ENFERMEDADES EMERGENTES Y CEFALEA COMO SÍNTOMA Concepto de enfermedad emergente Consideraciones generales:

ENFERMEDADES EMERGENTES Y CEFALEA COMO SÍNTOMA
Referencia: Manual de cefalea para el médico : minusvalía, incapacidad y accidente de trabajo: análisis de
las sentencias más relevantes
[Monografía] (2009). Editorial/es: Lettera Publicaciones, S.L. ISBN 13: 978-
84-936410-4-7.
Concepto de enfermedad emergente: se trata de enfermedades nuevas (emergentes), o
ya conocidas (re-emergentes) que reaparecen con una incidencia rápidamente creciente o lo
hacen en nuevas zonas geográficas.
Consideraciones generales:
1. La OMS insiste en que el envejecimiento y las consecuencias de la mala gestión de los
procesos de urbanización y globalización aceleran la propagación de las enfermedades a
nivel mundial e incrementan la carga de trastornos crónicos y no transmisibles
2. En el campo de la Medicina del Trabajo la preocupación por el estudio de estas
enfermedades emergentes ha llevado a diversos organismos públicos a la creación de
observatorios que permitan investigar los nuevos riesgos que aparecen con los cambios que
ha experimentado el mundo laboral.
3. Entre los riesgos más importantes de las enfermedades emergentes están: la falta de ejercicio
físico, la complejidad de las nuevas tecnologías, y la mayor vulnerabilidad de los
trabajadores de baja cualificación.
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4. En los lugares de trabajo el trabajador se puede ver expuesto a una combinación de
riesgos interrelacionados, como permanecer muchas horas sentados, ruido de fondo y estrés
que repercuten de forma muy variada en la salud de los trabajadores.
5. La mayor parte de estas enfermedades emergentes o re-emergentes cursan con
sintomatología muy variada, pero en una parte importante de ellas, sino en todas, la cefalea
es uno de sus síntomas destacados. Incluso puede ser uno de los síntomas de alarma y
agravarse de forma notable en aquellas personas que ya sufren de esta patología.
6. Interesa destacar de forma especial, el concepto de indicador sanitario o indicador de
salud como fuente de información que proporcione datos de interés para conocer el estado de
salud de la población, laboral en este caso, y que permita identificar daños y problemas
concretos de la salud de los trabajadores.
7. Se utilizará, un síntoma de alarma tan inespecífico como la cefalea, que puede aparecer en
las fases iniciales de enfermedades emergentes y también en otras patologías prevalentes en
ámbito laboral, como por ejemplo en intoxicaciones por determinados productos químicos,
que están en el entorno de trabajo en algunos sectores productivos.
PRINCIPALES ENFERMEDADES EMERGENTES EN MEDICINA
DEL TRABAJO CON REPERCUSIÓN EN SALUD PÚBLICA
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Síndrome del edificio enfermo (SEE)
ƒ
Sensibilidad química múltiple (SQM)
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I.- Síndrome del edificio enfermo (SEE)
Se describió inicialmente en personas que:
a) trabajan en espacios cerrados, como: instalaciones de tipo estratégico militar, con
síntomas como: cefaleas, irritación de mucosas, sensación de cansancio, y problemas de
claustrofobia.
b) en personas que trabajan en grandes edificios y con dificultades de ventilación.
En 1982 la OMS reconoció como enfermedad al llamado “Síndrome del edificio enfermo”
(S.E.E, en Español, SBS, en Ingles, Sick Building Syndrome), y lo definió como:
“Un conjunto de síntomas y signos inespecíficos de origen multifactorial, de los que no se
encuentran evidencias diagnósticas que los corroboren en las pruebas diagnosticas
realizadas, que no pueden relacionarse con ninguna enfermedad, y que se dan en más del
20% de los trabajadores de un mismo edificio”
Definición actual:
“Síndrome del edificio enfermo” es el nombre que se le da al conjunto de síntomas que
presentan las personas que trabajan en estos edificios, y que no van en general acompañados de
ninguna lesión orgánica o signo físico, diagnosticándose, a menudo, por exclusión.
Consideraciones clínicas:
ƒ
Se relacionan con la irritación de las mucosas, dolor de cabeza, y fatiga por causas
desconocidas.
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Otra cuestión de naturaleza distinta son las “enfermedades relacionadas con los
edificios”, que son menos frecuentes, pero a menudo más graves, y que suelen ir
acompañadas de signos físicos y hallazgos de laboratorio. Incluyen enfermedades
por hipersensibilidad (como la neumonitis por hipersensibilidad, la fiebre del
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humidificador, el asma, y la rinitis alérgica), e infecciones como la legionelosis, y
síndromes tóxicos.
Características comunes a los edificios enfermos:
Según la OMS, estos edificios tienen unas características comunes, como:
1. Casi siempre están provistos de un sistema de ventilación forzada, generalmente
común a todo el edificio o a amplios sectores dentro del mismo, y existe una
recirculación parcial del aire. Algunos edificios tienen la localización de las tomas
de aire en lugares inadecuados, mientras que en otros se usan intercambiadores de
calor que trasfieren los contaminantes desde el aire de retorno, al aire de suministro.
2. Con frecuencia son de construcción ligera y poco costosa
3. Las superficies interiores están, en gran parte, recubiertas con material textil,
incluyendo paredes, suelos y otros elementos de diseño interior
4. Practican el ahorro energético y se mantienen con un ambiente térmico
homogéneo
5. Son, generalmente, edificios herméticos en los que, las ventanas, por ejemplo, no
pueden abrirse
Los síntomas más significativos incluyen:
1. Irritaciones de ojos, nariz y garganta
2. Sensación de sequedad en membranas mucosas y piel
3. Cefalea
4. Náuseas, mareos y vértigos
5. Respiración dificultosa
6. Fatiga mental
7. Eritemas
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Posibles factores de riesgo:
1. Agentes químicos
2. Agentes biológicos
3. Agentes físicos
4. Factores psicosociales
En España la NTP-243 recoge una serie de recomendaciones relativas a los contaminantes
ambientales. Se cree que un exceso de anhídrido carbónico en una zona mal ventilada puede
ser el responsable de la cefalea
Metodología de evaluación
Notas Técnicas de Prevención:
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NTP-290: SEE cuestionario para su detección,
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NTP 380: SEE cuestionario simplificado
Se establecen cuatro fases para el estudio:
1. Investigación inicial
2. Medidas de inspección y guía
3. Medidas de ventilación, indicadores del clima y otros factores implicados
4. Examen médico e investigaciones asociadas
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Cuestionario de síntomas, NTP-380
En el caso de la cefalea, que es un síntoma fundamental por la frecuencia y
precocidad de su aparición en este síndrome, se debería tener en cuenta:
1. Su aparición y su evolución durante el día (debería ir aumentando por la tarde y
mejorando después de la jornada laboral).
2. Se deben descartar otros posibles orígenes o tipos de cefalea, como la tensional,
ya que puede estar añadida a la presión del entorno de trabajo.
3. En la cefalea del SEE se habla más de un malestar general, es más imprecisa que la
tensional, que tiene una localización y características más concretas.
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4. El que la cefalea, tienda a mejorar fuera del trabajo, descartaría otras cefaleas como
la desencadenada por motivos extralaborales.
5. Destacar la aparición de cefalea por esta causa, en aquellos trabajadores que antes
no la padecieran y donde se pueda establecer una relación causa-efecto concreta con
la sintomatología y las condiciones de trabajo ligadas al edificio.
6. Para aquellos pacientes con historial previo de cefaleas, recogeremos el hecho de
que su frecuencia o intensidad hayan aumentado desde que trabajan en ese edificio
y también que el tipo de cefalea, que aparece ahora, tiene otras características
diferentes de las que había tenido hasta entonces.
Posibles medidas correctoras/preventivas:
1. Desarrollo de materiales de construcción no contaminantes
2. Mejor conocimiento de los mecanismos provocadores de irritaciones y olores
3. Mejor identificación de la naturaleza de los contaminantes y de sus fuentes
4. Sustitución de los productos problemáticos por otros menos contaminantes
5. Mejoras y control periódico de los sistemas de ventilación
6. Vigilancia, control y seguimiento de los procesos organizativos en la empresa
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II.- Sensibilidad química múltiple (SQM)
Fue definida por Cullen en 1987 como "un trastorno adquirido caracterizado por síntomas
recurrentes, referibles a múltiples sistemas orgánicos, que se presentan como respuesta a la
exposición demostrable a muchos compuestos sin relación química entre sí a dosis muy por
debajo de las que se han establecido como causantes de efectos perjudiciales en la población
general.
En 1996, un comité de expertos de la OMS la redefine como Intolerancia Ambiental
idiopática, dada la complejidad y variedad de trastornos.
Sparks, en el 2000, define la Intolerancia Ambiental idiopática como un trastorno adquirido,
con síntomas recurrentes múltiples, relacionado con diversos factores ambientales tolerados por
la mayoría de las personas y que no se explica por ningún trastorno médico o psiquiátrico.
Diagnóstico:
Los criterios diagnósticos actualmente vigentes, son los llamados “Criterios de
Consenso definidos por Bartha y cols”:
1. La enfermedad es crónica
2. Los síntomas son reproducibles con la exposición repetida a agentes químicos
3. Los niveles bajos de exposición ocasionan manifestaciones del síndrome
4. Los síntomas mejoran o se resuelven cuando los incitantes son eliminados
5. Las respuestas se presentan ante múltiples sustancias sin relación química entre ellas
6. Los síntomas implican múltiples sistemas orgánicos
Principales síntomas (NTP-557).
1. SISTEMA NERVIOSO CENTRAL: Dolor de cabeza, fatiga, irritabilidad, pérdida de
memoria y capacidad de concentración, disfunciones cognitivas, insomnio, cambios de
humor, depresión y ansiedad
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2. MUSCULOESQUELÉTICO: Entumecimiento, debilidad, dolor muscular, tensión
muscular, falta de coordinación, dolor articular
3. RESPIRATORIO: Dificultad respiratoria, tos, ronquera, otitis recurrente, rinitis, afonía
4. CARDIOVASCULAR: Dolor pectoral, palpitaciones, ritmo irregular, taquicardia,
hipertensión
5. GASTROINTESTINAL: Espasmo esofágico, náuseas, vómito, diarrea recurrente,
estreñimiento, cambios de apetito, anorexia
6. PIEL Y MUCOSAS, OJOS: Irritación, prurito, eczema, irritación cutánea, hinchazón
facial, dolor de garganta, irritación y dolor ocular
7. GENITOURINARIO: Trastornos menstruación, vaginitis, dolor, disuria, retención
urinaria, impotencia
Protocolo diagnóstico: recogida de los síntomas que originan la consulta
1. Intolerancias de aparición reciente: frente al alcohol, medicamentos, comida u otras
sustancias.
2. Los síntomas y signos, aparecen al exponerse a los agentes desencadenantes, y estas
manifestaciones se repiten de forma similar.
3. Enfermedades previas, resultados de pruebas diagnosticas y los tratamientos. En el caso
de las cefaleas es importante estudiar: si ha presentado anteriormente el síntoma, a qué
factores desencadenantes lo asocia, si ha cambiado su frecuencia, forma o intensidad de
presentación. Los tratamientos que utilizaba, si siguen siendo eficaces ahora, o incluso si
pueden haberle desencadenado intolerancias, agravándole el cuadro.
4. Puede estar indicado realizar un examen psiquiátrico cuidadoso, que descartara
patología mental, así como tener en cuenta la posible ganancia económica o psicológica
que les puede reportar esta enfermedad.
5. No hay prueba analítica alguna de sangre u orina, ni exploración complementaria
específica que permita confirmar el diagnóstico, Aún así se recomienda en estos
pacientes la realización de algunas exploraciones para excluir otras causas de
enfermedad.
6. La exploración física de personas con SQM es normal, aunque puede objetivar los
signos irritativos de piel y mucosas en fases agudas.
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7. Hoy día se utiliza un cuestionario: QEESI (Quick Environmental Exposure and
Sensitivity Inventory) que recoge los agentes desencadenantes, las exposiciones, los
síntomas, y la gravedad y repercusión en la vida diaria.
Tratamiento/Prevención
ƒ
No podemos hablar de un tratamiento específico para la enfermedad, puesto que no
se conocen los mecanismos fisiopatológicos.
ƒ
Se han utilizado muchos tipos de tratamientos con resultados poco claros.
ƒ En la práctica, lo más importante es: Prevención
1. Evitar nuevas exposiciones a los agentes desencadenantes, ello supone alejar
a los pacientes del foco, y muchas veces se traduce en cambios en su rutina.
2. Mejorar la ventilación.
3. Evitar ambientes húmedos e irritantes.
4. Vigilar los alimentos de la dieta.
5. Prescindir del uso de desodorantes, perfumes.
6. En algunos casos puede llegar a necesitarse un cambio de vivienda o del
entorno laboral.
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Hay que considerar que estos pacientes necesiten apoyo psicológico, para afrontar
la evolución de la enfermedad, y los cambios en su estilo de vida.
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El debate que genera esta patología hace que muchos de ellos sean considerados
simuladores, no solo dentro de la medicina, sino también en su entorno familiar y
laboral.
Relación de los principales observatorios en la materia:
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Observatorio de Enfermedades Profesionales de la Seguridad Social: www.segsocial.es, en sección estadísticas
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Observatorio de salud laboral- condiciones de trabajo- Instituto de Seguridad e
Higiene en el Trabajo: www.insht.es; www.oect.es.
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Observatorio de Riesgos de la Agencia Europea de Seguridad y Salud en el Trabajo:
Con sede en Bilbao: http://osha.europa.eu/es
ƒ
Observatorio de Salud Laboral, una iniciativa promovida conjuntamente por la
Universidad Pompeu Fabra, el Instituto Sindical de Trabajo Ambiente y Salud
( ISTAS) Y Unión de Mutuas, con sede en Barcelona: www.osl.upf.edu
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El Ministro de Sanidad anunció en Octubre de 2008 la creación de un Observatorio
Nacional de Cambio Climático y Salud, que estudiará los efectos de las políticas
relacionadas con el medio ambiente en la salud y el bienestar de los ciudadanos.
respondiendo al informe de la OMS
ƒ
Existe también un nuevo portal de recursos de información en Seguridad y Salud en
el Trabajo, que se trata de una colaboración entre el Ministerio de Ciencia e
Innovación, el Instituto Carlos III, y la Escuela Nacional de Medicina del Trabajo, en
el que podemos encontrar el acceso a Observatorios y Redes de salud e información
de enfermedades laborales: http://infosaludlaboral.isciii.es
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SÍNDROME DEL EDIFICIO ENFERMO
REVISIÓN PUB.MED-ABSTRACT
Síndrome del Edificio Enfermo y Cefalea síntoma. Sick Building Syndrome AND headache
1.- Environ Int. 2009 Nov;35(8):1136-41. Epub 2009 Aug 8.
Symptoms prevalence among office workers of a sealed versus a non-sealed building: associations to
indoor air quality.
Rios JL, Boechat JL, Gioda A, dos Santos CY, de Aquino Neto FR, Lapa e Silva JR.
Federal University of Rio de Janeiro, Brazil. Clementino Fraga Filho University Hospital, Institute of
Thoracic Diseases. [email protected]
OBJECTIVES: An increasing number of complaints related to time spent in artificially ventilated
buildings have been progressively reported and attributed, at least in part, to physical and chemical
exposures in the office environment. The objective of this research was to investigate the association
between the prevalence of work-related symptoms and the indoor air quality, comparing a sealed office
building with a naturally ventilated one, considering, specially, the indoor concentration of TPM, TVOCs
and the main individual VOCs. METHODS: A cross-sectional study was performed to compare the
prevalence of sick building syndrome (SBS) symptoms among 1736 office workers of a sealed office
building and 950 of a non-sealed one, both in Rio de Janeiro's downtown. The prevalence of symptoms
was obtained by a SBS standardized questionnaire. The IAQ of the buildings was evaluated through
specific methods, to determine the temperature, humidity, particulate matter and volatile organic
compound (VOC) concentrations. RESULTS: Upper airways and ophthalmic symptoms, tiredness and
headache were highly prevalent in both buildings. Some symptoms were more prevalent in the sealed
building: "eye dryness" 33.3% and 27.1% (p: 0.01); "runny nose" 37.3% and 31.3% (p: 0.03); "dry throat"
42% and 36% (p: 0.02); and "lethargy" 58.5% and 50.5% (p: 0.03) respectively. However, relative
humidity and indoor total particulate matter (TPM) concentration as well as total volatile organic
compounds (TVOCs) were paradoxically greater in the non-sealed building, in which aromatic
compounds had higher concentration, especially benzene. The analysis between measured exposure levels
and resulting symptoms showed no association among its prevalence and TPM, TVOCs, benzene or
toluene concentration in none of the buildings. CONCLUSIONS: Other disregarded factors, like
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undetected VOCs, mites, molds and endotoxin concentrations, may be associated to the greater
prevalence of symptoms in the sealed building.
2.- Sick Building Syndrome: is mould the cause?
Med Mycol. 2009;47 Suppl 1:S217-22. Epub 2009 Mar 2
Terr AI.
UCSF Medical Center, San Francisco, California 94108, USA. [email protected]
Moulds are responsible for diseases in humans through the three pathogenetic mechanisms of infection,
allergy, and toxicity. Fungal infection is especially a risk factor for immunodeficient patients, but it
occurs in immunocompetent patients as well. Fungal allergy is manifested as bronchial asthma,
hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis, or allergic fungal sinusitis.
Mycotoxicosis is almost exclusively the result of ingestion of mould-contaminated foodstuffs. In each
case there is specificity for the etiologic mould. There is controversy regarding the ability of indoor
airborne mould spores to cause human disease through non-specific toxicity via the inhalation route.
Pulmonary mycotoxicosis is an established, although rare, occupational disease of farmers who inhale
enormous quantities of mycotoxins, endotoxins, and other toxic chemicals from contaminated silage.
Other conditions attributed to indoor airborne mycotoxin are unproven. These include infantile pulmonary
hemosiderosis, epistaxis, 'toxic encephalopathy', immune dysregulation and a variety of subjective
complaints without objective signs of pathology such as fatigue, headache, dyspnea, gastrointestinal
distress, neuromuscular and skeletal complaints, etc. Non-specific irritation from moulds via the
inhalation route is also a controversial subject that remains unproven. Published studies alleging an
epidemiologic causal relationship are unconvincing.
3.- Harefuah. 2008 Jul;147(7):607-8, 662.
[Sick building syndrome]
[Article in Hebrew]
Epstein Y.
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Over the past 50 years, a new man-made ecosystem has developed--the controlled indoor environment
within the sealed exterior shells of modern non-industrial buildings. Emitted toxic volatile compounds
from building materials, furnishings, and equipment, and inappropriate ventilation (resulting from the
need to reduce expenses) contribute to reduce indoor air quality (IAQ), which has considerable potential
to affect public health. Consequently, health problems related to this ecosystem have emerged. "Buildingrelated illnesses" (BRI) refers to a group of illnesses with a fairly homogeneous clinical picture, objective
abnormalities on clinical or laboratory evaluation, and one or more identifiable sources or agents known
to cause infectious, immunologic, or allergic diseases. The term "sick building syndrome" (SBS) is used
to refer to a heterogeneous group of work-related symptoms--including irritation of the skin and mucous
membranes of the eyes, nose, and throat, headache, fatigue, and difficulty concentrating. These are
considered illnesses because of the occurrence of symptoms, even though affected workers do not have
objective clinical or laboratory abnormalities and causative agents cannot be found. The clinical
symptoms of SBS, although not life-threatening are disruptive: they reduce productivity and increase
absenteeism from work. Noteworthy, the association of symptoms with psychosocial factors does not
mean that "the problem is all in the workers' heads". The results of psychological testing of symptomatic
and asymptomatic office workers are similar. To improve IAQ and reduce symptoms of SBS adequate
ventilation and fresh air, which will reduce volatile compounds, maintaining thermal comfort (with
humidity not exceeding 60%), and adequate lighting should be ensured.
4.- Indoor Air. 2008 Aug;18(4):301-16. Epub 2008 May 20.
Risk factors in heating, ventilating, and air-conditioning systems for occupant symptoms in US office
buildings: the US EPA BASE study.
Mendell MJ, Lei-Gomez Q, Mirer AG, Seppänen O, Brunner G.
Lawrence
Berkeley
National
Laboratory,
Indoor
Environment
Department,
CA,
USA.
[email protected]
Building-related symptoms in office workers worldwide are common, but of uncertain etiology. One
cause may be contaminants related to characteristics of heating, ventilating, and air-conditioning (HVAC)
systems. We analyzed data from 97 representative air-conditioned US office buildings in the Building
Assessment and Survey Evaluation (BASE) study. Using logistic regression models with generalized
estimating equations, we estimated odds ratios (OR) and 95% confidence intervals for associations
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between building-related symptom outcomes and HVAC characteristics. Outdoor air intakes less than 60
m above ground level were associated with significant increases in most symptoms: e.g. for upper
respiratory symptoms, OR for intake heights 30 to 60 m, 0 to <30 m, and below ground level were 2.7,
2.0, and 2.1. Humidification systems with poor condition/maintenance were associated with significantly
increased upper respiratory symptoms, eye symptoms, fatigue/difficulty concentrating, and skin
symptoms, with OR = 1.5, 1.5, 1.7, and 1.6. Less frequent cleaning of cooling coils and drain pans was
associated with significantly increased eye symptoms and headache, with OR = 1.7 and 1.6. Symptoms
may be due to microbial exposures from poorly maintained ventilation systems and to greater levels of
vehicular pollutants at air intakes nearer the ground level. Replication and explanation of these findings is
needed. PRACTICAL IMPLICATIONS: These findings support current beliefs that moisture-related
HVAC components such as cooling coils and humidification systems, when poorly maintained, may be
sources of contaminants that cause adverse health effects in occupants, even if we cannot yet identify or
measure the causal exposures. While finding substantially elevated risks for poorly maintained
humidification systems, relative to no humidification systems, the findings do not identify important
(symptom) benefits from well-maintained humidification systems. Findings also provide an initial
suggestion, needing corroboration, that outdoor air intakes lower than 18 stories in office buildings may
be associated with substantial increases in many symptoms. If this is corroborated and linked to groundlevel vehicle emissions, urban ventilation air intakes may need to be located as far above ground level as
possible or to incorporate air cleaners that remove gaseous pollutants.
5.- Arch Environ Occup Health. 2007 Fall;62(3):147-55.
Sick building syndrome: psychological, somatic, and environmental determinants.
Gomzi M, Bobic J, Radosevic-Vidacek B, Macan J, Varnai VM, Milkovic-Kraus S, Kanceljak-Macan B.
Institute for Medical Research and Occupational Health, Zagreb, Croatia. [email protected]
The authors aimed to examine potential relationships between work-related symptoms attributed to sick
building syndrome (SBS) and certain psychological, somatic, and environmental factors. The
multidisciplinary, cross-sectional study comprised 171 female subjects working in air-conditioned and
naturally ventilated nonindustrial office buildings. The authors collected information concerning
symptoms related to SBS and made assessments of quality of life by using appropriate questionnaires.
They assessed the women's levels of emotional stability or neuroticism using the Cornell Index. They
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determined skin and airway reactivity markers and indoor microclimate data by using standardized
methods. The study showed that the subjects had a high prevalence of fatigue (60.2%), sore and dry eyes
(57.9%), and headache (44.4%), as well as a generally high score according to the SBS Index.
Neuroticism and subjectively estimated physical health as well as the type of building ventilation
significantly contributed to the prediction of the SBS Index, explaining 15% of the variance.
6.- Indoor Air. 2008 Apr;18(2):156-70.
Outdoor ozone and building-related symptoms in the BASE study.
Apte MG, Buchanan IS, Mendell MJ.
Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA. [email protected]
Reactions between ozone and indoor contaminants may influence human health and indoor air quality.
The U.S. EPA Building Assessment Survey and Evaluation (BASE) study data were analyzed for
associations between ambient ozone concentrations and building-related symptom (BRS) prevalence.
Multiple logistic regression (MLR) models, adjusted for personal, workplace, and environmental
variables, revealed positive relationships (P < 0.05) between ambient ozone concentrations and upper
respiratory (UR), dry eyes, neurological and headache BRS (odds ratios ranged from 1.03 to 1.04 per 10
mug/m(3) increase in ambient ozone concentrations). Other BRS had marginally significant relationships
with ambient ozone (P < 0.10). A linear dose-response in UR symptoms was observed with increasing
ambient ozone (P = 0.03); most other symptoms showed similar but not statistically significant trends.
Ambient ozone correlated with indoor concentrations of some aldehydes, a pattern suggesting the
occurrence of indoor ozone chemistry. Coupled with the MLR ambient ozone-BRS analysis, this
correlation is consistent with the hypothesis that ozone-initiated indoor reactions play an important role in
indoor air quality and building occupant health. Replication with increased statistical power and with
longitudinal data is needed. If the observed associations are confirmed as causal, ventilation system ozone
removal technologies could reduce UR BRS prevalence when higher ambient ozone levels are present.
PRACTICAL IMPLICATIONS: This paper provides strong statistical evidence that supports (but does
not prove) the hypothesis that ozone entrained into buildings from the outdoor air is involved in
increasing the frequency that occupants experience and a range of upper and lower respiratory, mucosal
and neurological symptoms by as much as a factor of 2 when ambient ozone levels increase from those
found in low-ozone regions to those typical of high-ozone regions. Although replication is needed, the
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implication is that reducing the amount of ozone entrained into building ventilation systems, either by
ambient pollution reduction or engineered gas-phase filtration, may substantially reduce the prevalence of
these symptoms experienced by occupants.
7.- Indoor Air. 2008 Apr;18(2):144-55.
Air filter materials, outdoor ozone and building-related symptoms in the BASE study.
Buchanan IS, Mendell MJ, Mirer AG, Apte MG.
Indoor Environment Department, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA.
Comment in:
•
Indoor Air. 2009 Aug;19(4):346-7.
Used ventilation air filters have been shown to reduce indoor environmental quality and worker
performance and increase symptoms, with effects stronger after reaction of filters with ozone. We
analyzed data from the US EPA Building Assessment Survey and Evaluation (BASE) study to determine
if ozone and specific filter media have interactive effects on building-related symptoms (BRS). We
analyzed a subset of 34 buildings from the BASE study of 100 US office buildings to determine the
separate and joint associations of filter medium [polyester/synthetic (PS) or fiberglass (FG)] and outdoor
ozone concentration (above/below the median, 67.6 microg/m(3)) with BRS. Using logistic regression
models and general estimating equations, we estimated odds ratios (ORs) and 95% confidence intervals
for the association of filter medium, ozone, and filter medium x ozone with BRS. Relative to FG + low
ozone, PS alone or high ozone alone, were each significantly (P < 0.05) associated only with
fatigue/difficulty concentrating (ORs = 1.93 and 1.54, respectively). However, joint exposure to both PS
+ high ozone, relative to FG + low ozone, had significant associations with lower and upper respiratory,
cough, eye, fatigue, and headache BRS (ORs ranged from 2.26 to 5.90). Joint ORs for PS + high ozone
for lower and upper respiratory and headache BRS were much greater than multiplicative, with
interaction P-values <0.10. Attributable risk proportion (ARP) estimates indicate that removing both risk
factors might, given certain assumptions, reduce BRS by 26-62%. These findings suggest possible
adverse health consequences from chemical interactions between outdoor ozone and PS filters in
buildings. Results need confirmation before recommending changes in building operation. However, if
17
additional research confirms causal relationships, ARP estimates indicate that appropriate filter selection
may substantially reduce BRS in buildings, especially in high-ozone areas. PRACTICAL
IMPLICATIONS: The results indicate that a better understanding of how filters interact with their
environment is needed. While the mechanism is unknown and these findings need to be replicated, they
indicate that the joint risk of BRS from polyester/synthetic filters and outdoor ozone above 67.6
microg/m(3) is much greater than the risk from each alone. These findings suggest potential reductions in
BRS from appropriate selection of ventilation filter media or implementing strategies to reduce ozone
entrained in building ventilation systems. If the relationships were found to be causal, filter replacement
and ozone abatement should be undertaken.
8.- int Arch Occup Environ Health. 2008 Oct;82(1):21-30. Epub 2008 Feb 2.
Sick building syndrome in relation to air exchange rate, CO(2), room temperature and relative air
humidity in university computer classrooms: an experimental study.
Norbäck D, Nordström K.
Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University,
University Hospital, Uppsala, Sweden. [email protected]
OBJECTIVE: To study the effects of ventilation and temperature changes in computer classrooms on
symptoms in students. METHODS: Technical university students participated in a blinded study. Two
classrooms had higher air exchange (4.1-5.2 ac/h); two others had lower (2.3-2.6 ac/h) air exchange. After
1 week, ventilation conditions were interchanged between the rooms. The students reported symptoms
during the last hour, on a seven-step rating scale. Room temperature, relative air humidity (RH) carbon
dioxide (CO(2)), PM10 and ultra-fine particles (UFP) were measured simultaneously (1 h). Illumination,
air velocity, operative temperature, supply air temperature, formaldehyde, NO(2) and O(3) were
measured. Multiple logistic regression was applied in cross-sectional analysis of the first answer (N =
355). Those participating twice (N = 121) were analysed longitudinally. RESULTS: Totally 31% were
females, 2.9% smokers and 3.8% had asthma. Mean CO(2) was 993 ppm (674-1,450 ppm), temperature
22.7 degrees C (20-25 degrees C) and RH 24% (19-35%). Lower and higher air exchange rates
corresponded to a personal outdoor airflow of 7 l/s*p and 10-13 L/s*P, respectively. Mean PM10 was 20
microg/m(3) at lower and 15 microg/m(3) at higher ventilation flow. Ocular, nasal and throat symptoms,
breathlessness, headache and tiredness were significantly more common at higher CO(2) and temperature.
18
After mutual adjustment, ocular (OR = 1.52 per 1 degrees C), nasal (OR = 1.62 per 1 degrees C) and
throat symptoms (OR = 1.53 per 1 degrees C), headache (OR = 1.51 per 1 degrees C) and tiredness (OR =
1.54 per 1 degrees C) were significantly associated with temperature; headache was associated only with
CO(2) (OR = 1.19 per 100 ppm CO(2)). Longitudinal analysis demonstrated that increased room
temperature was related to tiredness (P < 0.05). CONCLUSION: Computer classrooms may have CO(2)
above 1,000 ppm and temperatures above 22 degrees C. Increased temperature and CO(2) may affect
mucosal membrane symptoms, headaches and tiredness. Room temperature was most important. CO(2)
associations may partly be temperature effects.
9.- Percept Mot Skills. 2007 Feb;104(1):111-22.
Projective drawings for assessing stress among subjects with medical symptoms compatible with sick
building syndrome, and validation of a modified version of the Stress Load Index from the Drawing
Personality Profile: a pilot study.
Runeson R, Wahlstedt K, Norbäck D.
Uppsala University Hospital, Sweden. [email protected]
It was hypothesized that subjects with medical symptoms would show more signs of stress in projective
drawings. A Stress Load Index, including five signs of stress in drawings, was evaluated. A questionnaire
with an instruction to draw "a person in the rain" was sent to a cohort of 195 subjects, and the drawings
were analysed blindly for eight stress items. Men had a higher index than women (p < .05) and drew
clouds more often (p < .05). Drawing of clouds was associated with headache (adjOR = 4.28; 95% CI
1.75; 11.68). Drawing of puddles was associated with ocular symptoms (adjOR = 3.22; 95% CI 1.38,
7.50), facial dermal symptoms (adjOR= 2.94; 95% CI 1.28, 6.81), and tiredness (adjOR = 2.44; 95% CI
1.05, 5.67). Drawing of long rain strokes was associated with nasal symptoms (adjOR = 2.28; 95% CI
1.05, 2.06) and headache (adjOR = 3.20; 95% CI 1.28, 8.05). Age and stress load were predictors of sick
building syndrome symptoms (p < .05). In conclusion, a nonverbal projective drawing test detected sex
differences which represent directions opposite to those with verbal methods. These need empirical
assessment.
10.- Indoor Air. 2007 Apr;17(2):92-108.
Passenger evaluation of the optimum balance between fresh air supply and humidity from 7-h exposures
in a simulated aircraft cabin.
19
Strøm-Tejsen P, Wyon DP, Lagercrantz L, Fang L.
International Centre for Indoor Environment and Energy, Department of Mechanical Engineering,
Technical University of Denmark, Lyngby, Denmark. [email protected]
A 21-seat section of an aircraft cabin with realistic pollution sources was built inside a climate chamber
capable of providing fresh outside air at very low humidity. Maintaining a constant 200 l/s rate of total air
supply, i.e. recirculated and make-up air, to the cabin, experiments simulating 7-h transatlantic flights
were carried out at four rates of fresh outside air supply--1.4, 3.3, 4.7, and 9.4 l/s per person (3, 7, 10, and
20 cfm/person)--resulting in humidity levels, ranging from 7% to 28% relative humidity (RH). Four
groups of 16-18 subjects acted as passengers and crew and were each exposed to the four simulated flight
conditions. During each flight the subjects completed questionnaires three times to provide subjective
ratings of air quality and of symptoms commonly experienced during flight. Physiological tests of eye,
nose, and skin function were administered twice. Analysis of the subjective assessments showed that
increasing RH in the aircraft cabin to 28% RH by reducing outside flow to 1.4 l/s per person did not
reduce the intensity of the symptoms that are typical of the aircraft cabin environment. On the contrary, it
intensified complaints of headache, dizziness, and claustrophobia, due to the increased level of
contaminants. PRACTICAL IMPLICATIONS: The investigation shows that increasing aircraft cabin
humidity by decreasing the ventilation flow rate of fresh outside air would not decrease reports of
discomfort made by cabin occupants.
11- Occup Environ Med. 2007 Mar;64(3):178-84.
Office work exposures [corrected] and respiratory and sick building syndrome symptoms.
Jaakkola MS, Yang L, Ieromnimon A, Jaakkola JJ.
Institute of Occupational and Environmental Medicine, University of Birmingham, Edgbaston,
Birmingham, B15 2TT UK. [email protected]
Erratum in:
•
Occup Environ Med. 2007 Jun;64(6):428.
20
OBJECTIVES: To assess the relation between exposure to carbonless copy paper (CCP), paper dust, and
fumes from photocopiers and printers (FPP), and the occurrence of sick building syndrome (SBS)-related
symptoms, chronic respiratory symptoms and respiratory infections. METHODS: A population-based
cross-sectional study with a random sample of 1016 adults, 21-63 years old, living in Pirkanmaa District
in South Finland was conducted. This study focused on 342 office workers classified as professionals,
clerks or administrative personnel according to their current occupation by the International Standard
Classification of Occupations-88. They answered a questionnaire about personal information, health,
smoking, occupation, and exposures in the work environment and at home. RESULTS: In logistic
regression analyses adjusting for age, sex and a set of other confounders, all three exposures were related
to a significantly increased risk of general symptoms (headache and fatigue). Exposure to paper dust and
to FPP was associated with upper respiratory and skin symptoms, breathlessness, tonsillitis and middle
ear infections. Exposure to CCP increased the risk of eye symptoms, chronic bronchitis and
breathlessness. It was also associated with increased occurrence of sinus and middle ear infections and
diarrhoea. A dose-response relations was observed between the number of exposures and occurrence of
headache. The risk of tonsillitis and sinus infections also increased with increasing number of exposures.
All chronic respiratory symptoms, apart from cough, were increased in the highest exposure category
(including all three exposures). CONCLUSIONS: This study provides new evidence that exposure to
paper dust and to FPP is related to the risk of SBS symptoms, breathlessness and upper respiratory
infections. It strengthens the evidence that exposure to CCP increases the risk of eye symptoms, general
symptoms, chronic respiratory symptoms and some respiratory infections. Reduction of these exposures
could improve the health of office workers.
12.- Indoor Air. 2007 Feb;17(1):60-9.
Pet keeping and dampness in the dwelling: associations with airway infections, symptoms, and
physiological signs from the ocular and nasal mucosa.
Bakke JV, Norbäck D, Wieslander G, Hollund BE, Moen BE.
Section for Occupational Medicine, Department of Public Health and Primary Health Care, University of
Bergen, Kalfarveien, Bergen, Norway. [email protected]
The aim was to utilize data from a study of occupational indoor environments to analyze symptoms and
physiological signs in relation to the home environment. A medical investigation was performed at the
21
workplace among university staff (n = 173) from four university buildings in Bergen, in March 2004.
Tear film break up time (BUT) was measured by two methods. Nasal patency was measured by acoustic
rhinometry. Nasal lavage fluid analysis (NAL) included eosinophilic cationic protein (ECP);
myeloperoxidase (MPO), lysozyme and albumin. Atopy was assessed by total serum IgE and specific IgE
(Phadiatop). Totally 21%, 21%, 18%, 11%, and 27% had weekly ocular, nasal, facial dermal symptoms,
headache and tiredness, respectively, 15% had a damp dwelling, and 20% had a cat or dog. Multiple
linear or logistic regressions were applied, controlling for age gender, smoking, and environmental
factors. Building dampness was associated with increased NAL-lysozyme (P = 0.02) and an increase of
airway infections [odd ratio (OR) = 3.14, P = 0.04]. Pet keeping was associated with difficulties to
concentrate (OR = 5.10, P = 0.001), heavy headedness (OR = 4.35, P = 0.004), four more days with
tiredness per month (P = 0.04), and less airway infections (OR = 0.32; P = 0.02). In conclusion, pet
keeping was associated with more central nervous system (CNS)-symptoms but less airway infections.
Dampness in the dwelling may have inflammatory effects on the airway mucosa, possibly mediated via
increased infection proneness. PRACTICAL IMPLICATIONS: The main health focus on pet keeping has
been allergen exposure. Our study indicates that effects on airway infections and other types of symptoms
should also be considered. The findings support the view that measures should be taken to reduce
building dampness in dwellings.
13- Indoor Air. 2006 Dec;16(6):445-53.
Personal and psychosocial factors and symptoms compatible with sick building syndrome in the Swedish
workforce.
Runeson R, Wahlstedt K, Wieslander G, Norbäck D.
Akademiska sjukhuset, Uppsala, Sweden. [email protected]
A random sample of 1000 subjects (20-65 years of age) received a postal questionnaire regarding sick
building syndrome (SBS), including the three-dimensional model of demand-control-support (DCS). The
response rate was 70% (n = 695), and 532 were occupationally active. Female gender and atopy were the
main predictors of symptoms. Eye symptoms were more common at low social support combined with
strained work situation [odds ratio (OR) 2.37], and at high social support combined with active work
situation (OR 3.00). Throat symptoms were more common at low social support combined with either
passive (OR 1.86) or strained situation (OR 2.42). Tiredness was more common at low social support
22
combined with either passive (OR 2.41), strained (OR 2.25), or active situation (OR 1.87), and at high
social support combined with active work situation (OR 1.83). Low social support combined with either
passive (P = 0.01) or strained job situation (P = 0.01) was associated with a higher symptom score (SC).
The lowest SC was found at a relaxed work situation, irrespective of social support. In conclusion, female
gender, low age, asthma, atopy and psychosocial work environment are associated with symptoms. The
three-dimensional model can predict symptoms compatible with SBS, but in a more complex way than
earlier research indicated. Practical Implications A multi-disciplinary approach, including psychosocial
stress factors as well as personal factors such as gender, age, atopy and asthma, and indoor exposures,
should be applied in studies on symptoms compatible with sick building syndrome (SBS). Males and
females perceive psychosocial work conditions differently, and may react differently to job stressors. The
psychosocial work environment can be as important as gender and atopy as a predictor of SBS symptoms.
14.- Am J Ind Med. 2006 Oct;49(10):819-25.
Prevalence of building-related symptoms as an indicator of health and productivity.
Niemelä R, Seppänen O, Korhonen P, Reijula K.
Good Indoor Environment Quality Theme, Finnish Institute of Occupational Health, Helsinki, Finland.
[email protected]
BACKGROUND: The prevalence of building-related symptoms (BRS) is commonly used to characterize
the indoor air quality in office buildings. To analyze the costs of building renovation and the
improvement of the indoor environment, it is useful to quantitatively relate the prevalence or intensity of
BRS to productivity. The intent of this study is to summarize the links between the BRS and productivity,
and demonstrate this linkage in two case buildings. MATERIAL AND METHODS: A literature was
surveyed for studies that measured simultaneously the prevalence or intensity of BRS and subjectively
reported or objectively measured productivity. Case studies in two office environments were performed.
An association between the prevalence of BRS and productivity of workers in a call center and in an
insurance office were investigated. In the first case study, the productivity was expressed using the direct
productivity metrics, namely the number of telephone contacts during active working hours while in the
second case, the productivity was assessed by using the data concerning sick leave rates. RESULTS:
Employees who report more BRS also have more often absences which relate to indoor environment
quality (IEQ). Their productivity is lower than those who have better IEQ in their offices. Despite
23
uncertainties related to the data concerning recorded sick leave and self-reported productivity, the number
of studies showing an association between BRS and productivity or sick leave suggests that such a
relationship exists. The present case studies also demonstrated an association between the BRS and the
direct productivity. Based on the data from the call center, a reduction of 10%-units in the prevalence of
general symptoms (such as fatigue, headache, nausea, etc.) corresponded with a gain of 1.5% in
performance. Based on the findings in the insurance company, a reduction of 10%-units in the prevalence
of irritation symptoms corresponded with a decrease of 0.7% in the short-term absenteeism.
CONCLUSIONS: A review of 23 studies suggests that a linkage exists between typical BRS and
productivity indicators such as task or work performance or absence from work. Quantitative associations
between BRS and productivity were demonstrated in two office environments. Quantitative associations
between BRS and economic metrics enable cost-benefits analysis.
15- Indoor Air. 2005;15 Suppl 10:7-16.
Molds in floor dust, building-related symptoms, and lung function among male and female
schoolteachers.
Ebbehøj NE, Meyer HW, Würtz H, Suadicani P, Valbjørn O, Sigsgaard T, Gyntelberg F; Members of a
Working Group under the Danish Mold in Buildings program (DAMIB).
Epidemiological Research Unit, Clinic of Occupational and Environmental Medicine, H:S Copenhagen
University Hospital, Bispebjerg, Copenhagen NV, Denmark. [email protected]
Five hundred and twenty-two teachers from 15 public schools, eight 'water-damaged' schools, and seven
'non-damaged' schools with no visible water damage were included in a cross-sectional design. Mold
growth was assessed by recording the amount of dust on the floor and in the air in classrooms and the
content of a number of mold species in the dust (CFU/g dust). The evaluation of health symptoms
included symptoms recorded by questionnaire and spirometry, bronchial challenge, and CO-diffusion
capacity. Nasal lavage fluid was analyzed for IL-8 and ECP. Personal and psychosocial factors were
included as confounders. In this study population mucus membrane irritation symptoms (MMI) and
general symptoms were reported more frequently by women than by men with odds ratios ranging from
1.4 to 2.1. Women's reports of symptoms from mucous membranes and skin and general symptoms were
positively associated with mold exposure. Odds ratio for 'difficult to concentrate' after adjustment for
confounders was 11.2 (1.4-90.1, 95% CI) at high levels of mold exposure. None of the lung function tests
24
performed in this study were associated with mold exposure, to the 'water damaged' vs. 'non-damaged'
classification, or to the symptoms reported. IL-8 and ECP were not associated either. PRACTICAL
IMPLICATIONS: Psychosocial and personal reasons dominate in MMI and general symptoms. Headache
and difficulties to concentrate associated with indoor mold exposure, mainly for women. No lung function
impairment associated with indoor mold exposure.
16.- Ind Health. 2005 Apr;43(2):341-5.
A case of sick building syndrome in a Japanese office worker.
Nakazawa H, Ikeda H, Yamashita T, Hara I, Kumai Y, Endo G, Endo Y.
Department of Otorhinolaryngology, Kansai Medical University, Fumizono-cho, Moriguchi, Osaka 5708506, Japan.
The adverse health effects caused by indoor air pollution are termed "sick building syndrome". We report
such a patient whose symptoms appeared in the workplace. A 36-year-old female office worker
developed nausea and headache during working hours in a refurbished office. After eight months of
seeking help at other clinics or hospitals without improvement, she was referred to our hospital. At that
time she reacted to the smells of various chemicals outside of the office building. Biochemical findings
were all within normal ranges. Specific IgE antibody to cedar pollen was positive and the ratio of
TH1/TH2 was 4.5. In the Eye Tracking Test (ETT), vertical eye movement was saccadic. Her anxiety
level was very high according to the State-Trait Anxiety Inventory (STAI) questionnaire. Subjective
symptoms, ETT findings and anxiety levels on STAI gradually improved during two years of follow-up.
One year after the onset of her illness, the formaldehyde concentrations in the building air ranged from
0.017-0.053 ppm. Even though relatively low, chemical exposure from building materials such as
formaldehyde induced a range of symptoms. Also, lack of recognition by superiors and doctors that sick
building syndrome might have been the source of her illness coupled with her high state of anxiety may
have exacerbated her symptoms and led to the onset of multiple chemical sensitivity. Thus psychosocial
factors may contribute to sick building syndrome in the workplace.
17.- Ann Allergy Asthma Immunol. 2005 Feb;94(2):234-9.
Allergy and "toxic mold syndrome".
Edmondson DA, Nordness ME, Zacharisen MC, Kurup VP, Fink JN.
25
Division of Allergy/Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee,
Wisconsin 53201, USA. [email protected]
Comment in:
•
Ann Allergy Asthma Immunol. 2005 Feb;94(2):213-5.
BACKGROUND: "Toxic mold syndrome" is a controversial diagnosis associated with exposure to moldcontaminated environments. Molds are known to induce asthma and allergic rhinitis through IgEmediated mechanisms, to cause hypersensitivity pneumonitis through other immune mechanisms, and to
cause life-threatening primary and secondary infections in immunocompromised patients. Mold
metabolites may be irritants and may be involved in "sick building syndrome." Patients with
environmental mold exposure have presented with atypical constitutional and systemic symptoms,
associating those symptoms with the contaminated environment. OBJECTIVE: To characterize the
clinical features and possible etiology of symptoms in patients with chief complaints related to mold
exposure. METHODS: Review of patients presenting to an allergy and asthma center with the chief
complaint of toxic mold exposure. Symptoms were recorded, and physical examinations, skin
prick/puncture tests, and intracutaneous tests were performed. RESULTS: A total of 65 individuals aged 1
1/2 to 52 years were studied. Symptoms included rhinitis (62%), cough (52%), headache (34%),
respiratory symptoms (34%), central nervous system symptoms (25%), and fatigue (23%). Physical
examination revealed pale nasal mucosa, pharyngeal "cobblestoning," and rhinorrhea. Fifty-three percent
(33/62) of the patients had skin reactions to molds. CONCLUSIONS: Mold-exposed patients can present
with a variety of IgE- and non-IgE-mediated symptoms. Mycotoxins, irritation by spores, or metabolites
may be culprits in non-IgE presentations; environmental assays have not been perfected. Symptoms
attributable to the toxic effects of molds and not attributable to IgE or other immune mechanisms need
further evaluation as to pathogenesis. Allergic, rather than toxic, responses seemed to be the major cause
of symptoms in the studied group.
18.- Indoor Air. 2004;14 Suppl 8:30-40.
The effects of moderate heat stress and open-plan office noise distraction on SBS symptoms and on the
performance of office work.
Witterseh T, Wyon DP, Clausen G.
26
International Center for Indoor Environment and Energy, DTU-Building 402, DK-2800, Kgs Lyngby,
Denmark. [email protected]
Three air temperatures (22/26/30 degrees C) and two acoustic conditions-quiet (35 dBA) or open-plan
office noise (55 dBA)-were established in an office. Thirty subjects aged 18-29 years (16 male), clothed
for thermal neutrality at 22 degrees C, performed simulated office work for 3 h under all six conditions.
Many more (68% vs. 4%) were dissatisfied with noise in the noise condition (P < 0.01). Warmth
decreased thermal acceptability (P < 0.001) and perceived air quality (P < 0.01) and increased odour
intensity (P < 0.05) and stuffiness (P < 0.01). After 2 h, some forehead sweating was observed on 4, 36
and 76% of subjects (P < 0.001) at 22, 26 and 30 degrees C, while 0, 21 and 65% felt "warm" (P < 0.001).
Raised temperature increased eye, nose and throat irritation (P < 0.05), headache intensity (P < 0.05),
difficulty in thinking clearly (P < 0.01) and concentrating (P < 0.01), and decreased self-estimated
performance (P < 0.001). Noise increased fatigue (P < 0.05) and difficulty in concentrating (P < 0.05) but
did not interact with thermal effects on subjective perception. In an addition task, noise decreased
workrate by 3% (P < 0.05), subjects who felt warm made 56% more errors (P < 0.05) and there was a
noise-temperature interaction (P < 0.01): the effect of warmth on errors was less in the noise condition.
Typing speed (P < 0.05) and reading speed (P < 0.05) were higher in noise. PRACTICAL
IMPLICATIONS: This paper demonstrates that open office noise distraction, even at the realistic level of
55 dBA, increases fatigue and has many negative effects on the performance of office work, as does a
moderately warm air temperature. These findings may be used to provide economic justification for the
provision of private offices and air temperature control in hot weather. The additional finding that noise
distraction and heat stress can sometimes counteract each other in the short term is of academic interest
only, as they both increase subjective distress and fatigue. In practice, neither should be deliberately
introduced to counteract the other.
19.- Indoor Air. 2004;14 Suppl 8:17-29.
Human response to personalized ventilation and mixing ventilation.
Kaczmarczyk J, Melikov A, Fanger PO.
International Center for Indoor Environment and Energy, Technical University of Denmark, Kgs Lyngby,
Denmark. [email protected]
27
The response of 60 human subjects to a personalized ventilation system (PVS), providing control of
positioning of the air terminal device and the airflow rate, was compared with the response to mixing
ventilation (MV). Perceived air quality, thermal comfort, intensity of Sick Building Syndrome symptoms
and performance of subjects were studied during 3 h 45 min exposures. In case of MV alone the room air
temperature was 23 degrees C and 26 degrees C. The PVS supplied outdoor air at 23 degrees C or 20
degrees C or recirculated room air at 23 degrees C when the room temperature was 23 degrees C, and
outdoor air at 20 degrees C when the room temperature was 26 degrees C. The PVS providing outdoor air
improved perceived air quality and decreased SBS symptoms compared to MV alone and when the room
air was re-circulated through the PVS. The percentage dissatisfied with air quality, 3 min after initial
occupancy, decreased from 22% with MV to 7% with PVS; and from 49% to 20%, at room temperatures
23 degrees C and 26 degrees C, respectively. Over time, these differences in percentage dissatisfied
decreased markedly. Headache and decreased ability to think clearly were reported as least intense when
the PVS supplied outdoor air at 20 degrees C, while the most intense symptoms occurred with MV. PVS
increased self-estimated performance. PRACTICAL IMPLICATIONS: Personalized ventilation can
improve occupants' thermal comfort, perceived air quality and decrease the intensity of SBS symptoms
compared to mixing ventilation. Occupants will use the provided individual control of airflow rate and
positioning of the air terminal device to obtain preferred microenvironment in rooms where the air
temperature is within the range recommended by indoor climate standards. Development of more efficient
air terminal devices is recommended.
20.- Indoor Air. 2004 Dec;14(6):394-404.
The influence of personality, measured by the Karolinska Scales of Personality (KSP), on symptoms
among subjects in suspected sick buildings.
Runeson R, Norbäck D, Klinteberg B, Edling C.
Department of Medical Science/Occupational and Environmental Medicine, Uppsala University,
University Hospital, Uppsala, Sweden. [email protected]
The aim was to study possible relationships between personality traits as measured by the Karolinska
Scales of Personality (KSP), a self-report personality inventory based on psychobiological theory, and
medical symptoms, in subjects with previous work history in suspected sick buildings. The study
comprised 195 participants from 19 consecutive cases of suspected sick buildings, initially collected in
28
1988-92. In 1998-89, the KSP inventory and a symptoms questionnaire were administered in a postal
follow-up study. There were 16 questions on symptoms, including symptoms from the eyes, nose, throat,
skin, and headache, tiredness, and a symptom score (SC), ranging from 0 to 16, was calculated. The
questionnaire also requested information on personal factors, including age, gender, smoking habits,
allergy and diagnosed asthma. The KSP ratings in the study group did not differ from the mean
personality scale norm scores, calculated from an external reference group. Females had higher scores for
somatic anxiety (P < 0.01), muscular tension (P < 0.001), psychic anxiety (P < 0.01), psychasthenia (P <
0.05), indirect aggression (P < 0.05), and guilt (P < 0.05), while males scored higher on detachment (P <
0.001). Subjects with higher SC were found to display higher degree of somatic anxiety (P < 0.001),
muscular tension (P < 0.001), psychic anxiety (P < 0.001), psychasthenia (P < 0.001), inhibition of
aggression (P < 0.05), detachment (P < 0.05), suspicion (P < 0.01), indirect aggression (P < 0.01), and
verbal aggression (P < 0.05). In addition, ocular, respiratory, dermal, and systemic symptoms (headache
and tiredness) were significantly related to anxiety- and aggressivity-related scales. There were
associations between personality scales and change of symptom score (SC) during the 9-year period. The
associations between KSP personality traits and symptoms were more pronounced in females. In
conclusion, there are gender differences in personality and SBS symptoms. Personality may play a role in
the occurrence of symptoms studied in indoor environmental epidemiology. Our results support a view
that measurement of personality could be of value in future studies and vulnerability to environmental
stress. PRACTICAL IMPLICATIONS: Personality and personal vulnerability should be considered in
both indoor environmental epidemiology and practical handling of building with suspected indoor
problem, especially when the technical investigations fail to identify any obvious technical malfunction.
Moreover, personality aspects should be considered among subjects with possible vulnerable personality
exposed to environmental stress, and personality diagnosis can be a complementary tool useful when
assessing 'sick building patients' in the medical services. We found no evidence of severe personality
pathology in among those working in workplaces with environmental problems so called 'sick buildings'.
21.- Int J Immunopathol Pharmacol. 2004 May-Aug;17(2 Suppl):103-8.
Sick building syndrome in like symptoms in emergency prefabricated accommodation.
Muzi G, Accattoli MP, dell'Omo M, Frillici C, Sapia IE, Abbritti G.
Occupational Medicine and Toxicology, University of Perugia, Italy.
29
The present study investigated the sources of discomfort and the symptoms reported by earthquake
victims residing in temporary emergency prefabricated accommodation (prefab). The investigation was
carried out by means of a questionnaire. 203 prefab occupants and 13 inhabitants of houses, who were
chosen as reference population, replied in winter and 233 prefab occupants and 154 inhabitants of houses
replied in summer. In both seasons more people living in prefabs indentified dry air, stuffy air, stale air,
dust, dampness, uncomfortable temperature and bad odours as sources of discomfort. They also
complained of general symptoms (headache, irritablility, insomnia, difficulty in concentration) and
irritative symptoms of the eyes, upper and lower airways and skin. Multiple regression analysis identified
the type of accommodation as the variable that most influenced the onset of general, ocular, upper and
lower airway symptoms. Intrinsic characteristics of the prefabs (being constructed with synthetic
materials, combustion sources, poor ventilation and insulation) and psychosocial factors e. losing their
home, could have contributed to the onset of symptoms.
22.- Indoor Air. 2004 Feb;14(1):65-72.
Molds in floor dust and building-related symptoms in adolescent school children.
Meyer HW, Würtz H, Suadicani P, Valbjørn O, Sigsgaard T, Gyntelberg F; Members of a Working
Group under the Danish Mould in Buildings program (DAMIB).
Epidemiological Research Unit, Clinic of Occupational and Environmental Medicine, H:S Copenhagen
University Hospital, Bispebjerg, Copenhagen NV, Denmark. [email protected]
This stratified cross-sectional epidemiological study included 1053 school children aged 13-17 years. All
pupils filled in a questionnaire on building-related symptoms and other relevant health aspects. The
following exposure measurements were carried out: room temperature, CO2 level, and relative humidity;
building characteristics including mold infestation were assessed, and dust was collected from floors, air,
and ventilation ducts during a working day. Dust was examined for endotoxin level, and cultivated for
viable molds. We did not find a positive association between building-related symptoms and extent of
moisture and mold growth in the school buildings. Five of eight building-related symptoms were
significantly and positively associated with the concentration of colony forming units of molds in floor
dust: eye irritation, throat irritation, headache, concentration problems, and dizziness. After adjusting for
different potentially confounding factors in separate analyses of each symptom, the above-mentioned
associations between molds in dust and symptoms were still present, except for concentration problems.
30
However, in none of the analyses was mold exposure the strongest covariate, being secondary to either
asthma, hay fever, recent airway infection, or psychosocial factors
23.- Indoor Air. 2004 Feb;14(1):16-23.
Class separation of buildings with high and low prevalence of SBS by principal component analysis.
Pommer L, Fick J, Sundell J, Nilsson C, Sjöström M, Stenberg B, Andersson B.
Department of Chemistry, Environmental Chemistry, Umeå University, Umeå, Sweden.
In this study, we were able to separate buildings with high and low prevalence of sick building syndrome
(SBS) using principal component analysis. The prevalence of SBS was defined by the presence of at least
one typical skin, mucosal and general (headache and fatigue) symptom. Data from the Swedish Office
Illness Study describing the presence and level of chemical compounds in outdoor, supply, and room air,
respectively, were evaluated together with information about the buildings in six models. When all data
were included the most complex model was able to separate 71% of the high prevalence buildings from
the low prevalence buildings. The most important variable that separates the high prevalence buildings
from the low prevalence buildings was a more frequent occurrence or a higher concentration of
compounds with shorter retention time in the high prevalence buildings. Elevated relative humidity in
supply and room air and higher levels of total volatile organic compounds in outdoor and supply air were
more common in high prevalence buildings. Ten building variables also contributed to the separation of
the two classes of low and high prevalence buildings
24.- Indoor Air. 2003 Sep;13(3):206-11.
Ocular, nasal, dermal and respiratory symptoms in relation to heating, ventilation, energy conservation,
and reconstruction of older multi-family houses.
Engvall K, Norrby C, Norbäck D.
Stockholm Office of Research and Statistics, Stockholm, Sweden. [email protected]
The aim was to study relationships between symptoms compatible with the sick building syndrome, type
of heating and ventilation system, energy saving, and reconstruction in older dwellings. In Stockholm,
4815 inhabitants in 231 multi-family buildings built before 1961 were randomly selected, of whom 3241
participated (77%). Symptoms and personal factors were assessed by a postal questionnaire. Independent
31
information on building characteristics, and energy saving measures was gathered from the building
owners. Multiple logistic regression analysis was applied to calculate odds ratios (OR) adjusting for age,
gender, hay fever, current smoking, population density, type of ventilation, type of heating system, and
ownership of the building. Subjects in buildings with a mechanical ventilation system had less ocular and
nasal symptoms (OR = 0.29-0.85). Heating by electric radiators, and wood heating was associated with an
increase of most symptoms (OR = 1.18-1.74). In total, 48% lived in buildings that had gone through at
least one type of reconstruction or energy saving remedies during the latest 10 years, including exchange
of heating or ventilation system, and sealing measures (exchange of windows, sealing of window frames,
roof/attic insulation, and phasade insulation). Energy saving was associated with both a decrease and
increase of different symptoms. Major reconstruction of the interior of the building was associated with
an increase of most symptoms (OR = 1.09-1.90), and buildings with more than one sealing measure had
an increase of ocular, nasal symptoms, headache and tiredness (OR = 1.22-2.49). In conclusion, major
reconstruction of the interior, direct heated electric radiators, wood heating, and multiple sealing of
buildings were associated with an increase of some symptoms. The study supports the view that
mechanical ventilation in dwellings is beneficial from a health point of view
25.- Int J Environ Health Res. 2003 Mar;13(1):71-80.
Multiple logistic regression modelling substantiates multifactor contributions associated with sick
building syndrome in residential interiors in Mauritius.
Jowaheer V, Subratty AH.
Department of Mathematics, University of Mauritius, Reduit.
This paper presents a mathematical model that depicts the relationship between the possibility of
occurrence of common health problems and factors leading to Sick Building Syndrome symptoms in
domestic interiors in Mauritius. The prevalence of upper respiratory symptoms (dry eyes, runny nose),
central nervous system symptoms (headache, nervousness), and musculoskeletal symptoms (pain/stiffness
in shoulders/neck) were found to be elevated when responses were statistically regressed to type of
building and age of respondents. The model presented here will be useful in helping to identify and
quantify the relative role of factors that contribute to Sick Building Syndrome. Thus it may be possible to
evaluate the effectiveness of current building operation practices and to prioritise allocations of resources
for reduction of risk associated with Indoor Environmental Air Quality.
32
26.- Kokuritsu Iyakuhin Shokuhin Eisei Kenkyusho Hokoku. 2002;(120):6-38.
[Indoor air and human health--sick house syndrome and multiple chemical sensitivity]
[Article in Japanese]
Ando M.
[email protected]
The number of complaints about the quality of indoor air has increased during the past two decades.
These complaints have been frequent enough that the term "Sick House Syndrome or Sick Building
Syndrome" and "Multiple Chemical Sensitivity" has been coined. Complaints are likely related to the
increased use of synthetic organic materials in house, furnishing, and consumer products; and the
buildings, furnishings, and consumer products; and the decreased ventilation for energy conservation in
homes. Approximately thousand volatile chemicals have been identified in indoor air. The main sources
of these chemicals are house materials, combustion fumes, cleaning compounds, and paints or stains.
Exposure to high levels of these emissions and to others, coupled with the fact that most people spend
more time indoors than outdoors, raises the possibility that the risk to human health from indoor air
pollution may be potentially greater than the risk posed from outdoor pollutants. The complaints most
frequently voiced with respect to Sick House Syndrome are irritations of the eye, nose, and throat; cough
and hoarseness of voice; headache and mental fatigue. The syndrome of multiple chemical sensitivities is
controversial subject with increasing impact on the field of indoor air quality. The controversy
surrounding Multiple Chemical Sensitivity includes its definition, theories of etiology and pathogenesis,
diagnostic, and life style. Multiple Chemical Sensitivity is considered the hypothesis that is a disease
caused by exposure to many chemically distinct environmental substances at very low.
27.- Int Arch Occup Environ Health. 2003 Feb;76(1):29-38. Epub 2002 Aug 21.
Symptoms and sense of coherence--a follow-up study of personnel from workplace buildings with indoor
air problems.
Runeson R, Norbäck D, Stattin H.
Department of Medical Science/Occupational and Environmental Medicine, University Hospital, Uppsala
University, 751 85 Uppsala, Sweden. [email protected]
33
OBJECTIVES: The aim was to study prevalence and change of symptoms in buildings with suspected
indoor air problems in relation to sense of coherence (SOC), a psychological measure of a life attitude.
METHODS: A cohort of 194 subjects initially working in 19 Swedish buildings with indoor
environmental problems was followed from 1988 to 1998. Information on 16 symptoms compatible with
sick building syndrome (SBS) was gathered by an initial questionnaire mailed between 1988 and 1992.
The same symptom questionnaire, as well as Antonovsky's SOC, was administered in a postal follow-up
study in 1998. The prevalence of symptoms and the change (incidence) plus reminiscence of symptoms
were calculated for individual symptoms and a total symptom score (SC). Bivariate analyses, as well as
multiple linear and logistic regression analyses, were applied and adjusted for age, gender, history of
atopy and tobacco smoking. RESULTS: SBS was more common in women, younger subjects and those
with a history of atopy. A low SOC was related to a higher prevalence of ocular, nasal, and throat
symptoms, tiredness, and headache. In addition, subjects with a low SOC developed more symptoms
during the follow-up period. Women had a lower SOC value, but there was no relation between SOC and
age, smoking, doctor's diagnosed asthma or a history of atopy. Subjects leaving the problem buildings
during the follow-up period had a decrease in symptoms and were more often non-smokers, but had the
same mean SOC score as those remaining in the same workplace. CONCLUSIONS: The study indicates
that SOC can detect personal vulnerability in relation to suspected environmental stress. Symptoms
reported in the buildings with suspected indoor air problems are partly reversible, as indicated by the
reduction of symptoms among those leaving these buildings. A multi-disciplinary approach including
personality aspects, allergic disorders and indoor exposures should be applied in investigations of
buildings with suspected indoor air problems.
28.- Anesth Analg. 2003 Jan;96(1):163-4, table of contents.
Bronchospasm induced by propofol in a patient with sick house syndrome.
Hattori J, Fujimura N, Kanaya N, Okazaki K, Namiki A.
Department
of
Anesthesiology,
School
of
Medicine,
Sapporo
Medical
University,
Japan.
[email protected]
IMPLICATIONS: Propofol is often used in patients with asthma, but it can induce bronchospasm. We
report a patient with sick house syndrome (nonspecific complaints of mucosal irritation, headache,
34
nausea, and chest symptoms) who suffered bronchospasm. This case suggests that propofol is not always
a safe anesthetic for patients with asthma, especially drug-induced asthma.
29.- Indoor Air. 2002 Jun;12(2):74-80.
Subjective perceptions, symptom intensity and performance: a comparison of two independent studies,
both changing similarly the pollution load in an office.
Wargocki P, Lagercrantz L, Witterseh T, Sundell J, Wyon DP, Fanger PO.
International Center for Indoor Environment and Energy, Technical University of Denmark, Lyngby,
Denmark. [email protected]
The present paper shows that introducing or removing the same pollution source in an office in two
independent investigations, one in Denmark and one in Sweden, using similar experimental methodology,
resulted in similar and repeatable effects on subjective assessments of perceived air quality, intensity of
sick building syndrome symptoms and performance of office work. Removing the pollution source
improved the perceived air quality, decreased the perceived dryness of air and the severity of headaches,
and increased typing performance. These effects were observed separately in each experiment and were
all significant (P < or = 0.05) after combining the data from both studies, indicating the advantages of
pollution source strength control for health, comfort, and productivity.
30 .- Environ Health Perspect. 2002 Aug;110 Suppl 4:663-7.
Indoor environmental exposures and symptoms.
Hodgson M.
Veterans Health Administration, Washington, DC 20420, USA. [email protected]
The label "sick building syndrome" is often used to imply the absence of a physiologic basis for
symptoms in the built environment. Although building-related illness is widely recognized but considered
rare, several well-studied mechanisms may be responsible for many symptoms in buildings. These
mechanisms do not explain why some individuals perceive disability. Until researchers distinguish
physiologic mechanisms from other aspects of disease and study them systematically, poorly defined
35
symptoms will remain poorly understood. The disability associated with such symptoms and syndromes,
not the physiology, is the primary interest and generates controversy.
31.- CMAJ. 2002 Apr 16;166(8):1049-55.
Identifying and managing adverse environmental health effects: 1. Taking an exposure history.
Marshall L, Weir E, Abelsohn A, Sanborn MD.
Environmental Health Clinic, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ont.
Comment in:
•
CMAJ. 2002 Oct 1;167(7):744; author reply 744, 746.
•
CMAJ. 2002 Apr 16;166(8):1041-3.
Public concern and awareness are growing about adverse health effects of exposure to environmental
contaminants. Frequently patients present to their physicians with questions or concerns about exposures
to such substances as lead, air pollutants and pesticides. Most primary care physicians lack training in and
knowledge of the clinical recognition, management and avoidance of such exposures. We have found that
it can be helpful to use the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal
habits, Diet and Drugs) as a tool to identify a patient's history of exposures to potentially toxic
environmental contaminants. In this article we discuss why it is important to take a patient's
environmental exposure history, when and how to take the history, and how to interpret the findings.
Possible routes of exposure and common sources of potentially toxic biological, physical and chemical
substances are identified. A case of sick-building syndrome is used to illustrate the use of the mnemonic.
32.- Med Pr. 2001;52(5):369-73.
["Sick building syndrome"--a new problem of occupational medicine]
[Article in Polish]
Wittczak T, Walusiak J, Pałczyński C.
Klinika Chorób Zawodowych Instytut Medycyny Pracy, Łodz. [email protected]
36
"Sick building syndrome" (SBS) is a group of symptoms experienced by people working in various
buildings. This term or another one "building-related illness" (BRI) is used to define illnesses related to
non-industrial and non-residential buildings, mainly modern offices, in which people spend many
working hours. Specific BRI applies to a group of illnesses with a fairy homogeneous clinical picture and
known etiology (infectious, immunological or allergic). Non-specific BRI applies to a group of
heterogeneous and non-specific, work-related symptoms, including irritation of skin and mucous
membranes of the eyes, nose and throat, headache, fatigue and concentration difficulties. BRI seems to be
related to inadequate ventilation, humidity and temperature changes, chemical and biological
contaminants from indoor and outdoor sources. Sick building syndrome is considered as an important
problem of occupational medicine, bearing in mind that 50% of the entire workforce in industrialized
countries work in this type of buildings, and nearly 20-30% of this group of workers report symptoms
suggesting the prevalence of sick building syndrome.
33.- Br J Med Psychol. 2001 Mar;74 Part 1:121-127.
Cacosmia in healthy workers.
Magnavita N.
Institute of Occupational Medicine, Catholic University School of Medicine, Rome, Italy.
Self-reported cacosmia (i.e. feeling ill from the odour of xenobiotic substances) was studied in 151 young,
healthy workers, unexposed to unpleasant odours and working in food stores without air-conditioning.
Almost half (46%) of the sample reported feeling ill from the smell of chemical materials. Chemical
odour intolerance induced headache, itching eyes, irritated or congested nose, dry and/or sore throat,
cough, dizziness, and itching or rash. Cacosmic subjects showed a slight prevalence of the female sex,
and had significantly higher symptom scores, anxiety, and depression than non-cacosmic subjects.
Cacosmia may be related to multiple chemical sensitivity, sick-building syndrome and psychopathology.
Individual variability in odour tolerance may substantially bias epidemiological studies on indoor air
quality and health.
34.- Appl Occup Environ Hyg. 2001 Nov;16(11):1065-77.
Indoor environmental quality in six commercial office buildings in the midwest United States.
37
Reynolds SJ, Black DW, Borin SS, Breuer G, Burmeister LF, Fuortes LJ, Smith TF, Stein MA,
Subramanian P, Thorne PS, Whitten P.
Department of Occupational and Environmental Health, College of Public Health University of Iowa,
Iowa City, USA.
The aims of this study were to characterize physical, mechanical, and environmental factors influencing
indoor environmental quality (IEQ) in commercial office buildings; document occupant perceptions and
psychosocial attributes; and evaluate relationships among these parameters. Six large office buildings in
metropolitan areas were selected in Iowa, Minnesota, and Nebraska. Comprehensive sampling was
conducted over one week in each building, during all four seasons. This paper presents the study methods
and selected results from the first round of sampling (November 1996 to April 1997). Air flow and
recirculation rates were quite variable, with the proportion of outdoor air provided to occupants ranging
from 10 to 79 CFM/person. Carbon dioxide, carbon monoxide, and temperature were within ranges
anticipated for nonproblem buildings. Relative humidity was low, ranging from 11.7 to 24.0 percent.
Indoor geometric mean concentrations of total volatile organic compounds (TVOCs) ranged from 73 to
235 microg/m3. The most prevalent compounds included xylene, toluene, 2-propanol, limonene, and
heptane. Geometric mean formaldehyde concentrations ranged from 1.7 to 13.3 microg/m3, and mean
acetaldehyde levels ranged from <3.0 to 7.5 microg/m3. Airborne concentrations of culturable bacteria
and fungi were low, with no samples exceeding 150 CFU/m3. Total (direct count) bioaerosols were more
variable, ranging from 5010 to 10,700 organisms/m3. Geometric mean endotoxin concentrations ranged
from 0.5 to 3.0 EU/m3. Respirable particulates (PM10) were low (14 to 36 microg/m3). Noise levels
ranged from 48 to 56 dBA, with mean light values ranging from 200 to 420 lux. Environmental
parameters were significantly correlated with each other. The prevalence of upper respiratory symptoms
(dry eyes, runny nose), central nervous system symptoms (headache, irritability), and musculoskeletal
symptoms (pain/stiffness in shoulders/neck) were elevated compared to other studies using similar
questionnaires. Importantly, psychosocial factors were significantly related to increased symptoms in
females, while environmental factors were more closely correlated with symptoms in males. Endotoxin
concentrations were associated with symptoms in both males and females. These data will help to identify
and quantify the relative role of factors that contribute to sick building syndrome. The data collected in
this study may also be used to evaluate the effectiveness of current building operation practices, and can
be used to prioritize allocations of resources for reduction of risk associated with IEQ complaints.
38
35.- Int Arch Occup Environ Health. 2001 May;74(4):270-8.
Sick building syndrome in relation to building dampness in multi-family residential buildings in
Stockholm.
Engvall K, Norrby C, Norbäck D.
Department of Medical Science/Occupational and Environmental Medicine, University Hospital, Uppsala
University, Sweden. [email protected]
OBJECTIVES: The aim was to study relationships between symptoms compatible with sick building
syndrome (SBS) on one hand, and different indicators of building dampness in Swedish multi-family
buildings on the other. METHODS: In Stockholm, 609 multi-family buildings with 14,235 dwellings
were identified, and selected by stratified random sampling. The response rate was 77%. Information on
weekly symptoms, age, gender, population density in the apartment, water leakage during the past 5
years, mouldy odour, condensation on windows, and high air humidity in the bathroom was assessed by a
postal questionnaire. In addition, independent information on building characteristics was gathered from
the building owners, and the central building register in Stockholm. Multiple logistic regression analysis
was applied, and adjusted odds ratios (OR) were calculated, adjusted for age and gender, population
density, and selected building characteristics. RESULTS: Condensation on windows, high air humidity in
the bathroom, mouldy odour, and water leakage was reported from 9.0%, 12.4%, 7.7% and 12.7% of the
dwellings, respectively. In total 28.5% reported at least one sign of dampness. All indicators of dampness
were related to an increase of all types of symptoms, significant even when adjusted for age, gender,
population density, type of ventilation system, and ownership of the building. A combination of mouldy
odour and signs of high air humidity was related to an increased occurrence of all types of symptoms (OR
= 3.7-6.0). Similar findings were observed for a combination of mouldy odour and structural building
dampness (water leakage) (OR = 2.9 5.2). In addition, a dose-response relationship between symptoms
and number of signs of dampness was observed. In dwellings with all four dampness indicators, OR was
6.5, 7.1, 19.9, 5.8, 6.1, 9.4, 15.0 for ocular, nasal, throat, dermal symptoms, cough, headache and
tiredness, respectively. CONCLUSION: Signs of high air humidity, as well as of structural building
dampness, are common in multi-family buildings in Stockholm. Reports of building dampness in
dwellings is related to a pronounced increase of symptoms compatible with the SBS, even when adjusted
for possible confounding by age, gender, population density, and building-related risk factors.
39
36.- Indoor Air. 2000 Dec;10(4):237-45.
Effects on eyes and nose in humans after experimental exposure to airborne office dust.
Pan Z, Mølhave L, Kjaergaard SK.
Department of Environmental and Occupational Medicine, University of Aarhus, Denmark.
To test sensory irritation symptoms and physiological effects on humans caused by airborne office dust,
ten subjects were exposed to both clean air and airborne non-industrial office dust for 3 h in a climate
chamber. The average dust concentration in exposure sessions was 394 micrograms/m3 total suspended
dust (TSD). Tear film break-up time, foam formation in the eye canthus, conjunctival epithelial damage,
nasal volume, and nasal minimal cross-sectional area were assessed. Tear film break-up time decreased
significantly after dust exposure and nasal volume showed a tendency to decrease. In a questionnaire
investigation, significant effects were found from the questions: "facial skin humidity", "throat irritation",
"feeling needs of coughing", "dry nose", "concentration difficulty", and "headache". Additionally, the
intensity of the questions "facial skin humidity", "dry nose", "body skin temperature", "sluggishness", and
"sleepiness" worsened over time. A correlation analysis showed that perceived "air quality" was
significantly correlated with "dry eyes", "eye irritation", "facial skin irritation", "nose irritation", and
"feeling stressed by chamber occupancy" for subacute responses, and with "odor intensity" for acute
responses. This supports that the perceived air quality may be a function of odor and irritation symptoms.
A number of localized symptoms of irritation (e.g. dry nose, throat irritation, coughing) and of general
symptoms (e.g. sluggishness, sleepiness, headache, ability to concentration) were mutually correlated
acutely and subacutely. These results indicate that non-industrial office dust may cause physiological
changes and sensory symptoms in eyes and nose and that these effects have
37.- Occup Environ Med. 2000 Sep;57(9):627-34.
Building sickness syndrome in healthy and unhealthy buildings: an epidemiological and environmental
assessment with cluster analysis.
Niven RM, Fletcher AM, Pickering CA, Faragher EB, Potter IN, Booth WB, Jones TJ, Potter PD.
North West Lung Centre, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK.
[email protected]
40
OBJECTIVES: Building sickness syndrome remains poorly understood. Aetiological factors range from
temperature, humidity, and air movement to internal pollutants, dust, lighting, and noise factors. The
reported study was designed to investigate whether relations between symptoms of sick building
syndrome and measured environmental factors existed within state of the art air conditioned buildings
with satisfactory maintenance programmes expected to provide a healthy indoor environment.
METHODS: Five buildings were studied, three of which were state of the art air conditioned buildings.
One was a naturally ventilated control building and one a previously studied and known sick building. A
questionnaire was administered to the study population to measure the presence of building related
symptoms. This was followed by a detailed environmental survey in identified high and low symptom
areas within each building. These areas were compared for their environmental performance. RESULTS:
Two of the air conditioned buildings performed well with a low prevalence of building related symptoms.
Both of these buildings out performed the naturally ventilated building for the low number of symptoms
and in many of the environmental measures. One building (C), expected to perform well from a design
viewpoint had a high prevalence of symptoms and behaved in a similar manner to the known sick
building. Environmental indices associated with symptoms varied from building to building. Consistent
associations between environmental variables were found for particulates (itchy eyes, dry throat,
headache, and lethargy) across all buildings. There were persisting relations between particulates and
symptoms (headache, lethargy, and dry skin) even in the building with the lowest level of symptoms and
of measured airborne particulates (building B). There were also consistent findings for noise variables
with low frequency noise being directly associated with symptoms (stuffy nose, itchy eyes, and dry skin)
and higher frequency noise being relatively protective across all buildings. CONCLUSIONS: This is the
first epidemiological study of expected state of the art, air conditioned buildings. These buildings can
produce an internal environment better than that of naturally ventilated buildings for both reported
symptoms and environmental variables. The factors associated with symptoms varied widely across the
different buildings studied although consistent associations for symptoms were found with increased
exposure to particulates and low frequency noise.
38.- Dtsch Med Wochenschr. 2000 May 5;125(18):545-50.
[Air pollution by volatile organic compounds (VOC) and health complaints]
[Article in German]
Pitten FA, Bremer J, Kramer A.
41
Institut für Hygiene und Umweltmedizin, Ernst-Moritz-Arndt-Universität Greifswald.
BACKGROUND AND OBJECTIVE: Complaints of well-being and health after moving in a new or
redeveloped building occur quite frequently. If these complaints persist for several months and are
indicated by the majority of occupants, an examination of the air quality is required. However, the
interpretation of these data can be difficult since different recommendations but no threshold limit values
for the indoor contamination with volatile organic compounds (VOC's) exist. PATIENTS AND
METHODS: This report presents a case with serious health complaints (14 males, average age 40.4 years;
44 females, average age 37.9 years) after moving in a completely redeveloped building. Complaints of
well-being and health were investigated by a standardised questionnaire and compared with a control
group (11 males, average age 41.4 years; 12 females, average age 33.3 years). The VOC-contamination
was analysed by various measurements. RESULTS: Two months after moving into the building a total
VOC-concentration of 2000-3000 micrograms/m3 was registered, after 10 months the concentration
decreased to 900-1300 micrograms/m3 due to intense airing. The following symptoms showed the
clearest differences between exposed persons and the control group: soreness of throat (odds ratio: 10.72;
95%-confidence interval: 1.46-465.2), irritations of mucous membranes (OR: 10.45; 95%-CI: 1.43453.8), headache (OR: 9.9; 95%-CI: 1.35-430.9) and increased weariness (OR: 7.55; 95%-CI: 1.55-71.2).
As a consequence extensive redevelopment measures were initiated. CONCLUSION: Contamination of
the indoor air with 900 micrograms/m3 VOC's (total value) can induce serious complaints of well-being
and health. Rooms with VOC-concentrations > 1200-1500 micrograms/m3 are not suited for regular stay
of unprotected people.
39.- Am J Epidemiol. 1999 Dec 1;150(11):1223-8.
Office equipment and supplies: a modern occupational health concern?
Jaakkola MS, Jaakkola JJ.
Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University,
Baltimore, MD 21205, USA.
Comment in:
•
Am J Epidemiol. 2000 Sep 15;152(6):593-4.
42
The Helsinki Office Environment Study, a population-based cross-sectional study was carried out in
Finland in 1991 among 2,678 workers in 41 randomly selected office buildings. The aim was to evaluate
the relations between work with office equipment and supplies and the occurrence of eye,
nasopharyngeal, skin, and general symptoms (often denoted as sick building syndrome (SBS)), chronic
respiratory symptoms, and respiratory infections. Work with self-copying paper was significantly related
to weekly work-related eye, nasopharyngeal, and skin symptoms, headache and lethargy, as well as to the
occurrence of wheezing, cough, mucus production, sinusitis, and acute bronchitis. Photocopying was
related to nasal irritation, and video display terminal work to eye symptoms, headache, and lethargy.
40.- Zentralbl Hyg Umweltmed. 1999 Aug;202(2-4):243-8.
The sick building syndrome as a subjective perception-theoretical approach and assessment methods.
von Mackensen S, Bullinger M, Morfeld M.
Institute for Medical Psychology, Munich, Germany.
The SBS is characterised by irritations of mucosa, vegetative complaints such as headache and fatigue as
well as mental health impairment, depression and irritability (WHO definition). Since well-being is a
subjective perception, the individual self report is mandatory. In the ProKlimA project a modular
questionnaire was developed in which SBS symptoms, general aspects of well-being and function as well
as psychosocial characteristics were included in a modular fashion. Assessment included sensory
irritation (SI list), psychosocial characteristics (POMS) and bodily complaints, assessed with a standard
German complaint list (BL). In addition the individual indoor-air perception, stress reactions, the
perceived work-environment, health locus of control, life satisfaction and work related use were assessed.
Analysis of the questionnaire filled out by 4596 employees at the first measure point showed a high
consistency of responses. Psychometric testing showed a high reliability and acceptable validity of the
questionnaire. The results suggests that well-being within the SBS complex can be assessed in a
methodological way and that the developed questionnaire can be used to assess SBS symptomatology as
well as psychosocial determinants also in further SBS studies.
41.- Occup Environ Med. 1999 Jun;56(6):397-402.
Germicidal ultraviolet irradiation in air conditioning systems: effect on office worker health and
wellbeing: a pilot study.
43
Menzies D, Pasztor J, Rand T, Bourbeau J.
Department of Medicine and Epidemiology and Biostatistics, McGill University, Montreal, Canada.
[email protected]
OBJECTIVES: The indoor environment of modern office buildings represents a new ecosystem that has
been created totally by humans. Bacteria and fungi may contaminate this indoor environment, including
the ventilation systems themselves, which in turn may result in adverse health effects. The objectives of
this study were to test whether installation and operation of germicidal ultraviolet (GUV) lights in central
ventilation systems would be feasible, without adverse effects, undetected by building occupants, and
effective in eliminating microbial contamination. METHODS: GUV lights were installed in the
ventilation systems serving three floors of an office building, and were turned on and off during a total of
four alternating 3 week blocks. Workers reported their environmental satisfaction, symptoms, as well as
sickness absence, without knowledge of whether GUV lights were on or off. The indoor environment was
measured in detail including airborne and surface bacteria and fungi. RESULTS: Airborne bacteria and
fungi were not significantly different whether GUV lights were on or off, but were virtually eliminated
from the surfaces of the ventilation system after 3 weeks of operation of GUV light. Of the other
environmental variables measured, only total airborne particulates were significantly different under the
two experimental conditions--higher with GUV lights on than off. Of 113 eligible workers, 104 (87%)
participated; their environmental satisfaction ratings were not different whether GUV lights were on or
off. Headache, difficulty concentrating, and eye irritation occurred less often with GUV lights on whereas
skin rash or irritation was more common. Overall, the average number of work related symptoms reported
was 1.1 with GUV lights off compared with 0.9 with GUV lights on. CONCLUSION: Installation and
operation of GUV lights in central heating, ventilation and air conditioning systems of office buildings is
feasible, cannot be detected by workers, and does not seem to result in any adverse effects.
42.- N Z Med J. 1999 Jun 25;112(1090):228-30.
A comparison of two studies reporting the prevalence of the sick building syndrome in New Zealand and
England.
Phipps RA, Sisk WE, Wall GL.
Building Technology Group, Massey University, Palmerston North.
44
AIMS: To determine if New Zealand office personnel experienced a prevalence of sick building
syndrome type symptoms similar to levels reported in the international literature. METHODS: A crosssectional study of 360 office workers in Palmerston North was conducted using a questionnaire based on
that used in a previous UK study to estimate the frequency of symptoms of the sick building syndrome.
RESULTS: More than 80% of both populations experienced some building-related symptoms, with
lethargy, stuffy noses, dry throat and headache regularly affect over 40% of both the Palmerston North
and UK samples. New Zealand subjects experienced comparable or slightly higher levels of symptoms,
except for itchy eyes, which were significantly more prevalent. A gender and employment bias was found
in both studies. CONCLUSIONS: Sick building syndrome was found to be sufficiently prevalent in both
surveys to warrant concern. There were sufficient similarities between the two populations to suggest that
the conclusions from the UK survey are applicable to the New Zealand context.
43.- Public Health Rep. 1998 Sep-Oct;113(5):398-409.
The indoor air we breathe.
Oliver LC, Shackleton BW.
Massachusetts General Hospital, Boston, USA. [email protected]
Increasingly recognized as a potential public health problem since the outbreak of Legionnaire's disease
in Philadelphia in 1976, polluted indoor air has been associated with health problems that include asthma,
sick building syndrome, multiple chemical sensitivity, and hypersensitivity pneumonitis. Symptoms are
often nonspecific and include headache, eye and throat irritation, chest tightness and shortness of breath,
and fatigue. Air-borne contaminants include commonly used chemicals, vehicular exhaust, microbial
organisms, fibrous glass particles, and dust. Identified causes include defective building design and
construction, aging of buildings and their ventilation systems, poor climate control, inattention to building
maintenance. A major contributory factor is the explosion in the use of chemicals in building construction
and furnishing materials over the past four decades. Organizational issues and psychological variables
often contribute to the problem and hinder its resolution. This article describes the health problems related
to poor indoor air quality and offers solutions.
44.- Funct Neurol. 1998 Jul-Sep;13(3):225-30.
Neurological symptoms of the sick building syndrome: analysis of a questionnaire.
45
Citterio A, Sinforiani E, Verri A, Cristina S, Gerosa E, Nappi G.
IRCCS C. Mondino Institute of Neurology, Pavia, Italy.
Sick building syndrome (SBS) is an excess of work-related irritations of the skin and mucous membranes
and of symptoms such as headache and fatigue in those working in modern air-conditioned buildings. We
aimed to analyse the neurological symptoms, especially headache, in workers with potential SBS. The
most frequent symptoms were headache and dry eyes. Sex was a major factor of difference: women report
more symptoms than men. A positive correlation emerged between the number of symptoms and the
asthenia scale score. Only 11 (8.2% of the whole sample) and 37 (27.4%) workers met all the IHS criteria
for migraine and tension-type headache respectively. At least one symptom of SBS was present in 92.6%
of workers. A negative correlation emerges between air conditioning and headache during working hours.
No correlation emerges between the workplace comfort indicator and SBS and asthenic symptoms while a
negative correlation was found between migraine and tension-type headache and comfort in the
workplace. SBS symptoms are very frequent among all workers but headache is the primary symptom.
45.- Environ Res. 1998 Feb;76(2):85-93.
The relationship between symptoms and IgG and IgE antibodies in an office environment.
Malkin R, Martinez K, Marinkovich V, Wilcox T, Wall D, Biagini R.
National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations, and
Field Studies, Cincinnati, Ohio 45226, USA.
Airborne fungi have been postulated as a cause of symptoms among office workers. Using the MAST
chemiluminescent system, this study evaluated 36 IgG and 36 IgE antibody levels in 47 office workers
from an area with elevated airborne fungal concentrations and 44 office workers from an otherwise
similar area with lower airborne fungal exposure. No difference was found in IgG antibody to fungi
between the lower and higher exposure areas, but high IgG antibody to one or more of the fungi studied
was detected in 67% of all the workers tested. IgE antibody to one or more antigens was detected in 40%
of the participants. Workers who reported atopic symptoms (sneezing, runny nose, and itchy eyes) or
"sick building" symptoms (any three of the following temporally related to work: headache, fatigue,
stuffy nose, irritated eyes, or sore throat) were more likely to have one positive IgE antibody test. Type I
46
hypersensitivity to aeroallergens besides fungi may play a role in some symptoms reported by some
participants in this office building.
46.- Occup Environ Med. 1997 Jan;54(1):49-53.
Prevalence of the sick building syndrome symptoms in office workers before and six months and three
years after being exposed to a building with an improved ventilation system.
Bourbeau J, Brisson C, Allaire S.
Epidemiology Research Group, Hôpital du St-Sacrement, Québec, Canada.
OBJECTIVE: The prevalence of symptoms associated with the sick building syndrome (SBS) has
recently been shown to decrease by 40% to 50% among office workers six months after they were
exposed to a building with an improved ventilation system. The objective of the present study was to find
whether the decrease in the prevalence of symptoms was maintained three years later. METHODS:
Workers from the same organisation occupied five buildings in 1991 and moved during that year to a
single building with an improved ventilation system. All buildings had sealed windows with mechanical
ventilation, air conditioning, and humidification. Workers completed a self administered questionnaire
during normal working hours in February 1991 before moving, in February 1992 six months after
moving, and in February 1995, three years after moving. The questionnaire encompassed symptoms of
the eyes, nose and throat, respiratory system, skin, fatigue, and headache, as well as difficulty
concentrating, personal, psychosocial, and workstation factors. During normal office hours of the same
weeks, environmental variables were measured. RESULTS: The study population comprised 1390
workers in 1991, 1371 in 1993, and 1359 in 1995, which represents 80% of the population eligible each
year. The prevalence of most symptoms decreased by 40% to 50% in 1992 compared with 1991. This was
similar in 1995. These findings were significant and remained generally similar after controlling for
personal, psychosocial, and work related factors. CONCLUSION: In this study, the decrease of 40% to
50% in the prevalence of most symptoms investigated six months after workers were exposed to a new
building with an improved ventilation system was maintained three years later. The results of the present
follow up study provide further support for a real effect of exposure to a new building with an improved
ventilation system on the prevalence of symptoms associated with the SBS.
47.- MMWR Morb Mortal Wkly Rep. 1996 Jan 12;45(1):6-9.
Outbreak of unexplained illness in a middle school--Washington, April 1994.
47
Centers for Disease Control and Prevention (CDC).
Mass sociogenic illness (MSI) is the occurrence of a group of nonspecific physical symptoms for which
no organic cause can be determined and that is transmitted among members of a group by "line of sight."
On April 22, 1994, the Snohomish (Washington) Health District (SHD) was notified of an outbreak of
unexplained illness characterized by abrupt onset of nausea and headache among students at a middle
school. This report summarizes the investigation of this outbreak by SHD, which determined that MSI
was the most likely cause of the outbreak.
48.- Occup Environ Med. 1995 Nov;52(11):709-14.
Ventilation rate in office buildings and sick building syndrome.
Jaakkola JJ, Miettinen P.
Department of Public Health, University of Helsinki, Finland.
OBJECTIVE--To examine the relation between ventilation rate and occurrence of symptoms of the eyes,
nose, throat, and skin as well as general symptoms such as lethargy and headache, often termed the sick
building syndrome. METHODS--A cross sectional population based study was carried out in 399 workers
from 14 mechanically ventilated office buildings without air recirculation or humidification, selected
randomly from the Helsinki metropolitan area. The ventilation type and other characteristics of these
buildings were recorded on a site visit and the ventilation in the rooms was assessed by measuring the
airflow through the exhaust air outlets in the room. A questionnaire directed at workers inquired about the
symptoms and perceived air quality and their possible personal and environmental determinants (response
rate 81%). The outcomes were weekly work related symptoms experienced during the previous 12
months and symptom groups defined either by their anatomical location or hypothesised mechanism.
RESULTS--In logistic regression analysis, the adjusted odds ratio (OR) for any symptom of interest was
3.03 (95% confidence interval (95% CI) 1.13 to 8.10) in the very low ventilation category of below 5 l/s
per person and 2.24 (0.89 to 5.65) in the high ventilation category of over 25 l/s per person compared with
the reference (15- < 25 l/s). The ORs for ocular (1.27, 1.11 to 1.46), nasal (1.17, 1.06 to 1.29), skin
symptoms (1.18, 1.05 to 1.32), and lethargy (1.09, 1.00 to 1.19) increased significantly by a unit decrease
in ventilation from 25 to 0 l/s per person. CONCLUSION--The results suggest that outdoor air ventilation
rates below the optimal (15 to 25 l/s per person) increase the risk of the symptoms of sick building
48
syndrome with the sources of pollutants present in mechanically ventilated office buildings. The Finnish
guideline value is 10 l/s per person.
49.- Occup Environ Med. 1995 Mar;52(3):170-6.
Influence of indoor air quality and personal factors on the sick building syndrome (SBS) in Swedish
geriatric hospitals.
Nordström K, Norbäck D, Akselsson R.
Department of Working Environment, Lund Institute of Technology, University of Lund, Sweden.
Comment in:
•
Occup Environ Med. 1995 Nov;52(11):782.
OBJECTIVES--Sick building syndrome (SBS) involves symptoms such as irritation to the eyes, skin, and
upper airways, headache, and fatigue. The relations between such symptoms and both personal and
environmental factors were studied in 225 female hospital workers, working in eight hospital units in the
south of Sweden. METHODS--Symptoms of SBS and personal factors were measured by means of a
standardised self administered questionnaire. The technical investigation comprised a building survey and
measurements of room temperature, supply air temperature, air humidity, and exhaust air flow.
RESULTS--The prevalence of symptoms differed from one unit to another. The mean value of weekly
complaints of fatigue was 30%, of eye irritation 23%, and of dry facial skin 34%. Eye irritation was
related to work stress, self reported exposure to static electricity, and was also more common in buildings
with a high ventilation flow and a high noise level (55 dB(A)) from the ventilation system. Nasal
symptoms were related to asthma and hay fever only. Throat symptoms were more common in smokers,
subjects with asthma or hay fever, new buildings, and in buildings with a high ventilation flow. Facial
skin irritation was related to a lack of control of the work conditions, and was more common in new
buildings, and buildings with a high ventilation flow and ventilation noise. General symptoms, such as
headache and fatigue, were related to current smoking, asthma or hay fever, work dissatisfaction, and
static electricity. CONCLUSION--As the prevalence of symptoms was high, there is a need to improve
the indoor environment as well as the psychosocial environment in hospitals. These improvements could
include a reduction of ventilation noise, minimised smoking, and improvements in the psychosocial
49
climate. Further research is needed to identify indoor climatic factors that cause the increased prevalence
of symptoms of SBS in new buildings.
50.- Integr Physiol Behav Sci. 1995 Jan-Mar;30(1):68-83.
Sick-building syndrome fatigue as a possible predation defense.
Chester AC.
Georgetown University Medical Center, Washington, D.C., USA.
Sick-building syndrome is an illness characterized by fatigue, headache, and upper-respiratory
complaints. It is usually associated with modern office buildings, structures with an impervious outer
shell and inoperable windows. Poor air quality, specific pollutants, and inadequate ventilation are
considered common causes. The ability to smell faint odors requires air that is free of contamination.
Human evolutionary ancestors depended on odors for survival. Even the slightest increase in the ability to
smell a predator conveyed a distinct, immediate survival advantage. Conversely, an enormous survival
advantage would also accrue to the animal that sought protection or avoided activity when this vital
olfactory information was unavailable. Such would be the case with fire on the savannah. The foraging,
olfactory dependent animal, unable to smell predators because of contaminated air, would be quickly
snatched by a keen-sighted carnivore. There exist, however, well-described reflexes from the nose
mediated through the trigeminal nerve that discourage activity when these free nerve endings are irritated.
This mechanism may serve as a defense against predation. In adulterated atmosphere the animal, subdued
by these reflexes, would be less likely to venture forth and, therefore, less vulnerable to predators. Similar
reflexes may persist in humans, activated by poor air quality, air ill-suited for the dissemination of odors.
I suggest that the human perception of these inhibitory reflexes is the feeling of fatigue associated with
the sick building syndrome.
51.- Arch Environ Health. 1994 May-Jun;49(3):175-81.
Textile wall materials and sick building syndrome.
Jaakkola JJ, Tuomaala P, Seppänen O.
Department of Public Health, University of Helsinki, Finland.
50
We studied the relation between the amount of textile and other soft fiber wall materials used in the office
and the symptoms related to sick building syndrome in two identical, mechanically ventilated, eight-story
office buildings. The study population consisted of 400 workers (85% of the source population): 264
males (66%) and 136 females (34%). A self-administered questionnaire inquired about the occurrence of
symptoms and related personal and environmental determinants. The office environment was assessed
concurrently. Exposure was defined as the surface area of textile or other soft wall material (SWM) in the
office. The outcomes were formed using the 7-d prevalences of individual symptoms, including mucosal
irritation score (eye irritation, nasal dryness, nasal congestion, pharyngeal irritation); allergic reaction
score (eye irritation, nasal congestion, nasal excretion, sneezing); asthma reaction score (wheezing,
breathlessness, cough); skin reaction score (dryness, itch, or irritation, rash); and general symptom score
(headache, lethargy). In the logistic regression controlling for potential confounders, the adjusted odds
ratio for the symptoms of mucosal irritation was 1.82 (95% confidence interval [95% CI] = 1.14, 2.90) in
the low-exposure group, compared with the unexposed reference group; and 2.46 (95% CI = 1.15, 5.28)
in the high-exposure group, compared with the reference group. Corresponding odds ratios for the
symptoms of allergic reaction were 1.82 (95% CI = 1.14, 2.90) and 3.16 (95% CI = 1.41, 7.09). No
difference was found in the risk for asthmatic or skin reactions or general symptoms. The results support a
hypothesis that textile and other soft-fiber wall materials used in the office environment are possible
determinants of sick building syndrome.
52.- Clin Infect Dis. 1994 Jan;18 Suppl 1:S43-8.
Concurrent sick building syndrome and chronic fatigue syndrome: epidemic neuromyasthenia revisited.
Chester AC, Levine PH.
Georgetown University Medical Center, Washington, D.C.
Sick building syndrome (SBS) is usually characterized by upper respiratory complaints, headache, and
mild fatigue. Chronic fatigue syndrome (CFS) is an illness with defined criteria including extreme fatigue,
sore throat, headache, and neurological symptoms. We investigated three apparent outbreaks of SBS and
observed another more serious illness (or illnesses), characterized predominantly by severe fatigue, that
was noted by 9 (90%) of the 10 teachers who frequently used a single conference room at a high school in
Truckee, California; 5 (23%) of the 22 responding teachers in the J wing of a high school in Elk Grove,
California; and 9 (10%) of the 93 responding workers from an office building in Washington, D.C. In
51
those individuals with severe fatigue, symptoms of mucous membrane irritation that are characteristic of
SBS were noted but also noted were neurological complaints not typical of SBS but quite characteristic of
CFS. We conclude that CFS is often associated with SBS.
53.- Environ Health Perspect. 1993 Aug;101(3):234-8.
Neurogenic inflammation and sensitivity to environmental chemicals.
Meggs WJ.
Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, NC
27858.
Comment in:
• Environ Health Perspect. 1994 Jan;102(1):12-3; author reply 13.
• Environ Health Perspect. 1994 Jan;102(1):12; author reply 13.
Neurogenic inflammation as a pathway distinct from antigen-driven, immune-mediated inflammation
may play a pivotal role in understanding a broad class of environmental health problems resulting from
chemical exposures. Recent progress in understanding the mediators, triggers, and regulation of
neurogenic inflammation is reviewed. Evidence for and speculations about a role for neurogenic
inflammation in established disorders such as asthma, rhinitis, contact dermatitis, migraine headache, and
rheumatoid arthritis are presented. The sick building syndrome and multiple chemical sensitivity
syndrome have been defined as clinical entities in which exposure to chemical inhalants gives rise to
disease. Current data on the existence of chemical irritant receptors in the airway and skin are discussed;
neurogenic inflammation arising from stimulation of chemical irritant receptors is a possible model to
explain many of the aspects of chemical sensitivities.
54.- Ann N Y Acad Sci. 1992 Apr 30;641:215-24.
Human upper respiratory tract responses to inhaled pollutants with emphasis on nasal lavage.
Koren HS, Devlin RB.
Health Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park,
North Carolina 27711.
52
A set of symptoms has been described during the past two decades. These symptoms, which have been
called the sick building syndrome, include eye, nose, and throat irritation; headache; mental fatigue; and
respiratory distress. It is likely that VOCs present in synthetic materials used in homes and office
buildings contribute to these symptoms. There have been few studies, however, in which humans have
been exposed to known amounts of VOCs under carefully controlled conditions. In this study, 14 subjects
have been exposed to a mixture of VOCs (25 mg/m3 total hydrocarbon) representative of what is found in
new homes and office buildings. Because irritation of the nose and throat are symptoms often associated
with the upper respiratory tract and may result from an inflammatory response in the upper airways, we
have used NAL to monitor PMN influx into the nasal passages following exposure to VOCs. We report
statistically significant increases in PMNs both immediately after a 4-hr exposure to VOCs, as well as 18
hr later.
55.- Arch Environ Health. 1992 Jan-Feb;47(1):39-44.
Exposure of humans to a volatile organic mixture. III. Inflammatory response.
Koren HS, Graham DE, Devlin RB.
United States Environmental Protection Agency, Health Effects Research Laboratory, Research Triangle
Park, North Carolina.
A set of symptoms has been described during the past two decades that has been called the "sick building
syndrome." These symptoms include eye, nose, and throat irritation; headache; mental fatigue; and
respiratory distress. It is likely that the volatile organic compounds (VOCs) present in synthetic materials
used in homes and office buildings contribute to these symptoms. However, there have been very few
studies in which humans have been exposed to known amounts of VOCs under carefully controlled
conditions. In this study, 14 subjects were exposed to a mixture of VOCs (25 mg/m3 total hydrocarbon)
that is representative of what is found in new homes and office buildings. Because irritations of the nose
and throat are symptoms often associated with the upper respiratory tract and may result from an
inflammatory response in the upper airways, we used nasal lavage to monitor neutrophil (PMN) influx
into the nasal passages following exposure to VOCs. There were statistically significant increases in
PMNs, both immediately after a 4-h exposure to VOCs and 18 h later.
(repetido)
53
56.- Arch Environ Health. 1992 Jan-Feb;47(1):31-8.
Exposure of humans to a volatile organic mixture. II. Sensory.
Hudnell HK, Otto DA, House DE, Mølhave L.
Neurotoxicology Division, U.S. Environmental Protection Agency, Research Triangle Park, NC.
Time-course functions for symptoms of the sick building syndrome were derived from 66 healthy males
who, during separate sessions, were exposed to clean air and to a volatile organic compound (VOC)
mixture. The mixture contained 22 VOCs (25 mg/m3 total concentration) commonly found airborne in
new or recently renovated buildings. Subjects rated the intensity of perceived irritation, odor, and other
variables before, and twice during, 2.75-h exposure periods. Eye and throat irritation, headache, and
drowsiness increased or showed no evidence of adaptation during exposure, whereas odor intensity
decreased by 30%. These results indicate that irritation intensity and other symptoms are not related in
any simple way to odor intensity, which suggests that the symptoms may not be a psychosomatic
response to the detection of an aversive odor. Instead, subthreshold levels of VOCs may interact
additively or hyperadditively and stimulate trigeminal nerve receptors. Also, air quality ratings improved
by 18% during exposure, which suggests that both odor and irritation intensity may influence assessments
of air quality.
57.- Environ Health Perspect. 1991 Nov;95:99-100.
Sick-building syndrome.
Stolwijk JA.
John B. Pierce Foundation Laboratory, Department of Epidemiology and Public Health, Yale University
School of Medicine, New Haven, CT 06510.
The sick-building syndrome (SBS) is defined as the occurrence of an excessive number of subjective
complaints by the occupants of a building. These complaints include headache, irritation of the eyes,
nose, and throat, lethargy, inability to concentrate, objectionable odors, and less frequently, nausea,
dizziness, chest tightness, etc. These complaints will always be reported by a fraction of the occupants of
any building if a questionnaire is administered that asks the respondent to recall any subjective symptoms
they remember having had in the last 2 weeks or or over some period of time. It is often considered that
54
SBS symptom reports have a minimum prevalence of about 15 to 20% for a 2-week recall period. SBS
symptoms reported by 30% or more of occupants are indicative of conditions in the building environment
that warrant attention. It is not often that a clear, single cause is responsible for the excess symptom
reports. The following factors, often in combinations, are seen to contribute to SBS: outdoor air supply
that is inadequate, ventilation distribution or effectiveness that is inadequate, the presence of temporary or
long-term sources of contaminants such as tobacco smoke, adhesives, composite materials such as
chipboard, and the growth of microorganisms in the HVAC equipment or in carpets or other furnishings.
Depending on which causes contribute, the condition may be intermittent or even temporary.
Psychosocial factors such as labor-management relations and satisfaction or dissatisfaction with other
factors in the work environment can have a profound influence on the level of response of the occupants
to their environment. Although hard data are difficult to collect, it is likely that productivity in the office
environment is sensitive to conditions causing SBS.
58.- Environ Health Perspect. 1991 Nov;95:67-9.
Severity of health effects associated with building-related illness.
Welch LS.
George Washington University School of Medicine, Division of Occupational and Environmental
Medicine, Washington, DC 20037.
Building-related illness ranges from mild rhinitis to potentially life-threatening hypersensitivity
pneumonitis and legionellosis. Sick-building syndrome, consisting of headache, mucous membrane
irritation, and fatigue, may be present in 30% of all office workers. Hypersensitivity pneumonitis, asthma,
and legionellosis are less common, and it is difficult from existing studies to estimate the incidence of
these more severe illnesses. There are even fewer data on an illness now being called multiple chemical
sensitivity and its relationship to indoor environments. New studies are needed to estimate the frequency
of all building-associated illnesses, and case definitions for these disorders must be delineated.
59.- J Occup Med. 1991 Jun;33(6):737-9.
Sick-hospital syndrome.
Brandt-Rauf PW, Andrews LR, Schwarz-Miller J.
55
Division of Environmental Sciences, Columbia University, New York, NY 10032.
An outbreak of complaints consisting primarily of eye and respiratory tract irritation accompanied by
headache, dizziness, fatigue, and nausea occurred among the operating room personnel of a large
metropolitan hospital. This initially was attributed to infiltration of diesel exhaust emissions into the
ventilation system. However, following correction of this problem and subsequent unrevealing air
monitoring, symptoms persisted and were noted in personnel in adjacent areas of the hospital as well. An
industrial hygiene and medical evaluation was undertaken. Monitoring for carbon monoxide,
formaldehyde, and anesthetic gases and review of medical records and patient examinations were
unrevealing, and the problem resolved gradually over several weeks. This outbreak represents a case of
building-associated illness among health professionals in a hospital setting that was triggered by a single,
identifiable noxious exposure but was sustained despite any apparent ongoing noxious exposures.
60.- South Med J. 1991 Jan;84(1):65-71, 76.
Sick building syndrome.
Lyles WB, Greve KW, Bauer RM, Ware MR, Schramke CJ, Crouch J, Hicks A.
Department of Psychiatry, College of Medicine, College of Health Related Professions, University of
Florida, Gainesville 32610.
"Sick building syndrome" (SBS) is one of the more colorful terms describing an increasingly common
pattern of symptoms found among workers in modern office buildings. Core symptoms include lethargy,
mucous membrane irritation, headache, eye irritation, and dry skin. To prompt a diagnosis of SBS, these
otherwise common symptoms must be "excessively" reported and primarily "work-related." The World
Health Organization now estimates that 30% of new or remodeled office buildings show signs of SBS,
and that between 10% and 30% of the occupants of these buildings are affected by SBS. Despite such
figures, SBS remains poorly researched and even more poorly understood. The following review provides
the clinician an overview of SBS that will allow a more accurate differential diagnosis and will help to
prevent the widespread suffering that can accrue when SBS is not quickly recognized.
61.- J Expo Anal Environ Epidemiol. 1991 Jan;1(1):63-81.
Indoor climate, air pollution, and human comfort.
56
Mølhave L.
Institute of Environmental and Occupational Medicine, University of Aarhus, Denmark.
The term sick building syndrome (SBS) is frequently used to describe a set of symptoms often reported
by occupants of certain buildings. The symptoms are supposed to be direct or indirect consequences of an
inadequate indoor climate. Typically, a majority of the occupants in these buildings complain, and the
most frequent complaint is irritation of eyes, nose, and throat. Many different factors are known to be
potential agents for the symptoms and no definitive causality has been identified yet. In consequence
authors of publications on indoor air quality have been using the SBS term in different ways. A review of
literature indicates that in supposed "sick buildings" only the prevalence of irritation of mucosal
membranes and headaches seems to differ significantly from the prevalence in buildings considered to
have a normal indoor climate. Volatile organic compounds (VOC) are known to have a potency to cause
symptoms like those included in SBS. A dose-response relation for sensory reactions and mucosal
irritation caused by volatile organic air pollutants is discussed, and a tentative guideline at 3 mg/m3
(about 0.9 PPM toluene equivalent) for the total volatile organic compounds (TVOC) is suggested for the
nonindustrial indoor climates.
62.- Arch Environ Health. 1990 May-Jun;45(3):135-40.
Self-leveling mortar as a possible cause of symptoms associated with "sick building syndrome".
Lundholm M, Lavrell G, Mathiasson L.
Department of Clinical Bacteriology, Academic Hospital, Uppsala, Sweden.
In newly constructed houses and buildings in which self-leveling mortar containing casein has been used,
residents and office employees have noted a bad odor and have complained of headache, eye and throat
irritation, and tiredness. These problems were suspected to result from the degradation products emitted
from the mortar. Samples obtained from dry mortar powder and from mortar in buildings where casein
was used and from control buildings were found to contain microorganisms (mean of 10(2) culture
forming units/g). Environmental species were predominantly found, e.g., Bacillus, Clostridium,
Micrococcus, and Propionibacterium. Fungi were found occasionally; no evidence of bacterial
degradation was found. Headspace and gas chromatographic-mass spectrometric analysis of air from the
newly constructed houses and from hydroxide-degraded casein revealed the presence of amines in the
57
0.003-0.013 ppm range and the presence of ammonia and sulfhydryl compounds, all of which in low
concentrations can cause the symptoms observed. These substances, however, were not detected in
control buildings.
63.- Allergy Proc. 1990 May-Jun;11(3):109-16.
Sick building syndrome: acute illness among office workers--the role of building ventilation, airborne
contaminants and work stress.
Letz GA.
Department of Medicine, School of Medicine, University of California, San Francisco 99143.
Outbreaks of acute illness among office workers have been reported with increasing frequency during the
past 10-15 years. In the majority of cases, hazardous levels of airborne contaminants have not been found.
Generally, health complaints have involved mucous membrane and respiratory tract irritation and
nonspecific symptoms such as headache and fatigue. Except for rare examples of hypersensitivity
pneumonitis related to microbiologic antigens, there have been no reports of serious morbidity or
permanent sequelae. However, the anxiety, lost work time, decreased productivity and resources spent in
investigating complaints has been substantial. NIOSH has reported on 446 Health Hazards Evaluations
that were done in response to indoor air complaints. This data base is the source of most of the published
accounts of building-related illness. Their results are summarized here with a discussion of common
pollutants (tobacco smoke, formaldehyde, other organic volatiles), and the limitations of the available
industrial hygiene and epidemiologic data. There has been one large scale epidemiologic survey of
symptoms among office workers. The results associate risk of symptoms to building design and
characteristics of the heating/air-conditioning systems, consistent with the NIOSH experience. Building
construction since the 1970s has utilized energy conservation measures such as improved insulation,
reduced air exchange, and construction without opening windows. These buildings are considered
"airtight" and are commonly involved in episodes of building-associated illness in which no specific
etiologic agent can be identified. After increasing the percentage of air exchange or correcting specific
deficiencies found in the heating/air-conditioning systems, the health complaints often resolve, hence, the
term "tight building syndrome" or "sick building syndrome."(ABSTRACT TRUNCATED AT 250
WORDS)
64.- Scand J Work Environ Health. 1990 Apr;16(2):121-8.
58
Indoor air quality and personal factors related to the sick building syndrome.
Norbäck D, Michel I, Widström J.
Department of Occupational Medicine, University Hospital, Uppsala, Sweden.
The "sick building syndrome" involves symptoms such as eye, skin and upper airway irritation, headache,
and fatigue. A multifactorial study was performed among personnel in consecutive cases of sick buildings
to investigate relationships between such symptoms, exposure to environmental factors, and personal
factors. The total indoor hydrocarbon concentration was significantly related to symptoms. Other indoor
exposures such as room temperature, air humidity, and formaldehyde or carbon dioxide concentration did
not correlate with the symptoms. Personal factors such as reported hyperreactivity and sick leave due to
airway diseases were strongly related to the sick building syndrome. Other factors associated with the sick
building syndrome were smoking, psychosocial factors, and experience of static electricity at work.
Neither atopy, age, sex, nor outdoor exposures correlated significantly with the number of symptoms. It
was concluded that the sick building syndrome is of multifactorial origin and related to both indoor
hydrocarbon exposure and individual factors.
65.- Scand J Work Environ Health. 1989 Aug;15(4):286-95.
Influence of personal characteristics, job-related factors and psychosocial factors on the sick building
syndrome. Danish Indoor Climate Study Group.
Skov P, Valbjørn O, Pedersen BV.
Clinic of Occupational Medicine, Rigshospitalet, University of Copenhagen, Denmark.
The influence of personal characteristics, life-style, job-related factors, and psychosocial work factors on
symptoms of the sick building syndrome was investigated in Greater Copenhagen, Denmark. The
buildings were not characterized beforehand as "sick" or "healthy." Of the 4369 employees sent a
questionnaire, 3507 returned them. Multivariate logistic regression analyses of the multifactorial effects
on the prevalence of work-related mucosal irritation and work-related general symptoms among the office
workers showed that sex, job category, work functions (handling of carbonless paper, photocopying, work
at video display terminals), psychosocial factors of work (dissatisfaction with superiors or colleagues and
quantity of work inhibiting job satisfaction) were associated with work-related mucosal irritation and
work-related general symptoms, but these factors could not account for the differences between the
59
buildings as to the prevalence of the symptoms. The building factor (i.e., the indoor climate) was strongly
associated with the prevalence of the symptoms.
66.- Tidsskr Nor Laegeforen. 1989 May 20;109(14):1526-9.
[Indoor climate as a cause of health complaints. A review]
[Article in Norwegian]
Levy F.
Energy conservation, insufficient ventilation and introduction of new building materials are accompanied
by increasingly frequent complaints of increasingly frequent mucosal irritation, headache and lethargy
among occupants, commonly called "sick building syndrome". Infections and toxic allergic reactions may
be caused by infected humidifiers. The article includes a review of symptoms and causes. Many of the
complaints can be prevented. Combined efforts by medical and technical personnel are necessary in
diagnosing and solving indoor climatic problems.
67.- Br Med J (Clin Res Ed). 1984 Dec 8;289(6458):1573-5.
The sick building syndrome: prevalence studies.
Finnegan MJ, Pickering CA, Burge PS.
Random samples or the entire workforce in nine offices in which similar clerical work was being
performed were studied using a doctor administered questionnaire that inquired into symptoms that have
been linked with the "sick building syndrome." Five of the offices were fully air conditioned, one had
recirculation of air and mechanical ventilation, and three were naturally ventilated. Workers in three air
conditioned and three naturally ventilated buildings were interviewed blind. Seven of the buildings were
studied at our request in the absence of any known problem. Comparison of prevalences of symptoms
between the naturally ventilated and the other buildings showed a repeated pattern of nasal, eye, and
mucous membrane symptoms with lethargy, dry skin, and headaches. There were highly significant
excesses of these six symptoms in the air conditioned buildings when compared by chi 2 tests with the
naturally ventilated buildings. It is suggested that these six symptoms represent the sick building
60
syndrome and that the size of the problem is probably greater than is currently recognised. Possible
causes are discussed.
61
REVISIÓN Y GRAFICAS DE LAS PUBLICACIONES DEL SEE-CONCLUSIONES
PRELIMINARES
1.- Por el autor:
nombre primer autor
Runeson R
Chester AC
Engvall K
Jaakkola JJ
Jaakkola MS
Norbäck D
Otros autores (52)
nº art primer autor
4
2
2
2
2
2
1
Nº articulos por primer autor
4
1
2
Runeson R Chester AC
2
Engvall K
2
2
Jaakkola JJ
Jaakkola
MS
2
Norbäck D
Otros
autores (52)
En la mayor parte de las publicaciones hay un único articulo científico por autor, sólo un reducido número
tienen mas de una publicación en la materia (poca especialización)
2.- Por la distribución en años o periodos de años.
Periodo de años
Año 1984-1997
Año 1998-2009
Porcentaje
31,8
68,2
Nº artículos
21
45
Porcentaje articulos por periodos
Nº articulos por periodo de
años
31,8%
Año 1984-1997
68,2%
45
Año 1998-2009
21
Año 1984-1997
62
Año 1998-2009
Nota: como transposición de la Directiva Europea 89/391/CEE, aparece la Ley 31/1995 de
Prevención de Riesgos Laborales (LPRL), modificada y actualizada por la Ley 54/2003, de 12
de diciembre, de reforma del marco normativo de la prevención de riesgos laborales.
Años
año 1984
año 1989
año 1990
año 1991
año 1992
año 1993
año 1994
año 1995
año 1996
año 1997
año 1998
año 1999
año 2000
año 2001
año 2002
año 2003
año 2004
año 2005
año 2006
año 2007
año 2008
año 2009
nº artículos
1
2
3
5
2
1
2
3
1
1
3
4
3
4
4
4
6
3
2
5
5
2
Nº articulos por año
6
5
5
4
3
2
1
3
2
3
4
3
2
1
4
4
3
2
1
5
2
1
año año año año año año año año año año año año año año año año año año año año año año
1984 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Hay un incremento en el número de publicaciones a partir de 1997 ¿coincidiendo con la
aplicación en la práctica de la normativa europea en prevención de riesgos laborales?
3.- Por el tipo de revista que lleva a cabo las publicaciones
63
Revista
Indoor Air
Occup Environ Med
Environ Health Perspect
Arch Environ Health
Int Arch Occup Environ Health
Scand J Work Environ Health
Otras revistas (33)
nº artículos
15
6
4
4
3
2
1
Nº de articulos por revista
15
6
4
4
Indoor Air
Occup
Environ Med
Revista
primeras 6 revistas
Resto: 33 revistas
Environ
Health
Perspect
Arch Environ
Health
Porcentaje
51,5
48,5
3
Int Arch
Occup
Environ
Health
2
Scand J
Work
Environ
Health
1
Otras
revistas (33)
nº artículos
34
32
Porcentaje de artículos
48,5
51,5
primeras 6 revistas
Resto: 33 revistas
Seis revistas copan prácticamente la mitad de las publicaciones en este tema, el resto (33 revistas) se
reparten el resto de las publicaciones en la materia.
64
4.- Por el país del que procede la publicación
País
USA
Denmark
UK
Alemania
Finland
Japan
Resto paises (7)
Porcentaje artículos
39,4
22,7
13,6
7,6
3
3
10,6
nº artículos
26
15
9
5
2
2
7
Nº artículos por país de la revista
26
15
9
7
5
USA
Denmark
UK
Alemania
2
2
Finland
Japan
Resto
paises (7)
Porcentaje de publicaciones por paises
3
10,6
USA
3
39,4
7,6
Denmark
UK
Alemania
Finland
22,7
Japan
13,6
Resto paises (7)
Estados Unidos y Dinamarca recogen más del 60% de las publicaciones en este tema.
65
5.- Por el tipo de estudio realizado
Tipo de estudio
Descriptivo
Observacional
Transversal
Experimental
Otros
Porcentaje publicaciones
39,4
30,3
13,6
10,6
6,1
nº publicaciones
26
20
9
7
4
Reparto según tipo estudio
26
20
7
9
Descriptivo
Observacional
Transversal
Experimental
4
Otros
Porcentaje segun el tipo de esudio
6,1
10,6
39,4
Descriptivo
Observacional
13,6
Transversal
Experimental
Otros
30,3
La mayor parte de los estudios son observacionales o descriptivos. Estudios elementales de
investigación. Pocos estudios experimentales o casos y controles.
66
6.- Por la repercusión o relevancia del estudio.
Relevancia
Clínico-laboral
Clínico
Social
Porcentaje publicaciones
69,7
28,8
1,5
nº publicaciones
46
19
1
Reparto según nivel de
evidencia
46
19
1
Clínico-laboral
Clínico
Social
Porcentaje por relevancia del estudio
1,5
28,8
Clínico-laboral
Clínico
69,7
Social
En la mayor parte de los estudios la relevancia es clínica o clínico laboral.
67
7.- Por la población objeto del estudio.
Sector poblacional
Servicios
Población general
Población laboral
Otros sectores
Porcentaje publicaciones
42,4
40,9
12,1
4,5
nº publicaciones
28
27
8
3
Reparto según actividad
28
27
8
Servicios
Población general Población laboral
3
Otros sectores
Porcentaje segun poblacion de estudio
4,5
12,1
42,4
Servicios
Población general
Población laboral
40,9
Otros sectores
En la mayor parte de los estudios la población es general o laboral general, como sector profesional
individual, destaca el sector servicios asociado generalmente a trabajos de oficina.
68
8.- Por los síntomas que acompañan a la cefalea, que esta presente en todos los casos.
Síntomas que acompañan a la cefalea
ORL
Oculares
Neurológicos
Dermatológicos
Respiratorios
Fatiga
Digestivos
Reumatológicos
Generales
nº publicaciones
48
42
33
26
21
19
6
3
3
Otros sintomas (nº artículos)
48
42
33
21
19
ivo
s
Re
um
at
ol
óg
ic
os
Di
ge
st
Fa
tig
a
Ne
ur
ol
óg
ico
s
De
rm
at
ol
óg
ic
os
Re
sp
ira
to
rio
s
O
cu
la
re
s
O
R
L
6
3
3
G
en
er
al
es
26
Además de cefalea, presente en todas las publicaciones destacan los síntomas en mucosas,
neurológicos y atópicos.
9.- Por los aspectos preventivos contenidos en la publicación.
Aspectos preventivos
Ninguno
Recomendaciones generales
Recomendaciones preventivas
Porcentaje publicaciones
53
40,9
6,1
69
nº publicaciones
35
27
4
Aspectos preventivos/Actuaciones emprendidas (nº
articulos)
35
27
4
Ninguno
Recomendaciones
generales
Recomendaciones
preventivas
Porcentaje segun aspectos preventivos
6,1
Ninguna
53
40,9
Recomendaciones generales
Recomendaciones preventivas
Como norma no existen aspectos preventivos contemplados en las publicaciones, en algunos casos
se incluyen recomendaciones generales y/o laborales.
SENSIBILIDAD QUÍMICA MÚLTIPLE
REVISIÓN PUB-MED. PUBLICACIONES
Sensibilidad Química Múltiple. Multiple chemical hypersensitivity AND headache
1.- Int Arch Occup Environ Health. 2009 Mar;82(4):509-17. Epub 2008 Aug 28.
Phenotypes of individuals affected by airborne chemicals in the general population.
Berg ND, Linneberg A, Dirksen A, Elberling J.
70
The Danish Research Centre for Chemical Sensitivities, Gentofte Hospital, University of Copenhagen,
Ledreborg Allé 40, Gentofte, Denmark. [email protected]
OBJECTIVE: To characterise the chemical exposures and symptoms affecting individuals with
subsequent adjustments of social life or occupational conditions, and further characterise these severely
affected individuals. METHODS: All individuals (n = 1,134) who reported symptoms from airborne
chemical exposures in a population-based questionnaire study of 6,000 individuals were included and
dichotomised according to severity. Logistic regression models were used to characterise the group of
severely affected individuals. RESULTS: Severely affected individuals reported more symptoms and
exposures related to symptoms than less severely affected individuals, and the number of symptoms was
more predictive for severity than the number of exposures. Most predictive for the severity of reported
symptoms were CNS-symptoms other than headache (OR = 3.2, P < 0.001) and exposure to freshly
printed papers or magazines (OR = 2.0, P = 0.001). CONCLUSION: CNS-symptoms except from
headache were a main characteristic of individuals severely affected by common chemical exposures in a
general population-based sample.
2.- Psychosom Med. 2007 Dec;69(9):855-9.
The association or otherwise of the functional somatic syndromes.
Kanaan RA, Lepine JP, Wessely SC.
King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK.
OBJECTIVE: To review the evidence for overlap in the phenomenology of the Functional Somatic
Syndromes (FSS). The FSS show considerable comorbidity, leading some to suggest they may be aspects
of the same disorder. METHODS: We conducted a selective review of peer-reviewed articles on the cooccurrence of FSS symptoms and diagnoses. RESULTS: Considerable evidence of overlap was found at
the level of symptoms, diagnostic criteria, and clinical diagnoses made. CONCLUSIONS:
Phenomenological commonalities support a close relationship between the FSS, although differences
remain in other domains. Whether the FSS may best be considered the same or different will depend on
the pragmatics of diagnosis.
3.- Inhal Toxicol. 2007 May;19(6-7):577-85.
Pesticide-initiated idiopathic environmental intolerance in South Korean farmers.
71
Lee HS, Hong SY, Hong ZR, Gil HO, Yang JO, Lee EY, Han MJ, Jang NW, Hong SY.
Department of Internal Medicine, Soonchunhyang University Hospital, Cheonan, Korea.
This study was designed to study patients with intolerance to pesticide smells. Ten subjects chosen were
complaining of vague symptoms such as headache, dizziness, fatigue, nausea, vomiting, abdominal pain,
myalgia, flu-like symptoms, etc., whenever exposed to the pesticide smells even at low intensity. To
determine whether the etiology of this kind of pesticide hypersensitivity was of organic or psychiatric
nature, all the subjects underwent tests as follows: complete blood cell count, urinalysis, and blood
chemistry as routine tests; esophogastroduodenoscopy and abdomen ultrasonography for the
gastrointestinal symptoms; chest x-ray, pulmonary function tests, and electrocardiography for the
respiratory and/or cardiac symptoms; nerve conduction velocity and brain magnetic resonance imaging
(MRI) for peripheral and central nerve system symptoms; and K-WAIS, Rey-Kim memory test,
Rorschach, Mini Mental State Examination (MMSE), and Minnesota Multiphasic Personality Inventory
(MMPI) for psychoanalysis. Of the 10 cases in which the chief complaint was headache, symptoms of
two cases were caused by maxillary sinusitis. Another two showed typical multiple chemical sensitivity
(MCS) or idiopathic environmental intolerance (IEI). Six out of the 10 cases, whose symptoms closely
resembled the others, did not conclusively meet the criteria of classic MCS or IEI. The subjects of this
case shared vague fears, both fear of pesticides and hypochondriasis. Some subjects faced financial
insecurity and social uncertainty; others felt uneasy about the future of their farming life. Thus, to help
verify the causes of MCS or IEI, which is strongly suggestive of pesticide smells, diagnosis needs a dual
approach: on the anima and soma. Psychoanalysis can delve into the mental status of the patients to see
whether the patients are aware of their symptoms. Clinical tests can see through the physical structure and
functions of the organs on which patients' complaints are centered.
4.- Int J Hyg Environ Health. 2005;208(4):271-8.
Self-reported chemical sensitivity in Germany: a population-based survey.
Hausteiner C, Bornschein S, Hansen J, Zilker T, Förstl H.
Department of Psychiatry and Psychotherapy, Technical University of Munich, Germany.
[email protected]
72
OBJECTIVES: Environmental clinics are frequented by patients with fears and complaints related to
environmental triggers. A dose-independent overreaction to small doses of widely used and generally
non-toxic chemicals is referred to as multiple chemical sensitivity (MCS), but no clearly defined clinical
syndrome with objective physical findings has been delineated so far. We aimed to obtain information
about symptoms, supposed environmental triggers, the frequency of self-reported chemical sensitivity,
and of the diagnosis MCS in Germany. METHODS: We conducted a representative survey among 2032
adult Germans. RESULTS: We found self-reported chemical sensitivity in 9% and physician-diagnosed
MCS in 0.5% of our representative sample. Physical complaints were common in the whole study
population and in chemically sensitive individuals, but there was no clear-cut symptom constellation
among the latter. The most common complaints were headache, fatigue, sleep disturbances, joint pain,
mood changes and nervousness. A subjective connection between complaints and environmental triggers
was denied by 67% of the whole group and by 35% of the self-reported chemically sensitive. Factor
analysis of environmental triggers suggested that a specific exposure situation rather than chemical
similarity is the basis for individual trigger combinations. CONCLUSIONS: The prevalence of subjective
sensitivity towards chemicals is similar to such rates reported from other countries. There is a relatively
low awareness of the MCS-concept, and it appears to be diagnosed less frequently than, e.g., in the USA.
Since symptoms and triggers in chemically sensitive individuals did not differ from the general
population, our data do not suggest the existence of a widespread new syndrome related to chemical
sensitivities in Germany. We outline the limitations of self-reported chemical sensitivity as the major
criterion for such a contentious diagnosis as MCS.
5.- Ind Health. 2005 Apr;43(2):341-5.
A case of sick building syndrome in a Japanese office worker.
Nakazawa H, Ikeda H, Yamashita T, Hara I, Kumai Y, Endo G, Endo Y.
Department of Otorhinolaryngology, Kansai Medical University, Fumizono-cho, Moriguchi, Osaka 5708506, Japan.
The adverse health effects caused by indoor air pollution are termed "sick building syndrome". We report
such a patient whose symptoms appeared in the workplace. A 36-year-old female office worker
developed nausea and headache during working hours in a refurbished office. After eight months of
seeking help at other clinics or hospitals without improvement, she was referred to our hospital. At that
73
time she reacted to the smells of various chemicals outside of the office building. Biochemical findings
were all within normal ranges. Specific IgE antibody to cedar pollen was positive and the ratio of
TH1/TH2 was 4.5. In the Eye Tracking Test (ETT), vertical eye movement was saccadic. Her anxiety
level was very high according to the State-Trait Anxiety Inventory (STAI) questionnaire. Subjective
symptoms, ETT findings and anxiety levels on STAI gradually improved during two years of follow-up.
One year after the onset of her illness, the formaldehyde concentrations in the building air ranged from
0.017-0.053 ppm. Even though relatively low, chemical exposure from building materials such as
formaldehyde induced a range of symptoms. Also, lack of recognition by superiors and doctors that sick
building syndrome might have been the source of her illness coupled with her high state of anxiety may
have exacerbated her symptoms and led to the onset of multiple chemical sensitivity. Thus psychosocial
factors may contribute to sick building syndrome in the workplace.
6.- Occup Med (Lond). 2003 Oct;53(7):479-82.
Central neurological abnormalities and multiple chemical sensitivity caused by chronic toluene exposure.
Lee YL, Pai MC, Chen JH, Guo YL.
Department of Environmental and Occupational Health, National Cheng Kung University Medicine
College, Tainan, Taiwan.
Multiple chemical sensitivity (MCS) is a syndrome in which multiple symptoms occur with low-level
chemical exposure; whether it is an organic disease initiated by environmental exposure or a
psychological disorder is still controversial. We report a 38-year-old male worker with chronic toluene
exposure who developed symptoms such as palpitation, insomnia, dizziness with headache, memory
impairment, euphoria while working, and depression during the weekend. Upon cessation of exposure,
follow-up neurobehavioural tests, including the cognitive ability screening instrument and the minimental state examination, gradually improved and eventually became normal. Although no further toluene
exposure was noted, non-specific symptoms reappeared whenever the subject smelled automotive exhaust
fumes or paint, or visited a petrol station, followed by anxiety with sleep disturbance. During
hospitalization for a toluene provocation test, there was no difference between pre-challenge and postchallenge PaCO(2), PaO(2), SaO(2) or pulmonary function tests, except some elevation of pulse rate. The
clinical manifestations suggested that MCS was more relevant to psychophysiological than
pathophysiological factors.
74
7.- Kokuritsu Iyakuhin Shokuhin Eisei Kenkyusho Hokoku. 2002;(120):6-38.
[Indoor air and human health--sick house syndrome and multiple chemical sensitivity]
[Article in Japanese]
Ando M.
[email protected]
The number of complaints about the quality of indoor air has increased during the past two decades.
These complaints have been frequent enough that the term "Sick House Syndrome or Sick Building
Syndrome" and "Multiple Chemical Sensitivity" has been coined. Complaints are likely related to the
increased use of synthetic organic materials in house, furnishing, and consumer products; and the
buildings, furnishings, and consumer products; and the decreased ventilation for energy conservation in
homes. Approximately thousand volatile chemicals have been identified in indoor air. The main sources
of these chemicals are house materials, combustion fumes, cleaning compounds, and paints or stains.
Exposure to high levels of these emissions and to others, coupled with the fact that most people spend
more time indoors than outdoors, raises the possibility that the risk to human health from indoor air
pollution may be potentially greater than the risk posed from outdoor pollutants. The complaints most
frequently voiced with respect to Sick House Syndrome are irritations of the eye, nose, and throat; cough
and hoarseness of voice; headache and mental fatigue. The syndrome of multiple chemical sensitivities is
controversial subject with increasing impact on the field of indoor air quality. The controversy
surrounding Multiple Chemical Sensitivity includes its definition, theories of etiology and pathogenesis,
diagnostic, and life style. Multiple Chemical Sensitivity is considered the hypothesis that is a disease
caused by exposure to many chemically distinct environmental substances at very low.
8.- Psychol Med. 2002 Nov;32(8):1387-94.
Psychiatric and somatic disorders and multiple chemical sensitivity (MCS) in 264 'environmental
patients'.
Bornschein S, Hausteiner C, Zilker T, Förstl H.
Psychiatric Clinic and Department of Toxicology, I, Medical Clinic, Technical University of Munich,
Germany.
75
BACKGROUND: An increasing number of individuals with diverse health complaints are currently
seeking help in the field of environmental medicine. Multiple chemical sensitivity (MCS) or idiopathic
environmental intolerances (IEI) is defined as an acquired disorder with multiple recurrent symptoms
associated with environmental chemicals in low concentrations that are well tolerated by the majority of
people. Their symptoms are not explained by any known psychiatric or somatic disorder. METHOD:
Within a 2-year period we examined 264 of 267 consecutive patients prospectively presenting to a
university based out-patient department for environmental medicine. Patients underwent routine medical
examination, toxicological analysis and the structured clinical interview for DSM-IV psychiatric disorders
(SCID). RESULTS: Seventy-five per cent of the patients met DSM-IV criteria for at least one psychiatric
disorder and 35% of all patients suffered from somatoform disorders. Other frequent diagnoses were
affective and anxiety disorders, and dependence or substance abuse. In 39% a psychiatric disorder, in
23% a somatic condition and in 19% a combination of the two were considered to provide sufficient
explanation of the symptoms. Toxic chemicals were regarded as the most probable cause in only five
cases. The suspected diagnosis of MCS/IEI could not be sustained in the vast majority of cases.
CONCLUSION: This investigation confirms previous findings that psychiatric morbidity is high in
patients presenting to specialized centres for environmental medicine. Somatoform disorders are the
leading diagnostic category, and there is reason to believe that certain 'environmental' or MCS patients
form a special subgroup of somatoform disorders. In most cases, symptoms can be explained by welldefined psychiatric and medical conditions other than MCS, which need specific treatment. Further
studies should focus on provocation testing in order to find positive criteria for MCS and on therapeutic
approaches that consider psychiatric aspects.
9.- Minn Med. 2002 Oct;85(10):33-6.
Idiopathic environmental intolerances.
Hall SW.
Damarco Solutions LLC, Occupational Health Services for the Minneapolis Veterans Affairs Medical
Center, Minneapolis, USA.
Health concerns related to the quality of the environment in offices, schools, homes, and residences have
increased dramatically over the past 2 decades. One health problem frequently confronting medical
practitioners and often attributed to environmental quality problems is idiopathic environmental
76
intolerances (IEI). Formerly known as multiple chemical sensitivities, IEI is an acquired disorder
characterized by adverse reactions attributed to exposure to a variety of substances under ordinary
conditions. Alleged precipitants include solvents, pesticides, detergents, dusts, and fragrances. Symptoms
include fatigue, malaise, headache, concentration and memory difficulties, lightheadedness, cough,
hoarseness, and rhinitis without objective physical signs or consistent laboratory abnormalities. The role
of the environment in precipitating these complaints continues to be controversial, and no intervention or
treatment has thus far been proven to be effective. While not progressive or life threatening, IEI is often
functionally disabling and very distressing to affected individuals. The investigation of IEI should
involve, at a minimum, a clinical evaluation of the affected person and in most cases an environmental
evaluation as well. IEI should be managed without overutilization of diagnostic tests or prescription of
unnecessary environmental, occupational, or dietary restrictions.
10.- Ann N Y Acad Sci. 2001 Mar;933:48-56.
The Iowa follow-up of chemically sensitive persons.
Black DW, Okiishi C, Schlosser S.
Department of Psychiatry, University of Iowa College of Medicine, Iowa City 52242-1000, USA.
Clinical symptoms and self-reported health status in persons reporting multiple chemical sensitivities
(MCS) are presented from a 9-year follow-up study. Eighteen (69%) subjects from a sample of 26 persons
originally interviewed in 1988 were followed up in 1997 and given structured interviews and self-report
questionnaires. In terms of psychiatric diagnosis, 15 (83%) met DSM-IV criteria for a lifetime mood
disorder, 10 (56%) for a lifetime anxiety disorder, and 10 (56%) for a lifetime somatoform disorder.
Seven (39%) of subjects met criteria for a personality disorder using the Personality Diagnostic
Questionnaire-IV. Self-report data from the Illness Behavior Questionnaire and Symptom Checklist-90Revised show little change from 1988. The 10 most frequent complaints attributed to MCS were
headache, memory loss, forgetfulness, sore throat, joint aches, trouble thinking, shortness of breath, back
pain, muscle aches, and nausea. Global assessment showed that 2 (11%) had "remitted", 8 (45%) were
"much" or "very much" improved, 6 (33%) were "improved", and 2 (11%) were "unchanged/worse".
Mean scores on the SF-36 health survey showed that, compared to U.S. population means, subjects
reported worse physical functioning, more bodily pain, worse general health, worse social functioning,
and more emotional-role impairment; self-reported mental health was better than the U.S. population
77
mean. All subjects maintained a belief that they had MCS; 16 (89%) acknowledged that the diagnosis was
controversial. It is concluded that the subjects remain strongly committed to their diagnosis of MCS. Most
have improved since their original interview, but many remain symptomatic and continue to report
ongoing lifestyle changes.
11.- Ann Intern Med. 2001 May 1;134(9 Pt 2):868-81.
A review of the evidence for overlap among unexplained clinical conditions.
Aaron LA, Buchwald D.
Department of Medicine, Division of Internal Medicine, Harborview Medical Center, 325 Ninth Avenue,
Box 359780, Seattle, WA 98104, USA. [email protected]
PURPOSE: Unexplained clinical conditions share features, including symptoms (fatigue, pain), disability
out of proportion to physical examination findings, inconsistent demonstration of laboratory
abnormalities, and an association with "stress" and psychosocial factors. This literature review examines
the nature and extent of the overlap among these unexplained clinical conditions and the limitations of
previous research. DATA SOURCES: English-language articles were identified by a search of the
MEDLINE database from 1966 to January 2001 by using individual syndromes and their hallmark
symptoms as search terms. STUDY SELECTION: Studies that assessed patients with at least one
unexplained clinical condition and that included information on symptoms, overlap with other
unexplained clinical conditions, or physiologic markers. Conditions examined were the chronic fatigue
syndrome, fibromyalgia, the irritable bowel syndrome, multiple chemical sensitivity, temporomandibular
disorder, tension headache, interstitial cystitis, and the postconcussion syndrome. DATA EXTRACTION:
Information on authorship, patient and control groups, eligibility criteria, case definitions, study methods,
and major findings. DATA SYNTHESIS: Many similarities were apparent in case definition and
symptoms, and the proportion of patients with one unexplained clinical condition meeting criteria for a
second unexplained condition was striking. Tender points on physical examination and decreased pain
threshold and tolerance were the most frequent and consistent objective findings. A major shortcoming of
all proposed explanatory models is their inability to account for the occurrence of unexplained clinical
conditions in many affected patients. CONCLUSIONS: Overlap between unexplained clinical conditions
is substantial. Most studies are limited by methodologic problems, such as case definition and the
selection and recruitment of case-patients and controls.
78
12.- Br J Med Psychol. 2001 Mar;74(Pt 1):121-7.
Cacosmia in healthy workers.
Magnavita N.
Institute of Occupational Medicine, Catholic University School of Medicine, Rome, Italy.
[email protected]
Self-reported cacosmia (i.e. feeling ill from the odour of xenobiotic substances) was studied in 151 young,
healthy workers, unexposed to unpleasant odours and working in food stores without air-conditioning.
Almost half (46%) of the sample reported feeling ill from the smell of chemical materials. Chemical
odour intolerance induced headache, itching eyes, irritated or congested nose, dry and/or sore throat,
cough, dizziness, and itching or rash. Cacosmic subjects showed a slight prevalence of the female sex,
and had significantly higher symptom scores, anxiety, and depression than non-cacosmic subjects.
Cacosmia may be related to multiple chemical sensitivity, sick-building syndrome and psychopathology.
Individual variability in odour tolerance may substantially bias epidemiological studies on indoor air
quality and health.
13.- J Gen Intern Med. 2001 Jan;16(1):24-31. Comorbid clinical conditions in chronic fatigue: a cotwin control study
.Aaron LA, Herrell R, Ashton S, Belcourt M, Schmaling K, Goldberg J, Buchwald D.
Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
98104, USA. [email protected]
OBJECTIVES: Chronically fatiguing illness, defined as fatigue for at least 6 months, has been associated
with various physical health conditions. Our objective was to determine whether there is a significant
relationship between chronically fatiguing illness and 10 clinical conditions that frequently appear to be
associated with fatigue, adjusting for the potentially confounding effects of psychiatric illness. DESIGN:
A co-twin control study controlling for genetic and many environmental factors by comparing chronically
fatigued twins with their nonfatigued co-twins. SETTING: A nationally distributed volunteer twin
registry. PARTICIPANTS: The study included 127 twin pairs in which one member of the pair
experienced fatigue of at least 6 months' duration and the co-twin was healthy and denied chronic fatigue.
Fatigued twins were classified into 3 levels using increasingly stringent diagnostic criteria.
79
MEASUREMENTS AND MAIN RESULTS: Twins reported on a history of fibromyalgia, irritable bowel
syndrome,
multiple
chemical
sensitivities,
temporomandibular
disorder,
interstitial
cystitis,
postconcussion syndrome, tension headache, chronic low back pain, chronic pelvic pain (women), and
chronic nonbacterial prostatitis (men). The prevalence of these comorbid clinical conditions was
significantly higher in the fatigued twins compared to their nonfatigued co-twins. Most notably, compared
to their nonfatigued co-twins, the chronically fatigued twins had higher rates of fibromyalgia (> 70% vs <
10%) and irritable bowel syndrome (> 50% vs < 5%). The strongest associations were observed between
chronic fatigue and fibromyalgia (odds ratios > 20), irritable bowel syndrome, chronic pelvic pain,
multiple chemical sensitivities, and temporomandibular disorder (all with odds ratios > or = 4).
Regression analysis suggested that the number of comorbid clinical conditions associated with chronic
fatigue could not be attributed solely to psychiatric illness. CONCLUSIONS: Chronically fatiguing
illnesses were associated with high rates of many other clinical conditions. Thus, patients with chronic
fatigue may present a complex clinical picture that poses diagnostic and management challenges.
Nonetheless, clinicians should assess such patients for the presence of comorbid clinical conditions.
Future research should provide a better understanding of the temporal relationship of the onset of fatigue
and these conditions, and develop strategies for early intervention.
14.- Med Hypotheses. 2000 May;54(5):734-8.
Chemical sensitivity and fatigue syndromes from hypoxia/hypercapnia.
Ross PM.
The American Health Foundation, New York, USA.
The multiple chemical sensitivities syndrome (MCS) and other chronic syndromes causing fatigue,
headache and other protean CNS symptoms without observable signs, are proposed to result from
hypoxia/hypercapnia (H/H) due to disturbed breathing. The concept is explained in terms of sleep apnea
(SA), although H/H could result from causes other than SA. Reasons for considering this etiologic linkage
are as follows: 1. MCS symptoms resemble those of SA. 2. The only physical signs associated with MCS
(upper airway inflammation and obstruction) can aggravate SA. 3. The only neuropsychiatric finding
common among MCS symptomatics, reduced verbal recall, is associated with SA. 4. Many MCS
symptomatics attribute onset of their condition to a pesticide or solvent exposure. Solvent neurotoxicity
may cause cacosmia, a symptom of MCS and SA. 5. Improved upper airway patency, a first-line therapy
80
in SA, may improve symptoms in some MCS-like conditions. Implications for diagnosis and treatment of
MCS are discussed. Copyright 2000 Harcourt Publishers Ltd.
15.- Public Health Rep. 1998 Sep-Oct;113(5):398-409.
The indoor air we breathe.
Oliver LC, Shackleton BW.
Massachusetts General Hospital, Boston, USA. [email protected]
Increasingly recognized as a potential public health problem since the outbreak of Legionnaire's disease
in Philadelphia in 1976, polluted indoor air has been associated with health problems that include asthma,
sick building syndrome, multiple chemical sensitivity, and hypersensitivity pneumonitis. Symptoms are
often nonspecific and include headache, eye and throat irritation, chest tightness and shortness of breath,
and fatigue. Air-borne contaminants include commonly used chemicals, vehicular exhaust, microbial
organisms, fibrous glass particles, and dust. Identified causes include defective building design and
construction, aging of buildings and their ventilation systems, poor climate control, inattention to building
maintenance. A major contributory factor is the explosion in the use of chemicals in building construction
and furnishing materials over the past four decades. Organizational issues and psychological variables
often contribute to the problem and hinder its resolution. This article describes the health problems related
to poor indoor air quality and offers solutions.
16.- Cephalalgia. 1997 Dec;17(8):873-95.
Investigations into the role of nitric oxide and the large intracranial arteries in migraine headache.
Thomsen LL.
Department of Neurology, Glostrup Hospital, Copenhagen, Denmark.
Previous studies suggest that nitric oxide (NO) is involved in headaches induced by i.v. infusion of the
vasodilator and NO donor glyceryl trinitrate (GTN) in healthy subjects. Extending these studies to
sufferers of migraine without aura, it was found that migraineurs experienced a stronger headache than
non-migraineurs. In addition, most migraineurs experienced a delayed migraine attack at variable times
(mean 5.5 h) after GTN provocation. This biphasic headache response in migraineurs may be linked to
81
hypersensitivity in the NO-cGMP pathway. Thus, compared to controls, migraineurs were found to be
more sensitive to GTN-induced intracranial arterial dilatation, which is known to be mediated via
liberation of NO and subsequent synthesis of cGMP Furthermore, histamine infusions in migraineurs
induced headache responses and intracranial arterial responses resembling those induced by GTN in
migraineurs. Histamine is known to liberate NO from the endothelium via stimulation of the H1 receptor,
which is present in the large intracranial arteries in man. Because both immediate histamine-induced
headache and intracranial arterial dilatation and delayed histamine-induced migraine are blocked by H1receptor blockade, a likely common pathway for GTN and histamine-induced headaches/migraines and
intracranial arterial responses may be via activation of the NO-cGMP pathway. The delay in the
development of these experimental migraines may reflect activation of multiple physiological processes.
The intracranial arteries of migraineurs were found supersensitive to the vasodilating effect of GTN
(exogenous NO). This relates to clinical findings suggesting dilatation of the large intracranial arteries on
the headache side during spontaneous migraine attacks. The function of arterial regulatory mechanisms
involving NO in migraine was therefore studied. In peripheral arteries, no endothelial dysfunction of NO
was found and cardiovascular and intracranial arterial sympathetic function was normal. A mild
parasympathetic dysfunction may be involved and may, via denervation supersensitivity, be responsible
for the observed supersensitivity to NO. Another possibility is that NO initiates a perivascular neurogenic
inflammation with liberation of vasoactive peptides. NO also mediates a variety of other physiological
phenomena. One of these, the pain-modulating effect observed in animals, was evaluated in a human
study using GTN infusion and measurements of pain thresholds. No definite effects of GTN were
demonstrated. The precise mechanisms involved in NO-triggered migraines and which part of the NOactivated cascade that is involved remain to be determined. The possibilities for pharmacological
stimulation and/or inhibition of several steps of the NO-activated cascade increase rapidly and soon may
be available for human studies.
No relacionado con este tema
17.- Environ Health Perspect. 1997 Mar;105 Suppl 2:417-36.
Profile of patients with chemical injury and sensitivity.
Ziem G, McTamney J.
Occupational and Environmental Medicine, Baltimore, Maryland, USA.
82
Patients reporting sensitivity to multiple chemicals at levels usually tolerated by the healthy population
were administered standardized questionnaires to evaluate their symptoms and the exposures that
aggravated these symptoms. Many patients were referred for medical tests. It is thought that patients with
chemical sensitivity have organ abnormalities involving the liver, nervous system (brain, including
limbic, peripheral, autonomic), immune system, and porphyrin metabolism, probably reflecting chemical
injury to these systems. Laboratory results are not consistent with a psychologic origin of chemical
sensitivity. Substantial overlap between chemical sensitivity, fibromyalgia, and chronic fatigue syndrome
exists: the latter two conditions often involve chemical sensitivity and may even be the same disorder.
Other disorders commonly seen in chemical sensitivity patients include headache (often migraine),
chronic fatigue, musculoskeletal aching, chronic respiratory inflammation (rhinitis, sinusitis, laryngitis,
asthma), attention deficit, and hyperactivity (affected younger children). Less common disorders include
tremor, seizures, and mitral valve prolapse. Patients with these overlapping disorders should be evaluated
for chemical sensitivity and excluded from control groups in future research. Agents whose exposures are
associated with symptoms and suspected of causing onset of chemical sensitivity with chronic illness
include gasoline, kerosene, natural gas, pesticides (especially chlordane and chlorpyrifos), solvents, new
carpet and other renovation materials, adhesives/glues, fiberglass, carbonless copy paper, fabric softener,
formaldehyde and glutaraldehyde, carpet shampoos (lauryl sulfate) and other cleaning agents,
isocyanates, combustion products (poorly vented gas heaters, overheated batteries), and medications
(dinitrochlorobenzene for warts, intranasally packed neosynephrine, prolonged antibiotics, and general
anesthesia with petrochemicals). Multiple mechanisms of chemical injury that magnify response to
exposures in chemically sensitive patients can include neurogenic inflammation (respiratory,
gastrointestinal, genitourinary), kindling and time-dependent sensitization (neurologic), impaired
porphyrin metabolism (multiple organs), and immune activation.
18.- Crit Rev Toxicol. 1996 Nov;26(6):617-31.
Multiple chemical sensitivity multiorgan dysesthesia, multiple symptom complex, and multiple
confusion: problems in diagnosing the patient presenting with unexplained multisystemic symptoms.
Salvaggio JE, Terr AI.
Tulane University School of Medicine, Department of Medicine, New Orleans, LA 70112, USA.
83
Patients are presenting in increasing numbers with multiorgan symptoms allegedly resulting from
exposure to environmental chemicals. Among the symptoms expressed by patients with alleged multiple
chemical sensitivities (MCS) are profound fatigue, mental confusion, myalgia, depression, anxiety,
dizziness, headache, insomnia, loss of appetite, and numbness of the extremities, all in the absence of
objective physical signs. Diagnostic criteria to assess the effects of environmental agents on organ
systems are sorely needed because patients with MCS often have no tissue pathology or physiological
abnormalities, but often do have diagnosable psychiatric illnesses. In treating patients with MCS, the
physician should first perform a complete history and physical examination, including a comprehensive
evaluation of chemical exposure. If the findings strongly suggest the presence of disease related to
particular organ systems, further diagnostic evaluation should be undertaken. If abnormal findings are
absent, psychiatric advice may be useful. The physician should keep an open mind about MCS but must
also remember that a cause-effect relationship between exposure to multiple chemicals and symptoms has
not been established.
19.- Regul Toxicol Pharmacol. 1996 Aug;24(1 Pt 2):S55-7.
Specificity and dosimetry of toxicologic responses.
Doull J.
University of Kansas, School of Medicine, Kansas City, USA.
Toxicology has two goals. The first is to identify and characterize the adverse effects that can be produced
in biological systems by exposure to chemicals and the second is to use this information to predict the
type and severity of responses in other species and exposure situations. The tools that the toxicologist
uses to detect and describe the adverse effects of chemical exposure include the traditional acute,
subchronic, and chronic studies in animals plus a variety of special studies designed to demonstrate
specific organ damage, reproductive and teratogenic effects, neurotoxicity, immunotoxicity, genotoxicity,
and other responses. These are often supplemented with studies of the kinetics and the mechanism of
action and more recently with studies designed to elucidate the molecular basis for cancer and other
effects. Theses studies together with the information on exposure provide the basis for subsequent
toxicologic predictions. Although general effects such as weight loss and mortality are included in
toxicity protocols, most of the toxicology tests are related to specific end-organ toxicity or to mechanism
or behavioral studies. We do not have animal protocols to study individually the subjective symptoms
84
described for multiple chemical sensitivity, such as depression, fatigue, headache, and memory loss, and
our tests lack sufficient specificity to evaluate a syndrome which is composed primarily of such
symptoms. Since all chemicals can produce adverse effects under some conditions of exposure,
toxicologic predictions are most useful when they specify both the type of adverse effect anticipated and
the dose required to produce the effect. Multiple chemical sensitivity does not appear to consistently
involve specific chemicals or specific adverse effects and the effects observed are reported to lack
evidence of a threshold and to occur at extremely low levels. It is difficult to include these parameters in
any reasonable toxicologic prediction relating cause and response in multiple chemical sensitivity or
similar conditions.
20.- Environ Health Perspect. 1993 Aug;101(3):234-8.
Neurogenic inflammation and sensitivity to environmental chemicals.
Meggs WJ.
Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, NC
27858.
Comment in:
• Environ Health Perspect. 1994 Jan;102(1):12-3; author reply 13.
• Environ Health Perspect. 1994 Jan;102(1):12; author reply 13.
Neurogenic inflammation as a pathway distinct from antigen-driven, immune-mediated inflammation
may play a pivotal role in understanding a broad class of environmental health problems resulting from
chemical exposures. Recent progress in understanding the mediators, triggers, and regulation of
neurogenic inflammation is reviewed. Evidence for and speculations about a role for neurogenic
inflammation in established disorders such as asthma, rhinitis, contact dermatitis, migraine headache, and
rheumatoid arthritis are presented. The sick building syndrome and multiple chemical sensitivity
syndrome have been defined as clinical entities in which exposure to chemical inhalants gives rise to
disease. Current data on the existence of chemical irritant receptors in the airway and skin are discussed;
neurogenic inflammation arising from stimulation of chemical irritant receptors is a possible model to
explain many of the aspects of chemical sensitivities.
85
21.- Environ Health Perspect. 1991 Nov;95:67-9.
Severity of health effects associated with building-related illness.
Welch LS.
George Washington University School of Medicine, Division of Occupational and Environmental
Medicine, Washington, DC 20037.
Building-related illness ranges from mild rhinitis to potentially life-threatening hypersensitivity
pneumonitis and legionellosis. Sick-building syndrome, consisting of headache, mucous membrane
irritation, and fatigue, may be present in 30% of all office workers. Hypersensitivity pneumonitis, asthma,
and legionellosis are less common, and it is difficult from existing studies to estimate the incidence of
these more severe illnesses. There are even fewer data on an illness now being called multiple chemical
sensitivity and its relationship to indoor environments. New studies are needed to estimate the frequency
of all building-associated illnesses, and case definitions for these disorders must be delineated.
86
REVISIÓN Y GRAFICAS DE LAS PUBLICACIONES DEL SEE-CONCLUSIONES
PRELIMINARES
1.- Por el primer autor:
nombre primer autor
nº art primer autor
Aaron LA
2
Resto autores (18)
1
Nº articulos por primer autor
2
1
Aaron LA
Resto autores (18)
En la mayor parte de las publicaciones hay un único articulo científico por autor, sólo un autor, tiene dos
publicación en la materia (poca especialización)
2.- Por la distribución en años o periodos de años.
AÑO
Nº publicaciones
Año 1991
Año 1993
Año 1996
Año 1997
Año 1998
Año 2000
Año 2001
Año 2002
Año 2003
Año 2005
Año 2007
1
1
2
1
1
1
4
3
1
2
2
Año 2009
1
periodo de años
Porcentaje de publicaciones
nº publicaciones
Año 1991-2000
35
7
Año 2000-2008
65
13
87
Nº articulos por año
4
3
2
1
Año 1991
2
1
1
Año 1993
Año 1996
1
Año 1997
Año 1998
1
Año 2000
2
1
Año 2001
Año 2002
Año 2003
1
Año 2005
Año 2007
Año 2009
Nº articulos por periodos
13
7
Año 1991-2000
Año 2000-2008
Porcentaje articulos por periodos
Año 1991-2000
Año 2000-2008
35%
65%
Nota: como transposición de la Directiva Europea 89/391/CEE, aparece la Ley 31/1995 de Prevención de
Riesgos Laborales (LPRL), modificada y actualizada por la Ley 54/2003, de 12 de diciembre, de reforma del
marco normativo de la prevención de riesgos laborales.
Hay un incremento en el número de publicaciones a partir de 1997 ¿coincidiendo con la
aplicación en la práctica de la normativa europea en prevención de riesgos laborales?
88
3.- Por el tipo de revista que lleva a cabo las publicaciones
nombre de la revista
nº de publicaciones
Environ Health Perspect.
3
Otras revistas (17)
1
Nº de articulos por revista
3
1
Environ Health Perspect.
Otras revistas (17)
Tan sólo una revista repite publicaciones en este tema, el resto (17 revistas) se reparten el resto de
las publicaciones en la materia.
4.- Por el país del que procede la publicaciónPaís de procedencia de la
revista
Porcentaje de publicaciones
nº publicaciones
USA
UK
Japan
Alemania
55
15
10
10
11
3
2
2
Korea
Dinamarca
5
5
1
1
Nº artículos por país de la revista
11
3
2
2
USA
UK
Japan
Alemania
89
1
Korea
1
Dinamarca
Porcentaje de articulos segun pais de la revista
5
5
USA
10
UK
Japan
55
10
Alemania
15
Korea
Dinamarca
Estados Unidos y Reino Unido recogen más del 60% de las publicaciones en este tema.
5.- Por el tipo de estudio realizado.
Tipo de estudio
Descriptivo
Observacional
Otros
Porcentaje de publicaciones
35
45
20
nº publicaciones
7
9
4
Reparto según tipo estudio
9
7
4
Descriptivo
Observacional
90
Otros
Porcentaje segun tipo de estudio
20
35
Descriptivo
Observacional
45
Otros
La mayor parte de los estudios son observacionales o descriptivos. Estudios elementales de
investigación.
6.- Por la repercusión o relevancia del estudio.
Relevancia del estudio
Porcentaje de publicaciones
nº publicaciones
Clínico
Clínico-laboral
45
55
9
11
Reparto según nivel de evidencia
11
9
Clínico
Clínico-laboral
91
Porcentaje segun relevancia del estudio
45
Clínico
55
Clínico-laboral
En la mayor parte de los estudios la relevancia es clínica o clínico laboral.
7.- Por la población objeto del estudio.
Poblacion del estudio
Porcentaje de publicaciones
nº de publicaciones
Poblacion general
Población laboral
60
30
12
6
Servicios
10
2
Reparto según población/actividad
12
6
2
Poblacion
general
Población laboral
92
Servicios
Porcentaje segun poblacion del estudio
10
Poblacion general
30
60
Población laboral
Servicios
En la mayor parte de los estudios la población es general o laboral general, como sector profesional
individual, destaca el sector servicios asociado generalmente a trabajos de oficina.
8.- Por los síntomas que acompañan a la cefalea, que esta presente en todos los casos.
Sintomas además de cefalea
nº publicaciones
Neurológicos
Fatiga
Dolor
ORL
Oculares
Respiratorios
Reumatologicos
Digestivos
18
10
7
7
4
3
3
2
Dermatológicos
2
Otros sintomas (nº artículos)
18
10
7
7
L
3
2
2
O
cu
l
O
R
or
Do
l
a
Fa
t ig
3
ar
es
Re
sp
ir a
to
Re
rio
um
s
at
ol
og
ic
os
Di
ge
st
De
iv
os
rm
at
ol
óg
ic
os
Ne
u
ro
ló
g
ic
os
4
Además de cefalea, presente en todas las publicaciones destacan los síntomas neurológicos,
generales y de mucosas.
93
9.- Por los aspectos preventivos contenidos en la publicación.
Aspectos preventivos
Porcentaje de publicaciones
nº publicaciones
Ninguno
55
11
Recomendaciones generales
45
9
Aspectos preventivos/Actuaciones emprendidas (nº articulos)
11
Ninguna
9
Recomendaciones generales
Porcentaje de aspectos preventivos
45
Ninguna
55
Recomendaciones
generales
Como norma no existen aspectos preventivos contemplados en las publicaciones, en algunos casos
se incluyen recomendaciones generales.
94