Fuel poverty increases risk of mould contamination, regardless of adult risk perception & ventilation in social housing properties

A Systematic Review of Associations between Energy Use, Fuel Poverty, Energy Efficiency Improvements and Health

Energy use in buildings can influence the indoor environment. Studies on green buildings, energy saving measures, energy use, fuel poverty, and ventilation have been reviewed, following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The database PubMed was searched for articles published up to 1 October 2020. In total, 68 relevant peer-reviewed epidemiological or exposure studies on radon, biological agents, and chemicals were included. The main aim was to assess current knowledge on how energy saving measures and energy use can influence health. The included studies concluded that buildings classified as green buildings can improve health. More efficient heating and increased thermal insulation can improve health in homes experiencing fuel poverty. However, energy-saving measures in airtight buildings and thermal insulation without installation of mechanical ventilation can impair health. Energy efficiency retrofits can increase indoor radon which can cause lung cancer. Installation of a mechanical ventilation systems can solve many of the negative effects linked to airtight buildings and energy efficiency retrofits. However, higher ventilation flow can increase the indoor exposure to outdoor air pollutants in areas with high levels of outdoor air pollution. Finally, future research needs concerning energy aspects of buildings and health were identified.

Model for Health Risk Assessment in Portuguese Housing Spaces

Currently, people spend most of their time inside their homes. However, poor conditions in terms of comfort and quality of the indoor environment can pose high risks to the inhabitants’ health. Therefore, a good quality environment is essential, since, in addition to the hazards present in indoor air (e.g., particles, (S)VOCs, CO, radon and tobacco smoke), extreme temperatures, relative humidity levels, pests (e.g., mold, dust mites and bioaerosols), noise, airborne infectious agents (e.g., SARS-CoV-2) and contamination through water and soil can cause physical injuries, respiratory diseases, damage to multiple organ systems as well as harmful effects on the mental health of the occupants. Faced with this requirement, housing evaluation models were studied together with the main types of risk that could affect the health of the inhabitants, with the objective of proposing a new evaluation model for housing health and safety risks, fitted to the occupants, and especially suitable for Portuguese dwellings, although applicable in other geographical contexts. As a result of this analysis, this article proposes a new model for evaluating health and safety risks in housing, applicable in Portugal, supported by an inspection form and, as the main difference from the existing models, parameter measurements, providing complementary data for the evaluation. This model was created based on a set of functional and regulatory requirements that were identified for the healthy use of living spaces. Twenty-eight hazards were identified, and the respective risk factors were assessed using different processes and target demographics, including visual inspection, parameter measurements, occupants’ age and location and age of housing. In order to validate the model and determine its usefulness, it was applied to a set of houses with different construction dates, locations and occupants. This exercise enabled the identification of hazard classes and the calibration and fine tuning of the model application. Finally, proposals for future work are presented in order to create a base of evolution for the model.

Changes in Domestic Energy and Water Usage during the UK COVID-19 Lockdown Using High-Resolution Temporal Data

In response to the COVID-19 outbreak, the UK Government provided public health advice to stay at home from 16 March 2020, followed by instruction to stay at home (full lockdown) from 24 March 2020. We use data with high temporal resolution from utility sensors installed in 280 homes across social housing in Cornwall, UK, to test for changes in domestic electricity, gas and water usage in response to government guidance. Gas usage increased by 20% following advice to stay at home, the week before full lockdown, although no difference was seen during full lockdown itself. During full lockdown, morning electricity usage shifted to later in the day, decreasing at 6 a.m. and increasing at midday. These changes in energy were echoed in water usage, with a 17% increase and a one-hour delay in peak morning usage. Changes were consistent with people getting up later, spending more time at home and washing more during full lockdown. Evidence for these changes was also observed in later lockdowns, but not between lockdowns. Our findings suggest more compliance with an enforced stay-at-home message than with advice. We discuss implications for socioeconomically disadvantaged households given the indication of inability to achieve increased energy needs during the pandemic.

House characteristics and condition as determinants of visible mold and musty odor: Results from three New Zealand House Condition Surveys in 2005, 2010, and 2015

This study assessed associations between house characteristics and mold and musty odor, using data from three consecutive (2005, 2010, and 2015) New Zealand House Condition Surveys, involving a total of 1616 timber-framed houses. Mold, musty odor, and house characteristics were assessed by independent building inspectors. We used multivariate logistic regression analyses mutually adjusted for other house characteristics for each survey separately. Positive and independent associations were found with tenure, ventilation, insulation, and envelope condition for both mold in living and bedrooms and musty odor. In particular, we found significant dose-response associations with envelope condition, ventilation, and insulation. Odds of mold increased 2.4-15.9 times (across surveys) in houses with the worst building envelope condition (BEC; p < 0.05-0.001 for trend); optimal ventilation reduced the risk of mold by 60% and the risk of musty odor by 70%-90% (p < 0.01 for trend). Other factors associated with mold and musty odor included: tenure, with an approximate doubling of odds of mold across surveys; and insulation with consistent dose-response patterns in all outcomes and surveys tested (p < 0.05 for trend in two surveys with mold and one survey for odor). In conclusion, this study showed the importance of BEC, ventilation, and insulation to avoiding harmful damp-related exposures.

The relationship between buildings and health: a systematic review

Background

The built environment exerts one of the strongest directly measurable effects on physical and mental health, yet the evidence base underpinning the design of healthy urban planning is not fully developed.

Method

This study provides a systematic review of quantitative studies assessing the impact of buildings on health. In total, 7127 studies were identified from a structured search of eight databases combined with manual searching for grey literature. Only quantitative studies conducted between January 2000 and November 2016 were eligible for inclusion. Studies were assessed using the quality assessment tool for quantitative studies.

Results

In total, 39 studies were included in this review. Findings showed consistently that housing refurbishment and modifications, provision of adequate heating, improvements to ventilation and water supply were associated with improved respiratory outcomes, quality of life and mental health. Prioritization of housing for vulnerable groups led to improved wellbeing. However, the quality of the underpinning evidence and lack of methodological rigour in most of the studies makes it difficult to draw causal links.

Conclusion

This review identified evidence to demonstrate the strong association between certain features of housing and wellbeing such as adequate heating and ventilation. Our findings highlight the need for strengthening of the evidence base in order for meaningful conclusions to be drawn.

Normal background levels of air and surface mould reserve in English residential building stock: a preliminary study towards benchmarks based on NAHA measurements

This paper reports results obtained from a surface (both visually clean and dirty/dusty surfaces) and active (aggressive or activated) air testing scheme on 140 residential rooms in England, without visible water damage or mould growth, along with a few rooms with visible mould growth/water damage tested for comparison purposes. The aim was to establish normal background levels of mould in non-water-damaged interiors to benchmark a 'normal' indoor environment, and in turn when there is a need for further investigation, and, possibly, remediation. Air and surface mould was quantified based on the activity of β-N-acetylhexosaminidase (EC 3.2.1.52; NAHA). The obtained readings showed a log-normal distribution. Ninety-eight percent of the samples obtained from visually clean surfaces were equal to or less than 25 relative fluorescence units (RFU), which is suggested to be the higher bound for the range which can be used as a success criterion for surface cleaning/remediation. Of samples obtained from visually dirty/dusty surfaces, around 98% were below 450 RFU, which is suggested to define the lower-bound for abnormally high levels of mould, rare even on dirty/dusty surfaces. Similarly, around 98% of the air samples were found to have 1700 RFU or below. Values above 1700 RFU are therefore deemed unlikely in a non-problem indoor environment and can be indicative of a possible problem inducing mould growth. The samples with values below 1700 were further divided into three proposed sub-categories. Finally, the obtained RFU values and the suggested benchmarks were compared to those obtained from 17 non-residential indoor environments tested previously in Copenhagen, and the benchmarks that are currently used in Danish national standards, and they were both found to be highly congruent, suggesting that local climate regimes and room functions might not be as influential on indoor mould levels as commonly thought, or that the nuances between England and Denmark in terms of these factors are not strong enough to lead to sizable changes in the typical indoor mould levels in these countries' building stocks.

Fuel poverty in Summer: An empirical analysis using microdata for Japan

The term fuel poverty is used to describe households that cannot afford the fuel costs of heating during winters. Fuel poverty is estimated on the basis of European criteria given that winters tend to be severe in Europe. However, it would be inappropriate to apply the same criteria to Asian regions with severe heat levels. Considering fuel poverty in the context of cooling expenses incurred during summers is also necessary. Thus, this study aims to examine potential fuel poverty households in Japan during summer and their occurrence condition using microdata. The estimation results reveal that only 0.93% of the surveyed households report fuel poverty. However, 5.53% poverty households can be classified as fuel poverty households. The results further show that households with elderly couples, particularly those living in old and/or large-floored homes with old room air conditioners, and single parent households are more vulnerable to fuel poverty. This study also conducts a binomial logistic regression analysis to clarify the occurrence condition for fuel poverty households. The findings suggest that elderly households easily fall into fuel poverty because of their low annual income and increased electricity expenditures owing to a rise in the energy amount rate.

Household energy efficiency and health: Area-level analysis of hospital admissions in England

INTRODUCTION

Fuel poverty affects up to 35% of European homes, which represents a significant burden on society and healthcare systems. Draught proofing homes to prevent heat loss, improved glazing, insulation and heating (energy efficiency measures) can make more homes more affordable to heat. This has prompted significant investment in energy efficiency upgrades for around 40% of UK households to reduce the impact of fuel poverty. Despite some inconsistent evidence, household energy efficiency interventions can improve cardiovascular and respiratory health outcomes. However, the health benefits of these interventions have not been fully explored; this is the focus of this study.

METHODS

In this cross sectional ecological study, we conducted two sets of analyses at different spatial resolution to explore population data on housing energy efficiency measures and hospital admissions at the area-level (counts grouped over a 3-year period). Housing data were obtained from three data sets covering housing across England (Household Energy Efficiency Database), Energy Performance Certificate (EPC) and, in the South West of England, the Devon Home Analytics Portal. These databases provided data aggregated to Lower Area Super Output Area and postcode level (Home Analytics Portal only). These datasets provided measures of both state (e.g. EPC ratings) and intervention (e.g. number of boiler replacements), aggregated spatially and temporally to enable cross-sectional analyses with health outcome data. Hospital admissions for adult (over 18 years) asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) were obtained from the Hospital Episode Statistics database for the national (1st April 2011 to 31st March 2014) and Devon, South West of England (1st April 2014 to 31st March 2017) analyses. Descriptive statistics and regression models were used to describe the associations between small area household energy efficiency measures and hospital admissions. Three main analyses were undertaken to investigate the relationships between; 1) household energy efficiency improvements (i.e. improved glazing, insulation and boiler upgrades); 2) higher levels of energy efficiency ratings (measured by Energy Performance Certificate ratings); 3) energy efficiency improvements and ratings (i.e. physical improvements and rating assessed by the Standard Assessment Procedure) and hospital admissions.

RESULTS

In the national analyses, household energy performance certificate ratings ranged from 37 to 83 (mean 61.98; Standard Deviation 5.24). There were a total of 312,837 emergency admissions for asthma, 587,770 for COPD and 839,416 for CVD. While analyses for individual energy efficiency metrics (i.e. boiler upgrades, draught proofing, glazing, loft and wall insulation) were mixed; a unit increase in mean energy performance rating was associated with increases of around 0.5% in asthma and CVD admissions, and 1% higher COPD admission rates. Admission rates were also influenced by the type of dwelling, tenure status (e.g. home owner versus renting), living in a rural area, and minimum winter temperature.

DISCUSSION

Despite a range of limitations and some mixed and contrasting findings across the national and local analyses, there was some evidence that areas with more energy efficiency improvements resulted in higher admission rates for respiratory and cardiovascular diseases. This builds on existing evidence highlighting the complex relationships between health and housing. While energy efficiency measures can improve health outcomes (especially when targeting those with chronic respiratory illness), reduced household ventilation rates can impact indoor air quality for example and increase the risk of diseases such as asthma. Alternatively, these findings could be due to the ecological study design, reverse causality, or the non-detection of more vulnerable subpopulations, as well as the targeting of areas with poor housing stock, low income households, and the lack of "whole house approaches" when retrofitting the existing housing stock.

CONCLUSION

To be sustainable, household energy efficiency policies and resulting interventions must account for whole house approaches (i.e. consideration of the whole house and occupant lifestyles). These must consider more alternative 'greener' and more sustainable measures, which are capable of accounting for variable lifestyles, as well as the need for adequate heating and ventilation. Larger natural experiments and more complex modelling are needed to further investigate the impact of ongoing dramatic changes in the housing stock and health.

STUDY IMPLICATIONS

This study supports the need for more holistic approaches to delivering healthier indoor environments, which must consider a dynamic and complex system with multiple interactions between a range of interrelated factors. These need to consider the drivers and pressures (e.g. quality of the built environment and resident behaviours) resulting in environmental exposures and adverse health outcomes.

Use of Simple Telemetry to Reduce the Health Impacts of Fuel Poverty and Living in Cold Homes

INTRODUCTION

In Great Britain, roughly half of people with at least one long-standing illness (LSI) live in low-income households. Lower-income households are at risk of fuel poverty and living in a colder house, which can worsen certain health conditions, causing related morbidity and mortality. This pilot study aimed to assess whether raising occupants' awareness of indoor temperatures in the home could initiate improved health and well-being among such vulnerable residents.

METHODS

Thermometers were placed inside a manufactured bamboo brooch to be worn or placed within homes during the winter of 2016/17. These devices were supplied to households (n = 34) already assisted by Community Energy Plus, which is a private social enterprise in Cornwall, United Kingdom (UK), using initiatives aimed at maintaining "healthy homes". Questionnaires were supplied to households before devices were supplied, and then again at the end of a three-month period, with further questions asked when devices were collected. Temperatures were recorded automatically every half-hour and used to draw inference from questionnaire responses, particularly around health and well-being.

RESULTS

Questionnaires were completed by 22 households. Throughout the winter, those declaring the poorest health when supplied with devices maintained homes at a higher average temperature. There were also indications that those with raised awareness of interior temperatures sought fewer casual medicines.

CONCLUSION

Simple telemetry could play a role in the management of chronic health conditions in winter, helping healthcare systems become more sustainable. The need for higher indoor temperatures among people with an LSI highlights the need to consider this approach alongside more sustainable household energy-efficiency improvements. A larger study is needed to explore this further and quantify the cost benefit of this approach.

Exposure to Indoor Mouldy Odour Increases the Risk of Asthma in Older Adults Living in Social Housing

Background: Indoor dampness is thought to affect around 16% of European homes. It is generally accepted that increased exposure to indoor dampness and mould contamination (e.g., spores and hyphae) increases the risk of developing and/or exacerbating asthma. Around 30% of people in the Western world have an allergic disease (e.g., allergy, wheeze and asthma). The role of indoor mould contamination in the risk of allergic diseases in older adults is yet to be fully explored. This is of interest because older people spend more time indoors, as well as facing health issues due to the ageing process, and may be at greater risk of developing and/or exacerbating asthma as a result of indoor dampness. Methods: Face-to-face questionnaires were carried out with 302 participants residing in social housing properties located in South West England. Self-reported demographic, mould contamination (i.e., presence of mould growth and mouldy odour) and health information was linked with the asset management records (e.g., building type, age and levels of maintenance). Multivariate logistic regression was used to calculate the odd ratios and confidence intervals of developing and/or exacerbating asthma, wheeze and allergy with exposure to reported indoor mould contamination. We adjusted for a range of factors that may affect asthma outcomes, which include age, sex, current smoking, presence of pets, education, and building type and age. To assess the role of mould contamination in older adults, we compared younger adults to those aged over 50 years. Results: Doctor-diagnosed adult asthma was reported by 26% of respondents, 34% had current wheeze while 18% had allergies. Asthma was common among subjects exposed to reported visible mould (32%) and reported mouldy odour (42%). Exposure to visible mould growth and mouldy odour were risk factors for asthma, but not for wheeze or allergy. Exposure to mouldy odour increased the risk of asthma in adults over the age of 50 years (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.10–5.34) and the risk was higher for females than for males (OR 3.5, 95% CI 1.37–9.08). These associations were modified by a range of built environment characteristics. Conclusions: We found that older adults living in social (public) housing properties, specifically women, may be at higher risk of asthma when exposed to mouldy odour, which has a number of implications for policy makers and practitioners working in the health and housing sector. Additional measures should be put in place to protect older people living in social housing against indoor damp and mould contamination.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.

Social and health outcomes following upgrades to a national housing standard: a multilevel analysis of a five-wave repeated cross-sectional survey

BACKGROUND

While existing research indicates that housing improvements are associated with health improvements, less is known about the wider social and health benefits of meeting national housing standards, as well as those of their specific constituent measures. This study evaluates the impacts of a managed housing upgrade programme through a repeated cross-sectional survey design.

METHODS

A five-wave repeated cross-sectional survey was conducted over a seven-year period from 2009 to 2016 (n = 2075; n = 2219; n = 2015; n = 1991; and n = 1709, respectively). The study followed a managed upgrade programme designed to meet a national social housing standard over an extended period. The data were analysed from a multilevel perspective to take account of the time-dependent nature of the observations and differences in socio-demographic composition.

RESULTS

The installation of the majority of individual housing measures (new windows and doors; boilers; kitchens; bathrooms; electrics; loft insulation; and cavity/external wall insulation) were associated with improvements in several social (housing suitability, satisfaction, and quality; thermal comfort and household finances) and health (mental, respiratory and general health) outcomes; and analyses showed relationships between the number of measures installed and the total amount invested on the one hand and the social and health outcomes on the other. There were however a few exceptions. Most notably, the installation of cavity wall insulation was associated with poorer health outcomes, and did not lead to better social outcomes. Also, no association was found between the number of measures installed and respiratory health.

CONCLUSIONS

The study suggests that substantial housing investments through a managed upgrade programme may result in better social and health outcomes, and that the size of the improvements are proportionate to the number of measures installed and amount invested. However, there may be risks associated with specific measures; and more attention is needed for mechanical ventilation when upgrading energy efficiency of houses through fabric work. In addition to providing new evidence regarding the wider social and health outcomes, the study provides an analytical approach to evaluate upgrade programmes that are delivered over multiple years.

Indoor Fungal Exposure and Allergic Respiratory Disease

A gathering body of evidence has repeatedly revealed associations between indoor fungi and initiation, promotion, and exacerbation of allergic respiratory disease. The relationship between the exposure and outcome are complicated by the difficulties in measuring both exposure and outcome, the multifactorial nature of the disease, and the wide range of potential confounders. New technologies are becoming available that may enable better measurement of exposure and tighter case definitions so as to build more confidence in the associations discovered. The growing strength of the evidence base will aid the design of future public health interventions and generate new hypotheses on the cause of the rapid increase in allergic respiratory disease prevalence.

Prevalence of Residential Dampness and Mold Exposure in a University Student Population

The impact of residential dampness or mold on respiratory health is well established but few studies have focused on university students. This study aims to: (a) describe the prevalence of exposure to residential dampness or mold in university students according to socio-geographic factors and (b) identify associated housing characteristics. A web survey was conducted in 2014 among the 26,676 students registered at the Université de Sherbrooke (QC, Canada). Residential dampness and mold being closely intertwined, they were considered as a single exposure and assessed using a validated questionnaire. Exposure was compared according to socio-geographic and housing characteristics using chi-square tests and logistic regressions. Among the 2097 participants included in the study (response rate: 8.1%), over 80% were tenants. Residential exposure to dampness or mold was frequent (36.0%, 95% CI: 33.9-38.1). Marked differences for this exposure were noted according to home ownership (39.7% vs. 25.5% among tenants and owners respectively; OR = 1.92%, 95% CI: 1.54-2.38). Campus affiliation, household composition and the number of residents per building were associated with exposure to dampness or mold (p < 0.01), while sex and age were not. Exposure was also associated with older buildings, and buildings in need of renovations and lacking proper ventilation (p < 0.001). This study highlights the potential risk of university students suffering from mold-related health effects given their frequent exposure to this agent. Further research is needed to fully evaluate the mold-related health impact in this at risk group.

Identifying risk factors for exposure to culturable allergenic moulds in energy efficient homes by using highly specific monoclonal antibodies

The aim of this study was to determine the accuracy of monoclonal antibodies (mAbs) in identifying culturable allergenic fungi present in visible mould growth in energy efficient homes, and to identify risk factors for exposure to these known allergenic fungi. Swabs were taken from fungal contaminated surfaces and culturable yeasts and moulds isolated by using mycological culture. Soluble antigens from cultures were tested by ELISA using mAbs specific to the culturable allergenic fungi Aspergillus and Penicillium spp., Ulocladium, Alternaria, and Epicoccum spp., Cladosporium spp., Fusarium spp., and Trichoderma spp. Diagnostic accuracies of the ELISA tests were determined by sequencing of the internally transcribed spacer 1 (ITS1)-5.8S-ITS2-encoding regions of recovered fungi following ELISA. There was 100% concordance between the two methods, with ELISAs providing genus-level identity and ITS sequencing providing species-level identities (210 out of 210 tested). Species of Aspergillus/Penicillium, Cladosporium, Ulocladium/Alternaria/Epicoccum, Fusarium and Trichoderma were detected in 82% of the samples. The presence of condensation was associated with an increased risk of surfaces being contaminated by Aspergillus/Penicillium spp. and Cladosporium spp., whereas moisture within the building fabric (water ingress/rising damp) was only associated with increased risk of Aspergillus/Penicillium spp. Property type and energy efficiency levels were found to moderate the risk of indoor surfaces becoming contaminated with Aspergillus/Penicillium and Cladosporium which in turn was modified by the presence of condensation, water ingress and rising damp, consistent with previous literature.