Executive Summary

INTRODUCTION

It is estimated that Americans spend more than 85 percent of their time indoors, either at home, work, school or in health care, retail, recreational, or entertainment facilities. The quality of indoor environments—levels of indoor contaminants such as chemicals and bioaerosols, temperature and humidity, lighting, noise level, and furniture and equipment design—can influence a person’s health,1 comfort, and ability to perform his or her job, to learn, to heal.

Indoor environmental quality (IEQ), in turn, is influenced by building design, including the exterior envelope (walls, roof, windows, doors, materials); heating, ventilation, and air-conditioning (HVAC) systems; construction materials; and lighting design. IEQ is also influenced by building operations, maintenance, and housekeeping procedures. Although Le Corbusier once described a building as “a machine for living,” a building is more like a living organism than an inanimate artifact. It is composed of integrated systems where actions in one area will have consequences that ripple through the entire building, affecting not only other building systems but also the-occupants in ways that are not fully predictable.

Increasing evidence, some scientific and much anecdotal, suggests that adverse health outcomes in employees, students, hospital patients, and others are linked to the presence of indoor pollutants and other aspects of poor-quality indoor environments. However, the certainty with which such attributions can be made varies. One confounding factor is that the effect on the population differs, with some groups or persons being more susceptible to contracting symptoms or diseases than others. In addition, some health-related impacts, such as lung cancer, occur only after long-term exposure to the causal agent.

Many buildings, even some of the best-designed ones, will develop problems that can affect the health of some occupants if operations, maintenance, or housekeeping practices are inadequate. Although the scientific evidence is not yet sufficient to document all of the suspected links between a variety of diseases and health problems to specific building features and practices, one point is clear: Building-related diseases and symptoms are substantially preventable. Prevention strategies include timely intervention to limit or eliminate exposure to causal agents, appropriate building design and construction, and good maintenance, operations, and cleaning practices.

1  

The World Health Organization defines “health” as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.



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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Executive Summary INTRODUCTION It is estimated that Americans spend more than 85 percent of their time indoors, either at home, work, school or in health care, retail, recreational, or entertainment facilities. The quality of indoor environments—levels of indoor contaminants such as chemicals and bioaerosols, temperature and humidity, lighting, noise level, and furniture and equipment design—can influence a person’s health,1 comfort, and ability to perform his or her job, to learn, to heal. Indoor environmental quality (IEQ), in turn, is influenced by building design, including the exterior envelope (walls, roof, windows, doors, materials); heating, ventilation, and air-conditioning (HVAC) systems; construction materials; and lighting design. IEQ is also influenced by building operations, maintenance, and housekeeping procedures. Although Le Corbusier once described a building as “a machine for living,” a building is more like a living organism than an inanimate artifact. It is composed of integrated systems where actions in one area will have consequences that ripple through the entire building, affecting not only other building systems but also the-occupants in ways that are not fully predictable. Increasing evidence, some scientific and much anecdotal, suggests that adverse health outcomes in employees, students, hospital patients, and others are linked to the presence of indoor pollutants and other aspects of poor-quality indoor environments. However, the certainty with which such attributions can be made varies. One confounding factor is that the effect on the population differs, with some groups or persons being more susceptible to contracting symptoms or diseases than others. In addition, some health-related impacts, such as lung cancer, occur only after long-term exposure to the causal agent. Many buildings, even some of the best-designed ones, will develop problems that can affect the health of some occupants if operations, maintenance, or housekeeping practices are inadequate. Although the scientific evidence is not yet sufficient to document all of the suspected links between a variety of diseases and health problems to specific building features and practices, one point is clear: Building-related diseases and symptoms are substantially preventable. Prevention strategies include timely intervention to limit or eliminate exposure to causal agents, appropriate building design and construction, and good maintenance, operations, and cleaning practices. 1   The World Health Organization defines “health” as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings POTENTIAL BENEFITS OF IMPLEMENTING HEALTH-PROTECTIVE FEATURES AND PRACTICES IN BUILDINGS The magnitude of the investment in buildings is staggering. There are more than 107 million residential buildings and approximately 4.7 million additional nonagricultural and nonindustrial or “commercial” buildings in the United States today. On average, 2 million new homes and 200,000 commercial buildings are constructed each year. New health care facilities alone account for approximately $15 billion per year in capital expenditures, a figure that is projected to increase to $25 billion by 2010. Given the magnitude of these numbers, researchers and others have projected that tens of billions of dollars could be saved annually from reduced absenteeism and improved employee performance if indoor environments were improved. Further, the National Occupational Research Agenda Indoor Environment Team has estimated that 6 million to 8 million respiratory infections, 1 million to 4 million episodes of asthma and allergies, up to 3,000 cases of Legionnaire’s disease (associated with more than 70 deaths), and 2,000 to 11,000 deaths from heart disease or lung cancer could be prevented each year in nonindustrial indoor workers. ABOUT THE WORKSHOP The Federal Facilities Council (FFC)2 and its parent organization, the Board on Infrastructure and the Constructed Environment (BICE) of the National Research Council (NRC), have a long-standing interest in the issue of indoor environmental quality. Prompted by increasing incidents of discomfort or illness in the nonindustrial workplace that could often be traced to indoor air quality issues, the BICE (then named the Building Research Board) issued the report “Policies and Procedures for Control of Indoor Air Quality” in 1987. In March 1996 the BICE convened a colloquium entitled “Building Performance and Worker Productivity: Issues in Research and Practice” to address how buildings could facilitate and enhance the performance of their occupants and how to do so in a quality indoor environment. A subsequent planning meeting was held in April 1998 to discuss the research questions that needed to be answered to quantify the relationships between the built environment and workplace productivity and establish a business case for implementing building features that enhance occupant wellness and productivity. To continue the exploration of these complex issues and discuss ongoing research and possible strategies for implementing change in standards and practices for indoor environmental quality, the FFC convened a workshop, “Implementing Health-Protective Features and Practices in Buildings,” in Washington, D.C., on November 17-18, 2003. (See Appendix A for the workshop agenda.) More than 50 researchers, scientists, architects, engineers, and economists from academia, government, and industry participated in the workshop. They provided a broad perspective on building performance and indoor environmental issues and their relationship to worker health and productivity. (See Appendix B for a list of participants.) The workshop was designed to address four key questions: What do we know about how building design and operations affect the health of indoor workers, hospital patients, students, and others? Why do organizations fail to implement building features and practices that have been shown to improve indoor environmental quality? What methods, strategies, and practices could be used to overcome barriers to implementing health-protective features and practices in buildings? What practical actions can be taken by those in the building, health care, and other industries to create more healthful indoor environments? 2   The FFC is a cooperative association of U.S. federal agencies having interests and responsibilities related to all aspects of federal facilities design, construction, operations, and management. Established in 1953, the FFC operates under the National Research Council, the principal operating agency of The National Academies, a congressionally chartered, private, nonprofit corporation.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings STATE OF KNOWLEDGE Cause-and-effect relationships have been scientifically documented between waterborne pathogens in natural and man-made water systems and Legionnaire’s disease and Pontiac fever in individuals; between microorganisms growing in contaminated ventilation and humidification systems and hypersensitivity pneumonitis and humidifier fever; between the release of carbon monoxide and carbon monoxide poisoning; between the presence of radon, environmental tobacco smoke (also called secondhand smoke), and asbestos in buildings and lung cancer. Poor or dim lighting in stairways and slight elevation changes in ramps can cause slips and falls that result in work-related injuries. Persuasive evidence exists that links a variety of sources—endotoxins found in humidifiers; visible moisture and mold in ventilation systems; poorly maintained air-conditioning drainage pans; environmental tobacco smoke; and chemicals used in building materials, furnishings, and cleaning products—to the exacerbation of asthma and other respiratory symptoms in individuals. Available research studies also suggest that the presence of moisture or contamination in HVAC systems, low-level concentrations of formaldehyde, and materials that emit plasticizers (additives that keep them soft and pliable) into the air increase the risk of developing allergies, asthma, and some lower respiratory tract symptoms in some individuals. However, more study is required to better document and understand these relationships and establish safe exposure limits. Building-related symptoms, sometimes referred to as “sick building syndrome,” are nonspecific symptoms that are reported subjectively by occupants of a building and that often improve once the occupants leave. The symptoms include eye, nose, and throat irritations; headaches; fatigue; difficulty breathing; itching; and dry, irritated skin. Building-related symptoms are associated with a variety of factors, including low ventilation rates, high temperatures, volatile organic compounds emitted from building materials and carpets, fleecy materials used in furnishings, and inadequate cleaning practices. PRACTICAL ACTIONS TO IMPROVE INDOOR ENVIRONMENTAL QUALITY Based on this evidence and their own experience, the workshop participants identified a range of practical actions that could be implemented immediately by those in the building, health care, education, and other industries to create more healthful indoor environments, as follows: Design and Construction Keep HVAC systems clean and dry—first by design and then by operation and maintenance. Provide adequate outdoor air ventilation and use natural ventilation where feasible. Commission newly constructed buildings and recommission existing ones to ensure they are built and operating as designed and specified.3 Check the credentials of contractors installing HVAC and other equipment to insure they have the appropriate training. Operation and Maintenance Develop an IEQ management plan and implementation procedures, and identify those accountable for implementation. Implement a proactive program to prevent indoor dampness and mold and remediate existing moisture problems. 3   Commissioning has been defined as a quality-focused process for verifying and documenting that a facility and all of its systems and assemblies are planned, designed, installed, tested, operated, and maintained to meet an owner’s project requirements. The scope of building commissioning includes integrated performance of the building envelope and architectural systems; site utilities; fire protection and suppression; special equipment; and mechanical and electrical controls.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Eliminate indoor environmental tobacco smoke by prohibiting smoking inside a building or restrict smoking to physically isolated, depressurized smoking rooms that exhaust air to the outdoors. Monitor buildings to ensure they remain clean, dry, well ventilated, well lit, acoustically sound, and comfortable in terms of temperature and vibration. Maintain HVAC and other mechanical equipment, following installation and maintenance specifications, and proper cleaning, such as regularly changing filters and cleaning cooling coil drainage pans. Meet, at a minimum, ventilation rates in existing codes and maintain those over the life of a building. Control Legionella in building water systems. Keep indoor relative humidity below 70 percent. Maintain temperatures within the comfort range specified in thermal comfort standards. Limit, control, or eliminate indoor sources of volatile organic compounds, such as formaldehyde. Minimize pesticide use. Establish a reporting and feedback system for complaints related to IEQ. Reported complaints should be taken seriously, the concerns investigated, potential corrective actions identified, and the actions taken communicated back to the occupants involved. BARRIERS TO KNOWLEDGE DISSEMINATION Although there is a good deal of information available linking occupants’ health and the quality of indoor environments, there is little evidence that building owners, designers, managers, occupants, or health care providers understand or routinely use this information to improve IEQ. Barriers to the dissemination of this information and its deployment in practice are many and varied. They include: Lack of leadership among building owners to champion or mandate health-protective features and practices within their properties; Fragmentation of the building industry and building processes and the resulting lack of accountability for IEQ; Lack of reporting and feedback systems for IEQ-related complaints; Lack of a “business case” to demonstrate a return on investment for implementing health-protective features and practices; Few building codes, standards, or regulations that are strictly health based; Lack of clarity regarding liability for building-related diseases or symptoms in occupants; A focus on the first costs (design and construction) of buildings as opposed to their life-cycle costs (planning, design, construction, operations, maintenance, renewal, disposal), health impacts, and impacts on productivity; Little or no formal training in health sciences among architects, engineers, facilities managers, and operators; and Competing, more urgent demands for limited resources. SHORT-AND LONG-TERM STRATEGIES TO OVERCOME IDENTIFIED BARRIERS Workshop participants identified a number of activities that could be implemented to overcome barriers to more widespread implementation of health-protective features and practices in buildings and provide lasting benefits for building occupants, owners, and the environment. Implementation of these activities will require sustained leadership for IEQ at all levels of management within organizations. Activities that could begin immediately include: Raising awareness of IEQ issues among the general public, building owners, and health care providers through public service announcements; Linking health-related processes and functions to existing programs or practices, such as energy savings performance contracts and energy audits;

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Establishing a “one-stop” information clearinghouse on the Web; Establishing incentive programs that motivate and recognize people for their contributions to improving IEQ; Establishing rating systems, similar to the U.S. Green Building Council’s LEED (Leadership in Energy and Environmental Design) or labeling programs similar to EnergyStar; Developing a “business case” for an IEQ program, including a measure of return on investment; Developing an evaluation matrix to demonstrate how one health-protective feature in a building might be traded off against other features and the resulting costs and benefits; and Identifying best-practice case studies and building on these success stories. Longer-term activities include: Changing the way materials and products are specified and developing coherent guidelines for their application and installation; Partnering with the insurance and banking industries and building owners to demonstrate financial opportunities in building a certain way or adopting certain innovations; Working with regulatory organizations to develop guidance designed to protect the health of building occupants; Improving formal education and training programs for building professionals, operators, owners, maintenance staff, occupants, health care providers, and insurance providers; and Creating contract language for projects to include IEQ-supportive provisions. RESOURCES A large publicly accessible online bibliography on the topic of indoor environmental quality, health, and productivity is available at http://www.IHPCentral.org. This Web site contains approximately 1,100 papers from more than 100 major journals and conferences, organized by reference and study type and categories. A recent paper, “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity,” contains a bibliography citing more than 600 rigorous studies on the relationship of hospital design to various clinical outcomes. (Available at http://www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf.) Additional resources for scientific and technical information related to health-protective features and practices in buildings are cited throughout this report. These resources include the following reports from the National Research Council: Indoor Allergens: Assessing and Controlling Adverse Health Effects (1993). http://books.nap.edu/catalog/2056.html Clearing the Air: Asthma and Indoor Air Exposures (2000). http://books.nap.edu/catalog/9610.html To Err is Human: Building a Safer Health Care System (2000). http://books.nap.edu/catalog/9728.html Damp Indoor Spaces and Health (2004). http://books.nap.edu/catalog/11011.html Keeping Patients Safe: Transforming the Work Environment of Nurses (2004). http://books.nap.edu/catalog/10851.html ORGANIZATION OF THIS REPORT Chapter 1 summarizes the discussions and formal presentations that took place during the course of the workshop. The material presented reflects the views and opinions of the participants, not the deliberations of a formal NRC study committee. Nor were the participants asked to come to consensus or to make recommendations

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings on the subject of indoor environmental quality and worker health. Nevertheless, the ideas expressed do provide guidance that building owners in both the public and the private sectors can implement immediately to improve indoor environmental quality. The summary also points to longer-term solutions that will require interactive dialogue within the broad community of stakeholders for better buildings and health care providers. Finally, there are research questions, yet unanswered, that should be addressed if the journey forward is to be focused and well disciplined. Chapters 2 through 6 summarize the formal presentations given. Chapter 2 reviews the state of knowledge about indoor environments and occupants’ health and cites findings from a number of scientific studies. Some parameters to measure the scope of the problem nationwide and potential financial and health-related benefits that could be achieved by investments in health-protective features and practices are discussed. Chapter 3 identifies research and empirical evidence to support health-related policies and practices in buildings as well as barriers to their implementation. Chapter 4 explores what is currently known about the effects of lighting on people’s visual and circadian (daily biological rhythms) systems and the relationship of lighting to IEQ for some segments of the working population (young people, seniors, night-shift workers). Chapter 5 addresses how an improved physical environment can be used as a legitimate treatment modality in health care. The research agenda being developed by the Center for Health Design and the center’s findings related to costs and benefits are the focus. Chapter 6 summarizes five case studies that analyzed the impacts on cost and time of changes to construction projects to incorporate specific health-related design elements—interior partitions, exterior enclosures, service systems, and structural elements. Proven approaches for incorporating desirable features across a wide range of buildings quickly and effectively are identified.