Health Hazard Evaluation Report 2015-0183-3255 Page 1

Evaluation of Indoor Environmental Quality 

and Health Concerns in a Juvenile Court 

Building 

HHE Report No. 2015-0183-3255

June 2016

Elena Page, MD, MPH

Jessica F. Li, MSPH

Sophia Chiu, MD, MPH

Kendra Broadwater, MPH

Gregory Burr, CIH

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
Page 2 Health Hazard Evaluation Report 2015-0183-3255

Contents

Highlights...............................................i

Abbreviations ..................................... iii

Introduction......................................... 1

Methods ............................................... 1

Results .................................................. 3

Discussion ............................................ 7

Conclusions........................................ 10

Recommendations............................. 10

Appendix A ........................................ 12

References.......................................... 17

Acknowledgements........................... 23

The employer is required to post a copy of this report for 30 days at or near the 

workplace(s) of affected employees. The employer must take steps to ensure 

that the posted report is not altered, defaced, or covered by other material.

The cover photo is a close-up image of sorbent tubes, which are used by the HHE 

Program to measure airborne exposures. This photo is an artistic representation that may 

not be related to this Health Hazard Evaluation. Photo by NIOSH.
Health Hazard Evaluation Report 2015-0183-3255 Page i

We evaluated indoor 

environmental quality in a 

juvenile court. We saw no 

widespread mold, water 

damage, or sewage problems. 

We detected no sewer gas. An 

underground diesel storage 

tank, a concern to some 

employees, complied with 

state regulations. Temperatures 

in occupied areas were not 

within recommended comfort 

guidelines, and the ventilation 

system had deficiencies. 

Many symptoms reported by 

employees have been associated 

with buildings or inadequate 

ventilation, but are also common 

in the general population. We 

recommended a comprehensive 

ventilation assessment.

Highlights of this Evaluation

The Health Hazard Evaluation Program received an employer request from a juvenile court. 

Employees were concerned about exposure to raw sewage and diesel odors in the building. 

We made a site visit in November 2015.

What We Did 

● We did a walk-through survey of courtrooms, offices, detention areas, basement 

mechanical rooms, and the roof.

● We looked for moisture, water damage, 

sewage, and mold. We also sampled for 

hydrogen sulfide (also called sewer gas).

● We measured carbon dioxide, temperature, and 

relative humidity.

● We measured airflow in offices and 

employee restrooms.

● We looked at the ventilation for the building.

● We interviewed employees. We asked about 

their work, medical history, and work-related 

health concerns.

What We Found 

● We did not see widespread signs of water 

damage or mold. We did see water leaks that 

the juvenile court managers were aware of in 

pod B and the public defender’s office. 

● An underground diesel storage tank next to the 

building complied with state regulations.

● We did not smell sewer gas or detect hydrogen 

sulfide in air.

● Carbon dioxide levels were high in some offices. 

This means that the ventilation did not provide enough outdoor air throughout the work day.

● Temperatures in offices and courtrooms were not within recommended comfort guidelines.

● No air was flowing from ceiling diffusers in the parentage office. 

● No supply or exhaust air was flowing in employee restrooms.

● None of the air handling units had visible evidence of microbial growth.

● Air filters were clean and properly installed in all air handling units except unit 4. That 

unit had a small (1 inch) gap between the air filters and the filter frame. 
Page ii Health Hazard Evaluation Report 2015-0183-3255

● Technicians did not have a ventilation test and balance report or an up-to-date set of 

building drawings that accurately showed ventilation system components. 

● Cast iron waste pipes under the building’s foundation were corroded but repair plans 

were proceeding. 

● Detainees reportedly flushed objects to intentionally clog the building’s sewage system. 

● Although we did not link employees’ symptoms and illnesses directly to the building, 

some nonspecific symptoms are likely related to poor ventilation.

● We found no evidence that health problems such as cancer, gallstones, and thyroid 

problems were related to working in the building.

What the Employer Can Do 

● Hire a licensed professional mechanical engineer to assess the ventilation systems.

● Encourage employees to report water leaks, water damage, or raw sewage to the 

building’s maintenance staff.

● Consider installing grinders or other types of controls in the building’s sewage system. 

● Create a system for employees to report building concerns and to receive feedback on 

how issues were resolved.

● Stop environmental sampling for chemical and biological causes of health symptoms.

What Employees Can Do

● Report work-related health concerns to juvenile court managers.

● See an occupational medicine physician about health problems you think may be 

related to work.

● Recognize that some symptoms may not have a medical diagnosis.

● Join the indoor environmental quality committee.
Health Hazard Evaluation Report 2015-0183-3255 Page iii

Abbreviations

ANSI/ASHRAE American National Standards Institute/ASHRAE

CO2 Carbon dioxide

EPA Environmental Protection Agency

IARC International Agency for Research on Cancer

IEQ Indoor environmental quality

NIOSH National Institute for Occupational Safety and Health

RH Relative humidity 
Page iv Health Hazard Evaluation Report 2015-0183-3255

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Health Hazard Evaluation Report 2015-0183-3255 Page 1

Introduction

The Health Hazard Evaluation Program received a request from the employer at a juvenile 

court and detention building. Employees thought cancer and other health issues including 

thyroid problems, gallstones, kidney stones, strokes, intestinal issues, immune system problems, 

burning eyes, headaches, and nausea might be related to exposure to raw sewage, leaks from an 

underground diesel storage tank, and mold from a May 2010 flood. During our November 2015 

site visit, we met with juvenile court administrators, employee representatives, representatives 

from the county health department, and staff responsible for maintaining the ventilation systems 

in the building. We also did an environmental and health assessment.

Background

An indoor environmental quality (IEQ) evaluation was conducted in September 2010 (after 

remediation for the flood) by a consultant the judicial court managers hired. The evaluation 

included carbon dioxide (CO2), carbon monoxide, temperature, and relative humidity (RH) 

sampling; passive air sampling for aldehydes and volatile organic compounds; and surface 

(10 square centimeters) swab samples for Escherichia coli and Enterococcus bacteria. 

No carbon monoxide was found; temperature and RH levels were within recommended 

ANSI (American National Standards Institute)/ASHRAE comfort guidelines; and CO2

concentrations were within recommended ANSI/ASHRAE IEQ ventilation guidelines. 

Aldehydes (with limits of detection of < 0.03 to < 0.04 parts per million) and volatile organic 

compounds (with limits of detection of < 0.07 to < 0.48 parts per million) were not detected. 

Surface swab samples were negative for bacteria. 

A new judge who came to the bench in the fall of 2014 asked her staff to interview current 

employees about their work environment. The judge learned that many employees had 

building-related health concerns that they associated with potential exposure to raw sewage, 

leaks from an underground diesel storage tank, and mold from the May 2010 flood. Some of 

the recurrent sewage backups in the building were from detainees purposely flushing items 

such as jumpsuits. 

A structural examination of the building by a consultant discovered corroded cast iron waste 

pipes that could result in sewage leaking beneath the concrete slab foundation. In December 

2014, the judicial court managers did air testing for volatile organic compounds and hired a 

consultant to test the drinking water. Air samples for volatile organic compounds were taken 

in the public defenders’ office and intake/pretrial area. Drinking water samples were taken 

from the first floor men’s restroom and a second floor water fountain. Acetone, isopropyl 

alcohol, and methylene chloride were detected in the air samples in very low concentrations 

(parts per billion range). Drinking water results were within acceptable limits, with the 

majority of regulated and unregulated contaminants below their limits of detection. 

Methods

Our objectives for this evaluation were to answer the following questions:

1. Does the building have a mold, sewage, or other IEQ problem?
Page 2 Health Hazard Evaluation Report 2015-0183-3255

2. Are employees reporting work-related health effects that are known to be associated 

with mold or sewage exposures or other aspects of IEQ?

Environmental Assessment 

Our walk-through survey included courtrooms, offices, detention areas, and locations not 

readily accessible to employees, such as the basement mechanical rooms and the roof. We 

checked floor drains for visual evidence of sewage. We measured for airborne hydrogen 

sulfide (sewer gas) near the drains using a direct-reading MultiRAE® Lite portable gas 

monitor. We also reviewed information on the underground diesel storage tank next to the 

building that provided fuel for emergency back-up electrical generators.

In addition to looking for water damage and potential mold contamination, we checked for 

hidden moisture using the following instruments:

● A FLIR® TG165 imaging infrared thermometer. We used this device to screen for 

potentially moist or water-damaged areas in surfaces such as walls, floors, and ceilings. 

It uses infrared thermal imaging technology to detect temperature differences. It 

identifies dry and wet materials, even materials that are not readily visible, such as 

behind drywall or above a suspended ceiling.

● A TRAMEX Moisture Encounter Plus nondestructive moisture meter. This handheld direct-reading device can measure the interior wall moisture levels. We used 

the moisture meter to confirm if suspected moist areas identified by the infrared 

thermometer were actually moist.

We measured CO2, temperature, and RH over 1.5 days using calibrated TSI Q-TrakTM Indoor 

Air Quality monitors. We also measured temperature and RH using Onset HOBO® Pro data 

loggers. We selected locations with varying occupancy levels throughout the work day, such 

as in the juvenile courtrooms. We also selected locations in the basement and on the first and 

second floors because they were ventilated by different air handing systems. We measured 

indoor and outdoor CO2 concentrations to determine if indoor occupied spaces are adequately 

ventilated [ANSI/ASHRAE 2016]. We measured temperature and RH because they can 

affect how employees perceive their indoor environment [ANSI/ASHRAE 2013]. Excessive 

humidity can also promote the growth of microorganisms and dust mites. 

We reviewed building drawings and discussed the design, operation, and maintenance of the 

ventilation systems with the ventilation maintenance staff. We measured airflow in offices 

and restrooms using a calibrated Alnor Balometer® capture hood. We used ventilation smoke 

tubes to visualize airflow direction in offices and restrooms.

Employee Interviews and Medical Record Review

We interviewed all available employees in the building about medical conditions or 

symptoms they thought were related to conditions or exposures in the building. We took 

a medical history to identify unrecognized occupational illness. Medical records were 

requested if employees reported seeing a physician for health issues that they attributed 
Health Hazard Evaluation Report 2015-0183-3255 Page 3

to conditions in the building. We did not request medical records for health problems we 

determined were not related to the building, such as gallbladder disease.

Results

Environmental Assessment

Building Description and Walk-through Survey

The three-story brick and masonry building was built in 1993; 134 employees worked there 

at the time of our evaluation. The administrative side included offices and courtrooms that 

operated between 8:00 a.m. and 4:30 p.m.; the detention side operated 24 hours per day, 

7 days per week. Most of the administrative office and courtroom areas were carpeted. The 

flooring on the detention side was primarily tile or sealed concrete. Since 1993 the building 

had undergone renovations to accommodate more employees, mainly by converting storage 

spaces to restrooms, individual offices, and office cubicles. Following a flood in May 2010 

the basement was renovated, and the ventilation ducts serving these areas were cleaned and 

sanitized. The detention area had a rated capacity of 86 beds and housed about 30 juvenile 

inmates at the time of our evaluation. 

We saw no evidence of past or current sewage around floor drains. We did not detect 

hydrogen sulfide (also called sewer gas) during this evaluation. The lowest concentration of 

hydrogen sulfide that can be detected varies from person-to-person but has been estimated to 

be as low as 0.2 parts per billion. This concentration is well below the limit of detection of 

many direct-reading instruments [ATSDR 1999; Nordic Council of Ministers 2001; Van Aalst 

et al. 2000]. Therefore, collecting air samples for hydrogen sulfide may not be useful because 

you can smell it at levels lower than it can often be measured. Although we did not smell 

sewer odors during our survey, because hydrogen sulfide can paralyze the nerves associated 

with your sense of smell over time (your olfactory system), its odor is not a reliable warning 

signal [Hathaway and Proctor 2004]. The building has trap primers that automatically add 

water to maintain water seals in traps. The trap primers prevent sewer gases from entering the 

building. We did not notice fragrance odors in most areas of the building.

One underground diesel tank is outside the building on the southeast side. The tank can store 

1,000 gallons of diesel fuel and is inspected monthly by the state. It complies with the state’s 

petroleum underground storage tank act, passing its last inspection in March 2015. The vent 

for the underground diesel tank is at ground level and not near the rooftop outdoor air intakes 

for the building’s air handling units.

We focused our moisture and mold assessment in the basement because of the 2010 flood. 

We saw no widespread evidence of water damage or mold growth. We saw water leaks near 

an exterior door in the pod B common areas of the detention center and under a sink faucet in 

the public defender’s office. The building managers were aware of the leaks, and both were 

scheduled for repair. Using the thermal imaging thermometer, we found that exterior walls 

on the basement level that were partially or completely below grade were cooler than nearby 

walls. After checking these walls with the moisture meter we found the surfaces were not wet 
Page 4 Health Hazard Evaluation Report 2015-0183-3255

or damp. We saw no evidence of poor drainage or standing water on the exterior of the building. 

Carbon Dioxide, Temperature, and Relative Humidity Measurements

Table 1 summarizes the CO2 concentrations, temperature, and RH levels measured in 

courtrooms and offices over 1.5 days. Figure 1 shows the CO2 levels throughout the work day 

in courtroom H. We are displaying results for courtroom H because they are representative 

of the other courtrooms and eight office areas where CO2 levels exceeded outdoor levels 

by at least 700 parts per million. The CO2 levels typically began increasing after lunch and 

continued to increase throughout the afternoon. 

Table 1. Carbon dioxide, temperature, and relative humidity measurements

Dates Location CO2,

parts per million

(range)

Temperature °F

(range)

% RH

(range)

11/16/15–11/17/15 Community probation

Court clerk (back)

Courtroom D

Courtroom H

Intake (front)

Parentage

Public defender

630–1,100

570–1,200†

530–1,300†

490–1,500†

510–1,400†

520–1,400†

490–1,300†

70–72*

72–75*

70–73*

69–72*

71–73*

71–73*

65–70*‡

44–50

39–44

39–54

43–53

38–50

41–49

49–56

11/17/15–11/18/15 Child protective services

Court clerk (front)

Courtroom A

Courtroom I

Intake (back)

Parole

Security

650–1,100

510–1,400†

500–1,100

430–1,400†

510–1,500†§

470–1,300†

460–1,420†

67–70*‡

71–74*

71–74*

71–74*

71–75*

67–71*‡

72–79*‡

46–51

46–52

49–58

48–58

46–53

51–61

41–54

Outdoor 370–380

*Temperatures were not within recommended thermal comfort guidelines for the summer 

(75°F–81°F) [ANSI/ASHRAE 2013]. 

†The maximum indoor CO2 concentrations exceeded outdoor concentrations by at least 

700 parts per million. This suggests that the ventilation system(s) was not providing enough outdoor 

air to maintain acceptable ventilation throughout the work day [ANSI/ASHRAE 2016].

‡Temperatures were not within recommended thermal comfort guidelines for the winter 

(68°F–77°F) [ANSI/ASHRAE 2013].

§The Q-Trak monitor lost power during the sampling period.
Health Hazard Evaluation Report 2015-0183-3255 Page 5

Figure 1. Carbon dioxide concentrations in courtroom H, November 16–17, 2015.

We compared the temperature and RH results to thermal comfort guidelines for summer and 

winter because this evaluation occurred in autumn (Table 1). The temperatures in all 14 areas 

checked were below the recommended thermal comfort guidelines of 75°F–81°F for summer, 

assuming a clothing insulation value of 0.5–1.0 (i.e., short-sleeve shirts/blouses, lighter 

weight clothing) [ANSI/ASHRAE 2013]. The temperatures in four of the 14 areas checked 

were not within the recommended thermal comfort guidelines of 68°F–77°F for winter, 

assuming a clothing insulation value of 1.0–1.3 (i.e., long-sleeve shirts/blouses, heavier 

weight clothing) [ANSI/ASHRAE 2013]. The temperatures in three of the 14 areas checked 

were below the recommended thermal comfort guidelines for summer and winter. The RH 

levels in all areas surveyed were within the recommended comfort guideline of less than 65% 

[ANSI/ASHRAE 2013].

Ventilation Systems and Airflow Measurements

Seven air handling units, located on the roof or in the basement, provided ventilation for 

the administrative and detention areas. None of the units had visible evidence of microbial 

growth. The pleated air filters (16′′×20′′×2′′ and 20′′×25′′×2′′) had a minimum efficiency 

reporting value of 8. The filters appeared clean and properly installed in all air handling 

units except unit 4, which had a 1-inch gap between the air filters and the filter frame. The 

ventilation technicians at the building had upgraded computer controls on six of the seven 

air handling units in 2015 (the upgrade for unit 4, the remaining air handler, was scheduled). 
Page 6 Health Hazard Evaluation Report 2015-0183-3255

These upgraded controls allow the ventilation technicians to monitor and adjust the ventilation 

systems in real time, enabling them to quickly detect and respond to ventilation problems.

The building’s ventilation design included variable air volume ventilation systems for offices 

and courtrooms and constant volume ventilation for the detention areas. Although we were 

informed that a recent ventilation test and balance report was available, the report could 

not be located. Additionally, the ventilation technicians did not have up-to-date building 

plans that accurately showed the ventilation system components or the design plans for the 

ventilation systems. 

We measured airflow from ceiling diffusers on the lower level (child services), first floor 

(parentage), and second floor (judicial suite). We selected these locations based on our 

ability to identify the correct variable air box that was supplying air to the diffusers in each 

area, using the available building plans. We then asked the ventilation technicians to adjust 

electronically the air damper in the variable air volume box in each of the three areas to its 

open and closed setting. Because we did not have detailed ventilation information, we could 

not determine if the variable air volume boxes provided the appropriate amount of supply air 

as originally designed. We found the following:

● We measured no air from some ceiling diffusers after electronically adjusting the 

damper in the variable air volume distribution box to its closed position. The ceiling 

diffusers should provide a minimum amount of airflow even when the air damper is 

closed. This will reduce perceptions of stagnant or “stale” air.

● We measured similar air volumes from ceiling diffusers regardless of whether the air 

damper was open or closed. A properly operating variable air volume distribution box 

should provide a range of air volumes to ceiling diffusers. 

Most restrooms that we checked with ventilation smoke tubes were under positive pressure in 

relation to the adjacent hallway, meaning that air flowed from these restrooms to surrounding 

areas. Restrooms should be kept under negative pressure to help keep odors from migrating 

into surrounding areas. We checked the supply airflow (the air coming into the room) and the 

exhaust airflow (air going out of room) in the following employee restrooms: records/clerk’s 

office (lower level), intake (first floor), and judicial suite (second floor). We measured zero 

supply and exhaust airflow in these restrooms. Restrooms should be ventilated at all times. 

We measured about 50 cubic feet per minute of exhaust airflow in the public restrooms on the 

lower level and second floor, which is an acceptable ventilation rate for restrooms 

[ANSI/ASHRAE 2016].

Some of the staff offices in the detention side of the building were under negative pressure in 

relation to the juvenile inmate common areas, meaning that air flowed from the inmate areas 

and into the staff offices. The staff offices should be under positive pressure so that air moves 

from these areas and into inmate common areas. This ventilation design helps prevent the 

spread of airborne infections from inmates to building staff [Centers for Disease Control and 

Prevention 2006]. 
Health Hazard Evaluation Report 2015-0183-3255 Page 7

Employee Interviews and Medical Record Review

We interviewed 119 of 160 employees; 79 were female. The length of employment ranged 

from less than 1 year to 50 years. Sixteen employees had worked less than 1 year. The 

average tenure of the remaining employees was 19 years. Several employees reported the 

presence of rodents and rodent droppings in the building. Of the 119 interviewed employees, 

65 reported no symptoms or medical conditions related to the building, and 54 reported 

symptoms or medical conditions that they felt were or might be related to the building. The 

most common reported symptoms thought to be related to the building were headache (14), 

sinus problems (13), worsening of allergic symptoms (10), eye irritation (8), and frequent 

upper respiratory infections (7). Symptoms or conditions reported by fewer than five people 

included fatigue, sore or dry throat, and cough. Seven employees reported having asthma, six 

of whom were diagnosed after beginning work at the building. Three of the seven reported 

their asthma symptoms were worse at work. Three additional employees reported symptoms 

consistent with asthma while at work. Medical records were requested for two of these 

employees; one did not seek medical care, and the symptoms have resolved. 

Medical records were reviewed for two of three employees for whom they were requested. 

Records were not available for the third employee because of problems accessing them 

electronically at the health care facility. Neither of the records reviewed had evidence 

supporting a work-related condition. 

Several employees reported conditions such as kidney stones, pyelonephritis (kidney 

infection), intestinal abscess, gallbladder disease, urinary tract infection, low folic acid, 

gastroesophageal reflux, and thyroid issues (hyperthyroidism, hypothyroidism, nodules, and 

cancer). None of these conditions is related to conditions or exposures in the building. Breast 

cancer had been diagnosed in eight current and former employees over an unknown time 

frame, and one employee each had been diagnosed with prostate cancer, thyroid cancer, and 

leukemia. These cancers are not related to the building either. Appendix A includes a detailed 

discussion of cancer and its potential relationship to the building. 

Discussion

We typically do not recommend environmental sampling for chemical or biological 

contaminants in situations similar to those in this juvenile court and detention building. 

Sampling results are difficult to interpret because of (a) the absence of guidelines, (b) the 

ubiquitous presence of airborne chemical and biological materials, and (c) uncertainty about 

the relationship between low levels of contaminants and specific health effects. Therefore, 

measuring indoor environmental contaminants, in this instance hydrogen sulfide (sewer gas), 

volatile organic compounds, or mold, has seldom proved helpful in determining the cause 

of symptoms. However, we often measure ventilation and comfort indicators such as CO2, 

temperature, and RH to provide information about the functioning and control of heating, 

ventilating, and air-conditioning systems. We then compare these parameters to see if they 

are within applicable ANSI/ASHRAE guidelines for indoor environments. In mechanically 

ventilated and occupied spaces like this building we can also measure indicator pollutants 
Page 8 Health Hazard Evaluation Report 2015-0183-3255

such as CO2 (released by occupants) to provide information about the effectiveness of 

heating, ventilating, and air-conditioning systems.

One of the most common deficiencies we have found over many years of health hazard 

evaluations in nonindustrial indoor environments is inadequate ventilation. Inadequate 

ventilation may be due to the improper operation and maintenance of ventilation systems or 

from ineffective ventilation systems. In this building our findings indicate that the ventilation 

systems are ineffective. For example, temperatures in the occupied spaces that we checked 

were not always within the ANSI/ASHRAE recommended thermal comfort guidelines. 

Additionally, maximum CO2 concentrations exceeded the ambient outdoor CO2 concentration 

by at least 700 parts per million in several offices, indicating inadequate ventilation. An 

analysis of the published scientific literature showed that nonspecific symptoms such as 

headache, fatigue, and mucous membrane irritation increase as ventilation rates decrease 

[Fisk et al. 2009]. Studies in schools and office buildings have found decreased illness 

absence with increased ventilation rates [Mendell et al. 2011; Milton et al. 2000; Shendell 

et al. 2004]. Thus, improving heating, ventilating, and air conditioning operation and 

maintenance and increasing ventilation rates can improve symptoms without ever identifying 

any specific cause-effect relationships. We believe similar benefits would occur if ventilation 

is improved in this building.

The lack of a ventilation test and balance report, along with outdated and inaccurate building 

plans, hampered our ability to collect comprehensive airflow measurements. However, 

airflow measurements we made in child services, parentage, and the judicial suite areas 

showed that stagnant air conditions could develop when the dampers in the variable air 

distribution boxes were closed. In other instances we also found no difference in airflows 

from ceiling diffusers regardless of the damper setting (open or closed) in the variable air 

distribution box. Additionally, we measured no airflow (supply or exhaust) in many employee 

restrooms. These findings suggest a need for a comprehensive ventilation assessment of the 

entire building. 

Regarding employee reports of exposure to raw sewage and sewer odors we learned from 

the maintenance staff of instances where detainees flushed objects such as clothing in the 

toilets to intentionally clog the sewage system. The building’s sewage system is not equipped 

with grinder pumps. Although automatic trap primers were functioning at the time of our 

evaluation, this had not been the case in the past. Non-functioning trap primers could result 

in dry drain traps, allowing sewer odors to enter occupied spaces of the building. Building 

administrators and the maintenance staff were aware of the deteriorated cast iron waste lines 

beneath the slab foundation and had plans to identify, remove, and replace them once funding 

was obtained. Considering that the waste lines are beneath a concrete slab foundation it is 

less likely they were associated with sewer odors or sewage back-ups. It is more likely that 

the odors were from intentional clogging of the sewage system by detainees or from nonfunctioning trap primers.

The employees’ symptoms that could be related to working in the building were headache, 

sinus problems, worsening of allergies, eye irritation, frequent upper respiratory infections, 

fatigue, throat irritation, and cough. These are common symptoms that we have frequently 
Health Hazard Evaluation Report 2015-0183-3255 Page 9

found in people working in buildings with poor ventilation. However, these symptoms can 

also be found frequently in the general population, and are associated with other causes as 

well. Of the general population, 86%–95% have one or more common symptoms during any 

given 2- to 4-week period, and the average adult reports a minimum of one symptom every 

4–6 days [Barsky and Borus 1995]. Table 2 lists the general population prevalences of many 

of the symptoms reported by employees in this judicial building. In addition, the average 

adult has two to three upper respiratory infections per year [Benninger et al. 2003]. According 

to the National Health Interview Survey, 12% of U.S. adults reported physician-diagnosed 

sinusitis in 2012 [Centers for Disease Control and Prevention 2014]. Women were more likely 

to be diagnosed with sinusitis (15% compared to 9% in men) [Centers for Disease Control 

and Prevention 2014]. Nonetheless, we have found that improving building ventilation often 

reduces the occurrence of many of these types of symptoms in building occupants. 

Table 2. General population prevalence of symptoms similar to those reported by employees

Clustered random 

sample of households 

in Australia

General medical 

practices in the 

United Kingdom

Representative sample 

of general population of 

New Zealand

Participants n = 3,016* n = 2,474† n = 1,000‡

Time frame 14 days 14 days 7 days

Number of symptoms 

asked about

12 25 46

Percent reporting at 

least one symptom

80 > 75 89

Number of symptoms 

reported, mean (range)

Not reported 3.6 (0–22) 5 (0–36)

Symptoms similar to 

those reported in this

building (%)

Stuffy nose (46)

Headache (33)

Unusually tired (30)

Cough (26)

Dry, itchy, or irritated 

eyes (25)

Dry or sore throat (22)

Skin rash (12)

Tired/run down (41)

Headache (39)

Sore throat (19)

Cough (18)

Fatigue (36)

Headache (35)

Congested or runny 

nose (34)

Cough (28)

*Reference: Heyworth and McCaul 2001

†Reference: McAteer et al. 2011

‡Reference: Petrie et al. 2014

The U.S. Environmental Protection Agency (EPA) conducted a systematic survey of 100 

randomly selected office buildings without known IEQ complaints in the United States to 

develop baseline data about U.S. office buildings [Brightman et al. 2008]. The National 

Institute for Occupational Safety and Health (NIOSH) conducted a similar study of 80 

buildings with IEQ complaints [Malkin et al. 1996]. Occupants in both studies reported 

work-related symptoms. The rank order of symptoms was the same, but rates were 

significantly higher in the buildings with IEQ complaints. The most common work-related 

symptoms reported in both studies were dry, itching, or irritated eyes; unusual tiredness or 

fatigue; headache; tension or irritability; pain in back, neck, and shoulders; stuffy or runny 
Page 10 Health Hazard Evaluation Report 2015-0183-3255

nose, or sinus congestion; sneezing; sore or dry throat; and difficulty remembering things or 

concentrating. Of the employees in the randomly selected buildings, 45% reported at least one 

work-related symptom. These common symptoms in the general population and in buildings 

are also among the most common symptoms reported by employees in this building.

Exposures that could be related to new-onset or worsening asthma include fragrances, dust 

mites, dander from rodents, and excrement of rodents and other pests such as cockroaches. 

Some allergens can be carried in on employees and visitors. The most common of these 

are cat and dog allergens, which can be an unrecognized source of allergic upper and lower 

respiratory and skin symptoms.

Several employees reported having medical conditions that we determined were unrelated 

to the building’s conditions or exposures in the building. These medical conditions were 

also not due to any common exposure, nor spread from one person to another. These 

included cancer, kidney stones, urinary tract infection, gallbladder disease, low folic acid, 

gastroesophageal reflux disease, hypothyroidism, hyperthyroidism, thyroid nodules, and 

intestinal abscess.

Conclusions

We saw no evidence of a current mold or sewage problem in the building during our 

evaluation, and the underground diesel storage tank was being routinely inspected and 

properly maintained. However, we identified several correctable problems, in particular 

inadequate building ventilation and a lack of up-to-date building plans that the maintenance 

staff could use to help maintain the ventilation systems. Many of the symptoms employees 

reported, such as sinus problems and headaches, have been associated with damp buildings or 

inadequate ventilation but are also common in the general population. We found no evidence 

that other health problems reported by some employees, such as cancer, gallstones, and 

thyroid problems, were related to working in the building. 

Recommendations

On the basis of our findings, we recommend the actions listed below to create a more 

healthful workplace. Our recommendations are based on the hierarchy of controls approach. 

This approach groups actions by their likely effectiveness in reducing or removing hazards. 

In most cases, the preferred approach is to eliminate hazardous materials or processes and 

install engineering controls to reduce exposure or shield employees. Until such controls 

are in place, or if they are not effective or feasible, administrative measures and personal 

protective equipment may be needed. 
Health Hazard Evaluation Report 2015-0183-3255 Page 11

Engineering Controls

Engineering controls reduce employees’ exposures by removing the hazard from the process or by 

placing a barrier between the hazard and the employee. Engineering controls protect employees 

effectively without placing primary responsibility of implementation on the employee. 

1. Hire a licensed professional mechanical engineer to do a comprehensive assessment of 

the building’s ventilation systems. The engineer should have experience in the design 

of heating, ventilating, and air-conditioning systems for buildings that include multiuse areas such as offices, courtrooms, and detention centers.

2. Evaluate using grinders or screens to minimize or prevent sewage blockages. 

3. Replace corroded cast iron waste pipes.

Administrative Controls

The term administrative controls refers to employer-dictated work practices and policies 

to reduce or prevent hazardous exposures. Their effectiveness depends on employer 

commitment and employee acceptance. Regular monitoring and reinforcement are necessary 

to ensure that policies and procedures are followed consistently.

1. Stop environmental sampling for chemical and biological agents to identify a cause for 

nonspecific symptoms among employees.

2. Establish a fragrance-free workplace policy. Ensure that it addresses perfumes and 

other scented personal care products, air fresheners, and potpourris. 

3. Ask employees to report signs of moisture intrusion to the facilities maintenance staff. 

Establish a system for responding to requests and notifying the requestor what is being 

done and when the work is complete.

4. Form a labor-management health and safety committee to discuss the 

recommendations in this report and develop an action plan. Those involved in the 

work can best set priorities and assess the feasibility of our recommendations for the 

specific situation at the building.

5. Encourage employees with health concerns to seek evaluation and care from a physician 

who is residency-trained and board certified in occupational medicine and is familiar 

with the types of exposures employees might have had and their health effects. 

Occupational medicine physicians can be found through a variety of sources, including 

the Association of Occupational and Environmental Clinics, at http://www.aoec.org/, 

and the American College of Occupational and Environmental Medicine, at http://www.

acoem.org/. It may be useful to provide the physician with a copy of this report.
Page 12 Health Hazard Evaluation Report 2015-0183-3255

Appendix A: Evaluation of Cancer Clusters

Cancer 

Cancer is a group of different diseases that share the same feature of uncontrolled growth 

and spread of abnormal cells. Each different type of cancer may have its own set of causes. 

Cancer is common in the United States. In the United States, one in two men and one in 

three women will develop cancer over the course of their lifetimes. This does not include 

basal or squamous cell skin cancers, which are very common (more than 3 million diagnosed 

annually), or any in-situ carcinomas other than bladder. If these were included, rates would 

be even higher. One of every four deaths in the United States is from cancer. Among adults, 

cancer occurs more frequently with increasing age. Cancer cases may appear to occur with 

alarming frequency even when the number of cases is not more than would be expected in 

the general population because cancer is common, the population is aging, and more people 

are surviving cancer. This perception is especially common among a small group of people 

who have something in common with the cases, such as working in the same building.

Many factors play a role in the development of cancer. The importance of these factors varies 

for different types of cancer. Most cancers are caused by a combination of several factors. 

Some of the factors include (1) personal characteristics such as age, sex, and race; 

(2) family history of cancer; (3) diet; (4) personal habits such as cigarette smoking and 

alcohol consumption; (5) the presence of certain medical conditions; (6) exposure to 

cancer-causing agents in the environment; and (7) exposure to cancer-causing agents in the 

workplace. In many cases, these factors may act together or in sequence to cause cancer. 

Although some causes of various types of cancer are known, we do not know everything 

about the causes of cancer. One important point to note is that the absence of a risk factor 

does not mean there is no risk for developing cancer. For example, employees often say to us 

that they got breast cancer despite having no family history of breast cancer, so it must be due 

to their work. In fact, while having a first-degree relative with breast cancer increases one’s 

risk of developing breast cancer, most people who get breast cancer do not have a family 

history of it.

Breast Cancer

Breast cancer is the most common cancer in women in the United States. Approximately 

250,000 cases of invasive breast cancer will be diagnosed in women in the United States in 

2016, not including 61,000 cases of carcinoma in situ [American Cancer Society 2016b]. One 

in eight women in the United States will develop breast cancer in her lifetime. Well-established 

breast cancer risk factors include family history of breast cancer, biopsy-confirmed atypical 

hyperplasia, early menarche (first menstrual period), late menopause, not having children 

or having the first child after age 30, overweight or obesity (especially after menopause), 

never breastfeeding a child, low physical activity levels, and higher levels of education and 

socioeconomic status [American Cancer Society 2016b; Weiderpass et al. 2011]. 

The International Agency for Research on Cancer (IARC) has classified alcoholic beverages 

of all types, in utero exposure to diethylstilbestrol, estrogen-progesterone oral contraceptives 
Health Hazard Evaluation Report 2015-0183-3255 Page 13

and hormone replacement therapy, and exposure to x-rays and gamma rays (types of ionizing 

radiation) as “carcinogenic to humans” with regard to breast cancer. The risk from ionizing 

radiation is highest if exposure occurs during childhood and is negligible if exposure occurs 

after age 40. IARC classifies digoxin, estrogen hormone replacement therapy, ethylene oxide, 

polychlorinated biphenyls, smoking, and shift work as “probably carcinogenic to humans.”

While scientific studies have found an association between certain substances or occupations 

and breast cancer, the results are conflicting or unconfirmed. Some studies have found 

increased risk of breast cancer among nurses, librarians, laboratory technicians, telephone 

operators, glass manufacturing workers, textile workers, meat wrappers and cutters, printers, 

security personnel, scientific researchers, and hairdressers/cosmetologists, among others 

[Coogan et al. 1996; Gardner et al. 2002; Labrèche et al. 2010; Morton 1995; Peplonska et al. 

2009; Shaham et al. 2006; Teitelbaum et al. 2003; Zheng et al. 2002]. 

Several studies have found teachers and other professional and managerial employees to 

have an increased risk for developing breast cancer [Bernstein et al. 2002; King et al. 1994; 

MacArthur et al. 2007; Pollán and Gustavsson 1999; Rubin et al. 1993; Snedeker 2006], but 

others have not [Calle et al. 1998; Coogan et al. 1996; Petralia et al. 1998]. No causative 

workplace exposures have been identified for these occupations, and it is postulated that the 

possible increase in risk is a result of non-occupational risk factors such as parity (number of 

times a woman has given birth), maternal age at first birth, contraceptive use, diet, and physical 

activity [MacArthur et al. 2007; Snedeker 2006; Threlfall et al. 1985]. Women with higher 

educational status are also more likely to have mammograms, thus increasing detection of 

breast cancer. Several studies have found that about one quarter to one third of invasive breast 

cancers detected by mammograms were overdiagnosed, i.e., would not have progressed or 

caused harm [Jørgensen and Gøtzsche 2009; Miller et al. 2014; Zahl et al. 2008]. 

Cancer Clusters 

Cancers often appear to occur in clusters, which scientists define as a greater than expected 

number of cancer cases that occurs within a group of people in a geographic area over a 

defined period of time [Centers for Disease Control and Prevention 2012]. A cluster also 

occurs when the cancers are found among employees of a different age group or sex than is 

usual. A statistically significant excess of cancer cases may have a common cause, but can 

occur without a clear cause and can occur by chance [Aldrich and Sinks 2002; Thun and 

Sinks 2004]. In many workplaces the number of cases is small. This makes detecting whether 

the cases have a common cause difficult, especially when no apparent cancer-causing 

exposures are present. It is common for the borders of the “cluster” to be drawn around 

where the cases of cancer are located, instead of defining the population and geographic 

area first. This often leads to “clusters” that are not real. This is referred to as the “Texas 

sharpshooter effect” because the Texas sharpshooter shoots at the barn and then draws his 

bull’s eye around the bullet hole. 

When cancer in a workplace is described, learning whether the type of cancer is a primary 

cancer or a metastasis (spread of the primary cancer into other organs) is important. Only 

primary cancers are used to investigate a cancer cluster. To assess whether the cancers among 
Page 14 Health Hazard Evaluation Report 2015-0183-3255

employees could be related to occupational exposures, we consider the number of cancer 

cases, the types of cancer, the likelihood of exposures to potential cancer-causing agents, and 

the timing of the diagnosis of cancer in relation to the exposure. These issues are discussed 

below in a series of questions that relate to this request.

Do employees at this building have more cancer than people who do not 

work at this building? 

No. Because cancer is a common disease, it may be found among people at any workplace. 

When several cases of cancer occur in a workplace they may be part of a true cluster when 

the number is greater than we expect compared to other groups of people similar in age, sex, 

and race. Disease or tumor rates, however, are highly variable in small populations and rarely 

match the overall rate for a larger area, such as the state, so that for any given time period 

some populations have rates above the overall rate and others have rates below the overall rate. 

Even when a higher rate occurs it may be consistent with the expected random variability. In 

addition, calculations like this make many assumptions that may not be appropriate for every 

workplace. Comparing rates without adjusting for age, sex, or other population characteristics 

assumes that such characteristics are the same in the workplace as in the larger population, 

which may not be true. However, general information on cancer rates is useful for providing 

perspective on the cancers in your population. The occurrence of 11 cases of cancer among 

over 150 employees over several years is not excessive. It is likely that many more current and 

former employees have been diagnosed with cancer than those who were reported to us, but 

the numbers and types of the reported cancers do not suggest a need for further case finding. As 

employees age, more cases of cancer (of many types) will appear.

Do employees at this building have an unusual distribution of types of 

cancer? 

No. Cancer clusters thought to be related to a workplace exposure usually consist of the 

same types of cancer. When several cases of the same type of cancer occur and that type 

is not common in the general population, it is more likely that an occupational exposure 

is involved. When the cluster consists of multiple types of cancer, without one type 

predominating, then an occupational cause of the cluster is less likely. The 10 most common 

cancers in women are (in order): breast; lung and bronchus; colon and rectum; uterine 

corpus; thyroid; non-Hodgkin lymphoma; melanoma of the skin; kidney and renal pelvis; 

pancreas; and ovary. The 10 most common cancers in men are (in order): prostate; lung and 

bronchus; colon and rectum; urinary bladder; melanoma of the skin; kidney and renal pelvis; 

non-Hodgkin lymphoma; oral cavity and pharynx; leukemia; and pancreas. Several female 

employees in this building (where 66% of employees are female) have been diagnosed with 

breast cancer, the most common cancer among women in the United States. Three other of 

the most common types of cancer were also diagnosed among employees. 
Health Hazard Evaluation Report 2015-0183-3255 Page 15

Is exposure to a specific chemical or physical agent known or suspected 

of causing cancer or other health effects occurring at this building?

No. The relationship between some agents and certain cancers has been well established. 

For other agents and cancers, there is a suspicion of a link but the evidence is not definitive. 

When a known or suspected cancer-causing agent is present and the types of cancer occurring 

have been linked with these exposures in other settings, we are more likely to make the 

connection between cancer and a workplace exposure. 

Office buildings rarely have hazardous exposures relevant to cancer. Asbestos can be a 

concern in older buildings, but it is known to cause lung cancer and mesothelioma, neither of 

which were reported among employees. Asbestos is not present in this building. Radon can 

be of concern in basement or lower floors of some buildings, but radon causes lung cancer, 

not other types of cancer. Radon monitoring is performed in the building every 2 years, and 

levels have been acceptable. 

Has enough time passed since exposure began? 

Latency is the time between first exposure to a cancer-causing agent and clinical recognition 

of the disease. Latency periods vary by cancer type but usually are a minimum of 10–12 

years [Rugo 2004]. This issue is not relevant when considering the reported cancers at this 

building because there is not an excess of cancer among employees, the distribution of 

cancers is not unusual, and no exposures were associated with the cancers diagnosed.

In conclusion, the available evidence does not suggest that the reported cancers are associated 

with work at this building. The number and types of cancers are not unusual, and the reported 

exposures are not linked to the types of cancers reported. 

The American Cancer Society estimates that about 171,000 cancer deaths in 2015 were 

caused by tobacco use alone. This is one third of all cancer deaths. It is well known that 

tobacco use increases the risk of cancer of the lung, mouth, nasal cavities, larynx, pharynx, 

esophagus, stomach, colorectum, liver, pancreas, kidney, bladder, uterine cervix, and ovary 

(mucinous), and myeloid leukemia [American Cancer Society 2016a]. There is limited 

evidence that tobacco smoking causes female breast cancer. 

Another one quarter to one third of cancer deaths are due to poor nutrition, physical 

inactivity, overweight, and obesity [American Cancer Society 2016a]. Being overweight 

or obese is clearly associated with increased risk for developing cancer of the breast (in 

postmenopausal women), colon and rectum, endometrium, kidney, and pancreas, and 

adenocarcinoma of the esophagus. Obesity increases the risk of gallbladder cancer and 

possibly cancers of the liver, cervix, and ovary; multiple myeloma; non-Hodgkin lymphoma; 

and aggressive forms of prostate cancer [American Cancer Society 2016a]. 
Page 16 Health Hazard Evaluation Report 2015-0183-3255

Alcohol consumption is another modifiable personal risk factor that increases risk of cancer, 

in addition to the almost two thirds of cancer due to smoking, poor nutrition, physical 

inactivity, overweight, and obesity. Alcohol causes cancers of the mouth, pharynx, larynx, 

esophagus, liver, colorectum, and breast [American Cancer Society 2016a]. Even a few 

drinks weekly increase the risk of breast cancer. 

Employees can take an active role in changing personal risk factors that are associated with 

certain types of cancer. The American Cancer Society posts general information about cancer 

on its website at http://www.cancer.org/ by clicking on “Learn about cancer.” For information 

about a specific type of cancer, click on “Select a Cancer Type,” select a type of cancer, then 

click “Go.”
Health Hazard Evaluation Report 2015-0183-3255 Page 17

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Keywords: North American Industry Classification System 922110 (Courts), Tennessee, 

indoor environmental quality, IEQ, ventilation, hydrogen sulfide, mold, diesel
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Health Hazard Evaluation Report 2015-0183-3255 Page 23

The Health Hazard Evaluation Program investigates possible health hazards in the workplace 

under the authority of the Occupational Safety and Health Act of 1970 (29 U.S.C. § 669(a)

(6)). The Health Hazard Evaluation Program also provides, upon request, technical assistance 

to federal, state, and local agencies to investigate occupational health hazards and to prevent 

occupational disease or injury. Regulations guiding the Program can be found in Title 42, Code 

of Federal Regulations, Part 85; Requests for Health Hazard Evaluations (42 CFR Part 85).

Disclaimer

The recommendations in this report are made on the basis of the findings at the workplace 

evaluated and may not be applicable to other workplaces.

Mention of any company or product in this report does not constitute endorsement by NIOSH.

Citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the 

sponsoring organizations or their programs or products. NIOSH is not responsible for the 

content of these Web sites. All Web addresses referenced in this document were accessible as of 

the publication date.

Acknowledgments

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Editor: Ellen Galloway 

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Medical Field Assistance: Mary-Margaret Fill

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Administration Regional Office have also received a copy. This report is not copyrighted 

and may be freely reproduced. 

This report is available at http://www.cdc.gov/niosh/hhe/reports/pdfs/2015-0183-3255.pdf.

Recommended citation for this report:

NIOSH [2016]. Evaluation of indoor environmental quality and health concerns in a 

juvenile court building. By Page E, Broadwater K, Chiu S, Li JF, Burr G. Cincinnati, 

OH: U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, Health Hazard 

Evaluation Report 2015-0183-3255, http://www.cdc.gov/niosh/hhe/reports/pdfs/2015-

0183-3255.pdf.
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