1. Sick Building Syndrome Dr. Emilia Zainal Abidin Faculty of Medicine and Health Sciences, UPM

2. Contents of lecture Indoor air quality Ambient air composition Sources of indoor air pollution Definition of sick building syndrome (SBS) Types of building associated illness Investigation SBS (individuals and building) Factors associated with SBS Code of practice on indoor air quality

3. Indoor air quality Indoor air level-2.5 x more pollutants than outdoor People spend more time indoor compared to outdoor Air is recycled again and again and pollutants easily trapped indoor Definition of Indoor air quality (IAQ) - The nature of air that affect the health and well being of occupant inside the building or quality of air in an indoor environment Involve 3 basic needs of human Thermal acceptability Maintenance of normal concentration of respiratory gas Dilution & removal of contaminants to levels below health or odor discomfort thresholds Quality of environment indoors (noise, lighting, ergonomic stressors etc.)

4. Factors that influence IAQ Sources of pollutants or odours Maintenance & operation of building ventilation system Moisture & humidity Occupant perception and susceptibility

5. Normal Ambient Air Composition major gas elements dry gas wet gas % volume% weight % volume% weight Nitrogen, N2 Oxygen, O2 Water, H2O Argon, Ar Total 78.09 20.94 - 0.93 99.96 75.54 23.13 - 1.28 99.95 75.65 20.29 3.12 0.9 99.96 74.08 22.64 1.94 1.27 99.95 ( Source: Bretshneider & Kursurst, 1982. Air Pollution Control Technology )

6. Minor gases elementDry airWet air Carbon dioxide(CO 2 ) Neon (Ne) Helium (He) Methane (CH 4 ) Crypton (Kr) Nitrogen dioxide(N 2 O) Water (H 2 O) Carbon monoxide (CO) Xenon (Xe) Ozone (O 3 ) Ammonia (NH 3 ) Nitrogen dioxide (NO 2 ) Sulphur dioxide (SO 2 ) Hydrogen sulfide (H 2 S) Hydrocarbon (C x Hy) Organic vapour ppmvg.m -3 ppm / weightppmvg.m -3 Ppm / weight 315 18 5.2 1.0 0.5 0.1 0.08 0.02 0.01 0.001 0.0002 - 0.02 567 14.9 0.85 0.656 3.43 0.90 0.0413 - 0.429 - 478 12.6 0.717 0.554 2.895 0.760 0.0348 0.200 0.362 - 0.010 0.003 0.0009 - 0.02 305 17.4 5.0 0.97 0.49 - 0.08 0.060 - 549 14.4 0.825 0.635 3.32 0.873 0.04 - 0.417 - 469 12.3 0.705 0.543 2.837 0.746 0.034 - 0.356 - Total341.4312-496.1967330.42-486.521 Normal Ambient Air Composition

7. Indoor furnishing outdoor Building material Human activities Sources of IAP Sources of IAP

8. Sources of Indoor Air Pollution Outdoor Penetrate indoor through any opening. e.g. O3, SO2, radon Building material Concretes, stone, plywood, particle board, insulator, fire retardant and paints. VOCs more in new building asbestos Indoor furnishing From cushions and curtains e.g. organic dust and fibrous particles Human activities Cooking, cleaning, smoking Source for CO2, CO, SO2, NO2, VOCs

9. Indoor Air pollutants Inorganic Combustion generated OrganicBiological

10. Inorganic contaminants Asbestos - Used for construction of building & industrial application – asbestosis, mesothelioma Radon Lead – used as pigments in paints, lead batteries and hair dye products, etc. Acute exposure (blood lead level >60 μg/dL) cause Shock, severe anemia, kidney damage, encephalopathy, nervous system damage Ozone Used in water to killed microbes Generated by photocopy machine & laser printer Outdoor source

11. Radon Colorless, odorless, radioactive gas which produced naturally from the breakdown of uranium Derived primarily from the soil Its decay product  adverse health effect e.g. lung CA,COPD Enter building via water from drilled well Basement Cracks in the foundation Entrance utility service lines

12. Combustion-generated contaminants Carbon monoxide (CO) From incomplete burning of carbon-based fuels Acute exposure to high concentration of CO  death CO bind with Hb in blood  Carboxyhaemoglobin Compete with Oxygen for Hb binding site - higher affinity to Hb (> 200 times higher than oxygen) Brain, CNS affected and can be fatal Sulphur dioxide (SO2) Colorless, nonflammable gas Fuel combustion, manufacture of sulphuric acid, coal burning Effect - Irritation of eyes and respiratory tract, Asthmatic symptoms ETS or environmental tobacco smoke - Contain tar, nicotine, CO, nitrogen oxides, formaldehydes, nitrosamines etc

13. Organics contaminants halogenated fluorinechlorine aliphaticoxygenated aldehydeketones estersethers acids aromatic

14. Organic contaminants Formaldehyde - The smallest & simplest aldehyde Colorless, pungent smelling, flammable gas Sources Particle board, hardwood, plywood paneling medium density fiberboard Disinfectant Effects low exposure  tears, skin irritation moderate exposure  burning eyes, nose & trachea  severe cough high exposure  lung inflammation  edema  death

15. Volatile Organic Compounds Organic compounds-boiling point 50-100 C  240-260 C no color, taste, smell source : DIY work, paint effect (chronic exposure) benzene  leukemia PAH  cancer 1,3-butiene  ↑ risk of cancer contribute to SBS (sick building syndrome)

16. Biological contaminants Sources Outdoor air Human Animals/pets Indoor surfaces Water reservoir Component of heating, ventilating, air conditioning (HVAC system) Growth encourage by indoor that is humid

17. Biological contaminants cont. Health effect Infection bacteria- Legionnaire disease- Legionella pneumophila TB – Mycobacterium tuberculosis Pneumonia- Mycoplasma pneumonia Anthrax-Bacillus anthracis virus- influenza, respiratory infection, measles, rubella, chicken pox fungi- mold Hypersensitivity diseases allergen from dust mites, insects & pets Odour

18. Sick building syndrome “Sick office syndrome”, “Tight building syndrome” or “Sick building syndrome” (WHO) or “Building associated illnesses” SBS occurs when a building in which its occupants complain of ill-health more commonly than might reasonably be expected e.g. when persons (20% or more) working or living in the building suffer from variety of non-specific symptoms, and where it is not possible to make a specific diagnosis

19. Sick building syndrome Building occupant experience acute health and discomfort effect Appeared to be linked with time spent in building No specific illness Cannot identify causes Symptom Headache, dry/itchy skin Eye, nose, throat irritation, dry cough Dizziness & nausea, rhinitis & fatigues Sensitivity to odor Relief when leaving the building

20. Different concept with Building-Related Illness and Work-Related Illness BRI Building occupants complain of symptoms such as cough chest tightness fever chills muscle aches The symptoms can be clinically defined & have clearly identifiable causes Complainants may require prolonged recovery times after leaving the building WRI Illness assoc. with specific work activities medical & dental sector illness related to exposure to formalin latex allergy to latex glove office-illness related to exposure to laser printer & photocopier

21. Sick Building Syndrome Developed countries – 50% of the workforce work in an office environment 30% of new and remodeled office blocks in developed countries – signs of SBS, 10-30% of occupants affected Concentrations of pollutants indoors may exceed standards for concentrations of pollutants outdoors People also spend more time indoor

22. Acute short latency illnesses Sick building syndrome Mass psychogenic illness Building associated hypersensitivity pneumonitis Infections - Legionnaires Disease Pontiac fever, Q Fever Potential chronic long latency illnesses COPD and cancer TYPES OF BUILDING ASSOCIATED ILLNESS (ML Fischman in La Dou)

23. Symptoms: relatively acute onset related to presence in building relieved by removal from exposure Syndrome is a group diagnosis Physician and building manager involved in diagnosis

24. Investigation of individuals with SBS Persons with symptoms must be examined by medical doctor Symptoms: Irritation to the eyes, skin and upper respiratory tract, fatigue, headache and nausea (WHO) Other symptoms : dizziness, difficulty in concentration, chest tightness No specific diagnostic criteria – medical history and association of symptoms with building occupancy

25. SBS questionnaire In the past 12 months have you had >2 episodes of: Itchy or watery eyes; Blocked or stuffy nose; Runny nose; Dry throat; Lethargy and/or tiredness; Headache; Dry, itchy or irritated skin. If ‘yes’, was it better on days away from office? (Raw, 1995)

26. The ‘Whitehall II’ SBS study Ongoing health survey of office based civil servants - longitudinal study of 10,308 m+f aged 35-55 at baseline. Self-report questionnaire 10 symptoms: Headache; cough; dry eyes; blocked/runny nose; tired for no reason; rashes/itches; cold/flu; dry throat; sore throat; wheeziness. 4052 participants (42-62 yrs, m+f) in 44 buildings. (Marmot et al, 2006)

27. Questionnaire survey Among all/representative sample Validated questionnaires available Building Inspection Ventilation and air conditioning Need for physical, chemical or biological measurement assessed Environmental measurements – Air exchange rate, dust levels, temperature, mould, bacteria, Investigation of SBS in building

28. FACTORS ASSOCIATED WITH SBS Air conditioning and ventilation problems (low humidity) Poor lighting. Increased use of synthetic building materials Use of electronic equipment

29. No specific disease explaining symptoms, no predisposing factors e.g. atopy present, building investigation revealed factor related with SBS – SBS probable – proceed to find source Patient does not have disease explaining symptoms, no factors related to building – cannot draw any firm conclusion Some disease may explain symptoms, no building related factors – probably not SBS Decision making on diagnosis of SBS

30. prevention maintaining good IAQ

31. Maintaining Indoor Air Quality Control source of pollutant Clean the air Mechanical filter Electronic filter: remove air borne particles Provide adequate ventilation

32. regulatory limits & guidelines authority & society initiatives

33. Code of Practice on IAQ in Malaysia Under Occupational Safety & Health Act 1994 (Act 154): Industrial Code of practice on indoor air quality(2010). set max. exposure limits - 5 common IA contaminant

34. Table : List of Indoor Air Contaminants and The Maximum Limits Where:  C is the ceiling limit  mg/m 3 is milligrams per cubic meter of air at 25 0 C and one atmosphere pressure  ppm is parts of vapour or gas per million parts of contaminated air by volume (Source: Dept. of Occupational Safety & Health, 2010. Industrial Code of Practice on IAQ) Indoor Air Contaminants Eight-hour time-weighted average airborne concentration ppmmg/m 3 Carbon dioxide Carbon monoxide Formaldehyde Respirable particulates Volatile organic compounds C1000 10 0.1 3 0.15 Code of Practice on IAQ in Malaysia

35. Healthy indoor environment FOUR (4) parameters set up by the Department of Occupational Safety and Health (DOSH) Malaysia to indicate whether an indoor environment is comfortable and healthy Chemical contaminants, such as carbon dioxide, carbon monoxide, formaldehyde and environmental tobacco smoke Physical conditions, such air temperature, air velocity and humidity Biological agents, such as mites, virus, and spores Radiation such as radon

36. Thank you for your attention