Paula Schenck, MPH Division of Occupational and Environmental Health

1. IEQ and Respiratory Health in School BuildingsIntegrating epidemiology and engineering to better understand the relationship and mitigate the problem Paula Schenck, MPH Division of Occupational and Environmental Health University of Connecticut Health Center (UCHC) 860-679-2368 schenck@nso2.uchc.edu

2. Co-authors: Eileen Storey, MD, MPH UCHC William A. Turner, MS, PE Turner Building Science, LLC John E. Yocom, PE, CIH Environmental consultant

3. UCHC “Schools Focus” • Supported by: • Connecticut Departments of Labor and Public Health • US Environmental Protection Agency • National Institute for Environmental Health Sciences • Oak Ridge Institute for Science and Education CDC/NIOSH • UCHC

4. UCHC Schools Team • Eileen Storey, MD, MPH • Angela Bermudez-Millan, MPH • Robert DeBernardo, MD, MPH • Anne Bracker, CIH, MPH • Cande Pettigrew, BSN COHN • Paula Schenck, MPH • Engineering collaboration with Turner Building Science

5. UCHC Experience Teachers evaluated with respiratory complaints, laryngitis, headaches, dizziness and vertigo in the occupational and environmental medicine clinic Industrial hygiene evaluations and intervention recommendations at school sites CT Resource Team support for “Tools for Schools” implementation throughout the state Involvement in Connecticut Academy of Science and Engineering (CASE) review of IEQ in CT schools Guidance to specific schools on IEQ

6. UCHC Pilot Research Six schools study- more frequent respiratory symptoms among asthmatics in “wet” buildings Middle school pulmonary function test- children’s cohort showed declining trend in respiratory function in problem school Asthma in elementary schools-the difference in the prevalence of asthma across a group of schools may be attributable to building environment School environment and health - indoor air quality measures in school rooms reflected the relative level of health complaints

7. Health and Quality of Life Concerns Health impacts Sick building syndrome Building related illness Allergic, irritant, toxic, infectious mechanisms Productivity Absenteeism Poorer student and teacher performance

8. Building-related Respiratory Disease • Rhinitis • Sinusitis • Laryngitis • Asthma • Hypersensitivity pneumonitis (HP), and • Infectious diseases, i.e. legionella

9. Strategies to Evaluate Risks and Health Effects Epidemiological studies questionnaires physiological testing Individual clinical assessment medical history/physical examinationphysiological testing Industrial hygiene evaluation contaminant levels exposure assessment hazard control recommendation

10. What Are the Roles Of: • Medical evaluations • Epidemiological studies • Industrial hygiene investigations • Engineering assessments

11. Medical and epidemiological approaches can help by: • clarifying the individual health problem; • suggesting the type of agent; • guiding the industrial hygienist to probable site of exposure(s); • bracketing the complexity and seriousness of the IEQ problem; • identifying individuals at risk; • supporting risk communication; and • monitoring the success of the intervention.

12. Industrial hygiene assessments of schools: • link illness with environment; • assess agents and exposures; • define risk and support communication with school community; • provide guidance on intervention opportunities to reduce exposures and prevent respiratory illness.

13. Engineering focus is critical to: • assessing the history and condition of the building; • finding the causes of IEQ problems; • formulating the options and costs for intervention;and • identifying priorities.

14. Medical and Epidemiological Approach • Occupational illness model and patient treatment • School nurse logs and interviews • Questionnaire surveys • On-site physiological testing

15. Epidemiological Approach • Questionnaire surveys • Describe the participants, their health status, and their symptoms • Explore factors in the occupant’s homes • Help define occupants’ exposure to the building’s environment • Explore work-relatedness • Provide guidance on intervention (correcting building indoor environment problems) • May identify individuals at risk

16. Epidemiological Approach • Physiological testing • Lung function measurements partially evaluate the health of the participant group while in the school (limited by power and difficulties of testing in a non-clinical setting) • Comparison of spirometry results across a school week may indicate building-related effects

17. Industrial Hygiene Investigation • Qualitative • review building history and past reports • interview staff • building assessment • explore outdoor sources • walk-through to characterize environment • review sources • presence of chemicals • evidence of microbial growth • use of equipment and other materials

18. Industrial Hygiene Investigation • Qualitative (continued) • assess pattern of air movement and operation of HVAC • identify exposure pathways • Quantitative • inventory materials used • environmental measurements • biological measurements • difficulties and limitations • establish need • Hazard control recommendations

19. Engineering Focus • Building-science lens • HVAC adequacy • Control known sources of agents • Stop all “sources of moisture” (as a surrogate for microbial contaminants) • Identify and prioritize options

20. Engineering and medical collaboration • Developing investigatory tool • useful in setting of health concerns • uses qualitative assessment of moisture and dirt, odor, as an indicator of mold contamination • preliminary experience in school • School case study

21. A public middle school case study • ~400 students----1999 • ~40 staff----1999 • 97.6% attendance • ~20 students average class size • 30 classrooms • Built in 1950s with a major add-on 1960s • District-wide building improvement program in planning stages

22. A school with an IEQ problem, initial signs • Staff with symptoms seeking care • Active, vocal parents expressing concern • IH surveys identify inadequate fresh air,evidence of microbial reservoirs and likely exposure pathways

23. School District Response • District hires engineer as facilities manager to manage IEQ problems and overall district-wide building project • Team approach adopted • Issues identified • IEQ • Risk communication • Solution development • Financing building improvements

24. Further indications of IEQ problem as work progresses • Teacher diagnosed with occupational respiratory disease, can’t tolerate being in the building and removed from the school. • Building assessment • moisture: failed roof system, likely water incursion through walls and windows • ventilation: inadequacy confirmed • bulk sampling confirms biological reservoirs, but chemical contaminants were not specifically identified • likely paths of exposure identified

25. Further indications-staff survey results • Irritant and “comfort” symptoms widespread and more prevalent then respiratory symptoms among the occupants • Occupant survey indicates patterns of respiratory disease corresponding to certain “zones” • Responses to selected IUAT, and Arnow and Fink questions indicate individuals possibly at risk (broad screen)

26. Developing a plan for solution • Phase the approach realistically and address the financing challenge • Identify what in the condition of the building has contributed to poor IEQ and incorporate actions into over building improvement project • Implement improvements to reduce known exposures immediately • Maintain IH oversight • Increase outreach to staff and parents • Monitor health of staff and students

27. The problem of IEQ in schools is complicated by many factors (increasing prevalence of respiratory disease, role of environment in schools, school systems pressures and challenges, and community priorities). Public health tools, environmental assessment and engineering have complementary strengths that work well together to address this issue.