EUROPEAN CONCERTED ACllON

INDOOR AIR QUALITY & ITS IMPACT ON MAN

COST Project 613

Environment and Quality of Life

Report No. 4

Sick Building Syndrome

A Practical Guide

,*

Commission of the European Communities

Directorate General for Science. Research and Development
Joint Research Centre - Institute for the Environment

EUR 12294 EN

August 1989

EUROPEAN CONCERTED ACTION

INDOOR AIR QUAL TY & ITS IMPACT ON MAN
COST Project 613

Environment and Quality of Life

Report No. 4

uilding Sy
A Practical Guide

prepared by

Working Group I
Claude MOLINA (chairman)
Universite de Clermont Ferrand (France)
C. Anthony C. PICKERING
Wythenshawe Hospital, Manchester (United Kingdom)
Ole VALBJBRN
Statens Byggeforsknings Institut, Herrsholm (Denmark)
Maurizio DE BORTOLI (secrefury)
C.E.C., Joint Research Centre. lspra (Italy)

reviewed by the Community-COST Concertation Committee

n
** * **

Commission of the European Communities

Directorate General for Science, Research and Development
Joint Research Centre - Institute for the Environment

EUR 12294 EN

August 1989

Published by the
COMMISSION OF THE EUROPEAN COMMUNITIES
Directorate-General
Information Market and Innovation
Batiment Jean Monnet
LUXEMBOURG

LEGAL NOTICE
Neither the Commission of the European Communities nor any person
acting on behalf of the Commission is responsible for the use which might
be made of the following information.

Cataloguing data can be found at the end of this publication.

Luxembourg: Office for Publications of the European Communities, 1989

63 ECSC - EEC - EAEC, Brussels - Luxembourg, 1989

Printed in Italy

CONTENTS
Foreword

1. Background

2. Extent of the problem

4. Symptornatology
6. Risk factors
6.1 The physical factors
6.2 The chemical factors
6.3 The biological factors
6.4 The psychological factors

................................................................................................................................................................

7. How to conduct building associated investigations

15

Step. 1. Technical and hygiene investigations ......................................................................

Step. 2, Inspection and guiding measurements
Step. 3. Measurements of ventilation, climate indicators
and other implicated factors

16
17

Step. 4.

19

Medical examination and associated investigations

18

References

20

Appendix 1. Symptomatology and diagnosis of SBS

Appendix 2. Checklist for building inspectio
Appendix 3. Example of a questionna
Appendix 4. WHO Air Quality Guidelin

26
29
30
32
35

Members of the Community - COST Co

FOREWORD
This r e p o r t deals with what i s called "sick building syndromet' (SBS). However, t h e
methods employed t o investigate SBS c a n be also used t o t a c k l e o t h e r building
r e l a t e d illnesses. "Sick building syndrome" is t h e n a m e given t o a set of varied
s y m p t o m s experienced predominantly by people working in a i r conditioned buildings,
although i t has a l s o been observed in naturally ventilated buildings.
T h e syndrome, t h e cause of which is probably multifactorial, i s n o t usually
accompanied by a n y organic lesion o r physical sign and is, therefore, diagnosed by
exclusion. SBS i s c u r r e n t l y t h e subject of numerous research projects. It h a s been
found in a l l t h e major c i t i e s of t h e Western world, among people who work o r live
f o r s e v e r a l hours a d a y in a n a r t i f i c i a l atmosphere. SBS c a n b e diagnosed only
a f t e r eliminating a l l o t h e r building r e l a t e d illnesses.

I.

BACKGROUND

As a result of t h e measures t a k e n t o control domestic heating and emissions of

industrial smoke a n d car exhaust fumes, outdoor pollution in t h e major towns and
c i t i e s i s now on t h e d e c r e a s e (except in cases of accident). However, t h e problem
of indoor a i r quality i s becoming a m a t t e r of concern. Most town-dwellers spend
less t h a n a n hour a d a y in t h e outside environment; t h e r e s t of t h e t i m e t h e y a r e at
home, at work o r in s o m e means of transport.
Since t h e s e v e n t i e s and t h e oil crisis, energy-saving measures h a v e led t o a
reduction in t h e ventilation of rooms. T h e use of synthetic materials which e m i t
various chemical substances has led t o a n increase in t h e concentration of indoor
pollutants.
In 1970, following t h e observations of Bansazak et al., t h e a t t e n t i o n of t h e medical
profession was d r a w n t o t h e development of a n allergic respiratory d i s o r d e r
(allergic alveolitis) among t h e employees working in air-conditioned offices. I t is
similar t o "humidifier fever1' which has been described both in homes (De Weck,
P a t t e r s o n et al., Burcke e t al.) and in industrial situations where cold w a t e r spray
humidification s y s t e m s have become heavily contaminated with microorganisms.
In Philadelphia in 1976 t h e r e was a n outbreak of a h i t h e r t o unknown infectious
disease: Legionnaire's disease. This serious illness, which primarily a f f e c t s t h e
lungs, was caused by a previously unidentified bacterium which had probably
developed in a cooling t o w e r adjacent t o t h e a i r conditioning s y s t e m s of a
Philadelphia h o t e l where t h e members of t h e Legion of Veterans of t h e American
Army w e r e meeting. It was given t h e n a m e Legionella. By extension f r o m t h e s e
observations, Legionnaire's disease and i t s more benign homologue, P o n t i a c fever,
are also considered t o be illnesses caused by a i r conditioning systems. They. a r e in
f a c t nothing of t h e kind, but r a t h e r a result of contamination of t h e incoming a i r
by Legionella organisms in vapour d r i f t f r o m contaminated cooling t o w e r s located

n e a r t o t h e air-conditioning system. Several epidemics h a v e been r e p o r t e d

worldwide. T h e s e h a v e been associated with a significant mortality. T h i s
publication is not concerned with diseases associated with Legionella pneumophila
(Legionnaire's disease and nonpneumonic legionellosis). These usually present with
easily recognised a c u t e clinical manifestations.
Apart from t h e s e allergic and infectious disorders, doctors a r e confronted every
d a y with a number of complaints affecting mucous membranes of eyes, nose and
throat; headache and lethargy. These symptoms appear t o be benign and related
t o t h e building in which t h e individuals work o r live and constitute t h e SBS.

11. EXTENT OF THE PROBLEM

"Sick building syndrome" is a worldwide problem. Air conditioning is used in many

d i f f e r e n t situations f o r t h e purposes of comfort, s a f e t y and even noise abatement,
i t is used in large blocks of f l a t s o r individual dwellings in hot countries (for
example detached houses, hospitals, hotels, department stores, city o f f i c e blocks,
museums, libraries containing valuable documents). I t is also used in numerous
industries where humidification is necessary, such as printing a n d high-tech
industries of electronics, d a t a processing and magnetic t a p e manufacture. There
are, therefore, millions of people living o r working in premises w h e r e t h e
ventilation is regulated and where use is made of a i r conditioning systems.
However, t h e problem is not limited t o a i r conditioned buildings (Finnegan et al.
1987).
An investigation carried out by Woods et'al. on 600 office workers in t h e USA
showed t h a t 20% of t h e employees experience symptoms of SBS and most of t h e m
w e r e convinced t h a t this reduces their working efficiency. O t h e r e s t i m a t e s report
t h a t u p t o 30% of new and refurbished buildings throughout t h e world may be
a f f e c t e d by this syndrome (WHO 1983 and 1986).
A s t u d y performed in t h e U K on 4373 office workers in 46 buildings revealed t h a t
29% of those studied experienced five o r more of t h e characteristic symptoms of
SBS (Wilson et al.).

111. COST-EFFECTIVENESS

A s WHO has pointed out in t h e publication on Indoor Air Quality Research (WHO
1986), t h e e f f o r t t o save energy will continue in t h e coming years. Unless those
responsible f o r designing and operating buildings realise t h a t energy economy is
not t h e sole criterion in evaluating costs t h e r e will be increasing problems in
buildings. They point out t h a t "energy-efficient but sick buildings o f t e n cost
society f a r more t h a n i t gains by energy savings" and "people's confidence in t h e
effectiveness of health and building authorities may be seriously harmed if sick

buildings become a common phenomenon. For many people sensory warnings have
a great emotional impact that may cause exaggerated responses even in buildings
with only minor environmental problems and may cause unjustified claims of
serious and persistent health effects. The added cost t o society of the increased
sensory irritation, t h e increased discomfort and t h e f e a r of more serious,
persistent health e f f e c t s among t h e occupants is likely t o exceed any of the gains
t h a t can be made on the margins of energy savings."
Recently Robertson made a comparative evaluation of the possible realistic cost
reduction in t h e heating and ventilation of a large building on the one hand and of
a 1% increase in absenteeism among t h e employees on the other. Under t h e
hypotheses assumed f o r t h e calculation, t h e c o s t of t h e a b s e n t e e i s m i s
approximately 8 times greater than t h e money gained through energy savings.
Moreover, t h e absenteeism attributed t o SBS is probably much greater than 1%.
This does not t a k e into account the reduced working efficiency. An improvement
which could be introduced in the organization of enterprises is t h a t of establishing
links between personnel management and t h e management of buildings. These two
functions a r e normally strictly separated.
Also t h e medical-legal aspect should not be forgotten. In some countries (e.g.
France) allergic. manifestations in employees working in air-conditioned buildings,
where t h e air conditioning systems a r e not properly and regularly maintained, a r e
considered among occupational diseases.
These concepts concern existing buildings, but a r e of primary importance in t h e
conception and construction of new buildings.

IV. SYMPTOMATOLOGY*
The symptomatology of this syndrome is varied, but five symptom complexes a r e
regularly encountered. These symptoms may occur singly or in combination with
each other.
1. Nasal manifestations

T h e symptoms most frequently experienced a r e nasal i r r i t a t i o n with

rhinorrhoea and nasal obstruction, usually described a s 'nasal stuffiness1.
2. Ocular manifestations

Dryness and irritation of the mucous membrane of t h e eye.

3. Orooharvngeal manifestations

Dryness and irritation of the throat.

See Appendix 1 for a more detailed description

Cutaneous manifestations
Dryness and irritation of the skin, occasionally associated with a rash on
exposed skin surfaces.
General manifestations
Headaches and generalised lethargy and tiredness leading t o poor
concentration.
These symptoms have a characteristic periodicity increasing in severity over the
working shift and resolving rapidly on leaving the building in the evening. Most
manifestations, therefore, with the exception of some cutaneous symptoms,
improve over weekends and all symptoms usually disappear on holiday.
Some constitutional diseases, e.g. eczema, sinusitis, may be exacerbated in certain
buildings.

V. DIAGNOSIS*
The diagnosis of sick building syndrome is suggested by the presence of the
preceding symptom complexes. Other causes of building related illness (asthma,
hypersensitivity pneumonitis or extrinsic allergic alveolitis, humidifier fever,
allergic rhinitis) should be excluded.
The Consequences of sick building syndrome are a dissatisfied workforce with
reduced working efficiency and increased sickness absence rates (Pickering).

VI. RISK FACTORS

Four major groups of factors are to be considered:

physical;
chemical;
- biological;
- psychological.

1. The physical factors

These have practically all been the subject of national or international

recommendations regarding the standards to be complied with (e.g. American

See Appendix 1 for a more debailed dcscriplion

Society of Heating, Refrigerating and Air-conditioning Engineers Standards).

(a) T e m p e r a t u r e
T h e s t a n d a r d s f o r maintaining a c e r t a i n a c c e p t a b l e level of c o m f o r t a n d
occupational activity fluctuate between 20 and 2 6 ' ~ , taking into account t h e
clothing and t h e relative humidity (IS0 1984). However, t h e r e a r e indications t h a t
t e m p e r a t u r e should be kept in t h e lower part of t h e comfort range. A reduction in
mental work capacity has been observed above 24'6 (Wyon, Wyon et al.). In a
r e c e n t study, J a a k o l a et al. found a significant statistical relationship between
room t e m p e r a t u r e s above 2 2 ' ~ and t h e appearance of SBS symptoms. Similar
findings a r e reported by V a l b j ~ r net al. (1 986, 1987) in offices as well as in homes.
Finally, higher t e m p e r a t u r e s will increase offgassing from materials.

(b) Relative humiditv:

Humidification processes cause many problems and deserve very close attention.
T h e r e is no agreement on what constitutes t h e ideal range of relative humidity. I t
is known t h a t high values (above 70%), particularly a s s o c i a t e d w i t h high
temperature, are uncomfortable and health may be threatened, at least through
t h e development of surface condensation and mould growth. Moreover, high
humidity may lead t o structural damages in building, especially in cold climates.
Very low relative humidity (less than 20%) can cause, in some individuals, drying
of t h e mucous membranes and of t h e skin (Andersen et al.) and a d e r m a t i t i s
(Rycroft, see also "Cutaneous manifestationstt in Appendix 1). Andersen et al.,
however, showed t h a t in 78-hour exposures t o dry clean a i r (R.H. 9%) no signs nor
symptoms were found, even in people with high metabolic rates. Consequently i t
appears t h a t t h e d i r e c t e f f e c t of low humidity on t h e prevalence of SBS can b e
considered unimportant, but indirect e f f e c t s could play a role, including t h e
buildup of s t a t i c electricity and consequent e l e c t r i c discharges, off gassing of
vapours following a significant humidity change o r variation of t h e respirable
suspended particulate matter.
T h e question should be considered whether humidification systems are necessary,
at least in t h e cases where t h e relative humidity is already in t h e acceptable
range.

(c) Ventilation
Insufficient ventilation due t o energy saving measures following t h e oil crisis has
been claimed as one of t h e main causes f o r SBS symptoms. Minimum ventilation
r a t e s d o nevertheless exist in many countries, but vary from country t o country

and, of course, from non smoking t o smoking conditions (range 2,5 - 20 litres per
second per person).
The latest information (IEA) indicates t h a t a r a t e of approximately 8 litres per
second (nearly 30 m3/h) per person (sedentary activity) will be adequate for non
smoking areas in order t o extract t h e bioeffluents of man (odours). At this level a
6 0 2 concentration of 0.1% will be present and 20% of people entering t h e room
will be dissatisfied with the environment. If a higher percentage of dissatisfied is
accepted (25-30%), t h e ventilation r a t e can be proportionally reduced (3.8-5.4
litres/sec. per person). In smoking areas the ventilation r a t e should be higher (Cain
et al., Gunnarsen et al.).
The ventilation c a n contribute by reducing t h e concentration of contaminants
from building materials and processes within t h e building and also heat produced in
t h e building. The most important measure t o reduce such contaminants remains
source control.
Ventilation should not by itself cause problems such as draught o r odour.
Therefore, attention must be laid on accurate commissioning and maintenance
(cleaning) of t h e ventilating plants. Also recirculation of air which introduces
contaminants t o working areas should be avoided.

(d) Artificial light

Some authors (Sterling et al. 1983), by varying both the quantity of ultraviolet
light and t h e ventilation, noted a reduction in eye symptoms, but not in t h e other
symptoms of SBS. Wilkins e t al., using a solid s t a t e high frequency ballast resulting'
in illumination with a reduced fluctuation, decreased t h e incidence of eye-strain
and headache by more than 50% in a group of office workers. It is also possible
t h a t visual stress plays a part in t h e development of eye irritation and headache,
f o r example through the lighting level, insufficient contrast, excessive brightness
and glare.
The prolonged use of visual display units requires particularly well designed
lighting.

(e) Noise and vibrations

Noise expressed as t h e equivalent sound pressure A-weighted level may be a
parameter causing tiredness in levels of 70-80 dB. The nature of the noise is
important. Infrasound which is defined as sound waves in 0.1 - 20 Hz range may
cause dizziness and nausea, but this is not found in levels below 120 dB. It is more
likely that low frequency noise (20-100 Hz) which is found in buildings with
industrial machines or ventilation machinery may cause problems. Tempest has
described some cases where the workers complained of unpleasant working

conditions in one factory department, but not in another, although t h e sound levels
were approximately equal (61 dB (A)) and t h e room f e a t u r e s were similar.
Frequency analysis showed that the sound pressure level in the 8-125 Hz range was
much higher in t h e "unpleasant" department.
Often t h e noise, although having a relatively low A-weighted, level contains some
pure tones, which may cause irritation or other disturbances. A correction for tone
adjustments, which takes into account t h e importance of pure tones in t h e sound
spectrum, is described elsewhere (IS0 1987).
Vibrations produced in the neighbourhood of buildings (for instance underground
railways) have also been accused of being a contributory factor. A considerable
amount of research has been carried out into the effect of vibration on man and
t h e I S 0 has issued a Standard on t h e subject (IS0 1985 a and b).
Hodgson e t al. observed t h a t irritability and dizziness experienced by a group of
secretaries working in new offices correlated significantly with t h e vibrations
measured on their desks. The vibrations were caused by an adjacent pump-room.
The authors s e e a causative link between these vibrations and their complaints
based on t h e f a c t t h a t certain body organs, specifically t h e eyes, h a v e
characteristics resonance frequencies in the range 1-20 Hz. However, t h e finding
requires confirmation in view of t h e very small size of t h e group studied (3
persons).

Presenting the hypothesis t h a t t h e lack of negative ions in t h e atmosphere may be

responsible for SBS, Finnegan e t al. (1987 b) used a negative ion generator in a
double-blind study of office workers in an a i r conditioned building, while
monitoring various parameters. They found t h a t the ion concentration in t h e
atmosphere did not influence the level of symptoms of SBS. Moreover, negative
ionizers have been described releasing significant amounts of ozone, a potent
airway irritant (Guillemin).

(k) Particles and fibres

Dust in t h e indoor air consists of organic and inorganic particles many of which
can be classified as fibres. The total dust concentration in a room is dependent on
ventilation, cleaning and activity levels and the degree of tobacco smoking. No
correlation has y e t been shown between SBS and total dust concentration.

Man made mineral fibres (MMMF) have been a m a t t e r of concern a n d t h e r e h a v e

b e e n reports of a correlation between airborne MMMF and eye-irritation and also
b e t w e e n non respirable MMMF on surfaces and skin irritation (Rindel et al.).
MMMF c o m e mainly from acoustic ceilings: especially high concentrations w e r e
found in rooms with uncovered ceilings, but also where t h e fibres w e r e bound by a
water-soluble g l u e and exposed t o w a t e r d a m a g e (0. Nielsen). T h e fibres are
t r a n s f e r r e d f r o m such surfaces t o skin and e y e s normally by d i r e c t hand contact.
F u r t h e r information on t h e biological e f f e c t s of man-made mineral f i b r e s may be
found elsewhere (WHO 1983 b).

2,

The chemical factors

C h e m i c a l f a c t o r s are t o o numerous t o be considered individually, but t h e y can b e

grouped into major categories.
T h e r e are those which are e m i t t e d indoors and those which s t e m f r o m outside air.
It should be noted t h a t threshold limit values in industrial workplaces a r e fixed f o r
a large number of chemicals by national o r international standards. T h e pollutant
concentrations normally observed in indoor a i r a r e much lower t h a n such limits.
However t w o f a c t o r s should be taken into account: firstly indoor environments are
c h a r a c t e r i z e d by complex mixtures of pollutants, in which synergistic mechanisms
c a n n o t be ruled out; and secondly work-place limits a r e defined f o r healthy a d u l t s
working a 40 hour week. Whereas children, elderly people and hypersensitive
individuals are exposed t o indoor pollution f o r much longer periods.
R e c e n t l y t h e WHO introduced a set of guidelines aiming "to provide a basis f o r
p r o t e c t i n g public h e a l t h from adverse e f f e c t s of a i r pollution and f o r eliminating
o r reducing t o a minimum those contaminants of a i r t h a t a r e known o r likely t o b e
hazardous t o h u m a n health and well being" (WHO 1987). The guidelines d o not
d i f f e r e n t i a t e b e t w e e n indoor and outdoor exposure, hence t h e y c o v e r indoor a i r as
well. T h e c o n c e n t r a t i o n values concerning 28 organic and inorganic substances a n d
f i b r e s are r e p o r t e d in Appendix 4 as a useful reference. These concentrations
should not b e used without referring t o t h e rationales given in t h e book.

(a) Environmental Tobacco Smoke (ETS)

Generally speaking, this is by f a r t h e most important source of chemical pollution
in indoor air. It is now generally accepted that ETS may cause cancer of t h e lung.
Sick building syndrome is statistically more pronounced in smokers than in non
smokers (Skov et al.) and there is an excess of symptoms in non smokers and exsmokers exposed t o ETS compared with t h e s a m e non exposed categories
(Robertson e t a1.1988).
Passive or involuntary smoking by exposed subjects can be measured by a series of
markers (CO, cotinine, thiocyanate ion). It is responsible for mucous membrane
irritation (the side stream of tobacco smoke being more irritant than t h e main
stream). It is well known, moreover, t h a t tobacco smoke contains several hundred
chemical compounds with particularly toxic constituents and t h a t tobacco can also
act as a n allergen affecting t h e bronchial or alveolar immune defence mechanisms
(Molina e t al., Warren, Lehrer). As a rule, smoking should be prohibited in working
environments and indoor spaces open t o t h e public.

(b) Formaldehvde
The presence of formaldehyde may result from t h e use of wood based products
(like particle board, plywood), urea-formaldehyde foam for insulation and a variety
of products, mainly used for disinfection, cleaning and painting. I t has been
suggested that formaldehyde may be t h e cause of sick building syndrome since it
irritates both t h e eyes and the upper or lower respiratory tract. It may also be
responsible for allergic disorders including asthma (Hendrick et al.).
Wanner et al. reported symptoms of ocular or pharyngeal discomfort and irritation
in connection with high concentrations of formaldehyde in new buildings where
insulating materials releasing formaldehyde had been used. Experiments with
climatic chambers carried out by these authors seem t o confirm t h e important
role of this pollutant.
In fact, concentrations in t h e ambient atmosphere of buildings a r e rarely
sufficient t o cause symptoms. SBS has been described where t h e r e was no
formaldehyde in t h e ambient atmosphere (Robertson e t al.). It is possible,
however, that low concentrations of this pollutant, potentiated by other factors,
may become important. It must therefore be considered a s one of t h e possible
contributors t o t h e SBS.
The WHO has recently introduced a concentration limit of 0.1 mg/m3 f o r indoor
air, because this is considered the threshold of irritation, whereas "significant
increases in symptoms of irritation s t a r t a t levels above 0.3 mg/m3 in healthy
subjects1' (WHO 1987).

(c) Volatile orpanic compounds (VOC)

Whether they c o m e from building materials, furniture, household maintenance
p r o d u c t s (waxes, d e t e r g e n t s , insecticides), p r o d u c t s of p e r s o n a l h y g i e n e
(cosmetics), do-it-yourself goods (resins), office materials (photocopier ink) o r ETS
t h e s e compounds may a f f e c t man in different ways and sometimes are also source
of odours.
Evidence on t h e r o l e of VOCs in SBS cases has not been convincing. Sterling e t al.
(1987) found no significant difference in t h e VOC concentration between rooms
with and without complaints in t h e s a m e building: t h e levels in t h e latter were
even higher t h a n those in t h e former. On t h e o t h e r hand Malhave (1986, 1987)
reported e f f e c t s (detectable through subjective sensation, performance tests o r
f i n e clinical observations, like the tear film stability of t h e eye) in chamber
experiments with t o t a l VOC concentrations equivalent t o those found in new o r
refurbished buildings.
Berglund et al. have found, moreover, t h a t t h e concentration of some VOC was
inversely proportional t o t h e relative humidity, which would explain why SBS
disorders can b e more severe in winter than in summer. T h e correlation was
a t t r i b u t e d t o t h e e f f e c t of a i r humidity on t h e emission from materials. P. A.
Nielsen working o n d a t a obtained in t h e Danish Townhall study, speculated on t h e
e f f e c t of VOC dissolution in (and successive release from) t h e w a t e r adsorbed on
material surfaces, particularly books and papers on open shelves and surfaces with
high adsorption rates (carpets, fabrics, etc.); t h e complaint r a t e in f a c t correlated
strongly with t h e amount of such surfaces in rooms, referred t o as shelf f a c t o r and
f l e e c e factor, respectively. In t h e s a m e s t u d y Wolkoff r e p o r t e d v e r y l a r g e
variations of VOC concentrations in space and time, depending on activities within
t h e space.
In a r e c e n t paper comparing t h e levels of VOCs in t w o preschools, one healthy and
t h e o t h e r closed because of SBS problems, Noma et al. put forward t h e hypothesis
t h a t concentration gradients r a t h e r than absolute concentrations of VOC may
t r i g g e r SBS.

(d) Biocides
Biocides a r e currently used in most cold water spray humidifiers t o c o n t r o l
microbial growth. These products a r e highly irritant irl concentrated form; when
dispersed in t h e indoor atmosphere, at low concentrations, they may cause mucous
membrane irritation in susceptible individuals. Consequently this practice should
not b e recommended.

(e) Other paseous substances

Carbon dioxide ( 6 0 2 ) is a gas which occurs naturally in the atmosphere and is an
indicator of adequate ventilation within buildings. A concentration higher than
0.1% is associated with an increased percentage of dissatisfied occupants (see
above "Ventilation"). The concentrations of Cop normally observed in buildings
a r e not associated with any symptom, except the sensation of stale and stuffy air.
Carbon monoxide (CO) is produced in incomplete combustion processes: unvented
heating, gas cooking, tobacco smoking; i t is present also in car exhaust, so that
t h e indoor CO concentrations may be increased if the air intake of t h e building is
a t s t r e e t level. The 8-hour mean concentrations observed in outdoor urban air a r e
generally lower than 20 mgIm3; in homes concentrations exceeding 50 mg/m3
have been reported (Boleij et al. 1982). The World Health Organization has
recently introduced a guideline concentration of 10 mg/m3 (8 hours averaging
time), designed t o protect non smokers from CO contained in ETS (WHO 1987).
Nitrogen dioxide (NOp) is also a possible source of irritation, especially in
households using unvented heating or gas cooking. In the frame of t h e COST 613
Action a paper is in preparation. It concludes that the association between
respiratory illness and/or impaired lung function on one side and indoor NO2
exposure or the use of gas for cooking (as a surrogate measure of exposure) on t h e
other side shows that there is a small, but real effect, even though several
negative studies have been reported (Community-COST Concertation Committee).
The above mentioned WHO Guideline indicates for NO2 a concentration limit of
0.15 mg/m3 and of 0.40 mg/m3 for exposure periods of 24 hours and 1 hour,
respectively.
Ozone (03), which is an irritant t o the respiratory tract, may be produced by
photocopying machines, laser printers (especially when not properly maintained)
and certain types of ionizers: relatively high concentrations can be achieved in
t h e proximity of these sources.
Sulphur dioxide (S02) from outside pollution enters buildings by air infiltration.
The concentration indoors is normally lower than outdoors (roughly half) because
of adsorption or reaction. The gas is irritant t o mucous membranes, but has never
been reported a s a source of SBS.

(f)

Odours

Many gases and vapours give rise t o sensory discomfort from odour and irritation,
which may be a disturbing factor, leading t o anxiety and stress, especially when
t h e sources are not identified.

Recently Fanger (1988) introduced t w o new units, "olf" and "decipoll',to quantify
a i r pollution sources and levels of pollution as perceived by human beings. O n e olf
is t h e emission r a t e of a i r pollutants (bioeffluents) from a standard sedentary
person in t h e r m a l comfort. The source strength of any other pollution source c a n
b e quantified in olfs, i.e. t h e number of standard persons required t o make t h e a i r
f e l t equally annoying. One decipol is t h e air pollution caused by one standard
person (1 olf), ventilated by 10 litreslsecond of unpolluted air. T h e decipol value
c a n b e assessed by a panel of judges. This method has been used successfully by
Fanger et al. to quantify pollution sources in spaces and ventilation systems in 1 5
o f f i c e buildings. Comprehensive "hidden olfs" were identified in t h e buildings. T h e
hidden olfs f r o m materials and systems are claimed t o be t h e major reason f o r t h e
sick building syndrome. However at t h e present t i m e no s t u d i e s h a v e b e e n
conducted comparing olf levels with sickness levels within buildings.

3.

T h e biological f a c t o r s

O f f i c e buildings normally present very low concentrations of mites , because they

d o n o t provide appropriate conditions f o r t h e growth of such microorganisms.
M i t e s are, however, relatively abundant in household dust. Korsgaard h a s
suggested t h a t m i t e s can be destroyed keeping absolute humidity below 7 glkg of
a i r (about 45%) during t h e winter time. In cases of buildings with structural faults
o r bad maintenance (leading t o high humidity o r cold surfaces) moulds c a n develop.
H e a l t h problems r e l a t e d t o moulds a r e usually a l l e r g i c in origin. Mould
proliferation h a s not been suggested as a cause of SBS.
R e c e n t studies (Nexe et al., Valbjern et al. 1987) demonstrated a correlation
between t h e organic dust content of c a r p e t s (predominantly skin scales, bacteria
and moulds) and t h e symptoms of SBS. Therefore, t h e role of organic dust and in
particular of moulds and their metabolic products needs t o be f u r t h e r investigated.

4.

The psychological f a c t o r s

I t h a s been t h e initial reaction of a number of professionals confronted with

r e p e a t e d complaints of ill-def ined discomfort t o blame psychological factors, and
all t h e more s o since these symptoms appear t o have no organic basis and women
a r e t h e most frequently affected.

Various studies have been carried out testing these patients e i t h e r with a set of
performance tests (memory, vigilance, reaction time, Berglund et al.) o r in t h e
f o r m of a psychosociological survey evaluating how these complainants viewed
t h e i r working conditions in air-conditioned environments (Breugnon et al.). T h e
performance tests show no significant differences between s y m p t o m a t i c a n d
control groups.

.
,.

Some researchers (Morris e t al., Hedge e t al.) have investigated t h e possible links
between SBS and stress: their results, though not clear-cut, lead t o think t h a t SBS
may well be responsible for t h e stress rather than t h e reverse.
Psychological factors may play a role by increasing the stress of people and thus
making them more susceptible t o environmental factors (WHO 1986). Skov e t al.,
in a multifactorial analysis of the data from t h e Danish Townhall Study, showed
t h a t in addition t o t h e building factor other factors like sex, job and psychosocial
f a c t o r s a r e associated with t h e prevalence of mucosal irritation and general
symptoms.
The psychophysical load at the working place (e.g. visual display units) can cause
e y e irritations, tiredness and headache, and can be an additional f a c t o r f o r
complaints on indoor climate and indoor air quality (Wanner).

VII. HOW TO CONDUCT BUILDING ASSOCIATED INVESTIGATIONS

Usually, building related problems show up when one or more persons complain t o
t h e management o r t h e persons responsible for t h e occupational environment t h a t
they have direct troubles from the physical climate as e.g. draught, changing
temperature, noise, or the like, or t h a t they have symptoms of mucous membrane
irritation, skin irritation, tiredness, or headache.
The initial response should be t o ask t h e maintenance engineer responsible for t h e
technical installat ions whether operational conditions a r e abnormal e.g. if t h e
ventilation is c u t off. Furthermore it should be investigated whether t h e persons
complaining a r e able t o change their indoor climate e.g. by adjusting temperature
and airflow.
If t h e operational conditions a r e considered normal and the complaints continue, a
technical and hygiene investigation of the conditions should be carried out. The
purpose of this investigation is t o decide the extent and the n a t u r e of t h e
problems. The investigation also forms the basis of t h e estimation of whether t h e
problems should be considered only from a technical point of view or if hygiene or
psychosocial experts should be consulted.

The stepwise actions recommended in t h e following a r e primarily worked out for a

building with SBS problems, but can be used with minor variations in all buildings
with indoor air quality and climate problems. Before undertaking t h e next step,
t h e results of t h e initial investigation should be evaluated, corrrective measures
taken and the e f f e c t s of the measures observed. More details on this subject can
be found in a paper by V a l b j ~ r ne t al. (in danish with english summary) from which
this chapter has been largely derived.

Table 1. Summary of stepwise investigations of buildings with problems

Performed by
(proposals)

Actions (examples)

Step

Type of investigation

Technical survey and

use of questionnaire

Industrial physician
Safety representative
Maintenance engineer

Contact experts for

evaluation, organize
new actions, inform.

Inspection and guiding

measurements of
climate-indicators

Safety engineer
Ventilation engineer

Clean and adjust

ventilation, stop
hu midif iers,(re) move
smokers and pollution
sources

~ e a s u r e ' m e n t of
s
ventiiation, climate
indicators and other
implicated factors

Safety engineer
Industrial hygienist
Ventilation engineer

Increase ventilation,
arrange sun-shielding

Medical investigation,
specific measurements
of suspected components

Medical doctor
Industrial hygienist

Renew furniture,
change on-going
activities or building
materials; move
staff, mount local
exhaust

S t e p 1.

Technical and hv&ene investigations.

At this preliminary s t e p a hygiene and technical review of the type and severity of
t h e indoor problems is carried out, in o r d e r t o d e c i d e w h e t h e r f u r t h e r
investigations and external expertise a r e required.
When general agreement is reached, that the problems have been satisfactorily
documented and t h a t actions should be taken, i t is recommended t h a t t h e
personnel experiencing problems a r e informed of the results of t h e review. A
technical survey of t h e building is also performed in order t o decide the relevant
actions t o be taken.
A simple questionnaire concerning symptoms and complaints about d i f f e r e n t
factors is distributed t o a randomly selected sample of employees. I t is not t h e
primary intention t o use the answers for individual actions. They should be used
f o r a statistical judgement of whether t h e prevalence of symptoms exceeds an
acceptable level. This level should be established by appropriate investigations in
each country.

An example of a questionnaire is in Appendix 3. The questionnaire should clearly

distinguish between symptoms experienced in the building and those experienced
when away from t h e building. The questionnaire may also include psychosocial
questions. The information contained in individual questionnaires and t h e identity
of specific buildings should be treated a s strictly confidential.
A technical survey of the building and the installation conditions is worked out
based on project plans and information from the building maintenance staff. An
example of a checklist is shown in Appendix 2.

Step 2,

Inspection and midint? measurements.

At this step t h e actual use and functioning of t h e building is compared with i t s

original plan design and function.
The following aspects should be observed:
Tobacco smoking. Where, how much, spread by recirculating air?
Building and furnishing materials.
Location of copying machines and laserprinters (preferably in separate and
ventilated rooms).
Odours. Characterize them and identify sources.
Cleaning level. Dust on floor carpets, bookshelves etc.
Intensive paper handling. Source of organic dust and gases from print.
Presence of green plants. Are chemicals used for treatment?
Water damage, water stains.
Occurrence of moulds.
Air infiltration from garage, laboratory, restaurant, workshop etc. in t h e s a m e
building.
Siting of outside air intake regarding short-circuiting of pollutants from
exhaust ventilation systems.
Use of centrally or locally situated humidifiers. Are they cleaned regularly?
Inlet and exhaust openings. Are they clean or blocked with dirt?
Use of sunshielding.
Number of employees in the offices. Are there more than planned?
Random measurements of climate indicators such as carbon dioxide and a i r
temperature, control of airflows by using smoke ampoules and evaluation of
factors which in the questionnaire a r e mentioned a s disturbing (e.g. noise or
lighting) should be carried out. Check both rooms with and without problems.

Step 3.

Measurements of ventilation, climate indieators and other im~licated

factors.

A t t h i s s t a g e a thorough analysis of t h e ventilation system and t h e indoor c l i m a t e

is carried out, assuming t h e actions taken during t h e preceding s t e p s have not
resulted in a reduction in t h e problems. This may b e assessed by readministering
t h e simple questionnaire a few months a f t e r t h e remedial actions have been taken.
T h e r e may b e a seasonal variation in symptoms and in complaints on specific
c l i m a t e f a c t o r s a n d t h i s may c o m p l i c a t e t h e evaluation of t h e r e p e a t e d
questionnaire.
T h e following f a c t o r s should be investigated:
Ventilation:

- Visual inspection of filters, heating and cooling batteries, h e a t exchangers with

regard t o t h e accumulation of d i r t and dust.
-

Control of adjustment of temperatures, start and s t o p settings etc.

- Testing of a l l functions of t h e automatic control systems.

-

Measurement of t h e degree of recirculation.

Measurement of supply and exhaust flows f o r t h e whole system and for a

representative sample of t h e rooms.

Air change measurements.

Ventilation e f f i c i e n c y m e a s u r e m e n t s where risks of low e f f i c i e n c y are

suspected.

Air quality and other factors:

-

Again indoor a i r quality indicators like carbon dioxide, carbon monoxide and a i r
t e m p e r a t u r e should be measured, but more extensively than previously and
including'measurement of diurnal changes which may be occuring. In this step,
if not earlier, measurements of specific f a c t o r s should b e made. T h e specific
f a c t o r s t o b e measured will be suggested by initial inspection of t h e building
and by t h e questionnaire responses.

In newly built o r refurbished buildings, if significant odours are present, t o t a l

o r individual volatile organics (in particular strong irritants) are measured and
if building m a t e r i a l s o r f u r n i t u r e are a possible s o u r c e of odour, a l s o
formaldehyde. Large variations in levels c a n occur during short periods of t i m e
(hours).
Pollution sources can be found by estimating t h e perceived a i r quality (in
decipol) and measuring t h e outdoor a i r supply a s described by Panger et al, T o
identify sources, t h e different compartments must be tested separately.

In t h e rooms where internal acoustic ceilings with man-made mineral fibres

appear unprotected or damaged, measurements of airborne fibres may be
made; the replacement or sealing of such ceilings is recommended.

In situations where poor cleaning is suspected or where large quantities of

paper a r e being handled, the dust content in t h e air and on t h e floor should be
measured. An evaluation of the composition of t h e dust may be of importance.

Lighting measurement - even in the absence of complaints.

users may have lighting problems that a r e not recognised.

Sound measurement: attention should be drawn t o low frequency noise from

ventilation systems or other machinery and t o irritating pure tones from office
machinery.

Visual display

- Measurements of air velocity distribution.

-

Where the ceilings a r e warmer than the air temperature either the ceiling
temperature o r t h e radiation temperature in t h e direction of t h e ceiling should
be measured.

S t e p 4.

Medical examination and associated investigations.

At this step a medical examination takes place. It may be necessary t o examine

employees with and without symptoms. The examination is normally carried out
by a n occupational medical unit.
In addition t o these examinations some specific exposures may be studied. This
might be a qualitative study of t h e volatile organics together with a toxicological
evaluation. A microbiological study together with provocation tests is another
possibility.
The medical examination can incorporate a detailed questionnaire related t o
symptoms and should ask questions about t h e psychosocial conditions a t work, t h e
relationships of individuals t o their colleagues and superiors and t h e type of work
they a r e performing, all of which may influence symptoms. This last s t e p requires
co-operation between specialists, but must be administered by occupational
physicians. It is normally not necessary as most of the problems in buildings a r e
solved by t h e previous steps. This should be t e s t e d by using t h e original
questionnaire some time a f t e r remedial measures indicated by Step 3 have been
carrried out.

The references a r e l i s t e d in alphabetical order. When there are more references of t h e

same author@) t h e y are listed chronologically and t h e year o f publication i s indicated in
t h e quotation in t h e text. When there are t w o papers o f the same-author($ in t h e same
year t h e y are labelled with the l e t t e r s a and b in t h e t e x t and this corresponds t o t h e order
in t h e l i s t (a=former paper).

ANDERSEN I., LUNDQUIST G. R., JENSEN P. L., PROCTOR D. F.

Human response to 78-hour exposure to dry air.
Arch. Environm. Health a(1974), 319-324
BANSAZAK E. F., THIEDE W. H., FINK J. N.
Hypersensitivity Pneumonitis due to Contamination o f an Air Conditioner.
N. Engl. J. Med., 283, (1970), 6,271-76
BERGLUND B., BERGLUND U., ENGEN T.
Do sick buildings affect human performance? How should one assess them?
INDOOR AIR '87, Proceedings of the 4th Intern. Conf. on Indoor Air Quality and Climate, Berlin (West)
17-21 August 1987, Inst. fur Wasser-, Boden- und Lufthygiene, Berlin. Vol. 2, 477-481
BOLEIJ J. 5. M, LEBRET E., SMIT J., BRUNEKREEF B., BIERSTEKER K.
lnnenluffverunreinigungen durch Kohlenmonoxid und Stickstoffoxide
(Indoor Air Pollution by Carbon Monoxide and Nitrogen Oxides)
in: Lufkqualitat i n Innenraumen, K. Aurand, B. Seifert and J. Wegner Eds. Gustav Fischer Verlag,
Stuttgait-New York 1982, 199-208.
BREUGNON N., CLEMENT P., MARTIN E., MASSERAND R., MOLJNA N.
Perception des conditions de travail en atmosphere climatisee.
Maladies des climatiseurs et des humidificateurs, Editiors INSERM, Paris 1986, p. 117-125.
BRUNDAGE J.F., SCOTT McN.R., LEDNAR W.M., SMITH D.W., MILLER R.N.
Building-associated risk o f febrile acute respiratory diseases in army trainees.
J. Am. Med. Ass 259(1988), 2108-21 12
BURCKE G. W., CARRINGTON C. B., STRAUSS R., FlNK J. N., GAENSLER E. A.
Allergic alveolitis caused b y home humidifiers. Unusual clinical features and electron microscopic
findings.
J. Am. Med. Ass. 238, (1977), 25,2705.
CAlN W. S., LEADERER B. P., ISSEROFF R., BERGLUND L. G., HUEY R.J., LlPSlTT E. D., PERLMAN D.
Ventilation requirements i n buildings-I. Control o f occupancy odor and tobacco smoke odor.
Atm. Env. E(1983) 1 183-1197
COMMUNITY-COST CONCERTATION COMMITTEE ON INDOOR AIR QUALITY
lndoor NO2 pollution in the European Community.
COST-613 report (in preparation)
DE WECK A. L.
Les pneumopathies interstitielles aux antigenes d'inhalation (du type poumon de ferrnier).
nouvelle forme d'affection pulmonaire allergique.
Praxis, l8, (1970), 647

Une

FANGER P.O.
Introduction o f the olf- and the decipol-unit to quantify air pollution perceived by humans rnaoors and
outdoors.
Energy and Buildings, l2, (1988), 1-6.
FANGER P. O., LAURIDSEN J., BLUYSSEN P., CLAUSEN G
Airpollution sources in offrces and assembly halls, quantrfred by the o l f unit.
Energy and Buildings l2, (1988), 7-19
FINNEGAN M.J. and PlCKERlNG C. A. C.
Work related astma and humidifier fever in air conditioned buildings.
Proceedingsof the 3rd International Conference on lndoor Air Quality and Climate
Eds. Berglund B., Lindvall T., Sundell J., Swedish Council for Building Research, Stockholm 1984, Vol 1,
256-262
FINNEGAN M.J.and PlCKERlNG C. A. C.
Prevalence o f symptoms o f the sick building syndrome i n buildings without expressed dissatisfaction.
INDOOR AIR '87, Proceedings of the 4th Intern. Conf. on lndoor Air Quality and Climate, Berlin (West)
17-21August 1987, Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol. 2,542-546
FINNEGAN M. J., PlCKERlNG C.A. C., GILL F. S., ASHTON 1.
Negative ions and the sick building syndrome.
ibid., Vol. 2, 547-551
FRANCK C.
Eye symptoms and signs in buildings with indoor climate problems ("office eye syndrome "1.
Acta Ofthalmologica 64 (1986), 306-3 1 1.
GUlLLEMlN M. P., TRlN VU DUC, BERNHARD C. A.
"Sick Building Syndrome" :psychose collective ou realite?
Congres SIRMCE (E.P.F.L.-IREC), HABITAT ET HABITATIONS SAINES, Lausanne 1987
GUNNARSEN L.and FANGER P.O.
Adaptation to indoor air pollution.
Healthy Buildings '88, Proceedings of a Conference, Stockholm 5-8 Jept. 1988. Swedish Council for
Building Research, Vol. 3, 157-167
HEDGE A., STERLING E. M., COLLETT C. W., MUELLER B., ROBSON R.
lndoor air quality investigation as a psychological stressor.
INDOOR AIR '87, Proceedings of the 4th intern. Conf. on lndoor Air Quality and Climate, Berlin (West)
17-21 Aug. 1987 Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol. 2,552-556
HENDRICK D.J and LANE D.J.
Occupational forrnalin asthma
Brit. J. Industr. Med. 34(1977), 11-18
HODGSON M. J., PERMAR E., SQUIRE G., CAGNEY W., ALLERA., PARKINSON D. K.
Vibrations as a cause o f "tight-building syndrome" symptoms.
ibid., Vol 2,449-453
INTERNATIONAL ENERGY AGENCY (IEA)
Energy conservation in buildings and community systems programme. Annex IX: Minimum ventrlation
rates.
L. Trepte, P. Warren and V. Meyringer Eds, Internat. Energy Agency, Paris 1987

INTERNATIONALSTANDARD ORGANIZATION (ISO)

Moderate thermal environments. Determination o f the PMV and PPD indices and specification o f the
conditions for thermal comfort.
IS0 7730, Geneve 1984
INTERNATIONALSTANDARD ORGANIZATION (ISO)
Evaluation o f human exposure to whole-body vibration. Part 1: General requirements.
I S 0 263 1.1, Geneve 1985
INTERNATIONALSTANDARD ORGANIZATION (ISO)
Evaluation o f human exposure to whole-body vibration. Part 3: Evaluation o f exposure to whole-body
z-axis vertical vibration i n the frequency range 0.1 to 0.63 Hz.
I S 0 2631.3. Geneve 1985
INTERNATIONALSTANDARD ORGANIZATION (150)
Acoustics. Description and measurement of environmental noise. Part 2: Aquisition o f data pertinent to
land use.
IS0 1996.2, Geneve 1987
JAAKKOLA J. J. K. and HEINONEN 0.P.
Mechanical ventilation in an office building and sick building syndrome, a short-term trial.
INDOOR AIR '87, Proceedings of the 4th Intern. Conf. on lndoor Air Quality and Climate, Berlin (West)
17-21 Aug. I987 Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol. 2, 454-458
KORSGAARD J.
House-dust mites and absolute indoor humidity.
Allergy 38(1983) 85-92
LEHRER 5.B., WILSON M. R., SALVAGGIO J. E.
lmmunogenrc properties o f tobacco smoke.
J. Allergy Clin. Immunol., 62(1978), 368.
MBLHAVE L.
Human react~onsto indoor air pollution: n-decane.
INDOOR AIR '87, Proceedings of the 4th Intern. Conf. on lndoor Air Quality and Climate, Berlin (West)
17-21Aug. 1987 Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol 1, 97-101
MBLHAVE L., BACH B., PEDERSEN 0. F.
Human reactions to l o w concentrations o f volatile organic compounds.
Environment International 12 (1986), 167-165.
MOLINA CI , AIACHE J-M., VIALLIER J.
Reactions immunitaires au tabac.
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MORRIS L. and HAWKINS L.
The role o f stress i n the sick buildrng syndrome.
INDOOR AIR '87, Proceedings of the 4th Intern. Conf. on lndoor Air Quality and limate, Berlin (West)
17-21 Aug. 1987 inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol 2, 566-571
NEX0 E , SKOV P. G. and GRAVESEN 5.
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NIELSEN P. A.
Potential pollutants, their importance to the sick building syndrome and their release mechanism.
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17-21 Aug. 1987 Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol. 2, 598-602

"

NIELSEN 0.
Man-made-mineral fibres in the indoor climate caused by ceilings o f man-made-mineral wool.
ibid., Vol. 1, 580-583
NOMA E., BERGLUND B., BERGLUND U., JOHANSSON I., BAlRD J.
Joint representation o f physical locations a n d volatile organic compounds in indoor air from a healthy
a n d a sick building.
Atmospheric Environment 2 (1988), 451-460.

i-

PATTERSON R., FINK J. N., MILES W. B., BASICH J. E., SCHLEUTER D. B., TINKELMAN D. G., ROBERTS
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private communication
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institutions-byggeri
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ROBERTSON G.
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SOLOMON W. R.
Fungus aerosols arising from cold mist vaporizers.
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Office Buildings Investigation.
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TEMPEST W.
lnfrasound and low-frequency vibration.
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VALBJ0RN O., HAGEN H., KUKKONEN E., SUNDELL J.
lndeklimaproblemer
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WANNER H.U.
personal communication
WANNER H. U. and KUHN M.
lndoor air pollution by building materials.
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Extrinsic allergic alveolitis: a disease common'in non smokers.
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WILKINS A. J., NIMMO-SMITH M. I., SLATER A., BEDOCS L.
Fluorescent lighting, headaches and eyestrain
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WILSON 5. and HEDGE A.
The office environmental survey.
Building Use Studies London 1987
WOLKOFF P.
Sampling o f VOC under conditions o f high time resolution.
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17-2IAug. I987 Inst. fur Wasser-, Boden- und Lufthygiene, Berlin; Vol. 1, 126-129.
WOODS J. E., DREWRY G. M., MOREY P. R.
Office worker perceptions o f indoor air quality effects on discomfort and performance.
ibid. Vol. 2, 464-468

WORLD HEALTH ORGANIZATION (WHO)

lndoor air pollutants :exposure and health effects.
EURO Reports and Studies No. 78,WHO Regional Office for Europe, Copenhagen 1983
WORLD HEALTH ORGANIZATION (WHO)
Biological effects o f man-made mineral fibres.
EURO Reports and Studies No. 81,WHO Regional Office for Europe, Copenhagen 1983
WORLD HEALTH ORGANIZATION (WHO)
lndoor air quality research.
EURO Reports and Studies No. 103,WHO Regional Office for Europe, Copenhagen 1986
r

+.

WORLD HEALTH ORGANIZATION (WHO)

Air quality gurdelines for Europe.
WHO Regional Publications, European Series No. 23
Copenhagen 1987
WYON D.P
The effects of moderate heat stress on typewritrng performance.
Ergonomics 17 (1974),309-318
WYON D.P and HOLMBERG I.
Sistematic observation o f classroom behaviour during moderate heat stress.
Thermal comfort and moderate heat stress, Proc. CIB ( W 45) Symposium, Garston 13-15 September 1972,
Building Establishment Report n. 2 (HMSO) London 1973

In addition, the following literature may be useful for general information on the topic:

FINNEGAN M. J. and PICKERING C. A. C.

Building related illness.
Clinical Allergy, 1986,l6, 389-405
MOLINA CI.
Les Maladies des clirna tiseuk et humidificateurs.
Editions de L'INSERM, Paris 1986.
VINCE I.
Sick Building Syndrome.
IBC Technical Services Ltd., London 1987

Appendix 1
SY MPTOMATOLOGY

Nasal manifestations

1.

Nasal stuffiness. This is the most frequently described nasal symptom. The
sensation of 'stuffiness' develops rapidly on entering the building, it persists while
t h e individual remains in the building and resolves rapidly on leaving t h e building.
It is not usually associated with either nasal itching or rhinorrhoea. In certain
individuals i t is specifically t e m p e r a t u r e related, appearing when high
temperatures occur within the building.
Nasal irritation and rhinorrhoea. These symptoms a r e more variable and not
necessarily persistent. Their character is highly suggestive of an allergic
a e t iology.
These symptoms do not necessarily occur s e p a r a t e l y and may o c c u r in
combination with each other.
2. Ocular manifestations

Dry, gritty o r burning sensations of the eyes a r e experienced. These symptoms

a r e not usually associated with any objective evidence of inflammation. A recent
Danish study (FRANCK) has suggested that there is break up of t h e t e a r film
covering t h e anterior aspect of the eye in those experiencing symptoms. The
presence of these ocular symptoms demonstrates considerable variability in their
severity from day t o day. There is one group of individuals, contact lens wearers,
who a r e particularly prone t o t h e development of ocular irritation. Many find
they have t o return t o wearing spectacles.
3. Oropharyngeal manifestations

The main symptom is one of dryness of the throat which is partially relieved by
drinking large volumes of liquid. Physical examination of t h e throat does not
usually reveal evidence of inflammation.
4.

Cutaneous manifestations
Dry skin is frequently experienced in buildings. Female subjects a r e particularly
aware of this symptom. It usually improves on holidays but not over shorter
periods away from work, such a s a weekend. A specific dermatitis has been
described (RYCROFT e t al.) which is caused by warm dry air and high a i r
movements. I t tends t o affect exposed skin surfaces.
h

5. Respiratory manifestations

There is one lower respiratory t r a c t symptom which is associated with sick

building sickness syndrome. This is a sensation of chest tightness or 'difficulty in
breathing in fully'. This symptom clears on taking two or three deep breaths of
fresh air outside the building and is not a symptom of bronchial asthma.
6. General manifestations

Headaches and excessive tiredness are two of the most frequent building related
symptoms. Headaches may occur daily, are frontal in position and usually occur
in t h e afternoon. In its most severe form work related migraine may be present.
This is usually relieved by moving the individual away from artificial (fluorescent
tube) lighting. Headaches a r e also reduced by wearing lightly tinted glasses. An
additional symptom described sometimes is "heavy headedness".

Constitutional diseases
Some constitutional diseases, e. g. eczema, sinusitis, may be exacerbated in
certain buildings
Excessive tiredness occurs over the second half of the working day. It is not
usually alleviated by manipulating dietary intake at lunchtime and is often
directly related t o high room temperatures,
DIAGNOSIS
Building related illnesses other than sick building syndrome fall into two main
categories as follows:
Allergy

Asthma, rhinitis
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Humidifier fever

Infections -

Bacterial, fungal, viral.

Allergy

Asthma, rhinitis
In general allergic responses of the upper and lower respiratory tracts occur
secondary to the inhalation of allergens in poorly maintained buildings where the
cold water spray humidifiers have become contaminated by micro-organisms.
Bronchial asthma i n a family has been described caused by a simple,
contaminated home humidifier (SOLOMON) and also in a factory situation where
print workers developed asthma due to heavy microbial contamination of a
central cold water spray humidifier (FINNEGAN et al, 1984). The features are
those of any form of occupational astnn~awith increasing asthmatic symptoms
over the working week, improving on days away from work, over weekends and
holidays.

Hypersensitivity pneumonitis
This is the most serious form of allergic response which may be related to
buildings. It occurs when heat exchange systems become contaminated usually by
thermophilic actinomycetes (for example micropolyspora faeni). The number of
cases reported in the literature have been small, occurring both in air-conditioned
office blocks in the centre of cities (BANSAZAK et al.) and also i n airconditioned homes (BURCKE et al., PATTERSON et al.). The principal symptoms
which occur some hours after exposure include fever, malaise and breathlessness,
Profound loss of weight may be an accompanying feature, On auscultation of the
lungs late inspiratory crackles are generally present and chest radiographs reveal
a micronodular infiltrate. Pulmonary function tests are abnormal. The classical
pattern is that of a restrictive lung defect with impaired gas transfer.
Serological tests usually show the presence of precipitating antibodies to the
causative allergen. Bronchial provocation studies may be used to confirm the
diagnosis.
The
Occasionally lung biopsy is necessary to establish the diagnosis.
characteristic histological changes are of a histiocytic cellular infiltration with
giant cells and granuloma formation.

Humidifier fever
This condition was first described in 1956 by PESTALOZZI. He described an
outbreak of systemic and respiratory symptoms in a group of workers in a
carpentry shop. Symptoms occur on t h e first day of the working week, a similar
periodicity t o byssinosis, developing over the second half of t h e working shift o r
in t h e evening a f t e r leaving the workplace. Although exposure continues a t work,
symptoms improve progressively over the working week and subsequent weekend,
recurring again on the first day back a t work a f t e r a weekend or holiday. The
symptoms of humidifier fever a r e 'flu-like', lethargy, myalgia, arthralgia,
headache and fever. In more severe cases these symptoms a r e associated with
cough and breathlessness. They resolve over a twelve hour period and t h e
individual is normally able t o work normally the following day.
Physical examination at the height of the reaction reveals the presence of l a t e
inspiratory crackles on auscultation and lung function shows a restrictive defect
with impaired gas transfer. Lung function is normal between attacks. In all
cases t h e chest radiograph is normal.
Immunological investigations almost always reveal t h e presence of precipitating
antibodies t o antigens extracted from the humidifiers.
Bronchial provocation tests with water from t h e humidifier usually reproduce t h e
symptoms and physiological changes in affected individuals but not in control
subjects.
The cause or causes of humidifier fever a r e not known. Outbreaks often occur
A
when humidifiers have become heavily contaminated by micro-organisms.
number of different causes have been postulated including NaegZeria gruberi,
Acanthamoeba polyphaga, Bacillus subtilis and endotoxin. A l l of these suggested
causes a r e based on serological investigations. A t the present time none has been
proved t o be t h e cause by provocation studies.
lnf ections

Bacterial
The most serious infection associated with air-conditioning systems is that caused
by Legionella pneumophila. Individuals a r e infected by vapour drift containing
this bacterium from contaminated cooling towers. This may occur in the s t r e e t s
in t h e vicinity of t h e cooling tower or inside buildings when water droplets a r e
drawn into t h e building via t h e air-conditioning system. Legionnaire's disease has
not been described a s a result of contaminated cold water spray humidifiers.
Fungal
Infections caused by the fungal species Aspergillus have been described as a
result of contaminated incoming air t o buildings and due t o contamination of duct
work.
This i s a p a r t i c u l a r problem in h o s p i t a l s , a f f e c t i n g old a n d
immunocompromised patients. Good maintenance procedures and appropriate
filters will prevent outbreaks of this type of disease.
Viral
An epidemic infection of measles has been described where the mode of spread
appeared t o be via t h e air-conditioning system (RILEY e t al.).

Appendix 2

Checklist for description of the building, its materials, installations, and the
conditions of both

Building age
Renovation within the latest years (work done and date).
Number of persons per office (average and max).
Office area per person (average and min).
Air volume per person (average and min).
The floor: material and covering.
The walls: material and covering.
The ceiling: material and covering.
The heating system: type and regulating system.
The ventilation sy&em: natural ventilation, mechanical exhaust and/or air supply
system, filters.

For air supply systems: additional information on

recirculation, humidification, cooling, air intake location.

The magnitude of ventilation: outdoor air change rate (ach) and the corresponding
average and minimum outdoor rates per person (litres/second~person)
(Indicate whether these values are based on assumption, design criteria or
measurements.)
The running procedure for heating and ventilation systems:

night setback,

recirculation, humidif ication.

-

Cleaning procedures: daily, weekly, monthly, annual procedures for floors,

furnitures etc.
(recent changes in procedures?).
Lighting conditions: general, individual.
Equipment producing noise, pollutants, heat: type and location.
Products used which can deteriorate the air quality (cleaning products, spray for
plants, etc.).
Water damage (previous or present).
Indoor climate measurements carried out.

Questionnaire for SBS investigations*

r

INDOOR CLIMATE
Work environment

Number

1-11

I,

I Company/institution

lT-17
D

~rofession

LULL1

User
Filled in by investigator

12-21

day

yePr

ENGLISH VERSlON

?a

Name

M M ~ E A
Date mom,

Group

m-

This questionnaire concerns your indoor climate and possible symptoms you
may be experiencing.
BACKGROUND FACTORS

n-a Year of birth 19

24

Sex

male

25

Do you smoke?

yes

female

01

NOU
2

Occupation

..................................... ................

HOWlong have you been at your present

piaceof work?
years

WORK ENVIRONMENT
Have you been bothered during the last three months by any or
several of the following factors at your work environment ?

mn

Yes, often
Yes,
(everyweek) sometimes

NO,
never

Yes,
often

Yes,
sometimes

No,
seldom

No,
never

C]

Do you have any chance to influence your working

u conditions?

C]

Do your follow-workers help you with problems you may

u have in your work?

Draught
Too high room temperature
Varying room temperature
Too low room temperature
Stuffy "bad" air
Dry air
Unpleasant smell
Static electricity, oftencausing shocks
Passive smoking
Noise
Light that is dim or causes glare andlor reflections
Dust and dirt

WORK CONDITIONS

40
41

Do you regard your work as interestingand

stimulating?
DOyou have too much to do?

Copyright: Environment Medicine Clinic, 0rebro Hospital, 0rebro (Sweden). The

questionnaire is adopted in the Scandinavian countries.

PAST/PRESEWT L)ISEASES/SYMPtOMS

M M 040 tA Page 2

Yes

No

Have you ever had asthmatic problems?

Have you ever had hay-fever?

Have you ever had eczema?

I3

Are there other allergic diseases in the family (asthma, hay-fever, eczema)?

'RESENT SYMPTOMS
Duringthe last 3 months have you had anyheveral of the following symptoms?

Yes, often
Yes,
(everyweek) sometimes
Fatigue

(11

Cr)

0
El

cl

Heavy headedness

Headache

No,
never

tf YES:
Do YOU belive that it is
due to your woric
envlronmsnt?

Yes

No

13)

13

Nausealdiuiness
Difficulties concentrating
Itching, burning, irritation of the eyes
Irritated, stuffy or runny nose
Hoarse, dry throat
Cough

Dry or flushed facial skin

Scallnghtching scalphars
Hands dry, Itching, red skin
other

................................................................

............................................................................................................................................................................
............................................................................................................................................................................
...........................................................................................................................................................................

,.....................1.......I.....................1.......1.........*......,.......,......,.............................~....................................................~......~..~.~'..g~..~*'.

............................................................................................................................................................................

..I.........................,,,,.....)...............,,.,,.........................,.......................................~................~..~~~.*.~~~'''..'''*'~''''*~

...................,...........(........,..,....,...,,**,.............,........*.....,........................................................~.~.~~~~*~
THANK YOU1

Appendix 4

AIR QUALITY GUIDELINES*

Table 2. Guideline values for individual substances

based on effects other than cancer or odour/annoyancea

Substance

Time-weighted
average

Carbon disulfide
Carbon monoxide

Nitrogen dioxide
Ozone
Styrene
Sulfur diaxide
Sulfur~cactd
Tetrachloroethylene
Toluene
Trtchloroethylene
Vanadturn

Chapter

1 year (rural areas)

1 year (urban areas)
2 4 hours
1 5 minutes
3 0 minutes
1 hour
8 hours
2 4 hours

Cadmium

1.2-Dichloroethane
Dtchloromethane
(Methylene chiortde)
Formaldehyde
Hydrogen sulfide
Lead
Manganese
Mercury

Averaging time

3 mg/mJ
1 0 0 pg/m3
1 5 0 pg/mJ
0.5-1 .Opg/m3
1 pg/m3
1 pg/m~d
(indoor air)
4 0 0 pg/m3
1 5 0 pg/m3
150-200 pg/mJ
100-1 20 pg/m3
8 0 0 pg/m3
5 0 0 pg/m3
3 5 0 pg/m3

2 4 hours
3 0 minutes
2 4 hours
1 year
1 yearC
1 year
1 hour
2 4 hours
1 hour
8 hours
2 4 hours
1 0 minutes
1 hour

-e

5 mg/m3
8 mg/m3
1 mg/m3
1 pg/mJ

2 4 hours
2 4 hours
2 4 hours
2 4 hours

a Informatton from this table should nor be used wtthout reference tothe rattonale glven In the
chapters lnd~cated.

Exposure at these concentrattons should be for no longer than the mdlcated tlrnes and
should not be repeated wtthln 8 hours.
Due to resptratory irrttancy. tt would be deslrable to have a short-term gu~deltne.but the
present data base does not permlt such estcrnattons.
The gurdelme value is gwen only for mdoor pollut~on.no gutdance IS glven on outdoor
concentrattons (vta deposltton and entry tnto the food cham) that rn~ghtbe of tndwect relevance.
See Chapter 30.
Note. When air levels in the general environment are orders of magn~tudelower than
the gu~dellnevalues. present exposures are unltkely to present a health concern.
Guideltne values in those cases are directed only to specif~crelease episodes or
spec~ftcindoor pollution problems.

The Tables in this Appendix are taken from WHO 1987

Table 4. Rationale and guideline values based on sensory effects

or annoyance reactions, using an averaging time of 30 minutes

Oetect~on
threshold

Substance

Gutdeltne
value

Recogn~tion
threshold

Carbon disulfide In
viscose emlsstons
Hydrogen sulfide

0.2-2.0 pg/m3

0.6-6.0 pg/m3

7 pg/m3

7 0 pg/ms

2 10-280 pg/m3

7 0 pg/m"

Styrene
Tetrachloroethylene

8 mg/mJ

Toluene

1 mg/m3

24-32

mg/m3

8 mg/m3
1 mg/m3

1 0m g h 3

Table 5. Carcinogenic risk estimates

based o n human studiesa
IARC Group
classchcatlon

Substance

Untt rlskb

Site of tumour

Acrylon~trtle

2A

2X

lung

Arsen~c

4X

lung
blood (leukaem~a)

Benzene

4 X 10-6

Chromtum (VI)

4X

lung

Ncckel

2A

4X

lung

Polynuclear aromattc
hydrocarbons
(carcinogencc f r a c t ~ o n ) ~
Vinyl chlor~de

9X

lo-*
- ~

1 X 1o

lung
liver and other sites

a Calculated wfth average relatwe r~skmodel.

Cancer rtsk estimates for ltfettme exposure to a concentratcon of 1pg/m'

Expressedas benzo[alpyrene(basedon benzo[a]p~reneconcentrat~on
of 1pg/m3$nair asa
component of benzene-solublecoke-oven emtss~ons).

Table 6. Risk estimates for asbestosa

Concentratton

Range of ltfettme r~skestimates

500 F'/mJ (0.0005 F/ml)

1o - -~1o - ~ (lung cancer In a populatton where

30% are smokers)

a See Chapter 18 for an explanat~on

of these ftgures
Nore. F' = fcbres measured by opttcal methods.

Table 7. Risk estimates and recommended action levela

for radon daughters

Lung cancer
excess lifet~mercsk
esttmate

Exposure

EER
1~ q / m
~

(0.7

10-~)-(2.1x

Recommended level
for remedial action
In buildmgs

loo ~ q / m 3EER
(annual average)

;i:

a See Chapter 29 for an explanat~on

of these f~guresand for further ~nformatlon.

MEMBERS OF THE COMMUNFTY-COST CONCEBTATION COMMITTEE

BELGIUM

IRELAND

Dr. Eddy MUYLLE

Institute of Hygiene and Epidemiology
Brussels

Dr. James P. Mc LAUGHLIN

Department of Physics
University College
Belf ield
Dublin

DENMARK

Prof. P. Ole FANGER

Laboratoriet for Varme- og Klimateknik
Danmarks Tekniske Hojskole
L Y ~ ~ Y
Dr. Lars M0LHAVE (vice chairman)
Institute of Environmental and
Occupational Medicine
Aarhus Universitet
Aarhus

Mr. Patrick A. WRIGHT

EOLAS
Glasnevin
Dublin

Prof. Marco MARONI

Istituto di Medicina del Lavbro
Clinica del Lavoro ItLuigi Devoto"
Universith di Milano
Milano

FRANCE

Prof. Bernard PESTY

Laboratoire dlHygiene
d e l a Ville d e Paris
Paris

Prof. Antonio REGGIANI

Istituto Superiore di Sanita
Roma
THE NETHERLANDS

Prof. Claude MOLINA

Hopital Sabourin
Clermont-Ferrand
GERMANY

Ir. Anton P.M. BLOM

Ministry of Housing, Physical
Planning and Environment
Leidschendam

Dr. Bernd SEIPERT (chairman)

Bundesgesundheitsam t
Institut fiir Wasser-, Boden- und Lufthygiene
Berlin

Prof. J a n S.M. BOLEIJ

Department of Air Pollution
Agricultural University
W ageningen

GREECE

PORTUGAL

Prof. Panayotis SISKOS

Laboratory of Analytical Chemistry
University of Athens
Athens

Eng. David A. BIZARRO LEANDRO

Direction-General for Hygiene and
Security a t Work
Lisboa

Dr. Athanasios VALAVANIDIS

Department of Chemistry
Laboratory of Organic Chemistry
University of Athens
At hens

SWITZERLAND

Dr. Heinz ROTHYYEILEB

Institut f u r Toxikologie
der ETH u. Universitat Zurich
Schwerzenbach
Prof. Dr. H. U. WANNER
Institut f u r Hygiene und
Arbeitsphysiologie d e ETH
Zurich
UNITED KINGDOM

Dr. P e t e r WARREN
Department of t h e Environment
Romney House
London
WORLD HEALTH ORGANIZATION

Dr. Michael J. SUESS

Regional Officer f o r
Environmental Health Hazards
Copenhagen
COMMISSION OF THE EC

Dr. Jean-Guy BARTAIRE

DG XI/B/2
Bruxelles
Mr. Louis GRAVIGNY
DG III/C/3
Guimard Room 1/18
Bruxelles
Dr. Maurizio DE BORTOLI (secretary)
JRC, Ispra Establishment
Ispra (Varese)
Dr. Helmut KNOPPEL
JRC, Ispra Establishment
Ispra (Varese)

European Communities - Commission

EUR 12294 - Europeanconcerted action

Indoor air quality and its impact on man.
COST Project 613:
Sick Building Syndrome
A PracticalGuide

The Community-COST concertation Committee

Luxembourg. Office for Official Publications of the European Communities

P

1989 - I-Vi, 36 pp. - 21.0x29.7 c m

Series: Environment and quality of life

EN

The report aims at giving a guide to those facing the problem of *sick building syndrome.. After a description of the other building related illnesses, which must not be
confused with the syndrome in object, the extent of the problem is presented, with particular emphasis on the economic implications. The report deals also with the symptoms
which must be present in order to diagnose the syndrome and with the various environmental and personal factors possibly contributing to the development of the trouble. Finally, the report contains a rather detailed, stepwise procedure for the detection and mitigation of the most frequently observed causes.