Sick building syndrome

Definition

Sick building syndrome (SBS) is a term used to describe certain health effects people experience that may be related to poor air in buildings. The problems can be localized, for instance experienced by workers in only one section of an office or factory; or they may be widespread and experienced throughout an entire building. SBS has been reported in various settings such as hospitals, schools, industrial and art business, and care homes, or any building or home with off gassing carpets, paints, and fumes, as well as buildings with ventilation problems and concentration of vapors, gases, solvents, or other airborne agents toxic to the skin, lungs or nervous system. In fact, sick building syndrome is a condition related to poor ventilation in some of America's schools.

Description

People who have SBS generally experience symptoms related to the eyes, nose, throat, and skin. They also may complain of overall symptoms such as feeling very tired. When caused by SBS, these symptoms have no other known cause or explanation. Other similar symptoms are related to SBS and may be confused with the syndrome. For instance, "building-related illness" (BRI) is the term used for a diagnosed illness attributed to contaminants that can be identified in a building. Often, the contaminants come from the ventilation system. Legionnaire's disease is a well-known example of BRI. Multiple chemical sensitivity (MCS) is another closely related condition; however, it is not caused by SBS. People with MCS have high sensitivity or allergy to many chemicals and other substances in the environment. They may experience symptoms in many organs and systems of their bodies from low levels of exposure to chemicals.

Like MCS, SBS is largely a modern phenomenon, first recognized by the World Health Organization (WHO) as a medical condition in 1982. When building designers sought to save energy during the 1970s oil embargo, they began creating virtually airtight buildings. However, the new energy-efficient structures reduced ventilation, even to the point of reducing health and comfort for occupants. SBS has resulted in lost productivity among affected workers and increased costs for those who own and operate the buildings with poor air quality and other problems. An entire industry has developed around producing air filters and other products, as well as engineering and design consulting.

Causes & symptoms

People who complain of SBS report symptoms of acute discomfort such as eye, nose, and throat irritation, a dry cough , and dizziness or nausea . Many also report dry, itchy skin. Some will have difficulty concentrating of experience sensitivity to odors, fatigue , and headaches. While many of these symptoms are common to other conditions, their relation to time spent in a specific building suggests the possibility of SBS.

The specific causes of SBS are unknown, but several factors may contribute to the condition. The most no-table factor is poor indoor air quality. If air is not properly ventilated, it may become too dry or too humid. Also, chemicals or biological contaminants (molds, pollen, viruses, etc.) may collect in the air. The World Health Organization (WHO) estimates that up to 30% of office buildings worldwide have significant indoor air quality problems. A 1995 study found that about one-half of schools in the United States had poor ventilation and sources of pollution inside the buildings.

More than 700,000 chemicals are in common use today. Chemical contaminants can enter indoor air from the outside or from the inside. For example, vehicle exhaust can enter a building through windows or through poorly located air intake vents. However, most chemical contaminants come from indoor sources. Commonly used materials for construction and cleaning emit byproducts that can cause acute health effects in people when concentrated at high levels. Even low or moderate levels of these contaminants can cause health effects in some people with certain sensitivities. Called volatile organic compounds (VOCs), the contaminants come from carpet glues, copy machines, manufactured wood products, cleaning agents, pesticides, and tobacco smoke. Formaldehyde is one of the most common VOCs.

Radon, a radioactive gas that forms when radium breaks down in certain rock formations, can be found in homes in several states. It enters the home through foundation cracks. Radon is colorless and odorless and can go undetected, building up to dangerous levels that can lead to lung cancer .

Biological contaminants can enter a building's ventilation system. They are formed in standing water from humidifiers, drain pans, or ducts. They also may form where water has collected on wet ceiling tiles, carpet, or insulation. Some biological contaminants are pollen, bacteria, viruses, and molds.

Dust also has been found to contribute to SBS. Dust irritates the mucous membranes. A study showed that improved methods of office cleaning reduced symptoms for at least two months after cleaning.

Diagnosis

Diagnosing SBS differs from diagnosing many other medical conditions. First, the diagnosis is made by patient history, physical and clinical finding. Rarely do laboratory or imaging tests confirm abnormalities. Second, the diagnosis involves a thorough review of the building and its occupants as much as an individual's symptoms. Finally, the medical community has debated for many years about whether or not SBS is a "real medical condition." Because many of the symptoms are self–reported and can't easily be measured, and since some reported cases of sick buildings have shown no signs of chemicals or other problems, some professionals dispute whether the syndrome exists. In addition, there are people who are more sensitive to low levels of VOCs who may experience symptoms even though other people in the building experience no symptoms.

For these reasons, SBS often remains undiagnosed or misdiagnosed. Schools may blame such other diseases as winter flu outbreaks or perhaps assign a child's symptoms to a condition such as attention deficit hyperactivity disorder. When a patient goes to a physician with symptoms typical of SBS — headache , fatigue, dizziness, nausea, runny or stuffy nose, a dry cough, dry and itchy skin, itchy or watery eyes, and difficulty concentrating — a complete history is critical. If no other medical condition can explain these symptoms, the physician needs to ask questions that might lead to a diagnosis of SBS. The trigger will come in questions involving time. For instance, if a child's symptoms worsen when he or she enters the school building, SBS is likely to blame. If an office worker didn't start having these symptoms until changing jobs or office locations, the office building could be the culprit.

To diagnose a "sick building," trained occupational health or industrial experts will perform a "walkthrough" to survey building occupants for common SBS symptoms and to check the building for signs of problems. If a number of occupants have these symptoms and there are problems in the building such as overcrowding, poor cleaning, poor ventilation, or water damage, the surveyor may recommend work that done to improve the building's indoor air quality.

Treatment

No specific treatment has proven effective at eliminating SBS. Many experts agree that the best treatment for SBS is prevention — removing the contaminants or other identified sources that are causing SBS. Individuals with SBS may be encouraged to avoid the building that is making them sick. However, this is not always possible and can lead to isolation or job loss.

A person with suspected SBS may ask that a building be inspected for possible contaminants. A course of detoxification under the guidance of a qualified practitioner can be helpful. This includes stimulating lung, liver, kidney and skin expulsion and release of toxic compounds, some of which are stored in fat tissues. If the affected individual cannot leave the building or if the source is not removed, treating the symptoms of SBS may help ease some discomfort. In this case, it is wise to see an environmental medicine specialist and other providers who can help with detoxification and symptom relief (acupuncture , massage, etc.) However, these therapies should be coordinated by a physician, since treating multiple symptoms with multiple remedies may possibly create additional interactions. And even herbal remedies may interact with the various chemical substances that are producing the sensitivities; they should be started in small doses and recommended only by trained practitioners.

Some patients with MCS will test for allergies to determine the sources of their sensitivities; similar testing might prove helpful for SBS patients who do not know the exact source of their symptoms. Efforts to relieve stress also may help deal with or lessen SBS symptoms. Aromatherapy, yoga, biofeedback , and massage may be helpful.

Allopathic treatment

Again, tests have shown that among those with chemical sensitivities, avoiding chemicals has proven to be the most effective treatment. If the environmental problem is not corrected, the individual must decide how to best avoid the SBS source. Clinicians will aim their treatment at easing patients' symptoms while trying to help them avoid or adapt to triggers. Like many conditions that are difficult to pinpoint, physicians must listen respectfully to patients and should not prematurely label symptoms as psychological. Once SBS is suspected, the building that is likely the source of trouble should be evaluated and improvements made as needed.

Expected results

Avoiding the source of SBS or making necessary environmental improvements to the building should improve most symptoms of SBS in a short time. No permanent complications of SBS have been reported as of 2004.

Prevention

Preventing SBS begins with the proper design and maintenance of buildings. In particular, attention should be paid to the heating, ventilation, and air conditioning (HVAC) systems. WHO has set guidelines for proper management of building ventilation systems that include avoiding introduction of biological contaminants as well as conducting regular inspection and maintenance. In late 2003, a medical journal reported that use of ultraviolet light irradiation in cooling coils and drip pans could kill the germs that cause SBS. In addition, designing buildings to minimize introduction of contaminants or inspecting older buildings for possible VOCs and correcting potential problems can prevent SBS in building occupants. Education and communication are essential for effective air quality management in any building.

Resources

PERIODICALS

Anderson, Ashley. "Ultraviolet Light Reduces Sick Building Syndrome." Supply House Times (January 2004): 28–29.

Burge, P. S. "Sick Building Syndrome." Occupational and Environmental Medicine (February 2004): 185–191.

Henckel, Leslie. "IAQ FYI: Proactive Management Can Help to Clear Buildings of Indoor Air Quality Problems." Journal of Property Management (July-August 2003): 48–52.

Sadovsky, Richard. "Assessing Patients with Medically Unknown Symptoms." American Family Physician (June 1, 2000): 3455.

Yurkovsky, Savely. "Multiple Chemical Sensitivity. From Treatments to Cure." Townsend Letter for Doctors and Patients (January 2001): 58.

ORGANIZATIONS

American Academy of Environmental Medicine. East Kellogg, Suite 625, Wichita, KS 67207. (316) 684-5500. <http://www.aaem.com>.

American Industrial Hygiene Association. 2700 Prosperity Avenue, Suite 250, Fairfax, VA 22031. (703) 849-8888. <http://www.aiha.org>.

Environmental Health Center. 1025 Connecticut Avenue, NW, Suite 1200, Washington, DC 20036. (202) 293-2270. <http://www.nsc.org>.

National Institute for Occupational Safety and Health, US Department of Health and Human Services. 4676 Columbia Parkway (Mail Drop R2), Cincinnati, OH 45226. <http://www.cdc.gov/niosh/homepage.html>.

OTHER

"Sick School Syndrome." KidsHealth for Parents and Nemours Foundation. 2004. [cited June 5, 2004]. <http://www.kidshealth.org>.

"Top Ten Tips for a Healthy Home." American Lung Association. 2004. [cited June 5, 2004]. <http://www.lungusa.org/>.

Teresa G. Odle

SICK BUILDING SYNDROME

The term "sick building syndrome" (SBS) more specifically termed "nonspecific building-related illness," describes a set of common and nonspecific symptoms that are experienced by individuals in office and other nonindustrial workplace settings but remit when the individuals are away from that environment. Symptoms typically include fatigue; cognitive complaints; headache; shortness of breath; irritation of the nose, oropharynx, and eyes; rashes; and complaints of unpleasant odor in the workplace. It is critical to distinguish SBS from building-related illness, which refers to conditions more readily diagnosable by practitioners and characterized by abnormal signs. These include carbon monoxide poisoning, asthma, hypersensitivity pneumonitis, and upper respiratory infections. The symptoms and paucity of signs that characterize SBS overlap substantially with the symptoms of various other medically unexplained syndromes such as chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivities, and even psychiatric conditions characterized by somatic symptoms. The key is that with SBS the symptoms wax and wane with exposure to a particular building environment. Sorting out their diverse causal influences is the key to prevention, and involves integration across many fields.

A number of factors have been identified in experimental and field studies which contribute to SBS, although there remains much uncertainty about specifics of exposure, dose, susceptibility, and in particular the development of chronic symptoms once an afflicted individual is removed from a building exposure. Strong observational epidemiologic data has shown relatively high rates of symptoms in office workers in a variety of countries and climates. At least 20 to 35 percent of workers report such symptoms, even in nonproblem buildings. One important clue to SBS is that rates of symptoms are strongly correlated with mechanical ventilation systems as opposed to natural ventilation. Elevated carbon dioxide levels are a marker for inadequate ventilation, but are not toxic, per se. Relative humidity below 20 percent and above 60 percent are correlated with mucous membrane discomfort or general symptoms.

It is clear from controlled exposure studies, as well as observational studies, that even relatively low levels of volatile organic compounds (VOCs) can acutely produce many of the symptoms of SBS, and that these symptoms remit once exposure is terminated. Attempts to document objective correlates of these symptoms with neuropsychological or respiratory tests have not been very successful. VOCs are emitted from many construction materials as well as office products, and while most noticeable with new buildings, many emission sources are chronic. VOCs can also be reintroduced during building maintenance and renovation, as well as normal business activities.

A number of studies document an increased rate of symptoms, independent of allergy, in buildings with moisture problems and/or documented bacterial and mold growth. Atopy (the tendency to be allergic) is a risk factor for symptoms, perhaps due to allergies to bacteria and fungi. Much work remains to be done in sorting out whether those reporting symptoms have a specific building related illness (e.g., asthma, rhino-sinusitis, interstitial lung disease) as opposed to SBS. Reports of systemic disease and immune system damage from mycotoxins also requires further study and verification, but there is compelling preventive logic to taking steps to avoid excessive moisture in buildings and to responding promptly when it occurs to reduce microbial growth.

Workplace stress can contribute to symptoms, according to numerous studies. The mechanism and degree of interaction of SBS with physical factors needs further study. Individual psychological characteristics can certainly influence who reports symptoms and the degree of distress associated with a given level of symptoms. Nevertheless, the strong ability of environmental factors to trigger symptoms means that preventive or ameliorative strategies aimed solely at workplace stress or personal characteristics will not be satisfactory over the long run.

Howard M. Kipen

(see also: Ambient Air Quality [Air Pollution]; Asbestos; Asthma; Environmental Determinants of Health; Occupational Disease; Residential Housing )

Bibliography

Hodgson, A. T.; Daisey, J. M.; and Grot, R. A. (1991). "Sources and Source Strengths of Volatile Organic Compounds in a New Office Building." Journal of Air and Waste Management Association 41(11):1461–1468.

Lynch, R. M., and Kipen, H. (1998). "Building Related Illness and Employee Lost Time Following Application of Hot Asphalt Roof: A Call for Prevention." Journal of Toxicology and Industrial Health 14(6): 857–868.

Mendell, M. J.; Fisk, W. J.; Deddens, J. A.; Seavey, W. G.; Smith, A. H.; Smith, D. F.; Hodgson, A. T.; Daisey, J. M.; and Goldman, L. R. (1996). "Elevated Symptom Prevalence Associated with Ventilation Type in Office Buildings." Epidemiology 7:583–589.

Menzies, D., and Bourbeau, J. (1997). "Building-Related Illnesses." The New England Journal of Medicine 337(21):1524–1531.

Sick Building Syndrome

Sick Building Syndrome (SBS) is a term applied to a building that makes its occupants sick because of indoor air pollutants. Indoor air quality (IAQ) problems fall into three categories: SBS, building-related illnesses, and multiple chemical sensitivity. Of the three, SBS accounts for 75% of all IAQ complaints.

Indoor air is a health hazard in 30% of all buildings, according to the World Health Organization. The Environmental Protection Agency (EPA) lists IAQ fourth among top environmental health threats. The problem of SBS is of increasing concern to employees and occupational health specialists, as well as landlords and corporations who fear the financial consequences of illnesses among tenants and employees. Respiratory diseases attributed to SBS account for about 150 million lost work days each year, $59 billion in indirect costs, and $15 billion in medical costs.

Sick building syndrome was first recognized in the 1970s around the time of the energy crisis and the move toward conservation . Because heating and air conditioning systems accounted for a major portion of energy consumption in the United States, buildings were sealed for energy efficiency . Occupants depend on mechanical systems rather than open windows for outside air and ventilation. A tight building, however, can seal in and create contaminants. Common complaints of SBS include headaches, fatigue, cough, sneezing, nausea, difficulty concentrating, bleary eyes, and nose and throat irritations. Symptoms are caused by a range of contaminants, including volatile organic compounds (VOC), which are chemicals that turn to gas at room temperature and are given off by paints, adhesives, caulking, vinyl, telephone cable, printed documents, furniture, and solvents. Most common VOCs are benzene and chloroform, both of which may be carcinogens. Formaldehyde in building materials also is a culprit.

Biological agents such as viruses, bacteria, fungal spores, algae, pollen, mold, and dust mites add to the problems. These are produced by water-damaged carpet and furnishing or standing water in ventilation systems, humidifiers, and flush toilets .

Carbon dioxide levels increase as the number of people in a room increases, and too much can cause occupants to suffer hyperventilation, headaches, dizziness, shortness of breath, and drowsiness, as does carbon monoxide and the other toxins from cigarette smoke .

Schoolchildren are considered more vulnerable to SBS because schools typically have more people per room breathing the same stale air. Their size, childhood allergies, and asthmas add to their vulnerability.

Sick buildings can be treated by updating and cleaning ventilation systems regularly and using air cleaners and filtration devices. Also, plants spaced every 100 ft² (9.3 m²) in offices, homes, and schools have been shown to filter out pollutants in recycled air.

A simple survey of the indoor environment can detect many SBS problems. Check each room for an air source; if windows cannot be opened, every room should have a supply vent and exhaust vent. Clean the vents. Check to see if air is circulating by placing a strip of tissue at each vent opening. The tissue should blow out at a supply vent and blow in at an exhaust vent. Move partitions, file cabinets, and boxes away from vents. Supply and exhaust vents should be more than a few feet apart. Dead spaces where air stagnates and pollutants build up should be renovated. Move printing and copying machines away from people and give those machines adequate exhaust. Check that the ventilation system operates fully in every season and whenever people are in the building.

The EPA enforces tough laws on outdoor air pollution , but not for indoor air except for some smoking bans. Yet almost every pollutant, according to the EPA, is at higher levels indoors than out. Help in detecting and correcting sick building syndrome is available from the National Institute of Occupational Safety and Health , the federal agency responsible for conducting research and making recommendations for safe and healthy work standards.

[Linda Rehkopf ]

RESOURCES

BOOKS

Kay, J. G., et al. Indoor Air Pollution: Radon, Bioaerosols, and VOCs. Chelsea, MI: Lewis, 1991.

Samet, J. M., and J. D. Spangler. Indoor Air Pollution: A Health Perspective. Baltimore, MD: Johns Hopkins University Press, 1991.

PERIODICALS

Soviero, M. M. "Can Your House Make You Sick?" Popular Science (July 1992): 80.