Building Related Illness

Fred Fung, M.D., M.S. (Tox)

Toxicology Consultant,

UC San Diego

Occupational Medicine, UC Irvine

Sharp Rees-Stealy Medical Group

Are They Good or Bad?

Diet cokeBBQ meatPeanut butterDonepezil Lovastatin We’ll get back to them later

Death & Death Rates, US 1999

ICD NumberDeath Rate Per 100,000

Percent of Total deaths

All Causes 2,391,630 877 100Heart diseases 724,915 265.8 30.3Cancer 549,787 201.6 23CVD (Stroke) 167,340 61.4 7COPD 124,153 45.5 5.2Accidents 97,298 35.7 4.1 MVA 42,437 15.6 1.8 Others 54,862 20.1 2.3DM 68,379 25.1 2.9Influenza 63,686 23.4 2.7Alzheimer’s 44,507 16.3 1.9Kidney 35,524 13 1.5Septicemia 30,670 11.2 1.3

Death & Death Rates, 1999

• Top 4 causes of death are associated with cigarette smoking

• Top 4 causes of death account for 65.5% or 1,566,195 deaths in 1999 is US

• “Sick Building syndrome” is not listed in 113 causes of death

Source: Centers for Disease Control National Vital Statistics Reports, Vol 49, June 26, 2001

Hypothesis testing

• Scientist provides and evaluates findings and evidence

• Scientist should avoid incriminating something/somebody based on belief

• Hypothesis must assume no relationship between A and B

• Must be tested by experiments

Hypotheses on Indoor Air Quality (IAQ) problems

1. VOC emission + inadequate ventilation.

2. Microbial + bioaerosol.

3. Heightened awareness (Limbic system: smell + emotion).

Disease vs comfort

• JS Billings, a physician, published 1st American work on building ventilation: Ventilation and Heating (1893)

• JSB believed that sufficient ventilation can prevent disease transmission (TB)

• Engineers were more concerned over odor control and comfort

• ASHRAE 62-1973 standard, first ventilation standard published

Spectrum of Indoor Air Quality (IAQ) symptoms

• Headaches

• Fatigue, memory problem

• Itchy or burning eyes, nose

• Skin irritations and rash

• Nasal congestion and dry throat

• Respiratory distress

* Symptoms are not diseases

Sick Building Syndrome(SBS)

• SBS is a misnomer. Buildings don’t get sick

• SBS consists of subjective symptoms. It is benign and self-limited

• Building related illness (BRI) can be serious

• BRI patient has symptoms and signs verified by diagnostic tests (disease)

Adverse health effects of Building related illness

• Allergy: rhinitis, asthma, HP

• Infection: TB, legionnaires disease

• Irritation: VOC, dust

• Toxicity: CO, NO2 , pesticides

Toxin and Disease relationship

• Toxins: CO, pesticides, VOCs, microbial toxins (endotoxins, glucans, mycotoxins)

• Diseases: irritation syndrome, rhinitis, sinusitis, bronchitis, hypersensitivity pneumonitis, asthma

• Building related: HVAC, Temp, humidity, filtration, off-gassing, cooking, smoking

Case studies-Chemical?

VOC emission + inadequate ventilation.

Pathology technician c/o nasal and throat symptoms better over weekends

What is the dx? What is the exposure?

Solution? Molhave, Menzies

Microbial source?

Microbial, bioaerosol.

Office worker c/o sneezing, wheezing and chest tightness soon after a flood

What is the dx? What is the exposure?

Solution?

Caveat: No controlled human studies to date

Stachybotrys Spores

Psychogenic illness?

Heightened awareness: Psychosomatic, stress, learned illness, conversion.

One employee detects a skunky smell, asks if anybody else smells anything, news of toxic gas permeates the entire building, Haz Mat

What is the dx? What is the exposure?

Solution? Staudenmayer

Professional smellers-Deodorant- $$$

All substances are poisons; there is none which is not a poison.

The right dose differentiates a poison from a remedy.

Paracelsus (1493-1541)

 

Good or bad?

Diet coke: AspartameBBQ meat: Benzo(a)pyrenePeanut butter: AflatoxinsDonepezil: AChE inhibitor (OP)Lovastatin: mold product

What is Mold all about?

Adverse health effects of mold exposure

• Allergy

• Infection

• Irritation

• Toxicity (oral ingestion only)

Clinical Issues-MD

• Exact disease must be determined

• Exposure must be specified (route, toxin, duration, concentration, data)

• Smoking, alcohol, drugs (side effects)

• Beware: Bad lab data, acute vs chronic, generalization, it is my personal experience!

Science v Emotion

Basis of medical diagnosis

• Specific disease (subjective complaints consistent with objective findings)

• Documented exposure (specific agent and concentration) provided by IH

• Medical exam, functional test, biologic level if available

• Differential Diagnosis (r/o other diseases by objective tests)

Basis of Scientific Opinion (MD +IH)

• Toxin-disease relationship (specific)• Exposure assessment (quantitative)• Sufficient dose (conc and duration)• Difference in opinion (peer review) *Science is usually not sensational (media factor)*Science is usually influenced by politics