# Presentation: 213587

## Perfume, Fragrance and Odor Intolerance and Other Indoor Air Quality Complaints—How Should They Be Handled?

- Samuel W. Hall, MDDirector, Occupational Health ServicesVeterans Affairs Medical CenterMinneapolis, Minnesota

## Introduction

- Building Indoor Air Quality (IAQ) problems:
- Common and distressing to occupants
- Cause symptoms and illness in workers
- Disrupt productivity and staff morale
- Dealing with IAQ problems:
- Time consuming, costly and stressful

## Purpose of Presentation

- Categorize IAQ problems and complaints
- Emphasize distinction between odor effects and toxic effects of chemicals and substances
- Describe approach to evaluation and management of IAQ concerns

## Indoor Environmental Quality

- 	Function of:
- 	Air Quality
- 	Noise
- 	Lighting
- 	Comfort
- 	Ergonomic stressors
- 	Psychosocial stressors

## Indoor Air Quality

- IAQ refers to quality of air inside buildings and is related to:
- General ventilation
- Pollutant concentrations
- Thermal conditions (temp and humidity)
- 	that affect health, comfort and performance of building occupants.

## Indoor Air Quality

- _Acceptable Indoor Air Quality (IAQ)_
- 	Air in which there are no known contaminants at harmful concentrations as determined by cognizant authorities and with which a substantial majority (80% or more) of the people exposed do not express dissatisfaction.

## Magnitude of IAQ Problems

- _NIOSH Data_
- # IAQ evals of offices since late 70’s = 1300
- 1980—8% of total requests
- 1990—38% (150) of all requests
- Since 1990—52% of all requests

## Why IAQ Problems Increased?  

- Changes in ventilation to conserve energy
- Changes in office work
- 		New equipment
- 		Ergonomic problems
- 		Organizational stress
- Increase in number of office workers
- Enhanced awareness of IAQ problems

## EPA:	I-BEAM Indoor Building Education and Assessment Model

- Computer software program integrating IAQ, energy efficiency and building economics into unique building management tool
- http://www.epa.gov/iaq/largebldgs/i-beam_html
- EPA/C-01-001V1.0

- I-BEAM

## I-BEAM Enables You To

- Improve IAQ—within budget
- Refine maintenance program for IAQ
- Better manage housekeeping services for IAQ
- Conduct IAQ building audit
- Train management and staff in IAQ
- Provide IAQ building practice documentation
- Reduce liability for IAQ complaints
- Improve building and rental space marketability

- I-BEAM

## I-BEAM Chapters

- Fundamentals of IAQ in Buildings
- HVAC
- IAQ Maintenance and Housekeeping Program
- Diagnosing and Solving Problems
- IAQ and Energy Efficiency
- Renovation and New Construction
- Managing for IAQ

- I-BEAM

## Occupant Symptoms Associated with Poor IAQ

- Acute effects
- Discomfort effects
- Performance effects
- Chronic effects
- Building Associated Illnesses

- I-BEAM

## Building Associated Illnesses

- Building Related Illness (BRI)
- Sick Building Syndrome (SBS)
- Idiopathic Environmental Intolerance (IEI) formerly known as Multiple Chemical Sensitivity (MCS)

- I-BEAM

## Building Related Illness

- Illness from known causative agent as a result of exposure to building air
- Hypersensitivity diseases—allergies
- Infectious diseases—Legionnaire’s disease
- Intoxications
- 	Acute—CO, metals, pesticides, VOC’s
- 	Chronic disease—asbestos, radon, ETS

## Sick Building Syndrome

- Nonspecific, largely subjective symptoms associated with building occupancy
- Headache
- Mucous membrane irritation
- Lethargy, fatigue
- Skin irritation
- Nausea and dizziness

## Building Factors Affecting IAQ

- _Factors affecting indoor climate_
- Temperature
- Relative humidity	30%-60%
- Airflow			15-20 cfm/person
- _Factors affecting indoor air pollution_
- Building fabric, furnishings and equipment
- Occupant-generated pollution
- Mechanical systems (HVAC)
- External sources

## Types of Pollutants

- Environmental Tobacco Smoke
- Combustion Products
- Biological Contaminants
- Volatile Organic Compounds
- Formaldehyde
- Soil gases
- Pesticides
- Particles and Fibers

- I-BEAM

## Contaminant Sources

- _Indoor Sources_
- Housekeeping and Maintenance
- Occupant-Related
- Building Uses as Major
- Building-Related
- HVAC System
- Moisture
- Motor Vehicle

- I-BEAM

## Contaminant Sources

- _Outdoor Sources_
- Ambient Outdoor Air
- Motor Vehicle
- Commercial/Manufacturing
- Utilities/Public Works
- Agricultural
- Construction/Demolition

- I-BEAM

## Contaminant Sources

- _Outdoor Sources_
- Building Exhaust
- Water Sources
- Birds and Rodents
- Building Operations and Maintenance
- Ground Sources

- I-BEAM

## Diagnosing IAQ Problems

- General Diagnostic Process
- Characterizing Problems
- Checking Potential Causes
- Basic Measurement Techniques

- I-BEAM

## Major Reasons for Poor IAQ 

- Indoor air pollution sources
- Poorly designed, maintained or operated ventilation systems
- Uses of building that were unanticipated or poorly planned for during design or renovation

## Terms and Definitions

- Odor: 		a smell, whether pleasant or 				unpleasant
- Fragrance: 	a pleasant odor
- Exposure: 	contact with a chemical agent
- Toxicity: 	ability to cause noxious effects 			It is a fixed property of a 					chemical

## Terms and Definitions

- Allergen: a substance capable of provoking an immune-mediated response
- Irritant: 	a substance capable of causing tissue inflammation
- Adverse Health Effect:	any abnormal, harmful or undesirable effect on the well-being of a person that results from an exposure
- Hypersensitivity: any allergic response

## Key Concepts

- Some chemicals have no odor or toxicity
- 		example:		nitrogen gas
- Some chemicals have an odor but no toxicity 	example:  	skunk musk
- Some chemicals have toxicity but no odor
- 		example:		carbon monoxide
- Some chemicals have both an odor and toxicity 	example:		hydrogen sulfide

## Key Concepts

- Working with or around a product, substance or chemical does not necessarily mean a person has been “exposed” to it.
- Even when someone has been exposed to a chemical, the exposure may not be biologically significant, i.e. no toxicity occurs.

## Key Concepts

- For toxicity to occur, a chemical has to be present at the biologic site of action in a sufficient concentration for a sufficient period of time.
- Most chemicals have an odor threshold hundreds of times lower than the level necessary for toxicity, i.e., smelling an odor does not equate to biologically significant exposure.

## Scented Products

- Personal Products
- 	perfumes, colognes, cosmetics, lotions, soaps, deodorants, hairspray
- Commercial Products
- 	cleaners, air fresheners, bleach, laundry detergent, candles, advertising inserts

## Chemical Sensitivity Prevalence

- 16% report allergy or unusual sensitivity to everyday chemicals
- 6% report doctor diagnosed multiple chemical sensitivity (MCS)
- 80% of the above say that fragrance is bothersome
- 				California Behavior Risk Factor Survey, 1995

## Adverse Reactions to Fragrances

- Skin
- Mucous membrane
- Respiratory
- Gastrointestinal
- Central nervous system
- Other

## Idiopathic Environmental Intolerances (IEI)

- Formerly known as MCS
- Proposed as new disease in 1950’s
- Adverse reactions from exposure to compounds under ordinary conditions
- Compounds: fragrances, detergents, solvents, pesticides, paints, dusts, drugs, etc.
- Symptoms: fatigue, headache, concentration + memory problems, nose + throat irritation, cough

## Epidemiology of IEI

- Age		40-50 yrs old
- Gender		80% female
- Education	average 14 yrs
- Onset		1/3 cannot recall initiating event
- Symptoms	CNS 	90%
- 				GI	12-83%
- 				CVS	28-83%
- 				Endo	22%
- 			Fiedler:	Env Health Perspect 1997;105(S2):409-415

## Theories Regarding IEI

- Physical illness from toxic exposure
- Psychological illness from toxic exposure
- Misdiagnosed psychological illness
- Culturally shaped illness behavior

## IEI Prognosis and Disability

- Symptoms distressing and often functionally disabling
- Large numbers of claims—health insurance, workers’ compensation, and disability
- Financial impact frequently significant
- Illness not progressive or fatal

## Evaluation of IAQ Complaint

- _Clinical Evaluation_
- History and physical examination
- Routine laboratory tests and medical imaging
- Psychosocial evaluation
- _Environmental Evaluation_
- Building engineer inspection
- Health and safety personnel inspection
- Industrial hygiene consultation/testing

## Clinical Evaluation

- _Environment or Work-related Disorders_
- Allergic disorders
- Irritant effects
- Intoxications
- _Personal Health Conditions_
- Metabolic-endocrine disorders
- Autoimmune diseases
- Neurological disorders
- _Psychosocial Factors_

## Confirmation of Diagnosis of Illness from Exposure to Toxic Substance 

- Are the subjective and objective findings explained by the suspected exposure?
- Is the chronological sequence appropriate?
- Is there confirmation of the exposure and quantification of the dose?
- Are there any other explanations for the illness?

- Institute of Medicine, 1988

## Management of IAQ Complaint

- Document disease
- Document exposure
- Document association (or lack of)
- Plan intervention
- Communicate
- Evaluate effectiveness
- Follow up

- VA Knowledge Network Broadcast (03/02)

## Suggested Management for IEI

- Validate symptoms
- Provide appropriate treatment for organic disease
- Give physiologic explanation if possible
- Provide reassurance re diagnostic uncertainty, prognosis and disability
- Trial removal from biologically significant exp
- Trial of cognitive behavioral therapy
- Address coexistent psychosocial problems