngitis/ Vocal cord dysfunction syndromes Dermatitis Toxic Syndromes – Cl,Pb, CO, etc. Toxic Syndromes – Cl 2, Pb, CO, etc. Lung cancer (biomass fuels, ETS) (Transmitted Infections —TB, Legionella, Flu and other respiratory viruses)

7. Sick Building Syndrome Itchy, dry eyes Nasal symptoms HeadacheFatigue/sleepinessCough Characterized by rapid improvement upon going outside

8. Point Sources-1:“ Sewage Workers Lung Disease” 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

9. Point Sources-2: (Asthma in a CT hospital building)

10. Clinical Evaluation Medical History— chronology, environmental context Environmental History— work, home, elsewhere Personal Habits Physical Exam Laboratory studies Radiologic studies Functional studies— bracketed spirometry

11. UCHC IH Walkthrough Inspection Plexiglas plates over diffusers (18 in 2 ); foam inserts. Installed by Hospital Engineering Dept to decrease/balance airflow from diffusers, 2-5 yrs prior Discolored for several years Stained ceiling tiles—minor history of leaks from the 2 nd floor plumbing Office located in a basement, with carpet over concrete floor

12. Plexiglass plate: Wipe Samples: culture results— Cladosporium sp. 200 (CFU per in 2 ) Cladosporium sp. 200 (CFU per in 2 ) Penicillium sp. 3,300 Penicillium sp. 3,300 Bacillus sp. 730,000 Bacillus sp. 730,000 Gram Neg sp. 64,000 Gram Neg sp. 64,000 After removal of the Plexiglas, and general remediation of the workplace, the patient was able to return to her job After removal of the Plexiglas, and general remediation of the workplace, the patient was able to return to her job

13. Approach to Environment-BRI Allergens - microbes, animals, chemicals Irritants - chemicals, dust Point Sources - water incursion, malfunctioning equipment, new materials Exposure mechanism (Pathways) Dilution ventilation

14. What about water incursion and indoor mold growth?

15. Clinical Effects of Indoor Fungi/Mold (Established Mechanisms) Infectious Disease Hypersensitivity Responses and Allergic Reactions Irritant Responses Toxic Effects

16. Mold-Induced Allergic/Hypersensitivity Reactions Upper Respiratory Syndromes Rhinitis/Sinusitis Rhinitis/SinusitisAsthma Hypersensitivity Pneumonitis Farmer’s Lung (Aspergillus species) Farmer’s Lung (Aspergillus species) Summer house HP (Trichosporon cutaneum) Summer house HP (Trichosporon cutaneum)

17. Irritant Agents from Molds Volatile Organic Compounds (VOC’s) –alcohols –aldehydes –organic acids –aromatic compounds (e.g., pinene, limonene) (1  3)-  -D-glucans — irritation and immunomodulation (Rylander et al) immunomodulation (Rylander et al)

18. Mold-Induced Irritant Effects Burning eyes Nasal stuffiness Sore throat Laryngitis Chest pain Cough Skin rash Headache, fatigue

19. Stachybotrys chartarum (Moisture Signature Fungi) Soil fungus/plant parasite commonly found indoors on wet materials containing cellulose, such as wallboard, jute backing on rugs, wicker, straw, and paper materials Thought to be allergenicMay produce potent mycotoxins –Trichothecenes (Satratoxins) –Hemolysins –Proteolytic enzymes (>6 types) ? mycotoxicosis Modified from University of Tulsa website; http//pollen.utulsa.edu/Medical%20Botany/mycotoxins.ppt

20. Indoor Mold, Bioaerosols and BRI Two areas of uncertainty re: indoor molds: –Exposure level in a given “problem” building No established standards for indoor fungi in air or on surfaces –Health effects that result from those exposures Dose response relationships not known –Are there Sensitive Populations, such as the elderly? –Toxicity resulting from threshold dosages? –Subspecies of Stachybotrys chartarum?

21. Indoor Mold, Bioaerosols and BRI Current approach –Vigilant observation of the patient –Prudent remediation of the structure (water incursion)

22. In summary: It is possible that Older Adults are more susceptible to deleterious effects of indoor air pollutants, including bioaerosols, than younger people for a variety of reasons. To understand the sum total of effects of ambient air pollution on the Older Adult, it will be necessary to include the role of indoor environments, where it appears the majority of elderly people spend most of their time ….

23. Indoor Air Pollution and Older Adults— 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?

24. Future Directions Assess the prevalence of BRI and SBS in older adults Evaluate housing stock where older adults live Evaluate the health impacts of allergens and irritants in the indoor environment on older adults.