The sick building syndrome in office buildings--a breath of fresh air

Humidification of indoor air for preventing or reducing dryness symptoms or upper respiratory infections in educational settings and at the workplace

BACKGROUND

Indoor exposure to dry air during heating periods has been associated with dryness and irritation symptoms of the upper respiratory airways and the skin. The irritated or damaged mucous membrane poses an important entry port for pathogens causing respiratory infections.

OBJECTIVES

To determine the effectiveness of interventions that increase indoor air humidity in order to reduce or prevent dryness symptoms of the eyes, the skin and the upper respiratory tract (URT) or URT infections, at work and in educational settings.

SEARCH METHODS

The last search for all databases was done in December 2020. We searched Ovid MEDLINE, Embase, CENTRAL (Cochrane Library), PsycINFO, Web of Science, Scopus and in the field of occupational safety and health: NIOSHTIC-2, HSELINE, CISDOC and the In-house database of the Division of Occupational and Environmental Medicine, University of Zurich. We also contacted experts, screened reference lists of included trials, relevant reviews and consulted the WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included controlled studies with a parallel group or cross-over design, quasi-randomised studies, controlled before-and-after and interrupted time-series studies on the effects of indoor air humidification in reducing or preventing dryness symptoms and upper respiratory tract infections as primary outcomes at workplace and in the educational setting. As secondary outcomes we considered perceived air quality, other adverse events, sick leave, task performance, productivity and attendance and costs of the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full texts for eligibility, extracted data and assessed the risks of bias of included studies. We synthesised the evidence for the primary outcomes 'dry eye', 'dry nose', 'dry skin', for the secondary outcome 'absenteeism', as well as for 'perception of stuffiness' as the harm-related measure. We assessed the certainty of evidence using the GRADE system.

MAIN RESULTS

We included 13 studies with at least 4551 participants, and extracted the data of 12 studies with at least 4447 participants. Seven studies targeted the occupational setting, with three studies comprising office workers and four hospital staff. Three of them were clustered cross-over studies with 846 participants (one cRCT), one parallel-group controlled trial (2395 participants) and three controlled before-and-after studies with 181 participants. Five studies, all CTs, with at least 1025 participants, addressing the educational setting, were reported between 1963 and 1975, and in 2018. In total, at least 3933 (88%) participants were included in the data analyses. Due to the lack of information, the results of the risk of bias assessment remained mainly unclear and the assessable risks of bias of included studies were considered as predominantly high. Primary outcomes in occupational setting:  We found that indoor air humidification at the workplace may have little to no effect on dryness symptoms of the eye and nose (URT). The only cRCT showed a significant decrease in dry eye symptoms among working adults (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.37 to 0.79) with a low certainty of the evidence. The only cluster non-randomised cross-over study showed a non-significant positive effect of humidification on dryness nose symptoms (OR 0.87, 95% CI 0.53 to 1.42) with a low certainty of evidence. We found that indoor air humidification at the workplace may have little and non-significant effect on dryness skin symptoms. The pooled results of two cluster non-RCTs showed a non-significant alleviation of skin dryness following indoor air humidification (OR 0.66, 95% CI 0.33 to 1.32) with a low certainty of evidence. Similarly, the pooled results of two before-after studies yielded no statistically significant result (OR 0.69, 95% CI 0.33 to 1.47) with very low certainty of evidence No studies reported on the outcome of upper respiratory tract infections. No studies conducted in educational settings investigated our primary outcomes. Secondary outcomes in occupational setting: Perceived stuffiness of the air was increased during the humidification in the two cross-over studies (OR 2.18, 95% CI 1.47 to 3.23); (OR 1.70, 95% CI 1.10 to 2.61) with low certainty of evidence. Secondary outcomes in educational setting: Based on different measures and settings of absenteeism, four of the six controlled studies found a reduction in absenteeism following indoor air humidification (OR 0.54, 95% CI 0.45 to 0.65; OR 0.38, 95% CI 0.15 to 0.96; proportion 4.63% versus 5.08%).

AUTHORS' CONCLUSIONS

Indoor air humidification at the workplace may have little to no effect on dryness symptoms of the eyes, the skin and the URT. Studies investigating illness-related absenteeism from work or school could only be summarised narratively, due to different outcome measures assessed. The evidence suggests that increasing humidification may reduce the absenteeism, but the evidence is very uncertain. Future RCTs involving larger sample sizes, assessing dryness symptoms more technically or rigorously defining absenteeism and controlling for potential confounders are therefore needed to determine whether increasing indoor air humidity can reduce or prevent dryness symptoms of the eyes, the skin, the URT or URT infections at work and in educational settings over time.

Trends in cabin air quality of commercial aircraft: industry and passenger perspectives

The small air space available per person in a fully occupied aircraft passenger cabin accentuates the human bioeffluent factor in the maintenance of air quality. The accumulation of carbon dioxide and other contributions to poor air quality that can occur with inadequate ventilation, even under normal circumstances, is related to the volume of available air space per person and various ventilation rates. This information is compared with established air quality guidelines to make specific recommendations with reference to aircraft passenger cabins under both normal and abnormal operating conditions. The effects of respiration on the air quality of any enclosed space from the respiration of a resting adult are estimated using standard equations. Results are given for different volumes of space per person, for zero air exchange, and for various air change rates. The required ventilation rates estimated in this way compared closely with results calculated using a standard empirical formula. The results confirm that the outside air ventilation required to achieve a target carbon dioxide concentration in the air of an occupied enclosed space remains the same regardless of the volume of that space. The outside air ventilation capability of older and more recent aircraft is then reviewed and compared with the actual measurements of cabin air quality for these periods. The correlation between calculated and measured aircraft cabin carbon dioxide concentrations from other studies was very good. Respiratory benefits and costs of returning to the 30% higher outside air ventilation rates and 8% higher cabin pressures of the 1960s and 1970s are outlined. Consideration is given to the occasional occurrence of certain types of aircraft malfunction that can introduce more serious contaminants to the aircraft cabin. Recommendations and suggestions for aircraft builders and operators are made that will help improve aircraft cabin air quality and the partial pressure of oxygen that is available to passengers at minimal cost. Also suggested are some measures that passengers can take to help improve their comfort and decrease their risk of illness, particularly on long-haul flights.

Passenger aircraft cabin air quality: trends, effects, societal costs, proposals

As aircraft operators have sought to substantially reduce propulsion fuel cost by flying at higher altitudes, the energy cost of providing adequate outside air for ventilation has increased. This has lead to a significant decrease in the amount of outside air provided to the passenger cabin, partly compensated for by recirculation of filtered cabin air. The purpose of this review paper is to assemble the available measured air quality data and some calculated estimates of the air quality for aircraft passenger cabins to highlight the trend of the last 25 years. The influence of filter efficiencies on air quality, and a few medically documented and anecdotal cases of illness transmission aboard aircraft are discussed. Cost information has been collected from the perspective of both the airlines and passengers. Suggestions for air quality improvement are given which should help to result in a net, multistakeholder savings and improved passenger comfort.

The sick building syndrome: a diagnostic dilemma

Sick building syndrome (SBS) is usually defined as an increased occurrence of non-specific symptoms among populations in determined buildings. This definition differs from those of other medical syndromes in that it refers to a system (a building inclusive of its population) rather than to a clinical state in a single individual. Such a definition should make the term SBS impossible to use as a diagnosis applied to individual persons. In spite of this, it is often used in this way, and the aim of the article is to discuss problems with this practice. It is a case study based on an office building with long-standing building-related health problems. Information concerning the building and its inhabitants comes from a large number of separate documentary sources. The study demonstrates that the diagnostic use of SBS suffers from serious weaknesses. It is proposed that such diagnostics could even have a normative force serving to maintain and reinforce building-related, non-specific health problems. It is therefore suggested that the term sick building syndrome should be abandoned.

Epidemiology of sick building syndrome and its associated risk factors in Singapore

OBJECTIVES

To investigate the occurrence of sick building syndrome in a tropical city, and its relation to indoor air quality and other factors.

METHODS

2856 office workers in 56 randomly selected public and private sector buildings were surveyed. The study consisted of a self administered questionnaire assessing symptoms and perception of the physical and psychosocial environment, inspection of the building plans and premises, and measurement of temperature, relative humidity, respirable particles, chemicals, bioaerosols, and other variables.

RESULTS

Symptoms typical of the sick building syndrome were reported in 19.6% of the respondents. Multivariate modelling substantiated contributions associated with low thermal comfort, high work related stress, too much noise, a history of allergy or other medical conditions, poor lighting, young employees, and female sex. Measurements of indoor air quality or ventilation were not found to be reliable predictors of the symptoms.

CONCLUSION

The survey confirmed the presence of sick building syndrome and its risk factors in the tropics. A biopsychosocial approach to the problem involving symptomatic treatment, environmental control, good ergonomic design, and stress management is recommended.

Effect of aerosolization on culturability and viability of gram-negative bacteria

Estimations of the bacterial content of air can be more easily made now than a decade ago, with colony formation the method of choice for enumeration of airborne bacteria. However, plate counts are subject to error because bacteria exposed to the air may remain viable yet lose the ability to form colonies, i.e., they become viable but nonculturable. If airborne bacteria exhibit this phenomenon, colony formation data will significantly underestimate the bacterial populations in air samples. The objective of the study reported here was to determine the effect of aerosolization on viability and colony-forming ability of Serratia marcescens, Klebsiella planticola, and Cytophaga allerginae. A collision nebulizer was used to spray bacterial suspensions into an aerosol chamber, after which duplicate samples were collected in all-glass impingers over a 4-h period. Humidity was maintained at ca. 20 to 25%, and temperature was maintained at 20 to 22 degrees C for each of two replicate trials per microorganism. Viability was determined by using a modified direct viable count method, employing nalidixic acid or aztreonam and p-iodonitrotetrazolium violet (INT). Cells were stained with acridine orange and observed by epifluorescence microscopy to enumerate total and viable cells. Viable cells were defined as those elongating in the presence of antibiotic and/or reducing INT. CFU were determined by plating on tryptic soy agar and R2A agar. It was found that culture techniques did not provide an adequate description of the bacterial burdens of indoor air (i.e., less than 10% of the aerosolized bacteria were capable of forming visible colonies). It is concluded that total cell count procedures provide a better approximation of the number of bacterial cells in air and that procedures other than plate counting are needed to enumerate bacteria in aerosol samples, especially if the public health quality of indoor air is to be estimated.

Epidemiological investigations into an outbreak of building-associated illness in Singapore

In August 1991, the Ministry of the Environment was informed of the occurrence of illnesses suspected to be related to a modern, multi-story office building. Investigations revealed that 34 of the occupants on two floors of the building had non-specific ailments such as eye, throat or skin irritation which caused acute discomfort but resolved upon leaving the premises. Case-control study identified a number of factors significantly associated with the illness; viz. a personal history of allergy, asthma or sinusitis; a high level of work-related stress; and a lack of thermal comfort. One feature of the affected offices was numerous high partitions which tended to obstruct air movement. Adjustments of central temperature to compensate for complaints of "stuffiness" had resulted in wide fluctuations of temperature and relative humidity. Indoor air quality measurements also revealed high bacterial counts, a condition aggravated by the raised relative humidity and inadequate air movement. The problems gradually resolved following major modifications at the offices and air-handling units. This episode confirmed the need for further studies of building-associated illness in the tropics.