A. Definition

1. Illness that arises in nonindustrial, nonresidential buildings - primarily office buildings
2. During past 30 years, many buildings constructed with heating/ ventilation/ cooling systems which restrict exchange of inside and outside air to increase energy efficiency
3. Many new building materials, finishes, carpeting and furnishings are constructed with volatile petrochemicals and other organic compounds which are released into the air
4. These compounds are released in large quantities at first, and then the amount tapers off over time
5. In a sealed environment, the petrochemical and other organic concentrations may reach clinically significant levels for sensitive individuals even after the intense initial off-gassing has ended
6. Sealed buildings may increase transmission of infectious illnesses
7. Some building related illness results from exposure to substances or conditions that would produce symptomatic illness in most individuals
   1. Carbon monoxide
   2. Nitrogen dioxide

B. Specific versus Nonspecific Building Related Illness

1. Specific building related illnesses (BRIs) are a group of illnesses with a homogeneous clinical picture
2. Specific BRIs produce abnormalities that can be identified objectively via lab or other diagnostic testing
3. Specific BRIs have one or more identifiable sources or agents known to cause infectious, immunologic or allergic disease
4. Nonspecific BRIs are a heterogeneous group of work related symptoms
5. Nonspecific BRIs may include skin and mucous membrance irritation, headache, fatigue, and impaired concentration
6. Nonspecific BRIs are difficult to identify with objective testing
7. Diagnosis usually made from patient report of symptoms and timing of symptom onset in relation to exposure

C. BRI and "Sick Building Syndrome"

1. Sick Building Syndrome suggests that the building is sick and requires treatment
2. Also implies that the building will produce illness in all individuals
3. Clinicians are confronted with individual patients, not populations
4. Individuals working in the same building may not react in the same way
5. Reaction to exposure to a building is probably related to:
   1. Genetic predisposition
   2. Combined air-borne exposures

D. Illnesses Associated With Buildings

1. Legionnaires' Disease (Pontiac Fever) - L. pneumophila
2. Flulike illness and common cold
3. Tuberculosis
4. Hypersensitivity pneumonitis and "humidifier fever"
   1. Various bacteria
   2. Fungi (aspergillus, penicillium)
   3. Actinomycetes
5. Dermatitis, rhinitis, contact urticaria, laryngeal edema, and asthma, from:
   1. Glass fibers (ceiling boards)
   2. Combustion products
   3. Alkylphenol novolac resin (used in carbonless copy paper)

E. Management of Specific BRI

1. Therapy depends on symptoms and causal agent
2. If infectious agent, treat patient using standard therapy, identify source, and eliminate
3. If noninfectious agent, remove or alter causal agent to prevent further exposure
4. Alterations that reduce exposure include:
   1. Increased air exchange with the outside
   2. Sealing an object or area
   3. Cleaning object
   4. Filtering air
5. Documentation of BRI
   1. Affected patients working in a building containing an agent need documentation
   2. Support and documentation from their physician are often required
   3. This is provided to the employer, landlord, or building management company
   4. Encourages appropriate interventions in building

F. Nonspecific BRI

1. Symptoms that people consider related to work occur in up to 60% of workers weekly
2. Include headache, fatigue, malaise, poor concentration, dizziness, dry eyes
3. Ten to 25% report symptoms that seem to be related to work twice per week or more often
4. These statistics are based on a cross-sectional survey of people working in buildings that were selected without regard to the occupants' health.
5. Characteristics of individuals who report nonspecific BRIs are younger age, female sex, and history of atopy
6. Individuals with psychological or psychiatric conditions are no more likely than those without to report a nonspecific BRI.
7. Diagnosis based primarily on the temporal relationship between arrival at building and onset of symptoms, and by symptom remission minutes to hours after leaving building
8. Most patients with nonspecific BRIs feel better on weekends and vacations
9. Improvement with Travel
   1. If patient travels for business or pleasure, symptoms should theoretically improve
   2. Evaluation must include non-leading questions about changes in symptoms with travel

G. Causal Agents in Nonspecific BRI

1. Surface dust and carpet are reservoirs for
   1. Fungi
   2. Dust mites
   3. Volatile organic compounds
2. Fungi and bacteria may be concentrated in areas of water damage or high humidity
3. Airborne pathogen levels have been low in most buildings associated with nonspecific BRIs
4. Similarly, volatile organic compounds are often present in office building air
   1. However, concentrations are relatively low
   2. Usually below those which produce symptoms in closed chamber testing
5. Ventilation Rate
   1. Lower rates of air exchange increase incidence of nonspecific BRI
   2. Prevalence of nonspecific symptoms higher in buildings supplying < 10 liters per second per person of outside air
   3. For rates < 10 liters/ second/ person, increasing it has been shown to reduce symptoms
   4. For rates > 10 liters/ second/ person, increasing rate has little effect on symptoms
6. Nonspecific BRI is probably due to cumulative effects on a patient's immune system
7. Examples
   1. Exposure to dust mites, fungi, and volatile organics additive with
   2. Low ventilation rates result in exposure of individual's symptom threshhold
   3. Result is a low grade allergic response

H. Therapy for Nonspecific BRI

1. Manage atopic component with general allergy therapy
   1. Antihistamine/decongestant combination
   2. Add ophthalmic, nasal and pulmonary anti-inflammatory drugs (steroids, cromolyn, etc)
   3. Treat for symptoms
2. Reduce exposure to building
3. Spend time away at lunch and breaks, reduce hours worked in building
4. Request increase in ventilation rate if <10 liters per person per second
5. Reduce exposure to allergens in immediate work area
6. Water Damage
   1. Inspect ceiling and floor for water damage
   2. Have ceiling and/or floor tiles replaced if water damage present
7. Reduce Surface Dust
   1. Vacuum area around workplace often
   2. Daily vacuuming may be necessary to reduce dust and dust mite level
8. Local ionizing or cartridge air filters on desk or close to work area may be helpful
9. Implement allergen control measures at home to raise threshold for reaction while at work
10. Clean or remove carpeting, drapery, pets from bedroom
11. Vacuum sleeping area often, encase mattress and pillows in allergy-resistant covers
12. If symptoms persist, consider skin testing and/or RAST to identify allergens
13. Desensitization therapy may be helpful for selected individuals

References

1. Menzies D and Bourbeau J. 1997. NEJM. 337:1524